Healthcare professionals can foster timely insulin initiation by supporting patients with realistic, accurate perceptions of diabetes and its treatment from day one.
A recent study1 provides insights into some of the ways health professionals (HCPs) can encourage people with type 2 diabetes (TD2) to start insulin, given research shows that one quarter of adults with T2D are unwilling to so, even if they’ve been told to by a health professional. The phenomenon known as psychological insulin resistance (PIR) can result in delays in treatment and poor health outcomes for people with TD2, including the risk of developing or worsening long-term diabetes complications.2
EMOTION1 is a global study developed to identify strategies to overcome concerns about insulin in researchers looked at 38 strategies used by HCPs to encourage people to start insulin therapy. Dr Elemer Balogh and colleagues3 analysed survey data for 125 UK adults with T2D who were either “not willing’ or “slightly willing” to be begin insulin when first asked to do so by their health professional.
Their findings show:
- 84% of participants found that a demonstration of the injection process was helpful for starting insulin, including talking the patient through the entire process;
- 82% reported that their HCP highlighting the benefits of insulin—explaining that it is a natural substance the body needs—was helpful; and
- 81% reported that encouragement from their health professional to seek support and ask questions about injecting was helpful.
On the other hand, participants said an ‘authoritarian’ communication style, including repeatedly trying to convince them they should start insulin, made them feel less likely to do so, and to even discontinue use. This occurred in more than a third of patient encounters.
TABLE 1: HEALTHCARE PROVIDER ACTIONS THAT HELPED PARTICIPANTS MAKE THE DECISION TO GIVE INSULIN A TRY3
Helpfulness among patients with occurrence
Mean (1–4 scale of helpfulness)
% helped moderately or a lot
HCP walked patient through the whole process of exactly how to take insulin
HCP encouraged the patient to contact his/her office immediately if the patient ran into any problems or had questions after starting insulin
HCP showed patient an insulin pen
HCP helped patient to see how simple it was to inject insulin
HCP told patient that blood glucose numbers would improve after patent started insulin
HCP had patient try an injection himself/herself while patient was there in the office
HCP showed patient how small the actual needle was
HCP reviewed patient’s blood sugar numbers with the patient, showing the patient that his/her diabetes was not under control and that action was needed
HCP helped patient to see that an insulin injection wasn’t as painful as patient thought it might be
HCP told patient that starting insulin could help the patient to live a longer and healthier life
HCP told patient that starting insulin would help the patient to feel better
HCP gave an injection while patient was there in the office
HCP explained to the patient that the final decision to try insulin was patient’s, not his/hers
HCP took time to answer all the patient’s questions and address his/her concerns about insulin
HCP explained that insulin was a natural substance that the patient’s body needed
HCP helped patient to understand how insulin works in patient’s body to lower blood sugars and improve patient’s health
HCP explained that the patient might not have to take insulin forever
HCP warned patient that he/she was likely to develop complications if the patient didn’t get started soon with insulin to control his/her diabetes
HCP helped patient to understand that taking insulin didn’t have to be as much of a burden as the patient had feared
HCP encouraged patient to try it for a while and see if it might help the patient feel better
HCP reassured patient that taking insulin didn’t mean that diabetes was now a more serious condition
HCP reassured patient that taking insulin wasn’t going to cause complications, like blindness, kidney disease or a heart attack
HCP reassured patient that the risk of having a serious problem with hypoglycemia while taking insulin was low
HCP told patient that by going on insulin, he/she might soon be able to discontinue other diabetes medications
HCP helped patient get over his/her fears that others would treat the patient differently because he/she were taking insulin
HCP gave patient leaflets or other reading material about insulin
HCP took the time to ask the patient about the reasons why the patient did not want to take insulin
HCP helped patient to recognise that insulin was more natural than the pills the patient was taking
HCP told patient about all of the positives and negatives of insulin, and explained how the positives outweighed the negatives
HCP and patient talked about the real costs of insulin and insulin supplies and together figured out a way to make it more affordable
HCP said that the he/she could not continue to treat patient if the patient refused to start insulin
HCP warned patient that he/she could not be responsible for what might happen if the patient did not start insulin soon
HCP reassured the patient that he/she would help the patient avoid or minimise any weight gain because of taking insulin
HCP helped patient meet other people who had already been taking insulin for a while
HCP helped patient to realise that insulin wasn’t going to cost patient as much money as the patient feared it would
HCP told patient that he/she just needed to trust that the HCP knew best and that getting started on insulin was the patient’s best option
HCP referred patient to a class to help learn more about insulin
Repeatedly over many visits, HCP kept trying to convince the patient to get started on insulin
Making a difference to diabetes
Understanding the barriers to treatment intensification has been the focus of a research program run by Professor Jane Speight and Research Fellow Dr Elizabeth Holmes-Truscott at the Australian Centre for Behavioural Research in Diabetes (ACBRD). Working in partnership with Deakin University and Diabetes Australia, the ACBRD is the first national research and advocacy centre in Australia and internationally, dedicated to investigating the behavioural, psychological and social aspects of diabetes.
Dr Holmes-Truscott (pictured), who also co-ordinates the National Diabetes Services Scheme (NDSS) Starting Insulin (type 2 diabetes) National Priority Area,4 says many people for whom insulin is clinically indicated, are reluctant to begin for a variety of reasons.
“Our data5-10 shed light on the common experience of negative insulin perceptions among people with T2D and the impact of them on timely uptake and adjustments to insulin use. For example, in a sample of 313 Australians with non-insulin treated T2D9 we identified that negative attitudes are common and associated with greater emotional burden and negative attitudes to other medications. This suggests that identifying and addressing these issues early may help to improve receptiveness and adjustment to future treatment.
“Clinicians, including pharmacists, have a responsibility and a unique opportunity to start a dialogue about insulin, providing a chance for the person to raise their concerns and questions early.”
“In a primary-care based study10 of 261 adults with T2D, we identified that a quarter of adults, for whom insulin was clinically indicated, were “not at all willing” to start insulin if recommended while a fifth were “very willing”. Importantly, greater receptiveness—or willingness—and higher hbA1c predicted insulin initiation at 12 months.7 This suggests that interventions to promote timely insulin initiation must address psychological barriers to insulin and improve receptiveness,” Dr Holmes-Truscott tells the AJP.
“Recognising a significant problem, the NDSS launched the ‘Type 2 Diabetes: Starting Insulin’ priority area,4 led by Prof Speight—and we developed the freely available NDSS Starting Insulin booklet13 to support people interested in learning more about starting insulin and what it might mean for them. The booklet was designed to address psychological barries to insulin as well as support informed decision making,” she says.
The booklet was produced in consultation with adults with T2D as well as HCP advisors about its content and structure. “This process has helped us feel confident that it meets a need and is accessible to many Australians with T2D. We are also delighted to see a referral to the booklet in the RACCP clinical management guidelines and we’ve received feedback that health professionals are using the booklet during consultations.”
Addressing negative attitudes to insulin may also support optimal use of, and adjustment to, insulin beyond prescription, she adds.
“84% of participants found that a demonstration of the injection process was helpful for starting insulin, including talking the patient through the entire process.”
“Cross-sectional surveys of participants with insulin-treated T2D identified that negative perceptions remain common following insulin initiation and are associated with lower emotional wellbeing and self-efficacy, as well as higher perceived and experienced diabetes-related stigma.5,6 While our interview study8 of 19 people with insulin-treated T2D revealed both positive and negative consequences of ongoing insulin use. These included continued concerns about the potential or actual need to intensify treatment and its association with worsening health or personal failure. This research highlights the impact of psychological barriers to insulin beyond uptake and the need to identify and address ongoing, or new concerns throughout treatment progression.”
All HCPs have a role in this, she says.
“Each member of the HCP team plays an important role in fostering realistic and accurate perceptions of diabetes and its treatment. This starts from day one—communicating effectively and accurately during each consultation about the progression nature of diabetes and associated treatments. Clinicians, including pharmacists, have a responsibility and a unique opportunity to start a dialogue about insulin, providing a chance for the person to raise their concerns and questions early,” she says.
“It is important to normalise any concerns, provide a balanced response, and acknowledge that adjusting to new treatments can take time. There is no need to sugar coat it—we want to support people with T2D to make an informed decision about their treatment, and this, of course, means understanding both the risks and benefits.”
“A good place to start is by taking a look at the NDSS Starting Insulin booklet13 which includes responses to 11 frequently asked questions about insulin, drawing on salient psychological barriers to insulin.”
Having a keen interest in communication issues around diabetes, she believes the language we use when talking to and about people with T2D is critical.
“Language absolutely shapes our beliefs. From before diagnosis of T2D, how others—health professionals, media, family and friends—talk about diabetes can influence long-term perceptions of the condition, it’s treatment, and our own health identity. Early and ongoing education can foster realistic and clinically accurate perceptions of the role of insulin and the potential for changing treatment needs. Alternatively, inappropriate and inaccurate language can and does reinforce the perception that insulin, and other forms of treatment, are a merely consequence of an individual’s behaviour, for example. This stigmatising communication can be harmful,” she says.
Dr Holmes-Truscott has also undertaken research into other non-insulin injectable medications to see if similar negative attitudes and concerns exist.
“We’ve completed a novel interview study with people with T2D with recent experience of starting non-insulin injectable medication. We wanted to understand whether psychological barriers to insulin were similarly reported about other injectable diabetes medications. The findings will soon be published. In brief, participants reported that their initial perceptions of GLP-1RA injections were informed by their beliefs about insulin, including their concerns. However, many of these concerns were minimised following discussion with HCPs about the potential benefits of treatment or experience of such benefits.”
She also hopes the outcomes of her most recent research will be of benefit.
“We are also currently testing a novel online intervention11 to reduce psychological barriers to insulin therapy among people with T2D. Our pilot study12 revealed that the intervention was acceptable to participants. We now await results from a randomised controlled trial. If successful, we hope to make the intervention freely accessible in the future to support people with T2D starting insulin.”
To access the free NDSS ‘the free ‘Starting Insulin’ Booklet which can be downloaded or viewed online go to: https://www.ndss.com.au/about-diabetes/resources/find-a-resource/starting-insulin-booklet/.
The ACBRD has also developed a number of NDSS resources for people affected by diabetes and HCPs relevant to the behavioural and psycho social aspects of diabetes. For example, NDSS The Diabetes and Emotional Health Practical Guide, 2nd edition, 2020 (co-authored Prof Jane Speight) has been developed to support health professionals to identify, address and communicate about emotional problems during consultations with adults with type 1 and type 2 diabetes. It is complemented by a toolkit containing summary cards of several chapters, questionnaires, and leaflets for people with diabetes. To access a free electronic copy, go to: https://www.ndss.com.au/about-diabetes/resources/find-a-resource/diabetes-and-emotional-health/
- Polonsky WH, et al. Identifying solutions to psychological insulin resistance: An international study. J Diabetes Complications. 2019;33(4):307-14. doi: 10.1016/j.jdiacomp.2019.01.001.
- The Australian Centre for Behavioural Research in Diabetes. https://acbrd.org.au/
- Balogh EG, et al. Key Strategies for overcoming psychological insulin resistance in adults with type 2 diabetes: the uk subgroup in the EMOTION Study. Diabetes Therapy. 2020;11;1735-44. doi: 10.1007/s13300-020-00856-4.
- Speight J, Holmes-Truscott E (2017-2020). National Diabetes Services Scheme (NDSS): Type 2 Diabetes: Starting Insulin National Priority Area.
- Holmes-Truscott E, et al. Negative appraisals of insulin therapy are common among adults with type 2 diabetes using insulin: Results from Diabetes MILES—Australia cross-sectional survey. Diabetic Medicine. 2015;32(10):1297-1303. doi:10.1111/dme.12729.
- Holmes-Truscott E, et al. Diabetes stigma is associated with negative treatment appraisals among adults with insulin-treated type 2 diabetes: results from the second Diabetes MILES—Australia (MILES-2) survey. Diabetic Medicine. 2018;35(5):658-62. doi:10.1111/dme.13598.
- Holmes-Truscott E, et al. Predictors of insulin uptake among adults with type 2 diabetes in the Stepping Up study. Diabetes Res Clin Pract. 2017;133: 204-10. doi: 10.1016/j.diabres.2017.01.002.
- Holmes-Truscott E, et al. The impact of insulin therapy and attitudes towards insulin intensification among adults with type 2 diabetes: a qualitative study. J Diabetes Complications. 2016;30(6):1151-7.
- Holmes-Truscott E, et al. Explaining psychological insulin resistance in adults with non-insulin-treated type 2 diabetes: the roles of diabetes distress and current medication. Prim Care Diabetes. 2016;10(1):75-82. doi: 10.1016/j.pcd.2015.06.006.
- Holmes-Truscott E, et al. Willingness to initiate insulin among adults with type 2 diabetes in Australian primary care: Results from the Stepping Up Study. Diabetes Res Clin Pract. 2016;114:126-35. doi: 10.1016/j.diabres.2015.12.011.
- Holloway EE, et al. ‘Is Insulin Right for Me?’ Development of a theory-informed, web-based resource for reducing psychological barriers to insulin therapy among adults with type 2 diabetes. Australasian Diabetes Congress; 11-13 November; Online 2020.
- Holmes-Truscott E, et al. Feasibility and acceptability of a web-based intervention to reduce psychological barriers to insulin therapy among adults with type 2 diabetes: a two-armed pilot randomised controlled trial of ‘Is Insulin Right for Me?’. Australasian Diabetes Congress; 11-13 November; Online 2020.
- NDSS. Starting insulin, Version 2. Diabetes Australia, August 2020. https://www.ndss.com.au/wp-content/uploads/resources/booklet-starting-insulin-type-2-diabetes.pdf