title: Barriers and facilitators to starting insulin in patients with type 2 diabetes: a systematic review.
abstract: OBJECTIVE
  To identify the barriers and facilitators to start insulin in patients with type 2 diabetes.
  
  
  METHODS
  This was a systematic review. We conducted a systematic search using PubMed, EMBASE, CINAHL and Web of Science (up to 5 June 2014) for original English articles using the terms 'type 2 diabetes', 'insulin', and free texts: 'barrier' or 'facilitate' and 'initiate'. Two pairs of reviewers independently assessed and extracted the data. Study quality was assessed with Qualsyst.
  
  
  RESULTS
  A total of 9740 references were identified: 41 full-text articles were assessed for eligibility. Twenty-five articles (15 qualitative, 10 quantitative) were included in the review. Good inter-rater reliability was observed for the Qualsyst score (weighted kappa 0.7). Three main themes identified were as follows: patient-related, healthcare professional and system factors. The main patient-related barriers were fear of pain and injection (n = 18), concerns about side effects of insulin (n = 12), perception that insulin indicated end stage of diabetes (n = 11), inconvenience (n = 10), difficulty in insulin administration (n = 7), punishment (n = 7) and stigma and discrimination (n = 7). Healthcare professionals' barriers were as follows: poor knowledge and skills (n = 9), physician inertia (n = 5) and language barriers (n = 4). System barriers included lack of time (n = 5). The most common facilitators were understanding the benefits of insulin (n = 7), not being afraid of injections (n = 5), and patient education and information (n = 5).
  
  
  CONCLUSIONS
  Major barriers to insulin initiation persist despite availability of newer and safer insulin. Healthcare professionals should explore and address these barriers. Targeted interventions should be developed to overcome these barriers.
authors.affiliation: Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
authors.forename: C J
authors.initials: CJ
authors.lastname: Ng
authors.affiliation: Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
authors.forename: P S M
authors.initials: PS
authors.lastname: Lai
authors.affiliation: Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
authors.forename: Y K
authors.initials: YK
authors.lastname: Lee
authors.affiliation: Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
authors.forename: S A
authors.initials: SA
authors.lastname: Azmi
authors.affiliation: Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
authors.forename: C H
authors.initials: CH
authors.lastname: Teo
mesh_terms: D003657:Decision Making; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use*; D010349:Patient Compliance; D061665:Time-to-Treatment / Q000706:statistics & numerical data*
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin