**1. Introduction**

The spread of the 2019 novel coronavirus was declared a global pandemic by the World Health Organization on 11 March 2020 [1]. The virus most often only causes mild symptoms similar to those of a typical influenza, but in some people, it can cause severe respiratory infections and multi-organ failure [2]. These severe symptoms are more likely to occur in specific high-risk groups. The designation of such high-risk groups has evolved during the course of the pandemic and has differed across countries. On 11 March, the Danish Health Authority declared people with poorly regulated diabetes (all types) as a group at high risk for becoming seriously ill if infected with the virus [3].

Studies investigating the prevalence of diabetes (all types) in COVID-19 patients have found it to be around 10% [4,5], but it remains unclear whether people with diabetes are more susceptible to COVID-19 [6,7]. However, numerous studies have shown an increased risk of severe COVID-19 and mortality in individuals with diabetes [4,6–12], as well as higher rates of hospitalization due to COVID-19 [13,14]. Thus, individuals with diabetes have been identified as having worse COVID-19 outcomes, particularly those with poor glycemic control [15,16].

This information on the association between diabetes and COVID-19 was not, however, available during the early stages of the pandemic due to the novelty of the virus [17]. As a result of this uncertainty and lack of evidence-based knowledge about the virus, the information and messages from health authorities, and therefore also from the media, have been mixed and unclear, with di fferent predictions and inconsistent risk communication [18]. This also applies to Denmark, where information from health authorities has varied over the course of the pandemic: Initially, only individuals with poorly regulated diabetes were said to be at risk of severe COVID-19, but later all people with diabetes, regardless of glycemic control and diabetes type, were categorized as a risk group [3].

Just as in many other countries, the Danish governmen<sup>t</sup> enforced a lockdown to avoid critical spreading of the 2019 novel coronavirus [19]. On 12 March, Denmark closed all schools and childcare institutions, sent home public sector employees with non-critical roles and banned gatherings of more than 10 people.

A pandemic-induced lockdown can be expected to reveal social, psychological and underlying philosophical issues that will have a lasting impact on societies and individuals [20]. To study how a complex societal development such as the lockdown a ffects the self-observations and perceptions of communicated risk among people living with a chronic disease, we need to apply complexity-oriented social theory that enables us to look closely at the interrelatedness of the individual and the social. In the present study, we look through the lens of Niklas Luhmann's operative constructivist systems theory [21–23]. The objective of the present paper is to study how COVID-19 lockdown a ffects psychosocial life with diabetes. By applying significant concepts from Luhmann's systems theory, and furthermore by analyzing using radical hermeneutics [24], we examine how people with diabetes observe themselves in relation to other people, various social systems in their environment as well as the lockdown as an important societal phenomenon. Applying a qualitative approach with a distinct focus on individuals' thoughts, perceptions, and views enable us to understand how people with diabetes create meaning out of the complex multitude of communications concerning the consequences of the 2019 novel coronavirus.

#### **2. Materials and Methods**

## *2.1. Empirical Data*

The dataset consists of 20 semi-structured individual interviews with people with diabetes (see Table 1 for characteristics). Due to the lockdown and the need for social distancing, the interviews were conducted and recorded online using a secure communication platform with the video function disabled. We decided to disable the video function because especially the older interviewees might be fairly unfamiliar with video conferences and could find this to be intimidating.


**Table 1.** Study population characteristics.

Relatively rare form of diabetes.

The relatively simple interview guide consisted of four main themes: (1) diabetes managemen<sup>t</sup> (in general and during lockdown): with questions focusing on the day-to-day issues regarding medication, exercise and diet, (2) quality of life (in general and during lockdown): with questions focusing on perceptions of general well-being, (3) perception of being at risk (in general and during lockdown): with questions focusing on health and risk communication and the specific relation between diabetes and COVID-19, and (4) relations and support (in general and during lockdown): with questions focusing on interactions with friends, family members, colleagues and healthcare professionals.

The participants were recruited through the user panels at Steno Diabetes Center Copenhagen and the Danish Diabetes Association. The user panels consist of people with diabetes who have volunteered to share information about their lives with diabetes. The panels include people from all parts of Denmark with type 1 diabetes (T1D) and type 2 diabetes (T2D, LADA, gestational diabetes and other rarer types of diabetes. Thus, the panels represent people with diabetes who are treated in di fferent primary and/or secondary care settings across Denmark. The panel members (*n* = 2430) received the invitation to participate in an interview via an e-mail newsletter sent out to all panel members. The interested panel members then contacted the research team by e-mail or telephone.

We decided to be open to recruit participants with T1Dand T2D so that we could study potentially di fferent reactions to the lockdown. During one interview we discovered that the interviewee actually had LADA, which is a relatively rare form of diabetes that has similarities with both T1D and T2D [25]. We decided to keep this interview in the dataset even though it did not contribute any insights into any specificities regarding living with LADA during lockdown. It did, however, contribute to the overall findings on living with diabetes during lockdown. Thus, in the present paper, we focus on persons with T1D and T2D

After each interview, the researchers discussed and systematically wrote down all the overarching themes that were touched upon in the particular interview. After 15 interviews, the research group used this overview to discuss the level of saturation and decided to conduct five additional interviews, because the interviews, especially with people with T2D, lacked information power. The recruitment procedure was not changed for the next five interviews that included three people with T2D and two people with T1D. When a total of 20 interviews had been conducted, we concluded that no new overarching new themes had emerged in the two latest interviews, meaning that the level of saturation and ensuing information power in the data were acceptable [26]. No changes were made in the interview guide at any point in the data collection period. All interviews were conducted over the course of two weeks and the average length was 40 min. None of the researchers had any prior relationship with any of the interviewees.

After collecting the full dataset, the interviews were transcribed verbatim, iteratively analyzed in Danish and then categorized using radical hermeneutics, which are a set of guidelines for content analysis that, as a combination of hermeneutics and constructivism, manages to simultaneously be empirically founded and theoretically complex [24]. Radical hermeneutics focuses on keeping a perpetual balance between theory, method and data by acknowledging how all of these elements influence each other in an interconnected process. The use of radical hermeneutics also entails constant alternation between analyzing and interpreting, which means it is necessary to present interpretive aspects while presenting the results.

Radical hermeneutics is a validated methodology consisting of three steps of data analysis. The first step involves reading the data with a view to observing specifically selected di fferences in them. This observation in itself constitutes an interpretation rather than a description, and its task is to reduce the complexity of the data. Elements within the scope of the di fferences selected by the interpreter are extracted from the data. The second step involves making these elements the subject of interpretation as an observation of the di fferences employed. The third step involves interpreting the sum of these di fferences [24].

In the present analysis, this approach meant that the analytical process was developed in several steps as we delved deeper into the data. The first step focused on extracting issues of direct relevance to diabetes and the COVID-19 lockdown from the empirical data. The second step involved analyzing and interpreting the extracted data using the theoretical background described below, and this step revealed the three main themes presented in the results section. The final step is then a separate interpretation of the data within each category–materializing as the findings presented for each of the three themes. Working with radical hermeneutics includes the awareness that the role of the researcher is that of an observer. This underlines how any research depends on an awareness of how all the

observations were made. This is exactly what radical hermeneutics and the use of guiding di fferences provide—a way to continually employ a high level of reflexivity in all aspects of the study.

The study was approved by the Danish Data Protection Agency (P-2020-271) and carried out in accordance with the Declaration of Helsinki. According to Danish legislation, interview studies require no approval from an ethics committee. All participants gave their informed consent based on thorough explanations of the purpose of the study. All participants were explained that they had the right to not answer any question and that they could stop the interview at any time if they were not comfortable with the situation. Furthermore, they were given details of whom to contact for answers to questions about the research and the research subject's rights.
