JMIR Publications

ABSTRACT

Background:

Background:

Gestational diabetes mellitus (GDM) is associated with risks for mother and child. The escalated GDM prevalence, due to obesity and changes in screening criteria demands for greater health care needs than before. This study aimed to understand the perception of patients and health care providers of the barriers to GDM management and preferred interventions to manage GDM in an Asian setting.

Methods:

This mixed-method study used a convergent parallel design. Survey data was collected from 216 women with GDM, and semi-structured interviews were conducted with 15 women and with health care providers (n = 8) treating patients with GDM. Participants were recruited from two specialized GDM clinics at the National University Hospital, Singapore.

Results:

Patients were predominantly Chinese (n=102 [47.6%]), employed (n=201 [73.9%]) , with higher education (n=150 [69.4%]) and prenatal attendance at a private clinic (n=138 [64.2%]), already on diet control (n=210 [98.1%]), and receiving support and information from the GDM clinic (n=194 [90.2%]) and online sources (n=131 [60.9%]). Particularly, working women reported barriers to GDM management including lack of reminders for blood glucose monitoring, diet control and insufficient time for exercise. Women most preferred getting such support directly from health care providers, whether at the GDM clinic (n=174 [80.9%]) or elsewhere (n=116 [53.9%]). Smartphone applications (‘Apps’) were the preferred means of additional intervention. Desirable intervention features identified by patients included more information on GDM, diet and exercise options, reminders for blood glucose testing, a platform to record blood glucose readings and illustrate or understand trends, and a means to communicate with care providers.

Objective:

to understand the perceptions and knowledge of GDM among the women and care providers, as well as related barriers and potential interventions to overcome the barriers.

Methods:

Design and study population This study was undertaken with pregnant women with a diagnosis of GDM attending the National University Hospital (NUH) in Singapore. Currently, all public hospitals in Singapore that provide prenatal medical care follow the latest WHO guidelines [19] for the diagnostic criteria of GDM and provide universal screening for GDM to pregnant women. Screening is typically offered between 24 and 28-weeks gestation. Women diagnosed with GDM attend a comprehensive multidisciplinary educational session to help equip them with the required knowledge to manage GDM during pregnancy. This study was conducted using mixed methods with quantitative and qualitative components, and a convergent parallel design (Figure 1). A cross-sectional survey was undertaken in pregnant women attending one of two specialized GDM care clinics at NUH. Inclusion criteria were being pregnant, aged 21 to 40 years, diagnosed with GDM during the index pregnancy and attendance at the GDM clinic’s workshop on GDM management (delivered by a nurse educator and a dietitian). Exclusion criteria were inability to speak English, and known type 1 or type 2 diabetes prior to the current pregnancy. Recruitment took place over two years between May 2015 and May 2017, with two phases of data collection. Study tools For the quantitative component, a 30-item cross-sectional survey was used to collect demographic information, participant knowledge, control and attitude towards GDM, perceived barriers to GDM management, and current and preferred GDM support. Women were asked to rate their GDM knowledge before and after attending the GDM clinic and the answer options included “Excellent, Good, Fair, Poor”. Questions related to GDM risk, perception and attitudes were adapted from validated tools.[20] Attitude-related questions measured perceived personal control (2 questions), worry (2 questions) and optimism regarding recurrent GDM in future pregnancies (1 question). The four responses ranged from “Strongly Agree” to “Strongly Disagree” and the scores on a four-point Likert scale (0 – 4). Average scores were calculated for each participant. For the qualitative component, semi-structured interviews were conducted using a topic guide based on published literature. This included questions on knowledge and attitude regarding GDM, existing sources of support and coping mechanisms, current lifestyle practices, perceived barriers, ways of managing and monitoring GDM, and preferred intervention for GDM management. Potential participants for the survey were approached in the waiting room of the GDM clinic. The study team refrained from approaching women who seemed tired or anxious. After getting informed consent, women were given the self-administered survey. No personal information was collected. In the first phase of the study, only a hard-copy (paper) of the survey was offered. An online survey was added in the second phase in order to increase the recruitment rate. The online form was created using the SurveyMonkey survey tool (SurveyMonkey Inc., San Mateo, California, USA) and tested for any technical difficulties. The data collection was carried out using a closed survey. Thirty questions were distributed over 3 screens. Those who elected to complete the survey online were sent the link to the survey via e-mail. Three additional ‘reminder’ emails were sent to women in the following six weeks inviting them to complete the survey before they were designated as true ‘non-responders’. For pregnant women who were willing to participate in prenatal interviews, sessions were scheduled based on their convenience. In the second phase, to increase the survey completion, the women were given an incentive of S$25. In the first phase, 50 patients participated in the survey. Of those 50 patients, 15 participated in the interviews. Two study members (J.A. and S.S.H.) conducted all the interviews in English. Most interviews were conducted at the health care facility or at the participants’ home, in a private space conducive for the participant to share thoughts effectively. Before the interview, participants provided informed consent, including for audio recording. Health care providers treating GDM patients from nursing, dietetics and obstetrics and gynaecology (Ob/Gyn) specialties were approached for interviews. The final number of interviews conducted was decided based on reaching thematic saturation as understood by the analysis which was conducted in parallel with the data collection. Data saturation was reached at the 15th patient interview and the 8th care provider interview. Patient interview participants were from the first phase and they were given S$50. Ethics approval was obtained from the National Healthcare Group (NHG) Domain Specific Review Board (DSRB), Singapore (NHG DSRB Ref: 2015/00196). The study flowchart outlines steps involved in the recruitment, consent and follow-up (Figure 2). Data analysis Univariate analysis was conducted to describe the study participants and GDM management. Results are presented using medians and interquartile ranges for continuous variables with skewed distributions, while categorical variables are presented with frequencies and percentages. Perceived improvement in GDM knowledge after attending the GDM workshop was analyzed using Fisher’s exact test. Those who received a score between 0 to 2 for GDM attitude-related factors, perceived GDM control and perceived worry for GDM control, were labeled as “low” and others were labeled as “high”. Body mass index was calculated using the self-reported height and weight. The analysis was undertaken using Stata statistical software (Stata Corp. 2013. Stata Statistical Software: Release 13. College Station, TX, USA). The interviews were audio recorded, transcribed verbatim, and analyzed thematically.[21] After listening to the audio recordings, verifying the transcripts for accuracy and removing any identifying information, one researcher (S.S.H.) coded the transcripts using Atlas Ti Software (QSR International Pty. Ltd., 2012) and Microsoft Excel™. Subsequently, related codes were grouped together to identify final themes and to build the hierarchy.

Results:

Results The average number of women attending the GDM clinic is 60 per month. In phase 1, the survey completion rate was 18.5%. In phase 2, 67.2% of the women visiting the clinic were interested in participating in the study with 75.4% actually completing the survey, giving a completion rate of 44.0%. Most of the non-participants declined to participate without reason, while some declined due to insufficient time. Demographic and pregnancy information Table 1 provides the demographic and health information of the survey participants (n=216), and Table 2 for interview participants (both patients and health care providers). In brief, the median age of the women was 32 years, 102 (47.6%) were Chinese, 201 (73.9%) were in full- or part-time employment, and 150 (69.4%) were university graduates. The median duration of pregnancy was 30 weeks, 109 (50.4%) the women were multiparous, and 138 (64.2%) attended a private clinic for their prenatal care. Approximately half (53.9%) were either overweight or obese before pregnancy and a large majority, 180 (83.3%) perceived their health as “good” or “excellent”. Table 1: Survey participants’ demographic characteristics Variable n (%) Age, median (Interquartile range) (n=209) 32 (22-40) Ethnicity (n=214) Chinese 102 (47.6) Malay 46 (21.5) Indian 43 (20.1) Other 23 (10.7) Employment (n=214) Full-time 146 (68.2) Unemployed 55 (25.7) Part-time 13 (6.1) Education (n=216) Degree or professional qualification 150 (69.4) Secondary education 62 (28.7) Lower than secondary education 4 (1.8) Pregnancy in weeks, median (Interquartile range) 30 (8-39) Multiparous (n=215) 109 (50.4) Prenatal care (n=215) Private clinic 138 (64.2) Subsidized clinic 77 (35.8) Pre-pregnancy body mass index (n=208) <23 kgm-2 96 (46.1) 23-27.5 kgm-2 59 (28.4) >27.5 kgm-2 53 (25.5) Health (n=216) Poor 1 (0.5) Fair 35 (16.2) Good 158 (73.1) Excellent 22 (10.2) Of the first 50 survey participants, 35 gave verbal consent to participate in the interviews. Those who replied to follow-up contact were interviewed according to their convenience. Data saturation was reached at the 15th interview. Half of the 15 participants fell in the 31-35-year age group, were primiparous or had a family history of type 2 diabetes mellitus (T2DM), and most were Chinese or Indian, employed full-time, with a degree, and attending a private prenatal clinic. Eight prenatal care providers at the GDM clinic were interviewed. Table 2 and 3 provide details of the interview participants. Table 2: Interview participant profile - Patients attending a GDM clinic Variable n (15) Age, years 26-30 3 31-35 8 36-40 4 Ethnicity Chinese 5 Malay 3 Indian 5 Filipino and Sri Lankan 2 Employment Full-time 11 Unemployed 3 Part-time 1 Education Degree or professional qualification 14 Secondary education 1 Parity- primiparous 8 Prenatal care Private clinic 12 Subsidized clinic 2 Family history 8 Table 3: Interview participant profile - Health care providers serving at a GDM clinic Variable n (8) Professional Qualification Ob/gyn 2 Diabetes care nurse educator 4 Dietitian 2 Years of total Experience 1–5 years 2 6–10 years 3 More than 10 years 3 Gender Female 6 GDM knowledge As reported by the participants, there was a significant improvement in perceived GDM knowledge after attendance at the GDM workshop (Chi2 (9) = 53.97, p < 0.05). The vast majority (93.5%) identified large for gestational age of the baby as a potential outcome of GDM, and 92% correctly identified the optimal range for pre- and post-prandial capillary blood glucose levels. As confirmed by the interviews, other than those women with a previous history of GDM, most were unaware or not fully aware of GDM before their clinical diagnosis. Those who had any knowledge of GDM mentioned that they had heard about it from peers with GDM. Most participants, even those with a family history of T2DM, still did not have sufficient information on GDM. However, the participants felt the clinic helped to “increase the understanding of GDM”. “Actually, I didn’t know anything about it… So, I … thought that if you were diabetic then you kind of get it. But then I didn’t know something you can just develop during pregnancy as well. So, it was quite new to me”. [ID_02] “Now, the understanding level has gone high. I know like how to control and then how to manage my diet and then when to measure, what are the steps I need to take”. [ID_13] GDM management Almost all of the participants, 210 (98.1%) controlled their diet, half, 103 (48.1%) were physically active, and 21 participants, one-tenth, were using insulin to regulate blood glucose concentrations. Most participants, 185 (85.6%), were able to follow typical recommendations from the GDM clinic to perform finger prick blood testing seven times a day on two days each week (Table 4). Women who were interviewed also managed their blood glucose using diet modifications and monitored blood glucose levels using finger prick blood testing. Employed women, mostly Chinese and Malay, more likely to consume outside food options rather than home-cooked food. Few of the interviewed women were physically active, and only two used insulin therapy. The women mentioned that they were asked to record their blood glucose levels from finger prick tests, and to submit the results to their prenatal care provider every two weeks. Most mentioned they performed the test more frequently than required and mainly used test results to “interpret the effectiveness of GDM control”, primarily diet. A few believed that physical activity helped with blood glucose control. “Mainly diet. I really watch my diet. Yes, actually now I, there’s only about a few choices that I can have every day.” [ID_08] “So, from there I monitor. Let’s say one weekend and one weekday I monitor. But, let’s say if I want to feel, say in the morning I want to watch I just go on. So, it doesn’t matter, two times a week. Let’s say, watch three times or more, depends I feel want to check my sugar.” [ID_09] Table 4: GDM management Variable n (%) GDM management (n=214) Diet management 210 (98.1) Physical activity 103 (48.1) Insulin use 21 (9.8) Finger prick blood test (n=216) Record seven readings two days or more 185 (85.6) Most of the time 20 (9.3) Sometimes or never 11 (5.1) Attitude towards GDM control In the survey, 97.7% of participants received a high score for perceived GDM control, while 74.5% scored high for the perceived worry score of GDM control. Most women, (72.3%) perceived that they would not be able to control getting GDM in future pregnancies. In the interviews, most women reported feeling worried or anxious when GDM was diagnosed, while the GDM clinic’s workshop helped to lessen their anxiety. At the time of the interview (subsequent to the clinic), many reported feelings of control related to diet and that they were “on the right track” in monitoring using the finger prick test. “That, I was just grappling around, reading on the internet, and then I was like ‘Oh my god, what do I do?’ So, I was panicking.” [ID_01] “Because I am actually monitoring the sugar level at the moment. And I think it’s actually ok. So, far I am actually on the right track.” [ID_06] Health care providers felt that most women were motivated to control their blood glucose levels and also stressed the importance of “discipline”, especially with respect to their food intake during this period. “Generally, this group of patients, they are very motivated. So, if they don’t have any language barriers, they should be able to understand that important for them… But in general, at least a good 80% of them seems to be quite receptive, I would say yeah…” [ID_04_ Dietitian] Barriers to GDM control Most survey participants did not feel that they faced any significant barriers to GDM control. However, a significant minority (24.9%) felt they had difficulties in remembering blood testing schedules, while 22% felt discouraged due to the lack of immediate effects from their lifestyle changes (i.e. continuing to have abnormal test results even after implementing GDM management). One-fifth of participants (21.5%) agreed or strongly agreed to not having sufficient knowledge about GDM, or to experiencing difficulties following the recommended diet and physical activity plan. On the other hand, most women reported they had sufficient help from family and friends, and that family, cultural beliefs or traditions did not interfere with GDM management (Figure 3). Conversely, based on the qualitative data, most employed women mentioned that they had barriers to GDM management mainly related to diet, increasing physical activity and monitoring blood glucose. Women felt that they had a “limited (food) variety” because they had few food options that helped control blood glucose levels. “I have still maybe about three, four months or even more to go. So, I think I must expand the variety to make life easier.” [ID_08] Only a few mentioned that they did exercise to control GDM. Although they had received advice to increase their physical activity, women felt unable to follow the recommendations mainly due to a “lack of time for exercise”. “I think one problem is that it’s not always very easy to exercise. Because one of the advice(s) is that you should have like a 10-15 minutes’ walk or some form of exercise after every meal. But it’s not very possible to do it after your lunch for example if you are working.” [ID_02] According to the clinical practice guidelines of the Ministry of Health, Singapore, women are required to self-monitor their blood glucose.[22] At the NUH GDM clinic, women were advised to submit seven blood glucose readings for one weekday and one weekend day each week. However, women had difficulty performing the required seven readings for each testing day, largely because they forgot to take the test: “So, it is very hard to get these seven readings [finger prick test reading]. So, one thing is that it is tiring, and the other thing is that you kind of unconsciously forget[s] with work and [a] lot [of] things as well. So, maybe you had your lunch and you finish[ed] it at one [pm] and then you take one [finger prick test] at three [pm]. And then you forget because you are like completely into your work.” [ID_02] Similarly, health care providers reported that working women experienced more barriers to managing GDM than non-working women. “Of course, if let’s say if they do work, then shift workers are quite difficult to tackle their meal timings and all. So, that is one of their barriers like limitation, their work commitments and all.” [ID_04_ Dietitian] Support to GDM Management Of 216 survey participants 194 (90.2%) reported receiving GDM-related information from a doctor, nurse or trained counselor at the GDM clinic and 131 (60.9%) from websites. Thirteen (6.1%) participants reported in-person support groups for expectant mothers as the method used least frequently (Figure 4). In the interviews, women were most likely to rely on health care providers to guide them with medical advice. Further, almost all mentioned that they used the internet to get additional information related to GDM management. However, most of the resources used were intended for Western populations. Most of the women received help from their family and from peers. In addition, they either approached peers with previous experience in controlling GDM or online forums. Most of them felt they had “sufficient support” in GDM management, while a few needed extra helps. “Internet and friends and doctors”. [ID_07] “I would say mainly like my husband and I would say my colleagues” [ID_02] “Well, one is you know because my colleague is also a pregnant woman and we are good friends, so we discuss a lot about it”. [ID_14] According to health care providers, support from physicians, nurse educators and dietitians was available in the usual clinic setting, and women were followed up fortnightly. On occasions requiring additional medical assistance, women were advised to approach the GDM clinic at the hospital. Some providers mentioned that they offered additional reading resources. In contrast, others pointed out the need to regulate the quality of supplementary material, especially of internet sources. Health care providers also acknowledged that, during this time, women may need additional emotional assistance from family members including husbands, and friends. “I mean we give them resources to read. The Royal College of Obstetricians and Gynecologists in the UK have lots [of] patient education leaflets that we can refer them to read at home and at leisure.” [ID_02_Ob/gyn] “And some of the database [are] based on different other countries like for an example [the] US. So, if you look at the US database, you realize that most of the calorie content, carbohydrate content slightly, maybe the portion size larger than us. So, that's why I always tell them, if you use a US database always to cut [portion size]. They need to reduce the amount of carbohydrate and amount [number] of calories.” [ID_03_ Dietitian] Preferred intervention for GDM management On the survey, among the preferred methods of information and support for GDM management, the preferred option for most participants 174 (80.9%) was “from a doctor, nurse or trained counselor at the GDM clinic”. Among their ranking, support from a doctor or nurse outside of the GDM clinic ranked second 116 (53.9%) and this replaced the current support option of ‘websites’, which ranked as the third preferred option 46 (21.3%). However, only a minority of participants (15.8%) were receiving this kind of care at the time of the survey (Figure 4). The other listed options of family members, friends/colleagues, in-person support groups for expectant mothers and support from other women who have previously managed GDM related to social support were less preferred. Most of the interview participants thought a smartphone application (an “app”) would be more helpful for GDM management (mainly for recording blood glucose readings) than a paper and pen, or a computer. They pointed out that such an intervention would be convenient, primarily because smartphones are now commonplace. In addition, women discussed the importance of having the means to “understand trends” and the steps that should be taken, if any, to rectify abnormal readings immediately. Further, they stated the need for reminders for finger prick test schedules, general information about GDM, calorie calculations and information about physical activity. Concerns about a possible app were relatively infrequently mentioned, but included the level of complexity, technical glitches and the need to charge the phone to access the application. “I mean the most useful, convenient is the app [smartphone application]. Because everyone has a smartphone, and everyone can access”. [ID_10] “Maybe there’s an indication, your reading is good, there’s a comment to supplement your, because sometimes when you write down your reading, you do not know if it is on target, not on target, high risk, or low risk”. [ID_11] Health care providers stressed the importance of strict control of blood glucose concentrations, and they also agreed an app would be a convenient platform to assist GDM control. As additional features, health care providers suggested the app could automate the transfer of blood glucose test results from the device to the provider overseeing the patient’s care. They felt that this step would increase the reliability of test results including an automated reported option and the convenience of timely monitoring. According to them, the intervention would be effective only if it was user-friendly and affordable, especially for those of lower socioeconomic status. “… They may forget to bring [blood glucose readings], that is what I was saying, they may forget to bring it [or] may not be accurate or they may not want to bring out to write it down. So, it will not be 100% accurate.” (ID_05_Nurse practitioner)

Conclusions:

Our study was able to understand women’s and care providers perception on improving GDM care. Most women preferred the assistance of health care providers to control their blood glucose levels. Further, the women, mostly who were employed, experienced barriers mainly due to limited reminders for monitoring blood glucose, difficulties in diet control and inadequate time to be physically active. Smartphone applications appear to be preferred by women to assist the standard of care to better support blood glucose control. Also, they anticipated that ‘a Mobile App’ can assist them to overcome their common difficulties as well to acquire reliable information on GDM and understand trends in blood glucose control. One systematic review indicated that women with GDM feel overwhelmed in the initial period post-diagnosis and that they are more likely to overcome these difficulties with appropriate medical assistance [23]. Our findings are consistent with these reported observations. GDM interventions have been shown to be important in helping women to curb adverse clinical outcomes as well as to elevate their quality of life [24]. These interventions appear to be successful due to receptiveness among highly motivated women who essentially want to safeguard their pregnancy. The participants in this study reported currently receiving advice primarily from specialized health care providers or online resources. However, among their preferences, the women conveyed the need for further assistance from health care providers other than the specialized GDM clinic. This highlights that women prefer to rely on medical personnel for advice although web and smartphone usage among pregnant women is a common phenomenon with significant ability to influence their health behaviors [25]. In the present environment, readily available health-related information from a wide variety of non-medical resources may increase the possibility of erroneous information. Therefore, it is important to get the assistance of health care providers to critically review online content for medical accuracy and suitability [25, 26]. In addition, the visible involvement of providers in the design and delivery of online information is likely to significantly increase its appeal to women. For most women, the second most common source of information on GDM was the internet. The information delivered through these websites is likely meant for different populations to those involved here. According to our qualitative findings, the working women in the study reported experiencing barriers including a lack of reminders for blood glucose monitoring, issues related to diet control, and lack of time for recommended exercise. Although physical activity has shown to be effective in regulating blood glucose concentrations among women with GDM [27], pregnant women in Singapore are less likely to be active especially in the latter stages of pregnancy [27]. This lack of a behavioral change may be further augmented by other commitments such as work-related responsibilities. Identified gaps in GDM management highlight the need for appropriate interventions to integrate into busy lifestyles. In general, smartphone apps are considered to be patient-centric interventions [28]. As pointed out by study participants, a smartphone app would be a viable solution for most of the identified issues and could help improve lifestyle behaviors. Two meta-analyses concluded that telemedicine interventions, primarily mobile applications, may conveniently replace face-to-face clinic visits between women and health care providers without compromising the quality of care [29-33]. However, both reports pointed out the limited number of such interventions and the need for further investigation of possible cost evaluations. As demands for health care are increasing, many parts of health systems including diabetes care are seeking help from telemedicine [7]. As defined by World Health Organization, telemedicine involves providing health care including information of diagnosis, treatment and disease prevention where distance is a critical factor [34]. Similarly, several intervention studies have been published on telemedicine solutions for women with GDM [35-38]. Interventions undertaken include recording information on food, physical activities, blood glucose concentrations, and insulin regimens. To date, few studies have been conducted to understand the usability and acceptance of smartphone apps among women with GDM [29, 30]. Neither of these reported studies assessed the perception and contribution of potential users before developing their programs. Most smartphone apps that have been developed for women with GDM to date focus primarily on using telemedicine for transferring blood glucose data from patient to health care provider. Having user input, both women with GDM and health care providers who treat women with GDM, is vital for successful implementation of such interventions as it increases user acceptability and intervention sustainability [39, 40]. According to our study findings, a potential smartphone app should include culturally tailored information on GDM and its management, particularly on diet and exercise. Additional features include reminders for blood glucose testing, recording of test results, provision of feedback on trends, and the ability to send results to health care providers (Figure 5). The mixed methods approach used here has deepened our understanding of the needs that women with GDM have regarding GDM management. The reported study has a few limitations. Data collection was conducted in one public hospital, which may not be entirely representative of other centers in Singapore. However, in 2016, 85-90% of women in Singapore who were 25 to 34 years of age were employed, and 56% either had a degree, diploma or professional qualification [41]. Our study sample has a similar demographic distribution, hence the findings appear largely generalizable to women with GDM in Singapore. Second, we were not able to measure the change in participant knowledge before and after the GDM workshop or to evaluate the effectiveness of the information delivery via the workshop [42]. A further limitation was that only one researcher coded and analyzed the qualitative data. Although measures were taken to increase the response rate, the overall response rate was low. In addition, only the women who can speak and write English were recruited. Therefore, it is possible that the results are biased towards those women who chose to participate. As suggested by a previously published meta-analysis, it is worth leveraging technology to facilitate behavior management and to make the intervention available to intended groups.[29] Recently, the National Health Service (NHS) in the United Kingdom approved the use of a smartphone application in the management of GDM. It is anticipated that the intervention will result in fewer clinic visits for working women, and reduce inconvenience and unnecessary workplace absenteeism [43]. In Singapore, most women of reproductive age are employed and may benefit from such technological advances. Due to increasing demand in the health care sector, telemedicine options have been gaining attention as a feasible option. The contribution of users is critical when designing a technological intervention, especially for pregnant women [44]. Our study identified the barriers experienced by women with GDM. These gaps may be addressed with a smartphone application. This was the commonly agreed intervention by the women and care providers to assist for optimal GDM management while easing the pressure on the local health system. In conclusion, as informed by this study, a carefully planned randomized control trial might be useful to assess the efficacy and cost-effectiveness of a smartphone application to minimize adverse maternal and fetal outcomes of GDM.