University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA PSYCHOLOGICAL INSULIN RESISTANCE AMONG PATIENTS WITH TYPE 2 DIABETES AT LEDZOKUKU - KROWOR MUNICIPAL ASSEMBLY HOSPITAL, TESHIE-ACCRA BY JUDE TETTEY WELLENS-MENSAH (10220314) A DISSERTATION SUBMITTED TO SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF A MASTER OF PUBLIC HEALTH DEGREE JULY, 2019 i University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Jude Tettey Wellens-Mensah, hereby declare that apart from references to peoples work that have been duly cited, this dissertation is the result of my own research undertaken under supervision and it has neither in whole nor in part been presented for another degree in this university or elsewhere. STUDENT ……………………. ………… ………………………. JUDE TETTEY WELLENS-MENSAH DATE ACADEMIC SUPERVISOR …………………………………………………. ………………………. DR. SAMUEL OKO SACKEY DATE i University of Ghana http://ugspace.ug.edu.gh DEDICATION This dissertation is dedicated to my wife, my parents and my sister. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I thank the Almighty God for the strength, favour and direction throughout the programme. I am very grateful to Dr Samuel Oko Sackey for his supervision of the study and the entire faculty of the School of Public Health for their contribution in diverse ways.
I am eternally grateful to all health workers at LEKMA Hospital, especially those of the Department of Medicine. Lastly, I thank all the study participants who agreed to partake in this study. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT
 Background: T2D is progressive, and over time, there is a decline in beta cell activity of the pancreatic islets resulting in the lack of insulin, which is vital in glucose homeostasis. There is, therefore, the need to initiate insulin, the most potent glucose- lowering agent, in the management of T2D, which often is delayed. Delay of insulin therapy is often due to reluctance by patients, which is known as psychological insulin resistance or reluctance by the clinician known as clinic inertia. The magnitude of psychological insulin resistance and its associated factors among people with type 2 diabetes in Ghana remains unknown. Objective: The objective of this study was to assess psychological insulin resistance among people with type 2 diabetes attending the diabetes clinic at LEKMA General Hospital. Methods: A descriptive cross-sectional study was conducted among people with type 2 diabetes attending the diabetes clinic at LEKMA Hospital for routine follow up. Patients were selected using a systematic random sampling procedure. Psychological insulin resistance was measured using the Insulin Treatment Appraisal Scale. Data on the independent variables were collected using a structured questionnaire. Patients were interviewed while they waited to see the doctor, and their fasting blood glucose values were retrieved from the clinic register. Data were analysed using STATA 15. Chi- square test and a stepwise multivariable logistic regression were done to determine the independent variables that were associated with psychological insulin resistance at 0.05 significant level. The variance inflation factor and tolerance statistics were used to test for multicollinearity. Results: Two hundred and three (203) participants were recruited for the study. Only 16.3% (n=33/203) of patients were on insulin despite a mean fasting blood glucose of 8.7 mmol/l. The majority (78.8%, n=160/203) of patients had poor knowledge of insulin iv University of Ghana http://ugspace.ug.edu.gh therapy. Psychological insulin resistance present in 57.1% (n=116/203) of patients. The adjusted multivariable logistic regression model showed that the odds of psychological insulin resistance was higher among patients with secondary school education compared to patients who had attained a tertiary level of education (aOR=3.03, 95%CI=1.12-8.13, p-value=0.028). Unemployed patients (aOR=3.44, 95%CI=1.17- 10.01, p-value=0.024) and patients with poor knowledge of insulin therapy (aOR=2.45, 95%CI=0.95-6.26, p-value=0.001) were more likely to exhibit psychological insulin resistance. All variables had variance inflation factors less than 10 and tolerance statistics greater than 0.10 indicating no potential collinearity. Conclusion: Educational status, occupation and knowledge of insulin therapy were associated with psychological insulin resistance among people with type 2 diabetes attending diabetes clinic at LEKMA Hospital. More than half of the patients exhibited psychological insulin resistance. Early intervention by clinicians to counsel people with type 2 diabetes effectively at the onset of diagnosis will help curtail the phenomenon of psychological insulin resistance. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION............................................................................................................ i DEDICATION.............................................................................................................. ii ACKNOWLEDGEMENT........................................................................................... iii ABSTRACT ............................................................................................................. iv TABLE OF CONTENTS ............................................................................................. vi LIST OF TABLES....................................................................................................... ix LIST OF FIGURES .......................................................................................................x LIST OF ABBREVIATIONS.................................................................................... xi DEFINITION OF TERMS…………………………………………………….……..xii CHAPTER ONE............................................................................................................ 1 1.0 INTRODUCTION .................................................................................................. 1 1.1 BACKGROUND..................................................................................................... 1 1.2 PROBLEM STATEMENT ..................................................................................... 4 1.3 JUSTIFICATION.....................................................................................................6 1.4 CONCEPTUAL FRAMEWORK........................................................................... 7 1.5 NARRATIVE SUMMARY (CONCEPTUAL FRAMEWORK)…..……..….....8 1.6 GENERAL OBJECTIVES ......................................................................................8 1.6.1 SPECIFIC OBJECTIVES ..................................................................................8 CHAPTER TWO .........................................................................................................10 2.0 LITERATURE REVIEW ......................................................................................10 2.1 Clinical course of Type 2 Diabetes.........................................................................10 2.2 Insulin therapy in Type 2 Diabetes.........................................................................11 2.3 Role of Healthcare professionals.............................................................................12 2.4 Knowledge of insulin therapy.................................................................................13 2.5 Psychological insulin resistance..............................................................................15 2.6 Synthesis of psychological insulin resistance........................................................ 18 2.7 Measurement of psychological insulin resistance ...............................................19 2.7.1 Insulin treatment appraisal scale........................................................................20 2.7.2 The barriers to insulin treatment questionnaire.................................................21 2.8 Factors associated with psychological insulin resistance...................................... 22 2.8.1 Demographic and clinical characteristics.......................................................... 22 2.8.2 Psychosocial factors...........................................................................................23 vi University of Ghana http://ugspace.ug.edu.gh 2.9 Psychological insulin resistance and type of medication used………..……..…… 27 2.10 Psychological insulin resistance as an on-going process......................................27 2.11 Strategies for reducing psychological insulin resistance .................................... 28 CHAPTER THREE .....................................................................................................30 3.0 METHODS ............................................................................................................30 3.1 STUDY DESIGN ...................................................................................................30 3.2 STUDY AREA.......................................................................................................30 3.3 VARIABLES .........................................................................................................31 3.3.1 DEPENDENT VARIABLE………………………………………….………..31 3.3.2 INDEPENDENT VARIABLES………………………………………………31 3.4 STUDY POPULATION.........................................................................................33 3.4.1INCLUSION CRITERIA.....................................................................................33 3.4.2 EXCLUSION CRITERIA ................................................................................ 33 3.5 SAMPLING TECHNIQUE .................................................................................. 33 3.6 SAMPLE SIZE...................................................................................................... 34 3.7 DATA COLLECTION TECHNIQUE................................................................... 35 3.8 QUALITY CONTROL ......................................................................................... 36 3.9 DATA PROCESSING........................................................................................... 36 3.10 DATA ANALYSIS...............................................................................................36 3.11 ETHICAL CLEARANCE…..…………………………....……………….…….37 3.12 PRE-TESTING………………………………………………………………….38 CHAPTER FOUR ...................................................................................................... 39 4.0 RESULTS ............................................................................................................ 39 4.1 Socio-demographic characteristics of study participants ....................................... 39 4.2 Clinical characteristics of study participants.......................................................... 39 4.3 Prevalence of insulin use and associated factors....................................................41 4.4 Knowledge of insulin therapy.................................................................................45 4.5 Factors associated with knowledge of insulin therapy…..………..………............47 4.6 Prevalence of psychological insulin resistance and associated factors...................49 4.6.1 Age and sex....................................................................................................... 50 vii University of Ghana http://ugspace.ug.edu.gh 4.6.2 Educational and occupational status..................................................................50 4.6.3 Family history and duration of diabetes............................................................. 50 4.6.4 Diabetes medications........................................................................................ 50 4.6.5 Knowledge of Insulin therapy……………………………….......……………51 4.7 Patients’ attitude towards insulin therapy……………..…………………………53 4.8 Multivariate analysis………………………………………………...…………....56 CHAPTER FIVE ...................................................................................................... 59 5.0 DISCUSSION ....................................................................................................... 59 5.1 Prevalence of Insulin use and associated factors.................................................... 59 5.2 Knowledge of insulin therapy................................................................................60 5.3 Prevalence of psychological insulin resistance......................................................61 5.4 Demographic and clinical factors associated with psychological insulin resistance……………………………………………………………………………..63 5.5 Attitudes reported towards insulin therapy……………………………………….64 5.6 Limitations of study........................................................................................... 65 CHAPTER SIX............................................................................................................ 67 6.0 CONCLUSIONS AND RECOMMENDATIONS .............................................. 67 6.1 Conclusion............................................................................................................. 67 6.2 Recommendations .................................................................................................67 REFERENCES.............................................................................................................69 APPENDICES............................................................................................................. 77 APPENDIX A (CONSENT FORM)........................................................................... 77 APPENDIX B (ASSENT FORM) ..............................................................................79 APPENDIX C (QUESTIONNAIRE) .........................................................................81 APPENDIX D (ETHICAL APPROVAL LETTER)……………………...................84 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Operational definition of variables Table 2: Demographic characteristics of study participants Table 3:Clinical characteristics of study participants Table 4: Prevalence and association of insulin use by demographic and clinical characteristics of study participants Table 5a: Knowledge assessment of insulin therapy among study participants Table 5b: Knowledge assessment of insulin therapy among study participants Table 6: Prevalence and association of knowledge of insulin therapy by demographic characteristics among study participants Table 7: Prevalence and association of psychological insulin resistance by demographic and clinical characteristics of study participants Table 8: Descriptive analysis of attitudes on the insulin treatment appraisal scale Table 9: Domains of psychological insulin resistance Table 10: Logistic regression showing predictors of psychological insulin resistance among study participants Table 11: Variance inflation factor test for multicollinearity ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual framework illustrating factors associated with psychological insulin resistance Figure 2: Location of study area Figure 3: Prevalence of insulin use among study participants showing 95% Confidence interval participants Figure 4: Patterns of duration of insulin use among insulin users Figure 5: Overall levels of knowledge assessment on insulin therapy among diabetic patients Figure 6: Prevalence of psychological insulin resistance among study participants Figure 7: Top five negative attitudes towards insulin therapy reported by study participants x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ADA American Diabetes Association BIT Barriers to Insulin Treatment DAWN Diabetes Attitudes Wishes and Needs Study DCCT Diabetes Control and Complications Trial DM Diabetes Mellitus HBA1c Glycated haemoglobin IDF International Diabetes Federation IHME Institute for Health Metrics and Evaluation ITAS Insulin Treatment Appraisal Scale LEKMA Ledzokuku - Krowor Municipal Assembly NCD Non-communicable diseases PIR Psychological Insulin Resistance OHA Oral Hypoglycemic Agent T2D Type 2 Diabetes Mellitus UKPDS United Kingdom Prospective Diabetes Study USA United States of America WHO World Health Organization xi University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS Hepatic glucose production The formation of glucose primarily from lactate and amino acids in the liver cells Hyperglycemia Elevated level of glucose in the blood Hyperinsulinemia Elevated level of insulin in the blood Hypoglycemia Reduced level of glucose in the blood Insulin resistance A state in which a person’s body tissues has a lowered level of response to insulin Postprandial hyperglycemia An exaggerated rise in blood sugar following a meal Pseudo-hyperinsulinemia A false state of elevated insulin in the blood Psychological insulin resistance Psychosocial barriers to initiation and persistence with insulin therapy xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 THE BACKGROUND Diabetes mellitus is a major non-communicable diseases (NCDs), which is fast becoming a public health concern. It is a chronic condition that occurs when the body cannot produce any or enough of the hormone insulin or use insulin effectively resulting in raised levels of glucose in the blood (IDF diabetes atlas, 2017). Insulin is the hormone that regulates blood glucose, and any abnormality in its production or action leads to hyperglycemia, which is a common effect of uncontrolled diabetes. Over time persistent hyperglycaemia leads to severe damage to many organ systems, especially the nerves and blood vessels. There are three main types of diabetes mellitus, type 1, type 2 and gestational diabetes mellitus. Type 2 diabetes mellitus (T2D) which results from the body's ineffective use of insulin is the most common type of diabetes accounting for about 90% of all diabetes cases globally (Holman, Young, & Gadsby, 2015). The criteria for diagnosing diabetes is either fasting plasma glucose ≥ 7mmol/L or random plasma glucose ≥ 11.1 mmol/L or glycated haemoglobin ≥ 6.5% (IDF diabetes atlas, 2017). Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 1980 showing how rapidly the prevalence of diabetes has increased (WHO, 2016). Diabetes is currently one of the most significant global health emergencies of the 21st century resulting in micro and macrovascular complications such as diabetic retinopathy, cerebrovascular accidents, myocardial infarction, renal failure and lower limb amputation due to diabetic foot ulcers (WHO, 2016). These 1 University of Ghana http://ugspace.ug.edu.gh complications lead to high rates of mortality among people living with diabetes if optimum glycemic control is not achieved. In 2015, it was estimated that 1.6 million deaths were directly caused by diabetes, and almost 2.2 million deaths were due to high blood glucose (WHO, 2016). In Ghana, the prevalence of diabetes mellitus is estimated to be 4.8% of the population, and the number of deaths from diabetes has been estimated to be 4400 (WHO, 2016). Early control of high blood glucose levels is therefore essential in reducing complications and mortality in people with diabetes as observed in the United Kingdom Prospective Diabetes Study (UKPDS) in 1998. Results showed that for each 1% reduction in HBA1C, there was a 21% decrease in diabetes-related death, a 14% decrease in mortality, a 43% decrease in amputation, and a 37% decreased risk for microvascular complications, each of which was statistically significant (Stratton et al., 2000). Another study, the Japanese Kumamoto study also found similar findings among patients with T2D (Schichiri et al., 2000). The defect in insulin secretion in T2D is progressive. This was demonstrated in a study of newly diagnosed patients who had 50% of normal insulin secretion, and then 6 years after diagnosis had 25% of normal insulin secretion (UKPDS Group, 1995). This progressive course of T2D makes achieving optimum glycaemic targets (fasting blood glucose of 6.1 mmol/L or HbA1c of 7%) sometimes challenging and difficult to maintain (Stratton et al., 2000). Several years after diagnosis, oral hypoglycemic agents (OHA) alone may not suffice in controlling high blood glucose levels and eventually, people with T2D will require insulin to achieve optimum control of blood glucose levels. Unfortunately, the initiation of insulin at the optimum time by clinicians is often 2 University of Ghana http://ugspace.ug.edu.gh met with hesitancy and reluctance from the majority of patients resulting in a delay of insulin initiation. This delay is due to multiple factors which include reluctance by patients which is known as psychological insulin resistance, failure by clinicians to initiate insulin therapy at the optimum time known as clinical inertia and systemic barriers (Polonsky & Jackson, 2004; Furler et al., 2011; Khunti et al., 2013). Psychological insulin resistance (PIR) was coined by Leslie, Satin-Rapaport, Matheson, Stone and Enfield (1994). It generally refers to psycho-social barriers to insulin use and more specifically to insulin initiation refusal, insulin injection omission or refusal to intensify the number of injections a day among patients and healthcare providers (Brod, Kongsø, Lessard, & Christensen, 2009; Gherman et al., 2011). Psychological insulin resistance in patients with diabetes has been examined in several studies globally and is considered as an essential barrier to achieving recommended levels of blood glucose control (Larkin, 2008; Polonsky et al., 2005). The primary patient contributing factors to PIR include inaccurate knowledge of insulin therapy and negative attitudes towards insulin therapy such as "fear of injection and self- testing, hypoglycaemia and weight gain; a perceived loss of control over one's life; poor self-efficacy concerning insulin treatment and perceived lack of positive outcomes related to insulin therapy" (Polonsky et al., 2005, p.2544). There have been very few studies investigating PIR and as such, the magnitude of PIR is largely unknown especially to clinicians. Gherman et al., (2011) identified factors for PIR into four main categories emotional, cognitive, social/cultural and physical factors. These encompass a range of factors that include fear of injection or pain, fear of hypoglycaemia and weight gain, poor self- efficacy about the skills required to administer insulin, anxiety over interference with daily living, anticipated social stigmatisation, and misconceptions about the rationale 3 University of Ghana http://ugspace.ug.edu.gh and efficacy of insulin therapy. Patients' explanations for avoiding insulin extend far beyond a pure fear of needles and often involve deeply held beliefs about insulin and the nature of diabetes which are invariably influenced by culture; hence reasons for avoiding insulin varies from region to region (Polonsky & Jackson, 2004). These negative attitudes toward insulin therapy contribute to unnecessarily long delays in initiating insulin treatment and consequently, to extended periods of hyperglycaemia which increase the risk of development of long term complications (Tan, Tan & Yeo, 2003; Selvin et al., 2004). Hence it is critical to understand these negative attitudes using insulin appraisal tools to help improve insulin receptiveness among people with T2D. 1.2 PROBLEM STATEMENT Despite evidence of the proven efficacy of insulin in reducing hyperglycemia and delaying the progression of diabetes-related complications, there exists a mismatch between the number of people with T2D using insulin and the proportion of patients with blood glucose levels indicative of the need to initiate insulin (UKPDS, 1998; Khunti, Davies, & Khunti, 2015). For instance, in the ‘Fremantle Study', it was noted that in people with T2D on oral hypoglycemic agents (OHA) transition to insulin occurred at a median diabetes duration of eight years and a median HbA1c of 9.4% (Davis, Davis, & Bruce, 2006). In another study in Australia, 24% of patients with T2D (approximately 250,000 people) were using insulin to manage their diabetes, despite mean HbA1c being above target (Australian National Diabetes Strategy 2016–2020, 2017). In a South London prospective observational cohort study of newly diagnosed adults with T2D (n=1,335), one-third of the 7% who had initiated insulin at follow-up 4 University of Ghana http://ugspace.ug.edu.gh had experienced an insulin initiation delay according to clinical guidelines (Keij, Ismail, & Winkley, 2016). Similar results have been found globally (Harris, Kapor, Lank, Willan, & Houston, 2010; Blak, Smith, Hards, Maguire, & Gimeno, 2012; Curtis & Lage, 2014). These studies, therefore, demonstrate that there is a delay in initiation of insulin among most T2D populations which may be partly due to PIR. Data published by the Institute for Health Metrics and Evaluation (IHME) revealed that there was an over 46% increase in diabetes death rates in Ghana from 2005 to 2016 (IMHE, 2018). This rapid increase in diabetes death rates is an indication of poorly controlled blood glucose levels among people with T2D in the Ghanaian population. Poor glycemic control among people with T2D is due to multiple factors of which PIR is a contributory factor. However, several studies on diabetes in Ghana have failed to explore PIR. Thus, PIR remains under-recognised and inadequately addressed by healthcare providers. Psychological insulin resistance negatively affects the initiation of insulin therapy, resulting in poor glycemic control and an increased risk of developing diabetic complications. Poor glycemic control significantly reduces the quality of life and increases mortality among people with T2D. With the high proportion of deaths among people with T2D globally attributable to poor glycaemic control (WHO, 2016), it is prudent to determine the magnitude of PIR among people with T2D and explore factors associated with this phenomenon to enable clinicians address PIR adequately. This will enhance insulin uptake or receptiveness to insulin therapy among people with T2D who require insulin, in order to achieve optimal glycaemic control. 5 University of Ghana http://ugspace.ug.edu.gh 1.3 JUSTIFICATION Several studies on the prevalence of PIR and its associated factors in many T2D populations across the world have been carried out. From literature reviewed, there has been no such assessment among people with T2D in Ghana to date. Majority of data on PIR comes from the developed world, and this might not directly reflect the situation in Ghana due to significant socio-cultural and economic differences. Hence the need to close this gap by assessing PIR among people with T2D in Ghana and identifying factors related to its presence. This study can provide evidence-based information for clinicians to help address the patient barriers associated with the delay of insulin therapy initiation thereby optimizing glycaemic control and, in turn, reducing the risk of diabetes-related complications among people with T2D. 6 University of Ghana http://ugspace.ug.edu.gh 1.4 CONCEPTUAL FRAMEWORK SOCIO-DEMOGRAPHIC AND CLINICAL FACTORS *Age *Type of medication used *Knowledge of insulin therapy *Sex *Duration of illness *Educational level *Occupation *Duration of insulin use *Family history of diabetes COGNITIVE EMOTIONAL FACTORS FACT ORS *Perception of poor SOCIO- *Injection related anxiety self-efficacy PATIENT -CULTURAL *Fear of consequences of *Personal failure HEALTHCARE FACTORS insulin use su ch as /ineffectiveness of PROVIDER hypoglycaemia & weight insulin RELATIONAL gain *Belief that diabetes *Social stigma FACTORS *Lifestyle is not serious *Embarrassment restriction/Inconvenience enough and insulin is for more severe diabetes PSYCHOLOGICAL INSULIN RESISTANCE POOR QUALITY OF INCREASED POOR BLOOD LIFE COMPLICATIONS/MORTALITY GLUCOSE CONTROL Figure 1: Conceptual framework illustrating factors associated with psychological insulin resistance 7 University of Ghana http://ugspace.ug.edu.gh 1.5 NARRATIVE SUMMARY (CONCEPTUAL FRAMEWORK) This framework illustrates how patients' socio-demographic and clinical factors influence attitudinal factors such as emotional factors (injection-related anxiety, fear of hypoglycaemia, lifestyle restrictions), cognitive factors (perception of poor self- efficacy, personal failure, belief insulin is for more severe diabetes), socio-cultural factors (stigma/embarrassment) and patient-healthcare provider relationship factors. These attitudinal factors, in turn, contribute to psychological insulin resistance resulting in poor blood glucose control leading to an increased risk of diabetic-related complications and mortality among people with T2D. The resultant effect of poorly controlled blood glucose levels is a poor quality of life, which further worsens psychological insulin resistance and increases the risk of diabetic-related complications/mortality. 1.6 GENERAL OBJECTIVES To assess psychological insulin resistance among people with T2D attending the Diabetes clinic at LEKMA General Hospital. 1.6.1 SPECIFIC OBJECTIVES 1. To determine the prevalence of insulin, use among people with T2D attending the Diabetes clinic at LEKMA General Hospital. 2. To assess knowledge of insulin therapy among people with T2D attending the Diabetes clinic at LEKMA General Hospital. 3. To determine the prevalence of psychological insulin resistance among people with T2D attending the Diabetes clinic at LEKMA General Hospital. 8 University of Ghana http://ugspace.ug.edu.gh 4. To identify patient factors associated with psychological insulin resistance among people with T2D attending the Diabetes clinic at LEKMA General Hospital. 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Clinical course of Type 2 Diabetes (T2D) Type 2 diabetes, previously referred to as adult-onset or non-insulin-dependent diabetes, can be viewed as a continuum. T2D progresses from an early asymptomatic stage characterized by insulin resistance to mild postprandial hyperglycaemia, then to frank diabetes requiring medical intervention (Gulam et al., 2017). A triad of metabolic defects characterizes T2D. These are insulin resistance, beta-cell dysfunction and inappropriately increased hepatic glucose production (Gulam et al., 2017). Insulin resistance, which is the primary and earliest lesion results in hyperinsulinemia, which is as a result of the beta-cell of the pancreas compensating for the pseudo hyperinsulinemia created by insulin resistance. This state of insulin resistance manifests as mild postprandial hyperglycaemia. Gradually, pancreatic beta-cell function declines and results in relative insulin deficiency and subsequently fasting hyperglycaemia then full-blown T2D. The gradual decline of insulin secretion and subsequently absolute insulin deficiency, leads to the loss of the inhibitory effect of insulin on hepatic glucose production. This contributes significantly to the development of fasting hyperglycaemia. Studies have shown that beta-cell decline generally occurs within 10 years at a rate of about 4 per cent each year (UKPDS, 1996). Therefore, patients with T2D often benefit from insulin therapy at some point after diagnosis. Understanding this natural sequence of T2D is very vital for the formulation of effective tailored treatment regimens. The natural history of T2D is also affected by factors such as obesity, ageing and physical inactivity resulting in its progression (Gulam et al., 2017). 10 University of Ghana http://ugspace.ug.edu.gh 2.2 Insulin therapy in Type 2 Diabetes Treatment options for T2D vary across the stages of T2D, with oral agents being able to control blood glucose in the early stages, but subsequently, when absolute insulin deficiency occurs, exogenous insulin is required. Insulin therapy is the only antidiabetic agent that can maintain optimal blood glucose levels throughout the progression of beta-cell failure (Khunti et al., 2013). Insulin is injected through the skin subcutaneously. To date, no less invasive alternative to insulin injections has been approved for clinical use (Shah, Patel, Maahs, & Shah, 2016). Insulin injections may be delivered either using a syringe and vial, preloaded or reloadable insulin pen injector, or an insulin pump (Shah, Patel, Maahs, & Shah, 2016). Early and intensive glycaemic control is vital in preventing microvascular and macrovascular complications as emphasized in the Diabetes Control and Complications Trial and the U.K. Prospective Diabetes Study (Stratton et al., 2000). Through the prevention of diabetes-related complications, insulin use can contribute indirectly to maintaining both quantity and quality of life (Pouwer & Hermanns, 2009). Prevention of diabetes-related complications can be achieved through the timely initiation of insulin therapy (Stratton et al., 2000). People with T2D for whom optimal glycaemic control is not achieved with maximum OHAs early initiation of insulin therapy is recommended (Inzucchi et al., 2015; Nathan et al., 2009). The American College of Endocrinology and the American Association of Clinical Endocrinologists recommend initiation of insulin therapy in patients with T2D with an initial HbA1C level greater than 9%, or if the diabetes is uncontrolled despite optimal oral hypoglycemic agents (Jellinger et al., 2007). Insulin may also be used alone or in combination with oral hypoglycemic such as sulphonylureas, 11 University of Ghana http://ugspace.ug.edu.gh biguanides, thiazolidinedione, alpha-glucosidase inhibitors and meglitinides. Despite insulin's proven efficacy among people with T2D (UKPDS,1998), oral hypoglycemic agents seem to be the preferred choice of people with T2D. Studies demonstrated a mismatch between the number of people with T2D using insulin and the number who have not achieved optimum blood glucose levels (Khunti, Davies, & Khunti, 2015). Statistics from United States Centres for Disease Control and Prevention: Diabetes data and trends, (2013) corroborates the low use of insulin among people with T2D, showing that only about 30% of all people with diabetes in USA use either insulin only or in combination with oral hypoglycemic agents. However, insulin use among people with diabetes in developing countries is lower than that of developed countries. This is mainly due to low socioeconomic status and inadequate knowledge of insulin therapy (Choudhury, Das, & Hazra, 2014). One advantage of insulin in the management of T2D over oral hypoglycemic agents is the flexibility in dosage adjustment in response to changes in the glucose levels. There is no indicated maximum dose for insulin; hence, optimum glycaemic control is attainable at extremely high blood glucose levels ("Insulin Administration", 2003). 2.3 Role of Healthcare professionals The clinical guidelines for the management of diabetes emphasize the need for patient- centred care (Inzucchi et al., 2012; The Royal Australian College of General Practitioners and Diabetes Australia, 2014). Patient-centred care requires healthcare professionals to be mindful of and responsive to the patient's preferences and needs. In as much healthcare professionals should be mindful of patient's preferences, 12 University of Ghana http://ugspace.ug.edu.gh appropriate assessment of glycaemic control and timely initiation of insulin when required is important. Early insulin education by healthcare professionals for people with T2D has been found to positively influence attitudes towards insulin therapy (Abu Hassan et al., 2013; Bogatean & Hâncu, 2004; Jenkins et al., 2010; Noakes, 2010; Patel, Stone, McDonough, et al., 2015; Tan et al., 2011). The structuring of diabetes education programs at diabetes clinics is key to providing patients with adequate knowledge and understanding of diabetes and its management, including insulin therapy. Thus, arming patients with adequate information to make informed treatment decisions on self- management activities such as self-monitoring of blood glucose, diet therapy and self- injection of insulin (Luijks et al., 2012; Teljeur, Smith, Paul, Kelly, & O'Dowd, 2013). A study of people living with diabetes by Yilmaz, Ak, Cim, Palanci & Kilinc (2016) showed that patients agreed to commence insulin therapy because their doctors explained how insulin worked and this gave them the confidence to start insulin therapy. People with T2D and clinicians have highlighted the importance of early education on diabetes and its treatment (Brown et al., 2002). However, in an attempt to engage people with T2D in their diabetes self-management healthcare professionals often include inaccurate and harmful language use which may, in effect, delay insulin initiation (Speight, Conn, Dunning, & Skinner, 2012). 2.4 Knowledge of insulin therapy Due to the progressive nature of T2D, a large proportion of people with T2D will, at some point in time require insulin for optimum blood sugar control. Thus, their knowledge of insulin therapy even if they are not using insulin, contributes to the formation of their attitudes towards insulin therapy. Two separate studies in India 13 University of Ghana http://ugspace.ug.edu.gh majority (80-82%) of patients reported that the action of insulin is to lower glucose in the blood (Surendranath et al., 2012: Jagadeesh, Ravi Shankar, & Krishnakanth, 2018). The practical usage of insulin in the management of diabetes remains a challenge, especially in Africa (Ogbera & Kuku, 2012). It is common for people with diabetes to have inadequate knowledge or misconceptions of insulin, especially at the time of initiation by their clinician (Brod et al., 2009). A study in Nigeria, assessing knowledge of insulin among 54 insulin-requiring diabetics revealed about 61.1% of patients had poor knowledge of insulin (Jasper et al., 2014). The lack of understanding of the significance of their condition and the effects of treatment results in most patients contributes to the refusal of insulin initiation thus their glucose control remains poor (Surendranath et al., 2012). Another study involving 1703 participants close to 95% of patients with type 2 diabetes reported to have heard of insulin but only 33% of patients knew how insulin works in the body and only 19% reported the mechanism of action of insulin correctly (Sabei & Sammund, 2015). Inadequate knowledge regarding insulin therapy is likely to influence patients' attitudes toward insulin initiation and adherence. Insulin literacy is lacking in many T2D populations, irrespective of treatment status. The majority of patients with T2D are not conversant with the mechanism of action of insulin (Jasper et al., 2014). Having good knowledge of insulin is associated with age (younger age groups were more knowledgeable of insulin use than their older counterparts), level of education attained (knowledge of insulin increased with the level of education attained) and employment status (Jasper et al., 2014). Knowledge of insulin use, however, was not associated with gender, religion, having a family history of diabetes and duration of illness (Jasper et al., 2014). Although most people with type 2 diabetes seem to have heard about insulin, 14 University of Ghana http://ugspace.ug.edu.gh the majority of them seem to be unaware of how insulin works. This disparity can partly be linked to poor diabetes education or poor insulin-related knowledge among health care professionals (Derr et al., 2007). Studies on insulin acceptance have shown that patients with diabetes who refused insulin lacked knowledge of insulin (Ak et al., 2015). Thus, if insulin needs to be initiated, it is imperative to change negative attitudes of patients towards insulin therapy, especially in patients with little or no education. Such patients require continuous education on the progressive nature of diabetes, the mechanism of insulin action and its role in glycaemic control. 2.5 Psychological Insulin Resistance There have been many studies looking at demographic, clinical and psychosocial factors associated with psychological insulin resistance in people living with T2D (Danne et al., 2015; Khunti et al., 2016; Khunti, Wolden, Thorsted, Andersen, & Davies, 2013). One such of pioneer studies was the International Diabetes Attitudes Wishes and Needs (DAWN) study. This study was the first to provide an insight into potential predictors of attitude towards insulin therapy in people with T2D from 13 countries worldwide (Peyrot et al., 2005). In another landmark study measuring psychological insulin resistance, the UK Prospective Diabetes Study (UKPDS) provided insight into the proportion of people with T2D who refused insulin therapy. This study showed that less than half as many participants refused oral hypoglycemic agents as compared to insulin self-injections (UKPDS, 1995). Quantifying insulin refusal rates among people with T2D may allow estimation of the rate of psychological insulin resistance. However, a major limitation of the use of unvalidated single items to 15 University of Ghana http://ugspace.ug.edu.gh assess patients' attitude towards insulin therapy is the inability to tell the reasons why patients refused insulin therapy. Thus, there is the need to confirm these findings using validated measures of attitudes towards insulin therapy such as Insulin Treatment Appraisal Scale (ITAS). An individual's attitude or beliefs is critical in determining whether he or she will undertake a health behaviour, for example, self-administration of insulin (Michie, Johnston, Francis, Hardeman, & Eccles, 2008). Negative attitudes or perceptions of the impact of insulin use may result in a reluctance to insulin initiation or sometimes outright refusal to insulin initiation. Initiating insulin therapy, therefore, becomes challenging in the clinical setting. One primary reason why patients with T2D often exhibit such reluctance to insulin initiation is that they often fail to understand the need for optimal glycaemic control or its role in preventing complications since symptom severity is not indicative of disease severity (Korytkowski, 2002). The lack of this understanding results in significant resistance to insulin therapy initiation and non- adherence in patients who even agree to start insulin therapy or are on insulin therapy (Marre, 2002). In patients on insulin therapy PIR manifests as omission of insulin injections for several reasons including skipping insulin intentionally to try to lose weight, skipping insulin to reduce interference with daily activities, pain or bruising and social stigma injecting in public (Olmsted et al., 2007; Olveria et al., 2007; Peyrot et al., 2010; Tak-Ying Shiu et al., 2003). These negative attitudes, beliefs and perception of insulin use have been conceptualized into a phenomenon termed as Psychological Insulin Resistance. 16 University of Ghana http://ugspace.ug.edu.gh Psychological Insulin Resistance (PIR) is defined in studies mostly as a diabetes management obstacle influenced by psycho-social factors (cognitive, emotional, relational, and cultural) and not as a psychological disorder (Brod et al., 2009). PIR prevents patients from taking the insulin they need and can cause patients' glycaemic levels to rise beyond recommended targets, and this puts patients at risk for developing complications which can, in turn, increase morbidity and mortality (Nathan et al., 2009). The prevalence of PIR in patients with T2D has been investigated in several studies. A large clinical trial in which patients with T2D were randomised to insulin therapy found that 27% of patients initially refused treatment (UKPDS, 1998). In a survey of 708 community patients with T2D not taking insulin, 28.2% reported that they would not take insulin even if prescribed by their physician (Peyrot et al., 2005; Polonsky et al., 2005). In a single clinic study exploring PIR among a UK Bangladeshi population, one in five participants were reluctant to initiate insulin therapy (Khan et al., 2008). These high insulin refusal rates, a behavioural consequence of psychological insulin resistance puts nearly a third of patients with T2D at a higher risk of poorly controlled blood glucose levels and diabetes-related complications (Peyrot et al., 2005; Polonsky et al., 2005). In another study by Nicholas et al. (2007) in Oregon USA, about 50% of type 2 diabetics with poor glycemic control did not timely start insulin therapy, and the initiation was usually three to five years after the failure of oral hypoglycemic agents. An even higher prevalence of PIR ranging between 51–72% was reported in Asian studies (Nur Azmiah et al., 2011; Wong et al., 2011; Yiu et al., 2010; Khan et al., 2016). In Africa, two studies, one in Kenya (Gulam et al., 2017) and the other in Libya (Sabei & Sammud et al., 2015) showed the prevalence of psychological insulin resistance 17 University of Ghana http://ugspace.ug.edu.gh (PIR) among the study participants to be 82.6% and 94.6% respectively. In Ghana, no studies have been carried out on PIR, and therefore, the need to carry out one is crucial to address patients' concerns regarding the initiation of insulin therapy when required. 2.6 Synthesis of Psychological Insulin Resistance Patients with T2D who are not on insulin therapy usually think insulin is not needed to achieve optimal blood glucose control. They usually doubt the efficacy of insulin (Wen Chen & Tseng, 2012; Tapu-Ta'ala, 2011) and believe that they can achieve optimal blood glucose control without insulin (Guimarães et al., 2010; Noakes, 2010; Tan et al., 2011). They readily indicate their preference for oral hypoglycemic agents (Tan et al., 2011). Participants in one study by Bogatean & Hâncu (2004), indicated that insulin is a personal preference of clinicians which is "in fashion these days", rather than it being of therapeutic necessity. These beliefs about the therapeutic necessity of insulin therapy are common among people of non-western descent. Barriers to insulin initiation in such ethnic minorities include the perception that insulin is an unnatural substance that can harm an individual (Brown et al., 2007). Other studies (Noakes, 2010; Lee et al., 2012) have cited religious beliefs as a barrier to insulin initiation in patients with T2D. Studies examining barriers of insulin therapy among patients with T2D who were on insulin therapy have also reported negative attitudes to insulin therapy (Jenkins et al., 2010). Generally, patients are more willing to initiate insulin therapy when they experience discomforting symptoms or complications of hyperglycaemia (Bogatean & Hâncu, 2004; Phillips, 2007). Unfortunately, asymptomatic patients and those not yet on insulin may not be moved to undertake self-monitoring of blood glucose levels thus may not see the initiation of insulin therapy as necessary (Patel et al., 2015). The impact of insulin therapy on blood glucose control is the most crucial aspect of diabetes 18 University of Ghana http://ugspace.ug.edu.gh management (Stratton et al., 2000). However, patient satisfaction with treatment is key to achieving optimal blood glucose levels. Treatment should incorporate flexibility, convenience and minimal side effects. Negative attitudes/experiences of insulin therapy which can be a barrier to insulin initiation can be categorised into themes which include physical consequences, lifestyle consequences and the implied meaning or symbolism of insulin use and consequences for self- identity (Holmes-Truscott, Pouwer, & Speight, 2014). 2.7 Measurement of Psychological Insulin Resistance Psychological Insulin Resistance is measured quantitatively via two main methods which are the assessment of hypothetical intention to start insulin therapy and evaluation of attitudes towards insulin therapy or insulin therapy appraisals. In assessing hypothetical insulin refusal among people with T2D, the proportion of patients who refuse insulin therapy initiation when recommended by their doctors is estimated as insulin refusal rate. Insulin refusal is assessed using a single item, for example, "If your doctor recommended that you start insulin, how willing would you be to take it?" (Polonsky et al., 2011). This method was used in several studies worldwide with varying insulin refusal rates (Larkin et al., 2008; Lee, 2015; Nur Azmiah, Zulkarnain, & Tahir, 2011; Polonsky, Fisher, Dowe, & Edelman, 2003; Polonsky, Fisher, Guzman, Villa-Caballero, & Edelman, 2005; Polonsky et al., 2011; Wong et al., 2011). Insulin refusal rates range from 6% in Spain to 37% in Italy, with an average of 17% (Polonsky et al., 2011). In Singapore and Malaysia insulin refusal rates among people with type 2 diabetes have been reported to be as high as 71% (Wong et al., 2011) and 51% (Nur Azmiah et al., 2011), respectively. 19 University of Ghana http://ugspace.ug.edu.gh The major limitation of measuring PIR via the assessment of hypothetical intention to start insulin therapy is the inability of this method to capture further information about why a person is unwilling to initiate insulin therapy. Thus, the need to use insulin appraisal scales that explore the positive and negative attitudes toward insulin therapy, which contribute to PIR. Three commonly validated insulin appraisal scales used are the ‘Barriers to Insulin Treatment' questionnaire (Petrak et al., 2007), the ‘Insulin Treatment Appraisal Scale' (Snoek, Skovlund, & Pouwer, 2007) and the ‘Study the Hurdles of Insulin Prescription' questionnaire (Martinez et al., 2007). All three scales measure both positive and negative attitudes towards insulin initiation. However, ‘Study the Hurdles of Insulin Prescription' questionnaire is not specific to T2D. 2.7.1 Insulin Treatment Appraisal Scale (ITAS) ITAS is a validated tool that was developed in the United States of America to capture current appraisal of insulin therapy and assesses both positive and negative attitudes of patients with T2D regardless of insulin use (Snoek, Skovlund, & Pouwer, 2007). It comprises 4 positive and 16 negative statements regarding insulin therapy. Participants are required to indicate on a 5-point Likert scale to what extent he or she agrees with each statement, from 1" strongly disagree" to 5 "strongly agree". Total scores can range from 20 to 100. The total score is estimated by summing all 20 items after reverse scoring the 4 positive attitudes questions. Lower scores indicate more positive attitudes/beliefs about insulin therapy and vice versa (Larkin et al.,2008; Woudenberg et al., 2012). It is, however, essential to note that there are no ITAS cut-off scores to indicate a presence or level of PIR. For this reason, calculating a total ITAS score is mostly useful 20 University of Ghana http://ugspace.ug.edu.gh to assess change in PIR over a period or after an intervention (Holmes-Truscott, 2014) ITAS can also be analysed using two subscales that the positive (4 positive attitude questions) and negative subscales (16 negative attitude questions). Subscales are estimated by taking a sum of relevant items. Higher negative subscale scores indicate greater PIR (Snoek et al., 2007). With the positive subscale, higher scores indicate more positive attitudes towards insulin but do not necessarily indicate less PIR. Although many people with T2D agree on the benefits of insulin, they are still reluctant to use it. Hence, endorsement of positive appraisals of insulin does not suggest an absence of psychological barriers (Lee et al., 2013). Studies have shown that it is preferable to use the positive and negative appraisal subscale scores separately, rather than the total score in measuring PIR (Van Steenbergen-Weijenburg et al., 2010). The ITAS statements can also be grouped into the 5 domains of PIR captured by the ITAS tool as “perceived personal blame, fear, self-pity/social stigma, perceived loss of control and dependence” (Snoek, Skovlund & Pouwer, 2007). 2.7.2 The Barriers to Insulin Treatment (BIT) Questionnaire A validated, quickly interpretable 14 item questionnaire developed in Germany for people with non-insulin-treated T2D (Petrak et al., 2007). The scale is grouped into five components: fear of injection and self-testing, expectations regarding positive insulin- related outcomes, expected hardship from insulin treatment, stigmatization by insulin injections and fear of hypoglycaemia (Petrak et al., 2007). An overall sum score of all values is collated, and the 14 items of the BIT Questionnaire are summarized into a single score. The five components of the BIT Questionnaire address some of the most important psychological barriers to insulin therapy. Each item represents a statement about insulin therapy with response options on a ten-point scale from ‘completely 21 University of Ghana http://ugspace.ug.edu.gh disagree' (0) to ‘completely agree' (10). Total and subscale scores can be calculated by taking a mean of item scores. To date no studies have been done to assess psychological insulin resistance in Ghana, and these tools have not been validated in the country. The ITAS tool was used in this study as it captures the patients' concerns on Insulin therapy, and it can be administered to both insulin naive as well as to insulin-treated patients. 2.8 Factors associated with Psychological Insulin Resistance 2.8.1 Demographic and clinical characteristics There are conflicting findings in various studies regarding the association of demographic factors to PIR. However, most studies have found female patients to have more negative attitudes towards insulin therapy (Fu et al., 2016; Davies et al., 2013; Nur Azmiah et al., 2011; Polonsky et al., 2003; Polonsky et al., 2005) Regarding age and educational status, studies have shown that older patients (Peyrot et al., 2005; Mashitani et al.,2015) and less educated patients (Chen et al., 2011; Wong et al., 2011) are more likely to exhibit PIR. However, Davies et al. (2013) reported in a systemic review that highly educated patients are more likely to exhibit negative attitudes towards insulin therapy. Studies exploring clinical predictors of PIR report that patients with poor glycaemic control and longer duration of diabetes are less likely to exhibit negative attitudes towards insulin therapy (Odawara et al., 2016; Danne et al., 2015; Khunti et al., 2013). The association of PIR with poor glycaemic control and longer duration of diabetes can be partly be due to delay in initiation of insulin by clinicians commonly known as clinical inertia (Peyrot et al., 2005). Unfortunately, the delay of insulin leads to a prolonged state of hyperglycaemia, increasing the risk of diabetic complications. Only 22 University of Ghana http://ugspace.ug.edu.gh one study has reported on the influence of duration of insulin use on negative insulin appraisals using a validated measure (Chen et al., 2011). There was no association between duration of insulin use and insulin appraisals in this study. However, further studies are needed to confirm or refute this finding. 2.8.2 Psychosocial factors Psychosocial barriers to the effective use of insulin have been established by the Diabetes Attitudes Wishes and Needs (DAWN) study to be widespread globally. Out of the 2,061 T2D insulin-naive patients, 57% were apprehensive about starting insulin therapy (Polonsky et al., 2005). Another 48% would blame themselves for failing to manage their diabetes adequately if insulin therapy is recommended for them and only 27% believed that insulin could help them manage their diabetes better (Polonsky et al., 2005). In this study, half of the clinicians interviewed reported that they used insulin as a threat to encourage adherence to treatment plans, which may contribute to patients blaming themselves for failing to manage their diabetes (Polonsky et al., 2005). Clinicians were unaware of the magnitude of the problem of self-blame associated with the reluctance to start insulin therapy in people with T2D (Polonsky et al., 2005). Studies have, however, revealed several other motives or reasons why patients with T2D refuse or avoid insulin or exhibit negative attitudes towards insulin therapy when recommended by a clinician. These negative connotations broadly include a sense of loss of control over one's life, a sense of personal failure to control their diabetes, fear of insulin use as regards needle phobia, weight gain and hypoglycaemia (Gulam et al., 2017). Furthermore, patients may face social stigma and self-pity as they perceive insulin therapy would make them appear sicker before family, friends and colleagues 23 University of Ghana http://ugspace.ug.edu.gh (Khan et al., 2008; Larkin et al., 2008). PIR factors relating to emotional states such as anxiety related to insulin side effects or symptoms such as fear of needles or injection pain tend to be the leading reason patients refuse the initiation of insulin therapy (Gulam et al., 2017). Most patients perceive insulin administration as an invasive and painful process, thus prefer non-injectable therapies (Guimarães et al., 2010; Tan et al., 2011). It has been showed that more than 50% of insulin naive patients with T2D are unwilling to start insulin therapy because of such fears (Khan et al., 2008; Larkin et al., 2008). Other patients also perceive insulin therapy to be a complex treatment regimen and doubt in their ability to administer insulin injections themselves and adjust doses as required (Chen et al., 2012). Others express concerns about the negative consequences of injecting incorrectly (Hassali et al., 2013; Morris et al., 2005). Concerns about the side effects of insulin use are commonly reported in both patients, regardless of insulin use. Among these side effects mentioned include weight gain and hypoglycemia (Guimarães et al., 2010; Tan et al., 2011), and bruising from injection sites (Hayes et al., 2006). The fear of hypoglycaemia is accompanied by a variety of profound cognitive, emotional and behavioural effects, which result in PIR (Karter et al., 2010). Hypoglycaemia is a concern, usually patients already on insulin. Such patients are reluctant to intensify insulin therapy because of the increased risk of experiencing hypoglycaemia (Simon, Gude, Holleman, Hoekstra, & Peek, 2014; Tong, Vethakkan, & Ng, 2015). A study by Larkin et al. (2008) showed that patients taking insulin gained more weight as compared to those on diet therapy, and this contributes significantly to PIR. Another factor associated with PIR is the fear of dependence (Larkin et al., 2008). Misconceptions of dependence on insulin akin to injection drug abusers also hinder the initiation and use of insulin. About 39% of patients with type 2 24 University of Ghana http://ugspace.ug.edu.gh diabetes not receiving insulin indicated that fear of addiction to insulin was a barrier to insulin therapy (Larkin et al., 2008). Cognitive predictors of PIR identified by Karter et al (2010) include lack of knowledge about insulin therapy, perceived interference with daily activities (close to 50% of patients believe that insulin would restrict their lives), the belief that taking insulin is a sign that their diabetes had become worse, perception of personal failure (about half of patients not taking insulin believed that starting this treatment would mean that they had not followed treatment recommendations correctly), belief that insulin causes complications, not regarding diabetes as severe enough (about 47% of patients not receiving insulin argue that their illness is not so severe and, thus, they do not need to begin insulin treatment) and low self-efficacy that is some of the patients do not feel confident that they could handle the day-to-day demands of insulin therapy (Karter et al., 2010; Makine et al., 2009; Bogatean et al., 2004; Blonde, 2007). Other factors associated with PIR cited in literature include beliefs that insulin is not effective in managing hyperglycemia and beliefs that proper glycaemic levels are achievable by exercising, strict diet and oral medications (Blonde, 2007; Karter et al., 2010). The social stigma associated with insulin self-injections is another critical factor associated with PIR which has been neglected (Browne, Ventura, Mosely, & Speight, 2013; Kalra & Baruah, 2015; Schabert, Browne, Mosely, & Speight, 2013). The use of needles and syringes are usually associated with intravenous drug addicts or severe illness (Tak-Ying Shiu, Kwan & Wong, 2003). Patient fears of injecting insulin in public places due to embarrassment or empathy from family and friends have been found to negatively influence optimal diabetes self-management with reports of 25 University of Ghana http://ugspace.ug.edu.gh omission or delaying insulin doses (Abu Hassan et al., 2013; Jenkins et al., 2011; Funnell, 2008; Tak-Ying Shiu, Kwan & Wong, 2003). The general perception of the complicated regimen of insulin self-injection among most people with T2D is that it is burdensome and requires much daily effort to monitor blood glucose and adjust insulin doses. As many such patients feel they might not be able to manage their diabetes by themselves resulting in their dependence on family members to support them with self-monitoring activities (Chen et al., 2012; Guimarães et al., 2010; Khan et al., 2008; Tan et al., 2011). Further studies (Abu Hassan et al., 2013; Patel et al., 2015; Lee et al., 2015) reported a family history of insulin use or observations of insulin experience of friends and close relatives contributes to the development of one's beliefs and attitudes towards insulin therapy. Conversely, other studies have reported that family misconceptions about insulin as barriers to insulin initiation, especially among non-western cultures (Khan et al., 2008; Patel et al., 2015). Another concern is "the inconvenience of insulin and the hassle it places on eating times and restrictions surrounding daily activities" (Abu Hassan et al., 2013). Lastly, the common belief among people with type 2 diabetes that initiation of insulin is synonymous to increasing severity of diabetes also contributes to the exhibition of negative attitudes towards insulin (Chen et al., 2012). It is interesting to note that the negative appraisal of insulin treatment by patients is modifiable by the initiation of insulin therapy (Hermanns, Mahr, Kulzer, Skovlund & Haak, 2010). This finding indicates that psychological insulin resistance is somewhat temporary and can be reversible if addressed appropriately. 26 University of Ghana http://ugspace.ug.edu.gh 2.9 Psychological insulin resistance and type of medication used In general patients with T2D on insulin in comparison to those on oral hypoglycemic agents have been found to report less negative ITAS scores (Bahrmann et al., 2014; Chen et al., 2011; Hermanns, Mahr, Kulzer, Skovlund & Haak, 2010; Snoek et al., 2007). The less negative ITAS scores observed between the two groups is because initiation of insulin may attenuate negative attitudes to insulin therapy due to the patient's insulin experience or simply because those on insulin already have less negative attitudes towards insulin. Further studies reveal that people with type 2 diabetes who initially were on oral hypoglycemic agents and started insulin therapy exhibited significantly less negative ITAS score (Hermanns et al., 2010; Liebl et al., 2013). However, a minority of insulin users exhibit negative attitudes towards insulin, of which the most commonly endorsed negative ITAS item is pain from insulin use (Snoek et al., 2007). Negative attitudes such as pain and embarrassment exhibited by insulin users towards insulin therapy may result in insulin omission or refusal to insulin dose intensification (Davies et al., 2013; Farsaei, Radfar, Heydari, Abbasi, & Qorbani; Peyrot et al., 2012). 2.10 Psychological Insulin Resistance as an on-going process The problem of PIR seems to be an on-going process which is solved by initiating insulin therapy. Studies have shown in general most patients with PIR were satisfied and continued insulin therapy after its initiation (Nam, Chesla, Stotts, Kroon & Janson, 2010). Patients' negative attitudes decreased after initiation of insulin therapy and would even recommend insulin to other patients (Polonsky & Jackson, 2004). A longitudinal study by Nathan et al. (2009) investigating PIR among patients who had initiated insulin therapy showed that about 43% of patients initially refused initiation 27 University of Ghana http://ugspace.ug.edu.gh of insulin therapy. At 6 months, half of the patients who initially refused insulin therapy started insulin treatment. Unfortunately, the other half was still reluctant to start insulin therapy after repeated counselling. Refusal to start insulin therapy may be very persistent, and some patients may not change their negative attitudes to insulin therapy as their diabetes progresses (Nathan et al., 2009). Additional longitudinal studies on PIR will be necessary to see how attitudes and behaviours deepen or change as the disease progresses. 2.11 Strategies for reducing Psychological Insulin Resistance Understanding the attitudes of patients with type 2 diabetes towards insulin initiation and how they develop is vital in helping reduce psychological insulin resistance. In addition to improving the receptiveness of insulin therapy among patients with type 2 diabetes, it is necessary to explore patients' perceptions and beliefs about diabetes and treatment modalities. Until 2012, no interventions had been developed to reduce psychological insulin resistance. However recent years have seen the development of pilot interventions to enhance attitudes toward or education about insulin therapy (Patel, Stone, Hadjiconstantinou, et al., 2015). Continuous and periodic patient education on the natural history of diabetes before they need insulin and introduction of the concept of insulin therapy right from the onset of diagnosis. Patient education should aim at breaking identifiable barriers to insulin initiation and at the same time tackling patient refusal to insulin therapy initiation by providing substantial evidence through experiences of other insulin users or publications. In a qualitative study Hassali et al., (2013) concluded that people with T2D were more receptive to insulin therapy after 28 University of Ghana http://ugspace.ug.edu.gh receiving education from healthcare professionals. Physicians should be encouraged to explain to patients the role of insulin, maintaining glucose homeostasis and insulin action times to prevent hypoglycemias. Health workers can also teach patients strategies to help minimise weight gain. Physicians should also further explain the action of newer and more flexible types of insulin that allow more flexibility for the daily schedule and offer more privacy. These pens have been reported by patients as user friendly (Hu et al., 2012; Jenkins et al., 2010; Tan et al., 2011). Primarily patient education should be tailored to address specific concerns or fears of individuals. Strategies to reduce PIR include exposing patients to an insulin injection under medical supervision, encouraging patients to try insulin for a short period of time while monitoring the factors that one is afraid of, negotiating an insulin therapy schema adapted to patients' schedules, systematic desensitisation and motivational interviewing with sharing success stories of other patients' experiences (Nathan et al., 2009; Rosenblum et al., 2003). General relief after injecting insulin for the first time is commonly reported by patients (Furler et al., 2011; Hayes et al., 2006; Jenkins et al., 2010; Morris et al., 2005; Noakes, 2010; Tapu-Ta'ala, 2011). Sometimes inclusion family or close persons of the patient in insulin education programmes and outlining their roles in the individual's healthcare has proven to reduce PIR (Hu et al., 2012; Patel et al., 2012). 29 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODS 3.1 STUDY DESIGN This study employed a descriptive cross-sectional type of design. 3.2 STUDY AREA The study was conducted at the Ledzokuku - Krowor Municipal Assembly (LEKMA) Hospital, situated at Teshie within the Greater Accra Region. The LEKMA hospital is a 100-bed capacity hospital with various specialist services, laboratory and radiological facilities. The hospital has a Diabetes Clinic with close to 1200 patients enrolled, which runs twice a week on Tuesdays and Thursdays. The study took place between April 2019 to June 2019 at the Diabetes clinic of LEKMA hospital. Figure 2: Location of study area 30 University of Ghana http://ugspace.ug.edu.gh 3.3 VARIABLES 3.3.1 DEPENDENT VARIABLE The primary outcome (dependent) variable in this study was the Psychological insulin resistance, which was measured using the Insulin Treatment Appraisal Scale. The primary outcome variable was a categorical variable. 3.3.2 INDEPENDENT VARIABLES Table 1: Operational definition of variables Variables Operational Indicator Variable definition type Age Self-reported age of Age at last birth day continuous respondent at last birth day Sex Self- reported gender Male or Female categorical of respondent Educational status Self-reported highest No education; Primary; categorical educational level Junior High School; attained Secondary; Tertiary Occupation Self-reported occupation Employed categorical Unemployed Retired 31 University of Ghana http://ugspace.ug.edu.gh Fasting blood Value of fasting blood > 6 mmol/l: poor categorical glucose glucose on day of glycaemia control clinic visit ≤ 6 mmol/l: good glycaemia Diabetes Type of treatment Insulin categorical medication patient is on Oral hypoglycemic agents Both Duration of Insulin Patient reported duration One year and less categorical use of insulin use More than a year Duration of Patient reported Less than a year categorical Diabetes duration of disease 1-4 years from year of first 5-9 years diagnosis 10 years or more Family history of Self-reported Family Yes or No categorical Diabetes history of diabetes Purchase of Source funds for Self categorical medications purchase of medication Other 32 University of Ghana http://ugspace.ug.edu.gh 3.4 STUDY POPULATION People diagnosed with type 2 diabetes attending routine care at the diabetes clinic at LEKMA Hospital. 3.4.1 INCLUSION CRITERIA Patients with confirmed diagnosis of type 2 diabetes based on the criteria set by the International Diabetic Federation 2017 which is fasting plasma glucose ≥ 7.0mmol/l or a random glucose > 11.1mmol/L or HbA1c ≥ 6.5%. Age at diagnosis of diabetes ≥ 18 Years. 

 3.4.2 EXCLUSION CRITERIA Patients with type 2 diabetes on follow up for any psychiatric illness and dementia as indicated in medical records.
Psychiatric illness was defined as a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory and therefore making it difficult for such a patient to participate in the study which entails obtaining accurate responses to the ITAS tool and the structured questionnaire. Patients with any physical impediment to insulin use. For example, the blind or amputated upper limbs. 3.5 SAMPLING TECHNIQUE Study participants were selected and enrolled from all people diagnosed with T2D attending the Diabetes clinic at LEKMA Hospital for routine follow up using a systematic random sampling procedure. The list of patients registered for the day formed a sampling frame for drawing the study sample. Based on systematic random sampling, every third patient who met the inclusion criteria was enrolled into the study 33 University of Ghana http://ugspace.ug.edu.gh after consent was sought and given. Patients were interviewed while they waited to see the doctor. Fasting blood glucose values were retrieved from the clinic register. 3.6 SAMPLE SIZE The sample size was calculated using the single population proportion formula, 𝑍2 𝑝𝑞 𝑁 = 2 𝑑 where "P" is the estimated prevalence of PIR in type 2 diabetic patients from previous studies, and "d" is the acceptable margin of error. N = sample size, 𝒛 = reliability coefficient of 1.96 𝒅 = error allowance of 0.05 The following assumptions were made: d is 5%, (Z1−α/2) at 95% confidence interval is 1.96 𝒑 = proportion of PIR of 83% = 0.83 Prevalence of PIR in studies in Kenya and Libya is estimated at 82.6% and 94.6% respectively (Gulam et al., 2017; Sabei and Sammud, 2015). However, prevalence of PIR in Kenya was used in this study due to similarities in socio-economic and cultural practices as compared to Libya. 𝒒 = 1- 𝑝 = 1-0.83=0.17 N= (1.96)2(0.83) (0.17)/ (0.05)2=217 Population size at diabetes clinic=1198. Using the finite population correction factor, n = n0*N n0 + (N - 1) 34 University of Ghana http://ugspace.ug.edu.gh where n is the sample size with the finite population correction factor n0 is the sample size N is the population size N= (217*1198) / 217 + (1198-1) = 184 Adjusting for 10% of non-response rate gives a total of 203 patients to be interviewed. 3.7 DATA COLLECTION TECHNIQUES Data were collected by trained research assistants once consent was sought. The patients enrolled in the study were interviewed using a structured questionnaire and a standard validated tool called Insulin Treatment Appraisal Scale (ITAS) (Snoek, Skovlund, & Pouwer, 2007) to collect data on insulin therapy in people with T2D. Both the questionnaire and the ITAS tool were interviewer-administered. Included in the structured questionnaire were socio-demographic and clinical characteristics including age, sex, educational status, marital status, occupation, family history of diabetes, diabetes medication, purchase of medicine, national health insurance status, duration of diabetes, duration of insulin use and fasting blood glucose. Questions to assess patients' knowledge of insulin therapy was also included. Insulin Treatment Appraisal Scale (ITAS) is a validated tool that was developed to assess both positive and negative attitudes towards insulin therapy among people with type 2 diabetes. It comprises 4 positive and 16 negative statements regarding insulin therapy. Participants were asked to indicate on a 5-point Likert scale to what extent he or she agrees with each statement, from 1" strongly disagree" to 5 "strongly agree". The four positive statements were reverse-scored before totalling. Scores can range from 20 to 100. To determine patients with PIR, the total negative subscale score was 35 University of Ghana http://ugspace.ug.edu.gh used. Scores can range from 16 to 80. Higher negative subscale scores represented more negative attitudes and beliefs about insulin therapy. 3.8 QUALITY CONTROL The research assistants were well trained. The measurement scales included in the data collection tool that was used in the study was previously validated in other studies and deemed appropriate for the purpose for which they were used in terms of perception and compliance. Respondent personal information was private and treated with confidentiality during data collection and analysis. Data collected were manually checked to ensure the absence of errors and distortions of participants answers as well as its completeness. 3.9 DATA PROCESSING Data from questionnaires were first entered into an Excel work sheet and then imported into Stata version 15, coded and cleaned. 3.10 DATA ANALYSIS Stata version 15 was used to analyse data obtained using significance level of 5% and 95% confidence interval. Means and standard deviations were reported for continuous variables and proportions for categorical variables. Each of the ITAS statement was analysed and grouped into the 5 domains of PIR captured by the ITAS tool that is perceived personal blame, fear, self-pity/social stigma, perceived loss of control and dependence. Pearson's Chi-square test was used to compare categorical variables and student t-test was used to compare means. Multivariate logistic regression analysis was used to assess the relationship between the independent and binary outcome variable. 36 University of Ghana http://ugspace.ug.edu.gh The multivariable logistic regression model was fitted using a backwards stepwise approach. A p-value of less than 0.05 was considered to be statistically significant. The variance inflation factor and tolerance statistics were used to test for multicollinearity. A variance inflation factor greater than 10 or tolerance statistics less than 0.10 indicates the presence of multicollinearity. Odds ratios were presented to show the likelihood of associations between variables. After analysis, data was presented in the form of tables and graphs.
 3.11 ETHICAL CLEARANCE Ethical clearance was sought and obtained from the Review Committee of the Ghana Health Service (GHS-ERC018/01/19). Approval for the study to be carried at Diabetes Clinic, LEKMA hospital was sought from the Medical Director of the facility and OPD in charge. Informed consent and assent were obtained from all study participants. This was done by explaining all the objectives of the study and procedures entirely to all participants either in English or translated into their preferred local dialect. Persons who agree to participate were made to sign or thumbprint in the presence of a witness who also signed or thumb-printed the same consent form. All the wishes of potential and enrolled participants in the study were respected by permitting withdrawal from the study at any time and protecting their privacy by providing unique identification numbers for each participant. The names or identity of participants were not revealed in any report that subsequently comes out of this study. All completed questionnaires were kept in boxes in a cabinet under lock and key to ensure confidentiality. Access to the final password-protected database was restricted to only the principal investigator. The study has no potential risks to the participants or facilities. Participants with PIR 37 University of Ghana http://ugspace.ug.edu.gh were enrolled in counselling sessions to help address their concerns. There was no compensation in any form for any participant. 3.12 PRE-TESTING The data collection instrument was pre-tested among 20 patients with T2D at the La General Hospital. All errors /omissions in the data collection instrument were duly corrected before the final data collection. 38 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS A total of two hundred and three (203) patients with type 2 diabetes who met the inclusion criteria and gave informed consent were enrolled into the cross-sectional study at the Ledzokuku - Krowor Municipal Assembly (LEKMA) Hospital in Teshie, Accra between April 2019 and June 2019. 4.1 Socio-Demographic characteristics of study participants Table 2 depicts the demographic characteristics of the study participants. The study participants consisted of forty- eight (48) males and one hundred and fifty-five females (155). The mean age of the study population was 59.9 (11.7) years, with ages ranging between 24-90 years. Most of the study participants (31%) were between 60-69 years of age. More than half (58.1%) of the patients were married, and almost all of them (99%) were enrolled in the National Health Insurance Scheme. Eighty (39.4%) of the patients had completed Senior High School with twenty-seven (13.3%) participants reporting no form of formal education. Majority of study participants (63.5%) were gainfully employed. 4.2 Clinical Characteristics of study participants Table 3 presents the clinical characteristics of the study sample. The majority (83.7%,170/203) of patients were on oral hypoglycemic agents alone, 12.8% (26/203) were on both insulin and oral hypoglycemic agents, and only 3.5% were on insulin alone. The mean duration of type 2 diabetes was 6.6 years, with a range of between 2 weeks to 35 years. Majority of the patients (37.9%) studied were living with diabetes for the past 1-4 years. About thirty-four patients (16.7%) had lived with diabetes for 11 39 University of Ghana http://ugspace.ug.edu.gh years or more. Patients on Insulin therapy had used insulin ranging from 1month to 25 years. Out of the two hundred and three study participants with type 2 diabetes, 48.3% had a positive family history of diabetes (Table 3). The mean fasting blood glucose of the study population was 8.7 mmol/l with a range of 3.2-23.5 mmol/l. Majority of the study subjects (77.8%) had poor glycaemic control in reference to their fasting blood glucose on the day of clinic attendance. Table 2: Demographic characteristics of study participants Demography Frequency Percentage Minimum Maximum Mean(SD) N=203 % Age group 24 90 59.9(11.7) ≤39 11 5.4 40-49 23 11.3 50-59 59 29.1 60-69 63 31 70+ 47 23.2 Sex Male 48 23.6 Female 155 76.4 NHIS Yes 201 99 No 2 1 Marital status Married 118 58.1 Divorced/Separated 32 15.8 Widow/Widower 44 21.7 Educational status None 27 13.3 Primary 33 16.3 JHS 31 15.3 SHS 80 39.4 Tertiary 32 15.8 Occupation Retired 40 19.7 Unemployed 34 16.7 Working 129 63.5 40 University of Ghana http://ugspace.ug.edu.gh Table 3: Clinical characteristics of study participants Clinical characteristics Frequency Percentage Minimum Maximum Mean(SD) N=203 % Medication Insulin 7 3.5 Oral hypoglycemic agent 170 83.7 Both 26 12.8 Duration of insulin use in 0.08 25 0.8(3.4) years None 171 84.2 ≤1 14 6.9 >1 18 8.9 Duration of illness in years 0.04 35 6.6(6.3) <1 19 9.4 1-4 77 37.9 5-10 73 36 ≥11 34 16.7 Family history No 105 51.7 Yes 98 48.3 Glycemic control 3.2 23.5 8.7(3.7) Good 45 22.2 Poor 158 77.8 4.3 Prevalence of insulin use and associated factors The prevalence of insulin use among patients (figure 3) was estimated to be 16.3%. Of this, 8.9% of insulin users had used insulin for 1 year and above, as shown in figure 4. 41 University of Ghana http://ugspace.ug.edu.gh 100 90 83.7 80 70 60 50 40 30 16.3 20 10 0 Insulin OHA Medication Figure 3: Prevalence of insulin use among study participants showing 95% Confidence interval 10.0 8.9 9.0 8.0 7.0 6.9 6.0 5.0 4.0 3.0 2.0 1.0 0.0 ≤1 >1 Duration of insulin use in years Figure 4: Patterns of duration of insulin use among insulin users 42 Percentage frequency Percentage frequency University of Ghana http://ugspace.ug.edu.gh Insulin use by demographic characteristics (table 4) showed that patients within the age group 50-59 years used more insulin (22.0%). Greater proportion of patients within the age group 70 years and above used oral hypoglycemic agents (91.5%). There were no differences in the type of medication used by sex (16.7% vs 16.1%). Interestingly, all patients who were not holding a valid NHIS used oral hypoglycemic agents, whiles 16.4% of patients on NHIS were on insulin. Patients who had been diagnosed with T2D for 11 years or more had more insulin users (38.2%). In contrast, all patients who had been diagnosed with diabetes less than 1 year used oral hypoglycemic agents. The proportion of patients with a family history of diabetes and poor glycaemic control who used insulin was 23.5% and 18.9% respectively. Type of medication used by demographic characteristics showed age group, duration of illness and family history to be significantly associated with type of medication. 43 University of Ghana http://ugspace.ug.edu.gh Table 4: Prevalence and association of insulin use by demographic and clinical characteristics of study participants Variable Medication χ2(P-value) Insulin Oral hypoglycemic agent Total n=33(16.3) n=170(83.7) N=203 n (%) n (%) n (%) Age group 13.01(0.011) * <=39 5(45.5) 6(54.5) 11 40-49 5(21.7) 18(78.3) 23 50-59 13(22.0) 46(78.0) 59 60-69 6(9.5) 57(90.5) 63 70+ 4(8.5) 43(91.5) 47 Sex 0.01(0.930) Male 8(16.7) 40(83.3) 48 Female 25(16.1) 130(83.9) 155 NHIS (1.000)** Yes 33(16.4) 168(83.6) 201 No 0(0) 2(100) 2 Marital status 7.11(0.068) Single 3(33.3) 6(66.7) 9 Married 23(19.5) 95(80.5) 118 Divorced/Separated 1(3.1) 31(96.9) 32 Widow/Widower 6(13.6) 38(86.4) 44 Education primary 4.21(0.379) None 1(3.7) 26(96.3) 27 Primary 5(15.2) 28(84.8) 33 JHS 6(19.4) 25(80.6) 31 SHS 14(17.5) 66(82.5) 80 Tertiary 7(21.9) 25(78.1) 32 Occupation 1.95(0.377) Retired 6(15.0) 34(85.0) 40 Unemployed 3(8.8) 31(91.2) 34 Working 24(18.6) 105(81.4) 129 Duration of illness 17.28(0.001) * <1 0(0.0) 19(100) 19 1-4 12(15.6) 65(84.4) 77 5-10 8(11.0) 65(89.0) 73 ≥11 13(38.2) 21(61.8) 34 Family history 7.24(0.007) * No 10(9.5) 95(90.5) 105 Yes 23(23.5) 75(76.5) 98 Glycemic control 2.31(0.129) Good 4(8.9) 41(91.1) 45 Poor 29(18.4) 129(81.6) 158 * p < 0.05 – statistically significant **Fisher’s exact test 44 University of Ghana http://ugspace.ug.edu.gh 4.4 Knowledge of insulin therapy The majority (64.0%) of patients in this study had heard of insulin, but only 22.2% of the one hundred and thirty patients reported knowing how insulin works in the body (table 5a). This is evident since the majority (78.3%) of the study participants had no idea of the mechanism of action of insulin. Only 21.2% of patients reported correctly the mechanism of action of insulin, which is the regulation of blood glucose levels in the body (table 5a). Table 5b shows that about 22.7% and 9.4% of patients agreed and strongly agreed that error in insulin dose could cause side effects respectively. Another 21.7% and 7.4% of patients agreed and strongly agreed respectively, that error in injection technique could cause side effects. Also, 16.7% and 9.9% of patients agreed and strongly agreed that improper storage of insulin could affect glucose control respectively. Table 5a: Knowledge assessment of insulin therapy among study participants Variable Frequency Percentage Heard of insulin No 73 36 Yes 130 64 Total 203 100 Know how insulin works No 158 77.8 Yes 45 22.2 Total 203 100 Mode of action No idea 159 78.3 Makes one hungry 1 0.5 Reduce blood sugar 43 21.2 Total 203 100 45 University of Ghana http://ugspace.ug.edu.gh Table 5b: Knowledge assessment of insulin therapy among study participants Strongly Strongly Variable disagree Disagree Don't know Agree agree Error in insulin dose can cause side effect 28(13.8) 110(54.2) 46(22.7) 19(9.4) Error in injection technique can cause side effect 26(12.8) 1(0.5) 117(57.6) 44(21.7) 15(7.4) Improper storage of insulin dose can affect glucose control 26(12.8) 123(60.6) 34(16.7) 20(9.9) Overall knowledge assessment shows that, only 21.2% diabetic patients had good knowledge of insulin therapy (figure 5). 90 78.8 80 70 60 50 40 21.2 30 20 10 0 Poor Good Knowledge of insulin therapy Figure 5: Overall levels of knowledge assessment on insulin therapy among diabetic patients 46 Percentage frequency University of Ghana http://ugspace.ug.edu.gh 4.5 Factors associated with knowledge of insulin therapy Patterns and association of demographic characteristics with knowledge of insulin therapy (table 6) showed that a significant proportion (46.9%) of patients with tertiary education had good knowledge of insulin therapy. While majority (92.6%) who had no education had poor knowledge of insulin therapy. Among patients living with T2D for 11 years, or more, 50.0% exhibited poor knowledge of insulin therapy. While among patients living with T2D for less than 1 year an overwhelming 94.7% of patients exhibited poor knowledge of insulin therapy. Additionally, a higher proportion (87.6%) of those with no family history had poor knowledge of insulin therapy. Patients who used insulin exhibited better knowledge of insulin therapy (66.7%) as compared to those on oral hypoglycemic agents who exhibited poor knowledge of insulin therapy (87.7%). Insulin users with insulin use duration of 1 year and below showed better knowledge of insulin therapy (64.3%).The following characteristics, educational status, duration of illness, family history of diabetes, type of medication used and duration of insulin use were associated with knowledge of insulin therapy. 47 University of Ghana http://ugspace.ug.edu.gh Table 6: Prevalence and association of knowledge of insulin therapy by demographic characteristics among diabetic patients Variable Knowledge of insulin therapy Poor=160(78.8) Good=43(21.2) N=203 χ2(P-value) n (%) n (%) n (%) Age group 7.57(0.109) ≤39 6(54.5) 5(45.5) 11 40-49 16(69.6) 7(30.4) 23 50-59 45(76.3) 14(23.7) 59 60-69 54(85.7) 9(14.3) 63 70+ 39(83.0) 8(17.0) 47 Sex 0.11(0.736) Male 37(77.1) 11(22.9) 48 Female 123(79.4) 32(20.6) 155 NHIS 1.00(0.316) Yes 159(79.1) 42(20.9) 201 No 1(50.0) 1(50.0) 2 Marital status 3.94(0.268) Single 6(66.7) 3(33.3) 9 Married 90(76.3) 28(23.7) 118 Divorced/Separated 29(90.6) 3(9.4) 32 Widow/Widower 35(79.5) 9(20.5) 44 Education status 17.83(0.001) * None 25(92.6) 2(7.4) 27 Primary 25(75.8) 8(24.2) 33 JHS 27(87.1) 4(12.9) 31 SHS 66(82.5) 14(17.5) 80 Tertiary 17(53.1) 15(46.9) 32 Occupation 2.80(0.247) Retired 28(70.0) 12(30.0) 40 Unemployed 29(85.3) 5(14.7) 34 Working 103(79.8) 26(20.2) 129 Duration of illness 21.63(0.000) * <1 18(94.7) 1(5.3) 19 1-4 64(83.1) 13(16.9) 77 5-10 61(83.6) 12(16.4) 73 ≥11 17(50.0) 17(50.0) 34 Family history 10.09(0.001) * No 92(87.6) 13(12.4) 105 Yes 68(69.4) 30(30.6) 98 Glycemic control 1.10(0.295) Good 38(84.4) 7(15.6) 45 Poor 122(77.2) 36(22.8) 158 Medication 48.83(0.000) * Insulin 11(33.3) 22(66.7) 33 Oral Hypoglycemic agent 149(87.6) 21(12.4) 170 Duration of insulin use 38.89(0.000) * None 148(86.5) 23(13.5) 171 ≤1 5(35.7) 9(64.3) 14 48 University of Ghana http://ugspace.ug.edu.gh >1 7(38.9) 11(61.1) 18 * p < 0.05 – statistically significant 4.6 Prevalence of Psychological Insulin Resistance and associated factors The mean total Insulin Treatment Appraisal Scale (ITAS) score for the study population was 59.2 whiles mean ITAS negative score was 48.6. Prevalence of psychological insulin resistance (figure 6) among patients was estimated to be 57.1%. This represents the proportion of patients that scored 4 or higher on the negative insulin appraisal subscale items, which indicates likely barriers to insulin use. 
 70 57.1 60 50 42.9 40 30 20 10 0 No Yes PIR status Figure 6: Prevalence of Psychological Insulin Resistance among study participants 49 Percentage fregquency University of Ghana http://ugspace.ug.edu.gh Table 7 shows the association of psychological insulin resistance by demographic and clinical factors in the study population. The associated factors are discussed below: 4.6.1 Age and sex There were no statistically significant differences in PIR by age and sex (Table 7). 4.6.2 Educational and Occupational status There was a significant association between educational status and patients' attitude towards insulin therapy (p=0.015). Patients who had at least tertiary education exhibited less negative attitudes. Only 31.3% of patients with tertiary education demonstrated negative attitudes toward insulin therapy in comparison with patients with primary, high school or no education. Likewise, occupational status and patients' attitude towards insulin therapy showed a significant association (p=0.012). Greater proportion of patients who were unemployed (79.4%) or on retirement (57.5%) exhibited resistance to insulin therapy. 4.6.3 Family history and duration of diabetes Family history and the duration of diabetes were not associated with patients' attitude towards insulin therapy (Table 7). 4.6.4 Diabetes medications A higher proportion (60.6%) of patients on oral hypoglycemic agent had a more negative attitude towards insulin therapy compared to 39.4% of those on insulin, and this was statistically significant (p=0.024). However, the duration of insulin use was not associated with psychological insulin resistance (p=0.248). 50 University of Ghana http://ugspace.ug.edu.gh 4.6.5 Knowledge of Insulin therapy There was a significant association between knowledge of insulin therapy and psychological insulin resistance (p=0.000). Majority of patients (67.4%) who had good knowledge of insulin therapy exhibited less negative attitudes as compared to the patients with poor knowledge of insulin. 51 University of Ghana http://ugspace.ug.edu.gh Table 7: Prevalence and association of Psychological Insulin Resistance by demographic and clinical characteristics of study participants Variable Resistance χ2(P-value) No=87(42.9) Yes=116(57.1) N=203 n (%) n (%) n (%) Age group 5.98(0.201) ≤39 8(72.7) 3(27.3) 11 40-49 12(52.2) 11(47.8) 23 50-59 25(42.4) 34(57.6) 59 60-69 23(36.5) 40(63.5) 63 70+ 19(40.4) 28(59.6) 47 Sex 0.04(0.849) Male 20(41.7) 28(58.3) 48 Female 67(43.2) 88(56.8) 155 NHIS Total 1.51(0.218) Yes 87(43.3) 114(56.7) 201 No 0(0.0) 2(100) 2 Marital status 4.75(0.191) Single 3(33.3) 6(66.7) 9 Married 56(47.5) 62(52.5) 118 Divorced/Separated 15(46.9) 17(53.1) 32 Widow/Widower 13(29.5) 31(70.5) 44 Educational status 12.30(0.015) * None 9(33.3) 18(66.7) 27 Primary 16(48.5) 17(51.5) 33 JHS 11(35.5) 20(64.5) 31 SHS 29(36.3) 51(63.7) 80 Tertiary 22(68.8) 10(31.3) 32 Occupation 8.77(0.012) * Retired 17(42.5) 23(57.5) 40 Unemployed 7(20.6) 27(79.4) 34 Working 63(48.8) 66(51.2) 129 Duration of illness 4.94(0.176) <1 9(47.4) 10(52.6) 19 1-4 31(40.3) 46(59.7) 77 5-10 27(37.0) 46(63.0) 73 ≥11 20(58.8) 14(41.2) 34 Family history 0.00(1.000) No 45(42.9) 60(57.1) 105 Yes 42(42.9) 56(57.1) 98 Glycemic control 2.59(0.107) Good 24(53.3) 21(46.7) 45 Poor 63(39.9) 95(60.1) 158 Medication 5.07(0.024)* Insulin 20(60.6) 13(39.4) 33 Oral Hypoglycemic agents 67(39.4) 103(60.6) 170 Duration of insulin 2.79(0.248) None 69(40.4) 102(59.6) 171 ≤1 8(57.1) 6(42.9) 14 >1 10(55.6) 8(44.4) 18 52 University of Ghana http://ugspace.ug.edu.gh Knowledge of insulin therapy 13.46(0.000) * Good 29(67.4) 14(32.6) 43 Poor 58(36.2) 102(63.8) 160 * p < 0.05 – statistically significant 4.7 Patients’ attitude towards insulin therapy Table 8 represents the scores for each of the 20 questions on the insulin treatment appraisal score. Negative attitudes towards insulin therapy were grouped into domains of psychological insulin resistance (see table 9 and fig 7). The most common negative attitude exhibited among the study participants was injection phobia (59.6%) followed by painful injection (44.8%) and then being embarrassed about injecting themselves (32%). The mean positive ITAS score among patients was 13.3. Overall, only 36% of the study population exhibited positive attitudes towards insulin therapy. 53 University of Ghana http://ugspace.ug.edu.gh Table 8: Descriptive analysis of attitudes on the Insulin Treatment Appraisal Scale Strongly Strongly Variable Disagree Disagree Don't know Agree Agree Q1 6(3.0) 33(16.3) 123(60.6) 38(18.7) 3(1.5) Q2 2(1.0) 20(9.9) 123(60.6) 55(27.1) 3(1.5) Q3* 0(0.0) 3(1.5) 122(60.1) 72(35.5) 6(3.0) Q4 0(0.0) 35(17.2) 110(54.2) 55(27.1) 3(1.5) Q5 1(0.5) 15(7.4) 144(70.9) 41(20.2) 2(1.0) Q6 4(2.0) 57(28.1) 21(10.3) 102(50.2) 19(9.4) Q7 0(0.0) 20(9.9) 151(74.4) 30(14.8) 2(1.0) Q8* 0(0.0) 5(2.5) 129(63.6) 66(32.5) 3(1.5) Q9 3(1.5) 26(12.8) 160(78.8) 14(6.9) 0(0.0) Q10 1(0.5) 25(12.3) 152(74.9) 21(10.3) 4(2.0) Q11 2(1.0) 52(25.6) 131(64.5) 13(6.4) 5(2.5) Q12 1(1.0) 72(35.5) 118(58.1) 12(5.9) 0(0.0) Q13 1(0.5) 51(25.1) 89(42.4) 61(30.0) 4(2.0) Q14 0(0.0) 19(9.4) 85(41.9) 83(40.9) 16(7.9) Q15 0(0.0) 49(24.1) 128(63.1) 26(12.8) 0(0.0) Q16 0(0.0) 52(25.6) 129(63.5) 20(9.9) 2(1.0) Q17* 0(0.0) 7(3.5) 123(60.6) 63(31.0) 10(4.9) Q18 0(0.0) 33(16.3) 123(60.6) 41(20.2) 6(3.0) Q19* 0(0.0) 10(4.9) 141(69.5) 48(23.7) 4(2.0) Q20 2(1.0) 46(22.7) 142(70) 13(6.4) 0(0.0) *positive attitudes 70 59.6 60 50 44.8 40 32 28.6 28.6 30 20 10 0 Injection Phobia Painful injection Embarassed about diabetes has make other people injecting insulin become much worse see them as more sick. Negative attitudes reported Figure 7: Top five negative attitudes towards insulin therapy reported by study participants 54 Percentage frequency University of Ghana http://ugspace.ug.edu.gh Table 9: Domains of Psychological Insulin Resistance Perceived Personal blame 20.2% believed that taking insulin means that they had failed to manage their diabetes with 
diet and tablets. 28.6% believed that taking insulin means their diabetes has become much worse. Fear Injection phobia was noted in 59.6 % of the patients studied. 44.8% believed that insulin injections were painful. 15.8% cited risk of hypoglycaemia with insulin therapy. 
 6.9% cited weight gain with Insulin use 5.9 % believed that their health will deteriorate with insulin use. Perceived Loss of Control 21.2% believed insulin makes life less flexible 12.3% believed that insulin use takes a lot of time and energy. 8.9% believed that they would have to give up activities that they enjoy. Injecting the correct amount of Insulin everyday was noted to be a problem with 12.8%. 10.8% believe that insulin use makes it more difficult to fulfil responsibilities. 
 Self-Pity/Social stigma 28.6% believed insulin use will make other people see them as more sick 32% believed injecting insulin is embarrassing. 23.2% believed that being on insulin causes family and friends to be more concerned about 
them. 
 55 University of Ghana http://ugspace.ug.edu.gh Dependence
 Insulin use was associated with more dependence on their doctor in 6.4%. 4.8 Multivariate analysis and test for multicollinearity The multivariable logistic regression model (Table 10) was fitted using a backwards stepwise approach while controlling for age group, marital status, educational status, occupation, duration of illness, type of medication used, duration of insulin use and knowledge of insulin therapy.
Factors significantly associated with psychological insulin resistance were educational status, occupation and knowledge of insulin therapy. Patients with secondary school education were 3.03 times as likely to experience psychological insulin resistance compared to patients who had attained a tertiary level of education [aOR(95CI) p-value= 3.03(1.12-8.13)0.028]. Unemployed patients were 3.44 times as likely to exhibit negative attitudes towards insulin therapy initiation compared to patients gainfully employed [aOR(95CI) p-value=3.44(1.17- 10.01)0.024]. Lastly, patients with poor knowledge of insulin therapy were 2.45 times as likely to exhibit psychological insulin resistance compared to patients with good knowledge of insulin therapy [aOR(95CI) p-value=2.45(0.95-6.26)0.001]. The results from table 11, shows that all variables had variance inflation factors less than 10 and tolerance statistics greater than 0.10 which indicates that there was an absence of multicollinearity in the multivariable models. 56 University of Ghana http://ugspace.ug.edu.gh Table 10: Logistic regression showing predictors of psychological insulin resistance among study participants Predictor cOR[95%CI] p-value aOR[95%CI] p-value Age group ≤39 Ref Ref 40-49 2.44[0.51-11.62]0.261 3.52[0.63-19.7]0.153 50-59 3.63[0.87-15.06]0.076 4.36[0.94-20.2]0.060 60-69 4.64[1.12-19.24]0.035 4.11[0.84-19.9]0.080 70+ 3.93[0.92-16.74]0.064 3.84[0.69-21.4]0.124 Sex Female Ref Male 1.06[0.55-2.05]0.849 Marital status Married Ref Ref Single 1.81[0.43-7.56]0.418 2.56[0.38-16.9]0.327 Divorced/Separated 1.02[0.47-2.23]0.953 0.73[0.30-1.76]0.488 Widow/Widower 2.15[1.02-4.52]0.043 2.12[0.84-5.36]0.109 Educational status Tertiary Ref Ref None 4.40[1.47-13.15]0.008 1.80[0.52-6.23]0.353 Primary 2.34[0.84-6.43]0.100 1.09[0.32-3.68]0.884 JHS 4.00[1.40-11.42]0.010 2.72[0.85-8.68]0.090 SHS 3.87[1.61-9.39]0.002 3.03[1.12-8.13]0.028* Occupation Working Ref Retired 1.29[0.63-2.64]0.484 1.15[0.43-3.03]0.783 Unemployed 3.68[1.49-9.05]0.005 3.44[1.17-10.01]0.024* Duration of illness >11 Ref Ref <1 1.59[0.51-4.91]0.423 1.32[0.34-5.07]0.668 1-6 2.12[0.93-4.82]0.073 1.92[0.71-5.26]0.200 7-11 2.43[1.06-5.59]0.036 2.31[0.85-6.25]0.100 Glycemic control Good Ref Poor 1.72[0.88-3.35]0.110 Medication Insulin Ref Ref Oral Hypoglycemic agent 2.36[1.10-5.07]0.027 1.16[0.14-3.23]0.769 Duration of insulin use >1 Ref None 1.85[0.69-4.91]0.219 ≤1 0.94[0.23-3.83]0.928 Knowledge of insulin therapy Good Ref Ref Poor 3.64[1.78-7.44]0.000 2.45[0.95-6.26]0.001* *p < 0.05 – statistically significant aOR-adjusted odds ratio 57 University of Ghana http://ugspace.ug.edu.gh Table 11: Variance inflation factor test for multicollinearity Variable VIF 1/VIF Age 1.53 0.654422 Sex 1.12 0.697781 Marital status 1.29 0.737659 Educational status 1.04 0.773049 Occupation 1.43 0.803054 Duration of illness 1.36 0.808841 Glycemic control 1.09 0.863512 Medication 1.16 0.890141 Duration of insulin use 1.24 0.920941 Knowledge of insulin therapy 1.25 0.961392 Mean VIF 1.25 58 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION Generally, there is a paucity of data on psychological insulin resistance, especially from developing countries. In Africa, the only countries where studies have been carried out to assess Psychological Insulin Resistance among T2D populations are in Kenya and Libya. However, in Ghana, there is no data available on PIR. This study is the first of such a study aimed at examining the prevalence of PIR and its associated demographic and clinical factors among patients with T2D at LEKMA Hospital in Teshie, Accra. 5.1 Prevalence of Insulin use and associated factors This study found the prevalence of insulin use in the study population to be 16.3% (n=33) despite 77.8% (n=158) of patients having poor glycaemic control. This was consistent with findings in the UKPDS studies investigating insulin use in diabetic populations with suboptimal glycaemic control (UKPDS, 1998). Even in developed countries such as Australia (24%) and the United States of America (30%) the prevalence of insulin use among people with T2D have been reported to be low (Australian National Diabetes Strategy 2016–2020, 2017; CDC Diabetes data and trends, 2013). Available data shows the prevalence of insulin used to be even lower in developing countries (Hazra, Choudhury & Das, 2014). Generally, oral hypoglycemic agents continue to be the preferred choice of medication over insulin in type 2 diabetic populations worldwide (Khunti, Davies, & Khunti, 2015). This may be mainly a result of low socioeconomic status, inadequate knowledge of insulin therapy and more negative attitudes towards insulin observed in non-western ethnic groups usually found in developing countries. Univariate analysis showed that the type of medication used was significantly associated with age group, duration of illness and family history. 59 University of Ghana http://ugspace.ug.edu.gh Insulin use was greater in the older age groups, probably because they had a longer duration of illness, thus are more likely to require insulin because their illness may have progressed. Individuals with a family history of diabetes may have observed or shared in a relative's insulin experience hence making them comfortable to use insulin therapy as reported in studies (Hu et al., 2012: Patel et al., 2012). This accounts for the high number of insulin users in people with T2D with a family history of diabetes. 5.2 Knowledge of insulin therapy Although 64% (n=130) of patients had heard of insulin, knowledge of insulin therapy was noted to be poor with only 21.2% (n=43) of patients admitting having heard of insulin and at the same time reporting knowing how insulin works and its exact mechanism of action. The proportion of patients with poor knowledge of insulin was 78.8% (n=160), and this is consistent with findings in a Nigerian study where 61.1% of patients with T2D were reported to have poor knowledge of insulin (Jasper et al., 2014). Conversely, studies conducted in India and Bangalore have reported the prevalence of knowledge of insulin among people with T2D to be 68% and 86.7% respectively (Surendranath, Nagaraju, & Padmavathi, 2012). This is attributable to the lack of education on the role of insulin in the management of diabetes in developing countries. In the current study, more than half of patients were unaware that errors in dosage, storage of insulin and technique of insulin administration might result in side effects. The chi-squared analysis showed that knowledge of insulin therapy was significantly associated with educational status, duration of illness, family history of diabetes, type of medication used and duration of insulin use. 60 University of Ghana http://ugspace.ug.edu.gh Studies have documented an association between knowledge of insulin therapy and educational status, whereby patients who had attained higher levels of education were more knowledgeable with regards to insulin therapy (Jasper et al., 2014). Unlike the findings of this study, knowledge of insulin therapy, however, was not associated with having a family history of diabetes and duration of illness (Jasper et al., 2014). Patients in this study who reported a family history of diabetes seem to have a better knowledge of insulin therapy. By sharing in their insulin experiences, relatives become more knowledgeable of insulin therapy and its use. Patients diagnosed with diabetes for longer durations had a better knowledge of insulin therapy attributable simply to the fact that living with diabetes for longer periods gives patients better insight into treatment modalities. Over time, there is a greater likelihood of patients being started on insulin, making them familiar with insulin and its action, (Jasper et al.,2014). Studies on insulin acceptance show that patients with diabetes who refused insulin lacked knowledge of insulin (Ak et al., 2015). This is in agreement with the findings of the current study in which insulin users and the use of insulin for long periods showed better knowledge of insulin therapy. Generally, although most people with type 2 diabetes seem to have heard about insulin, the majority of them seem to be unaware of about how insulin works. This is probably as a result of poor diabetes education or poor insulin-related knowledge among health care professionals who are responsible for diabetes self-management education (Derr et al., 2007). 5.3 Prevalence of Psychological Insulin Resistance This study reported a mean ITAS score of 59.2 which was comparable to that found in studies in developing countries like Kenya (Gulam et al., 2017) and developed countries like Denmark (Snoek, Skovlund, & Pouwer, 2007) where the mean ITAS score was 61 University of Ghana http://ugspace.ug.edu.gh 52.7 and 55.5 respectively. The prevalence of PIR in this study was noted to be 57.1% (n=116), meaning that approximately 3 out of 5 of study participants resented insulin therapy. The prevalence of PIR in the current study is comparable to earlier reports from the international DAWN study (Peyrot et al., 2005) and that of a Malaysian study (Nur Azmiah et al., 2011) which reported a prevalence of 54.9% and 51% respectively. In comparison to studies from Europe (6-50%), this study reported a slightly higher prevalence of PIR (UKPDS, 1998; Peyrot et al., 2005; Polonsky et al., 2011). In comparison to the two studies (Gulam et al., 2017; Sabei and Sammud et al., 2015) that have been carried out in Africa that is in Kenya (82.6%) and Libya (94.6%), the prevalence in the current study was low. This is because these studies used different tools and methods to determine PIR. The Insulin treatment appraisal scale was used to assess PIR in the current study and the Kenyan study. The measurement of PIR in this study was done using the negative appraisal subscale which, when summed up, gives a score between 16 and 80, with higher scores representing more negative attitudes to insulin therapy. On the contrary, in the Kenyan study, PIR was measured using the total ITAS score, which was produced by summing all 20 items after reverse-scoring the positive items. A total ITAS score of above 40 indicated more negative attitudes toward insulin therapy. Studies, however, have shown that there are no total ITAS cut-off values to indicate the presence of PIR (Diabetes and emotional handbook and related toolkit, 2016). The total ITAS score is mostly useful for measuring changes in PIR over time or after an intervention. Further studies have demonstrated that it is preferable to use the positive and the negative appraisal subscale separately, rather than the total score (Van Steenbergen-Weijenburg et al., 2010). However, endorsement of positive appraisals of insulin does not represent an absence of PIR because many people may be reluctant to use insulin even though they endorse its benefits. 62 University of Ghana http://ugspace.ug.edu.gh Overall the prevalence of PIR has been reported to be high, and the disparity in prevalence across the globe is attributed to the difference in culture and healthcare systems as emphasized in the DAWN study (Peyrot et al., 2005). 5.4 Demographic and Clinical factors associated with Psychological Insulin Resistance Educational status, occupational status, type of medication used and knowledge of insulin therapy were found to be significantly associated with PIR resistance in this study after univariate analysis. The statistically significant predictors for PIR which after multivariate analysis were educational status, occupation and knowledge of insulin therapy. Patients with secondary school education were 3.03 times more likely to experience PIR compared to patients who had attained a tertiary level of education. Other studies (Chen et al., 2011; Wong et al., 2011) have also demonstrated that patients who are less educated are more likely to exhibit psychological insulin resistance. This is because less-educated patients are most likely less knowledgeable about diabetes and insulin therapy hence may develop negative attitudes towards insulin therapy. Unemployed patients were 3.44 times more likely to exhibit negative attitudes towards insulin therapy initiation compared to patients gainfully employed. Likewise, patients who were unemployed or on retirement exhibited greater resistance to insulin therapy. This is probably because unemployed patients are more likely to have poorer emotional well-being and experience diabetic distress due to their illness and unemployment which has been found to increase negative appraisal of insulin (Holmes-Truscott, 2014). The lower prevalence of negative insulin appraisals among insulin users in this study was as a result of insulin users adapting and gaining more insight of insulin therapy after initiation of insulin therapy as studies (Khan et al., 2008; Hermanns et al., 63 University of Ghana http://ugspace.ug.edu.gh 2010; Odawara et al., 2016)
have demonstrated. A longitudinal study (Hermanns et al., 2010) reported barriers towards insulin therapy are somewhat temporary than permanent and as such negative attitudes towards insulin therapy are easily malleable by the commencement of insulin therapy. Lastly, patients with poor knowledge of insulin therapy were 2.45 times more likely to exhibit psychological insulin resistance compared to patients with good knowledge of insulin therapy. Inadequate knowledge regarding insulin therapy is likely to influence patients' attitude toward insulin initiation and adherence. Studies on insulin acceptance have shown that patients with diabetes who refused insulin lacked knowledge of insulin (Ak et al., 2015). Thus, the need for patients to have early and continuous education on the progressive nature of diabetes, the mechanism of insulin action and its role in glycaemic control to be able to modify any negative attitudes towards insulin therapy. 5.5 Attitudes reported towards insulin therapy Overall, very few patients reported positive attitudes toward insulin therapy. The most endorsed benefit of insulin therapy by patients was its ability to help prevent diabetic complications. Injection phobia was noted to be the leading barrier to insulin therapy reported by patients followed by injection pain. This was comparable to the Libyan study (Sabei & Sammud, 2015) in which injection phobia was reported to be the leading barrier to insulin therapy. About a third of patients reported being embarrassed about injecting insulin, especially in public with another third reporting social stigma as they feel other people see them as sicker if they use insulin. This is corroborated by data from the Gulam et al. (2017) study which revealed that close to half of patients reported facing social stigma and 30% reported embarrassing insulin injections as barriers to insulin therapy. 64 University of Ghana http://ugspace.ug.edu.gh There is a misconception in the general populace that insulin therapy is the last resort to the management of T2D as emphasized by earlier treatment guidelines. This misconception, coupled with the notion that self-injections are synonymous to drug addiction, has contributed to social stigmatisation making insulin users feeling embarrassed to self-inject insulin when required in public. The results from this study reiterate the importance of healthcare professionals, especially clinicians intervening, early to counsel people with T2D effectively to curtail psychological insulin resistance. There is the need for healthcare professionals to emphasize on insulin therapy during diabetes self-management education programmes to change negative attitudes towards insulin therapy and put in place interventions to assist patients experiencing psychological insulin resistance. This will go a long way to improve the uptake of insulin therapy and help patients achieve optimal glycaemic control and prevent diabetic complications. 5.6 Limitations of the study There were some potential limitations in this study. The first limitation was the response bias. There was some element of neutral responding by some participants who typically were looking to answer questions quickly so they can proceed to see the doctor. There was also the tendency for some participants to give answers that made them look good thus introducing some social desirability bias. This could have resulted in under or over reporting of attitudes towards insulin therapy. Social desirability bias was minimized by assuring participants of the anonymity of the names. Secondly, the exclusion of participants with psychiatric illness which was done by reviewing their medical files could have introduced some selection bias. Thus it is possible that some participants 65 University of Ghana http://ugspace.ug.edu.gh who had psychiatric disorders which were undiagnosed or not reported in their medical files were included in the study. The results of this study showed an association and no causal relationship between predictors and psychological insulin resistance. There are relevant predictors of psychological insulin resistance that were not assessed, for example, cultural background, use of herbal medication use and religion. The Insulin Treat Appraisal Scale (ITAS) has not been validated in the socio-cultural setting and diabetes care practice in Ghana. 
 66 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX 6.0 CONCLUSION & RECOMMENDATIONS 6.1 Conclusion In this study, approximately 1 out of 5 people with T2D attending the Diabetes clinic at LEKMA Hospital used insulin in managing T2D, despite close to 4 out of 5 patients having poor glycaemic control. More than half of the patients exhibited psychological insulin resistance. Knowledge of insulin therapy among patients was poor, with approximately 1 out of 5 patients having good knowledge of insulin therapy. Educational status, occupation and knowledge of insulin therapy were significantly associated with PIR. Therefore, early and continuous patient education by clinicians on diabetes, insulin therapy and its benefits will help enhance insulin uptake among patients with T2D when required. 6.2 Recommendations Health care professionals • Diabetes self-management educators and clinicians should discuss the beneficial use of insulin therapy in the management of diabetes from the onset of diagnosis. • Diabetes self-management educators should have "diabetes ambassadors" or patients on insulin share their insulin success stories with patients who exhibit negative attitudes towards insulin therapy at education sessions. • Clinicians should liaise with clinical psychologists to have counselling sessions for patients who exhibit negative attitudes towards insulin therapy initiation to help address their concerns. 67 University of Ghana http://ugspace.ug.edu.gh • Clinicians should develop interventions which will aid the desensitization of patients with injection phobia — for example, the use of dummies to demonstrate insulin self-injections or self-injection under medical supervision. Opportunities for further research • Future studies are required to assess clinical inertia and health care system factors as an essential contributor to psychological insulin resistance. • Further studies are required to explore more patient factors associated with psychological insulin resistance to capture the most relevant predictors to develop appropriate strategies to overcome negative attitudes towards insulin therapy. 
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A questionnaire study to analyze the reasons of insulin refusal of DM patients on maximum dose of oral hypoglycemic agents (OHA) among 3 GOPC in Kowloon West Cluster.Retrieved 30/10/2018 from 76 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX A (PARTICIPANT INFORMATION SHEET) School of Public Health College of Health Sciences University of Ghana TOPIC-Psychological Insulin Resistance among patients with type 2 diabetes at LEKMA Hospital, Teshie-Accra Dear Participant My name is Jude Tettey Wellens-Mensah, a student of the School of Public Health, University of Ghana, undertaking a study on the above topic in partial fulfillment of my Masters in public health. The objective of this study is to assess psychological insulin resistance among patients with type 2 diabetes and its associated factors. The information gathered from this study could be used by health professional in addressing the many challenges that comes with initiating insulin therapy in type 2 diabetics, so as to reduce the increasing morbidities and complications that comes with poorly controlled blood glucose. This study seeks to interview patients with type 2 diabetes attending the diabetes clinic at LEKMA Hospital who will meet the inclusion criteria. The interview will last for a maximum of 20 minutes. The study requires you to give responses to the issues in the questionnaire attached. Participation in this study is voluntary and you can choose to partake. You are at liberty to withdraw from the study at any time without any penalty and without having to give any reasons. This study, it is hoped, will provide evidence-based information for clinicians to help address the patient barriers associated with the delay of insulin therapy initiation thereby achieving good blood glucose control thus reducing morbidity and mortality. 77 University of Ghana http://ugspace.ug.edu.gh No cost will be cost will be incurred by participants and there will be no remuneration for participants. You are assured that information provided is confidential and will be used solely for the purpose of the project. This study is solely sponsored by the principal investigator.Your involvement in the study will aid in the acquisition of knowledge to aid a good cause.Your written consent in a form of your signature is required before the questionnaire can be administered, for any participant who can’t sign for any reason a thumbprint option is available in the presence of a credible witness. A copy of the information sheet will be given to you after it has been signed or thumb-printed. Any concerns about this study can be addressed to: Jude Tettey Wellens-Mensah School of Public Health, University of Ghana Mobile number: +233264216141 Email: judewellens@hotmail.com Any concerns relating to ethics and your right as a participant can be addressed to: Hannah Frimpong The Administrator Ethics Review Committee Mobile number:+2335070412 78 University of Ghana http://ugspace.ug.edu.gh APPENDIX B (CONSENT FORM) Patients with type 2 diabetes Participant statement I………………………………………………………………. certify that I voluntarily agree to answer the survey questions, that the survey as well as its purpose, procedures, risk and benefits of this study have thoroughly explained to me in: English Ga Twi I understand I am free to discontinue participation at any time if I so choose. I understand I will be given copies of the participants information and signed or thumb- printed consent form for my personal records before administration of the research questionnaire. Signature of participant ………………………. Or Thumbprint (participant)…………………………. Date ……………………………………………… Witness statement I …………………………………………………………. certify that I have willingly witnessed the participation of the above named in this research. Witness Signature……………………………. Date ……………………………………………… Interviewer Statement I the undersigned have explained the consent form to the subject in simple language that he /she understands, clarified the purpose of the study, procedures to be followed 79 University of Ghana http://ugspace.ug.edu.gh as well as risks and benefits involved. All questions raised by the participant have been addressed. Signature of interviewer…………………………………… Date ……………………………………………………… 80 University of Ghana http://ugspace.ug.edu.gh APPENDIX C (QUESTIONNAIRE) PSYCHOLOGICAL INSULIN RESISTANCE AMONG TYPE 2 DIABETICS AT LEKMA HOSPITAL. Demographic/Clinical data Client ID: 1) Age: ……… 2) Sex: Male Female 3) National health insurance: Yes No 4) Marital status: Single Married Divorced Separated Widow/Widower 5) Educational status: Primary Junior High School Secondary Tertiary No education 6) Occupation: 7) Year of Diagnosis/Duration of DM: … 8) Family history of DM: Yes No 9) DM medication used: Insulin Oral Hypoglycemic agents Both 81 University of Ghana http://ugspace.ug.edu.gh 10) Duration of insulin use (If on insulin): 11) Purchase of medications: Self Relative Friend No means 12) HbA1C: ………. Knowledge of Insulin therapy among patient with type 2 diabetes 1. Have you heard about insulin before? Yes No 2. If yes, do you know how it works in the body? Yes No 3. If yes, how does it work? …………………………………………………………….. 4. Error in insulin dose can cause side effects? Agree Disagree Don’t know 5. Error in injection technique can cause side effects? Agree Disagree Don’t know 82 University of Ghana http://ugspace.ug.edu.gh 83 University of Ghana http://ugspace.ug.edu.gh 84 University of Ghana http://ugspace.ug.edu.gh 85