Background
Pregnancy is ‘a window of opportunity’ for promoting positive health behaviours because it is a time when women are more inclined to give up unhealthy habits [
1]. While women realise the importance of optimising their health before pregnancy [
2], many studies have shown that women of reproductive age demonstrate low levels of knowledge and behaviour related to preconception care (PCC) [
2‐
6]. In one study, it was reported that less than 50% of women supplement their diet with folate during the periconception period [
3] even though there is strong evidence that folate supplementation reduces the risk of neural tube defects (NTDs) [
7].
National and international guidelines outlining evidence-based recommendations for the delivery and uptake of PCC have been published [
8‐
11]. These recommendations focus on medical risk factors such as infection, immunisation status, previous adverse pregnancy outcomes, and patient lifestyle (eg, smoking, nutrition, alcohol, and physical activity). The delivery of PCC is generally achieved in a primary health care setting, but many women find that general practitioners (GPs) rarely discuss the availability of and need for PCC [
12]. This assertion is further supported by a study which reported that only 53% of women who had heard of folate reported doing so from a GP or obstetrician [
3]. Therefore, there is a need to understand why there is inadequate delivery of PCC guidelines by GPs.
Implementation researchers have emphasised that the identification of theoretical domains that are causally related to behaviour allows for the appropriate targeting of interventions for increasing guideline implementation [
13‐
18]. A consensus of experts has identified a set of theoretical domains that may be considered when designing strategies to improve the implementation of evidence-based practice [
19]. This set of domains has been used previously to understand implementation difficulties in different health care settings such as mental health care [
20], primary health care [
21], intensive care [
22], and chiropractic care [
23]. Theoretical domains have also been used to identify the barriers and enablers to careful hand hygiene as perceived by nurses and hospital administrators [
24]. Therefore, theoretical domains can potentially be used to identify aspects of GPs’ behaviour which can be targeted for intervention to improve the delivery and uptake of PCC guidelines.
Our previous study examined women’s views on the barriers and enablers to the delivery and uptake of PCC [
12], but there is little information on the views of GPs on the barriers and enablers to the delivery and uptake of PCC guidelines. Consequently, the aim of this study was to examine GPs’ views on the barriers and enablers to the delivery and uptake of PCC guidelines issued by the Royal Australian College of General Practitioners (RACGP) [
25] using theoretical domains related to behaviour change.
Results
We found that the barriers and enablers to the delivery and uptake of PCC guidelines, as perceived by GPs, were primarily related to four theoretical domains: (1) beliefs about capabilities; (2) motivations and goals; (3) environmental context and resources; and (4) memory, attention, and decision making. Statements which accurately depicted the theme for each theoretical domain were chosen accordingly. Theoretical domains that were found to not be relevant included emotion, social/professional role and identity, and skills.
Beliefs about capabilities
GPs felt that they did not have the opportunity to deliver the PCC guidelines as women often did not present at the preconception stage. GPs also stated that they were often unaware of a woman’s intention to conceive, or that women only presented when they were already pregnant.
“You’ve got to motivate them to actually come in; my main barrier is that they don’t come.” (Female GP, High SES)
“It’s very rare for people to come in and say that they’re planning to have a baby. Most of them come when they are already pregnant.” (Male GP, High SES)
GPs also stated that increased awareness in women of both the availability and the importance of PCC would facilitate the delivery of PCC guidelines.
Motivation and goals
A number of GPs stated that spina bifida and NTDs were too rare to warrant specific action. This view was reflected by the fact that few of the GPs had ever seen a case of NTD. They were also of the opinion that folate isn’t 100% effective in preventing NTDs, and that even if they did discuss the use folic acid during early pregnancy, their efforts may not be worthwhile because NTDs were still a possibility.
“… even if everyone did take folate, there will still be neural tube defects, it will never be eradicated.” (Female GP, Low SES)
GPs also frequently stated that they did not raise PCC with women of reproductive age because of other competing preventive care priorities. Examples of other preventive care priorities included chlamydia screening, pap smears, and cervical cancer vaccination. Some GPs preferred to spend more time addressing issues such as alcohol and smoking as they could see more potential benefits.
“It’s a big consultation and there is a lot of competing preventive health at the moment.” (Female GP, Low SES)
Environmental context and resources
Overall, the biggest barrier to the delivery of PCC as perceived by GPs was the time limits on consultations. GPs pointed out that the delivery of PCC guidelines would take longer than a standard consultation, and that trying to cover all of the issues related to PCC was a real challenge. They found it particularly problematic when PCC issues were raised at the end of a consultation for another issue.
“There is a problem with adding in more preventive type consultations in practices that are stretched to the limit. I don’t know if we can physically do it….” (Male GP, Rural)
“The main commodity is time, and all of us are stretched at the moment so by taking on this additional work, we don’t know where to fit it in.” (Male GP, High SES)
More importantly, both rural and low SES groups of GPs felt that patients were not willing to spend more time and money on attending multiple consultations dedicated to PCC.
“There is also the cost as well, because they won’t want to pay for that.” (Female GP, Rural)
Another major barrier identified by GPs was the lack of both GP and patient resources (eg, patient information sheets, evidence-based websites) for PCC. The majority of resources utilised by GPs were patient information sheets produced by pharmaceutical companies. Consequently, GPs expressed a need for resources to be produced by more credible, unbiased organisations.
Another barrier that was mentioned by GPs was the limited access to individual GPs, particularly for rural patients. There was some concern that not all GPs were willing to deliver PCC, and, consequently, there could be considerable delay to see those that do.
“A problem is that in our practice, there is a lot of doctors who don’t do prenatal care and, if they want to see me, it’s a long wait.” (Female GP, Rural)
“Another problem is that I’m not always there, which makes it more difficult if they want to see me.” (Female GP, Low SES)
One final barrier that was identified was the potential increase in burden on clinics if the number of PCC consultations was increased. GPs commonly believed that this may result in sick patients getting limited access to clinics. GPs stated that they often pushed themselves to make additional time for patients who were unwell, but they were not necessarily willing to keep adding more time to consultations for opportunistic or preventive issues.
“If I book for half hour to talk about this, I’ve got other patients who are actually sick and are coming with hepatitis, influenzas etc.… and I have to make time for them, so I’m not going to allow more time for something that is preventive or an opportunistic thing.” (Male GP, Low SES)
Memory, attention and decision making
A perceived enabler identified by GPs was the availability of PCC checklists to ensure that the entire PCC guideline is discussed. Patient brochures, handouts, and waiting room posters outlining the benefits and availability of PCC consultations were also viewed as beneficial.
“I like the idea of having a checklist of things so when people come in you can go over everything.” (Male GP, Low SES)
Discussion
Using the theoretical domain framework, our study has identified some of the barriers and enablers to the delivery and uptake of PCC guidelines, as perceived by GPs. The biggest barrier we identified was the time constraints faced by GPs – they simply felt that there was not enough time to deliver PCC in a standard consultation. Other barriers to the delivery of PCC guidelines were the lack of women presenting at the preconception stage, other competing preventive care issues, the availability of and access to GPs who deliver PCC, the cost associated with extending consultations to include PCC, and the lack of resources for assisting in the delivery of preconception care guidelines. Perceived enablers to the delivery and uptake of PCC guidelines included the availability of PCC checklists as well as patient brochures, handouts, and waiting room posters outlining the benefits and availability of PCC consultations.
The results of our study highlight the need for developing interventions that respond to concerns from GPs about their capability to deliver PCC when faced with time constraints. The availability of a checklist may prove useful for GPs as it will ensure that all aspects of the PCC guidelines are discussed with patients, even when time is limited. There is also the potential for PCC to be delivered by a practice nurse or for a risk screen to be undertaken online by patients prior to a consultation. Both options could potentially remove some of the burden on GPs without compromising the delivery of PCC to patients.
The lack of women presenting at the preconception stage also contributes to the difficulty in delivering PCC guidelines. Interventions should focus on increasing patient awareness of the need for and availability of PCC. The lack of women presenting specifically for PCC results in GPs being deprived of the opportunity to devote a consultation to this purpose. As a consequence, PCC issues are often raised at the end of the consultation where they may compete with other preventive care issues. Dealing with PCC in an “opportunistic” way is problematic because non-attendees and those who are most in need may inadvertently be denied access to PCC. A shift in emphasis is required that extends women’s awareness to attend for antenatal care at the preconception stage. Some have even suggested extending PCC to the family planning setting whilst acknowledging the difficulty of talking to a predominantly young clientele about preparing for pregnancy at a time when they are presenting for contraceptive services [
30].
GPs also face difficulties with prioritising PCC together with other preventive care issues. GPs are unsure about which of the many preventive care issues are most important to address. This issue has potential implications for those attempting to implement other preventive care guidelines related to cancer screening, chronic disease prevention, and screening for sexually transmitted diseases such as chlamydia. The problem may lie with the opportunistic way in which preventive care is delivered by GPs. A potential solution to this problem may be to schedule all consultations related to preventive care so that the burden of deciding which preventive care issue is most important is removed from the GPs. Alternatively, GPs could systematically identify and recall patients who are in need of preventive care.
Both the cost of and access to preventive services in low SES and rural areas were viewed by GPs in our study as problematic to the delivery of PCC guidelines. These issues are often discussed in literature from the US, where insurance coverage for women of reproductive age living in low SES and rural areas is a problem [
31]. Inadequate access to PCC may be overcome by work-role substitution, where practice nurses undertake the delivery of PCC. Also, the availability of a financial incentive specifically for PCC would overcome the cost of accessing PCC, which is especially relevant for women living in low SES areas.
In our study, GPs also mentioned the need for GP and patient resources to facilitate the delivery of PCC guidelines. Specifically, GPs thought that the availability of checklists would ensure that the entire guideline is discussed during a consultation. Guidelines often have a multitude of recommendations and, therefore, GPs need assistance with resources and time management strategies to enable them to deliver the recommendations in a more holistic way. Our findings are consistent with a previous study that examined the barriers to counselling women of childbearing age on the potential risks of birth defects when using certain medications during pregnancy. In this study, primary care providers expressed a desire for resources such as patient information materials, electronic decision support tools, and clinical care systems that routinely assess patients' pregnancy risk, which they believed would help counsel patients about the teratogenic risks associated with certain medications [
32]. Another study also highlighted the need for patient information leaflets to support GPs in the delivery of PCC to women with diabetes, especially when there are time constraints [
33]. Consequently, potential interventions for improving the delivery of PCC guidelines should also focus on providing tools and resources to assist GPs in delivering the content and evidence base of the guidelines.
Our study is limited by the relatively small number of GPs involved and the fact that they were recruited from only one state in Australia. Despite this, the barriers and enablers (and, therefore, the corresponding theoretical domains) identified by GPs were consistent across the three regional general practice support organisations. Although GPs in low SES and rural groups already consult ethnically diverse populations, our study could have been further strengthened by recruiting GPs who work in locations with high indigenous populations. Indigenous populations have proportionately higher rates of perinatal morbidity and mortality relative to the rest of the Australian population. Therefore, the views of those GPs on the barriers and enablers to the delivery and uptake of PCC would have provided an interesting comparison with our data.
The results of our study are also limited by the qualitative design. While focus groups are suitable for exploring common experiences, they may increase the conformity of responses. Because the GPs in our study volunteered to participate, they may also represent a subgroup of GPs who have a higher degree of interest in PCC compared with other GPs, thus limiting the generalisability of our findings. The barriers reported by GPs may also be different to those observed in real practice. For example, a lack of time to deliver PCC may, in reality, reflect a lack of motivation. Conducting a similar study on a larger scale or incorporating quantitative methodologies may provide a greater understanding of the issues raised in our study.
Acknowledgements
We thank the members of the project advisory committee for their input: Professors Shane Thomas and Sally Green, Associate Professor Jane Halliday, Dr Bronwyn Harvey. We would also like to thank Ms Elizabeth Logan and Ms Danielle Rigoni for their advice. We would also like to thank Dr Maria de Leon-Santiago for her assistance in preparing this manuscript. Finally, we would like to thank the Bayside GP Network, Dandenong Division of GP and South Gippsland GP Network for their assistance in recruitment, and the participating GPs.
Funding
DM undertook this work with the support of a National Institute of Clinical Studies (NICS) - HCF Foundation Fellowship. NICS is an institute of the National Health and Medical Research Council (NHMRC), Australia’s peak body for supporting health and medical research. AC was supported by funding from the Shepherd Foundation. Both funding bodies had no involvement in the research process.
Competing interests
The authors declare that they have no financial or non-financial competing interest.
Authors’ contributions
DM conceived the study, DM and AC drafted the paper, and SM contributed to the writing and review of the manuscript. All authors read and approved the final manuscript.