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

Jean Claude Mutabazi; Pascal Roland Enok Bonong; Helen Trottier; Lisa Jayne Ware; Shane Norris; Katherine Murphy; Naomi Levitt; Christina Zarowsky

doi:10.5334/ijic.5600

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

Int J Integr Care. 2022 Sep 21;22(3):20. doi: 10.5334/ijic.5600. eCollection 2022 Jul-Sep.

Authors

Jean Claude Mutabazi^{1

2

3}, Pascal Roland Enok Bonong^{1

3}, Helen Trottier^{1

3}, Lisa Jayne Ware⁴, Shane Norris⁴, Katherine Murphy⁵, Naomi Levitt⁵, Christina Zarowsky^{1

2

6}

Affiliations

¹ Département de Médecine sociale et Préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montréal, QC H3N 1X7, Canada.
² Centre de Recherche en Santé Publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Canada.
³ Centre de Recherche du Centre Hospitalier Universitaire Sainte Justine, Montréal, H3T 1C5, QC, Canada.
⁴ SAMRC Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, ZA.
⁵ Division of Endocrinology, Department of Medicine, Faculty of Health Science, University of Cape Town, Chronic Disease Initiative for Africa, Cape town, Western Cape, South Africa.
⁶ School of Public Health, University of the Western Cape, Robert Sobukwe Rd, Bellville 7535, South Africa.

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.

Grants and funding

No funding has been received for the study but it was part of a PhD project. The first author, JCM held a PhD scholarship of her supervisor Christina Zarowsky from the Canadian Institutes of Health Research (CIHR) under the “Team Grant – Implementation Research in the Prevention and Treatment of Type II Diabetes in Low- and Middle-Income Countries” competition. This funding is for the following randomized trial: integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO). HT holds a salary award (chercheur-boursier) from the “Fond de la recherche en santé- du Québec (FRQ-S)” and a salary award (New Investigator Salary Award) from Canadian Institutes of Health Research (CIHR).