The 2nd Diabetes Attitudes, Wishes & Needs (DAWN2) study: objectives and methodology

1. The 2nd Diabetes Attitudes,
Wishes & Needs (DAWN2) study:
objectives and methodology
Richard Holt
University of Southampton, UK
on behalf of the DAWN2 Study Group
Rachid Malek, Johan Wens, João Eduardo Salles, Katharina Kovacs Burns, Michael Vallis,
Xiaohui Guo, Ingrid Willaing, Gérard Reach, Norbert Hermanns, Bernhard Kulzer, Frans
Pouwer, Antonio Nicolucci, Marco Comaschi, Hitoshi Ishii, Miguel Escalante, Andrzej
Kokoszka, Alexandre Mayorov, Edelmiro Menendez, Ilhan Tarkun, Melanie Davies, Angus
Forbes, Neil Munro, Mark Peyrot, Søren Eik Skovlund, & Christine Mullan-Jensen

2. Richard Holt 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 and has received funding for travel and
accommodation to attend DAWN2 International Publication
Planning Committee meetings and to attend this meeting

3. DAWN study in 2001
5426
Adults with diabetes
13
Countries
3982
Healthcare professionals
Platform for stakeholder dialogue and engagement
To improve outcomes in diabetes,
we must focus on the person with the condition

4. 1. Improve dialogue and communication between people
with diabetes and healthcare professionals
DAWN call to action
The 2nd DAWN International Summit 5 November 2003, London, UK:
Practical Diabetes International, Volume 21, Issue 5, 2004
1
1. Improve team-based care of and communication among
healthcare professionals2
1. Increase delivery of individual support for more active
self-management and healthier lifestyle3
1. Overcome emotional barriers to effective therapy among
healthcare professionals and people with diabetes4
1. Enable healthcare professionals to assess and address
needs for psychological support and treatment among
people with diabetes
5

5. Why was a new study required?
1. International Diabetes Federation (IDF). IDF Diabetes Atlas, 6th edition revision, 2014.www.idf.org/diabetesatlas; 2. IDF
Diabetes Atlas, Fifth Edition, 2011 3. http://www.who.int/mediacentre/factsheets/fs312/en/index.html
387million
People with diabetes
today 1
Will increase to
592 million by 20352
10seconds
Three more people
will develop diabetes3
Every
Primary health systems are under-
resourced and poorly designed to
deliver empowering and supportive
preventive diabetes and chronic care
Active broad involvement of people with
diabetes and their family members, use
of chronic care models, and IT/mobile
technologies are yet to be fully realised
DAWN2 required to
provide new global evidence and a partnership
platform to drive long-term change for
person-centered chronic care and prevention

6. Society: A healthcare system,
government, and public that are
willing to listen, change, and be
supportive of my condition
Me: Being able to cope with my
condition, and living a full, healthy,
and productive life
Family and friends: Emotional
and practical support in all aspects
of my condition
Community:
Medical care and treatment: Access
to quality diagnosis, treatment, care,
and information
Work/school: Support for, and
understanding of, my condition
Living: Having the same opportunities
to enjoy life as everybody else
The DAWN™ needs model 2011. DAWN Study 2001
DAWN Youth Study 2008; DAWN2 Dialogue Events 2011
A new needs model for diabetes

7. The DAWN2 study

8. Long-term study goals
 Raise awareness of the unmet
needs of people with diabetes, their
family members, and healthcare
professionals
 Facilitate new dialogue and
collaboration among all key
stakeholders in diabetes to
improve patient involvement and
equal access to quality care,
self-management education,
and support
 Drive scientific benchmarking and
better practice sharing to facilitate
global, national, and local action for
person-centered diabetes care
To enable all people
with diabetes to live
full, healthy, and
productive lives, and be
actively engaged in
preserving their own
health and quality
of life

9. Unique elements
 A participatory process: from concept to action
 Building on a decade of DAWN insights worldwide
 Use of IDF, IAPO, and WHO models for person-centered
chronic care, rights, and responsibilities
 A 360º approach to explore also the needs of family
members and healthcare professionals
 Benchmarking person-centered diabetes care
 Benchmarking national policies for person-centered care
 Personal narratives of all stakeholder groups
IDF, International Diabetes Federation; IAPO, International Alliance of
Patients’ Organizations; WHO, World Health Organization

10. Objectives
Primary Outcome
 Assess potential barriers to and facilitators of active self-
management of diabetes among people with diabetes and their
family members and healthcare professionals
Secondary Outcomes
 Establish national benchmarks for health status, quality of life,
access to self-management education and to self-care in diabetes
 Assess the access to, and use and benefit of, support from
healthcare teams, family and friends, communities and society
 Explore and pinpoint the most important facilitators and barriers
to person-centered chronic care for each stakeholder group
 Identify successes, wishes, needs, preferences and priorities for
change for all stakeholders

11. Participating countries
Mexico
Netherlands
Poland
Russian Fed.
Spain
Turkey
UK
USA
Algeria
Canada
China
Denmark
France
Germany
India
Italy
Japan
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84

12. Key stakeholders identified for study
participation
 People with diabetes (≥18 years)
− Type 1
− Type 2
 Treated with insulin (Insulin Med)
 Treated with diabetes medication other than insulin (Non-Insulin Med)
 Not treated with any diabetes medication (Non-Med)
 Adult family members of adults with diabetes
 Healthcare professionals who treat people with diabetes
− Primary care/General practitioners (PCPs/GPs)
− Diabetes specialists
− Nurses/Educators
− Dieticians/Nutritionists
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84

13. Qualification criteria:
Healthcare professionals
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84
PCPs/GPs
• Primary specialty of
general practice or
internal medicine
• 5+ adult patients with
diabetes per month
• Initiate oral diabetes
medication
Specialists
• Primary specialty of
endocrinology,
diabetology, or general
practice/internal medicine
with sub-speciality in
diabetes
• 20->50 adult patients
with diabetes per month
(varies by country)
• Prescribe insulin for
diabetes
Nurses/Dieticians
• General practice and
diabetes nurses, nurse
practitioners, physician
assistants, dieticians,
and nutritionists
• 5+ adult patients with
diabetes per month
• Agree to participate upon review of the informed consent form provided
• Currently reside in each country
• Have been in practice/their profession for at least 1 year
All
participants
must
Specific criteria

14. Qualification criteria:
People with diabetes and family members
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84
• Diagnosed with diabetes by a
healthcare professional
• At least 12 months ago
• Not only during pregnancy
People with diabetes
• Not diagnosed with diabetes
• Live in the same household
with an adult 18+ years of
age with diabetes (not only
during pregnancy)
• Involved in the care of the
adult with diabetes
Family members
• Agree to participate upon review of the informed consent form provided
• Currently reside in each country
• Be 18+ years of age
All
participants
must
Specific criteria

15. Recruitment and interviewing process
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84
Identified from
 Online panels and databases
 Phone lists
 General population directories,
physician/hospital directories
 Referrals from participating people with
diabetes (family members only)
 Professional association lists (healthcare
professionals only)
Invited by
 Email
 Phone
 Hospital intercept
 In-person methods
Surveys conducted
 Online
 By phone (people with diabetes
and family members only)
 In-person (people with diabetes
and family members only)
Survey language
 Local language(s)
(except for India healthcare
professionals – English)

16. Data collection
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84
1. National geographic coverage was ensured for
the majority of the countries
Geographic
coverage
1. A wide range of socio-economic status was
ensured for people with diabetes and family
members
Demographic
representation
1. The surveys were conducted between
March and September 2012
Data collection
timing

17. Country sample quotas
GP, general practitioner; PCP, primary care physician
T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus
Total participants per country
n=900
People with diabetes
n=500
T1DM
n=80
T2DM (n=420)
-Insulin medicated (n=150)
-Non-insulin medicated (n=170)
-Non-medicated (n=100)
Family members
n=120
Healthcare professionals
n=280
PCPs/GPs
n=120
Diabetes specialists
n=80
Nurses/dietitians
n=80
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84

18. Total participants globally
n=15,438
People with diabetes1
n=8596
Type 1
n=1368
Type 2 (n= 7228)
-Insulin Med (n=2591)
-Non-Insulin Med (n=2937)
-Non-Med (n=1700)
Family members2
n=2057
Healthcare
professionals3
n=4785
PCPs/GPs
n=2066
Diabetes specialists
n=1350
Nurses
n=827
Dietitians
n=542
Total study population
1. Nicolucci A, et al. Diabet Med 2013;30:767–77; 2. Kovacs Burns K, et al. Diabet Med 2013;30:778–88
3. Holt R, et al. Diabet Med 2013;30:789–98

19. Questionnaire development
 Questionnaires developed by international multi-disciplinary
workgroup including people with diabetes
 Questionnaire based on person-centered model for
chronic care
 Questionnaires for each stakeholder group mirror each other
 Original DAWN study questions for evaluation of trends
 New questions for issues such as discrimination and
education
 Validated measures (and adaptations thereof) for the
purpose of cross-national and longitudinal
benchmarking
 Open-ended questions to capture individual stories
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84
Stuckey H, et al. ADA 2013, Chicago; Abstract 2013-A-4653

20. Questionnaire topics
Peyrot M, et al. Diabetes Res Clin Pract. 2013;99:174–84
Attitudes and beliefs
about diabetes
Care and
support/involvement
Diabetes education
and information
Health/quality of life
(people with diabetes and
family members)
Diabetes profile
Active
self-management
Diabetes training
(healthcare professionals)
Future needs
Demographic and
practice characteristics

21. The first DAWN2™
benchmarking
results

22. Percentage of people concerned about
the risk of hypoglycemia by country
The dotted line represents the mean value relative to the entire sample of people with diabetes.
Nicolucci A, et al. Diabet Med 2013;30:767–77

23. Barriers to diabetes medications
People with
diabetes would be
willing to start
insulin if
recommended
Base: All qualified people with diabetes who currently receive meds other than insulin or other injectables or do not receive any diabetes
medications (variable base)
Q1458/Q1460 Please rate to what extent you agree with the following statements about diabetes medication based on your own experience or
knowledge/about diabetes treatment and medication. Scale of: fully disagree, mainly disagree, mainly agree, fully agree, not sure
A
People with diabetes
would be willing to start
injectables other than
insulin if recommended
B
AB
ABC
ABD
Starting insulin means
people with diabetes have
not followed treatment
recommendations properly
B AB

24. Risk of hypoglycaemia associated with insulin
Taking insulin increases the risk of low blood sugar
(% of people with diabetes on medication who mainly or fully agree)
Base: All qualified people with diabetes (Type 1: n=1,368; Type 2 Insulin users: n=2,591; Type 2 Non-Insulin users: n=2,937)
Q1458 Please rate to what extent you agree with the following statements about diabetes medications based on your own experience or
knowledge. Scale of: fully disagree, mainly disagree, mainly agree, fully agree, not sure
D
BD

25. Access to mental health professionals for
referral
A
ABD
A
% of health care professionals feeling there should be better
access to psychologists or psychiatrists for referral
(ratings of 5 or 6 on a 6-point agreement scale)
Base: All qualified health care professionals (PCPs/GPs: n=2,066; Specialists: n=1,350; Nurses: n=827; Dietitians: n=542)
Q955 Thinking generally about diabetes care in your country, please indicate the extent to which you agree or disagree
with each of the following statements. Scale of: fully disagree (1) to fully agree (6)

26. 33%
43%
26%
49%
61%
36%
0% 100%
I prefer to delay the initiation of GLP-1
analogues until it is absolutely essential
I prefer to delay the initiation of
insulin until it is absolutely essential
I prefer to delay the initiation of oral
therapy until it is absolutely essential
PCPs/GPs (A) Specialists (B)
‘Fully/Mainly Agree’ Ratings
Attitudes about type 2 treatments
(Physicians)
Base: All Qualified Physicians (PCPs: n=2,066; Specialists: n=1,350)
Q1010 Please indicate the extent to which you agree or disagree with the following treatment approaches for Type 2 patients with diabetes.
B
B
B

27. 48%
74%
72%
65%
68%
69%
87%
89%
43%
72%
65%
68%
60%
66%
78%
83%
0% 100%
Less pain or discomfort when taking medications
Greater effect on multiple risk factors for complications
Greater effect on lowering blood sugar
Fewer daily doses
Greater flexibility of dosing times to fit a patient's lifestyle
Fewer side effects (other than hypoglycemia and weight gain)
Less risk of weight gain
Less risk of hypoglycemia
PCPs/GPs (A) Specialists (B)
Improvements in diabetes medication
(Physicians)
Base: All Qualified Physicians (PCPs: n=2,066; Specialists: n=1,350)
Q1015 Please consider the treatments that are currently available. Which improvements in diabetes
medication would be most helpful for improving outcomes for your patients with diabetes?
Improvements Physicians Find Most Helpful To Achieve Better Patient Outcomes
Physicians could select more than one response
A
A
A
A
A

28. Summary
 The DAWN2 study is a multinational, multidisciplinary and multi-stakeholder
survey
− Conducted in 17 countries, on four continents, taking a 360° perspective
− Importantly, the study includes family members of people with diabetes
 Study goals are to:
− Achieve a broader humanistic and societal perspective on the burden of diabetes
− Provide a voice for people with diabetes and those caring for them, reflecting unmet
needs and new opportunities
− Identify areas for improvement and determine drivers of change towards person-
centred diabetes care
− Facilitate collaborative advocacy and action for the improvement of self-management
and psychosocial support and related aspects of diabetes care and prevention
 Findings from DAWN2 will impact on future research, clinical practice, and
public policy