This study highlights the wide range of barriers to insulin initiation in Malaysia and provides an overview as to why the use of insulin remains low. What is remarkable is the similarity of the barriers encountered in a multicultural, Asian country to barriers reported in studies conducted in the West. A Pubmed search of qualitative studies which focus on barriers to insulin initiation identified eight studies from North American [25
], UK [27
], European [31
] and South African [32
] settings. Thematic consistency is apparent between these studies and our study, suggesting that these barriers are widely held ideas and that the results of this study are generalisable.
Studies on psychological insulin resistance amongst multi-ethnic populations have found that ethnicity is an important determining factor. Studies in the west have found that Hispanic and ethnic minorities are less willing to start insulin therapy [19
]. Reasons for this resistance include perceived lack of access to care and language barriers between healthcare provider and patient [34
]. Malaysian society consists of three main racial groups, each with distinct cultural practices and close-knit community structures. The healthcare professionals cited patients’ misconceptions of insulin as a major barrier. Our study identified three misperceptions that arise out of this multicultural setting: religious barriers, use of complementary medicines and lethal connotations about insulin.
The majority of Malaysia’s population are Muslim, in which the origin of food and products must comply to strict religious standards in order to be considered lawful (‘halal’). Healthcare professionals need to reassure Muslim patients that modern, synthetic insulin is not derived from a porcine source [36
], which is strictly forbidden except under emergency situations [37
]. Another concern for Muslim patients is the use of insulin during Ramadan, where the Muslims would be on a full-day fast from food and drink [38
]. Healthcare professionals (including non-Muslims) must be able to advise Muslim patients on appropriate insulin regimes during the fasting month of Ramadan [39
Patients’ preference to try out complementary therapies before insulin usage is often overlooked by the healthcare professionals in Malaysia. In a local study, the use of complementary therapies was prevalent among people with type 2 diabetes mellitus [40
]. Half of Malaysian patients with chronic diseases do not report their use of complementary therapy to their doctors or pharmacists [40
]. This is of concern as the use of traditional herbs has been identified elsewhere as a barrier to insulin therapy whereby patients were perceived to have more faith in herbs than in insulin [32
]. Increasing healthcare professional awareness on complementary and traditional therapies will help to reduce healthcare professionals’ anxiety in advising patients on the use of such therapies [41
]. Healthcare professionals need to play a more active role in asking their patients about their use of complementary therapies when initiating insulin [42
Patients often associate insulin usage with co-morbidities. Although it has been reported elsewhere that patients associate insulin with disease severity [25
], this misconception appeared to be more serious among the Malaysian patients who consider insulin to be lethal. Healthcare professionals should, therefore, address this misconception by counselling patients about the natural progression of diabetes at early stage of the illness. It should be emphasised to patients that early initiation of insulin helps to reduce morbidity and mortality. The myth about the association between insulin and advanced disease and deaths should be dispelled by providing accurate and timely information to the patients.
In this study, most system barriers are similar to those found elsewhere, including short consultation times, rapid staff turnover and lack of continuity of care [32
]. However, further matrix analysis of the data identified two issues which were only identified in healthcare professionals from the public healthcare system in Malaysia. Firstly, the lack of continuity of care is particularly problematic in the public healthcare setting due to fast turnover of doctors and patients not being given a choice on who they would like to consult. Continuity of family physician care in patients with diabetes is associated with better quality of life [44
], and lower mortality and hospitalization in elderly patients [45
]. According to Prochaska’s transtheoretical model [46
], insulin initiation requires patients to move from stages of precontemplation, contemplation and finally to action, with patients often cycling back and forth between these stages [47
]. Continuity of care would play an important role as healthcare professionals assess the stage of patient’s readiness to initiate insulin and customize a follow-up plan to help patients initiate and optimize the use of insulin [48
The language barrier was especially pressing in rural and semi-rural locations of the public healthcare system. Patients with limited language proficiency have problems with healthcare access, comprehension, adherence and receive lower quality of care overall [49
]. As a self-administered injection, insulin requires an understanding of injection techniques and self-titration. Thus, difficulty in communication during patient education still poses a substantial barrier to insulin initiation in Malaysia. Strategies to overcome language barriers in practice include employing a diverse healthcare workforce and using translation services when necessary [50
]. Preparing healthcare professionals to serve in diverse communities can be done by offering medical language courses in medical schools to help familiarise students with medical terminologies they will encounter in different communities [51
Both public and private healthcare professionals stated that the lack of resources was an important barrier to insulin initiation. Diabetes nurse educators are an important, but lacking resource for insulin initiation, with less than 600 diabetes nurse educators in the country serving a diabetes population of approximately 1.6 million [52
]. The cost and lack of availability of self monitoring of blood glucose (SMBG) contribute to patients’ reluctance to start insulin. Although the cost of insulin is subsidized in Malaysia, glucometers and test-strips are not. There is evidence to suggest that the frequency of SMBG is inversely related to out-of-pocket expenses [53
] and countries with the highest relative strip-cost have the lowest use of self-monitoring [55
]. Thus, one place to start is to look into providing patients with financial assistance to acquire glucometers and test-strips for SMBG as they are essential for monitoring the response to and side effects of insulin therapy.
Patients perceive that their diabetes is advanced once they are advised to start insulin therapy [19
]. This perception may stem from the healthcare professionals’ belief that insulin could only be started once the patients reach maximum numbers and doses of oral glucose-lowering drugs. Previous Malaysian CPGs recommended that insulin should only be considered in patients with poor glycaemic control after lifestyle modifications and maximum oral glucose-lowering therapy [56
]. In the latest CPG released in 2009, the recommendation has been changed and healthcare professionals are now advised to start insulin early, especially for patients who have poor glycaemic control at diagnosis. More research is needed on the prevalence of the ‘legacy effect’ of past guidelines and changes made from previous guidelines should be highlighted during the training and dissemination of new guidelines [57
The strength of this study lies in the fact that the sample encompassed all healthcare sectors and stakeholders who were involved in insulin initiation. We were thus able to gain an in-depth understanding of the barriers to insulin initiation from a wide range of perspectives. Analysis of barriers according to participant ethnicity did not reveal significant differences in terms of themes mentioned as healthcare professionals treat patients from various ethnicities and encounter a range of barriers in patients. However, participant responses highlighted the nature of culture-specific barriers as the examples provided were often specific to one culture, such as the names of traditional herbs.
There are a few limitations in this study. Only participants from three states (Kuala Lumpur, Selangor and Seremban) in Malaysia were included in this study. The culture of patients in other states, in particular the East coast of the peninsula and East Malaysia, might be different and hence the patients might face different barriers when starting insulin. This limits transferability. Future studies should include participants from other states of Malaysia. As sample size was determined by thematic saturation, the sample population was too small to be analysed according to healthcare professions. Lastly, only healthcare professionals’ perspectives were included for this study. However, this study forms part of a larger study and we are embarking on a study exploring patients’ views and perceived barriers to starting insulin. More research is necessary to explore the patients’ perspectives of insulin therapy. This will help substantiate the findings from this study and identify the needs of patients when starting insulin.