Open access Original research Key factors for overcoming psychological insulin resistance: an examination of patient perspectives through content analysis Heather Stuckey,1 Lawrence Fisher,2 William H Polonsky,3 Danielle Hessler,2 Frank J Snoek,4 Tricia S Tang,5 Norbert Hermanns,6 Xavier Mundet-­Tuduri,7 Maria Elizabeth Rossi da Silva,8 Jackie Sturt,9 Kentaro Okazaki ‍ ‍,10 Dachuang Cao,11 Irene Hadjiyianni,12 Jasmina I Ivanova,13 Urvi Desai ‍ ‍,13 Magaly Perez-­Nieves11 To cite: Stuckey H, Fisher L, Abstract Polonsky WH, et al. Key Objective To understand participant perceptions Significance of this study factors for overcoming about insulin and identify key behaviors of healthcare psychological insulin professionals (HCPs) that motivated initially reluctant What is already known about this subject? resistance: an examination ►► Actions of healthcare providers have a meaningful adults from seven countries (n=40) who had type 2 of patient perspectives impact on helping adults with type 2 diabetes over- through content analysis. diabetes (T2D) to start insulin treatment. Research design and methods Telephone interviews come psychological insulin resistance and initiate BMJ Open Diab Res Care were conducted with a subset of participants from an insulin treatment. 2019;7:e000723. doi:10.1136/ bmjdrc-2019-000723 international investigation of adults with T2D who were What are the new findings? reluctant to start insulin (EMOTION). Questions related to: ►► This study illustrates—from a patient’s perspec- (a) participants’ thoughts about insulin before and after tive—how healthcare providers can help alleviate Received 17 July 2019 initiation; (b) reasons behind responses on the survey that Revised 17 September 2019 reluctance to insulin initiation—by demonstrating were either ‘not helpful at all’ or ‘helped a lot’; (c) actions the insulin pen/needle as well as the actual injection Accepted 1 October 2019 their HCP may have taken to help start insulin treatment; process, explaining the benefits of insulin, using a and (d) advice they would give to others in a similar collaborative process of insulin initiation, and being situation of starting insulin. Responses were coded by two available for support. independent reviewers (kappa 0.992). Results Starting insulin treatment was perceived as a How might these results change the focus of negative experience that would be painful and would lead research or clinical practice? down a ‘slippery slope’ to complications. HCPs engaged in ►► These findings help healthcare providers to better four primary behaviors that helped with insulin acceptance: understand ways in which they can engage reluctant (1) showed the insulin pen/needle and demonstrated the people with type 2 diabetes with specific strategies. injection process; (2) explained how insulin could help with diabetes control and reduce risk of complications; (3) used collaborative communication style; and (4) offered support non-­insulin injectables, and insulin, in addi- and willingness to answer questions so that participants would not be ‘on their own’. Following initiation, most tion to lifestyle changes comprising healthy participants noted that insulin was not ‘as bad as they eating, exercise, and weight control.1 2 Because thought’ and recommended insulin to other adults with T2D. T2D is a progressive disease, over time, the Conclusions Based on these themes, two actionable effectiveness of oral medications and non-­ strategies are suggested for HCPs to help people with insulin injectables is no longer sufficient to © Author(s) (or their psychological insulin resistance: (1) demonstrate the provide glycemic control and hence insulin employer(s)) 2019. Re-­use injection process and discuss negative perceptions of needs to be initiated.3 Despite the demon- permitted under CC BY-­NC. No insulin as well as potential benefits; (2) offer autonomy in a strated efficacy of insulin in achieving commercial re-­use. See rights person-­centred collaborative approach, but provide support and permissions. Published adequate glycemic control and lowering the and accessibility to address concerns. These findings help by BMJ. HCPs to better understand ways in which they can engage risks of long-­term complications associated For numbered affiliations see reluctant people with T2D with specific strategies. with T2D,1 2 4–6 as many as 30% of people end of article. with T2D are reluctant to initiate insulin for a significant period of time (up to 2 years) after Correspondence to Background Dr Heather Stuckey; an initial recommendation to do so has been Treatments for type 2 diabetes (T2D) include ​hstuckey@​pennstatehealth.​ made by their healthcare provider (HCP).7 oral antihyperglycemic (OHA) medications, psu.​edu Numerous studies have examined this BMJ Open Diab Res Care 2019;7:e000723. doi:10.1136/bmjdrc-2019-000723 1 Clinical care/Education/Nutrition phenomenon, termed 'psychological insulin resistance' insulin use, and agreed to participate in the follow-­up (PIR)8–15 and have documented that initiation of insulin interviews. The details of the study have been described therapy is often delayed due to a variety of physician-­ elsewhere.19 Briefly, the study included adults with T2D related factors (eg, lack of time, lack of knowledge about who indicated an initial reluctance to beginning basal patients’ concerns about insulin, clinical inertia)11–13 as insulin treatment, but then eventually agreed to do so well as patient-­ related factors (eg, anticipated weight (within 3 years prior to survey completion). Adults with gain, fear of injections, feelings of personal failure).14–16 prior insulin use or a diagnosis of type 1 diabetes were Emerging research has suggested that HCP actions— excluded. Participants were recruited from seven coun- particularly those suggesting a collaborative approach tries (Brazil, Canada, Germany, Japan, Spain, UK, and tailored to the individual—have a meaningful impact on USA) through consumer panels, a diabetes registry, helping adults with T2D overcome PIR and initiate treat- diabetes website announcements, and physician referrals. ment.17–19 For example, in the multinational AccEpting All participants of the EMOTION study completed a Insulin TreatMent for Reluctant PeOple with Type 2 30 min online survey between January and August 2017 DIabetes Mellitus—A GlObal Study to IdeNtify Effective that, among other patient-­ related attributes, captured Strategies (EMOTION) survey—the source of informa- information about HCP statements and actions regarding tion for the present study—we found that HCPs who insulin initiation that may have occurred during medical are able to take the time to address injection concerns visits using a battery of 38 items included in the ‘PIR by showing and/or demonstrating the actual injection Action Survey’ (PAS). Each PAS item was rated on a process, explaining the benefits of insulin, and adopting 5-­point Likert scale: 1 (did not occur) to 5 (did occur, a collaborative, communication style are most likely to and helped a lot). On survey completion, a convenience help participants overcome PIR.19 The importance of sample approach was used to identify participants for the HCP interventions on compliance with insulin treatment present study based on the subset of the survey participants has also been evaluated previously. For example, a recent who agreed to be contacted for the follow-­up interview via multinational study among people with T2D using insulin phone. Participants were sent an informed consent form found that people whose physicians took time to commu- in their native language prior to the interviews and only nicate treatment goals experienced greater adherence participants who provided consent proceeded with the to insulin treatment.20 Similarly, the quantitative analysis interviews. The interviews were conducted in the local from the EMOTION survey found that participants whose language. Country representatives received training from HCPs took the time to explain the benefits of insulin and the lead qualitative investigator (Dr. Stuckey) for consis- dispel any myths around insulin were less likely to discon- tency of interview method across countries. All interviews tinue insulin for 7+days after initiation.19 were recorded and transcripts were translated in English The present study builds on this previous quantitative for coding purposes; participant identifying information research on how actions of HCPs can facilitate acceptance (eg, names) was removed from the transcripts. of insulin among people with PIR, but more importantly explores the personal experiences of adults with T2D Study procedures during the process of transitioning to insulin treatment. Telephone interviews were typically 45–60 min long, A better understanding of peoples’ perspective through during which participants were asked questions that key real life examples may help HCPs to successfully pertained to four primary areas of exploration: (a) partic- facilitate the difficult process of insulin initiation among ipants’ thoughts and perceptions about insulin before adults with T2D. Specifically, this study provides a deeper and after initiation and any related factors (eg, through understanding about perceptions about insulin before observation of other family members using insulin); (b) and after initiation as well as important patient-­reported reasons behind participants’ responses to the individual behaviors of HCPs that helped initially reluctant patients PIR Action Survey questions (eg, responses that were to start insulin. Information was gathered from explor- either answered on a particular end of the spectrum, as atory interviews conducted with a subset of participants in ‘not helpful’ or ‘helped a lot’); (c) other actions their from the aforementioned EMOTION study. Based on the HCP may have taken that convinced them to start insulin study findings, actionable strategies are suggested that treatment; and (d) what advice, if any, they would give to the HCPs can use to help patients through the insulin other people with T2D who may face a similar PIR. initiation process. Analysis Because there is little research on the experience of insulin Methods initiation in T2D from a patient’s perspective, we selected a Study design and sample modified grounded theory approach to analyze the qualita- Telephone interviews were conducted with a subset of 40 tive data.21 22 In the first phase of coding (emergent coding), people who completed a quantitative survey administered we marked conceptual labels on preliminary groupings of as part of the EMOTION study, an international inves- similar phenomena. In the second phase (axial coding), tigation focused on adults with T2D who initially expe- the primary investigators returned to the data to revise rienced significant PIR prior to the initiation of regular groupings and strengthen conceptual links (themes). As a 2 BMJ Open Diab Res Care 2019;7:e000723. doi:10.1136/bmjdrc-2019-000723 Clinical care/Education/Nutrition distribution of males (55%) and females (45%). Partici- Table 1 Demographic and clinical characteristics (n=40) pants had a mean (SD) of 11.2 (7.7) years since diagnosis Characteristic Total n=40 of diabetes to first basal insulin initiation. Mean HbA1c Country, n (%) (HemoglobinA1c) (SD) was reduced from time of insulin  USA 7 (17.5) initiation (9.9% (2.9%) or 84.7 mmol/mol (31.2 mmol/  Canada 9 (22.5) mol)) to current self-­reported levels (8.3% (2.7%) or  UK 9 (22.5) 67.7 mmol/mol (30.0 mmol/mol)). Table 2 describes the codes that were identified from  Germany 4 (10.0) reviewing the interview transcripts as responses to the key  Spain 3 (7.5) research questions. The codes were organized in chrono-  Brazil 2 (5.0) logical order, including (a) perceptions about insulin  Japan 6 (15.0) before initiation that may have contributed to PIR; (b) Age (years), mean (SD) 58.4 (9.9) HCP actions that were helpful (or not helpful) in insulin initiation; and (c) thoughts about insulin now, after initi- Male, n (%) 22 (55.0) ation. The range of responses, particularly related to the Education (years), mean (SD) 14.3 (2.5) HCP actions, were further categorized to identify unique Employment status at survey themes. completion, n (%)  Working full-­time 13 (32.5) Perceptions about insulin that Contributed to PIR  Working part-­time 5 (12.5) Not surprisingly, the key theme emerging from the  On sick/disability leave from work 3 (7.5) interviews regarding perceptions about insulin before  Not employed 4 (10.0) initiation was that participants had negative perceptions of going on insulin, including it would hurt, or would  Retired 15 (37.5) require more time and energy from their daily routines. Years since first diabetes diagnosis to 11.2 (7.7) To the participants, going on insulin meant they had basal insulin initiation, mean (SD) failed, and that they were not able to manage diabetes HbA1c (%) before insulin initiation, 9.9 (2.9) without injections. Even when they made adjustments in mean (SD)* their diet and tried to improve diabetes management, HbA1c (mmol/mol) before insulin 84.7 (31.2) they felt like they were not able to get their blood sugar initiation, mean (SD)* under control to avoid insulin. Going on insulin also HbA1c (%) current, mean (SD)* 8.3 (2.7) meant that they were at an end point, a ‘last straw’, and HbA1c (mol/mol) current, mean (SD)* 67.7 (31.0) that their condition was getting more severe or deteri- 2 BMI before insulin initiation (kg/m )/ orating. A main contributor to this perception was the Current BMI participants’ observation of the experiences of their  Mean (SD) 31.7/31.8 (7.8/7.0) family and friends who used insulin. For example, one  <18.5, n (%) 1/0 (2.5%/0.0%) participant noted that their neighbor used insulin and died, which led them to believe that insulin was ‘some-  18.5–24.9, n (%) 5/4 (12.5%/10.0%) thing meant only to delay the inevitable’. Another noted  25.0–29.9, n (%) 13/16 (32.5%/40.0%) that they had ‘grandmothers that were on insulin. Both  ≥30.0, n (%) 21/20 (52.5%/50.0%) of them were blind when they died.’ *Mean HbA1c was calculated among the patients with a self-­ reported known test result (n=23 before insulin initiation and HCP actions that helped overcome PIR n=29 for most recent result within a year before survey). A wide range of responses were elicited regarding the BMI, body mass index; HbA1c, Hemoglobin A1c; SD, standard behaviors of the HCP that helped initially reluctant deviation. adults with T2D to overcome their hesitancy. Participant responses broadly conformed to four themes, including: (1) HCP showed the insulin pen/needle and demon- part of the analysis, the study team developed the initial strated the injection process; (2) HCP explained how codebook for emergent coding, adjudicated by two inde- insulin could help with diabetes control and reduce pendent researchers (kappa=0.992) using Nvivo 10 PRO the risk of complications; (3) HCPs used a collaborative software. This analysis sought to identify commonalities communication style; and (4) HCPs were supportive and that existed within the entire sample rather than investi- accessible to answer questions so the person with T2D gating differences among countries. would not be on their own. Each is illustrated below. Results Theme 1: HCPs showed the insulin pen/needle and demonstrated Demographics and clinical characteristics of the 40 the injection process respondents interviewed are described in table 1. Mean Participants reported that the injection itself was often age (SD) was 58.4 (9.9) years, with a relatively even the biggest obstacle, and that injecting oneself was BMJ Open Diab Res Care 2019;7:e000723. doi:10.1136/bmjdrc-2019-000723 3 Clinical care/Education/Nutrition Table 2 Codebook used in qualitative analysis with codes associated with the research question (n=40) Primary code Secondary code # sources # quotes Negative thoughts PRIOR about going on insulin It would hurt OR don’t like needles 21 50 Would take time and energy 19 32 Diabetes is stigmatized or judged as bad by others 6 8 Weight gain 4 5 Would affect family negatively 4 7 Would cause me to lose my job or status in society 3 5 Was hesitant in general (no specific reason stated) 13 15 First reaction to going on insulin Fearful 28 53 Thought my health had gotten worse 21 27 Thought I had failed 18 28 Surprised 14 17 Sad 11 15 Not surprised 11 13 Friends or family member actions Knew other people on insulin 28 54 Friends or family provided support for insulin 14 29 HCP actions (positive) Said insulin would help with diabetes control 28 56 Established trust with me 26 65 HCP available for support or questions 22 41 Gave me injection in the office 21 36 HCP explained giving insulin was easy 19 32 Referred me to a specialist, endocrinologist, etc 17 25 Told me about the side effects of insulin (ie, 15 23 hypoglycemia) Honest about what could happen if I didn’t comply 13 26 Gave reading material about insulin 12 18 Shared decision making for going on insulin 9 16 Referred me to a diabetes education, nutrition class 7 9 HCP positives in general (not listed above) 11 14 Negative thoughts NOW about going on insulin Burden overall 21 49 Causes weight gain for me 12 14 More worry from friends and family 11 14 Causes hypoglycemia for me 6 7 Makes me feel different (ie, in society) 4 4 Positive thoughts NOW about going on insulin Helps me control my diabetes 31 57 Not as bad as I thought 28 72 Lifestyle hasn’t had to change much 16 25 Helps me feel better 11 13 Insulin is a natural substance for the body 8 10 Easy to take the right amount of insulin 7 8 Continued 4 BMJ Open Diab Res Care 2019;7:e000723. doi:10.1136/bmjdrc-2019-000723 Clinical care/Education/Nutrition Table 2 Continued Primary code Secondary code # sources # quotes Can look up information on my own about insulin 5 6 General (other) 17 27 Advice or helpful information to others going on insulin 24 41 Finances and cost Financial successes of insulin 30 41 Financial struggles of insulin 8 21 Finance insulin comments (in general) 7 11 HCP, healthcare professional. perceived as ‘horrible’ and ‘terrible’. To alleviate this used a collaborative approach to decision-­making. Their fear of needles, participants described how their HCP HCP told them that it was up to them; where they were explained that the needle was small and the pain, minor. not pushed into taking the medication, but that it was an Several people reported that their HCP injected the option and their choice, all of which helped the partici- needle (from an insulin syringe or an insulin pen), in the pants feel like they had a sense of autonomy in the deci- office and they did not feel any pain at all, which encour- sion to start insulin. aged participants to begin insulin treatment. The doctor could quite easily have said ‘you need to take The doctor brought a needle like the one that would be insulin now, here it is,’ but it wasn’t like that, it was I felt as used. I said ‘Wow, it is quite small and very thin’. So as though I was being consulted in the choice…I was led to soon as I saw the needle, I already accepted it more. I the choice that this was the best way forward … It wasn’t then did a test and I injected myself on the stomach. And a case of ‘you’re taking that’, it was to make sure I was when I did it, I said ‘Wow, I can’t feel anything’. comfortable with it before I started. It wasn’t rushed. I think that my doctor showing me in the office was a He [the HCP] wasn’t forceful and he left it with my big help … if I had to come home and do it without him willingness. It was like we both were thinking the same showing me, I would have been scared. thing at the same time… Theme 2: HCPs explained how insulin could help with diabetes Additionally, HCPs were reported to be willing to control and reduce the risk of complications engage in a dialogue with the participants, which helped An important HCP action to overcome insulin resistance them make an informed decision rather than just was telling their patients how insulin could help with following the direction of the HCP. Participants were diabetes control by lowering their HbA1c and reducing also grateful that they were not rushed into making a the chances of developing complications in the future. decision, and they reported having several discussions Some HCPs had expressed concern about the HbA1c with their HCPs around their treatment options before being too high and told participants that they needed a decision was made. One participant noted how his HCP the insulin to lower it. Some HCPs also mentioned other would explain how the pancreas worked and how the benefits of going on insulin, such as the reduction of the insulin-­producing cells were not working well enough. ‘burden on the body’, which would help people with T2D The insulin was giving a ‘wee gentle help’ and the image feel better overall. created for one participant was that of a ‘little old female insulin cell with a crutch’. This description helped the Basically what he said is, the only thing that’s going to allow participants feel confident in the HCPs’ recommenda- you to up your diet and the number of carbohydrates is tions. The quotes below further exemplify how the need you are going to have to lower your blood sugar and the only way you can do it is with insulin. to go on insulin was discussed collaboratively, and then a They mentioned the benefits. That it is good for my mutual decision reached: [overall] health, because of the high levels … and the use of insulin does not cause any complications … it was He said ‘you’ve done really well on the tablets, you’ve a sensible decision that I did not reject it … it also helped really worked at it, but it’s getting to the stage where it’s disperse my worries and fears. nothing you’re doing, it’s just how the diabetes is going He told me that taking insulin would be a good and maybe you need to have this to bring it back to where opportunity to give the liver and kidneys a rest [from the you can manage it’. So I actually said to them ‘I think other medication]. you’re right, I’m going to have to go down the insulin route’. After all, if such an understanding doctor suggested Theme 3: HCPs used a collaborative communication style insulin, you would accept it but on the other hand, if Several participants described how, even though their a doctor were demanding me to try harder, do this, do HCP recommended that they go on insulin, their HCPs that… That would make me think “Never!” BMJ Open Diab Res Care 2019;7:e000723. doi:10.1136/bmjdrc-2019-000723 5 Clinical care/Education/Nutrition Theme 4: HCPs were supportive and accessible to answer insulin treatment. One respondent’s sister asked them questions so people with T2D would not be on their own to not give up and to just ‘see how it works’, which also People with T2D said that it was good to know that HCPs helped them overcome PIR. would be there at any time if there were concerns or queries during the insulin initiation process, rather than Financial considerations needing to wait until the next appointment. It was reas- While some financial struggles with insulin were suring for participants to have a medical professional mentioned, generally, they were not a prominent factor at the end of the line, ready to answer questions. The in the decision to begin insulin use. While we do not know doctor’s or nurse’s availability showed support because it how many of these individuals had insurance or national reinforced that the participants were not on their own, healthcare plan coverage, many participants did note which helped to alleviate worry. One woman was unsure that they received free or reimbursed insulin, covered by of the process of giving insulin while at home, and she insurance, such as this woman: ‘The insulin…like I said, called her provider who walked her through the steps I never really know what it costs because I don’t have to several times until she was confident of the injection pay for that’. process. If the insulin dose was not improving blood Discussion sugar, some patients felt comfortable reaching out to Consistent with other research, this study found that their doctor and tell them they were struggling. The few adults with T2D who had PIR generally had negative minutes spent listening to patient concerns and asking perceptions about insulin.14–16 The key motivating factors ‘is this working for you?’ was helpful in feeling supported to eventual insulin acceptance and use were supportive through the insulin initiation process. actions taken by HCPs to provide a better understanding They have always been available by email or if I have of the injection process, the benefits about insulin, and needed to phone call. But I have emailed if I had any the collaborative and supportive relationship. Although questions or concerns and we have emailed back and this paper was completed independently from the forth. quantitative survey, the results are consistent with the The doctor was going to let me come in every day and EMOTION survey,19 as well as results reported by other have them help me through it. studies.17 18 20 Additionally, the qualitative study helps us understand the ways in which HCPs can engage in the Current participant perceptions about insulin specifics of these behaviors. These observations also align After participants had been using insulin, many of them with the most recent recommendations from the Amer- saw insulin as ‘no big deal’, and nearly all said that they ican Diabetes-­Association (ADA)/European Association would recommend insulin to others who needed it. They for the Study of Diabetes (EASD)2 for the management noted how taking insulin had become part of their life of hyperglycemia in T2D, underscoring the importance or an ‘old hat’, and the fear of the unknown had been of a personalized, patient-­centred approach. worse than the injection itself. One said after she got over Our study findings add to this literature by providing the ‘initial hurdle of ‘I’ve got to stick this in myself’, she a greater understanding of the drivers of patients' got used to it and it no longer was ‘as daunting as what perceptions about insulin and how it evolves over time. it used to be’. Another noted that although it may seem Of particular note is the role the HCP can play in the like a ‘massive thing’, after a while, ‘you do adapt to it; it’s eventual initiation of insulin. For example, more than not the end of the world, even though you often think it half of the adults had preconceived negative assumptions is’. One other participant offered the following advice to regarding the large size of the needle and the pain asso- other adults with T2D who may be facing a similar chal- ciated with taking the injection. These assumptions were lenge as he once did: subsequently dispelled when the HCP showed them the size of the needle and administered an injection in their It’s really easy to cope with it, and you will feel better and you will get your blood sugars down – you just own office. Similarly, through observations of outcomes have to be organized and make sure you take enough among other people using insulin, participants thought tests throughout the day to make a pattern of what’s that using insulin is associated with more complications. happening. You can correlate your blood sugar levels to However, they were pleasantly surprised when they saw what you’re eating to work on an informed basis and you the drastic reductions in their blood glucose levels after can go fine. And you will feel better and healthier. starting insulin and felt better overall. Based on these qualitative data and in line with the grounded theory approach, we outline a series of action- Additional considerations noted by the participants able HCP strategies that, as reported by participants, Two additional themes emerged from participant help with insulin initiation among adults with T2D who responses. initially demonstrate PIR. Friend or family member support Two actionable HCP strategies to help overcome PIR A few participants noted that receiving support from their 1. When recommending insulin therapy, HCPs should friends and family also helped them initiate and continue ask adults with T2D about their perceptions regarding 6 BMJ Open Diab Res Care 2019;7:e000723. doi:10.1136/bmjdrc-2019-000723 Clinical care/Education/Nutrition insulin and the injection process, and take necessary as the actual injection process, explaining the benefits actions to alleviate any concerns. of insulin, using a collaborative process of insulin initia- a. Many people with T2D generally have several false tion, and being available for support. Additionally, based assumptions about the injection process, such as in- on the study findings, two actionable strategies that the sulin needles are big and that they hurt. To alleviate HCPs can use to help patients through the insulin initia- such concerns, HCPs could ask questions such as, tion process are suggested: (1) discuss and alleviate nega- ‘What do you think about taking insulin injections? tive perceptions of insulin as well as discuss the potential What do you know about the size of the needle?’ benefits of insulin; (2) support autonomy using a person-­ They could show the pen/size of the needle and centred collaborative approach to treatment while also demonstrate the injection process to build compe- being available to address concerns. tency. b. Many people with T2D believe that beginning in- Author affiliations 1 sulin is a concrete indication that their diabetes is Pennsylvania State University, Hershey, Pennsylvania, USA 2 University of California San Francisco, San Francisco, California, USA getting worse and that complications are inevitable 3 Behavioral Diabetes Institute, University of California, San Diego, Del Mar, (the ‘slippery slope’). HCPs could ask questions California, USA such as, ‘How do you think going on insulin would 4 Amsterdam University Medical Centre Vrije Universiteit, Amsterdam, The affect your health? Worse? Better?’, and reassure Netherlands 5 them that insulin will most likely improve blood University of British Columbia, Vancouver, British Columbia, Canada 6 glucose and reduce the risk of complications. Diabet Acad Mergentheim FIDAM, Bad Mergentheim, Germany 7 Universitat Autonoma de Barcelona, Bellaterra, Spain 2. Support autonomy by using a collaborative communi- 8 Hospital das Clínicas da Faculdade de Medicina da USP, Sao Paulo, Brazil cation style to engage people with T2D in the decision-­ 9 King’s College London, London, UK making process, since ultimately it is their decision, 10 Nagoya University Graduate School of Medicine, Nagoya, Japan 11 and be available to address concerns as they transition Eli Lilly and Company, Indianapolis, Indiana, USA 12 to insulin. Lilly Deutschland GmbH, Bad Homburg, Germany 13 Analysis Group Inc Boston, Boston, Massachusetts, USA Once insulin therapy is initiated, continue discus- sions about their experience on insulin and share these Acknowledgements The authors thank Ariel Rokito, an employee of Analysis with other people with PIR to help them overcome the Group, Inc. at the time of the study for her support in conducting the data analyses. reluctance. Contributors HS contributed to study design, data collection and analysis, The results of this study underscore the importance of interpretation of results, and critical revision of the manuscript. UD contributed to understanding and addressing patient perceptions about data collection and analysis, interpretation of results, and drafting the manuscript. disease progression as well as insulin use early in the All other authors contributed to the study design and interpretation of findings, and critically revised the manuscript for important intellectual content. treatment process, and of providing a supportive envi- ronment to help facilitate insulin initiation. However, Funding Research funding was provided by Eli Lilly and Company, Indianapolis USA. this study should be viewed within the context of certain Competing interests HS, DH, FJS, XM-­T, and MERS have served as consultants limitations. Due to the small sample size, the interviewed for Eli Lilly and Company. WHP has served as a consultant for Eli Lilly, Novo participants may not be representative of all people with Nordisk, Sanofi, Astra Zeneca, Dexcom, Intarcia, Merck and Mannkind. LF has T2D who are reluctant to initiate insulin. For example, served as a consultant for Eli Lilly and Abbott Diabetes Care. TST has served as T2D is most prevalent among non-­White ethnicities23 24; a consultant for Eli Lilly and Omni Pod. JS has served as a consultant for Eli Lilly and Spirit Healthcare. NH reports grants and personal fees from Abbott, Berlin however, in this study, the majority of participants were Chemie, Ypsomed, Lilly, Dexcom and Roche. KO has served as a consultant for Eli Caucasian. Similarly, people volunteering to participate Lilly and Eli Lilly Japan K.K., ONO Pharmaceutical Co., Kowa Co., Sanwa Kagaku in research, and in particular those agreeing for in-­depth Kenkyusho Co., Mitsubishi Tanabe Pharma Corporation, ARKRAY Inc., Sanofi K.K., interviews following the initial online survey, may have a Abbott Japan Co., MSD K.K., Novartis Pharma K.K., Novo Nordisk, and Nippon Boehringer Ingelheim Co. DC is an employee of Eli Lilly and Company. IH and MP-­N higher literacy level than the overall T2D patients. Addi- are employees and stockholders of Eli Lilly and Company. UD is an employee of tionally, this study may be subject to limitations that are Analysis Group, Inc., a company that received funding for this research from Eli inherent to survey-­based studies (ie, self-­reported data for Lilly and Company. JII was an employee of Analysis Group, Inc. at the time of the past events may be subject to recall bias). However, given study. that the initiation of insulin is an important milestone in Patient consent for publication Not required. diabetes management, it is likely that people can accu- Ethics approval This study was performed in accordance with principles of the rately recall their experience and the events that aided Declaration of Helsinki. Regulatory approval for this study was provided by the their successful initiation. Future interventions could test Western Institutional Review Board (Puyallup, WA), Pennsylvania State University Hershey College of Medicine IRB (Hershey, PA) as well as Nagoya University IRB, the actionable strategies to reduce PIR and improve T2D Nagoya, Japan. outcomes in more diverse patient populations. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement No data are available as the information collected during patient interviews is considered confidential, and disclosure to third parties Conclusions is not permitted. The study illustrates—from a patient’s perspective—how Open access This is an open access article distributed in accordance with the HCPs can help to alleviate reluctance to insulin initia- Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which tion—by demonstrating the insulin pen/needle as well permits others to distribute, remix, adapt, build upon this work non-­commercially, BMJ Open Diab Res Care 2019;7:e000723. doi:10.1136/bmjdrc-2019-000723 7 Clinical care/Education/Nutrition and license their derivative works on different terms, provided the original work is 11 Nakar S, Yitzhaki G, Rosenberg R, et al. 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