Characteristics of participants
Out of the 30 participants approached, 15 patients with type 2 diabetes and 12 healthcare providers; 7 physicians, 3 nurse, and 2 pharmacists participated in the study. Three of the patients who met the eligibility criteria did not participate for personal reasons. As shown in Table 1, most of patient participants were in the age range of 40-50 years old, female, with duration of illness less than 5 years and with more than half having no formal or primary level education. The provider participants were mostly female and had practice experiences ranging from 2 years to 20 years and had entry-level professional degree with the exception of the medical doctors as illustrated in Table 2.
Thematic areas
According to the results of the study, initiation of insulin is a process practiced by the physician who decides which patient starts insulin therapy. Nurses were found to be involved in provision of diabetes related health education at the waiting area and a one to one diabetes education and counseling sessions. The clinic at the time of the study used treatment guideline from American Diabetes Association (ADA) and IDF as a general practice but adapted to local situations of a resource-limited setting.
The clinic is using treatment guidelines from ADA and IDF but adopted to our settings. Physician, Male
However, the process of initiation of insulin was not found to be uniform.
The process of initiation is not as it is expected to be. There is delayed initiation of insulin and I don’t believe that there is proper initiation of insulin. Physician, Male
Participants discussed factors resulting in delayed initiation of insulin with patient, physician, and healthcare institution perspectives.
Table 1
Profiles of the patient participants with delayed initiation of insulin interviewed at the diabetes clinic of TASH, Addis Ababa, Ethiopia, 2017. (N=15)
Socio-demographic and other patient characteristics | Number |
Age |
| 30-40 | 3 |
41-50 | 6 |
51-60 | 3 |
Above 60 | 3 |
Gender |
| Male | 5 |
Female | 10 |
Religion |
| Orthodox Christian | 13 |
Muslim | 2 |
Educational level |
| No formal education (can’t write or read/ can read and write) | 4 |
Primary level education (1-8th grade) | 4 |
Secondary level education (9-12th grade) | 4 |
Diploma/Certificate | 3 |
Type of Job |
| House wife | 8 |
Pensioner | 1 |
Guard | 2 |
Merchant | 3 |
Company Driver | 1 |
Duration of Illness |
| < 5 years | 5 |
5-10 years | 4 |
10-15 years | 2 |
>15 years | 4 |
Initiated Insulin |
| Yes | 6 |
No | 9 |
Source of payment for medication |
| Self-Paying | 9 |
Government- Paying | 6 |
Patient factors
Perceived adherence problems to prescribed insulin therapy
Patients who already had adherence problem to the prescribed OAMs due to religious or stressful conditions think the same will happen with insulin. Thus, patients want to stick with OAMs with perceived better adherence.
I also think I have adherence problem and I don’t think taking insulin will make any difference taking my life style into consideration. I would be happy if I can see it with oral medications of more doses. Patient, Female, 41 years
Table 2
Profiles of the healthcare providers interviewed at the Diabetes Clinic of TASH, Addis Ababa, Ethiopia, 2017. (N=12)
Sociodemographic and background profiles | Number |
Sex |
| Male | 5 |
Female | 7 |
Year of practice at the diabetes clinic |
| < 5 years | 7 |
5-10 years | 4 |
>10 years | 1 |
Type of profession |
| Physician | 7 |
Nurse | 3 |
Pharmacist | 2 |
Academic qualification |
| Doctor of Medicine/ Bachelor’s Degree | 7 |
Internal Medicine Specialty (CSIM) | 2 |
Endocrinology Sub-specialty certificate | 3 |
Beliefs about the necessity of insulin
Patients believe that OAMs and insulin are the same with regard to efficacy except that insulin requires complicated monitoring and management.
I have one question though. Does taking insulin really change the blood glucose level better than the oral medications? I am taking the tablets and I think I am not sick and I do not think I need to be shifted to insulin as long as I am walking healthy. Patient, F, 41 yrs. old
Patients also lack awareness on the natural course of the disease where they believe insulin is prescribed when the disease reaches advanced level. However, the present study has observed belief towards the necessity of insulin increased in patients who already started insulin. In fact, they promote timely initiation of insulin therapy as prescribed.
I found insulin to be a good medicine now […] I advise others to start insulin as soon as they are told. If I started insulin the day I was told, I wouldn’t have faced such problem with my kidney [I am having kidney problem due to the diabetes]. Patient, F, 41 yrs. old
Concerns related to starting insulin
Fear of side effects and complications
Fear of side effects like hypoglycemia and weight gain were reported to be among the reasons for patients to resist insulin treatment.
I also heard that insulin results in weight gain and I proved that right when I am taking it now. Patient, F, 40 yrs. old
Patients also think insulin results in complications and is thus, lethal. Patients usually perceive complications as part of taking the insulin but not part of the disease process.
I know of a patient who died as a result of infection that occurred from insulin at the injection sites. I still have a concern of infection and then death. Patient, F, 41 yrs. old
Fear of injections
Patients past exposure to injections and having undergone some forms of blood taking at regular levels resulted in fear of injection.
I have a fear of needle. I even have a fear to take dust out of my eye or take a splinter out from my hands leave alone to inject myself with needle. Patient, F, 41 yrs. old
Poor socioeconomic conditions
Self-paying patients who have to buy the medication out of pocket can’t afford to buy insulin and patients think shifting to insulin will incur another cost.
Definitely, insulin is expensive. It depends on the brand you are buying actually. For example, the oral medication cost them a maximum of 60 birr when they take 2 tablet 2 times a day but when we come to insulin taking the average usage of 50 unit per day, they need 2 vials which is around 112 birr. It actually is more than this since we only considered with the average usage. Pharmacist, F
To enroll into the free government medical service, a patient is required to bring letter from the local administration (Kebele/Woreda) every four months or every year indicating they are unable to pay for their medication. Given the bureaucracy and time required to process such letters, few patients find it hard to provide support letter every month they show up at the clinic.
The hospital requires letter from Kebele every month and I could not renew my ID for a free service at Tikur Anbessa Hospital and that is my problem not to start insulin. You don’t always go to Kebele begging that you cannot afford and it is difficult. I cannot afford the oral medicines and it is going to be more expensive with insulin. Patient, F, 48 yrs. old
Perceived difficulty in insulin administration and loss of independence/reliance on others
Older patients with visual impairments and/or those patients who cannot read or write were found to have difficulty of handling the technique of insulin injection at home. Few patients who refused to start insulin until the end of the study period do not even have someone at home who would inject them.
But, it would be impossible for me to take it with the prescribed dose […] what if I take it with the wrong dose than the prescribed one and that might kill me…That is my problem. I am illiterate and can’t read or write well…..Patient, F, 70 yrs. old
Even, some of them are frail to inject themselves despite the fact that they can read and write. I remember from my experience where patients in the same neighborhood were injecting each other with only the same dose that one patient was prescribed with. Nurse, F
Few patients also mentioned lack of trust where same patients who are dependent on their caregivers for administration foresaw future inconvenience if caregiver support becomes diminished or compromised due to different changes.
I don’t trust myself with anyone […] you can’t trust anyone; I should prepare and do it myself but my eye sights are getting weak. For example: this girl is a student and it might get late until she comes home and inject me. Patient, F, 68 yrs. Old
Not amenable to religious healing (e.g. holy water use) and practices (e.g. fasting)
Patients put down “holy water” as an alternative means to lower down their glucose level instead of shifting to insulin therapy.
I said to the doctor “I need some time”. I am trying to lower the blood glucose level with “holy water”. I believe it is better to lower it down with this instead of going to insulin. Patient, F, 50 yrs. old
In addition, the interference of shifting to insulin therapy with the fasting seasons was also a concern among patients following Orthodox Christian religion. Patients heard that insulin requires having proper meal and they do not think they are capable of avoiding the fasting season; they are overwhelmed with overall religious practices. This is more evident among patients of old age who are daily observant of religious practices and ceremonies. This was strengthened as follows.
I do not take my medication regularly. I go to church early in the morning and attend “mass” services. The “mass” ends around 9 am and the medicine should be taken by then. So, this is one problem for me which will be worse if I start insulin. Patient, F, 68 yrs. old
Similarly, one patient explained that fasting decreases the blood glucose level and thus, prefer it instead of following a proper meal and uninterrupted medication schedule.
I am fasting even, the fasting decreases the glucose level and it is good. Patient, F, 70 yrs. old
One of the patients also reported on the belief where mixing religious practices, such as drinking or bathing with holy water and performing “Holy Communion”, with OAMs does not get along with her religious belief. And, she thought the same will happen if she starts insulin therapy.
Religious leaders actually insist that we should take our medicines properly even if we are taking “holy water” or doing the “Holy Communion” procedure. But, I believe it is not right. It is my belief that restricts me from taking the medicines during those procedures. I don’t want to mix the medicine with the body and blood of Christ. What happens if I start insulin? Patient, F, 68 yrs. Old
Social factors
One aspect of it is that patients are not willing to inject themselves when they are at work or when they are invited to weddings or friends or relatives’ house thinking their friends or colleagues will stigmatize them. In addition, patients may be busy with social engagements like weddings, funerals, “Idir” (a traditional social institution to support each other in times of need, in most cases funerals), and “Iqub” (traditional saving institution). Some patients reported that insulin needs refrigeration and is not convenient to carry when moving from place to places on these occasions.
It even gets late when taking the tablet, I don’t follow it properly. I might have to go somewhere early in the morning [friend’s house or relative or some things I wish to accomplish]. So I take the meal and then the medicine sequentially at once thinking that it might get late by the time I get home. That is because of my tight schedule and it will be worse with insulin. Insulin needs refrigeration to carry it with me and I am not expected to take it with the meal at once, right? I need to wait some minute. So, it will be difficult. Patient, F, 41 yrs. old
Similarly, entertaining guests coming to their house was found to keep patients busy. They think insulin takes time to inject and it is against the norm and culture to stand up from the conversation having the guest sitting at home.
I may have a wedding, a funeral, or a guest might come to my place unexpectedly. Some might come to my house to seek for advice. In such cases, I cannot interrupt my conversation to take insulin since it takes time. It is against our culture to get up from a conversation. So, I do not think I can do that for the sake of taking insulin. Patient, F, 68 yrs. Old
Perceived resistance to insulin
Resistance to the medication is another concern related to insulin therapy. It is believed that patients with diabetes will through time develop resistance to insulin like the oral medications have failed to help over time.
The main reason is that I had a fear thinking what if my body adapts to the insulin as well? It should not be stopped right? It means I am going to stop the medication if my body adapts to it and it will have no alternative medicine. That is my fear. What am I going to take after that? Patient, M, 60 yrs. old
Physician barriers
Perceived Patient’s Situation
Side effects patients anticipate to occur creates sense of fear among physicians to initiate insulin therapy. The physician fears that the patient will resist or go through unexpected events, such as hypoglycemia and weight gain or might disappear from follow up if prescribed with insulin therapy. Patients also have memory problems or may not be able to read or write to initiate them on insulin therapy, according to a few physicians.
We don’t tend to initiate as well if the patient doesn’t fit for insulin mentally, doesn’t have assistance, or have visual impairment [...]patient may have forgetting problem. Physician, M
Lack of expertise and experience
Residents’ lack expertise/lingering experience and are not comfortable or familiar to communicate with patients on the appropriate pattern of insulin initiation and titration.
There might be limited knowledge/experience on the indications. There is also lack of experience on the target FPG numbers and insulin initiation. Physician, M
Lack of motivation and confidence
Lack of motivation and confidence among some residents (frontlines to diagnose and treat patients) who rotate frequently as part of their residency program and avoiding responsibility was found to be a factor to delay insulin.
To actually tell the truth, practically, residents are coming to diabetes clinic for short period of time as part of their rotation and they don’t want to take the responsibility to initiate insulin therapy in this time. They just want to see and send the patient with the present medication he/she is taking. Physician, M
Lack of communication skill
Physicians mainly residents lack communication skill to interact with patients regarding the disease and the medications. The communication in most cases follow a paternalistic approach where the physician dictates the patient instead of taking time to gather and provide information from and to the patient.
While initiating insulin therapy, I do a simple run down on the symptoms they will encounter and on how to treat the hypoglycemia. But the details are given by nurses. Physician, F
Some of the doctors take time to explain and some do not even listen to what you are complaining let alone explaining the situation….the second ones just write your results and he/she doesn’t take your points into consideration. Personality of doctors matters. The first doctor I have seen was so good to explain on initiation of insulin and titrate my dose and the second replaced physician was so fast that I couldn’t catch her advices. Patient, F, 41 yrs. old
Physicians also fail to communicate well on the course of the disease and sensitize patients from the beginning on the necessity or inevitable need of insulin. In fact, insulin is considered to be a prescription as a punishment for patients who are unable to manage their blood glucose level.
The physician tells the patient that he/she will start him on insulin if the patient doesn’t behave with oral medications and other factors to be considered. This means the physician is not telling the patient as insulin is imminent on the course of treatment but insulin is a punishment. Physician, F
The physician used to tell me that I should behave with oral medications and otherwise it will be changed to the injection. May be he wants me to behave and do things right but he was trying to scare me with the injection thing at the same time. Patient, F, 38 yrs. old
Health institution barriers
Absence of HbA1c test
HbA1c test is not available at the hospital laboratory and the test, according to physicians interviewed, is not accessible and affordable to patients. This forces the physicians to only use FPG results to make decisions of initiating insulin therapy. Physicians, thus, demand series of records of results to decide on whether to shift to insulin therapy despite the present indications.
We advise them to take a couple of records at home for the next appointment. HemoglobinA1C is expensive for most of the patients and we usually rely on FPG. Still most of the patients can’t afford to go and check their FPG. So, what you base yourself is on the thing you can have as evidence in your hand. Physician, M
Lack of Continuity of Care
Coming to contact with different physicians at different times and appointment dates, patients show lack of trust and frustration against the rotating residents prescribing the insulin therapy.
Since I started my follow up here, I was being checked up by different doctors. And, some of them are young and I am sure they are taught well to do that and I have no problem with their knowledge. But we see different face of doctors each time we come for clinic visit and it is difficult. Patient, F, 68 yrs. old
Absence of guidelines for diabetes management including insulin initiation
The treatment guidelines and titration system used at the time in the diabetes center were designed for developed countries while the system operates in the context of a developing country in which the setup is different.
I can’t say the treatment approach is uniform and that is one factor. Besides, we don’t have our national guideline and we are using developed countries guideline which doesn’t fit to our setting. Physician, M
Lack of health educational resources
Absence of enough teaching and learning materials prepared for the patient in local language (Amharic and others) on the general concept of diabetes and insulin presents a problem.
In my follow up at this clinic thus far, I have never encountered a patient education material prepared in Amharic. I bought one prepared material today in years. And, attention should be given to assist the patient. Patient, F, 38 yrs. old
Inadequate staff for diabetes care and education
Nurses are necessary to have a regular health education system and counseling sessions about insulin at the diabetes clinic but their low number resulted in irregular schedules at the setting.
Nurses are leaving the clinic for further education or personal reasons. And there is shortage of nurses in our setting. Sometimes, we are only two nurses to fulfill the overall activities. It is tough. Nurse, F
Time barrier- High patient load and long appointment periods
Follow up appointments are prolonged in the diabetes clinic which can extend up to six months due to high patient flow. This was difficult to follow a patient in short visits and timely prescribe insulin therapy.
In my earlier year of experiences, the number of patient seen per day was 25 and now the number is high since they cannot shift to Menelik or Ras Desta Hospital as Tikur Anbessa is known to have better supply of medicines. Nurse, F
The appointment system is one factor. The physician has a fear of initiating insulin therapy thinking that it is impossible to see the patient in a short day appointment and follow him accordingly. The system does not allow appointing the patient whenever you want and that is a challenge to the physician to start insulin. Physician, F