This qualitative study explores the perceptions among black African and African-Caribbean people with type 2 diabetes regarding insulin treatment. People's perceptions of insulin were influenced by four themes: beliefs, quality of life, the health system, and education. Psychological insulin resistance was present with underlying fear, worries and stigma about insulin commonly expressed. Most people taking tablets believed that insulin represented a worse stage of the condition with death imminent. In contrast, most insulin-treated participants held a strong belief in the efficacy of the treatment and how it prolonged life. Barriers that may prevent or delay black African and African-Caribbean people starting insulin need to be addressed through tailored educational interventions.
Early, intensively managed glycaemic control has sustainable long-term benefits in reducing microvascular and cardiovascular risk (UK Prospective Diabetes Study Group, 1998; Holman et al, 2008). The challenge remains in addressing the progressive deterioration of glycaemic control over time, since a stepwise- addition of tablets, followed by early initiation of insulin, will be necessary for many people with type 2 diabetes (Wright et al, 2002; NICE, 2009).
Reluctance to initiate insulin has been termed "psychological insulin resistance" (PIR) and is recognised as barriers that prevent or delay treatment among people with diabetes (Polonsky and Jackson, 2004; Marrero, 2007). If insulin is required, diabetes is perceived as a more serious condition and believed to have progressed to a severe stage (Hunt et al, 1997; Peyrot et al, 2005; Brown et al, 2007).
Ethnic disparities continue to exist in the management of diabetes, particularly among people of black African and African-Caribbean descent with type 2 diabetes. Millet et al (2007) observed that reduced insulin prescribing and less improvement in [HbA.sub.1c] was seen in these ethnic groups compared with the white British population. Resistance to prescribe insulin therapy among primary care professionals has largely been due to lack of support, confidence and experience (Jeavons et al, 2006), although the role of the community diabetes specialist nurse has developed to support insulin initiation in primary care (Shepherd et al, 2007).
Black African and African-Caribbean people are up to five times more likely than white people to develop diabetes and have an earlier onset of diabetes and its complications (Diabetes UK, 2006). These communities represent nearly a quarter of the population in Lewisham, a deprived borough of South East London. Little research has focused on beliefs and attitudes about insulin among these black ethnic minonty communities in the UK and how this may influence the uptake of treatment. Health beliefs, defined by McAllister and Farquhar (1992) as a person's beliefs about health or illness and exposure to health promotion, appear to have a major impact on black African and African Caribbean peoples' adherence to their diabetes treatment (Brown et al, 2007).
The aim of this study was to explore perceptions of insulin treatment among black African and African-Caribbean people with type 2 diabetes, to gain insight into the barriers to treatment and strategies to overcome resistance. The study was not designed to establish differences between these...