Psychological Insulin Resistance in Patients Diagnosed with Type 2 Diabetes Mellitus: A cross Sectional Study at a Rural Setting in Sri Lanka

Background: Timely insulin initiation in long-standing type 2 diabetes (T2DM) is vital to prevent complications, yet reluctance to start it, known as psychological insulin resistance (PIR) remains common. Evidence on PIR in South Asia is limited. We aimed to determine the prevalence, determinants and latent constructs of PIR among patients with T2DM in rural Sri Lanka.
Methods: A cross-sectional study was conducted among adults (aged >18 years) with T2DM
attending the endocrinology clinic, District General Hospital, Hambantota. PIR and psychological status were assessed using the 20-item Insulin Treatment Appraisal Scale (ITAS) and General Health Questionnaire-12, respectively. PIR was defined as a total score greater than the sample median. Exploratory factor analysis (EFA) was performed to identify the latent constructs underlying ITAS. Associations between PIR and sociodemographic and clinical characteristics were assessed using multiple logistic regression, odds ratios with 95% confidence intervals are presented.
Results: Data of 311 participants (mean age 54.7 years; SD+10.4, female 63.7%, median duration of T2DM four years; IQR3-8) were included in the analysis. Over one-third (34.4%) had only primary education, over 60% had low income (<50,000LKR/month), and 59.5% were unemployed. The prevalence of PIR was 76.8%(n=239) and psychological distress was 6.4%(n=20). EFA revealed five latent factors within PIR; loss of autonomy with insulin use (35.4%), negative impact of injecting insulin (28.7%), emotional discomfort with injecting insulin (35.9%), positive impact of insulin (38.3%), and personal failure in diabetes management (66.4%). Increasing age (OR=1.05;1.01-1.08), being insulin naïve (OR=1.99;1.11-3.97), and having middle level of family income comparted to lowest level (OR=2.64;1.12-6.17) increased the risk of PIR, while longer duration of diabetes had lower risk of PIR (OR=0.92;0.87-0.97).
Conclusion: The prevalence of PIR in Sri Lankan rural settings is high, posing a substantial barrier to effective diabetes management. This resistance is particularly pronounced among those who are older, insulin-naive, and from middle-income families.