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 .
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 . 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 . 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 . 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.