Article Figures & Data
Tables
- Table 1.
Demographics and Clinical Characteristics of Surveyed Adult Type 2 Diabetes Mellitus Patients Experiencing Psychological Insulin Resistance Before Regular Insulin Use, 2017
Characteristic Values by Location United States (n = 120) Canada (n = 74) Type of recruitment, n (%) Panel 83 (69.2) 60 (81.1) Health care provider referral 0 (0.0) 13 (17.6) Recruitment through Diabetes.co.uk 1 (0.8) 1 (1.4) TCOYD registry 36 (30.0) 0 (0.0) Age, mean (SD) 56.8 (10.9) 55.8 (10.2) Male, n (%) 35 (29.2) 47 (63.5) Ethnicity, n (%) United States Asian 5 (4.2) — Black/African American 6 (5.0) — Latino/Hispanic/Chicano 10 (8.3) — Non-Hispanic white/Caucasian 89 (74.2) — Multiple ethnic background 5 (4.2) — Other 5 (4.2) — Canada Canadian — 59 (79.7) English — 4 (5.4) French — 3 (4.1) Other — 8 (10.8) Bachelor’s degree (e.g., BA or BS) or higher education, n (%) 45 (37.5) 28.0 (37.8) Current employment status, n (%) Working full-time or part-time 52 (43.3) 37 (50.0) Not employed 18 (15.0) 10 (13.5) Retired 33 (27.5) 20 (27.0) Other 17 (14.2) 7 (9.5) Years since first diabetes diagnosis to basal insulin initiation, mean (SD) 9.8 (8.0) 8.9 (7.3) Year of first basal insulin use, n (%) 2015 47 (39.2) 26 (35.1) 2016 51 (42.5) 36 (48.6) 2017 15 (12.5) 11 (14.9) Prior use of injectable diabetes medications, n (%) 25 (20.8) 15 (20.3) HbA1c before starting insulin* HbA1c (%), mean (SD) 9.5 (1.9) 10.0 (2.8) Unknown, n (%) 40 (33.3) 29 (39.2) HbA1c at the time of survey* HbA1c (%), mean (SD) 7.9 (1.5) 7.5 (2.0) Unknown, n (%) 22 (18.3) 17 (23.0) BMI before starting insulin (kg/m2) Mean (SD) 35.5 (9.6) 30.6 (8.2) BMI at the time of the survey (kg/m2) Mean (SD) 34.6 (8.4) 30.2 (7.9) BA, Bachelor of Arts; BS, Bachelor of Science; BMI, body mass index; HbA1c, hemoglobin A1c; SD, standard deviation; TCOYD, Taking Control of Your Diabetes.
↵* Mean HbA1c was calculated among the patients who had a test in the past year and knew the test result.
- Table 2.
Thoughts and Feelings Right Before Taking Insulin for the First Time—Surveyed Adult Type 2 Diabetes Mellitus Patients Experiencing Psychological Insulin Resistance Before Regular Insulin Use, 2017
Thoughts and Feelings before Starting Insulin for the First Time, n (%) Agree/Strongly Agree Values by Location United States (n = 120) Canada (n = 74) Taking insulin would mean I had failed to manage my diabetes with diet and tablets. 102 (85.0) 58 (78.4) Taking insulin would mean my diabetes had become much worse. 103 (85.8) 47 (63.5) Taking insulin would help to prevent complications of diabetes. 80 (66.7) 53 (71.6) Taking insulin would mean other people would see me as a sick/sicker person. 60 (50.0) 30 (40.5) Taking insulin would make life less flexible. 80 (66.7) 49 (66.2) I was afraid of injecting myself with a needle. 74 (61.7) 41 (55.4) Taking insulin would increase the risk of low blood glucose levels (hypoglycemia). 42 (35.0) 33 (44.6) Taking insulin would help to improve my health. 78 (65.0) 53 (71.6) Insulin would cause weight gain. 51 (42.5) 29 (39.2) Managing insulin injections would take a lot of time and energy. 63 (52.5) 40 (54.1) Taking insulin would mean I would have to give up activities I enjoy. 31 (25.8) 25 (33.8) Taking insulin would mean my health would deteriorate. 34 (28.3) 24 (32.4) Injecting insulin would be embarrassing. 45 (37.5) 23 (31.1) Injecting insulin would be painful. 73 (60.8) 44 (59.5) It would be difficult to inject the right amount of insulin correctly at the right time every day. 55 (45.8) 39 (52.7) Taking insulin would make it more difficult to fulfill my responsibilities (at work, at home). 36 (30.0) 23 (31.1) Taking insulin would help to maintain good control of blood glucose (sugar levels). 81 (67.5) 54 (73.0) Being on insulin would cause family and friends to be more concerned about me. 70 (58.3) 40 (54.1) Taking insulin would help to improve my energy level. 32 (26.7) 34 (45.9) Taking insulin would make me more dependent on my doctor. 53 (44.2) 36 (48.6) Taking insulin might cause serious health problems, like blindness, kidney problems or amputations. 26 (21.7) 24 (32.4) Taking insulin would mean that my diabetes would become a much more serious disease. 64 (53.3) 40 (54.1) Taking insulin would mean that I had failed, that I hadn’t done a good enough job taking care of my diabetes. 95 (79.2) 51 (68.9) Taking insulin would cause me to lose my job. 14 (11.7) 16 (21.6) Taking insulin would mean that I would need to take insulin forever. 96 (80.0) 54 (73.0) ITAS Scores Total negative items ITAS*,†,‡, mean (SD) 54.2 (9.9) 53.1 (11.2) Total positive items ITAS*,†,§, mean (SD) 14.3 (2.1) 15.1 (2.8) Total ITAS*,†,‡,§,∥, mean (SD) 64.0 (10.5) 62.0 (11.4) ITAS, Insulin Treatment Appraisal Scale; SD, standard deviation.
↵* Agreement with statements was categorized as “strongly disagree” (corresponding to 1), “disagree” (corresponding to 2), “neither agree nor disagree” (corresponding to 3), “agree” (corresponding to 4), and “strongly agree” (corresponding to 5).
↵† ITAS scoring is based on Snoek et al.32
↵‡ Total negative ITAS score was calculated by averaging the level of agreement to responses of 16 negatively oriented survey questions.
↵§ Total positive ITAS score was calculated by averaging the level of agreement to responses of four positively oriented survey questions.
↵∥ Total ITAS score was calculated by averaging the level of agreement to responses of the negatively oriented and positively oriented survey questions. The values of the positive-oriented survey questions were reversed (5 = 1, 4 = 2, 3 = 3, 2 = 4, 1 = 5). Higher total ITAS score indicates more negative appraisal of insulin treatment.
- Table 3.
Patient Reaction When Health care Provider First Said It Was Time to Start Taking Insulin and Insulin Taking Behavior of Surveyed Adult Type 2 Diabetes Mellitus Patients Experiencing Psychological Insulin Resistance Before Regular Insulin Use, 2017
Patient reaction to the Initial recommendation for insulin by their HCP Values by Location United States (n = 120) Canada (n = 74) Level of surprise when HCP first said it was time to take insulin, mean (SD) 2.3 (1.0) 2.2 (1.0) Not surprised at all, n (%) 30 (25.0) 20 (27.0) Slightly surprised, n (%) 42 (35.0) 28 (37.8) Moderately surprised, n (%) 34 (28.3) 14 (18.9) Very surprised, n (%) 14 (11.7) 12 (16.2) Level of being upset when HCP first said it was time to take insulin, mean (SD) 2.8 (0.9) 2.6 (1.0) Not upset at all, n (%) 5 (4.2) 8 (10.8) Slightly upset, n (%) 46 (38.3) 27 (36.5) Moderately upset, n (%) 40 (33.3) 22 (29.7) Very upset, n (%) 29 (24.2) 17 (23.0) Health care professional that helped most in decision to try insulin, n (%) Primary care physician 72 (60.0) 26 (35.1) Nurse practitioner 11 (9.2) 3 (4.1) Physician assistant 5 (4.2) 6 (8.1) Medical assistant 1 (0.8) 1 (1.4) Endocrinologist 16 (13.3) 23 (31.1) Nurse 2 (1.7) 2 (2.7) Dietician 4 (3.3) 1 (1.4) Diabetes educator 4 (3.3) 12 (16.2) Other 5 (4.2) 0 (0.0) Time passed between HCP first recommended taking insulin and actually taking it regularly, n (%) I started taking it right away 62 (51.7) 32 (43.2) Less than 1 week 9 (7.5) 7 (9.5) About 1 or 2 weeks 10 (8.3) 7 (9.5) About 1 month 4 (3.3) 8 (10.8) 2–3 months 14 (11.7) 6 (8.1) 4–6 months 7 (5.8) 5 (6.8) 7–12 months 9 (7.5) 2 (2.7) More than 1 year 5 (4.2) 7 (9.5) Stopped insulin for period of 7 or more days since first starting insulin, n (%) 12 (10.0) 10 (13.5) During the first month after I first started taking insulin 2 (16.7) 3 (30.0) 1–3 months after I first started taking insulin 3 (25.0) 3 (30.0) 3–6 months after I first started taking insulin 0 (0.0) 2 (20.0) More than 6 months after I first started taking insulin 7 (58.3) 2 (20.0) HCP, health care provider; SD, standard deviation.
- Table 4.
United States Health care Provider Actions That Helped to Make the Decision to Give Insulin a Try—Surveyed Adult Type 2 Diabetes Mellitus Patients Experiencing Psychological Insulin Resistance Before Regular Insulin Use, United States, 2017
Description Patients with Occurrence (n = 120) Helpfulness among Patients with Occurrence n % Mean (1–4 Scale of Helpfulness*) % Helped Moderately or a Lot HCP walked patient through the whole process of exactly how to take insulin 91 (75.8) 3.19 (79.1) HCP encouraged the patient to contact his/her office immediately if the patient ran into any problems or had questions after starting insulin 99 (82.5) 3.14 (75.8) HCP showed patient an insulin pen 85 (70.8) 3.13 (74.1) HCP had patient try an injection himself/herself while patient was there in the office 47 (39.2) 3.13 (74.5) HCP told patient that starting insulin could help the patient to live a longer and healthier life 86 (71.7) 3.12 (79.1) HCP explained to the patient that the final decision to try insulin was patient's, not his/hers 72 (60.0) 3.10 (72.2) 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 106 (88.3) 3.08 (73.6) HCP helped patient to see how simple it was to inject insulin 80 (66.7) 3.01 (76.3) HCP warned patient that he/she was likely to develop complications if the patient did not get started soon with insulin to control his/her diabetes 85 (70.8) 3.00 (67.1) HCP told patient that blood glucose numbers would improve after patient started insulin 110 (91.7) 2.92 (70.0) HCP took time to answer all the patient’s questions and address his/her concerns about insulin 95 (79.2) 2.92 (65.3) HCP told patient that by going on insulin, he/she might soon be able to discontinue other diabetes medications 55 (45.8) 2.89 (63.6) HCP reassured patient that taking insulin was not going to cause complications, like blindness, kidney disease, or a heart attack 70 (58.3) 2.86 (62.9) HCP helped patient to see that an insulin injection was not as painful as patient thought it might be 68 (56.7) 2.84 (61.8) HCP showed patient how small the actual needle was 70 (58.3) 2.81 (62.9) HCP told patient that starting insulin would help the patient to feel better 100 (83.3) 2.81 (61.0) HCP explained that insulin was a natural substance that the patient’s body needed 93 (77.5) 2.81 (64.5) HCP helped patient to understand that taking insulin did not have to be as much of a burden as the patient had feared 91 (75.8) 2.79 (64.8) HCP gave patient leaflets or other reading material about insulin 74 (61.7) 2.77 (60.8) HCP helped patient to understand how insulin works in patient’s body to lower blood sugars and improve patient’s health 93 (77.5) 2.76 (63.4) HCP said that the he/she could not continue to treat patient if the patient refused to start insulin 21 (17.5) 2.76 (61.9) HCP reassured patient that taking insulin did not mean that diabetes was now a more serious condition 76 (63.3) 2.74 (56.6) HCP explained that the patient might not have to take insulin forever 69 (57.5) 2.72 (58.0) HCP told patient about all of the positives and negatives of insulin and explained how the positives outweighed the negatives 85 (70.8) 2.72 (62.4) HCP took the time to ask the patient about the reasons why the patient did not want to take insulin 74 (61.7) 2.72 (59.5) HCP and patient talked about the real costs of insulin and insulin supplies and together figured out a way to make it more affordable 51 (42.5) 2.67 (54.9) HCP encouraged patient to try it for a while and see if it might help the patient feel better 83 (69.2) 2.65 (54.2) HCP reassured patient that the risk of having a serious problem with hypoglycemia while taking insulin was low 74 (61.7) 2.65 (51.4) HCP reassured the patient that he/she would help the patient avoid or minimize any weight gain because of taking insulin 53 (44.2) 2.64 (54.7) HCP gave an injection while patient was there in the office 36 (30.0) 2.64 (55.6) HCP helped patient to recognize that insulin was more natural than the pills the patient was taking 60 (50.0) 2.63 (53.3) 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 69 (57.5) 2.62 (56.5) HCP helped patient get over his/her fears that others would treat the patient differently because he/she were taking insulin 52 (43.3) 2.62 (53.8) HCP helped patient to realize that insulin wasn’t going to cost patient as much money as the patient feared it would 57 (47.5) 2.60 (56.1) HCP helped patient meet other people who had already been taking insulin for a while 17 (14.2) 2.53 (52.9) Repeatedly over many visits, HCP kept trying to convince the patient to get started on insulin 60 (50.0) 2.47 (48.3) HCP referred patient to a class to help learn more about insulin 48 (40.0) 2.46 (39.6) HCP warned patient that he/she could not be responsible for what might happen if the patient did not start insulin soon 40 (33.3) 2.45 (42.5) HCP, health care provider.
↵* Level of helpfulness was scored on a scale of 1 (it did not help at all) to 4 (it helped a lot). Items that did not occur for patients were considered missing.
- Table 5.
Canadian Health care Provider Actions That Helped to Make the Decision to Give Insulin a Try—Surveyed Adult Type 2 Diabetes Mellitus Patients Experiencing Psychological Insulin Resistance Before Regular Insulin Use, Canada 2017
Description Patients with Occurrence (n = 74) Helpfulness among Those with Occurrence n % Mean (1-4 Scale of Helpfulness*) % Helped Moderately or a Lot HCP walked patient through the whole process of exactly how to take insulin 66 (89.2) 3.38 (83.3) HCP encouraged the patient to contact his/her office immediately if the patient ran into any problems or had questions after starting insulin 61 (82.4) 3.34 (82.0) HCP helped patient to see how simple it was to inject insulin 60 (81.1) 3.22 (76.7) HCP showed patient how small the actual needle was 51 (68.9) 3.22 (82.4) HCP told patient that blood glucose numbers would improve after patient started insulin 69 (93.2) 3.19 (78.3) HCP took time to answer all the patient’s questions and address his/her concerns about insulin 69 (93.2) 3.19 (81.2) HCP helped patient to see that an insulin injection was not as painful as patient thought it might be 54 (73.0) 3.19 (79.6) HCP gave an injection while patient was there in the office 34 (45.9) 3.15 (73.5) HCP explained that the patient might not have to take insulin forever 40 (54.1) 3.13 (77.5) HCP told patient that by going on insulin, he/she might soon be able to discontinue other diabetes medications 52 (70.3) 3.12 (71.2) HCP told patient that starting insulin would help the patient to feel better 65 (87.8) 3.11 (75.4) HCP showed patient an insulin pen 62 (83.8) 3.10 (74.2) HCP told patient that starting insulin could help the patient to live a longer and healthier life 64 (86.5) 3.09 (75.0) HCP explained to the patient that the final decision to try insulin was patient’s, not his/hers 57 (77.0) 3.09 (77.2) HCP helped patient to understand that taking insulin did not have to be as much of a burden as the patient had feared 68 (91.9) 3.07 (75.0) HCP had patient try an injection himself/herself while patient was there in the office 41 (55.4) 3.07 (75.6) 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 70 (94.6) 3.07 (78.6) HCP explained that insulin was a natural substance that the patient's body needed 67 (90.5) 3.04 (73.1) HCP encouraged patient to try it for a while and see if it might help the patient feel better 54 (73.0) 3.04 (77.8) HCP warned patient that he/she was likely to develop complications if the patient did not get started soon with insulin to control his/her diabetes 62 (83.8) 3.03 (71.0) HCP reassured patient that the risk of having a serious problem with hypoglycemia while taking insulin was low 62 (83.8) 2.97 (72.6) HCP reassured patient that taking insulin was not going to cause complications, like blindness, kidney disease, or a heart attack 51 (68.9) 2.96 (70.6) HCP and patient talked about the real costs of insulin and insulin supplies and together figured out a way to make it more affordable 41 (55.4) 2.95 (70.7) HCP took the time to ask the patient about the reasons why the patient did not want to take insulin 55 (74.3) 2.95 (67.3) HCP helped patient to understand how insulin works in patient's body to lower blood sugars and improve patient's health 62 (83.8) 2.94 (74.2) HCP reassured patient that taking insulin did not mean that diabetes was now a more serious condition 61 (82.4) 2.92 (65.6) HCP helped patient get over his/her fears that others would treat the patient differently because he/she were taking insulin 33 (44.6) 2.88 (75.8) 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 51 (68.9) 2.86 (62.7) HCP warned patient that he/she could not be responsible for what might happen if the patient did not start insulin soon 29 (39.2) 2.86 (69.0) HCP gave patient leaflets or other reading material about insulin 48 (64.9) 2.83 (62.5) HCP helped patient to recognize that insulin was more natural than the pills the patient was taking 50 (67.6) 2.82 (64.0) HCP told patient about all of the positives and negatives of insulin, and explained how the positives outweighed the negatives 60 (81.1) 2.82 (65.0) HCP reassured the patient that he/she would help the patient avoid or minimize any weight gain because of taking insulin 39 (52.7) 2.79 (59.0) Repeatedly over many visits, HCP kept trying to convince the patient to get started on insulin 37 (50.0) 2.76 (59.5) HCP referred patient to a class to help learn more about insulin 36 (48.6) 2.75 (58.3) HCP helped patient to realize that insulin was not going to cost patient as much money as the patient feared it would 41 (55.4) 2.71 (58.5) HCP said that the he/she could not continue to treat patient if the patient refused to start insulin 20 (27.0) 2.70 (70.0) HCP helped patient meet other people who had already been taking insulin for a while 20 (27.0) 2.30 (50.0) HCP, health care provider.
↵* Level of helpfulness was scored on a scale of 1 (it did not help at all) to 4 (it helped a lot). Items that did not occur for patients were considered missing.
