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Perceptions of Key Informant Health Professionals before implementing tighter glycaemic targets for women with gestational diabetes mellitus in New Zealand

Background Tighter glycaemic targets may be of benefit for women with GDM and their infants. Barrier and enabler identification prior to implementation of tighter glycaemic targets for women with GDM may support a successful transition. Methods A cross-sectional questionnaire survey was conducted among Key Informant Health Professionals in ten hospitals in New Zealand. The survey assessed what was currently working using less tight glycaemic targets; what barriers and enablers were considered likely when introducing tighter glycaemic targets and whether these perceptions differed by health professional groups. Results Sixty Key Health Informant Health Professionals completed the survey. When using the lower glycaemic targets, participants considered that women with GDM found the targets easy to use and that collaborative collegial support was effective. No significant barriers were identified. Perceived enablers identified prior to implementation of tighter targets included receiving collegial support (40, 67%), attending education sessions (38, 63%), use of pocket prompt cards (31, 52%), availability of wall charts (25, 42%) and glycaemic target reminder stickers (24, 40%). For health professionals referring into the Diabetes in Pregnancy Service effective communication (50, 83%) was considered important. Perceived barriers were confusion over glycaemic targets use (27 (45%), not being informed of the glycaemic target change (31, 52%), non-involvement with multidisciplinary decisions (29, 48%) and increased difficulty of blood glucose control for women (48, 80%). Overall, barriers and enablers between Health Professional groups did not differ. Discussion Key Informant Health Professionals reported effective communication as a key perceived enabler and that woman would find it more difficult to control their blood glucose concentrations. Education sessions, multidisciplinary engagement, wall charts and stickers were considered effective to overcome the perceived barriers. Further research is needed to assess if the barriers perceived were realised and if the perceived enablers supported the implementation of the tighter glycaemic targets effectively.


Introduction
Gestational diabetes mellitus (GDM) is increasing globally [1]. GDM significantly increases the risk of maternal and infant complications short and long term [2,3]. Currently in New Zealand 6.2% of pregnant women develop GDM during their pregnancy [4,5]. Treatments, guided by glycaemic treatment target recommendations, include lifestyle changes and/or medication that aim to reduce or prevent adverse health outcomes associated with GDM [6,7]. Research has mainly focussed on diagnostic criteria, management of GDM and treatments [8][9][10]. Recommendations on glycaemic treatment targets vary internationally and are based on consensus due to a lack of high-quality evidence [10][11][12] with some research recommending tighter glycaemic targets may be of benefit for women with GDM and their infants [13,14].
There has been a growing interest in the literature of identification of perceived barriers and enablers that are key to guide effective implementation of practice and behaviour change [15,16]. Translating knowledge into practice needs to be tailored to specific barriers and enablers for clinical practice to change [17,18]. Only "14% of significant research findings and discoveries ever enter the real-word context" (p. 178) and this is believed to be due to a lack of clear understanding of how to implement the research results without local barrier and enabler identification [19]. The National Institute of Clinical Studies [20] report stated 'Identifying barriers to evidence uptake' highlights that there is a lack of information relating to health professionals' attitudes, beliefs, perceptions and practices. The NICS report recommended that findings from Key Informant Health Professional questionnaire surveys may be one way of informing effective practice change [20]. A Key Informant has been identified as a person who is knowledgeable and experienced about a certain issue or problem, someone who can 'unlock' key information [21,22]. Published studies comparing perceptions of implementation of tighter glycaemic treatment targets for women with GDM between different groups of health care professionals are limited [13,23].
In 2014 the New Zealand Ministry of Health published clinical practice guideline recommendations for health professionals on the screening, diagnosis and treatment of gestational diabetes in New Zealand [24]. The guideline was developed as there was variation throughout New Zealand in the care provided to women for diagnosis and treatment of GDM. During development of the guideline, diagnosis, glycaemic treatment targets and treatment recommendations were often agreed by the guideline panel by reaching consensus rather than being able to base recommendations on high-quality research evidence. One of the research recommendations made by the guideline panel identified that a further randomised trial was needed to establish optimal glycaemic treatment targets for women diagnosed with GDM [24]. In response to this the TARGET (Optimising Glycaemic Targets for Gestational Diabetes) Trial comparing use of tight to less tight treatment targets was undertaken (Australian New Zealand Trial Registry: ACTRN12615000282583), [25]. This present study, nested within the TARGET Trial, sought the perception of Key Informant Health Professionals at the participating hospitals on barriers and enablers prior to the introduction of tighter glycaemic treatment targets for women with GDM (fasting plasma glucose �5.0mmol/L; 1 hour postprandial �7.4mmol/L; 2 hours postprandial �6.7mmol/L) ). The less tight glycaemic treatment targets recommended for women with GDM used by most participating hospitals were fasting plasma glucose �5.5mmol/L; 1 hour postprandial �8.0mmol/L; 2 hours postprandial �7.0mmol/L. The researchers wanted to specifically assess the perception of Key Informant Health Professionals who may suggest effective ways to optimise the implementation of the tighter glycaemic treatment targets recommended in the clinical guideline [24] and used in the TARGET trial. This would provide insight into the perceptions of all health disciplines involved who need to support the implementation of tighter glycaemic targets and enable identified barriers and enablers to be addressed before and during the implementation of tighter glycaemic targets. The specific research questions of this study were: 1. What has worked well and not so well using less tight glycaemic treatment targets amongst Key Informant Health Professionals caring for women with GDM?
2. What are Key Informant Health Professionals' perception for barriers and enablers prior to the implementation of tighter glycaemic targets?
3. Are there differences of enabler and barrier perception prior to implementing tighter glycaemic targets between Key Informant Health Professionals' groups?

Study design and setting
A cross-sectional questionnaire survey was conducted among Key Informant Health Professionals recruited from the ten hospitals collaborating in the Target

Study participants
At each of the 10 hospitals one Key Informant from six health professional groups providing care for women with GDM were identified by the Target Trial site investigator. The six health professional groups included: endocrinologist or diabetes physician, obstetrician, clinical nurse specialist: diabetes or diabetes midwife, diabetes dietitian, hospital midwife and community midwife (lead maternity carer (LMC) midwife). The Key Informant Health Professional had to have been associated with the provision of care for women with GDM for at least four months. The identified Key Informants were contacted by the researcher (RM) and informed about the study and their consent sought for participation.

Study processes
Participants completed a questionnaire survey, designed for this study, before the implementation of tighter glycaemic treatment targets for women with GDM at their hospital. The questionnaire survey comprised 16 questions and included demographic characteristics of the Key Informant Health Professionals, their thoughts relating to what worked well and what was challenging using the less tight glycaemic treatment targets for women with GDM at their hospital. The questionnaire survey asked the participant's perception of how the implementation to tighter glycaemic treatment targets may work well or be challenging. The tighter glycaemic targets were fasting plasma glucose �5.0mmol/L; 1 hour postprandial �7.4mmol/L; 2 hours postprandial �6.7mmol/L) [25]. After face validity (Health professionals with expert knowledge read through the questions) was applied to the developed survey questionnaire, an assessment followed of the question constructions (are they confusing, double-barrel or leading questions). The questionnaire survey was then piloted with one obstetrician and one diabetes midwife following which a 'don't know' box was added to one question. Questionnaire surveys were conducted face to face. All participants answered all questions.
The administration of the questionnaire survey was linked to the timing of the stepped wedge randomised trial design of the TARGET Trial [25]. Site visits were conducted prior to commencement of the trial when less tight targets were used and prior to changing over to the tighter glycaemic targets.

Data analysis
The data were entered into an Excel spreadsheet and analysed using Pivot Tables in Microsoft Office Excel 2016. Descriptive statistics and frequencies were used to analyse the Key Informant Health Professionals' demographics and questionnaire survey responses.

Results
All 60 Key Health Informant Health Professionals approached gave consent to participate in this questionnaire survey. All participants answered all the questions. Demographic characteristics of the participants showed that the majority were female (83%), the mean time of the Key Informant Health Professionals practising in their profession was 20.4 years (SD 10.2) and the mean years providing care for women with GDM was 13.2 (SD 7.8) (Table 1). While all Key Informant Health Professionals provided care for women with GDM, 46 (76%) indicated that they directly advised or treated women with GDM. Awareness of the less tight glycaemic treatment targets in use was indicated by 54 (90%) Key Informant Health Professionals, with one obstetrician and five community midwives (LMC) indicating no awareness of these (Table 1).

Enablers with use of less tight glycaemic treatment targets
Over half of the Key Informant Health Professionals identified that women with GDM in their care found the lower glycaemic targets easy to adhere to (36, 60%), successfully controlled the woman's capillary blood glucose (CBG) concentration (36, 60%), and there was collaborative collegial support in using the same glycaemic treatment targets (32, 53%). Study folders and education materials that were available to support and guide the use of the less tight glycaemic treatment targets were considered to be working well by 16 (27%) Key Informant Health Professionals ( Table 2).
The questionnaire survey invited participants to add other comments in free text boxes and 11 (18%) opted to do so ( Table 2). A range of comments were presented, occurring only one time each in the responses and ranged from groups sessions working well to drop-in clinics, having church-based diet talks and a consistent approach among staff ( Table 2). Three (5%) Key Informant Health Professionals commented that glycaemic target reminder stickers and wall charts were helpful reminders for recommending the current less tight glycaemic treatment targets for women with GDM ( Table 2).

Perceived enablers to implementation of tighter glycaemic treatment targets
The Key Informant Health Professionals reported perceived enablers for staff to implement use of tighter glycaemic treatment targets as attending education sessions for staff (38, 63%), use of small pocket prompt cards (31, 52%), receiving collegial support (40, 67%), regular reminders of the targets in use (26, 43%) and wall posters detailing the targets in use (25, 42%) ( Table 3).
For women with GDM who would be using tighter glycaemic targets, Key Informant Health Professionals perceived those women would be more likely to adhere to the tighter treatment glycaemic targets because they would believe that this was better for their baby (48, 80%) and that they would have a better birth outcome (39, 65%) ( Table 3). No increase in morbidity was expected by 20 (33%) Key Informant Health Professionals (Table 3).
Hospital services might possibly be impacted by implementing tighter glycaemic treatment targets. Key Informant Health Professionals saw enabling the implementation through effective communication (41, 68%), an increase in multidisciplinary engagement (38, 63%) and through effective information dissemination (27, 45%) ( Table 3).
In New Zealand, community midwives, also known as Lead Maternity care (LMC) providers, provide autonomous care for pregnant women in their care, unless a referral or hand-over to specialists' care is required. Community midwives often continue the care for women with GDM in a shared care arranged with their diabetes and obstetrician colleagues. A change of glycaemic treatment targets may have an impact on community midwives' provision of care. The two main perceived enablers by Key Informant Health Professionals were effective communication (50, 83%) and involvement with multidisciplinary decisions (29, 48%) ( Table 3).
Further enablers were listed by 41 (68%) participants in the free text box who perceived clinic room wall charts (25) and stickers (24) that detailed the treatment targets in use to be the most effective means for successful implementation of tighter glycaemic targets (Table 3) by the staff involved. Stickers would be used for women's blood glucose recording booklets and for patient notes if documentation was in hard copy form.
For the women, other perceived enablers centred around information to be provided in their own language (4) or visual (3) to enhance the women's understanding of their glycaemic targets and GDM in general. Having a free pick-up service for clinic appointments was perceived as enabling successful use of tighter glycaemic targets for women with GDM (3).
Most participants perceived no other enablers were needed for the wider hospital services, with 'business as usual', as changing to tighter glycaemic treatment targets would not impact on hospital resources (Table 3).  (17) Overall health cost reduction 17 (28) Overall health cost increases 10 (17) (Continued ) Effective communication, perceived as enablers for community midwives, was further supported with additional comments in the free text box by Key Informant Health Professionals, that included evidenced based information sharing (9), electronic communication (2) and multidisciplinary study days (5) ( Table 3). Three participants identified perceived enablers as providing financial support for community midwives to attend specialist's clinic appointments with the woman (3) ( Table 3), to enable effective communication, and everyone being on 'the same page'.

Perceived barriers to implementation of tighter glycaemic treatment targets
Participants reported perceived barriers for the implementation of tighter glycaemic targets for staff, women, wider hospital and community midwives ( Table 3).
The top two perceived barriers for staff were identified as confusion over which glycaemic targets to use (27, 45%) and different treatment thresholds being used by different health professionals (20, 33%). For the women with GDM, perceived barriers reported were difficulty to control capillary blood glucose (CBG) concentration (48, 80%) and inability to attend more frequent clinic appointments (17, 28%), which would be necessary if the perception of increased difficulty of blood glucose control was realised. Ineffective communication was perceived as a barrier for other hospital services (21, 35%) and community midwives (31, 52%). Lack of resources for the hospital (20, 33%) and non-involvement with multidisciplinary decisions for community midwives (29, 48%) ( Table 3) were reported. Conversely these were reflected as perceived enablers by the Key Informant Health Professionals (Table 3).
Other perceived barriers identified was the belief that the information on change to use of tighter glycaemic targets may not be disseminated to all relevant staff (5) ( Table 3). For the wider hospital services, the two main perceived barriers were facility provisions, such as a perceived increase in clinic appointments requiring more rooms being available (3) and the perceived increase in re-admissions and induction of labour (3) requiring more beds to be available ( Table 3).
The biggest perceived barrier for LMC community midwives centred around not being informed of the treatment target change (7) by the health professionals providing the diabetes care for the pregnant women and the inability to attend specialists' appointments with the women (4) ( Table 3).

Differences in perceived enablers between Health Professionals prior to implementation of tighter glycaemic targets
Endocrinologists (6, 60%), obstetricians (7 (70%), hospital midwives (7, 70%) and community midwives (10, 100%), most frequently perceived education sessions and collegial support would enable staff to accept, support and implement tighter glycaemic targets (Table 4). While diabetes dietitians and clinical nurse specialist, and diabetes midwives indicated collegial support as well (7, 70%), only 4 (40%) perceived education sessions as enabling effective implementation. There were a range of 'other' free text enablers identified (Table 4). All Key Informant Health Professionals, except the community midwives, reported in the free text section, as the most frequent perceived enablers the provision of clinical wall charts and stickers detailing the tighter glycaemic targets (Table 4).
All the endocrinologists (10, 100%) perceived women would respond well to use of tighter glycaemic targets, as women would believe that it will be better for their infants, and similarly perceived by 80% (8) of clinical diabetes nurse specialist or diabetes midwives, hospital midwives and diabetes dietitians (Table 4). Obstetricians and community midwives (both 7, 70%) had a slightly lesser perception of this enabler (Table 4). If women with GDM identify this enabler as well then providing information about the tighter glycaemic targets could be the central message.
Hospital wide perceived enablers were reported as effective communication and an increase in multidisciplinary engagement by all Key Informant Health Professionals. There was a small variation between Key Informant Health Professionals with 80% (8) obstetricians and clinical diabetes nurse specialist, 70% (7) endocrinologists or diabetes physician, 60% (6) diabetes dietitians, hospital midwives and LMC community midwives supporting these enablers. A health cost reduction was only identified as a substantial enabler by the obstetricians (6, 60%) that may affect the wider hospital services (Table 4). There were no other significant perceived enablers noted between Key Informant Health Professionals (Table 4).
Many pregnant women with GDM in New Zealand are cared for by community midwives, who refer the women once diagnosed with GDM to the Diabetes in Pregnancy Service, usually at the nearest tertiary or secondary hospital. Introducing tighter glycaemic targets and any prescribed treatments need to be communicated to the LMC community midwife, who often provides ongoing pregnancy care. In this context it is seems reasonable that effective   (Table 4). Additionally, obstetricians (6, 60%) and clinical nurse specialists: diabetes or diabetes midwives (8, 80%) perceived that multidisciplinary involvement with decisions were important enablers ( Table 4). All identified perceived enablers supported the coming from the 'same page' approach.

Differences in perceived barriers between by Health Professionals prior to implementation of tighter glycaemic targets
There were considerably fewer perceived barriers identified by all Key Informant Health Professionals compared to enablers. The most important perceived barrier identified for staff was the possible confusion over which glycaemic targets to use, by 60% (6) endocrinologists/diabetes physicians and obstetricians, by 50% (5) community midwives, by 40% (4) clinical nurse specialists: diabetes or diabetes midwives and by 30% (3) both by diabetes dietitian and hospital midwives (Table 5). Additionally, diabetes dietitians and community midwives (both 5, 50%) reported different treatment thresholds used by different health professionals was a perceived barrier (Table 5). For women with GDM, the major perceived barrier by the Key Informant Health Professional was the potential increase in difficulty of controlling their blood glucose concentrations. Ninety percent (9) of the clinical nurse specialists: diabetes or diabetes midwives, the diabetes dietitians and community midwives reported this perceived barrier and 70% (7) each of the endocrinologists/diabetes physicians, obstetricians and hospital midwives Key Informant Health Professionals (Table 5). Only the endocrinologists/diabetes physicians (4, 40%) reported higher insulin usage under 'others' as a perceived barrier (Table 5). Endocrinologists/ diabetes physicians are usually the initiator of insulin treatment when indicated for women with GDM in New Zealand. Further prescriptions are then usually followed up with the     clinical nurse specialists: diabetes or the diabetes midwives, who did not report this as a perceived barrier. Great variations with low percentage results were identified between Key Informant Health Professionals reporting perceived barriers for the wider hospital services (Table 5). Results above 50% (5) include endocrinologists or diabetes physicians who reported perceived barriers for in-effective communication across hospital services and community midwives (5, 50%) perceiving lack of resources (Table 5).
In-effective communication was reported as a perceived barrier not only for hospital services but for community midwives (Table 5). Over half of the obstetricians (8, 80%), endocrinologists or diabetes physicians (5, 50%), diabetes dietitian (5, 50%) and community midwives (5, 50%) reported this barrier perception, closely followed by 40% (4) each of the clinical nurse specialists: diabetes or diabetes midwives and the hospital midwives (Table 5). All Key Informant Health Professionals groups identified non-involvement with multidisciplinary decisions as a perceived barrier to varying degrees. Sixty percent (6) of clinical nurse specialists: diabetes or diabetes midwives and of community midwives and 50% (5) of obstetricians and hospital midwives perceived this as a potential barrier (Table 5). Community midwives were the only Key Informant Health Professionals who reported significantly on other perceived barriers with 50% (5) identifying not being informed of treatment change (Table 5).

Discussion
This study was seeking to answer three research questions by identifying current enablers and barriers and the perception to implementing tighter glycaemic targets for women with GDM from Key Informant Health Professionals involved in care for women diagnosed with GDM.  The results aimed to inform the implementation of tighter glycaemic treatment targets prior to the commencement of the TARGET Trial [25].

What has worked well and not so well using less glycaemic treatment targets amongst Key Informant Health Professionals caring for women with GDM?
When using the lower glycaemic treatment targets participants considered that women with GDM found the targets easy to use and that collaborative collegial support was effective. No significant barriers were identified. In the free text option, stickers and wallcharts were identified as working well. These enablers were identified in multiple areas in the survey and would benefit consideration to use when implementing tighter glycaemic treatment targets for women with GDM.

What are Key Informant Health Professionals' perception for barriers and enablers prior to the implementation of tighter glycaemic targets?
The second research question was analysed in subsections for easier perceived enabler and barrier identification from different GDM care providers and services.
a. For staff involved in using/recommending glycaemic targets Similar to the findings on the use of less tight glycaemic targets, participants identified collegial support as the main perceived enabler, closely followed by education sessions and pocket prompt card for health professionals involved with the care of women with GDM. Additionally, over half of the participants who opted to answer in the free text option section commented that clinic wall charts and stickers detailing the tighter glycaemic targets would be seen as enabling. Nearly half of the participants identified confusion over which glycaemic targets to use as a perceived barrier, with an additional third of participants perceiving that different treatment thresholds would be used by different health professionals. The identified perceived enablers would potentially address these barriers and can be used to guide the implementation of tighter glycaemic treatment targets for women with GDM.
b. For women using the tighter glycaemic targets While the less tight glycaemic targets were identified as working well, it was perceived by most participants that tighter glycaemic targets would be more difficult to achieve for women with GDM. Despite this concern, the majority of Key Informant Health Professionals perceived that the tighter glycaemic targets would be acceptable to women with GDM, as women would believe these targets would be better for the baby and their own health, as well as women would believe that they would have better birth outcomes.
These findings indicate that women with GDM benefit from receiving clear information, but a study to explore women's views on enablers and barriers to tighter glycaemic targets is warranted.
c. For wider hospital services Over two thirds of Key Informant Health Professionals perceived effective communication and increased multidisciplinary engagement would enable the implementation of tighter glycaemic successfully. There was a small perceived concern about needing more clinic rooms if women required more antenatal appointments and more hospital beds for admissions as there may be a higher induction of labour with tighter glycaemic target recommendations. Although 'business as usual' was perceived by nearly half of the participants who opted to enter further perceived enablers in the other free text box, a third of participants perceived an overall health cost reduction, whilst a tenth of participants were concerned about a perceived overall health cost increase. Cost-benefit analysis and resource demand when changing to tighter glycaemic treatment targets may be an area to consider when planning to address potential enablers and barriers.

d. For LMC, community midwives
Effective communication was the most significant perceived enabler for LMC community midwives, followed by involvement with multidisciplinary decisions. This was conversely reflected in the perceived barrier identification by participants for tighter glycaemic targets implementation identified as in-effective communication and noninvolvement with multidisciplinary decisions. Communication and multidisciplinary engagement have been shown to be effective tools for behaviour change and implementation of clinical recommendations and skills [27].

Are there differences of enabler and barrier perception prior to implementing tighter glycaemic targets between Key Informant Health Professionals' groups?
The third research question attempted to elicit if the health professional groups providing care and services for women with GDM identify different significant enablers and barriers as these results may be useful for targeting different professional groups with different implementation strategies for a change over to tighter glycaemic targets for women with GDM.
a. For staff involved using glycaemic targets Different Key Informant Health Professionals groups identified different perceived enablers for staff involved with glycaemic treatment targets. Education sessions were perceived as important enablers to implement tighter glycaemic targets for women with GDM by all community midwives, over half of the hospital midwives, obstetricians and endocrinologists or diabetes physicians. For clinical nurse specialists, diabetes or diabetes midwives and hospital dieticians this was not a significant enabler. Collegial support was identified by all Key Informant Health Professionals as an enabler for the implementation of tighter glycaemic targets, with the highest indicator from diabetes dieticians and clinical nurse specialists: diabetes or diabetes midwives and endocrinologists or diabetic physicians. What collegial support means for each of the health professional groups was not clear and warrants further research. Regular reminders and pocket prompt cards were identified by the majority of the obstetricians and community midwives and by over half of the endocrinologists or diabetic physicians. Except for the community midwives, all other Key Informant Health professionals, commented additionally in the free text section for perceived enablers the provision of clinical wall charts and stickers listing the tighter glycaemic targets. PowerPoint presentations were not seen as enabling by any of the Key Informant Health Professionals. While the barrier identification did not identify any significant areas, half of the endocrinologists, obstetricians and community midwives anticipated confusion amongst health professionals over which glycaemic targets to use. These results indicate the importance of supporting different health professional groups with different resources to enable them to implement the tighter glycaemic treatment targets for women with GDM.
b. For women using the tighter glycaemic targets The majority of Key Informant Health Professionals perceived that woman diagnosed with GDM would not find it easy to accept the tighter glycaemic targets, as it would be more difficult to control capillary blood glucose concentrations. This did not differ significantly across all Key Informant Health Professionals groups. It was perceived that women would manage this challenge, as once women with GDM were provided with in depth information to understand the reason for tighter glycaemic targets, they would believe it was good for their health, better for their infant and that they would have better birth outcomes. While these beliefs were enablers identified highly across all Key Informant Health Professionals, all endocrinologists or diabetes physicians had this perception. Nearly half of the clinical nurse specialist, diabetes or diabetes midwives perceived that tighter glycaemic target would require more frequent clinic visits and perceived this as a barrier, as women with GDM may not be able to attend increased clinic appointments. This was of low concern for all other Key Informant Health Professional groups. Health literacy and access to health services was always a concern and is an area that would need careful attention when implementing tighter glycaemic targets. The survey questionnaire results have contributed to the understanding of barriers and enablers perception by Key Informant Health Professionals providing care for women diagnosed with GDM. The overarching perceived barriers and enablers by participating Key Informant Health Professionals identified the importance of regular and clear communication and multidisciplinary health professional involvement when implementing change to use of tighter glycaemic targets and the perception that women diagnosed with GDM may find it more difficult to control their blood glucose concentrations.
There is currently a lack of international studies and in New Zealand addressing enabler and barrier identification from a Health professional perspective for implementing any glycaemic treatment targets for women with GDM. Previous studies within the diabetes field from Australia and the USA, not specifically in women with GDM, have reported sub-optimal communication and lack of professional relationships between health professionals as barriers to effective implementation when change is required [28,29]. A qualitative study with 18 health care professionals in the Netherlands, who were providing diabetic care, not for women with GDM, explored perception of barriers and enablers for diabetes care [30,31]. Health professionals perceived multidisciplinary collaboration was effective with clear communication. A survey conducted with 10 World Diabetes Foundations who supported GDM projects in low and middle-income countries (LMIC) identified one of the major barriers for effective GDM services as lack of clear communication about standard protocols in particular about referrals and follow-up care [16]. Identifying potential enablers and addressing potential barriers prior to implementing health care changes is supported in the literature as an effective way to achieve enduring change [17,20,32].
Key Informant Health Professionals in this study reported simple, inexpensive enablers that may support the perceived communication concerns and the desired multidisciplinary approach. Education sessions, multidisciplinary engagement, wall charts and glycaemic target reminder stickers were perceived to be effective to overcome the perceived barriers. Further investigation is needed after the implementation of the tighter glycaemic targets to assess if the perceived enablers supported the implementation of tighter glycaemic targets effectively.
No perceived enablers were identified by Key Informant Health Professionals of the identified barrier perception that women diagnosed with GDM will find it more difficult to control their blood glucose concentrations. As this was reported by the majority of participants the question arises if this message is conveyed to women diagnosed with GDM at their first clinic appointment. This could have a potential negative impact on women's attitude towards understanding and accepting their glycaemic targets. Clinician's attitude, beliefs and knowledge about diabetes can influence diabetes management and patient's perception [29]. A recent small mixed method study with women diagnosed with GDM and health professionals providing care for women with GDM in Singapore highlighted the lack of effective communication and access to understandable information or reminders for women with GDM [33]. That study recommended to explore if a GDM-focused smartphone app integrating reminders of glycaemic targets, test results, in depth information, support for dietary and physical exercise interventions are a feasible and acceptable intervention to overcome the identified barriers for women with GDM and health professionals [33]. This may provide consistent communication and information for women with GDM, and health professionals involved in providing care.
The strength of the current study is the survey of Key Informant Health Professionals across six professional groups involved in gestational diabetes care at 10 hospitals across New Zealand with a 100% response rate. Given the lack of research in this area in New Zealand and internationally, this study is exploratory and encourages further follow-up research. Often studies single out one health care provider group. Women diagnosed with GDM have care provided by several health professionals groups. Therefore, it is important to identify collectively and individually from involved health professional groups what barriers or enablers are perceived before implementing tighter glycaemic targets. This can inform effective strategies to enable the implementation of change collectively or with a health professional specific approach. This will enhance effective care for women with GDM.
A limitation of the current study is the small sample size, therefore the study findings cannot be generalised and applied to all New Zealand Diabetes in Pregnancy Services and their involved health professionals. Accessing all health professionals providing care for women with GDM at all New Zealand hospitals was too difficult, hence access to Key Informants was considered the best option at the ten hospitals who consented to participate in the Target Trial. It is recognised that women who have been diagnosed with GDM need to be included into research about enablers and barriers to implementing tighter glycaemic targets. As part of the TARGET study this has been conducted and is published elsewhere [34,35].

Conclusions
Key Informant Health Professionals reported effective communication and multidisciplinary health professional involvement as key perceived enablers. A perceived barrier for women with GDM was identified as women would find it more difficult to control their capillary blood glucose concentrations, but that women will believe it is better for their health and the health of their infant. Education sessions for staff and women, multidisciplinary engagement, wall charts and stickers were perceived to be effective to support the identified enablers and to overcome the perceived barriers. This study identifies that an effective strategy for implementing tighter glycaemic treatment targets for women with GDM needs to be carefully planned. Further research is needed after the implementation of the tighter glycaemic treatment targets for women diagnosed with GDM to assess if the barrier perceptions were realised and if the perceived enablers supported the implementation effectively.
Supporting information S1 File. The survey template is available with this publication. (PDF)