Barriers and facilitators of cardiovascular disease prevention services for women with prior gestational diabetes or hypertensive disorders of pregnancy in low-income, middle-income and high-income settings: a scoping review protocol

Scoping review rationale

We chose to complete a scoping review with the goal of exploring the extent, range and nature of existing literature on barriers and facilitators to postpartum CVD preventive care in women with previous GDM or HDP and to determine the gaps in literature.18 The conduct of this scoping review will be guided by the Arksey and O’Malley’s Scoping Review Methodological Framework,19 and the Joanna Briggs Institute (JBI) guidance for conducting systematic scoping review.20 As both guidelines are similar in approach and designed with the primary aim to provide an overview of existing literature regardless of quality, we combined the principles of these two guidelines in developing this protocol with the aim of enhancing the quality of this review.21–24 The Arksey and O’Malley’s Scoping Review Methodological Framework consists of six stages to inform and validate findings.19 This includes: identifying the research question(s); identifying relevant studies; study selection; charting the data; collating, summarising and reporting the results; and, consultation exercises. We will report the results of this review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.25

Identifying the review question

To increase the generalisability of this scoping review, we developed the review question in a collaborative manner. Initially, the review question emanated from the results of multiple focus groups (total n=31 participants, 4–8 participants per 6 focus groups, including women with lived experience) and an all-day Think Tank event involving nearly 50 stakeholders (women with lived experience, providers and researchers). Our focus groups revealed the following barriers to accessing CVD preventative services after HDP or GDM: (1) lack of knowledge and awareness; (2) competing interest with caregiving responsibilities; (3) fear and uncertainty; (4) appointment scheduling difficulties; (5) trivialisation of diagnosis; (6) access to healthcare providers; and, (7) health insurance. Our all-day Think Tank event led to the following suggested solutions for improving access to CVD prevention care for women with prior GDM and HDP: (1) improving population-level awareness of CVD risk (education campaigns, destigmatise CVD in women through education, understanding community to tailor education); (2) improving system-level issues that impact prevention (communication to patients about risks, health insurance coverage); and (3) understanding the impact of culture on access and uptake of preventative care. The questions arising from our focus groups and Think Tank influenced our review question. We developed the research question in accordance with the population, concept, context (PCC) mnemonic recommended by the JBI for scoping reviews.26 The population includes postpartum women with previous GDM, HDP (including pre-eclampsia, pre-eclampsia superimposed on chronic hypertension, gestational hypertension and chronic hypertension). The key concept of the study was to understand what factors limits access and uptake of screening and prevention programmes, and what interventions, programmes or strategies facilitate or enhance access to care services for women with prior HDP or GDM. The context includes reported individual, interpersonal, organizational, and system level factors that prevent or facilitate access to CVD prevention services in the postpartum period among women with GDM or HDP in low-income, middle-income and high-income settings.

As a result, our review question is ‘What are the barriers and facilitators to postpartum CVD preventive care services among women with previous GDM or HDP in low-income, middle-income and high-income settings?’.

The main objectives of the review are as follows:

1. To summarise the individual, interpersonal, organizational, and system level barriers to postpartum CVD preventive care among women with prior GDM and HDP.

2. To describe the individual, interpersonal, organizational, and system factors that facilitate access to postpartum CVD preventive care among women with prior GDM and HDP.

3. To summarise knowledge gaps where further research is needed, or where full systematic reviews may be warranted.

Study design, inclusion and exclusion

We kept inclusion and exclusion criteria broad to be consistent with the requirements of our methodological framework and guidelines. We will include original research studies that investigated factors that are barriers or facilitators of postpartum CVD preventive care services in women with previous GDM or HDP, irrespective of the study design and setting (where study was conducted). We will include both quantitative and qualitative studies published in English or French, and papers published from the date of database inception (eg, Medline, 1946) up the end of April 2024. We will exclude studies that do not investigate women with previous GDM or HDP, and those without a defined research question including opinion pieces, editorials and letters to editors. Studies not written or reported in English or French, or papers for which full texts are not available will be excluded.

Participants/population

The participants/population of interest will be women with a history of GDM or HDP (including pre-eclampsia, eclampsia, gestational hypertension and chronic hypertension), aged 18 years and older. We will stratify our findings according to GDM-specific or HDP-specific barriers and facilitators.

Search strategy

In consultation with a medical research librarian at the University of Ottawa Heart Institute (UOHI), we developed a working framework for a search strategy. The design of the search strategy was based on the research question, inclusion and exclusion criteria, which were based on the PCC recommendation for scoping reviews, as outlined above.26 The PCC is a less restrictive alternative to the population, intervention, comparator and outcome, which is recommended for systematic reviews. A comprehensive search strategy developed together with the research librarian and three members of our research team (authors DYQ, RL and KS) will be drafted in Medline via Ovid using a combination of relevant keywords and subject headings informed by ‘target’ articles identified during initial project planning meeting. No limitations to date, geographical location or language will be applied; however, where possible results will be limited to human-only studies. The search will be peer reviewed by a second librarian together with a senior author, K-AM, in accordance with the Peer Review of Electronic Search Strategies guideline.27 The final search will be translated to be run from database inception in Medline, Embase and CINAHL (see online supplemental tables for draft searches).27 A second search using all identified keywords and index terms will be undertaken across all included databases. A handsearch of the reference lists and subsequent citations (backwards and forward citation searching) of included studies will be performed by authors DYQ, RL and KS. We will also identify grey literature via Proquest Dissertations and Theses. The language of inclusion will be English or French and the publication date will be from the inception of the included database up to the end of April 2024. We did this to keep our inclusion criteria broad by being less restrictive and to evaluate the extent of literature on the subject.

Study selection

Once the search has been completed, the citations will be exported from electronic search interfaces to Covidence (https://www.covidence.org/) for duplicate elimination and screening. Each title and abstract will be screened independently by two authors based on eligibility criteria (table 1). Following the title and abstract screening, each full text will be reviewed for study eligibility independently by two authors. Once the full-text review has been completed, the remaining list of citations will be finalised, and data will be extracted and charted. Any disagreements throughout the screening process will be resolved via discussion led by a third author (DYQ or K-AM) with the aim of reaching a consensus. Figure 1 shows the flow chart of study selection.28

Figure 1

Flow chart of inclusion and exclusion of articles. CVD, cardiovascular disease.

Data extraction and charting the results

In collaboration with the medical research librarian, we have developed a checklist containing appropriate variables for data extraction using a standardised form (box 1). This standard form may require revision, if necessary. Two to three authors (depending on the number of included studies) will independently perform the initial data charting process and one other author will review and verify all data extracted. The analysis and summary of findings will be discussed with all authors, including the two women with lived GDM and HDP experience. Box 1 shows the initial draft of variables to be extracted from all included papers in the scoping review. This includes bibliographic information (authors, title of study, year of publication, country of origin), study characteristics (aims, design, population, etc), key findings (reported barriers and facilitators to postpartum CVD care services), limitations and conclusions.

Collating, summarising and reporting findings

The findings of this review will be reported in accordance with the PRISMA-ScR Checklist.25 29 The lead author will summarise and classify the evidence from the included studies with support from other members of the research team, including the women with lived experience, as necessary. Findings from qualitative studies will be integrated into themes. For the primary outcomes, the main themes for the barriers and facilitators to CVD preventive care services will be summarised as individual, interpersonal, organizational, and system level factors. Thematic synthesis of qualitative studies provides explicit and clear links between conclusions and the text of primary studies by ensuring rigorous discussion of the content.22 This will enable analytical abstraction of the results. Findings from the quantitative papers will be absorbed within the themes using the multisource synthesis method.30 Multisource synthesis is an analytical technique that enhances transparency when synthesising quantitative and/or contextual data, thus providing a platform for comparison between studies.30 It also serves as a systematic guide in synthesising data from primary studies to give a meaningful and broad understanding of the subject, especially in the context of a scoping review. Since scoping reviews are intended to describe the literature rather than provide recommendations, no critical appraisal of the review findings will be conducted.19

Consultation

The methodological framework of scoping reviews adopted in this study suggests consultation involving stakeholders as an option.19 The objectives of this scoping review were informed by both empirical evidence and preliminary findings from focus groups with women with lived experience and providers. This was conducted as part of the activities of our research group to develop a network for CVD prevention among women with previous GDM and HDP. We will disseminate the methods and findings of this scoping review to our stakeholder groups, who will be asked to provide feedback. We will incorporate stakeholder feedback, where applicable, in the reporting of our findings.

Patient and public involvement

The Canadian Women’s Heart Health Centre at the University of Ottawa Heart Institute focuses on improving clinical care, education and research related to women’s cardiovascular health. In 2023, members of our research team conducted focus groups, qualitative interviews and a Think Tank event with nearly 50 stakeholders to identify gaps and design solutions related to the prevention, diagnosis and management of CVD and CVD risk factors among high-risk women, including women with a previous pregnancy-related cardiovascular risk indicator (HDP or GDM). Details of our focus groups and all-day Think tank event have been described above under ‘Identifying the review question’. Our research question was further validated and reviewed by two women with prior GDM and HDP. These women with lived experiences will be further involved and engaged in the execution of this review. They will be involved in screening of eligible papers, extraction of data from included papers and summarising and charting the findings of the review. They will also participate in reporting the findings of the scoping review, particularly the synthesis of results and interpretation of findings from the lived experience point of view.