Understanding gestational diabetes in Hong Kong: women’s needs, self-management challenges, and the potential of digital health solutions in culturally sensitive care | BMC Pregnancy and Childbirth

This study applied the Health Belief Model (HBM) to explore the self-management experiences of Hong Kong Chinese women with GDM. A central finding was that the unique sociocultural context of Hong Kong fundamentally shapes the manifestation of core HBM constructs. While our analysis confirmed the established relevance of perceived susceptibility, severity, barriers, benefits, cues to action, and self-efficacy, it uniquely revealed how local factors like cultural dietary conflicts and filial piety pressures specifically moulded these perceptions.

Participants faced multifaceted barriers that were deeply embedded in their environment. These included conflicts between dietary restrictions and cultural food practices, physical activity limitations exacerbated by time constraints and third-trimester fatigue, insufficient guidance from healthcare providers, and a notable lack of psychological support. Conversely, their engagement in self-management was driven by perceived susceptibility to complications, an understanding of GDM severity, appreciation of the benefits, and cues to action from healthcare providers and peer experiences. Notably, digital tools emerged as a modern and crucial enabler, providing real-time information and support that is often absent in traditional care settings.

Barriers to GDM self-management

A key finding from our participants was the experience of multifaceted barriers deeply embedded in their local environment. They encountered challenges and cultural conflicts in modifying their diet and exercise. These findings align with previous studies highlighting similar barriers, such as difficulties with diet control, persistent hunger, and frustration in following food advice guidelines [35,36,37]. In one study, women reported that pregnancy became a physical hindrance to performing exercise [23]. During the third trimester, they reported that fatigue, dizziness, swollen legs, and leg cramps made regular exercise challenging [38]. Additionally, their expanding abdominal size further hindered their ability to stay active.

Our findings highlight that a significant barrier arose from the conflict between clinical guidelines and established local cultural norms. Hong Kong Chinese family dietary practices are deeply rooted in southern Chinese food therapy traditions, which place a high value on long-boiled soups (e.g., chicken, fish maw, and herbal broths) as sources of vital essence (精髓) believed to strengthen maternal–foetal health (補身) and replenish qi and blood (補氣血), alongside cultural preferences for carbohydrate-rich staple foods [39]. These traditions and cultural preferences for carbohydrate-rich staple foods often conflict with evidence-based GDM management recommendations [23]. From a clinical perspective, these soups can be high in hidden fats and calories, while the emphasis on refined carbohydrates like white rice contributes to high glycaemic loads, both of which directly challenge the core goals of GDM management: glycaemic control and appropriate gestational weight gain [40]. This cultural conflict creates considerable challenges for daily self-care, as Chinese women with GDM struggle to reconcile medical advice with strong intergenerational expectations and filial obligations. These women often face a dilemma between prioritising their health needs and maintaining family harmony, which compounds the psychological burden of GDM management [41].

These findings highlight an urgent need for culturally sensitive dietary guidelines that incorporate a broader spectrum of Chinese foods [42] and educate both women with GDM and their families, particularly older members who often influence household eating patterns. Evidence from a review and meta-analysis of 23 randomised controlled trials demonstrates that family-based interventions can improve family support, diabetes control, and psychological well-being in adults with diabetes, particularly in Asian regions [43]. Family-based interventions for women with GDM have also been implemented in Western countries [44], although further refinement is needed to optimise outcomes [45]. These interventions could serve as a reference for local healthcare providers to involve families in designing effective strategies to support women with GDM.

Our results identified a critical gap in structured psychological support, which participants reported as a major barrier. Women expressed a strong need for real-time, personalised feedback to manage the emotional toll of GDM. This finding underscores the importance of integrating psychosocial care, which is supported by existing evidence. Pregnancy is a short but important period requiring women to adopt new health behaviours rapidly [46]. Adapting to dietary and exercise changes during this time is inherently stressful as the outcomes directly affect both the mother and unborn child, even with diligent adherence. The absence of structured psychological support in clinical settings was particularly notable.

These findings reveal the importance of integrating comprehensive psychological care into standard GDM management protocols. Psychosocial interventions have been shown to positively influence self-management behaviours, lifestyle changes, depression, anxiety, self-efficacy, stress, and glucose levels in women with GDM [47, 48]. Informational and motivational support interventions provide tailored advice and encouragement and can significantly enhance self-management [47, 48]. Additionally, educational interventions that improve women’s knowledge of and motivation in GDM self-management are particularly effective, empowering them to make informed decisions and adopt healthier behaviours [49]. Thus, implementing the type of support requested by our participants is an evidence-based strategy.

Health beliefs and cues to action as motivators

Women in this study reported profound shock upon receiving a GDM diagnosis, particularly those who perceived themselves as having a low risk due to healthy lifestyles. Consistent with prior research [46, 50], the GDM diagnosis prompted them to reassess their health status and recognise their new high-risk condition. This urgent threat appraisal triggered immediate concerns about their health and pregnancy outcomes. The diagnostic experience [51] served dual roles: first, as a susceptibility marker, it helped women realise that metabolic complications could develop despite healthy behaviours, and second, as a behavioural catalyst, it motivated them to engage in intensive self-education about GDM management. These initial emotional responses were often followed by heightened concerns about pregnancy outcomes, which further encouraged the participants to seek GDM-related knowledge and adopt self-management strategies actively.

Notably, women’s perceived benefits of GDM self-management (reducing the risk of medical complications for both the mother and baby) further sustained their efforts. External triggers such as healthcare providers emphasising outcome-linked benefits or peers sharing success stories, a nuance that extends traditional HBM frameworks by highlighting sociocultural influences, often reinforced these beliefs. Notably, although the diagnostic experience initially heightened susceptibility perceptions [51], ongoing adherence relied on women’s ability to reframe GDM as a controllable condition with tangible rewards, aligning with the findings of Karavasileiadou et al. [21] regarding benefit-focused motivation. The perceived severity of GDM, such as the risks of macrosomia, emergency caesarean session, and long-term complications of developing type 2 diabetes in later life, intensified behavioural change urgency, consistent with the findings of previous studies [25, 52].

This study identified two key behavioural cues for women with GDM: professional medical guidance and peer support through digital platforms. The participants valued healthcare professionals’ evidence-based recommendations while relying on peer networks for culturally adapted implementation strategies, consistent with findings from systematic reviews of online support communities for GDM management [53]. These digital platforms proved particularly effective when delivering culturally tailored solutions, such as peer-shared recipe modifications or provider-customised advice that translated clinical guidelines into practical actions. The synergy between professional authority and peer-experiential knowledge in digital environments promoted sustainable self-management practices. However, maintaining motivation requires continuous support, which current healthcare systems often struggle to provide due to resource constraints. Women strongly desire the increased involvement of healthcare professionals in digital health tools to improve information quality and patient care [54]. Increased engagement in digital health platforms and strategic use of social media for health education could significantly enhance knowledge-sharing and support for women managing GDM.

Digital tools: bridging gaps in GDM care

Digital health technologies—from glucose-tracking mobile applications to AI-driven coaching platforms—are redefining gestational diabetes self-management [55]. Designed for the transient yet intensive demands of GDM, these tools provide real-time, personalized support that complements traditional care [56]. Beyond traditional HBM constructs, digital tools have emerged as novel enablers, addressing real-time needs unmet by routine care. The findings of this study underscore the need for digital health solutions for women with GDM. Evidence suggests that digital platforms can deliver self-management training as effectively as conventional face-to-face interventions [57]. These tools offer several advantages, including real-time support and feedback, overcoming geographic barriers, and reducing healthcare costs through resource pooling [56]. Mobile applications are well-suited for women with GDM as they address clinicians’ limited time to manage and educate patients requiring short-term therapy adjustments [54, 58, 59]. Educational resources can be accessed anytime and anywhere, facilitating efficient utilisation of healthcare resources [54, 58, 59]. Women reportedly prefer mHealth apps (mobile applications) featuring clinician-approved recipes, comprehensive food databases, and glycaemic index data to simplify dietary choices [60].

Digital platforms also enhance healthcare professionals’ ability to deliver personalised care. An integrative systematic review of GDM self-management found that digital tools facilitate self-monitoring through data tracking and feedback, provide tailored information, support behavioural changes through customised coaching features, and expand access to information and peer support [61]. Moderate-to-high-certainty evidence indicates that digital health interventions improve glycaemic control and reduce caesarean delivery rates among pregnant women with GDM, thus positively affecting maternal and foetal outcomes [55]. These findings underscore the need for contextually appropriate digital tools tailored to local GDM management. Such solutions could simultaneously support women and educate family members, mitigating cultural conflicts surrounding dietary practices.

Digital tools are not merely adjuncts but also essential enablers of sustainable GDM care [55, 62]. By integrating these technologies, healthcare providers can transform barriers into opportunities, delivering personalised, culturally sensitive, and continuous support that aligns with women’s experiences. Adopting digital health solutions represents a feasible and impactful approach to improving care delivery and clinical outcomes [54, 58]. This transformation is particularly relevant given the growing demand for healthcare services and the widespread availability of mobile technology and data coverage globally.

Contextualising the findings: why Hong Kong?

This study’s findings offer potential explanations for the notably high prevalence of GDM in Hong Kong, moving beyond purely physiological factors to consider socio-cultural and structural determinants. The intense cultural conflict surrounding traditional Cantonese “food therapy” (食療) [41] and carbohydrate-rich diets creates a unique and significant barrier to dietary adherence that may be more pronounced than in Western contexts [39]. Furthermore, the familial pressure and obligation to conform to elder expectations, rooted in filial piety (孝道), adds a layer of psychological distress that can undermine self-management efforts. The reported gaps in tailored, culturally competent guidance from healthcare providers mean women are often left to navigate these complex conflicts alone. When combined with the city’s fast-paced lifestyle, which exacerbates time constraints and physical fatigue, these factors converge to create a socio-ecological risk environment that exacerbates disease prevalence and complicates effective management. Therefore, the high rates of GDM in Hong Kong may be attributable not only to genetic predisposition but also to this specific socio-cultural environment that simultaneously heightens risk and complicates management. Consequently, effective interventions must be as much about cultural translation and family engagement as they are about clinical science.

Implications for practice

This study calls for the development of integrated, family-centred digital health solutions to support GDM self-management. Digital platforms should be designed to deliver culturally adapted dietary guidance, trimester-specific physical activity support, and embedded psychological care, actively involving family members as partners in the process. These platforms would function best within a dual-support framework that combines automated tracking with personalised communication from healthcare providers.

To implement this effectively, healthcare providers require training in remote monitoring, motivational messaging, and cultural competency for virtual consultations. Concurrently, healthcare institutions must invest in robust IT infrastructure that leverages AI-assisted data analysis while ensuring strict data privacy [63]. This dual focus on workforce capacity and technological infrastructure is essential for scaling these interventions successfully.

Recommendations for future research

To translate these findings into practice, future research should prioritize implementation science approaches to develop and pilot the family-centered digital solutions proposed in this study. Key foci should include evaluating their impact on clinical outcomes (e.g., glycaemic control), user experience, and family engagement metrics. Furthermore, research is needed to explore the longitudinal impact of GDM on maternal mental health beyond the postpartum period. The evidence generated from such studies is crucial for informing sustainable, evidence-based policy adjustments to maternal care programs.

Limitations

This study has several limitations. The sample included 16 Chinese women, achieving saturation but excluding ethnic minorities in Hong Kong and potentially introducing selection bias, limiting generalizability and perspective diversity. Future studies should use purposive sampling for greater diversity in ethnicity, age, socioeconomic status, and GDM severity. Furthermore, the analysis did not distinguish between perspectives of women currently managing GDM and those reflecting postpartum; potential recall bias from this hindsight is a consideration. Future longitudinal research is needed to track evolving health beliefs and self-efficacy from diagnosis through postpartum.

Additionally, reliance on self-reported data may not fully capture GDM management efficacy; reviewing clinical record books could offer more objective insights. Finally, the exclusive focus on Hong Kong Chinese women may limit geographic applicability. Comparative studies of Chinese women in other regions could elucidate sociocultural influences on self-management practices.