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BMJ Open Diabetes Res Care. 2019 Dec 11;7(1):e000723. doi: 10.1136/bmjdrc-2019-000723. eCollection 2019.

Key factors for overcoming psychological insulin resistance: an examination of patient perspectives through content analysis.

Author information

Pennsylvania State University, Hershey, Pennsylvania, USA.
University of California San Francisco, San Francisco, California, USA.
Behavioral Diabetes Institute, University of California, San Diego, Del Mar, California, USA.
Amsterdam University Medical Centre Vrije Universiteit, Amsterdam, The Netherlands.
University of British Columbia, Vancouver, British Columbia, Canada.
Diabet Acad Mergentheim FIDAM, Bad Mergentheim, Germany.
Universitat Autonoma de Barcelona, Bellaterra, Spain.
Hospital das Clínicas da Faculdade de Medicina da USP, Sao Paulo, Brazil.
King's College London, London, UK.
Nagoya University Graduate School of Medicine, Nagoya, Japan.
Eli Lilly and Company, Indianapolis, Indiana, USA.
Lilly Deutschland GmbH, Bad Homburg, Germany.
Analysis Group Inc Boston, Boston, Massachusetts, USA.



To understand participant perceptions about insulin and identify key behaviors of healthcare professionals (HCPs) that motivated initially reluctant adults from seven countries (n=40) who had type 2 diabetes (T2D) to start insulin treatment.

Research design and methods:

Telephone interviews were conducted with a subset of participants from an international investigation of adults with T2D who were reluctant to start insulin (EMOTION). Questions related to: (a) participants' thoughts about insulin before and after initiation; (b) reasons behind responses on the survey that were either 'not helpful at all' or 'helped a lot'; (c) actions their HCP may have taken to help start insulin treatment; and (d) advice they would give to others in a similar situation of starting insulin. Responses were coded by two independent reviewers (kappa 0.992).


Starting insulin treatment was perceived as a negative experience that would be painful and would lead down a 'slippery slope' to complications. HCPs engaged in four primary behaviors that helped with insulin acceptance: (1) showed the insulin pen/needle and demonstrated the injection process; (2) explained how insulin could help with diabetes control and reduce risk of complications; (3) used collaborative communication style; and (4) offered support and willingness to answer questions so that participants would not be 'on their own'. Following initiation, most participants noted that insulin was not 'as bad as they thought' and recommended insulin to other adults with T2D.


Based on these themes, two actionable strategies are suggested for HCPs to help people with psychological insulin resistance: (1) demonstrate the injection process and discuss negative perceptions of insulin as well as potential benefits; (2) offer autonomy in a person-centred collaborative approach, but provide support and accessibility to address concerns. These findings help HCPs to better understand ways in which they can engage reluctant people with T2D with specific strategies.


patient-provider relationship; psychological insulin resistance; type 2 diabetes

Conflict of interest statement

Competing interests: HS, DH, FJS, XM-T, and MERS have served as consultants for Eli Lilly and Company. WHP has served as a consultant for Eli Lilly, Novo Nordisk, Sanofi, Astra Zeneca, Dexcom, Intarcia, Merck and Mannkind. LF has served as a consultant for Eli Lilly and Abbott Diabetes Care. TST has served as a consultant for Eli Lilly and Omni Pod. JS has served as a consultant for Eli Lilly and Spirit Healthcare. NH reports grants and personal fees from Abbott, Berlin Chemie, Ypsomed, Lilly, Dexcom and Roche. KO has served as a consultant for Eli Lilly and Eli Lilly Japan K.K., ONO Pharmaceutical Co., Kowa Co., Sanwa Kagaku Kenkyusho Co., Mitsubishi Tanabe Pharma Corporation, ARKRAY Inc., Sanofi K.K., Abbott Japan Co., MSD K.K., Novartis Pharma K.K., Novo Nordisk, and Nippon Boehringer Ingelheim Co. DC is an employee of Eli Lilly and Company. IH and MP-N are employees and stockholders of Eli Lilly and Company. UD is an employee of Analysis Group, Inc., a company that received funding for this research from Eli Lilly and Company. JII was an employee of Analysis Group, Inc. at the time of the study.

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