Identifying the unmet needs of individuals with Type 2 diabetes: an international web-based survey

This international web-based survey identified several potential patient-related concerns and unmet needs among individuals with T2D in Brazil, China and Russia.

With regard to the T2D diagnosis context, almost half of the participants (45%) were diagnosed by chance during a routine check-up, while 55% of participants sought medical attention because of diabetes-related symptoms (mainly dry mouth, excessive thirst and fatigue). Despite 94% of participants having symptoms prior to diagnosis, only a third of these participants suspected diabetes, primarily because of a family history of the disease. On average, participants waited almost 1 year after developing symptoms before seeking medical attention, mainly because they felt their symptoms were not severe enough or they were afraid of the diagnosis. These findings indicate that there is a need to disseminate general diabetes information to increase overall awareness of symptoms and the importance of visiting a healthcare professional as soon as they develop, and to address the fear induced by a diabetes diagnosis in some people.

At the time of their T2D diagnosis, most participants felt fear and apprehension, and had difficulty accepting their disease. The participants’ main concerns were the development of severe complications, including vision impairment, diabetic foot and heart disease, and multiple food restrictions, while chronic kidney disease was mentioned as a concern by a minority of patients. After diagnosis, participants reported using the internet to seek further diabetes-related information, mainly about food and diet advice and long-term disease complications.

When comparing participants’ responses between countries, more participants in Brazil than in China and Russia sought medical attention for diabetes-related symptoms, while more participants in Russia than in Brazil and China were diagnosed with T2D by chance. The proportion of participants who had their first consultation with a diabetes specialist was lower in Brazil than in other countries; however, the mean duration of the first visit was longer in Brazil than in other countries. More participants in Brazil versus other countries combined were satisfied overall with their first T2D consultation. Participants reported lower mean satisfaction scores for the amount of disease information in Russia than in other countries. Mean QoL scores were lower in Russia versus other countries immediately after diagnosis, at 6 months after diagnosis and at the time of the survey.

The participants’ perspectives in our study are consistent with and add to those of previous studies that examined the unmet needs of patients with diabetes. In the cross-national DAWN study (which included patients from 13 countries including Australia, India, Japan, the USA and a number in Europe), the majority of participants reported diabetes-related psychological problems, including anxiety, depression and stress, as well as poor psychological well-being [17]. Many healthcare professionals could not identify these psychological problems or provide the support to their patients [17]. Similarly, in the DAWN2 study (of patients in 18 countries), healthcare professionals reported that access to quality care was poor and more diabetes-related training is needed [14]. Diabetes was associated with physical, emotional, social and financial impact on the participants’ lives and presented many psychosocial challenges. The majority of participants did not feel that they received sufficient support from a healthcare professional, despite this being a high priority for most. The DAWN2 study identified unmet needs in the availability of psychosocial support, self-management education and person-centered diabetes care [14,16]. Participants also reported several challenges with regard to the impact of diabetes on work (and vice versa) [18]. In the DIABASIS study, the shortcomings of the diabetes healthcare system in France were highlighted by most participants, who reported high levels of distress at the time of their diagnosis, as well as the need for more information to help cope with this distress [19]. The importance of educational activities and the need for information at disease onset were under-recognized and routine healthcare professional visits were too short for in-depth counseling. Similar to the DAWN studies, many participants reported feelings of anxiety, depression and helplessness, fear, dismay or anger [19].

In our study, the main potential unmet needs were more information and support about food and diet, a new solution for noninvasive monitoring blood glucose levels and increased awareness of T2D symptoms to possibly allow for earlier diagnosis. Although the benefits of self-monitoring of blood glucose in patients with T2D who are not receiving insulin are questionable [23,24], noninvasive monitoring devices may address a lack of adherence due to the pain of invasive monitoring techniques [25]. In our study, most participants (78%) were not receiving injectable therapy at the time of the survey; however, our results indicate that the participants recognized the potential benefits of a noninvasive, painless device for blood glucose monitoring, particularly once insulin therapy was ultimately needed. The participants also expressed a need for consistent and detailed guidelines and support regarding their food and diet.

Our study also identified possible opportunities for innovative solutions to address these unmet needs. A smartphone application was considered the most appropriate format for providing a new solution for individuals living with T2D and other conditions associated with increased cardiovascular risk, and if available, should be recommended by healthcare professionals. The participants favored an ‘all-in-one’ approach that covers multiple topics related to disease management, including disease information, food and diet, blood glucose control, lifestyle, treatment and potential complications, rather than a diabetes-only option.

The main strengths of our study were its large study population of individuals with confirmed T2D diagnosis from three countries and its robust three-phase methodology. Using a sequential approach, our study developed a quantitative questionnaire that was built entirely from participant feedback, allowing us to form reliable conclusions from our findings. In addition, the multi-channel method of recruitment allowed us to have a varied sample of the T2D population. Participants responding to an online questionnaire are probably more willing to share their experiences as they feel free to express themselves anonymously without their doctor’s involvement. As this was a self-reported questionnaire, the main study limitations were the possibility of bias in the participant responses (i.e., sampling bias, nonresponse bias and recall bias), which is common in web-based surveys and the exclusion of individuals diagnosed with T2D before 2014. There was also the possibility of selection bias, as participants responding to an online questionnaire may be more likely to use a smart phone application for disease information and management than the general population. Another limitation is that the diagnosis and clinical data collected were not provided by healthcare professionals but rather by participants themselves (i.e., current medical prescription, diagnosis evidence), except for the individuals with T2D recruited via their practicing doctor (e.g., about 40% in Brazil), which may lead to recall bias. Further, the samples from each country were not fully representative of the general population of patients with diabetes in each country, in particular regarding the male/female ratio in the samples from China and Russia [4,5] and the age groups of the sample from Brazil [3]. However, the participant baseline characteristics were generally well balanced between countries, thus reducing the risk of major bias when comparing countries. Finally, individuals who do not have computer or internet access were excluded, which may lead to a potential recruitment bias.

This international web-based survey identified several potential unmet needs among individuals with T2D in Brazil, China and Russia, including the need for more information and support regarding food and diet, the need for a new solution for noninvasive monitoring blood glucose levels, and the need for increased awareness of T2D symptoms, which may facilitate earlier diagnosis. Several possible innovative solutions were identified, although further research is needed to confirm whether these solutions can help to address these needs.

E Court was involved in the conception and design of the study, reading and revising the manuscript drafts, and approval of the final manuscript. JF Raposo, MV Shestakova, J Lu and AY Mayorov were involved in reviewing and analyzing the study results, reading and revising the manuscript drafts, and approval of the final manuscript.

The authors thanked S Greig of Springer Healthcare Communications who prepared the outline and first draft of this manuscript.

The study was performed by STETHOS International (Sèvres, France) funded by Servier. E Court is an employee of Servier. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

This medical writing assistance was funded by Servier.

Participants provided written informed consent prior to taking part in the qualitative interviews or focus groups or in the quantitative questionnaire. The study was conducted in accordance with the appropriate regional, national or local guidelines for noninterventional studies and used guidelines of the International Chamber of Commerce/European Society for Opinion and Marketing Research (International Chamber of Commerce 2016), the European Pharmaceutical Market Research Association (European Pharmaceutical Market Research Association 2019) and Good Pharmacoepidemiology Practices (International Society for Pharmacoepidemiology 2015) as a minimum standard.

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