Stereotypes, simplistic care models and clinicians with limited knowledge are driving stigma about type 2 diabetes and leading to patients feeling shamed and judged, a large Aussie review has found.
The analysis from a team at The Australian Centre for Behavioural Research in Diabetes reviewed 61 studies into the manifestations and impacts of T2D stigma on patient care, and their results paint a stark warning for clinicians about the prevalence with which patients anticipate and experience stigma in the course of their care.
Writing in Diabetes Research and Clinical Practice, the authors said the dynamics with which care is delivered can impact a patient’s psycho-social wellbeing, their health-seeking behaviours and the overall quality of the diabetes care they receive.
“Beyond the actual T2D diagnosis, individuals are also stigmatised (marked) on the basis of high glucose levels, complications, higher weight and both younger and older age,” wrote PhD candidate in health psychology at Deakin University, Emmanuel Ekpor, and colleagues [link here].
Inside the patient experience
The authors considered 41 pieces of evidence relating to the manifestation of stigma, drawing out the following key themes based on patient reports:
- A significant number of patients reported being judged by their health care providers, including through the language used in their care and the tone it was delivered.
- Across the studies, between 22.8% and 88.5% of patients said their were perceived as having a lack of knowledge about self-care,
- Patients also reported having health systems, like high blood pressure, dismissed because of assumptions about their broader health.
“While evidence from HCPs’ own stigmatising practices was limited, there was overlap with the narratives of people with T2D,” the authors said.
One study of health workers found 42% self-reported they had stigmatising attitudes about T2D, while in another, clinicians reported overhearing their colleagues make disparaging remarks.
Drivers and impacts
‘Authoritarian behaviour’ of clinicians was identified as a key driver of stigma within the clinic.
“Across several qualitative studies, people with T2D described healthcare encounters characterised by controlling communication (e.g., threats to initiate insulin and pessimistic messaging to enforce “compliance”.”
Emmanuel Ekpor.
This included cases where patients received dismissals or denial of care, reporting feeling infantilised and unheard.
The data also highlights the troubles with “overly simplistic” care models and advice. This included consultations where the only focus or advice was on narrow biomedical metrics like HbA1c or body weight, instead of considering a patient’s personal circumstances and needs.
“This framing portrayed T2D management as linear and easily controllable, implicitly attributing suboptimal outcomes to personal failure,” the authors said.
When clinicians were asked about this in the research, they pointed to prescriptive guidelines within their institutions which limited the type of care they were able to deliver.
A call to action
The evidence showed a relationship between stigma and quality of care and outcomes for patients, the authors said.
“People with T2D described receiving substandard care characterised by limited support, empathy, or compassion.”
Negative perceptions and stereotypes undermined the relationship between patient and doctor, which in turn discouraged patients from asking important questions about their health challenges and seeking out more information about their care.
Across the studies, the review’s authors found both patients and clinicians calling out for better communications training to help address the issue.
“Diabetes stigma reduction interventions within healthcare remain limited, which may partly reflect a lack of nuanced understanding of how stigma is perpetuated in clinical contexts,” the authors said.
“Future work should translate the findings of this review into actionable recommendations that can guide stigma-free clinical practice and inform the development and testing of interventions, with meaningful involvement of people with lived experience of T2D in addition to HCPs.”