Comparing a telephone- and a group-delivered diabetes prevention program: Characteristics of engaged and non-engaged postpartum mothers with a history of gestational diabetes
Introduction
Diabetes and gestational diabetes mellitus (GDM) are growing problems worldwide with a global prevalence of diabetes in adults estimated at 9–10% and 7% of all pregnancies are complicated by GDM [1], [2]. In addition, 30–84% of women with GDM will experience it in a subsequent pregnancy [3]. Women with previous gestational diabetes have a 7-fold increased risk of developing type 2 diabetes (T2DM) [4]. The risk of developing diabetes doubles by 5 years postpartum following GDM pregnancy [4], and may potentially be averted with early prevention efforts. Studies have consistently shown poor dietary and physical activity behaviours among women with histories of GDM [5], [6], which may contribute to their increased risk of developing diabetes. Women with histories of GDM are a growing population in need of diabetes prevention programs, but existing prevention programs are typically developed for an older population.
Lifestyle modification is effective in preventing diabetes in the general population when participants are engaged [7], [8]. Women with a history of GDM and impaired glucose tolerance at the time of intervention showed substantially reduced TD2 M onset following participation in an intensive diabetes prevention program (DPP) [9]. However other interventions in postpartum women have seen inconsistent effects [10], [11], [12], [13], [14], [15], possibly owing to the difficulties in adhering to healthy behaviours during this busy period. Recruiting and retaining postpartum women in lifestyle interventions is inherently challenging [16], [17] – the median attrition rate reported in systematic review is 17% and this can rise up to 42% in some studies [12], [17]. For those successfully retained, poor engagement or attendance can result in a non-significant changes in outcome measures, despite the number of sessions offered [15]. Time, childcare duties, tiredness and financial constraints were among the barriers to lifestyle change described by postpartum women with histories of GDM [18], [19], [20], [21], [22]. As engagement is the central issue with postpartum mothers, a theoretically-grounded investigation into factors associated with engagement in this group is needed to guide future program implementation.
Home-based DPPs (delivered via internet or telephone) are a potential solution to the multiple participation barriers faced by postpartum women with previous GDM [23], [24]., Although various combinations of strategies and delivery methods have been investigated to prevent diabetes in women with a history of GDM [25], very few are based on previously demonstrated effective models of diabetes prevention. The Health Action Process Approach (HAPA) is a behavioural change model shown to be effective in preventing diabetes in the general population [26], [27] but its application to the postpartum population has not been explored.
Our study aimed to explore the demographic and psychological characteristics associated with post-recruitment engagement in a group- or a telephone-based DPP for postpartum women.
Section snippets
Subjects
Participants were recruited prospectively and retrospectively into a randomized-controlled, DPP trial (Mothers After Gestational Diabetes in Australia, MAGDA) described in full within our protocol and results publications [28], [29], [30]. Briefly, prospective recruitment involved approaching women in an urban antenatal clinic soon after GDM diagnosis (∼24–28 weeks). Eligible women were provided with a patient information and consent form to be returned via pre-paid envelope within 4 weeks. If
Group-delivered program
The group-delivered program was an RCT of an evidence-based lifestyle modification DPP modified for postpartum women with previous GDM and was based on an effective DPP for older adults [28], [29]. The group-delivered program consisted of two phases: an active intervention and a maintenance phase. The active intervention was completed over three months and comprised of an individual session in the woman’s home and five fortnightly group sessions delivered by a trained facilitator. The
Telephone- versus group-delivered program
Baseline characteristics of telephone- and group-delivered participants are overall similar (Table 1). The majority (82%) of the telephone-delivery participants engaged with the program compared with 38% of the group-delivery ones (Table 1). The telephone-delivered program had a lower proportion of low income participants and higher proportion with more than one child (Table 1). Significant weight loss was reported in both group-delivery and telephone-delivery participants (Table 1).
Discussion
We found that a telephone-delivered program was associated with greater engagement in postpartum women. For the group-delivered program engagement was associated with greater risk perception and outcome expectancy at baseline and resulted in greater reductions in weight and waist circumference. The differences in the HAPA measures by engagement group were not present at 12 months following completion of the group-delivered program. Postpartum women identified the flexibility of telephone
Conflict of interest
None.
Acknowledgements
We sincerely thank all participants and organizations who participated in the trial; the MAGDA-DPP Manual Training Committee and the MAGDA-DPP RCT Working Group for supporting the intervention delivery; Liz Eakin for developing the telephone intervention; Dino Asproloupos for senior project management; Jessica Bucholc for field data collection; and all the additional staff who delivered the intervention and collected data for this complex trial. The views expressed in this publication do not
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