Patient Barriers to Insulin therapy
LITERATURE REVIEW
With the raise of T2DM, many countries have performed studies and research on the perception of insulin therapy among T2DM patients.
DAWN STUDY – Diabetes Attitudes Wishes and Needs.
The DAWN Study, was initiated by Novo Nordisk in collaboration with the International Diabetes Federation. The first DAWN study was instituted in 2001. (DAWN, 2001). Novo Nordisk has organized international summits in 2002, 2003,2006 and 2008 for concerted advocacy and action. The latest summit was held in Budapest city.
Since then many countries have allied together to bring a broader expertise in the treatment and management of diabetes. Since its implementation the DAWN study have published over 300 scientific publication worldwide. The DAWN study has made partners with other Health organizations so to optimize concerted actions for the management of diabetes.
This study helps in reducing the burden of disease of patients with diabetes. It analyses different psychological, social and cultural barriers and help patients explore new avenues for the improvement of diabetes care.
It also helps the medical staff – nurses, specialists, dieticians, general practitioners to improve their management skills and practice for a better follow up and management of diabetes. The DAWN study also helps policy makers to develop national programmes to help the population understand the issues and concerns of diabetes.
In 2001, the DAWN study involved 5426 adults with diabetes, 2194 primary care physicians, 556 endocrinologists and 1122 nurses. This accounted to 13 countries in total. The research performed consisted of face to face interviews and telephone interviews of around 30 to 40 minutes each. (DAWN, 2001)
The results of this study showed that most patients affected with diabetes did not follow the recommendations of their doctors because patients think that the treatment of diabetes is demanding and if affects this daily lifestyle.
Patients and medical staff were asked to explain their fears specially towards insulin therapy. It was found that people with T2DM had an excessive fear of starting insulin. Only one out of five patients believe that insulin would help them improve their insulin status. One third of medical practitioners would postpone insulin until absolutely essential.In 2005 a research performed by the DAWN study stated that 50 to 55% of general practitioners delayed the use of insulin therapy amongst T2DM patients owing to the reluctance of patients. The research demonstrated that the attitude towards insulin therapy depended on many socio-cultural beliefs and the level of literacy of the patients. It was found that patients having complications owing to T2DM had stronger beliefs of the use of insulin therapy.(M PEYROT, 2005)
The study advocated the identification of the source of fear, and actions needed to be able to overcome the latter so as to enable both patients with T2DM and specialists to start insulin therapy at earlier stage so as to achieve optimal management of the chronic disease. One the main proposals was to allow more time for patients affected with diabetes to communicate with their medical practitioners so as to enhance their knowledge on the false pre-conceived ideas they have on insulin therapy and diabetes. This will help patients to overcome their emotional barriers and promote more self-management and thus lead to a better health condition and lifestyle.(DAWN, 2001)
The research made by the DAWN study is very important for the population of Mauritius. The fact that our country has one of the highest prevalence of diabetes in the world, the DAWN study reports are beneficial for the proper management of T2DM. Local physicians, nurses, other medical staff involved in diabetes treatment, should be trained after the DAWN study protocols so that the approach of insulin therapy toward the patient is performed in a way that does not fear them away.
Physicians do attend seminars on management of diabetes, explaining to them the proper use of insulin, the new therapies available, but it is very rare that there are training for the proper way of analysis of insulin fears of each T2DM patient and no training on the way to communicate and to announce the patient that he or she need to start using insulin therapy.
Perception of insulin therapy in Pakistan
In 2016, a cross sectional study was performed on the perception of insulin therapy amongst T2DM patients, in Pakistan, by a few professors. A total of 160 T2DM patients were interviewed. This study revealed a few surprising barriers towards insulin therapy which most particularly concerned cultural beliefs and misconceived ideas.
Pakistan is a country which has a different cultural of practice compared to western European cultures. They have a more dependent collective culture compared to the individualism culture of western countries. In such cultures, relationships with other members of the group and the interconnectedness between people play a central role in each person’s identity.So, what other people think, especially spiritual leaders do also play a role in the use of insulin therapy.
The results of the research were that nearly 65 % of patients were unwilling to use insulin and 90% had a negative perception of insulin. During this study, it was also found that 55% of the patients thought they would die of hypoglycaemia and 44 % would start having cardiac diseases. 35 % agreed that insulin would make them blind and 30 % also concluded that it was haram since insulin could be derived from pork tissues. Moreover 65 % patients were not confident to measure the exact dose of insulin. The fear of the needle was observed in more than 55% of patients.(Dr imran Massod, 2016).
This study demonstrated that there are many barriers to insulin therapy. In one word, the barriers could be named ‘FEAR’. The fear of hypoglycaemia, the fear of needles, the fear of haram, the fear of wrong dosage. Dr Imran Massod was the research leader concluded that this was a fear that started from childhood where the parents would use needles as scare tactics and also that this fear originated from the level of health literacy of a population. The culture of people of Pakistan also played a role in altering the perception of insulin therapy. Part of the population believe that is prohibited by their religion.
The fact that Mauritius is a multi-cultural society with part of the population who is of Muslim origin, it is fact that insulin therapy is of a concern. The fact that people do not know the actual origin and production process of insulin does affect its use during diabetes treatment. The best way to eradicate this concern is through the media, communication, education.
Psychological insulin resistance in the United States of America
A study on the measurement of psychological insulin resistance(PIR) was performed from the Massachusetts University of Boston by Larkin and Al. The purpose of the study was to identify and define predictors of PIR and to identify the barriers of insulin therapy.
It was a prospective study involving 100 insulin naïve adults affected with T2DM in an outpatient department. The results of the study were that 33% of these people did not agree to start on insulin therapy. The most common negative attitudes were the fear of hypoglycemia, the fear of being on insulin therapy during all their life, poor lifestyle with less flexibility and the feeling of failure. Around 40 % of the patients expressed fears on insulin self-injection and with the thought of painful injection. Many patients also thought that starting insulin therapy would actually mean a severe deterioration of their health and thus lead to anxious states.
This study does identify the important fears of patients with T2DM. It shows that people who are insulin naïve have a communication and information issue. They have preconceived defined ideas about how the use of insulin would affect their life. Sitting down with the patient and proper explanation of insulin and its use would actually help them understand and give them a better insight about insulin therapy.(AL L. A., 2008).
Leaflets, television talk shows, newspapers, radio programmes on diabetes is commonly used to disseminate information about diabetes in Mauritius. The Ministry of Health with the National Non-Communicable Disease programme is investing onto these tools to educate and create awareness amongst the population. It is important that policy makers start to look deeper into the matter, know what are the concerns and work on them. Finding the causes of the root of psychological resistance will be a very helpful policy.
Barriers of Insulin therapy
According to the American Diabetes Association, timely initiation of oral medication combined with insulin therapy is the paramount in succeeding a good glycaemic control for T2DM. Dr Mary T Korytkowski in collaboration with experts from ADA, had a research performed on the barriers of insulin therapy. Dr korytkowski states that insulin therapy means different things to different people. It is very important for physicians to know about the fears that are common in people who are asked to shift from oral to insulin therapy. Without this knowledge, the physician will encounter resistance from T2DM patients who would refuse to start insulin therapy. The physician who is planning to change the therapy of their patients’ needs to know and assess the level of concern of the patient. Previously physicians used to use scare tactics for their patients to start exercising and have proper meals, but the system actually backfires when the patient really need to start using insulin therapy.
Dr Mary T Korytkowski actually advise physicians to acknowledge the fear of their patients towards the use of insulin and to provide them with adequate information on insulin for reassurance. Physicians should speak about their experience of prescribing insulin and its benefits over oral therapy. Showing patients, the size of insulin needles also helps them dissipate the phobia of needles. Physicians can also refer the patients who need insulin therapy to more specialised staff such as endocrinologist, diabetes specialised nurses.
The conclusion of this report is that the medical staff needs to create a proactive, collaborative relationship with patients so that both the patient and the clinician benefit from the best available therapies for T2DM. (korytkowski, 2010).
In Mauritius though several campaigns are being carried out unfortunately no proper policies has been created for the medical staff to collaborate together for a better communication strategy between patient and staff.
Chronic Anxiety of hypoglycaemia.
A study performed in Luton and Dunstable University Hospital NHS Foundation Trust, UK, found out that Chronic anxiety about hypoglycaemia would affect their lifestyle, work, sleep condition and their quality of life. (NHS, 2015)
In February 2016, the research program unit of diabetes and obesity of the University Finland, conducted a study on the fear of hypoglycaemia amongst 798 participants with diabetes. The results showed that 61.7% were self reportedly afraid of hypoglycaemias and 70.9% reported eating just in case because of the fear of hypoglycaemia.(Nutrition, 2016)
It is of one the most feared condition of patients that are about to start insulin, especially if one of their family member or friends have had an episode of hypoglycaemia and they have witnessed it. This can be a traumatising experience which would in turn hinder the T2DM patient and cause a psychological fear in them. When a patient is going to be started on insulin therapy, the doctor needs to assess all the concerns and explain properly about how hypoglycaemic states can be avoided and reassure the patient about the safety of insulin therapy. Patients who are on insulin and have a recurrent fear of hypoglycaemia very often put on weight and they blame it on the product. It is true that insulin prevent lipolysis in certain condition but patient put on more weight because of the fear of hypoglycaemia. They perform defensive snacking every time they feel abnormal, even if it might not be a low blood sugar causing this abnormal condition.
This was not only an issue for the patients but also for doctors also, for they feared the risk of hypoglycaemia for their patients. According to the survey: 72% of primary care physicians and 79% of diabetes specialists have reported that they would treat patients more intensively if hypoglycaemia was not a concern.(Nutrition, 2016)
The best method to start insulin therapy for a T2DM patient would be to admit them and have a regular glycaemic control for a few days, the medical staff would be present in case of a hypoglycaemic crisis, but unfortunately this is not possible because of the shortage of beds and increasing number of emergencies that need admission. Doctors need to use the means and tools given to them by giving adequate information prior to insulin therapy to the patients and family members. Training of medical staff is also important, so that they can tackle the concern of hypoglycaemia during insulin therapy, doctors need to be constantly updated on ways to avoid insulin related hypoglycaemia and how to communicate properly to their patient for a correct understanding and diabetes management.
Inhaled insulin therapy versus subcutaneous insulin therapy
The American Diabetes Association performed a research with the collaboration of PFIZER pharmaceutics on the use of inhaled insulin therapy versus subcutaneous insulin therapy. The research method was a randomized of 149 patients. The results of the study were found that people with T2DM aged between 35 to 45 years old, only 10.6% were agreeable for sub cutaneous insulin therapy. People with T2DM, between 55 to 65 years old, 17.6% agreed on sub cutaneous insulin therapy. (Hollander, 2004)
This study showed that young people have more concerns about subcutaneous insulin therapy. The question is why is it that young people, though more literate are less keen on using insulin therapy. Is it the fear of insulin derived from childhood traumas or the fear of severe deterioration of heath condition. People with an older age gap are more adaptive to insulin therapy. This is an age where people are more conscious about their health knowing that they are aging and they have to embrace the fact that their health is no more like when they were young.
It is very important for the parents and family members not to use needles and injections as scare tactics for children to listen to them. This causes an early childhood phobia that carries itself through the adulthood and once the need arises to use sub cutaneous insulin, this become one their major concerns. It is important to educate patents about a proper upbringing so that there is less psychological trauma and concerns once the child is an adult. The Ministry of health needs to train medical staff who are involved with the parents for example vaccination nurses, they can advise the parents during the vaccination programmes. The Ministry of Education can also be part of this policy. The training of teachers could include a session where they teach about chronic diseases and reassure the students about injections and discuss about their concerns in class.
Perception of insulin therapy amongst the Asian population in Singapore
The Taipei University made a study on the perception of insulin therapy amongst the Asian population in Singapore
The professors wanted to assess the rate of T2DM patients who would refuse the use of insulin therapy. A cross sectional study was performed with interviews with 265 T2DM patients in a primary health care center. Seven out of ten patients (70.6%) refused to use insulin. The major fear present among 47% of the patients were the fact that they would not be able to perform the proper dosing of insulin. The fear of pain was the other issue concerning 45% of patients. 46% of the patients stated that they would not be able to have a normal life that included fulfilling daily chores, going to work and performing their duties if they had to initiate insulin therapy. It was also noted that people who had studied up to the tertiary level were more open to insulin therapy. Depending on the literacy level of the patients there would be significant perceptions of insulin therapy.
The conclusion of the study was that the focus of these fear should be aimed at insulin injection concerns, find the sources and analyze where the fear of injections arises and conceive new means which are less painful of injecting insulin. Misconceptions of insulin therapy have over their lifestyles must be approached with the physician. It is very important that all the fears that a T2DM patient must be discussed with the treating physician. The doctor needs to be trained for proper patient approach and need to be skilled to as to talk about the concerns of the patient. The element of trust and understanding is elementary in these situation for a proper management of diabetes. Physicians need to be trained to a correct therapeutic and psychological approach. (S WONG, 2011).
Psychological Insulin Resistance in Patients With Type 2 Diabetes (PIR).
In October 2015, a study for PIR was performed by the ADA in collaboration with the University of California and San Francisco. The study was designed because studies have shown that around one quarter of the T2DM patients are reluctant or delay their insulin therapy once its prescribed to them. They developed a self-report survey on PIR for a large number of T2DM patients who were reluctant to insulin therapy.
The questionnaires of the surveys were handed over to T2DM patients during diabetes conferences in different states of America. The questionnaire was based on the willingness and unwillingness of initiated insulin therapy. A Likert 6 six-point scale paper was also handed out to the patients to assess how the level of agreement or disagreement of barriers of insulin mentioned in the questionnaire. A regression type of survey was used based on the sex, age, ethnicity, diabetes duration and willingness for insulin therapy.
The results out of 3833, 1267 returned completely filled questionnaires and 708 patients were T2DM not willing for insulin therapy. The average age of the patients was 57.4 with a duration an average diabetes duration of 6.9 years. The majority of patients were female with 63.8%.
The barriers to insulin therapy were quite numerous and most commonly with 45% was the use of permanent insulin therapy during their whole life and restrictions in their daily routine,work, lifestyle family life. 43.3 % of the patients had the fear of issues concerned with hypoglycaemia, they would fear falling more often sick than their present condition. 43% of patients also thought that insulin would be of no use to improve their diabetes status.
The conclusions of the report were that most patients who refused insulin therapy thought that beginning insulin would mean that the oral treatment is failing and that their diabetes is turning into a more critical stage. Patients also think that when their physician start to talk about insulin therapy, it is a threat to them or they take it as a scare tactic. PIR represents a complex number of negative beliefs about insulin therapy. There is a definite lack of information shared between the patient and the physician. The report advocates before the initiation of insulin therapy, it is better for the physician to ask about their knowledge of insulin rather than start by saying we need to start insulin therapy.Patients affected with T2DM can also be called to attend limited groups so as to educate them that insulin is not an end therapy and life can carry on normally with its use so as to clarify the fears and barriers involved in the use of insulin therapy.
Barriers to proper management of T2DM.
The journal of diabetes research and clinical practice has published a report on the barriers to the proper management of T2DM. Despite new medical products are available on the market for proper follow up and management of diabetes, poor glycemic control still prevails. Data from the NHANES 1999-2000 – National Health and Nutritional Examination Survey showed that there is a smaller percentage of T2DM patients who have reached the glycemic HbA1C control range of 7%. Ten years there was 46 % of T2DM population who had a controlled HbA1C whereas in 2000 the level has gone down by 38%. It was also found that the T2DM patients receiving insulin therapy, more than half of them did not achieve good glycemic control despite the use of new and more advance medication. (CDC, 2000)
The question is why is it that instead of improving the glycemic control patients with T2DM are actually deteriorating. Insulin is a safe and potent medication of patients with diabetes, unfortunately it is not used early enough by both the clinician and the patient. It is frequently delayed and postpone owing to several concerns.
A summary of barriers of insulin is important to analyze the ways to improve the management of diabetes. The barriers for the patients are attitude towards insulin, their beliefs, their culture, their health literacy level, their financial means and social support affects the management of diabetes. Education and access to medication is the mainstay to improve the management. Early health classes would empower children and adolescents to manage diabetes in an improved way enabling a healthier future population who is ready to adhere to insulin therapy when required.
The barriers for clinician are the lack of knowledge of insulin use, the lack of communication skill for the proper approach of insulin therapy. Without a proper communication and understand of insulin therapy, many T2DM showed major reluctance in initiating the therapy.
Social impact of T2DM on insulin therapy.
A comprehensive study of the social impact of diabetes mellitus is essential for informing policy and practice, yet these fields are being under researched. A research has been performed in Geneva, in collaboration with the World Health Organisation that showed that people who do not have diabetes assume that the disease is a non-stigmatised. In contrast people with T2DM is often subject to stigmatisation from their environment – work place, relationships. This aspect of negative stigmatisation affects the psychological state of the patient thereby hindering the optimal treatment of diabetes. (WHO, 2011)
Social stigma is a common concern in Mauritius and it is difficult for physicians to tackle this issue. Medical expertise such as psychologist, social experts need to team up together to devise policies to decrease this stigmatisation of insulin therapy.
Cultural beliefs on insulin- pork derived
A study performed in Malaysia Medical Centre University of Kebangsaan Family Medicine department conducted a study on cultural beliefs of insulin therapy. Prof Rahman Mohammad Amin, Dr Abu Assan. (RAHMAN, 2010)
They discussed about the studies concerning insulin perception and fears and that they were mostly carried out in western countries that usually practice independent individualism culture(IIC) compared to Asian countries who practice dependent collectivism culture(DCC). IIC is the prioritisation of an individual over an entire group for example the person can take his decision solely, whereas in DCC, emphasize the needs and goals of the group as a whole over the needs and wishes of each individual. In such cultures, relationships with other members of the group and the interconnectedness between people play a central role in each person’s identity.
IIC people would not consider insulin as a cultural barrier since they have their own concept of insulin whereas in DCC patients would be more involved into what their group chief usually religious leader would say about this product and misconceptions may often reign in such groups such as insulin is a pig derivative and considered not apt for their use owing to their religious beliefs.
This is an erroneous beliefs since nowadays biosynthetic human insulin is being used which has been proven to be identical to human pancreatic insulin. human insulin, is produced by a method known as ‘recombinant technology’: the insulin is made by yeast cells into which a gene (DNA) has been introduced.
Insulin therapies: Current and future trends at dawn
The best way to use insulin therapy is through the injection of insulin in sub cutaneous manner using needles. Researches are working over new means of injection for the use of insulin therapy. Previously syringes were used as a method of insulin delivery in the majority of patients with diabetes. The latest medical device created so as to avoid daily needle injection is the Continuous insulin pump (CIP) and Insulin pens. The CIP method provides continuous insulin throughout the day with a more precise control of the glycemic control. The benefit of this mean of insulin delivery is more freedom, more flexible lifestyle. This diminish the fear of daily insulin injection and the fear of hypoglycemia since the glucose level is constantly being monitored. The insulin pen is also more convenient that the syringe. The advantage is that insulin vials do not need to be carried along and the pen is less painful that the syringe needle. Moreover dosing the insulin is much more easier with the insulin pen compared to aspirating insulin from vials with a conventional insulin syringe.
Other means of insulin delivery are still under research which consist of inhaled insulin through and aerosol pumpand oral insulin. With the advent of Nano technologies, these methods are delivery are now being considered and hopefully one day we will no need to use subcutaneous insulin. (diabetes, 2013)
It is a fact that progress is indeed pacing very fast and far, but during this process we need to use the best means of insulin therapy to provide optimum glycemic control for patients affected with T2DM. In the future, we might use an alternative source of insulin delivery which need will dissipate the fear of needle prick, this would be in ideal condition. We have not reached that stage yet but hopefully one day we will be able to provide the best treatment for this chronic disease.
Discussion and Data Analysis on the Perception of insulin therapy amongst type 2 Diabetes (T2DM) patients.
The results of my study showed that a large number of factors accounted for psychological insulin resistance in patients; the main categories were emotional, cognitive, social, cultural, and interaction with health care providers.
Through my interviews I have discovered several aspects that influenced T2DM patients from switching oral therapy to insulin therapy. There are some factors which is typical for Mauritius, this is mainly due to our multi-cultural, ethnical and social background.
Emotional concern of insulin.
This fear consists of hypothesized set of stress, anxiety and traumatic experiences of life. It is a psychological concern that builds up probably at an early age and builds up with time. It comes with the childhood traumas, for example traumatic moments during immunisation. During my interviews, I have very often come across with T2DM patients complaining of fear of needles. It was a common concern with many patients and finding the root of this problem was challenging and very interesting.
Emotional fear
During my interviews, one of the major emotional concern for the use of insulin therapy voiced out by T2DM patients is the emotional fear needle prick injection. Also known as trypanophobia, it is present in around 20% of the general population of the world. It is both a learnt and inherited experience. Most people acquire needle phobia around the age of four to six years old.The American society of Hygiene carried out a survey on 2000 people about the fear of needle phobia. The phenomenon was found to be more prevalent in female patients and lower in the elderly. (HAMILTON, 1995)
Also known as trypanophobia is present in around 20% of the general population. The main causes are usually traumatic childhood experiences during early vaccinations.Parents also play a role in acquiring this phobia, it is commonly used as a scare tactic for the children to listen to them and behave. It is important to avoid this kind of recurrent fear for a child because when the child will grow up to become an adult, and if in that he or she needs to perform insulin therapy, it will be difficult to adhere to insulin. Therefore, it is very important to educate the young parents and parents to be, about helping their children to overcome the fear of needles and not to scare them away and create this phobia.
Another way children grow this feeling of fear is by seeing other children fainting during the vaccination programmes which is either done at school or in the local health centres. Them empathy of seeing their friends at school, fainting during the immunisations sessions enhances this fear.
A study done in a dental clinic in Germany showed that if the nurse prepared the injection out of the sight of the patient, it would cause less needle phobia.(WILLERHAUSEN, 1999)
The medical staff has also a role to play in limiting the needle fear of patients, ideally, they need to prepare vaccines earlier and make sure to reassure the child that this is procedure is going to be fine and it will be beneficial for him to grow as a healthy adult. Moreover, each child during vaccination, must be performed in close compounds either with the use of curtains so that other children do not see the vaccination process. This will avoid the fear empathy.
The proper training of nurses and doctors is essential for the decrease in the needle phobia. Special attention and training should be given to nurses who are trained for school immunisation so as to minimise this fear. I have myself often attended many school vaccination programmes and unfortunately the vaccines are often prepared in front of the children and after reading this research next time I will surely advise the staff for a more suitable vaccination programme such as preparing the vaccine whilst the child is waiting outside and not in front of them.
Cognitive fear of insulin therapy.
This is the fear or perception, judgement and reasoning. The pre-conceived perception of insulin therapy. Very often this fear comes from the surrounding of people, the rumours people talk about, their shared fears of something which they do not know about. Through my interviews I have often come upon this cognitive concern as soon as I utter the word insulin therapy.
This was a fear that was very common during my interview, Mauritius is a country which is deeply rooted into family, friends and surroundings compared to the western culture. This creates people to listen around especially to false rumours leading to believe things are not correct.
During my interview, I once overheard my patients saying that his friend told him that once he is on insulin therapy, he has only a few years to live. Another example during my interview, one patient told me that insulin therapy is detrimental to the kidneys, he will have to undergo renal dialysis if he is put on insulin. They were concerned that if they started on insulin therapy, they will be falling sick more often, more common examples were – “I would faint more often with hypoglycaemia if I started on insulin”.
Cognitive fear results in what people think and say into their surroundings. Hypoglycaemia was found to be one of the most common concerns people talked about during my interview.
It is a fact that hypoglycaemia is a life-threatening condition when if the patient is not doing the right dosage of insulin at the right time. Through my interview I observed that those people who had the most fear of hypoglycaemia were the ones who had a low literacy level. They feared that they would not be able to read the syringe gauge properly. Many patients with T2DM have issues to read properly either affected with a cataract or having diminished eye vision owing to age, they end up refusing to do insulin because of this condition.
Another cognitive fear was that patients were worried about was the issue of weight gain during insulin therapy. Insulin is a hormone that inhibits lipolysis as well as promoting protein synthesis.Patients treated with insulin may often indulge in ‘defensive snacking’, whereby they consume carbohydrate-rich foods in an attempt to prevent hypoglycaemic events or when they perceive impending hypoglycaemia thus making them put on more weight.
Other cognitive fears were about the hyperpigmentation at the site of injection, more concerned of their looks and how would their skin react to the medication. It is true that hyperpigmentation can occur if the patients do their insulin injection at the same site all the time but with proper injections at different sites this is less bound to happen.
Overall all these fears arise with false rumours from their surroundings. People would just create rumours concerning insulin inside the society to which they belong.
Other concerns noted during my interview was the fact that T2DM patients who were asked to start insulin therapy would directly correlate that they are in a critical of their disease and they will not survive long. They tend to associate a severe critical illness with the start of insulin therapy.
The most reliable way to reassure patients about the use of insulin is to tackle their concerns through proper physician-patient communication, taking time to speak to them, let the patients voice out their concerns and explain to them the facts and the benefits of using insulin therapy. Informing patients through the media that it can be safe if properly explained by the physicians.
Social fear of insulin therapy
Social fear in Mauritius is something which is very common. Fear of social stigma is deeply anchored in the population of Mauritius. Unfortunately, it is a major concern to the population when the use of insulin therapy is approached. This fear would also depend on the health literacy level of the patient.
During my interview, I have on several occasions noted a certain social fear amongst T2DM patients. I realised that many patients had the fear of a social stigma, of what would other people – including the family, friends and neighbours in their surrounding would say when they would start insulin therapy.
Mauritius has a population who is involved into more social aspects than European countries. When somebody is on insulin therapy, they are stigmatised as severe disease in the end stage. This natural fear of ‘what would people say’ creates a barrier for the use of insulin for many patients and causes a negative social stigma.
The attitude of blame often by other people, family and friends in the society is also very common and this creates a sense of fear and reclusion. During my interview, I have come across with people who would fear the reaction of their children if insulin therapy was initiated. The would fear that their children would reject them, would shout at them, who would refuse to help them with their insulin therapy.
On one interview, I had a T2DM patient of thirty years old who had this uncommon reason to the refusal of insulin therapy, his fear was that “if my girlfriend finds out that I am on insulin therapy, she will leave me” though this was a presumptive fear, it is of a social concern which involves fear of losing dear ones, fear of being judged and discriminated by other.
Some people also complained about their lifestyle restriction if they were to be started on insulin therapy. They stated that insulin therapy would impinge on their working conditions, such as people who work in emergency departments such as fire and police. Their working schedules and constraints are not appropriate for them to use insulin in case of emergencies. One of them- a security guard- stated “doctor what happens to me when I do my insulin and ten minutes later I have an emergency”.
It is a fact that in these specific cases insulin therapy can be less practical but each patient needs to find time for their treatment.Identifying mitigating strategies is essential to reduce diabetes related stigma so as to enhance resilience amongst people with diabetes.
Cultural fear of insulin
Erroneous beliefs were often attached to insulin therapy.
In our country, we are all proud to live in a multi-cultural society, this carries many advantages but also its fair share of issues.
During my interview, I came across with a few patients who had insulin barrier issues owing to the production of insulin, they thought that insulin which was currently was of pork derivative and in some communities and religions, it is forbidden to use and consume these kinds of products. The main concern was what was insulin consisted of from where was it produced.
It is prohibited to consume any product from pork and non-halal meat in the Islamic religion. Previously purified insulin derived from pig and non-halal beef was used in patients with diabetes. Though the Islamic legal rules stipulated that it is permissible to inject highly purified insulin made from pig to patients only in extreme circumstances, many people of Islamic origin refused to follow the therapy owing to their religious beliefs.
In Mauritius, the population follows a dependent collectivism culture compared to European and American population who follow an independent individualism culture. This difference of cultures favours the European and the American population compared to the Mauritian culture. In the collectivism culture, it a group of people with the same culture who will listen and do the same thing as others more frequently they would listen to their religious leaders. The group affects all the individual within that specific structure.In such cultures, relationships with other members of the group and the interconnectedness between people play a central role in each person’s identity.
Fear of interaction with health care providers.
For many people, they have the fear of going to see a doctor when they are not well. It is called iatrophobia. Patient tend to put off visiting a doctor, no matter how serious their condition is, they think that staying at home, waiting for the disease to go away would be a better option. Unfortunately, this has probably been caused because of traumatic experiences in the hospital during their childhood or afterwards. Many patients with iatrophobia related doctors to needles and have issues with following authority of doctors. Nowadays the patients’ trust in doctors is also declining. A survey done in the United States has shown that nearly 40% of patients believe that doctors do not care about the patient wellbeing as much as they did decades ago.
During my interview, I did come across with two patients who told me that they actually delayed their T2DM treatment because they were afraid of seeing doctors. One patient admitted that he did not trust the doctor working in the public sector, that asked to start on insulin therapy and instead of following his instructions went to see a doctor in a private clinic, where she was told it was unnecessary for her to start insulin therapy and she could carry on with oral therapy.
This is indeed very conflictual for the patients and this situation causes patients to be confused and hence lack the trust in her treating doctor.
It is important for the patient to trust his treating doctor, to be able to approach the latter when any doubt about the treatment prescribed. Doctors in Mauritius need to have training on how to approach patient when they are planning to start on insulin therapy, they have to anticipate their fear and deal with their concerns in a way so that the patient feels comfortable to discuss about it. Without this approach, the patient will have difficulties to adhere to the required insulin treatment and thus have poor glycaemic control and deteriorate their health condition.
Materials and Methodology
This study aims to investigate the concerns of T2DM patients for insulin therapy. A qualitative approach has been used with open ended questions about the feelings of patients. An unstructured interview with open ended questions has been selected and has been conducted.
Thirty-five patients have been interviewed. The choice of the patients was made randomly in a diabetes clinic in a few area health centres and community centres on different days during one month. The patients were clearly explained about the purpose of the study and were asked to sign a consent form after agreeing to go through the interview.
The sample of the study was 35 patients because at this point, there was already a saturation of data. The answers given by the patients were almost similar and I had enough data to carry on with my report.
The inclusion criteria of the study were:
- Clinically diagnosed T2DM patients already on insulin therapy
- Clinically diagnosed T2DM patients who are on oral therapy and have been advised insulin therapy.
- Age of the participants in the range of 20 to 55 years old.
Exclusion criteria were:
- T2DM respondents not consenting
- Patients not able to provide information example – mentally disabled patients.
The questions asked during the interview were as follows:
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