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Chen R, Aamir AH, Feroz Amin M, Bunnag P, Chan SP, Guo L, Khamseh ME, Mohan V, Nicodemus N, Roberts A, Tarigan TJE, Won KC, Mehta R. Barriers to the Use of Insulin Therapy and Potential Solutions: A Narrative Review of Perspectives from the Asia-Pacific Region. Diabetes Ther 2024; 15:1261-1277. [PMID: 38625535 PMCID: PMC11096289 DOI: 10.1007/s13300-024-01568-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/14/2024] [Indexed: 04/17/2024] Open
Abstract
The rising prevalence of type 2 diabetes (T2D) is posing major challenges for the healthcare systems of many countries, particularly in the Asia-Pacific Region, in which T2D can present at younger ages and lower body mass index when compared with Western nations. There is an important role for insulin therapy in the management of T2D in these nations, but available evidence suggests that insulin is under-utilized and often delayed, to the detriment of patient prognosis. The authors of this article gathered as an advisory panel (representative of some of the larger Asia-Pacific nations) to identify their local barriers to insulin use in T2D, and to discuss ways in which to address these barriers, with their outputs summarized herein. Many of the key barriers identified are well-documented issues of global significance, including a lack of healthcare resources or of an integrated structure, insufficient patient education, and patient misconceptions about insulin therapy. Barriers identified as more innate to Asian countries included local inabilities of patients to afford or gain access to insulin therapy, a tendency for some patients to be more influenced by social media and local traditions than by the medical profession, and a willingness to switch care providers and seek alternative therapies. Strategies to address some of these barriers are provided, with hypothetical illustrative case histories.
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Affiliation(s)
- Roger Chen
- Department of Endocrinology, St Vincent's Hospital, 406 Victoria Street, Darlinghurst, Sydney, NSW, 2010, Australia.
- University of New South Wales, Sydney, Australia.
| | - Azizul Hasan Aamir
- Department of Diabetes, Endocrinology and Metabolic Diseases, MTI Hayatabad Medical Complex, Peshawar, Pakistan
| | - Mohammod Feroz Amin
- Department of Endocrinology and Metabolic Disease, BIRDEM Hospital, Dhaka, Bangladesh
| | - Pongamorn Bunnag
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Siew Pheng Chan
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Lixin Guo
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Mohammad E Khamseh
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Nemencio Nicodemus
- Department of Biochemistry and Molecular Biology, University of the Philippines-College of Medicine, Manila, Philippines
| | - Anthony Roberts
- South Australian Endocrine Clinical Research, Keswick, Adelaide, SA, Australia
| | - Tri Juli Edi Tarigan
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Kyu-Chang Won
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Roopa Mehta
- Unidad de Investigación en Enfermedades Metabólicas, Departamento de Endocrinología y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Mechanick JI, Leroith D. Synthesis: Deriving a Core Set of Recommendations to Optimize Diabetes Care on a Global Scale. Ann Glob Health 2018; 81:874-83. [PMID: 27108155 DOI: 10.1016/j.aogh.2016.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Diabetes afflicts 382 million people worldwide, with increasing prevalence rates and adverse effects on health, well-being, and society in general. There are many drivers for the complex presentation of diabetes, including environmental and genetic/epigenetic factors. OBJECTIVE The aim was to synthesize a core set of recommendations from information from 14 countries that can be used to optimize diabetes care on a global scale. METHODS Information from 14 papers in this special issue of Annals of Global Health was reviewed, analyzed, and sorted to synthesize recommendations. PubMed was searched for relevant studies on diabetes and global health. FINDINGS Key findings are as follows: (1) Population-based transitions distinguish region-specific diabetes care; (2) biological drivers for diabetes differ among various populations and need to be clarified scientifically; (3) principal resource availability determines quality-of-care metrics; and (4) governmental involvement, independent of economic barriers, improves the contextualization of diabetes care. Core recommendations are as follows: (1) Each nation should assess region-specific epidemiology, the scientific evidence base, and population-based transitions to establish risk-stratified guidelines for diagnosis and therapeutic interventions; (2) each nation should establish a public health imperative to provide tools and funding to successfully implement these guidelines; and (3) each nation should commit to education and research to optimize recommendations for a durable effect. CONCLUSIONS Systematic acquisition of information about diabetes care can be analyzed, extrapolated, and then used to provide a core set of actionable recommendations that may be further studied and implemented to improve diabetes care on a global scale.
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Affiliation(s)
- Jeffrey I Mechanick
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Derek Leroith
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY
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Lee YK, Lee PY, Ng CJ, Teo CH, Abu Bakar AI, Abdullah KL, Khoo EM, Hanafi NS, Low WY, Chiew TK. Usability and utility evaluation of the web-based "Should I Start Insulin?" patient decision aid for patients with type 2 diabetes among older people. Inform Health Soc Care 2017; 43:73-83. [PMID: 28139158 DOI: 10.1080/17538157.2016.1269108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study aimed to evaluate the usability (ease of use) and utility (impact on user's decision-making process) of a web-based patient decision aid (PDA) among older-age users. A pragmatic, qualitative research design was used. We recruited patients with type 2 diabetes who were at the point of making a decision about starting insulin from a tertiary teaching hospital in Malaysia in 2014. Computer screen recording software was used to record the website browsing session and in-depth interviews were conducted while playing back the website recording. The interviews were analyzed using the framework approach to identify usability and utility issues. Three cycles of iteration were conducted until no more major issues emerged. Thirteen patients participated: median age 65 years old, 10 men, and nine had secondary education/diploma, four were graduates/had postgraduate degree. Four usability issues were identified (navigation between pages and sections, a layout with open display, simple language, and equipment preferences). For utility, participants commented that the website influenced their decision about insulin in three ways: it had provided information about insulin, it helped them deliberate choices using the option-attribute matrix, and it allowed them to involve others in their decision making by sharing the PDA summary printout.
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Affiliation(s)
- Yew Kong Lee
- a Department of Primary Care Medicine , Faculty of Medicine, University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Ping Yein Lee
- b Department of Family Medicine , Faculty of Medicine and Health Sciences, Universiti Putra Malaysia , Serdang , Malaysia
| | - Chirk Jenn Ng
- a Department of Primary Care Medicine , Faculty of Medicine, University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Chin Hai Teo
- a Department of Primary Care Medicine , Faculty of Medicine, University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Ahmad Ihsan Abu Bakar
- a Department of Primary Care Medicine , Faculty of Medicine, University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Khatijah Lim Abdullah
- c Department of Nursing Science , Faculty of Medicine, University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Ee Ming Khoo
- a Department of Primary Care Medicine , Faculty of Medicine, University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Nik Sherina Hanafi
- a Department of Primary Care Medicine , Faculty of Medicine, University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Wah Yun Low
- d Dean's Office, Faculty of Medicine , University of Malaya, Jalan Universiti , Kuala Lumpur , Malaysia
| | - Thiam Kian Chiew
- e Department of Software Engineering , Faculty of Computer Science & Information Technology, University of Malaya , Kuala Lumpur , Malaysia
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Bin rsheed A, Chenoweth I. Barriers that practitioners face when initiating insulin therapy in general practice settings and how they can be overcome. World J Diabetes 2017; 8:28-39. [PMID: 28138362 PMCID: PMC5237815 DOI: 10.4239/wjd.v8.i1.28] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/29/2016] [Accepted: 10/18/2016] [Indexed: 02/05/2023] Open
Abstract
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.
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Holmes-Truscott E, Blackberry I, O'Neal DN, Furler JS, Speight J. Willingness to initiate insulin among adults with type 2 diabetes in Australian primary care: Results from the Stepping Up Study. Diabetes Res Clin Pract 2016; 114:126-35. [PMID: 26818893 DOI: 10.1016/j.diabres.2015.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/25/2015] [Accepted: 12/28/2015] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth Holmes-Truscott
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, 570 Elizabeth Street, Melbourne 3000, VIC, Australia; School of Psychology, Deakin University, 221 Burwood Highway, Burwood 3125, VIC, Australia.
| | - Irene Blackberry
- Department of General Practice, The University of Melbourne, 200 Berkeley St, Carlton 3052, VIC, Australia; John Richards Initiative, Australian Institute of Primary Care and Ageing, La Trobe University, PO Box 821, Wodonga 3689, VIC, Australia.
| | - David N O'Neal
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, 3065, VIC, Australia.
| | - John S Furler
- Department of General Practice, The University of Melbourne, 200 Berkeley St, Carlton 3052, VIC, Australia.
| | - Jane Speight
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, 570 Elizabeth Street, Melbourne 3000, VIC, Australia; School of Psychology, Deakin University, 221 Burwood Highway, Burwood 3125, VIC, Australia; AHP Research, 16 Walden Way, Hornchurch RM11 2LB, United Kingdom.
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Lee PY, Lee YK, Khoo EM, Ng CJ. How do health care professionals assess patients when initiating insulin therapy? A qualitative study. Prim Care Diabetes 2014; 8:49-55. [PMID: 24315732 DOI: 10.1016/j.pcd.2013.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/07/2013] [Accepted: 11/09/2013] [Indexed: 01/28/2023]
Abstract
AIMS To explore how health care professionals (HCPs) assess patients when initiating insulin therapy in type 2 diabetes. METHODS Focus group discussions and in-depth interviews were conducted with 41 health care professionals in Malaysia in 2010-2011. A semi-structured topic guide was used for the interview. The interviews were transcribed verbatim and analysed using the Nvivo9 software based on a thematic approach. RESULTS HCPs were less likely to initiate insulin therapy in patients who were older, with irregular dietary patterns and poor financial status. They also assessed patients' knowledge, views and misconceptions of insulin. However, there was a variation in how doctors assessed patients' comorbidities before starting insulin therapy. Medical officers were more likely to initiate insulin therapy in patients with comorbidities and complications, whereas family medicine specialists were more cautious. In addition, most HCPs considered patients' psychosocial status, including self-care ability, social support and quality of life. CONCLUSIONS HCPs' assessment of patients' need to start insulin therapy depends on their perception rather than objective evaluation of patients' background, knowledge, perception and abilities. The background and the type of practice of HCPs influence their assessment.
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Affiliation(s)
- Ping Yein Lee
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia.
| | - Yew Kong Lee
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Lee YK, Ng CJ, Lee PY, Khoo EM, Abdullah KL, Low WY, Samad AA, Chen WS. What are the barriers faced by patients using insulin? A qualitative study of Malaysian health care professionals' views. Patient Prefer Adherence 2013; 7:103-9. [PMID: 23378747 PMCID: PMC3559078 DOI: 10.2147/ppa.s36791] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients with type 2 diabetes often require insulin as the disease progresses. However, health care professionals frequently encounter challenges when managing patients who require insulin therapy. Understanding how health care professionals perceive the barriers faced by patients on insulin will facilitate care and treatment strategies. OBJECTIVE This study explores the views of Malaysian health care professionals on the barriers faced by patients using insulin. METHODS Semi-structured qualitative interviews and focus group discussions were conducted with health care professionals involved in diabetes care using insulin. Forty-one health care professionals participated in the study, consisting of primary care doctors (n = 20), family medicine specialists (n = 10), government policymakers (n = 5), diabetes educators (n = 3), endocrinologists (n = 2), and one pharmacist. We used a topic guide to facilitate the interviews, which were audio-recorded, transcribed verbatim, and analyzed using a thematic approach. RESULTS FIVE THEMES WERE IDENTIFIED AS BARRIERS: side effects, patient education, negative perceptions, blood glucose monitoring, and patient adherence to treatment and follow-up. Patients perceive that insulin therapy causes numerous negative side effects. There is a lack of patient education on proper glucose monitoring and how to optimize insulin therapy. Cost of treatment and patient ignorance are highlighted when discussing patient self-monitoring of blood glucose. Finally, health care professionals identified a lack of a follow-up system, especially for patients who do not keep to regular appointments. CONCLUSION This study identifies five substantial barriers to optimizing insulin therapy. Health care professionals who successfully identify and address these issues will empower patients to achieve effective self-management. System barriers require government agency in establishing insulin follow-up programs, multidisciplinary diabetes care teams, and subsidies for glucometers and test strips.
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Affiliation(s)
- Yew Kong Lee
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Correspondence: Yew Kong Lee Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia Tel +60 3 7949 2306 Fax +60 3 7957 7941 Email
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ping Yein Lee
- Department of Family Medicine, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khatijah Lim Abdullah
- Department of Nursing Sciences, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wah Yun Low
- Faculty of Medicine Dean’s Office, University of Malaya, Kuala Lumpur, Malaysia
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