Gender Inequality and Well-Being of Healthcare Workers in Diabetology: A Pilot Study

: Several factors affect the relationship between a diabetic patient and a healthcare worker. Among these, there is the well-being of healthcare workers and how they perceive their work environment, especially in the context of the presence or absence of gender inequality. To show the importance of these aspects, a selected sample of healthcare workers who were exposed daily to people (mainly diabetic patients) within the working environment were interviewed. The different opinions of the interviewees show that in an environment where factors that negatively affected their work and personal well-being were minimized, healthcare workers were able to fully express their potential. They expressed great satisfaction with their work involving daily contact with patients, while achieving the type of patient–healthcare worker relationship model desired for a better management of diabetic


Introduction
Currently, the debate on gender inequality and healthcare workers' well-being is central. Healthcare workers are entrusted with teaching patients [1] about their diabetes and showing them how to live autonomously with the disease. The outcome of this attitude is a significant improvement in the treatment process [2]. As reported within the DAWN study [3], effective communication between the patient and the sanitary team and the subsequent improved relationship offer the prerequisite to the correct approach to overcome the comprehension and self-treatment barriers generated by the disease, and to improve the healthcare in general [4]. The synergistic work of the whole sanitary team to implement a correct coordination and collaboration attitude is the major factor in achieving this goal. The availability of an interdisciplinary team, solely established and coordinated for the diabetes treatment, has been identified as a major factor to the disease treatment [5]. Healthcare workers who interface with diabetic patients must be able to express their full potential in a healthy work environment not characterized by gender inequalities, which ultimately affect personal well-being and motivation. Listening to and understanding those healthcare workers who work primarily in contact with diabetes patients leads to an understanding of the influence of the working wellness, the gender inequality, and subsequent impact on the relationship with patients.

Gender Inequality in the World and in the Health Sector
According to the definition provided by the European Institute for Gender Equality, gender inequality is framed in a social and cultural state in which sex and/or gender determine different rights and dignity for men and women; this is reflected in their unequal assumption of social and cultural roles [6]. It's important to analyze the phenomenon of gender inequality from a statistical point of view in order to have a true perception of the gap in Europe and the world. The Global Gender Gap Index, elaborated in the Global Gender Gap Report 2021, tracks the progress of gender gaps over time (it measures scores on a scale from 0 to 100 and represents the distance from parity, i.e., the percentage of the gender gap that has been bridged); in 2021, it was equal to 67.7% (calculated on 153 countries). Compared with the previous year, the gender gap widened by an average of about 0.6 percentage points. In the global ranking, Iceland and Finland showed better results in terms of gender equality: they bridged at least 85% of their gap. In general, Western Europe had the best performance, further improving its gender gap in 2021 (from 76.7% in 2020 to 77.6% in 2021) [7]. Within the European Union, women earn on average 16% less than men; this happens as women concentrate on lower-level and lower-paid jobs and are more likely to choose a part-time job. The gender pay gap among healthcare workers is particularly wide when compared with other sectors, reaching up to 33% [8]. Healthcare is one of the main global sectors comprised of women. Despite women making up about 70% of the global healthcare workforce, they are largely relegated to lower-paid sectors and jobs, with men holding most of prestigious positions. Women hold only a minority of leadership positions in the healthcare sector (25%) [9]. Addressing the issue of gender equality within healthcare workforce is important because the present disparity contributes to largely inexplicable gender pay gaps. Prejudices and discrimination constitute additional obstacles for women in the healthcare workforce, keeping them away from leadership positions by excluding them from reaching their full potential. This feeds the vicious cycle of inequality and discrimination that is already present and undermines the well-being of healthcare workers.

The Well-Being of Healthcare Workers in Diabetology and their Relationships with Patients
Chronic illnesses, such as diabetes, are one of the greatest health issues which must be perceived differently from a nursing point of view. Healthcare workers have a fundamental role to educate and guide patients to autonomy, which consists of learning to self-manage the disease to be able to function in a normal daily life. The new role of the diabetology team is to be an educator of patients, who have the right to be guided by a trained operator throughout their treatment. This role goes beyond purely assisting to becoming an educational guide, passing from a set of pure and simple technical notions to a real interpersonal and interdisciplinary relationship aimed at the patients' acquisition of knowledge, competence, and autonomy [10]. Therefore, education undertakes a significant role, because through education, the patient can become aware and responsible for the choices they make in maintaining a state of well-being [11].
In this contemporary era, people possess a higher cultural level. When someone turns to healthcare services, they ask to no longer undergo the dehumanizing process in which the experience of suffering and illness is simply reduced to a technical identification of a given biochemical or diseased organ. Patients are less likely to accept and undergo a health intervention in which they as a human being are not contemplated. This becomes a necessity in diabetology: the chronic patient needs to be accompanied in their treatment by a healthcare worker who exercises a relationship no longer characterized only by technical and pharmacological activities, but also by complementary non-pharmacological interventions of humanization of care that can respond to the new needs of today's patients. The center of care must be the patient, who should always feel supported, understood, and stimulated, in order to avoid conflicting and destabilizing behaviors. A "person-centered" care is essential to achieving optimal results in the treatment of diabetes [12].
Healthcare workers must improve the ability to enter into a relationship with patients (improve active listening, communication, and reception) and to identify and manage the emotional aspects; only in this way will they be able to "take care" of diabetic patients [13]. In this perspective, the work of the diabetology team is fundamental; that is, it is not limited to a pure exchange of information but is divided into a communicative process that stimulates the ability to interpret and participate with the aim of arriving at the formulation of effective strategies [14]. A cohesive diabetological team, whose objective is to achieve the best patient-healthcare worker relationship, requires the presence of a working environment in which healthcare workers are able to recognize and express their full potential. This allows them to become highly motivated and fully grasp the meaning of their work and the benefits it has on their relationships with those who need constant care and support.

Materials and Research Methods
To understand how gender inequality and work well-being affect the patient-healthcare worker relationship, a survey was taken on a small sample of healthcare workers who were in constant contact with diabetic patients. Chronic diabetic patients require a different approach to the treatment process that takes place in close connection with healthcare workers. The relationship between patients and healthcare workers can be influenced by the emotional approach to work assumed by the healthcare workers. The survey aimed to investigate the way healthcare workers approach this relationship and their work by exploring three related aspects: the way they perceive the phenomenon of gender inequality and how this affects their daily activities; their state of well-being; and finally their emotional approach to work (focusing on direct contact with the patient). The anonymous questionnaire was divided into four specific areas: 1.
Gender inequality in the work environment, 10 questions; 3.
Emotional approach to work, 14 questions.
The social-personal characteristics section aimed to understand the distribution of the personal and social characteristics of the sample, such as gender, age group (respondents were asked to choose the age group they belonged to, from 20 to 60+), educational qualifications, and the geographical area in which they worked. The gender inequality section aimed to understand the degree of agreement/disagreement of the respondent with some statements related to the presence of gender inequality in their working environment. Possible answers were formulated according to the method of the Likert scale (completely disagree, in disagreement, partially in disagreement, neither in agreement nor in disagreement, partially in agreement, in agreement, or completely in agreement) and evaluated according to the most frequent answer. Questions were not formulated to establish which gender was disadvantaged in their work environment but to understand how healthcare workers perceive and relate to the phenomenon gender inequality. The third section (current state of well-being) had the specific intent to investigate the state of well-being of the interviewee within the last month (a limited period of time to which respondents can refer to evaluate their feelings). The last section (emotional approach to work) aimed to understand the state of the well-being of healthcare workers in the context of their work through multiple-choice questions. Finally, a space dedicated to further comments (optional) for the interviewee on the gender inequality theme was included, in which it was possible to express in one sentence the personal reflection on the theme covered in the interview. The answers were analyzed through data analysis and visualization tools in order to be summarized in the corresponding sections and obtain useful information to investigate the main topic.

Results Obtained
The questionnaire was submitted to 176 healthcare workers who came from 34 different Italian provinces. The last optional section was filled in by about 36% of respond-ents.

Social-Personal Characteristics
As shown in Table 1, the average respondent identified as a woman between the ages of 51 and 60.

Gender Inequality in the Work Environment
The first question ("In the healthcare company where I work there is the phenomenon of gender inequality") directly addressed the phenomenon of gender inequality; from the answers ( Table 2), it can be noted that there was no polarization of opinions between agreement or disagreement, as 50% of respondents declared that they did not perceive the phenomenon, compared with 32.38% who agreed with the statement (the remaining part remained neutral). Almost all male respondents did not perceive the phenomenon of gender inequality, while female respondents were almost equally distributed between agreed, disagreement, and impartial answers. In the following questions, respondents took different positions regarding the presence of gender inequalities in career advancement, pay, and leadership positions. In particular, as can be seen from Table 3, the majority of respondents did not believe that men receive a higher salary than women for the same position in their company (men and women both disagreed with the statement). The percentage of respondents who did not feel either in agreement or disagreement with the statement remained high. Respondents did not perceive that it is easier and faster for men to advance their careers to more prestigious and top positions; men disagreed with these statements, while women had different opinions (Tables 4 and 5). However, most of the respondents found that top or managerial positions are held more by men than by women (Table 6). This could confirm the claim that, in the healthcare workforce, women shun leadership positions, which prevents them from reaching their full potential. Respondents (both women and men) disagree that male candidates are preferred over female candidates for the purposes of recruitment with equal curriculum (Table 7).    In general, the majority of respondents (both women and men) completely disagreed with the claim that the presence of gender inequality in the workplace affects their emotional state and daily tasks (Tables 8 and 9). It is useful to report that the data show that the percentage of respondents who feel in agreement with the previous statements are placed on different age groups from 20 to 60+: the negative influence of the presence of gender inequality has no age.

State of Current Well-Being
The interviewees' state of well-being was characterized, for about 29%, by a state of anxiety and nervousness that does not affect daily tasks. On the other hand, the remaining part did not perceive a state of anxiety and nervousness or perceived in only slightly ( Table 10). The state of anxiety and worry varied among respondents: 42% said they had never been in such a state in the last month, 27.8% said they felt anxiety and worry half the time, and up to 17% found themselves in a state of anxiety most of the time. Just under half of the respondents said they had never felt down in the last month and that they had been mostly cheerful and felt motivated and confident most of the time. However, it is worth noting that among respondents, 13.1% felt a lack of energy, and 12.5% felt down most of the time. Similar percentages were obtained for the states of lacking joy, motivation, and self-confidence. Although most interviewees demonstrated a high state of personal well-being, there remained a small number of healthcare workers who experienced states of anxiety, worry, low motivation, and self-confidence.
Respondents who declared that (in the last month) they had almost never found themselves in a state of anxiety and worry and that they felt motivated and self-confident did not particularly perceive the phenomenon of gender inequality in their company.

Emotional Approach to Work
In general, for the most healthcare workers, interfacing with patients was simple and effective: 54.54% of respondents said they easily understood what their patients thought often during the week, and 26.14% said they could always understand their patients (Table 11). Almost all respondents managed to effectively address their patients' problems during the week by making them feel comfortable (Tables 12 and 13). From the answers analyzed, we found that the healthcare workers understood the importance of their role in front of patients and the value that this can bring in the path of care. In fact, interviewees thought they had accomplished useful things through their work either almost always (63.64%) or always (32.95%) ( Table 14). Working in contact with people was a source of satisfaction every day of the week for 46% of the interviewees and often during the week for 32.38% (Table 15). However, a significant proportion of respondents said they often felt fatigued during the week (35.2% often during the week, and 15.3% every day of the week). Working in contact with people did not appear to be tiring for most of the interviewees (Table 16).
The comments on the optional section highlighted that, although the issue of gender inequality was considered important by the healthcare workers, they considered their workplace (in particular, diabetology) a place where they could express their potential as people and as professionals.

Discussion of Results
From the interviews submitted to healthcare workers who work in contact with diabetic patients, we found that there was not a clear position on the presence of gender inequality in the work environment. Although some related aspects were particularly felt by the interviewees (for example, the majority of prestigious positions being held by men, or the disagreement with wage disparity). The data show that interviewees who perceived the presence of gender inequality in their company often felt fatigued by their work during the week and experienced anxiety and concern. In general, the state of anxiety and lack of motivation by some interviewees was attributed in part to the presence of gender inequality. However, the relationship with the patient seemed to be in most cases profitable, effective, and a source of satisfaction for most respondents. Healthcare workers were satisfied with working in contact with people and being part of their care path. The reasons why healthcare workers may experience situations of malaise in the workplace can be different (this includes gender inequality, personal hardships, the physical structures where they work, etc.). In the same way, the possible solutions and models through which organizations can promote all those factors that directly or indirectly affect the well-being and motivation of healthcare workers and can remove or decrease those negative effects are disparate. Promoting the well-being of healthcare workers in general, but especially for those working with chronic illnesses such as diabetes, improves the patient-healthcare worker relationship and allows healthcare workers to express their full potential by putting the patient at the center of care and allowing them to better cope with their illness.

Limits of Research and Future Studies
The phenomenon of gender inequality is very complex and occurs in different forms and nuances, depending upon the environment, people, and social context. The results presented relate to a small sample of respondents working in different geographical areas. Extending the survey to a larger number of respondents would allow for a more detailed and comprehensive analysis in order to study which variables might directly or indirectly affect the patient-healthcare worker relationship.
Author Contributions: Conceptualization, T.L.; methodology, T.L.; formal analysis, T.L.; investigation, T.L., S.C. and C.P.; data care, S.C.; preparation of the original draft, T.L., S.C. and C.P.; revision and modification, T.L., S.C. and C.P. All authors have read and agreed to the published version of the manuscript.