The Barbados Insulin Matters (BIM) study: Barriers to insulin therapy among a population-based sample of people with type 2 diabetes in the Caribbean island of Barbados

Barriers of Doctors and Patients in Starting Insulin for Type 2 Diabetes Mellitus

Background Management of patients with type 2 diabetes mellitus (T2DM) may involve insulin therapy. However, this treatment may be avoided or delayed by physicians or patients due to the presence of certain barriers. This study aimed to evaluate the barriers to initiating insulin therapy for both physicians and patients with T2DM.  Method This was a cross-sectional, questionnaire-based study. Data related to the physicians' personal and professional experience were collected, and 15 barriers to initiating insulin therapy were scored by each physician on a four-point Likert scale. Also, the patients' general data were collected, including previous insulin experience, discontinuation reason, and willingness to start insulin therapy if indicated. Twenty-one other barriers were examined with yes/no questions as well. Results For physicians, the patient's treatment compliance, motive, dependence on others for insulin therapy, hypoglycemia, socioeconomic status, occupation, and lack of follow-up were the most highly ranked barriers to initiating insulin therapy. A history of insulin use was reported in 42 (20.7%) patients, 31 of whom had decided to discontinue insulin therapy themselves (73.8%). The three most common reasons for discontinuing insulin therapy among patients were deterioration of T2DM and causing complications, hypoglycemia, and needle injections. Based on the findings, 99 (48.8%) patients were willing to start insulin therapy, if indicated. The family history of insulin therapy was positively correlated with the patient's willingness to start insulin. On the other hand, it was negatively correlated with a low educational level and some barriers to insulin therapy, such as fear of death, dependence on others, the difficulty of carrying insulin while traveling, follow-up challenges, the difficulty of dosing accuracy, the difficulty of keeping insulin, inconveniences in daily life, considering insulin as the last resort, the deterioration of T2DM with insulin, and social stigma. Conclusion The physicians believed that the barriers to initiating insulin therapy were mainly related to the patient's attitudes and thoughts about this therapy. While hypoglycemia and weight gain are well-known side effects of insulin therapy, the most important patient-related barriers to insulin therapy were related to its impact on the patient's social life and misperceptions about the side effects of insulin.

Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review

BACKGROUND

Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders.

METHODS

We conducted a systematic review in MEDLINE, Web of Science, SciELO, and LILACS. We included studies of disease management, prevention of complications and risk factor management. We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management according to the Theoretical Domain Framework and described their relative frequencies.

FINDINGS

We included 60 studies from 1,595 records identified. 54 studies (90%) identified factors related to the environmental context and resources, highlighting the importance of questions related to health care access or lack of resources in the health system, and the environmental context and living conditions of the patients. Issues related to "social influences" (40 studies) and "social/professional role and identity" (37 studies) were also frequently addressed, indicating the negative impact of lack of support from family and friends and clinicians' paternalistic attitude. 25 studies identified patients beliefs as important barriers, identifying issues such as a lack of patients' trust in the effectiveness of the medication and/or the doctor's advice, or preferences for alternative therapies.

CONCLUSIONS

Successful diabetes management in LAC is highly dependent on factors that are beyond the control of the individual patients. Successful disease control will require emphasis on public policies to reinforce health care access and resources, the promotion of a patient-centred care approach, and health promoting infrastructures at environmental level.

Experiences of Attending Group Education to Support Insulin Initiation in Type 2 Diabetes: A Qualitative Study

INTRODUCTION

Type 2 diabetes is a progressive condition and many people require insulin therapy 5-10 years post diagnosis. Considering the global increase in type 2 diabetes, group education programmes to initiate insulin are beneficial as they are cost-effective and provide peer support. However, group education to initiate insulin has not been widely evaluated and there is a need to elicit the views and experience of people with type 2 diabetes who start insulin in groups. The aim of this study was to explore the perspectives of people with type 2 diabetes who receive nurse-led group-based insulin education.

METHODS

Qualitative, semi-structured interviews of people with type 2 diabetes in south London, UK, who had attended group education sessions to start insulin. Inductive thematic analysis identified themes within the data.

RESULTS

Fifteen people with type 2 diabetes were interviewed. Three main themes were identified: creating a supportive environment; facilitator skills; and effectiveness of group. Factors which created a supportive environment included peer support, providing reassurance and printed materials. Facilitator skills associated with positive experiences included addressing negative insulin beliefs and managing group dynamics. The effectiveness of the group was determined by ongoing self-management success, need for more peer support, and insulin concerns post insulin education group.

CONCLUSION

Positive experiences of insulin group education for people with type 2 diabetes were associated with sharing experiences with other people starting insulin, reassurance from healthcare professionals, appropriate supportive materials, and skill of the facilitator to address insulin concerns and manage group dynamics. People with type 2 diabetes may benefit more from education if healthcare professionals are skilled in psychological techniques to facilitate group education aimed at addressing concerns around insulin therapy. Further research needs to assess the effectiveness of structured insulin group education for people with type 2 diabetes.

Facilitators and barriers to successful recruitment into a large comparative effectiveness trial: a qualitative study

Background: Recruitment of participants into research studies, especially individuals from minority groups, is challenging; lack of diversity may lead to biased findings. Aim: To explore beliefs about research participation among individuals who were approached and eligible for the GRADE study. Methods: In-depth qualitative telephone interviews with randomized participants (n = 25) and eligible individuals who declined to enroll (n = 26). Results: Refusers and consenters differed in trust and perceptions of risk, benefits and burden of participation. Few participants understood how comparative effectiveness research differed from other types of trials; however, some features of comparative effectiveness research were perceived as lower risk. Conclusion: We identified facilitators and addressable barriers to participation in research studies.

Prevalence and determinants of psychological insulin resistance among type 2 diabetic patients in Kinshasa, Democratic Republic of Congo

Background

Psychological insulin resistance (PIR) is a common but unappreciated phenomenon by health care providers with a negative impact on the control of type 2 diabetes mellitus.

Aim

To determine the frequency of PIR and its determinants in patients with type 2 diabetes.

Setting

This study was conducted in Kinshasa in three health centres providing management of diabetic patients.

Methods

This study was a multicentric, cross-sectional study conducted from 01 November 2017 to 31 March 2018 in Kinshasa among 213 type 2 diabetic patients who were taking oral anti-diabetic drugs. A standardised questionnaire, the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ), was used for data collection.

Results

The average age of participants was 59.8 ± 11.1 years with a male to female ratio of 1.5. The prevalence of PIR was 42.7%; and its main determinants were 50 years of age (odds ratios [OR] adjusted 2.05; 95% confidence interval [CI] 1.98–4.27; p = 0.045), the presence of complications (OR adjusted 3.33; 95% CI 1.68–6.60; p = 0.001), lack of knowledge about insulin therapy (OR adjusted 1.96; 95% CI 1.03–3.71; p = 0.040) and the high cost of insulin (OR adjusted 2.32; 95% CI 1.08–4.95; p = 0.030).

Conclusion

The study showed that almost half of type 2 diabetic patients had PIR with the main determinant factors related to the patient and the health system. The establishment of a therapeutic education programme, improved ‘provider–patient’ communication and the development of approaches to increase access to drugs are crucial to reduce the prevalence of PIR.