Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross-national benchmarking indicators...

Research: Educational and Psychological Issues

Diabetes Attitudes, Wishes and Needs second study

(DAWN2TM): Cross-national comparisons on barriers and

resources for optimal care—healthcare professional

perspective

R. I. G. Holt1, A. Nicolucci2, K. Kovacs Burns3, M. Escalante4, A. Forbes5, N. Hermanns6,S. Kalra7, M. Massi-Benedetti8, A. Mayorov9, E. Men�endez-Torre10, N. Munro11,S. E. Skovlund12, I. Tarkun13, J. Wens14 and M. Peyrot15 on behalf of the DAWN2Study Group*

1Faculty of Medicine, University of Southampton, Southampton, UK, 2Consorzio Mario Negri Sud, Santa Maria Imbaro, Chienti, Italy, 3Edmonton Clinic Health

Academy, University of Alberta, Edmonton, AB, Canada, 4University of Guadalajara, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico, 5Kings

College London, London, UK, 6Research Institute Diabetes, Diabetes Zentrum Mergentheim, Bad Mergentheim, Germany, 7Bharti Hospital and BRIDE, Karnal,

India, 8UBF for International Health Research, HIRS, Perugia, Italy, 9National Research Centre for Endocrinology, Moscow, Russia, 10Hospital Central de Asturias,

Oviedo, Spain, 11University of Surrey, Guildford, UK, 12Novo Nordisk, Copenhagen, Denmark, 13Kocaeli University, Kocaeli, Turkey, 14University of Antwerp,

Antwerp, Belgium and 15Loyola University Maryland, Baltimore, MD, USA

Accepted 22 May 2013

Abstract

Aims The second Diabetes Attitudes, Wishes and Needs (DAWN2) study sought cross-national comparisons of

perceptions on healthcare provision for benchmarking and sharing of clinical practices to improve diabetes care.

Methods In total, 4785 healthcare professionals caring for people with diabetes across 17 countries participated in an

online survey designed to assess diabetes healthcare provision, self-management and training.

Results Between 61.4 and 92.9% of healthcare professionals felt that people with diabetes needed to improve various

self-management activities; glucose monitoring (range, 29.3–92.1%) had the biggest country difference, with a

between-country variance of 20%. The need for a major improvement in diabetes self-management education was

reported by 60% (26.4–81.4%) of healthcare professionals, with a 12% between-country variance. Provision of diabetes

services differed among countries, with many healthcare professionals indicating that major improvements were needed

across a range of areas, including healthcare organization [30.6% (7.4–67.1%)], resources for diabetes prevention

[78.8% (60.4–90.5%)], earlier diagnosis and treatment [67.9% (45.0–85.5%)], communication between team members

and people with diabetes [56.1% (22.3–85.4%)], specialist nurse availability [63.8% (27.9–90.7%)] and psychological

support [62.7% (40.6–79.6%)]. In some countries, up to one third of healthcare professionals reported not having

received any formal diabetes training. Societal discrimination against people with diabetes was reported by 32.8%

(11.4–79.6%) of participants.

Conclusions This survey has highlighted concerns of healthcare professionals relating to diabetes healthcare provision,

self-management and training. Identifying between-country differences in several areas will allow benchmarking and

sharing of clinical practices.

Diabet. Med. 30, 789–798 (2013)

Introduction

The rapidly increasing number of people with diabetes and

disease burden may reach 552 million by 2030 [1]. This calls

for a review of the current detection and management

procedures and evaluation of additional measures necessary

to support healthcare professionals, people with diabetes and

their families.

Correspondence to: Richard Holt. E-mail: [email protected]

*Data access: the DAWN2 study is a global partnership initiative for the

advancement of person-centred diabetes care and the results will be made

available for public research purposes under the guidance of the DAWN2

International Publication Planning Committee (IPPC) once the primary

publications are published. For more information contact

[email protected]

ª 2013 The Authors.Diabetic Medicine ª 2013 Diabetes UK 789

DIABETICMedicine

DOI: 10.1111/dme.12242

In 2001, the Diabetes, Attitudes, Wishes and Needs

(DAWN) study conducted in 13 countries evaluated the

non-medical factors that may prevent people with diabetes

from achieving optimal treatment outcomes [2]. DAWN

revealed that insufficient care and support was available to

meet the psychological and educational needs of people with

diabetes and their healthcare professionals in both developed

and developing countries. Improved collaboration within a

multidisciplinary team of healthcare professionals was iden-

tified as an important factor in improving outcomes for people

with diabetes [3]. A ‘patient-centred’ approach to diabetes

care, which emphasizes the individual’s role as part of the

treatment team, is essential for achieving optimal outcomes

and patient satisfaction [4,5], while a multidisciplinary

healthcare professional approach from the outset encourages

healthcare professionals to improve the delivery of care [6,7].

The DAWN study findings initiated a ‘DAWN Call to

Action’ programme that focused on new evidence-based

strategies for psychosocial and self-management education

for people with diabetes and support from healthcare

professionals [8,9]. Effective interaction and understanding

between people with diabetes and their healthcare profes-

sionals are paramount in diabetes self-management and

improving healthcare [10]. However, despite advances in

knowledge and improved collaboration, person-centred

diabetes care worldwide remains key to providing people

with diabetes with the care they deserve.

One decade after DAWN, the DAWN2 study was initiated

as a global partnership initiative between several established

national and international organizations, including the Inter-

national Diabetes Federation, the International Alliance of

Patients’ Organizations (IAPO) and the Steno Diabetes

Center, and Novo Nordisk [11] for the advancement of

person-centred diabetes care. This parallels the Global

DAWN Call to Action [8], World Health Organization

(WHO) frameworks for people-centred and innovative

chronic illness care and the IAPO declaration for patient-

centred health care [12]. The DAWN2 study aims to: (1)

improve our understanding of the unmet needs of people with

diabetes and those who care for them; (2) facilitate dialogue

and collaboration among all key stakeholders to strengthen

active patient involvement and self-management; and (3)

establish a cross-culturally validated multinational survey

system for assessing and benchmarking psychosocial and

educational aspects of diabetes care delivery. While a number

of different analyses and publications are expected from the

DAWN2 data, here we present the core descriptive data for

one of the DAWN2 surveys, which assessed the perceptions

and opinions of healthcare professionals on quality of life and

treatment burden, societal issues, involvement and empow-

erment of people with diabetes, self-management activities,

healthcare provision and education/training. This initial

report of cross-national benchmarking indicators with estab-

lished validity and reliability of source measures is intended to

serve the function of cross-national benchmarking in which

differences between countries can help identify country-spe-

cific needs and provide a baseline for future studies investi-

gating any changes in the needs and perceptions of healthcare

professionals treating people with diabetes. This report is one

of three linked papers within this edition of Diabetic

Medicine that describe the core data for the three stakeholder

groups surveyed in DAWN2 (people with diabetes, their

family members and healthcare professionals); each report

provides complementary data to the others.

Participants and methods

Study design and participants

Detailed methods for the international, interdisciplinary,

multi-stakeholder DAWN2 study (UTN no: U1111-1123-

7509; NCT01507116) have been described previously [11].

The study was conducted in 17 countries: Algeria, Canada,

China, Denmark, France, Germany, India, Italy, Japan,

Mexico, the Netherlands, Poland, Russian Federation, Spain,

Turkey, the UK and the USA.

A minimum of 280 healthcare professionals per country

was recruited with quotas for general practitioners/primary

care physicians, specialist physicians (endocrinologists and

diabetologists), diabetes nurses and dietitians. Sample quotas

were higher for physicians because worldwide they are the

main providers of diabetes care; quota for generalists were

higher than specialists for the same reason. All participating

healthcare professionals had been in practice for ≥ 1 year

and were treating ≥ 5 adults (aged ≥ 18 years) with diabetes

per month or ≥ 50 adults per month for diabetes specialists.

Recruitment methodology

Healthcare professionals were identified from online panels

and databases in each country, as well as telephone lists and

What’s new?

● The original DAWN study found that diabetes is often

associated with multiple psychosocial problems that are

barriers to self-management behaviours, and that cur-

rent healthcare resources in various countries are poorly

equipped or utilized to support people with diabetes.

● The current DAWN2 study has provided a new

in-depth understanding of the views and needs of

healthcare professionals, allowed for cross-national

comparisons and identified areas for improvement to

achieve optimal diabetes care.

● Healthcare professionals stress the importance of

improvinghealthcare organization, aswell as addressing

emotional problems and improving self-management

activities in people with diabetes.

790ª 2013 The Authors.

Diabetic Medicine ª 2013 Diabetes UK

DIABETICMedicine DAWN2: healthcare professional’s perspective � R. I. G. Holt et al.

physician directories. This hybrid approach ensured that the

study population is as representative as possible of the

healthcare professionals in each country and limits potential

bias if the entire sample is obtained through a single method.

Potential participants were then invited by email or

telephone and received a web link by email to a secure

server enabling them to complete the survey online.

Questionnaires

The healthcare professional survey comprised standardized

questions adapted from the original DAWN study and

modified versions of validated measures, including the

Healthcare Professional Patient Assessment of Chronic

Illness Care DAWN Short Form (HCP-PACIC-DSF) and

healthcare professional Health Care Climate DAWN Short

Form (HCP-HCC-DSF) questionnaires, as well as questions

developed for use with healthcare professionals specifically

for this survey. Finally, open-ended questions were included

to allow participants to share their experiences. The ques-

tionnaire was reviewed, approved and tested in English, then

translated into local languages before being back translated

to ensure harmonization [11]. The questionnaire was

reviewed and evaluated in each country by members of the

DAWN2 advisory board and the final questionnaire was

pilot-tested in detail with representatives of the respondent

group in each case prior to study execution. Measures

reported in this paper are described in the Supporting

Information (Table S1).

Ethical considerations

Surveys were conducted in accordance with the relevant

ethical requirements and followed local, national and

international guidelines relating to the conduct of non-

interventional studies [11].

Statistical analysis

Results from each country were subjected to descriptive

statistics for all variables and summarized as mean � stan-

dard deviation (SD) for continuous variables or percentages

for categorical variables. Questionnaire scores, calculated on

the entire study population (global score), are reported as

mean � SD. Results from single-item questions are shown as

the number and percentage of respondents. Data are reported

as median, minimum and maximum country scores. All the

scale scores range from 0 to 100, with higher values

indicating a higher level of the dimension measured.

Cronbach’s alpha coefficient was used to measure the

reliability (internal consistency) of multi-item questionnaires

(≥ 0.7 indicates an acceptable degree of internal consistency)

with median, minimum and maximum country coefficients.

Multi-level regression models [13,14] with an uncon-

structed correlation-type matrix [15] were used to account

for non-independent observations within countries and

estimate how much of the independent variation (residual

variance) is explained by differences between countries.

Criteria to evaluate indicators for benchmarking activities

included acceptable reliability in each country, as measured

with the Cronbach’s alpha coefficient, and statistically

significant between-country variation. The identical sampling

design for each country allowed us to make comparisons

without adjustment for differences in sample proportions.

Results

Between March and August 2012, 4785 healthcare profes-

sionals (2066 primary care physicians/general practitioners,

1350 diabetes specialists, 827 nurses and 542 dietitians) were

surveyed; participant characteristics are summarized in

Table 1.

Descriptive statistics for key indicators are presented in

Table 2. The country-level analysis showed that the Cron-

bach’s alpha coefficient was most reliable for recommenda-

tions relating to the ‘chronic illness care’ (HCP-PACIC-DSF)

questionnaire, but least reliable for assessment of perceived

‘helpfulness of active patient involvement’ (HAPI-DSF; Help-

fulness of Active Patient Involvement-DAWN short form),

with six countries falling below0.7. Four countries also had an

alpha score below 0.7 for the HCP-HCC-DSF questionnaire.

Cross-national comparison

There were significant between-country differences for all the

domains investigated, and the residual variancewas significant

for all the benchmarking indicators (P < 0.001), ranging

between 2% (‘need for more training on effective communi-

cation and motivation strategies to support long-term behav-

iour change’) and 23% [‘healthcare organization should

promote better communication within the team’ (Table 2)].

The estimated means or proportions (%) with 95%

confidence intervals that have been adjusted for clustering

for each indicator by country are presented in the figures and

in the Supporting Information (Table S2). All country-

specific references are based on these data. Individual data by

country were ranked according to the cluster-adjusted data

and, although some countries rank higher for certain

indicators, no country stands out as being consistently better

or worse than other countries.

Quality of life and treatment burden

Over half of healthcare professionals indicated that they had

discussed emotional issues with their patients; however,

approximately 13% reported a lack of resources to offer

support for people with diabetes who are emotionally

distressed or at risk of depression (Table 2; Fig. 1). In

addition, one third of healthcare professionals felt that people

with diabeteswere subjected to social discrimination, but there


Research article DIABETICMedicine

was a marked difference among the countries (11.4–79.6%;

Table 2); the lowest proportionwas inCanada and the highest

in Algeria (see also Supporting Information, Table S2).

Empowerment and self-care activities

A large proportion of respondents believe that it would be

helpful if people with diabetes could play a more active part

in the management of their condition (78.0 � 18.9; Table 2)

and take more responsibility for this (Table 2; see also

Supporting Information, Fig. S1). Sixty per cent of healthcare

professionals recommend a major improvement in self-man-

agement by people with diabetes, with physical activity

(92.9%), healthy eating (90.7%; Fig. 2) and maintaining a

healthy weight (89.8%) most commonly reported to require

greater attention. Improvements in self-monitoring of blood

glucose and dealing with emotion were recommended by

62.3 and 62.5% of healthcare professionals, respectively.

Opinions varied considerably across countries, with the

largest observed cross-national difference (29.3–92.1%)

being the need for glucose monitoring improvement; the

proportion of participants recommending improved glucose

monitoring was lowest in Denmark and highest in China (see

also Supporting Information, Table S2).

Healthcare provision

The provision of diabetes services differed among the 17

countries (Table 2). The majority of healthcare professionals

indicated the need for major improvements in the prevention

of Type 2 diabetes (78.8%), despite approximately 70%

reporting that resources such as interventions for weight loss

and physical exercise were available in their country. Early

diagnosis and treatment (67.9%) was another area requiring

improvement.

Several areas of healthcare provision requiring improve-

ment for chronic disease management were identified

(Table 2), including the availability of diabetes self-manage-

ment education [60.9% (see also Supporting Information,

Fig. S2)]. Only 30.6% believed that health care was well

organized for managing chronic conditions (Fig. 3). Respon-

dents agreed that diabetes should be a greater priority

(52.1%) and that better communication among healthcare

team members (56.1%) and greater availability of resources

to provide psychological support and care are needed

(62.7%; Fig. 4), including access to psychology or psychiatry

support (Table 2).

Nearly two thirds of respondents recognized the need for

more diabetes specialist nurses [63.8%; Table 2 (see also

Supporting Information, Fig. S3)] and the importance of

involving family members of people with diabetes (69.9%).

The need for formal training in effective communication for

all diabetes care specialists was also recognized (63.0%).

The provision of diabetes care by respondents during

regular clinic visits over the past 12 months was reported

according to the ‘chronic illness care’ (HCP-PACIC-DSF) and

‘healthcare climate’ (HCP-HCC-DSF) questionnaires. The

composite mean scores were 61.8 � 17.9 and 75.7 � 18.6,

respectively, indicating that many respondents felt that they

provided person-centred chronic illness care and high levels of

Table 1 Population characteristics of the healthcare professionals participating in the survey

Healthcare professionalcharacteristics

Primary carephysicians/generalpractitioners Specialists Nurses Dietitians Overall(n = 2066) (n = 1350) (n = 827) (n = 542) (n = 4785)

Gender, n (%)Men/women 1449/617

(70.1)/(29.9)858/942(63.6)/(36.4)

113/714(13.7)/(86.3)

85/457(15.7)/(84.3)

2505/2280(52.4)/(47.6)

Age (years), median(interquartile range)

48 (38–55) 45 (38–53) 42 (34–50) 37 (30–47) 45 (36–53)

Working in a team, n (%) 1429 (69.2) 1169 (86.6) 769 (93.0) 415 (76.6) 1003 (79.0)

Characteristics of healthcare professionals’clinical practiceAdults with diabetes mellitus seen permonth, median (interquartile range)

50 (30–100) 150 (85–250) 64 (40–100) 20 (10–50) 65 (30–140)

Type of diabetes, median% (interquartilerange):Type 1 5 (3–15) 10 (5–20) 15 (5–30) 10 (2–20) 10 (5–20)Type 2 90 (85–96) 90 (75–95) 80 (70–93) 90 (80–98) 90 (80–95)

Adults with diabetes mellitus andprivate insurance, median %(interquartile range)

10 (5–50) 15 (5–50) 20 (5–70) 20 (5–60) 15 (5–55)

Adults with diabetes mellitus anddifficulties reading writteninstructions, median %(interquartile range)

10 (5–30) 14 (5–30) 20 (10–45) 10 (5–30) 15 (5–30)




Table 2 Views and perceptions of healthcare providers on matters relating to diabetes care (key benchmarking indicators)

% of totalvarianceexplainedby country

Country alpha,median (range)

CategoriesIndicators

Global score,n (%)*

Country score,median (range)

QoL/treatment burdenSupport in providing psychological care for emotionallydistressed patients:

‘I have no resources to offer patients who are emotionallydistressed or at risk of depression’

631 (13.2) 12.1 (4.6–32.2) 9 NA

Attitudes to discussing emotional issues:‘I discuss emotional issues with most or all patients I see…’ 2529 (52.9) 5 NA

Involvement/empowermentHAPI-DSF: Helpfulness of Active Patient Involvement;‘how helpful is it/would it be to the healthcare professionalif people with diabetes engaged in different behavioursindicative of patient empowerment’

78.0 � 18.9* 79.7 (65.9–83.7) 8 0.71 (0.48–0.92)

People with diabetes engaged in different behavioursindicative of patient empowerment (% healthcareprofessionals indicating activities are/would be ‘somewhator very helpful’):

• Preparation of questions before consultations 4034 (84.3) 85.6 (67.9–95.4) 8 NA• Indicate how healthcare professional can best support them 4064 (84.9) 85.9 (65.0–92.9) 6 NA• Find information themselves on self-management 3383 (70.7) 70.4 (26.1–91.1) 13 NA• Participate in community activities to improve self-care 4025 (84.1) 86.8 (59.7–94.3) 11 NA

Self-managementAreas needing major improvement in self-management bypeople with diabetes (% healthcare professionals indicatingapproximately half to most/all of their patients)

• Eating healthily 4341 (90.7) 93.2 (71.4–95.4) 8 NA• Being physically active 4446 (92.9) 94.6 (84.8–97.1) 6 NA• Taking medications as recommended 2938 (61.4) 58.4 (34.6–88.2) 13 NA• Testing blood sugar 2981 (62.3) 55.4 (29.3–92.1) 20 NA• Dealing with diabetes-associated emotions 2990 (62.5) 63.2 (37.8–82.5) 8 NA• Maintaining healthy weight 4298 (89.8) 92.6 (79.1–95.8) 6 NA• Taking responsibility for managing their condition 4009 (83.8) 86.6 (66.8–91.2) 5 NA

Healthcare provisionAreas needing major improvement:

• Availability of self-management education 2872 (60.0) 57.3 (26.4–81.4) 12 NA• Availability of resources for the provision of psychologicalsupport and care

3001 (62.7) 65.7 (40.6–79.6) 7 NA

• Earlier diagnosis and treatment 3247 (67.9) 71.1 (45.0–85.5) 11 NA• Prevention of Type 2 diabetes 3772 (78.8) 78.5 (60.4–90.5) 5 NA

Self-reported provision of person-centred chronicillness care (composite score):HCP-PACIC-DSF 61.8 � 17.9* 62.6 (44.6–74.6) 19 0.82 (0.74–0.86)

• Healthcare professionals saying they ask their patients‘how their diabetes affects their life’ (% reporting ‘mostof the time/always’)

2480 (51.8) 50.7 (34.0–74.6) 7 NA

HCP-HCC-DSF 75.7 � 18.6* 75.6 (62.4–88.5) 12 0.74 (0.52–0.81)Healthcare organization (rating 5 or 6 on a 6-pointagreement scale, where 6 = fully agree):

• Healthcare is well organized for the management of chronicconditions

1464 (30.6) 29.6 (7.4–67.1) 21 NA

• Diabetes should be given higher priority 2495 (52.1) 49.6 (23.6–79.3) 15 NA• More qualified nurse educators or specialist diabetes nursesshould be available

3052 (63.8) 61.4 (27.9–90.7) 22 NA

• There should be better communication within the team 2686 (56.1) 52.1 (22.3–85.4) 23 NA• There should be better access to psychologists orpsychiatrists for referral

2811 (58.7) 58.2 (27.6–83.9) 14 NA

• The healthcare remuneration system is a barrier 1532 (44.8) 50.0 (16.7–76.2) 16 NA• People with diabetes are sufficiently involved in influencingdiabetes care policies

971 (20.3) 14.8 (9.9–54.3) 13 NA

• Improving the availability of diabetes self-managementeducation will help reduce the burden

2915 (60.9) 61.8 (36.8–85.4) 14 NA

• Healthcare professionals must collaborate more withpatient and volunteer organizations

2356 (49.2) 48.9 (20.5–80.0) 18 NA

• All diabetes care professionals should have formaltraining in effective communication

3017 (63.0) 60.0 (39.6–89.3) 14 NA



Table 2 (Continued)

% of totalvarianceexplainedby country

Country alpha,median (range)

CategoriesIndicators

Global score,n (%)*

Country score,median (range)

• Involvement of family members of people with diabetesis a vital part of good diabetes care

3343 (69.9) 71.1 (43.2–90.7) 15 NA

• Healthcare professionals need more tools to help peopleat risk of diabetes lose weight

3020 (63.1) 64.4 (39.6–85.0) 11 NA

Availability of prevention resources:• Reimbursement for preparation time 350 (13.5) 10.0 (2.8–33.3) 17 NA• Interventions for weight loss or physical exercise 1801 (69.7) 72.7 (29.4–92.7) 16 NA

EducationCompleted/attending postgraduate diabetes education/training:

• Medical management of diabetes 3012 (62.9) 65.8 (30.6–89.0) 14 NA• Dietary/nutritional management of diabetes 2483 (51.9) 45.1 (36.4–84.6) 11 NA• Effective communication and motivation strategies to supportlong-term behaviour change

1448 (30.3) 31.1 (13.4–50.9) 7 NA

• Provision of diabetes self-management education and supportto patients with diabetes

1604 (33.5) 33.3 (19.3–51.4) 5 NA

• Management of psychological aspects of diabetes 937 (19.6) 17.9 (9.4–41.1) 9 NA• None of these 974 (20.4) 19.6 (3.6–37.0) 15 NA

Would like to receive more training:• Medical management of diabetes 2249 (47.0) 46.4 (30.0–64.6) 5 NA• Dietary/nutritional management of diabetes 2433 (50.8) 48.7 (26.4–68.9) 6 NA• Effective communication and motivation strategies to supportlong-term behaviour change

2679 (56.0) 55.1 (46.9–72.0) 2 NA

• Provision of effective self-management education and supportto patients with diabetes

2399 (50.1) 48.1 (34.3–73.6) 5 NA

• Management of psychological aspects of diabetes 2828 (59.1) 55.9 (43.5–77.5) 5 NASociety

Discrimination against people with diabetes because ofdiabetes:

Need for a major improvement in accepting people withdiabetes as equal members of society

1568 (32.8) 29.6 (11.4–79.6) 17 NA

*Unless otherwise stated as mean � SD.HAPI-DSF, Helpfulness of Active Patient Involvement–DAWN Short Form; HCP-HCC-DSF, Healthcare Professional–Health Care Climate–DAWN Short Form; HCP-PACIC-DSF, Healthcare Professional–Patient Assessment of Chronic Illness Care–DAWN Short Form; NA,not applicable (indicates that no Cronbach alpha was computed because inter-item agreement cannot be assessed for single-item measures);QoL, quality of life.Note: All questionnaire materials are copyrighted either by Novo Nordisk or by an original copyright holder. The DAWN2 questionnaires,available in 22 different languages, can be obtained for local and cross-national diabetes research and quality improvement purposes.Guidelines and procedures for using or translating the DAWN2 questionnaires are available at www.dawnstudy.com.

FIGURE 2 Proportion of healthcare professionals (percentage with 95%

confidence intervals adjusted for clustering) reporting that ‘about half’ to

‘most/all’ of their patients require a significant improvement in healthy

eating habits to self-manage their condition. The dotted line represents

the mean value relative to the entire sample of healthcare professionals.

FIGURE 1 Proportion of healthcare professionals (percentage with

95% confidence intervals adjusted for clustering) reporting they have

no resources to offer patients who are emotionally distressed or at risk

of depression. The dotted line represents the mean value relative to the

entire sample of healthcare professionals.




practical or communicative support for people with diabetes,

such as actively listening, encouraging and involving patients

in their own care management. Notably, over half (51.8%) of

healthcare providers indicated that they had asked their

patients how diabetes impacted their life (Table 2).

Education and information

Access to diabetes education or training programmes is

limited, with one in five healthcare professionals (median

19.6%, but up to one third in some countries) not receiving

any postgraduate training. Over 50% of respondents showed

an interest in attending training programmes that would

equip them with the knowledge and tools to provide better

care for people with diabetes (Table 2).

Discussion

A review of the perceptions of healthcare professionals

treating adult patients with diabetes regarding their diabetes

practice, management and procedures is an important step to

ensure that people with diabetes and all those involved in their

care receive the best possible support. The original DAWN

studyprovided insights fromamultinational perspectiveon the

needs of both people with diabetes and healthcare profession-

als to help improve diabetes care locally and internationally

[2,3]. DAWN also highlighted a good relationship between

healthcare professionals and people with diabetes, and that

better collaboration between these groupswas associatedwith

favourable outcomes [16]. This allowed healthcare profes-

sionals to assess the needs of people with diabetes more

effectively and implement appropriate changes to current care.

The DAWN2 study provides a multinational insight into

current health care for the management of people with

diabetes from the perspectives of healthcare professionals,

people with diabetes and their family members. This report

has highlighted the concerns of healthcare professionals

regarding diabetes healthcare provision, self-management

and training. The DAWN2 results show substantial variation

in the perceptions of healthcare professionals in different

countries. Despite these differences, healthcare professionals

across all countries considered the current healthcare provi-

sion for people with diabetes to be inadequate. Consistent

with DAWN [17], the majority of healthcare professionals

who participated in DAWN2 believe that, despite techno-

logical advances and the availability of improved treatments,

current national healthcare systems remain poorly equipped

to manage and treat people with diabetes effectively; and

although self-management education was considered to be

important, its provision was seen as lacking.

DAWN2 highlighted that psychosocial support is consid-

ered a key aspect of diabetes care, but that healthcare

professionals lack adequate resources, training and reim-

bursement to provide it. Some healthcare professionals

reported having no resources to address emotional problems

in people with diabetes, and only approximately half

reported that they discuss emotional problems with their

patients or ask about the impact of diabetes on their patients’

lives, but the latter may differ from the perception of people

with diabetes being asked about this. Dealing with the

emotional difficulties faced by people with diabetes and their

lack of adherence to treatment can leave healthcare profes-

sionals feeling overwhelmed and frustrated [18,19]. There is

often a lack of clarity for healthcare professionals regarding

who should manage the psychosocial aspects of diabetes and

many avoid addressing these issues, concerned that they are

ill-equipped or have insufficient education and training

[2,18,20]. A number of countries have introduced national

postgraduate education programmes for professionals to

improve their knowledge and understanding of diabetes and

the requirements of people with diabetes to ensure that they


95% confidence intervals adjusted for clustering) reporting that

healthcare in their country is well organized for the management of

chronic conditions, including diabetes (rating 5 or 6 on a 6-point scale).

The dotted line represents the mean value relative to the entire sample

of healthcare professionals.


95% confidence intervals adjusted for clustering) reporting that a

major improvement is needed in making resources available for the

provision of psychological support and care. The dotted line represents

the mean value relative to the entire sample of healthcare professionals.



are offering comprehensive, effective diabetes self-manage-

ment education. Although the type of specialist training

offered differs between countries, the benefits of such

programmes have been demonstrated [21,22].

Healthcare professionals agreed that diabetes self-manage-

ment is suboptimal and needs improving; however, there may

be differences between healthcare professionals and people

with diabetes in their perceptions of how to encourage

self-management. Peoplewith diabetes often face psychosocial

issues when accepting and making and maintaining lifestyle

changes to improve the management of their diabetes. To help

support people with diabetes, healthcare professionals should

be able to identify and consider societal issues such as

discrimination, intolerance, lack of community support and

religious practices (e.g. fasting during themonth ofRamadan).

Ultimately, healthcare professionals also need to engage

people with diabetes better to develop a plan that allows the

individual to lead a full and active life, to encourage hope, and

to console them and help them understand the consequences

when treatment goals are not met [4,5,23].

Healthcare professionals agreed that involving family

members of people with diabetes is a vital part of diabetes

care. However, family members also need education on

diabetes to help support their relative with diabetes, and may

also require psychological and emotional support; both of

these factors can contribute to a positive outcome [24,25].

Successful management of diabetes is facilitated by good

relationships between people with diabetes, their family

members and a multidisciplinary team of professionals,

including doctors trained in diabetes, dietitians, nurses and

psychologists [26]. Close collaboration within the multidis-

ciplinary team is key to ensuring that people with diabetes

receive the correct level of support at the correct time.

Communication should be extended not only to people with

diabetes, but also to individuals considered to be at high risk

of this condition [26,27].

Over two thirds of healthcare professionals indicated the

need for major improvements in diabetes prevention, early

diagnosis and treatment. The development and implementa-

tion of diabetes prevention programmes worldwide has been

a challenge, but advances in scientific research and clinical

trials have led to pragmatic improvements in the primary

healthcare setting [27,28]. Many healthcare professionals in

this survey indicated that, while resources to help prevent the

onset of diabetes were available in their country, there is a

need to improve the delivery of such resources to those at risk.

The ability to monitor the quality of diabetes care across

the globe has been limited by the lack of standard definitions

of indicators of the disease and lack of standard systems for

providing these indicators in representative population sam-

ples [29]. The DAWN2 questionnaires contain a series of

reliable tools suitable for measuring desired outcomes, as

well as their barriers and drivers, in healthcare professionals

across countries. This allows us to understand the differences

in several aspects of diabetes care between countries, and

therefore permits benchmarking and sharing of better clinical

policies and practices. However, several study limitations can

be noted, such as the challenges of ensuring a representative

population of the country and areas sampled [11]. The

proportion of healthcare professionals in the various disci-

plines differed across countries and participants included

only those healthcare professionals who treat adults, result-

ing in a lack of input from paediatric diabetes services.

Furthermore, as participation was voluntary, this sample of

healthcare professionals may be more motivated than

non-participants and therefore, results from DAWN2 may

not wholly reflect the entire population of diabetes health-

care professionals. In addition, caution is required when

drawing conclusions from healthcare professionals describ-

ing their own behaviour and practices. Finally, although

every effort was made to ensure appropriate translations into

native languages, this process is fraught with difficulty and

may result in misinterpretation or misunderstanding.

The outcomes examined here may be partially explained by

differences in the organization of chronic illness care between

the countries, including national diabetes and chronic illness

policies.Many other factors may have influenced the DAWN2

findings, such as socio-economic and cultural factors and

disciplinary differences. For outcomes in the healthcare

professional survey, disciplinary differences may vary by

and interact with country, rather than being consistent across

countries. While analysis and discussion of these issues are

beyond the scope of this manuscript, further analyses are

ongoing to identify and investigate differences between

countries, professions and stakeholder groups. For healthcare

professionals, further analyses are required to elucidate and

understand fully the specific needs of the individual disciplines

within diabetes teams. Subsequent DAWN2 publications will

combine data for people with diabetes, family members and

the different healthcare disciplines, as well as health policy

perspectives, to generate multi-perspective analyses of barri-

ers and drivers for the provision of optimal person-centred

diabetes care in participating countries.

In summary, despite improvements in healthcare provision

and healthcare organization, feedback from healthcare pro-

fessionals indicates the need for better resources, education,

training and collaboration among an interdisciplinary team of

healthcare professionals caring for people with diabetes.

Healthcare professionals remain concerned about the gap in

healthcare provision to meet the needs of people with diabetes

and family members. The increasing prevalence of diabetes

and the lack of resources for effective care calls for a new,

proactive and preventive approach, in which psychosocial

issues are managed within collaborative teams, including

people with diabetes and their family members. DAWN2

provides benchmarks for further study to determine the

progress made and to identify the barriers that remain in

diabetes care. As a collaborative study that has involved global

organizations, it is anticipated that the DAWN2 findings will

help drive multinational changes in patient-centred care.




Funding sources

The DAWN2 study is funded by Novo Nordisk A/S. Medical

writing and editorial support in the preparation of this

manuscript, which was funded by Novo Nordisk A/S, was

provided by Bioscript Medical Ltd. In collaboration with

national, regional and global partners, including the Inter-

national Diabetes Federation, International Alliance of

Patient Organizations and the international Steno Diabetes

Center, the DAWN2 survey working group, the DAWN2

International Publication Planning Committee (IPPC) and

Harris Interactive, Novo Nordisk has assisted with the

planning and designing of the DAWN2 study. Data collec-

tion was independently performed by Harris Interactive, who

were funded by Novo Nordisk. Data analysis and publica-

tion preparation were performed by members of the

DAWN2 IPPC and authors.

Competing interests

RIGH has received funding for travel and accommodation to

attend DAWN2 IPPC meetings, but has not received any fee

for this work from Novo Nordisk. He has acted as an

advisory board member and speaker for Novo Nordisk, and

as a speaker for Sanofi-Aventis, Eli Lilly, Otsuka and

Bristol-Myers Squibb. He has received grants in support of

investigator trials from Novo Nordisk. AN has received

research grants in the last year from Novo Nordisk, Eli Lilly,

Sanofi-Aventis, Merck Sharp and Dohme, Bristol-Myers

Squibb/Astra Zeneca and Bayer. KKB and AF have been

reimbursed for travel and accommodation expenses from

Novo Nordisk to attend the DAWN2 IPPC meetings, but

have not received any fee for this work from Novo Nordisk.

ME has acted as an advisory board member for Novo

Nordisk, Eli Lilly, Sanofi and Boehringer. He also received

speaking honoraria from Novo Nordisk, Eli Lilly, Bris-

tol-Myers Squibb and BoehringerMexico. NH is a member of

the IPPC of the DAWN2 study and member of the national

German DAWN2 Advisory Board supported by Novo Nor-

disk. He is further a member of the global Diabetes Educator

Advisory Board of Eli Lilly. Research support was obtained

from Eli Lilly, Sanofi-Aventis, Berlin Chemie and DEXCOM.

SK is a member of the IPPC and has been reimbursed for

travel and accommodation expenses from Novo Nordisk to

attend the DAWN2 IPPC meetings, but has not received any

fee for this work from Novo Nordisk. MMB is a non-paid

member of the Board of the NN Italian Barometer Initiative

and of the Steering Committee of the International Diabetes

Federation (IDF) Good Metabolic Control campaign sup-

ported by Sanofi Italy. He has received speaking honoraria

from Sanofi. AM has received funding from Novo Nordisk,

Eli Lilly, Life Scan and Roche Diagnostic for attending

scientific meetings and congresses and received honoraria for

lectures. EM-T is a member of the International DAWN2

Advisory Board. He has received speaking honoraria from

Novo Nordisk, Novartis, Eli Lilly and Sanofi. NM has acted

in an advisory board (Advisory Panel) or teaching capacity

(Speakers Bureau) for Abbott, AstraZeneca/Bristol-Myers

Squibb, Boehringer Ingelheim, Eli Lilly, Novo Nordisk,

Merck Sharp and Dohme and Sanofi in the last 12 months.

SES is an employee of Novo Nordisk A/S, Copenhagen,

Denmark. _IT has received speaking honoraria in the last year

from Novo Nordisk, Bristol-Myers Squibb, Astra Zeneca and

Eli Lilly. JW has acted as an advisory board member for Eli

Lilly, AstraZeneca/Bristol-Myers Squibb and Novo Nordisk.

MP has recently received research grants and/or consulting

fees from Amylin, Genentech, Eli Lilly, MannKind, Med-

tronic, and Novo Nordisk. He has received speaking hono-

raria from Novo Nordisk and has participated in advisory

panels for Novo Nordisk and Roche. He has received

financial support from Novo Nordisk for his participation

as Principal Investigator for the DAWN2 study.

Acknowledgements

The DAWN2 Study Group consists of a national lead

investigator from each country and members of the DAWN2

IPPC: Rachid Malek, Algeria; Johan Wens, Belgium; Jo~ao

Eduardo Salles, Brazil; Katharina Kovacs Burns and Michael

Vallis, Canada; Xiaohui Guo, China; Ingrid Willaing and

Søren Eik Skovlund, Denmark; G�erard Reach, France;

Norbert Hermanns and Bernd Kulzer, Germany; Sanjay

Kalra, India; Antonio Nicolucci and Marco Comaschi, Italy;

Hitoshi Ishii, Japan; Miguel Escalante, Mexico; Frans

Pouwer, the Netherlands; Andrzej Kokoszka, Poland; Alex-

ander Mayorov, Russia; Edelmiro Men�endez Torre, Spain;

Ilhan Tarkun, Turkey; Melanie Davies, Richard Holt, Angus

Forbes and Neil Munro, the UK; Mark Peyrot, the USA.

The authors wish to acknowledge the contribution of the

International Diabetes Federation and the numerous other

international and national experts and patient advocates who

have contributed directly to the design of the DAWN2 study

during 2010–2011. The complete list of study experts and

people with diabetes advisers is available at www.dawn

study.com. Fabio Pellegrini, Giuseppe Lucisano and Basilio

Pintaudi from Consorzio Mario Negri Sud performed the

statistical analyses for this study and prepared the figures

presented in this publication, and Christine Mullan-Jensen

assisted with the design and execution of the study and

provided input to this publication.

All DAWN2 surveys were conducted by Harris Interactive

Inc., an independent research organization. The authors wish

to acknowledge Anna Ginovker of Harris Interactive for

directing the global fieldwork and Bioscript Medical Ltd for

providing assistance with obtaining ethical approvals in

several countries, as well as Tawhid Ahmad and Helen

Swainston of Bioscript Medical Ltd for medical writing and

editorial support. Harris Interactive conducted the surveys,

and provided expertise in designing the questionnaires and

planning survey implementation, including sampling frames



and strategies, questionnaire administration strategies,

weighting criteria, etc.

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Supporting Information

Additional Supporting Information may be found in the

online version of this article:

Figure S1. Proportion of healthcare professionals reporting

that ‘about half’ to ‘most/all’ of their patients require a

significant improvement in taking responsibility for manag-

ing their own condition.

Figure S2. Proportion of healthcare professionals reporting

that a major improvement is needed in making self-manage-

ment education available to people with diabetes.

Figure S3. Proportion of healthcare professionals indicating

that more qualified nurse-educators or specialist diabetes

nurses should be available.

Table S1. DAWN2 HCP Questionnaire Measures.

Table S2. The views and perceptions of healthcare profes-

sionals on matters relating to diabetes care.




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