Healthcare professionals should assess the social determinants of health in people with diabetes mellitus to better guide them to the most appropriate resources.

The social determinants of health are the social, cultural, political, economic and environmental conditions in which people are born, grow up, live, work and age, and their access to power, decision making, money and resources that give rise to these conditions of daily life. The social determinants of health influence a person’s opportunity to be healthy, their risk of illness, health behaviours and healthy life expectancy. Health inequities result from the uneven distribution of these social determinants. 

In Scotland, there is evidence that socioeconomic deprivation is associated with higher mortality in people with type 1 diabetes, that the effect of deprivation is larger than in the general population and that inequalities appear to be widening over time.

There is also evidence that life expectancy for people with type 1 diabetes in Scotland is significantly lower in those at the lowest socioeconomic quintile than in those at the highest quintile.

It is essential to consider factors that shape our health as part of the routine assessment of individuals living with type 1 diabetes and to tailor patient-centred support and education accordingly. Questionnaires completed before a consultation may be beneficial tools in the assessment.

Given the importance of the social determinants of health and adverse childhood experiences on clinical outcomes, including the lifetime risk of diabetes-related complications, having a social worker embedded in diabetes services is desirable as they have the skills to make an effective assessment of needs and can signpost appropriately for any support that is required.

Diagram adapted by Scottish Government from Booske et al., 2010 and King's Fund – A Vision for Population Health.

The factors which shape our health (or social determinants of health) range from the individual, to the local, to the national, to the international, and include:

1. Income and social protection
2. Level of education
3. Employment issues and unemployment
4. Food insecurity
5. Housing, basic amenities, and the environment
6. Early childhood development
7. Social inclusion and non-discrimination
8. Access to health services

See an interactive checklist of the social determinants of health here:

A communication style that uses person-centred language and emphasises positive affirmative action and active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care should be used to optimise patient health outcomes and health-related quality of life.

The Scottish Government Realistic Medicine report notes:

“Many clinicians encourage patients to engage in shared decision making and to have a say. Similarly, most patients want to discuss options and share their opinions about treatment with their clinicians, and clearly many seek to be, or want to be, more involved in clinical decisions. Nevertheless, longstanding cultural norms can make it difficult for patients to speak up, ask questions, actively participate, or challenge clinicians’ expertise. Clinicians serve patients best when we frame treatment and care options in terms of the values and goals that patients and their families articulate.”

See the NHS Education for Scotland website The Health Literacy Place for resources, e-learning tools and techniques recommended for good health literacy practice.

Telemedicine, including periodic phone calls, smartphone-web interactions, and periodic supervision by healthcare professional interactions, is strongly recommended to treat people with diabetes, provide diabetes education, remotely monitor glucose and/or insulin data to indicate the need for therapy adjustments, and improve diabetes-related outcomes/control through better engagement.

Since the Covid-19 pandemic, health services for people with type 1 diabetes in Scotland have offered a hybrid approach using telemedicine and in-person consultation to support person-centred care models. Diabetes technology has been evolving rapidly and the use of continuous glucose monitors, smart pens and hybrid closed loop systems with cloud-based software enables telemedicine consultations.

Telemedicine should be offered as a choice, as an alternative to outpatient visits or as a supplement to them, preferably with joint virtual review of data. However, there remains a 'digital divide' and difficulties accessing the internet and downloading data have the potential to further exacerbate existing health inequalities.

See related section on glucose-lowering and glucose-monitoring technologies.

Providers and healthcare professionals should address inequalities in continuous glucose monitoring (CGM) access and uptake by:

• monitoring who is using CGM
• identifying groups who are eligible but who have a lower uptake
• making plans to engage with these groups to encourage them to consider CGM.

Continuous glucose monitoring (CGM) is available on prescription for everyone with type 1 diabetes in Scotland. Diabetes teams should proactively initiate discussions about CGM with people with type 1 diabetes who are not currently using the technology to establish and explore potential barriers to uptake relating to either the system or the person's own circumstances, and then to revisit the topic regularly. Fully informed equitable decision making by the individual about CGM is key to ensuring that a person with diabetes is not disadvantaged because of lack of information, support or any of the social determinants of health. The Diabetes Improvement Plan supports timely access to technology and the Scottish Health Technologies Group recommendation for closed loop systems states the importance of attempting to ensure equitable access and uptake of the technology.

Healthcare teams should be aware that access to compatible smartphones may be required to allow parents/carers/partners to monitor the blood glucose of individuals using CGM. This has the potential to widen inequalities and should be taken into account when determining the most suitable device.

See sections on the social determinants of health and on glucose-lowering and glucose-monitoring technologies.

Pupils should be supported at school to use diabetes technology including continuous subcutaneous insulin infusion, connected insulin pens, and automated insulin delivery systems as prescribed by their diabetes care team.

Young people with diabetes should have the same access to education as other pupils, in a safe and supportive environment that enables them to successfully manage their diabetes and school staff should be provided with the knowledge to assist them. See The International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines 2022 for further information and recommendations on management and support of children and adolescents with diabetes in school.

Make the Grade

Diabetes UK has a wide range of resources and information to make sure children with type 1 diabetes are supported at school so that they are safe, happy and have equal opportunities at school.

The Make the Grade schools pack can be ordered by schools, or by parents and guardians for use in schools, and is designed to help schools introduce policies, learn about diabetes, and provide the best care possible.

The Make the Grade parents pack is designed to help parents and schools to work together to give the best care.

The Juvenile Diabetes Research Foundation also provides a school pack.

See the section on glucose-lowering and glucose-monitoring technologies.

Give age- and culturally appropriate education and guidance for physical activity and lifestyle modification to all children and adolescents with type 1 diabetes.

Education and guidance for physical activity and lifestyle modification for children and adolescents with type 1 diabetes needs to be personalised and appropriately tailored, to account for the child's and family's culture, language, religion and health literacy skills.

Implementation of culturally specific education has shown improvements in self-management behaviours which can help minimise long-term risks of complications.

Issues such as sexual activity, friendships and drug and alcohol use may affect young people with diabetes in different ways to those without diabetes, and are areas to be considered for specific support.

Materials are available for parents of children and young people with type 1 diabetes:

A guide for parents and carers (JDRF)

A parent and carer's guide to type 1 diabetes (Diabetes UK)

A video platform and app to help young people, families and communities to manage Type 1 Diabetes (Digibete)