This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.
The increasing prevalence of gestational diabetes mellitus (GDM) among women of different ethnic backgrounds provides new challenges for health care professionals, who often find it difficult to provide information about the management of this disease to such individuals. Mobile health (mHealth) may act as a useful tool for blood sugar control and care process enhancement. However, little is known about health care professionals’ experiences and attitudes toward the use of mHealth for women with GDM.
The aim of this study was to explore how health care professionals perceived the provision of care to pregnant women who managed their GDM using the culture-sensitive Pregnant+ app in a randomized controlled trial.
Individual interviews with 9 health care professionals providing care for women with GDM were conducted. Braun and Clark’s method of thematic content analysis inspired the analysis. This study included health care professionals who were primarily responsible for providing care to participants with GDM in the Pregnant+ randomized controlled trial at 5 diabetes outpatient clinics in Oslo, Norway.
Health care professionals perceived mHealth, particularly the Pregnant+ app, as an appropriate tool for the care of women with GDM, who were described as individuals comprising a heterogeneous, motivated group that could be easily approached with health-related information. Some participants reported challenges with respect to provision of advice to women with different food cultures. The advantages of the Pregnant+ app included provision of information that women could access at home, the information provided being perceived as trustworthy by health care professionals, the culture sensitivity of the app, and the convenience for women to register blood sugar levels. Technical problems, particularly those associated with the automatic transfer of blood glucose measurements, were identified as the main barrier to the use of the Pregnant+ app. Strict inclusion criteria and the inclusion of participants who could not speak Norwegian were the main challenges in the recruitment process for the randomized controlled trial.
The findings of this study suggest that mHealth is a useful tool to enhance the care provided by health care professionals to women with GDM. Future mobile apps for the management of GDM should be developed by a trustworthy source and in cooperation with health care professionals. They should also be culture sensitive and should not exhibit technical problems.
Gestational diabetes mellitus (GDM) is defined as glucose intolerance recognized for the first time during pregnancy [
The prevalence of GDM is increasing globally, and the rates may range from 1% to 20% depending on the screening procedures employed and the characteristics of the population [
The increasing prevalence of GDM provides new challenges for health care professionals in antenatal care. In Norway, the team responsible for the care of women with GDM includes obstetricians, internists, midwives, and nurses with a specialization in diabetes care. At the time of this study, women with 75 g oral glucose tolerance test (OGTT) values of ≥9.0 mmol/L (2 h plasma glucose) received specialized care at diabetes outpatient clinics (DOCs) [
The first-line treatment for GDM includes provision of information on the advantages of a healthy diet, physical activity, and regular blood sugar level measurements [
Women diagnosed with GDM emphasize the need for individually tailored, culturally appropriate information [
This study was part of the Pregnant+ randomized controlled trial (RCT) which tested the addition of a culture-sensitive mobile phone app to the standard care protocol for GDM and compared the findings to those of the standard care protocol alone in five different DOCs in Norway [
The aim of this RCT targeting a multi-ethnic study population was to explore the attitudes and experiences of health care professionals using a culture-sensitive mobile phone app to manage GDM. In addition, the health care professionals’ general experiences with regard to provision of care to women diagnosed with GDM were also analyzed and described because previous evidence on this topic was very limited.
This study included individual interviews with 9 health care professionals who provided care to pregnant women with GDM participating in the Pregnant+ RCT. A qualitative study design was chosen because mHealth interventions are considered to be complex to evaluate due to their novelty and different outcome measurements [
The interviews were conducted by the second and third authors at the working sites of the participants between May and June 2017 and lasted for approximately 16–35 min. A semistructured interview format was pilot tested with one of the participants, and the main themes in the interview guide were (1) general experiences of providing care to women with GDM; (2) attitudes toward the use of mHealth; (3) experiences of recruiting participants for the Pregnant+ RCT; (4) and experiences of providing care to participants in the Pregnant+ RCT.
The researchers aimed to interview all health care professionals responsible for recruitment and/or provision of care to participants in the Pregnant+ RCT. In total, the interviewers asked 11 health care professionals to participate in the study, of which one refused because he or she believed that they did not have much to contribute and another declined as he or she was unavailable. The 9 health care professionals who were willing to participate received verbal and written information about the study, and the study protocol was approved by the Norwegian Social Science Data Services (ID number: 2014/38942).
The interviews were audiotaped and transcribed by the second and third authors. The transcripts were read by the first author and randomly compared with the audiotapes to ensure accuracy of the transcription process. Braun and Clark’s method of thematic content analysis inspired the analysis [
Data analysis identified three themes representing the participants’ attitudes toward and experiences of caring for pregnant women with GDM participating in the Pregnant+ RCT, and these were as follows: (1) general experiences of caring for women with GDM depicted the health care professionals’ motivation and perceived challenges toward caring for women with different ethnic backgrounds; (2) attitudes toward and experiences of using mHealth illustrated their personal attitudes toward mHealth tools and their previous experiences of using them for disease management and patient-client communication; and (3) experiences of using the Pregnant+ mobile phone app in the follow-up of women with GDM revealed the health care professionals’ evaluation of the Pregnant+ app, the facilitators and challenges of providing care to participants who had access to the Pregnant+ mobile phone app, and the professionals’ experiences of the recruitment process.
Educational backgrounds and work experiences of the study participants. Fictional names have been used.
Participant | Educational background | Work experience |
Kari | Midwife | Nurse for 6 years Midwife for 10 years 7 years at a DOC |
Anne | Midwife | 20 years at a DOC Specialization in diabetes care |
Kristin | Midwife | Midwife for 20 years 5 years at a DOC |
Nina | Midwife | Midwife for 10 years 5 years at a DOC |
Linn | Diabetes specialist nurse | 7 years at a DOC |
Anette | Diabetes specialist nurse | Diabetes specialist nurse for 16 years 14 years at a DOC |
Gunn | Diabetes specialist nurse | 10 years at a DOC |
Lise | Midwife | 16 years at a DOC |
Julie | Midwife | Midwife for 15 years 8 years at a DOC |
This overarching theme included 3 sub-themes: (1) motivation to provide care to women with GDM; (2) description of the characteristics of women with GDM; and (3) experiences of providing information about diet and physical activity.
The majority of the participants reported that they were strongly motivated professionally to provide continuous care to women with GDM. The participants described the women with GDM as being a very heterogeneous group with regard to their ethnic and socioeconomic backgrounds and were surprised to meet women who had developed GDM despite not exhibiting any of the known risk factors. In general, pregnant women with GDM were perceived as being very motivated and easy to approach with health-related information. This was illustrated by the following statement made by a participant who described the reaction of women after being diagnosed with GDM:
Women take it very seriously. Some get very sad. It happens very rarely that they don’t care.
The participants reported that it was very important for them to provide women with information about healthy eating and physical activity, especially because they found that the women appeared to have little knowledge about GDM. They felt that the majority of the women followed their advice, and it was very important for them to achieve long-term changes in the women’s health behaviors. All of the participants focused on the prevention of diet-related diseases in their consultations, as illustrated by the following statement by a midwife:
There should be more focus on preventing disease instead of treatment.
One midwife felt that it was important to build a good relationship with the women to achieve behavioral changes. However, the participants also reported experiencing challenges in providing dietary advice, mainly because the pregnant women were often confused by contradictory dietary information obtained from different health care professionals or the media. The participants also reported that women with GDM were often advised to adopt a low-carb diet or to stay away from all foods containing sugar.
All of the participants had experienced providing dietary advice to women with different ethnic backgrounds, and a majority of them did not find it difficult to adjust their advice to other food cultures. In fact, they emphasized that it was important for them to have this knowledge about different food cultures. However, two midwives reported finding provision of dietary advice to women with different food cultures challenging, and one statement made by a midwife suggested that she believed ethnic Norwegian women had more knowledge about diet than immigrant women:
Ethnic Norwegian women do often know what they have to do, but struggle to accomplish it; whereas immigrant women often get surprised about what they should do.
Another midwife reported challenges related to non-verbal communication with non-ethnic Norwegian women. For instance, she was unsure if women from South Asia understood what she told them because they were less expressive in their communication and provided fewer responses than ethnic Norwegian women. Several participants also experienced difficulties with consultations that included an interpreter and felt that pregnant women who needed an interpreter did not receive equal care. One midwife stated that they were unable to prioritize patients requiring an interpreter due to their busy schedule.
The following sub-themes were identified within this theme: (1) former experiences with mHealth and (2) attitudes toward mHealth. All of the three nurses specialized in diabetes care and one midwife had previously experienced using mHealth in their consultations. The participants stated that a mobile app could be a useful tool during consultations, and one nurse specialized in diabetes care stated the following:
I use an app to provide information about carbohydrates. That’s useful since you always have it with you, because these leaflets always get lost.
However, two participants expressed barriers associated with using mobile apps during consultations with women with GDM. One participant felt that the app would not let a pregnant woman communicate all the emotions she was feeling adequately upon being diagnosed with GDM, and this would affect the participant’s communication/relationship with the woman.
Although half of the participants did not use mHealth apps personally, participants who had no previous experiences with mHealth mentioned several advantages of using mHealth during consultations. For instance, one midwife stated the following:
We have this information material that we show to the women, but I think this could get too much in the first consultation and I experience that I have to repeat things several times. So I think it would be good to have an app you can read undisturbed.
Other perceived advantages included those related to the management of GDM by women. Participants assumed that it would be more convenient for women to register their blood sugar values on a mobile phone compared with a booklet because the latter could be easily lost. They also thought that the use of mHealth would increase in the future and felt that it was important for them to keep up with new developments.
Four sub-themes were identified in this theme: (1) professionals’ evaluation of the Pregnant+ app; (2) experiences with the Pregnant+ app in the care of women with GDM; (3) experiences with recruitment of participants for the RCT; and (4) organizational challenges. Eight of the participants had prior knowledge about the contents and features of the Pregnant+ app and felt that it had several advantages with regard to the follow-up of these women as well as their ability to manage their own GDM. For instance, health care professionals liked that the app contained a lot of different information that women could access repeatedly at any time after the consultation. Several participants mentioned that they had confidence in the contents of the Pregnant+ app and that the information was in agreement with their advice. They sometimes meet women with apps to manage their diabetes that were unknown to them and expressed that it could be difficult to know if they could rely or would approve of the content of these apps.
Although the health care professionals were asked to refrain from using the Pregnant+ app as an active communication tool during their consultations, their experiences of providing care to women who had access to it were recorded. Several participants had asked the pregnant women about their experiences with the Pregnant+ app and found that they preferred registering their blood sugar levels in the app and liked how the information was presented. On the other hand, the participants also encountered women who had experienced technical difficulties with the app, particularly with regard to the automatic transfer of blood sugar values from the measuring device to the mobile phone. The participants believed that technical issues could be a major barrier to the use of mHealth, both for self-management of GDM as well as during consultations.
Moreover, the participants stated that the Pregnant+ app could be a very useful tool for women with different backgrounds, mainly because it used simple and culture-sensitive illustrations that made the text more understandable. Although none of the participants could report experiences of using the Somali or Urdu versions of the app, they believed that English would be the most important language to reach women with different ethnic backgrounds. One participant was surprised that women from Somalian or Urdu ethnic backgrounds did not use the app in their own mother tongues. She related this to her experience of recruiting study participants for the RCT where it was difficult to include participants who could not speak Norwegian:
I was surprised that there were not more women who used the Somali or Urdu version of the app. It seems that those women who wanted to participate in the study, have good knowledge of the Norwegian language.
Although the participants felt that they received sufficient help from the research team, they found the recruitment process for the RCT challenging due to its strict inclusion criteria. Others struggled with the organization of care for women with GDM at their hospitals, and some participants stated that the lack of cooperation between the different health care professionals involved in the care process was a barrier to the recruitment process as well as the use of mHealth.
The results of this study showed that health care professionals perceived mHealth, particularly the Pregnant+ app, as an appropriate tool for the care and follow-up of women with GDM, who were described as individuals comprising a very heterogeneous and motivated group that could be easily approached with health-related information. Some participants reported challenges associated with providing advice to women with different food cultures. The advantages of the Pregnant+ app were provision of information that women could access at home, the provided information being trustworthy, the culture sensitivity of the app, and the convenience of automatic transfer of blood sugar levels to the mobile phones. Technical problems were mentioned as the main barrier to the use of the Pregnant+ app, whereas the strict criteria and inclusion of participants who could not speak Norwegian were the main challenges in the recruitment process.
There is growing evidence in support of the impact of mHealth interventions on the management of diabetes [
One of the key advantages of mHealth, particularly the Pregnant+ app, was the possibility of providing vast quantities of health-related information that women could access repeatedly at their own convenience after the consultation. The participants in our study, who were strongly engaged professionally in the care of women with GDM, often felt that the women had difficulty remembering all of the information given to them. This was in agreement with other studies that had reported an information overload among pregnant women [
Similar to previous reports, some participants in our study experienced difficulties providing diet-related information to women with different ethnic backgrounds [
To increase the effectiveness of mHealth interventions, possible disadvantages have to be overcome. Several participants reported technical issues as being the main barrier to using mHealth and the Pregnant+ app. The participants emphasized the convenience of automatic transfer of blood sugar levels as one of the most important advantages of the Pregnant+ app. However, this was also the feature that exhibited the most technical problems, and these challenges were mainly linked to software updates, either of the protocol being used to send the data from the glucometer to the mobile phone or of the operating system of the phone itself. A standard Bluetooth interface was used during the test and verification stage, while in the clinical intervention the meters had changed using Bluetooth low energy. As a result, not all phones used by the study participants were able to use Bluetooth low energy, and thus were hampered by a more cumbersome set-up and data exchange. This kind of incompatibility between older and newer versions of equipment is imminent in digital studies and cannot be avoided. However, sensor communication has developed considerably, and more than 97% of phones in countries like Norway are currently equipped to easily exchange data with sensors such as glucometers, suggesting that these problems are avoidable in the future. A recent review of health care professionals’ acceptance of eHealth also reported technical problems as a key limitation of mHealth tools [
The first limitation of this study was the small sample size, which is typical for qualitative studies [
To the best of our knowledge, this is the first study to investigate the experiences of health care professionals providing care for women managing GDM using a mobile phone app. The findings of this study showed high levels of acceptance of mHealth among the participants, and this was in agreement with a previous study [
The findings of this study suggest that mHealth acts as a useful tool to enhance the health care professionals’ experience of caring for women with GDM. Future mobile apps for the management of GDM should be developed by a trustworthy source and in cooperation with health care professionals. Moreover, efforts should be made to ensure that they are culture sensitive and do not exhibit technical problems. Further research targeting immigrant women who do not speak the local language are needed to determine the effects of culture-sensitive mHealth interventions.
diabetes outpatient clinic
gestational diabetes mellitus
randomized controlled trial
This study was financed by the Norwegian Research Council (project number 228517/H10).
LGH was involved in development of the study design, analysis, and interpretation of the interviews and writing the manuscript. THA conducted, transcribed, analyzed, and interpreted the interviews and commented on this manuscript. MWS conducted, transcribed, and analyzed the interviews and commented on this paper. ML was involved in the development of the study design, analysis and interpretation of the interviews, and writing the manuscript. JN was involved in development of the study design and the Pregnant+ app and was the technical expert during implementation of the RCT.
None declared.