Women’s perspectives on motivational factors for lifestyle changes after gestational diabetes and implications for diabetes prevention interventions

Abstract Introduction Gestational diabetes mellitus (GDM) is a common complication in pregnancy and constitutes a public health problem due to the risk of developing diabetes and other diseases. Most women face barriers in complying with preventive programs. This study aimed to explore motivational factors for lifestyle changes among women with a history of GDM and their suggestions for preventive programs. Methods This study used a qualitative approach in six focus group interviews with a total of 32 women. The selection criteria were time since onset of GDM, including women diagnosed with GDM, six months and five years after GDM, diagnosed and not diagnosed with diabetes. Inductive analysis was performed. Results The women reacted with anxiety about their GDM diagnosis and experienced persistent concerns about the consequences of GDM. They were highly motivated to take preventive initiatives, but faced major adherence challenges. The demotivating factors were lack of time and resources, too little family involvement, lack of knowledge and social norms that may obstruct healthy eating. A powerful motivational factor for complying with preventive strategies was the well‐being of their children and partners. Conclusions Preventive initiatives should be rooted in the women's perception of GDM/diabetes and based on their experiences with barriers and motivational factors. The well‐being and the quality of life within the family are dominant motivational factors which offer powerful potentials for supporting the women's coping capability. Further, there is a need to be responsiveness to the women and their families even a long time after the onset of GDM.


| INTRODUC TI ON
Gestational diabetes mellitus (GDM) is common during pregnancy with a prevalence in Europe between 2-6% 1-3 and <24% worldwide, depending on the population and diagnostic criteria. 4 An increase in GDM has been observed worldwide for decades, due to the increase in obesity and older age at conception. [5][6][7] GDM is a strong predictor for developing type 2 diabetes for the mother and child 8,9 : 50% will develop diabetes within 10 years, and the women´s lifetime risk is seven times higher than among women without a history of GDM. 2,[9][10][11] The offspring has eight times increased risk of developing diabetes and doubled risk of overweight later in life. 2 Moreover, partners to women with GDM have increased risk of developing diabetes, 12,13 suggesting that diabetes also is socially embedded in the sense that not only biological but also patterns of behaviour related to, for example, lifestyle factors in the families and social relations play an important role.
Prevention of diabetes is possible using lifestyle changes. [14][15][16] Systematic reviews found promising strategies including promotion of physical activity, healthy diet and weight control. However, barriers to lifestyle changes after GDM have been identified, especially lack of time, energy and social support, which may lead to poor adherence. 15,[17][18][19] Postpartum care following GDM is characterized by uncertain division of responsibilities in the healthcare sector, and women experience little attention regarding their needs, which results in dropping out from programs following GDM. 20 Women's experiences with GDM and barriers to comply with preventive interventions have been studied, but there is still a need to explore what motivates the women to attend preventive programs and maintain lifestyle changes, especially over time. This study aimed to explore the perspectives and motivational factors for initiating and maintaining lifestyle changes among women with a history of GDM. The purpose was to initiate a future preventive program targeting women's needs in a local Danish setting. In the context of the study, we defined motivation as a concept referring to a process which engender behaviour from intentions to actual actions with the aim of reaching certain goals; and motivational factors were defined as conditions which provide meaning to do an effort to reach certain goals.

| Design, participants and data collection
The study applies qualitative method, using focus group interviews as data collection method. The method allows the participants' to exchange experiences and views, thus contributing to knowledge about the extent of consensus and diversities among the participants. 21 Accordingly, the focus group interviews provided more than the sum of individual interviews because the participants questioned and spoke to each other.
Six focus group interviews were conducted. To explore timerelated changes, time from GDM diagnosis to participation in the interview was important, and the study covered a 5-year period after the onset of GDM. One group included pregnant women diagnosed with GDM; one group included women six months after GDM; two groups included women five years after GDM, all diagnosed with diabetes; two groups included women five years after GDM without diabetes. The participants were recruited from the Department of Obstetrics at the local hospital where the study took place. Women characterised by the inclusion criteria defining the respective focus groups were selected consecutive from the department register until 10-12 persons for each group was achieved. They were contacted by telephone for invitation to participate in the focus group interviews and upon acceptance, a written invitation explaining the purpose of the study and the use of data was mailed to them. 32 of the listed 67 potential participants, agreed participation. The main reasons for refusal were unanswered calls or lack of time. A few women mentioned lack of resources or insufficient knowledge of Danish. Most participants were above 30 years and had two children. About half of the women had experience with GDM in more than one pregnancy Table 1.
The focus group interviews took place at the local hospital. 4-7 women participated in each focus group. Rapport between interviewers and participants was established initiating the focus group interviews by informal conversations and the researchers introducing themselves and their reasons for doing the research project. The interviews were directed by a thematic, semi-structured interview guide, focusing on experiences of being diagnosed with GDM; attitude to risk factors; attitude and experiences regarding barriers to and motivation for prevention of consequences of GDM; What this study has found?
• The women experienced long-term (min. five years) worries of the health consequences of the GDM diagnosis and were motivated to participate in preventive programs over a similar long period of time.
• The women's suggestions concerning preventive initiatives were rooted at the core of their everyday life which strengthened their sense of coherence.

What are the clinical implications of the study?
• It is important to pay attention to the women for a long time after the GDM diagnosis and to base preventive programs within the women's perspectives of GDM/diabetes and preventive initiatives.
perceptions of meaningful and relevant preventive initiatives. Small tasks were used to stimulate discussions among the participants, for example cards with statements about prevention and lifestyle. To allow comparison across the groups, this approach was implemented in each group. Two of the female authors, who were trained and experienced within qualitative research, (LØ and DH) implemented the focus group interviews which were conducted in Danish. Each interview lasted approximately two hours, was recorded digitally and transcribed verbatim. Notes were written after the interview, focusing on the proceeding of the interview and interaction of the participants. Table 2 presents the study setting.

| Data analysis
The data analysis followed an inductive process based on a thematic analysis 22  Initial codes were generated from the data, tested by coding two interviews and adjusted by two authors (LØ, AMM), for example reduced from eight to six codes due to overlaps and clarification of definitions. The final codes were discussed and agreed upon by all authors (see Table 3  Quotations are used throughout to illustrate the findings of the study. They were selected from a broad range of the participants to cover views among all participants. When perspectives from a specific focus group are critical to understand the importance of the finding the group-for example women five years after GDM with/ without diabetes-is mentioned in the text.
NVivo 11.0 QSR software was used to handle the data.
Consolidated criteria for reporting qualitative research (COREQ checklist) was used to provide a quality assessment of the reporting of the methodology. 23

| Ethics
The study was approved by the Danish Data Protection Agency

| RE SULTS
The codes were condensed into four themes using the definition of motivation as previously described: experiences of GDM as motivating preventive strategies; experiences of demotivating barriers to prevention strategies; experiences of motivational factors for prevention strategies; suggestions for motivating preventive programs.

| Experiences of GDM as motivating preventive strategies
Being diagnosed with GDM was an upsetting experience for most of the women, as told by one of them:

TA B L E 2 Description of the study setting
This study was performed at the Regional Hospital West Jutland, one of five hospitals in the central Denmark region. This hospital serves approximately 300,000 citizens who live in a rural area with six provincial municipalities. Approximately 150 women with GDM are treated annually at the hospital's Department of Obstetrics. The Danish healthcare system is funded by taxes and is provided free of charge with equal access to healthcare services for all people. According to the national guidelines, women with GDM receive specialized healthcare services with a focus on blood glucose levels, ultrasound imaging for the foetus and advice on lifestyle changes from doctors at outpatient clinics in local hospitals with obstetric departments. The postpartum follow-up is provided by a general practitioner who is responsible for individual diabetes screening and guidance of lifestyle factors regarding prevention of diabetes. Preventive follow-up programs are missing from the routine clinical set-up as well as standardized referrals to these possible local programs.
group, but anyway, I was very upset and thought, oh It appeared they felt reassured by being monitored at the hospital during their pregnancy, but as the quote illustrates they also experienced a moralistic attitude from the health service providers.
Although the women after childbirth were happy about being well again, they still experienced diabetes as a potential risk. This appeared in groups of women respectively six months and five years after their GDM diagnosis: Thus, even many years after their GDM diagnosis the women continued to be concerned about the risk and were therefore motivated to prevent the long-term consequences of GDM.

| Experiences of demotivation barriers to prevention strategies
When talking about preventive strategies, all of the women mentioned the importance of diet and physical activity. They intended to live a healthy lifestyle after childbirth, but found it difficult to comply with the guidelines from healthcare professionals. They experienced a range of demotivating factors, analytically condensed into four sub-themes: lack of time and resources; lack of family involvement; barriers to healthy eating; and lack of knowledge.

| Lack of time and resources
All the women stressed that they, as new mothers, had their focus elsewhere; several were mothers with two to three children, and taking care of these and other domestic responsibilities were prioritized over their own health: One thing is that you are very motivated when pregnant because it depends on you to do the best for

| Lack of family involvement
The women experienced that GDM and prevention of diabetes in the public and the healthcare system were handled as 'a women's issue' rather than a family concern which was a serious barrier to their management of risk factors. Some of the women explained:

| Barriers to healthy eating
The women experienced that the social context in which food is embedded was a central barrier to accomplish healthier eating. Food was described an essential part in social gatherings and a vital symbol of hospitality. In combination with the experience of diabetes as a taboo, the women found it difficult to decline food served at social events: You always eat when you are going out. You want to make an effort for your guest and make them feel welcome-and it is often rich food. You cannot really take the liberty to decline. It is easier at home to say 'stop', where no one will notice.
The women experienced a lack of understanding and social pressure from their peers to eat unhealthy food. This was especially significant among the groups of women who were not diagnosed with diabetes. Some women occasionally stayed away from social gatherings to avoid the temptation to eat unhealthy food, but most said that they did not want to isolate themselves. Furthermore, several women described their perception of sweets, cakes and other unhealthy foods as a pleasure and a reward, which was difficult to resist. As the quote illustrates, the women were not satisfied with the postpartum support and felt they were on their own with worries regarding prevention of the long-term consequences of GDM. The deficient knowledge thus leads to feeling insecure regarding how to handle the situation after GDM.

| Experiences of motivational factors for prevention strategies
The well-being of the family in the present and the future appeared children, but they also specified a need for inspiration to develop such initiatives further. Lastly, social support from friends and extended family appeared as an essential motivating factor.

| Suggestions for motivational preventive programs
Based on their experiences with GDM/diabetes and preventive strategies, the women provided suggestions for organizing motivating preventive programs. The most important issues are presented in this section, while Table 4 provides an overview of frameworks for preventive initiatives. Finally, the women highlighted the importance of the program being managed by experienced healthcare professionals. The women preferred longer transport as long as the programme was led by competent healthcare professionals.

| CON CLUS IONS
The study revealed three main findings. Firstly, being diagnosed with Location • Some transport is not a barrier to participate in a course if the course gives meaning, makes sense and is of good quality • If possible, it is preferable to gather women and their families from within a local area because it will be easier for the women to keep in touch with the community when the program ends • It is preferable to organize the program under the auspices of local authority (eg the municipality)

Contacts
•  29,30 while this study found a strong preference for face-to-face interactions with healthcare professionals as well as peers and eHealth as a supplement. This result was also supported by another study. 12 While other studies found the women being motivated during pregnancy, this study supplements by showing that women were highly motivated to participate in preventive programs over time. Across the 5-year timespan, the women expressed the same worries concerning consequences,difficulties in complying with preventive strategies,and motivational factors and suggestions to the organization of preventive programs.
Thus, this study provides two important recommendations: the need to be responsiveness to the women and their families even revising the manuscript critically for important intellectual content.
Anne-Mette Hedeager Momsen: involved in substantial contribution to conception and design, processing and interpretation of data; drafting the article and revising it critically for important intellectual content.

DATA AVA I L A B I L I T Y S TAT E M E N T
No further data than presented in this manuscript is available.