Atlanta Health Care Providers’ and Women’s Perceived Barriers to the Management of Gestational Diabetes Mellitus

1. Atlanta Health Care Providers’ and Women’s Perceived Barriers to the Management of Gestational Diabetes Mellitus Sarah Collier, MPH, ORISE Fellow National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry and should not be construed to represent any agency determination or policy.

2. Gestational Diabetes Background • Impaired glucose tolerance during pregnancy • Affects 4%-8% of all pregnancies • Unplanned pregnancies common • Increased risk for adverse pregnancy outcomes • Tightly controlled blood glucose important

3. Guidelines for Treatment of Diabetes in Pregnancy • American Diabetes Association (ADA) publishes guidelines for management of diabetes in pregnancy • Limited information on extent healthcare providers follow ADA guidelines • Limited information on extent women adhere to recommendations

4. Study Design • Formative research using focus group methodology • Conducted in two phases • Among healthcare providers • Among women with a history of diabetes in pregnancy (either pre-existing diabetes or gestational diabetes)

5. Formative Research Objectives - Providers • Perceptions of women’s pregnancy planning • Concerns before and during pregnancy • Perception of women’s concerns • Perceived barriers to management of diabetes in pregnancy • Adherence to ADA guidelines

6. Formative Research Objectives - Women • Perceived effects of gestational diabetes • Barriers to management of diabetes in pregnancy • Adherence to ADA guidelines

7. Study Methods ― Healthcare Providers (HCPs) • 6 focus groups (n=53) • 2 with physicians (n=15) • 2 with NPs/PAs (n=19) • 2 with diabetes educators (n=19) • Recruitment via Medical Marketing Services • Qualitative analysis using Atlas.ti • 2 coders, inter-rater reliability (>70%)

8. Study Methods ― Women • 9 focus groups with women (n= 49) • 3 with non-Hispanic black women (n=17) • 3 with non-Hispanic white women (n=12) • 3 with Hispanic women (n=20) • Variety of approaches used for recruitment • Qualitative analysis using Atlas.ti • 2 coders, inter-rater reliability (>70%)

9. Results

10. Planning Pregnancy: Providers’ Perceptions • A majority of providers reported that <5-10% of patients discussed pregnancy planning with them • Providers did not routinely address pregnancy planning unless prompted

11. Providers’ Concerns for Women with Gestational Diabetes • Concerns for the fetus • Medical concerns (macrosomia, fetal demise, hypoglycemia of infant) • Concerns for the woman • Medical problems/general health • Social/behavioral (compliance, access) • Need for diabetes education • Conversion to type 2 diabetes not a major theme

12. Providers’ Perceptions of Concerns Women Have About GDM • Main concerns women express about themselves • Will this go away? • Will I need to take shots? • Main concerns women express about their babies • Will the baby have diabetes?

13. Providers’ Perceptions of Barriers to Glycemic Control • Lack of knowledge or awareness • Compliance (not taking responsibility, not proactive in care, no motivation, denial) • Access to care (financial and insurance)

14. Quotes: Providers’ Perceptions of Barriers to Glycemic Control “Scheduling diabetic teaching – that for me has been a nightmare. I mean it’s with the insurance issue and the precerts, it’s just a nightmare. I can see why patients end up not going. It just shouldn’t be that hard to get educated.” (MD)

15. Quotes: Providers’ Perceptions of Barriers to Glycemic Control “Managed care says get them out, but you don’t have the resources to teach them while they’re there. You don’t have the time to do it.” (NP/PA)

16. Quotes: Providers’ Perceptions of Barriers to Glycemic Control “Denial. You have diabetes. ‘No, I don’t.’ Well, your labs and your doctor say you do, and this is why I’m talking to you…They’re in denial – ‘That test was wrong.’ ‘There’s none of that in my family.’ ” (Diabetes Educator)

17. Providers’ Use of Guidelines • Several sources: ACOG, ADA, AADE, ACE • ACOG most frequently cited source followed by ADA • Internal checklists or no formal guidelines • Guidelines for education

18. Pregnancy Planning - Women Women did not regularly mention pregnancy planning as a way to ensure a healthy pregnancy in the future

19. Womens’ Perceptions of Possible Effects of GDM • Fetal effects • Macrosomia • Poor outcome for the baby • Baby developing diabetes • Effects on the mother • Weight gain • Diabetes would not go away

20. Women’s Barriers to Glycemic Control • Financial • Physical activity/healthy diet • Communication/informational • Lack of social support • Testing/injections • Denial

21. Quotes: Womens’ Barriers to Glycemic Control “How am I going to eat right when I don’t have any money? I’ve got to grab a pack of chips from the store and drink water out of the faucet if necessary, because your money issues are definitely a factor … It really affects you overall. “ (Non-Hispanic black participant)

22. Quotes: Womens’ Barriers to Glycemic Control “I know some English, I’m not bilingual, but it’s very hard to try to understand in English because there are medical terms … I didn’t find any book in Spanish that could have given me information about this.” (Hispanic participant) “They give us English to Spanish translations which are really bad.” (Hispanic participant)

23. Quotes: Womens’ Barriers to Glycemic Control “I did not think mentally that I really had diabetes, that there was something wrong.” (Non-Hispanic black participant)

24. Women’s Perceptions of Guideline Use Women confused by providers’ use of differing guidelines

25. Limitations • Samples obtained from an urban area in the southern U.S. • Formative research cannot be used to draw definitive conclusions

26. Conclusions:Pregnancy Planning • Women at risk are not discussing pregnancy planning with providers • Providers don’t discuss routinely

27. Conclusions: Concerns • Many providers’ concerns noted in women’s groups • Macrosomia • Poor fetal outcomes • Providers’ perceived concerns echoed by women • Will diabetes go away after delivery? • Other concerns of providers (education, compliance, access) are barriers women noted

28. Conclusions: Missed Theme Conversion to Type 2 diabetes later in life was not a major theme for either providers or women.

29. Conclusions:Barriers To Glycemic Control • Providers • Knowledge and awareness • Compliance and access to care • Minimal ability to change • Women • Financial • Informational • Social support

30. Conclusions:Guidelines • Variety of guidelines used by providers • Women confused by differences in guidelines from one provider to another • Educational guidelines not universally used

31. Next Steps • Develop quantitative survey among healthcare providers and women with a history of diabetes and pregnancy • Examine various practice guidelines mentioned for concurrence • Explore educational resources available for health care providers and women • Develop educational materials to address gaps discovered through our explorations.

32. Acknowledgements: Patricia Mersereau, Janet Bobo, Karen Kroeger; Battelle CPHRE Jennifer Williams, Celene Mulholland, Chris Prue, Joe Mulinare, Adolfo Correa CDC, NCBDDD Khadija Turay, Hilda Razzaghi; Rollins School of Public Health Thank You!

33. Health Care Provider Focus Group Participants

34. % totals might exceed 100% due to multiple responses*

35. Women’s Focus Group Participants • Demographics varied by recruiting source • One important source of participants was Grady Hospital’s diabetes and pregnancy clinic • Women recruited from the community more likely to have higher SES, private insurance