Co-producing a physical activity programme for women with previous gestational diabetes
Introduction Gestational diabetes, or GDM, is a form of glucose intolerance that occurs during pregnancy. It affects approximately 3% of pregnancies in the UK, depending on diagnostic criteria used, and its prevalence is increasing. GDM typically dissipates after delivery, but women with previous GDM are at seven-fold increased risk of being diagnosed with Type 2 diabetes in comparison to women who have given birth but never had GDM. Physical activity in women with previous GDM can reduce future risk of Type 2 diabetes, but the majority of these women are inactive. Interventions to increase physical activity in this group have had mixed results. An intervention that aims to increase physical activity in women with previous GDM using a systematic intervention development and novel methods of co-production could bring significant benefit to the population. As such, this PhD project aimed to develop a feasible, acceptable and sustainable intervention to increase physical activity in women with a history of GDM. Methods and results There have been five main studies within this programme of doctoral research: Study One: A mixed-methods systematic review. By synthesising qualitative and quantitative literature together, a new perspective of physical activity interventions and their effectiveness for women with previous GDM was gained, which can help practitioners and researchers develop more effective interventions. There have been other reviews that summarise the intervention literature systematically, but none have synthesised both qualitative and quantitative literature together. The evidence from this review informed the intervention that was ultimately developed. Study Two: Interviews with key stakeholders to understand the local context of physical activity and healthcare for women with GDM were conducted. Fifteen stakeholders were interviewed from community physical activity and GDM-related healthcare settings to understand their views on physical activity in women with previous GDM and if an appropriate programme was already in place in the community. Seven community-based physical activity professionals were interviewed to understand the physical activity programmes they led. Overall, none of these programmes appeared to be suitable for women with previous GDM. The healthcare providers all related to care of women with GDM and described their views on physical activity levels in this group (overall low) and the barriers they believed women with current and previous GDM faced when thinking about becoming more physically active. Study Three: Interviews with 25 women with current and previous GDM to understand the barriers and facilitators to physical activity they face in their everyday lives. When asked about factors influencing physical activity in their postpartum life, the most frequently mentioned barriers were not being a priority in your own life; leisure centres were not suitable; difficulties in time management and issues surrounding childcare (or lack of). The most frequently mentioned facilitators or reasons for pursuing physical activity (or considering pursuing physical activity) were improving mental health; keeping yourself physically healthy; reducing risk of future disease and having easy access to green space. Study Four: The fourth study was an intervention development workshop that took place over a secret Facebook group for two weeks. Using a secret Facebook group for intervention development was novel and important for this hard-to-reach group. This allowed participants with busy and irregular schedules (usually due to small children or infants) to participate in a capacity that worked for them. Through the workshop, it became clear that participants wanted a mental health intervention alongside the physical activity programme. As mentioned, a lack of self-care and self-prioritisation plays a significant role in why participants did not engage in physical activity. Additionally, this group felt judged and uncomfortable going to leisure centres and fitness classes, preferring to exercise at home if possible. Overall, the workshop was well-received with most participants saying they would take place in a similar study again. Study 5 was a small-scale and in-person feasibility test with four participants to discuss the theory of action and test key intervention components. A key theory of change that was developed suggested that women need to improve their mental health and increase “easier” self-care behaviours before adding physical activity into their lives. The mental health programme was developed as a modified Mindful Self-Compassion programme, based on an evidence-based programme from the United States. Materials were developed by working with a Mindful Self-Compassion teacher and positive feedback was received from Study 5 participants. Through the mental health training, the goal is for women to begin to generate key outcomes that will allow a physical activity programme to be more acceptable and sustainable. The programme logic model and draft intervention components have been developed and are ready for further testing. Discussion Co-production and the use of a systematic intervention development framework resulted in a novel intervention and the use of new and underutilised methods of participation for hard-to-reach groups. Findings from this PhD suggest that novel online methods are well-suited to develop interventions for women with young children, such as women with previous GDM. These methods, in particular the use of a secret Facebook group for co-production, also hold potential for other time-constrained and hard-to-reach audiences to participate in research, as well as when face-to-face contact is restricted. Regarding a physical activity intervention for this audience, this research suggests that self-compassion plays a key role in improving physical activity behaviours. A feasible and acceptable intervention for women with previous GDM involves a Mindful Self-Compassion programme prior to a home-based, online physical activity programme to achieve key outcomes needed before physical activity is able to be a priority. Future studies could include further feasibility testing, a pilot study and a large-scale intervention, as well as exploring embedding in healthcare systems.