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Development and Testing of Mobile Health Application for Management of Gestational Diabetes – (mHealth for GDM)

GDM project is an ambitious health project started in December 2019 in Dhulikhel Hospital, Nepal with an aim of developing and testing a new mobile app that supports self-management and treatment for Nepalese women with gestational diabetes. It’s collaborating partner is Rutgers, the State University of New Jersey, USA.

Gestational Diabetes Mellitus (GDM) is a condition characterized by an elevated level of glucose in the blood during pregnancy. The prevalence of GDM is rapidly increasing worldwide, overwhelming health systems and resources particularly in low- and middle-income countries (LMICs). Nepal has reported an alarming GDM prevalence ranging from 6.6% to 28%. 

Timely and proper management of GDM is critical to prevent adverse maternal and fetal outcomes such as preeclampsia, birth injuries and labor complications. Although GDM usually resolves after delivery, women with GDM and their children are at an increased risk to develop type 2 diabetes and obesity in later life. Thus, constituting a significant burden on both patients and the healthcare system.

Although Mobile health (mHealth) technology has been widely applied and proven efficacious for self-management of diabetes outside of pregnancy, mobile-based lifestyle interventions for GDM are just emerging. Only a few smartphone apps for GDM have been developed and evaluated in high-income countries, and while the results are promising, more studies are needed.

GDM project is the first of its kind in LMICs and may provide hard evidence that mHealth may be a viable tool to augment care and support self-management of GDM among women. The use of mHealth to improve health behaviors and antenatal care holds particular significance in Nepal, where mobile service penetration exceeds 100 percent but resources in healthcare are limited.

Participants for this study are Nepalese pregnant women with gestational diabetes (GDM) diagnosis, and they are recruited from the Obstetric Outpatient Department (OPD) at Dhulikhel Hospital, Nepal. 

The study design is qualitative for the first phase (app development phase) involving focus groups with GDM patients and key informational interviews with clinicians and family members to inform the design and features of the mobile app.

The app development phase is followed by a pilot randomized control trial in which 60 women who are newly diagnosed with GDM are randomly assigned to one of two treatment conditions: either (A) mGDM app + standard care +Telemonitoring, or (B) standard care + Telemonitoring, from 28 weeks of gestation to 6 weeks postpartum. We provide a glucometer machine and a blood pressure machine to both control and intervention group of women diagnosed with GDM to monitor their glucose and blood pressure at home. And,100 women with high GCT only but not diagnosed with GDM are randomly assigned to one of two treatment conditions: either (A) mGDM app + standard care, or (B) standard care alone.

Objective

The main objective of the project is to develop and test a new mHealth app that supports self-management and treatment for GDM patients. 

The app development phase has the objective to develop a mobile health app for GDM. The intervention phase has the objective to assess the usability, acceptability and preliminary efficacy of the app. 

Additionally, this project pilots the first telemedicine program in Dhulikhel Hospital and test its implementation, feasibility and acceptability among patient and healthcare providers.

Outcome

The tiring efforts of project team members consisting of doctors, dieticians, physiotherapists, computer engineers and researchers resulted in a new user-centered app called GDM-DH. The app has various features that aids on a critical part of GDM management such as glucose monitoring, blood pressure monitoring, dietary and physical activity recommendations, appointments for doctors, and educational videos about gestational diabetes.

The app aims to assist in the self-management of GDM by increasing the patient’s knowledge and self-efficacy to adhere to the recommended diet and physical activity regimens. The app also helps clinicians by generating easily digestible visual displays of patient data and behaviors, which can aid in their clinical decision-making and counseling. 

Currently, the project is in its trial phase and its results are awaited to be disseminated by December 2022. The ongoing feedback from the app users- women with gestational diabetes- reveals that the app is easy to use, reliable and helpful for managing their blood glucose level. The project team have high hopes for its successful outcomes.

Exploratory treatment outcomes will be: glycemic control measures at 6 weeks postpartum, neonatal birthweight, neonatal glucose levels, neonatal APGAR score, NICU admittance, insulin prescription in pregnancy, a hypertensive disorder in pregnancy, and gestational weight gain and rates of labor induction and cesarean delivery. 

Findings from this pilot project will empirically inform a future randomized control trial that will be fully powered to test the efficacy and cost-effectiveness of the mGDM app in improving treatment outcomes, using an R01 mechanism.

We expect that the research activities and capacity-building initiatives in this project will build the institutional skills and create the organizational structure needed to enable future mHealth research initiatives at Kathmandu University, even beyond the scope of this pilot project.

Team Members

Principal Investigators: Shristi Rawal, Archana Shrestha

Co-investigators: Abha Shrestha, Meghnath Dhimal, Prabin Raj Shakya, Shrinkhala Shrestha, Abha Shrestha

Project Coordinator: Jyoti Nepal

Research Assistants: Smriti Shrestha, Sneha Maskey, Sangam Banjara, 

Supported by: National Institute of Health (NIH), U.S.A.