Which Aspect of Patient–Provider Relationship Affects Acceptance and Adherence of Insulin Therapy in Type 2 Diabetes Mellitus? A Qualitative Study in Primary Care

Blessy Koottappal Mathew,1 Jacqueline Giovanna De Roza,2 Changwei Liu,2 Ling Jia Goh,3 Chai Wah Ooi,2 Elya Chen,4 Shixuan Poon,1 Wern Ee Tang3 1National Healthcare Group Polyclinics, Toa Payoh Polyclinic, National Healthcare Group, Singapore; 2National Healthcare Group Polyclinics, Geylang Polyclinic, National Healthcare Group, Singapore; 3National Healthcare Group Polyclinics, Hougang Polyclinic, National Healthcare Group, Singapore; 4National Healthcare Group Polyclinics, Clinical Research Unit, National Healthcare Group, SingaporeCorrespondence: Blessy Koottappal MathewNational Healthcare Group Polyclinic, 2003 Toa Payoh Polyclinic, Lorong 8, Toa Payoh, 319260, Singapore, Email blessy_mathew@nhgp.com.sgPurpose: In type 2 diabetes mellitus (T2DM), insulin therapy is often recommended to achieve the optimal control of disease, thereby preventing the onset and progression of diabetes-related complications. Despite knowing about the benefits, it has been reported that 71% of patients refuse insulin and the adherence rate ranges from 30 to 80%. Patient–provider relationship (PPR) may affect such insulin-related behaviours, but little is known about which aspect of PPR affects this. This study aimed to explore the key aspect of the patient–provider relationship that affects the initial insulin acceptance and continued adherence.Patients and Methods: We used the grounded theory approach in this qualitative research. The study was conducted at two primary care clinics between September 2019 and January 2021. Patients with T2DM on basal or premixed insulin were recruited using maximum variation sampling. Data were collected using semi-structured in-depth interviews and transcribed verbatim for analysis using constant comparison and synthesis.Results: Twenty-one participants with different levels of diabetes control and adherence were recruited. Four themes that emerged were 1) patient–provider interaction, 2) addressing the psychological fears, 3) gaining confidence in handling insulin equipment and 4) follow-up after insulin initiation. Among the subthemes, trust in doctors, provider’s communication skills, patient-centred decision-making and continuity of care positively influenced insulin acceptance and adherence. Conversely, fear of being judged by the provider hindered open communication around non-adherence. Various aspects of interaction with nurses helped in alleviating patient’s fear of injection and gaining confidence with the insulin equipment.Conclusion: Many aspects of PPR affect insulin acceptance and adherence. Among these, gaining patients’ trust, effective patient–provider communication, patient-centred decision-making, and ensuring continuity of care improve both insulin acceptance and treatment adherence. Various interactions with nurses help in addressing fears surrounding injection and gaining acceptance towards insulin therapy. Patients’ fear of being blamed or judged by the provider negatively affects open communication around non-adherence.Keywords: insulin initiation, insulin adherence, insulin acceptance, healthcare provider, patient interactions, primary care