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Gestational diabetes mellitus (GDM) is one of the most common medical complications during pregnancy. eHealth technologies are proving to be successful in supporting the self-management of medical conditions. Digital technologies have the potential to improve GDM self-management.
The primary objective of this systematic literature review was to identify the views of health professionals (HPs) and women with GDM regarding the use of eHealth for GDM self-management. The secondary objective was to investigate the usability and user satisfaction levels when using these technologies.
Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach, the search included primary papers in English on the evaluation of technology to support self-management of GDM from January 2008 to September 2021 using MEDLINE, CINAHL, Embase, ACM, and IEEE databases. The lists of references from previous systematic literature reviews, which were related to technology and GDM, were also examined for primary studies. Papers with qualitative, quantitative, and mixed methodologies were included and evaluated. The selected papers were assessed for quality using the Cochrane Collaboration tool, National Institute for Health and Care Excellence clinical guidelines, Critical Appraisal Skills Programme Qualitative Checklist, and McGill University Mixed Methods Appraisal Tool. NVivo (QSR International) was used to extract qualitative data, which were subjected to thematic analysis. Narrative synthesis was used to analyze the quantitative data.
A total of 26 papers were included in the review. Of these, 19% (5/26) of studies used quantitative research methodologies, 19% (5/26) used qualitative methods, and 62% (16/26) used mixed methods. In all, 4 themes were identified from the qualitative data: the benefits of using technology, engagement with people via technology, the usability of technology, and discouragement factors for the use of technology. The thematic analysis revealed a vast scope of challenges and facilitators in the use of GDM self-management systems. The challenges included usability aspects of the system, technical problems, data privacy, lack of emotional support, the accuracy of reported data, and adoption of the system by HPs. Convenience, improved GDM self-management, peer support, increased motivation, increased independence, and consistent monitoring were facilitators to use these technologies. Quantitative data showed that there is potential for improving the usability of the GDM self-management systems. It also showed that convenience, usefulness, increasing motivation for GDM self-management, helping with GDM self-management, and being monitored by HPs were facilitators to use the GDM self-management systems.
This novel systematic literature review shows that HPs and women with GDM encountered some challenges in using GDM self-management systems. The usability of GDM systems was the primary challenge derived from qualitative and quantitative results, with convenience, consistent monitoring, and optimization of GDM self-management emerging as important facilitators.
Gestational diabetes mellitus (GDM) is defined as any degree of carbohydrate intolerance with onset or first recognition during pregnancy [
GDM is associated with serious maternal [
In light of increased adoption of technology to access information and communication, a digital GDM self-management system might offer advantages such as reducing patient travel and waiting time [
Digital GDM self-management systems developed in recent years are available mostly as mobile apps or websites [
Furthermore, most GDM self-management systems are not widely used [
The primary aim of this systematic literature review was to identify the views of health professionals (HPs) and women with GDM regarding barriers and facilitators of using technology for GDM self-management. The secondary aim was to investigate the usability and user satisfaction of these technologies.
The search strategy was developed by following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach [
To achieve the aims of this review, the criteria for inclusion and exclusion were developed as presented in
Views of health care professionals, pregnant women diagnosed with gestational diabetes mellitus (GDM) or postpartum women with a history of GDM about their pregnancy period
Technology (eHealth or telemedicine being used, evaluated, reviewed, or discussed by participants) or usability evaluation or reports of user satisfaction levels
Any primary research studies
Aspects of GDM management (eg, blood glucose control, diet, weight, physical activity, medication adherence, or information)
Published papers written in any language other than English
Women with preexisting type 1 and type 2 diabetes (except papers that provide information about GDM distinct from type 1 and 2 diabetes)
Any nondigital technology
Papers published before 2008
Posters, abstracts, and news items
Systematic literature reviews
Usability results for task performance
A search was carried out using 3 search terms—“self-management,” “gestational diabetes,” and “technology” (
The search included publications written in English from January 2008 to September 2021 in the MEDLINE, CINAHL, Embase, ACM, and IEEE databases. This date limitation was chosen to represent contemporary technology for GDM self-management.
The screening process was conducted by the first author in line with previous studies [
Identification: the results of the search from different databases were exported to the EndNote X7 software. Furthermore, the reference lists of previous systematic literature reviews related to technology and GDM were examined in the primary studies. All citations were collated into one group and duplicate records were removed.
Screening: the titles and abstracts of the remaining citations were screened based on the inclusion and exclusion criteria to select potential papers by the first author. At this stage, 2 other members of the research team independently conducted a double screening of the first 10% of the results. Following a discussion phase, this screening process was repeated to ensure reliability based on inclusion and exclusion criteria.
Eligibility: Mendeley software was used to keep electronic copies of the full text of potential papers. The full text of the papers was assessed based on the inclusion and exclusion criteria.
Included: the final papers were selected from the full text based on the inclusion and exclusion criteria by the first author. The papers were discussed with the research team if there was any lack of clarity in their inclusion.
The study characteristics were extracted from the final 26 included papers. A predefined data extraction table was populated with information, such as study design, sample size, location, analysis method, participants’ ages, inclusion and exclusion criteria, analysis methods, study goals, quantitative and qualitative data collection tools, and key findings (
NVivo 12 was used to extract relevant qualitative data to achieve the primary aim of the review. A predefined table, including the author, measures, scale items, and results, was used to extract relevant quantitative data.
Appropriate appraisal tools were chosen based on the methodology and study design. Each of the studies included in this review was critically assessed using an appropriate tool: the Cochrane Collaboration tool for randomized controlled trials (RCTs) [
To meet the aims of this systematic literature review and not to exclude data relevant to this review, the quality of papers was not assessed with the purpose of excluding them. Instead, limitations of the included studies were considered during the analysis and synthesis of data.
The analysis was completed in 2 phases for qualitative and quantitative data. Thematic analysis with an inductive approach [
Level 1 (reviewing codes of each theme for existence of coherent patterns) and level 2 analyses (reviewing the themes to assess whether they reflect the entire data set) were conducted by the first author and the second coauthor. Interrater reliability was not carried out, in line with the recommended process by Braun and Clarke [
Narrative review was used to analyze the quantitative data owing to the heterogeneity of research methods used. A narrative review is flexible and allows different types of evidence to be combined into a coherent summary. The narrative review process [
The search and screening strategies are shown in
A total of 26 papers were included from the full text based on the inclusion and exclusion criteria. Of the included papers, 19% (5/26) were quantitative, 19% (5/26) were qualitative, and 62% (16/26) used mixed methods (
Study identification flowchart. GDM: gestational diabetes mellitus; HP: health professional.
In general, the 26 included studies showed some degree of bias in their research.
On the basis of the nature of the included studies that used technology as a core of their research, it was impossible to blind participants and researchers from the knowledge of the intervention participants received [
Quality appraisal of the remaining studies (
Risk of bias summary—each risk of bias item across included randomized controlled trial studies. Green: Yes (low risk of bias); Red: No (high risk of bias); Yellow: Unclear (bias is not clear or bias cannot be determined) [
Risk of bias graph—the risk of bias item presented as percentages across included randomized controlled trial studies. Green: Yes (low risk of bias); Red: No (high risk of bias); Yellow=Unclear (bias is not clear or bias cannot be determined).
Of the included studies, 73% (19/26) contributed qualitative data to the thematic analysis. The views of women and HPs were integrated and reported together throughout the analysis. A total of 4 themes were identified: benefits of using technology, engagement with people via technology, usability of technology, and discouragement factors for the use of technology (definitions of the themes and subthemes are available in
Thematic map showing themes and subthemes. GDM: gestational diabetes mellitus.
Both women and HPs reported their confidence in [
Convenience was the predominant benefit of using technology for GDM management. A total of 50% (13/26) papers reported that women with GDM and HPs found the convenience of reduced travel and clinical appointments, as well as the pervasive use of technology, the most beneficial reasons for its use. Women in the studies of Khalil [
I am amazed with the technology and it suited me much better than having to travel in a lot and wait, especially with little ones
Generally, women and HPs lauded the ease and convenience of using technology rather than traditional paper logbooks. This was mainly because of the ability to access technology anytime [
Women and HPs also recognized constant access to information related to GDM [
Saving time is another convenient aspect of technology use for both women [
They don’t want to spend all of their time trying to get to the hospital and look for parking and spend long periods waiting at hospital.
Improving the ability of women to self-manage GDM is another prominent benefit of using such technology. Increasing awareness of one’s own data has been perceived as an important element of using technology for GDM self-management [
Women also found information related to diet [
Both women and HPs perceived increased independence through technology [
myDiabby helped patients self-manage their health. [
Technologies help us being more autonomous. We feel more responsible. [
This theme included 2 main components including engagement with peers and engagement with health care professionals.
Women with GDM indicated that accessing “peer support” by a digital GDM self-management system would be useful [
Regarding engagement with health care professionals, women appreciated the possibility of receiving additional support using technology. They valued sharing their data and having regular GDM monitoring by HPs via technology [
Although some women and HPs felt comfortable communicating via technology [
I like the one to one contact so you can ask questions. [
Nevertheless, women still felt there was a need to provide more interaction and communication between HPs and women via mobile app technology [
Women and HPs provided various perspectives on the usability of digital GDM systems in this theme. The content of the systems, including the quality of information and format and presentation of patients’ data, was the main usability aspect discussed by women and HPs in the included papers.
When women and HPs found the GDM systems “easy to use” [
When usability concerns arose, they were also related to the data format and layout. Women and HPs suggested improving the layout and format of the information by changing the size of images or the amount of text [
To look back and see is there a blood sugar previous to try and identified yourself which was the pre and which was the post [meal test]. [
In the study by Pustozerov and Popova [
Discussions on usability were also directed at the effectiveness of GDM apps in fulfilling the needs of women. Participants in different studies provided opinions about the lack of functionality in their GDM self-management systems. Some of their diverse suggestions included an option to scan barcodes of food [
Women were also interested in having pop-up messages [
To be able to review previous (entered) results and comments, to get an alert notice if results are out of the ideal range... [
A final aspect of usability concerned the effectiveness of information content. Women and HPs found the GDM information in both older technology [
Despite the clear views of some women and HPs that using GDM self-management technology was more efficient in monitoring [
For something that was quite simple, it would take actually a long time to find it. [
I’ve never managed to do it for a long period, because of the amount of commitment. [
The apparent disinterest of HPs was a cause of discouragement for women with GDM. Some said HPs lacked interest [
I had no interest in writing it two places, and I understood that no one was going to read or use my app…They always asked for my book, so I used that. [
Similarly, HPs were concerned about women’s abilities to use technology:
they’re all on their screens but at the end of the day, some of them don’t actually have credit to even look at a website or download a piece of information. [
Confirming this, some women reported little or no experience of using “message boards and things of that nature” [
In addition, HPs were concerned about the time required to use the systems and thought it would increase their workload [
We have some women who have got quite a low socioeconomic status, most of them still have phones...but not all have [mobile] data. [
Women with GDM and HPs also experienced technical problems as barriers to the use of GDM self-management technology. Both women and HPs reported some difficulties with data transmission [
A narrative review was used to analyze the quantitative data, including the usability and user satisfaction results from 50% (13/26) of the included studies. Quantitative data from the remaining 27% (7/26) studies were not included in the analysis, as the results were not related to usability or user satisfaction [
Quantitative studies used various measurements to gather data. Of these, only 12% (3/26) included a usability questionnaire to evaluate their systems, as summarized in
Of the included studies, 8% (2/26) applied the system usability scale (SUS) developed by Brook in 1996 [
In short, although these results suggest that previous GDM systems have usability challenges, it is impossible to draw any reliable conclusions with only 12% (3/26) studies providing results from a usability questionnaire.
Included studies that used a usability questionnaire.
Usability | Type |
Gianfrancesco et al [ |
SUSa questionnaire |
Jo and Park [ |
SUS (Korean version) |
Pustozerov and Popova [ |
Custom usability questionnaire (10-point scale questions on |
aSUS: system usability scale.
The included studies used different measurements to evaluate user satisfaction. Given et al [
The included studies reported generally high user satisfaction in their evaluations of GDM systems [
Assessment of the aspects of convenience was common. Caballero-Ruiz et al [
Improvement of GDM self-management was a highly rated aspect of the studied systems, including helping women to record BG levels [
Confidence or trust in GDM systems was rated well. Women with GDM reported confidence that the health care team checked their BG levels on the GDM system [
Slightly lower satisfaction scores were reported for other aspects of ease of use: clarity of visualization of changes to treatment was rated approximately 7 out of 10 [
Overall, based on the usability results (scores just under or above the acceptable threshold), there is much room for improvement in the usability of GDM self-management systems. However, with the limited number of papers providing a quantitative usability evaluation and the heterogeneity of questions assessing satisfaction, more studies are needed to identify where the improvement of usability and user satisfaction should be focused.
User satisfaction question topics in the included studies.
Summary of key measures of user satisfaction questionnaires | Study | ||||||||
|
Varnfield et al [ |
Johnson and Berry [ |
Mackillop et al [ |
Peleg et al [ |
Caballero-Ruiz et al [ |
Peleg et al [ |
Bartholomew et al [ |
Hirst et al [ |
Given et al [ |
Convenient |
|
|
✓a |
|
|
|
|
✓ |
|
Avoiding displacement |
|
|
|
|
✓ |
|
|
|
|
Fit in with life or did not complicate it |
|
|
✓ | ✓ | ✓ | ✓ |
|
✓ |
|
Adapt to daily life and context changes |
|
|
|
✓ |
|
✓ |
|
|
|
Number of hospital consultations is enough |
|
|
✓ |
|
✓ |
|
|
|
|
Help to record BGLsb | ✓ |
|
|
|
|
|
|
|
|
Help to remember to take medication and take BGc |
|
✓ |
|
|
|
|
|
|
|
Help to eat healthier or become more active |
|
✓ |
|
|
|
|
|
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|
Helps to improve GDMd knowledge |
|
|
|
|
✓ |
|
|
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|
Increased motivation for self-management |
|
|
|
|
|
|
✓ |
|
|
Improved diabetes control |
|
|
|
|
|
|
✓ |
|
|
Help to feel confident in managing GDM | ✓ |
|
|
✓ |
|
✓ |
|
|
|
Feel confident that health care team checked BGLs | ✓ |
|
|
|
|
|
|
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|
Recommending to others |
|
✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
|
|
Using it again |
|
✓ | ✓ | ✓ |
|
✓ |
|
|
✓ |
Useful |
|
|
|
✓ | ✓ |
|
|
|
|
Easy to use |
|
|
|
✓ |
|
|
✓ |
|
✓ |
Ease to learn how to use |
|
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✓ | ✓ |
|
|
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|
Helps data interpretation |
|
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✓ | ✓ |
|
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|
Clarity or effectiveness of visualization |
|
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✓ | ✓ |
|
|
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|
Clarity of activities’ sequence in app |
|
|
|
✓ |
|
|
|
|
|
Personalized |
|
|
|
|
|
|
✓ |
|
|
System response time |
|
|
|
✓ |
|
✓ |
|
|
|
Experiencing error with the system |
|
|
|
✓ |
|
|
|
|
|
Time consuming |
|
|
|
|
|
|
✓ |
|
|
Trust is being well controlled |
|
|
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✓ |
|
|
|
|
Trust it to work |
|
|
|
|
|
|
|
|
✓ |
Reliable to use |
|
|
✓ |
|
|
|
|
✓ |
|
Satisfaction regarding diabetes follow-up |
|
|
|
|
✓ |
|
|
|
|
Satisfied with the system | ✓ |
|
|
|
|
|
|
|
✓ |
Enjoyable or interesting |
|
|
|
✓ |
|
|
✓ |
|
|
Paying for the system |
|
|
|
✓ |
|
✓ |
|
|
|
a✓: illustrates where a study included a measure of user satisfaction in its participant questionnaire.
bBGL: blood glucose level.
cBG: blood glucose.
dGDM: gestational diabetes mellitus.
The primary objective of this systematic literature review was to identify the views of HPs, women with GDM, and postpartum women who have had GDM regarding GDM self-management technology. The secondary objective was to investigate the usability and user satisfaction levels of existing technologies and quantitatively evaluate these factors.
Regarding the first objective, thematic analysis of the qualitative data in the selected papers identified four themes: (1) the benefits of using technology, (2) engagement with people via technology, (3) usability of technology, and (4) discouragement factors for the use of technology.
The thematic analysis of qualitative data revealed barriers to usability, including technical problems, data privacy, lack of emotional support, the accuracy of reported data, and adoption of the system by HPs. Convenience, improving GDM self-management, peer support, increasing motivation, increasing independency, and providing consistent monitoring were common facilitators of using this technology.
For the second objective, the narrative review of the quantitative data (usability and user satisfaction) showed that there is room for improvement in the usability of GDM self-management systems.
The influence of convenience in our analysis, in both the qualitative and quantitative findings, is echoed in other literature on telemedicine. Pérez-Ferre et al [
Although our findings indicated a strong positive desire to reduce in-person clinics through technology, not everyone wanted clinical visits replaced altogether. This was affirmed in a recent systematic review that highlighted the negative impact of losing in-person contact between women with GDM and HPs [
Our results revealed that women appreciated the use of technology to manage various aspects of their condition. These findings are consistent with those of relevant studies outside the scope of this review. Leziak et al [
In summary, evidence suggests that technology could help women optimize their GDM self-management abilities, leading to benefits for both themselves and their baby’s health. As a result of good practices initiated through GDM self-management technology, women could also improve control over their health, which could be maintained habitually after giving birth to prevent the development of type 2 diabetes.
As mentioned earlier, this theme consists of 2 main components: “engagement with peers” and “engagement with health care professionals.”
The results of the thematic analysis demonstrated the benefits of peer support in digital GDM self-management systems [
Our thematic analysis described women’s interest in sharing data with their clinicians by remote means, to obtain reassurance and to be monitored more consistently. This is also evident in some previous studies. Dalfra et al [
Although the evidence available regarding the usability of digital GDM self-management systems is limited [
Our review also identified limitations in the functionality of the systems as another usability concern across the included studies. Previous reviews of general diabetes self-management apps have highlighted important missing functionality, including automatic transfer of BG data from a glucometer to a mobile app, personalized diabetes management advice [
The limited functionality of diabetes self-management systems can be considered a usability problem [
Quantitative evaluation of GDM self-management apps in the studies by Jo and Park [
Our quantitative analysis identified the need to improve the usability of GDM self-management systems. However, with the limited number of papers providing a quantitative usability evaluation, the heterogeneity of questions assessing satisfaction and the variation in systems being assessed, it is difficult for quantitative studies to identify where the improvement of usability and user satisfaction should be focused. Therefore, it is an aspect that needs further investigation.
Despite the perceived benefits of GDM technology, our analysis revealed technical problems as a prevalent barrier across the included studies. Previous studies have reported similar technical problems when using eHealth and self-management systems [
In addition to technical problems, the privacy of personal health information was a concern for some women. Simblett et al [
Although most women across all studies were interested in using self-management technology, some suggested that their HPs were disinterested. Similarly, Wake et al [
The strengths of this review were its application of a rigorous process in paper selection and summarizing results that include both qualitative and quantitative data to cover a wide scope of understanding. Although this systematic literature review was conducted by the first author, we mitigated the potential for bias through a double screening of a proportion of papers’ citations (title and abstract) by the entire research team, in line with previous systematic literature reviews published in JMIR. Two of the authors were also involved in theme development and the methods and results were reviewed by all authors.
Thematic analysis was restricted to the qualitative data contained in the papers (19/26, 73%). It is possible that the authors of the included studies did not report significant results. However, it is unlikely that the key findings were not reported in the original papers.
The details of the methods and methodologies applied were limited in some studies. The available evidence is also limited by several factors. First, some studies used small sample sizes. Methodologically robust trials of greater sizes are needed to confirm the findings of our review. Second, the number of quantitative studies that measured usability was limited. Third, most of the evaluations of satisfaction did not address the validity and reliability of the satisfaction questionnaires. Furthermore, some questions in the satisfaction questionnaires were generic. Using standard evaluation tools and valid questionnaires would offer consistent and robust results across different studies.
Overall, further work is required to improve the usability of GDM self-management systems. There is a need to evaluate the systems using various usability approaches [
Further work is also needed to assess the design and development process of these GDM self-management technologies that might help identify the source of these usability challenges.
This is the first systematic literature review to carry out a comprehensive review of the perspectives of HPs, women with GDM, and postpartum women who have had GDM about using technology for GDM self-management during pregnancy. Despite the existence of several studies on technology and GDM, information about the perceptions of women with GDM and HPs regarding GDM self-management technology is limited. More rigorous studies are needed to reveal evidence-based barriers to and facilitators of using existing GDM self-management systems.
Keywords and search strategy.
Study characteristics.
Quality assessment.
Definition of the themes and subthemes.
Satisfaction measurements.
blood glucose
gestational diabetes mellitus
health professional
mobile health
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
system usability scale
The authors would like to take this opportunity to thank the Engineering and Physical Sciences Research Council (EPSRC) for the funding support and opportunity to conduct this research project. They also thank Professor Annalu Waller, Dr Rachel Menzies, and Mr Scott McGregor for providing their help and advice during this review.
None declared.