Key Strategies for Overcoming Psychological Insulin Resistance in Adults with Type 2 Diabetes: The UK Subgroup in the EMOTION Study.

INTRODUCTION: Many patients with type 2 diabetes mellitus (T2DM) delay initiation of insulin therapy despite healthcare professional (HCP) advice. This phenomenon has been referred to as 'psychological insulin resistance' (PIR), and various contributing factors have been identified. Studies discussing approaches to overcoming PIR are lacking. Our aim was to identify the key strategies used by HCPs that most helped adults with T2DM and PIR in the UK to initiate insulin. METHODS: As part of a global study, UK adults with T2DM and PIR were recruited (N = 125) to take a survey that included 38 HCP statements and actions about insulin initiation. Data assessed were perceived occurrence and helpfulness of these strategies in facilitating insulin initiation. RESULTS: The most helpful strategies involved demonstrating the injection process (e.g. HCP talked patient through the process of taking insulin [83.6%]) and adopting a collaborative approach (HCP encouraged patient to contact the clinic immediately in case of any problems/questions [80.5%]). Additionally, HCPs highlighting the benefits of insulin (HCP explained that insulin was a natural substance needed by patient's body [81.2%]) and allaying patients' concerns (HCP explained that patient might not have to take insulin forever [78.0%]) helped patients initiate insulin. The least helpful action was HCPs repeatedly persuading patients to initiate insulin (40.9%). CONCLUSIONS: The study recommends key strategies that HCPs can adopt to help adults with T2DM overcome PIR in the UK.

Many patients with type 2 diabetes (T2DM) are reluctant to start insulin therapy despite it being recommended by their doctor. This can lead to a delay in receiving effective treatment to control blood sugar. There are many reasons to explain this reluctance­which is also referred to as psychological insulin resistance (PIR)­including fear of injections and lack of understanding. EMOTION was a global study which set out to identify strategies to overcome PIR. It looked at 38 things, identified by people with diabetes, that doctors/nurses can do or say to encourage a patient to try insulin. Analysis of results for the 125 UK patients with T2DM who were reluctant to start insulin showed that the most helpful approach was demonstrating the injection procedure. Actually talking a patient through how to inject insulin and demonstrating how the pen works can help reduce their fears about the injection process. Adopting a collaborative approach was found to be important, encouraging patients to get in touch with any problems or questions. Other helpful strategies included highlighting the benefits of insulin­explaining that it is a natural substance the body needs­and addressing any specific concerns a patient may have about insulin. The least helpful strategy was taking an authoritarian approach and repeatedly trying to persuade a patient to start insulin. This is the first study which provides evidence-based clinical strategies that UK healthcare professionals can use to help overcome PIR in their patients with T2DM.

A cross-sectional survey of general practice health workers' perceptions of their provision of culturally competent services to ethnic minority people with diabetes.

AIMS: To explore General Practice teams cultural-competence, in particular, ethnicity, linguistic skillset and cultural awareness. The practice teams' access to diabetes-training, and overall perception of cultural-competence were also assessed. METHODS: A cross-sectional single-city-survey with one in three people with diabetes from an ethnic minority group, using 35 semi-structured questions was completed. Self-reported data analysed using descriptive statistics, interpreted with reference to the Culturally-Competent-Assessment-Tool. RESULTS: Thirty-four (52%) of all 66 practices in Coventry responded between November 2011 and January 2012. KEY FINDINGS: (1) One in five practice staff was from a minority group in contrast with one in ten of Coventry's population, (2) 164 practice staff (32%) spoke a second language relevant to the practice's minority population, (3) 56% of practices were highly culturally-competent at providing diabetes services for minority populations, (4) 94% of practices reported the ethnicity of their populations, and (5) the most frequently stated barriers to culturally-competent service delivery were language and knowledge of nutritional habits. CONCLUSIONS: Culturally-competent diabetes care is widespread across the city. Language barriers are being addressed, cultural knowledge of diabetes-related-nutrition requires further improvement. Further studies should investigate if structured cultural-competence training for diabetes service providers produces positive effects in diabetes-related outcome-measures in minority populations.

Influence of primary care practices on patients' uptake of diabetic retinopathy screening: a qualitative case study.

BACKGROUND: The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes in England by enabling prompt diagnosis of sight-threatening retinopathy. However, the rate of screening uptake between practices can vary from 55% to 95%. Existing research focuses on the impact of patient demographics but little is known about GP practice-related factors that can make a difference. AIM: To identify factors contributing to high or low patient uptake of retinopathy screening. DESIGN AND SETTING: Qualitative case-based study; nine purposively selected GP practices (deprived/affluent; high/low screening uptake) in three retinopathy screening programme areas. METHODS: Semi-structured interviews were conducted with patients, primary care professionals, and screeners. A comparative case-based analysis was carried out to identify factors related to high or low screening uptake. RESULTS: Eight possible factors that influenced uptake were identified. Five modifiable factors related to service and staff interactions: communication with screening services; contacting patients; integration of screening with other care; focus on the newly diagnosed; and perception of non-attenders. Three factors were non-modifiable challenges related to practice location: level of deprivation; diversity of ethnicities and languages; and transport and access. All practices adopted strategies to improve uptake, but the presence of two or more major barriers made it very hard for practices to achieve higher uptake levels. CONCLUSIONS: A range of service-level opportunities to improve screening attendance were identified that are available to practices and screening teams. More research is needed into the complex interfaces of care that make up retinopathy screening.

Securing recruitment and obtaining informed consent in minority ethnic groups in the UK.

BACKGROUND: Previous health research has often explicitly excluded individuals from minority ethnic backgrounds due to perceived cultural and communication difficulties, including studies where there might be language/literacy problems in obtaining informed consent. This study addressed these difficulties by developing audio-recorded methods of obtaining informed consent and recording data. This report outlines 1) our experiences with securing recruitment to a qualitative study investigating alternative methods of data collection, and 2) the development of a standardised process for obtaining informed consent from individuals from minority ethnic backgrounds whose main language does not have an agreed written form. METHODS: Two researchers from South Asian backgrounds recruited adults with Type 2 diabetes whose main language was spoken and not written, to attend a series of focus groups. A screening tool was used at recruitment in order to assess literacy skills in potential participants. Informed consent was obtained using audio-recordings of the patient information and recording patients' verbal consent. Participants' perceptions of this method of obtaining consent were recorded. RESULTS: Recruitment rates were improved by using telephone compared to face-to-face methods. The screening tool was found to be acceptable by all potential participants. Audio-recorded methods of obtaining informed consent were easy to implement and accepted by all participants. Attrition rates differed according to ethnic group. Snowballing techniques only partly improved participation rates. CONCLUSION: Audio-recorded methods of obtaining informed consent are an acceptable alternative to written consent in study populations where literacy skills are variable. Further exploration of issues relating to attrition is required, and a range of methods may be necessary in order to maximise response and participation rates.