---
title: "Social determinants of health and postnatal well-being in Thai women with type 2 diabetes: mixed‑m"
id: "plos-one-8-social-determinants-of-health-and-postnatal-wellbeing-among-women-with-type-2"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-8-social-determinants-of-health-and-postnatal-wellbeing-among-women-with-type-2"
content_type: "clinical_feed_article"
specialty: "Endocrinology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354735"
published_at: "2026-07-29T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Social determinants of health and postnatal well-being in Thai women with type 2 diabetes: mixed‑m
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-8-social-determinants-of-health-and-postnatal-wellbeing-among-women-with-type-2
- **Specialty:** [Endocrinology](https://medichelpline.com/clinical-feed/endocrinology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354735)
- **Published At:** 2026-07-29T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This protocol describes an explanatory sequential mixed‑methods study in Thailand investigating how **social determinants of health** (SDoH) relate to **postnatal well-being** among women with **type 2 diabetes** (T2DM). - The study has four objectives: (1) culturally adapt and translate the **Postnatal Well-being in Transition** scale into Thai; (2) quantitatively describe SDoH and postnatal well‑being during the postpartum diabetes transition; (3) qualitatively explore lived experiences of SDoH in relation to postnatal well‑being scores; and (4) integrate quantitative and qualitative findings. - The design is an explanatory sequential mixed‑methods approach: a quantitative strand followed by qualitative interviews to explain quantitative results. Triangulation will be used to integrate findings. - Sample targets: 50 postnatal women with T2DM who delivered within the past six weeks for the quantitative phase; a purposive subsample of 12 women for semi‑structured one‑to‑one qualitative interviews. - Study sites are two public hospitals in Thailand — one urban tertiary hospital in Bangkok and one suburban hospital in Samut Prakan — selected to maximize variation in socioeconomic and geographic context. - The translation and cultural adaptation of the Postnatal Well‑being in Transition instrument follows Beaton et al.'s six‑stage process with forward and back translations and expert review. Content validity was assessed by three postnatal care experts. - Quantitative data planned: demographics, SDoH measures, and postnatal well‑being scores. Qualitative data planned: semi‑structured interviews to deepen understanding of how SDoH shape postpartum experiences during the diabetes transition. - Ethics approval was obtained from the Human Research Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University. Data have not yet been collected; data availability is therefore restricted. - The authors report no specific funding and declare no competing interests. Results are intended for publication in international journals.
## Clinical Analysis & Structured Key Points
Social determinants of health and postnatal wellbeing among women with type 2 diabetes in Thailand: An explanatory sequential mixed-methods study protocol | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Introduction Type 2 diabetes mellitus affects pregnancy and can lead to maternal complications. Women affected by diabetes during pregnancy have ongoing physical, psychological, and social needs until birth preparation and after childbirth. The Social Determinants of Health (SDoH) can have a greater impact on health outcomes than healthcare services or personal lifestyle choices alone. To date, no study has explored how women with type 2 diabetes experience life after childbirth. To help close this knowledge gap, the proposed study aims to: 1) Culturally adapt and translate the Postnatal Well-being in Transition scale into Thai. 2) Quantitatively describe the SDoH and postnatal well-being during the diabetes transition among Thai women with T2DM. 3) Explore Thai women’s experiences regarding their SDoH, based on the mean scores of their postnatal well-being during the diabetes transition. And 4) Explore and analyze the impact of postnatal care on women with T2DM using a mixed-methods approach. Methods This is an explanatory sequential mixed-methods study protocol with two distinct phases. The first phase involves the translation of the study instrument, while the second phase focuses on data collection for the mixed-methods study. Data will be collected from 50 postnatal women with type 2 diabetes mellitus who have delivered a baby within the past six weeks. Participants will provide data on demographics, social determinants of health, and their postnatal well-being in transition. From this group, 12 women will be selected to participate in semi-structured, one-on-one interviews to gain a deeper understanding of their experiences. The study will use triangulation to integrate and validate the findings from both the quantitative and qualitative data sources. Ethics and dissemination Human Research Ethics Committee approval has been received from the Faculty of Medicine Ramathibodi Hospital, Mahidol University. The study findings will be reported in international journals. Citation: Phonyiam R, Srichalerm T, Sawatpanich A, Keawpugdee J (2026) Social determinants of health and postnatal wellbeing among women with type 2 diabetes in Thailand: An explanatory sequential mixed-methods study protocol. PLoS One 21(7): e0354735. https://doi.org/10.1371/journal.pone.0354735 Editor: Sandra India Aldana, Icahn School of Medicine at Mount Sinai, UNITED STATES OF AMERICA Received: October 7, 2025; Accepted: July 10, 2026; Published: July 29, 2026 Copyright: © 2026 Phonyiam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: Data cannot be shared publicly because data has not been collected. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction As healthcare focuses more on population health and value-based care, addressing social determinants of health (SDoH) has become a key strategy for achieving health equity [ 1 ]. Healthy People 2030 defines SDoH as the conditions in the environments where individuals are born, live, work, play, worship, and age [ 2 ]. The five key domains of SDoH include economic stability, access to and quality of education, access to and quality of healthcare, the neighborhood and built environment, and social and community context. These factors play a significant role in shaping an individual’s health and well-being [ 2 , 3 ]. Research suggests that SDoH can have a greater impact on health outcomes than healthcare services or personal lifestyle choices alone [ 4 , 5 ]. The relationship between SDoH and diabetes care during pregnancy is significant, particularly disparities in maternity care [ 6 ]. Type 2 diabetes mellitus (T2DM), among other chronic conditions, affects pregnancy and can lead to maternal and neonatal complications [ 7 ]. While extensive global research exists on how SDoH impact diabetes in adults, there is a specific need to understand these factors in Asian populations. In Thailand, for instance, a prior study revealed that pregnant women with T2DM face unique challenges in managing their condition. These include difficulties with food cravings, episodes of hypoglycemia, avoiding physical activity due to fear of miscarriage, and limited health literacy concerning insulin injections [ 8 ]. These challenges may not only occur during pregnancy but may also persist during childbirth and the postnatal period [ 9 , 10 ]. Women with different SDoH backgrounds may face unique challenges and require needs. The transition to motherhood is especially critical for women with T2DM. After delivering the baby, they often experience breastfeeding difficulties, such as delayed lactation—particularly when the baby is separated from the mother due to neonatal health issues like neonatal hypoglycemia and the Neonatal Intensive Care Unit (NICU) admission [ 11 ]. Additionally, in the early postnatal period, those women may struggle to breastfeed while maintaining reasonably stable blood glucose levels [ 12 , 13 ].Health professionals play a vital role in supporting women with diabetes, yet many women report that their healthcare providers do not offer adequate knowledge, skills, or support during the transition to motherhood. During this transition, women with diabetes seek advice and support from health professionals who can communicate meaningfully, recognize their self-management efforts, treat them as equals, and show empathy, understanding, and respect [ 8 ]. To date, no study has explored how women with type 2 diabetes experience life after childbirth. This study aims to describe the social determinants of health and postnatal well-being during the transition for postnatal women with T2DM. The research will help fill the gap in knowledge and make postnatal care more effective and tailored to the needs of women with type 2 diabetes. Thus, identifying women’s SDoH and gaining a better understanding of their experiences with postnatal care will make it more effective and better suited to the needs of women with type 2 diabetes. Such exploration is necessary because we need to not only provide care for pregnant women with diabetes during their pregnancy, but also understand their preparation for birth and beyond, into the postnatal period. Women affected by diabetes in pregnancy have ongoing physical, psychological, and social needs [ 14 ]. A study from a multi-ethnic, low socioeconomic women population showed that preparation for birth and postnatal diabetes follow-up were areas requiring significant improvement [ 15 ]. These challenges were mitigated through care from a consistent diabetes care which extended support to both the mother and her baby [ 15 ]. To address this knowledge gap, the present study employs an explanatory sequential mixed-methods design [ 16 ]. This design enhances the understanding of postnatal well-being by systematically integrating quantitatively derived patterns with women’s lived experiences. The quantitative component provides generalizable evidence on the associations between social determinants of health and postnatal well-being during the postpartum diabetes transition among Thai women with type 2 diabetes, while the qualitative component offers in-depth contextual insights into how and why these associations manifest in everyday life. The integration of both phases enables the identification of convergences, divergences, and complementary explanations that may not be fully captured through a single-method approach. Building on this framework, the study is structured around four objectives: (1) to culturally adapt and translate the Postnatal Well-being in Transition instrument into Thai; (2) to quantitatively examine the social determinants of health and postnatal well-being during the postpartum diabetes transition; (3) to qualitatively explore women’s lived experiences of social determinants of health in relation to their postnatal well-being scores; and (4) to integrate findings from both phases to generate a comprehensive assessment of postnatal well-being in this population. Overall, this mixed-methods approach facilitates a more nuanced and comprehensive understanding of postnatal well-being among Thai women with type 2 diabetes, thereby informing the development of culturally appropriate, evidence-based interventions and health policies aimed at improving postpartum outcomes. Methods Study design This is an explanatory sequential mixed-methods study protocol to be conducted in Thailand. The purpose of an explanatory sequential design is to expand and elaborate on the study findings from the quantitative strand through qualitative methods in the second strand to better understand the social determinants of health and postnatal wellbeing among women with type 2 diabetes ( Table 1 ). Download: PNG larger image TIFF original image Table 1. Explanatory sequential mixed methods flow chart diagram. https://doi.org/10.1371/journal.pone.0354735.t001 Research setting This study will be conducted across two public hospitals in Thailand—one urban and one suburban. The urban site is a tertiary care center in Bangkok, serving a high-density population with diverse socioeconomic backgrounds, ranging from low to high income. In contrast, the suburban hospital in Samut Prakan serves a more stable, residential, and primarily middle-income community. This dual-site approach utilizes maximum variation sampling to capture a diverse range of experiences, drawing on participants from both urban and rural settings to reflect their distinct contexts. By selecting sites with contrasting geographical and socioeconomic characteristics, the study aims to account for the varying SDoH that influence maternal well-being during the postpartum transition. This study is divided into two phases: 1) translation of the instrument and 2) data collection for the mixed-method study. Part 1: Translation tool Written authorization to translate, adapt, and validate the Postnatal Well-being in Transition questionnaire was granted by the developer of the original tool. We followed the six-stage translation process approach developed by Beaton and colleagues in 2000 [ 17 ]. For its use in the Thai population, we culturally translated and adapted the questionnaire into Thai, then back-translate it to ensure clarity and cultural appropriateness. For the forward translation phase, two bilingual Thai-English nursing faculty members independently translated the instrument from English to Thai, with careful consideration given to cultural appropriateness (Forward 1 and Forward 2). The research team then reviewed both versions to produce a synthesized third version (Forward 3). Subsequently, the Forward 3 was sent to two different bilingual Thai-English nursing faculty members for independent back-translation from Thai to English (Back 1 and Back 2). Finally, the research team convened a meeting to resolve any discrepancies and establish the final Thai version of the ‘Postnatal Well-being in Transition’ scale prior to validation. The questionnaire was validated by three experts in postnatal care in Thailand, and the content validity index was calculated before implementation with Thai women with type 2 diabetes. The Item-level Content Validity Index (I-CVI) was calculated as the proportion of experts who gave a rating of 3 (quite relevant) or 4 (very relevant). The Scale-level Content Validity Index (S-CVI), specifically the average scale-level index (S-CVI/Ave), was calculated by summing the I-CVIs of all items and dividing by the total number of items. Any item receiving a score of 1 (not relevant) was considered unacceptable and removed from the scale. Items requiring modification based on expert feedback were revised, and all such adjustments are reflected in the final version of the instrument. Validation has been completed; the I-CVI and S-CVI were both 1.0, as determined by a panel of three experts. Part 2: Study data collection Eligibility criteria Inclusion criteria. Postnatal women with type 2 diabetes mellitus who have delivered a baby within the past 6 weeks [ 18 ], either primigravida or multigravida; aged 20–44 years; are able to speak Thai; and are able to provide consent. Participants will be eligible for inclusion regardless of infant clinical status (including, but not limited to, NICU admission, congenital anomalies, stillbirth, or neonatal death). Exclusion criteria. Pregnant women with type 1 diabetes mellitus (T1DM) and gestational diabetes mellitus (GDM) as well as those with health complications, such as heart disease, chronic kidney disease, or other conditions affecting hearing or vision that may be indicative of long-term diabetes and require advanced diabetes management, will be excluded from the study. Potential participants will be identified at urban and suburban hospital sites through medication records and clinical visits during the postnatal period. Interested individuals will be directed to a secure online platform (Research Electronic Data Capture: REDCap), where they will view the online informed consent form. Participants must pass a brief ‘consent check’ question before the system allows them to proceed to the survey, ensuring they have read and understood the study requirements. We will monitor non-response rates by tracking the number of individuals who do not wish to complete the survey. Additionally, mode equivalence will be monitored to ensure that data collection remains consistent across both urban and suburban settings. Translation of the tool has been completed. Participant recruitment and data collection commenced in September 2025. We expect to complete data collection by December 2026, and the results are projected to be finalized by June 2027. Quantitative phase As this study is descriptive rather than comparative in nature, statistical significance does not drive the determination of target sample size. This study will recruit 50 participants (Maghalian et al., 2024) through both online methods and face-to-face outreach at postnatal units in two public hospitals. Recruitment. Participants for the survey will be recruited from postnatal units in two public hospitals in Thailand. The recruitment process will involve contacting the head nurse of each postnatal unit to describe the study objectives and request permission for data collection. Once permission is granted, the head nurses will distribute the advertisement document in the form of an e-poster to postnatal women who are hospitalized in their unit. Qualitative phase A total of 12 women will be contacted for qualitative interviews: six participants (n=6) with the lowest mean total scores (indicating lower well-being) and six participants (n=6) with the highest mean total scores (indicating higher well-being). Semi-structured phone interviews will be conducted to gain a deeper understanding of postnatal well-being during the transition to motherhood. The sample size of qualitative arm was guided by the previous study among Thai pregnant women as data saturated at 12 participants [ 8 ]. If data saturation is not reached by the 12th interview, we will continue interviewing participants from both the lower and higher well-being groups accordingly until no new themes emerge. The qualitative component utilized three types of purposeful sampling: nested. Nested sampling, a feature of explanatory sequential mixed methods designs, involves re-sampling the same individuals who participated in the quantitative phase for the qualitative phase. As a result, the same inclusion and exclusion criteria from the quantitative phase were applied to the qualitative phase [ 16 ]. The use of a nested approach is intentional, as this inter-relationship is a recognized strength of the explanatory sequential design; it allows for a deeper understanding of the extreme cases identified in the first phase. This study’s qualitative research used purposeful sampling, supported by nested sampling, to select information-rich cases. Purposeful sampling involves intentionally choosing specific units or cases based on a clear objective, rather than random selection, and it can be used to achieve representativeness or comparability [ 16 ]. This method allowed for a broader range of cases to be selected and facilitated comparisons across different types. Results from the quantitative phase were examined to inform the qualitative sampling strategy, with the potential to apply stratified and theoretical sampling techniques. Stratified sampling helped identify subgroups and enabled comparisons between them, which aligned with the qualitative research question. It was particularly valuable as it captured variations in the phenomenon of interest. To apply this, participants from the quantitative phase were stratified based on postnatal well-being scores during their transition. This approach aims to explore the challenges these women experience that contribute to their reduced well-being during the postnatal period as they adjust to motherhood. Recruitment. Participants for the semi-structured interviews will be recruited from the same pool of postnatal women who participated in the survey. They will be invited to participate in the interviews via online platforms (1) Facebook Page: Chat about Mom and 2) Phone call) or direct communication (meet in-person at data collection sites), providing them with the opportunity to further contribute to the study through in-depth discussions. Quantitative data collection Three questionnaires are as follows: First, we will collect demographic data using a questionnaire, which will include the mother’s age, marital status, duration of diabetes, parity, date of delivery, gestational age at delivery, and current medications. Second, we will assess the social determinants of health across five domains [ 3 ]. The questionnaire for this measure is based on previous research and evidence [ 6 ]. This 20-item tool consists of two open-ended questions and 18 frequency-based items designed to quantify women’s experiences with social determinants of health (SDoH). There is no formal scoring system for this tool; the responses will be rated as frequency of each item. Validation has been completed; the I-CVI and S-CVI were both 1.0, as determined by a panel of three experts. Domain 1: Economic Stability (4 items)– Family income and employment status. Domain 2: Education Access and Quality (1 item)– Educational attainment. Domain 3: Health and Healthcare (4 items)– Health insurance, tobacco use, alcohol use, and comorbidities. Domain 4: Neighborhood and Built Environment (7 items)– Transportation and access to healthy foods Domain 5: Social and Community Context (4 items)– Unsafe neighborhoods and community interaction Third, we will measure postnatal well-being using the Postnatal Well-being in Transition questionnaire [ 18 ]. This 30-item questionnaire, which uses for each item a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Data analysis For quantitative data, information from questionnaires will be entered and analyzed using IBM SPSS version 25.0. The analyses include calculating means, standard deviations, and ranges for continuous variables and frequencies and percentages for categorical variables. Missing values will be replaced using item mean imputation; any missing value for a
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