A research critique demonstrates your ability to critically read an investigative study. For this assignment, choose a research article related to nursing.
· Articles must be qualitative or quantitative research papers.
· The selected articles should be original research articles. Review articles, concept analysis, meta-analysis, meta-synthesis, integrative review, and systemic review should not be used.
· Mixed-methods studies should not be used.
· Dissertations should not be used.
Your critique should include the following:
Research Problem/Purpose
· State the problem clearly as it is presented in the report.
· Have the investigators placed the study problem within the context of existing knowledge?
· Will the study solve a problem relevant to nursing?
· State the purpose of the research.
Review of the Literature
· Identify the concepts explored in the literature review.
· Were the references current? If not, what do you think the reasons are?
· Was there evidence of reflexivity in the design (qualitative)?
Theoretical Framework
· Are the theoretical concepts defined and related to the research?
· Does the research draw solely on nursing theory or does it draw on theory from other disciplines?
· Is a theoretical framework stated in this research piece?
· If not, suggest one that might be suitable for the study.
Variables/Hypotheses/Questions/Assumptions (Quantitative)
· What are the independent and dependent variables in this study?
· Are the operational definitions of the variables given? If so, are they concrete and measurable?
· Is the research question or the hypothesis stated? What is it?
Conceptual Underpinnings, Research Questions (Qualitative)
· Are key concepts defined conceptually?
· Is the philoosoophical basis, underlying tradition, conoceptual framework, or ideological orientation made explicit and is it appropriate for the problem?
· Are research questions explicitly stated? Are the questions consistent with the study’s philosophical basis, underlying tradition, conceptual framework, or ideological orientation?
Methodology
· What type of design (quantitative, qualitative, and type) was used in this study?
· Was inductive or deductive reasoning used in this study?
· State the sample size and study population, sampling method, and study setting.
· Did the investigator choose a probability or non-probability sample?
· State the type of reliability and the validity of the measurement tools (quantitative only)
Qualitative studies (answer the following questions in addition to those above except the last bulleted item)
· Were the methods of gathering data appropriate?
· Were data gathered through two or more methods to achieve triangulation?
· Did the researcher ask the right questions or make the right observations and were they recorded in an appropriate fashion?
· Was a sufficient amount of data gathered?
· Was the data of sufficient depth and richness?
Were ethical considerations addressed? Were appropriate procedures used to safeguard the rights of study participants?
Data Analysis
· What data analysis tool was used?
· Was saturation achieved? (qualitative)
· How were the results presented in the study?
· Were the data management (e.g., coding) and data analysis methods sufficiently described? (qualitative)
· Identify at least one (1) finding.
Summary/Conclusions, Implications, and Recommendations
· Do the themes adequately capture the meaning of the data?
· Did the analysis yield an insightful, provocative and meaningful picture of the phenomenon under investigation?
· Were methods used to enhance the trustworthiness of the data (and analysis) and was the description of those methods adequate?
· Are there clear explanation of the boundaries/limitations, thick description, audit trail?
· What are the strengths and limitations of the study?
· In terms of the findings, can the researcher generalize to other populations? Explain.
· Evaluate the findings and conclusions as to their significance for nursing (both qualitative and quantitative).
The body of your paper should be 4–6 double-spaced pages plus a cover page and a reference page. The critique must be attached to the article and follow APA guidelines.
Perspectives on Prevention of Type 2 Diabetes After Gestational
Diabetes: A Qualitative Study of Hispanic, African-American
and White Women
Joyce W. Tang • Krys E. Foster • Javiera Pumarino •
Ronald T. Ackermann • Alan M. Peaceman •
Kenzie A. Cameron
Published online: 25 November 2014
� Springer Science+Business Media New York 2014
Abstract Women with gestational diabetes (GDM) have
a fivefold higher risk of developing type 2 diabetes
(T2DM). Furthermore, Hispanic and African-American
women are disproportionately affected by GDM, but their
views on prevention of T2DM after gestational diabetes are
largely unknown. We conducted semi-structured inter-
views with 23 women (8 Hispanic, 8 African-American, 7
non-Hispanic White) from two academic clinics in Chi-
cago, IL. Interview questions elicited perspectives on pre-
vention of T2DM; the interview protocol was developed
based on the Health Belief Model. Two investigators
applied template analysis to identify emergent themes.
Women conceptualized risk for T2DM based on family
history, health behaviors, and personal history of GDM. A
subgroup of women expressed uncertainty about how
GDM influences risk for T2DM. Women who described a
strong link between GDM and T2DM often viewed the
diagnosis as a cue to action for behavior change.
T2DM
was widely viewed as a severe condition, and desire to
avoid T2DM was an important motivator for behavior
change. Children represented both a key motivator and
critical barrier to behavior change. Women viewed pre-
ventive care as important to alert them to potential health
concerns. Identified themes were congruent across racial/
ethnic groups. Diagnosis with GDM presents a potent
opportunity for engaging women in behavior change. To
fully harness the potential influence of this diagnosis,
healthcare providers should more clearly link the diagnosis
of GDM with risk for future T2DM, leverage women’s
focus on their children to motivate behavior change, and
provide support with behavior change during healthcare
visits in the postpartum period and beyond.
Keywords Gestational diabetes � Type 2 diabetes �
Qualitative research � Risk perception � Barriers and
motivators
Background
Gestational diabetes (GDM) affects approximately 4 % of
women [1], of whom an estimated 20–60 % will develop
type 2 diabetes (T2DM) within 5–10 years of initial diag-
nosis [2]. In addition, for women who become pregnant
again, their future offspring also may be adversely affected
if women enter a subsequent pregnancy with undiagnosed
T2DM or experience recurrent GDM [3–5]. Racial and
ethnic minorities are disproportionately affected by GDM:
the incidence of GDM among Hispanic women is 1.5 times
that of White women [6, 7]. While the incidence of GDM is
only marginally higher for African-American than for
White women, their rate of progression to T2DM is much
more rapid than for other racial/ethnic groups [8, 9]. Both
intensive lifestyle modification and use of metformin can
J. W. Tang (&) � J. Pumarino � R. T. Ackermann �
K. A. Cameron
Division of General Internal Medicine and Geriatrics,
Feinberg School of Medicine, Northwestern University,
750 N. Lake Shore Drive, 10th floor, Chicago, IL 60611, USA
e-mail: joyce-tang@northwestern.edu
K. E. Foster
Department of Family Medicine, Jefferson Medical College,
Philadelphia, PA, USA
A. M. Peaceman
School of Population and Public Health, University of British
Columbia, Vancouver, Canada
A. M. Peaceman
Department of Obstetrics and Gynecology, Feinberg School of
Medicine, Northwestern University, Chicago, IL, USA
123
Matern Child Health J (2015) 19:1526–1534
DOI 10.1007/s10995-014-1657-y
http://crossmark.crossref.org/dialog/?doi=10.1007/s10995-014-1657-y&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s10995-014-1657-y&domain=pdf
help prevent T2DM, but remain underutilized [10]. Prior
studies have demonstrated low participation rates in life-
style interventions during the postpartum period [11–13].
Willingness to engage in preventive behaviors may be
influenced by the perceived threat of T2DM, barriers and
motivators to making lifestyle changes, and the presence of
a cue to action [14–16]. Although several qualitative
studies have examined how postpartum women interpret
the impact of GDM on their future health, most of these
studies were conducted outside of the United States [16–
20]. Few studies have included African-American and
Hispanic women [15]. Because differences in health care
systems, cultural beliefs and community norms can influ-
ence risk perception and perceived motivators and barriers
to preventive health behaviors [21–24] we designed this
qualitative study to explore the perspectives of Hispanic,
African-American, and White women affected by GDM.
Our goal is for this work to inform the development of
effective approaches to engage diverse populations affec-
ted by GDM in taking steps to reduce their risk for T2DM.
Materials and Methods
Conceptual Framework
The study design was informed by the Health Belief Model
(HBM), which is a framework for understanding individual
perceptions that affect personal engagement in behavior
change [26, 27]. According to the HBM, individuals will
take action to improve their health if they think (1) they are
susceptible to the health threat, (2) the health threat has
serious consequences, (3) taking the action will decrease
their risk of developing the health threat, (4) benefits out-
weigh the barriers to taking action, and (5) a cue to action
exists [26, 27].
Sample and Recruitment
We conducted semi-structured, face-to-face interviews
with a purposive sample of women diagnosed with GDM,
with stratification across 3 racial/ethnic groups (African-
American, Hispanic, and non-Hispanic White). We started
with a goal of conducting 12 interviews total to identify
overarching common themes, as prior research has identi-
fied that 12 interviews often are adequate to achieve the-
matic saturation [28]. We chose to conduct additional
interviews to further explore if differences by race/ethnic-
ity emerged [28].
Participants were recruited from two academic clinics
affiliated with a women’s hospital in Chicago, Illinois.
Together, the clinics have a staff of 28 obstetrician/gyne-
cologists, 44 resident physicians, and a volume of 1,200
deliveries per year. The patient population served is eth-
nically and socioeconomically diverse: 50 % are African-
American or Hispanic; approximately 47 % have Medic-
aid. During the study period, the clinics utilized a universal
1-step screening protocol for GDM (2 h 75 g glucose tol-
erance test) [29]. Using this screening method, approxi-
mately 200 women were diagnosed with GDM per year.
Per clinic protocol, women identified with GDM were seen
by a nutritionist for at least one visit, and saw a nurse
practitioner every 2 weeks to discuss glucose control and
nutrition during their pregnancy. Women requiring medi-
cation for their GDM received insulin under the supervi-
sion of an endocrinologist.
Eligible participants were within 12 months of delivery at
the time of initial contact and spoke either English or
Spanish. A programmer analyst identified eligible patients at
each of the clinics through query of electronic health record
databases. Eligible women had a positive glucose tolerance
test result per the IADPSG guidelines: C1 abnormal value
on their 2 h (75 g) GTT obtained between 24 and 28 weeks
(i.e., fasting glucose C92 mg/dl, 1 h glucose C180 mg/dl or
2 h glucose C153 mg/dl). A research assistant contacted
potential participants by phone to assess their interest in
participation. We excluded participants who reported a
history of T2DM prior to their pregnancy or diagnosis with
T2DM subsequent to delivery. Patients also could self-
identify in response to a flyer in one of the obstetrics clinics.
This research was approved by the Northwestern University
Institutional Review Board.
Development of Interview Guide
A multidisciplinary research team, including 2 general
internists, an obstetrician/gynecologist, and a communica-
tion expert, devised a semi-structured interview guide (See
Appendix). Three team members had training and experi-
ence with qualitative research methods [30–33]. Interview
questions were designed based on the constructs of the
Health Belief Model to elicit perspectives relevant to
engagement in diabetes prevention behaviors (perceived
susceptibility to T2DM, perceived severity of GDM and
T2DM, motivators and barriers to improving lifestyle
behaviors, cue to action, see Appendix). Demographic
characteristics (age, race/ethnicity, education) were
obtained through self-report. The interview guide was
translated to Spanish by a bilingual research assistant.
Data Collection
A total of 23 interviews were conducted: we conducted an
additional 11 interviews following our initial 12 to explore
if racial/ethnic differences emerged. Analysis, as is com-
mon in qualitative research, was on-going, and upon
Matern Child Health J (2015) 19:1526–1534 1527
123
reaching 23 interviews the team agreed that we had reached
thematic saturation of our data. The in-person interviews
were conducted either in the Division of General Internal
Medicine research office (n = 21) or in the home of the
participant (n = 2), and were led by either a bilingual
(English and Spanish) research assistant (JP) or an inves-
tigator (JT). Participants provided written, informed con-
sent. Interviews lasted approximately 30–60 min. Women
received $50 cash on completion of the interview.
Data Analysis
All interviews were digitally recorded and professionally
transcribed. Interviews conducted in Spanish (n = 2) were
translated to English. We conducted qualitative analysis
applying template analysis to code and organize themes
[34]. Template analysis provides a systematic process for
organizing important themes through use of a hierarchical
coding template, which has previously been applied in
qualitative healthcare research studies [35, 36]. Codes were
generated through two strategies. First, a limited set of
tentative a priori codes was developed by the study team
based on elements of the Health Belief Model (e.g., per-
ceived risk for T2DM). Second, additional codes were
added based on new ideas that emerged from review of the
transcripts. An initial coding template was developed after
reviewing an initial set of 5 transcripts (representing
women from each of the three racial/ethnic groups). This
coding template organized the codes within a hierarchical
structure under tentative overarching themes. Subse-
quently, two investigators independently applied the cod-
ing template to all 23 interviews, using NVivo 9 to
organize the data. We added additional codes as needed
when new ideas emerged. The template was iteratively
modified after reviewing subsequent transcripts to more
clearly reflect the relationships between the codes; all
discrepancies were resolved by consensus. The frequency
with which codes and themes were mentioned by unique
participants was also tabulated.
Results
Baseline Sample Characteristics
We completed interviews with 23 women [8 Hispanic (H),
8 African-American (AA), and 7 non-Hispanic White
(NHW)]. Twenty-two women were recruited via phone
outreach; 1 self-identified in response to a flyer. The
average age was 33.1 years (SD 6.0) (Table 1). Eighty-two
percent of the women had completed at least some college
education. Eight women (35 %) had two or more children.
One participant had previously been diagnosed with GDM.
Most women managed their GDM through diet only
(78 %); the remainder used insulin. Women completed
interviews on average 7 months after delivery (range
3–13 months). No significant differences in age or educa-
tion level emerged across racial/ethnic groups.
Perceived Susceptibility to T2DM
Women considered multiple factors in conceptualizing
their risk for T2DM, including both unmodifiable risk
factors (family history of T2DM [n = 18], personal history
of GDM [n = 14]), and modifiable risk factors (i.e.,
weight, current and future health behaviors [n = 20])
(Table 2). A subgroup of women expressed uncertainty
about the relationship between GDM and T2DM (n = 6).
These women expressed confusion about whether there
was an association, the magnitude of the association, and
the timing of the association. Half of the participants
(n = 12) described high risk for developing T2DM: ‘‘High,
very high, due to the fact that my father’s side has diabetes,
I obviously had the gestational diabetes so I am more at
high risk, and because I am overweight.’’ (33, H). Only 3
women felt their risk of T2DM was low: ‘‘I am confident.
Nobody in my family ever had it. I am a pretty active
person. I do not eat, how can I say, I think I eat pretty
healthy. I am not a big fan of fast food and things like that.
Table 1 Participant demographics (n = 23)
Age, mean (SD) 33.1 (5.9)
Race, n (%)
White 7 (30 %)
Black 8 (35 %)
Hispanic 8 (35 %)
Language, n (%)
English 21 (91 %)
Spanish 2 (9 %)
Education, n (%)
Less than high school 2 (9 %)
High school graduates 2 (9 %)
Some college 7 (30 %)
College graduates 12 (52 %)
Postpartum GTT obtained 16 (70 %)
Number of
children
1 15 (65 %)
2 4 (17 %)
3 4 (17 %)
Previous GDM 1 (4 %)
Management of GDM
Diet 18 (78 %)
Insulin 5 (22 %)
Interviews were conducted on average 6.9 months after
delivery
(range was from 3 to 13 months after delivery)
1528 Matern Child Health J (2015) 19:1526–1534
123
Table 2 Key themes related to engaging women in type 2 diabetes prevention, based on the health belief model
HBM construct Theme Illustrative quotes Implications for future work
Perceived
susceptibility
Personal risk for
diabetes is
driven by…
Women attributed perceived risk for T2DM to
family history, health behaviors, and GDM.
Some women were unclear about the link
between GDM and T2DM
Due to women’s uncertainty related to the risk
of GDM leading to diabetes, healthcare
providers should provide clearer messages
about the degree to which GDM increases
women’s personal risk for T2DM and the
timeframe over which diabetes may develop
Health
behaviors
(n = 20)
If I don’t change what I am doing now, I think I
will get it…Because I eat a lot of sweets…
Chocolate donuts, coffee, chocolate (32 H)
Family history
(n = 18)
It’s still something that can occur because it is
something that is hereditary within my family.
It’sjustallamatterofwhenandwhatage(39AA)
GDM (n = 14) I am concerned about having diabetes in the
future. That is one of the risks for patients with
gestational diabetes (39 H)
Unclear how
GDM affects
risk for diabetes
(n = 6)
If I do get pregnant again, is there a chance,
what is the percent chance that I will get it
again? Does that affect me getting regular
diabetes? I just want to know if that has any
affect later on me having diabetes (28 NHW)
Perceived severity Diabetes is a
severe illness
(n = 11)
I don’t want my toes to get numb and have to be
cutoff. Just amounts of medications or just
even I think I ran into someone who was like
…I need to hurry up and get something sweet
in my mouth because I am a diabetic and I
haven’t eaten anything and it was just like oh
my god, you know (40 AA)
Women already recognize the severity of
T2DM. Rather than attempting to increase
perceptions of severity of T2DM, healthcare
providers should focus on linking the
existence of GDM with personal risk of future
T2DM
Perceived benefits to
engaging in healthy
behaviors
Avoid diabetes
(n = 11)
I go running around the park… It is something I
never ever did in my life and it is because of
that… It is just in my mind that I do not want
to get diabetes in the long run (40 H)
When motivating women to engage in healthy
behaviors, healthcare providers should focus
not only on ability to avoid T2DM, but also
leverage women’s focus on their children. For
example, providers could emphasize the
importance of staying healthy to
care for
children (long term benefit) and the potency of
role modeling (short term benefit)
Stay healthy to
care for
children
(n = 8)
I am definitely more worried about what my kids
eat than what I eat and so that always makes
me feel bad because then I think well no, I
want to be alive for my kids. I want to be
healthy for my kids (38 NHW)
Serve as a role
model for
children
(n = 5)
I don’t [change my eating habits] so much for
protecting me from getting diabetes; I do it so
that my son, as he is learning to eat, he learns
to eat healthier (39 AA)
Perceived
barriers to
engaging in healthy
behaviors after
delivery
No time/lack of
childcare
(n = 11)
So the baby still gets up a bunch during the
middle of the night…then he needs to be cared
for in the morning and then I go to work and
then he needs to be cared for and put to bed…
I can’t leave the house with as much
flexibility…Time is the biggest barrier (35
NHW)
Physical activity that involves one’s child(ren)
or that could be done while at home may be
more effective in engaging women with GDM
Emotional
barriers to
accepting
childcare
(n = 8)
Now you see on the news that babysitters hurt
the baby, or the father hurts the baby. My
sister-in-law tells me to leave him with her,
but I can’t. I could have left him there now to
be here, but I can’t do it. I can’t explain it. If I
go to my brother’s house and his wife tells me
that she’ll take care of him, I’m always after
her checking on him. I think it’s normal for
first-time mothers to be afraid (25 H)
Lack of
motivation
(n = 10)
I am not motivated to do what I need to do and
that is my fault. I need to eat right and lose
weight. Slowly but surely I will but now I am
just not motivated to do it…I need someone
there to help motivate me (33 AA)
Motivation is difficult to sustain. Strategies that
integrate social support (e.g., peer support
models) may be more effective in enhancing
motivation
Matern Child Health J (2015) 19:1526–1534 1529
123
It is going to be hard to get it’’ (35, NHW). The remainder
of the women expressed uncertainty about their risk, using
terms such as ‘‘more at risk,’’ ‘‘probable,’’ ‘‘possible,’’ or
‘‘can occur.’’ Women were well aware that T2DM could be
prevented through lifestyle change (n = 20).
Perceived Severity of T2DM and GDM
Women perceived T2DM to be a severe condition
(n = 11), which could result in blindness or amputation,
and which reduced both lifespan and quality of life. Many
women described knowledge about T2DM in relation to
experiences with family members, spouses, or colleagues:
‘‘It is not a nice experience. It is not. I don’t want to be just
tired all the time and just in bed because that is how I also
see my family members, in bed, tired, don’t feel like doing
anything, you know, losing their eyesight’’ (40, H). Beyond
severity of the condition, women also mentioned signifi-
cant inconvenience in managing the condition, specifically
fear of needles or requiring insulin.
While women were familiar with T2DM and generally
felt T2DM to be a severe condition, women reported
having little understanding of GDM prior to diagnosis and
perceived severity of GDM was more variable. For many
participants, fear about serious consequences to the baby
was pervasive at the time of diagnosis (n = 19): ‘‘I was
scared for the baby’s sake… Are there any irreversible
effects that I cost the baby?’’ (28, NHW). As the preg-
nancy progressed, many described eventual minimization
of the diagnosis because it was common, mild, easy to
control, and temporary (n = 10). As one woman stated,
‘‘A lot of people I talked to were like oh everybody gets it,
it’s 50/50 and if you get it is not a big thing’’ (39, AA).
Another woman described: ‘‘It is like a cold, but it lasts a
little bit longer because of the baby, but you stay on the
diet or take the medicine and you will be fine afterwards’’
(35,
NHW).
Perceived Benefits to Health Behavior Change
Women described several motivations for improving their
health behaviors. These motivations included to avoid
T2DM (n = 11), to stay healthy to care for children
(n = 8), and to serve as a role model for their children
(n = 5): ‘‘You want to stay healthy, especially when you
are dealing with young kids or a new child. You want to be
there for your child. You don’t want to get sick. You don’t
want it to get worse. You don’t want them to start taking
care of you and have insulin and things like that, so it has
definitely changed’’ (40, AA).
While prevention of T2DM was a motivator for
behavior change, women did not spontaneously describe
prevention of GDM in a future pregnancy as a motivator.
When queried about ability to prevent GDM in the future,
many women described benefits to behavior change as
being limited to the time of a subsequent pregnancy
(n = 10), with fewer describing benefit to initiating pre-
ventive behaviors prior to a subsequent pregnancy.
Potential Barriers to Behavior Change
While children were an important motivator to behavior
change, they were also a key barrier to implementing
behavior change. Needing to care for their newborn child
and older children and lack of childcare took away time
from opportunities to exercise or plan meals (n = 11).
Although women desired assistance with child care, many
women expressed emotional barriers to accepting avail-
able child care options (n = 8). Some women described
lack of trust in non-familial caregivers or concern for
Table 2 continued
HBM construct Theme Illustrative quotes Implications for future work
Cue to action GDM as a cue to
action (n = 11)
Importance of
preventive care
visits (n = 19)
I think it was a wakeup call for me. I don’t want
to say it was a good thing, but it did kind of put
me into reality that I do have to have a
healthier lifestyle. I do have to eat better. I do
have to watch my carbs. It just kind of puts a
reality on you that you are not immune from it.
That you can get it. I did get it and so what am
I going to do about it and the information that I
learned. I have to move forward with it (28 H)
I have always been a person going to the doctor
on a schedule, like every six months…I want
to make sure I am healthy, so the doctor visits
are very, very important, especially now at my
age moving forward (40 AA)
Many women view diagnosis with GDM as a
cue to take action to improve their lifestyle,
but this momentum is not always sustained
after delivery
Given that women value preventive care,
healthcare systems should consider developing
protocols to ensure women have or are
referred to a PCP and that appropriate handoff
(from OB/GYN to PCP) occurs after delivery
such that the focus on diabetes prevention can
be reinforced (i.e., repeated cues to action)
1530 Matern Child Health J (2015) 19:1526–1534
123
overburdening relatives: ‘‘I don’t leave the children alone
with non-family members and so that is difficult because
if I am not exercising with them, with me, then I feel I
have really leaned on my mother a lot for sitting so I
don’t want to over-do it’’ (39, H). For other women, guilt
was a primary emotional barrier: ‘‘I don’t want to say that
exercising feels almost selfish. It feels like if it is taking
time. Either I have to get up at five o’clock and do it
before they wake up or it is taking time away that I could
be spending with them’’ (38, NHW). In addition to
childcare related barriers, women also acknowledged that
lack of motivation was an important to making behavior
changes (n = 10).
Cue to Action
Many women described the diagnosis and experience of
having GDM as a cue to take action to improve their health
behaviors (n = 11). These women tended to strongly link
GDM to future T2DM: ‘‘It made me become aware
because you know sometimes you may say ‘yeah it runs in
the family but I won’t get it.’ Then when they diagnosed
me I knew it was a possibility one day I can just have
diabetes so I have changed my eating habits’’ (33, AA).
Despite the importance of GDM as a cue to action, the
momentum created by the diagnosis was not always sus-
tained after delivery, as women became busy with taking
care of a new baby: ‘‘Right now I am just like whatever. It
is just me. I am not worrying about another human being in
my womb. It makes a big difference. Right now, I just need
to get energy to take care of this guy right here’’ (33,
NHW).
Nearly all women also noted preventive health care
visits were important to alert them to potential problems
with their health (n = 19): ‘‘If anything is wrong that I
don’t know about, you know, hopefully they will catch
anything I have in time that we can treat it. If I never go to
the doctor, you know, sometimes you can have something
wrong and feel fine and never know until is too late. This
way, if I do have something wrong, I can catch it in time or
prevent it’’ (28, NHW). Nearly all women (n = 21)
described plans to obtain follow-up care with a general
internist (n = 15) and/or an OB/GYN (n = 8).
Discussion
Within our ethnically diverse sample, the major themes
were remarkably congruent. Women conceptualized their
risk for T2DM in relation to family history of T2DM,
personal history of GDM, and their ongoing and future
health behaviors; a notable sub-group of women were
uncertain about the impact of GDM on future T2DM.
Diagnosis with GDM was perceived to be an important cue
to action for many women, but the momentum of behavior
change initiated during pregnancy was often not sustained.
While women perceived strong benefits to engaging in
healthy behaviors (avoid T2DM, stay healthy for children),
multiple barriers (no time/lack of child care, lack of
motivation) frequently precluded their ability to make
changes.
Perceptions of risk for T2DM were variable within our
sample, with about half perceiving high risk. While prior
survey-based studies in the United States and Australia
have shown that few women with GDM perceive high risk
for T2DM [14, 37], findings from qualitative studies have
been more mixed; some of the variability may relate to the
population studied and proximity to delivery [16, 17, 38].
Similar to prior studies, women in our study linked their
risk for T2DM to presence or absence of family history of
T2DM, their weight status, and current health habits [14,
39]. Our finding that a sub-group of women are uncertain
about the relationship between GDM and T2DM highlights
the need for clearer and ongoing communication in this
area. Healthcare providers should consider providing
messages that clearly describe the magnitude (i.e., fivefold
higher risk) and the timing of risk for T2DM (rare in the
immediate postpartum period, but high over the next
2–10 years).
While women generally perceived T2DM as a severe
illness, perceptions about the severity of GDM were more
variable. While it is expected that fear related to a new
diagnosis will decrease over time as individuals develop
new skills to manage a new diagnosis [17], the degree to
which women in our study minimized the diagnosis was
surprising. Women’s minimization of the diagnosis of GDM
have only been raised in one prior study, conducted among
women in Australia, in which women based such beliefs on
the evidence that their test results were borderline and their
blood sugars remained normal on subsequent evaluation
despite unchanged diet [20]. It is possible that we may have
seen more frequent minimization of GDM in our study
population as the use of a more sensitive screening test
(following IADPSG guidelines) for GDM led to identifica-
tion of a larger group of women with relatively mild (diet-
controlled) disease [40]. Further studies should assess the
prevalence with which women minimize risk and if mini-
mization of risk influences health behavior change during
pregnancy and after delivery (to prevent recurrent GDM).
The centrality of children in women’s lives as both a
prominent motivator and barrier to adopting healthy habits
has been well documented [16, 17, 41], and was a con-
sistent finding across our diverse sample. Healthcare pro-
viders should leverage women’s focus on their children,
using messages that emphasize the importance of staying
healthy to care for children (long term benefit) and the
Matern Child Health J (2015) 19:1526–1534 1531
123
potency of role modeling healthy behaviors (short term
benefit). Our study highlighted also additional complexities
that should be considered in developing future preventive
interventions: despite the need for instrumental support
with childcare, women often faced emotional barriers to
accepting help with child care (mistrust, guilt). Such bar-
riers could make it difficult for women to participate in
intensive, group-based classes such as offered under the
Diabetes Prevention Program. Prior studies have described
low uptake and adherence in class-based interventions
among this population [42, 43]. In contrast, interventions
that could be done during flexible hours within the home
(e.g., delivered via the internet) may have higher uptake
among women with GDM. Physical activity that involves
one’s children may also be of interest to women.
While GDM represents a potentially important cue to
action, this momentum is often not sustained after delivery.
Given that women in our study planned to seek preventive
care and expected providers to alert them to potential
health concerns, healthcare settings appear to be a suitable
channel through which to engage women in preventive
behaviors. Prior studies conducted in England, Canada, and
Australia have described that women felt abandoned after
delivery due to the transition from close monitoring to
minimal contact in the postpartum period [16, 41, 44].
Ideally, healthcare systems might strengthen their role in
these areas by developing protocols to ensure women have
or are referred to a PCP, and that appropriate handoff (i.e.,
from OB/GYN to a PCP) occurs after delivery. This
handoff could help promote a consistent message in the
postpartum period regarding risk for T2DM (despite the
apparent resolution of GDM after delivery), improve
receipt of recommended follow-up glycemic testing, and
increase opportunities to activate and provide resources to
support behavior change.
The overall consistency in themes across racial/ethnic
groups in our sample was striking. One explanation for the
consistency in themes is that the universal challenges of
being the mother of a young child may have surpassed and
overwhelmed other lesser challenges, particularly in the first
year after a child’s birth. Second, many women across all
racial/ethnic groups had a family history of diabetes, and the
experiences of their family members were closely tied to
their perceptions about risk for diabetes, severity of diabetes,
and desire to avoid diabetes. Our results did not identify
unique experiences among African-American or Hispanic
that might impact behavior change, and do not support the
need for tailored approaches to engage African-American or
Hispanic women in behavior change for T2DM prevention.
There are several limitations to this study. First, it is
possible that our results may have been influenced by
selection bias. Women who participated in our study, as
compared with those who chose not to participate, may have
greater knowledge about GDM and T2DM, may be more
motivated to improve their health, may face fewer barriers to
behavior change, and may utilize healthcare more fre-
quently. However, we believe that our use of a proactive
outreach strategy for recruitment should have minimized
this bias. Second, because most women in our study were
able to control their GDM through dietary changes alone, it
is possible that the lower disease severity in our sample may
have increased the frequency with which women minimized
the diagnosis of GDM. Third, although the patient sample
was racially and ethnically diverse, the overall educational
level of the participants was very high. Women with lower
levels of education may have access to fewer resources and
may have different perspectives about their diagnosis and
future health risks. Fourth, our sample size may have been
insufficient to identify minor differences between the racial/
ethnic groups. However, given the striking concordance of
themes across our sample of 23, we feel this would be
unlikely [28]. Fifth, our study was focused more narrowly on
understanding individual level factors influencing behavior
change, and thus did not assess multiple, broader level
contextual factors influencing uptake of diabetes prevention
behaviors at the organizational, community and policy levels
[25].
Our study highlights several potential target areas for
future diabetes prevention interventions. Providers should
recognize that women may benefit from clearer messages
about the strong relationship between GDM and T2DM.
Women with GDM also may benefit from a more coordi-
nated healthcare response (i.e., involving OB/GYN provid-
ers as well as PCP’s) after delivery to ensure that women
and their providers fully engage in diabetes prevention.
Acknowledgments We would like to thank the patients and staff of
the Prentice Ambulatory Clinic, the Northwestern Medical Faculty
Foundation Obstetrics and Gynecology Clinic, and the Northwestern
Memorial Physician’s Group Obstetrics and Gynecology clinic. Dr.
Tang was supported by a pilot grant through the Feinberg School of
Medicine Center for Equity in Clinical Preventive Services (a Center
of Excellence funded by the Agency of Healthcare Research and
Quality P01 HS021141, David W. Baker, PI). The funding agency
had no involvement in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; and preparation,
review, or approval of the manuscript; and decision to submit the
manuscript for publication. A portion of these results were previously
presented at the 2013 SGIM National Meeting in Denver, CO.
Appendix: Health Beliefs and Lifestyle Behaviors
of Women Diagnosed with Gestational Diabetes
Patient Qualitative Interview Protocol
1. As you know, we are particularly interested in hearing
more about your experience with having gestational
1532 Matern Child Health J (2015) 19:1526–1534
123
diabetes during your recent pregnancy. Take me back
to when you first heard that you had gestational dia-
betes (during your recent pregnancy). Can you
describe how you found out that you had GDM?
2. Can you tell me about what that experience was like
for you?
3. How did you go about learning more about gestational
diabetes? Who are the main people you talked with to
find out more about
gestational diabetes?
4. Can you tell me what questions you still have about
gestational diabetes?
5. How did having gestational diabetes affect your pregnancy?
6. How does having had gestational diabetes affect your
health now, if at all, after having
your baby?
7. Did you get any testing for diabetes after delivering
your baby?
a. If no or unsure, were you given any information
about needing a test for diabetes?
i. If yes, can you tell me more about what may
have prevented you from getting testing?
b. If yes, what did it show?
8. How would you describe your chance of getting
gestational diabetes with a future pregnancy? Tell me
more, if you will, about
your thinking on that.
a. Is there anything you can do to lower your chances
of getting gestational diabetes?
9. How would you describe your chance of getting
diabetes in the future? Tell me more, if you will, about
your thinking on that.
a. Is there anything you can do to lower your chances
of getting diabetes?
We’ve been talking about your experiences with having
had gestational diabetes. Next I’d like to ask you some
general questions about your current health.
10. Tell me about your most important health concerns
right now. Can you tell me more about that?
11. How important, if it all, is it for you to see a doctor
regularly for your health? Can you tell me more
about your thinking on that? Do you plan to see a
doctor for your health in the next year? Who do you
consider your primary doctor (e.g., obstetrician/
gynecologist, family medicine doctor, internist)?
12. How do you feel about your current level of
exercise? What would you like to be doing?
13. How do you feel about your diet?
14. How do you feel about your weight?
15. What are the biggest challenges you face to
exercising more? To improving your diet?
16. Who could help make it easier for you to exercise/eat
more healthily?
That covers the things I wanted to ask. Can you think of
anything else that I should have asked you, but didn’t think
to ask?
Before we finish, do you mind if I ask you…
How would you describe your race or ethnicity?
How much schooling have you completed?
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- c.10995_2014_Article_1657
Perspectives on Prevention of Type 2 Diabetes After Gestational Diabetes: A Qualitative Study of Hispanic, African-American and White Women
Abstract
Background
Materials and Methods
Conceptual Framework
Sample and Recruitment
Development of Interview Guide
Data Collection
Data Analysis
Results
Baseline Sample Characteristics
Perceived Susceptibility to T2DM
Perceived Severity of T2DM and GDM
Perceived Benefits to Health Behavior Change
Potential Barriers to Behavior Change
Cue to Action
Discussion
Acknowledgments
Appendix: Health Beliefs and Lifestyle Behaviors of Women Diagnosed with Gestational Diabetes
Patient Qualitative Interview Protocol
References
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