The experiences of women from culturally and linguistically diverse backgrounds with gestational diabetes mellitus: A mixed methods systematic review

Abstract Background Gestational diabetes mellitus (GDM) is experienced at a higher rate in women from culturally and linguistically diverse (CALD) backgrounds. The aim of this systematic review is to describe the experiences of women with GDM from CALD backgrounds and compare their experiences to women with GDM from non‐CALD backgrounds. Materials and Methods MEDLINE, EMBASE, PsycINFO, Scopus, WOS and CINAHL databases were searched for qualitative and quantitative studies which included data on the experiences of CALD background women with GDM during all stages of pregnancy. Quality appraisal utilized checklists for analytical cross‐sectional studies and qualitative research. Thematic analysis was performed using nVivo software. Results Of the 3054 studies identified, 24 studies met the inclusion criteria. Data synthesis produced five key themes: (1) Response to diagnosis, (2) Experiences with self‐management, (3) Interactions with the healthcare system, (4) Mental health challenges and (5) Facilitators and barriers to support. Women with GDM from CALD and non‐CALD backgrounds similarly expressed mental health challenges, feeling burdened by recommendations, and challenges interacting with healthcare professionals (HCP). The major difference in experience was the cultural relevance of recommendations, especially related to diet recommendations. Conclusion Gestational diabetes mellitus is a burdensome diagnosis for CALD and non‐CALD women, with CALD women uniquely experiencing a lack of culturally relevant recommendations for self‐management. The similarities and differences in experience call for optimisation of GDM management and support for women with GDM.


INTRODUCTION
Rationale 6 Gestational Diabetes Mellitus (GDM) is the diagnosis of new onset glucose intolerance during the second or third trimester of pregnancy (1). Poorly managed GDM can lead to adverse maternal and foetal outcomes, such as large birth weight, delivery complications and increased risk of maternal type 2 diabetes mellitus (2)(3)(4). In 2016-17, the incidence of GDM in Australia was 15%, with a predominance towards women from culturally and linguistically diverse (CALD) backgrounds, such as Asia, India, and the Middle East (5, 6). The literature has shown that high levels of stress, anxiety and confusion are experienced by women with GDM (7-9). Poor comprehension of diagnosis and management of GDM has been identified as a key factor for increased stress (10,11). Additionally, time constraints, lower educational standards and varying cultural beliefs surrounding food traditions have been identified as confounders for differences in experience (10,12). Therefore, the aim of this literature review is to summarise what is known about the experiences of CALD background women with GDM, to highlight areas where synthesis of their experience is needed and to suggest what future investigation is needed. To summarise the experiences of CALD background women with GDM and how their experiences are similar and different to that of non-CALD women.
To suggest future investigations and strategies that could be implemented to optimise the GDM experience for CALD women.

METHODS
Eligibility criteria 8 Specify the study characteristics (such as PICO, study design, setting, time frame) and report characteristics (such as years considered, language, publication status) to be used as criteria for eligibility for the review The aim was to answer our specific PICO question: The specific inclusion criteria include a clear GDM definition, women with a new diagnosis of GDM or history of GDM, women from CALD background, and qualitative or quantitative data on the woman's perspective or experience of GDM during any stage pregnancy The specific exclusion criteria included studies that had women with a previous diagnosis of diabetes mellitus (T1DM or T2DM) prior to pregnancy, did not differentiate between GDM and T2DM, did not separate CALD from non-CALD data, focused on outcome, incidence/prevalence, or risk factors for GDM or post-partum experience, or was not a primary study Information sources 9 Describe all intended information sources (such as electronic databases, contact with study authors, trial registers or other grey literature sources) with planned dates of coverage The initial search strategy will be performed in MEDLINE and then adapted for each of the different databases.   (16021) 10 exp Ethnic Groups/ (167208) 11 ((minority or ethnic or divers* or non-english) adj2 (culture* or group* or minorit* or speak*)).mp. (182556) 12 ((first or native or mother or foreign) and (language* or tongue*)).mp. (45422) 13 ((foreign or overseas) adj3 born).mp. (4258) 14 (first adj3 generation*).mp. (20641) 15 Refugees/ (11854) 16 refugee*.mp. (16404) 17 1 or 2 (20292) 18 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 (397737) 19 17 and 18 (847) 20 limit 19 to humans (773) 21 limit 19 to (english language and humans) (760) 22 limit 19 to (english language and humans and yr="2000 -Current") (686) 23 limit 19 to (humans and yr="2000 -Current") (698) *************************** Study records: Data management 11a Describe the mechanism(s) that will be used to manage records and data throughout the review Endnote and Covidence will be used to remove duplicated articles. Two reviewers will use Covidence to title, abstract and full text screen the obtained studies. JBI critical appraisal checklists for analytical cross-sectional studies and qualitative research will be used to assess the risk of bias and methodological quality of the studies in this review. Data analysis: for qualitative data analysis the software, nVivo, will be used to draw out themes. While quantitative data will be qualitized into a mutually compatible qualitative format via narrative description.
Selection process 11b State the process that will be used for selecting studies (such as two independent reviewers) through each phase of the review (that is, screening, eligibility, and inclusion in meta-analysis) Two independent reviewers, CH and RL will independently screen all records according to title, abstract and full text papers against the eligibility criteria. Any discrepancies will be discussed by CH and RL, and if consensus cannot be reach, taken to the third reviewer SG.
Data collection process 11c Describe planned method of extracting data from reports (such as piloting forms, done independently, in duplicate), any processes for obtaining and confirming data from investigators De-duplication was initially conducted in Endnote. Further de-duplication will occur in Covidence. The two primary reviewers (CH and RL) will independently screen the titles, abstracts and full texts using Covidence. Studies will be excluded if they do not meet the eligibility criteria. Data items 12 List and define all variables for which data will be sought (such as PICO items, funding sources), any pre-planned data assumptions and simplifications 12. Outcomes/results (specify each outcome) A) Diagnosis: response and understanding B) Access to care and interaction with HCP C) Self-management: education, dietary, exercise, and blood glucose control D) Mental health: anxiety, stress, or burden E) Support: emotional or otherwise Outcomes and prioritization 13 List and define all outcomes for which data will be sought, including prioritization of main and additional outcomes, with rationale The primary outcome of this systematic review is to summarise the experiences of CALD background women with GDM and how their experiences are similar and different to that of non-CALD women.
The secondary outcome of this review is to suggest future investigations and strategies that could be implemented to optimise the GDM experience for CALD women.

Risk of bias in individual studies 14
Describe anticipated methods for assessing risk of bias of individual studies, including whether this will be done at the outcome or study level, or both; state how this information will be used in data synthesis.
For every included study CH will independently do a quality appraisal using The JBI critical appraisal checklists for analytical cross-sectional studies and qualitative research were used to assess the risk of bias and methodological quality of the studies in this review. The scoring will be determined as: yes, no, unclear, or not applicable. Data synthesis 15a Describe criteria under which study data will be quantitatively synthesised The authors will look for quantitative and qualitative assessments of "experiences" in CALD women in the studies, and synthesise similar measured outcomes together. However, it should be noted that it will be difficult to find many studies that measure the same outcomes in the inclusion criteria, such the quantitative data will be qualitized into a mutually compatible qualitative format of narrative description. 15b If data are appropriate for quantitative synthesis, describe planned summary measures, methods of handling data and methods of combining data from studies, including any planned exploration of consistency (such as I 2 , Kendall's τ) When multiple studies are reporting the same outcomes, a meta-analysis will be performed in R. Where applicable, heterogeneity of effect for studies within a meta-analysis will be assessed with the I2 statistic. 15c Describe any proposed additional analyses (such as sensitivity or subgroup analyses, meta-regression) A subgroup analysis is not proposed If quantitative synthesis is not appropriate, describe the type of summary planned If the studies do not report the same outcomes, the results of each study will be interpreted qualitatively. Transformation of the quantitative data into a mutually compatible qualitative format will be done to compare results and produce more complex analysis. Meta-bias(es) 16 Specify any planned assessment of meta-bias(es) (such as publication bias across studies, selective reporting within studies) N/A Confidence in cumulative evidence 17 Describe how the strength of the body of evidence will be assessed (such as GRADE) The quality of evidence applied to the outcomes from this study can be assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) quality rating. * It is strongly recommended that this checklist be read in conjunction with the PRISMA-P Explanation and Elaboration (cite when available) for important clarification on the items. Amendments to a review protocol should be tracked and dated. The copyright for PRISMA-P (including checklist) is held by the PRISMA-P Group and is distributed under a Creative Commons Attribution Licence 4.0.