Aims: The aim of this study was to investigate the relationship between diabetes stigma as experienced by adults with type 1 diabetes and diabetes outcomes using the novel, validated measure of the Type 1 Diabetes Stigma Assessment Scale. Methods: A total of 1594 adults with type 1 diabetes completed a questionnaire on socio-economic factors, psychosocial health, and diabetes stigma and these self-reported data were linked with data from electronic clinical records on glycaemic control, diabetes duration, age, and diabetes-related complications. Bivariate analyses and multivariate linear regressions were performed to assess the relationship between diabetes stigma as measured by three subscales, Identity concern, Blame and judgement, and Treated differently on the one hand, and patient characteristics and diabetes outcomes on the other. Results: Endorsement of the stigma statements ranged from 3.6–78.3% of respondents. Higher stigma scores in relation to Identity concern and Blame and judgement were significantly associated with being female, of lower age, lower diabetes duration, and having at least one complication. Those who reported higher levels of perceived stigma reported significantly higher levels of diabetes distress (β = 0.37 (95% CI: 0.33–0.40), 0.35 (95% CI: 0.30–0.39), 0.41 (95% CI: 0.35–0.46)), and HbA1c levels (β = 0.11 (95% CI: 0.02–0.21), 0.28 (95% CI: 0.16–0.40), 0.26 (95% CI: 0.14–0.42) for Identity concern, Blame and judgement, and Treated differently, respectively). Conclusions: The findings demonstrated that diabetes stigma is negatively associated with both diabetes distress and glycaemic control and should be considered part of the psychosocial burden of adults with type 1 diabetes.

OBJECTIVE:The aim was to explore relationships between work-related factors, work-related diabetes distress (WRDD), diabetes distress (measured by Problem Areas in Diabetes [PAID]-5 scale), intentional hyperglycemia at work (IHW), and glycemic control.RESEARCH DESIGN AND METHODS:A cross-sectional survey was conducted with 1,030 working adults with type 1 diabetes and linked with electronic health record data from a specialist diabetes clinic in Denmark. With use of structural equation modeling, two alternative models were compared, based on fit indices, statistical significance, and theoretical meaningfulness.RESULTS:A combined model provided the best fit to the data. WRDD was more strongly affected by work ability, opportunity to self-manage at work, being treated differently, and job demands. PAID-5 was more strongly affected by identity concern and blame and judgment. Both PAID-5 and WRDD were associated with more frequent IHW, which was associated in turn with worse glycemic control.CONCLUSIONS:Work-related factors are associated with WRDD and PAID-5. Distress increases the frequency of IHW, which is, in turn, associated with worse glycemic control. Future studies should investigate ways to balance diabetes management and work life without compromising diabetes care.

We aimed to (a) culturally and linguistically adapt the Type 1 Diabetes Stigma Assessment Scale (DSAS-1) from English (for Australia) into Danish and (b) examine psychometric properties of the measure among Danish adults with type 1 diabetes.

Aim: Diabetes distress captures a range of emotional responses and reactions to life with diabetes and is considered a part of the experience of managing diabetes and its treatment Given the importance of the social context of work life for people of working age we set out to explore whether work-related diabetes distress is a distinct and important dimension of diabetes-related emotional distress in working people with type 1 diabetes. Methods: A questionnaire with self-reported measures of psychosocial health and well-being at work was completed by 1126 working people with type 1 diabetes from a specialist diabetes clinic in Denmark. Work-related diabetes distress was assessed with two questions about worry and exhaustion related to reconciling work life and diabetes. Diabetes-related emotional distress was assessed with the Problem Areas in Diabetes scale (PAID-5), a short form version of the full PAID scale. We performed inter-item correlation analyses, exploratory factor analysis, and hierarchical multiple regression analyses. Results: Inter-item correlations and exploratory factor analysis indicated that work-related diabetes distress was distinct from diabetes-related emotional distress. Further, work-related diabetes distress was found to be a unique contributor to work ability, quality of life, intentional hyperglycaemia at work, and absenteeism, after adjusting for covanates and diabetes-related emotional distress. Conclusions: The findings suggest that work-related diabetes distress captures an aspect of distress so far unaccounted for in workers with type 1 diabetes Further studies are needed to strengthen the conceptual basis of work-related diabetes distress, explore its clinical usefulness and clarify its risk factors. (c) 2018 Elsevier B.V All rights reserved.

For people with type 1 diabetes, extensive tasks involved in diabetes self-management have a significant impact on overall care and quality of life. Members of the working population with type 1 diabetes spend one third of their time at work, yet little attention has been paid to challenges specific to balancing diabetes management and work life. Diabetes is associated with increased absenteeism and presenteeism, as well as disability retirement and lower lifetime income. These quantitative outcomes are corroborated by qualitative studies highlighting some of the challenges of reconciling diabetes self-management with work life. This qualitative study expands on previous research by examining illness behavior in work life using Alonzo's concept of containment. Forty in-depth interviews with Danish people with type 1 diabetes were conducted from May to December 2016 and analyzed using abductive reasoning. We found that working people with type 1 diabetes live in tension between competing logics linked to diabetes and to work life. We illustrate how diabetes management can be articulated as a matter of containment, which refers to the assemblage of practices and mental and emotional work required to keep diabetes at the level of a side-involvement and maintain proper situational involvement in work life. The containment framework illuminates and characterizes diabetes management in the context of work life and reveals a hidden burden of disease carried by working people with type 1 diabetes. Further research is needed to advance the theory of containment.

The impact of disease-related changes in the extracellular matrix (ECM) on the mechanical properties of human resistance arteries largely remains to be established. Resistance arteries from both pig and human parietal pericardium (PRA) display a different ECM microarchitecture compared with frequently used rodent mesenteric arteries. We hypothesized that the biaxial mechanics of PRA mirror pressure-induced changes in the ECM microarchitecture. This was tested using isolated pig PRA as a model system, integrating vital imaging, pressure myography, and mathematical modeling. Collagenase and elastase digestions were applied to evaluate the load-bearing roles of collagen and elastin, respectively. The incremental elastic modulus linearly related to the straightness of adventitial collagen fibers circumferentially and longitudinally (both R2 ≥ 0.99), whereas there was a nonlinear relationship to the internal elastic lamina elastin fiber branching angles. Mathematical modeling suggested a collagen recruitment strain (means ± SE) of 1.1 ± 0.2 circumferentially and 0.20 ± 0.01 longitudinally, corresponding to a pressure of ~40 mmHg, a finding supported by the vital imaging. The integrated method was tested on human PRA to confirm its validity. These showed limited circumferential distensibility and elongation and a collagen recruitment strain of 0.8 ± 0.1 circumferentially and 0.06 ± 0.02 longitudinally, reached at a distending pressure below 20 mmHg. This was confirmed by vital imaging showing negligible microarchitectural changes of elastin and collagen upon pressurization. In conclusion, we show here, for the first time in resistance arteries, a quantitative relationship between pressure-induced changes in the extracellular matrix and the arterial wall mechanics. The strength of the integrated methods invites for future detailed studies of microvascular pathologies.NEW & NOTEWORTHY This is the first study to quantitatively relate pressure-induced microstructural changes in resistance arteries to the mechanics of their wall. Principal findings using a pig model system were confirmed in human arteries. The combined methods provide a strong tool for future hypothesis-driven studies of microvascular pathologies.

Background: The number of new technologies for risk assessment available in health care is increasing. These technologies are intended to contribute to both improved care practices and improved patient outcomes. To do so however, there is a need to study how new technologies are understood and interpreted by users in clinical practice. The objective of this study was to explore patient and physician perspectives on the usefulness of a new technology to detect Cardiovascular Autonomic Neuropathy (CAN) in a specialist diabetes clinic. The technology is a handheld device that measures resting heart rate and conducts three cardiac autonomic reflex tests to evaluate heart rate variability.Methods: The study relied on three sources of data: observations of medical consultations where results of the CAN test were reported (n = 8); interviews with patients who had received the CAN test (n = 19); and interviews with physicians who reported results of the CAN test (n = 9). Data were collected at the specialist diabetes clinic between November 2013 and January 2014. Data were analysed using the concept of technological frames which is used to assess how physicians and patients understand and interpret the new technology.Results: Physicians generally found it difficult to communicate test results to patients in terms that patients could understand and to translate results into meaningful implications for the treatment of patients. Results of the study indicate that patients did not recall having done the CAN test nor recall receiving the results. Furthermore, patients were generally unsure about the purpose of the CAN test and the implications of the results.Discussion: Involving patients and physicians is essential when a new technology is introduced in clinical practice. This particularly includes the interpretation and communication processes related to its use.Conclusions: The integration of a new risk assessment technology into clinical practice can be accompanied by several challenges. It is suggested that more information about the CAN test be provided to patients and that a dialogue-based approach be used when communicating test results to patients in order to best support the use of the technology in clinical practice.

PURPOSE:To explore the feasibility of a research-based program for patient-centered consultations to improve medical adherence and blood glucose control in patients with type 2 diabetes.PATIENTS AND METHODS:The patient-centered empowerment, motivation, and medical adherence (EMMA) consultation program consisted of three individual consultations and one phone call with a single health care professional (HCP). Nineteen patients with type 2 diabetes completed the feasibility study. Feasibility was assessed by a questionnaire-based interview with patients 2 months after the final consultation and interviews with HCPs. Patient participation was measured by 10-second event coding based on digital recordings and observations of the consultations.RESULTS:HCPs reported that EMMA supported patient-centered consultations by facilitating dialogue, reflection, and patient activity. Patients reported that they experienced valuable learning during the consultations, felt understood, and listened to and felt a trusting relationship with HCPs. Consultations became more person-specific, which helped patients and HCPs to discover inadequate diabetes self-management through shared decision-making. Compared with routine consultations, HCPs talked less and patients talked more. Seven of ten dialogue tools were used by all patients. It was difficult to complete the EMMA consultations within the scheduled time.CONCLUSION:The EMMA program was feasible, usable, and acceptable to patients and HCPs. The use of tools elicited patients' perspectives and facilitated patient participation and shared decision-making.

Purpose– The purpose of this paper is to explore educator competencies and roles needed to perform participatory patient education, and develop a comprehensive model describing this.Design/methodology/approach– Data collection in the qualitative study proceeded through two phases. In the first phase, 28 educators were involved in exploring educator competencies needed to perform participatory, group-based patient education. The paper used qualitative methods: dialogue workshops, interviews and observations. In the second phase, 310 educators were involved in saturating and validating the insights from phase one using workshop techniques such as brainstorming, reflection exercises and the story-dialogue method. A grounded theory approach was used to analyse data.Findings– A model called “The Health Education Juggler” was developed comprising four educator roles necessary to perform participatory patient education: the Embracer, the Facilitator, the Translator and the Initiator. The validity of the model was confirmed in phase two by educators and showed fit, grab, relevance, workability and modifiability.Practical implications– The model provides a tool that can be used to support the focus on “juggling” skills in educators: the switching between different educator roles when performing participatory, group-based patient education. The model is useful as an analytical tool for reflection and supervision, as well as for observation and evaluation of participatory, group-based patient education.Originality/value– The study proposes a comprehensive model consisting of four equally important roles for educators performing participatory, group-based patient education.

Action research is potentially a useful method for changing clinical practice by involving practitioners in the process of change. The aim of this study was to explore the utility of action research in bridging the gap between research and practice. Diabetes educators in collaboration with researchers developed and implemented a participatory, group-based diabetes education program in a diabetes clinic in the Danish health care system. The research process included a variety of qualitative methods: workshops, classroom observations, video recordings and semi-structured interviews. These methods aimed at obtaining contextual sensitivity, allowing dynamic interactions with educators and people with diabetes. Despite challenges, the study demonstrates how action research methods contribute to development and change of diabetes education practice while simultaneously adding knowledge to the action research community.

Rationale, aims and objective: Most patient education is based on a professional understanding of patients’ needs for learning, rather than a patient perspective. This generates a risk of neglecting issues that are important to patients, but unrecognised by educators. The aim of this study was to develop a health educational model for group-based patient education in chronic illness based on patient-perceived challenges.Methods: Design Thinking was used as a method of inquiry. Four interactive workshops with 25 Danish patients with Type 2 diabetes, heart disease and chronic obstructive pulmonary disease provided data on patient-perceived challenges. Workshops with 28 educators informed the development of the model. A constant comparative method was used for analyses.Results: Patients with chronic illness experience a constant need to balance their lives, which imposes new challenges in their everyday life. We identified 4 main challenges: Bodily Infirmities, Lowered Expectations, Challenging Relations and Changeable Moods. In response to these challenges, researchers and educators developed The Balancing Person, a health educational model with 4 interconnected meta-needs for the education process: Wholeness, Clarity, Timeliness and Connectedness.

AIMS:The aim of this study was to benchmark the Danish sample of the second Diabetes, Attitudes, Wishes and Needs (DAWN2) study with the global average in order to determine Denmark's comparative position for health status, healthcare provision, self-management and social support from the perspective of people with diabetes, family members of people with diabetes and healthcare professionals.METHODS:A total of 502 Danish people with diabetes (PWD), 122 adult family members of people with diabetes (FM) and 283 healthcare professionals (HCPs) participated in the study. Data on healthcare provision and physical and psychosocial wellbeing were collected from the 17 participating countries.RESULTS:Psychological wellbeing was higher among Danish PWD; conversely, self-management behaviour of PWD ranked below the global average. A substantial gap was found in the perceptions of PWD and HCPs regarding the extent to which healthcare provision was deemed person-centred. The gap was found to be larger, however, when looking at the global data. Danish FM reported higher education participation and satisfaction rates as well as lower distress than the global average, but there appears to be an untapped potential when it comes to converting education participation of FM into social support for PWD.CONCLUSIONS:Our findings suggest that PWD in Denmark rank above the global average on measures of psychological wellbeing, despite psychological wellbeing being under-prioritised by HCP. However, there is room for improvement when it comes to self-management behaviours. Special attention is needed to address this issue without compromising the psychological wellbeing of the PWD.

Sir, If the 21st century should indeed become the century of the patient, as it has been stated,[1] radically new methods and models for person-centered practice are required. Patient education is a cornerstone in caring for patients with chronic illness, such as type 2 diabetes, heart disease and chronic obstructive pulmonary disease (COPD). For patient education to be truly person-centered, patients must participate in identifying their problems and in formulating solutions to problems. Unfortunately this is rarely the case.[2] Most patient education is based on a professional understanding of patients’ needs for learning, rather than patient perspectives and preferences.[3] This generates a risk of neglecting issues that are important to patients but unrecognized by educators. As shown in the large DAWN and DAWN2 studies, psychosocial issues such as diabetes distress are pronounced among people with diabetes. Hence, there is still a substantial need globally for translating this research into the actual delivery of person-centered diabetes care.[4] Health education as a professional task potentially has a lot to offer the healthcare system in using patient input to design and implement person-centered care.[2] Following this we were guided by two health education concepts dialogue and participation in the development of tools to be used in person-centered patient education: Dialogue is to be understood in a broad sense as an approach to patient education. Patient education has most commonly been delivered using the one-way didactic model, in which the educator provides information to participants in a teacher-student relationship. This approach has proven successful in conveying information but is less useful when it comes to encouraging, enabling and supporting patients to change behavior and manage their condition. Behavior change theory indicates that educators must engage participants in a dialogue to identify challenges, set goals, increase self-efficacy, and address barriers to change. Participation likewise implies a shift from a disease-centered and paternalistic approach toward care centered on the challenges of persons living with and managing chronic illness. These principles are currently translated into the development of flexible tools to be used in group-based patient education for people with chronic illness, in individual consultations targeting people with diabetes with high blood sugars and low medication adherence, for individual patient education in diet, and for vulnerable people with diabetes. The tools make use of pictures, quotes, and statements to engage and give voice to the people with chronic illness. The tools and the participatory and patient-centred approach thus support the call for flexible and dynamic approaches to patient education.[5] The tools have shown promise in feasibility studies. Further research is needed to assess whether they will actually translate into better quality of care and better health outcomes.