Experiences Of People With Type 2 Diabetes Who Have Changed From Oral Medication To Self-Administered Insulin Injections Article Review Example

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Introduction. Despite the impressive evidence on usefulness of insulin in diabetes type 2 when other strategies are not effective, psychological resistance to this type of treatment remains the main barrier for starting the therapy in patients. The qualitative study of Morris, Povey,& Street (2005) aims to assess the sources of this resistance by investigation of the type 2 diabetes mellitus patients’ “lived experiences” from the insulin therapy.
Purpose of the study and research questions. The title of the study reflects the main concept (experiences of the patients) comprising both psychological barriers (expectations), benchmarking those to real feelings (actual experiences), and changing perceptions after the treatment start (life impact). All these variables are covered by the abstract which makes the purpose of the article clear to the reader. However some concepts introduced in the abstract (significant awareness of insulin psychological benefits) are neither mentioned in the article nor supported by the evidence from other studies. The study rather dwells upon psychological fears without contrasting them to benefits.
The correlation between the patients’ beliefs and their educational needs which the authors attempted to establish as a second study outcome is also mentioned both in the abstract and the introduction. The introduction structures the problem in a logical way revealing the main underlying causes of the patients’ psychological resistance and grouping them into 3 main categories: initial triggers to start insulin therapies (personal beliefs about the necessity to start), perceptions of treatment (expectations) and factors which influenced the decision. However the last group (factors influencing the decision) is not included into the questionnaires though the study of Bogatean and Hancu (2004) where this grouping was introduced is referred to several times as a benchmark. It would have been more illustrative to compare and contrast outcomes against the similar pre-defined set of parameters of the “benchmark” study, though the data on the triggers of the patients’ decision to start possibly fall out of the main study scope of “barriers to treatment” . As these barriers were described in few studies at the time of the present research, the authors use only a couple of recent research examples (2002-2004) basing the argument mainly on the supportive evidence derived 10 years before. Still, these studies are of good quality and support either the main research question (Bogatean & Hâncu, 2004) or the theoretical framework (Winocour, 2002).
The reason for conducting the research is clearly stated and is based on Winocour (2002) data of insulin therapy demand in 50% patiens with diabetes type 2 after commencement of the therapy by other oral antidiabetic agents. Thus, the main purpose of the study is identification of the initial barriers of the patients, the assessment of patients’ actual experiences and the monitoring of changes in their perceptions in course of therapy, as the answers to those questions can facilitate the therapy start
Methods. The design of study perfectly fits into its goals, as it includes the elements of longitudinal study, with first interview conducted in 2 weeks after the treatment initiation, and a second one – in a month after it. However the time span selected for longitudinal observation, as well as a time lag between 2 interviews is too short. The insulin therapy is life-long, and some psychological effects of it can be observed only in many months after the treatment start. To contrast the perceptions, interviews prior to treatment initiation would have also been useful. Though during the first interview the initial perceptions were still “well-documented” in the patients’ memory, they could have been affected by the events which had taken place. The evolution of the patients’ perceptions through the lifespan cannot be derived from the study, and only short-term trends can be discussed. Both phenomenological approach, with its in-depth investigation of an unknown (or almost not studied) phenomenon from the participant’s perspective (Jeanfreau, 2010) and qualitative design to have a descriptive and comprehensive picture of population’s experiences are appropriate. The sampling plan of a purposeful sample selection, patients’ inclusion (recently started on insulin) and exclusion (unable to converse in English or to bear 40-minutes interview) criteria are well defined and thoroughly described. However the sample size is too small and the population of the study is very heterogeneous (3 men and 3 women with different complications) to extrapolate the data on general population. The large discrepancies in other variables such as range of disease duration, race, and initial background, affect the results’ interpretation as psychological barriers can differ in different cultural and race groups, stages of disease and people with diverse initial backgrounds.
The data collection and analysis methods are described appropriately. 40-minutes interviews allowing a detailed depth exploration of the participant’s experiences are the main data source, properly audio-taped and documented. The ethical approval and the patients’ privacy are properly ensured. The Interpretative Phenomenological Analysis method as one of the most appropriate techniques for qualitative studies enabled the authors to get a clear account of process and adequate data analysis (Jeanfreau, 2010). The results are presented in a clear and well-structured manner covering 3 main domains of the concept and highlighting the key points, supporting them by verbatim quotes. Both master and sub-themes which emerged in participants’ answers have been classified, grouped and analyzed. The results give a clear picture of main psychological domains where the barriers were initially faced (fear of physical pain, shock or harm, anger and powerlessness, social stigma (“Frankensteins” or losing normality), and the subsequent impact of reality on these perceptions change (acceptance, empowerment, positive experience of injections). The discussion is benchmarked against the results of Bogatean and Hancu (2004) study though as indicated above, inclusion of the set of factors triggering the decision to start would have been very useful given the participants’ initial negative therapy perceptions. The authors themselves indicate the appropriateness and completeness of interview questions as a study limitation. However the trends of growing confidence after the therapy start are consistent with Bogatean and Hancu (2004) evidence and may also be indicative of proper study design. The correlation between the prior patients’ education by clinicians and level of psychological readiness to the therapy is derived subjectively, based on the patients’ answers about the health professionals having taken responsibility for the decision. To establish appropriate correlation between the locus of control shift and health professional counselling prior to the insulin therapy, further research is necessary.
Overall grading: Though the study is of a low evidence level (Level 3) as a qualitative research, and the sample size is unsufficient, the general quality of study is good.
Implications for practice. The major implication for nursing practice is need of presentation of insulin benefits to the patients at the early stage which can be beneficial in terms both of overcoming psychological barriers to treatment and improving the treatment outcomes. If the clinicians really understimate the barriers in patients, more attention and in-depth approach to these barriers is required from nursing side. Awareness of these barriers will let the nurses concentrate on patients’ psychological needs and improve the perceptions of the treatment.
Conclusion. The study describes and analyzes the experiences of the patients such as barriers to insulin treatment and shift in the psychological perceptions of the treatment, with appropriate design and method (qualitative phenomenological research) being used to explore the concept. However the sample size and heterogenity do not allow extrapolating the results to the general population. The correlation between the prior health professional counselling and the patients’ positive perception of the treatment requires a more detailed and multivariate analysis.To evaluate the efficiency of presentation of insulin’s benefits concept to the patients at the early stage, further studies of another design are essential.

References

1. Bogatean, P.M, Hâncu, N. (2004). People with type 2 diabetes facing the reality of starting insulin therapy: factors involved in psychological insulin resistance. Pract Diabetes Int , 21, 247–252.
2. Jeanfreau, S. (2010). Appraising Qualitative Research in Health Education: Guidelines for Public Health Educators. Health Promot Pract.,11(5), 612–617.
3. Morris, J.E., Povey, R.C., Street, G.C.(2005). Experiences of people with type 2 diabetes who have changed from oral medication to self-administered insulin injections. Pract Diab Int, 22(7),239-243.
4. Winocour, P.H. (2002). Effective diabetes care: A need for realistic targets. BMJ, 324, 1577–1580.