Integrating Gestational Diabetes Screening and Care and Type 2 Diabetes Mellitus Prevention After GDM Into Community Based Primary Health Care in South Africa-Mixed Method Study

Abstract

Background: Despite high gestational diabetes mellitus (GDM) prevalence in South Africa (9.1% in 2018), its screening and management are not well integrated into routine primary health care and poorly linked to post-GDM prevention of type 2 diabetes mellitus (T2DM) in South Africa's fragmented health system. This study explored women's, health care providers' and experts' experiences and perspectives on current and potential integration of GDM screening and prevention of T2DM post-GDM within routine, community-based primary health care (PHC) services in South Africa.

Methods: This study drew on the Behaviour Change Wheel (BCW) framework and used a mixed method, sequential exploratory design for data collection, analysis and interpretation. Individual semi-structured interviews were conducted with key informants (n = 5) from both national and provincial levels and health care providers (n = 18) in the public health system of the Western Cape Province. Additionally, focus group discussions (FGDs) with Community Health Workers (CHWs n = 15) working with clinics in the Western Cape province. A further four FGDs and brief individual exit interviews were conducted with women with GDM (n = 35) followed-up at a tertiary hospital: Groote Schuur Hospital (GSH). Data collection with women diagnosed and treated for GDM happened between March and August 2018.Thematic analysis was the primary analytical method with some content analysis as appropriate. Statistical analysis of quantitative data from the 35 exit interview questionnaires was conducted, and correlation with qualitative variables assessed using Cramér's V coefficient.

Results: Shortage of trained staff, ill-equipped clinics, socio-economic barriers and lack of knowledge were the major reported barriers to successful integration of GDM screening and postnatal T2DM prevention. Only 43% of women reported receiving advice about all four recommendations to improve GDM and decrease T2DM risk (improve diet, reduce sugar intake, physical exercise and regularly take medication). All participants supported integrating services within routine, community-based PHC to universally screen for GDM and to prevent or delay development of T2DM after GDM.

Conclusion: GDM screening and post-GDM prevention of T2DM are poorly integrated into PHC services in South Africa. Integration is desired by stakeholders (patients and providers) and may be feasible if PHC resource, training constraints and women's socio-economic barriers are addressed.

Keywords: GDM; South Africa; T2DM; Type 2 diabetes; gestational diabetes; integration; primary health care.

Figure 1

Behavioural Change Wheel framework [28] (Figure used with permission of Prof. Susan Michie).

Figure 2

Process of diabetes screening during pregnancy in Cape Town.

Figure 3

Multiple correlation between advices received by patients and their views on nurses’ interest in their health* * All variables have two categories “Yes” vs. “No”, except variable Nurse concerned about health whose two categories are “No concerned/Somewhat concerned” vs. “Appropriately concerned”.