The objective of this study was to determine the prevalence of insulin refusal amongst Singaporean patients with Type 2 diabetes mellitus, to compare perceptions regarding insulin therapy use between patients who were willing to use insulin and those who were not and to identify demographic factors that might predict insulin refusal.
A cross-sectional interviewer-administered survey incorporating demographic variables and 17 perceptions regarding insulin use (14 negative and three positive) was conducted among a sample of 265 patients attending a public primary healthcare centre.
Seven of every 10 patients expressed unwillingness to use insulin therapy (70.6%). The greatest differences in perceptions between patients willing to use insulin therapy and those who were not included fear of not being able to inject insulin correctly (47.4 vs. 70.6%), fear of pain (44.9 vs. 65.8%), belief that insulin therapy would make it difficult to fulfil responsibilities at work and home (46.2 vs. 66.8%) and belief that insulin therapy improved diabetes control (82.1 vs. 58.3%). A tertiary level of education was associated with willingness to use insulin (odds ratio 3.3, confidence interval 1.8-6.1), and significant differences in perceptions were present in patients with different educational levels.
Insulin refusal is an important problem amongst our patients with Type 2 diabetes mellitus. Findings of this study suggest that interventions aimed at increasing insulin therapy use should focus on injection-related concerns, perceived lifestyle adaptations and correction of misconceptions. Different interventions may also be required for patients of different educational groups.
"The items related to fear of hypoglycemia, weight gain and complications of insulin which appear to be important in other studies , , , , , , , – were not consistently weighted in the exploratory factor analysis of this study population. Similar findings were also found in another study interviewing Chinese subjects . "
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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'.
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.
PLoS ONE 11/2013; 8(11):e78933. DOI:10.1371/journal.pone.0078933 · 3.23 Impact Factor
"In fact, one third of insulin users had difficulties in fulfilling their work and personal responsibilities . Wong et al. (2011) suggested that this factor could reflect their lower selfefficacy , which was also reported by the participants in this current study. As injection-related concerns were prevalent among diabetics, this should be evaluated and addressed appropriately by healthcare providers. "
[Show abstract][Hide abstract] ABSTRACT: Many Type 2 Diabetes Mellitus (T2DM) patients refuse insulin therapy even when they require this modality of treatment. However, some eventually accept insulin. This study aimed to explore the T2DM patients' reasons for accepting insulin therapy and their initial barriers to use insulin.
This qualitative study interviewed twenty-one T2DM patients at a primary care clinic who had been on insulin for more than a year through three in-depth interviews and three focus group discussions. A semi structured interview protocol was used and the sessions were audio-recorded. Subsequently, thematic analysis was conducted to identify major themes.
The participants' acceptance of insulin was influenced by their concerns and beliefs about diabetes and insulin. Concerns about complications of poorly controlled diabetes and side effects of other treatment regime had resulted in insulin acceptance among the participants. They also had a strong belief in insulin benefits and effectiveness. These concerns and beliefs were the results of having good knowledge about the diabetes and insulin, experiential learning as well as doctors' practical and emotional support helped them to accept insulin therapy and become efficient in self-care management. These factors also allayed their negative concerns and beliefs towards diabetes and insulin, which were their barriers for insulin acceptance as it caused fear to use insulin. These negative concerns were related to injection (self-injection, needle phobia, injection pain), and insulin use (inconvenience, embarrassment, lifestyle restriction, negative social stigma, and poor self-efficacy), whereas the negative beliefs were 'insulin could cause organ damage', 'their diabetes was not serious enough', 'insulin is for life-long', and 'insulin was for more severe disease only'.
Exploring patients' concerns and beliefs about diabetes and insulin is crucial to assist physicians in delivering patient-centered care. By understanding this, physicians could address their concerns with aim to modify their patients' misconceptions towards insulin therapy. In addition, continuous educations as well as practical and emotional support from others were found to be valuable for insulin acceptance.Trial registration: Universiti Kebangsaan Malaysia FF-214-2009.
BMC Family Practice 10/2013; 14(1):164. DOI:10.1186/1471-2296-14-164 · 1.67 Impact Factor
"Thus, many patients were not using insulin as a modality in their diabetes management, owing to the fact that subcutaneous insulin is not the preferred choice of many patients compared with oral anti-diabetic medications. The technicality involved with insulin (Brod et al. 2009; Meece 2006) as well as psychological hindrance and prejudicial patient perception (Brod et al. 2009; Gherman et al. 2011; Tan et al. 2011; Wong et al. 2011) leads to resistance to insulin initiation and acceptance of insulin injections. All these factors, along with misunderstandings about insulin therapy (Brod et al. 2009; Tan et al. 2011), make prescribing insulin for the management of diabetes difficult, especially in patients whose hyperglycaemia is not controlled with oral anti-diabetic agents. "
[Show abstract][Hide abstract] ABSTRACT: Aim
To gain insight into type-2 diabetic patients’ perceptions and beliefs about the use of insulin, to explore barriers to initiation of insulin and to evaluate the impact of a short educational intervention regarding patients’ resistance to using insulin injections.
Subjects and methods
This is an exploratory qualitative study. One-to-one in-depth interviews were conducted with a purposive sample of type-2 diabetic patients. Then, a short educational intervention was conducted with the participants. After the intervention, the participants were interviewed to evaluate their acceptance of insulin initiation. The interviews were audio-taped and transcribed verbatim. Thematic content analysis was conducted and the analysis was reviewed independently by two researchers.
A total of 13 diabetic patients were included in the study. Before the intervention, 11 subjects refused initiation of insulin. Resistance to initiation of insulin was influenced by misconceptions about insulin therapy, psychological barriers and fear, lack of self-efficacy and fear of adverse effects. All subjects perceived that insulin should only be initiated in very severe diabetes. Some participants demonstrated lack of belief in insulin efficacy. Psychological barriers and fears such as fear of self-injection and personal phobia about blood, needle and pain as well as perceived side effects also hindered insulin acceptance.
The study findings revealed that misconceptions about insulin use and psychological barriers played a major role in patients’ resistance to initiation of insulin therapy. The study demonstrated, however, that a short educational intervention could dispel patients’ fears and erroneous beliefs and help them to start insulin therapy.
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