Insulin therapy refusal among type II diabetes mellitus patients in Kubang Pasu district, Kedah, Malaysia

Abstract

INTRODUCTION Diabetes mellitus is a rising non-communicable disease in Malaysia. Insulin therapy refusal is a challenge for healthcare providers, as it results in delayed insulin initiation. This study was conducted to determine the prevalence of insulin therapy refusal and its associated factors. METHODSThis cross-sectional study was conducted at seven public health clinics in Kubang Pasu district of Kedah, Malaysia, from March to October 2012. A newly developed and validated questionnaire was used and participants were selected via systematic random sampling. Only patients diagnosed with type II diabetes mellitus (T2DM) and under the public health clinic care in Kubang Pasu were included in the study. Multiple logistic regression was used to study the association between insulin therapy refusal and its associated factors.RESULTS There were 461 respondents and the response rate was 100%. Among these 461 patients with T2DM, 74.2% refused insulin therapy. The most common reason given for refusal was a lack of confidence in insulin injection (85.4%). Multiple logistic regression revealed that respondents who had secondary education were 55.0% less likely to refuse insulin therapy than those who had primary education or no formal education (adjusted odds ratio [OR] 0.45, 95% confidence interval [CI] 0.25-0.82, p = 0.009). There was also a significant inverse association between glycated haemoglobin (HbA1c) level and insulin therapy refusal (adjusted OR 0.87, 95% CI 0.76-1.00, p = 0.047).CONCLUSION Insulin therapy refusal is common in Kubang Pasu. Educational status and HbA1c level should be taken into consideration when counselling patients on insulin therapy initiation.

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“…Unlike other studies, we found that participants with tertiary education were less willing to commence insulin compared to those with less education [9,23]. Participants with better educational backgrounds are expected to be more knowledgeable about diabetes and might therefore be more likely to accept the need to commence insulin.…”

“…The unwillingness to commence insulin therapy in this study was higher than that reported in the USA (28 and 33%) [20,21]. However, it is lower than those reported in different regions of Asia with the highest prevalence in Iran (77%), Malaysia (74.2%, 50.7%) and Singapore (70.6%) [9,23,24,31]. The differences in prevalence of unwillingness to begin insulin and the attitudes towards insulin therapy between countries may be related to cultural and health care system factors.…”

“…Not surprisingly, if patients believe that insulin will negatively impact their health, they may be more resistant to initiate insulin therapy [25]. Another contributing reason for this mistaken belief is due to a lack of diabetic education among Type 2 diabetes patients on the long term complications of diabetes [23]. Lifestyle adaptations and restrictions were also reported by our respondents as common negative attitudes to accepting insulin.…”

“…taking insulin can cause diabetic complications such as blindness), they may be quite wrong. The latter perception was also commonly found amongst Malaysian (72.2%) and Singaporean patients (54.5%) [9,23]. Patients link diabetic complications such as renal failure and blindness to insulin therapy rather than poor diabetes control [25,36,37].…”

“…Similarly, in one study in Bangladesh, 42.5% of these patients refused to start insulin therapy initially, with 20.3% refusing insulin use despite repeated counselling [22]. In another survey in Malaysia, insulin refusal was common in 74.2% of patients with Type 2 diabetes attending public health clinics; 85.4% of them cited lack of confidence in insulin injection as the most common barrier [23]. Similar results were obtained in a survey conducted among 265 Singaporean patients who attended a public primary healthcare centre.…”