Original research••

It takes two to tango: the recruiter’s role in accepting or refusing to participate in group antenatal care among pregnant women—an exploration through in-depth interviews

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Abstract

Objective The purpose of this study was to explore how women are recruited for group antenatal care (GANC) in primary care organisations (PCOs), what elements influence the behaviour of the recruiter, and what strategies recruiters use to encourage women to participate.

Method Using a qualitative research design, we conducted 10 in-depth interviews with GANC facilitators working in PCOs. Selected constructs of the domains of the Consolidated Framework for Implementation Research and the Theoretical Domains Framework helped to develop interview questions and raise awareness of important elements during interviews and thematic analyses. GANC facilitators working in multidisciplinary PCOs located in Brussels and Flanders (Belgium) were invited to participate in an interview. We purposively selected participants because of their role as GANC facilitators and recruiters. We recruited GANC facilitators up until data saturation and no new elements emerged.

Result We identified that the recruitment process consists of four phases or actions: identification of needs and potential obstacles for participation; selection of potential participants; recruitment for GANC and reaction to response. Depending on the phase, determinants at the level of the woman, recruiter, organisation or environment have an influence on the recruitment behaviour.

Conclusion Our study concludes that it takes two to tango for successful recruitment for GANC. Potential participants’ needs and wishes are of importance, but the care providers’ behaviour should not be underestimated. Therefore, successful recruitment may be improved when introducing a multidisciplinary recruitment plan consisting of specific strategies, as we suggest.

What is already known on this topic

Although the group antenatal care (GANC) model has been widely accepted by participants, organisations perceive the recruitment of participants as a challenge. This is partly related to women’s preferences, although attendance also depends on those that recruit. To fill the current research gap, this study explores the recruitment process of women in primary care organisations.

What this study adds

Unlike other studies that focus on the role of potential participants, this study examines the role of recruiters in the enrolment of women into GANC. Recruitment involves more than merely asking for participation and consists of multiple stages.

How this study might affect research, practice or policy

Successful recruitment is crucial for the implementation and sustainment of GANC. The present study proposes a recruitment plan consisting of specific strategies.

Introduction

Group antenatal care (GANC), a model of antenatal care, is based on the Centering Pregnancy model and consists of three key components: health assessment, social support and interactive learning.1 2 These components are integrated into a series of ten 2-hour group sessions (nine during and one after pregnancy). To create a psychologically safe support group, each session consists of the same providers (eg, a midwife, general practitioner or obstetrician) and 8–12 pregnant women with similar expected days of delivery, along with their significant others, if desired. Before the discussions, a woman receives a short individual physical assessment with one provider. This is done within the group room but shielded to ensure privacy. Meanwhile, other group members measure their weight and blood pressure. During the discussions, healthcare providers act as GANC facilitators. They use interactive methods to encourage participants to share information and experiences on pregnancy-related topics (eg, breast feeding, psychological well-being and family planning). Compared with conventional individual antenatal care, GANC results show comparable or better maternal and neonatal outcomes.3–5 On the other hand, research shows that women who received GANC are more satisfied3 6 and report ‘‘getting more than they realised they needed’.7

In Belgium, the awareness and interest in GANC are increasing. Currently, it is implemented in 10 organisations, both hospitals and primary care organisations (PCOs). The latter include independent midwife practices and community health centres. In general, PCOs have fewer patients. The majority of pregnant women chooses a follow-up in hospitals with an obstetrician as their primary caregiver.8 Midwives do play an important role in GANC in Belgium, as currently every pair of GANC facilitator consists of at least one midwife.

Although the GANC model is widely accepted and associated with positive effects on pregnancy outcomes, the implementation and sustainment of GANC remains challenging. Besides practical issues, such as scheduling and staffing, recruiting participants appears to be the main implementation challenge depending on the context.9 10 Recruiting women for GANC is time-consuming and deviates attention from what is supposed to be the main concern: the actual delivery of care.11

Inadequate recruitment results in insufficient enrolment (ie, getting women into the groups).9 As a result, there are not enough participants to form a group and organisations are forced to cancel the sessions or to run non-cost-effective groups. Hence, to achieve cost-effectiveness12 and effective group dynamics and cohesion,1 the groups need to be large enough (estimated 8–12 women). In the longer term, low group attendance discourages staff and administrators from continuing due to financial or motivational reasons.9 11 13 Therefore, successful recruitment is important for the sustainability of GANC. This is even more so for Belgian PCOs.

In previous research, the participants’ rates of attendance varies from 20% to 96%.1 14 15 This may be related to women’s preferences, although attendance also depends on those that recruit. Variation in participation between practices indicates that elements at the organisational and professional level, such as attitudes and recruitment style of the facilitator need to be considered.16

Little is known about recruitment behaviour and strategies. To fill the current research gap, this study explores how women are recruited in PCOs, what elements influence the behaviour of the recruiter and what strategies recruiters use to encourage women to participate.

Methods

Study design

We adopted a qualitative approach to explore the experience of recruiters when interacting with potential participants. This approach, and by means of in-depth interviews, allowed us to collect in-depth information about the phenomena from the perspective of respondents.

Setting and participants

Participants were recruited from eight PCOs in Brussels and Flanders. The selected settings are, to our knowledge, the only settings offering GANC in a non-hospital setting who at that time had sufficient experience (at least 1 year) in recruiting women for GANC. These organisations primarily provide GANC to psychosocially vulnerable women, as defined by Amuli et al,17 as most GANC organisations in Belgium do. The participants were purposively selected because of their role as GANC facilitators and recruiters. Ten participants were approached by email and all accepted the invitation. The researchers applied an iterative approach of recruiting, data collection and data analysis. We recruited GANC facilitators until data saturation was reached and no new elements emerged.

Data collection

Data collection occurred from January 2021 to February 2022. Depending on the participant’s preferences, the semi-structured interview took place in person (1/10) or online (9/10) by two researchers (FT and AVD). Prior to the interviews, the researchers provided a brief introduction of their own backgrounds, the study, the goal of the study and confidentiality. The interview questions were based on selected constructs of the Consolidated Framework for Implementation Research (CFIR)18 and the Theoretical Domains Framework (TDF).19 This combination allows to explore the individual-level behaviour (TDF) and a more overarching perspective (CFIR).20 Both frameworks identify barriers and enablers during implementation of an innovation. While the CFIR operates at multiple levels (ie, intervention characteristics, outer and inner setting, characteristics of individuals and process), the TDF mainly focuses on individual-level behaviour change (ie, skills, emotions and beliefs about capabilities). To gain in-depth insights into behaviour (TDF), while maintaining the overarching perspective (CFIR), we opted to combine the frameworks. The open-ended questions posed during the interview were not directly based on the frameworks, but more general such as ‘How do you experience the recruitment of pregnant women for GANC?’, we explored specific domains of the frameworks depending on the participants’ answers.19 21 On the other hand, the interview guide also contained the constructs of the CFIR and TDF to explore specific topics in more detail. This flexible approach allowed an inductive examination while the frameworks draw the interviewer’s attention to the domains that could have an impact. Field notes made during and after every interview were used to guide the following interviews and to assist in the analysis of the data. Examples of interview questions are shown in table 1.

Table 1

Examples of interview questions

Analyses

Interviews were audio recorded and transcribed ad verbatim by two team members (FT and AVD). We applied the steps recommended by Braun and Clarke22 to conduct thematic analysis. To become familiar with the data, the researchers (re)read the transcripts while noting emerging codes. Initially, open codes (ie, emerging from the data, rather than being predetermined) were assigned. The researchers compared their codes from the first round of interviews (ie, two per researcher) and agreed which codes to merge. The codes were combined to form themes and compared with the constructs of the frameworks TDF19 and CFIR.18 The research team (FT, AVD and KB) decided to use the larger domains of the CFIR to subdivide the themes. The domains and constructs of TDF19 and CFIR18 allowed a structure, but enough flexibility to identify emerging themes. The team defined, refined and renamed the themes before finalising. An advisory committee reviewed the results during meetings. The researcher triangulation avoids single researcher bias23 and increases the trustworthiness of the findings.24 In addition, FT presented the findings at a meeting with five of the respondents and a workshop at a conference with GANC facilitators from the Netherlands and Belgium. The participants confirmed the findings. NVivo was used to support the analysis process.25

The respondents provided verbal informed consent for recording and use of anonymised quotations. The deidentified recordings, transcripts and coded data were stored on a password-protected and encrypted computer. Our study was reported according the consolidated criteria for reporting qualitative studies (online supplemental appendix 1).

Results

Length of the interviews ranged from 31 to 70 min. The participants (table 2) differ in terms of professional occupation, level of experience as a GANC facilitator and working region (ie, five in Flanders and five in Brussels).

Table 2

Characteristics of respondents (n=10)

Figure 1 includes the main constructs resulting from the analysis. We identified that the recruitment process consists of four phases or actions (arrows in figure 1). Depending on the phase in the process, different determinants may influence: level of the woman (individuals domain from the CFIR), level of the recruiter (individuals domain from the CFIR and domains of TDF), elements at the organisational level (inner setting domain from the CFIR) and environmental level (outer setting domain from the CFIR).

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Figure 1

Recruitment process workflow. GANC, group antenatal care.

Phase 1: identification of needs and potential obstacles for participation

During this phase, the woman’s characteristics primarily guide the recruiter’s behaviour. When the recruiter meets the woman for the first time, her needs, wishes and expectations are identified. This concerns the follow-up preference and psychosocial and medical needs (quote 1, table 3).

Table 3

Quotes phase 1

One respondent indicated to use a tool during this conversation (quote 2, table 3). The recruiter is also mindful of barriers (such as the presence of other children) and facilitating factors (such as the need for pregnancy information) that influence participation in GANC. The recruiter detects information that will help to introduce GANC.

Phase 2: selection of potential participants

During this phase, the recruiter decides whether or not to propose GANC based on detected needs and obstacles in the previous phase. In addition, elements beyond those related to women influence recruiters’ behaviour: elements at the level of the organisation, environmental level and level of the recruiter.

Determinants at the organisational level

How GANC is organised within the organisation influences the selection of participants. Respondents indicated they consider the imposed terms and conditions. This is related to the funding (eg, projects) or the organisation’s functioning (eg, community health centres focusing on a specific neighbourhood). As a result, some organisations only offer GANC to a specific target audience (quote 3, table 4).

Table 4

Quotes phase 2

The selection of people also depends on whether groups are continuously organised. In some cases, groups are scheduled regularly, resulting in continuous recruitment. They are assigned to a group, depending on characteristics, such as gestational age or language. Alternatively recruiters adopt a pragmatic approach and recruit for a specific group. They select women with characteristics, of which gestational age is the main one, until enough women form the group (quote 4, table 4).

Determinants at the environmental level

The COVID-19 pandemic is a major barrier to recruit in most cases. This led to the suspension of groups. One respondent argued that the pandemic was advantageous to GANC, as they were obliged to recruit smaller groups (quote 5, table 4).

Determinants at the level of the recruiter

Most respondents expressed a positive attitude towards GANC and emphasised the added value for women. One respondent was not convinced that GANC was an added value compared with individual follow-up (quote 6, table 4). Respondents did not mention that their view of GANC (either positive or neutral) impacted the selection of potential participants. However, the trade-off between the interest of the group and the benefit for an individual woman, did. Respondents indicated that the inclusion of each individual may impact the group. Especially when a woman has specific needs, such as intensive psychosocial support or the presence of a child in the group due to no childcare, this may affect the group dynamics.

Another aspect of this relation between group versus individual interest is the bandwidth of variety in gestational age between the women. In case of a large spread, the needs within the group differ. In addition, some will give birth earlier and the group will fall apart prematurely, which again impacts the group dynamics and cohesion.

Finally, it is also possible that the group has already been formed, the group dynamics and cohesion is established, and new participant may not be accepted by other members. For some, the interests of the group outweigh an individual. Consequently, they do not propose GANC. Others do not make a selection and suggest it to everyone, regardless of the perceived impact on the group (quote 7, table 4).

Others look at recruitment from the point of view of feasibility. They assess whether it is feasible, as GANC facilitators, to guide the groups when including a new member (quote 8, table 4).

Phase 3: recruitment for GANC

During this phase, the actual recruitment takes place. It consists of informing about GANC and responding to needs and obstacles. These subphases run simultaneously and are not always distinguishable. The actual recruitment is mainly characterised by the interaction between the recruiter and the woman, for which the determinants cannot be described separately. Thus, in this section, we included the determinants when describing the recruiter’s behaviour, which varies in what, when and how they inform.

What: information content

Regarding the content of information about GANC, the emphasis is usually placed on the social aspect and sharing experiences among peers (quotes 9 and 10, table 5).

Table 5

Quotes phase 3

Respondents indicate that there is no standard explanation but that the arguments are adapted to the woman’s needs. They focus on the elements of GANC that respond best to the women’s needs (quote 11, table 5). A recruiter will emphasise sharing experiences and information to a primipara with little experience. For others, the social aspect of GANC will be emphasised. For multiparae, who indicate to possess enough prenatal information and experience, her presence for the group is highlighted.

In addition, recruiters anticipate on potential obstacles to participate when informing (quote 12, table 5). Experienced recruiters know which factors can form a barrier, for example, time and respond to it immediately (quote 13, table 5).

How: communication style

In terms of communication style, the motivation regarding the GANC model is key and is reflected in the way they present GANC. Potential participants are more easily convinced when the recruiter is enthusiastic about GANC (quotes 14 and 15, table 5). Some indicate that, although they have always been convinced about GANC, positive experiences with GANC help to strengthen the attitude and drive (quote 16, table 5).

Another aspect is to inform about GANC in a calm, self-confident and non-intrusive way. The topic ‘GANC’ is incorporated into the conversation by presenting it as an equal possibility to receive the pregnancy follow-up. It helps to indicate that it is a standard way of pregnancy follow-up in this organisation (quote 17, table 5) and not as a project or a new offer (quote 18, table 5).

We observed a variation among recruiters in terms of self-confidence. When asked to what extent they believed they succeed in recruiting women, most are positive about this (quotes 19 and 20, table 5), but some have less self-confidence (quote 21, table 5).

According to several respondents, the level of experience as a GANC facilitator impacts the style of recruitment and the way GANC is presented. Experienced GANC facilitators have more confidence in their recruitment abilities compared with when they started GANC or compared with less experienced recruiters. Experience helps to convey in a calm and self-confident manner (quotes 22 and 23, table 5).

It is important that women know and feel they still have a choice to opt-out and continue in a traditional individual care path (quote 24, table 5).

Finally, a minority uses tools (eg, flyer or scheme) to recruit. However, most indicate that tools do not increase the participation and are only helpful on top of the verbal explanation of GANC (quote 25, table 5).

When: timing

The timing of introducing GANC is another crucial aspect. Respondents indicate that it is a matter of feeling whether the woman is receptive. According to one participant, proposing GANC too early causes women to reject (quote 26, table 5).

Thus, the degree of receptiveness is influenced by an existing bond of trust between the woman and the recruiter. The recruiter must first strive to establish the bond before proceeding to the recruitment. If a woman is referred, there is usually no pre-existing relationship between the woman and the recruiter. Development of the trusting relationship is even more important in this case. It is favourable when the referrer emphasises their trust in the recruiter’s expertise and to inform women about GANC through different caregivers and at different moments in time (quotes 27 and 28, table 5).

Phase 4: reaction to response

During this phase, we mainly identified elements at the level of the woman and the recruiter that determine how the recruiter will act.

After the presentation of GANC by the recruiter, the woman will either accept, doubt or refuse to participate. The women who accept immediately often do so because GANC provides more information and time. Some accept without any particular reason or intrinsic motivation, but to meet expectations of the care provider (quote 29, table 6).

Table 6

Quotes phase 2

Women report different reasons for refusing or doubting participation in GANC. The first group concerns logistical factors, such as no transport or absence of childcare. A second group of motives is rather intrinsic; it includes fear of the unknown (eg, new people or place and a different way of follow-up) and no interest in GANC (eg, sharing information and experiences) (quote 30, table 6).

Recruiters show a variation in the degree of persuasion. When the woman refuses, some recruiters indicate to persuade the woman to a lesser or greater extent. Others will leave it as it is (quote 31, table 6).

This response is determined by the extent to which the recruiter anticipates the degree of drop out (eg, due to the absence of childcare) and, therefore negatively affect the group cohesion. As a result, some recruiters will persuade less when they estimate that the woman might drop out. Others will make an extra effort for women they deem GANC to be important for. However, all respondents were unanimous in the view that persisting has to be avoided, as it is counterproductive. A better strategy is to leave the possibility open to participate.

Discussion

When recruitment falls short, implementation of GANC can fail.9 10 Recruitment often comes on top of other tasks related to the organisation of GANC, and its complexity is often underestimated.

The current research indicates that regarding enrolment in GANC, not only does the potential participant plays a role; the recruiter also affects this process. The process involves four phases: identification of needs and potential obstacles for participation, selection of potential participants, recruitment for GANC and reaction to response. It is influenced by determinants at the level of the woman, recruiter, organisation and environment. Although the environment has an impact on specific components and the overall implementation of GANC, this is less applicable for recruitment. Thus, to maximise recruitment success, the GANC organisation should deploy strategies to influence the level of the remaining determinants.

Strategies to influence determinants at the level of the organisation

The results demonstrate that some recruiters are obliged to select potential participants based on terms and conditions imposed by the organisation (eg, adolescents), making the group of potential participants scarcer. In addition, depending on the organisation, groups are not continuously organised. In Belgium, this is due to a small patient volume in PCOs. Organisations counter this by employing strategies such as rolling groups (ie, no consistent groups) or composing groups with a larger variation in gestational age.26 However, these strategies can jeopardise the fidelity of GANC, and therefore, affect the model components. In contrast, a high patient volume facilitates enrolment and the start of groups on a regular basis.9 This is an argument to cluster women from different (GANC) organisations. In this regard, it is necessary to engage other care providers to refer. Talrich et al27 state that the team should reflect on and execute an action plan to ensure a successful referral.

Internationally, organisations choose an opt-out method, meaning that women receive GANC unless it is impossible for them or state they prefer individual care.28 However, women need to make an informed choice and this method might force them toward GANC. Nonetheless, currently individual care is often offered as the sole option. Thus, the right balance is to present both possibilities.

Strategies to influence determinants at the level of the recruiter

Primarily, the recruiting team must be informed and motivated—the proper knowledge and motivation influence recruitment at different levels. As Novick et al28 put it: ‘An ideal recruiter would understand the intricacies of group care, enabling them to address patient concerns.’ This quote and current results suggest a training, comprising informing and motivating recruiters, stressing out the importance of basic skills as a care provider and teaching the ‘problem-solution’ technique (ie, linking the benefits of GANC to women’s needs or desires). To inform and motivate recruiters, targeted information includes a presentation of the model and research evidence (eg, outcomes and satisfaction of women), invitation to observe a GANC session and conduct the training using GANC activities.

Next, the training should emphasise how important basic skills as a care provider are during the recruitment, such as conducting an anamnesis to find out the needs and wishes, forming a trusting relationship, knowing when a person is receptive for information and inform in a understandable yet comprehensive manner, adapted to the individual.16 However, these skills are necessary for any type of care and are not specific to GANC.

Finally, current results show that the ‘problem-solution’ technique commonly motivates women to participate.

Vonderheid et al29 encourage a similar technique, the 3-step communication strategy, in which the caregiver (1) asks an open-ended question to identify the impression or concerns (eg, ‘What are your thoughts about GANC?’), (2) affirms this expressed concern using verbal or non-verbal communication and (3) responds to these concerns using targeted information. Recruiters, especially new ones, can benefit from a document that lists the most common concerns and barriers and the appropriately targeted information. Recruiters can also learn these skills through role-playing to become more self-confident, which is an important feature when recruiting according to the results. Given the existing challenges regarding recruitment, it may be useful to address this topic more extensively during the current GANC-facilitator training in Belgium and other countries.

Finally, recruiters should be encouraged to propose GANC to all women and not to make a selection based on assumptions they have about women’s likelihood of participation. These assumptions are misleading and do not predict whether a woman will participate. Regardless of their background or characteristics, all women can benefit from or be interested in GANC. An additional argument is that when recruitment is limited to a specific target group, GANC facilitators might encounter difficulties facilitating the group. Due to their challenges, the individuals in the group are less able to offer support themselves and force a facilitator to take up this role. A group with diverse characteristics and backgrounds is enriching and supportive for everyone. The group and not just the facilitators provide the support.

Strategies to influence determinants at the level of the woman

Respondents in the current study described the most common obstacles that discourage women from coming to GANC. Some are logistical barriers, others rather intrinsic. The latter included fear of the unknown and no interest in GANC. These barriers are similar to those demonstrated in previous research.16 30 31 The GANC organisation can introduce measures to overcome the first type of barriers, such as providing childcare, bus tokens and adapting hours to the preferences of the women. The second type of barriers can be remedied by increasing the visibility and normalisation of GANC. Advertisement using brochures, posters and video matrices placed in strategic locations (such as the waiting room) help raise awareness of the existence of GANC.29 Preconception care can reach couples even before pregnancy and inform them about all follow-up options during pregnancy, including GANC. An additional strategy is to offer all women who have positive pregnancy tests a joint initial group consultation instead of a one-to-one consultation.32 The group receives an introduction according to the principles of GANC in the room where GANC is offered. It is also an opportunity to provide testimonials of women who previously received GANC. By offering GANC and an individual assessment as standard approach at the beginning of pregnancy women get the opportunity to make a more informed choice.

Limitations and strengths

The researchers focused on recruitment within PCOs. In Belgium, these organisations face the most difficulties in assembling sufficiently large groups, due to a smaller patient population compared with hospitals. In addition, the number of respondents is relatively low. However, data saturation was reached; therefore, the researchers assessed to have sufficient amount of data. Moreover, the number of organisations offering Group Care in Belgium is currently limited, and as a result, we covered most of the PCOs.

This study is limited to the recruitment behaviour of a GANC facilitator. Still, to ensure successful recruitment, it is crucial to be aware of blind spots before and after the recruitment. Referral is an important aspect that has been examined by Talrich et al.27 Next, avoiding drop out remains a challenge, as in one-to-one care, and is even more pronounced in psychosocially vulnerable groups.33 The role of this aspect in the recruitment process remains to be analysed in future research.

Finally, the results have to be interpreted within the specific Belgian context, including its healthcare and financing system, on the one hand. On the other hand, the target group to whom GANC is mainly offered in Belgium are women with an increased risk of vulnerability. This may hamper the transferability of results. However, we believe that lessons learnt and proposed strategies are applicable to new start-up innovations or programmes in other fields of healthcare. The strengths of this study are the triangulation with the research team, participants and study population (GANC facilitators). Additionally, our research identifies determinants at different levels and provide specific strategies which GANC organisations can apply relatively easily.

Conclusion

We conclude that it takes two to tango for successful recruitment for GANC, since this is not only dependent on women’s needs and wishes, but maybe more so on the recruiters’ behaviour. This in turn is influenced by elements at the level of the woman, recruiter, organisation and environment. Thus, recruitment and the likelihood of successful implementation can be enhanced when introducing a multidisciplinary recruitment plan consisting of specific strategies, as we suggest. Thorough reflection, planning and preparation before the launch of GANC are crucial.

Contributors: All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. FT is the responsible author for the overall content as the guarantor.
Funding: This work was supported by the National Institute for Health and Disability (CGV 2018/363).
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Anonymised coded data available in Dutch upon request to the author.

Ethics statements

Patient consent for publication:

Ethics approval:

This study involves human participants and ethical approval was obtained from the Medical Ethics Committee of the University Hospital Brussels (Approval number 2019-365) on 20 November 2019. Participants gave informed consent to participate in the study before taking part.

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Overview

Abstract
Introduction
Methods
Results
Discussion
Conclusion
References

Supplementary files
Footnotes
Publication history
Rapid Responses

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