The scale of the problem makes the details of the survey worth unpacking. Insulin remains the cornerstone of diabetes management when lifestyle modification and oral agents fail to achieve glycaemic targets. Physiologically, the hormone performs two essential tasks: it drives glucose uptake into peripheral tissues such as muscle and fat, and it suppresses the liver’s production of glucose. When these actions are insufficient, chronic hyperglycaemia insidiously damages blood vessels and nerves, setting the stage for cardiovascular disease, nephropathy, retinopathy, neuropathy and premature death. Yet despite well-defined guidelines and decades of evidence, clinicians worldwide delay insulin initiation, a phenomenon researchers call therapeutic inertia. In Lahore, that inertia has now been measured with statistical precision, and the results suggest it is driven by a dense web of patient, physician and health-system factors that reinforce one another.

The research team, led from The University of Lahore, recruited physicians from Internal Medicine, Endocrinology, Gastroenterology and Nephrology at a public sector tertiary hospital. Using a calculated minimum sample of 384, they invited 910 eligible doctors and achieved a remarkable 88.8 percent response rate, with 808 completed questionnaires. The instrument, refined through a pilot study of 20 physicians and content-validated by a panel of 10 endocrinologists, achieved a content validity index of 0.90 and acceptable internal consistency, with Cronbach’s alpha values of 0.73 for the barriers section and 0.79 for the feedback section. Respondents were demographically diverse: 54.3 percent were women, 58.5 percent were aged 41 to 55, and the largest qualification group held the FCPS fellowship, followed by MBBS, MRCP and MRCS credentials. Most participants managed panels in which 11 to 30 percent of patients required insulin.

The barrier data, collected on four-point Likert scales and dichotomised for analysis, paint a picture of systemic strain. Beyond the twin giants of poor education and hypoglycaemia fear, physicians reported complex administration techniques as a barrier in 84.1 percent of cases, inadequate communication in 84 percent, fear of needles in 83 percent, misconceptions about weight gain in 81.5 percent and financial constraints in 81.4 percent. Patient resistance to insulin itself was ubiquitous. These figures resonate strikingly with international comparisons cited by the authors: in Trinidad, primary care physicians flagged needle fear in 98.6 percent of cases; in Saudi Arabia’s Jazan region, 80.5 percent reported injection phobia among patients; and in Nigeria, fear of hypoglycaemia topped the list at 81.3 percent. The consistency across such different health systems suggests that the psychology of insulin refusal is close to universal, even if its intensity varies with local literacy and economic conditions.

Statistical testing revealed that the experience of barriers was not evenly distributed across the medical workforce. Kruskal-Wallis tests with Bonferroni adjustment found highly significant differences by qualification in several domains. Patients’ resistance to insulin, difficulty explaining the differences between short-acting and long-acting formulations, the influence of cultural beliefs, and hesitation rooted in hypoglycaemia fear and regimen complexity all varied significantly across degree holders, with p values below 0.001. Binary logistic regression added a demographic dimension: male physicians were significantly more likely than female colleagues to report barriers, with an adjusted odds ratio of 1.392. Holders of the MRCP qualification faced elevated odds of 1.657 after adjustment, while physicians with 5 to 10 years of clinical experience were markedly less likely to report barriers than those with fewer than 5 years, with an adjusted odds ratio of 0.588. The authors caution that the reasons underlying the gender difference remain unclear and may reflect differences in clinical experience or practice patterns rather than any intrinsic factor.

The experience gradient deserves particular attention. That mid-career physicians encounter fewer obstacles than their juniors suggests a learnable skill set: the counselling techniques, cultural fluency and regimen-management strategies that accumulate with practice. Conversely, the finding that MRCP holders reported more barriers may reflect the complexity of the patients they manage or differing thresholds for perceiving problems. Either way, the authors argue, the pattern points toward targeted professional development rather than one-size-fits-all training. In a country where literacy rates lag behind those of many comparison nations, the dominance of patient education as the leading barrier, reported by 85.8 percent of respondents, takes on added weight. A parallel study from Singapore found that educational level was significantly associated with patients’ willingness to accept insulin, and the Lahore data are consistent with that relationship operating at population scale.

Perhaps the most actionable portion of the study is the physicians’ own prescription for reform. When asked what support was lacking in helping patients understand insulin therapy, the most common answer, endorsed with highly significant differences across qualification groups, was access to diabetes educators. For improving adherence, regular follow-up appointments dominated, and for sustaining patient responses over time, regular follow-up and support was the leading recommendation, chosen by 156 FCPS holders and 105 MRCP holders. On communication, an overwhelming majority across all credential groups selected a combined approach: written instructions, verbal counselling and shared decision-making. When asked how to improve the prescribing process itself, most favoured an all-of-the-above package of streamlined electronic prescribing systems, better patient education resources, improved access to formulary information and closer collaboration with diabetes specialists.

These recommendations align with a growing evidence base. A 2025 systematic review by Aslam and colleagues found that behavioural intervention programmes incorporating patient education, counselling and structured follow-up are effective in preventing and managing diabetes in adults. Pakistan’s rapidly expanding telecommunications infrastructure offers a plausible delivery channel for such programmes, potentially extending education and follow-up beyond hospital walls. Meanwhile, screening initiatives such as the Risk Assessment of Pakistani Individuals for Diabetes aim to identify high-risk individuals before complications develop. The survey’s authors also situate their findings within the broader literature on therapeutic inertia, which attributes roughly 20 percent of clinical delay to health-system factors, including medication cost, resource limits, discontinuity of care and workforce overload, and about 30 percent to patient-related factors such as injection phobia, fear of weight gain and low health literacy.

The study is not without limitations, and the authors are candid about them. Convenience sampling at a single urban tertiary hospital limits generalizability, particularly to rural settings where the majority of Pakistan’s population receives care. Self-reported data carry the risk of recall and social desirability bias. The inclusion of an all-of-the-above response category may have introduced overlap in the chi-square analyses, and the regression models did not formally assess multicollinearity or clustering by department. Crucially, because only physicians were surveyed, the barriers documented are physician perceptions, which may not fully mirror patients’ lived experience. The cross-sectional design identifies associations but cannot establish causation, and the interventions physicians recommended were not tested within the study itself.

Even with those caveats, the research delivers a clear message at a moment when Pakistan’s diabetes epidemic is accelerating. Insulin works; the obstacle is everything surrounding it. The Lahore survey transforms anecdote into quantified evidence, showing that the path to better glycaemic control runs through diabetes educator access, structured follow-up, culturally attuned communication and financial support, tailored to the experience level and professional background of the prescriber. Future intervention-based studies, the authors conclude, must now test whether these physician-endorsed strategies actually reduce barriers and improve outcomes. For a country where one in four urban adults lives with diabetes, the cost of therapeutic inertia is measured not in percentages but in amputations, blindness and lost years of life. What 808 physicians have described is, in effect, a map of where the system is failing, and a first draft of how to fix it.

Subject of Research: Barriers to insulin prescribing and physician-recommended interventions in diabetes care in Lahore, Pakistan

Article Title: Insulin Prescribing Challenges and Physician‐Suggested Interventions: Evidence From a Tertiary Care Hospital in Lahore, Pakistan

Article References: Aamir, M., Nafeesa, B., Aslam, A., Ghulam Mustafa, A., Elahi, M., Elahi, A., Barkat, K., Ashraf, M. U., Wahab, M. S. A., & Akhtar, S. S. (2026). Insulin Prescribing Challenges and Physician‐Suggested Interventions: Evidence From a Tertiary Care Hospital in Lahore, Pakistan. Endocrinology, Diabetes & Metabolism, 9(5), Article e70337. https://doi.org/10.1002/edm2.70337

Image Credits: AI Generated

DOI: 10.1002/edm2.70337

Keywords: insulin therapy, type 2 diabetes, Pakistan, therapeutic inertia, patient education, hypoglycaemia, physician survey, diabetes educators, cross-sectional study, tertiary care, medication adherence, health systems