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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 98-102

Investigation of the barriers about insulin therapy in patients with type 2 diabetes


1 Department of Nursing, Health Sciences Faculty, Firat University, Elazığ, Turkey
2 Department of Nutrition and Dietetics, Health Sciences Faculty, Firat University, Elazığ, Turkey

Date of Submission11-Mar-2019
Date of Acceptance18-Sep-2019
Date of Web Publication10-Jan-2020

Correspondence Address:
Dr. P Soylar
Health Sciences Faculty, Firat University, 23119, Elazig
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_138_19

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   Abstract 


Aims: This study aimed to explore barriers regarding insulin initiation in patients with Type 2 diabetes and investigate the relationship of some demographic characters of patients. Materials and Methods: A cross-sectional study was conducted with 142 patients with Type 2 diabetes whose doctors had recommended insulin therapy and who had been unwilling to comply. The participants were patients at an endocrine outpatient clinic in Kovancilar State Hospital in the rural area in Elazig, from November 2016 to May 2017. Results: Half of the patients were illiterate, 60.6% of the participants were female, and the mean age was 57.33 ± 10.56. The most commonly reported barrier was injection-related anxiety (63.4%). In total, 58.5% of the patients refused insulin therapy because they felt it indicated that their disease had worsened and that they had failed at diabetes management. Female patients were 6.9 times more likely to think injection-related anxiety that affecting their decision about insulin therapy than male patients. Elderly patients were 8.2 times more likely to think of their disease worsened than younger patient. Conclusions: Patients' beliefs related to insulin therapy were very much influenced by their gender, educational status, and age. Giving patient-centered education is a cost-effective way to decrease negative health behaviors.

Keywords: Insulin, insulin initiation, Type 2 diabetes mellitus


How to cite this article:
Soylar P, Kadioglu B U, Kilic K. Investigation of the barriers about insulin therapy in patients with type 2 diabetes. Niger J Clin Pract 2020;23:98-102

How to cite this URL:
Soylar P, Kadioglu B U, Kilic K. Investigation of the barriers about insulin therapy in patients with type 2 diabetes. Niger J Clin Pract [serial online] 2020 [cited 2020 Jan 26];23:98-102. Available from: http://www.njcponline.com/text.asp?2020/23/1/98/275609




   Introduction Top


Insulin is the most-effective treatment to control glycemia owing to the progressive characteristics of Type 2 diabetes.[1] Good glycemic control reduces the risk of microvascular and macrovascular complications caused by chronic hyperglycemia.[2],[3]

Many people diagnosed with Type 2 diabetes will require insulin therapy after failure of oral glucose-lowering agents.[4],[5] In addition to this, poor glycemic control in those with delayed insulin therapy may result in patients becoming frustrated with their efforts to control their diabetes.[6]

Although most of the patients with type 2 diabetes are ultimately prescribed insulin therapy either alone or in combination with oral glucose-lowering agents, there are many barriers to insulin initiation among patients with Type 2 diabetes. Many studies have investigated patients' beliefs and perceptions toward insulin therapy.[7],[8] A large sample study conducted with 2,061 patients from 13 countries found that most of the patients were anxious about initiating insulin therapy.[9] Another study reported that almost half of the participants were unwilling to start insulin. Patients commonly believe that insulin therapy will have a negative effect on their health and restrict their lives.[10] Another widespread misconception is that insulin use will cause side effects such as hypoglycemia, insulin addiction, and weight gain.[11] These negative beliefs and attitudes have been seen in approximately one-third of patients with Type 2 diabetes in some studies.[12],[13],[14]

It has been reported that most of the patients do not believe the efficiency of insulin in the DAWN study. In the same study, only one out of five patients stated that insulin would help them control their diabetes.[9],[15] However, 44% of the patients are unwilling to initiate as they do not believe they do not believe they can comply with insulin therapy.[13]

The present study aimed to determine the barriers affecting initiation of insulin therapy in patients with Type 2 diabetes and investigate the relationship of some demographic characteristics of patients.


   Materials and Methods Top


This cross-sectional study was conducted with 142 patients with Type 2 diabetes whose doctors had recommended insulin therapy and who had been unwilling to comply. The participants were patients at an endocrine outpatient clinic in Kovancilar State Hospital in the rural area in Elazig, from November 2016 to May 2017. To be eligible, patients were required to be reluctant to initiate insulin therapy and were asked to provide consent to the study. Patients who could not communicate in Turkish and/or had cognitive impairment were excluded. The data were collected in Turkish using in person interviews by educated nurses. The first section of the questionnaire was composed of socio- demographic and disease status questions. The second section included questions regarding insulin therapy was developed by researchers according to literature. More specifically, these questions were about injection-related anxiety, make think their disease worsened, difficulties in determining the correct dosage, and concern over insulin addiction, social stigma, and the inconvenience of insulin therapy in daily life.

This study was approved by the Ethics Committee for Non Interventional Studies of the Firat University, and permission was also received to conduct the study at the Elazig Kovancilar State Hospital. Written consents were obtained from all participants, and their identities were kept confidential. All of the participants were informed about the goal of the study and also notified that they could cease participation at any time.

The data were analyzed using SPSS 22.0. The significance level was P < 0.05. Descriptive analysis was used to summarize the demographic characteristics of the patients. Logistic regression analysis was constructed to predict the odds ratio for the relationship between demographic characteristics and barriers.


   Results Top


In total, 142 patients with Type 2 diabetes participated in this study. However, 60.6% of the participants were female and the mean age was 57.33 ± 10.56. Half of the patients were illiterate while the remaining had completed education ranging from primary level to high school. In addition, 64.8% had already received some form of diabetes education since their diagnosis. The time since diabetes diagnosis was 9 years and or more in half of the patients [Table 1].
Table 1: The sociodemographic characteristics of the patients

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The most commonly reported barrier was injection-related anxiety (63.4%). Many patients mentioned the fear of needles and fear of pain as the causes of their injection-related anxiety. Approximately, 58.5% of the patients refused insulin therapy because they felt it indicated that their disease had worsened and that they had failed at diabetes management. The next most common barrier was difficulty in determining the correct insulin dosage owing to being illiterate and old age. Almost half of the patients thought that using insulin would cause them to become addicted to it. The social stigma was an important factor for one-third of the patients (35.9%). However, 27.5% of the patients believed that starting insulin meant they would lose control of their lives and restrict their lives [Table 2].
Table 2: Descriptive information of the barriers

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[Table 3] presents the association between patients' characteristics and barriers affecting patients' decision initiating insulin. All of the barriers were statistically associated with patients' gender except barrier 5. Female patients were 6.9 times more likely than male patients to think that barrier 1 (injection-related anxiety) was affecting their decision about insulin therapy (P < 0.01). In terms of age, patients with 65 years and older reported mostly barrier 2 (fear of their disease worsened) and barrier 4 (make addicted to insulin) than 35–64 years (P < 0.01 and P < 0.05). Elderly patients were 8.2 times more likely to cite the fear of their disease worsening (barrier 2) than younger patients. Illiterate patients cited barrier 2, 3, 4, and 5 than more often literate patients (P < 0.01). Difficulty with determining correct dosage was 16.3 times more likely to be a barrier in illiterate patients than literate patients. There was no significant association between patients' previous education about Type 2 diabetes and factors affecting their decision initiating insulin.
Table 3: Variables associated with factors on initiation insulin with Type 2 diabetes patients

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   Discussion Top


There are many barriers that influence delayed insulin initiation. This study tried to explore the main barriers according to patients' perspectives.

Some barriers, such as injection-related anxiety, concern that their disease has worsened, difficulties in determining the correct dosage, and concern to over becoming addicted to insulin, were more common among female Type 2 diabetes patients in our study. In a previous study of female diabetic patients, half of them mentioned deliberately refusing insulin because of psychological distress about insulin therapy.[16] Similarly, Nam S et al. found that psychological factors to insulin therapy were mostly seen in women with Type 2 diabetes.[17] Women were more unwilling to initiate insulin therapy and showed a greater fear of injection than men. This result is alarming women with diabetes are less likely than men to manage their disease.[18]

In the present study, the fear of becoming addicted to insulin was an important barrier for female, illiterate, and elderly patients making decisions on insulin therapy. Many studies reported similar results that reluctant patients were female, primarily elderly, and with low educational status.[19],[20],[21] Some of these barriers may be intensified among elderly and illiterate patients. Evaluating and using any information related to health is worse among illiterate and elderly individuals. They have problems to understand the importance of treatment plans and risk of disease complications. As a result, poorer health consequences cause progression of the current disease.[22],[23]

We found that negative beliefs related to insulin therapy, such as restrictions in daily life, inconvenience, and negative social stigma affected patients' decision to start insulin. Similar to our study, patients felt that using insulin would restrict their lives in a number of study.[7],[13],[21],[24] Patients also fear that injecting insulin in public areas may lead to embarrassment and social stigma.[10],[14],[24] Patients frequently think that insulin therapy will be cause of unsuitability for their lives. One of the common misconceptions is that insulin therapy is used as a last solution among patients before major complications. Another frequent misconception is that using insulin can source loss of control over their lives.[25] Taken together, negative attitudes are more common among patients with diabetes mellitus.

Patients' knowledge about diabetes was not associated with barriers in our study. However, previously educated patients had positive attitudes toward insulin initiation in some studies and increasing patients' knowledge about barriers was an important factor in decreasing resistance to insulin.[26],[27]

Whether negative attitudes toward insulin therapy are common among patients with diabetes in Turkey is unknown. Therefore, this study is important because the prevalence of Type 2 diabetes mellitus has been rising in Turkey.

Patients' anxiety and beliefs related to insulin therapy are influenced by their gender, educational status, and age. Studying the factors influencing insulin acceptance is crucial for developing effective strategies for insulin initiation. It is important to deal with the issues that may affect patient adherence, given the relationship between poor adherence and health complications. One of the most important messages to transmit to patients is that they have not “failed” themselves by requiring insulin treatment. Patients need to understand that Type 2 diabetes mellitus is a progressive illness beginning from the disease. Providing patient-centered education will contribute to overcome the barriers faced primarily by vulnerable groups such as women, the elderly, and illiterate patients.[28]

The results of this study are limited because it was carried out in a hospital that is located in the rural area. Therefore, these findings may not represent the whole population.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. The patients understand that their names and initials will not be published.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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