Research

my reference list has to be current which has to be before 2010 and do the reference list APA style
please read the general article and answer the questions accurately and clearly. i would just like to inform you that the last assignment you did wasn’t very
good so please do follow the instructions and read the journal article thoroughly and answer the questions below
QUESTIONS ARE AS FOLLOWS
these are the questions which have to be answered based on the general article
1. Background of the study (Total: 5 marks)
1.1 Briefly describe the health issue of the study focused?
1.2 What is the significance of the study?
2. Overview of research design (Total: 5 marks)
2.1 What was the aim of the research?
2.2 What research design did the researchers use? Was it appropriate? Why/why not?
3. Sampling (Total: 10 marks)
3.1 Who were the study participants?
3.2 What are the inclusion and exclusion criteria of the sample? Why is it important to have these criteria identified before recruitment?
3.3 What sampling technique was employed in this study? Was the sampling technique appropriate for the research design? Why/why not?
3.4 How was the sample size determined? Was it appropriate and why?
4. Data collection (Total: 10 marks)
4.1 How was the data collected?
4.2 Was the data collection method appropriate for the study question and the research design? Why/why not?
4.3 What measures were or were not taken to ensure rigour?
5. Data analysis/findings (Total: 10 marks)
5.1 Identify and describe the data analysis? Was it appropriate? Why/why not?
5.2 What were the findings?
5.3 Can the study findings be used in other settings? Why/why not?
6. Evidence utilization (Total: 5 marks)
Would you implement the findings of this study in clinical practice? Why/why not?
7. Presentation (Total: 5 marks)
7.1 Referencing in-text and in reference list conforms to APA referencing style
7.2 Critique support by relevant literature using at least 3 recent academic references published from 2009
7.3 Correct sentence, paragraph, grammatical construction, spelling, punctuation and presentation
THIS IS THE ARTICLE
Women’s experiences of factors that facilitate or
inhibit gestational diabetes self-management
Mary Carolan1*, Gurjeet K Gill2 and Cheryl Steele3
Abstract
Background: Gestational diabetes rates have increased dramatically in the past two decades and this pattern of
increase appears to relate primarily to the obesity epidemic, older maternal age and migration from world areas of
high GDM risk. Women from disadvantaged and migrant backgrounds are most at risk of developing and of
mismanaging this condition. The aim of the study was to explore the factors that facilitated or inhibited gestational
diabetes self-management among women in a socially deprived area.
Methods: Fifteen pregnant women, with a diagnosis of gestational diabetes, were purposively recruited for this
study. Qualitative semi structured interviews and 1 focus group were conducted when participants were
approximately 28–38 weeks gestation. The study’s theoretical framework was based on interpretative
phenomenology and data was analysed using a thematic analysis approach.
Results: Women in this study identified a number of factors that complicated their task of GDM self-management.
Barriers included: (1) time pressures; (2) physical constraints; (3) social constraints; (4) limited comprehension of
requirements, and (5) insulin as an easier option. Factors facilitating GDM self-management included: thinking about
the baby and psychological support from partners and families.
Conclusion: Women from low socio economic and migrant backgrounds often struggle to comprehend GDM
self-management requirements. To improve adherence to management plans, these women require educational
and supportive services that are culturally appropriate and aimed at a low level of literacy.
Keywords: Gestational diabetes, Disadvantaged, Barriers, Self-management
Background
Gestational Diabetes Mellitus (GDM), or glucose intolerance
that first presents in pregnancy, affects approximately
12,000 pregnant women in Australia annually [1].
This figure represents approximately 4.5-5.0% of all
births, although specific groups are at greater risk of
developing this disorder [1]. GDM rates have increased
dramatically in the past twenty years [2-4] and this pattern
of increase appears to relate primarily to the obesity
epidemic [5], increasing maternal age [4,6], and migration
from high risk areas, such as South East Asia [7]. In
Australia, highest rates of GDM are reported among
women born in Polynesia, Asia, South Asia (Indian subcontinent)
and the Middle East. These populations are
at least three times more likely to develop GDM
compared to locally-born women [1,8]. Factors such as
low socio-economic status and concomitant levels of
obesity compound the risk of developing GDM [4].
GDM impacts on the health of both mothers and
infants, and gives rise to higher rates of maternal hypertension
and pre-eclampsia [9] increased intervention in
birth, such as caesarean section [10] and later development
of type 2 diabetes [11]. This risk is substantial and
women who have had GDM in pregnancy, are at least 6
times more likely to develop type 2 diabetes during their
lifetime [11,12]. Gestational diabetes also exposes the
fetus to hyperglycemia, which stimulates an increase in
fetal insulin and an increased rate of fetal fat storage
[6,13]. These two factors in turn predispose the fetus to
future obesity and type 2 diabetes. More immediately,
the infants of mothers with GDM are more likely to be
stillborn [14] or to suffer a range of perinatal morbidities
such as birth injuries [15], macrosomia, hypoglycaemia
and respiratory problems [10,16]. These morbidities result
in higher rates of neonatal nursery admission [16].
Overall, the evidence suggests that women from disadvantaged
and migrant communities are the most at risk of
both developing GDM [4,17,18] and of misunderstanding
and mismanaging the condition [19,20]. Risks of GDM
complications are highest for these groups [4,21].
First-line management of GDM involves a complicated
self-care regimen of regular blood glucose level (BGL)
testing, and dietary adjustment based on the woman’s
BGLs. An increase in exercise is also encouraged in a
bid to boost the woman’s metabolism [22]. The overall
aim of treatment is to maintain BGLs within recommended
ranges [22] and this is achieved primarily by reducing
energy intake by replacing calorie dense foods
with healthier choices [23]. This approach of dietary and
exercise adjustment is suitable for approximately 65–90%
of women diagnosed with GDM [24-26]. Women with
more severe hyperglycaemia and those who are unable to
achieve glycaemic goals with diet and exercise require insulin
to control their GDM [27]. High levels of insulin administration
are a concern however, as women who
require insulin to control their GDM are considered to be
at higher risk of developing type 2 diabetes in the future
[28-30].
In light of these serious implications, for morbidity
among both mothers and infants, it is critical that
women with GDM are supported to take on the tasks of
self-management. This study builds on earlier research
which found that knowledge of GDM, food values and
GDM management plans was deficient among women
in this region [19,20]. This situation of poorer comprehension
seemed to relate principally to lower socio economic
status, poorer levels of maternal education and
lower health literacy (the ability to read and comprehend
health related material, such as food labels). The current
study sought specifically to understand the factors that
facilitated or inhibited women’s understanding and adherence
to GDM dietary self-management principles. It
was intended as the initial step in the development of an
educational and self-management program, aimed specifically
at supporting women, with GDM, from disadvantaged
and migrant backgrounds.
Methods
A qualitative approach was chosen to address the complex
issues of GDM self-management. This approach
was informed by Interpretative Phenomenological Analysis
(IPA), as endorsed by Smith and Osborn [31] and
Chan et al. [32]. Interpretative phenomenology aims to
explore participants’ lived experience of events in order
to understand how they make sense of their personal
and social worlds (p. 3, 31). The main emphasis is on
the exploration of personal experience as the individual
narrates his/her account and appraises events [31,32].
This narrative approach also draws on the philosopher
Kierkegaard’s [33] insights into the discourses that
underpin the lived experience of the narrator in certain
situations. Kierkegaard believed that the individual’s
stories offered an opportunity for others to see what the
storyteller noticed, and to become aware of the particular
emphasis he/she accorded to events, including the
items that were a concern for him/her [33]. This approach
is considered appropriate in this study as it may
help uncover the particular concerns and difficulties participants
encountered, when self-managing their GDM.
The approach is also consistent with an appreciation of
the individual woman, which was an important consideration
for this study.
Semi structured interviews and one focus group were
conducted using a pre-determined set of questions, as
below. These questions were intended to loosely guide
the interview. A parallel paper, from this study, has
reported on the women’s experiences of GDM [34]. This
paper reports on the factors that facilitated or hindered
the women’s GDM self-management. The study was
approved by the Western Health Ethics Committee
(Sunshine Hospital). Written consent was obtained prior
to interviews and focus group. Pseudonyms were used
throughout to ensure the women’s anonymity.
Questions for interview
1. Can you tell me a little about your experience of
Gestational Diabetes?
2. Can you tell me a little about the information you
received?
3. What other information would you have liked?
4. What made it difficult for you to manage your
gestational diabetes?
5. What made it easy for you to manage your
gestational diabetes?
6. What management strategies (ways of dealing with
your diabetes) worked for you?
7. What advice would you give to someone who was
newly diagnosed with GDM
8. What information do you know now, that would
have been helpful at the beginning?
Sample and recruitment
Participants were recruited purposively from a Pregnancy
Diabetes Clinic in the Western Region of Melbourne. This
clinic serves a socially disadvantaged area with a large
multi-ethnic population. Women in this area present with
increased risk factors for developing GDM and for poorer
GDM self-management, such as low socio-economic status
[4,35,36], obesity and poor diet [37], sedentary lifestyle [37],
ethnic minority status [4,8] and lower health literacy [19].

Women who met the following inclusion criteria, were
invited to participate: pregnant; diagnosis of GDM; able
to speak conversational English; singleton pregnancy
with no known serious abnormalities. Access to women
was facilitated by the diabetes educator, who coordinates
the women’s care at the clinic. GDM testing of
participants was consistent with Australasian Diabetes in
Pregnancy Society (ADIPS) GDM diagnostic criteria
[38], using the 75-g 1 h glucose challenge test (GCT)
followed by the 75-g 3 h oral glucose tolerance test
(OGTT), if the GCT is positive. A universal approach to
screening was employed, as is usual in Australia [4]. Participants
were recruited after they had attended for
GDM education and had a minimum of 3 weeks experience
of self-managing their condition.
In all, 30 women who met the inclusion criteria, and
who indicated an interest in the study, were approached.
Of this number, 20 women agreed to participate in the
study. However, 5 women were unavailable on the day of
interview and the most common reason for declining to
participate at this stage, was ‘too busy preparing for
baby’. A total of 15 women participated in the study
Data collection and analysis
Data were collected during audio-recorded focus group
and interviews. Participants were offered three choices
for participation: (1) focus group in a room adjacent to
the clinic, (2) individual interview by phone, (3) face to
face interview at a venue of their choice. One focus
group discussion was conducted involving 4 women, 10
interviews were conducted by phone and the final interview
was conducted at the woman’s home. Although the
use of focus groups within phenomenological methods is
contested [39,40] the most frequent objection is based
on the belief that the ‘essence’ of a phenomenon is best
explored by individuals who must describe their experience,
without interference [39]. However, others argue
that focus groups may permit a detailed examination
and interpretation of events by allowing participants to
share their experiences and engage in a joint sense making
endeavour with the focus group facilitator and other
participants [41,42]. The use of focus groups in phenomenology
is additionally common in nursing and health
studies and is generally justified on the premise that participants
who share certain features, can relate to each
others comments and share experiences to come to a
deeper understanding of the phenomenon [43-45]. We
would argue that the use of the focus group, as in this
study, added to the data in a similar way, and enhanced
rather that inhibited the women’s exploration of their
experiences.
Data were analysed using Burnard’s [46] method. The
following steps were employed:
_ Interview and focus group data were transcribed to
facilitate initial familiarisation with the content
_ Audio-tapes were listened to and transcripts were
read several times which allowed for an initial
identification of themes. This step involved memowriting
and commentary on content
_ Units of meaning (themes) and values were sought.
This involved a transformation of memos and notes
into themes
_ Data was classified under broad headings, which
involved a clustering of emergent themes and ideas
_ Reliability of analysis was addressed by asking a coresearcher
to independently generate a theme list
_ Headings were amended and collapsed as data
analysis progressed. This involved a stage of higher
abstraction and themes were collapsed and refined
as meanings became clearer.
_ Emergent understandings were tested against the data,
which involved returning to the transcripts to confirm
that the interpretations were true to the data
_ Alternate explanations were sought
Results
Participants came from the following self-identified ethnic
backgrounds: Caucasian (n = 5), Indian (n = 4), Vietnamese
(n = 2), Arabic (n = 1), Chinese (n = 1), Cambodian (n = 1),
Filipino (n = 1). Additional demographic characteristics are
presented in Table 1. These groups are also similar to the
largest groups to give birth in Victoria, Australia [47]. Most
women (73%) were aged between 30–39 years, with an agerange
of 23–40 years. Educational level was lower than the
Australian population average, and the majority of women
reported High School (Secondary) level (73%), as their
highest academic achievement. Four women (27%) reported
a non-school qualification, which included 3 women
(20%) with a university degree. This figure is lower than the
Australian population average of 59% non-school qualification,
which includes approximately 25% university degree
[48]. Parity varied, although the majority (9 women) were
primiparous (60%), one third of participants (5 women)
were expecting their second baby (33%) and the final participant
was expecting her fifth baby. Eleven women (73%)
were dealing with GDM for the first time (see Table 1).
Themes
Women in this study identified a number of factors that
assisted or made their task of GDM self-management
more difficult. These factors are considered separately
under barriers and facilitators of GDM self-management.
In this first section, barriers are discussed. The following
five themes emerged as barriers: (1) time pressures; (2)
physical constraints; (3) social constraints; (4) limited comprehension
of requirements, and (5) insulin was an easier
option. These themes are illustrated in Figure 1 below:

Table 1 Demographic characteristics of participants
Women’s pseudonyms Age Highest education level Occupation Gravida Ethnicity
1. Lili 34 yrs University Financial manager 2 Caucasian
2. Loan 38 yrs High school Bank teller 1 Vietnamese
3. Rita 31 yrs High school Looking for work 2 Caucasian
4. Tran 30 yrs High school Office worker 1 Vietnamese
5. Xioquan 29 yrs High school Casino croupier 1 Chinese
6. Prani 30 yrs High school Carer 1 Indian
7. Flora 32 yrs High school Office worker 1 Filipino
8. Leanne 38 yrs High school Receptionist 2 Caucasian
9. Kate 32 yrs University Nurse 2 Caucasian
10. Margaret 23 yrs High school Stay at home mother 2 Caucasian
11. Suji 24 yrs High school Factory worker 1 Cambodian
12. Leni 34 yrs University Nurse 1 Indian
13. Gurtha 34 yrs Technical college Husband’s business 1 Indian
14. Fatima 40 yrs High school Stay at home mother 5 Arabic
15. Pina 34 yrs High School Not working 1 Indian
Barriers to GDM self-management
Theme 1: Time pressures
Participants discussed, at length, the difficulties they
encountered when learning to self manage their GDM.
Time pressure was identified as possibly the greatest
challenge the women faced. This included limited time
to understand and make sense of their GDM diagnosis,
together with a sense of urgency to effect immediate
blood glucose control by adopting the advised dietary regime.
Two sub-themes were identified: the urgency of
immediate change and finding time for everything.
The urgency of immediate change
Most women described a time of shock and confusion as
they came to terms with their diagnosis of GDM. This
stage was made all the more difficult because of the
immediate and quite dramatic dietary change required.
Such urgency left participants with what Lili describes as
no time to think it through. Generally, it took some time
for women to make sense of what was required and to
understand the seriousness of their condition. Tran
describes her experience:
First week, I mean they told me which foods to avoid
and so forth, but again that was very limited. I wasn’t
eating very much anyway during my pregnancy . . .
quite a few scores [BGL values] were over what they
suggested. I hadn’t really looked after what I had been
eating. . .I really wasn’t trying that first week I guess . . .
I didn’t think it would affect the sugar levels so much. . .
She (diabetes educator) thought it was very bad. . . They
suggested insulin after that first week and I didn’t want
that at all. I did try to explain, “. . . I understand why
they are high.” I need another chance. . . Tran
Finding time for everything
Finding time for everything was identified as a major
challenge for most women. This difficulty related to the
busyness of the women’s lives as they juggled work,
household chores and family obligations. There were
two elements to this sub-theme: dietary self-management
and additional requirements. Dietary self-management, in
particular, represented an enormous time challenge to
women, requiring time to learn about food values in order
to create nutritious and appealing meals. For some
women, like Leanne, this meant learning to cook, for the
first time:
Like where do you find the time. . . having to go from
being able to buy foods (ready cooked) and having to
actually think about it, prepare it and cook healthy
food. Yeah, lots of processed food (previously). . .
That’s my biggest change, probably, going from never
cooking. Leanne
Most women felt they needed some time to adjust to
their new eating regime, and initially, it was difficult to
even remember the GDM self-management tasks
required. Kate explains:
Because I do shift work, I’ve found I’ve had to
make a really strict monitoring sort of system. So
I set alarms on my phone every time I have
something to eat, so I remember to do the two
hours afterwards [BGL], otherwise I’ll just forget.
And I set a final alarm to go off before I go to
bed so that I can remember to take the night time
[insulin]. . .Kate
Having GDM meant additional requirements such as
extra clinic visits to specialists and dieticians. Very often
appointments could not be arranged for the woman’s
convenience:
Sometimes . . . I have to actually go back there [clinic]
twice a week, I think the dieticians only, you can only
book them on a Friday. . .but the obstetrician, only
. . .on a Monday. . . so that is hard with work. . . Flora
Participants also identified finding time to exercise as
a particular difficulty, although additional exercise was
recommended as part of their diabetes self-management
plans. Leanne explains:
. . . the doctor said to walk for an hour after meals. I
mean, I start (work) at seven and finish at three and
then I’ve got to pick my daughter up from school.
Trying to fit that in, it’s just . . . I think, well, God, I’ll
be dead by the time I get back, you know? . . . Leanne
Theme 2: Physical constraints
The second theme, physical constraints, contains the
common explanations offered by women who felt unable
to meet with the exercise guidelines of their selfmanagement
program. The most common reason
offered by women who felt unable to undertake regular
walking exercise, as advised by the diabetes educator
and midwife, was pain. This pain most often manifested
as pelvic (symphysis pubis) pain or backache. Tran
describes her difficulty:
Because I have had pelvic pain, I haven’t been able to
move a lot. And I have been quite ill. . . Tran
Theme 3: Social constraints
The third theme explores the social constraints identified
by participants as creating difficulties for them when
self-managing their GDM. There were three sub-themes:
disruption to the family, finding the balance, and social
events/festivities.
Disruption to the family The first sub-theme encompasses
the day-to-day difficulties of having to comply
with GDM meal guidelines. Women discuss preparing
separate meals for themselves or altering family meals
to meet with GDM guidelines. This frequently resulted
in a disruption to the family and an additional cost to
the family budget.
We had three different dinners every night. . . I could
have eaten the same thing without the carbs. . . but so
boring. . . I made the choice. . . and you may not have
the budget to buy crazy expensive things. . . but you
have to expect a little bit more. . . maybe buying organic,
interesting vegetables. Do something nice with it, you
know, just make mealtimes feel nice. . . Lili
Finding the balance The second sub-theme illustrates
the difficulties participants faced when surrounded by
tempting foods at home, or when going to restaurants or
visiting family and friends. Although participants were
appreciative when family and friends supported them by
not having high calorie/high sugar content foods around,
they equally did not expect others to entirely change
their dietary habits to accommodate the woman’s GDM
diet. Xioquan and Suji speak of the difficulties they faced
at home:
Because I live with my parents-in-law. . . Sometimes
there is some chocolate or ice cream, sponge cake in
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the fridge. It is just so hard for me to not touch
them. . .a lot of temptations. . . Xioquan
I don’t cook the food. . . it is bad to say I won’t eat
(the food that her mother-in-law cooks). . . rice. . . she
says it is healthy for the baby. . . Suji
While Loan found social outings to restaurants, particularly
difficult:
Whenever I go to a restaurant with friends that’s the
worst case. . . and especially having the desserts
there. . . But once you go out, like, once a week you
want to eat. . .Loan
Most women describe having small amounts of proffered
foods when visiting family and friends. This approach
was used so as not to cause offense or difficulty
for others, while at the same time trying to adhere to
dietary guidelines. Rita explains:
The other week I had a small bowl of pasta. . . my
sugars were very high then. . . .Because when I’m
eating with my Mum. . . it’s like you can’t expect
everybody to change everything. . . Rita
Festivities and social functions The third sub-theme
overviews particular social constraints around special
occasions such as religious festivals. Most of these events
are accompanied by the provision of high calorie celebratory
foods, which are prohibited on GDM selfmanagement
plans. Although women are not obliged to
eat these foods, food is a large part of the celebration
and women felt they missed out when unable to participate
in the celebratory meal. Leni explains:
I’m myself Indian and we have lot of Indian sweets
and that sort of thing. When I didn’t know that I was
diabetic I was eating sweets as well, like Indian proper
sweets. And just the religious festivals and eating
certain foods, but now I’ve stopped that as well.
Actually it’s not compulsory. It’s up to you if you want
to eat it or not. You just feel a bit out of things. . .
Leni
Theme 4 Limited comprehension
Theme 4, limited comprehension, explores the participants’
confusion and doubt about dietary self-management,
especially in the early days following GDM
diagnosis. Two sub-themes were identified: limited
understanding of GDM, and limited understanding of
GDM self-management requirements.
Limited understanding of GDM In this sub-theme,
participants expressed their confusion and lack of
knowledge of GDM. This included a limited understanding
of the importance of blood glucose control and dietary
self-management. Here, Prani expresses her
uncertainty, almost ten weeks after GDM diagnosis:
They didn’t tell me what’s the side effects for the
baby. They just told me, “You’ve got diabetes, you’d
better control with this and that.” But they didn’t tell
me, like, what are the side effects for having sugar
levels up. . . like why it’s really important to monitor
your sugar levels. . . Prani
Limited understanding of GDM self-management
requirements Participants struggled to make sense of
what they needed to do in order to maintain their blood
glucose within the recommended range. This confusion
was exacerbated by a limited amount of consistent information
to guide their self-management efforts. Women
described getting general dietary guidelines but insufficient
information on ‘how to’ effect the necessary changes. This
made the task more difficult and time consuming. Lili
explains:
You get a list of food but no instructions. . . you don’t
know “if I eat a smaller potato is that okay?” And then
you follow it (the diet) through the pregnancy. . . .You
would like to say, “Follow this diet, you’ll be fine, off
you go.” It isn’t like that, so a greater effort is needed,
and encouragement, and just well, time. . . you really
have to work it out yourself. . . Lili
This difficulty was compounded by insufficient information
about different foods and ingredients, and this
was particularly the case for women who didn’t follow a
Western diet. Tran explains:
I did get appointments where I got some information.
But I found it more outside of those appointments. I
mean it was helpful, but it wasn’t really in depth. Well
like the food for instance, it wasn’t a very extensive
list of what you could eat, it was very limited and
most of the food I eat wasn’t on it. . . Tran
The information needs of women, in this study, varied
and although many women felt the information
they received was insufficient to help them manage
their GDM successfully, others were happy with the
depth of information they received while a small
number of women felt that they received too much
information:
Well the information they gave me was very basic
so I looked up a lot on the internet and worked it
out myself really. . .Tran
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They give me a chart, like you can use these things
[food] and you have to avoid these things. Exercise.
They told me to do it at least 15 min exercise at the
morning and evening. When I went to them they just
give me information about how to control the diet.
They told me everything. . . Gurtha
No at hospital they give me too much information
about diabetes (indicates feeling overwhelmed). . . Pina
Theme 5 Insulin as an easier option
Theme 5 explores the women’s commonly expressed belief
that the use of insulin was an easier option, rather
than dietary and exercise self-regulation alone. Women
who struggled to adhere to the dietary regime were
happy to commence on insulin as they felt it made their
task more achievable. None of the women on insulin
expressed any concern about long-term implications of
insulin use and were mostly happy to accept it as a solution
to the current situation.
Yeah, it’s painful, I have to say, but it really works. I have
to say that is a good thing. Because it’s easier to help me
manage my diet and control my sugar level. . . Yeah, the
drugs (insulin) can help my condition . . .it was so hard
to deal with cravings. . . Xioquan
Facilitators for GDM self-management
Factors identified as motivating and encouraging adherence
to GDM self-management regimes included thinking
about the baby, support from a variety of sources
and realising that GDM self-management was in the
woman’s hands. These three themes; (A) the baby, (B)
support, and (C) realisation, are illustrated in Figure 2
below.
Theme A the baby
Women in this study had a powerful interest in maximising
fetal health and this desire motivated them to
avoid prohibited food items and to adhere to the GDM
self-management regime, as closely as possible. Participants
described being willing to do whatever they were required
to do, in the baby’s best interests. Most understood clearly
that GDM could impact negatively on the baby’s health.
Xioquan explains:
It will affect your baby, so you have to do the right
thing by the baby. I do have the temptation. But those
times I control and I eat well for my baby because I
be there for the baby. . . I do just monitor what I eat
and, you know, more exercise definitely than before. . .
Xioquan
Although participants were uniformly concerned about
the baby’s welfare, and equally prepared to act in the
baby’s best interests, their understanding of how diet
and exercise would improve the baby’s health was sometimes
a little sketchy:
Just cooking healthy food. . . and just walking, yeah,
that makes the baby stronger. . .Fatima
Some women were additionally motivated by a strong
desire to right earlier behaviours such as overeating and
eating unhealthy foods. These women aimed to redress
the balance in favour of the baby. Lili explains:
I was very determined to make sure I could do
absolutely anything within my power to not allow any,
something to happen to the baby. I knew I had
brought it on myself by being overweight. . .I felt very
responsible. . .Lili
Theme B support
Participants unanimously identified psychological support
as very important in helping and encouraging them
to master the everyday tasks of GDM self-management.
This support had the effect of making the woman feel
less isolated in her undertaking. Margaret explains:
Well I think I could, I probably could do it on my
own but having that support base, having som
kind of do it with you . . . makes you feel you’re not
alone doing it. . .Margaret
Support came from two key sources, the woman’s family
and from health professionals such as dieticians, midwives,
doctors and diabetic educators. Husbands and partners
provided the most support and supported the women in
terms of accompanying them on walks for exercise and encouraging
them to adhere to the GDM diet as well as providing
encouragement and emotional support when the
woman was learning to take blood glucose levels and administer
insulin. Several husbands/partners ate the same
food, thus avoiding the need for the woman to cook separate
meals. Some examples follow:
My husband, he was telling that I maybe . . . shouldn’t
have that much [to eat], during the yum cha. . . .
Xioquan
I was a bit fed up and upset with myself. My husband
was very supportive. . . he helped me get over things
like the finger pricks. . . he did his own one day just to
show it wasn’t a big deal. . . Lili
He (husband) he’s fond of sweet. – now he eats, but
not as much as before. He always – like, he try to
control, as well. . . he won’t eat it in front of me. . .
‘cause whenever he, like, have sweet or other things, I
want to eat. . .Gurtha
The woman’s mother or sisters were also a valuable
source of support and encouragement, and mostly provided
help in terms of advice about appropriate foods and ways
of cooking food to reduce calorie content. Prani explains:
Yeah, especially my mother. . . she’s very worried
about me, so she usually call(s) every day (from India).
To find out, like, I’m okay. Don’t eat this. Don’t eat
this. . . and she always try to give me some home
recipes, so that I get through my diabetes. . . Prani
The second source of support was from health professionals,
and this support was rated by the women as valuable,
but as less important than family support. Educational
support that improved the women’s comprehension and
sense-making endeavours were valued most. Lili and Xioquan
explain:
The first pregnancy I had a lady (educator) that was
really excellent, very understanding, very approachable.
She would listen to my concerns and we had a
conversation rather than just a one-way flow of
information. And so I had a very positive experience
with her. . . Lili
The diabetes educator is really friendly. . .she
explained things very like, in a very good way Yes, yes
and – like, she did a demo in front of me, how to
inject yourself. It was really scary first time. . .
Xioquan
Theme C realisation
Women in this study described a stage of realising that
they were responsible for their own care and that, other
than the support that they harnessed from a variety of
sources, essentially they had to do the work of GDM
self-management alone. Two sub-themes were identified:
realising I had to do it myself, and an opportunity to
prevent type 2 diabetes.
Realising I had to do it myself This sub-theme encompasses
the women’s realisation that, although they could
draw on family and health professionals for emotional
and practical support, and also request assistance to develop
management strategies, essentially the task of selfmanagement
fell to the individual woman. Leni and Lili
explain:
‘Yeah, well you just have to do it yourself. . .you have
to take it on. . . if you have it (GDM) you have it, you
can’t do anything else’. . . Leni
I realised it was up to me. . .no one else. . . there was
no point in cheating. . . I would be just cheating
myself. . . Lili
An opportunity to prevent type 2 diabetes The second
sub-theme explores the women’s realisation that their
GDM diagnosis offered them an opportunity to put in
place strategies to prevent future type 2 diabetes. This
realisation motivated the women to adhere to GDM
management guidelines. Leanne’s account is typical:
It’s good to learn about it, otherwise the way I was
going, definitely I would have diabetes 2. I didn’t
know about it but now I can control myself and
. . .Yeah, because the way I’m not having anything, I
was having heaps of sugars every day . . .Leanne
Discussion
This study aimed to explore the factors that facilitated
or hindered GDM self-management among a group of
women attending for pregnancy care in a low socioeconomic
setting. Findings suggest that women encountered
a number of barriers in their quest to self-manage
their condition. This included difficulty comprehending
the urgency of immediate diet control. Most women
spoke of the challenge of implementing a complex regimen
of blood testing and dietary manipulation, within a
very short time frame, while they were still coming to
terms with the shock of diagnosis. Many reported commencing
on insulin within 1–2 weeks of GDM diagnosis,
and some women felt they would have mastered the
requisite GDM self-management behaviours in a more
generous time frame. This urgency of immediate treatment
of maternal hyperglycaemia is echoed in the literature,
where an immediate reduction of maternal blood
glucose is recommended in order to minimize adverse
pregnancy outcomes [13,49]. Moreover, recent studies
also indicate that maternal hyperglycaemia, at lower
levels that those previously recognised, has a detrimental
effect on fetal welfare [25] and this finding has further
increased pressure on health professionals to effect an immediate
reduction in maternal blood glucose levels [13].
Participants in this study, found dietary self-management
difficult, related to the time required to learn food values,
and to cook healthy food. Social factors such as eating with
family and friends also contributed to the dilemmas
women faced, while a lack of clear guidelines was identified
as hindering the process of diet control. Only two study
participants succeeded in self-managing their GDM without
insulin and both women, identified personal character
strengths and determination as assisting them to master
the necessary skills and behaviours. This very low rate of
non-insulin use was a surprising finding, particularly as
women were recruited on a first come basis rather than on
the basis of management regimens. However, further explication
of this finding is beyond the scope of this qualitative
study of women’s experience and future quantitative evaluation
is recommended. The finding may be incidental,
however, it is consistent with generally higher use of insulin
at the clinic where limited maternal education and
understanding are thought to impact on poorer dietary
adherence and higher rates of hyperglycaemia [19,20].
Whatever the reasons, rates of dietary self-management
alone were considerably lower, among study participants
than the recommended 65–90% of women discussed in
the literature [24-26]. This feature may also reflect limited
appropriate, culturally based educational resources for
women in this area.
In general, dietary self-management is recognised as
challenging [50,51] and as requiring motivation, understanding
of food values and of the amount to eat [22].
This knowledge and motivation may have been deficient
in our population due to their social circumstances and
may have also been affected by cultural beliefs about
particular foods, such as rice. Many participants struggled
to believe that traditional foods such as rice could be considered
‘bad’ food, in terms of excess calories, related to
portion sizes. Parallel findings present in the literature and
dietary change is recognized as difficult to achieve, particularly
among low socio-economic and migrant groups
[52,53]. Such difficulties relate to cultural mores, views
about traditional foods and a lack of appropriate food
alternatives [50,51,53,54]. Many participants in our
study were hesitant to change their diet, while at the
same time they were willing to eat less in order to
avoid hyperglycaemia. Parallel findings present in the
literature, and participants in Rhoads-Baeza and Reis’
study among low income Latino women with GDM,
were also reluctant to change from their traditional
consumption of fatty meats to healthier alternatives
[53]. On the other hand, Bandyopadhyay et al. [54] who
studied South Asian women with GDM in Australia,
found that participants predominantly changed to the
recommended diet, but were nonetheless unhappy
about the type and quantity of food allowed, and complained
of always feeling hungry.
One surprising factor in this study, was the frequency
with which women identified the use of insulin as an
easier option, rather than dietary control alone. This
finding is not evident in the literature and appears to relate
to the women’s concerns about hyperglycaemia at
the same time as encountering difficulties with dietary
restrictions and behavioural change. Women who
regarded insulin as easier than diet control alone,
expressed limited concerns about insulin use and
regarded it simply as a solution to their current dilemma
of high blood glucose and difficulty in effecting diet control.
None of these women displayed any knowledge of a
possible link between insulin use in GDM and subsequent
development of type 2 diabetes.
In terms of facilitators, women in this study were intensely
interested in maximizing fetal health and this
finding of concern for the fetus is echoed in other research
on women’s experiences of GDM [53-55]. Concern
for the fetus motivated participants to take on the
tasks of GDM self-management and, although many
women struggled to understand food values and to prepare
healthy meals, they remained dedicated to the
baby’s welfare. This manifested in the discomfort they
endured by eating less than they desired, eating foods
they did not enjoy, doing blood glucose levels and
administering insulin, and trying to meet with exercise
requirements. In the literature, a desire to protect the
fetus, or evidence of maternal-fetal attachment, is similarly
associated with greater pregnancy investment and
adoption of health promoting behaviours, such as
healthy diet [56,57].
Successful GDM self-management in our study was
mediated by support from family and health professionals.
Women identified husbands and partners as the
most important source of psychological support. A less
important, but additional form of psychological support
was offered by health professionals, including diabetes
educators, midwives, doctors, and dieticians. Similar
findings of psychological support as important in
Carolan et al. BMC Pregnancy and Childbirth 2012, 12:99 Page 9 of 12
http://www.biomedcentral.com/1471-2393/12/99
encouraging GDM self-management, are found in the
literature [58,59]. In particular, the partner’s support is
seen as especially valuable in effecting behavioural
change such as increasing exercise [59] while support
from health professionals was recognised as encouraging
women to view GDM as within their control [58].
Finally, this study has some limitations and the recruitment
of women who could speak conversational English
may have excluded many other migrant women in the area.
For this reason, a number of interpreter mediated focus
group discussions are planned for the future, which will include
representation of the most populous ethnic groups
in the area. Additionally, this small sample is from one geographical
area, which means that the findings cannot be
generalised to the Australian population as a whole [60].
However, the intent of the study was not to provide generalisable
information, but to explore the facilitators or impediments
to GDM self-management, among women in our
area. This aim has been achieved and, although findings
are not generalisable, they may also be applicable to other
similar populations [60].
Implications for practice
This study has important implications for practice, as
rates of GDM continue to increase globally, particularly
among women with risk factors such as obesity, lower
socio-economic status and migration from world regions
of high GDM risk. It is therefore important that strategies
are adopted to encourage these groups of ‘at risk’
women to self-manage their GDM. Such selfmanagement
will reduce the incidence and severity of
GDM related complications. The greatest challenge
faced by health professionals, engaged in the care of
women with GDM, is to provide sufficient and appropriate
education and support at what is a stressful time in a
woman’s pregnancy. Most women describe being
shocked and upset at their diagnosis of GDM and take
some time to adapt. At the same time, there is a relatively
narrow window of opportunity for women to master
the complex tasks of GDM self-management, and
thus reduce their hyperglycaemia. Dwindling health
resources add to this conundrum, as educational
resources are already stretched, often where they are
most needed.
There is a need for targeted educational resources for
women with GDM, and earlier studies indicate that
initiatives that address the cultural context of the group
in question, may produce the best results [55,61]. Additionally,
there is strong evidence to suggest that emotional
support from the woman’s partner/husband/family
improves adherence to GDM self-management regimens
and, with this in mind, a family approach to GDM education
may produce better results. This careful targeted
approach may effect more successful dietary
management and may thus reduce the percentage of
women requiring insulin to control their condition. Successful
GDM self-management, in turn, is associated
with lower rates of serious pregnancy complication and
serious infant morbidity. It is also associated with a
lower risk of later developing type 2 diabetes.
Conclusion
In conclusion, this study has indicated that women from
low socio-economic and migrant backgrounds often
struggle to comprehend and adhere to GDM dietary and
exercise guidelines. They require supportive services that
are culturally appropriate and pitched at an appropriate
level of health literacy. A keen interest in the baby’s welfare
is likely to increase women’s receptiveness to
interventions.
Competing interests
The authors declare that there are no competing interests.
Authors’ contributions
Study conception and design, MC, GG, CS. Coordination and implementation
of the study MC. Data collection MC. Data analysis, MC, GG, CS. Preparation
of the manuscript MC. Editorial assistance, GG. All authors read and
approved the final manuscript.
Acknowledgements
We would like to acknowledge the women who took part in the study.
Thanks also to the Ian Potter Foundation, Melbourne for the small grant to
support the study. Finally, we would like to acknowledge Maureen Farrell
and Nicole Carver for their contribution to data collection.
Author details
1School of Nursing and Midwifery, St Alban’s Campus, Victoria University,
PO Box 14228, Melbourne 8001 , Australia. 2Australian Community Centre for
Diabetes (ACCD), Victoria University, St Alban’s Campus, PO Box 14228,
Melbourne 8001 , Australia. 3Western Health, Diabetes Education Service,
Western Hospital, Gordon St. Footscray, Victoria 3011 Victoria, Australia.
Received: 19 March 2012 Accepted: 10 September 2012
Published: 18 September 2012
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doi:10.1186/1471-2393-12-99
Cite this article as: Carolan et al.: Women’s experiences of factors that
facilitate or inhibit gestational diabetes self-management. BMC
Pregnancy and Childbirth 2012 12:99.
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