Diabetes UK defends its type 2 diabetes awareness campaignBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7025 (Published 27 November 2013) Cite this as: BMJ 2013;347:f7025
All rapid responses
I am writing this in response to the letter written by Louise Ansari and the comments given by Koula Asimakopoulou, Jane Speight and Timothy Skinner on Diabetes UK’s Type 2 diabetes awareness campaign.
Firstly, the letter states that an online risk assessment tool was carried out to identify people’s chances of developing diabetes; however, this tool had a limited coverage. Many people from ethnic minorities whose English is not a first language as well as several others who do not have skills to access information online because of computer illiteracy were left out from this assessment. This is particularly the case for South Asians who are four to six times more likely to develop the condition and at an earlier age compared to their white European counterparts . My in-depth interviews with Type 2 South Asian diabetic patients revealed a considerable knowledge gap regarding diabetes, physical activity and a healthy diet which is further constrained by language barriers in accessing relevant information during the course of their treatment.
Secondly, I agree with the comments given by Asimakopoulou, Speight and Skinner in that the campaign did not target people who have already been diagnosed with Type 2 diabetes. Mine and other research findings have shown that South Asians have a large knowledge gap with regards to what diabetes is, its causes, how to manage the condition and the future complications of it despite being highly educated [2-4]. This lack of knowledge has resulted in poor management of their condition and thus has costed the NHS a lot of money. Therefore, it is pertinent for Diabetes UK to focus on including risk assessments and improving the management of diabetes in South Asians preferably in their own language.
Thirdly, the Department of Health expects diabetics in the UK to ‘be empowered’ and manage this chronic condition on their own as mentioned by Asimakopoulou, Speight and Skinner . However, there are no guidelines or strategies on how diabetic patients should be empowered to self-manage their condition particularly if English is not their first language. As soon as patients are screened for diabetes and identified as a high-risk individual, they should be given comprehensive knowledge on diet, physical activity and other contributing lifestyle factors on a regular basis to manage their blood sugar levels. Recent research shown that face-to-face diabetic education along with the DESMOND programme has helped patients become empowered in self-managing their blood sugar levels [6-7].
Finally, it is high time that the NHS should invest in recruiting an army of dieticians and diabetic nurses labelled as 'health promotion nurses' at GP surgeries so that they can educate high-risk patients about diabetes and cardio-vascular diseases (which are already imposing a major disease burden on the NHS). Some ethnic minorities whose English is not a first language particularly South Asians require this sort of interaction on a more regular basis (every year) to make them realise the seriousness of the future complications of diabetes. I agree with Louise Ansari in that the 'high-risk patients' should be told about the foresee complications (including risk of amputation, kidney failure and blindness) so that they can make changes to their diet, physical activity and lifestyle effectively; and postpone these complications as far as possible. If these changes are implemented, it can result in enormous savings for the NHS.
Miss Leher Gumber
Coventry and Warwickshire Partnership NHS Trust
1. Bellary S, O’Hare JP, Raymond NT, Gumber A, Mughal S, Szczepura A, Kumar S, Barnett AH on behalf of UKADS Study Group . Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial. Lancet 371 (9626):1769-1776, 2008.
2. Gumber L. The effects of cultural factors on the diagnosis and treatment of Type 2 diabetes in the South Asian community in UK. A Level Extended Project Qualification. August 2013.
3. Alam R, Speed S, Beaver K. A scoping review on the experiences and preferences in accessing diabetes-related healthcare information and services by British Bangladeshis. Health and Social Care in the Community 2012; 20(2): 155-171.
4. Choudhury SM, Brophy S, Williams R. Understanding and beliefs of diabetes in the UK Bangladeshi population. Diabetic Medicine 26: 636-640, 2009.
5. Department of Health . Liberating the NHS: No decision about me without me, 2012.
Available on: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
[Accessed on 19 Jan 2014].
6. Snow R, Humphrey C, Sandall J. What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study. BMJ Open 2013 Nov 14; 3(11):e003583
7. Khunti K, Gray LJ, Skinner T, Carey ME, Realf K, Dallosso H, Fisher H, Campbell M, Heller S, Davies MJ. Effectiveness of a diabetes education and self-management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. BMJ 2012 Apr 26;344:e2333
Competing interests: No competing interests
I am responding to comments by Koula Asimakopoulou, Jane Speight and Timothy Skinner about Diabetes UK’s Type 2 diabetes awareness campaign.
They suggest the campaign failed to offer those who might be at high risk of Type 2 diabetes something practical they could do about it. But this is simply incorrect. The advertising was very specific that if people were concerned, they should get their risk assessed at a pharmacy, GP surgery, or use our online Risk Score.
Neither is it correct that people already know that having a family history of diabetes is a risk factor for Type 2. Market research we commissioned ahead of the campaign showed that, unprompted, barely one in 10 people identified family history as a risk factor. Awareness that being from a South Asian background is a risk factor was even lower.
The authors also criticise us for the photographs we used. But we face a situation where too few people understand the seriousness of diabetes. It is still all-too-often seen as a relatively mild condition, whereas in fact it brings with it the risk of devastating complications such as amputation, blindness and kidney failure. Yes, the imagery we used was challenging, but this was necessary to challenge this misconception.
I should add that we did not choose this imagery lightly. We presented different options to focus groups of people at high risk and they overwhelmingly identified this approach as the one that would be most likely to have an impact on them. This was then confirmed by quantitative research. I am not persuaded that the contrary evidence the authors present – a study of 21 participants from Australia – challenges this.
In terms of people who already have Type 2 diabetes, it was certainly not our intention to upset them. But again, diabetes is a serious condition that can have devastating consequences if not properly managed and we need to raise awareness, including among those with diabetes, that this is the case.
Lastly, I never meant to suggest that the 30,000 people who took our online risk assessment was the full extent of the impact of the campaign. It wasn’t. Thanks to our campaign, millions more people were made aware that diabetes is a serious condition and as well as the 30,000 people who had their risk assessed online, many more were risk assessed at pharmacies and GP surgeries.
But I do find it disappointing that the authors have chosen to attempt to diminish the impact of our campaign by presenting the 30,000 people who checked their risk online as a drop in the ocean compared to the estimated 850,000 people who have undiagnosed Type 2 diabetes.
Clearly, diabetes is one of the biggest challenges we face today; 3 million have been diagnosed it, as well as the 850,000 with undiagnosed Type 2, and the condition accounts for 10% of the entire NHS budget. We have never suggested it is a challenge that one advertising campaign – or, indeed, any one single thing – is likely to fix. But like any big and daunting challenge, we need to tackle it bit by bit. That is what we do day in, day out at Diabetes UK and I am proud of the contribution this advertising campaign has made to that.
Competing interests: I am Director of Communications for Diabetes UK
First do no harm – a response to Louise Ansari, Diabetes UK
We were interested to read the Letter to the Editor by Louise Ansari, Diabetes UK Director of Communications, who wrote to defend the recent Diabetes UK campaign designed to raise awareness of the seriousness of type 2 diabetes. The campaign, she indicates, targeted people at high risk of developing type 2 diabetes and was informed by consultation and market research. Of course, we welcome this as an evidence-based approach to enhancing the effects of public health campaigns . However, we have concerns about several aspects of the campaign.
First, the letter states that “…people do not understand how serious type 2 diabetes is, why people at high risk must try to prevent it, or why those who already have it need to be diagnosed…”. This may well be true for people without the illness, although no reference to scientific research was offered to support this claim. More importantly, the campaign, showing various versions of tearful adults, offered no concrete knowledge message other than that of type 2 diabetes being associated with great emotional devastation. It is unclear why eliciting feelings of fear and devastation would be considered conducive to helping people “understand how serious type 2 diabetes is”, or why it might help “those who already have it [understand the] need to be diagnosed” in the absence of any concrete information for people to process?
Research has shown clearly that fear campaigns per se are unhelpful in leading people to take preventive health action, unless such campaigns are closely coupled with offering the target audience meaningful ways to engage in reducing the fear [2-5]. Admittedly, the posters did encourage people to take an online risk assessment to assess their chance of developing diabetes; however, in the absence of ways to cope with the portrayed devastation, that, in itself, is contrary to all psychological evidence of optimal ways to motivate the enactment of health-protecting behaviours.
Second, we know that those who are at high risk for type 2 diabetes through family history are already distressed and worried about developing diabetes, coronary heart disease (CHD) or having a stroke, because of their exposure to family members who already have these conditions . It is unclear what benefit might be expected from increasing their distress further.
Third, although the campaign was targeted at people without diabetes, it was insensitive to the reactions of people who already have diabetes, for whom the messages would naturally be more salient. Our work, along with that of others, has shown that people with type 2 diabetes hugely over-estimate their risks of developing diabetes-related comorbidities, such as CHD and stroke [7-8]. Furthermore, ‘worries about the future and the possibility of serious complications’ is consistently the foremost concern of people with diabetes of all types , and one of the most reliable predictors of diabetes-related distress in people with the condition . Thus, bombarding them with images of great emotional devastation related to diabetes is incompatible with ensuring a more accurate estimation of the likely impact of diabetes on their health and relieving their anxieties.
In the UK, the NHS expects people with diabetes to self-manage their condition, and ‘be empowered’ to look after themselves . It is hard to see how the recent awareness campaign goes any way towards supporting this cause. Indeed, such campaigns and negative media attention may even contribute to a growing social stigma related to diabetes . Contrary to the findings of Diabetes UK’s focus groups, our own qualitative research has identified that people feel more positive messaging is needed: “There’s no good news stories about type 2 diabetes. Perhaps there should be. Perhaps it should be ‘it isn’t necessarily a death sentence” .
Finally, Ms. Ansari claims that the campaign worked, stating that “public understanding of the seriousness of type 2 diabetes increased immensely” and that “30,000 carried out an online risk assessment” but citing no evidence of that effect. At best, even if all 30,000 were found to be at high risk or to be diagnosed, this would be just 3.5% of the estimated 850,000 people with silent, undiagnosed type 2 diabetes in the UK. What is more likely is that many of these 30,000 are the ‘worried well’.
Overall, the evidence we review here suggests that the recent Diabetes UK campaign is unlikely to effect change in substantial numbers of people without diabetes and, at the same time, is likely to be unduly distressing to people with diabetes.
As such, and in the absence of evidence to the contrary, we have to question Ms Ansari’s claim that “above all, the campaign worked”.
Dr. Koula Asimakopoulou,
King's College London, UK
Professor Jane Speight,
The Australian Centre for Research in Diabetes, Diabetes Australia - Vic;
Centre for Mental Health and Wellbeing Research, School of Psychology, Deakin University;
AHP Research, UK
Professor Timothy Skinner
Head of School, Psychological and Clinical Sciences, Charles Darwin University
1. Kreuter MW, Wray RJ. Tailored and targeted health communication: strategies for enhancing information relevance. Am J Health Behav 2003;27 Suppl 3:S227-32.
2. Witte K, Allen M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Educ Behav 2000;27(5):591-615.
3. Floyd DL, Prentice-Dunn S, Rogers RW. A Meta-Analysis of Research on Protection Motivation Theory. Journal of Applied Social Psychology 2000;30(2):407-29.
4. Milne S, Sheeran P, Orbell S. Prediction and Intervention in Health-Related Behavior: A Meta-Analytic Review of Protection Motivation Theory. Journal of Applied Social Psychology 2000;30(1):106-43.
5. Soames Job RF. Effective and ineffective use of fear in health promotion campaigns. American journal of public health 1988;78(2):163-7.
6. Dorman JS, Valdez R, Liu T, Wang C, Rubinstein WS, O'Neill SM, et al. Health beliefs among individuals at increased familial risk for type 2 diabetes: implications for prevention. Diabetes research and clinical practice 2012;96(2):156-62.
7. Asimakopoulou KG, Skinner TC, Spimpolo J, Marsh S, Fox C. Unrealistic pessimism about risk of coronary heart disease and stroke in patients with type 2 diabetes. Patient education and counseling 2008;71(1):95-101.
8. Asimakopoulou KG, Fox C, Spimpolo J, Marsh S, Skinner TC. The impact of different time frames of risk communication on Type 2 diabetes patients’ understanding and memory for risk of coronary heart disease and stroke. Diabetic Medicine 2008;25(7):811-17.
9. Reddy J, Wilhelm K, Campbell L. Putting PAID to diabetes-related distress: the potential utility of the problem areas in diabetes (PAID) scale in patients with diabetes. Psychosomatics 2013;54(1):44-51.
10. McGuire BE, Morrison TG, Hermanns N, Skovlund S, Eldrup E, Gagliardino J, et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia 2010;53(1):66-9.
11. DOH. Liberating the NHS: No decision about me without me. In: Department of Health. London, 2012.
12. Schabert J, Browne JL, Mosely K, Speight J. Social stigma in diabetes : a framework to understand a growing problem for an increasing epidemic. Patient 2013;6(1):1-10.
13. Browne JL, Ventura A, Mosely K, Speight J. 'I call it the blame and shame disease': a qualitative study about perceptions of social stigma surrounding type 2 diabetes. BMJ open 2013;3(11):e003384.
Competing interests: No competing interests