Gestational diabetes in Uganda and India: Design and Evaluation of Educational Films for improving Screening and Self-management (GUIDES)

Gestational diabetes mellitus (GDM) is a condition in which the body of pregnant women cannot control the levels of blood sugar. This can result in a number of short- and long-term health problems for both the mother and her child. This condition is now becoming much more common in developing countries, yet most women are not diagnosed on time, and those who are diagnosed do not usually receive appropriate care. This is because the doctors and pregnant women in these countries don't know enough about this condition, as it is a relatively new experience for these societies.

The aim of our research is to assess whether an educational and behavioural intervention, delivered primarily through film, can improve the care of women with GDM. Films are a simple and low-cost way of delivering health interventions, and they are particularly suitable for people who are not very literate. So far, films have been shown to be useful in imparting health education and changing health-related behaviours in developed countries, but not in developing countries, which is a primary motivation for our research.

We will develop and evaluate an intervention with three different components. The first will be a training programme for doctors and nurses. Films will cover how to identify and treat GDM, and how to support women to make changes to their lifestyle (healthy eating, more physical activity). Secondly, a short film for pregnant women and their families, designed to raise awareness of GDM, will be shown in the waiting areas where women receive antenatal care (routine health care in pregnancy). Thirdly, a programme for women diagnosed with GDM to help them manage their condition. These films will educate them about treatment, and will support them to make changes for a healthier lifestyle. Films will be supplemented by Q&A sessions run by a trained nurse.

We will carry out our research in Uganda (Entebbe) and India (Bengaluru) because they are at different stage of economic development. First, we will carry out research to understand people's daily lives in these countries to develop an intervention that is suitable for their culture. Then we will test and refine it further until it is fit-for-purpose. We will then assess whether the intervention improves care for women with GDM in independent studies in both sites. In each site, thirty maternity units will be selected, from which half will be randomly chosen to receive the new intervention. Women visiting the participating clinics during pregnancy will be invited to join the study. To evaluate whether the interventions are successful, we will measure three things. Firstly, whether women have been screened for and/or diagnosed with GDM. Secondly, we will invite women who tell us that have been diagnosed with GDM to visit clinics so we can take a blood sample. We will test this blood to see how well their blood sugar is being controlled. Thirdly, we will calculate how many women have experienced a negative birth outcome which could be because of GDM (for example, having a baby who is larger than average, or giving birth by caesarean section). We will also conduct interviews with women and health providers to help us understand how and why the intervention may be (or may not be) successful.

If the intervention is successful in improving the detection and management of GDM, we expect there to be financial savings from a reduction in maternal and infant complications associated with GDM. We also think that the intervention may reduce the number of women who are diagnosed with type 2 diabetes later in life. In the longer term, it is hoped that the intervention will encourage the provision and quality of GDM screening and care across all LMICs.

The prevalence of gestational diabetes mellitus (GDM) is rising rapidly in many low-middle income countries (LMICs). It is associated with adverse short-term and longer-term consequences for the mother and child. Most women with GDM in LMICs are undiagnosed and/or inadequately managed due to a lack of knowledge and skills about GDM on the part of both providers and patients. Therefore, we propose to develop and evaluate a package of three interconnected educational/behavioural interventions aimed at: a) improving knowledge and skills of GDM guidelines and skills of health providers; b) raising awareness of importance of GDM screening among pregnant women and their families; and c) improving confidence and skills in self-management among those diagnosed with GDM. We plan to deliver the intervention through the medium of film as they are low-cost and scalable, and can transcend barriers of literacy, making them ideal for LMICs. Evidence on effectiveness of films in changing behaviours is currently limited to high-income countries.

The research will be carried out in Uganda (Entebbe) and India (Bengaluru). A careful contextual analysis will precede the development of a culturally-tailored film-based intervention for each setting, which will be iteratively refined using qualitative research methods till it is fit for purpose. Then the effectiveness of the intervention will be evaluated in independent cluster randomised trials, involving ~10,000 pregnant women across 30 maternity units at each site. Our principal research question is whether a low-cost educational/behavioural intervention delivered through a package of culturally-tailored films can provide scalable improvements in timely detection and management of GDM. The ultimate aim of the project is to contribute to scientific evidence underpinning the use of films in cost-effectively scaling up behavioural interventions in low-literacy settings.

The scientific outputs of this research are to a) contribute robust evidence regarding the use of film in health interventions in low- and middle-income country (LMIC) settings, and b) to evaluate whether an educational/behavioural film-based intervention can improve the care of women with gestational diabetes mellitus (GDM). The proposed research has the potential to realise a number of impacts:

- We expect an impact on economic productivity in Uganda and India. GDM is a risk factor for type 2 diabetes mellitus (T2DM), and encouraging healthy lifestyles in pregnant women will help to prevent progression to T2DM. In India there are 60 million people with diabetes. Sub-Saharan Africa is witnessing an 'epidemic' of T2DM, with 6% of total mortality attributable to diabetes. In LMICs, diabetes-associated morbidity and mortality is highest in the most economically active age groups. A reduction in prevalence will improve economic productivity through increased contribution to the labour force. Women tend to be gatekeepers to health services for the whole family. Improving their relationship with health providers will impact on the health of other family members, including the future labour force (children).

- Another impact of the study will be changes in healthcare and related industries. Many of the benefits of staff training provided through the intervention will not be restricted to GDM care (e.g. improved communication skills). Although our study does not provide financial support for GDM screening, we anticipate that increasing awareness and demand for screening will have an indirect impact on stimulating and strengthening screening capacity in both the public and private health sector. The intervention may also stimulate the growth of other wellness and counselling industries, for example by increasing demand for fitness centres and gyms.

- The proposed intervention has the potential to reduce gender inequality. The International Diabetes Federation describes GDM as "a severe and neglected threat to maternal and child health". One key component of our planned intervention is improving women's self-efficacy and their confidence in managing their own health. This - in conjunction with training in communication skills for health providers - should result in improved patient-provider relationships and more timely care-seeking. There will be additional benefits for peer supporters, as this role may act as a springboard to other training and employment opportunities, improving the material circumstances of women.

- Our study will strengthen the role of film in public health, and therefore expand the growth of the film industries in the two countries. In the short-term, there will be opportunities for local film professionals to be involved in the production of intervention films. In the longer-term, this will contribute to a new stream of income for film industries. India has a highly developed film industry and the largest film market in the world. There is great potential for knowledge and skills exchanges between the two countries; we anticipate a particular benefit for Uganda, which has a small but growing film industry.

- A reduction in diabetes-associated complications may also result in benefits to other aspects of society. Public expenditure savings from treating and managing health complications could be diverted to other areas of need, for example, education. Better health will improve quality of life, and will lead to an increase in other activities (e.g. sport). Benefits to families and households will include freeing up of income, as many healthcare costs are borne by individuals and their families, with this burden disproportionately felt by the most disadvantaged.

Although the immediate impact of this research will be most obvious in India and Uganda, our choice of two country settings at different stages of the economic transition will mean that impacts should be generalisable to all LMICs.