Implementation determinants of risk-stratified gestational diabetes mellitus screening in community-based women’s peer groups in rural western Kenya

Abstract

Background: Gestational Diabetes Mellitus (GDM) contributes to maternal and neonatal complications and is a growing concern in Kenya. The 2-hour oral glucose tolerance test (OGTT) is recommended to diagnose GDM between 24 and 28 weeks of pregnancy, but uptake remains low in settings experiencing financial and structural barriers to health care access. The Stratification Risk of Diabetes in Early pregnancy (STRiDE) tool is a risk-prediction model designed to identify women at elevated risk for GDM. The STRiDE-GDM screening approach integrates this tool within community-based peer groups to guide targeted, risk-stratified GDM screening and referrals to local health care facilities. However, little is known about implementation of STRiDE-GDM in Kenya. This study explored determinants (facilitators and barriers) of STRiDE-GDM implementation among pregnant and postpartum women in western Kenya. Methods: Community Health Promoters (CHPs) recruited 18 women from Chamas, a community-based women’s peer group program to complete in-depth interviews exploring beliefs, perceptions, and experiences related to the STRiDE-GDM screening approach. Transcribed audio-recordings were translated from Swahili to English. We conducted thematic analysis using a hybrid inductive-deductive coding approach to identify and explore facilitators and barriers to STRiDE-GDM implementation. The resulting themes were then systematically mapped to the Theoretical Domains Framework (TDF) domains. Results: Participants had a mean age of 26.6 years (SD=7.2); 39% were pregnant, with most experiencing their first pregnancy and one-half were enrolled in the national health insurance. Key implementation determinants were mapped to relevant domains within the TDF. Facilitators to engage in the STRiDE-GDM screening included motivations to maintain maternal health in order to fulfill caregiving responsibilities, perceived benefits of early GDM diagnosis, support from Chamas peer groups and guidance from trusted CHPs. Barriers included limited awareness about GDM screening, transportation and cost constraints, competing household responsibilities, stigma, disclosure concerns within the Chamas peer groups, limited spousal support, and fear of adverse outcomes. Conclusion: Findings highlight that individual, social and structural factors influence engagement in STRiDE- GDM screening. Community-based peer groups, such as Chamas emerged as an ideal setting to support screening. Addressing modifiable barriers including low GDM screening awareness, transportation, cost, and scheduling constraints prior to implementation may improve feasibility and uptake