Why it’s so tough to use insulin in Type 2 diabetic patients?

Barriers to initiate Insulin Therapy in Type 2 Diabetes patients in

Muar.

1. Introduction

The prevalence of Type 2 DM continues to rise in an exponential rate around

the world. In Malaysia, the Third National Health Morbidity Survey showed
that the prevalence of Type 2 for adults aged 30 years old and above is
14.9%, upped by almost 79.5% in the space of 10 years from 1996 to
2006(1). Studies also found that the majority of diabetes patients did not
have their disease under control4 where 61.1% of patients had HbA1c
greater than 8.0%(2).Based on local Diabetic audit 2009, majority of patients
with type 2 diabetes mellitus in Muar who attend primary care health
centre’s have unsatisfactory glycaemic control.

Due to declining β -cell function, insulin therapy will be necessary for

most patients with Type 2 diabetes. Insulin is safe, effective, and the most
potent drug available to achieve glycemic targets.There is increasing
evidence suggests that early intensive glycemic control reduces long-term
vascular outcomes and potentially may prolong β-cell lifespan and function
(3,4,5). Unfortunately, it is not used early enough, often enough, or
aggressively enough to cause patients to achieve glycemic goals that have
been proven to reduce morbidity and mortality. Recent evidence suggest
that 28% of the patients may refuse insulin therapy once it is prescribed (6).
The initiation of insulin therapy is often delayed due to a variety of reasons,
including patients' reluctance to accept insulin therapy [7,8], barriers related
to clinicians, health care systems and medications. The patient barriers can
be include belief of personal failure, scepticism about insulin effectiveness,
insulin causes complications or even death , loss of dependence , injection-
related anxiety and fear of insulin side effects eg: fear of hypoglycaemia,
weight gain(9,10).

Little is actually known about this phenomenon, often termed “psychological

insulin resistance” (PIR), how common it may be, or why patients feel this
way in Malaysia.A recent study in Malaysia revealed that 50.7% of the Type 2
DM patients were unwilling to accept insulin therapy(11). This study hoped to
explore patients’ willingness to take insulin if it was prescribed and identify
the patients’ attitudinal barriers towards insulin therapy in our community.
We hope that by identifying and addressing patient concerns regarding
initiation of insulin therapy, it can help health care providers to tailor
education and treatment to the patient's needs.
2. Study Questions

2.1 What is the prevalence of willingness to use insulin therapy in Type

2 Diabetes patients in Muar?

2.2 What are the attitudinal barriers towards insulin therapy among
Type 2 Diabetes patients?

3. Study objectives:

3.1 General Objective:

To determine factors influencing willingness to use insulin among

Type 2 DM attending Muar Primary Health Clinic.

3.2 Specific objectives:

3.2.1 To identify prevalence of willingness to use insulin among Type 2

DM

3.2.2 To identify perceived attitudinal barriers towards insulin therapy.

4. Methodology

This is a descriptive, cross sectional study which will be conducted in all

Primary Health Clinic in Muar District from July 2010 until September 2010.

The study population are type 2 DM who is attending Primary Health Clinic
in Muar who is not on insulin therapy.

Type 2 DM who is already on insulin, who is illiterate, patient who is

unable to read in Malay language and very ill patient will be excluded from
the study.

The sample size was calculated using sample size calculator for
prevalence studies. The prevalence of insulin is taken as 50%, level of
confident as 95% and 20% of non respondents. The minimum sample sizes
required are 460. For each health clinic, 42 will be selected using systematic
random sampling.
Instruments and data collection.
 A self administered questionnaire survey was designed which consisted of
two parts:

Part 1: Data on demographic profile. This data will be obtained from

record review.

Part 2: Assessment of psychological barriers to insulin treatment will be

assessed using self administered well validated Barriers to Insulin
Treatment Questionnaire by Petrak at el (12). It consist of 14 item of
question with 5 subscales: fear of injection and self testing, expectations
regarding positive insulin related outcome, expected hardship from insulin
treatment, stigmization by insulin injections and fear of hypoglycemia.
The patient was asked to score using 10 point Likert-type scale with the
extreme score labeled “completely disagree” and “completely agree” for
each item. Face to face interview will be used to obtained data for the
part 2.

5. Outcome Variables

1. Prevalence of willingness to use insulin

2. Perceived attitudinal barriers towards insulin therapy

6. Ethical consideration

Ethical approval was obtained from medical research and ethics committee
(MREC) Malaysia Ministry of Health and verbal consent was also obtained
from the participants.

7. Variables

Variables Operational Scale of

definitions measurements

Gender According to Nominal

identification card

Age (years) Age at last birth Year (continuous)

date

Ethnicity As reported by Malay

 patient Chinese

India

Others

Educational level Highest level of Not schooling

education
Primary

Secondary

Tertiary (College/
University)

Duration of Diabetes Number of years Years (continuous)

diagnosed to
have Type 2 DM
till now

Diabetes Complication As reported in the Nephropathy

record
Retinopathy

Neuropathy/Foot
complication

CVD( IHD,
CVA,Peripheral
Vascular Disease)

Willingness to insulin As reported by Agree or disagree

therapy patient (nominal)

Afraid when injecting As reported by Likert scale(strongly

insulin patient disagree, disagree,
agree nor disagree,
agree, strongly agree)

Afraid of injections As reported by Likert scale 1-10

patient
 Afraid of pain during As reported by Likert scale 1-10
regular blood check ups patient

Insulin works better As reported by Likert scale 1-10

patient

Insulin feel better As reported by Likert scale 1-10

patient

Insulin prevent long term As reported by Likert scale 1-10

complications patient

No time for regular doses As reported by Likert scale 1-10

patient

Can’t pay close attention to As reported by Likert scale 1-10

diet patient

Can’t organize days As reported by Likert scale 1-10

patient

Embarrassing As reported by Likert scale 1-10

patient

Dependence As reported by Likert scale 1-10

patient

Feel like drug addicts As reported by Likert scale 1-10

patient

Hypoglycemia – damage As reported by Likert scale 1-10

health patient

Afraid of hypoglycaemia As reported by Likert scale 1-10

symptoms patient

8. Plan for data analysis and interpretation

The raw data will be processed and entered as soon as the patients are
recruited until end of the study.

Table 1: Demographic profile

Variables n %

Gender

Age

Ethnicity

Educational status

Duration of Type 2 DM

Complication of
diabetes

Table 2: Willingness to use insulin by sociodemographic profile

Unwilling n (%) Willing n (%) Statistical P value

test

Overall

Gender Chi square

Male

Female

Age (years) T test

( compare
mean)

Ethnicity Chi square

Educational Chi square

level

Mean T test
Duration

Mean attitude T test

score
Attitude Chi square

+ve

-ve

Total mean score for 14 attitudinal belief items……………

Table 3: Attitudes towards insulin use according to subscales

Means ± SD Percentages of
negative attitude

Scale 1: Fear of injections

and testing

1. Afraid when injecting

insulin

2. Afraid of injections

3. Afraid of pain during

regular blood check
ups

Scale 2: Expectations
regarding insulin outcomes

4. Insulin works better

5. Insulin feel better

6. Insulin can prevent

long term
complication

Scale 3: Expected hardship

from insulin therapy

7. No time for regular

doses
8. Can’t pay close
attention to diet
9. Can’t organize days
 Scale 4: Stigmization by
insulin injections

10. Embarrasing
11. Dependance
12. Feel like drugs
addict

Scale 5:
13. Afraid of
hypoglysemia
symptoms
14. Possible
permanent damage
to health

9. Project management

Activities May June July Augu Sep Okt Nov

st t
201 201 2010
0 0

Finalize draft x
research
proposal

Recruit x
research
assistant/
training of MO

Data collection x x

Data analysis x x

Report x x x x
10. Literature review

1. Zanariah H. Prevalence Of Diabetes Mellitus In Malaysia In 2006: Result

Of The 3RD National Health And Morbidity Survey 9NHMS III) 2006.

2. Ismail, IS, Nazaimoon, W, Mohamad, W, Letchuman, R, Singaraveloo,

M, Hew, FL, Shuguna, C, and Khalid, BAK. Ethnicity and glycaemic
control are major determinants of diabetic dyslipidaemia in Malaysia.
Diabetic Medicine 2001, 18:501-508.

3. Weng J, Li Y, Xu W, Shi L, Zhang Q, Zhu D, Hu Y, Zhou Z, Yan X, Tian H,

Ran
X, Luo Z, Xian J, Yan L, Li F, Zeng L, Chen Y, Yang L, Yan S, Liu J, Li M,
Fu Z, Cheng H: Effect of intensive insulin therapy on beta-cell function
and glycaemic control in patients with newly diagnosed type 2
diabetes: a multicentre randomised parallel-group trial. Lancet 2008,
371:1753–1760.

4. Pfutzner A, Schondorf T, Seidel D, Winkler K, Matthaei S, Hamann A,

Forst T: Impact of rosiglitazone on beta-cell function, insulin
resistance, and adiponectinconcentrations: results from a double-blind
oral combination study with glimepiride. Metabolism 2006, 55:20–25.

5. Alvarsson M, Sundkvist G, Lager I, Berntorp K, Fernqvist-Forbes E,

Steen L, Orn T,Holberg MA, Kirksaether N, GrillV: Effects of insulin vs.
glibenclamide in recently diagnosed patients with type 2 diabetes: a 4-
year follow-up. Diabetes Obes Metab 2008, 10:421–429.

6. Polonsky WH FL, Guzman S, Villa-Caballero L, Edelman SV, .

Psychological Insulin Resistance in Patients With Type 2 Diabetes: The
scope of the problem. Diabetes Care. 2005;28(10):2543-5.

7. Wallace TM, Matthews DR: Poor glycaemic control in type 2 diabetes: a

conspiracy of disease, suboptimal therapy and attitude. Q J Med 2000,
93:369-374.

8. Korytkoski M: When oral agents fail: practical barriers to starting

insulin. Int J Obes Relat Metab Disord 2002, 26:S18-S24

9. Martha MF: Overcoming barriers to the initiation of insulin therapy.

Clinical Diabetes 25: 36- 38, 2007
10. Meece J: Dispelling myths and removing barriers about insulin in type
2 diabetes. Diabetes Educator 2006, 32(1):9S-18S.

11. A Z Nur Azmiah, A K Zulkarnain, K Zaiton, A Tahir: Willingness to

use insulin in Type 2 Diabetic patients. Medical Journal Malaysia Vol
65, Supplement A June 2010.

12. Petrak et al: Development and Validation of a New Measure to

Evaluate Psychological Resistance to Insulin Treatment. Diabetes Care
2007,30:2200-2204
 Appendix 1

BORANG KAJISELIDIK HALANGAN PENGGUNAAN TERAPI INSULIN DI KALANGAN PESAKIT DM

TYPE-2

Bahagian A Untuk kegunaan

pejabat

1. No. Daftar Kajian: …………………………..(Tidak perlu diisi)

1 ……………….

2. No. Kad Pengenalan: …………………………………………..

3. Jantina: 1 Lelaki 2 Perempuan 3

4. Umur (dalam tahun) : ………… tahun 4 ……………..

5. Bangsa: 1 Melayu 2 Cina 3 India 4 5

Lain-lain
6

6. Tahap pendidikan: 1 Tidak bersekolah 2 Pendidikan

rendah

3 Pendidikan menengah 4 Kolej / Universiti 7

7. Komplikasi diabetes 1 Nephropathy 2 Neuropathy / foot

complication

3 Retinopathy 4 CVD (IHD, CVA, Peripheral

vascular disease) 8 ………………

9
8. Pada tahun berapakah anda disahkan menghidap Diabetes…………(dalam

tahun)

9. Adakah anda bersetuju untuk menerima rawatan insulin jika perlu

 1 Ya 2 Tidak

Bahagian B: Penilaian halangan terhadap rawatan insulin

Berikut merupakan soalan berkaitan jangkaan dan keperluan bagi pesakit Diabetes tentang
keadaan dan rawatan. Dengan menandakan (/) jawapan berdasarkan markah 1 hingga 10 seperti
di bawah, sila beritahu kami setakat mana anda SANGAT SETUJU atau SANGAT TIDAK
BERSETUJU pada setiap soalan di bawah.
1. Saya takut rasa sakit semasa suntikan insulin diberi.
Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

2. Selain rasa sakit, saya hanya takut kepada suntikan.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

3. Saya takut sakit setiap kali menjalani pemeriksaan gula dalam darah.
Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

4. Insulin lebih berkesan dari ubat pil.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

5. Menggunakan suntikan insulin, penyakit diabetes lebih terkawal.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

6. Insulin boleh mencegah komplikasi akibat diabetes dalam jangkamasa panjang.

 Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

7. Saya tidak ada cukup masa untuk menyuntik dos insulin secara teratur setiap hari.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

8. Saya tidak dapat menjaga pemakanan saya dengan teratur sebagaimana yang
diperlukan oleh rawatan insulin.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

9. Mengambil insulin akan membataskan pergerakan saya.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

10. Menyuntik insulin di tempat terbuka amat memalukan saya. Makan pil lebih tertutup.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

11. Insulin perlu diambil berterusan sepanjang hayat dan tidak boleh berhenti.
 Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

12. Bila seseorang menyuntik insulin, ia membuatkan mereka rasa seperti penagih dadah.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

13.Terlebih dos insulin boleh menyebabkan paras gula dalam darah menjadi sangat
rendah atau “hypoglycemia”. Saya takut akan gejala seperti menggigil, pening kepala
dan pengsan.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10

14.Terlebih dos insulin boleh menyebabkan paras gula dalam darah menjadi sangat
rendah atau “hypoglycemia”. Saya takut akan menjejaskan kesihatan saya secara
berterusan.

Sangat tidak setuju Sangat setuju

1 2 3 4 5 6 7 8 9 10