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Development of an Empowering Language Assessment Tool for Type 1
Diabetes

Gwen Geiger Wolfe, MPH, MLS*a, Sally Bowler-Hill, MA, MSIS, PMPb, Lisa M. Acuff,
MPH, MSIS, AHIPb

aScience and Engineering Librarian, KU Libraries, University of Kansas, Lawrence, Kansas,
https://www.orcid.org/0000-0002-3309-2488 , gwen.geigerwolfe@ku.edu,

bManager, Administrative Operations, Health Sciences Library and Informatics Center,
University of New Mexico, Albuquerque, New Mexico,
https://www.orcid.org/0000-0002-8371-0408 , sbowler-hill@salud.unm.edu,

bEducation and Research Librarian, Health Sciences Library and Informatics Center,
University of New Mexico, Albuquerque, New Mexico,
https://www.orcid.org/0000-0001-8427-4073 , LAcuff@salud.unm.edu,

Cite as: Geiger Wolfe G, Bowler-Hill S, Acuff LM. Development of an Empowering
Language Assessment Tool for Type 1 Diabetes. Hypothesis. 2024;36(1).
doi:10.18060/27668

Geiger Wolfe, Bowler-Hill, Acuff. All works in Hypothesis are licensed
under a CC BY-NC 4.0 DEED Attribution-NonCommercial 4.0 International. Authors own
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and the copy is used for educational, not-for-profit purposes. For any other use of articles,
please contact the copyright owner(s).

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https://www.orcid.org/0000-0002-3309-2488
https://orcid.org/
mailto:gwen.geigerwolfe@ku.edu
https://www.orcid.org/0000-0002-8371-0408
https://orcid.org/
sbowler-hill@salud.unm.edu
https://www.orcid.org/0000-0001-8427-4073
https://orcid.org/
mailto:LAcuff@salud.unm.edu
https://creativecommons.org/licenses/by-nc/4.0/


Peer Reviewed Article Hypothesis, Vol. 36, No.1, 2024

Abstract

Introduction: This brief report describes the early development of an Empowering Language
Assessment Tool (T1D-ELAT) for patient education materials (PEMs) designed for people
with type 1 diabetes (T1D), consisting of a checklist to assess the frequency of
disempowering language.

Methods: The authors followed professional society guidelines to develop a checklist to
quantify the use of disempowering words and phrases. We determined inclusion and
exclusion criteria and grouped checklist terms into functional categories. We also collected
descriptive characteristics about each PEM, such as publication date, authorship, and country
of origin, and created a codebook defining these terms and descriptive characteristics.

Results: The authors tested the checklist in two rounds and added nine term variations as a
result. We removed the imperative can/can’t/cannot during testing because it was not
consistently used as an imperative.

Discussion: Pilot testing the checklist informed revisions to the checklist and study protocol.
Future phases of this research project will also explore the context in which disempowering
terms are used in these materials.

Introduction
This brief report describes the development of an Empowering Language Assessment Tool
(T1D-ELAT) for patient education materials (PEMs) designed for people with type 1 diabetes
(T1D) and their caregivers. The tool consists of a checklist to document the frequency of
disempowering language usage in PEMs authored by academic, clinical, government, and
health-related organizations. Disempowering language in diabetes care and education
includes the use of stigmatizing, blaming, and condition-first words and phrases, such as
“diabetic,” “good/bad control,” or “must.” The authors anticipate future usage of the
T1D-ELAT in academic and clinical settings or by any professional evaluating PEMs for
community dissemination. Background information for this research is available on the Open
Science Framework1 and in the Journal of Consumer Health on the Internet2.

Methods
Professional society guidelines on the use of language in diabetes care and education
informed the development of the checklist3. The guidelines list disempowering words and
phrases with empowering alternatives. The checklist includes disempowering language
relevant to written PEMs and excludes terminology specific to clinical communications. The
T1D-ELAT assesses disempowering language because empowering alternatives are many and
various. Empowering alternatives for the word “control” used as a noun, for example “good
control,” include “an A1C less than 7%” or “glucose values within target,” which focus on
factual terms that are neutral3.

The authors grouped T1D-ELAT words and phrases into functional categories: control (verb
or adjective), control (noun), diabetic (adjective or noun), imperatives, prevent, and test (verb

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Peer Reviewed Article Hypothesis, Vol. 36, No.1, 2024

or noun); and excluded medical terms, such as diabetic ketoacidosis. Table 1 provides a
complete list of T1D-ELAT terms. In addition to disempowering language, the checklist
collects descriptive characteristics, including country of origin, authorship, audience, and
publication date. The authors subsequently excluded the audience characteristic because the
terminology in PEMs for people with T1D was similar for adults, parents, and children.
Finally, we created a codebook to define the disempowering terms and descriptive
characteristics and guide the application of the tool.

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Peer Reviewed Article Hypothesis, Vol. 36, No.1, 2024

Table 1. T1D-ELAT Disempowering Words and Phrases by Category

Category Disempowering Words and Phrases

Control as Verb or Adjective Controlled / Uncontrolled

Well controlled / Poorly controlled

Control your / Control the/ Controlling your

Control as Noun Gylycemic control / Glucose control / Blood
sugar control

Poor control / Bad control

Good control / Tight control

Diabetic as Adjective or Noun Diabetic person / Diabetes patients

Diabetic / Nondiabetic (*exclude diabetic ke-
toacidosis)

Imperatives Should / Shouldn’t/Should not

Have to / Need to

Must /Must not

Prevent Prevent / Prevention / Preventing/ Preventable

Test as Verb Test blood glucose / Test blood sugar / Test
your blood sugar / Blood sugar tested

Test as Noun Blood test

Test strips

Results
The authors pilot tested the checklist in two rounds: informally with PEMs about type 2
diabetes and formally with eleven PEMs about T1D. We added nine variations during formal
testing: control your, controlling, blood sugar control, preventing, preventable, test blood
sugar, test your blood sugar, blood sugar tested, and blood test. We removed the terms can,
can’t, and cannot during testing because they occurred in multiple contexts, often not as
imperatives. The authors presented results from the formal pilot study at the Empirical
Librarians Conference in March 20234.

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Peer Reviewed Article Hypothesis, Vol. 36, No.1, 2024

Outcomes
The authors did not count instances of disempowering words in organizational names like the
Centers for Disease Control and Prevention during pilot testing; however, we included them in
the revised checklist because they potentially impact people’s perceptions and experiences.
After pilot testing, the authors used the revised checklist to assess a sample of twenty-nine
publicly available PEMs, and we are currently engaged in descriptive analyses.

The changing nature of language, such as the shift from condition-first to person-first
language in diabetes care and education, is one limitation of the T1D-ELAT. In future phases
of this research, the authors plan to explore the context in which PEMs use disempowering
language. In summary, the T1D-ELAT offers a tool for assessing the real-world use of
disempowering language in PEMs about T1D.

Author Contributions
Gwen Geiger Wolfe: Conceptualization, Investigation, Methodology, Writing – original draft,
and Writing – review

Sally Bowler-Hill: Conceptualization, Investigation, Methodology, Writing – original draft,
and Writing – review

Lisa M. Acuff: Conceptualization, Investigation, Methodology, Writing – original draft, and
Writing – review

References
1. Acuff L, Geiger Wolfe G, Bowler-Hill S. Disempowering language in online patient
education materials for people with type 1 diabetes: A summative content analysis. Open
Science Framework. 2023. Available from: https://osf.io/wqh35

2. Acuff L, Geiger Wolfe G, Bowler-Hill S. The language of type 1 diabetes: Why it matters
in online patient education. J Consum Health Internet. 2023, Mar 07. Cited 2023 Oct 20;
27(1):86-97. doi:10.1080/15398285.2023.2167424

3. Dickinson JK, Guzman SJ, Maryniuk MD, O’Brian CA, Kadohiro JK, Jackson RA, et al.
The use of language in diabetes care and education [Internet]. Diabetes Care. 2017 Dec 1.
Cited 2022 Aug 26; 40(12):1790–9. doi:10.2337/dci17-0041

4. Eaker C, Sergiadis A. Empirical Librarians Conference. Open Science Framework. 2023.
Available from: https://osf.io/7hjte

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https://osf.io/wqh35
https://dx.doi.org/10.1080/15398285.2023.2167424
https://dx.doi.org/10.2337/dci17-0041
https://osf.io/7hjte

