Diabetes in the Dominican Republic: The DR-DAWN2 Study

Diabetes is often described primarily in terms of blood glucose, medication, diet and the prevention of complications. But living with the disease also involves a daily psychological and behavioral workload. A 2025 study known as Diabetes Attitudes, Wishes and Needs in the Dominican Republic, or DR-DAWN2, examined that broader experience among adults receiving outpatient diabetes care in Santo Domingo. The researchers found substantial levels of depressive symptoms and diabetes-related distress, along with relatively low adherence to self-care behaviors, particularly physical activity.

The study is important because it moves the discussion of diabetes beyond laboratory measurements. Its results suggest that the experience of managing a chronic disease can affect how people feel, how they assess their quality of life and how consistently they carry out activities that are part of diabetes self-management. At the same time, the study was cross-sectional and conducted at a single outpatient center, so its results should not be treated as a prevalence estimate for the entire Dominican population.

What the DR-DAWN2 Study Investigated

The study, published in The Science of Diabetes Self-Management and Care, was designed to assess the psychosocial status of people with diabetes and their perceptions of the health care services they received at a local outpatient center in Santo Domingo. The research team included Manuel Soto, Nadja García, Jessica Ortiz and Berniza Calderón, with affiliations including the Centro Médico de Diabetes, Obesidad y Especialidades (CEMDOE), Instituto Tecnológico de Santo Domingo and the Sociedad Dominicana de Endocrinología y Nutrición.

The researchers enrolled 385 Dominican adults with diabetes. They collected demographic and clinical information and used several established questionnaires to examine different dimensions of living with diabetes. These included the WHO-5 Well-Being Index, the EuroQol-5D Visual Analogue Scale, the Problem Areas in Diabetes Scale, the Summary of Diabetes Self-Care Activities and the Patient Assessment of Chronic Illness Care.

That combination matters because no single questionnaire can describe the full experience of a chronic disease. The instruments addressed psychological well-being, health-related quality of life, diabetes-specific emotional distress, everyday self-care and patients’ perceptions of the organization and coordination of chronic care.

The Study Found Depressive Symptoms in 18.7% of Participants

One of the study’s most prominent findings was that 18.7% of participants exhibited symptoms of depression. The rate was higher among women and younger participants.

It is important to use the study’s terminology precisely. The researchers reported symptoms of depression, not a clinical diagnosis of depressive disorder in 18.7% of the sample. The WHO-5 Well-Being Index is a measure of psychological well-being that can be used to identify people who may have depressive symptoms or low well-being; a screening result should not automatically be interpreted as a diagnosis made by a clinician.

This distinction is particularly important when interpreting health research for a general audience. Depression is a clinical mental health disorder characterized by persistent depressed mood or loss of interest or pleasure, among other symptoms. A screening instrument can identify people who warrant further assessment, but it does not by itself establish that a person has the disorder.

The World Health Organization also recognizes a close relationship between diabetes and mental health. People living with chronic diseases such as diabetes may experience depression in connection with the difficulties of managing their condition, while depression and physical inactivity can also intersect with chronic disease risk. These relationships are complex and should not be interpreted as proof that diabetes caused the depressive symptoms observed in the Dominican study.

Diabetes Distress Is Not the Same as Depression

The DR-DAWN2 results also identified diabetes-related distress in 22.6% of participants. The proportion was particularly notable among younger participants and people who were employed.

Diabetes distress is related to the emotional burden of living with and managing diabetes, but it is not synonymous with clinical depression. It can involve frustration with daily disease management, concerns about complications, worries about treatment, difficulties maintaining recommended behaviors and the feeling that diabetes demands constant attention.

This distinction helps explain why the two percentages in the study should not simply be added together. The measures assess different psychological experiences, and the same individual could potentially experience both. Conversely, someone can have substantial diabetes distress without meeting criteria for a depressive disorder.

The distinction also has practical implications. A person may feel overwhelmed by glucose monitoring, medication schedules, dietary changes or worries about future complications without necessarily having depression. That experience can still affect how manageable diabetes feels and how consistently a person follows a treatment plan.

WHO has emphasized the broader connection between mental health and chronic noncommunicable diseases, including diabetes. Its guidance supports approaches that recognize physical and psychological needs together rather than treating them as completely separate areas of care.

Quality of Life Was Measured Through a Patient-Reported Scale

The researchers assessed health-related quality of life using the EuroQol-5D Visual Analogue Scale (EQ-VAS). Participants had a mean score of 77.6 out of 100, with a standard deviation of 18.

The EQ-VAS is a patient-reported measure in which people rate their overall health status on a scale. A score is therefore not equivalent to a percentage of health, nor does it represent a laboratory measurement. Instead, it captures how participants themselves viewed their health at the time of assessment.

The authors interpreted the overall findings as indicating a reduced quality of life alongside significant psychological burdens. That conclusion is consistent with the study’s broader design: quality of life was examined alongside well-being, diabetes distress and self-care rather than in isolation.

For people living with diabetes, quality of life can encompass much more than the absence of acute symptoms. The practical demands of treatment, concerns about complications, physical limitations, emotional well-being and the ability to maintain ordinary work and social activities can all influence how people perceive their health.

Physical Activity Was the Weakest Self-Care Behavior

Among the self-care activities assessed by the study, physical activity had the lowest reported adherence. The researchers used the Summary of Diabetes Self-Care Activities to examine diabetes-related behaviors.

This finding is significant because physical activity is a recognized component of diabetes management. The World Health Organization recommends regular physical activity for people living with type 2 diabetes as part of efforts to support physical and mental health and overall well-being. WHO also identifies regular physical activity as one of the measures that can help prevent or delay type 2 diabetes and its complications.

However, the DR-DAWN2 study does not establish why physical activity was the least-adhered-to behavior. The data show an association within the reported self-care patterns, but they do not demonstrate that depression or diabetes distress caused low physical activity. A cross-sectional study measures participants at one point in time and cannot establish the direction of cause and effect.

That limitation is important. Lower physical activity could coexist with psychological distress, but the study cannot determine whether distress reduced activity, low activity contributed to poorer well-being, or whether other factors influenced both. Social circumstances, work schedules, physical health, access to suitable spaces for exercise, symptoms, treatment demands and other factors could also play a role, but they should not be attributed to this study unless they were directly examined.

What the Study Says About Self-Care

Self-care in diabetes is not a single behavior. It involves a collection of activities that may include following dietary recommendations, taking medication as prescribed, monitoring blood glucose when indicated, engaging in physical activity and attending to other aspects of disease management.

The DR-DAWN2 researchers found generally low adherence to self-care behaviors, with physical activity standing out as the least-adhered-to activity. This is relevant because the effectiveness of diabetes treatment depends not only on what health professionals prescribe but also on what patients can realistically incorporate into everyday life.

Self-management can become demanding when several tasks have to be maintained over long periods. For someone working full time, caring for family members or dealing with other health problems, adding exercise, dietary changes, monitoring and medication routines can create a substantial daily workload.

This is one reason diabetes distress deserves attention independently of depression. Emotional strain may arise from the practical demands of diabetes even when a person does not have a depressive disorder. Recognizing that distinction can help health professionals ask more specific questions about what makes diabetes management difficult.

How Health Care Was Perceived by Participants

DR-DAWN2 also examined how participants perceived the care they received using the Patient Assessment of Chronic Illness Care, a measure related to the chronic care model.

The study found a moderate alignment between patients’ perceptions of their care and the chronic care model. Participants enrolled in a chronic disease management program reported a higher perceived alignment with that model.

The authors associated participation in chronic disease management programs with perceptions of more coordinated care and greater patient activation. Importantly, the study’s conclusion uses cautious language around potential health effects: the authors stated that these experiences could improve health outcomes. The study did not establish that enrollment itself caused better clinical outcomes.

The finding nevertheless points to an important principle in chronic disease care: patients do not experience the health system only through prescriptions or test results. They also experience how well services are coordinated, whether they are involved in decisions and whether they receive support for the practical work of managing a chronic condition.

Why the Dominican Context Matters

Diabetes is already a recognized public health concern in the Dominican Republic. The country’s Ministry of Public Health maintains clinical protocols for diabetes care, including a protocol for the diagnosis, treatment and control of type 2 diabetes mellitus. The ministry has also published a national diabetes report describing diabetes as a major chronic disease burden and documenting government efforts to encourage regular health checks and timely treatment.

WHO describes diabetes as a chronic metabolic disease in which the body cannot adequately regulate blood glucose. Over time, uncontrolled high blood glucose can damage blood vessels and nerves and contribute to complications affecting the heart, kidneys, eyes and feet. Management therefore requires more than a single intervention; it can involve lifestyle measures, medication, monitoring and screening for complications.

The DR-DAWN2 findings add another dimension to that established clinical picture. They suggest that, among the adults studied in Santo Domingo, psychological well-being, diabetes-specific emotional burden, quality of life and self-care were important parts of the diabetes experience.

That does not mean that the study represents everyone living with diabetes in the Dominican Republic. The participants came from a single outpatient center in Santo Domingo, and the research used a cross-sectional design. The findings should therefore be understood as evidence about the people included in this clinical setting rather than as a nationally representative survey.

Why the Difference Between Symptoms and Diagnosis Matters

Health reporting can easily blur the distinction between a screening result and a medical diagnosis. In this case, doing so would overstate what DR-DAWN2 demonstrated.

The study found that 18.7% of participants exhibited symptoms of depression according to the study’s measurement approach. It did not establish that 18.7% had been clinically diagnosed with depression.

Depression is a medical condition that requires appropriate clinical assessment. WHO describes it as different from ordinary fluctuations in mood and notes that effective treatments are available. A screening result can indicate that additional evaluation may be appropriate, but it should not be treated as a substitute for diagnosis.

Diabetes distress follows a different concept. It refers specifically to the emotional burden associated with diabetes and its management. A person can therefore experience diabetes distress without having clinical depression, and the two conditions should not be treated as interchangeable labels.

For patients, the distinction can make conversations with health professionals more useful. Instead of asking only whether someone is “depressed,” clinicians can also explore whether the person feels overwhelmed by diabetes, worried about complications, frustrated with treatment demands or unable to maintain recommended self-care routines.

What the Findings Mean for Diabetes Care

The authors of DR-DAWN2 concluded that the findings support psychological screening, patient-centered care and broader implementation of the chronic care model in this population.

Psychological screening does not mean diagnosing everyone with a mental health disorder. It means creating opportunities to identify people whose well-being or diabetes-related emotional burden may require further assessment or support.

Patient-centered care takes a similar approach to self-management. Instead of assuming that a patient simply needs more instructions, it considers the person’s circumstances, concerns, priorities and ability to carry out the recommended plan. For diabetes, that can mean discussing physical activity, diet, medication routines and emotional barriers as interconnected elements of long-term care.

The WHO also supports integrated approaches to chronic disease management. Its work on diabetes emphasizes comprehensive care that combines healthy behavior, physical activity, medication when required and regular assessment for complications. Its guidance on the relationship between mental health and chronic disease likewise supports identifying and addressing psychological needs within broader health care systems.

What the Study Does Not Prove

Several limitations should remain central when interpreting the results.

• It was cross-sectional. The study measured participants at one point in time, so it cannot establish causal relationships between psychological symptoms, self-care, physical activity and quality of life.
• It was conducted at one outpatient center. The sample provides valuable evidence from Santo Domingo but should not automatically be generalized to all adults with diabetes in the Dominican Republic.
• Several outcomes were measured through questionnaires. Patient-reported measures are useful for understanding lived experience, but they are different from clinical diagnoses or objective measurements.
• The depression finding concerns symptoms, not confirmed diagnoses. The 18.7% figure should therefore not be reported as the prevalence of diagnosed depression in the Dominican Republic.
• The study does not identify a single cause of low physical activity. It found that physical activity was the least-adhered-to self-care activity, but it did not establish why.

These limitations do not make the findings unimportant. They define what the research can legitimately tell us. The study provides a focused picture of psychosocial and self-management issues among adults with diabetes in a Santo Domingo outpatient setting and identifies areas that may deserve greater attention in diabetes care and future research.

How DR-DAWN2 Fits Into the Broader Evidence

The Dominican findings are consistent with a wider body of research showing that diabetes can have psychological and social consequences in addition to its physical effects. The original international DAWN2 program examined psychosocial outcomes among thousands of people with diabetes across 17 countries and used measures including the WHO-5, PAID-5, quality-of-life instruments and diabetes self-care assessments.

That international research also distinguished between likely depression and diabetes-related distress, reinforcing why the concepts should not be combined into a single measure of “mental health.” The Dominican study follows this broader framework while providing data from a local clinical setting.

More recent research in the Dominican Republic has also examined psychosocial distress among adults with type 2 diabetes in rural communities. That separate 2026 study involved 501 participants and reported depressive symptoms, acute stress and other forms of psychosocial distress. Because it used a different population, setting and methodology, its results should not be substituted for the DR-DAWN2 findings. Taken together, however, the studies indicate that psychosocial aspects of diabetes are an active area of research in the country.

Why Physical Activity Deserves Particular Attention

The DR-DAWN2 finding on physical activity deserves attention because exercise is both a component of diabetes management and a behavior that can be difficult to sustain over time.

WHO’s guidance for people living with type 2 diabetes emphasizes physical activity as part of disease management and overall physical and mental well-being. WHO also recommends at least 150 minutes of moderate physical activity per week for adults as part of diabetes prevention and management guidance, while recognizing that recommendations need to be adapted to individual circumstances.

The Dominican study does not tell us whether participants had adequate access to safe spaces, time, transportation, organized programs or other resources for physical activity. It therefore cannot be used to identify a specific social or environmental explanation for the low adherence. What it does show is that physical activity was the weakest self-care area measured in this group.

For clinicians and health programs, that finding can support more detailed conversations about barriers rather than simply repeating general advice. A recommendation to exercise is more useful when patients can discuss what prevents them from doing so and identify realistic ways of incorporating activity into daily life.

What the Findings Mean for Patients and Families

For people living with diabetes, the study reinforces that psychological burden is a legitimate part of chronic disease management. Feeling overwhelmed by diabetes does not necessarily mean someone has depression, but it can be a reason to discuss the experience with a health professional.

Family members can also play an important practical role, although DR-DAWN2 did not directly measure family members’ experiences. Support can include helping with routines, encouraging healthy behaviors and making it easier to attend medical appointments, while respecting the person’s autonomy in managing their condition.

For health professionals, the findings suggest that questions about emotional well-being and diabetes-related burden can complement traditional clinical monitoring. A patient whose glucose management appears difficult may be facing psychological or practical barriers that are not visible through laboratory results alone.

The Broader Lesson for Diabetes Care in the Dominican Republic

The central message of DR-DAWN2 is not that diabetes should be viewed primarily as a mental health problem. Rather, the study shows why diabetes care needs to account for several dimensions of the disease at the same time.

Blood glucose and medical complications remain fundamental. But for patients, successful long-term management also involves the ability to maintain daily self-care, remain physically active, cope with the emotional burden of a chronic condition and preserve a reasonable quality of life. Those dimensions can influence how manageable diabetes feels from one day to the next.

The study’s findings therefore add a psychosocial layer to the clinical picture already recognized by Dominican health authorities and international health organizations. They do not establish causal relationships or provide a national estimate, but they identify measurable burdens among adults receiving diabetes care in Santo Domingo.

For the Dominican Republic, that distinction matters. Improving diabetes outcomes is not simply a question of telling patients what to do. The DR-DAWN2 results suggest that understanding how people experience the disease may be an important part of designing care that patients can realistically follow over the long term.

As diabetes continues to require sustained management, the study provides a clear reason to look beyond glucose readings alone. Depressive symptoms, diabetes distress, quality of life, physical activity and self-care are different dimensions of the same chronic disease experience. Keeping those distinctions clear can lead to better interpretation of the evidence and, potentially, more comprehensive approaches to diabetes care.

Primary sources: Soto M, García N, Ortiz J, Calderón B, Diabetes Attitudes, Wishes and Needs in the Dominican Republic (DR-DAWN2), The Science of Diabetes Self-Management and Care, 2025; PubMed PMID 39921430; World Health Organization diabetes and mental-health guidance; Dominican Republic Ministry of Public Health diabetes protocols and national diabetes reporting.