S Kalra, M Baruah, M Ganapathy, A Ganie, R Sahay, A Unnikrishnan
S Kalra, M Baruah, M Ganapathy, A Ganie, R Sahay, A Unnikrishnan. Patient Centred Approach To Diabetes Management: The Dawn Philosophy. The Internet Journal of Family Practice. 2009 Volume 8 Number 1.
Diabetes mellitus is a chronic condition which over 300 million people worldwide. A life-long disorder, it leads to various complications if left untreated. This article discusses the DAWN philosophy of management of diabetes, and lays a framework for future activities.
The Ground Reality
In spite of the availability of many modern drugs, insulin, monitoring devices, physical activity aids, “health diets” and treatments for co morbid conditions, a large proportion of people with diabetes continue to have poor control.
At times, people with diabetes choose not to take any form of treatment. Others prefer to take complementary and alternative medicine of unproven efficacy, rather than use modern evidence- based medicine. Yet others do take modern drugs but in suboptimal frequency and dosage, or avoid insulin, preferring to continue oral drugs even if they have lost their efficacy.
All such patients have poor glycemic control, and suffer from easily avoidable symptoms, acute complications, poor quality of life, depressions, and micro-as well as macro-vascular diseases.
There is another group of patients, however, who are prescribed( and hopefully take) optimal doses of best quality drugs and insulin in appropriate regimes, may or may not have good glycemic control, yet are unhappy with their condition and quality of life.
Through patients are given appropriate medical care, they are often unsatisfied with the psychosocial support and care that they receive. Because of this, patients also feel that they are not in charge of their condition or life. They also face a lot of discrimination and stigmatization (1,2 )
Poor satisfaction with health care professionals, and lack of communication with health care providers, are associated with poor concordance with suggested therapy and suboptimal glycemic control.
The Concept Of Therapeutic Patient Education
This realization led to concept of therapeutic patient education (TPE). TPE was propagated by Assal J et al as an essential part of diabetes care (3). The concept of TPE states that educating and empowering patients about their diabetes leads to therapeutic benefits per se, and improves the benefit noted with other therapeutic modalities such as diet, physical activity and drugs.
TPE is a patient centered approach focusing on patient’s need, resources, values and strategies. It helps them change their behavior by utilizing approaches such as motivational interviewing, cognitive behavior therapy and behavior change counseling. (4)
Many approaches, strategies and activities come under the TPE umbrella (5). A need to crystallize and formalize these concepts and ideas, and to spread awareness about patient- centered approach of diabetes management, has been felt.
The Concept Of DAWN
This has led to the starting of the DAWN movement. DAWN stands for Diabetes Attitudes, Wishes and Needs. The DAWN Programme was created because more than half of people with diabetes do not achieve good health and quality of life, despite the availability of effective medical treatments. (6)
The DAWN Study
It was noted that gaps in knowledge existed, particularly concerning data which would allow for international comparisons of management, assess the relationships between people with diabetes, their families and health care providers, and enable policy makers to recommend necessary changes. The first DAWN study in 2001 showed that diabetes care which focuses solely on medical targets is seriously flawed. More than half of people with diabetes do not enjoy good health and life quality, and the DAWN study revealed a major underlying cause: the negative effects of ignoring the psychosocial impact of diabetes on those who live with the condition every day. The DAWN Study highlighted the need for a new approach to diabetes care that looks beyond the blood glucose readings and prescribed diet and exercise regimes to the person behind the disease. (6)
The DAWN Philosophy
The DAWN philosophy therefore is based on concerted advocacy and practical actions to help put the individual – rather than the disease – at the centre.
A key goal of the ongoing DAWN programme is to support diabetes healthcare professionals to adopt new patient-centred treatment strategies through facilitation of training programs, insights and practical tools and strategies.
Special attention is given to supporting children and their families and ethnic minorities with diabetes to achieve optimal health and quality of life.
All stakeholders in diabetes care must work together in a new collaborative framework in order to reach the goals for improved diabetes care. These stakeholders include people with diabetes, families, friends and carers, healthcare providers, payers, policy makers, industry and non-governmental organizations.(6)
Five goals for improved diabetes care were identified from the global DAWN Study and reaffirmed at the DAWN Summit. To improve the health and quality of life of people with diabetes we must (6):
enhance the communication between people with diabetes and healthcare providers
promote improved communication and co-ordination between healthcare providers
promote effective self-management
reduce the barriers to effective therapy
improve psychological care for people with diabetes.
Call To Action
Five calls to action have been formulated to ensure that the DAWN goals are achieved (6).
Raising awareness and advocacy
Leaders and trendsetters in psychosocial aspects of diabetes must share their knowledge with peers, and should collaborate to raise awareness and promote advocacy for improved psychosocial support in diabetes care. This article is an example of raising awareness. Work done by the Partners for Excellence in Endocrine Research (PEER) group, India, has also contributed to raising awareness of this aspect of diabetes.
Engaging and educating people with diabetes
Patients must have access to basic information in order to make informed decisions. They need access to health education about prevention, professional education about treatment options and the prevention of complications, as well as community-based support to cope with the psychosocial impact of diabetes
As experts in the management of their own condition, people with diabetes must be included while developing new approaches, tools and guidelines. People with diabetes must be involved in informing healthcare providers, policy makers, and others about their psychosocial needs. People with diabetes can be engaged by holding regular camps and discussions, as in done at diabetes clinics in Bangalore, Guwahati, Hyderabad and Srinagar, in India.
Training healthcare providers
In order to place people with diabetes at the centre of healthcare provision, healthcare providers must cultivate listening and communications skills, as well as team work. These will enable the carers to understand, assess, and address the psychosocial needs of people with diabetes. An example of appropriate training is the Multipurpose Diabetes Worker (MPDW) training programme at Bharti Hospital, Karnal, India (7).
Provision of practical tools and systems
Diabetes care teams need practical tools and systems to support their work. Such tools and systems include strategies for psychological intervention, referral guidelines, listening and communications skills, scales for the assessment of quality of life, and personal care records, e.g. diabetes passports
An example of a practical tool is an economical Snakes and Ladders game, designed to improve motivation and concordance with therapy, designed at Bharti Hospital, Karnal, India.(8)
Driving policy and healthcare systems change
People with diabetes and those at risk of developing diabetes must be provided adequate healthcare services and treatments to achieve optimum health and quality of life. Governments and healthcare systems must be lobbied to adopt the chronic care model developed by World Health Organization. The Government of Bangladesh successfully introduced a bill which led to the historic United Nations declaration on diabetes mellitus in 2006.
Developing psychosocial research in diabetes
More psychosocial research must be conducted in the field of diabetes. Research should follow the RE-AIM principles of Reach, Efficacy, Adoption, Implementation, and maintenance. The DAWN Award 2009 has been awarded to such a project, focusing on improvement of coping strategies in youth with diabetes. Work done at Gwalior, Karnal and Kochi in India has shed light on the coping mechanisms used by boys and girls with diabetes (9).
DAWN Youth is a part of DAWN that explores the attitudes, wishes and needs of young people affected by diabetes and their families. It hopes to address the unmet needs of young people with diabetes, their families, peers and healthcare professionals and uncover viable solutions to ensure all children and youth with this disease receive the best care and support.(10) Fact finding work in over 20 countries of the world has led to an increased understanding of the requirements and problems of youth with diabetes.
The DAWN movement, including DAWN Youth, needs to be spread throughout the globe, as it holds the potential to revolutionize the way in which we think about diabetes management, and thereby improve the quality of medical care, and quality of life, of people with the illness.