Lisa Garnweidner-Holme

Designing and Developing a Mobile Smartphone Application for Women with Gestational Diabetes Mellitus Followed-Up at Diabetes Outpatient Clinics in Norway

The prevalence of Gestational Diabetes Mellitus (GDM) is increasing worldwide. Controlling blood sugar levels is fundamental to the management of GDM. Current practice in Norway includes patients registering blood sugar levels in a booklet and receiving verbal and/or written health information. A smartphone application may provide patients individually targeted and easily available advice to control blood sugar levels. The aim of this paper is to document the process of designing and developing a smartphone application (the Pregnant+ app) that automatically transfers blood sugar levels from the glucometer and has information about healthy eating and physical activity. This formative research included expert-group discussions among health professionals, researchers and experts in data privacy and security. User-involvement studies were conducted to discuss prototypes of the app. Results indicated that the content of the application should be easy to understand given the varying degree of patients’ literacy and in line with the information they receive at clinics. The final version of the app incorporated behavior change techniques such as self-monitoring and cues to action. Results from the first round of interactions show the importance of involving expert groups and patients when developing a mobile health-care device.

Knowledge about Iodine in Pregnant and Lactating Women in the Oslo Area, Norway

Background: Lack of knowledge about iodine may be a risk factor for iodine deficiency in pregnant and lactating women. The aim of this study was to assess knowledge about iodine and predictors of iodine knowledge scores among pregnant and lactating women. The study also examined whether iodine knowledge scores were associated with iodine status. Methods: A cross-sectional study was performed on 804 pregnant women and 175 lactating women from 18 to 44 years of age in 2016 in the Oslo area, Norway. Knowledge about iodine was collected through a self-administered, paper-based questionnaire. Iodine concentrations in urine and breast milk were measured using an inductively coupled plasma mass spectrometer (ICPMS). Results: 74% of the pregnant women and 55% of the lactating women achieved none to low iodine knowledge scores. Higher educated pregnant women and those who had received information about iodine had significantly higher knowledge scores. In lactating women, increased age was associated with higher knowledge scores. Knowledge scores were not associated with participants’ iodine status. Conclusion: This study revealed a lack of knowledge about the importance of iodine in pregnant and lactating women, as well as about the most important dietary sources. Public education initiatives are required to increase the awareness about iodine in these population groups.

Smartphone application for women with gestational diabetes mellitus: a study protocol for a multicentre randomised controlled trial

Introduction The promotion of a healthy diet, physical activity and measurement of blood glucose levels are essential components in the care for women with gestational diabetes mellitus (GDM). Smartphones offer a new way to promote health behaviour. The main aim is to investigate if the use of the Pregnant+ app, in addition to standard care, results in better blood glucose levels compared with current standard care only, for women with GDM. Methods and analysis This randomised controlled trial will include 230 pregnant women with GDM followed up at 5 outpatient departments (OPD) in the greater Oslo Region. Women with a 2-hour oral glucose tolerance test (OGTT) ≥9 mmol/L, who own a smartphone, understand Norwegian, Urdu or Somali and are <33 weeks pregnant, are invited. The intervention group receives the Pregnant+ app and standard care. The control group receives standard care only. Block randomisation is performed electronically. Data are collected using self-reported questionnaires and hospital records. Data will be analysed according to the intention-to-treat principle. Groups will be compared using linear regression for the main outcome and χ2 test for categorical data and Students t-test or Mann-Whitney-Wilcoxon test for skewed distribution. The main outcome is the glucose level measured at the 2-hour OGTT 3 months postpartum. Secondary outcomes are a change in health behaviour and knowledge about GDM, quality of life, birth weight, mode of delivery and complications for mother and child. Ethics and dissemination The study is exempt from regional ethics review due to its nature of quality improvement in patient care. Our study has been approved by the Norwegian Social Science Data Services and the patient privacy protections boards governing over the recruitment sites. Findings will be presented in peer-reviewed journals and at conferences. Trial registration number NCT02588729, Post-results.

Suboptimal Iodine Status among Pregnant Women in the Oslo Area, Norway

Norway has been considered iodine replete for decades; however, recent studies indicate reemergence of inadequate iodine status in different population groups. We assessed iodine status in pregnant women based on urinary iodine concentration (UIC), urinary iodine excretion (UIE), and iodine intake from food and supplements. In 804 pregnant women, 24-h iodine intakes from iodine-rich foods and iodine-containing supplements were calculated. In 777 women, iodine concentration was measured in spot urine samples by inductively coupled plasma/mass spectrometry (ICP-MS). In addition, 49 of the women collected a 24-h urine sample for assessment of UIE and iodine intake from food frequency questionnaire (FFQ). Median UIC was 92 µg/L. Fifty-five percent had a calculated iodine intake below estimated average requirement (EAR) (160 µg/day). Iodine intake from food alone did not provide the amount of iodine required to meet maternal and fetal needs during pregnancy. In multiple regression models, hypothyroidism, supplemental iodine and maternal age were positively associated with UIC, while gestational age and smoking were negatively associated, explaining 11% of the variance. This study clearly shows that pregnant women in the Oslo area are mild to moderate iodine deficient and public health strategies are needed to improve and secure adequate iodine status.

Suitability Assessment of Printed Dietary Guidelines for Pregnant Women and Parents of Infants and Toddlers From 7 European Countries

OBJECTIVES To evaluate selected European printed dietary guidelines for pregnant women and parents of infants and toddlers using the suitability assessment of materials (SAM) method. METHODS A descriptive study to determine the suitability of 14 printed dietary guidelines from 7 European countries based on deductive quantitative analyses. RESULTS Materials varied greatly in format and content: 35.7% of materials were rated superior and 64.3% were rated adequate according to the overall SAM score for patient education material. None of the materials were scored not suitable. Among the categories, the highest average scores were for layout and typography and the lowest average scores were for cultural appropriateness and learning stimulation and motivation. Interrater reliability ranged from Cohens kappa of 0.37 to 0.62 (mean, 0.41), indicating fair to moderate agreement among the 3 investigators. CONCLUSIONS AND IMPLICATIONS Overall, the suitability of the assessed printed dietary guidelines was adequate. Based on the SAM methodology, printed dietary guidelines may increase in suitability by emphasizing aspects related to health literacy and accommodating the needs of different food cultures within a population.

Health Care Professionals’ Attitudes Toward, and Experiences of Using, a Culture-Sensitive Smartphone App for Women with Gestational Diabetes Mellitus: Qualitative Study

Background The increasing prevalence of gestational diabetes mellitus (GDM) among women of different ethnic backgrounds provides new challenges for health care professionals, who often find it difficult to provide information about the management of this disease to such individuals. Mobile health (mHealth) may act as a useful tool for blood sugar control and care process enhancement. However, little is known about health care professionals’ experiences and attitudes toward the use of mHealth for women with GDM. Objective The aim of this study was to explore how health care professionals perceived the provision of care to pregnant women who managed their GDM using the culture-sensitive Pregnant+ app in a randomized controlled trial. Methods Individual interviews with 9 health care professionals providing care for women with GDM were conducted. Braun and Clark’s method of thematic content analysis inspired the analysis. This study included health care professionals who were primarily responsible for providing care to participants with GDM in the Pregnant+ randomized controlled trial at 5 diabetes outpatient clinics in Oslo, Norway. Results Health care professionals perceived mHealth, particularly the Pregnant+ app, as an appropriate tool for the care of women with GDM, who were described as individuals comprising a heterogeneous, motivated group that could be easily approached with health-related information. Some participants reported challenges with respect to provision of advice to women with different food cultures. The advantages of the Pregnant+ app included provision of information that women could access at home, the information provided being perceived as trustworthy by health care professionals, the culture sensitivity of the app, and the convenience for women to register blood sugar levels. Technical problems, particularly those associated with the automatic transfer of blood glucose measurements, were identified as the main barrier to the use of the Pregnant+ app. Strict inclusion criteria and the inclusion of participants who could not speak Norwegian were the main challenges in the recruitment process for the randomized controlled trial. Conclusions The findings of this study suggest that mHealth is a useful tool to enhance the care provided by health care professionals to women with GDM. Future mobile apps for the management of GDM should be developed by a trustworthy source and in cooperation with health care professionals. They should also be culture sensitive and should not exhibit technical problems.

A Scoping Review of Facilitators of Multi-Professional Collaboration in Primary Care

Introduction: Multi-professional collaboration (MPC) is essential for the delivery of effective and comprehensive care services. As in other European countries, primary care in Norway is challenged by altered patient values and the increased expectations of health administrations to participate in team-based care. This scoping review reports on the organisational, processual, relational and contextual facilitators of collaboration between general practitioners (GP) and other healthcare professionals (HCPs) in primary care. Methods: A systematic search in specialist and Scandinavian databases retrieved 707 citations. Following the inclusion criteria, nineteen studies were considered eligible and examined according to Arksey and O’Malley’s methodological framework for scoping reviews. The retrieved literature was analysed employing a content analysis approach. A group of stakeholders commented on study findings to enhance study validity. Results: Primary care research into MPC is immature and emerging in Norway. Our analysis showed that introducing common procedures for documentation and handling of patient data, knowledge sharing, and establishing local specialised multi-professional teams, facilitates MPC. The results indicate that advancements in work practices benefit from an initial system-level foundation with focus on local management and MPC leadership. Further, our results show that it is preferable to enhance collaborative skills before introducing new professional teams, roles and responsibilities. Investing in professional relations could build trust, respect and continuity. In this respect, sufficient time must be allocated during the working day for professionals to share reflections and engage in mutual learning. Conclusion: There is a paucity of research concerning the application and management of MPC in Norwegian primary care. The work practices and relations between professionals, primary care institutions and stakeholders on a macro level is inadequate. Health care is a complex system in which HCPs need managerial support to harvest the untapped benefits of MPC in primary care. As international research demonstrates, local managers must be supported with infrastructure on a macro level to understand the embedding of practice and look at what professionals actually do and how they work.

Women's experiences with using a smartphone app (the Pregnant+ app) to manage gestational diabetes mellitus in a randomised controlled trial

OBJECTIVE The purpose of this study was to explore the experiences of women with gestational diabetes mellitus (GDM) with controlling their blood glucose values and receiving health and nutrition information using a smartphone app (the Pregnant+ app). DESIGN AND PARTICIPANTS The study utilised the interpretative phenomenological analysis method. Semi-structured interviews were conducted with 17 participants among those participating to the randomised controlled trial. RESULTS The women experienced sorrow and disappointment when they were diagnosed with GDM, but they all went through a process of learning to self-manage their condition that was strongly motivated by theirdesire to care for their unborn babies. The women found that the app increased their confidence in their self management of GDM and their motivation for behavioural change. For some women, the app contributed to feelings offrustration or obsession. In addition, some technological problems and a lack of support from health-care professionals limited several women from using the app. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTISE The findings suggest that asmartphone app may have potential for supporting women with GDM, particularly in their blood glucose management. However, it also highlights some of the potential challenges of using mHealth technologies. The findings indicate that a closer collaboration between health-care professionals and patients is of great importance in the implementation of apps for women with GDM.

‘It is a difficult topic’ – a qualitative study of midwives´ experiences with routine antenatal enquiry for intimate partner violence

BackgroundIntimate partner violence (IPV) during pregnancy may jeopardize maternal and fetal health (IJFWM 49:159-164, 2004; IJGO 133:269-276, 2016). In recognition of the significant public health impact of IPV, the Norwegian Directorate of Health issued new guidelines in 2014, which recommend that health professionals routinely ask all women in antenatal care about their exposure to violence. The objective of this study was to gain an in-depth understanding of midwives’ experiences with routine enquiry for intimate partner violence during the antenatal period.MethodsThe study had a qualitative design. Individual semi-structured interviews with eight midwives providing antenatal care at eight Mother and Child Health Centres (MCHC) in Norway were conducted. Graneheim and Lundmans method of content analysis inspired the analysis.ResultsThree main themes emerged: Midwives do ask about violence; It can be a challenge; and Factors that make it easier to ask. All midwives enquired, but not on a regular basis, about violence. The midwives’ personal interest in the topic was an important factor that made it easier for them to ask about violence. Lack of time, fear of not knowing how to deal with a positive answer and lack of organizational support were barriers to asking pregnant women about their experiences of violence.ConclusionMidwives were aware of the guidelines and made some efforts to implement them. However, further education and organisational support is needed to enable midwives to routinely ask all pregnant women about IVP.

Talking about intimate partner violence in multi-cultural antenatal care: a qualitative study of pregnant women’s advice for better communication in South-East Norway

BackgroundIntimate partner violence (IPV) against women constitutes a major public health problem. Antenatal care is considered a window of opportunity to disclose and to communicate about IPV. However, little is known about how women from different ethnic backgrounds wish to communicate about their experiences with IPV during pregnancy in antenatal care. The aim of the present study was to explore how women from different ethnic backgrounds experienced IPV and what their recommendations were about how midwives should communicate about IPV in antenatal care.MethodsQualitative individual interviews with eight women who had experienced IPV during pregnancy were conducted and analysed using thematic analysis. The participants were purposively recruited from three crisis shelters in South-East Norway.ResultsThe participants either had immigrant backgrounds (n = 5) or were ethnic Norwegians (n = 3). All participants received antenatal care by a midwife. Although none of the participants were asked about IPV during antenatal care, they wished to talk about their experiences. Most participants felt that it would be important for the midwife to make them aware that they were victims of violence. Participants offered different suggestions on how and when midwives should talk about IPV. Facilitators to talk about IPV with the midwife were a good relationship with and the trustworthiness of the midwife, information about possible negative health outcomes for the newborn owing to IPV and knowing that the midwife could help them. The main barriers to talk about IPV with the midwife were that the participants were accompanied by their husbands during antenatal care, fear that the Child Welfare Service would take away their children after disclosure and cultural acceptance of violence. Participants with immigrant backgrounds also experienced difficulties in talking about IPV owing to their limited language skills. They thought that professionally trained interpreters with experience of IPV could overcome this barrier.ConclusionEven though none of the participants were asked about IPV in antenatal care, they offered different suggestions on how and when midwives should talk about IPV. Participants irrespective of their ethnical backgrounds perceived antenatal care as a key area to facilitate disclosure of IPV. Midwives’ communication and strategic skills to address IPV are crucial for help-seeking women. Training midwives’ skills in culture-sensitive communication might help to overcome cultural barriers to talk about violence.