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.