title: Engaging GPs in insulin therapy initiation: a qualitative study evaluating a support program in the Belgian context.
abstract: BACKGROUND
  A program supporting the initiation of insulin therapy in primary care was introduced in Belgium, as part of a larger quality improvement project on diabetes care. This paper reports on a study exploring factors influencing the engagement of general practitioners (GPs) in insulin therapy initiation (research question 1) and exploring factors relevant for future program development (research question 2).
  
  
  METHODS
  We have used semi-structured interviews to answer the first research question: two focus group interviews with GPs who had at least one patient in the insulin initiation program and 20 one-to-one interviews with GPs who were not regular users of the overall support program in the region. To explore factors relevant for future program development, the data from the GPs were triangulated with data obtained from individual interviews with patients (n = 10), the diabetes nurse educator (DNE) and the specialist involved in the program, and data extracted from meeting reports evaluating the insulin initiation support program.
  
  
  RESULTS
  We found differences between GPs engaged and those not engaged in insulin initiation in attitude, subjective norm and perceived behavioural control regarding insulin initiation. In general the support program was evaluated in a positive way by users of the program. Some aspects need further consideration: job boundaries between the DNE and GPs, job boundaries between GPs and specialists, protocol adherence and limited case load.
  
  
  CONCLUSIONS
  The study shows that the transition of insulin initiation from secondary care to the primary care setting is a challenge. Although a support program addressing known barriers to insulin initiation was provided, a substantial number of GPs were reluctant to engage in this aspect of care. Important issues for future program development are: an interdisciplinary approach to job clarification, a dynamic approach to the integration of expertise in primary care and feedback on protocol adherence.
  
  
  BACKGROUND
  ClinicalTrials.gov Identifier: NCT00824499.
authors.affiliation: Department of General Practice and Primary Health Care, Ghent University, De Pintelaan, 185, 9000 Ghent, Belgium. patricia.sunaert@ugent.be.
authors.forename: Patricia
authors.initials: P
authors.lastname: Sunaert
authors.forename: Sara
authors.initials: S
authors.lastname: Willems
authors.forename: Luc
authors.initials: L
authors.lastname: Feyen
authors.forename: Hilde
authors.initials: H
authors.lastname: Bastiaens
authors.forename: Jan
authors.initials: J
authors.lastname: De Maeseneer
authors.forename: Lut
authors.initials: L
authors.lastname: Jenkins
authors.forename: Frank
authors.initials: F
authors.lastname: Nobels
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Samyn
authors.forename: Marie
authors.initials: M
authors.lastname: Vandekerckhove
authors.forename: Johan
authors.initials: J
authors.lastname: Wens
authors.forename: An
authors.initials: A
authors.lastname: De Sutter
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D001530:Belgium; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000523:psychology; D005260:Female; D058006:General Practice / Q000379:methods*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000379:methods*; D036301:Qualitative Research
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin