Implementing Patient Decision Aids for Insulin Initiation in China: What are the Barriers and Facilitators? A TDF-Based Qualitative Study

Abstract

Background: When oral antidiabetic drugs are insufficient to achieve glycemic control in Type 2 diabetes mellitus (T2DM), patients face the decision of whether to initiate insulin therapy. Patient decision aids (PtDAs) facilitate shared decision-making (SDM) by supporting informed, preference-congruent choices about insulin initiation. However, PtDA implementation in China remains challenging, with limited understanding of context-specific barriers.

Objective: This study is aimed at identifying the barriers and facilitators to implementing PtDAs for supporting informed decisions about insulin initiation in T2DM management in China, from the perspectives of key interest holders (patients, endocrinologists, nurses).

Methods: A qualitative descriptive study was conducted using semistructured interviews guided by the Theoretical Domains Framework (TDF). A purposive sample of 26 participants (10 patients with T2DM, 6 physicians, and 10 nurses) was recruited from a university-affiliated hospital in Beijing. Interviews were audio-recorded, transcribed verbatim, and analyzed using a framework analysis approach assisted by NVivo.

Results: Fifteen barriers and five facilitators were identified for healthcare professionals, whereas six barriers and five facilitators were identified for patients. Key barriers included a lack of knowledge about PtDAs and insufficient skills for their use among both groups. Notable barriers related to social/professional role and identity were found, with physicians often self-identifying as sole "decision-makers" and nurses expressing role ambiguity regarding SDM. The absence of reinforcement mechanisms and concerns about increased workload and limited resources were substantial organizational barriers. Facilitators included positive beliefs about PtDAs' consequences and the readiness of nurses, whose established health education practices position them as potential champions for implementation. Patients demonstrated a positive intention to use PtDAs once their purpose was understood.

Conclusions: The implementation of a PtDA for informed decision-making about insulin initiation in T2DM patients in China is influenced by a complex array of factors. Moving beyond the common barrier of time constraints, this study highlights foundational gaps in knowledge, skills, and role alignment as primary hurdles. A multifaceted implementation strategy is essential, comprising comprehensive education and training, clear role delineation, adaptation of PtDAs to fit clinical workflows, and strong organizational commitment with integrated monitoring and support.

Keywords: Theoretical Domains Framework; Type 2 diabetes mellitus; insulin initiation; patient decision aids; qualitative study.