Addressing the Unique Challenges of Diabetes Care in Refugee and Asylum-seeker Populations

Diabetes is among the fastest-growing non-communicable diseases worldwide, affecting an estimated 537 million adults in 2021, with projections exceeding 780 million by 2045. For the world's forcibly displaced population—surpassing 100 million people in 2023—the burden of diabetes is disproportionately severe. Displacement systematically dismantles the routines required for chronic disease management: consistent access to medications, stable nutrition, and continuous medical oversight. According to the UNHCR Global Trends report, prevalence rates for diabetes in refugee camps and urban settlements often exceed those of host communities, driven by pre-existing health inequities, limited access to treatment, and high levels of psychological stress. Without targeted, systemic interventions, these populations suffer higher rates of complications, including nephropathy, retinopathy, and cardiovascular disease. This article examines the specific barriers faced by refugees and asylum seekers living with diabetes and outlines actionable strategies grounded in clinical evidence and humanitarian best practices.

Unique Barriers to Diabetes Care for Displaced Populations

The challenges faced by refugees and asylum seekers with diabetes are not isolated obstacles; they are tightly interlocking constraints that compound one another. Understanding the depth and interaction of these factors is essential for designing effective responses. Each barrier reinforces the next, creating a cycle of poor health outcomes that cannot be broken by addressing only one element in isolation.

Transience and Fragmented Health Systems

Displaced individuals frequently move between temporary shelters, camps, and provisional urban housing. This transience makes it nearly impossible to establish a continuous therapeutic relationship. A patient stabilized on insulin in one location may be relocated to a region with a different drug formulary, inadequate cold-chain storage, or no diabetes services at all. Medical records are often lost during flight, and few humanitarian health systems maintain interoperable electronic health records. Even when clinics are accessible, operating hours may conflict with work obligations, and rigid appointment systems fail to accommodate the walk-in needs of patients living without stable schedules. The World Health Organization (WHO) consistently reports that refugees face lower rates of chronic disease management continuity compared to host populations. Without a single, trusted provider who knows their history, patients are forced to re-explain their condition at every encounter, increasing the likelihood of clinical errors and therapeutic delays. This fragmentation also means that preventive care—regular eye exams, foot checks, and kidney function monitoring—is almost never systematically delivered.

Language Barriers, Cultural Beliefs, and Limited Health Literacy

Effective diabetes self-management relies on detailed communication: interpreting glucose readings, calculating insulin doses, recognizing hypoglycemia, and adhering to dietary modifications. When patients and providers lack a shared language, the potential for life-threatening errors increases substantially. Professional medical interpretation is frequently unavailable, leading to reliance on family members, including minors, who may inadvertently filter or mistranslate critical instructions. Cultural beliefs about health and illness also shape care engagement. Some communities view diabetes as a divine punishment or a condition better managed with traditional herbal remedies than with insulin. Without cultural humility and explicit negotiation of treatment plans, providers risk dismissing these beliefs, eroding trust and reducing adherence. Health literacy, which includes numeric skills necessary for dose adjustment, is often limited in populations whose formal education was disrupted by conflict. A 2020 study in Diabetic Medicine found that refugees demonstrated significantly lower diabetes knowledge scores, which correlated directly with worse glycemic control. The complexity of modern diabetes regimens—multiple daily injections, sliding scales, carbohydrate counting—assumes a level of health literacy that cannot be taken for granted in any population, but is especially precarious among those whose education was interrupted by war and displacement.

Housing Instability and Food Insecurity

Diabetes management depends on predictability. Patients require consistent meal timing, safe medication storage, and regular physical activity. Refugees living in shelters, informal settlements, or on the street often lack refrigeration, rendering temperature-sensitive insulin ineffective within days. Food insecurity forces reliance on emergency rations that are typically high in refined carbohydrates and unhealthy fats, causing dangerous postprandial hyperglycemia and weight gain. The chronic stress of not knowing where the next meal will originate also undermines motivation and the ability to adhere to structured meal plans. Monthly fluctuations in food availability make insulin dose adjustments nearly impossible without daily glucose monitoring, a resource rarely available in these settings. For patients dependent on food banks or humanitarian distributions, the timing and composition of meals are completely outside their control. A diet consisting predominantly of white rice, bread, and oil—common in emergency food parcels—can spike blood glucose to dangerously high levels even when medications are taken correctly. Without access to fresh vegetables, lean proteins, or whole grains, refugees face an impossible choice between caloric sufficiency and glycemic control.

Psychological Trauma, Toxic Stress, and Mental Health

Pre-migration trauma, including persecution, violence, and loss, combined with post-migration stressors such as poverty, discrimination, and uncertain legal status, results in elevated rates of depression, anxiety, and post-traumatic stress disorder (PTSD). These conditions are not merely comorbidities; they directly affect glucose metabolism through elevated cortisol and catecholamine levels. Mental health symptoms also reduce motivation for self-care, leading to missed medication doses, neglected foot exams, and avoidance of clinic appointments. A systematic review in The Lancet Diabetes & Endocrinology documented that depression is three times more common among refugees with diabetes than in the general diabetes population, and it is associated with significantly higher HbA1c levels and increased complication rates. The bidirectional relationship between diabetes distress and mental health is well established: fear of complications, frustration with self-management demands, and guilt over perceived failures all amplify psychological suffering, which in turn worsens metabolic control. For refugees, this cycle is intensified by unresolved trauma, grief for lost loved ones and homeland, and the daily indignities of living in limbo. Standard diabetes education that does not acknowledge this emotional burden will fall short because it asks patients to perform complex self-care behaviors while they are struggling to survive.

Legal status determines access to health insurance, work permits, and social services in most host countries. Asylum seekers may face waiting periods of months or years before eligibility for public health coverage begins. Many are required to provide proof of residence or identification documents that they cannot obtain. Without legal employment, refugees lack the income to purchase insulin, test strips, or healthy food. Even where humanitarian assistance exists, it is often short-term and inconsistent. These systemic gatekeeping mechanisms create delays in diagnosis and treatment initiation that can result in irreversible complications. The financial burden of diabetes is crushing even for people with stable incomes and comprehensive insurance. For refugees without either, the cost of a single vial of insulin or a box of test strips can represent weeks of income. Many are forced to ration insulin, skipping doses or extending the interval between injections, which leads to diabetic ketoacidosis and hospitalization. The resulting emergency care is far more expensive for health systems than providing consistent outpatient management would have been, creating a false economy that harms both patients and providers.

Social Isolation and Loss of Support Networks

Diabetes self-management is sustained by social support: family members who prepare appropriate meals, friends who encourage physical activity, and community networks that share information about health resources. Displacement shatters these networks. Refugees often arrive alone or with only a fragment of their family, leaving them without the practical and emotional scaffolding that makes daily disease management possible. Women, who frequently bear primary responsibility for both childcare and diabetes management within their households, face an especially heavy burden when they lack extended family support. Social isolation also reduces accountability: without a community that knows their condition and checks on them, patients are more likely to neglect foot care, skip medications, and miss appointments. Peer relationships that form in camps or resettlement programs can partially fill this gap, but building trust takes time, and many refugees cycle through multiple living situations before achieving any stability.

Actionable Strategies for Improving Diabetes Care in Humanitarian Settings

Effective interventions must extend beyond the clinic to address the structural and social determinants of health. The following strategies have demonstrated success across diverse refugee contexts. No single approach is sufficient; these interventions are most powerful when implemented as a coordinated package that addresses multiple barriers simultaneously.

Culturally and Linguistically Adapted Education Materials

Patient education materials must go beyond literal translation. They require deep cultural adaptation, including images of familiar foods (such as injera, rice, beans, and flatbreads), acknowledgment of traditional remedies, and analogies that transcend literacy barriers. For example, explaining insulin resistance as a lock that cannot open, causing sugar to back up, is an accessible metaphor. Color-coded blood glucose ranges and pictogram-based dosing instructions can assist patients with limited numeracy. Engaging refugee community leaders in the design and testing of these materials ensures relevance and trust. The CDC's Diabetes Toolkit for Refugees provides an example of field-tested, adaptable resources. Educational content should also address practical questions that arise in refugee contexts, such as how to store insulin without a refrigerator (using clay pots, underground storage, or cool water) and how to make healthier choices from limited food options. Materials should be offered in multiple formats—print, audio, video, and in-person group sessions—to accommodate different learning preferences and literacy levels.

Workforce Training in Cultural Humility and Trauma-Informed Care

Healthcare workers require more than a single diversity module. Effective training involves understanding specific refugee experiences, practicing trauma-informed communication, and developing skills in motivational interviewing. Trauma-informed care avoids retraumatizing patients by explaining each step of an examination, using gentle language, offering choices, and never employing coercive measures. Cultural humility means recognizing that providers do not have all the answers and must partner with patients to find acceptable treatment plans. For instance, clinicians should be prepared to adjust insulin regimens during Ramadan for Muslim patients who choose to fast, requiring pre-Ramadan planning and close follow-up. Training should also address implicit bias and its impact on clinical decision-making. Studies have shown that refugee patients receive less intensive diabetes treatment than host-country patients with identical clinical profiles, suggesting that bias—conscious or unconscious—affects prescribing patterns. Ongoing supervision and peer case discussions help reinforce these skills and prevent burnout among providers who work in high-stress humanitarian settings.

Ensuring Access to Affordable Medications and Diagnostic Supplies

Cost remains the foremost barrier to diabetes care. Insulin and glucose test strips are prohibitively expensive for uninsured or underinsured refugees. Humanitarian organizations can leverage bulk purchasing agreements and the WHO Prequalification Program to source lower-cost, high-quality biosimilar insulins. Clinics operating in camp settings should maintain on-site pharmacies with consistent formularies to prevent treatment interruptions. For patients without stable addresses, mail-order pharmacy delivery is impractical; supply pickup points should be co-located with food distribution centers or community gathering spaces. Prescribing longer-acting insulin analogs, when feasible, reduces injection frequency and decreases dependence on cold-chain storage. Blood glucose meters and test strips should be provided at no cost, and patients should be trained on how to use them reliably. For settings where glucose monitoring is not possible, clinical algorithms based on symptoms and urine glucose testing can provide a partial substitute, though these are far less precise and should be seen as a temporary measure while working toward full monitoring capacity.

Leveraging Mobile Health, Telemedicine, and Community Outreach

When refugees cannot travel to clinics, care must come to them. Mobile health units deployed near shelters provide essential services including blood glucose testing, foot exams, medication refills, and provider follow-up. Outreach workers, ideally from the refugee community itself, conduct home visits to reinforce self-management education and connect individuals to food assistance or housing resources. Telemedicine offers a scalable solution for remote consultations, particularly when supported by low-bandwidth platforms such as SMS and WhatsApp for appointment reminders and self-management tips. During the COVID-19 pandemic, several UNHCR telemedicine pilots demonstrated that diabetes patients in remote camps could be effectively monitored and managed through scheduled video calls and digital data sharing. However, telemedicine is not a panacea. It requires reliable electricity, functioning devices, and sufficient digital literacy, none of which can be taken for granted in refugee settings. A hybrid model—where community health workers facilitate digital connections and provide in-person support when technology fails—offers the greatest resilience.

Peer Support and Community Health Worker Interventions

Peer support groups, where refugees with well-controlled diabetes mentor newcomers, build self-efficacy and reduce the isolation that so often undermines adherence. Community health workers (CHWs) who share the cultural and linguistic backgrounds of the patient population serve as critical bridges between communities and formal health systems. CHWs can conduct home visits, lead group education sessions, and track defaulters to ensure follow-up. The Diabetes UK peer support model has been adapted for camp settings with promising improvements in glycemic control and patient satisfaction. CHWs should receive structured training in diabetes fundamentals, communication skills, and when to escalate concerns to professional providers. They should also be compensated fairly for their work, rather than expected to serve as unpaid volunteers. Integrating CHWs into the formal health system—with supervision, career pathways, and recognition—improves both retention and program quality. For refugee patients, seeing someone from their own community in a position of authority and expertise can be powerfully motivating and destigmatizing.

Nutritional Interventions and Food System Integration

Improving diabetes outcomes in refugee settings requires addressing the food environment directly. Humanitarian food distributions should be redesigned to include lower-glycemic options such as legumes, whole grains, and fresh or dried vegetables whenever possible. Nutrition counseling should be integrated into food distribution points, with CHWs offering brief, practical guidance on how to prepare healthy meals from available rations. Cooking demonstrations using camp-appropriate equipment (single burners, shared kitchens) show patients that they can prepare satisfying, culturally familiar meals without compromising their blood glucose control. For patients with the most severe food insecurity, direct food vouchers or cash transfers earmarked for nutritious foods can provide the flexibility needed to make healthier choices. These programs must be monitored to ensure that they are not diverted or captured by non-diabetic household members, and that they truly improve dietary quality rather than simply increasing caloric intake.

Systemic Change: Policy Reform, Integrated Care, and Community Co-Design

Clinical innovations will fail without corresponding policy changes that address the root causes of inequity. Sustainable improvement requires action at the legislative, funding, and community levels. The most effective programs in the field are those that combine direct service delivery with advocacy for structural change, recognizing that individual care cannot be separated from the policies that determine who gets care, when, and at what cost.

Policy Initiatives to Guarantee Coverage and Continuity

National governments can expedite health insurance enrollment for asylum seekers by eliminating waiting periods and waiving documentation requirements that displaced individuals cannot meet. Refugee health programs should receive dedicated, multi-year budget allocations rather than relying solely on emergency ad hoc funds. At the international level, organizations such as the WHO and UNHCR can advocate for harmonized essential medicine and supply lists across humanitarian response systems, ensuring that a patient who moves from one camp to another receives the same insulin formulation and monitoring equipment. Tax incentives or advanced purchase commitments for pharmaceutical companies that donate diabetes medications to humanitarian agencies could substantially increase supply reliability. Portability of health benefits across borders within regional economic zones would also protect refugees who move between countries during their displacement journey. These policy changes require sustained advocacy by humanitarian organizations, refugee-led groups, and allied health professionals who can present evidence of both the human cost of inaction and the economic savings of early, continuous care.

Integrating Mental Health Services into Diabetes Clinics

Given the tight linkage between trauma and glycemic control, integrated care models are essential. Co-locating mental health professionals within diabetes clinics reduces stigma and improves attendance for counseling. Stepped care models, where trained lay counselors deliver brief behavioral interventions for mild to moderate depression, and specialized psychiatrists manage severe cases, allow for resource-efficient delivery. Cognitive behavioral therapy tailored to diabetes-specific challenges, such as fear of hypoglycemia or coping with food insecurity, provides patients with practical coping strategies while addressing the psychological drivers of poor adherence. Group therapy formats can be particularly effective in refugee settings, as they also address social isolation and allow patients to learn from one another's experiences. Screening for depression, anxiety, and PTSD should be a routine part of every diabetes visit, using validated instruments that have been adapted for the linguistic and cultural context. Patients who screen positive should receive immediate support, not a referral to a distant mental health service that may not exist.

Community Engagement and Co-Design of Services

Sustainable interventions cannot be imposed on communities from the outside. Establishing community advisory boards composed of refugees at each health facility ensures that services remain responsive to emerging needs. For example, if a new policy requires a government-issued ID to collect insulin, the advisory board can flag this barrier and advocate for accommodations. Participatory research approaches, where refugees are involved in designing studies and interpreting findings, lead to interventions that are more acceptable, feasible, and effective. Involving end-users in the design of mobile health applications and educational materials dramatically increases their uptake and impact. Community advisory boards should be compensated for their time and expertise, and their input should be formally documented and acted upon, not merely collected as a token gesture. When refugees are treated as partners in care design rather than passive recipients of services, the resulting programs are more likely to align with actual needs, cultural values, and practical constraints.

Data Systems and Accountability Mechanisms

Improving diabetes care at scale requires data. Humanitarian health systems should implement minimum data sets that track diabetes diagnosis, treatment, and outcomes across refugee populations. These data systems must be designed with privacy protections appropriate for vulnerable populations, but they also need to follow patients across displacement sites to support continuity of care. Simple indicators—percentage of diagnosed patients on medication, proportion with a documented HbA1c in the past six months, rates of foot exams—can drive quality improvement even in low-resource settings. Accountability mechanisms, including regular audits and community scorecards, ensure that health services are meeting their commitments to refugee patients. When data reveals disparities in outcomes between refugee and host populations, it should trigger immediate investigation and corrective action, not be accepted as inevitable.

Conclusion

Refugees and asylum seekers living with diabetes face an extraordinary convergence of challenges: fragmented systems, language barriers, food insecurity, psychological trauma, social isolation, and exclusionary policies. These obstacles are deeply embedded in the structures of humanitarian responses and host country systems. Yet, evidence from the field demonstrates that change is achievable. Culturally adapted education, trauma-informed workforce training, reliable supply chains, mobile outreach, peer support, and community health worker programs dramatically improve outcomes when implemented thoughtfully. Integrated care models that address mental health alongside diabetes management are essential. Nutritional interventions that reshape the food environment itself can give patients a realistic chance at glycemic control. Ultimately, achieving health equity for displaced populations requires sustained political will, dedicated financing, data-driven accountability, and an unwavering commitment to partnership with communities themselves. Every barrier removed for refugees brings global health systems closer to delivering care that is truly fair, effective, and humane. The moral imperative is clear: diabetes does not discriminate by nationality or legal status, and neither should our commitment to treating it.