Objectives: Many patients with type 2 diabetes are uncontrolled on maximum oral treatment. The early introduction of insulin can lower diabetes-related complications. The purpose of this study was to explore the reasons behind a perceived reluctance of patients with type 2 diabetes to commence insulin therapy despite objective evidence for the augmentation of oral treatment with insulin. Secondary objectives were to review the demographic data of these patients, to review the patients' knowledge of their disease and of insulin and to compare the knowledge and difficulties of those who agreed to be initiated on insulin with that of those who refused.

Design: The study used an observational analytical design. All uncontrolled patients with type 2 diabetes on maximum oral therapy were interviewed using face-to-face interviews with open- and closed-ended questions.

Setting and subjects: The study was conducted over a three-month period at the Phoenix Community Health Centre, a state-run institution, in Durban, KwaZulu-Natal.

Outcome measures: The education level of the patients, their knowledge of the disease, understanding of insulin, family support and fear of needles and pain were notable outcome measures.

Results: Fifty-nine patients were enrolled in the study. The mean haemoglobin A_1c was 9.6. Level of academic education was not associated with a willingness to start insulin therapy (p-value = 0.426). Forty-seven per cent of the patients had no understanding of insulin. Forty-four per cent of the patients were willing to initiate insulin therapy and 55% refused. There was no significant difference in knowledge score between those who accepted and refused insulin therapy (p-value = 0.554). Seventy-nine per cent of patients were afraid of the pain associated with injections.

Conclusion: As a fear of injections and needles was the only significant factor that was associated with the refusal to initiate insulin therapy (p-value < 0.001), health professionals need to address this during patient education, so as to initiate insulin treatment successfully and timeously.