TABLE 1.

Key Themes of Domains and Participants’ Responses

Themes	Participant Responses
Domain 1. Gap between engagement and perception of future type 2 diabetes risk
Difficult to reduce type 2 diabetes risk with poor patient compliance	“I guess it is more difficult to assess their compliance postpartum. A lot of the focus is on them when they are pregnant until the point of delivery. And after they have delivered, the stress and pressure have gone down quite a lot. It is not that we demand a lot from them after they deliver as well . . . . If they are less diligent with their monitoring, we don’t want [to] chase after them.” (Endocrinologist)
Shared responsibility	“I think I have a responsibility, but mainly on an educational aspect. I think it is very important. But, I don’t have the resources to enforce and to check up on their lifestyle. I would—of course, if they are obese or get any other underlying IGT [impaired glucose tolerance test]—then I definitely will refer them to an endocrinologist or a primary care physician to follow-up with them. Because they are better able to keep track of them.” (OB/GYN)
Message framing	“During the pregnancy when they are having GDM, because it is going to be a big thing, and it will hit them. It is a life-changing event. I do think that it is the real starting point, where you can do the most changes . . . convince the patient the most.” (OB/GYN)
	“. . . if they are anxious like Singaporeans and [who] have ‘kiasu’ [afraid to lose out] kind of personalities . . . . Some of them [are] like ‘oh’ and [are] motivated to push then: ‘Oh, my gosh, I need to do something about it.’ But, they actually get frightened—so frightened that they will go into a denial phase. So that is also difficult.” (Endocrinologist)
	“Because I guess the doctors always have a greater authority than us in terms of asking them, you know, ‘You need to lose some weight,’ for example.” (Dietitian)
Competing priorities	“I think in family practice, family medicine, preventive care is our goal. It is not just treatment of the disease.” (PCP)
	“One [highest level] will be most important. I think one. It is most important to prevent diabetes, post-delivery.” (Dietitian)
	“Maybe seven [lower level]. I mean for O and G [obstetrics and gynecology] being a very sub-specialized specialty, unfortunately, [it is] not very highly screened for type 2 diabetes in our practice.” (OB/GYN)
Domain 2. Immediate postnatal period: responsibilities for postpartum OGTT ordering and follow-up
Responsibility for postpartum OGTTs	“I think so. Because, those who are still positive [with positive OGTT results] we will normally channel them to an endocrinologist . . . sort of like we close the loop . . . . Otherwise, they are still positive [have not resolved GDM after their delivery], and if they don’t do the test, they would not know.”(Nurse)
Inconsistent processes for follow-up	“. . . what we are doing now is [postpartum OGTT] is just a one-off thing. So, the monitoring, the screening, the annual screening, that is also still important. But, I don’t think that is being routinely done.” (Dietitian)
Patient barriers	“I guess that I am not sure. Maybe more of the patients are forgetting over time that they had this problem [GDM] before because there are other things in [their] life to worry over. And if it is a once a year thing [annual screening for type 2 diabetes], then [it’s] very easy to forget.” (Endocrinologist)
Domain 3. Follow-up care after postpartum period: roles for proactive care management to prevent type 2 diabetes
Handing over care to PCPs	“At least in primary care, they will have the same doctor [who] always sees the patient, knows everything about the patient. So that is some sort of ownership.” (Endocrinologist) “We usually do an OGTT and subsequently, we might do another OGTT or venous fasting depending on the patient’s preference. Again, there is no real guideline on whether we should do it subsequently.” (PCP)
Health care system readiness	“Because, the involvement of primary care, which is the polyclinics . . . that is much poorer here [Singapore] compared to everywhere else. I mean, the only example I know is the U.K., because we always learn their guidelines . . . . yearly follow-up with their [U.K.] primary care. . . . So, I guess that is something that we could work in partnership with the primary care [general practitioners], as well [as] the polyclinics, who have regular follow-up with these women. Because we already know that they are at risk.” (OB/GYN)
	“It is untagged. Everybody is floating around freely. Once they have their 6 weeks [OGTT] they are let loose. So, we have no chance to get them back. So, if there is a tagging system in the hospital, because that is where they get diagnosed with GDM in the first place . . . ” (PCP)
Community influences	“The Diabetes Prevention Program in the U.S. . . . . They started as a study, [and] they have managed to implement it [in] real life, and it is run as a community partnership, such as [with] the YMCA [Young Men’s Christian Association]. That is particularly effective because they utilize peer support . . . . There is a link to primary care, but, the program doesn’t rest completely on the physician to deliver everything.” (Endocrinologist)
Stakeholders in proactive care	“If we want to reduce all these various public health problems, you have to hit the root of the matter, isn’t it? When it comes to healthy eating and healthy lifestyle, who else is better than the government and the community?” (Nurse)