Psychological resistance to insulin therapy in adults with type 2 diabetes: mixed-method systematic review

A qualitative study of the experiences of insulin use by older people with type 2 diabetes mellitus

BACKGROUND

There is a rising prevalence of type 2 diabetes among older people. This population also suffers from co-morbidity and a greater number of diabetes related complications, such as visual and cognitive impairment, which can potentially affect their ability to manage insulin regimens. Understanding the experiences of older people when they transition to insulin will help the development of healthcare interventions to enhance their diabetes outcomes, overall health and quality of life.

AIMS

The aims of this exploratory study were to (1) understand the experiences of older people with type 2 diabetes in relation to insulin treatment initiation and management and (2) use this understanding to consider how the insulin management support provided to older people by healthcare providers could be more tailored to their needs.

METHOD

A qualitative study using semi structured (remote) interviews with older people with diabetes (n = 10) and caregivers (n = 4) from the UK. Interviews were audio recorded and transcribed, and framework analysis was used to analyse the data.

RESULTS

Three main themes, along with six subthemes, were generated from the study data. Participants generally felt at ease with insulin administration following training, yet some reported feelings of failure at transitioning to insulin use. Participants were also frustrated at what they perceived were insufficient resources for effective self-management, coupled with a lack of professional interest in optimising their health as older people. Some also expressed dissatisfaction regarding the brevity of their consultations, inconsistent information from different healthcare professionals and poor treatment coordination between primary and secondary care.

CONCLUSION

Overall, the study emphasised that older people need better support, education and resources to help manage their insulin use. Healthcare professionals should be encouraged to adopt a more individualised approach to supporting older people that acknowledges their prior knowledge, physical and psychological capabilities and motivation for diabetes self-management. In addition, better communication between different services and greater access to specialist support is clearly needed for this older population.

PRACTICE IMPLICATIONS

An integrated care pathway for insulin use in older people could be considered. This would include an assessment of the older person's needs and capacity on their initiation to insulin; targeted education and training in self-management; timely access to appropriate emotional and peer support resources; care plans developed collaboratively with patients; and individualised glucose targets that recognise the needs and preferences of the older person.

Current barriers to initiating insulin therapy in individuals with type 2 diabetes

Insulin is an essential drug in the treatment of diabetes, often necessary for managing hyperglycemia in type 2 diabetes mellitus (T2DM). It should be considered in cases of severe hyperglycemia requiring hospitalization, after the failure of other treatments, in advanced chronic kidney disease, liver cirrhosis, post-transplant diabetes, or during pregnancy. Moreover, in specific patient subgroups, early initiation of insulin is crucial for hyperglycemia control and prevention of chronic complications. Clinical guidelines recommend initiating insulin when other treatments fail, although there are barriers that may delay its initiation. The timing of initiation depends on individual patient characteristics. Typically, insulinization starts by adding basal insulin to the patient's existing treatment and, if necessary, progresses by gradually introducing prandial insulin. Several barriers have been identified that hinder the initiation of insulin, including fear of hypoglycemia, lack of adherence, the need for glucose monitoring, the injection method of insulin administration, social rejection associated with the stigma of injections, weight gain, a sense of therapeutic failure at initiation, lack of experience among some healthcare professionals, and the delayed and reactive positioning of insulin in recent clinical guidelines. These barriers contribute, among other factors, to therapeutic inertia in initiating and intensifying insulin treatment and to patients' non-adherence. In this context, the development of once-weekly insulin formulations could improve initial acceptance, adherence, treatment satisfaction, and consequently, the quality of life for patients. Currently, two once-weekly basal insulins, insulin icodec and basal insulin BIF, which are in different stages of clinical development, may help. Their longer half-life translates to lower variability and reduced risk of hypoglycemia. This review addresses the need for insulin in T2DM, its positioning in clinical guidelines under specific circumstances, the current barriers to initiating and intensifying insulin treatment, and the potential role of once-weekly insulin formulations as a potential solution to facilitate timely initiation of insulinization, which would reduce therapeutic inertia and achieve better early control in people with T2DM.

Correlates of disordered eating and insulin restriction behavior and its association with psychological health in Taiwanese youths with diabetes mellitus

BACKGROUND

Adolescents and young adults (AYAs) with diabetes mellitus (DM) are prone to eating disorders that may worsen metabolic control. This study investigated the clinical and behavioral correlates of disordered eating and insulin restriction (DE/IR) behavior and its association with psychological health among AYAs with DM.

METHODS

We enrolled patients with DM aged 10-30 years receiving insulin treatment in a tertiary medical center from 2019 to 2021. After obtaining informed consent, we assessed various visit-to-visit HbA1c measures indicating glycemic control, DE/IR behavior using the modified SCOFF questionnaire, weight-control practices (e.g., self-medication, induced vomiting, and over-exercising), and anxious and depressive symptoms using the Hospital Anxiety and Depression Scale. Correlation and hierarchical regression analyses were applied to understand the clinical and behavioral correlates of DE/IR behavior and its association with anxiety and depression.

RESULTS

Among the 110 patients with type 1 and type 2 DM recruited, we found 17.6% restricting insulin use and 6.3% self-medicating for weight control (higher in type 2 DM than type 1 DM). Hierarchical regression analyses showed HbA1c standard deviation (odds ratio = 2.18, [95% confidence interval 1.07-4.42]), body image (1.83, [1.05-3.20]), and dieting (4.74, [1.70-13.23]) associated with DE/IR behavior. Moreover, DE/IR behavior was further associated with anxiety (1.17 [1.08-1.27]) and depression (1.12 [1.03-1.22]).

CONCLUSION

DE/IR behavior is not uncommon among AYAs with DM, particularly those with type 2 DM, and may be associated with anxiety and depressive symptoms. In addition, HbA1c variability is correlated with DE/IR behavior, and the clinical implications need further exploration.

'For me, it didn't seem as drastic a step as being controlled by insulin': A qualitative investigation of expectations and experiences of non-insulin injectable therapy among adults with type 2 diabetes

AIMS

This qualitative study aims to explore beliefs, attitudes and experiences of injectable glucagon-like-peptide-1 receptor agonists (GLP-1RAs) use and discontinuation, as well as attitudes to further injectable treatment intensification, among adults with type 2 diabetes (T2D).

METHODS

Nineteen in-depth semi-structured interviews lasting (mean ± standard deviation) 45 ± 18 min were conducted, face-to-face (n = 14) or via telephone (n = 5). Transcripts were analysed using inductive template analyses. Eligible participants were English-speaking adults with T2D who had recently initiated (≤3 years) GLP-1RA treatment.

RESULTS

Participants were aged 28-72 years, who predominantly lived in metropolitan areas (n = 15), and had an experience of daily (n = 11) and/or once-weekly (n = 13) GLP-1RA formulations. Six participants had discontinued treatment and seven had trialled two or more formulations. Expectations and experiences of GLP-1RA were related to the perceived: (1) symbolism and stigma of injectable diabetes treatment; (2) ease of injectable administration and device preferences; (3) treatment convenience and social impact; (4) treatment efficacy and benefits, and; (5) negative treatment side effects. Some participants reported increased receptiveness to insulin therapy following their GLP-1RA experience, others emphasised unique concerns about insulin beyond injectable administration.

CONCLUSIONS

This study provides a novel understanding of expectations and experience of non-insulin injectables among Australian adults with T2D. Our data suggest expectations may be informed by attitudes to insulin therapy, while perceived treatment benefits (e.g. weight-related benefits, administration frequency) may motivate uptake and ongoing use despite concerns. Experience of GLP-1RA injections may impact receptiveness to future insulin use.

Utility and acceptability of a brief type 2 diabetes visual animation: A mixed-methods feasibility study (Preprint)

Background

Visualizations of illness and treatment processes are promising interventions for changing unhelpful perceptions and improving health outcomes. However, these are yet to be tested in patients with type 2 diabetes mellitus (T2DM).

Objective

This study assesses the cross-cultural acceptability and potential effectiveness of a brief visual animation of T2DM at changing unhelpful illness and treatment perceptions and self-efficacy among patients and family members in 2 countries, New Zealand and Saudi Arabia. Health care professionals’ views on visualization are also explored.

Methods

A total of 52 participants (n=39, 75% patients and family members and n=13, 25% health care professionals) were shown a 7-minute T2DM visual animation. Patients and family members completed a questionnaire on illness and treatment perceptions and self-efficacy before and immediately after the intervention and completed semistructured interviews. Health care professionals completed written open-ended questions. Means and 95% CIs are reported to estimate potential effectiveness. Inductive thematic analysis was conducted on qualitative data.

Results

All participants rated the visual animation as acceptable and engaging. Four main themes were identified: animation-related factors, impact of the animation, animation as an effective format for delivering information, and management-related factors. Effect sizes (ranged from 0.10 to 0.56) suggested potential effectiveness for changing illness and treatment perceptions and self-efficacy among patients and family members.

Conclusions

Visualizations are acceptable and may improve the perceptions of patients’ with diabetes in a short time frame. This brief visual animation has the potential to improve current T2DM education. A subsequent randomized controlled trial to investigate the effects on illness and treatment perceptions, adherence, glycemic control, and unplanned hospital admission is being prepared.

Factors influencing diabetes self-management in adults: an umbrella review of systematic reviews

OBJECTIVE

The objective of this review was to identify and describe the factors influencing diabetes self-management in adults by summarizing the available evidence concerning their types, categories, and relative importance.

INTRODUCTION

A wide range of factors, acting simultaneously, influence diabetes self-management and interfere with its actual application by patients. There is a variety of systematic reviews of these factors; however, a more thorough examination of their influences was lacking.

INCLUSION CRITERIA

Systematic reviews of qualitative or quantitative literature focusing on factors influencing adult diabetes self-management in general or on individual behaviors (ie, management of oral antidiabetic medication and insulin injections, self-monitoring of blood glucose, foot care, healthy eating, regular exercise, and smoking cessation) will be included.

METHODS

We performed an extensive search of 11 bibliographic databases, including gray literature, up to June 2019. Quantitative and qualitative findings were summarized separately and labeled according to their types (eg, facilitator/barrier, strength and direction of association), categories (eg, demographic, social), and frequency of occurrence.

RESULTS

We identified 51 types of factors within 114 systematic reviews, which mostly addressed medication-taking behavior. Thirty-two (62.7%) factors were reported in both qualitative and quantitative literature. The predominant influences were psychological factors and behavioral attributes/skills factors. The most frequently reported facilitators of diabetes self-management were motivation to diabetes self-management, a favorable attitude to diabetes self-management, knowledge about the disease, medication and behaviors associated with diabetes self-management, skills, and self-efficacy/perceived behavioral control. The predominant barriers were the presence of depression, and polypharmacy or drug regimen complexity. The demographic factor of female sex was frequently reported for its negative influence on diabetes self-management, whereas older age was a positive factor. The social/cultural and physical environment were the least-studied categories. Other factors such as social support from family, friends, or networks; interventions led by health professionals; and a strong community environment with good social services favoring diabetes self-management were reported as major facilitators of diabetes self-management.

CONCLUSIONS

Essential components of interventions to promote effective diabetes self-management should aim to help adults manage the effects of specific factors related to their psychological and practical self-management experience. Screening for depression, in particular, should become an integral part of the support for adult diabetes self-management, as depression is a particular obstacle to the effectiveness of diabetes self-management. Future studies should more deeply examine the influence of factors identified in the sociocultural and physical environment categories. Research should properly consider and invest efforts in strengthening social support and innovative community care approaches, including pharmacist- and nurse-led care models for encouraging and improving adult diabetes self-management. Finally, researchers should examine non-modifiable factors - age, sex, or socioeconomic status - in the light of factors from other categories in order to deepen understanding of their real-world patterns of action on adult diabetes self-management.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084665.

Women in Relationships and Their Pornography Use: A Systematic Review and Thematic Synthesis

A systematic review and thematic synthesis were conducted on the motivations, purposes, and influence of pornography use among women who are in committed relationships. Pornography use was identified as having both positive and negative outcomes for women's sexual and relationship lives. Women watched pornography for diverse reasons: to feel sexually empowered, to enhance sexual arousal, and for masturbation purposes. Shared use of pornography with partners provided variety in sexual activities, could aid communication about sexual issues and helped improve intimacy. Pornography use can help some women feel sexually empowered, relaxed and better able to enjoy their sexual lives.

Shocked to happy: Experiences of Iranian diabetics in reaction to the bad news of the diagnosis

Diagnosis of a chronic disease like type 2 diabetes mellitus (T2DM) is frequently shocking for patients, which influences their lives. Getting aware of bad news such as obtaining a chronic illness diagnosis is a sensitive issue in patients' lives. Conversely, reactions to the reception of a diagnosis of diabetes are often varied for a few reasons. To manage the diseases through care planning, the identification and modification of the causes of various reactions are necessary. The aim of the present survey was to investigate the reaction of diabetics to the reception of diabetes diagnosis and its possible reasons. In this qualitative study, in-depth interviews were used. Furthermore, traditional content analysis of semi-structured interviews was conducted using a qualitative strategy with 20 individuals with type 2 diabetes. The purposeful sampling approach was employed for recruiting the participants. Eleven male and nine female participants having type 2 diabetes had been transferred to the diabetes association of Iran for receiving consulting assistance in the areas of nutrition, psychology, and health care. Four categories of reactions have arisen from the investigation including behavioral, emotional, contextual, and cognitive reactions. Reactions to the prognosis of diabetes may be different for some reasons. The findings of the present investigation may be employed by health care providers to obtain a more comprehensive understanding of unusual and usual reactions, their causes, and the context in the early years after the diagnosis and planning care programs for disease management.

Validation of the Chinese version of the insulin treatment appraisal scale

AIMS

To test the reliability and validity of the Chinese version of the Insulin Treatment Appraisal Scale (ITAS) questionnaire in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 200 patients with T2DM were consecutively recruited from the outpatient clinic in Taiwan. The World Health Organization guideline was followed to translate the questionnaire. The internal consistency was assessed by Cronbach's α coefficient and item-total correlations. The construct validity was evaluated by using confirmatory factor analysis, convergent validity, and discriminate validity.

RESULTS

The Cronbach's α coefficient for estimates of internal consistency of the total scale was 0.72, and ranged from 0.76 to 0.77 for the subscales. A value of ≥0.40 was considered being substantial. The item-total correlation values were 14 out of 20 items having substantial correlations (4 out of 4 items on the positive appraisal scale and 10 out of 16 items on the negative appraisal scale). The confirmatory factor analysis confirmed both positive and negative factors with total explained variance 33.9% (12.2% for positive subscale and 21.7% for negative subscale). The success rate, calculated from the item-total correlation values, was 70% for the convergent validity (100% for positive subscale and 63% for negative subscale) and 90% for discriminate validity (100% for positive subscale and 88% for negative subscale), respectively. Both the ceiling effect and floor effect were 0%.

CONCLUSIONS

The Chinese version of the ITAS questionnaire is a valid and reliable instrument for measuring the perceptions of insulin injection in patients with T2DM.

Psychosocial Moderators of the Impact of Diabetes Stigma: Results From the Second Diabetes MILES - Australia (MILES-2) Study

OBJECTIVE

To examine the association of diabetes stigma with psychological, behavioral, and HbA_1c outcomes and to investigate moderation effects of self-esteem, self-efficacy, and/or social support.

RESEARCH DESIGN AND METHODS

The national Second Diabetes MILES - Australia (MILES-2) survey included adults with type 1 diabetes (n = 959, 41% of whom were male, with mean ± SD age 44 ± 15 years), insulin-treated type 2 diabetes (n = 487, 60% male, age 61 ± 9 years), and non-insulin-treated type 2 diabetes (n = 642, 55% male, age 61 ± 10 years). (Un)adjusted linear regression analyses tested the association between diabetes stigma (Diabetes Stigma Assessment Scale [DSAS]) and psychological outcomes (depressive symptoms [eight-item version of the Patient Health Questionnaire (PHQ-8)], anxiety symptoms [Generalized Anxiety Disorder 7-item (GAD-7) questionnaire], and diabetes-specific distress [20-item Problem Areas In Diabetes (PAID) scale]), behavioral outcomes (healthy diet and physical activity [Summary of Diabetes Self-Care Activities (SDSCA)]), and self-reported HbA_1c. Interaction effects tested whether associations varied by self-esteem (Rosenberg Self-Esteem Scale [RSES]), self-efficacy (Confidence in Diabetes Self-Care [CIDS] scale), or diabetes-specific social support (Diabetes Support Scale [DSS]).

RESULTS

Significant positive associations were observed between DSAS and PHQ-8, GAD-7, and PAID across diabetes type/treatment groups (all P < 0.001), whereby each SD increase in DSAS scores was associated with approximately one-half SD deterioration in emotional well-being. Associations between DSAS and SDSCA and HbA_1c were nonmeaningful. Self-esteem moderated psychological outcomes among participants with type 1 and non-insulin-treated type 2 diabetes and diabetes distress among those with insulin-treated type 2 diabetes. Interaction effects were partially observed for social support but not for self-efficacy.

CONCLUSIONS

This study provides evidence of the association between diabetes stigma and depressive/anxiety symptoms and diabetes distress and for the moderating effects of self-esteem and social support among adults with type 1 and type 2 diabetes. Further research is needed to examine associations with objectively measured behavioral and clinical outcomes.

Decisional Balance for Insulin Injection: Scale Development and Psychometric Testing

Background

Insulin-naive patients are often reluctant to receive insulin treatment, and even insulin-treated patients frequently have poor rates of adherence to their prescribed insulin injection regimes. Assessing attitudes toward insulin injection may help in the design of interventions that improve the insulin injection behaviors of patients with type 2 diabetes (T2DM). The concept of decisional balance has been associated with behavior in many studies and may be useful in assessing the attitude of patients with T2DM toward insulin injection. Decisional balance for insulin injection (DBII) has not been widely assessed in patients with T2DM.

Purpose

The aim of this study was to develop an insulin injection (DBII) scale that is valid for insulin-naive and insulin-treated patients and to test the psychometric characteristics of this scale based on the concept of decisional balance.

Methods

This cross-sectional study administered an 18-item DBII scale, including pro and con subscales, to 95 insulin-naive and 237 insulin-treated patients in Taiwan. The decisional balance score was calculated as the mean score of the pro subscale minus the mean score of the con subscale. Construct validity was examined using exploratory factor analysis and confirmatory factor analysis; concurrent validity was assessed by examining the association between the score of the DBII scale and the stages of behavioral change and of hemoglobin A1c for, respectively, insulin-naive patients and insulin-treated patients; and reliability was assessed using internal consistency and test–retest reliability.

Results

A 13-item DBII scale supported by exploratory factor analysis and confirmatory factor analysis was developed. The stages of behavioral change and hemoglobin A1c levels were found to be significantly associated with the scores of decisional balance of the 13-item DBII scale for both insulin-naive and insulin-treated patients. The Cronbach's α ranged between .78 and .92.

Conclusions

The 13-item DBII scale is appropriately short and possesses satisfactory validity and reliability for both insulin-naive and insulin-treated patients with T2DM. Healthcare providers may use this scale as a checklist to guide clinical discussions related to insulin therapy with both insulin-naive and insulin-treated patients with T2DM across time.

Perceptions of insulin therapy in people with type 2 diabetes and physicians: a cross-sectional survey conducted in France

OBJECTIVE

To evaluate perceptions of people with type 2 diabetes (T2D) and treating physicians living in France toward insulin therapy.

METHODS

Adults with T2D receiving oral glucose-lowering treatment alone (INS^-) or basal insulin for ≥2 months (INS⁺) completed an online cross-sectional survey comprising 39 questions, including some regarding perceptions and fears of insulin therapy. Physicians were interviewed by telephone using eleven similar questions. The survey was designed by French clinicians experienced in treating diabetes and conducted under the auspices of an independent market-research agency.

RESULTS

The questionnaire was completed by 590 adults with T2D (two-thirds INS⁺) and 130 physicians (65 diabetologists/endocrinologists, 65 general practitioners). INS⁺ adults reported fewer negative feelings and more positive feelings than INS^- adults. Two-thirds of INS⁺ adults reported that transitioning to insulin therapy was less difficult than expected. Overall, 44% of INS⁺ adults and 26% of physicians reported a fear of diabetic complications as being important, and 80% of physicians and 21% of INS⁺ adults considered injections to be a major patient fear.

CONCLUSION

Most people with T2D reported that transitioning to insulin therapy was less difficult than they had feared. People with T2D and physicians exhibited differing perceptions regarding the transition. Reasons for the apprehension surrounding the transition to insulin therapy in people with T2D need to be better identified. Support from insulin-treated peers may enable this transition to occur with fewer anxieties in insulin-naïve people with T2D.

Patients' Perspectives of Oral and Injectable Type 2 Diabetes Medicines, Their Body Weight and Medicine-Taking Behavior in the UK: A Systematic Review and Meta-Ethnography

The aim of this review is to identify peoples' perspectives of their glucose-lowering and anti-obesity drugs in relation to diabetes and weight control and to explore how these views affect medication adherence. Theoretical perspectives associated with medicine-taking behavior are also explored. The systematic review was based on a meta-ethnography of qualitative studies identified through a search of 12 medical and social science databases and subsequent citation searches. The quality of all studies was assessed. Sixteen studies were included with data from 360 UK individuals. No relevant studies were identified which focused on anti-obesity and non-insulin injectable drugs. The review revealed that the patients' perspectives and emotional state were influenced by starting and/or changing to a new glucose-lowering medicine. These were also influenced by prior medication experience, disease perceptions and interactions with clinicians. Despite reports of positive experiences with and positive perceptions of medicines, and of participation in strategies to regain life control, medication non-adherence was common. Accepting glucose-lowering medicines impacted on the individual's perception of lifestyle changes, and it was notable that weight loss was not perceived as a strategy to support diabetes management. Synthesis revealed that more than one theory is required to explain medicine-taking behavior. New insights into the underlying factors of poor adherence and the specific practical issues identified in this review can help in the development of patient-centered interventions.

FUNDING

Diabetes UK.

Dapagliflozin improves blood glucose in diabetes on triple oral hypoglycemic agents having inadequate glucose control

AIMS

The aim of this study was to evaluate whether a combination drug therapy that consists of dapagliflozin with three other oral hypoglycemic agents (OHAs) would have a beneficial safety and efficacy profile in T2DM patients who have uncontrolled glucose levels compared to a treatment regimen that contains of basal insulin with two different OHAs.

METHODS

A total of 162 type 2 diabetic patients who are unable to control glucose on their current therapy consisting of 3 OHAs were enrolled in dapagliflozin group and 148 patients in insulin glargine group for the 24-week study period.

RESULTS

The mean changes in HbA1c level were comparable as -0.97 ± 1.29% in dapagliflozin group and -0.95 ± 1.41% in insulin glargine group (p = 0.911). Also, the fasting plasma glucose or post-prandial 2 h glucose were comparably decreased in dapagliflozin or insulin glargine. In terms of the body-weight, there was a significant decrease of -2.36 ± 0.51 kg following treatment of dapagliflozin, whereas the increment of 1.93 ± 0.49 kg was in insulin glargine (p < 0.001). In terms of adverse events, hypoglycemic events were higher in insulin glargine rather than dapagliflozin (15.1% vs. 1.6%, p < 0.05).

CONCLUSIONS

Our findings demonstrated that the addition of dapagliflozin to an existing drug regimen consisting of three different OHAs in patients exhibiting inadequate blood glucose control could be alternate treatment modality in T2D who hesitate to initiate insulin therapy.

A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting

Quality issue

Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients.

Initial assessment

Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care.

Choice of solution

This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework.

Implementation

A bundle of improvement activities were implemented at the home, clinic and institutional level.

Evaluation

Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control.

Lessons learned

Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.

Strategies for implementing effective mealtime insulin therapy in type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2D) is a growing global epidemic. Due to the progressive nature of the disease, many people with T2D require insulin at some point, most commonly a long-acting (basal) insulin to assist with 24-h control of glucose levels.

OBJECTIVE

This opinion paper provides an overview of considerations for primary care providers (PCPs) in intensifying the treatment regimen when basal insulin therapy is inadequate.

RESULTS

Control of mealtime hyperglycemia, in addition to fasting hyperglycemia, has been shown to be crucial in reaching A1c goals of <7.0%. However, initiating and optimizing mealtime insulin therapy can be challenging for both people with T2D and PCPs, due to a perceived lack of efficacy and burden of insulin treatment, causing "psychological insulin resistance" in people with T2D and clinical inertia among PCPs. Successful implementation of mealtime insulin therapy requires not only choosing appropriate treatment strategies, but also addressing patient-related behavioral and emotional barriers. Simplified treatment algorithms, combined with the use of advanced technology (devices such as insulin pens, pumps, and patches), and collaborative decision-making can help decrease barriers to effective mealtime insulin therapy.

CONCLUSIONS

It is possible to implement an effective basal-bolus insulin regimen in people with T2D in a way that improves glucose control while minimizing negative effects on quality-of-life, treatment satisfaction, and psychological well-being.

Translation and validation of the Insulin Treatment Appraisal Scale in Hong Kong primary care patients

AIMS/INTRODUCTION

Patients with type 2 diabetes mellitus often delay the initiation or titration of insulin treatment due to psychological factors. This phenomenon is referred to as psychological insulin resistance (PIR). The Insulin Treatment Appraisal Scale (ITAS) is a 20-item instrument for assessing PIR. A previous Chinese version of the ITAS (C-ITAS) was found to be subject to problems arising from its translation. The present study aimed to translate and validate this instrument, which will facilitate research and aid in counseling in a clinical setting.

MATERIALS AND METHODS

The C-ITAS was modified to develop the Hong Kong version of the C-ITAS (C-ITAS-HK) according to published guidelines for the translation of transcultural research. A total of 328 diabetes mellitus patients who were followed-up in 10 different publically funded primary care outpatient clinics were recruited for self-administration of the C-ITAS-HK. Demographic data were recorded, and clinical data (e.g., presence of diabetes mellitus complications) were obtained from case records. The C-ITAS-HK results were subjected to psychometric analysis, including the assessment of Cronbach's alpha, factor analysis and test-retest reliability.

RESULTS

Factor analysis supported a two-factor structure with good internal consistency (whole scale 0.846, negative subscale 0.882, positive subscale 0.619). The test-retest reliability correlation coefficients for all items were positive, at 0.871, 0.782, and 0.692 for the whole scale, negative subscale and positive subscale, respectively. The ITAS scores differed significantly between participants with PIR and those without in the expected direction, suggesting good discriminant validity.

CONCLUSIONS

The C-ITAS-HK is a valid tool for measuring and assessing PIR in the Hong Kong primary care diabetes mellitus population.

Clinical and sociodemographic variables associated with diabetes-related distress in patients with type 2 diabetes mellitus

Objective:

To evaluate the relation between diabetes-related distress and the clinical and sociodemographic characteristics of type 2 diabetes mellitus patients.

Methods:

A cross-sectional study based on a secondary analysis of data collected at a specialized care outpatient center in Brazil. Participants completed a questionnaire on sociodemographic and clinical characteristics and the Brazilian version of the Diabetes Distress Scale (B-DDS).

Results:

About 31% of the 130 eligible patients reported diabetes distress, and the mean B-DDS score was 2.6. Multiple regression analysis showed the B-DDS score was positively correlated with marital status (p=0.0230), use of diet and physical activities for diabetes management (p=0.0180), and use of insulin therapy (p=0.0030). The "emotional burden", "regimen-related distress", and "interpersonal distress" domains from B-DDS were associated with the use of insulin therapy (p=0.0010), marital status (p=0.0110), and the presence of three or more comorbidities (p=0.0175).

Conclusion:

These findings suggest the clinical and sociodemographic variables are relatively weak predictors of diabetes-related distress. The highest scores in the B-DDS were observed in the emotional burden domain, indicating the presence of diabetes distress among the participants of the study.

Objetivo:

Avaliar a relação entre o estresse relacionado ao diabetes e as características clínicas e sociodemográficas de pacientes com diabetes mellitus do tipo 2.

Métodos:

Estudo transversal com base na análise secundária de dados coletados em um ambulatório de atendimento terciário no Brasil. Os participantes preencheram um questionário sobre as características sociodemográficas e clínicas, e a versão brasileira da Diabetes Distress Scale (B-DDS).

Resultados:

Aproximadamente 31% dos 130 pacientes elegíveis relataram estresse relacionado ao diabetes, e a média do escore da B-DDS foi de 2,6. O modelo de regressão múltipla mostrou que a pontuação B-DDS foi positivamente correlacionada com o estado civil (p=0,0230), realização de dieta e atividades físicas (p=0,0180), e uso de insulina (p=0,0030). Os domínios da B-DDS "carga emocional", "estresse relacionado ao regime terapêutico" e "estresse nas relações interpessoais" foram associados a uso de insulina (p=0,0010), estado civil (p=0,0110) e presença de três ou mais comorbidades (p=0,0175).

Conclusão:

Estes resultados sugerem que as variáveis clínicas e sociodemográficas são preditores relativamente fracos para o estresse relacionado ao diabetes. No domínio "carga emocional", foi observada a maior pontuação da B-DDS, indicando a presença do estresse relacionado ao diabetes entre os pacientes deste estudo.

Assessing Psychological Insulin Resistance in Type 2 Diabetes: a Critical Comparison of Measures

PURPOSE OF REVIEW

This study aims to examine the operationalisation of 'psychological insulin resistance' (PIR) among people with type 2 diabetes and to identify and critique relevant measures.

RECENT FINDINGS

PIR has been operationalised as (1) the assessment of attitudes or beliefs about insulin therapy and (2) hypothetical or actual resistance, or unwillingness, to use to insulin. Five validated PIR questionnaires were identified. None was fully comprehensive of all aspects of PIR, and the rigour and reporting of questionnaire development and psychometric validation varied considerably between measures. Assessment of PIR should focus on the identification of negative and positive attitudes towards insulin use. Actual or hypothetical insulin refusal may be better conceptualised as a potential consequence of PIR, as its assessment overlooks the attitudes that may prevent insulin use. This paper provides guidance on the selection of questionnaires for clinical or research purpose and the development of new, or improvement of existing, questionnaires.

The prevalence of diabetes mellitus and abnormal glucose metabolism in the inpatient psychiatric setting: A systematic review and meta-analysis

OBJECTIVE

To systematically determine the prevalence of diabetes mellitus (DM), impaired fasting glucose (IFG), and impaired glucose tolerance (IGT) in psychiatric inpatients and explore the impact of patient and study variables on prevalence estimates.

METHOD

We searched EMBASE, PsychINFO, Medline and CENTRAL from database inception until 1st December 2015. We included studies of any design reporting prevalence of abnormal glucose metabolism in any adult psychiatric inpatients. We conducted a random effects meta-analysis to generate pooled prevalence estimates. Chi-square tests compared differences within categorical variables (inpatient setting, continent of study and patient diagnostic category) and Spearman's correlation analyses assessed the impact of linear variables (age, year of data collection and study quality). Study quality was assessed using an adapted Newcastle-Ottawa Scale.

RESULTS

36 study reports representing 42 unique cohorts were included. Across all studies prevalence of unspecified type DM was 10% (95%CI: 9-12), of T1DM was 1% (0-1), of T2DM was 9% (6-13), of IFG 18% (8-28), and of IGT was 22% (16-28). These estimates were not affected by study quality.

CONCLUSIONS

All estimates are higher compared to the general population. Mental health professionals should be aware of this elevated prevalence to improve screening and management of abnormal glucose metabolism.

Barriers that practitioners face when initiating insulin therapy in general practice settings and how they can be overcome

AIM

To explore primary care physicians’ perspectives on possible barriers to the use of insulin.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight electronic databases were searched (between January 1, 1994 and August 31, 2014) for relevant studies. A search for grey literature and a review of the references in the retrieved studies were also conducted. Studies that focused on healthcare providers’ perspectives on possible barriers to insulin initiation with type 2 diabetic patients were included, as well as articles suggesting solutions for these barriers. Review articles and studies that only considered patients’ perspectives were excluded.

RESULTS

A total of 19 studies met the inclusion criteria and were therefore included in this study: 10 of these studies used qualitative methods, 8 used quantitative methods and 1 used mixed methods. Studies included a range of different health care settings. The findings are reported under four broad categories: The perceptions of primary care physicians about the barriers to initiate insulin therapy for type 2 diabetes patients, how primary care physicians assess patients prior to initiating insulin, professional roles and possible solutions to overcome these barriers. The barriers described were many and covered doctor, patient, system and technological aspects. Interventions that focused on doctor training and support, or IT-based decision support were few, and did not result in significant improvement.

CONCLUSION

Primary care physicians’ known delay in insulin initiation is multifactorial. Published reports of attempts to find solutions for these barriers were limited in number.

Treating psychological insulin resistance in type 2 diabetes

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Psychological insulin resistance (PIR) has been described for 2 decades.

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Interventions to treat PIR have not been well described.

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In our study, 28.4% had high PIR and 61.2% had a moderate degree of PIR.

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PIR was treated with 4 intervention strategies by certified diabetes educators.

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Strategies included teaching, demonstrations, return demonstrations, and managing expectations.

Aims

The phenomenon of psychological insulin resistance (PIR) has been well documented for two decades, but interventions to treat PIR have not been well described. The aim of this study was to describe interventions used to treat psychological insulin resistance by certified diabetes educators (CDE’s).

Methods

A secondary data analysis study using empirical data from a trial (N = 234) that included four CDEs providing counseling for psychological insulin resistance. Participants not currently using insulin completed the 10-item Barriers to Insulin Therapy measure. The four CDE interventionists documented their approach to addressing participants’ barriers to taking insulin using a standard form. Recommendations were collated and summarized.

Results

Strong PIR was shown by 28.4% of participants reporting that they “would not start insulin” and a moderate degree of PIR was shown by 61.2% who said they “would be upset, but would start insulin.” The CDE’s treated PIR with four primary interventions: 1) teaching and providing explanations, 2) demonstrations and sharing examples of success using insulin therapy, 3) return demonstrations, and 4) addressing feelings and positively managing expectations.

Conclusion

This is the first study to describe in some detail potentially effective patient management strategies for PIR. A randomized controlled trial testing the efficacy of PIR interventions is needed.

The impact of insulin therapy and attitudes towards insulin intensification among adults with type 2 diabetes: A qualitative study

BACKGROUND

As type 2 diabetes (T2DM) is a progressive chronic condition, regular clinical review and treatment intensification are critical for prevention of long-term complications. Our aim was to explore the personal impact of insulin therapy, both positive and negative consequences, and attitudes towards future insulin intensification.

METHODS

Twenty face-to-face interviews were conducted, and transcripts were analysed using thematic inductive analysis. Eligible participants were adults with T2DM, using insulin injections for <4years. Participants were mostly men (n=13, 65%), (median (range)) aged 65 (43-76) years, living with T2DM for 11.5 (2-27) years.

RESULTS

Five themes emerged regarding the consequences (positive and negative) of insulin therapy, including: physical impact, personal control, emotional well-being, freedom/flexibility, (concerns about) others' reactions. Increased inconvenience and the perceived seriousness of using fast-acting insulin were both reported as barriers to future insulin intensification, despite most participants being receptive to the idea of administering additional injections.

CONCLUSIONS

Positive and negative experiences of insulin therapy were reported by adults with T2DM and most were receptive to insulin intensification despite reported barriers. These findings may inform clinical interactions with people with T2DM and interventions to promote receptiveness to insulin initiation and intensification.

Willingness to initiate insulin among adults with type 2 diabetes in Australian primary care: Results from the Stepping Up Study

AIMS

To determine 'hypothetical willingness' to initiate insulin, and identify associated factors, among adults with type 2 diabetes (T2DM) in primary care for whom insulin is clinically indicated.

METHODS

Eligible participants were adults with T2DM with an HbA1c ≥7.5% (58mmol/mol) and prescribed maximum oral hypoglycaemic agents. A total of 261 participants were recruited from 74 Victorian general practices: mean age 62±10 years; 39% (n=103) women; diabetes duration 10±6 years; HbA1c 9.0±1.3% (75±14mmol/mol). Data collected by the Stepping Up Study: demographic and clinical characteristics, 'willingness' to initiate insulin, insulin appraisals, depressive symptoms, and diabetes-related distress. A multinomial regression investigated predictors of 'willingness'.

RESULTS

Nineteen percent (n=50) were 'very willing' to initiate insulin, if recommended. The final regression model (R(2)=.44, χ(2)(12) 145.91, p<.001) demonstrated higher socioeconomic status and less negative attitudes to insulin were associated with increased willingness to initiate insulin.

CONCLUSIONS

Among adults with T2DM for whom insulin is clinically indicated, only one in five are 'very willing' to begin insulin therapy. Independent of demographics, clinical factors and emotional wellbeing, insulin appraisals were associated with 'willingness'. This study highlights the importance of addressing attitudinal barriers to insulin therapy among adults with T2DM in primary care to improve insulin receptiveness.

Association of more negative attitude towards commencing insulin with lower glycosylated hemoglobin (HbA1c) level: a survey on insulin-naïve type 2 diabetes mellitus Chinese patients

Background

Delay in commencing insulin among type 2 Diabetes Mellitus (DM) patients is common.  One of the reasons is patients' psychological insulin resistance, which is particularly prevalent in Chinese patients. This study examined the correlation between socio-demographic and clinical characteristics; and attitudes towards commencing insulin in Chinese primary care patients.

Method

A cross-sectional survey was conducted on 303 insulin-naïve Type 2 DM patients recruited from 15 primary care clinics across Hong Kong using the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ). Subject selection criteria were patients on maximal oral anti-diabetes treatment who needed to commence insulin therapy. Linear regression was used to identify correlations between age, sex, educational level, occupation, body mass index, diabetes disease duration, laboratory test indicating disease control and biochemical markers including glycosylated hemoglobin (HbA1c) level, low density lipoprotein level and estimated glomeruli filtration rate, and presence of diabetic complications with the four sub-scales (self-image and stigmatization; factors promoting self-efficacy; fear of pain or needles; time and family support ) and the overall Ch-ASIQ score.

Results

The most prevalent negative attitude was ‘fear of needle injections’ (70.1 %). The most common positive attitude was ‘I can manage the skill of injecting insulin’ (67.5 %). The mean Ch-ASIQ score of 2.50 (S.D. = 0.38) was equal to the mid-score, which signified an overall ambivalent attitude among the study population. Women scored significantly higher in the fear of pain or needles subscale (p = 0.011) and had an overall more negative attitude towards commencing insulin (p = 0.016). Subjects with lower HbA1c levels also had a significantly lower Ch-ASIQ sum score (p = 0.048) indicating a more negative attitude towards commencing insulin.

Conclusion

In Chinese primary care patients with Type 2 DM, the need to commence insulin was associated with a number of negative emotions, which lead to a lower motivation to accept treatment. Perception of need as indicated by HbA1c level may be an important influencing factor determining a patient’s overall attitude towards starting insulin. Fortunately, in our setting, the injection technique does not appear to be a major barrier. However, needle fears are common, especially amongst women. Target interventions to acknowledge and help them to overcome their fears are essential before insulin treatment is commenced.

Psycholosocial factors associated with psychological insulin resistance in primary care patients in Hong Kong

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No relationship was found between depression and PIR.

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Prevalence of PIR was 47.2% in insulin-naïve patients and 8.7% in insulin users.

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PIR etiology is likely multifactorial in Hong Kong primary care population.

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PIR was associated with multiple social factors.

Aim

Patients with diabetes mellitus (DM) often delay the initiation of insulin treatment and titration due to psychological factors. This phenomenon is called psychological insulin resistance (PIR). The insulin treatment appraisal scale (ITAS) that was initially developed for Western populations has been translated and validated to measure PIR in Taiwanese populations (C-ITAS). This study aims to estimate the prevalence of PIR in primary care patients with DM in Hong Kong and to examine the relationship between PIR and psychosocial factors.

Method

402 DM patients from a government-funded general outpatient clinic completed the C-ITAS and a health questionnaire (the Patient Health Questionnaire-9, PHQ-9). Patient demographics were recorded and associations among C-ITAS scores, PHQ-9 scores and demographic data were evaluated.

Results

There was no relationship between the presence of depression and PIR. Furthermore, the prevalence of PIR was 47.2% in insulin-naive patients but only 8.7% in current insulin users. Tools such as the C-ITAS may help clinicians understand the etiology of PIR, which this study suggests is likely the result of multiple risk factors. Factors associated with a lower prevalence of PIR included current insulin use, a family history of insulin use, a high education level, male sex, and having received counseling from a physician about insulin within the previous 6 months.

Barriers to initiating insulin in type 2 diabetes patients: development of a new patient education tool to address myths, misconceptions and clinical realities

Purpose

The purpose of this study was to identify patient beliefs as well as clinical realities about insulin that may be barriers to type 2 diabetes patients initiating insulin treatment when recommended by their physician. This information was then used to develop a clinically relevant, cross-culturally valid patient education tool with the goal of providing unbiased, medically informative statements addressing these barriers.

Methods

Thirteen focus groups were conducted in five countries (Germany, Sweden, The Netherlands, UK, and USA) to collect qualitative data on attitudes about insulin therapy from type 2 diabetes patients aged 18 or older whose physician had recommended initiating insulin treatment in the past 6 months (n = 87). Additionally, a panel of four clinical experts was interviewed to ascertain obstacles they experience in initiating insulin with their patients.

Results

On the basis of the interview data, the ten questions that asked about the most important barriers were generated. The clinical expert panel then generated clinically accurate and unbiased responses addressing these concerns, and the educational tool “Questions about Starting Insulin: Information on the Myths, Misconceptions and Clinical Realities about Insulin” was drafted. The draft tool was pilot tested in a group of patients and finalized.

Conclusions

Patient misconceptions, as well as some clinical realities, about insulin treatment and diabetes can influence the decision to initiate insulin treatment and ultimately impact disease management. The educational tool developed through this study was designed to help patients who are deciding whether or not to initiate insulin therapy as recommended by their physician, and facilitate patient–health-care provider interactions.

Facilitators and barriers of adaptation to diabetes: experiences of Iranian patients

Background

Diabetes mellitus is one of the most challenging and burdensome chronic diseases of the 21st century and More than 1% of the Iranian urban population older than 20 years develops Type 2 diabetes each year. Living with diabetes mellitus has been described as a dynamic personal transitional adaptation, based on restructuring of the illness perceived experience and management of the self. Adaptation to Type 2 Diabetes mellitus is an integral part of diabetes care.

This study explored the experiences of facilitators and barriers adaptation to Type 2 Diabetes by Iranian patients.

Methods

This study was conducted by using qualitative content analysis. Data were collected via in-depth, semi-structured and face to face interviews with 15 patients with type2 diabetes.

Results

Three themes emerged from collected data, including a) individual context with Beliefs, personal background, and previous experience subthemes. b) supportive system with Family, Society and Health organizations subthemes and c) self-comparison with comparison with other diabetes and comparison with other diseases subthemes.

Conclusions

Identifying and managing Facilitators and Barriers adaptation to Type 2 Diabetes mellitus are an integral part of diabetes care. This study provides a better understanding of the factors from perspective of patients and it can be utilized by health care providers to adapt their health care and education contents to better meet the needs of people with diabetes.

Development and validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for primary care patients with type 2 diabetes

OBJECTIVES

To develop and evaluate the psychometric properties of a Chinese questionnaire which assesses the barriers and enablers to commencing insulin in primary care patients with poorly controlled Type 2 diabetes.

RESEARCH DESIGN AND METHOD

Questionnaire items were identified using literature review. Content validation was performed and items were further refined using an expert panel. Following translation, back translation and cognitive debriefing, the translated Chinese questionnaire was piloted on target patients. Exploratory factor analysis and item-scale correlations were performed to test the construct validity of the subscales and items. Internal reliability was tested by Cronbach's alpha.

RESULTS

Twenty-seven identified items underwent content validation, translation and cognitive debriefing. The translated questionnaire was piloted on 303 insulin naïve (never taken insulin) Type 2 diabetes patients recruited from 10 government-funded primary care clinics across Hong Kong. Sufficient variability in the dataset for factor analysis was confirmed by Bartlett's Test of Sphericity (P<0.001). Using exploratory factor analysis with varimax rotation, 10 factors were generated onto which 26 items loaded with loading scores > 0.4 and Eigenvalues >1. Total variance for the 10 factors was 66.22%. Kaiser-Meyer-Olkin measure was 0.725. Cronbach's alpha coefficients for the first four factors were ≥0.6 identifying four sub-scales to which 13 items correlated. Remaining sub-scales and items with poor internal reliability were deleted. The final 13-item instrument had a four scale structure addressing: 'Self-image and stigmatization'; 'Factors promoting self-efficacy; 'Fear of pain or needles'; and 'Time and family support'.

CONCLUSION

The Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) appears to be a reliable and valid measure for assessing barriers to starting insulin. This short instrument is easy to administer and may be used by healthcare providers and researchers as an assessment tool for Chinese diabetic primary care patients, including the elderly, who are unwilling to start insulin.

On pens and needles: Treatment strategies for psychological insulin resistance in type 2 diabetes mellitus

Background: Psychological insulin resistance (PIR) refers to psychological opposition towards insulin therapy. Although not a formal psychological diagnosis, PIR is an under-recognized issue clinicians may encounter when treating patients with diabetes requiring insulin therapy.

Methods: Review articles, clinical trials, and practice guidelines were located using online databases. A total of 39 abstracts were reviewed and 11 articles were included in the analysis.

Results: Eleven articles were included. Proposed strategies used to mitigate the occurrence of PIR include: identifying the patient's personal obstacles via administration of PIR questionnaires, use of insulin pens as opposed to conventional syringe and needle, education on the risk of hypoglycemia and continuous emphasis of the importance of self-monitoring of blood glucose (SMBG) readings.

Discussion: The management of type 2 diabetes mellitus (T2DM) in patients requiring insulin may present challenges such as PIR. Tailoring a patient's treatment plan to account for physiological, psychological, social and financial needs may thwart some of these challenges. Other factors to consider include the cost of the agent and/or devices required. Insulin-dependent patients with T2DM should be assessed for both physiological and psychological changes.

Conclusion: Current treatment strategies for clinicians treating T2DM patients with PIR include administering the PIR or BIT questionnaire, initiating lower doses of insulin, switching from insulin vials to insulin pens, including assessment results in individualized treatment plans and using clinical outcomes to screen patients who are at risk for refusing the use of insulin. Further research evaluating clinical outcomes associated with treatment strategies is necessary.

Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews

This article provides an overview of mixed methods research and mixed studies reviews. These two approaches are used to combine the strengths of quantitative and qualitative methods and to compensate for their respective limitations. This article is structured in three main parts. First, the epistemological background for mixed methods will be presented. Afterward, we present the main types of mixed methods research designs and techniques as well as guidance for planning, conducting, and appraising mixed methods research. In the last part, we describe the main types of mixed studies reviews and provide a tool kit and examples. Future research needs to offer guidance for assessing mixed methods research and reporting mixed studies reviews, among other challenges.

Common standards of basal insulin titration in type 2 diabetes

Type 2 diabetes mellitus has become a worldwide major health problem, and the number of people affected is steadily increasing. Thus, not all patients suffering from the disease can be treated by specialized diabetes centers or outpatient clinics, but by primary care physicians. The latter, however, might have time constraints and have to deal with many kinds of diseases or with multimorbid patients, so their focus is not so much on lowering high blood glucose values. Thus, the physicians, as well as the patients themselves, are often reluctant to initiate and adjust insulin therapy, although basal insulin therapy is considered the appropriate strategy after oral antidiabetic drug failure, according to the latest international guidelines. A substantial number of clinical studies have shown that insulin initiation and optimization can be managed successfully by using titration algorithms-even in cases where patients themselves are the drivers of insulin titration. Nevertheless, tools and strategies are needed to facilitate this process in the daily life of both primary health care professionals and patients with diabetes.

Psychological insulin resistance among low-income, U.S. racial minority patients with type 2 diabetes

AIMS

To examine psychological insulin resistance (PIR), the unwillingness to accept insulin therapy, within a unique U.S. population of patients with diabetes.

METHODS

A cross-sectional survey of PIR among low-income, U.S. Latino and African-American (AA) patients with type 2 diabetes recruited from a diabetes specialty clinic.

RESULTS

Data from 136 insulin-naïve respondents (57% female, 69% Latino, mean age 51.1 ± 10.3 years; $200-$1000 median monthly household income; grade 8-12 median education) revealed a 48% prevalence of complete unwillingness to begin insulin. In comparing Latinos to AA, Latino respondents were younger, lived fewer years in the U.S., had less education, were more likely unwilling to use insulin (53% vs. 30%, p = 0.03), and reported a more negative attitude to 8 of 9 PIR domains (p ≤ 0.01 for each). Fewer years in the U.S. predicted greater unwillingness and a more negative attitude on 8 of 9 PIR domains (p ≤ 0.03 for each); and less education predicted greater feelings of unfairness (p = 0.01).

CONCLUSIONS

PIR is highly prevalent among low income, U.S. Latino patients with type 2 diabetes. Our data may help to better guide culturally appropriate counseling regarding insulin use.

Prevalent obstacles and predictors for people living with type 2 diabetes

Background. Type 2 diabetes (T2DM) is a chronic, progressive disease with serious micro- and macrovascular complications. A person affected by T2DM should learn to accept the new restricted lifestyle. Aims. The aim of the study was to identify the prevalence of obstacles in coping with daily life for people with T2DM and the magnitude of the relationships of the obstacles with various patient characteristics. Methods. Participants were recruited from randomly selected GPs' lists in Estonia. Respondents completed the Estonian version of the Diabetes Obstacles Questionnaire (DOQ). The statements were assessed on a 5-point scale. Biomedical and clinical variables were measured. The central tendency statistics and skewness and kurtosis for all statements were computed to find out those that reflect obstacles. Then obstacles of the DOQ were stratified. Multinomial logistic regression (MLR) was computed to estimate the influences of descriptive variables on the statements. Results and Conclusions. Altogether, 138 diabetic patients were enrolled in the study. Fourteen statements were identified as obstacles. Variables such as age, type of diabetes treatment, and BMI had significant effects on five of them. Younger age, BMI, and insulin nonuse were revealed as the strongest predictive characteristics for perceiving obstacles more often in coping with daily life.