P-476 Barriers and facilitators to nationwide implementation of fertility screening interventions: a qualitative study
Authors: Zainal H , Chan S  L , Pong C , Koon T , Li X  M , Tan K  J Y , Alias N  S , Thumboo J , Boivin J , Ng K  C , Chua K  H , Yu S  L 
Published: July 2024

Abstract

Study question
What are the barriers and facilitators to the potential nationwide implementation of Fertility Health Screening (FHS) and/or Fertility Awareness and Education (FAE) in Singapore?

Summary answer
The study reveals implementation factors that shed light on how advanced societies can adopt evidence-based interventions to deliver fertility education together with behavioural change nudges.

What is known already
Fertility awareness surveys have consistently shown low public awareness of age-related fertility decline and the limitations of fertility treatments. Furthermore, preventive public health messages to increase fertility awareness are known to produce limited sustained effects. While there is evidence that tailored interventions are more effective than generic ones at increasing fertility awareness, interventional studies targeted at those of reproductive age are scarce. An effectiveness-implementation hybrid type I 3-arm open-label randomized clinical trial (RCT) is underway to evaluate the effects of two theory-based interventions on knowledge, attitudes and practices around childbearing among young married couples in Singapore.

Study design, size, duration
The present qualitative study was conducted to explore experiences and perspectives on the interventions and their potential implementation among healthcare professionals (HCPs) involved in implementing the interventions and a sub-sample of couples randomized into either treatment group. Recruitment used purposive sampling. Individual semi-structured interviews were conducted from June 2021 to December 2023. The Consolidated Framework for Implementation Research (CFIR) was used to develop the interview guide. Sample size was determined by data saturation.

Participants/materials, setting, methods
Couples in either treatment group were recruited after completing their final follow-up visit, while HCPs were recruited at their convenience. After taking written informed consent, the interviews were conducted in person or over Zoom and audio recorded. The interviews were transcribed verbatim and inductive thematic analysis was used to evaluate the data. Themes were then mapped to CFIR constructs. The results were reported according to O’Brien et al.’s (2014) Standards for Reporting Qualitative Research.

Main results and the role of chance
Twenty HCPs (10 doctors, 8 embryologists, 1 nurse and 1 manager) and 29 heterosexual couples (FHS n = 16; FAE n = 13) participated in the interviews. Median age was 30 (women) and 32 (men) years with most participants having post-secondary education. In FHS, couples underwent an Anti-Mullerian Hormone (AMH) test and semen analysis (SA), doctor’s consultation, and standardized counselling by a trained nurse. In FAE, couples watched a video of other couples’ pre-pregnancy experiences, completed an adapted fertility status awareness tool (FertiSTAT), and received an educational brochure. FHS barriers (CFIR constructs n = 6) included the discomfort when producing SA samples, male partners’ reluctance to share personal information with embryologists for SA, stigma associated with undergoing fertility-related tests, lack of time for appointments, limited cost effectiveness, and shortage of human resources due to potential increase in service demand. FHS facilitators (constructs n = 4) included evidence-based testing, increased knowledge of reproductive potential, advice from trained HCPs and comprehensible brochures. Perceived facilitators for FAE (constructs n = 2) included compelling video messages and clearly designed questionnaires. No major barrier was reported for FAE. Overall, insights gained from the interviews can inform strategies to address barriers and leverage facilitators for each intervention.

Limitations, reasons for caution
Barrers and facilitators may differ between countries. There may also be selection bias in the recruitment strategy, as participants were likely those who wished to have children. Moreover, the lack of diversity in educational qualifications and ethnicity may exclude the influence of class and cultural factors on parenthood intentions.

Wider implications of the findings
The findings contribute to an understanding of personalised fertility interventions coupled with behavioural change influences by showing how qualitative process indicators could complement research on interventions’ effectiveness. This has implications for other developed countries that are seeking to explore how implementation factors can expedite clinical best practice after research discovery.

Trial registration number
NCT04647136