EDITORIAL

Addressing Insulin Hesitancy in Primary Health Care

Diabetes is an ever-growing problem, with clinical as well as public health significance [1]. Despite advances in diagnostics and therapeutics, the outcome of diabetes management remains suboptimal. This, in part, is due to inappropriate communication between the healthcare profession and persons living with diabetes. Primary care is the foundation of health care [2] and is a major determinant of outcomes of secondary and tertiary care as well. A mutually respectful patient-provider-public relationship, based on the sharing of information, ensures agreement upon desired strategies, and achievement of relevant outcomes.

One important aspect of diabetes care, where such communication and collaboration are needed, is insulin usage. Though insulin is a life-saving drug, that has been in service for over a century, inertia and hesitancy toward its use are still common [3]. This may be because of an inadequate understanding of the rationale and benefits of its use. Such misunderstanding is common amongst both doctors and members of the public. The first step, therefore to addressing the issue of insulin inertia is to assess the perceptions of physicians and persons with diabetes towards insulin use.

Therapeutic inertia is defined by the American Diabetes Association as “a lack of timely adjustment to therapy when a patient’s treatment goals are not met” [4]. Insulin hesitancy is “the hesitation that a person living with diabetes (or his/her caregiver) experiences, when advised to take insulin” [5]. This person-centric, non- judgmental phrase does not criticise the person living with diabetes and encourages primary care professionals to view insulin acceptance in a person-friendly manner.

The Insulin Treatment Appraisal Scale (ITAS) was used to explore the attitudes of 264 persons living with type 2 diabetes towards insulin. This study was conducted in Karachi, Pakistan, and included persons from varied linguistic backgrounds. Negative perceptions, such as a feeling of failure, a fear of injections, the complexity of taking insulin, and a perception of disease progression, accompanied insulin in a high percentage of respondents. Positive perceptions such as insulin preventing complications, improving health, controlling

glucose, and enhancing energy, were less common. The authors highlighted the negativity associated with insulin use and identified a window of opportunity to enhance positive thoughts regarding the medication.

This understanding will help us plan effective strategies to improve insulin acceptance. Insulin education should begin at the primary care level and should focus on not only persons with diabetes but the public as well. Physicians should ensure that negative perceptions are dispelled, with easily understandable explanations, and positive perceptions strengthened, while they discuss and prescribe insulin.

International guidelines on injection technique allude to motivation for insulin [6]. Good quality Pakistani publications discuss ways of motivating patients to accept insulin as well [7, 8]. These should be translated and converted to practical modules which can be disseminated amongst primary care physicians as well. One should also focus on the unique religious, cultural, and commercial determinants of insulin perception in Pakistan. Using religion to promote acceptance of health care, inculcating a sense of social responsibility to enhance self-care, and minimizing the cost of drugs, will help increase acceptance of, and adherence to, insulin therapy.

We thank the authors for their well-conducted study and hope that this will promote insulin usage, and glucose control, not only in Karachi and Pakistan but across the world.

REFERENCES

diabetes.org/about-therapeutic-inertia. Accessed  23  February

2024