DC2-project 2: Diabetes distress and health literacy in foot ulcer development and self-care and interventions to improve outcome.


People experiencing diabetic foot ulcers generally have low health literacy. Health literacy refers to the combination of personal competencies and situational resources needed for people to access, understand, appraise, and use information and services to make decisions about their health and self-care. Low health literacy limits access to (self-)care and may increase the risk of amputation and/or recidivist foot ulcers. Organizational literacy may be of crucial significance for the prevention of diabetic foot ulcers to people at risk. This refers to the way in which services, organisations, and resources are made available and accessible to people according to their individual health literacy level.

Diabetes distress is the emotional reaction to living with diabetes which can take the many forms including difficulty in self-care of diabetes. Moderate to high levels of diabetes distress are likely to have a negative influence on outcomes of diabetic foot disease and may play a considerable role in the prevention of foot ulcers and amputation; however, knowledge about diabetes distress levels among people with or at high risk of diabetic foot ulcers is very limited – if existing.

This project addresses diabetes distress and health literacy among people with or at high risk of foot ulceration; two potentially important components with influence in terms of the ability to prevent foot ulcers and amputations. The project will investigate the role of these components in foot ulcer development and self-care and how they can be addressed systematically in routine care to improve self-care and prevention of foot ulcers in people at high risk (as identified in WP3). The project will actively involve people with or at risk of foot ulceration and their health professionals in the exploration and development of methods and/or techniques to be pilot tested in clinical practice. The project will deliver a program for communicative and psychosocial support for appropriate health literacy response and to reduce diabetes distress.


The doctoral candidate will 1) assess diabetes distress levels among people with recidivist foot ulcers or at high risk of ulcer development and 2) explore health literacy needs among people at risk of foot ulcers 3) explore organisational health literacy responsiveness and 4) explore options for initiatives improving equitable communication with and access to healthcare services for people with or at risk of diabetic foot ulcers with a particular focus on improving diabetes distress reduction and organizational health literacy responsiveness. The doctoral candidate will study people with or at risk of ulcer development and health care professionals using the diabetes distress scale (DDS-T1-28/PAID-20) to assess diabetes distress levels, as well as interviews. Existing interventions to reduce diabetes distress will be modified for this population and pilot tested. The candidate will use the Conversational Health Literacy Assessment Tool (CHAT) in interviews and appropriate scales to investigate individual health literacy needs (e.g., Health Literacy Questionnaire (HLQ)). The Ophelia (Optimising health literacy and access) approach will be applied to develop feasible organisational literacy initiatives responding to local needs. The Ophelia approach is a systematic intervention development and testing methodology that entail a series of steps: needs assessment, idea generation, co-designing intervention and testing intervention.

Our research team

Steno Diabetes Center Copenhagen (SDCC) is a diabetes center within the public authority of the Capital Region of Copenhagen. SDCC is the largest diabetes clinic in Scandinavia and treats each year more than 11,000 people with diabetes from the Capital Region. SDCC is organised in four departments (Patient Care, Clinical Research, Health Promotion Research, and Education) that work closely together around the unifying focus of translational research, diabetes care, and prevention. The doctoral candidate will be part of the Diabetes Management Research group which is embedded within the Health Promotion Research Department. The candidate will learn from and collaborate with a multidisciplinary team of clinicians and researchers. The doctoral candidate will also work together with another doctoral candidate from DIALECT at SDCC who, in an epidemiologic study, focuses on ulcer risk stratification in high-risk people with diabetes.

External supervision in this project comes from DIALECT partners at Amsterdam University Medical Centers (AMC, Amsterdam, the Netherlands) and King’s College Hospital (KCH, London, United Kingdom). Amsterdam UMC is a leading institute in the world on biomechanical and clinical research on diabetic foot disease, in particular on the prevention of foot ulceration and amputation. The Diabetic Foot Clinic at King’s College Hospital is renowned for their multidisciplinary treatment of people with diabetic foot disease, and has a longstanding clinical and research experience in this field.

Your experience

  • Candidates should be eligible to enrol for a doctoral program in Denmark, for example by having a master’s degree in public health, anthropology, psychology, sociology, medicine, nursing, or related field
  • Higher education track record and broad scientific curiosity 
  • Analytical and communication skills
  • Experience with qualitative and quantitative research methods
  • Demonstrable fluent spoken and written English skills
  • Capable of functioning in a multidisciplinary environment, with researchers and clinicians

In addition, the following skills and experiences are advantages:

  • Language skills to communicate with Danish speaking patients
  • Experience with effective language acquisition (courses in Danish are available), as we expect the doctoral candidate to be willing to learn to speak Danish (if not already capable)
  • Experience with patient and public involvement in research

We seek a highly motivated scientist who enjoys an interdisciplinary environment and an interdisciplinary project, able to work independently but also as part of a team. The research project should result in a PhD thesis.

Our offer

This PhD position is funded by the Marie Skłodowska-Curie Actions (MSCA) of the European Union’s “Horizon Europe 2022” research and innovation program under grant agreement No 101073533. You will be appointed as fulltime PhD for 3 years at the Steno Diabetes Center Copenhagen. The MSCA programme offers competitive and attractive working conditions. The successful candidate will receive a salary in accordance with the MSCA regulations for early-stage researchers. Gross salary will consist of a Living Allowance (= €40.800/year, correction factor to be applied for Denmark: 1.32) and a monthly Mobility Allowance of €600. An additional monthly allowance of €660 is applicable depending on family situation. Please be aware that these amounts are subject to taxes, the exact salary will be confirmed upon appointment. In addition to their individual scientific projects, all Doctoral Candidates in DIALECT will benefit from further continuing education, which includes internships and secondments, a variety of training modules as well as transferable skills courses and active participation in workshops and conferences.

Steno Diabetes Center Copenhagen

Steno Diabetes Center Copenhagen (SDCC) is a diabetes center within the public authority of the Capital Region of Copenhagen. SDCC is the largest diabetes clinic in Scandinavia and treats each year more than 11,000 people with diabetes from the Capital Region. The ambition of SDCC is to improve the entire field of diabetes in the Capital Region, but also to contribute with inspiration and new knowledge nationally and internationally. SDCC is focused on clinical care, research and teaching and currently has more than 400 employees. The clinical staff in the center includes doctors, nurses, dieticians, patient coordinators, podiatrists, and lab technicians. More than half of the employees are involved full-time or part-time in research. In 2021, World Economic Forum’s Global Coalition for Value in Healthcare nominated SDCC as one of the best hospitals in the world in relation to developing a value-based healthcare system for the benefit of people with diabetes and other chronic diseases. For more information, please visit www.sdcc.dk and follow us on LinkedIn and Twitter.

University of Copenhagen

University of Copenhagen (UCPH) will be the PhD awarding institute for the doctoral candidate Driven by intellectual creativity and critical thinking since 1479, researchers and students at the University of Copenhagen have expanded horizons and contributed to moving the world forward. With its 5,000 researchers and 37,500 students, the University boasts an international research and study environment and is highly ranked on the leading ranking lists of the world’s best universities. The University offers researchers and students the opportunity to develop their talent and launches ambitious interdisciplinary initiatives to support its strong academic communities. Through research-based teaching – and by involving them in research – students are equipped to address society’s challenges and needs. The doctoral candidate will be enrolled at the doctoral program of the Department of Clinical Medicine, UCPH (see https://ikm.ku.dk/english/ for more information).