Cultural and Digital Health Literacy Appropriateness of App- and Web-Based Systems Designed for Pregnant Women With Gestational Diabetes Mellitus: Scoping Review

Women's perspectives on mHealth behavior change interventions for the management of overweight, obesity, or gestational diabetes: A qualitative meta-synthesis

mHealth interventions play an increasingly important role in health behavior change for gestational diabetes or peripartum obesity management. This qualitative systematic review and meta-synthesis aims to explore women's perceptions of mHealth behavior change interventions for gestational diabetes and/or overweight/obesity management during pregnancy and the postpartum period. Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane, Excerpta Medica Database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), and Psychological Information Database (PsycINFO) databases were searched using a Sample, Phenomenon of Interest, Design, Evaluation and Research type (SPIDER) concept framework through to February 2024. Included studies were quality assessed using the Critical Appraisal Skills Programme checklist. Study findings were evaluated using reflexive thematic analysis and GRADE-Confidence in the Evidence from Reviews of Qualitative Research (CERQual) checklist. We identified 29 studies, representing 604 women's views from one upper middle-income and nine high-income countries. Two themes were generated: mHealth as a supportive tool; and mHealth as a personalizable tool. Women highlighted the importance of self-monitoring, information trustworthiness, peer support, motivational tools (goal setting, risk awareness, and problem solving) and convenience in achieving behavior change using mHealth technology. They suggest mHealth programs incorporate these elements to support user engagement and improved health outcomes. Understanding what women want as mHealth users is particularly important for effective interventions in gestational diabetes, weight management, and chronic disease prevention. Creating a better, more woman-centered experience by addressing central engagement issues should result in improved maternal health outcomes.

The mediating effect of e-health literacy on social support and behavioral decision-making on glycemic management in pregnant women with gestational diabetes: a cross-sectional study

Background

Social support and e-health literacy are closely related to individual health behaviors, while behavior is premised on decision-making. Few studies have identified the relationships among social support, e-health literacy, and behavioral decision-making, and the nature of these relationships among pregnant women with gestational diabetes remains unclear. Therefore, this study aimed to investigate relationships among social support, e-health literacy, and glycemic management behavioral decisions in pregnant women with gestational diabetes.

Methods

Using continuous sampling, an online cross-sectional survey was conducted among pregnant women with gestational diabetes who met the inclusion and exclusion criteria at four Class 3 hospitals in Fujian Province from October to December 2023. A structured questionnaire was used to collect data on general characteristics, socioeconomic status, social support, e-health literacy, and behavioral decision-making regarding glycemic management. Descriptive statistical analyses, correlation analyses, and mediation effects were used to assess associations.

Results

A total of 219 pregnant women with gestational diabetes participated, and 217 valid results were obtained. The level of glycemic management behavior decision-making in women with gestational diabetes was positively correlated with e-health literacy (r = 0.741, p < 0.01) and with perceived social support (r = 0.755, p < 0.01). E-health literacy was positively correlated with perceived social support (r = 0.694, p < 0.01). The indirect effect of perceived social support on glycemic management behavior decisions through e-health literacy (a*b) was 0.153, accounting for 38% of the total effect.

Conclusion

Social support and e-health literacy in pregnant women with gestational diabetes are related to behavioral decision-making in glycemic management. The results of this study provide a reference for developing targeted measures to improve glycemic management behaviors in pregnant women with gestational diabetes, which is crucial for achieving sustainable glycemic management.

Call to action for a life course approach

Gestational diabetes remains the most common medical disorder in pregnancy, with short-term and long-term consequences for mothers and offspring. New insights into pathophysiology and management suggest that the current gestational diabetes treatment approach should expand from a focus on late gestational diabetes to a personalised, integrated life course approach from preconception to postpartum and beyond. Early pregnancy lifestyle intervention could prevent late gestational diabetes. Early gestational diabetes diagnosis and treatment has been shown to be beneficial, especially when identified before 14 weeks of gestation. Early gestational diabetes screening now requires strategies for integration into routine antenatal care, alongside efforts to reduce variation in gestational diabetes care, across settings that differ between, and within, countries. Following gestational diabetes, an oral glucose tolerance test should be performed 6-12 weeks postpartum to assess the glycaemic state. Subsequent regular screening for both dysglycaemia and cardiometabolic disease is recommended, which can be incorporated alongside other family health activities. Diabetes prevention programmes for women with previous gestational diabetes might be enhanced using shared decision making and precision medicine. At all stages in this life course approach, across both high-resource and low-resource settings, a more systematic process for identifying and overcoming barriers to preventative care and treatment is needed to reduce the current global burden of gestational diabetes.

Acceptability of Gynecologic e-Health Modalities by Hispanic/Latina Women of Reproductive Age

Introduction

Electronic health (e-Health) modalities effectively address healthcare access limitations; however, there are limited data on their adoption by Hispanic/Latina women who are disproportionally affected by health disparities.

Methods

We conducted a cross-sectional study by disseminating an anonymous electronic questionnaire via social media to assess the perception of Hispanic/Latina women of reproductive age regarding facilitators and barriers for using e-Health modalities, including telemedicine and mobile apps, to monitor gynecologic health.

Results

The questionnaire was completed by 351 Hispanic/Latina participants with high levels (98.3%) of advanced technological expertise. Current use of a gynecologic mobile app was reported by 63.8%, primarily for menstruation (85.1%) and ovulation (46.3%) tracking. While only 17.6% of participants were offered the option of a gynecologic consultation via telemedicine, the majority (90.5%) would agree to one. Higher education and advanced technological expertise correlated with acceptance of telemedicine for gynecological consults. Being younger (<29 y/o), a student, not having a preferred gynecologist and having a lower income significantly correlated with gynecologic mobile app acceptability.

Conclusions

We showed that e-Health modalities are highly acceptable for Hispanic/Latina women of reproductive age to facilitate gynecological care and documented factors that are significantly associated with e-Health acceptability. These findings are relevant to public health emergencies that cause access to care limitations disproportionally affecting this already underserved population.

An Infrastructure Framework for Remote Patient Monitoring Interventions and Research

Remote patient monitoring (RPM) enables clinicians to maintain and adjust their patients' plan of care by using remotely gathered data, such as vital signs, to proactively make medical decisions about a patient's care. RPM interventions have been touted as a means to improve patient care and well-being while reducing costs and resource needs within the health care ecosystem. However, multiple interworking components must be successfully implemented for an RPM intervention to yield the desired outcomes, and the design and key driver of each component can vary depending on the medical context. This viewpoint and perspective paper presents a 4-component RPM infrastructure framework based on a synthesis of existing literature and practice related to RPM. Specifically, these components are identified and considered: (1) data collection, (2) data transmission and storage, (3) data analysis, and (4) information presentation. Interaction points to consider between components include transmission, interoperability, accessibility, workflow integration, and transparency. Within each of the 4 components, questions affecting research and practice emerge that can affect the outcomes of RPM interventions. This framework provides a holistic perspective of the technologies involved in RPM interventions and how these core elements interact to provide an appropriate infrastructure for deploying RPM in health systems. Further, it provides a common vocabulary to compare and contrast RPM solutions across health contexts and may stimulate new research and intervention opportunities.

Person-Generated Health Data in Women's Health: Scoping Review

BACKGROUND

The increased pervasiveness of digital health technology is producing large amounts of person-generated health data (PGHD). These data can empower people to monitor their health to promote prevention and management of disease. Women make up one of the largest groups of consumers of digital self-tracking technology.

OBJECTIVE

In this scoping review, we aimed to (1) identify the different areas of women's health monitored using PGHD from connected health devices, (2) explore personal metrics collected through these technologies, and (3) synthesize facilitators of and barriers to women's adoption and use of connected health devices.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews, we searched 5 databases for articles published between January 1, 2015, and February 29, 2020. Papers were included if they targeted women or female individuals and incorporated digital health tools that collected PGHD outside a clinical setting.

RESULTS

We included a total of 406 papers in this review. Articles on the use of PGHD for women steadily increased from 2015 to 2020. The health areas that the articles focused on spanned several topics, with pregnancy and the postpartum period being the most prevalent followed by cancer. Types of digital health used to collect PGHD included mobile apps, wearables, websites, the Internet of Things or smart devices, 2-way messaging, interactive voice response, and implantable devices. A thematic analysis of 41.4% (168/406) of the papers revealed 6 themes regarding facilitators of and barriers to women's use of digital health technology for collecting PGHD: (1) accessibility and connectivity, (2) design and functionality, (3) accuracy and credibility, (4) audience and adoption, (5) impact on community and health service, and (6) impact on health and behavior.

CONCLUSIONS

Leading up to the COVID-19 pandemic, the adoption of digital health tools to address women's health concerns was on a steady rise. The prominence of tools related to pregnancy and the postpartum period reflects the strong focus on reproductive health in women's health research and highlights opportunities for digital technology development in other women's health topics. Digital health technology was most acceptable when it was relevant to the target audience, was seen as user-friendly, and considered women's personalization preferences while also ensuring accuracy of measurements and credibility of information. The integration of digital technologies into clinical care will continue to evolve, and factors such as liability and health care provider workload need to be considered. While acknowledging the diversity of individual needs, the use of PGHD can positively impact the self-care management of numerous women's health journeys. The COVID-19 pandemic has ushered in increased adoption and acceptance of digital health technology. This study could serve as a baseline comparison for how this field has evolved as a result.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/26110.

Pre-pregnancy Weight and Racial-Ethnic Disparities in Pregnancy-Associated Conditions in the State of Georgia: A Population-Based Study

INTRODUCTION

We investigate racial-ethnic disparities in pre-pregnancy obesity and pregnancy weight gain, which are known to increase the risk of pregnancy-associated conditions.

METHODS

We used 4-year (2017-2020) combined Georgia Pregnancy Risk Assessment Monitoring System data (N = 3208) to investigate racial-ethnic disparities in the incidence of gestational hypertension (GHT), gestational diabetes mellitus (GDM), and postpartum depression (PPD) and their associated risk with pre-pregnancy overweight/obesity after controlling for demographic and other confounders using regression modeling. The geographic distributions of hypertension and PPD rates at the county level were compared to the patterns of racial-ethnic populations and hospitals.

RESULTS

The PPD rates were higher among Asian (17.6), Hispanic (14.4), and Black (14.3); GDM was highest among Asian (16.0) mothers; and GHT was the highest among Black (11.7) followed by White mothers (9.0). Pre-pregnancy overweight and obese conditions increased the odds of hypertension in Black (2 ½ times) and White (> 3 ½ times) mothers. Premature birth increased the odds of hypertension (2-3 times) in all mothers. Pre-pregnancy weight also increased the odds of GDM (3-7 times) in these racial groups. Premature birth increases the odds twice as likely for PPD in Hispanic and White mothers. The convergence of high PPD and hypertension rates with high proportions of racial and ethnic minorities, and lack of hospital presence, indicates areas where healthcare interventions are required.

CONCLUSIONS

These findings underscore the importance of promoting a healthy pre-pregnancy weight to reduce the burden of maternal morbidity and pregnancy outcomes in general. More comprehensive prenatal monitoring using technological interventions for self-care has a great promise of being effective in maintaining a healthy pregnancy.

Designing and Developing a Mobile App for Management and Treatment of Gestational Diabetes in Nepal: User-Centered Design Study

BACKGROUND

Mobile apps can aid with the management of gestational diabetes mellitus (GDM) by providing patient education, reinforcing regular blood glucose monitoring and diet/lifestyle modification, and facilitating clinical and social support.

OBJECTIVE

This study aimed to describe our process of designing and developing a culturally tailored app, Garbhakalin Diabetes athawa Madhumeha-Dhulikhel Hospital (GDM-DH), to support GDM management among Nepalese patients by applying a user-centered design approach.

METHODS

A multidisciplinary team of experts, as well as health care providers and patients in Dhulikhel Hospital (Dhulikhel, Nepal), contributed to the development of the GDM-DH app. After finalizing the app's content and features, we created the app's wireframe, which illustrated the app's proposed interface, navigation sequences, and features and function. Feedback was solicited on the wireframe via key informant interviews with health care providers (n=5) and a focus group and in-depth interviews with patients with GDM (n=12). Incorporating their input, we built a minimum viable product, which was then user-tested with 18 patients with GDM and further refined to obtain the final version of the GDM-DH app.

RESULTS

Participants in the focus group and interviews unanimously concurred on the utility and relevance of the proposed mobile app for patients with GDM, offering additional insight into essential modifications and additions to the app's features and content (eg, inclusion of example meal plans and exercise videos).The mean age of patients in the usability testing (n=18) was 28.8 (SD 3.3) years, with a mean gestational age of 27.2 (SD 3.0) weeks. The mean usability score across the 10 tasks was 3.50 (SD 0.55; maximum score=5 for "very easy"); task completion rates ranged from 55.6% (n=10) to 94.4% (n=17). Findings from the usability testing were reviewed to further optimize the GDM-DH app (eg, improving data visualization). Consistent with social cognitive theory, the final version of the GDM-DH app supports GDM self-management by providing health education and allowing patients to record and self-monitor blood glucose, blood pressure, carbohydrate intake, physical activity, and gestational weight gain. The app uses innovative features to minimize the self-monitoring burden, as well as automatic feedback and data visualization. The app also includes a social network "follow" feature to add friends and family and give them permission to view logged data and a progress summary. Health care providers can use the web-based admin portal of the GDM-DH app to enter/review glucose levels and other clinical measures, track patient progress, and guide treatment and counseling accordingly.

CONCLUSIONS

To the best of our knowledge, this is the first mobile health platform for GDM developed for a low-income country and the first one containing a social support feature. A pilot clinical trial is currently underway to explore the clinical utility of the GDM-DH app.

Personalization and localization as key expectations of digital health intervention in women pre- to post-pregnancy

Health behaviors before, during and after pregnancy can have lasting effects on maternal and infant health outcomes. Although digital health interventions (DHIs) have potential as a pertinent avenue to deliver mechanisms for a healthy behavior change, its success is reliant on addressing the user needs. Accordingly, the current study aimed to understand DHI needs and expectations of women before, during and after pregnancy to inform and optimize future DHI developments. Forty-four women (13 pre-, 16 during and 15 postpregnancy; age range = 21-40 years) completed a 60-minute, semistructured, qualitative interview exploring participant's experience in their current phase, experience with digital health tools, and their needs and expectations of DHIs. Interviews were audio-recorded, transcribed verbatim and thematically analyzed. From the interviews, two core concepts emerged-personalization and localization of DHI. Between both concepts, five themes and nine subthemes were identified. Themes and subthemes within personalization cover ideas of two-way interactivity, journey organization based on phases and circumstances, and privacy trade-off. Themes and subthemes within localization cover ideas of access to local health-related resources and information, and connecting to local communities through anecdotal stories. Here we report, through understanding user needs and expectations, the key elements for the development and optimization of a successful DHI for women before, during and after pregnancy. To potentially empower downstream DHI implementation and adoption, these insights can serve as a foundation in the initial innovation process for DHI developers and be further built upon through a continued co-design process.

Exploring experiences and needs of perinatal women in digital healthcare: A meta-ethnography of qualitative evidence

OBJECTIVE

The aim of this review is to identify, appraise, and synthesize the available qualitative evidence on the experiences and needs of perinatal women by using digital technologies in healthcare.

METHODS

This review was consolidated following the eMERGe meta-ethnography reporting guidance. We conducted a comprehensive search in eight databases from inception to 12 October 2021. Published and unpublished qualitative and mixed-method studies published in English were included. The methodological quality was assessed using the critical appraisal skill program checklist. A meta-ethnographic synthesis was used according to Noblit and Hare's seven-step iterative process.

RESULTS

A total of 3,843 articles were retrieved, and 27 qualitative studies pertaining to 3,775 perinatal women from 13 countries across different ethnicities were included. Four overarching themes emerged for the aspect of experiences: (1) normalization of experience, (2) attainment of valuable knowledge, (3) empowerment and self-confidence boosting, and (4) beneficial features of digital platforms. For the aspect of needs, the derived themes included the following: (1) necessity of credible resources, (2) importance of personalization, (3) concern about cybersecurity, and (4) urging additional support. Our line-of-argument for interpreting the perinatal women's experiences can offer a much greater engagement in digital healthcare, while the findings on the perinatal women's needs can add value for improving the design of digital healthcare in the future.

CONCLUSION

This review offers a deeper understanding of the perinatal women's experiences and needs when using digital technologies in healthcare. Our findings provide meaningful recommendations for clinical practice and future research.