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Cite this article: Alkhaifi M, Al Khusaibi G , Theodorson T, Ward MA, Al Mazrou’I A (2015) Barriers in Initiating Insulin Treatment in Type 2 Diabetes Mellitus among Physicians in Wilayat of Bowsher in Oman. J Family Med Community Health 2(3): 1034.

Abstract

Objective of the study: The goal of this qualitative study was to explore the barriers of initiating insulin for patients with Type II Diabetes among general practitioners and family physicians in primary care settings.

Method: This qualitative study was composed of 3 focus groups of General Practitioners and Family Physicians (n=18) who had experience in treating patients with type 2 Diabetes. A semi -structured questionnaire was used to guide the interview in 3 focus group discussions held over 3 consecutive days. The discussion was then transcribed verbatim and analyzed.

Result: Initiating insulin therapy was shown to be affected by physician, patient and system related factors. Each barrier was identified by highlighting the main categories. Physician factors which included physician knowledge, beliefs, fears and concerns. Patient factor included patient education, compliance and socio-economic status. System factors included short consultation time and lack of resources.

Conclusion: Overcoming barriers to the initiation of insulin therapy will require further education amongst physicians regarding insulin initiation and preferably the use of standardized guidelines. Moreover, patient education and awareness of the benefits of insulin in preventing diabetic complications is indicated. A patient-centered approach with improved communication between physicians and patients may improve patient knowledge, address misconceptions of insulin, improve compliance and help overcome barriers. This may be partly achieved by reorganizing aspects of the health care delivery system. Further research is needed to investigate these recommendations and to assess patients’ perceptions and systems- related factors on initiating insulin therapy.

*Corresponding authorMichael A. Ward, Department of Family and Community Medicine, University of Toronto, Canada, Email:

Submitted: 22 January 2015

Accepted: 01 April 2015

Published: 03 April 2015

Copyright© 2015 Ward et al.

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Keywords•Insulin barriers•Diabetes•Focus group•General practitioners

Research Article

Barriers in Initiating Insulin Treatment in Type 2 Diabetes Mellitus among Physicians in Wilayat of Bowsher in OmanMuna Alkhaifi1, Ghaitha Al Khusaibi1, Thord Theodorson1, Michael A. Ward2,3* and A. Al Mazrou’I4 1Department of Family and Community Medicine, Sultan Qaboos University, Oman 2Department of Family and Community Medicine, University of Toronto, Canada 3Department of Family Medicine, Queens University, Kingston, Canada 4Department of Internal Medicine, Sultan Qaboos University, Oman

INTRODUCTIONThe incidence of diabetes is increasing globally. Twenty years

ago 10 percent of Omani adults were suffering from diabetes mellitus and a similar proportion had impaired glucose tolerance. A more recent National Health Survey (2000) has shown diabetes to have increased significantly to 11.6%. [1] Currently, a substantial proportion of the Ministry’s budget is spent on chronic disease management including diabetes mellitus and its cardiovascular and renal complications. This puts Oman’s health care system at a crossroads. One of the challenges to this

objective was integrating and improving the quality of health care provided to people with diabetes [1].

Good glycaemic control in people with type 2 diabetes is known to reduce the risk of micro vascular events. Insulin is the most effective therapy to lowering blood sugar in these patients. Due to the progressive nature of type 2 diabetes, many people with type 2 diabetes will require insulin therapy to maintain adequate glycaemic control [2-4]. Unfortunately, in clinical practice, insulin is often not initiated early enough in the disease process. This is due to many factors, including physician, patient and system related barriers.

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The glycaemic burden associated with not initiating insulin therapy appropriately may lead to an increased risk of microvascular and macrovascular complications [4,5]. In addition, poor control of diabetes may result in patients becoming frustrated with their efforts to control their glucose levels leading to reduced motivation and less active self-care and management [5]. Furthermore, poor glycaemic control may exacerbate co-morbid depression. Clearly there is a need to reduce concurrent delay in insulin initiation to optimize glycaemic control.

STUDY METHODSThree focus group discussions were conducted, in the

directorate of primary care services in Wilayat of Bowsher, with Medical Officers (MO) and family medicine specialists (Table 1) who are attending Health centers. The discussions were tape recorded and transcribed verbatim. Written informed consent from participants and approval from the Ethics Committee of Sultan Qaboos University and Ministry of health Muscat were obtained. The data were collected on 29, 30 and 31st of December 2012.

Sample

18 physicians were recruited from four health centers in Wilayat of Bowsher. Each health centers runs a diabetic clinic 5 times / week. The physicians had been practicing for five to ten years and they each reviewed a minimum of five diabetic patients / per day (Table 1).

These physicians were categorized as medical officers, senior medical officers, family medicine specialists and senior family medicine specialists depending on their experience (Table 1).

Focus groups

Twenty one physicians were contacted and invited to participate. Eighteen agreed resulting in six participants in each of three groups. An interview guide was developed based on literature review and clinical knowledge and included questions on [16,15]: (i) physician’s knowledge, (ii) concerns and fears about initiating insulin therapy; (iii). Whether patient awareness of insulin therapy, compliance and low social economic status will have impact on insulin initiation iv) whether health system factors have an impact on insulin initiation (Table 2). The discussion for each group lasted for fifty to sixty minutes.

Data analysis

All focus groups were audio-taped and transcribed verbatim. Using the strategy of constant comparison analysis, the transcripts were examined independently by the two main two main investigators [15,16]. Researchers familiarized themselves with the data by reading and re-reading the transcripts. They coded two transcripts independently and identified the key words, phrases and concepts in each group. Subsequently, similarities and potential connections among key words and concepts among each of the focus groups were determined by team analysis. Transcripts were manually coded and the items were categorized using Microsoft Excel spread sheets. The coding was then compared for inter-rater consistency and any coding discrepancies were resolved by discussion until consensus was reached on the list of notes (themes) and coding descriptions.

The Final stage of analysis involves comparing the central themes identified across all the focus group. This allowed for the identification of relationships or patterns between and among the central themes (physician related factors, physician related factors and system related factor). Though out the process, the researchers attended to personal and professional biases that operationally could have influenced the interpretation of the data.

RESULTS

Physician related factors

During our discussion with the focus group of physicians, most of them agreed strongly that proper protocols on starting insulin therapy were not available. Some adamant that there is no clinical audit performed for physicians which lowers their confidence in starting insulin treatment for patients. Many other factors such as physicians’ fears and concerns were mentioned.

Characteristic Number (n= 18)

Age

23-35 yr36-45 yr46-55 yr>55 yr

01611

Sex

Female Male

180

Professional background

Medical officer S. Medical office Family medicine specialist Family medicine S. specialist

4707

Years of Experience

< 5 years 5- 10 years > 10 years

16

11 Number of patient seen/ day

< 5 pt5- 10 pt> 10 pt

03

15

Table 1: Principal characteristics of participating GPs.

• Do you think that there is a delay in initiating insulin in type 2 DM in your clinical practice?

• What are your fears and concerns of starting treatment with insulin in Type 2 DM?

• Do you think that there is a gap between knowledge and clinical practice in starting insulin?

• Is patient compliance effect your decision in starting insulin?• Is the health system in primary care In Oman is effecting your decision in

initiating insulin therapy?• Is the system helps you in the continuity of care and follow up? • Is socio-economic effect your decision in starting insulin therapy?• What is the major barrier among the one we discuss u think that if we

improve it, it will change the clinical practice dramatically?

Table 2: Arriers to insulin initiation interview/focus group guide.

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Below is the summary of representing physicians’ knowledge and beliefs about insulin therapy.

Physician knowledge and beliefs

Many participants agreed there is a knowledge gap and lack of confidence related to inexperience in initiating insulin therapy. They also agreed that there are no guidelines in primary care sectors to help them make appropriate decisions regarding starting insulin therapy. Some mentioned that they have no idea when and how to determine start times for insulin therapy. The lack of internal or external auditing was cited as an ongoing concern; most of the respondents felt an active audit program might help with quality improvement in regards to their insulin use and knowledge.

One of the medical officers (MO) interviewed did not fully understand the benefit of starting insulin therapy in patients with type 2 DM. This physician did not agree with the fact that her patients would have to inject themselves with insulin, so she prefers to keep them on oral hypoglycemic (OHG) agents.

Physician fears and concerns

Most of the physicians were reluctant to initiate insulin therapy because they feared complications of insulin, mainly the risk of hypoglycemia. Physicians also had concerns with starting insulin in elderly patients, who do not have assistance with care provided at home ”most of the elderly have low vision and injecting themselves with the correct does is difficult for them especially when there is no social support provided for them”. Not all physicians comfortable with the responsibility of initiating insulin and preferred that a more senior physician or specialist make that decision for them.

Some physicians mentioned their concern about patient’s individual knowledge regarding insulin therapy and their worry that individuals in the local community may misinform their patients and derail the attempts at initiating therapy. For

example, patients may be told by a relative or friend not to start on insulin therapy because it will cause weight gain or perhaps insulin usage signals an end-stage disease process. Other stories include not taking insulin if you have a diabetic foot as it may increase the risk of amputation.

Patient related factors

All physicians agreed and stated jointly their belief that the patients are the main barriers for them in starting insulin therapy. Many of them mentioned the education level of patients which makes it difficult to start insulin therapy.

Some of the doctors voiced with emotion and concerns that they are reluctant to start insulin due to low socio- economic status of some patients and lack of a good care provider, especially for older adults.

Patient education

Lack of health education is a significant issue that all physicians agreed on. This lack of knowledge is a barrier to starting insulin in these patients

The group also expressed concerns that patients and their families may hold widespread beliefs and fears about insulin that have no basis in truth. For example, many patients believe that insulin is only used by doctors when their Diabetes has progressed to the end stage and where there is no other hope for cure for them. The physician group report similar stories of family members and friends convincing their patients to stop their insulin for fear of bad outcomes/complications.

Patient compliance

Many physicians stated that most of the patients do not take their disease seriously. They felt that oral hypoglycaemic agents should be enough to keep this group of patients under control.

There were examples of patients being offered insulin to help control their DM only to leave the particular doctor or clinic and attend another who was willing to keep them on the OHG agents; this was clearly seen as a barrier to starting insulin.

They also agreed on that many patients have needle phobia and that they may refuse to take injections in this regard.

The patient’s occupation also was a big issue in starting a patient on insulin therapy. One of the physicians stated that ‘Male patients who works in fields like and the desert are not compliant with this treatment due to longer hours at work and irregular meal times”.

Patient socio-economics

Physicians agreed that patients with poor socio-economic status will have more concerns about starting treatment with insulin. Some physicians stated that ‘Patients with low socio-economic are difficult to consider for insulin therapy as they will not be able to take care of themselves due to limited financial support, irregular meals, and may not be able to have a place to refrigerate their insulin’.

More over; this group of patients may not able to control their sugar due to difficulties in acquiring blood glucometers and

Physician barrier Lack of confidenceLack of knowledgeFear of complication Lack of training ( workshops)

Patient barrier Lack of education and awareness Patient stigma Misconception about insulin Insulin addiction Insulin is lethal Negative influence from family and friends Low socioeconomicPatient occupation Lack of health care provider for elderly pt

System barrier Lack of resourcesLack of continuity of careShort consultation time Lack diabetic team

Table 3: Barriers to insulin initiation faced by wilayat of Bowsher Health center’s physicians.

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strips. They are costly and are not available in our primary sectors making it difficult to maintain insulin treatment.

System barriers

Participants identified various system related barriers, including short consultation times, lack of continuity of care, busy health centers and lack of availability of clear guidelines. In addition, there is a lack of different insulin modalities, (insulin pens for example) which would make insulin treatment perhaps easier.

DISCUSSIONThis study identifies a wide range of barriers to insulin

initiation in Oman and provides an overview as to why the use of insulin remains low. It identifies numerous doctors, system and patient related barriers to the initiation of insulin therapy. Many of the themes identified were similar to the barriers to optimal diabetes care documented in other countries. What is remarkable is the similarity of the barriers encountered in a multicultural, Asian country to barriers reported in studies conducted in the West. A Pubmed search of qualitative studies which focus on barriers to insulin initiation identified eight studies from South African [24], UK [19-22], North American [17,18] and European [23] settings. Thematic consistency is apparent between these studies and our study, suggesting that these barriers are widely held ideas and that the results of this study are generalisable.

The most important barriers addressed by the physician in starting insulin therapy were the patient barriers. Lack of health education and misconception about insulin is the biggest issue. It appears that patients believe that insulin is the last thing a doctor should think of, because it means that the disease has come to the end and that there is no other cure for them. This could be due to the low educational level of the patients and/or lack of health education in the diabetic clinics.

In our study, negative community effect and social stigma were considered as barriers which were not mentioned clearly in other studies [17-30]. Patients might be told by a relative or friend not to start on insulin therapy because it will cause weight gain or it means that all diabetes complications have occurred, (for example diabetic foot and that they will end up with leg amputation). Sometimes patients take their opinions seriously which will delay starting them on insulin. This can be overcome by addressing the patients concerns and providing them with proper resources.

There was a strong perception that poor socio-economic conditions impeded patients’ compliance with treatment. Lack of refrigerators to store insulin and inability of patients to afford blood glucose meters was cited as a barrier. Moreover, participant’s perception of lack of patient compliance was an issue, as adherence with current treatment may obviate the need for insulin. Patient adherence with therapy is a complex issue, but the manner in which diabetes care is structured, delivered, and financed is likely to have a major impact on the ability of patients to manage their diabetes. Moreover, patients’ needle phobia, patient’s’ occupation and patients’ belief and concerns play a role in delaying the process of starting insulin. Regardless of the cause of non-compliance, the MOs’ understanding of an effective

action to improve adherence needs to be greatly improved. Good communication and mutual decision making between doctor and patient are likely to improve adherence to a regimen.

Physician barriers also included lack of confidence, knowledge, guidelines, and fear of hypoglycemia. Lack of confidence is one of the most commonly mentioned barriers; some physicians interviewed had no idea of when to consider insulin therapy and the proper administration of insulin. Moreover, participants identified that the last update of diabetic care guideline in Oman was in 2003. Some found that it not evidence-based and did not include clear instructions on how and when to initiate insulin. This uncertainty with no clear policy makes them reluctant to start insulin. Clearly, great attention needs to be focused on ensuring consensus when such documents are developed; they must address the need for further auditing, education and training required in diabetic care. The physician’s’ fear of inducing hypoglycemia with insulin therapy is also understandable, particularly in elderly. There are concerns with starting insulin in the elderly who do not have a reliable care provider and where there may be a fear of poor compliance. However hypoglycemia is preventable through patient education and cautious prescribing by the practitioner (starting with low-dose insulin).

In this study, most system barriers are similar to those found elsewhere [8-10], including short consultation times, lack of continuity of care, clear guidelines and proper resources. However, further matrix analysis of the data identified two important issues which were more often identified in our primary healthcare as viewed by the health care professionals involved in this study. Firstly, the lack of different types of insulin (pen or injections) and oral hypoglycemic medications available limiting physician and patients choices to select the most suitable methods for them.

Second, the lack of continuity of care is particularly problematic in the primary health care setting in Oman due to frequent turnover of doctors. Continuity of family physician care in patients with diabetes is associated with lower mortality and hospitalization in elderly and an overall improvement in patient’s quality of life [11,12].

According to Prochaska’s trans-theoretical model [31], insulin initiation requires patients to move from stages of pre-contemplation, contemplation and finally to action, with patient’s often cycling back and forth between these stages. Continuity of care would play an important role as healthcare professionals assess the stage of patient’s readiness to initiate insulin and customize a follow-up plan to help patients initiate and optimize the use of insulin [32-33].

Several recommendations were mentioned by the participants in each group to overcome the barriers to initiation of insulin therapy in poorly controlled diabetic patients on oral medication in primary health care in Oman. Developing uniform and practical guidelines by experts in the field, with the active participation of primary health care professionals would be of value. Interactive workshops in which these guidelines are introduced and problems discussed at subsequent meetings should be an integral part of an effective implementation strategy. The introduction of an effective district nursing service would

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help in the follow up of elderly and disabled patients who cannot attend a health center regularly. A patient-centered approach may be useful in improving adherence. Improved training of nursing staff in the technique of insulin injections, monitoring, identifying and treatment of hypoglycaemia, and methods to provide patient education and involve family members would be essential.

Some motioned that organization of the health system in Oman also requires change. It would be useful to establish an appointment system for the attending physician that allows for continuity of care. Providing insulin pens, different types of insulin and hypoglycemic medications (example sitagliptin) may help in managing the patient’s illness. Increase in the consultation time and a decrease in patient turn over would provide more time for counseling and DM education which would ultimately help in the patient’s quality of care, increase patient’s level of understanding and, ultimately, improve compliance.

CONCLUSIONPrevious research revealed numerous barriers to insulin

initiation at the level of provider, patient, and healthcare organizations. However our research has revealed that the patient’s individual barriers are the most commonly addressed by the physician group we interviewed. Patient education and awareness of insulin benefits in preventing further diabetic complications was the most important factor we have discovered. Strong emphasis should be placed on patient education and counseling in the primary health care system. Moreover Physicians should improve their knowledge regarding insulin initiation/use I the hopes of overcoming their fears and concerns. Our research suggests that training physicians more thoroughly in regards to insulin management increasing access to physicians through booking processes that allow appropriate time for assessments, and developing polices and guidelines for diabetes management, will help achieve better outcomes for our diabetic population. Systematic improvement including provision of insulin pens in our health care centers, establishment of an appointment system and promoting continuity of care would also be of value.

LIMITATION OF THE STUDYThis study addresses barriers to insulin initiation form a

physician perspective which may well be different than a patient’s perspective. Further research is needed to investigate these recommendations and to assess patients’ perceptions of barriers to insulin initiation. Moreover, all physicians interviewed were female which may add some level of bias to our conclusions.

ACKNOWLEDGEMENT We would like to acknowledge the following for help:

Dr Badryia Alrashdi head of directorate of health services in Wilayat Bousher for her kind cooperation with our research, and all physicians who contributed both for their time and their experience.

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Alkhaifi M, Al Khusaibi G, Theodorson T, Ward MA, Al Mazrou’I A (2015) Barriers in Initiating Insulin Treatment in Type 2 Diabetes Mellitus among Physicians in Wilayat of Bowsher in Oman. J Family Med Community Health 2(3): 1034.

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