TABLE 2.

HCP-Identified Patient Barriers to Diabetes Care and Self-Management During Pregnancy

Theme	Subtheme	Exemplary Quotation
Environment	Inflexible work schedule	“People who work and their work schedule doesn’t coincide with when they need to eat and check their sugars and take insulin, [or] care for other children and family members, which can make it hard for them to take care of their diabetes. Definitely things like not sleeping, eating, [or] working on a specific schedule.”
	Transportation challenges	“Like getting here and getting to the appointment and parking . . . is what they’re like focused on, and they get here, and I respect that.”
	Lack of childcare	“I also would just say trying to identify with the patient what their barriers are to getting here, whether it be child care or transportation or just their own, you know, personal belief in that, ‘Well, it’s okay if I don’t come for that week.’”
	Difficulty of lifestyle changes	“When I was doing counseling for prenatal patients, their diet changes were so hard for them. I’ve done fewer nutritional assessments here, but I feel like behavior or change around diet is such a big one.”
	Unavailability of nutritious food	“We had a patient come this week . . . she just looked off. I made a comment, saying, ‘Oh, you don’t look right, what’s wrong?’ And she said that she felt very dizzy. So [a nurse] asked her, ‘When was the last time you ate or drank something?’ And she said, ‘Yesterday.’ And this was afternoon clinic, too, and so right there, I said, ‘Are you having a hard time having food in your house?’ She said, ‘Yes.’”
Access	Administrative/insurance challenges	“We do have a few moms we see [who] are lower income with gestational diabetes, type 1, type 2, and the moms who have the challenge they might have insurance, but it doesn’t cover their urine dipstick or it doesn’t cover . . . their meds. So, it’s a bit of a challenge for the providers. It’s kind of like trial and error.”
	Poor prescription and supply access	“They don’t have enough glucose test strips, and there’s no way for them to actually test their glucose three, four times a day because they have to stretch out the small supply that they have.”
Institutional	Overburdened clinic	“. . . It’s hard for me in that limited time slot to brainstorm with them ways that they can incorporate taking care of themselves in the greater matrix of everything that’s going on.”
	Prioritization/multiple comorbidities	“When they come in with multiple comorbidities or other complications in pregnancy [such as] fetal anomalies or what have you, . . . there’s a hierarchical need, and at some points, especially if the fetal side of things is complicated or if there are other comorbid medical conditions [that] are so severe . . . it sort of overshadows the diabetic side of things.”
	Lack of continuity with patient	“They usually show up for their first visit, and then . . . sometimes it can be spotty. They want to come for their 20-week ultrasound, so they’ll show up for that visit.”
	Lack of culturally appropriate materials	“I think it’s resources that are geared toward this population, like how do you meet these goals given your circumstances and also [be] culturally sensitive and [have] culturally sensitive materials? What are the actual food items that make sense that . . . they’re actually [going to] eat?—not [that] you’ve given them a list of foods that are not typical of [their] diet.”
Interpersonal	“Policing” patients	“You come in with this empty report card. I don’t even have to say anything. I just walk in the room, and I just put it down, and automatically patients will say something or try to explain it. You know, it makes me feel like the police. . . . like the assumption [is] that around our management of this disease, we expect you to be this disciplined person in an environment and in a world that is inherently undisciplined. How do you begin to do that? And I think it’s really hard because it breaks apart that alliance, and it breaks apart the ability to adequately come up with a game plan . . . . I think sometimes it’s hard to communicate to patients without feeling like you’re receiving all of your power as a physician, or you are becoming strictly paternalistic in overriding what they want to do.”
	Patient lack of disclosure	“I feel like people are sheepish. ‘Oh, I have to tell my doctor that I walked three times this week, so I should probably go out and walk,’ or people will just lie if it really makes them feel bad. . . . You don’t want people to feel bad about not accomplishing their goal.”
Knowledge	Incorrect information	“One of the biggest barriers that I notice with my patients in terms of their diet and managing diabetes in pregnancy also relates to cultural barriers, and that’s [that] they get different information from their clinicians and their providers and different information from their family members, who might tell them to eat for two or, ‘You should eat more,’ or ‘Why aren’t you eating? You need to eat more to have a healthy baby’ as opposed to the clinicians, who might be prescribing [a] more restricted diet, and they’re not sure who to believe or who to follow. . . . And then, I also think that it’s just difficult in general to follow a specific diet when it comes to managing diabetes in pregnancy, especially due to food security issues.”
	Complexity of diabetes	“You have to remember a lot for diabetes. . . . Like, first of all, it’s confusing. I find it confusing, and I’m extremely health literate compared to someone who didn’t go through all this training, and it’s hard. . . . It’s just overwhelming for people.”
	Low health literacy	“A lot of the times, our gestational diabetes patients have a hard time or just their health literacy of gestational diabetes tends to be very low, and they need a lot of education.”

Individual characteristics presented in Table 4.