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

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.

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).

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).

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.

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.

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).

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.

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.