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

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

A qualitative investigation into the perceptions and experiences of the stigma attached to gestational diabetes mellitus among women in Denmark.

AIM: The aim of this study was to explore the perceptions of women with gestational diabetes mellitus (GDM) in Denmark, with a particular focus on GDM-specific stigma. METHOD: We conducted semi-structured interviews with 20 women with GDM from January to May 2022. All interviews were transcribed and analysed abductively using Braun and Clarke's framework for applied reflexive analysis. RESULTS: Five themes were identified, 1) victim-blaming narrative, 2) identity threat, 3) non-disclosure and anticipated stigma, 4) stigma in a clinical setting, and 5) stigma reduction in a clinical setting. Additionally, intersectionality was identified between GDM-specific stigma, notions of how to be a good mother, and stigma associated with having type 2 diabetes mellitus and overweight. Implications of GDM-specific stigma included suboptimal GDM care and management, i.e., not attending screening for GDM, and not wanting to disclose the diagnosis. CONCLUSION: The impact of GDM-specific stigma on the informants' lives included some informants not accepting all services provided by the healthcare system, and some not wanting to identify with the diagnosis. These findings may help inform both healthcare personnel and future health promotion interventions to minimize the reproduction of a victim-blaming narrative and thereby promote well-being among women with GDM.

A conceptual framework for selecting appropriate populations for public health interventions.

This article suggests a conceptual framework for choice of target populations for public health interventions. In short, who should benefit? Taking the seminal work of Geoffrey Rose on "individuals at risk" versus the "whole population approach" as a point of departure, we explore later contributions. Frohlich and Potvin introduced the notion of "vulnerable populations" applying relevant social determinants as the defining selection criterion. Other interventions focus on a "physical space" (spatial demarcations) such as a neighborhood as a means to define intervention populations. As an addition to these criteria, we suggest that the life-course perspective entails an alternative means of selecting target populations based on a "temporal" perspective. A focus on the various age phases ranging from fetal life and infancy to old age may guide selection of population segments for targeted public health interventions. Each of the selection criteria has advantages and disadvantages when used for primary, secondary, or tertiary prevention. Thus, the conceptual framework may guide informed decisions in public health planning and research regarding precision prevention versus various approaches to complex community-based interventions.

Health literacy levels among women in the prenatal period: A systematic review.

BACKGROUND: A pregnant woman's health literacy refers to her knowledge, motivation, and skills to access, understand, appraise, and apply health information to make decisions in everyday life concerning her health. Inadequate health literacy increases the risk of adverse pregnancy and birth outcomes. This systematic review aimed to explore existing evidence of women's health literacy levels in the prenatal period. METHODS: We searched four databases: MEDLINE, Embase, CINAHL, and PsycInfo. Study eligibility criteria were: 1) a study population of women in the prenatal period, 2) an English language text, and 3) a clear statement of health literacy assessment. We used the Joanna Briggs Institute (JBI) appraisal checklist for quality assessment of the included studies. We synthesized results using thematic synthesis in three stages 1) coding text, 2) developing descriptive themes, and 3) generating analytical themes. RESULTS: Of the 2,238 studies screened, we included forty-four in the systematic review. Most studies were conducted in the United States of America, some in Iran and Europe, and a few in Australia and Africa. We identified twenty different health-literacy measurement tools used in included studies. Four themes were synthesized: 1) socio-economy and determinants, 2) functional health literacy, 3) interactive health literacy, and 4) critical health literacy. CONCLUSIONS: Low health literacy is associated with socio-economy, including education, employment and ethnicity and age in the prenatal period. Most identified studies (n = 24) addressed functional health literacy including information, understanding, knowledge, oral health knowledge, perception, behavior, and lifestyle. Some studies addressed interactive health literacy (n = 13) including active technology engagement, social network, interaction with health professionals, and group prenatal care. Few studies addressed critical health literacy (n = 4). Evidence of critical health literacy in the prenatal period is sparse, and high-quality research warranted.

Experiences with cross-sectional healthcare and treatment in heart failure patients: implications for medical education.

Objectives: to explore how cross-sectional healthcare and treatment is experienced a) by patients with advanced heart failure and multimorbidity and b) by hospital-employed healthcare professionals. Methods: Individual telephone interviews with 18 patients and close relatives were conducted. Furthermore, a focus group session was conducted with four specialised hospital-employed healthcare professionals. Purposeful sampling was used and interviews were semi-structured. Data were analysed using qualitative inductive content analysis. Results: Three main themes emerged from the interviews with patients and close relatives. These included: 1) A need for improved coordination to ensure continuity of care; 2) a plea for patient-centred care; and 3) recognition of the need to care for close relatives. Analysis of the interviews with hospital-employed healthcare professionals also produced three themes. These concerned: 1) recognition of the role and needs of close relatives; 2) limited resources for and difficulties in meeting these needs; and 3) agreement on the need for patient-centred care. Furthermore, we learned that perceived challenges are rooted in time constraints and the need for an adequate level of medical knowledge of chronic conditions and complex treatment strategies. Conclusions: This study indicates that cross-sectional healthcare and treatment of patients with advanced heart failure and multimorbidity lacked coordination, was insufficiently patient-centred and did not cater for close relatives' needs. The study identifies patient-centredness and coordination of healthcare services targeting patients and close relatives alike as critical to proper care, medical curriculum development and continued medical training courses.

Strategies to promote health behaviors in parents with small children-A systematic review and realist synthesis of behavioral interventions.

In this systematic review and realist synthesis, we aimed to identify strategies to improve dietary and physical activity behaviors for parents with small children. A systematic literature search was conducted in MEDLINE, Embase, CINAHL, and PsycINFO in July 2021. Included studies had to: (i) target one or both parents with at least one child (0-3 years), (ii) aim to improve diet and physical activity, and (iii) report on diet and physical activity outcomes. Intervention context, delivery, and outcomes were extracted, and behavior change techniques were coded. A program theory was developed, and context-mechanism-outcome configurations were identified. In total, 17 interventions reported in 28 studies (19 effectiveness studies; nine protocols) were included. Nine interventions showed small improvements: in diet (n = 5), physical activity (n = 2), or both (n = 2) in mothers. The realist synthesis revealed three strategies to improve health behaviors: (1) using knowledge and role modelling to improve family dynamics, (2) providing various home-based activities to change home environment, and (3) offering flexible delivery, for example, phone or website-based to increase social support. Future interventions for parents with small children should consider involving the whole family, focusing on home-based and practical components, and offering various delivery modes. The protocol for the systematic review and realist synthesis was registered in Research Registry (registration ID: reviewregistry860) March 30th, 2020.

Diabetes prevention interventions for women after gestational diabetes mellitus: an overview of reviews.

AIMS: To present an overview of reviews of interventions for the prevention of diabetes in women after gestational diabetes mellitus (GDM) with the overall aim of gaining information in order to establish local interventions. METHODS: Six databases were searched for quantitative, qualitative or mixed-methods systematic reviews. All types of interventions or screening programmes were eligible. The outcomes were effectiveness of reducing diabetes incidence, encouraging healthy behavioural changes and enhancing women's perceptions of their increased risks of developing type 2 diabetes following GDM. RESULTS: Eighteen reviews were included: three on screening programmes and seven on participation and risk perceptions. Interventions promoting physical activity, healthy diet, breastfeeding and antidiabetic medicine reported significantly decreased incidence of postpartum diabetes, up to 34% reduction after any breastfeeding compared to none. Effects were larger if the intervention began early after birth and lasted longer. Participation in screening rose up to 40% with face-to-face recruitment in a GDM healthcare setting. Interventions were mainly based in healthcare settings and involved up to nine health professions, councillors and peer educators, mostly dieticians. Women reported a lack of postpartum care and demonstrated a low knowledge of risk factors for developing type 2 diabetes. Typical barriers to participation were lack of awareness of increased risk and low levels of support from family. CONCLUSIONS: Lifestyle interventions or pharmacological treatment postpartum was effective in decreasing diabetes incidence following GDM. Women's knowledge of the risk of diabetes and importance of physical activity was insufficient. Early face-to-face recruitment increased participation in screening. Programmes aimed at women following a diagnosis of GDM ought to provide professional and social support, promote screening, breastfeeding, knowledge of risk factors, be long-lasting and offered early after birth, preferably by face-to-face recruitment.

Diabetes after pregnancy prevention trials: Systematic review for core outcome set development.

Diabetes prevention intervention studies in women with previous gestational diabetes have increased, but no consensus exists on core outcomes to support comparisons and synthesis of findings. We aimed to systematically catalogue outcomes in diabetes after pregnancy prevention interventions with the goal of developing a core outcome set. Embase, Medline, Cochrane Library, Cochrane Pregnancy and Childbirth Trials Register, and CINAHL were searched from inception to October 2017. Post-partum lifestyle and diabetes screening intervention studies in women with previous gestational diabetes and/or their families were eligible. No limits were placed on intervention type, duration, or location. Two authors independently screened and performed data extraction on outcomes, measurement tools, and relevant study characteristics. We analysed data from 38 studies (29 randomised controlled trials and 9 pre-post intervention evaluations) comprising 12,509 participants. Most publications (80%) occurred between the years 2012 and 2017. Among 172 outcomes, we identified 36 outcome groups and classified them under three domains: health status (body weight, body composition, diabetes risk, cardiometabolic risk, diabetes development, mental health, pregnancy outcomes, and fitness), health behaviours (dietary, physical activity, diabetes screening, behaviour change, and breastfeeding), and intervention processes (implementation). The health status domain contained the most commonly reported outcomes, but measurement tools were very heterogeneous. Despite the recent explosion in diabetes after pregnancy prevention studies, large variation in outcomes and measurement methods exists. Research is needed to define a core outcome set to standardise diabetes after pregnancy prevention interventions. The core outcome set should engage a wide group of stakeholders to identify impactful indicators for future trials.

A qualitative study about the experiences of ethnic minority pregnant women with gestational diabetes.

BACKGROUND: Gestational diabetes mellitus demands rapid health behaviour changes for the pregnant woman to obtain stable blood glucose levels. In Denmark, the general incidence of gestational diabetes mellitus is about 3%, but more than 4.5% among non-Western immigrants and descendants. Women belonging to ethnic minorities may be particularly challenged by health behaviour changes due to educational, language and cultural barriers. AIM: To explore how non-Western ethnic minority pregnant women in Denmark experience the hospital-based information about gestational diabetes mellitus and how they integrate this information into their everyday life. A secondary aim was to investigate how health literacy and distributed health literacy affect this process. METHODS: Semistructured, qualitative interviews with 11 women. Thematic analysis was conducted with a special focus on health literacy as analytical approach. RESULTS: Three themes were identified: Reaction to the diagnosis, Everyday life and Information needs. All women felt sad and worried by the diagnosis. Some struggled to implement the recommended behaviour changes, and many lacked supports from their spouse. The hospital-based information was positively evaluated, but in some cases, the information was misunderstood. Social networks, language skills, and the ability to seek and assess information were important factors influencing the degree to which the women experienced gestational diabetes mellitus to be a challenge. CONCLUSION: Women were generally satisfied with the hospital-based information. Women with low health literacy/poor Danish language skills seem to be most challenged by the diagnosis. Future research should examine ways to organise patient-centred health care while simultaneously supporting women's opportunity to increase health literacy through, for example social network and the Internet.

The Sano study: justification and detailed description of a multidisciplinary biopsychosocial rehabilitation programme in patients with chronic low back pain.

OBJECTIVE:: To justify and describe an integrated rehabilitation programme for patients with chronic low back pain prior to evaluation in a randomized controlled trial. METHOD:: The Template for Intervention Description and Replication (TIDieR) checklist was used as a structural framework for the description of the integrated rehabilitation programme. As a part of the description, the Medical Research Council guidance, 'Developing and evaluating complex interventions', was used as a framework to justify the integrated rehabilitation programme. INTERVENTION DESCRIPTION:: The integrated rehabilitation programme adopts a participatory biopsychosocial approach integrating inpatient activities supported by a multidisciplinary team and learning located within the patient's own environment. The integrated rehabilitation programme comprises 3 weeks of inpatient stay and 11 weeks of home-based activities. The inpatient part of the programme consists of 38 clinical activities, some of them delivered more than once. The 38 clinical activities were described in an activity sheet developed for this purpose, combining five items from the TIDieR. CONCLUSION:: An integrated rehabilitation programme for patients with chronic low back pain has been justified and described. The intervention description is currently being used for successful structuring and standardization of the content and delivery of the integrated rehabilitation programme in a randomized controlled trial. TRAIL REGISTRATION:: ClinicalTrials.gov: NCT02884466.

Achieving penetration and participation in diabetes after pregnancy prevention interventions following gestational diabetes: A health promotion challenge.

AIM: Health behaviour change interventions have potential to reduce diabetes after pregnancy (DAP) rates following gestational diabetes mellitus (GDM). Recruitment success is arguably as important as intervention effectiveness, but receives less attention. We examined penetration into target populations and participation in DAP prevention interventions in women with a GDM history. METHODS: Five databases were searched for studies published up to December 2017. Studies were reviewed by at least three reviewers and data were qualitatively synthesized. Penetration (invited/target population) and participation (enrolled/invited) rates were calculated after data extraction. RESULTS: Among 2859 records, 33 intervention studies were identified, among which 16 had sufficient information to calculate penetration or participation. Penetration proportion (n = 9 studies) was between 85 and 100% for two-thirds of studies included. Participation proportion (n = 16 studies) varied substantially; when recruitment occurred during pregnancy or early postpartum, participation was 40% or more, especially if face-to-face contact was used within the GDM care setting, compared to under 15% in mid/late postpartum with mailed invitation and/or telephone contact. CONCLUSIONS: Although penetration and participation reporting is sub-optimal, penetration is generally high while participation is variable. Leveraging and structuring recruitment within standard GDM care and settings appears to be important to engage women in DAP prevention activities.

The effect of cardiorespiratory fitness assessment in preventive health checks: a randomised controlled trial.

Background: Poor cardiorespiratory fitness (CRF) increases morbidity and mortality risks. Routine CRF assessment in clinical practice has thus been advocated, but little is known about the effect. In this study, we investigated the effect of CRF assessment on CRF in a preventive health check programme. Methods: We used a randomised design, in which we invited 4153 middle-aged adults and included 2201 participants who received a preventive health check with CRF assessment (intervention) or without CRF assessment (control). After 1 year, participants were examined. The primary outcomes were adjusted absolute (l/min), relative (ml/kg/min), and poor (%) CRF assessed by the Astrand-Ryhming test. We adjusted for baseline physical activity and intra-cluster correlation within general practices. Results: A total of 901 attended the 1-year follow-up. In the intervention group, absolute CRF, relative CRF, and poor CRF were 2.7 l/min (95% confidence interval [CI]: 2.6; 2.8), 34.5 ml/kg/min (95% CI: 33.5; 35.4), and 31.0% (95% CI: 26.8; 35.2). In the control group, the corresponding figures were 2.8 l/min (95% CI: 2.7; 2.9), 35.2 ml/kg/min (95% CI: 34.2; 36.1), and 25.9% (95% CI: 21.8; 30.0). Adjusted absolute CRF was lower in the intervention group (-0.1 l/min [95% CI: -0.2; -0.01]). Adjusted relative CRF (-0.7 ml/kg/min [95% CI: -2.0; 0.6]) and poor CRF (5.0% [95% CI: -0.002; 10.1]) did not differ between groups. No differences were found when adjusting for potential confounding factors. Conclusion: Preventive health checks with CRF assessment did not provide higher CRF levels at 1-year follow-up than preventive health checks without CRF assessment.

How to prevent type 2 diabetes in women with previous gestational diabetes? A systematic review of behavioural interventions.

OBJECTIVES: Women with previous gestational diabetes (GDM) have a seven times higher risk of developing type 2 diabetes (T2DM) than women without. We aimed to review the evidence of effective behavioural interventions seeking to prevent T2DM in this high-risk group. METHODS: A systematic review of RCTs in several databases in March 2016. RESULTS: No specific intervention or intervention components were found superior. The pooled effect on diabetes incidence (four trials) was estimated to: -5.02 per 100 (95% CI: -9.24; -0.80). CONCLUSIONS: This study indicates that intervention is superior to no intervention in prevention of T2DM among women with previous GDM.

Social relations, depressive symptoms, and incident type 2 diabetes mellitus: The English Longitudinal Study of Ageing.

AIMS: We examined whether social relations are associated with the risk of developing type 2 diabetes mellitus (T2DM) and furthermore, whether social relations modify the association between depressive symptoms and incident T2DM. We hypothesized that the risk of developing T2DM would be lower for individuals with stronger social relations compared to those with weaker social relations, and that the association between depressive symptoms and incident T2DM would be attenuated for those with stronger social relations. METHODS: Non-diabetic participants (n=7662) of the "English Longitudinal Study of Ageing" (3398 men) aged 50-91years were followed until 2012/2013, after baseline assessment of depressive symptoms, social support, relational strain, and network size. Hazard ratios (HR) for incident diabetes were calculated using Cox proportional hazard models, adjusting for relevant confounders. RESULTS: Age and sex adjusted HRs showed that social relations were associated with incident diabetes (Support: HR 0.98 95% CI 0.97; 0.99, Strain: HR 1.02 95% CI 1.01; 1.04, Networklimited: HR 1.19 95% CI 0.98; 1.44), however, when adjusted for age, sex, ethnicity, marital status, household wealth, health behaviour, and body mass index the associations were attenuated and were no longer statistically significant. Depressive symptoms were associated with higher diabetes risk. This effect was not modified by any of the social variables. CONCLUSIONS: People with stronger social relations are at lower risk of developing T2DM; however, this effect is largely explained by known diabetes risk factors. No evidence was found that stronger social relations reduce the association between depressive symptoms and incident T2DM.

High prevalence of poor fitness among Danish adults, especially among those with high cardiovascular mortality risk.

Background: : Poor cardiorespiratory fitness (CRF) is an independent predictor of cardiovascular and all-cause mortality. Yet, our knowledge about the prevalence of poor CRF is limited. We investigated the prevalence of poor CRF among middle-aged Danish adults from a community-based health promotion program, including identification of a subgroup with high cardiovascular mortality risk. This cross-sectional study included 2,253 middle-aged adults, who completed a preventive health check including CRF testing. CRF (ml O 2 /min/kg) was assessed using the Astrand-Ryhming cycle ergometer test. High 10-year cardiovascular mortality risk as defined in the Danish 2016 guidelines was assessed using questionnaires, health examinations, and prescription data from the Danish National Prescription Registry. The prevalence of poor CRF was 51.7% (95% confidence interval [CI] 48.7-54.7) among men and 31.3% (95% CI 28.7-34.1) among women. A total of 216 (19.4%) men and 220 (19.3%) women were identified with a high 10-year cardiovascular mortality risk. Among these, 65.0% of men (95% CI 58.2-71.3) and 44.1% of women (95% CI 37.4-50.9) had poor CRF. Half of men and one third of women participating in a community-based health promotion program were identified with poor CRF. Among high-risk individuals, two thirds of men and almost every second woman had a poor CRF. Our results emphasise the need for effective public health strategies and interventions to increase CRF in the general population and among high-risk individuals in particular in order to improve public health and reduce mortality.