Perception towards Insulin Therapy and Factors Related to Insulin Refusal among Insulin Naive Type 2 Diabetes Mellitus Patients in Primary Care Clinics PKD Lipis


  • Noralina Zakaria Perkhidmatan Klinik Bergerak (Bas) Lipis, Pejabat Kesihatan Daerah Lipis, 27200 Kuala Lipis, Pahang
  • Narasimman Baskaran Klinik Kesihatan Sungai Koyan, 27200 Lipis, Pahang
  • Wan Lin Lim Klinik Kesihatan Benta, 27100 Jerantut, Pahang



Insulin Refusal, Insulin Naive, Type 2 Diabetes Mellitus


Introduction: Insulin is one of the suggested treatments to prevent and reduce long-term diabetes complications. However, due to many factors such as socio-demographic factors, many Type 2 diabetes mellitus patients refuse this treatment. This study aimed to determine perception towards insulin among naive Type 2 diabetes mellitus patients, to calculate the prevalence of rejecting insulin therapy, and to find out factors related to the refusal.

Materials and methods: This cross-sectional study involved 188 insulin naive Type 2 diabetes mellitus patients attending five primary health clinics in Lipis district, Pahang from October to November 2017. A five-point Likert Scale was used to determine perception towards insulin therapy and the Chi-square test was used to assess the proportion of acceptance of the therapy. Simple and multiple logistic regressions were utilised to study the associated factor(s).

Results: Mean score of 60.5 ± 8.2 pointed towards a negative appraisal of insulin therapy. Embarrassment to inject in public (69.1%) and concern of frequent hypoglycaemia (52.7%) were the most common perception. Nearly half of the respondents (46.3%) refused insulin therapy upon suggestion. After adjusting the variables using multiple logistic regressions, only gender (Adjusted OR=0.20, 95% CI=0.10-0.40, p<0.001), educational level (Adjusted OR=0.17, 95% CI=0.06-0.50, p=0.001), age (Adjusted OR=1.04, 95% CI=1.01-1.08, p=0.012) and glycated haemoglobin level (Adjusted OR=1.33, 95% CI=1.07-1.67, p=0.013) remained significant.

Conclusion: In conclusion, insulin refusal among insulin naive patients was common in Lipis with an overall negative perception towards therapy. By tailoring strategies according to the patient’s factors such as gender, educational level, age, and glycated haemoglobin level, the insulin refusal rate might decrease in the future.


Abraira, C., Colwell, J. A., Nuttall, F. Q., Sawin, C. T., Nagel, N. J., Comstock, J. P., ... & VA CSDM Group. (1995). Veterans Affairs Cooperative Study on glycemic control and complications in Type II diabetes (VA CSDM): results of the feasibility trial. Diabetes care, 18(8), 1113-1123. DOI:

Azmiah, N. Z., Zulkarnain, A. K., & Tahir, A. (2011). Psychological insulin resistance (PIR) among Type 2 diabetes patients at public health clinics in federal territory of Malaysia. International Medical Journal Malaysia, 10(2), 7-12. doi:10.31436/imjm.v10i2.675 DOI:

Batais, M. A., & Schantter, P. (2016). Prevalence of unwillingness to use insulin therapy and its associated attitudes amongst patients with Type 2 diabetes in Saudi Arabia. Primary care diabetes, 10(6), 415-424. DOI:

Centers for Disease Control and Prevention. (2012). Principles of epidemiology in public health practice, Third Edition – An introduction to applied epidemiology and biostatistic. Retrieved from:

Chen, C. C., Chang, M. P., Hsieh, M. H., Huang, C. Y., Liao, L. N., & Li, T. C. (2011). Evaluation of perception of insulin therapy among Chinese patients with Type 2 diabetes mellitus. Diabetes & metabolism, 37(5), 389-394. DOI:

Fonseca, V., Gill, J., Zhou, R., & Leahy, J. (2011). An analysis of early insulin glargine added to metformin with or without sulfonylurea: impact on glycaemic control and hypoglycaemia. Diabetes, Obesity and Metabolism, 13(9), 814-822. DOI:

Gerstein, H. C., Yale, J. F., Harris, S. B., Issa, M., Stewart, J. A., & Dempsey, E. (2006). A randomized trial of adding insulin glargine vs. avoidance of insulin in people with Type 2 diabetes on either no oral glucose?lowering agents or submaximal doses of metformin and/or sulphonylureas. The Canadian INSIGHT (Implementing New Strategies with Insulin Glargine for Hyperglycaemia Treatment) Study. Diabetic Medicine, 23(7), 736-742. DOI:

Ghadiri-Anari, A., Fazaelipoor, Z., & Mohammadi, S. M. (2013). Insulin refusal in Iranian patients with poorly controlled Type 2 diabetes mellitus. Acta Medica Iranica, 567-571.

Hassan, H. A., Tohid, H., Amin, R. M., Bidin, M. B. L., Muthupalaniappen, L., & Omar, K. (2013). Factors influencing insulin acceptance among Type 2 diabetes mellitus patients in a primary care clinic: a qualitative exploration. BMC family practice, 14(1), 164. doi:10.1186/1471-2296-14-164 DOI:

Hayward, R. A., Manning, W. G., Kaplan, S. H., Wagner, E. H., & Greenfield, S. (1997). Starting insulin therapy in patients with Type 2 diabetes: effectiveness, complications, and resource utilization. Jama, 278(20), 1663-1669. doi: 10.1001/jama.1997.035502000392029 DOI:

Hunt, L. M., Valenzuela, M. A., & Pugh, J. A. (1997). NIDDM patients' fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes care, 20(3), 292-298. DOI:

Kaur T, Dubey A, & Agrawal B. (2018). Why are Type 2 diabetics refusing insulin? A hospital based study to find the factors influencing the patient’s readiness for insulin. International Journal of Scientific Research. Apr: 4:7. doi: 10.36106/ijsr DOI:

Khalili M, Sabouhi F, Abazari P, Aminorroaya A (2016). Comparing the quality of life in insulin recipient and refusal patients with Type 2 diabetes. Iranian journal of nursing and midwifery research. 21(4):351. doi: 10.4103/1735-9066.185571 DOI:

Khan, H., Lasker, S. S., & Chowdhury, T. A. (2008). Prevalence and reasons for insulin refusal in Bangladeshi patients with poorly controlled Type 2 diabetes in East London. Diabetic Medicine, 25(9), 1108-1111. DOI:

Korytkowski, M. (2002). When oral agents fail: practical barriers to starting insulin. International Journal of Obesity, 26(3), S18-S24. DOI:

Ministry of Health. (2012). Non-Communicable Disease Section. National Diabetes Registry Report. Retrieved from:

Ministry of Health. (2015). National Health & Morbidity Survey 2015. Non-Communicable Diseases, Risk Factors & Other Health Problems. Retrieved from:

Ministry of Health. (2020). Clinical Practice Guidelines. Management of Type 2 Diabetes Mellitus (6th Edition): Ministry of Health.

Polonsky, W. H., Hajos, T. R., Dain, M. P., & Snoek, F. J. (2011). Are patients with Type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population. Current medical research and opinion, 27(6), 1169-1174. DOI:

Polonsky, W. H., & Jackson, R. A. (2004). What's so tough about taking insulin? Addressing the problem of psychological insulin resistance in Type 2 diabetes. Clinical diabetes, 22(3), 147-150. DOI:

Rubino, A., McQuay, L. J., Gough, S. C., Kvasz, M., & Tennis, P. (2007). Delayed initiation of subcutaneous insulin therapy after failure of oral glucose?lowering agents in patients with Type 2 diabetes: a population?based analysis in the UK. Diabetic Medicine, 24(12), 1412-1418. DOI:

Tan, W. L., Asahar, S. F., & Harun, N. L. (2015). Insulin therapy refusal among Type II diabetes mellitus patients in Kubang Pasu district, Kedah, Malaysia. Singapore medical journal, 56(4), 224-227. doi: 10.11622/smedj.2014170 DOI:

Vinik, A. (2007). Advancing therapy in Type 2 diabetes mellitus with early, comprehensive progression from oral agents to insulin therapy. Clinical therapeutics, 29(6), 1236-1253. DOI:

Westphal, S. A., & Palumbo, P. J. (2006). A case for introducing insulin early in the treatment of Type 2 diabetes mellitus. Insulin, 1(2), 65-69. DOI:

Wong, S., Lee, J., Ko, Y., Chong, M. F., Lam, C. K., & Tang, W. E. (2011). Perceptions of insulin therapy amongst Asian patients with diabetes in Singapore. Diabetic medicine, 28(2), 206-211. DOI:




How to Cite

Zakaria, N., Baskaran, N. ., & Lim, W. L. (2021). Perception towards Insulin Therapy and Factors Related to Insulin Refusal among Insulin Naive Type 2 Diabetes Mellitus Patients in Primary Care Clinics PKD Lipis. Journal of Pharmacy, 1(2), 70–78.



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