Background: The purpose of the Addressing the Challenge and Constraints of Insulin Sources and Supply (ACCISS) Study is to identify the main barriers of access to insulin then develop interventions to reduce these barriers. To do this, the study investigated the issue from diverse perspectives, from manufacturers to supply chain mark-ups and prices. As diabetes is a condition that is managed by the person living with the condition 95 percent of the time (1), it was also important to understand insulin access and use from the user’s perspective.  

Aims: The aim of this qualitative study was to gain insights on some of the critical issues insulin users have accessing and using their insulin, as told from a diverse group of people, across insulin and diabetes types and in multiple countries. These issues include – how insulin is used on a daily basis, where people actually get their insulin from and how much they pay for it, how they feel about what they are using, and how much (if any) impact national diabetes associations, doctors or marketing by manufacturers might have on their insulin knowledge and choices.   

Methods: Informal interviews with insulin users were conducted via phone, Skype, Google Hangout, direct email, and printed hardcopy questionnaires. 

Results: In total, 36 people were interviewed in 11 countries, three high-income countries and eight low-and middle income countries. The results found that human insulins are primarily used in lower-income settings, while analogues insulins are used in higher-income settings.  In general people are satisfied with the insulin they are using, regardless of the type. However, this did not equate to not having other issues with their diabetes or insulin management. 
In terms of insulin brands, most users know the brand name of the insulin they use, but did not know the company that manufactured it, nor did this seem to be a priority. Further, most did not know the differences between human, analogue or animal insulin, or could not identify these types accurately. In terms of willingness to change insulins, brand loyalty seemed more important than company loyalty.  
The interviews revealed that insulin users in 10 of the 11 countries are struggling to pay for insulin and/or diabetes supplies. 
Finally, the interviews highlighted the important impact that both diabetes associations and doctors can have on insulin users in terms of their insulin choices and overall choices in diabetes management. 

Discussion: The findings point to certain trends in how insulin is used on a day-to-day basis, particularly on where users receive insulin from, the relationship users have with their doctors, and the perceptions of their treatment. It also points to the shared struggles that insulin users, across countries and type of diabetes go through, and the opportunity it presents to work together to further the cause of access to affordable, high-quality insulin for all.   

1.	Martha Mitchell Funnell, MS, RN, CDE; Robert M. Anderson, EdD  The Problem With Compliance in Diabetes, JAMA. 2000;284(13):1709. doi:10.1001/jama.284.13.1709-JMS1004-6-1   (http://jamanetwork.com/journals/jama/fullarticle/1843382).

“you just have to do the best you can and hang on" - Global access to insulin from the user’s perceptive