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Citation: Timm, A.; Kragelund
Nielsen, K.; Alvesson, H.M.; Jensen,
D.M.; Maindal, H.T. Motivation for
Behavior Change among Women
with Recent Gestational Diabetes and
Their Partners—A Qualitative
Investigation among Participants in
the Face-It Intervention. Nutrients
2023,15, 3906. https://doi.org/
10.3390/nu15183906
Academic Editors: Jenna Hollis,
Michelle Kilpatrick and Susan J.
De Jersey
Received: 25 May 2023
Revised: 26 August 2023
Accepted: 6 September 2023
Published: 7 September 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
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Attribution (CC BY) license (https://
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4.0/).
nutrients
Article
Motivation for Behavior Change among Women with Recent
Gestational Diabetes and Their Partners—A Qualitative
Investigation among Participants in the Face-It Intervention
Anne Timm 1,2 ,* , Karoline Kragelund Nielsen 1, Helle Mölsted Alvesson 3, Dorte Møller Jensen 4,5,6
and Helle Terkildsen Maindal 1,2
1Health Promotion Research, Copenhagen University Hospital—Steno Diabetes Center Copenhagen,
2730 Herlev, Denmark; karoline.kragelund.nielsen@regionh.dk (K.K.N.); htm@ph.au.dk (H.T.M.)
2Department of Public Health, Aarhus University, 8000 Aarhus, Denmark
3Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden;
helle.molsted-alvesson@ki.se
4Steno Diabetes Center Odense, Odense University Hospital, 5000 Odense, Denmark;
dorte.moeller.jensen@rsyd.dk
5Department of Gynaecology and Obstetrics, Odense University Hospital, 5000 Odense, Denmark
6Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark,
5000 Odense, Denmark
*Correspondence: anne.timm@regionh.dk
Abstract:
Promoting diet and physical activity is important for women with recent gestational
diabetes mellitus (GDM) and their partners to reduce the risk of future type 2 diabetes (T2D). The
study aimed to understand how motivation for changing diet and physical activity behaviors among
women with recent GDM and their partners was experienced after participation in the Danish Face-it
intervention. Fourteen couples’ interviews were conducted. Data analysis followed a reflexive
thematic analysis. Guided by self-determination theory and interdependence theory, we identified
four themes affecting couples’ motivation for health behavior change: (1) The need to feel understood
after delivery; (2) adjusting health expectations; (3) individual and mutual preferences for health
behaviors; and (4) the health threat of future T2D as a cue to action. We found that couples in general
perceived the Face-it intervention as useful and motivating. Using couple interviews increased
our understanding of how the women and partners influenced each other’s perspectives after a
GDM-affected pregnancy and thus how targeting couples as opposed to women alone may motivate
health behavior change.
Keywords:
gestational diabetes; health promotion; behavior change; process evaluation; diabetes
prevention; diet; physical activity; intervention; couple interviews
1. Introduction
Gestational diabetes mellitus (GDM) affects 14% of all pregnancies globally [
1
] and
is the most common complication in pregnancy [
2
]. In Denmark, 6% of all pregnancies
are affected by GDM [
3
]. Although usually a transient condition, GDM is associated
with an increased risk of short- and long-term adverse health outcomes in both women
and their offspring [
1
,
4
]. Also, the risk of recurrent GDM is high, ranging between 30
and 84% [
5
]. In the long term, women with prior GDM and their offspring are at an
increased risk of developing type 2 diabetes (T2D) [
6
–
8
], and body mass index (BMI)
remains the main modifiable risk factor for T2D development among women with prior
GDM [
9
]. Structured interventions targeting weight loss have shown that reducing T2D
risk is possible through changes in diet and physical activity in this group of women [
10
,
11
].
Also, persistent changes in diet and physical activity have been found to uphold T2D risk
reduction after 10 years among women with prior GDM [
12
]. Still, it remains unclear how
Nutrients 2023,15, 3906. https://doi.org/10.3390/nu15183906 https://www.mdpi.com/journal/nutrients
Nutrients 2023,15, 3906 2 of 16
health behaviors can be sustained in the long term [
13
]. According to a meta-analysis of
interventions applying self-determination theory, some types of motivation increase the
likelihood of sustained behavior change across target populations and behaviors [
14
]. Thus,
motivation is most likely an active mechanism in seeking to explain the maintenance of
healthy behavior [
15
]. Identifying such mechanisms of change is essential to understanding
how intervention effects have occurred and how an intervention may be replicated in
other settings [
16
]. Thus, investigating motivation as an assumed mechanism for health
behavior change is important to understand how prevention efforts targeting T2D risk may
be improved.
Many qualitative studies have shown that social support from a partner is a key
motivational factor for improving health behaviors among women with prior GDM [
17
],
even in the Danish context [
18
]. Still, few interventions have focused on the family set-
ting, which may explain the limited success of interventions in demonstrating long-term
behavior change. Few interventions have involved women with prior GDM and their
partners [
19
,
20
]. McManus et al. showed that when these women and their partners
participated together, women’s retention in the intervention increased, and when their
partners lost weight, the women’s weight tended to follow [
19
]. Furthermore, Brazeau
and colleagues documented that physical activity levels increased in both women with
prior GDM and their partners after engaging in an intervention including mutual physical
activity and meal sessions [
20
]. For both interventions, retention among couples remained
high [
19
,
20
]. Couples often share daily routines in the household and health behaviors,
which most likely results in them influencing each other’s health status [
21
,
22
]. This may
explain why partners of women with prior GDM have also been found to be at increased
risk of T2D [
8
,
23
]. This conjoint risk [
24
] suggests the need for directing health inter-
ventions at both parties [
25
]. Digital technology, e.g., text messages, seems to increase
retention, acceptability, and health behavior outcomes of interventions among postpartum
women [
26
,
27
] and women with prior GDM [
28
]. Still, a knowledge gap exists on how
health promotion interventions influence motivation for health behaviors among women
with prior GDM and their partners.
1.1. The Face-It Intervention
The Face-it health promotion intervention was developed to reduce the risk of T2D and
increase the quality of life in women with prior GDM and their families. The effectiveness
of the intervention is being evaluated in a randomized controlled trial, and details are
published elsewhere [
29
,
30
]. Women with GDM and their partners were recruited from
2019 to 2022 through obstetric departments in the three largest cities in Denmark, where
the intervention was delivered. Women could participate in the trial regardless of whether
they had a partner or not. Thus, women without a partner and women with partners who
declined to participate could participate alone. If both the woman and her partner accepted
participation and the couple was randomized to the intervention group, the partner was
invited to all intervention activities.
The Face-it intervention commenced 10–14 weeks after delivery and continued until
the baby was around 12 months old. The intervention was based on three major components.
The first component comprised active involvement of health visitors in addition to usual
care through three home visits supported by a dialogue tool “the family wheel”, which
addressed five topics: GDM and risk/prevention of T2D; daily routines; food and meals;
exercise/movement; and family, friends, and network (Figure S1). Municipality-based
health visitors (nurses trained in newborn health and family wellbeing) delivered the home
visits. The second component consisted of digital health technology. This technology
included (a) goal setting, (b) real-time meetings, and (c) asynchronous coaching (text and
video). Trained health coaches (primarily health visitors) delivered digital health technology
through the digital platform “the LIVA app” [
31
]. The LIVA app included customizable
materials for health coaches to personalize guidance for families, encouraging healthy
behaviors. The third intervention component involved communication and coordination
Nutrients 2023,15, 3906 3 of 16
across health sectors to ensure that couples were provided with coherent information in
the postpartum period. The three home visits were planned to be delivered at fixed time
points, coordinated in collaboration between the couples and the health visitor. Digital
health coaching was delivered with varying intensity across the nine months according to
the needs and preferences of the family (see Figure 1).
Nutrients 2023, 15, x FOR PEER REVIEW 3 of 16
guidance for families, encouraging healthy behaviors. The third intervention component
involved communication and coordination across health sectors to ensure that couples
were provided with coherent information in the postpartum period. The three home visits
were planned to be delivered at fixed time points, coordinated in collaboration between
the couples and the health visitor. Digital health coaching was delivered with varying
intensity across the nine months according to the needs and preferences of the family (see
Figure 1).
Figure 1. Overview of the planned delivery of the Face-it intervention [32].
The healthcare professionals delivering the intervention received education about
GDM and training on communicating about GDM, including the care pathway and the
risk of T2D. Also, they were supported in embedding a health-promoting perspective as
defined by the World Health Organization (WHO) Europe, i.e., empowering,
participatory, holistic, equitable, and multi-strategy [33]. For example, healthcare
professionals were trained to focus on social support and well-being as pre-requisites for
health behavior change and to be sensitive to the family’s situational needs. This
education was intended to enable healthcare professionals to promote health in general
as well as physical activity, healthy dietary behaviors, and breastfeeding through the
following mechanisms: social support, motivation, self-efficacy, risk perception, and
health literacy. To improve our understanding of how the Face-it intervention may induce
changes in health behaviors among couples after participation, we explored motivation as
an assumed mechanism.
1.2. Self-Determination Theory and Interdependence Theory
Theory-driven evaluation designs are recommended when investigating
mechanisms of change in interventions to beer understand intervention effects [34]. To
advance our understanding of how couples’ motivation for health behavior changes was
affected by the Face-it intervention, we applied the self-determination theory (SDT) [35]
and the interdependence theory [36].
SDT is a theoretical perspective on human motivation that highlights humans’ inner
resources for personality development and behavioral self-regulation [35]. In this study,
SDT was used in the analysis to understand women’s and their partners’ motivation for
health behavior change. SDT distinguishes between extrinsic and intrinsic motivation.
Intrinsic motivation is characterized by actions driven by a personal interest in practicing
a behavior, e.g., joy, whereas extrinsic motivation is driven by external factors such as
Figure 1. Overview of the planned delivery of the Face-it intervention [32].
The healthcare professionals delivering the intervention received education about
GDM and training on communicating about GDM, including the care pathway and the risk
of T2D. Also, they were supported in embedding a health-promoting perspective as defined
by the World Health Organization (WHO) Europe, i.e., empowering, participatory, holistic,
equitable, and multi-strategy [
33
]. For example, healthcare professionals were trained to
focus on social support and well-being as pre-requisites for health behavior change and
to be sensitive to the family’s situational needs. This education was intended to enable
healthcare professionals to promote health in general as well as physical activity, healthy
dietary behaviors, and breastfeeding through the following mechanisms: social support,
motivation, self-efficacy, risk perception, and health literacy. To improve our understanding
of how the Face-it intervention may induce changes in health behaviors among couples
after participation, we explored motivation as an assumed mechanism.
1.2. Self-Determination Theory and Interdependence Theory
Theory-driven evaluation designs are recommended when investigating mechanisms
of change in interventions to better understand intervention effects [
34
]. To advance
our understanding of how couples’ motivation for health behavior changes was affected
by the Face-it intervention, we applied the self-determination theory (SDT) [
35
] and the
interdependence theory [36].
SDT is a theoretical perspective on human motivation that highlights humans’ inner
resources for personality development and behavioral self-regulation [
35
]. In this study,
SDT was used in the analysis to understand women’s and their partners’ motivation for
health behavior change. SDT distinguishes between extrinsic and intrinsic motivation.
Intrinsic motivation is characterized by actions driven by a personal interest in practicing
a behavior, e.g., joy, whereas extrinsic motivation is driven by external factors such as
rewards, obligation, social acceptance, and individual goals and values. SDT posits that the
more internalized a motivation is to perform a behavior, the more likely the individual is to
sustain it. According to SDT, relatedness,perceived competence, and autonomy are underlying
personal attributes that contribute to the internalization of individual motivation. Related-
ness concerns the need to feel understood through the establishment of a non-judgmental,
Nutrients 2023,15, 3906 4 of 16
positive, and empathic environment. Perceived competence refers to one’s experienced abil-
ity to perform a behavior. SDT posits that motivation becomes more autonomously driven
when individuals experience relatedness and perceived competence. Thus, autonomy
involves the need to consider oneself the driver of one’s own behaviors [35].
The interdependence theory developed by Lewis et al. is a dyadic theory that can
be used to understand each partner’s perspective, thereby revealing both individual and
collective influences on health behaviors [
36
]. Interdependence theory was applied in the
analysis to investigate couples’ mutual motivation for health behavior change. The main
hypothesis behind interdependence theory is that mutual support within the relationship
is the most effective way to sustain health behaviors and that when health behaviors are
perceived as meaningful to the couple and their relationship, the incentive for them to
perform these behaviors increases. Lewis et al. incorporate pre-dispositional factors, which
influence couples’ motivation for health behavior change. Preferences for outcomes refer
to the extent to which the couples agree on project goals in terms of performing health
behaviors within couples. Another pre-dispositional factor is couples’ interpretation of
health threats, which, in the case of GDM, is how couples’ perceive the risk and consequences
of T2D as a cue to preventive action [
36
]. Interdependence theory includes three other
factors: relationship functioning,communication style, and gender, which were less evident in
the data and thus absent in the results.
2. Materials and Methods
2.1. Study Design and Setting
The current study followed a qualitative interview-based design and contributes to
the process evaluation of the Face-it intervention [29].
In Denmark, screening for GDM is based on selected risk factors, including pre-
pregnancy BMI
≥
27 kg/m
2
, family history of diabetes, previous birth of a child with a birth
weight
≥
4500 g, glucosuria, polycystic ovary syndrome, and multiple pregnancies [
37
].
According to current Danish guidelines, pregnant women are diagnosed with GDM by
a 2 h, 75 g oral glucose tolerance test with a diagnostic glucose threshold of
≥
9 mmol/L
(venous plasma or capillary blood) or
≥
10 mmol/L (capillary plasma) [
38
]. After diagnosis,
women are advised about diet, physical activity, and self-monitoring of blood glucose, and
if this treatment is not sufficient to prevent high blood glucose levels, insulin treatment is
started [
39
]. Due to the risk of fetal and birth complications, the women are closely mon-
itored by a multidisciplinary team including midwives, obstetricians, nurses, dieticians,
and endocrinologists [
40
]. Following childbirth, Danish guidelines recommend consis-
tent screening for T2D at 4–12 weeks postpartum, with subsequent screenings scheduled
every 1–3 years with their general practitioner [
39
]. Additionally, they advise providing
counseling on dietary habits and physical activity to mitigate the women’s risk of devel-
oping T2D in the future. However, diabetes screening uptake is low among women with
prior GDM, with only 17% attending screening after 4–6 years [
41
]. Nonetheless, no other
systematic follow-up or preventative initiatives exist in Denmark.
2.2. Data Collection
The first author, AT, conducted semi-structured couple interviews with women with
recent GDM and their partners. All women and their partners who had completed the
Face-it intervention within the last year, between January 2020 and January 2021, were
invited to participate through a written information letter sent via a secure digital platform
(e-Boks). Non-respondent couples received a reminder text message approximately four
weeks after the invitation. AT telephoned the couples who agreed to participate to schedule
an interview. The majority of interviews were carried out in the homes of the partici-
pants [
42
]. However, due to restrictions during the COVID-19 pandemic, four interviews
were performed online. All interviews were conducted between mid-November 2021 and
mid-February 2022 and were performed in Danish.
Nutrients 2023,15, 3906 5 of 16
Of the 27 couples invited, 14 agreed to participate in an interview. Nine couples did
not respond, and four couples declined participation. Two couples indicated disinterest,
and two couples lacked time and energy to participate. The characteristics of the couples
participating in interviews are presented in Table 1.
Table 1. Couple characteristics (n= 14).
Characteristics
n= Couples
Interview setting
Participants’ home 10
Online with video 4
Child (ren) present during interview
No 8
Yes 6
Number of children within the couple
1 11
2 3
Time of interview after intervention ended (n= months)
Mean (Range) 5.3 (1–9)
Age of the participating women (years)
Mean (Range) 34.8 (25–42)
Age of the participating partners (years)
Mean (Range) 35.8 (27–46)
AT, a female researcher in her late twenties with a background in public health science,
conducted all interviews. Prior to this study, AT was involved in the development of the
Face-it intervention and, among other things, participated in the education of healthcare
professionals delivering the intervention. Moreover, AT had also conducted interviews
with the intervention deliverers in the early stages of implementation [
43
]. Thus, AT was
highly integrated in the intervention, which she actively leveraged in this study to develop
and challenge her assumptions about the impact of the intervention on couples’ motivation
for health behavior change. AT had no contact with the couples prior to inviting them to
participate in the interviews for this present study.
An interview guide was developed by AT and discussed with KKN and HTM, as
well as with other researchers in the Face-it Study. An explorative approach focused on
motivation was employed. The interview guide included questions about parenthood, per-
ceptions of health, experiences with home visits, and digital health coaching
(see Table S1)
.
All interviews were audio recorded and/or online video recorded. The interviews lasted
between 48 and 79 min.
Before the interviews were initiated, the couples were informed that the interviews
would be used to provide knowledge to strengthen care for families in which the woman
had GDM. During the interviews, an overview of the intervention activities (Figure 1) and
the family wheel (Figure S1) were used as prompts to help women and partners recall their
experiences with the intervention. The woman and partner were asked to write down their
respective perceptions of the ‘useful’ and ‘less useful’ aspects of the intervention (Table S1).
The woman or partner who said the least was asked to provide her/his reflections first to
ensure their engagement in the interview. This exercise was not included in interviews
performed online, and the presence of a child made it difficult for the couple to reflect
separately on their answers.
2.3. Data Analysis
Data analysis followed an abductive approach using reflexive thematic analysis, in
which the researcher’s position is continuously reflected upon to advance analysis [
44
,
45
].
Nutrients 2023,15, 3906 6 of 16
Interviews were transcribed verbatim by AT or a research assistant. Initially, AT listened to
all audio recordings to familiarize herself with the data and then coded all transcripts induc-
tively. During the first reading of the empirical data, AT explored couples’ perspectives on
health behavior change during and after participating in the Face-it intervention. During
this process, AT coded both assumed and unintended mechanisms of change, e.g., “changes
in resources after having a baby” or “perception of T2D risk”. In the second coding of the
empirical data, AT identified patterns related directly to motivation and thereafter looked
for theories to complement and nuance the data. The second round of coding was guided
by SDT and interdependence theory [
35
,
46
]. Themes and subthemes were created during
this phase. Example quotes were translated to English and confirmed by a native English
speaker and the co-authors. Nvivo v12 was used to structure the coding process [
47
].
Examples of the data analysis process are presented in Supplementary Table S2.
2.4. Ethical Considerations
The Face-it trial is registered with ClinicalTrials (gov NCT03997773). The woman and
her partner gave written consent to participate through the Danish digital platform (e-Boks)
after receiving information on study aim, pseudo-anonymity, and voluntary participation.
Consent for audio and/or video recordings was obtained prior to the interviews. During
couple interviews, staying sensitive to couple dynamics is important, and therefore, AT
abstained from going into discussions that might negatively affect the couple’s relation-
ship [
48
]. The study is reported according to the Consolidated Criteria for Reporting
Qualitative Research (COREQ) [49].
3. Results
We identified the four following themes related to couples’ motivation for health
behavior change: (1) the need to feel understood after delivery; (2) adjusting health expecta-
tions; (3) individual and mutual preferences for health behaviors; and (4) the health threat
of future T2D as a cue to action.
3.1. The Need to Feel Understood after Delivery
In the first theme, we find that couples’ experiences of feeling understood by the
healthcare professionals delivering the Face-it intervention affected their motivation for
health behavior change. The couples described their everyday lives as characterized by a
limited ability to be spontaneous, time restrictions, and an increased need for collaboration
to ensure the baby’s wellbeing. Due to these requirements, many participants expressed
that they would not have accepted participation if it had required them to leave their homes.
Also, most participants described it as critical that the hardship they faced caring for a baby
be acknowledged in their interaction with the healthcare professionals.
“We had some good talks about planning and what we wanted to do using the family
wheel [dialogue tool used in the home visits], especially that sometimes you need to accept
that the energy just isn’t there. And how you’re not supposed to rearrange your life at
this time but rather use this period to regain energy.” (Woman, Couple 11)
For instance, several couples stated that they experienced a need to relax to regain
energy, e.g., by watching television after the baby was put to bed. When healthcare profes-
sionals recognized such needs as well as the emotional burden of being a parent, including
the feeling of guilt of not living up to societal expectations of “proper” parenthood, most
couples reported feeling understood by the healthcare professional. In particular, advice
given by healthcare professionals on family habits, e.g., meal planning, household chores,
and delegation of assignments between couple members, was mentioned by couples as
enabling them to rethink their habits in a positive and non-judgmental way. Also, many cou-
ples stressed the importance of discussing coping strategies with the healthcare professional
to relieve their stress, sleep deprivation, and emotional burden:
Nutrients 2023,15, 3906 7 of 16
“I’m glad I took part in [the intervention] because obviously one has learned something.
It’s not all about exercising and what one eats. It’s about feeling good at the same time.
When [name of healthcare professional] suggested that I should insert a goal into the LIVA
app reminding me to relax—that was just amazing instead of having a bad conscience
about everything I didn’t do.” (Woman, Couple 10)
However, couples noted that the LIVA app sometimes compromised the supportive
environment established with the healthcare professional when they received feedback
on the app that could be perceived as impersonal and auto-generated. As a consequence,
couples mentioned instances of performative reporting in the LIVA app that did not match
their actual goals or health behaviors. Also, the LIVA app was unable to automatically
synchronize with their Android-based smartphones. This meant that couples had to
manually register their health behaviors and goals into the app, which was perceived to be
incompatible with the busy everyday life of the family. Motivated by external factors, e.g.,
registering in the app to please the health coach, couples’ motivation to comply with the
advice decreased.
“If I hadn’t registered for a week, then I had to sit and scroll back for each day, and I
simply didn’t want to continue. I thought it was too much trouble.” (Partner, Couple 5)
3.2. Adjusting Health Expectations
The second theme deals with how feelings of competence and autonomy among the
couples affected their motivation to engage in healthy dietary and physical activity behav-
iors. Most couples equated a healthy meal with a meal that was homecooked, and physical
activities concerned “putting on a sports bra or running shoes”. Lack of time was often de-
scribed by couples as the main barrier to conducting such health behaviors. However, many
couples described how the healthcare professionals in the Face-it intervention broadened
their views on the kind of behavior changes that could be considered health-promoting.
This new understanding of how even small changes might add up and positively affect
health was accompanied by an expressed increase in perceived competence, which in turn
internalized their motivation to perform health behaviors.
She [healthcare professional] said “count everything when you talk about physical activity.
It’s okay to go out in the garden and pick tomatoes or do garden work for 5 min. Walk
to the grocery store. Take the stairs. If you spend 15 min pram walking, that’s fine”.
(Partner, Couple 4)
Furthermore, some couples described being encouraged by the healthcare professional
to keep performing their preferred physical activities. As a result, couples were more likely
to practice that behavior because it resonated with their current interests, e.g., walking.
Getting support from healthcare professionals to identify alternative solutions to unhealthy
habits was also described as useful for couples. As an example of a behavioral change
adopted after participating in the intervention, one couple mentioned buying cans of
carbonated soft drinks instead of 1.5 L bottles, and another couple stated:
Partner: We used to have a fast-food Friday with food from the grill or McDonalds. In
a period where we had limited energy, we talked to her [healthcare professional] about
finding fast-food alternatives.
Woman: Now, we can have a fast-food day with homemade pizza with salad and less
cheese and more vegetables. So, healthier alternatives, but we still call it fast-food day.
(Couple 12)
Couples also reported situations during which their motivation to perform health
behaviors became more externalized. Some couples considered the advice on health behav-
iors inappropriate because their own health was not considered a priority while they had a
small baby. Some couples described the advice from healthcare professionals as prescriptive
in the sense that they felt that the healthcare professional told them what to do without
considering their family’s current resources, needs, and preferences. Consequently, these
Nutrients 2023,15, 3906 8 of 16
couples expressed feelings of low autonomy and support from the healthcare professional,
which externalized their motivation to improve diet and physical activity behaviors.
“I think she [the healthcare professional] was a tough lady. She made some suggestions,
but they weren’t always realistic. I don’t know if they have too many families [in the
intervention] but she didn’t really consider who we are. I felt like she said, “just eat
cabbage”, but with a small child and a husband who works a lot, it’s not that easy.”
(Woman, couple 7)
External motivation was also underscored when some women mentioned that they
initially participated in the intervention mainly to support research rather than to change
health behaviors themselves.
3.3. Individual and Mutual Preferences for Health Behaviors
The third theme focuses on how concordant and discordant preferences among couples
affect their individual and mutual motivation to perform health behaviors. Due to the
demands of the child, couples viewed their family and its functionality as their main
priority, which took precedence over individual health behaviors. Performing health-
related activities with their children as a family was a shared priority among most couples.
Experiencing support and advice from healthcare professionals on planning family-based
activities, which focused on family well-being, increased their mutual motivation for
engaging in such activities despite the competing demands of everyday chores, as portrayed
by Couple 14:
Woman: We talked to the healthcare professional about wanting to go out more—like a
walk in the woods. Not necessarily for the sake of being physically activity, but just as
much for the fresh air and energy and the kids’ enjoyment.
Partner: It reminded us that even though we’re busy and we should also set up an
office and clean up the kitchen and stuff like that. No! We’ll have to go outdoors for
everyone’s sake.
As such, it seemed that couples’ mutual motivation increased when health behaviors
were performed as a family, since this made them more fun. However, couples also
expressed divergent individual preferences for engaging in health behaviors. Women were
more likely than their partners to express their preference for spending time with their
child over their interest in performing individual health behaviors. As one woman put it:
“What if I had spent time at the gym, which I could have spent better with my children?”
(Woman, Couple 10).
In addition to wanting to engage in family-based activities, partners also described
an interest in individual activities or activities with their child(ren) without their spouse.
Some couples, although mainly the partners, had successfully used digital health coaching
through the LIVA app to increase their personal focus on weight loss, step counts, etc. and
found the possibility of individual support appealing.
“When the opportunity presents itself, I take the pram with great pleasure and walk down
to pick him [baby] up from the nursery instead of taking the car. Then it’s just us time. I
hadn’t thought about that before [the intervention] in the same way. It’s healthy for me
and for us that these healthcare professionals have rattled us in a well-intentioned way.”
(Partner, Couple 7)
3.4. The Health Threat of Future T2D as a Cue to Action
The fourth theme addressed how couples cognitively and emotionally respond to
their risk of T2D diabetes and its perceived impact on their motivation for health behavior
change. Most couples expressed being aware of the women’s future T2D risk. It was also
evident that couples’ motivation was affected very differently by how they interpreted the
health threat. Many women indicated that the GDM diagnosis was linked to uncertainty
Nutrients 2023,15, 3906 9 of 16
because it was unclear to them why they had developed GDM. The healthcare professionals
often calmed the women and couples by trying to explain GDM as a diagnosis triggered by
genes. These explanations seemed to calm the women and remove the guilt some women
felt towards receiving the GDM diagnosis. The couples expressed how demystifying the
GDM diagnosis increased their motivation to pursue health behaviors to reduce their
T2D risk.
“My first thought was, what could I have done differently? What did I do wrong? The
fact that someone tells you that this [GDM] is just something the body does—and it’s [the
risk] more pronounced among some women and some are placed in the GDM category.”
(Woman, Couple 2)
The majority of couples acknowledged the fact that changing their health behaviors
might reduce their future T2D risk, which in turn increased their motivation for health
behavior change. The fact that the child was also at increased risk of developing T2D
was of great concern to the couple. This information acted as a cue to action for health
behavior engagement due to the importance couples attributed to being a healthy family.
Nonetheless, some couples perceived it as unrealistic to promote their health behaviors
while having a small baby.
“When the baby is out, you relax a bit. It’s hard. You don’t get the sleep you need and
you’re tired and all those things and you’re overwhelmed by emotions, then it’s not carrots
in the fridge you think about.” (Woman, Couple 1)
Others described the development of GDM as a natural bodily response to pregnancy.
In these situations, couples’ motivation for health behavior change seemed to be negatively
affected by their belief that their risk of future T2D diabetes would be unaffected by
changing their health behaviors.
Woman: Diabetes runs in the family. So, it wasn’t because of anything else that I
developed gestational diabetes.
Partner: Yes, it was actually really random.
In general, the way in which the women interpreted their own risks affected their
partners’ motivation to support them by engaging in health behaviors. For example, when
knowledge of T2D risk motivated the women to increase their focus on health behaviors,
their partners tended to become supportive, which contributed to a mutual motivation for
health behavior change.
You [woman] had figured out what it really was—what gestational diabetes meant and
what you could do to prevent it—and you told me many times that it’s not just you
it affects. It’s also [baby]. And then I thought “Okay, this is the way we need to go.”
(Partner, Couple 3)
Though most partners acknowledged the woman’s and child’s risk of T2D, none of
the partners mentioned being at risk of diabetes themselves.
“Of course, it’s mostly the woman’s body, which is affected. It’s not about my body.”
(Partner, Couple 2)
Rather, partners considered their participation in the intervention to be highly relevant
with regard to supporting health behaviors and thereby reducing the risk of diabetes in
women and children.
4. Discussion
Our study investigated motivation as an assumed mechanism for health behavior
change among couples after participating in the Face-it intervention. We found that couples
experienced a need to feel understood by the healthcare professional, which affected
their motivation to engage in health behaviors. Further, when the healthcare professional
supported adjustments of health expectations to fit couples’ everyday lives, it seemed
Nutrients 2023,15, 3906 10 of 16
to increase competence and autonomy to engage in diet and physical activity behaviors.
Differing and mutual preferences for health behaviors existing within couples are also
linked to their motivation for health behavior change. Lastly, couples’ perception of T2D as
a health threat was identified as impacting their motivation to engage in health behaviors.
Consistent with SDT, relatedness was established through creating a non-judgmental
environment and removing couples’ pressure to live up to the norms of perfect parent-
hood [
35
]. SDT posits that when patients and clinicians interact and medical advice is
expected, it is important to establish relatedness before giving advice. Relatedness makes
recipients more inclined to view the advice as informative rather than prescriptive [
35
].
The family wheel may have facilitated relatedness by enabling conversations about norms
of health and parenthood through its diverse health-related topics. Consistent with studies
on women with prior GDM, topics on mental health may facilitate motivation to engage
in physical activity [
50
]. Also, role modeling healthy behaviors and home-based activities
have been identified as potential effective intervention strategies for health promotion in
families with small children [
51
]. Further, qualitative studies have highlighted expectations
of prioritizing the family over oneself as a barrier to engaging in health behaviors [
52
,
53
].
Employing health visitors as the primary profession to deliver the intervention may have
alleviated a non-judgmental environment due to their knowledge about health promotion
in a family context [
40
]. Drawing from SDT, directing attention toward pursuits aligned
with the family’s intrinsic interests, such as joy, might resonate with the family’s innate
motivation, thereby fortifying their impetus to undertake health behaviors [
35
]. Thus,
health visitors’ experience with realistic changes in a family setting may have spurred
autonomous motivation by resonating with couples’ need to feel recognized while ensuring
alignment with couples’ own interests.
Due to the need for manual registration and automated messages received in the LIVA
app, couples’ mutual motivation for digital health coaching seemed to decrease due to
its perceived incompatibility with family life. A recent review highlighted personalized
goal setting and video coaching as highly acceptable features of digital health technology
among women with prior GDM [
28
]. In the feasible MobileMums intervention, mothers
reported that a personal connection to the intervention deliverer was facilitated by using
first names, SMS texts, and possibly an initial face-to-face meeting [
26
]. Thus, our findings
seem to be only partly consistent with the literature on digital interventions for postpartum
mothers. Greenhalgh et al. argue that when an alternative solution to digital technology
exists, the likelihood of withdrawal may increase [
54
]. Thus, the combination of home visits
and digital coaching in the Face-it intervention may have decreased couples’ use due to
feeling adequate support through home visits. Another reason for couples’ lack of interest
in digital coaching was identified in a study on healthcare professionals’ perspectives [
43
].
In this study, it seemed that those health coaches who also conducted home visits generally
preferred home visits due to the feeling that the online interaction compromised their
relationships with couples [
43
]. Golob et al. found that women with lower educational
attainment preferred face-to-face counseling vs. digital coaching [
55
], indicating that
offering both digital coaching and home visits may be infeasible. Still, qualitative studies
highlight the need for differentiated care to accommodate diverse needs among postpartum
mothers and women with prior GDM [
53
,
56
]. Interestingly, more women than partners
registered in the LIVA app, also indicating differing levels of interest in digital health
coaching [
32
]. Partners may have felt underprioritized in the intervention due to their
recruitment being based on their partners’ GDM diagnosis. Though partner support seems
vital to increasing physical activity among mothers with small children [
57
], digital coaching
may be more effective if offered to the woman and partner separately. For example, mothers
in MobileMums indicated that they were satisfied with the sole focus on themselves as
mothers [
26
]. Future studies should investigate how acceptability and adoption may be
increased among women with prior GDM and their partners.
The current literature suggests that some women with prior GDM underestimate their
risk of T2D development [
58
], which may decrease their motivation for health behavior
Nutrients 2023,15, 3906 11 of 16
change [
59
]. Similarly, for many couples in the current study, risk perception seemed to
have a small or no effect on their motivation for health behavior change. Parson et al.
explored risk among women with prior GDM and concluded that fear of T2D onset can
work as a motivational factor for engaging in health behaviors [
60
]. Parson and colleagues
proposed that diabetes risk may most optimally be addressed by considering both the
woman’s personal beliefs and the socio-cultural context [
60
]. However, communicating
about diabetes risk to couples was identified as troublesome by healthcare professionals
in the development and delivery of the Face-it intervention [
30
,
43
]. Similar concerns have
been documented among nurses, who have been found to under-communicate potential
risks to avoid conflict with individuals they want to support [
61
]. Still, it seemed that some
couples in our study had a shared interest in changing health behaviors in order to become a
healthy family. Thus, ensuring a non-judgmental environment while providing information
about the risk of diabetes (without it being normative or prescriptive) may be the most
motivating way to create mutual, internalized motivation for health behaviors among
couples. Still, more research is needed to understand how a motivational understanding of
risk can be established in couples with a history of GDM.
We also identified how a woman’s perception of risk affected her partner’s inter-
pretation of risk, with both positive and negative implications for their motivation for
health behavior change. Although evidence of the partner’s role remains limited in the
literature, in the context of couples with a history of GDM, partners seem to be motivated
to support family health behaviors [
25
]. In our study, we found that partners did not con-
sider themselves to be at risk, which, according to the interdependence theory, may have
decreased their motivation for health behavior change [
36
]. A lack of motivation among
partners may evoke an unsupportive home environment if partners persist in upholding
unhealthy habits [
62
]. Although T2D risk among partners is addressed in the intervention
manual for delivery of the Face-it intervention, it may be that healthcare professionals
could have emphasized this shared risk of T2D even further to increase mutual motivation
for health behavior change. Altogether, couples’ perceptions of diabetes risk seemed to
have differing effects on their motivation for health behavior change, which should be
investigated further.
Strengths and Limitations
A strength of this study is our focus on couples, which allowed us to explore both
individual and mutual motivations for health behavior change [
42
]. For example, we might
not have identified the intrinsic motivation among couples for engaging in family-based
activities if only the woman or the partner had been present. Also, our study sheds light
on couples with a history of GDM as a highly relevant target group for T2D prevention,
which is relevant to inform future health promotion interventions. The dual role that AT
held as an intervention coordinator and the substantial engagement that AT had with the
intervention could potentially have influenced the analysis and findings. Throughout the
process, AT took reflective fieldnotes and documented preconceptions at the outset of the
study. Also, AT worked closely with her co-authors, who read and provided feedback on
three of the interview transcripts. HMA (third author) was not familiar with the Face-it
intervention prior to overseeing the analytical process, which altogether increased the
trustworthiness of the findings [
63
]. Our study also had limitations. For example, couples
may have exaggerated their preference for family-based values due to the presence of
their partner. Furthermore, couples sometimes found it difficult to recollect details about
their experiences with the intervention, which may be a consequence of the interviews
being performed up to 9 months after its completion. On the other hand, interviewing
participants after they had completed the intervention rather than during the intervention
allowed couples to reflect on the intervention as a whole. Directing questions at both
women and their partners secured more equal involvement, facilitating more insights into
partners’ views on the intervention.
Nutrients 2023,15, 3906 12 of 16
We employed reflexive thematic analysis, which encourages researchers to continu-
ously reflect upon and challenge their assumptions, to ensure transparent and trustworthy
data collection and analysis [
44
]. For example, in interviews with couples, AT sought to up-
hold an explorative approach to health by asking: “What is health to you and your family?”
SDT and interdependence theory helped to understand how motivation was established in
couples by considering both individual and social dimensions of health behavior change.
Combining these extensive theories increased sensitivity towards different interpersonal
mechanisms. However, by focusing solely on motivation, we may have excluded other
factors affecting couples’ health behavior change. For example, employing the Capability,
Opportunity, Motivation-Behavior model by Michie et al. may have further advanced our
findings [64].
5. Conclusions
Understanding the motivation for health behavior change among couples with a
history of GDM gives a unique insight into how health promotion efforts may be tailored
to the everyday lives of this target group. Across themes, individual tailoring to couples’
situational needs and beliefs seems vital to internalizing their motivation for health behavior
change. Thus, to secure the engagement of the diverse group comprising women with
prior GDM and their partners, we suggest targeting motivation through differentiated care.
Knowledge gained from this study will contribute to the interpretation of the effects of the
Face-it intervention and support the evidence base for health promotion among couples at
increased T2D risk.
Supplementary Materials:
The following supporting information can be downloaded at:
https://www.mdpi.com/article/10.3390/nu15183906/s1, Figure S1: The interactive dialogue tool,
the family wheel; Table S1: Key questions in the interview guide for couple interviews;
Table S2: Examples of the analytical process: Manifest content, interpretation, and theme.
Author Contributions: Conceptualization, A.T., K.K.N. and H.T.M.; methodology, A.T., K.K.N. and
H.T.M.; software, A.T.; validation, A.T., K.K.N., H.T.M., H.M.A. and D.M.J.; formal analysis, A.T.,
K.K.N. and H.T.M.; investigation, A.T., K.K.N. and H.T.M.; resources, A.T., K.K.N. and H.T.M.; data
curation, A.T., K.K.N. and H.T.M.; writing—original draft preparation, A.T., K.K.N., H.T.M., H.M.A.
and D.M.J.; writing—review and editing, A.T., K.K.N., H.T.M., H.M.A. and D.M.J.; visualization, A.T.;
supervision, H.T.M., K.K.N. and D.M.J.; project administration, H.T.M.; funding acquisition, H.T.M.,
K.K.N. and D.M.J. All authors have read and agreed to the published version of the manuscript.
Funding:
This paper was embedded within AT’s PhD project which was funded by Aarhus University,
Steno Diabetes Center Copenhagen, and the Face-it study. The Face-it study was funded by a grant
from the Novo Nordisk Foundation NNF16OC0027826 and by in-kinds from the participation
institutions (Principal Investigator, Helle Terkildsen Maindal).
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki and approved by the Research Ethics Committee for Science and Health in the Capital
Region of Denmark (H-18056033).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
The qualitative data are unavailable due to privacy and ethical restrictions.
Acknowledgments:
We would like to thank all the women and their partners who participated in
interviews for this study. The authors also wish to thank the Face-it study group. Furthermore, we
would like to thank the following institutions for their support: Steno Diabetes Center Aarhus, Steno
Diabetes Center Copenhagen, Steno Diabetes Center Odense, Aarhus University, Rigshospitalet,
Odense University Hospital, Aarhus University Hospital, Aarhus Municipality, Copenhagen Munici-
pality, Odense Municipality, and LIVA Healthcare. We are grateful to the families who participated in
the Face-it study and to the healthcare professionals involved in recruitment, data collection, and
intervention delivery.
Nutrients 2023,15, 3906 13 of 16
Conflicts of Interest:
A.T., K.K.N. and H.T.M. are employed at Steno Diabetes Center Copenhagen, a
public hospital and research institution under the Capital Region of Denmark, which is partly funded
by a grant from Novo Nordisk Foundation. D.M.J. is employed at Steno Diabetes Center Odense,
Odense University Hospital, a public hospital, and research institution under the Region of Southern
Denmark, which is also partly funded by a grant from Novo Nordisk Foundation. The funders had
no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of
the manuscript; or in the decision to publish the results. H.M.A. is employed at Karolinska Institutet
where she also receives funding. She reports no conflict of interest.
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