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Gestational diabetes mellitus (GDM) is associated with risks for both the mother and child. The escalated prevalence of GDM because of 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.
This mixed methods study used a convergent parallel design. Survey data were collected from 216 women with GDM, and semistructured interviews were conducted with 15 women and with 8 health care providers treating patients with GDM. Participants were recruited from 2 specialized GDM clinics at the National University Hospital, Singapore.
The patients were predominantly Chinese (102/214, 47.6%), employed (201/272, 73.9%), with higher education (150/216, 69.4%) and prenatal attendance at a private clinic (138/214, 64.2%), already on diet control (210/214, 98.1%), and receiving support and information from the GDM clinic (194/215, 90.2%) and web-based sources (131/215, 60.9%). In particular, working women reported barriers to GDM management, including the lack of reminders for blood glucose monitoring, diet control, and insufficient time for exercise. Most women preferred getting such support directly from health care providers, whether at the GDM clinic (174/215, 80.9%) or elsewhere (116/215, 53.9%). Smartphone 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.
A GDM-focused smartphone app that is able to integrate testing, education, and communication may be a feasible and acceptable intervention to provide support to women with GDM, particularly for working women.
Gestational diabetes mellitus (GDM) is a well-established risk factor for type 2 diabetes mellitus (T2DM). In parallel with the growing T2DM epidemic [
As with other types of diabetes, women with GDM receive medical advice on appropriate nutrition alongside directions to perform self-monitoring of blood glucose and to administer insulin therapy if required [
Asian populations are at a disproportionately higher risk of T2DM [
It is widely accepted that patients’ active collaboration with health care providers and their appropriate behavior changes are key factors in optimal GDM management [
In response to the anticipated increased prevalence from universal screening, to make improvements in the health care system to serve the needs of women diagnosed with GDM, it is important to understand the patients’ requirements. Therefore, this feasibility study explored 2 aims to understand (1) women’s perceptions of knowledge and management of GDM and (2) women and care providers’ perceptions and attitudes toward GDM control, related barriers, and potential interventions to overcome the barriers.
This study was undertaken with pregnant women who were diagnosed with GDM at the National University Hospital (NUH) in Singapore. Currently, all public hospitals in Singapore that provide prenatal medical care follow the latest World Health Organization (WHO) guidelines [
This study was conducted using mixed methods with quantitative and qualitative components and a convergent parallel design (
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 before the current pregnancy. Recruitment took place over 2 years between May 2015 and May 2017, with 2 phases of data collection.
Convergent parallel mixed methods design. GDM: gestational diabetes mellitus; NUH: National University Hospital.
For the quantitative component, a 27-item cross-sectional survey (
For the qualitative component, semistructured interviews were conducted using a topic guide based on published literature. This included questions on knowledge and attitudes 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 a 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. A web-based survey was added to the second phase to increase the recruitment rate.
The web-based form was created using the SurveyMonkey survey tool (SurveyMonkey Inc) and tested for any technical difficulties. The data collection was carried out using a closed survey. A total of 30 questions were distributed over 3 screens. Those who elected to complete the survey on the web were sent the link to the survey via email, and 3 additional
For pregnant women who were willing to participate in prenatal interviews, sessions were scheduled based on their convenience. In the second phase, to increase survey completion, the women were given an incentive of $25 (US $17.5). In the first phase, 50 patients participated in the survey.
Of these 50 patients, 35 gave verbal consent to participate in the interviews and 15 participated in the interviews, and 2 study members (JA and SH) conducted all the interviews in English. Most interviews were conducted at the health care facility or at the participants’ homes, in a private space conducive for the participant to share thoughts effectively. Before the interview, participants provided informed consent, including consent for audio recording. Health care providers treating GDM patients from nursing, dietetics, and obstetrics and gynecology 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 eighth care provider interview. Patient interview participants were from the first phase and were given Singapore $50 (US $35). 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 the steps involved in the recruitment, consent, and follow-up (
Study flow chart. GDM: gestational diabetes mellitus; NUH: National University Hospital; Ob/gyn: obstetrician/gynecologist.
Univariate analysis was conducted to describe the study participants and GDM management. Results are presented using medians and IQRs for continuous variables with skewed distributions, whereas categorical variables are presented using frequencies and percentages. Perceived improvement in GDM knowledge after attending the GDM workshop was analyzed using the Fisher exact test. Those who received a score between 0 and 2 for GDM attitude-related factors, perceived GDM control, and perceived worry for GDM control were labeled as
The interviews were audio recorded, transcribed
The average number of women attending the GDM clinic was 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 nonparticipants declined to participate without a reason, whereas some declined due to insufficient time. There were no significant differences between the 2 groups in terms of demographic characteristics (
The women who participated in interviews had a demographic profile similar to that of the survey questionnaire participants. Half of the 15 participants in the age group of 31 to 35 years were primiparous or had a family history of T2DM, and most of them 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.
Survey participants’ demographic characteristics.
Variable | Values | |
Age (years) (n=209), median (IQR) | 32 (22-40) | |
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Chinese | 102 (47.6) |
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Malay | 46 (21.5) |
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Indian | 43 (20.1) |
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Other | 23 (10.7) |
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|
|
|
Full time | 146 (68.2) |
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Unemployed | 55 (25.7) |
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Part time | 13 (6.1) |
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Degree or professional qualification | 150 (69.4) |
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Secondary education | 62 (28.7) |
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Lower than secondary education | 4 (1.8) |
Duration of pregnancy in weeks, median (IQR) | 30 (8-39) | |
Parity—multiparous (n=215), n (%) | 109 (50.4) | |
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Private clinic | 138 (64.2) |
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Subsidized clinic | 77 (35.8) |
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<23 kgm−2 | 96 (46.1) |
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23-27.5 kgm−2 | 59 (28.4) |
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>27.5 kgm−2 | 53 (25.5) |
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Poor | 1 (0.5) |
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Fair | 35 (16.2) |
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Good | 158 (73.1) |
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Excellent | 22 (10.2) |
Interview participant profile—patients attending a gestational diabetes mellitus clinic (N=15).
Variable | Participants, n (%) | |
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26-30 | 3 (20) |
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31-35 | 8 (53) |
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36-40 | 4 (27) |
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Chinese | 5 (33) |
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Malay | 3 (20) |
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Indian | 5 (33) |
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Filipino and Sri Lankan | 2 (13) |
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Full time | 11 (73) |
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Unemployed | 3 (20) |
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Part time | 1 (7) |
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Degree or professional qualification | 14 (93) |
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Secondary education | 1 (7) |
Parity—primiparous | 8 (53) | |
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Private clinic | 12 (80) |
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Subsidized clinic | 3 (20) |
Family history of gestational diabetes mellitus | 8 (53) |
Interview participant profile—health care providers serving at a gestational diabetes mellitus clinic (N=8).
Variable | Participants, n (%) | |
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Obstetrics and gynecology | 2 (25) |
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Diabetes care nurse educator | 4 (50) |
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Dietitian | 2 (25) |
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1 to 5 | 2 (25) |
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6 to 10 | 3 (37) |
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More than 10 | 3 (37) |
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Female | 6 (75) |
As reported by the participants, there was a significant improvement in perceived GDM knowledge after attendance at the GDM workshop (
As confirmed by the interviews, most of the women with a previous history of GDM 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, felt that they did not have sufficient information on GDM. However, the participants felt that the clinic helped to
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.
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.
Almost all of the participants, 98.1% (210/214), controlled their diet; half, 48.1% (103/214), were physically active; and 21 participants, one-tenth, used insulin to regulate blood glucose concentrations. Most participants, 85.6% (185/216), were able to follow typical recommendations from the GDM clinic to perform finger prick blood testing 7 times a day for 2 days each week (
Similarly, women who were interviewed also managed their blood glucose levels using diet modifications and monitored blood glucose levels using finger prick blood testing. Employed women, mostly Chinese and Malay, are more likely to consume outside food rather than home-cooked food. Few of the interviewed women were physically active, and only 2 used insulin therapy:
Mainly diet. I really watch my diet. Yes, actually now I, there’s only about a few choices that I can have every day.
In addition, most women mentioned that they performed the test more frequently than required and mainly used test results to
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.
Management of gestational diabetes mellitus.
Variable | Value, n (%) | |
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Diet management | 210 (98.1) |
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Physical activity | 103 (48.1) |
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Insulin use | 21 (9.8) |
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Record 7 readings on 2 days or more | 185 (85.6) |
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Most of the time | 20 (9.3) |
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Sometimes or never | 11 (5.1) |
In the survey, 97.7% of participants received a high score for perceived GDM control, whereas 74.5% had a high score for the perceived worry of GDM control. Most women (72.3%) perceived that they would not be able to control getting GDM in future pregnancies.
Consistent with the survey findings, at the time of the interview (subsequent to the clinic), many reported feelings of control related to diet and that they were
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.
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.
Most women reported feeling worried or anxious when GDM was diagnosed, although the GDM clinic’s workshop helped to lessen their anxiety.
Health care providers also felt that most women were motivated to control their blood glucose levels and also stressed the importance of
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...
Most survey participants did not feel that they faced any significant barriers to GDM control. However, a significant minority (30.4%) felt they had difficulties in remembering blood testing schedules, whereas 22% felt discouraged because of the lack of immediate effects from their lifestyle changes (ie, continuing to have abnormal test results even after implementing GDM management). One-fifth of participants (21.5%) agreed or strongly agreed to experiencing difficulties following the recommended diet and physical activity plan. On the other hand, most women reported that they had sufficient help from family and friends and that family, cultural beliefs, or traditions did not interfere with GDM management (
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 levels. Women felt that they had a
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.
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 the
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.
According to the clinical practice guidelines of the Ministry of Health, Singapore, women are required to self-monitor their blood glucose levels [
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.
Similarly, health care providers reported that working women experienced more barriers to managing GDM than nonworking 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]
Barriers to management of gestational diabetes mellitus.
Barrier | Strongly disagree, n (%) | Disagree, n (%) | Agree, n (%) | Strongly agree, n (%) |
Difficult to remember to take medication or blood tests at the scheduled times | 28 (13.4) | 117 (56.0) | 59 (28.2) | 5 (2.4) |
Feel discouraged due to lack of immediate results (eg, high blood sugar) | 23 (10.7) | 144 (67.3) | 45 (21.0) | 2 (1.0) |
Difficult to follow a specific diet and physical activity plan | 28 (13.1) | 140 (65.4) | 41 (19.2) | 5 (2.3) |
Busy with family or work to manage my GDM properly | 34 (16.0) | 138 (64.8) | 38 (17.8) | 3 (1.4) |
Nonspecific educational resources/opportunities about GDM | 31 (14.6) | 147 (69.0) | 29 (13.6) | 6 (2.8) |
Family’s cultural beliefs/ traditional practices conflict with GDM management | 69 (32.4) | 125 (58.7) | 17 (8.0) | 2 (1.0) |
Family and friends are not supportive of my efforts to eat right | 74 (34.6) | 127 (59.3) | 12 (5.6) | 1 (0.5) |
Of the 216 survey participants, 194 (90.2%) reported receiving GDM-related information from a physician, nurse, or trained counselor at the GDM clinic and 131 (60.9%) from websites. Moreover, 6.1% (16/216) of participants reported in-person support groups for expectant mothers as the method used least frequently (
The interview themes appeared concordant with the survey results. Women were most likely to rely on health care providers to guide them with medical advice. Furthermore, almost all mentioned that they used the internet to obtain 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 families and peers. In addition, they either approached peers with previous experience in controlling GDM or online forums. Most of them felt they had
Internet and friends and doctors.
I would say mainly like my husband and I would say my colleagues.
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.
The following interview results further support the above findings. 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.
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.
Source of gestational diabetes mellitus information.
Source | Value, n (%) |
Doctor, nurse or trained counselor at the GDMa clinic | 194 (90.2) |
Websites | 131 (60.9) |
Family members | 66 (30.7) |
Friends or colleagues | 59 (27.4) |
Web-based forums or support groups for new or expectant mothers | 44 (20.5) |
Doctor or nurse other than the GDM clinic | 34 (15.8) |
In-person support groups for expectant mothers | 13 (6.0) |
aGDM: gestational diabetes mellitus.
In the survey, among the preferred methods of information and support for GDM management, the preferred option for most participants 80.9% (174/216) was
Additional information regarding preferred interventions for GDM management was provided during the interviews. Most of the interview participants thought a smartphone app would be convenient
I mean the most useful, convenient is the app [smartphone application]. Because everyone has a smartphone, and everyone can access.
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.
Furthermore, the women stated the need of 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 they included the level of complexity, technical glitches, and the need to charge the phone to access the app. Health care providers stressed the importance of strict control of blood glucose concentrations, and they also agreed that an app would be a convenient platform to assist GDM control. As additional features, health care providers suggested that 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)
Our study was able to understand women’s and care providers’ perceptions on improving GDM care. Most women preferred the assistance of health care providers to control their blood glucose levels. Furthermore, the women, most of whom 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 apps appear to be preferred by women to assist the standard of care to better support blood glucose control. In addition, they anticipated that a
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 [
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 been shown to be effective in regulating blood glucose concentrations among women with GDM [
The participants in this study reported receiving advice primarily from specialized health care providers or web-based resources currently. 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 a significant ability to influence their health behaviors [
As demands for health care are increasing, many parts of health systems, including diabetes care, are seeking help from telemedicine [
In general, smartphone apps are considered to be patient-centric interventions [
Preferred features of a smart phone app for gestational diabetes mellitus management. GDM: gestational diabetes mellitus.
The mixed methods approach used here has deepened our understanding of the needs that women with GDM have regarding GDM management. This study has a few limitations. Data collection was conducted in 1 public hospital, which may not be entirely representative of other centers in Singapore. However, in 2016, 85% to 90% of women in Singapore who were 25 to 34 years old were employed, and 56% of the women either had a degree, diploma, or professional qualification [
In conclusion, as informed by this study, a carefully planned randomized control trial is likely to be useful in assessing the effectiveness and cost-effectiveness of a smartphone app to minimize adverse maternal and fetal outcomes of GDM and the optimal use of health care resources in Singapore.
Cross-sectional survey questionnaire.
Participants’ characteristics by data collection phase.
domain-specific review board
gestational diabetes mellitus
National Healthcare Group
National University Hospital
National University of Singapore
type 2 diabetes mellitus
World Health Organization
The authors thank the survey and interview participants and health care providers at the GDM clinic, NUH, Singapore. This research study was supported by the National University of Singapore (NUS) Global-Asia Institute NUS Initiative to Improve Health in Asia Research Grant (Grant No. NIHA-2013-1-002).
JY, JA, and SH conceptualized and designed the study, established the research question, designed the questionnaire, and obtained necessary ethics approval. SH, JA, and ES collected the data. SH performed the data cleaning and analyses. SH performed the statistical analyses, prepared graphics, assisted in drafting the manuscript, and finalized the draft based on comments from other authors’ feedback. CC and TY assisted in participant recruitment and critical review of the manuscript. JY assisted by critically reviewing the manuscript. All authors approved the final manuscript.
CC and TWY have received research funding from Jana Care project for the work related to the subject matters discussed in this manuscript. All other authors declared no conflicts of interest.