Key Factors for Overcoming Psychological Insulin Resistance—An Examination of a Large International Sample through Content Analysis
Authors: STUCKEY HEATHER L. , POLONSKY WILLIAM , FISHER LAWRENCE , HESSLER DANIELLE M. , SNOEK FRANK J. , TANG TRICIA S. , HERMANNS NORBERT , MUNDET XAVIER , SILVA MARIA ELIZABETH R. , STURT JACKIE A. , OKAZAKI KENTARO , CAO DACHUANG , HADJIYIANNI IRENE , IVANOVA JASMINA I. , DESAI URVI , PEREZ-NIEVES MAGALY 
Published: June 2018

Treatment with insulin is often associated with higher rates of achieving glycemic control. This qualitative analysis identified the key patient-reported behaviors of health care providers (HCP) that motivated reluctant patients from 7 countries (n=40) to start insulin treatment. As part of a larger mixed methods study (EMOTION), which included a quantitative survey, explanatory interviews with a subset of surveyed patients were conducted, transcribed, and coded (.992 kappa) with the purpose of clarifying responses to the survey. Frequently reported HCP behaviors that helped patients overcome insulin resistance included: (1) explaining that insulin would help with diabetes control and/or avoid complications in the future [We have tried all the best you could do with oral treatment; insulin might now be a better option]; (2) establishing trust with the patient [If I don’t trust a physician, I go somewhere else, because that’s very important]; (3) being available for support or questions [She always talks to me about my medications and she wants to make sure that if I have any questions that I ask them]; (4) having the patient give an insulin injection while in the office [He showed me how to stick the needle in and I didn’t even feel anything]; (5) explaining that injecting insulin was easy [He let me know that I wouldn’t even notice it if I injected the way he told me about]; and (6) referring the patient to a specialist [First it was the GP, but he referred me to the endocrinologist who told me about starting on insulin]. Many of the patients understood that the path of the disease was leading toward insulin, but it was the HCP who made the recommendation based on hemoglobin A1C results. Reluctance to insulin initiation can be alleviated by HCPs by preparing patients for insulin initiation by explaining the benefits of insulin, establishing trust, being available for support, and demonstrating the insulin injection process.

Disclosure
H.L. Stuckey: Consultant; Spouse/Partner; Calibra Medical, Eli Lilly and Company. Research Support; Spouse/Partner; Novo Nordisk Inc.. Research Support; Self; Eli Lilly and Company, Novo Nordisk Inc. W. Polonsky: Consultant; Self; Abbott, AstraZeneca, Dexcom, Inc., Sanofi, Novo Nordisk Inc., Eli Lilly and Company, Intarcia Therapeutics, Inc., Servier, Ascensia Diabetes Care, Merck & Co., Inc., MannKind Corporation, Glooko, Inc., Roche Diabetes Care Health and Digital Solutions. L. Fisher: Consultant; Self; Eli Lilly and Company, Abbott, Merck & Co., Inc. D.M. Hessler: Consultant; Self; Eli Lilly and Company. F.J. Snoek: None. T.S. Tang: Consultant; Self; Eli Lilly and Company. N. Hermanns: Speaker's Bureau; Self; Berlin-Chemie AG. Advisory Panel; Self; Abbott. Research Support; Self; Abbott. Speaker's Bureau; Self; Abbott. Research Support; Self; Berlin-Chemie AG. Advisory Panel; Self; Eli Lilly and Company. Speaker's Bureau; Self; Eli Lilly and Company. Advisory Panel; Self; Roche Diabetes Care Health and Digital Solutions. Research Support; Self; Ypsomed AG, Dexcom, Inc.. Speaker's Bureau; Self; Novo Nordisk Inc. X. Mundet: Research Support; Self; Eli Lilly and Company. Advisory Panel; Self; Merck & Co., Inc.. Research Support; Self; Novartis Pharmaceuticals Corporation, Boehringer Ingelheim Pharmaceuticals, Inc.. M.R. Silva: None. J.A. Sturt: Advisory Panel; Self; Eli Lilly and Company. Consultant; Self; Eli Lilly and Company, Spirit Healthcare UK. K. Okazaki: Advisory Panel; Self; Eli Lilly and Company. Research Support; Self; Taisho Pharmaceutical Co., Ltd.. Speaker's Bureau; Self; Ono Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Corporation, Novo Nordisk A/S, Astellas Pharma US, Inc., Takeda Development Center Asia, Pte. Ltd., Terumo Medical Corporation, MSD K.K., Sanwa Kagaku Kenkyusho Co., Ltd.. Other Relationship; Self; Aichi prefecture government and Nagoya city government. D. Cao: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. I. Hadjiyianni: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. J.I. Ivanova: Other Relationship; Self; Eli Lilly and Company. Employee; Spouse/Partner; Boehringer Ingelheim Pharmaceuticals, Inc. U. Desai: Other Relationship; Self; Eli Lilly and Company, AstraZeneca. M. Perez-Nieves: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company.