Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town

Abstract

Background. The majority of patients with type 2 diabetes mellitus in Cape Town who attend primary care community health centres (CHCs) have unsatisfactory glycaemic control. Insulin is rarely prescribed despite its being indicated for type 2 diabetic patients with inadequate metabolic control on maximum oral glucose-lowering agent (OGLA) therapy. Objective. The study examined barriers to initiating insulin therapy in poorly controlled type 2 diabetes patients on maximum OGLAs in CHCs in the Cape Town metropole. Methods. Five focus group discussions and 10 in-depth semi-structured individual interviews were conducted with 46 medical officers working at the CHCs. The discussions and interviews were transcribed and common themes were identified and categorised. Results. Doctor, patient, and system barriers to initiating insulin therapy were identified. Doctors’ barriers include lack of knowledge, lack of experience with and use of guidelines related to insulin therapy, language barriers between doctor and patients, and fear of hypoglycaemia. Patient barriers were mistaken beliefs about insulin, noncompliance, lack of understanding of diabetes, use of traditional herbs, fear of injections, and poor socioeconomic conditions. System barriers were inadequate time, lack of continuity of care and financial constraints. Conclusion. Suggestions for overcoming barriers include further education of doctors on insulin initiation and the use of standardised guidelines. In addition, a patient-centred approach with better communication between doctors and patients, which may be achieved by reorganising aspects of the health system, may improve patient knowledge, address mistaken beliefs, improve compliance and help overcome barriers. Further research is needed to investigate these recommendations and assess patients’ and nurses’ perceptions on initiating insulin therapy.