Overcoming Barriers to Diabetes Technologies: The Human Factor

Tackling common reasons for both patient and clinician resistance to using the latest devices that promise more effective diabetes management and improved health outcomes.

With Katharine Barnard, PhD, and David T. Ahn, MD

There have been substantial technologic advances in the management of diabetes in the past few years, including continuous glucose monitors (CGMs), artificial pancreas (AP) systems, and continuous subcutaneous insulin infusion (CSII). Evidence of efficacy has been introduced for each of these devices, which offer improved glycemic control and a significant reduction in hypoglycemic events when compared with traditional diabetes treatment approaches.1

Despite these benefits, too few patients with type 1 diabetes (T1D) actually initiate the use of these diabetes care devices, and adherence/ persistence remains suboptimal.1 Alon Liberman, PhD, a clinical psychologist at Bar Ilan University in Israel, and Katharine Barnard, PhD, investigated why these new diabetes devices are not being optimally used and readily embraced;1 their findings were published in Diabetes Technology & Therapeutics.

Clinicians may not readily embrace diabetes technology due to unfamiliarity.

Reasons for Patient Refusal to Embrace New Diabetes Technologies 

Data from more than 16,000 participants in the Type 1 Diabetes Exchange clinic registry (T1D registry) indicate that 65% of younger children (6-12 years) use an insulin pump, as do 58% of adolescent children (13-17 years).2 Children using an insulin pump reported an increased number of blood glucose readings per day – 89% and 61% had at least three readings per day, respectively. However, only 8% of children aged 6-12 years and 5% of those aged 13 to 17 years use CGM, and fewer than one in five of them have a hemoglobin A1c less than 7.5% (20% and 16%, respectively).2

The authors examined 11 recently published articles on this topic each of which addressed psychosocial factors that appear to influence the use of diabetes technology – from the perspectives of clinicians, patients, and parents.3-13

“Physicians really need to have an understanding of the psychological factors that impact on diabetes self-management, not least because many of the reasons that individuals struggle with glycemic control are based on psychosocial factors rather than biomedical factors,” Katherine Barnard, PhD, faculty of health and social sciences at Bournemouth University in Bournemouth UK, told EndocrineWeb.

Understand the Patient’s Perceptions of New Technology

“In order to effectively identify individuals who would benefit most from a diabetes treatment device, it is crucial to understand expectations of the healthcare provider and the person with diabetes about what the technology will and won’t do. Armed with this knowledge, a collaborative exchange can take place about how the person will engage with the technology and what outcomes are desired/acceptable,” Dr. Barnard said.

David T. Ahn, MD, an endocrinologist at UCLA Health in San Diego, California, agreed, noting that “the best care is patient-centered and takes into consideration every person’s unique situation. Every person has their own combination of habits, physical attributes, preferences, and annoyances that might affect their choice in a diabetes device.”

Consequently, one role of physicians is to help their patients identify the devices that fit their lifestyles and comfort and to present options that best interface with their home and work/school situations.

Know Reasons for Patients' Rejection of Devices Aimed to Improve Outcomes

There were many similarities in the study findings. Patients generally report positive experiences with the diabetes technologies, but state challenges in adapting to them,  such as dealing with the alerts and alarms associated with CGM use.3

Ironically, one study found that although patients who use continuous glucose monitors reported more positive attitudes about the emerging technologies than did nonusers, younger patients—who are thought to be more ‘tech savvy’, are in fact less likely than older patients to embrace the use of CGMs.5

One possible explanation may be that diabetes devices are visible to others, causing unwanted attention by peers and greater scrutiny of the data by parents and HCPs, said Dr. Bernard, “This technology can be a difficult trade-off given “the promise of improved glycemic control versus drawing unwanted attention.”

Another study found that younger children appear more fascinated with the novelty of newer systems, whereas their parents are more concerned with the mechanisms, risks, and benefits of the devices.6  Similarly, another study found that because parents of young children have minimal experience with the pump, it lowered their confidence in managing hypoglycemia successfully, causing heightened anxiety.12

With Diabetes, Benefits Outweighed By Unfamiliarity 

Despite the numerous benefits, some parents appear to have difficulty accepting the devices. One of the most significant findings by Troncone et al concerned parental barriers to AP technology – specifically, parents of children who were beginning to use an artificial pump were fearful of their inexperience with the new system, concerned about relinquishing control over their children’s disease to the device, and anxieties surrounding the need to alter the current ‘familiar’ diabetes regimen.6  

Dr. Barnard emphasized the tough job parents face in supporting their child with diabetes, but noted that “clarity in communication around expectations and desires of a technology go a long way to unravel some of the challenges.”

There is a lack of consensus concerning the effect of early initiation of insulin pump on glycemic control and the quality of diabetes management. Recently, researchers who examined the ‘right’ time to initiate CSII in children found that beginning CSII at diagnosis compared with later in the course of treatment was consistently associated with lower HbA1c, with apparently no change in hypoglycemia, diabetic ketoacidosis (DKA) or quality of life (QoL).9

However, Dr. Bernard indicated that “the need for comprehensive diabetes education, including in the use of CSII at treatment outset, and the need for concurrent mental health counseling to address and optimize psychosocial outcomes” is clearly needed.1

Impact on Cognitive Functioning; Drawbacks to Easy Adoption of Devices

An ongoing area of research concerns the effect of type 1 diabetes on cognitive functioning. For instance, an open-label, prospective, crossover study found no differences in subjective and objective measures of cognitive functioning between patients who used a nighttime Android-based hybrid closed-loop system versus a sensor-augmented pump with low-glucose suspend function for four consecutive nights.7 Nevertheless, Dr. Bernard and her co-author postulated that prolonged use of diabetes technologies that enable continuous monitoring and/or automatic insulin delivery are likely to prevent cognitive decline in people with diabetes.1

Using structured theoretical models, investigators are examining the impact of the current AP prototype compared to sensor-augmented pump therapy on treatment satisfaction and fear of hypoglycemia, while also examining acceptance of AP technology.11 Study participants had a positive attitude towards the AP system, with no apparent fear of hypoglycemia.

However, this and other studies have found that despite apparent awareness and appreciation of the benefits of the technology, patients have concerns regarding specific technical issues of the device. Notably, patients were turned off by having the device on their body, voiced dislike of the alarms, and were insecure about a lack of understanding of device functions and features.10,11

Match Patients Deemed Good Candidates to New Diabetes Technologies

Identifying appropriate candidates who are likely to successfully use CSII therapy is an important and challenging component of the therapy. It is believed that appropriate candidates are those who are engaged in their diabetes care, highly motivated to achieve control over their blood glucose levels, yet unable to do so using their current therapy.

Ideal candidates also need to demonstrate both the willingness and the ability to utilize this complex and time-consuming technology. A recent multicenter cross-sectional study applied the concept of locus of control and found that adults with an internal control orientation – those who attribute success or failure to their own efforts – were more likely to engage with pump use than those with an external locus of control.8

According to Dr. Barnard, it may be more valuable to find out “what the person with diabetes wants to achieve and discuss how the device will/won’t support those goals. Technologies don’t make people adherent – they are nothing more than tools to help people self-manage their diabetes.”

What are the Barriers that Prevent Clinicians from Adopting Diabetes Devices?

Researchers have also examined the barriers that may explain the low uptake of diabetes technology by clinicians. Younger clinicians appear to be more open to the use of insulin pumps and CGM, with more positive attitudes towards diabetes technology compared with older cohorts.10 The investigators highlighted the need for psychoeducation as well as practical support to facilitate a comfort with diabetes devices to foster better acceptance of and adherence in patients.

They recommended development of and reliance on a structured protocol that a diabetes team can follow to initially present the technology to a patient.

“Setting expectations is the most important factor when initiating pumps and CGM’s. …everybody has their own fears and hopes for starting a new method of treatment, so it helps to manage expectations, especially since these devices usually have a steep learning curve,“ Dr. Ahn told EndocrineWeb.

“Along those same lines, allotting enough time at the initial visit and having frequent follow-ups, in the beginning, are crucial in helping patients quickly get up to speed,” and addressing the potential for better adoption and adherence, said Dr. Ahn.

Improving the Introduction of Diabetes Technologies to Patients

There is evidence that patients may be more “adherent” in the 1- to 2-week period prior to physician visits than they are the rest of the time.13 Physicians utilize self-report as well as downloadable data to gather information regarding the patient’s glycemic control; newer technology provides a more complete picture, and thus improve real-time access to necessary and accurate data needed before recommending changes to current insulin regimens.

Dr. Barnard said, “Living with diabetes isn’t just about glycemic control, it’s also often about enduring the ignorance of others. Matching the right therapy/device to the right patient at the right time requires an understanding of the current medical status of the individual, what their needs are, and how a technology may or may not meet those needs. Diabetes technologies are fantastic and when used effectively, hugely improve the biomedical and psychosocial outcomes for people who have to wear them/live with them.”

“I strongly recommend that patients and their families join social network communities, such as Facebook Groups (eg. Diabetes Strong Community, CGM In the Cloud, Parents of Type 1 Diabetics). In the real world, meeting other people with diabetes is extremely difficult, but online communities introduce you to thousands,” said Dr. Ahn.


Neither Dr. Barnard, her co-author, nor Dr. Ahn have any competing financial conflicts.

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