The Diabetes Attitudes, Wishes, and Needs (DAWN) Program: A New Approach to Improving Outcomes of Diabetes Care

 
Lifestyle and Behavior

      The Diabetes Attitudes, Wishes, and Needs (DAWN) Program:
      A New Approach to Improving Outcomes of Diabetes Care
      Soren E. Skovlund, Msc, Bsc, and Mark Peyrot, PhD, on behalf of the DAWN International Advisory Panel*

      *The DAWN International Advisory Committee includes Ib Brorly (a person with diabetes), Denmark; Ruth Colagiuri,
      RN, Australia; P. Geelhoed-Duijvestijn, MD, the Netherlands; Hitoshi Ishii, MD, Japan; Line Kleinebreil, MD, France;
      Rüdiger Landgraf, MD, Germany; Torsten Lauritzen, MD, Denmark; David Matthews, MD, United Kingdom; A.
      Ramachandran, MD, India; Richard Rubin, PhD, United States; and Frank Snoek, PhD, the Netherlands.

      The Diabetes Attitudes, Wishes, and        studies as one of the possible causes of        plications is commonly observed in
      Needs (DAWN) program is an inter-          poor outcomes of diabetes care in               general practice settings. Both patient
      national partnership effort to improve     general practice.3,4 A multitude of             and provider beliefs appear to con-
      outcomes of diabetes care by increas-      research studies, mainly in the                 tribute to the delayed use of effective
      ing the focus on the person behind the     Western world and with relatively               therapy (e.g., misconceptions of the
      disease, especially the psychosocial       small patient samples, has indicated            consequences of initiating medication,
      and behavioral barriers to effective       the potential importance of a multi-            that medication is not efficacious or
      diabetes management. DAWN was              tude of psychological, social, and              may have serious side effects).16,17
      initiated by an international survey of    behavioral factors for patient self-            These factors lead to a reluctance to
      > 5,000 people with diabetes and           management.5,6 Access to patient-               intensify treatment regimens, which
      almost 4,000 diabetes care providers.      centered self-management support                may be overcome through improved
      The DAWN program has facilitated a         and education has been shown in sev-            communication.
      number of concrete initiatives to          eral studies to improve outcomes of
      address the gaps in diabetes care iden-    diabetes care.7                                 What Is DAWN?
      tified by the DAWN study.                      Psychosocial research points to an          DAWN is an international collabora-
                                                 integral role of psychosocial issues in         tive program initiated in 2001 by
      Why Do We Need DAWN?                       all aspects of diabetes care,8 and in           Novo Nordisk in partnership with the
      Diabetes is one of the major world         particular comorbid depression is asso-         International Diabetes Federation and
      health problems. Recent estimates          ciated with impaired self-management            an international expert advisory panel
      from the World Health Organization         and metabolic control. Psychological            representing leading spokespeople for
      predict that if current trends continue,   treatment may help to improve both              medical, educational, psychological,
      the number of people with diabetes         quality of life and diabetes self-man-          and advocacy issues related to improv-
      will more than double, from 176 to         agement.9 Furthermore, monitoring of            ing a person-centered approach to dia-
      370 million people by 2030.1 Diabetes      psychological health may improve                betes care. Panel members were from
      is already the single most costly health   patient-reported outcomes as part of            Denmark, France, Germany, India,
      care problem in Westernized coun-          ongoing diabetes care.10                        Japan, the Netherlands, the United
      tries. Among those diagnosed with the          In terms of the structure and               Kingdom, and the United States.
      disease, at least half still do not        processes of care, effective communi-           National activities are developed by
      achieve satisfactory glycemic control,     cation between patients and                     multidisciplinary national expert
      despite the availability of effective      providers has been suggested to be              groups drawing on relevant best prac-
      treatments.2 As a consequence, mil-        important for optimal treatment out-            tices for putting DAWN into action.
      lions of people with diabetes are at       comes.11,12 For instance, application              The goal of DAWN is to improve
      elevated risk of suffering needlessly      of motivational interviewing tech-              outcomes of diabetes care by increas-
      from serious complications of the dis-     niques has been shown to improve                ing the focus on the person behind the
      ease. With the growing number of           the success rate of behavior change             disease, especially the psychosocial
      people with diabetes, there is an          consultations.13                                and behavioral barriers to effective
      urgent need to find better ways of             Access to a coordinated interdisci-         diabetes management. DAWN was
      curbing the human and economic bur-        plinary diabetes care team to offer             initiated by an international study
      den of this chronic progressive dis-       appropriate care, whether the need is           designed to identify a broad set of
      ease, through prevention, detection,       self-management education, medical              attitudes, wishes, and needs among
      and treatment. A review of the litera-     advice, or psychosocial support, has            diabetes patients and care providers
      ture suggests several important areas      been identified as an important factor          (physicians and nurses) in order to lay
      that have the potential to address         for improving treatment outcomes in             a foundation for national and interna-
      these problems.                            diabetes.14,15                                  tional efforts to improve diabetes
          Suboptimal diabetes self-manage-           Delayed initiation of medication            care.18 The DAWN study examined
      ment has been identified by several        therapies to prevent long-term com-             several factors related to quality of
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Lifestyle and Behavior

diabetes care: levels of diabetes self-     sites, as opposed to rural and subur-           taking, glucose testing, and appoint-
management and psychological dis-           ban sites. Physicians had a longer              ment keeping was low. Fewer than
tress among people with diabetes,           average duration of practice (15.9              one in five people with diabetes
quality of relationships between peo-       years) than nurses (10.6 years).                (19.4% of those with type 1 diabetes
ple with diabetes and their care                The third sample consisted of               and 16.2% of those with type 2 dia-
providers, collaboration among dia-         adults with type 1 or type 2 diabetes           betes) reported that they completely
betes care providers (team care), and       with a quota for each region of 250             complied with all aspects of their pre-
barriers to effective medication thera-     people with self-reported type 1 dia-           scribed regimens. Providers rated
py for diabetes.                            betes and 250 with self-reported type           adherence substantially worse than
   Once the DAWN study was com-             2 diabetes. For the purpose of analy-           did people with diabetes (7.3% of
pleted, the results provided the impe-      sis, people were classified as having           providers estimated that their typical
tus for a number of initiatives             type 1 diabetes if they were diagnosed          type 1 patient completely complied
designed to remedy the problems             with diabetes before age 40 and treat-          with all aspects of their prescribed
identified. Some of these initiatives       ed with insulin both at diagnosis and           regimens, and 2.9% of providers esti-
were already underway, and the              at the time of the survey; others were          mated the same for their typical type
results stimulated support for their        classified as having type 2 diabetes.           2 patient).
development; other initiatives grew         Respondents who did not provide
out of the collaborative efforts of the     information necessary to classify type          Distress
international community exposed to          of diabetes according to this algo-             People with diabetes reported that
the findings of the DAWN study.             rithm were deleted from the analyses,           diabetes-related distress is high at
                                            leaving a usable sample of 5,104.               diagnosis (85.2% reported feeling
The DAWN Study                                  People with diabetes were divided           shocked, guilty, angry, anxious,
All data are self-reports gathered dur-     almost equally by sex (54.0% female)            depressed, or helpless). Long after
ing 2001 by structured interviews           and lived primarily in urban areas              diagnosis (mean duration of almost
conducted face-to-face or by tele-          (58.0%). The median age at which                15 years), problems of living with dia-
phone, using DAWN questionnaires            formal education was completed was              betes were prevalent, including fear of
that had been developed based on a          17 years. Approximately one-third               future complications and resulting
literature review and focus groups in       were classified as having type 1 dia-           social disabilities, as well as immedi-
eight countries and translated into the     betes; Japan was an anomaly with                ate social and psychological burdens
languages of the countries studied.         < 5% having type 1 diabetes.                    (Table 1). Three of four (73.6%)
Interviews were conducted in 11             Compared to people with type 2 dia-             reported at least one of these fears or
regions (representing 13 countries):        betes, those with type 1 diabetes had a         burdens. Providers reported that the
Australia, France, Germany, India,          younger average age (38.0 vs. 59.3              majority of their patients with type 1
Japan, the Netherlands, Poland,             years) and a longer average duration            or type 2 diabetes experience psycho-
Scandinavia (Sweden, Denmark, and           of diabetes (19.2 vs. 11.2 years).              logical problems (67.9 and 65.6%,
Norway), Spain, the United Kingdom,                                                         respectively). Almost half of all people
and the United States. The                  What DAWN Taught Us                             with diabetes in the DAWN study had
Scandinavian samples were evenly            The results reported here draw on               poor well-being according to the
divided among the three countries.          a number of forthcoming articles                WHO-5 well-being index.19
    The study was conducted with            and analyses presented at research                 There was a linkage between poor
three independent samples. The first        conferences. 19–25                              adherence and psychological prob-
sample consisted of 2,705 physicians                                                        lems. The majority of providers
with a quota of 250 per region: 200 in      Adherence                                       (68.3%) reported that psychological
primary care and 50 specialists             Reported adherence with recommen-               problems influence regimen adher-
(endocrinologists and diabetologists        dations for diet, exercise, medication          ence. Moreover, a poor reaction at
with 2 years of experience and treat-
ing > 50 diabetes patients per month).        Table 1. Percentage of Patients Experiencing Various Aspects
The second sample consisted of 1,122                           of Diabetes-Related Distress
nurses with a quota of 100 per region:
50 specialists (treating > 50 people         Diabetes-related distress                               Percentage of respondents
with diabetes per month) and 50 gen-                                                                        who agree
eralists. Caring for at least five people    I feel stressed because of my diabetes.                            32.7
with diabetes per month was an inclu-        I feel burned out because of my diabetes.                          18.1
                                             I feel that diabetes is preventing me from                         35.9
sion criterion for the study, and only
                                                doing what I want to do.
one provider was selected from a             I am constantly afraid of my diabetes getting worse.               43.8
given practice.                              I worry about not being able to carry out my                       30.1
    Physician respondents were pre-             family responsibilities in the future.
dominantly male (72.6%), whereas             My diabetes causes me worries about my financial future.           25.8
nurses were predominantly female             My family and friends put too much pressure                        14.7
(95.2%). Both physicians (69.5%)                on me about my diabetes.
and nurses (69.0%) worked in urban           The community I live in is intolerant of diabetes.                 13.6

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Lifestyle and Behavior

      diagnosis (characterized by an inabili-
      ty to accept the diagnosis and a strong      Table 2. Percentage of Physicians Reporting That Their Typical
      negative emotional response) was                 Patient Sees Various Diabetes Care Providers Annually
      associated with a variety of poor
                                                                                                         Respondent
      patient-reported outcomes, including         Discipline Seen                        Primary Care                Diabetes Specialist
      regimen nonadherence (Figure 1).                                                      Physician                     Physician
         Despite the widespread prevalence         Primary Care Physician                     NA                           39.2
      of diabetes-related distress and its         Diabetes Specialist Physician              38.6                         NA
      important negative consequences,             Diabetes Specialist Nurse*                 24.6                         35.6
      only a small minority of people with         Dietitian/Nutritionist*                    31.3                         40.9
      diabetes (3.3%) had received psycho-         Eye Specialist                             67.0                         64.4
      logical treatment for diabetes-related       Foot Specialist                            32.5                         35.7
      problems within the 5 years prior to         Behavioral Specialist*                      6.0                         14.0
      the survey.                                  Data are %.
                                                   *Significant (P < 0.05) difference between primary care and diabetes specialist.
      Patient-Provider Relationships
      The quality of patient-provider rela-       four or more additional providers               too complicated, and one in three
      tionships was rated high by patients;       (22.0 vs. 12.0%). Annual appoint-               (33.7%) is tired of complying with
      88.8% reported that they have a good        ments were common only for eye doc-             their medication regimen. Of those
      relationship with the people who care       tors (approximately two or three                not taking insulin and who feel that
      for their diabetes. However, most           respondents described such visits as            their diabetes is not well controlled,
      providers reported that they need to        typical), and typical appointments              only one in four (26.9%) believes that
      better understand the psychological         with most other providers were                  insulin would help them to manage
      consequences of diabetes (69.8%) and        reported by only one in three partici-          their diabetes better. Nearly one in
      the various ethnic cultures that they       pants, with behavioral specialists              two providers (43.4%) prefers to
      deal with (78.8%).                          reported as team members for the typ-           delay initiation of oral medication
                                                  ical patient by < 10% of physicians.            until it is “absolutely essential.” And
      Provider Collaboration                      Only half of people with diabetes               only half (49.2%) of health care
      Team care was less than optimal             (51%) felt that their diabetes health           providers believe that earlier use of
      (Table 2). To assess levels of team         care providers talked to each other             insulin would decrease the overall cost
      care, physicians were asked how             about their care.                               of diabetes care. Patients who are
      many of seven providers a typical                                                           resistant to effective medication regi-
      patient of theirs saw on an annual          Barriers to Use of Effective                    mens and who are treated by
      basis (primary care practitioner, dia-      Medication Therapy                              providers who share their resistance
      betes specialist physician, diabetes        Many people with diabetes have wor-             are likely to experience delays in the
      nurse, dietitian/nutritionist, eye doc-     ries about starting diabetes medica-            intensification of treatment even in the
      tor, foot doctor, behavioral specialist).   tion and intensifying existing medica-          face of persisting need.
      Most providers (65.6%) said their           tion regimens. And providers are not
      diabetes patients saw two or fewer          eager to use medication to achieve              Summary
      providers in addition to themselves;        treatment goals. Of those taking anti-          The DAWN study has identified sev-
      specialist physicians were more likely      hyperglycemic medication, one in six            eral important gaps in the manage-
      than primary care physicians to report      (16.6%) feels that their treatment is           ment of diabetes across a number of
                                                                                                  countries. Diabetes self-management
                                                                                                  is less than optimal and is compro-
                                                                                                  mised frequently by diabetes-related
                                                                                                  distress, which often is not treated.
                                                                                                  Although the quality of patient-
                                                                                                  provider relationships is generally
                                                                                                  good, providers need a better under-
                                                                                                  standing of the social and psychologi-
                                                                                                  cal problems that people with dia-
                                                                                                  betes face. Team care is uncommon,
                                                                                                  with few providers providing their
                                                                                                  patients with comprehensive multidis-
                                                                                                  ciplinary care. People with diabetes
                                                                                                  and health care providers often resist
                                                                                                  initiating effective medication thera-
                                                                                                  pies. These problems combine and
                                                                                                  reinforce one another, leading to an
      Figure 1. Poor reaction to diagnosis predicts later problems. QoL, quality of               unnecessary increase in the burden of
                                                                                                  diabetes.
      life.
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Lifestyle and Behavior

   While these findings confirm what       overcome the barriers to optimal                patients’ needs and providing counsel-
many diabetes health care profession-      health and quality of life faced by             ing and psychosocial support to peo-
als already believe, the DAWN study        people with diabetes. In plenum, vot-           ple with diabetes is needed in order to
provided the first quantitative data       ing systems enabled all participants to         diminish the psychological burden of
from a large-scale, international study    take part in the final selection of key         living with diabetes and overcome the
regarding both the magnitude and           goals for future action. Based on the           psychological barriers to effective dis-
nature of these problems. Further-         key findings of the DAWN study, the             ease self-management.
more, the study offered a host of new      following five goals were confirmed
insights about concordance and the         for concerted advocacy and action to            3. Enhance communications between
lack thereof in the perceptions of dif-    improve diabetes care worldwide                 people with diabetes and health care
ferent participants in diabetes care.      (Table 3).27,28                                 providers.
Importantly, the study identified                                                          Effective patient-centered communica-
major gaps in the provision of dia-        1. Promote active self-management.              tion is considered a prerequisite for
betes care today, including a failure      Active self-management is a key deter-          understanding and addressing the
to take fully into account the individ-    minant of treatment outcome in dia-             individual psychosocial barriers to
ual barriers to achieving full health      betes, and therefore the diabetes care          diabetes self-management in daily
and quality of life among people with      team’s ability to facilitate active self-       care. Because enhanced communica-
diabetes.                                  management and patient involvement              tion requires the active involvement of
                                           in the care process is central to achiev-       both the person with diabetes and
Implications of the DAWN Study             ing optimal treatment outcomes.                 health care professionals, efforts in
To transform the wealth of insights        Health care professionals should                this area should involve initiatives to
from the DAWN study into concrete          encourage better self-management by             empower and engage both people
actions to improve diabetes care, two      taking into account individual                  with diabetes as well as health care
international DAWN summits were            patient’s circumstances, needs, and             professionals to communicate effec-
held, each attended by > 100 leading       resources when creating treatment               tively. People with diabetes should be
health care professionals, researchers,    plans and considering psychosocial              supported in taking responsibility for
decision-makers, people with diabetes,     barriers to self-management as an               their own disease and expressing their
media personnel, and representatives       integral part of the care process.              treatment and support needs clearly to
of major nongovernmental diabetes                                                          their health care professionals.
organizations and the pharmaceutical       2. Enhance psychological care.
industry. The 1st International            Although many people with diabetes              4. Promote communication and
DAWN Summit was held in Oxford,            cope well and live normal, healthy              coordination between health care
United Kingdom, in April 2002.26           lives with diabetes, far too many suf-          professionals.
This 2-day meeting involved presenta-      fer emotionally without receiving               Diabetes is a complex condition, and
tion and discussion of the primary         basic psychosocial support. Improved            its effective management requires a
DAWN findings. Major themes were           access to health care professionals and         coordinated multidisciplinary care
identified through discussion of find-     psychologists trained in identifying            approach. The role of every team
ings in discipline-specific and country-                                                   member should be enhanced, and
specific break-out groups.                     Table 3. DAWN Goals and                     strategies are needed to promote team
   The 2nd International DAWN                          Strategies                          building and dialogue among all dia-
Summit was held in London in                                                               betes professionals to ensure a coher-
November 2003 with a goal of initi-         Goals of the DAWN Program                      ent, integrated approach to optimizing
ating concrete action.27 The 2-day          1. Promote active self-management.             treatment.
meeting included presentations from         2. Enhance psychological care.
government policymakers, representa-        3. Enhance communications between              5. Reduce barriers to effective therapy.
                                               people with diabetes and health care
tives of the International Diabetes            providers.
                                                                                           Patient understanding of the conse-
Federation and the World Health             4. Promote communication and coordi-           quences of not treating diabetes opti-
Organization, and leading                      nation between health care profes-          mally requires that health care
researchers. The common theme was              sionals.                                    providers give the information and
defining feasible actions that could be     5. Reduce barriers to effective therapy.       support necessary to enable patients
taken to address the gaps in diabetes                                                      to make informed decisions about
care identified by the DAWN study.          Strategies to Achieve DAWN Goals               intensification of therapy. All health
                                            1. Raise awareness and advocacy.
Best practices were shared by speak-        2. Educate and mobilize people with
                                                                                           care professionals should be aware of
ers from countries that had already            diabetes and those at risk.                 the health implications of postponing
taken action based on the DAWN              3. Train health care providers and             necessary therapy and should enable
findings at a national level. These            enhance their competencies.                 patients to make genuinely informed
presentations laid the foundation for       4. Provide practical tools and systems.        choices about therapy. This requires
multidisciplinary, multinational            5. Drive policy and health care systems        increased awareness and information
workshops in which participants                change.                                     about diabetes treatment options that
could identify concrete and feasible        6. Develop psychosocial research in            suit the individual lifestyle and treat-
actions that could be taken to help            diabetes.                                   ment needs of each patient.
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Lifestyle and Behavior

      Translating Goals Into Action               access to empowering information in                Examples of action. In the United
      The DAWN Call to Action27,28 was            order to make informed decisions                States, a continuing medical education
      developed on the basis of internation-      about their health and quality of life.         program on how to put DAWN into
      al dialogue among patients, educators,      As experts in the management of their           clinical practice was created for dia-
      physicians, health care researchers,        own condition, people with diabetes             betes educators based on one of sever-
      politicians, and nongovernmental            need to be engaged to play a key role           al DAWN symposia held as part of
      organizations. It identifies concrete       in new approaches, tools, and guide-            the annual meetings of the American
      strategies that can be implemented at       lines for patient-centered care. People         Association of Diabetes Educators.20
      the local, regional, national, and inter-   with diabetes inform health care                In Poland, the DAWN study revealed
      national levels to promote the              providers, policymakers, and others             a major national need for training pri-
      achievement of the five goals of the        about the needs and wants of people             mary care in an integrated medical
      DAWN program and the translation            with diabetes.                                  and psychosocial approach to treating
      of DAWN study insights into real               Examples of action. The Assisting            type 2 diabetes. Using DAWN as a
      quality-of-life improvements on a           Young Diabetics in Egypt Project suc-           foundation, train-the-trainer work-
      large scale (Table 3). Guided by this       cessfully offered psychological sup-            shops and simple daily assessment
      framework, numerous initiatives have        port and therapeutic patient educa-             tools were developed and disseminat-
      been proposed and implemented by            tion to > 2,000 children and families           ed widely in that country, and today
      groups and organizations in different       with diabetes over just 2 years’ time.          > 4,500 Polish health care profession-
      countries. Below, we define the strate-     This project was identified by the              als have been trained in both the psy-
      gies and provide examples of these          DAWN international advisory board               chological and medical aspects of
      initiatives.                                as the winner of the 2004 DAWN                  treating diabetes. In Germany,
                                                  Award. The DAWN international                   > 1,000 general practitioners, and dia-
      Strategy 1. Raise awareness and             and national advisory boards involve            betes specialists and nurses were
      advocacy.                                   people with diabetes, and the DAWN              trained in skills focusing on communi-
      Those individuals and organizations         summits offer people with diabetes              cation and psychosocial matters in
      with an understanding of the benefits       opportunities to speak to internation-          order to increase patient empower-
      of providing psychosocial support for       al audiences about their needs. In              ment. Drawing on experiences from
      people with diabetes must play an           Germany and the Netherlands, con-               > 300 diabetes nurse specialists from
      active role in sharing their knowledge      crete activities include the issuance of        14 countries who took part in a new
      with their peers and raising awareness      diabetes passports to all people with           DAWN workshop concept for dia-
      in the public about the importance of       diabetes to encourage active self-man-          betes teams, a set of diabetes team
      changing our approach to diabetes           agement and clear communication                 workshops and DVD- and video-
      care and focusing more on the atti-         and agreement among patients and                enhanced training tools was devel-
      tudes, wishes, and needs of people          providers about the mutual responsi-            oped in 2004; these have been adopt-
      with diabetes and their caregivers.         bilities involved in optimal diabetes           ed by many providers in countries
         Examples of action. The                  management. In New Zealand, peo-                such as Australia, Germany, Israel,
      International Diabetes Federation           ple with diabetes attending a large             Sweden, the United Kingdom, and the
      (IDF) published a special issue of its      diabetes center were offered a patient          United States.
      journal Diabetes Voice, which was           involvement form before each consul-
      distributed in 140 countries; this issue    tation to encourage active patient              Strategy 4. Provide practical tools
      was dedicated to the implications of        participation and clear communica-              and systems.
      the DAWN study and the resulting            tion during diabetes visits.                    The adequate identification of psy-
      international DAWN Call to Action                                                           chosocial and educational needs
      and triggered many new DAWN                 Strategy 3. Train health care                   requires first and foremost effective
      activities.28 In the United States, the     providers and enhance their                     listening and communication skills on
      American Diabetes Association’s             competencies.                                   the part of health care professionals,
      patient magazine, Diabetes Forecast,        In order to overcome the psychosocial           an essential element of the chronic ill-
      highlighted the key insights from the       barriers to effective diabetes manage-          ness care model.30 In addition, patient
      DAWN study, reaching millions of            ment identified by DAWN, health                 self-report assessment tools and deci-
      readers nationwide.29 In the Arabic         care systems need to identify ways to           sion-support tools can facilitate inclu-
      world, Asia, Europe, and Latin              improve the identification of these             sion of psychosocial aspects in routine
      America, lay media coverage of              barriers and develop approaches to              clinical encounters between health
      DAWN findings has helped reach out          effectively address these in general            care professionals and patients to
      to millions more people at risk for         practice settings. Training opportuni-          improve patients’ well-being.10,31
      and with diabetes.                          ties should be made more easily avail-              Examples of action. In response to
                                                  able for diabetes health care                   the DAWN study, several countries
      Strategy 2. Educate and mobilize            providers, along with simple and                have introduced internationally
      people with diabetes and those at           practical strategies to promote sus-            endorsed measures of psychological
      risk.                                       tainable institutionalization of feasible       well-being, diabetes-related distress,
      People with diabetes and those at risk      person-centered approaches to deliv-            and barriers to self-management into
      of developing the condition need            ering diabetes care.                            quality-of-care monitoring systems.
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Lifestyle and Behavior

During the period from 2002 to 2004,       will be publishing its global treatment         program has stimulated momentum to
> 15,000 people with diabetes from         guideline by the end of 2005 with a             support national action and provided
> 15 countries have completed the          separate section on psychosocial care           a platform for sharing best practices
WHO-5 well-being index and other           in diabetes.                                    worldwide.
diabetes-specific items from the                                                              A key challenge for putting the
DAWN survey questionnaire, offering        Strategy 6. Develop psychosocial                insights from the DAWN study into
a wealth of new insights about the         research in diabetes.                           effect is the ongoing promotion of
needs of people with diabetes and the      More collaborative clinical research            broad dialogue and the creation of
associations between psychological         on psychosocial aspects of diabetes             sustainable partnerships involving all
variables, perceived quality of care,      needs to be conducted to demonstrate            key parties in diabetes care, with peo-
and clinical outcomes. A one-page          the health and economic benefits to             ple with diabetes at the center. Only
patient form was developed in New          society of improved patient-centered            through such partnerships can the
Zealand and several other countries for    diabetes care and adoption of the call          proposed new approach to diabetes be
use by patients prior to each consulta-    to action specified here. A better              fully embedded into whole communi-
tion to help identify relevant psychoso-   understanding is required of the effec-         ties and national diabetes programs.
cial issues and promote more active        tive patient-centered approaches to             Furthermore, an increased focus on
involvement of the patient in the con-     support self-management and enhance             the attitudes, wishes, and needs of
sultation and decision-making process.     long-term health and quality of life of         special populations (including chil-
                                           people with diabetes.                           dren and adolescents with diabetes
Strategy 5. Drive policy and health            Examples of action. The European            and people with diabetes in under-
care systems change.                       Depression in Diabetes Research                 privileged communities or who belong
In diabetes management guidelines,         Consortium (EDID), a multinational              to ethnic minorities) is critically need-
reimbursement systems, and quality         research initiative stimulated by the           ed to identify opportunities to
systems, the psychosocial needs of         DAWN Call to Action, has begun to               improve care and quality of life for
people with the condition should be        assess the psychosocial burden of dia-          these groups.
approached with the same priority as       betes by promoting the use of a com-               Continuous and increasing collab-
their medical needs. Toward this end,      mon set of measures so that national            orative efforts are needed to trans-
governments and health care systems        comparisons can be made.33 In coun-             form care for diabetes and other
can be lobbied to adopt the chronic        tries such as Argentina and Israel,             chronic diseases from the acute to the
care model advocated by the World          evaluation studies are ongoing to               chronic care model. Future focus
Health Organization.                       assess the impact of intervention and           needs to be placed on implementation
   Examples of action. The DAWN            education programs aimed at bringing            and translational research, with inter-
program has facilitated two interna-       the DAWN findings into action. A                national sharing of effective tools for
tional guideline meetings in 2004 and      multicountry DAWN study in Europe               furthering a person-centered
2005 aimed at promoting consensus          is examining the feasibility of daily           approach to chronic disease manage-
regarding evidence-based recommen-         use of psychosocial assessments in pri-         ment and prevention.
dations for psychosocial care for peo-     mary care settings in Europe. In the
ple with diabetes. At the DAWN             United States, a large DAWN research
guideline meeting in Wuerzburg,            initiative has been launched to evalu-          Acknowledgments
Germany, in April 2005, experts in         ate specific approaches to increasing           The DAWN study was initiated and
psychosocial aspects of diabetes from      active participation in diabetes care           funded by Novo Nordisk, which pro-
12 different countries developed a         among people with diabetes from dif-            vided access to the data presented in
joint statement that “diabetes melli-      ferent ethnic groups.                           this article and support for its writing.
tus is an emotionally and behavioral-                                                      Aggregate country-specific data may
ly demanding condition, and psy-           Next Steps                                      be made available for local quality-of-
chosocial factors are integral to its      The paradigm for treating diabetes              care improvement activities. (See
prevention, diagnosis, treatment, and      care is changing on a global scale.             www.dawnstudy.com.) Novo Nordisk
outcomes.”                                 Governments, health insurers, health            has provided ongoing support for the
    In response to the DAWN Call to        care professionals, and nongovern-              DAWN program, including DAWN
Action, the national care guidelines in    mental organizations are increasingly           summits and various national DAWN
Japan were updated to include psy-         recognizing the importance of new               initiatives.
chosocial treatment recommendations        partnerships and new ways of adopt-
for diabetes, and the Psychology and       ing more effective approaches to help-          References
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                                           Diabetes Spectrum   Volume 18, Number 3, 2005
Lifestyle and Behavior

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                                                                                                                  Soren E. Skovlund, Msc, Bsc, is a
                                                              Geelhoed-Duijvestijn P, Peyrot M, Skovlund S,
      12
       Piette JD, Schillinger D, Potter MB, Heisler M:      Rubin R, Matthews D, Kleinebreil L, Lauritzen         senior adviser at Novo Nordisk in
      Dimensions of patient-provider communication          T, Colagiuri R, Snoek F: Physician resistance to      Bagsvaerd, Denmark. Mark Peyrot,
      and diabetes self-care in an ethnically diverse       prescribing insulin: an international study           PhD, is a professor of sociology at
      population. J Gen Intern Med 18:624–633, 2003         (Abstract). Diabetologia 46 (Suppl. 1): A274,         Loyola College in Baltimore, Md.
      13
                                                            2003
        Rubak S, Sandbaelig AK, Lauritzen T,
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                                                              Peyrot M, Matthews D, Snoek F, Colagiuri R,         Note of disclosure: Mr. Skovlund is
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      55:305–312, 2005                                      Geelhoed-Duijvestijn P, Skovlund S: An interna-
                                                            tional study of psychological resistance to insulin
                                                                                                                  received honoraria and research sup-
      14
        Ovhed I, Johansson E, Odeberg H, Rastam L:          use among persons with diabetes (Abstract).           port from and served on an advisory
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      Scand J Caring Sci 14:253–258, 2000                   26
                                                             The Oxford International Diabetes Summit:
                                                                                                                  ufactures products for the treatment
                                                            Implications of the DAWN Study, April 7–8,            of diabetes and has provided financial
      15
          Campbell SM, Hann M, Hacker J, Burns C,           2002. Pract Diabetes Int 19:187–195, 2002             support for the DAWN initiative.

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                                                            Diabetes Spectrum     Volume 18, Number 3, 2005
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