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Factors Contributing to Non-Adherence to Postpartum Diabetes Screening

Discuss About The Adherence To Postpartum Diabetes Screening.

This review was aimed at synthesizing the factors associated with non-adherence to postpartum diabetes screening. Generally, a significant majority of women showed non-adherence to postpartum screening. Different factors were established to cause non-adherence. For instance, a study by McCloskey, Bernstein, Winter, Iverson, & Lee-Parritz (2014) established that non-adherence was attributed to lack of awareness and difficulties in accessing health care centers. On the other hand, results conducted in England associated non-adherence to concern only for risks of Gestational Diabetes Mellitus (McGovern et al, 2014). These results generally show that the adherence to postpartum diabetes screening is very low despite having guidelines in place in clinical settings. However, studies showed that non-adherence decreases when an active search is conducted. To illustrate this, women who began postpartum visits showed an increased adherence compared to those who completely do not attend the visits (Lawrence, Black, Hsu, Chen, & Sacks, 2010). Similarly, Hunt & Conway (2008) illustrates that non-adherence decreased after a nurse was hired to contact the patients and even conduct screening in the patients’ homes.  

Changes in the structure of the health system also significantly increase the rate of adherence to postpartum diabetes screening. To begin with, the implementation of programs aimed at caring for patients contributes to increasing the rate of adherence to postpartum screening. Such programs include initiation of programs that care for the patients (Aroda et al, 2015). For example, a nurse could be assigned specific number of patients to care for. In so doing, the nurse can send telephone messages to remind the patients of postpartum screening schedules. As a result of constant follow-up, the adherence of the patients is significantly increased as highlighted by Dietz et al (2008). Similarly, the patients could be divided into groups and a group leader assigned to each group. The creation of groups promotes sharing of information and encouragement. In addition, collaboration between the patients and the nurses improves the rate of patient visits for postpartum screening (Bernstein, McCloskey, Gebel, Iverson, & Lee-Parritz, 2016). Therefore, the low adherence obtained in this study can be attributed to inadequate follow-up strategies. For instance, failure to send reminders to the patients could have contributed to the low rate of adherence obtained.

The development of strategies to address the issue of low rates of adherence to postpartum screening guidelines does not seem to be satisfactory in practice. The study of the questionnaires filled by the patients reveals varying reasons why a majority of patients fails to conduct postpartum screening. These reasons include difficulty in caring for the newborn, lack of awareness, difficulties in accessing health care centers, and concern only for risks of Gestational Diabetes Mellitus to the fetus (Clark, Graham, Karovitch, & Keely, 2009). In addition, the factors that are associated with non-adherence to postpartum diabetes screening were found to be different for different studies. For instance, age, level of income, and level of education are reported by one of the studies (Tovar, Chasan-Taber, & Eggleston, 2015). On the contrary, other studies report association between non-adherence and obesity (Hunt& Conway, 2008). These variations mean that the results for a particular study must be treated with care. The results of an investigation depend on the sample size and therefore the interpretation must be based on this consideration. A study in which the sample size is significantly small limits the number of variables that can be studied and hence influences the factors that are associated with the adherence to postpartum screening. It is therefore difficult to exclude certain factors from a list of factors, which influence the rate of adherence to postpartum screening guidelines. As a result applying a single result in practice would not yield the expected results.

Strategies to Improve Adherence

Regardless of the sample size, follow-up of the patients is established to influence the rate of adherence to postpartum screening. All the studies reviewed indicated that the rate of postpartum adherence significantly increased whenever a follow-up program was put in place. Particularly, diabetes prevention program resulted in a change of the lifestyle of the patient, which minimized the risk factors for development of type 2 diabetes mellitus. With increased sensitization of the patients, an increase in the postpartum visits is realized (Van Ryswyk, Middleton, Hague, & Crowther, 2016). Therefore, postpartum visits are not only important for detection of type 2 diabetes mellitus but also targets interventions measures aimed at reducing that risk factors associated with diabetes. It is therefore crucial that patients carry out postpartum screening as spelt out in the screening guidelines in order to detect and treat type 2 diabetes during the early stages of diagnosis. As well, postpartum visits presents an opportunity for the patients to be enlightened on the preventive measures such as change I lifestyle that can be undertaken to minimize chances of developing diabetes during subsequent pregnancies.

Based on the Grading Recommendations Assessment, Development, and Evaluation (GRADE) approach, the certainty of the evidenced was rated as low. In the first place, the included studies had a substantial risk of bias given that the number of patients studied was significantly different thus the results could be different if the same sample size was used for each study. In addition, the strategies used for each study to undertake patient follow-up were different. In some cases, the follow-up activities entailed use of telephone to send reminds to patients while in other studies, patients were organized into groups.

Firstly, the identification of studies of factors associated with non-adherence to postpartum diabetes screening electronically was challenging. Some cases, electronic sources provided alternative searches such as risk factors associated with postpartum diabetes screening which could potentially be a source of biasness. Additionally, the literature scope of the literature sources was widened to include studies conducted in low and high-income countries. The socio-demographic status of the patients in these countries is different and thus could influence the rate of adherence differently. Another limitation of this review is that unpublished data could not be obtained so as to ascertain if indeed the data obtained from the published sources were the actual raw data obtained from the field. Finally, the study excluded other systematic reviews yet the reviews could have provided an insight on the potential biases from the previous reviews, which could have been avoided in this study.

The factors associated with the adherence to postpartum diabetes screening were found to be different in the two studies that were considered in this review. In a study by Tovar, Chasan-Taber, & Eggleston (2015) the factors responsible for adherence to postpartum screening include high levels of education and income, higher age, and treatment with insulin at the time of pregnancy.  On the other hand, this study did not find any relationship between the adherence to postpartum screening and level of income and education. However, the two studies established that the rate of adherence to postpartum screening was associated with history of Gestational Diabetes Mellitus and the age of the patient. The disagreement in the two studies under consideration could be attributed to the differences in the sample sizes. Specifically, the study by Tovar, Chasan-Taber, & Eggleston (2015) used a sample size consisting of 1000 patients while this study considered 148 women. The low sample size probably had impacts on the socio-demographic variable that could be studied during the review process. The disagreement presented in these two studies does not negate that fact that the adherence of patients to postpartum screening is low. Moreover, the two studies have ascertained that the rate of adherence to postpartum visits is associated with history of Gestational Diabetes Mellitus. As such, intervention measures can be based on this finding. As presented by most studies, strategies developed towards enhancing patient follow up generally improve adherence to post-partum visits.

Overall Completeness and Applicability of Evidence

Conclusion

In conclusion, the postpartum diabetes screening in patients with Gestational Diabetes Mellitus is a global challenge based on the evidence of the studies and articles reviewed. In this study, the rate of adherence was found to be 13.8%, which was associated with history of Gestational Diabetes Mellitus and socio-demographic factors. To address the challenge of low adherence, active patient search measures should be implemented by the care providers to promote postpartum patient visits. Example of such measures include initiating mobile clinics in to provide postpartum screening services for patients who have difficulties in attending healthcare centers, and having patient contact centers.

References

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Bernstein, J. A., McCloskey, L., Gebel, C. M., Iverson, R. E., & Lee-Parritz, A. (2016). Lost opportunities to prevent early onset type 2 diabetes mellitus after a pregnancy complicated by gestational diabetes. BMJ Open Diabetes Research and Care, 4(1), e000250.

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Clark, H. D., Graham, I. D., Karovitch, A., & Keely, E. J. (2009). Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. American Journal of Obstetrics & Gynecology, 200(6), 634-e1.

Dietz, P. M., Vesco, K. K., Callaghan, W. M., Bachman, D. J., Bruce, F. C., Berg, C. J., ... & Hornbrook, M. C. (2008). Postpartum screening for diabetes after a gestational diabetes mellitus–affected pregnancy. Obstetrics & Gynecology, 112(4), 868-874.

Grant P. (2016). Long term follow up of women with Gestational Diabetes Mellitus. Australian Journal of Obesity 26(1), 17-22.

Hunt, K. J., & Conway, D. L. (2008). Who returns for postpartum glucose screening following gestational diabetes mellitus?. American Journal of Obstetrics & Gynecology, 198(4), 404-e1.

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Van Ryswyk, E. M., Middleton, P. F., Hague, W. M., & Crowther, C. A. (2016). Women's views on postpartum testing for type 2 diabetes after gestational diabetes: Six month follow-up to the DIAMIND randomised controlled trial. Primary care diabetes, 10(2), 91-102.

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