Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

"I feel like I'm being talked to like an equal": Diabetes language matters to adults with diabetes, a mixed-methods study

AIM

To explore reactions to and preferences for words/phrases used in communications about diabetes among adults with diabetes and parents of children with diabetes.

METHODS

Eligible adults (aged 18+ years) living with diabetes, or parenting a child with diabetes, were recruited via social media to complete an online cross-sectional, mixed-methods survey. Study-specific items were used to examine 22 commonly used diabetes words/phrases in terms of participants' cognitive perceptions ('helpful', 'respectful', 'accurate', 'harmful', 'judgmental' and 'inaccurate') and emotional reactions ('optimistic', 'motivated', 'supported', 'understood', 'offended', 'blamed', 'distressed' and 'angry'). Open-ended questions invited further feedback on (non-)preferred language and its impact(s). Data were analysed using descriptive statistics and inductive thematic analysis.

RESULTS

Participants (N = 865) included adults with diabetes (type 1: n = 519; type 2: n = 180, other types: n = 48) and parents of children with diabetes (n = 118). Words/phrases most commonly associated with negative perceptions/emotional responses were 'non-compliant' (60% judgmental; 47% felt blamed) and '…good/bad' (54% judgmental; 43% blamed). Positive perceptions were reported for 'managing diabetes' (73% helpful, 47% felt understood), 'person with diabetes' (72% respectful; 49% understood), '…within/outside target range' (60% helpful, 44% understood), and 'condition' (58% respectful; 43% understood). Participants' qualitative responses illuminated perceptions, experiences and impacts across five themes: (1) accuracy and simplicity; (2) identity; (3) blame, judgement and stigma; (4) respect and trust and; (5) support, hope and feeling understood. Themes were consistent across diabetes types.

CONCLUSIONS

These findings provide novel evidence into (non-)preferred, and potential (negative and positive) impacts of, commonly used diabetes words/phrases, supporting the international #LanguageMatters movement.

The experiences of individuals who have had gestational diabetes: A qualitative exploration

AIM

To qualitatively explore the experiences of individuals with Gestational Diabetes Mellitus (GDM) in Australia, and to recognise opportunities for leveraging digital health to enhance the support of GDM management.

METHOD

A cross sectional online survey assessed the experiences of individuals with GDM, the healthcare system and their digital health usage. Respondents (recruited via a national diabetes registry or social media) were adults receiving GDM care within Australia in the last 5 years, who responded to any of three open-ended questions (n = 815) exploring positive, negative and other GDM experiences. Thematic analysis was utilised, and themes were mapped to the socio-ecological systems framework.

RESULTS

At a system level, themes related to (1) accessibility of care including the value of digital health and the inflexible or inconsistent perception of the (2) implementation of guidelines. At an interpersonal level, themes covered the need for adequate (3) health information provision, and (4) supportive care, as well as highlighting (5) experiences of stigma including a desire for greater awareness of GDM. Individual-level themes included: (6) differential barriers to accessing care; (7) negative emotional burden; (8) internalisation of stigma; (9) dietary freedom and social impact and (10) opportunity for change derived from having GDM.

CONCLUSION

Findings suggest a demand for more supportive, person-centred GDM care, improved information provision and individualised implementation of clinical guidelines. Such mechanisms may support reduced barriers to accessing care or negative psychosocial impacts of GDM. Though not central to the identified experiences, digital health tools may help address the need for optimised GDM care.

Diabetes misconceptions, seriousness, motivation, self-efficacy and stigma: A cross-sectional comparison of eight Australian diabetes communication campaign videos

AIM

This study examines potential intended (attitudes, motivation and self-efficacy) and unintended (stigmatisation of diabetes) consequences of past Australian National Diabetes Week campaign videos. Further, outcomes are compared by the extent to which participants perceived their allocated video as stigmatising diabetes.

METHODS

In this cross-sectional, ten-arm study, participants (adults with or without diabetes; 1:2 ratio) were randomly allocated to view one of eight archival diabetes campaign videos (intervention), or either an active or passive control group. Post-exposure, study-specific scales measured diabetes Misconceptions and Seriousness, General and Diabetes Risk-Reduction Motivation and Self-efficacy, and perceptions of video Stigmatisation of diabetes. Scores were compared by condition (intervention vs. control) and by campaign Stigma (highest vs. lowest tertile score), separately by cohort (with or without diabetes).

RESULTS

The sample included n = 1023 without diabetes; and n = 510 with diabetes (79% type 2 diabetes). No significant differences in outcomes were observed between conditions (intervention vs. control), with one exception: a modest effect on General Self-efficacy among those without diabetes only. Those perceiving high campaign Stigma (15%), relative to low Stigma (60%), reported significantly greater diabetes Misconceptions, lower perceived Seriousness and (among those without diabetes only) lower General Motivation but higher Diabetes Risk Reduction Motivation.

CONCLUSION

Though limited to a single-exposure, we found little meaningful positive influence of past diabetes campaign videos on diabetes attitudes, behavioural intentions or self-efficacy. Further, campaign videos were perceived as stigmatising by a minority-a potential harmful impact. This novel study has implications for the design, implementation and evaluation of future diabetes campaigns.

Recognition of language barriers in comprehending non-communicable disease management among rural elderly people in the DIMAMO surveillance area: a case of AWI-Gen participants

BACKGROUND

Language plays a critical role in health communication, particularly in the management and understanding of non-communicable diseases (NCDs) among elderly populations. This study aimed to explore the language barriers that affect elderly participants' comprehension of NCDs, focusing on how these barriers impact their understanding of disease causes, symptoms, treatment, and self-management. The study also investigated how linguistic differences between healthcare workers and patients influence the effectiveness of health interventions in a rural South African context.

METHODS

This qualitative phenomenological study was conducted with elderly participants aged 60 years and above, all of whom have chronic diseases. In-depth face-to-face interviews were conducted using an interview guide during the AWI-Gen 2 research feedback sessions in the Ga-Dikgale area. Data analysis was performed using QSR NVivo 10 to identify key themes.

RESULTS

Five major themes emerged regarding participants' understanding of NCDs and the perceived language barriers. These include Limited Knowledge and Awareness of NCDs, Misconceptions about NCDs, Mixed perceptions regarding NCD causes and treatment, Discrepancies in healthcare workers' communication, and the Importance of interpreters in facilitating NCD-related communication.

CONCLUSION

The study revealed significant misconceptions about diabetes and hypertension, as well as traditional practices like bloodletting, which were perceived to relieve hypertension symptoms. It also identified critical communication barriers, including limited time for health practitioners to explain diagnoses and treatments. The findings emphasize the need for interpreters and culturally sensitive communication strategies to improve health literacy and care. Collaborative efforts between traditional and western health practitioners are recommended to address these issues and enhance community health interventions.

Type 2 diabetes mellitus in adults: pathogenesis, prevention and therapy

Type 2 diabetes (T2D) is a disease characterized by heterogeneously progressive loss of islet β cell insulin secretion usually occurring after the presence of insulin resistance (IR) and it is one component of metabolic syndrome (MS), and we named it metabolic dysfunction syndrome (MDS). The pathogenesis of T2D is not fully understood, with IR and β cell dysfunction playing central roles in its pathophysiology. Dyslipidemia, hyperglycemia, along with other metabolic disorders, results in IR and/or islet β cell dysfunction via some shared pathways, such as inflammation, endoplasmic reticulum stress (ERS), oxidative stress, and ectopic lipid deposition. There is currently no cure for T2D, but it can be prevented or in remission by lifestyle intervention and/or some medication. If prevention fails, holistic and personalized management should be taken as soon as possible through timely detection and diagnosis, considering target organ protection, comorbidities, treatment goals, and other factors in reality. T2D is often accompanied by other components of MDS, such as preobesity/obesity, metabolic dysfunction associated steatotic liver disease, dyslipidemia, which usually occurs before it, and they are considered as the upstream diseases of T2D. It is more appropriate to call "diabetic complications" as "MDS-related target organ damage (TOD)", since their development involves not only hyperglycemia but also other metabolic disorders of MDS, promoting an up-to-date management philosophy. In this review, we aim to summarize the underlying mechanism, screening, diagnosis, prevention, and treatment of T2D, especially regarding the personalized selection of hypoglycemic agents and holistic management based on the concept of "MDS-related TOD".

Associations between weight self-stigma and healthy diet and physical activity among adults with type 2 diabetes: Cross-sectional results from the second Diabetes MILES - Australia (MILES-2) study

AIMS

To examine associations between weight self-stigma and healthy diet or physical activity, and potential moderating effects of self-esteem, diabetes self-efficacy, and diabetes social support, among adults with type 2 diabetes.

METHODS

Diabetes MILES-2 data were used, an Australian cross-sectional online survey. Participants with type 2 diabetes who considered themselves overweight, and reported concern about weight management (N = 726; 48% insulin-treated), completed the Weight Self-Stigma Questionnaire (WSSQ; total score and subscales: self-devaluation, fear of enacted stigma), measures of diabetes self-care (diet, exercise), and hypothesised psychosocial moderators (self-esteem, diabetes self-efficacy, and diabetes social support). Adjusted linear regression tested associations and interaction effects, separately by insulin treatment status.

RESULTS

Greater weight self-stigma (WSSQ total) was associated with less optimal dietary self-care (both groups: β = -0.3), and with a lower level of exercise (non-insulin only: β = -0.2; all p < 0.001). All hypothesised moderators were negatively associated with weight self-stigma (range r = -0.2 to r = -0.5). Positive associations were identified between the hypothesised moderators and self-care behaviours (strongest between diet and diabetes self-efficacy, r = > 0.5). No significant interaction effects were observed.

CONCLUSIONS

This study provides novel evidence of negative associations between weight self-stigma and self-care behaviours among adults with type 2 diabetes. Weight self-stigma is a demonstrated barrier to self-care behaviours in type 2 diabetes cohorts. Acknowledgement and strategies to address weight self-stigma are needed in clinical care and health programmes.

Diabetes Stigma and Clinical Outcomes: An International Review

Diabetes stigma is the social burden of living with diabetes. People with diabetes may experience or perceive an adverse social judgment, prejudice, or stereotype about living with diabetes at work, school, in healthcare settings, popular culture, or relationships. This review describes the methods that have been used to assess diabetes stigma, and explores the prevalence of diabetes stigma, associated sociodemographic and socioeconomic factors, cultural factors, and how diabetes stigma is associated with clinical outcomes, including HbA1c levels, diabetic ketoacidosis, severe hypoglycemia, and chronic complications, in addition to psychosocial complications in youth, adolescents, and adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). The prevalence of diabetes stigma has been reported as high as 78% in adults with T1D, 70% in adults with T2D, 98% in youth and adolescents with T1D, and is unknown in youth and adolescents with T2D. Diabetes stigma has been associated with lower psychosocial functioning, decreased self-care behaviors, higher HbA1c levels, and higher frequency of diabetes complications in adults with T1D and T2D. In adolescents and young adults with T1D, diabetes stigma is associated with lower psychosocial functioning, higher HbA1c levels, and higher frequency of diabetic ketoacidosis and severe hypoglycemia episodes in addition to chronic complications. In youth and adolescents with T2D, one study demonstrated an association of diabetes stigma with lower psychosocial functioning, higher HbA1c levels, and presence of retinopathy. Gaps exist in our understanding of the mechanisms of diabetes stigma, particularly in youth and adolescents with T2D.

Adiposity in Chinese people with type 1 diabetes

Adiposity, synonymous with obesity, is prevalent among both children and adults with type 1 diabetes in China. Recent literature underscored the patho-physiological and socioeconomic factors associated with adiposity, and consistently highlighted its impact on cardiovascular, kidney, and metabolic diseases among Chinese individuals with type 1 diabetes. Addressing and managing adiposity in individuals with type 1 diabetes are complicated and entail comprehensive approaches including lifestyle modifications, cognitive-behavioral therapy, insulin dose titration, and other diabetes treatment medications. The condition calls for coordination among policymakers, researchers, clinicians, and patients.

Call to action for a life course approach

Gestational diabetes remains the most common medical disorder in pregnancy, with short-term and long-term consequences for mothers and offspring. New insights into pathophysiology and management suggest that the current gestational diabetes treatment approach should expand from a focus on late gestational diabetes to a personalised, integrated life course approach from preconception to postpartum and beyond. Early pregnancy lifestyle intervention could prevent late gestational diabetes. Early gestational diabetes diagnosis and treatment has been shown to be beneficial, especially when identified before 14 weeks of gestation. Early gestational diabetes screening now requires strategies for integration into routine antenatal care, alongside efforts to reduce variation in gestational diabetes care, across settings that differ between, and within, countries. Following gestational diabetes, an oral glucose tolerance test should be performed 6-12 weeks postpartum to assess the glycaemic state. Subsequent regular screening for both dysglycaemia and cardiometabolic disease is recommended, which can be incorporated alongside other family health activities. Diabetes prevention programmes for women with previous gestational diabetes might be enhanced using shared decision making and precision medicine. At all stages in this life course approach, across both high-resource and low-resource settings, a more systematic process for identifying and overcoming barriers to preventative care and treatment is needed to reduce the current global burden of gestational diabetes.

Diabetes Research Matters: A Three-Round Priority-Setting Survey Consultation with Adults Living with Diabetes and Family Members in Australia

OBJECTIVE

We aimed to identify the health and quality-of-life research priorities of Australians with diabetes or family members.

METHODS

Through an iterative, three-step, online survey process we (1) qualitatively generated research topics (long list) in response to one question "What research is needed to support people with diabetes to live a better life?"; (2) determined the most important research questions (short list); and (3) ranked research questions in order of importance (priorities). We aimed to recruit N = 800 participants, with approximate equal representation of diabetes type and family members.

RESULTS

Participants (N = 661) were adults (aged 18+ years) in Australia with a self-reporting diagnosis of diabetes (type 1, n = 302; type 2, n = 204; prior/current gestational, n = 58; less common types, n = 22, or a family member, n = 75). Retention rates for Surveys 2 and 3 were 47% (n = 295) and 50% (n = 316), respectively. From 1549 open-text responses, 25 topics and 125 research questions were identified thematically. Research priorities differed by cohort, resulting in specific lists developed and ranked by each cohort. The top-ranked research question for the type 1 diabetes cohort was "How can diabetes technology be improved …?" and for the type 2 diabetes cohort: "How can insulin resistance be reversed …?". One question was common to the final lists of all cohorts: "What are the causes or triggers of diabetes?" Within cohorts, the top priorities were perceived as being of similar importance.

CONCLUSIONS

The research priorities differ substantially by diabetes type and for family members. These findings should inform funding bodies and researchers, to align future research and its communication with community needs.

Progress toward universal health coverage in Vietnam: Evidence on dispensing trends of diabetes medications from 2015 to 2021

AIMS

This study aims to investigate the trends in treatment coverage through dispensing diabetes medications in Vietnam from 2015 to 2021. The findings will serve to inform health policies to mitigate the health burden of Type 2 diabetes mellitus (T2DM).

METHODS

We collected information on major antidiabetic medicines from General Department of Vietnam Customs and payments for antidiabetics via the National Health Insurance Program. We applied ordinary least squares models, accounting for economic and health outcome characteristics, to estimate the association between the annual mass of medications and related factors.

RESULTS

Nationally, the total mass/doses of all antidiabetic drugs increased rapidly from 2015 to 2021, based on both databases. Metformin was the most frequently prescribed medicine, with the total mass increasing nearly threefold over the study period. Gliclazide, a Sulfonylureas drug, ranked second. In the multivariate regression analysis, a one-unit increase in adults with diabetes (in 1,000 s) was associated with 0.11 % (95 %CI = 0.0005; 0.0076) and 0.13 % (95%CI = 0.0007; 0.0242) higher mass of Metformin and Glimepiride, respectively.

CONCLUSION

Our data suggested that policies changes were related to significant increase in antidiabetic medication dispenses in Vietnam. The high treatment coverage indicates impressive progress in achieving universal health coverage in Vietnam, meeting the UN Sustainable Development Goal (SDG).

Impact of Negative or Stigmatizing Messages on Diabetes Outcomes: An Integrative Review

PURPOSE

The purpose was to determine if negative or stigmatizing language and messaging have an impact on diabetes distress, outcomes, or care behaviors in people with diabetes. Since 2012, when the first language position statement was published, the way health care professionals talk to people with diabetes has been an ongoing topic of discussion. However, there have been no recent literature reviews evaluating the impact of problem language on outcomes among people with type 1 and type 2 diabetes.

METHODS

An integrative review was conducted using 4 electronic databases: CINAHL, Embase, Web of Science, and Medline (Ovid). Studies reporting on diabetes, language, stigma, diabetes distress, glycemic outcomes, and self-care behaviors were included.

RESULTS

The review included 9 studies, all of which were of high quality. The impact of negative or stigmatizing language on self-care behaviors was the most commonly addressed outcome. Whereas some studies revealed no change, others reported a decrease in self-care behaviors by people with diabetes who had negative perceptions of provider messages. Actual or perceived use of negative or stigmatizing language is linked to higher A1C. Four studies reported an association between messages and diabetes distress.

CONCLUSIONS

Negative/stigmatizing language has both an immediate and long-term effect on people with diabetes. The inconsistent approaches to studying language in diabetes makes it challenging to compare outcomes and identify themes. Future research is needed to identify effective interventions to change the messages in diabetes.