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January 2023, Volume 73, Issue 0

Primary Care Diabetes

Insulin hesitancy: A language-based model

Sanjay Kalra,  ( Department of Endocrinology, Bharti Hospital, Karnal, )
Bharti Kalra  ( Department of Gynaecology, Bharti Hospital, Karnal, India )
Saptarshi Bhattacharya  ( Department of Endocrinology, Indraprastha Apollo Hospitals, Sarita Vihar, Delhi, India )


Psychological insulin resistance is a well known entity. This communication proposes the term ‘insulin hesitancy’ to describe the hesitation that a person living with diabetes experiences, when advised to take insulin. It approaches hesitancy through a triage model, based upon the language used by the patient. By identifying the predominant adverb, “will not”, “shall not”, or “cannot” in the patient’s speech, the diabetes care professional can assess the degree of insulin hesitancy, and tailor his or her conversation towards overcoming it.


Keywords: Diabetes education, insulin motivation, insulin technique, patient centred care, person centred care, psychosocial aspects.


DOI: 10.47391/JPMA.04-23




Insulin is an important tool in diabetes management. Yet, even a hundred years after its discovery, it continues to be resisted by a significant number of persons who need it.  The reasons for insulin hesitancy, skepticism and refusal are well-known to diabetes care professionals1,2. A wide variety of psychological and social factors create an environment which is hostile to insulin.3 This is unfortunate, because lack of insulin acceptance leads to suboptimal glucose control and avoidable chronic complications.

In such a scenario, it becomes the responsibility of diabetes care professionals to explain the advantages and benefits of insulin to persons living with diabetes, and encourage them to take insulin in a timely manner.4 This, however, is easier said than done.


Terminology: Hesitancy vs. Resistance


We suggest the use of the term ‘insulin hesitancy’, rather than ‘insulin resistance’ or “insulin refusal.”5 Insulin hesitancy can be defined as the hesitation that a person living with diabetes (or his/her caregiver) experiences, when advised to take insulin. This is a more person-centric and less judgmental phrase, which does not criticise the person living with diabetes. It helps the diabetes care professional to view insulin acceptance process through “human” eyes. It also avoids potential confusion between “biomedical” insulin resistance and psychological insulin resistance. Most important of all, it allows a graded appraisal of the individual’s reasons for hesitancy, and creates a platform for their resolution.


Insulin Language Reveals The Degree Of Hesitancy


We propose a simple triage system to assess insulin hesitancy , based upon the language used by the concerned person. When the topic of insulin is broached, the predominant reply may be one of the following.6

“I will not take insulin” or “I will never accept insulin”

“I shall not take insulin” or “I do not wish to inject insulin”

“I cannot take insulin” or “I am incapable of initiating insulin”

These sentences can easily be understood in Urdu as “Main insulin nahin loonga, nahin lena chahta, nahin le sakta”


Approach to insulin hesitancy


Once the predominant thought process is identified, the diabetes care professional should proceed with an in depth exploration of the reasons for such a negative opinion. One can then go on to address the specific situation, and offer necessary support information and advice. Table-1 describes a framework that can be used to address insulin hesitancy or refusal, using exemplars from our clinical practice.





A focus on language helps analyze and resolve much of the insulin hesitancy we encounter in clinical practice. Careful reflection, upon the words our patients use, can help us counsel them in a more appropriate and effective manner.




1.      Polonsky WH, Fisher L, Hessler D, Stuckey H, Snoek FJ, Tang T, et al. Identifying solutions to psychological insulin resistance: an international study.  J Diabetes Complications. 2019;33:307-14.

2.      Kalra S, Bajaj S, Sharma SK, Priya G, Baruah MP, Sanyal D, et al. A practitioner’s toolkit for insulin motivation in adults with type 1 and type 2 diabetes mellitus: evidence-based recommendations from an international expert panel. Diabetes Ther. 2020;11:585-606.

3.      . Kalra S, Arora V, Verma M, Aggarwal S. Social insulin resistance:The forgotten frontier. J Pak Med Assoc. 2020;70:1860-1.

4.      Kalra S, Deb P, Gangopadhyay KK, Gupta S, Ahluwalia A. Capacity and confidence building for general practitioners on optimum insulin use. J Family Med Prim Care. 2019;8:3096-3107.

5.      Song Y, Ku BJ, Cho J, Jun Y, Kim B, Nam S. The prevalence of insulin refusal and psychological insulin resistance among Korean patients with type 2 diabetes mellitus. Ann. Transl. Med.. 2019;7;760-772.

6.      Kalra S, Verma K. Handling insulin-related emotions. DiabetesTher.2018;9:1415-9

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: