Tilburg University
Diabetes Attitudes Wishes and Needs 2 (DAWN2)
Peyrot, M.; Burns, K.K.; Davies, M.M.; Forbes, A.; Hermanns, N.; Holt, R.I.G.; Kalra, S.;
Nicolucci, A.; Pouwer, F.; Wens, J.; Willaing, I.; Skovlund, S.E.
Published in:
Diabetes Research and Clinical Practice
DOI:
10.1016/j.diabres.2012.11.016
Publication date:
2013
Document Version
Publisher's PDF, also known as Version of record
Link to publication in Tilburg University Research Portal
Citation for published version (APA):
Peyrot, M., Burns, K. K., Davies, M. M., Forbes, A., Hermanns, N., Holt, R. I. G., Kalra, S., Nicolucci, A., Pouwer,
F., Wens, J., Willaing, I., & Skovlund, S. E. (2013). Diabetes Attitudes Wishes and Needs 2 (DAWN2): A
multinational, multi-stakeholder study of psychosocial issues in diabetes and person-centred diabetes care.
Diabetes Research and Clinical Practice, 99(2), 174-184. https://doi.org/10.1016/j.diabres.2012.11.016
General rights
Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain
• You may freely distribute the URL identifying the publication in the public portal Take down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.
Diabetes
Attitudes
Wishes
and
Needs
2
(DAWN2):
A
multinational,
multi-stakeholder
study
of
psychosocial
issues
in
diabetes
and
person-centred
diabetes
care
Mark
Peyrot
a,1,*
,
Katharina
Kovacs
Burns
b,1,
Melanie
Davies
c,1,
Angus
Forbes
d,1,
Norbert
Hermanns
e,1,
Richard
Holt
f,1,
Sanjay
Kalra
g,1,
Antonio
Nicolucci
h,1,
Frans
Pouwer
i,1,
Johan
Wens
j,1,
Ingrid
Willaing
k,1,
Søren
E.
Skovlund
l,1aDepartmentofSociology,LoyolaUniversityMaryland,4501NorthCharlesStreet,Baltimore,MD21210,USA
bInterdisciplinaryHealthResearchAcademy,EdmontonClinicHealthAcademy,UniversityofAlberta,Edmonton,Canada cDiabetesResearch,DepartmentofCardiovascularSciences,UniversityofLeicester,LeicesterLE15WW,UK
dDepartmentofPrimaryandIntermediateCare,FlorenceNightingaleSchoolofNursingandMidwifery,King’sCollegeLondon,London,UK e
ResearchInstituteoftheDiabetesAcademyMergentheim(FIDAM),BadMergentheim,Germany
fHumanDevelopmentandHealthAcademicUnit,FacultyofMedicine,UniversityofSouthampton,Southampton,UK gBhartiHospital&B.R.I.D.E.,Karnal132001,Haryana,India
hDepartmentofClinicalPharmacologyandEpidemiology,ConsorzioMarioNegriSud,S.MariaImbaro,Chieti,Italy iDepartmentofMedicalandClinicalPsychology,TilburgUniversity,Tilburg,TheNetherlands
j
DepartmentofMedicineandHealthSciences,PrimaryandInterdisciplinaryCareAntwerp,UniversityofAntwerp,Antwerp,Belgium
k
StenoHealthPromotionCenter,StenoDiabetesCenter,DK-2820Gentofte,Denmark
lPatientResearch,Advocacy&Support,NovoNordiskA/S,Copenhagen,Denmark
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received22November2012 Accepted22November2012 Publishedonline27December2012 Keywords:
Peoplewithdiabetes Familymembers Healthcareproviders Survey Person-centredcare Psychosocial Self-management
a
b
s
t
r
a
c
t
Aims:TheDiabetesAttitudesWishesandNeeds2(DAWN2)studyaimstoprovideaholistic assessmentofdiabetescareandmanagementamongpeoplewithdiabetes(PWD),family members(FM),andhealthcareprofessionals(HCPs)andexplorespotentialdriversleadingto activemanagement.
Methods: DAWN2surveyover16,000individuals(9000PWD,2000FMofPWD,and5000 HCPs)in17countriesacross4continents.Respondentscompleteagroup-specific question-naire;itemsaredesignedtoallowcross-groupcomparisonsoncommontopics.The ques-tionnaires comprise elements from the original DAWN study (2001), as well as psychometricallyvalidatedinstrumentsandnovelquestionsdevelopedforthisstudyto assessself-management,attitudes/beliefs,disease impact/burden,psychosocialdistress, health-relatedqualityoflife,healthcareprovision/receipt,socialsupportandprioritiesfor improvementinthefuture.Thequestionnairesarecompletedpredominantlyonlineorby telephoneinterview,supplementedbyface-to-faceinterviewsincountrieswithlow inter-netaccess.Ineachcountry,recruitmentensuresrepresentationofthediabetespopulation intermsofgeographicaldistribution,age,gender,educationanddiseasestatus.
Discussion: DAWN2aimstobuildontheoriginalDAWNstudytoidentifynewavenuesfor improvingdiabetescare.Thispaperdescribesthestudyrationale,goalsandmethodology.
#2012ElsevierIrelandLtd.
*Correspondingauthor.Tel.:+14106175140;fax:+14106172215. E-mailaddress:mpeyrot@loyola.edu(M.Peyrot).
1 OnbehalfoftheGlobalDAWN2StudyGroup.
ContentsavailableatSciverseScienceDirect
Diabetes
Research
and
Clinical
Practice
j o u r n a lh o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / d i a b r e s
0168-8227#2012ElsevierIrelandLtd.
http://dx.doi.org/10.1016/j.diabres.2012.11.016
Open access under CC BY-NC-ND license.
1.
Introduction
In2001,theDiabetes, Attitudes,WishesandNeeds(DAWN) studyshowedthatself-managementofdiabeteswas consid-ered poor by people with diabetes (PWD) and healthcare professionals(HCPs).Diabetes-relateddistresswas common amongst PWD and hampered efforts to self-manage their condition, but few received psychological treatment [1]. Although recognition by HCPs of emotional problems and diabetes-specificdistressamongstPWDwaslow,HCPsdesired abetterunderstandingofsuchissues[2].Collaborationamong diabetescareproviderswasidentifiedasanimportantfactorfor improvingdiabetesoutcomes,butinterdisciplinaryteamcare wasuncommon[2],andtherewassomeresistancebyPWDand HCPstothetimelyinitiationofeffectivetherapies[3].
FollowingDAWN,patientrepresentativesandan interdis-ciplinarygroupofdiabetescareexperts discussed howthe DAWNfindings couldbetranslatedinto improved diabetes care[4].Theresulting‘DAWNCalltoAction’[5]encouraged multiplestakeholders(HCPs,PWDandtheirfamilymembers [FMs]/carers,payers, policy makers, industry and non-gov-ernmentorganisations)toimplementperson-centred diabe-tescare,andactivelyinvolvePWDinself-managementwith supportfromaninterdisciplinaryteamofHCPs[2].
TheDAWNfindingssupportaparadigmshiftfromanacute care model to a person-centred, integrated chronic care model, such as the WHO Innovative Care for Chronic Conditionsframework to diabetes[6]. Thismodel involves careatthreelevels:micro,mesoandmacro,whichreferto individual, healthcare organisation/community, and policy levels,respectively[6].Optimaldiabetescareisbestachieved bycollaborationbetweenPWD,FM,communitypartnersand healthcareteamsthatareinformed,motivated,prepared,and able towork together. This collaboration issupportedand influenced by the broader healthcare organisations and communities,and by the policy environment [6]. Scientific evidenceprovidesthefoundationfortheapproachestocare
[6], but the PWDperspective is important in informing all levelsofhealthcare[7].PWDhavetherighttobeinformedand educated,tohaveaccesstoproperdiabetescareandoptimal medicine,andnottobediscriminatedagainstbecauseoftheir condition[8].
ItisadecadesincetheDAWNstudyhighlightedtheneed for collaborative action across countries to improve self-management and psychosocial support. Despite major advancesincollaborativecaremanyPWDstilldonotachieve desirabletreatmentoutcomes.Thegrowingburdenof diabe-tescallsforstrongerandbroaderglobally-coordinatedefforts. As more countries recognise the effect of diabetes on populationhealth,andtheeconomicandpersonalburdens, wemustexpandourknowledgetoincludethediversesocial institutionsandculturesofthesecountries.Asourknowledge hasadvanced,wehaveidentifiedgapsinourknowledgeofthe roleofsupportfromfamilyandcommunityinlivingwithand caringforPWD.Acrossnations,thereisapressingneedfora newglobaltranslationalresearchinitiativethatcanformthe foundation formeasurement-guided multi-stakeholder col-laborationfor theadvancement ofperson-centred diabetes careworld-wide.Thus,itistimeforanewDAWN.
TheDAWN2studyinitiative,undertakenbyNovoNordisk in partnership with the International Diabetes Federation (IDF), the International Alliance of Patient Organisations (IAPO), the Steno Diabetes Center, and a range of other national,regionalandglobalpartners,aimsto(a)improveour understandingofthe unmetneedsofPWDandtheir care-takers,(b)facilitatedialogueandcollaborationamongallkey stakeholderstostrengthenpatientinvolvementandimprove self-managementand(c)establishacross-culturally validat-ed multi-national survey framework for assessing and benchmarking psychosocial and educational aspects of diabetescaredelivery.Theoverallaimistoidentifyavenues forimprovementatallthreelevelsofcare–atthemesoand macro-levelsfor diabetescare fundingandcareprovision, andatthemicrolevelfordeliveryofcare.Thestudyexplores how PWD, FMs and HCPs perceive diabetes care and investigatesthevalueofaperson-centredmodelofdiabetes care that emphasises the needs of the individual in the contextofcurrentchroniccare,self-managementeducation and psychosocialsupport. This paper describes the study methodology.
2.
Materials
and
methods
2.1. Studyobjectives
Within anationaland internationalsetting, thepredefined objectivesoftheDAWN2studyare:
Primaryobjective:
Toassesspotentialbarrierstoandfacilitatorsofactiveand successfulmanagementofdiabetesamongPWD,FMs,and HCPs.
Secondaryobjectives:
Toestablishnationalbenchmarksforhealthstatus,quality oflife(QoL),accesstoself-managementeducationandto self-careindiabetes.
Toassesstheaccessto,anduseandbenefitof,supportfrom healthcare teams, family and friends, communities and society.
Toexploreandpinpointthemostimportantfacilitatorsand barrierstoperson-centredchroniccareforeachstakeholder group.
To identify successes, wishes, needs, preferences and prioritiesforchangeamongallkeystakeholdersindiabetes. 2.2. Studydesign
Diabetes,andmultipleotherorganisationsinvolvedin person-centreddiabetescare.FieldworkbeganinMarch2012. 2.3. Ethicalconsiderations
Ineachcountry,thestudyisbeingconductedinaccordance with the relevant ethicalrequirements, followingregional/ national/local guidelines relating to the conduct of non-interventionalstudiesandusesguidelinesoftheInternational Chamber of Commerce/European Society for Opinion and Marketing Research [9], the Council of American Survey ResearchOrganizations[10]andGoodPharmacoepidemiology Practices[11]asaminimumstandard.
2.4. Studyparticipants
DAWN2isbeingconductedin17countries:Algeria,Canada, China,Denmark,France,Germany,India,Italy,Japan,Mexico, The Netherlands, Poland, Russia, Spain, Turkey, United Kingdom (UK) and United States of America (USA). Brazil was originally included inthe study plan, howeverdue to timingissues,theDAWN2studyinBrazilwillbeconducted separately.
The participating countries represent 4 continents – Europe,Asia, NorthAmerica,andAfrica.Countries volun-teered for participation in DAWN2, including providing studyfunding,mainlytoidentifywaystoenhancediabetes careandthelivesofPWDandtheirFM.Othercountriesare currentlyapplyingorplanningtoapplycomponentsofthe DAWN2studydesignaspartofthewiderDAWNnetwork; however, these research activities are not part of the 17-country DAWN2 study. Overall, the study population comprises 16,100 participants:9040 PWD, 2160 FMs and 4900 HCPs. Inclusion/exclusion criteria are presented in
Table 1. Each country’s sample is a minimum of 900 participants:500 PWD,120FMs and280HCPs (seeFig. 1). IntheUSA,anadditionalsampleof540PWDand120FMsof African-American,HispanicandAsianethnicoriginand140 HCPswhotreatminoritypopulationsisincludedtoobtain adequate numbers for subgroup analyses. In general, the threeparticipantgroupsareindependent(e.g.,participants in PWD sample are not treated by participants in HCP sample). However, for the FM sample, some of the 120 participants dolive inthe samehouseholdas individuals who participated in the PWD survey. The data for these participants enables linkage between this subset of PWD andtheirFMs.
TheHCPsamplecomprisesspecialistphysicians (endocri-nologists and diabetologists), primary care (PC) providers, generalpractitioners(GPs)andinternalmedicinephysicians (with a sub-speciality in diabetes) and other HCPs (e.g., diabetes nurses, dietitians, diabetes educators, counsellors orphysician’sassistants,whovarybycountry).Thesampleof PWD predominantly comprises those withtype 2 diabetes (with quotas for different treatment regimens), but also includesparticipantswithtype1diabetes.
The global study sample (and subsample) sizes are sufficienttoachievemorethan80%powerfora‘small’effect size(e.g.,Cohen’sd=0.2).NationalsamplesofPWDandHCP weredesignedtoachieve80%powerfora‘medium’effectsize
(e.g.,Cohen’sd=0.5).Minimumnationalsamplesizewas120 toachieve80%powertodetectadifferenceinproportionsof 10%. Minimum national subsample size was 80 to permit effectiveweighting(especiallyimportantwhenproportional samplingwouldgenerateasmallersubsamplethatwouldnot yieldareliablesubsampleestimate).
2.5. Recruitmentmethodology 2.5.1. HCPs
Inallcountries,potentialparticipantsareidentified primar-ily from online panels and databases. When necessary, other sources such as telephone lists and physician directories are used for recruitment. All potential partici-pants areinvitedtotakepart viaemailor phone.Aswith otherDAWN2surveygroups,allparticipantsreceivea web-link to a secure server to enable them to complete the surveyonline.
2.5.2. PWDandFMs
Web, telephone and in-person methods relevant to each country’s situation were applied while trying tomaximise comparability of methodologies and survey populations acrosscountries.
Table1–Inclusionandexclusioncriteria.
Inclusioncriteria
Allparticipants:Internetaccessathomeorconvenient locationorabletoattendaface-to-faceortelephone interview;informedconsentbeforethestartofany study-relatedactivities
PWD:Adultsaged18yearsdiagnosedwithdiabetesbyan HCPatleast12monthsago(type1ortype2;notonlyduring pregnancy)
FM:Adultsaged18yearswhoarenotdiagnosedwith diabetes,liveinthesamehouseholdwithanadult (18years)withdiabetes(type1ortype2;notonly duringpregnancy)andareinvolvedinhis/hercare HCP:GPs,PCphysiciansandinternalmedicinephysicians
whohavebeeninpracticefor1yearandwhopersonally treat5adults(18years)withdiabetespermonthand initiateoralmedication
HCP:Diabetesspecialists(endocrinologists/diabetologists orGP/PCphysicians/internalmedicinephysicianswith sub-specialityindiabetes)whohavebeeninpracticefor 1year,personallytreat50adults(18years)with diabetespermonthandprescribeinsulin(mayalso prescribeoralmedicationorotherinjectablediabetes medications).Thresholdmaybeadjustedaccording tocountry-specificrequirements
HCP:OtherHCPs(diabetesnurses/dietitians/otherHCPs) whohavebeenintheirrespectiveprofessionsfor 1yearandprovidecarefor5adults(18years)with diabetespermonth
Exclusioncriteria
Allparticipants:Inabilitytounderstandandcomplywith writtenandverbalinstructions
PWD:Individualsaged<18yearsand/ordiagnosedwith diabeteslessthan12monthsagoand/ordiagnosedwith diabetesonlyduringpregnancy
2.5.3. Hybridonlineandtelephonemethodology
In11DAWN2countrieswithhighinternetpenetration(USA, Canada, UK, France, Germany, Italy, Spain, Denmark, Netherlands, Poland, Japan) ahybrid online and telephone methodologyisusedtorecruitPWDandFMs.Inthesegroups, participantsareenrolledusingweb-basedrecruitmentorby telephone. This recruitment methodology is intended to ensure the study population in these countries is as representativeaspossibleofthewiderdiabetescommunity andtoaddressconcernsregardingpotentialbiasiftheentire samplewereobtainedthroughweb-basedrecruitment.
Fortheonlinesample,potentialparticipantsareidentified from multiple online panels and databases per country. Individuals identified from these sourcesare contacted by email and invited to participate in the study. Participants recruited bytelephone maycomplete the survey either by telephoneoronline.Dependingontheirpreference, partici-pantsareeithersenta web-linkviaemail tocompletethe surveyonlineorareinterviewedbytelephone.
For the telephone sample, potential participants are identifiedfromavarietyofsources(generaltelephonelists, proprietary databases, lists from past research, patient association lists). They are contacted by telephone and, if eligible,invitedtoparticipateinthestudy.Proceduraldetails for non-web-based recruitment are country-specific and complywithlocallogisticsandethicalregulations.
2.5.4. Face-to-face-methodology
Intheremaining sixDAWN2countrieswithlowerinternet access (Algeria, China, India, Mexico, Russia and Turkey) participantsarerecruitedbytelephoneorface-to-faceusing telephone lists, patient association lists, proprietary data-bases, and hospital and physician directories. Participants completethequestionnaireviaaface-to-faceinterview.
2.6. Questionnaires
Themulti-dimensional scientificsurveydesign forDAWN2 wasdevelopedbytheGlobalDAWN2SurveyWorkingGroup accordingtoaperson-centredmodelforchronicillnesscare withinputfrommulti-national,multi-disciplinarymeetings involvingrepresentativesofallthecountriesparticipatingin DAWN2,andpatientadvocacyandscientificexpertsfromthe collaboratingorganisations.A summaryofthe main topics and subtopicscoveredbythePWD,FM,and HCP question-naires is presented in Table 2. The questionnaires were designed to permit comparison across respondent types wherepossible.
Thequestionnairesincorporateseveralelements, includ-ing: items from the original DAWN study (to enable evaluationoftrendsindiabetescareoverthepastdecade); newly developed questions (to investigate areas such as discrimination and the needs and preferences for better education and support); and open-ended questions (to capture the individual stories of the respondents). Some new questions were developed with inspiration from, or adapted/modified from existing validated instruments, as relevant in each case with the originators of the ques-tionnaires, including the Diabetes Empowerment Scale-short form (DES-SF) [12,13]; Diabetes Family Behavior Checklist(DFBC)[14]andtheHealthCareClimate Question-naire (HCC) [15]. In addition, several standardised instru-mentswereincorporatedintothequestionnairesinoriginal or shortened forms, including: the Problem Areas in Diabetes-short form (PAID-5) [12–20]; Patient Assessment ofChronicIllnessCare(PACIC)[16,17];SummaryofDiabetes Self-Care Activities Measure (SDSCA) [21]; WHOQOL-BREF
[22]; EuroQol (EQ-5D)[23]; andthe WHO Well-Being Index (WHO-5)[24].
HCPs (n=280)
Nurses/dietitians and other HCPs (n=80)
*In the USA, additional 540 PWD and 120 FMs recruited to better represent African-American, Hispanic and Asian ethnic groups, plus 140 HCPs who work with minority populations.
†Some of the 120 FMs live with PWDs, allowing linkage between this subset of PWD and
their FMs.
FM: family members; GPs: general practitioners; HCP: healthcare professional; PWD: people with diabetes
Endocrinologists/ diabetologists (n=80) GPs (n=120) PWDs (n=500) FMs (n=120)† Type 2 - insulin treated (n=150) - non-insulin medication (n=170) - diet/exercise only (n=100) Type 1 (n=80)
Participants per country (n=900)*
Table2–SummaryofmaintopicsandsubtopicscoveredbythePWD,FM,andHCPquestionnaires.
Topic Subtopic
PWD FM HCP
Sociodemographics Age;gender;height;weight; ethnicorigin; country-specificeducationand income;country-specific socioeconomicquestions; worksituation;geographical location;country-specific regionquestions
Age;gender;ethnicorigin; country-specificeducation andincome;country-specific socioeconomicquestions; worksituation;geographical location;country-specific regionquestions
Age;gender;geographical location;yearsinpractice/ profession;areaofspeciality/ subspecialty
Diabetesprofile Diagnosis;timeofdiagnosis; typeoftreatmentreceivedat diagnosisandcurrently; medication/treatmentstatus (currentdiabetestreatment, typesofpills,modeof insulinadministration, numberofinsulin injections);hypoglycaemia (self-treated,severe, hypoglycaemiaawareness); existingcomorbidities/ complications
Diagnosis;timeofdiagnosis; typeoftreatmentreceivedat diagnosisandcurrently; medication/treatmentstatus (currentdiabetestreatment, typesofpills,modeof insulinadministration, numberofinsulin injections);hypoglycaemia (self-treated,severe,number oftimesreceivedmedical assistance,awareness);type ofdiabetes
Patients(%)withtype1/type 2diabetes;medication/ treatmentstatus(current diabetestreatment,typesof pills,modeofinsulin administration,numberof insulininjections)
HealthandQoL QoL(WHOQOL-BREF);health status(EQ-5Dmobility, self-care,usualactivities,pain/ discomfort,anxiety depression,VASScale); emotionalwell-being/mental health(WHO-5);BMI;weight
QoL(self–WHOQOL-BREF); emotionalwell-being/mental health(self–WHO-5);weight
Patients(%)withclinical depression
Diabetesimpact andburden
Diabetesdistress(PAID); overallimpact;impacton physicalhealth;personal relationships;financial impact;productivity/work/ leisureactivities;impacton emotionalwell-being; depressionrelatedto diabetes;dietaryrestrictions
Diabetesdistress(PAID FamilyVersions);overall impact;physicalhealth; impactonpersonal relationships;financial impact;productivity/work/ leisureactivities;impacton emotionalwell-being; depressionrelatedto diabetes;dietaryrestrictions; burdenofcaring
Needforimprovementin dealingwithemotions arounddiabetes;societal burdenofdiabetes
Diabetescontrol Perceivedcontrol; improvementsneededin HbA1c;bloodpressure;lipid profile/cholesterol;weight
Perceivedcontrol; improvementsneededin HbA1c;weight
HbA1clevels;improvements neededinweight
Diabetesmanagement Self-management
behaviours(SDSCAincluding diet,exercise,bloodsugar testing,feetchecking,taking medication,smoking); improvementsneeded
Self-management behaviours(improvements neededindiet,exercise, bloodsugartesting/control, takingmedication,dealing withemotionsaround diabetes,weight)
Self-management behaviours(improvements neededin:diet,exercise, bloodsugartesting,taking medication,dealingwith emotionsarounddiabetes, weight,takingresponsibility) Familyandsocial
support
Non-HCPsupportbehaviours (modifiedDFBC);non-HCP involvement;reasonsfor non-involvement;living situation;familyconflict; overallsocialsupport
Non-HCPsupportbehaviours (modifiedDFBC);non-HCP involvement;reasonsfor non-involvement;living situation;familyconflict; splitofresponsibilities; overallsocialsupport; assistancewith hypoglycaemia
Table2 (Continued)
Topic Subtopic
PWD FM HCP
Healthcaresupport Person-CentredChronic IllnessCare:(modified PACIC/HCC:askingabout QoLandmedication problems,patientactivation, listening,goal-setting, problem-solving,giving confidence,planning on-goingfamily/community support,group
interventions,pro-active follow-up,careorganisation) Accesstomedicalcare/ medicalsupplies; accessibility;HCP assessments(HbA1c,blood pressure,lipidprofile/ cholesterol,weight,feet, anxiety/depression,diet, exercise);earlydiagnosis
Accessingmedicalcare; discussion/improvementof preventionactivities;early diagnosis
Person-CentredChronic IllnessCare(HCPPACIC items/HCCversion:asking aboutQoLandmedication problems,patientactivation, listening,goal-setting, problem-solving,giving confidence,planning on-goingfamilyandcommunity support,group
interventions,pro-active follow-up,overallcare organisation);teamcare Accesstomedicalcare/ medicalsupplies; accessibility;HCP assessments(HbA1c,blood pressure,lipidprofile/ cholesterol,weight,feet, depression,eyes) Practice/provisionaround: screening/earlydetection, diabetesprevention,HbA1c labtests,emotionaldistress, structurededucation Clinicresourcesfor:Carefor vulnerablegroups,individual counselling,IT-systemsfor qualitymonitoring/ improvementand coordinatedcare, involvementofpatientsto improvelocalcare; healthcareremuneration system
Roleofdietitians/educators Educationandinformation Educationattendedand
helpfulness;education, informationandsupport reliedon,desired; understandingof medications
Educationattendedand helpfulness;education, informationandsupport reliedon,desired
Educationattended, resourcesandreferral optionsforHCPs;desired futuretraining;roleof educatorsanddietitians; informationandsupport methods
Workplace,community andwiderenvironment
Community/societal improvements(acceptance healthyeating,exercising, workplaces,earlydiagnosis andtreatment) Discrimination;community support/activities;virtual support Community/societal improvements(acceptance healthyeating,exercising, workplaces,earlydiagnosis andtreatment,public awareness,prevention,good medicalcare)
Discrimination;community support/activities;virtual support;tolerance;diabetes inthemedia
Community/societal improvements(acceptance healthyeating,exercising, workplaces,earlydiagnosis andtreatment,public awareness,prevention) Discrimination;Community support,collaboration, preventionprogrammes; virtualsupport; reimbursement Attitudesandbeliefs Illnessandtreatmentbeliefs
andattitudes,activationand empowerment;intentionsto improveself-management; medicationbeliefs;insulin beliefs;willingnesstostart medication;fearof hypoglycaemia;dietand exercisebeliefs
Illnessandtreatmentbeliefs andattitudes,activationand empowerment,intentionsto improveself-management; fearofhypoglycaemia; confidenceindealingwith hypoglycaemia;inspiration fromPWD;understandingof diabetes
All surveyswere reviewed andapproved inthe original English version by leading experts from all participating countries. Thethree surveyquestionnaires inEnglishwere testedfurtherwith16participants(7PWD,3FMsand6HCPs) fromIndia,Canada,USA,andtheUK,toassesswhetherthe questionnairecontentwasunambiguousandunderstandable andtoensurefacevalidityandacceptability.Questionnaires weresubjectedtoadditionalwrittenreviewsbypeoplewith type1andtype2diabetespriortofinalisation.
Questionnairesforthethreesurveysweretranslatedinto theprimarylanguage(s) ofeachparticipatingcountrybyat leasttwoindependentlocalprofessionaltranslatorswhowere nativespeakersintherelevantlocallanguage.These transla-tions were reviewed by national diabetes experts in each countrytoconfirmtheaccuracy andcross-cultural equiva-lenceofthetranslations.Asubsetofselected psychometri-cally validated scales and items intended for scientific benchmarkingwithinandacrosscountrieswereback trans-lated into English by a third independent professional translator and a review and harmonisation process was undertaken.Thisinvolvedtheapprovalbyacademicexperts andoriginatorsoftheoriginalscientificscales,aswellasPWD, where feasible. This process also involved multi-national harmonisation of previously published local language ver-sions of scientific instruments, including the PAID-5, the WHO-5,theWHOQOL-BrefandtheSDSCA.
2.7. Researchquestions
TheDAWN2surveys weredesigned toprovide data-driven guidancerelevantforallstakeholdersindiabetesandchronic illness management regarding how diabetes care may be optimisedlocally,nationallyorinternationallyatthemicro, mesoormacrolevelwithinaholisticperson-centredchronic careframework.Keyresearchquestionsinclude:
1. Howdothe participatingcountriescompare interms of healthcareprocessesandoutcomesbasedonthemeasures
that are proposed as suitable for benchmarking (e.g., establishedvalidityandreliabilityofsourcemeasures)? 2. What are the determinants of QoL and psychosocial
adaptationofPWD?
3. Whatarethedeterminantsofself-managementbehaviour byPWD?
4. What are the determinants of HCP delivery of person-centred diabetescare/support (especially those forms of care/support that arefound to have a majorimpact on patientoutcomes)?
5. WhatarethedeterminantsofburdenforFMsandfamily supportforPWD,especiallythoseformsofsupportthatare foundtohaveamajorimpactonpatientoutcomes? 6. Whatisthecurrentlevelofaccesstodiabeteseducation,
howisitprovided,andwhatarethebenefitstoPWD?What aretherolesofnurses,dietitiansandotherHCPproviders? 7. What are the determinants of medication initiation,
adherence,persistenceandintensification?
8. WhatchangeshaveoccurredintheperiodbetweenDAWN andDAWN2?
9. Whatarethekeyeventsthathavecreatedturning-pointsin howpeoplelivewithandmanagediabetes?What individ-ualandsocietalchangesdosurveyrespondentswant?
Numerousadditionaltopics willbeaddressed,but afull listingofquestionsisbeyondthescopeofthispaper. 2.8. Supplementaryresearch
Inparallelwiththethreemainsurveys,aseparatesituational assessment isbeingperformedineachcountry,comprising literature research on national guidelines, policies and activitiesrelatedtoperson-centreddiabetescare, supplemen-ted byinterviews with arange ofdifferent national stake-holders.Thesearedesignedtoprovideanassessmentofthe existingdiabetesandchroniccaredeliverysystemsineach country,againstwhichtheperceptionsofsurveyrespondents can be compared. Representatives of patient associations,
Table2 (Continued)
Topic Subtopic
PWD FM HCP
Wishesandfuture needs
Desiredfuturefamilyand socialsupport;improvement areasincountry/region; improvementsin self-management
Desiredfuturefamilyand socialsupport;improvement areasincountry/region
Desiredfuturefamilyand socialsupport;desired improvementsof medications;improvement areasincountry/region; improvementsneededin medicalcareand psychosocialsupport Personalexperiences Open-endedquestions
(impactfulstoryabouthow tomanagediabetes, challenges,successes, wishes)
Open-endedquestions (impactfulstoryaboutliving withsomeonewithdiabetes/ involvementindiabetescare ofPWD,challenges, successes,wishes)
Open-endedquestions (challenges,successes, wishes)
policy-makersand thoughtleadersineachcountryarekey contributorstothisstudycomponent.Thesituational assess-mentallowseachcountrytobenchmarkitselfrelativetoother countriesinrelationtohealthpolicies,guidelines,healthcare infrastructures,nationalprogrammes,andcommunity struc-turesrelatedtoperson-centred chronic illnesscare,and to identify concrete opportunities for national improvement fromtheDAWN2surveyresults.
2.9. Analysis
SurveydataareprovidedtothePrincipalInvestigatorsofeach country’s national advisory or survey group as descriptive statisticsforallvariablesforeachparticipantgroup.Topermit generalisationfromthesampletolargerpopulations, individ-ual weights are provided. These weights are based on populationproportionsforeachcountry,asprovidedbyeach country’s survey advisorygroup, and on publicly available epidemiologicaldata.
Furthermore, the subset of FMs who live in the same householdasindividualswhocompletethePWDquestionnaire arelinkedtooneanotherforanalysis.Thisenablescomparison oftheperceptionsofprovisionofpracticalandemotionalcare andsupportfrombothmembersofthedyadandassessmentof theassociationbetweenthebehaviourofsupportgiversandthe impactonsupportrecipients.Fornon-linkedsamples, concor-dancebetweenrespondentscanbeassessedstatisticallyfor itemsthatareidentical,butotheritemscanonlybecompared numerically(e.g.,thepercentageofPWDwhoreportengagingin a behaviour and the percentage of PWD that physicians estimatetoengageinthatbehaviour).
Publicationswillusetheappropriatestatisticaltestsfora particular hypothesis and type of data. These include nonparametric bivariate statistics (e.g., chi-squared test, Kendall correlation coefficient, Mann–Whitney test, Krus-kal–Wallistest),parametricbivariatestatistics(e.g.,analysisof variance, Pearson correlation) and multivariate tests (e.g., logisticregression,ordinaryleastsquaresregression,analysis ofcovariance).
Inaddition, psychometricvalidationofmulti-item mea-sures in eachcountrywill beperformed to confirm cross-culturalvalidityandsuitabilityforclinicalandbenchmarking purposes.
3.
Discussion
The‘DAWNCalltoAction’[5]identifiedstrategicareasforthe improvementofdiabetescarebyfocusingonthepsychosocial issues attached to living with diabetes [2,5]. Strategies for nationalactiontoimproveaccesstoperson-centreddiabetes care,asguidedbythefirstDAWNstudy,included:(1)raising awarenessofthePWDperspective,(2)empowermentofPWD throughinformationandeducation,(3)trainingofHCPs,(4) developmentofinnovativetoolstodeliverPWDsupport,(5) improvementofguidelines/policiesforperson-centredcare, and(6)translationalresearchintodeliveryofperson-centred diabetescare.
Evidencesuggeststhatsubstantialprogresshasbeenmade within these areas, but there is a need for continued
implementation of these strategies, including training of HCPsinperson-centredchronicillnesscare[25,26],newtools and interventionstrategies forimproving the psychosocial careofPWD[2,27],revisionofguidelinestoincludesectionson the self-management and psychosocialaspects ofdiabetes care[28–39],andresearchonpsychosocialandperson-centred diabetescare[40].
DAWN2buildsuponadecadeofmulti-nationally coordi-nated actions and efforts to improve person-centred care. FollowingDAWN,otherdiabetessurveyshavebeeninitiated toexplorepsychosocialissuesindiabetes,butpredominantly in relation to medical therapy and not addressing FM, community,orpatientorganisationperspectives.
The scope of DAWN2 is broad and should further our understandingofissuesindiabetesandperson-centredcare, overandabovethatprovidedbyotherdiabetessurveys.By surveying the attitudes, wishes and needs of over 16,000 peoplefromthethreestakeholdergroupsinvolvedin day-to-daylivingwithandmanagementofdiabetes,DAWN2aimsto provideaunique,comprehensive,systematicperspectiveon the facilitators and barriers to achieving optimal person-centreddiabetescare.
Thedesign ofthe DAWN2questionnairesshouldenable identificationofdiscrepanciesbetweenthe‘feltneeds’ofPWD andtheir‘perceivedneeds’byFMsandHCPs.Comparisonsof the resultsacross countries,within thecontextofdiffering nationalguidelines, policiesandcaredeliverymodels,may identifyoptimalandsub-optimalnationalandlocalmodelsof care,educationandcommunitysupport.Throughthe cross-cultural validation of the multiple scientific measurement instruments incorporated into the DAWN2 survey, each country can incorporate mini-DAWN2 surveys into clinic, local,andregionalqualityimprovementprogrammes,toallow forwithin-countrybenchmarking.
ComparisonofDAWN2datawiththosefromDAWNallows for the determination of temporal trends in the profile of diabetes care and, possibly, whether differences between thesedataincountriesthatparticipatedinbothstudiesreflect a growingrecognition and acceptance of the psychosocial aspectsofdiabetescareinthepast10years.
3.1. Studylimitations
ManychallengesareassociatedwithconductingDAWN2,the largestmulti-nationalstudyofitskindindiabetes,including how to represent the population within each country accurately.SinceDAWN2aimstostudyvariationsinaccess toandconsequencesofdiabetescare,communitysupportand educationwithinandbetweencountries,samplesneededto be geographically and socio-demographically dispersed in eachcountry.Therefore,recruitingthroughalimitednumber of centresor clinics,as oftendone indiabetes surveysfor practical reasons,would notbe appropriate forDAWN2as resultswouldbebiasedtowardswell-resourcedclinics.
proportionsshouldhelpminimisesuchbiases.However,in somecountries,telephonepenetrationispoor.Whiletheuse offace-to-facerecruitmentandinterviewingintheDAWN2 studyhelpsovercomethisbarriertorepresentativeness,the expenseassociatedwithoutreachtoruralareasincountries withbroadgeographicdispersionmakessamplingofallareas of the country infeasible. In addition, some countries and regionsarenotrepresented,e.g.,Indonesia,Thailand,theArab countries, sub-Saharan Africa and South America. Thus, resultscannotbegeneralisedtotheentireglobalpopulation ofthethreekeydiabetesstakeholdergroups.
4.
Conclusions
TheoriginalDAWNstudyidentifiedamajorgapbetweenthe psychosocialandeducationalsupportneedsofPWD,andthe careandsupport availableindevelopedandlessdeveloped countries.However,despitedevelopmentsinthefieldof self-managementeducationandpsychosocialcareduringthepast decade,toomanyPWDreceiveinadequatecareandsupportto enable them to achieve optimal health and well-being. In response, DAWN2 seeks to identify possible areas for improvementanddeterminethedriversofchangetoachieve optimal person-centred diabetes care. DAWN2 has been designedtofacilitateeasytranslationofthestudyfindings, including involvement of a broad foundation of multiple nationalandinternationaldiabetesstakeholders.
AsthefirstmajorsurveyoftheopinionsofFMsofPWD, DAWN2aimstoachieveabroader humanisticand societal perspectiveontheneedsofPWDandthosecaringforthem. Responding to the IDF declaration on patients’ rights and responsibilities,andincludingallareasoflifewithdiabetes,it ishopedthatDAWN2willpromoteimprovementsin condi-tionsforPWD.Ultimately,DAWN2aspirestoprovideavoice forPWDandthosecaringforthem,whichreflectstheirunmet needs.
TheDAWN2study shouldenable newopportunities for improving diabetes self-management and QoL, and for ascertainingthecriticaldriversofactivemanagementaswell as improvement in person-centred diabetes care. These findingsmayfacilitateinnovativeeffortsbyallstakeholders to improve self-management and psychosocial support in diabetes.
Conflict
of
interest
Melanie Davies has acted as consultant, advisory board member and speaker for Novartis, Novo Nordisk, Sanofi-Aventis,Lilly,MerckSharpandDohme,andRoche,andasa speaker forServier. She hasreceived grants in support of investigator and investigator-initiated trials from Novartis, NovoNordisk,Sanofi-Aventis,Lilly,Pfizer,MerckSharpand Dohme,GlaxoSmithKlineandServier.
RichardHolthasreceivedfundingfortraveland accom-modationtoattend DAWN2InternationalPublication Plan-ningCommitteemeetings,buthasnotreceivedanyfeeforthis workfromNovoNordisk.Hehasactedasanadvisoryboard memberandspeakerforNovoNordisk,andasaspeakerfor
Sanofi-Aventis,EliLilly,OtsukaandBristolMyersSquibb.He hasreceivedgrantsinsupportofinvestigatortrialsfromNovo Nordisk.
Norbert Hermanns is a member of the International DAWN2AdvisoryBoard. Hehasreceivedresearchgrantsin thelastyearfromRoche,BerlinChemie,EliLillyandSanofi Aventis. He also received speaking honoraria from Novo, Germany, Lilly,BerlinChemie, Lifescan,SanofiAventisand MenariniDiagnostics.
AntonioNicoluccihasreceivedresearchgrantsinthelast yearfromNovoNordisk,EliLilly,SanofiAventis,MerckSharp andDohme,BristolMyersSquibb-AstraZenecaandBayer.
MarkPeyrothasrecentlyreceivedresearchgrantsand/or consulting fees from Amylin, Genentech, Lilly, MannKind, Medtronic, and Novo Nordisk. He has received speaking honorariafromNovoNordiskandhasparticipatedinadvisory panelsforNovoNordiskandRoche.Hehasreceivedfinancial supportfromNovoNordiskforhisparticipationasPrincipal InvestigatorfortheDAWN2study.
JohanWenshasactedasanadvisoryboardmemberfor Eli-Lilly,BristolMyersSquibb-AstraZenecaandNovoNordisk.
Søren Skovlund is an employee of Novo Nordisk A/S, Copenhagen,Denmark.
AngusForbes,IngridWillaing,SanjayKalraandKatharina KovacsBurnshavenoconflictsofinteresttodisclose.
Acknowledgements
The DAWN2 Study Group consists of a national lead investigatorfromeachcountryandmembersofthe interna-tionalDAWN2publicationplanningcommittee:RachidMalek, Algeria; Johan Wens, Belgium; Joa˜o Eduardo Salles, Brazil; KatharinaKovacsBurnsandMichaelVallis,Canada;Xiaohui Guo,China;IngridWillaing,Denmark;Ge´rardReach,France; Norbert Hermanns and Bernhard Kulzer, Germany; Sanjay Kalra, India; Antonio Nicolucci and Marco Comaschi, Italy; HitoshiIshii,Japan;MiguelEscalante,Mexico;FransPouwer, The Netherlands; Andrzej Kokoszka, Poland; Alexandre Mayorov, Russia; EdelmiroMenendez, Spain; Ilhan Tarkun, Turkey;MelanieDavies,RichardHolt,AngusForbes,andNeil Munro, United Kingdom; Mark Peyrot, United States of America.
Inadditiontotheauthorsofthismanuscript,theauthors wish toacknowledgesignificantcontributionstothis paper fromChristineMullan-Jensen.Furthermore,theauthorswish tothankMassimoBenedettiforhisreviewofthemanuscript andtoacknowledgethecontributionofWimWientiensofthe International DiabetesFederation,and thenumerous other internationalandnationalexpertsandpatientadvocateswho havecontributeddirectlytothedesignoftheDAWN2study during2010–2012.ThecompletelistofstudyexpertandPWD advisersisavailableatwww.dawnstudy.com.
StirlingLtd.for providingassistancewith obtainingethical approvalsinseveralcountries.HarrisInteractiveconducted thesurveys, and providedexpertiseindesigning the ques-tionnaires and planning survey implementation, including samplingframesandstrategies,questionnaireadministration strategies,weightingcriteria,etc.
r
e
f
e
r
e
n
c
e
s
[1] PeyrotM,RubinRR,LauritzenT,SnoekFJ,MatthewsDR, SkovlundSE.Psychosocialproblemsandbarriersto improveddiabetesmanagement:resultsofthe Cross-NationalDiabetesAttitudes,WishesandNeeds(DAWN) Study.DiabetMed2005;22:1379–85.
[2] SkovlundSE,PeyrotM.TheDiabetesAttitudes,Wishes,and Needs(DAWN)program:anewapproachtoimproving outcomesindiabetescare.DiabetSpectr2005;18:136–42. [3] PeyrotM,RubinRR,LauritzenT,SkovlundSE,SnoekFJ,
MatthewsDR,etal.Resistancetoinsulintherapyamong patientsandproviders.Resultsofthecross-national DiabetesAttitudes,Wishes,andNeeds(DAWN)study. DiabetesCare2005;28:2673–9.
[4] ConferenceReport:2ndInternationalDAWNSummit:a call-to-actiontoimprovepsychosocialcareforpeoplewith diabetes.PractDiabetesInt2004;21(5):201–8.
[5] InternationalDiabetesFederation:puttingpeopleatthe centreofcare:DAWNinaction.DiabetesVoice2004;49:1– 49.
[6] WorldHealthOrganization.Innovativecareforchronic conditions:buildingblocksforaction:globalreport. Availablefrom:http://www.who.int/diabetesactiononline/ about/icccreport/en/;2002[cited19.04.11].
[7] KnottnerusJA,TugwellP.Thepatients’perspectiveiskey, alsoinresearch.JClinEpidemiol2012;65:581–3.
[8] IDFcharterofrightsandresponsibilitiesofpeoplewith diabetes.Availablefrom:http://www.idf.org/webdata/docs/ advocacy-kit/Charter-of-rights.pdf;April2011.
[9] InternationalChamberofCommerce/EuropeanSocietyfor OpinionandMarketingResearch(ICC/ESOMAR)
internationalcodeonmarketandsocialresearch.Available from: http://www.esomar.org/uploads/pdf/professional-standards/ICCESOMAR_Code_English_.pdf;December2007. [10] CouncilofAmericanSurveyResearchOrganizations
(CASRO)codeofstandardsandethicsforsurveyresearch. Availablefrom:http://www.casro.org/pdfs/
10CodeOfStandards.pdf;2011.
[11] InternationalSocietyforPharmacoepidemiology GuidelinesforGoodPharmacoepidemiologyPractices. Availablefrom:http://www.pharmacoepi.org/resources/ guidelines_08027.cfm;2007.
[12] AndersonRM,FunnellMM,FitzgeraldJT,MarreroDG.The diabetesempowermentscale:ameasureofpsychosocial self-efficacy.DiabetesCare2000;23:739–43.
[13] AndersonRM,FitzgeraldJT,GruppenLD,FunnellMM,Oh MS.Thediabetesempowermentscale-shortform(DES-SF). DiabetesCare2003;26:1641–2.
[14] SchaferLC,McCaulKD,GlasgowRE.Supportiveand nonsupportivefamilybehaviors:relationshipsto adherenceandmetaboliccontrolinpersonswithtypeI diabetes.DiabetesCare1986;9:179–85.
[15] ParkinT,SkinnerTC.Discrepanciesbetweenpatientand professionalsrecallandperceptionofanoutpatient consultation.DiabetMed2003;20:909–14.
[16] GlasgowRE,WagnerEH,SchaeferJ,MahoneyLD,ReidRJ, GreeneSM.Developmentandvalidationofthepatient
assessmentofchronicillnesscare(PACIC).MedCare 2005;43:436–44.
[17] GlasgowRE,WhitesidesH,NelsonCC,KingDK.Useofthe patientassessmentofchronicillnesscare(PACIC)with diabeticpatients:relationshiptopatientcharacteristics, receiptofcare,andself-management.DiabetesCare 2005;28:2655–61.
[18] PolonskyWH,AndersonBJ,LohrerPA,WelchG,Jacobson AM,AponteJE,etal.Assessmentofdiabetes-related distress.DiabetesCare1995;18:754–60.
[19] WelchG,WeingerK,AndersonB,PolonskyWH. ResponsivenessoftheProblemAreasinDiabetes(PAID) questionnaire.DiabetMed2003;20:69–72.
[20] McGuireBE,MorrisonTG,HermannsN,SkovlundS,Eldrup E,GagliardinoJ,etal.Short-formmeasuresof diabetes-relatedemotionaldistress:theProblemAreasinDiabetes Scale(PAID)-5andPAID-1.Diabetologia2010;53:66–9. [21] ToobertDJ,HampsonSE,GlasgowRE.Thesummaryof
diabetesself-careactivitiesmeasure:resultsfrom7studies andarevisedscale.DiabetesCare2000;23:943–50. [22] TheWHOQOLGroup.DevelopmentoftheWorldHealth
OrganizationWHOQOL-BREFqualityoflifeassessment. PsycholMed1998;28:551–8.
[23] SzendeA,OppeM,DevlinN,editors.EQ-5Dvaluesets: inventory,comparativereviewanduserguide. EuroQol groupmonographs,TheNetherlands:Springer;2007. [24] BechP,GudexC,JohansenKS.TheWHO(ten)well-being
index:validationindiabetes.PsychotherPsychosom 1996;65:183–90.
[25] WestbergSM,BumgardnerMA,BrownMC,FruehJ.Impact ofanelectivediabetescourseonstudentpharmacists’ skillsandattitudes.AmJPharmEduc2010;74:49. [26] UplingerN,TurkelMC,AdamsPC,Nelson-SlemmerD,
PierceS.DevelopmentofaDiaBEATesNurseChampion Program.DiabetesEduc2009;35:713–4.
[27] TheDAWNstudy.Availablefrom:http://
www.dawnstudy.com/ToolsAndResources/default.asp
[accessed08.05.12].
[28] InternationalDiabetesFederationClinicalGuidelinesTask Force.Psychologicalcare.Globalguidelinefortype2 diabetes.Availablefrom:http://www.idf.org/webdata/ docs/GGT2D%2004%20Psychological%20care.pdf;2005.p. 19–21[chapter4,accessed09.01.12].
[29] FunnellMM,AndersonRM,AustinA,GillespieSJ.AADE positionstatement:individualizationofdiabetes self-managementeducation.DiabetesEduc2007;33:45–9. [30] SiminerioLM,DrabSR,GabbayRA,GoldK,McLaughlinS,
PiattGA,etal.Diabeteseducators:implementingthe chroniccaremodel.DiabetesEduc2008;34:451–6.
[31] DrabS.Translatingclinicalguidelinesintoclinicalpractice: roleofthepharmacistintype2diabetesmanagement.J AmPharmAssoc2009;49:E152–62.
[32] AmericanDiabetesAssociation.Executivesummary: standardsofmedicalcareindiabetes–2011.DiabetesCare 2011;34(Suppl.1).
[33] FunnellMM,BrownTL,ChildsBP,HaasLB,HoseyGM, JensenB,etal.Nationalstandardsfordiabetes self-managementeducation.DiabetesCare2011;34:S89–96. [34] NationalCollaboratingCentreforChronicConditions.Type
1diabetesinadults.Nationalclinicalguidelinefor diagnosisandmanagementinprimaryandsecondarycare. Availablefrom:http://www.nice.org.uk/nicemedia/live/ 10944/29393/29393.pdf;2004[accessed09.01.12].
[36] NationalInstituteforClinicalExcellence(NICE)clinical guidelines66type2diabetes:fullguidance.Availablefrom:
http://www.nice.org.uk/nicemedia/pdf/
CG66NICEGuideline.pdf;May2008[accessed08.05.12]. [37] NationalInstituteforClinicalExcellence(NICE)clinical
guidelines87type2diabetes–neweragents:short guideline.Availablefrom:http://www.nice.org.uk/ guidance/index.jsp?action=download&o=44318;August 2011[accessed08.05.12].
[38] NationalInstituteforClinicalExcellence(NICE)quality standardsdiabetesinadults.Availablefrom:http://
www.nice.org.uk/media/FCF/87/
DiabetesInAdultsQualityStandard.pdf;March2011 [accessed08.05.12].
[39] PetrakF,HerpertzS,AlbusC,HirschA,KulzerB,KruseJ. Psychosocialfactorsanddiabetesmellitus:evidence-based treatmentguidelines.CurrDiabetesRev2005;1:255–70. [40] HarknessE,MacdonaldW,ValderasJ,CoventryP,GaskL,
