CLR

Assignment: The Critical Literature Review

Assessment type;

Review

Word limit/length;

·
An overall max total of 4000 words – This includes the critical review [ ~ 3000 words-see assessment details for breakdown below] and also the revised Method section from assignment 2 [up to 750 words].

·
The word count also includes in-text references but not the reference list.You must clearly indicate a word count (excluding the reference list) at the start or end of the paper.

Please convert ALL the method and result diagrams/figures and tables used into images so that they are not included in the word count.

Minimum of 30 references

Overview

Produce a robust, reproducible, comprehensive critique of the literature relevant to your discipline and research interest.

Learning Outcomes

This assessment task is aligned with the following learning outcomes:

1. Analyze, refine and manage results of a systematic literature search

2. Provide an evidence-based rationale for further research or practice change

Assessment details

You aim to produce a robust, reproducible, comprehensive critique of the literature in an appropriate format that includes a discussion justifying future research and/or practice change. A structure for the assignment is provided below. An
approximate word count per section is provided but there can be variations.

Title: 20 words

· Provide a succinct, clear, and informative title for your critical review.

Introduction: 750 words –
please adopt the information from assignments 1 & 2 as applicable.

·
What we already know about the topic – Include your problem statement and background to clarify what is already known on your topic and to define relevant key terms/theories.

·
What we do not know about the topic – Give a justification for conducting the review specifying what this review will add to the existing literature. Consider: How? Why? What could happen if this review is not done? Outline who will benefit (e.g., consumers, carers, professionals, policymakers, and community and society as a whole).

· Your
research question needs to be included at the end of the introduction.

Method: 750 words –
please adopt from assignment 2

· You should incorporate your revised Assignment 2 (the Method section) into this critical literature review. You will have used the feedback provided to make any necessary changes to the method. NO rephrasing is required. It is Ok if the research question is repeated here.

Results: up to 900 words

·
Descriptive findings – Present a summary of the final included studies in an integrated way including descriptive findings such as the number of final included studies; countries/settings the studies were conducted; population numbers and their characteristics; study designs.

·
Advanced synthesis – Provide critical/advanced synthesis of the information (e.g. different interventions being used in the studies, comparisons between them, different themes, and key issues emerging).

·
Data extracted table – Include results table (see Table 2 template Week 4, Page 2). The table of data extraction can vary based on the type of reviews, but generally, it can include a) name of the authors/year of publication or citation; b) the aim of the study; c) method (e.g., research design, sample size, participants, and method of data collection); d) findings; e) limitations.
Please do not critically interpret any of the studies in this section (save for Discussion).

Discussion: up to 900 words

· Provide
critical interpretation of the key findings while referring to the studies in the results table/s (e.g., Table 2) but do not introduce new results in this section (revise the Results section if you become aware of new results). Identify current issues, concerns, viewpoints, and arguments. Link to the content of the introduction while avoiding repetition; discuss the extent of current knowledge on the topic by referring to background citations.

· Comment on the
strengths and weaknesses of your methods, the included study designs, and your key findings.

· Discuss
implications for future research and practice change, and justify your recommendations (e.g. possible study designs or strategies to implement).

Conclusion and recommendations: 400

· Summarise the main findings or the
highlights of the review, as well as
recommendation/s (for individuals, policy, and practice, as applicable). Only include information already presented and discussed in the review; this is a summary in your own words so no in-text citations are required and you should not introduce any new material or ideas (if you think of anything new, go back and add it to the finding section).

References

· Support statements correctly with in-text citations and appropriate referencing. Apply the APA 7th edition style correctly throughout, including a correctly formatted References section.

Please note that in-text citations are included in the word count but reference list citations are not.

Please indicate the total word count without the reference list clearly at either the start or end of the paper.

Reason: Reviews necessarily include many papers and therefore many required citations in the reference list. This would eat up too many of your words allocated so just for this assignment
the reference list is not included in the word count.

Presentation

· The tone should be directed toward an intelligent, non-expert audience. Avoid plagiarism and self-plagiarism by allowing time to check the similarity report on Turnitin and revising, and re-submitting before the due date. Use APA 7th style. Follow conventions for labeling tables (above the table) and graphics (centered above). Write all numbers less than ten in words and never start a sentence with a numeric symbol. For example, “Thirteen studies met the inclusion criteria for this literature review. Three of the 11 retrospective studies used a control group.”

·

A reminder to to convert your figures and tables into images so that they are not included in the word count. Please follow the below steps to do so:

Cut the entire table and paste it into a new word doc so you have it separate if you need to make last-minute changes later. Save this file then follow the steps below:
1. Copy the entire table from the new document (copy only, not cut)
2. Go to your assignment where you want to put it, right-click, and select “paste as picture” … it looks like a clipboard with a photo in front of it. The word should have then dropped your whole table as an image into that spot. Please refer to the below link for further information:

https://www.techwalla.com/articles/insert-jpg-microsoft-word

14

Assignment 3 rubric

Criterion

HD (≥51)

DI (45-50)

CR (39-44)

PA (30-38)

F (<30) Title (2%) · Summarises the main theme and has: “A Critical Literature Review” in the title. · Concise, clear, and informative title All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described. Introduction/background (10%) · Topic competently introduced including problem statement, the rationale for doing a review with justification and beneficial aspects. · Background studies provided showing the importance of what is known on the topic and defining key terms/theories. · Research question/purpose of review explaining what it intends to accomplish All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described. Method (no marks but must be included in final review) · The complete, revised version of Assignment 2, including figures and table. All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described. Results/findings (15%) Summary of study designs and findings: · Integrate summary of study designs and findings of included articles · Include results table/s (e.g. Table 2: sample size, the age range of participants, method of data collection findings, and other relevant study variables) · Provides a summary of key issues and themes that emerge from the analysis of studies as shown in Table 2 · No provision for interpretation of these studies in this section. All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described. Discussion (15%) · Links to Introduction and discusses current knowledge on the topic · Key findings were critically interpreted and included articles cited (no new results discussed). · Current issues, concerns, contradictions, viewpoints, and arguments identified · Comments on strengths and weaknesses of study designs and key findings · Implications for practice and/or future research discussed · Justify recommendations for practice change and/or future research, including proposed implementation strategy/study design All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described. Conclusion and recommendations (8%) · Summarises the main ideas presented in the review, including recommendations · No new material, ideas, or citations All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described. Presentation (5%) · Appropriate font size, page numbering, subheadings · Tables and graphics numbered and appropriately titled · Adheres to word count · Appropriate for an intelligent audience, not necessarily from the same discipline · Correct grammar, spelling, and punctuation with no repetition All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described. Referencing (5%) · APA 7th edition style correctly applied · Statements correctly supported with appropriate referencing · References listed correctly All criteria were met and clearly described. Some criteria were met and described. Criteria not met or described.

A Critical Literature Review of The Influence on Nursing Morale secondary to Leadership Factors

Introduction:

Staff morale, or workplace culture, is a workforce phenomenon that certainly, on occasion, challenges every organisation (Day, Minichello & Madison, 2006). Morale is a formidable indication of organisational well-being and efficiency (Brode, 2012). The consideration of morale is imperative as it can have substantial and widespread impacts and consequences for an organisation (Day et al., 2006). So often, organisational culture can be deep-seated and challenging to shift. (Brunges & Foley-Brinza, 2014). Attaining, supporting, and maintaining workforce culture is one of the many tests associated with leadership (Brode, 2012).

Both intrinsic and extrinsic factors can influence staff morale. Professional support, leadership traits and management styles, fears about job security, and excessive workload, which are all extrinsic factors, are the leading themes in poor morale amongst nurses and healthcare workers. Intrinsic factors that impact staff morale include feeling valued and respected, having good relationships with colleagues, and giving good patient care (Day et al., 2006). By conducting a literature review, these factors can be explored and analysed. The significance of morale has been thoroughly documented in nursing literature, however, there are no systematic reviews pertaining to how differing factors of leadership generate influence over workplace culture (Stapleton, Henderson, Creedy, Cooke, Patterson, Alexander, Haywood, & Dalton, 2007).

Nurses are exiting the workforce for other professions, taking the skills, knowledge, and education with them resulting in a loss not only to the organisation, but also to the nursing workforce. Turnover and low morale in nursing has the capacity to cause numerous undesirable affects, involving increased workload, a rise in medication errors, adverse outcomes, and excessive costs to managers and employers when attempting to replace personnel (Madathil, Heck, & Schuldberg, 2014). Employees are the most valuable asset in any organisation, who clearly affect the operational success of the organisation for which they work. The economic cost to an organisation in failing to adequately support employees in the delivery of satisfactory patient care and sound clinical practice is significant (O’Donnell, Livingston, & Bartram, 2012).

Australian and global research summarises an account of causes and effects of poor workplace culture on nursing personnel. It is clear that the results of poor workplace culture not only add great expense to organisations, but also have detrimental influences on the care patients receive, even though there is an absence of agreement regarding the determinants of workplace culture (Day et al. 2006). Nurses’ abilities to meet organisational goals and research on what leadership factors nurses perceive as influential on their staff morale has not been explored (Germain & Cummings, 2010). Previous research has implied that the retention of staff is prompted by ‘on-the-job’ aspects which further influence low morale and dissatisfaction, fueling a ‘wish’ to exit the organisation, and causes staff to leave when they sense comparative effortlessness in exiting the organisation. Therefore, inciting inner enthusiasm in employees will produce a deeper lasting feeling of fulfilment, contentment, increased morale, and related efficiency at work Stapleton et al., 2007).

Nurse manager behaviours that influence nurses’ morale are most commonly described only theoretically, and chiefly from the perspective of the nurse managers. Limited research articles have investigated the personal anecdotal experiences of the nursing workforce concerning the connection linking their levels of morale and career fulfilment and the leadership practices of their executives (Feather, 2015). While styles of leadership have been extensively examined, they continue to be weakly grasped. For instance, a key awareness into the association concerning the morale of nurses and the behaviour of nurse managers could support nursing directors and managers to embrace strategic directives (Feather, 2015).

Nurse managers are in a position to influence the morale of their staff, thus affecting patient outcomes, career fulfilment and retain nursing staff due to their leadership practices (Bormann & Abrahamson, 2014). Organisational achievements and staff member’s capability to succeed are prompted by a leader’s proficiency to provoke exceptional performance within the individual. When a leader generates a meaningful work atmosphere or a sense of optimism, this can facilitate the best in employees, consequently generating inherent morale, ongoing learning, and motivation (Stapleton et al., 2007). Low morale and motivation, increased turnover, and employee dissatisfaction should be primary concerns in any workplace setting.

The structured question formulated for this critical review is ‘What factors of leadership do nurses perceive as influential on staff morale?’ The aim of this critical literature review is to address the identified research gap and provide insight and value into identifying and exploring the factors of leadership that influence the morale of nurses.

Method:

The most appropriate systematic review typology for this topic of research is an experiential (qualitative) review, with the emphasis on evaluating nurses’ perceptions of leadership traits that influence staff morale. Munn, Stern, Aromataris, Lockwood, & Jordan (2018) convey that the question format guides its development, therefore influencing the type of review required. As the research question is specifically examining the subjective experience of nurses’ perceptions, a non-positivist approach is best suited (Munn et al., 2018).

The PICo format, in this instance, is employed to drive the formation of the question and examine the population’s subjective perception of the phenomenon of significance within an environment (Munn et al., 2018). The population is staff nurses; the Phenomenon of Interest is factors of leadership; and the Context is the influence on staff morale.

In guaranteeing that primarily an appropriate question was solicited, and that it is associated with the issue, this stipulates the foundation for retrieving the material from diverse areas, (Munn et al, 2018). Submitting the formulated question using the PICo technique, is a methodical formula which identifies the problem statement and makes sure all sections of the question will augment evidence-based searching of the research (Milner & Cosme, 2017). Munn et al (2018) highlights the magnitude of generating a well-structured and precise question to advance with collecting applicable documentation on a subject for additional study or employing a practice modification or guideline. The question criteria, population, phenomenon of interest, and context guarantee that the search of the primary literature is thorough, and recognises bias while developing the systematic review, (Pollock & Berge, 2018).

The Academic Search Planner, CINAHL, MedLine, ProQuest, and Scopus electronic data bases accessible via University Library were used to conduct systematic searches for literature. These databases were chosen as they are appropriate to nursing and allied health and are readily accessible and simple to navigate. The following key search terms were selected and combined with Boolean operators: (leadership and management styles in nursing) AND (staff perceptions or attitudes or opinion or experience or view or reflection or beliefs). Academic Search Planner, CINAHL and MedLine all had the same key search strategies. ProQuest and Scopus required extensive delimiters and different key search strings due to their different operational structure. Secondary and grey sources of literature were excluded from this review.

The search strategy, including the databases, key search terms and the number of articles found using this method, is shown in
Table 1. The search was undertaken during March 2019; it was limited to articles published between 2006-2019 to capture research that was current, accurate, and evidence-based. The following inclusion criteria were applied during article selection:

–

Population was over the age of 20 and had to be either an enrolled or registered nurse in a healthcare setting

– Published between 2006-2019

– Discussion of Leadership and Management perceptions and/or expectations of staff nurses

– Scholarly (peer reviewed) journals

– Studies that addressed nurse assessed leadership practices/factors

– Language – English

These criteria were employed to ensure that the research question is answered appropriately without returning too many articles and duplications.

Table 1. Databases and search terms used to identify literature for review

Database

Search terms

No. articles

Academic Search Planner

leadership and management styles in nursing

6

AND

staff perceptions or attitudes or opinion or experience or view or reflection or beliefs

Limiters:

English; 2010-2019; Scholarly (peer reviewed) journals

CINAHL

leadership and management styles

4

AND

staff perceptions or attitudes or opinion or experience or view or reflection or beliefs

OR

Limiters:

2010-2019; English; Scholarly (peer reviewed) journals; Subject Headings: job satisfaction, nurses, staff nurses, organisational culture, nurse attitudes

MedLine

leadership and management styles in nursing

3

AND

staff perceptions or attitudes or opinion or experience or view or reflection or beliefs

Limiters:

2010-2019; English; Academic Journals

ProQuest

what factors of leadership do nurses perceive as influential on staff morale

12

Limiters:

2010-2019; Scholarly (peer reviewed articles) journals; Excluded Subject Headings: colleges & universities, human resource management, physicians, teaching, corporate culture, medicine, business schools, diplomatic and consular services, education, medical personnel, schools, students, teachers; Subject Headings: leadership, nurses, managers, organisational culture

Scopus

staff AND morale

31

AND

leadership AND management AND styles

AND

Staff AND perceptions

Limiters:

2010-2019, English, articles; nursing; excluded subject headings: Medicine, Business, Management & Accounting

Total records identified after database searching

56

Total records after duplicates removed

55

Figure 1 demonstrates how the articles were screened and selected. This literature search method yielded 56 articles. Once the duplicate (n=1 article) was removed, the abstract of 55 articles were screened for inclusion in this review. Most of the rejected articles (n=40) were either focused on the nursing manager’s perceptions or conflict-resolution based, not based on the inclusion criteria, or literature reviews. Elements of these articles were also, not current and were not concentrated on nursing. These articles were excluded. The remaining 15 full-text articles were screened for inclusion in this review. A further two articles were excluded for the following reasons:

– The work environment/resources, quality of care and job satisfaction were addressed, but no leadership factors were discussed. (Chevalier, Lejeune, Fouquereau, Coillot, Gillet, Gandemer, Michon,. & Colombat, 2017)

– Johansen and Cadmus (2016) discussed conflict management as opposed to factors of leadership.

– Both Chevalier et al. (2017) and Johansen and Cadmus (2016) targeted very specific specialties, emergency and paediatric oncology, within nursing, which could potentially influence the research outcomes, as different specialties usually have quite specific requirements.

– Chevalier et al. (2017) discussed the mediation role between managerial and nursing organisational resources, therefore demonstrating that the study lacked relevance to the research topic.

The remaining articles (n=13) were both Australian and international studies. These studies often overlapped and used differing study designs and data collection methods for the different sections within their research. The studies included 2 phenomenological-hermeneutic approaches; 2 mixed method designs; 4 cross-sectional designs; 2 quasi-experimental, pre-post-test designs; 2 explorative descriptive designs; 1 descriptive correlational; 1 descriptive phenomenological; and 1 longitudinal design.

Potentially relevant articles identified through database searching
(n = 56)

Articles excluded after evaluation of titles/abstract (n=40)

· Nursing manager focused

· Conflict-Resolution based

· Literature reviews

Articles after duplicates removed

(n = 55)

Full-text articles assessed for eligibility
(n = 15)

Articles excluded with reasons, after full-text assessment (n= 2)

· Incorrect aim

· Incorrect setting

· Conflict Management

Additional studies identified through reference list search (n=0)

Total articles included in review (n =13, based on multiple study designs)

Articles included in review {(13 articles based on multiple study designs, that often overlapped: mixed-method (2), cross sectional (4), explorative (4), phenomenological-hermeneutic (2), longitudinal (1), and quasi-experimental pre and post (2)}.

Figure 1. Modified PRISMA flow Diagram of article screening and selection

Results:

The final set of included studies and their characteristics are presented in
Table 2. Of the thirteen studies, published between 2006-2019, three were conducted in Australia, one in Italy, one in Iceland, one in Saudi Arabia, one in Ghana, West Africa, one in the United Kingdom (UK), one in Canada, two in Sweden, and two in the United States of America (USA). The studies reflected nurses’ perceptions of leadership factors, how staff morale was influenced, and the subsequent impact/s. Demographics of nurses were reported in ten out of the thirteen studies. The majority of respondents were female registered nurses, working in a healthcare facility, averaging 40 years of age, with an approximate mean of at least nine years nursing experience. The female predominance is reflective of the current global nursing workforce demographic, as ninety percent of the nursing population is female (Fischer, 2017). However, one study, that still had a predominantly female sampling population claimed in its limitations section that the male population was over represented (Mannix, Wilkes, & Daly, 2015). Two of the sample populations were selected randomly, four purposively, and seven via the convenience method. The sample populations ranged in size from 14 (O’Donnell et al., 2012) to 1249 (Lornudd, Tafvelin & von Thiele Schwarz, 2015).

Seven out of 13 studies were guided by either a theory, framework or model; some incorporated more than one theory in each research article. This is significant as theories, frameworks and models offer a justification for development of hypotheses and pragmatically examine associations regarding variables and concepts (LoBiondo-Wood & Haber, 1998). Five out of 13 studies used the Transformational Leadership (TL) Theory. TL ‘is defined as a leadership style in which the leader encourages his or her subordinates to achieve higher levels of performance through training programs, mentoring, and skill development programs; they are type of leader that make an impact on organisational growth’ (Akrajindanon, 2018). Sellgren, Ekvall & Tomson, (2006) and Lornudd et al. (2015), both used the change, production, employee (CPE) model to evaluate ‘desired’ leadership behaviours. Sellgren et al. (2006) and Lornudd et al. (2015) both used this model to develop the questionnaires presented to their sample populations. Although the CPE model has predominantly been assessed for use in the private industrial sector, relevance of the model in the healthcare setting is supported (Lornudd et al., 2014). Sellgren et al. (2006), Bormann & Abrahamson (2014) and Morsiani, Bagnasco, & Sasso (2016), all employed the Multifactor Leadership Questionnaire (MLQ) which is based on the ‘Full Range Leadership Development Theory’ by Bass and Avolio (1995) which explores nine leadership styles and is associated with measuring effectiveness, extra effort and outcomes of satisfaction (Bass & Avolio, 1995). Saleh, O’Connor, Al-Subhi,Alkattan, Al-Harbi and Patton (2018) employed the Ricoeur philosophy, which uses a hermeneutic phenomenological approach for describing and interpreting the data that was collected through out their study. Hermeneutic phenomenology is not just a method of research, nonetheless, more accurately, it is both a conjectural perspective and an approach. Ricoeur’s philosophy warrants being deliberated over by the human science researchers who pursue a rigorous basis for their studies (Tan, Wilson, & Olver, 2009). Brunetto, Farr-Wharton and Shacklock (2011) utilised the Leader-member exchange (LMX) theory which maintains that in perfect environments valauble collegial associations – particularly the employer-employee relationship steers towards advantages for the staff member and the workplace. This theory claims that supervisors govern staff contrarily and subsequently, some staff have good work experiences and outcomes and others don’t, but in empowering employees, best management practices are employed (Brunetto et al., 2011). In using the LMX theoretical framework, staff should sense an increase in autonomy when the messages coming from their supervisors are clear and succinct, and subsequently would distinctly comprehend their allocated work duties and understand who to approach for assistance required to address the needs of their patients (Brunetto et al., 2011). Dahinten, MacPhee, Hejazi, Laschinger, Kazanjian, McCutcheon, Skelton-Green, & O’Brien-Pallas (2014) used a theoretical workplace empowerment framework which is centred on executive and organisational theories and social-psychological theories and a conceptual model of programme effects (Dahinten et al., 2014). This framework emphasises the significance of developing high-quality leader-staff connections that empower the nursing workforce.

Four methods of data collection were identified. Some studies used more than one method for data collection. Two studies conducted interviews (Saleh et al., 2018; Azaare & Gross, 2011). Morsiani et al. (2017) and O’Donnell et al. (2014) utilised focus groups. Mannix et al. (2015), Borman and Abrahamson (2014), Madathil et al. (2014), and Brunetto et al. (2011) all used surveys and eight studies used questionnaires. Twenty-five different instruments were used to measure factors of leadership that nurses perceive as influential on staff morale. Seven out of 13 studies used the Likert Scale. Likert scales are used to investigate how participants rate their response to a question or account by having them select a numbered category or statement. Likert scales are useful for gathering participants’ opinions, feelings, or attitudes on the topic in question. The responses are given a score by the researchers and the variables are subsequently measured (Norman, 2010). Three out of 13 used the MLQ. The MLQ distinguishes the main common leadership styles and practices. It ensures firm validity and reliability as a measurement of leadership (Bormann & Abrahamson, 2014). Two out of 13 used the CPE tool. The CPE tool measures leadership from three fundamental dimensions, change/development, employee/relations and production/task/structure, which can be combined into leadership profiles (Sellgren et al., 2006). Many of the included studies used multiple measurement instruments, indexes, tools, and scales throughout different sections of their analyses.

Sixteen different factors, in total, were reported by nurses that influenced their morale in the final group of studies reported on in
Table 2. However, out of these 16 factors, there were five key themes, and five constant affects. The five key themes identified are Transformational Leadership, Autonomy, Empowering Staff, Professional Development, and Communication. The five constant affects of these factors were job satisfaction, motivation, organisational commitment, morale, and retention.

If nursing managers and leaders are conscious of their own leadership profile, the healthcare organisation in which they are employed, the expectations of their role, in combination with being able to enhance the performance of their staff by addressing the aforementioned factors and affects, they can positively influence the morale and motivation of staff to perform; and subsequently have the greatest potential for success in empowering and retaining their staff.

Table 2. Results Table

Author/Year/Country

Study Design

Sample Size

Age Range

Method of Data Collection

Results

Limitations

Saleh,
O’Connor,
Al-Subhi, Alkattan,
Al-Harbi, Patton,
(2018), Saudi Arabia

Phenomenologic-hermeneutic approach, cross-sectional design

35

–

Interview

4 major themes relating to leadership:
Relational; preferential; communication chain; and ineffectual leadership styles.

Small sample size
Cross-sectional design

Morsiani, Bagnasco, Sasso, (2016), Italy

Mixed Method Study

82

Average age of 40 years

Questionnaire and 3 x focus groups

Two contrasting themes identified: transactional VS transformational leadership

Small sample size
The focus group participants were not involved in the original questionnaire, thus limiting generalisability of results

Sveindöttir, Ragnarsdöttir, Blöndal, (2015), Iceland.

Cross-sectional explorative survey design

189

>40 years of age

Questionnaire

Nurses who received little or rare praise considered leaving their department

Small number of participants and only half of the eligible nurses participated.
Recall and method bias from rating one’s own behaviour

Mannix, Wilkes, Daly, (2015), Australia

Mixed Method Design

66

<25 - >45 years

2 x Surveys

Desirable traits of leaders identified: providing support, being an effective communicator, showing appreciation, challenging processes

Small sample size
Overrepresentation of male nurses
Method bias when contextualising characteristics

Author/Year/Country

Study Design

Sample Size

Age Range

Method of Data Collection

Results

Limitations

Lornudd, Tafvelin, von Thiele Schwarz, Bergman, (2015), Sweden

Cross-sectional study design

1249

–

Questionnaire

All leadership orient-ations were negatively related to employee distress

Cross-sectional study design

Bormann, Abrahamson, (2014), Kentucky, US.

Descriptive, correlational design

115

Mean age of 42 years

Survey & Questionnaire

Transformational and transactional leadership styles were positively related to staff nurses overall job satisfaction

Participants only worked in 1 facility
Response rate to the survey was lower than is optimal

Madathil, Heck, Schuldberg, (2014), Montana & New York, US.

Quasi-experimental, pre-post-test design

89

–

Survey and Questionnaire

Leadership styles and work role autonomy are likely factors that protect against burnout in nurses

Method bias from rating one’s own behaviour
Sample size

Dahinten, Macphee, Hejazi, Laschinger, Kazanjian, McCutcheon, Skelton-Green, O’Brien-Pallas, (2014), Canada

Quasi-experimental, pre-post-test design

129

Mean age of 46 years

Questionnaires

Greater staff organisational commitment was secondary to leader-empowering behaviours and programme attendance

Sample size

O’Donnell, Livingston, Bartram, (2012), Australia

Descriptive phenom-enological approach

Group 1 – 9
Group 2 – 5

20-40+ years

Two focus groups that participated in taped interviews

Lack of HRM training of NUMs consequently resulted in reduced staff morale, decreased staff satisfaction and retention issues

Very small sample size

Author/Year/Country

Study Design

Sample Size

Age Range

Method of Data Collection

Results

Limitations

Munir, Nielsen, Garde, Albertsen, Carneiro, (2012), United Kingdom

Longitudinal Design

188

Mean age of 45 years

Questionnaire

Work-life conflict, job satisfaction and psychological well-being are directly associated with transformational leadership

Method bias from rating one’s own behaviour
Some explanatory variables and demographic information were not included in the study
The sample was of nurses only working in aged care and predominantly female, therefore the study can not be generalised to other settings

Brunetto, Farr- Wharton, Shacklock, (2011), Australia

Cross-Sectional Design

900

<30 - >45 years

Survey

The 4 hypotheses all influenced nurses’ level of affective commitment

Low response rate
Method bias from the use of self-report surveys
Only private sector hospital staff were the sample participants
Female predominance

Azaare, Gross, (2011), Ghana

Qualitative, explorative, and descriptive design

20

20-59 years

Taped interviews

Nurse managers employed intimidation and minimal consultation to control their employees

Study findings are not entirely conclusive or transferable due to possibility of ethnic and cultural differences
Sample size

Author/Year/Country

Study Design

Sample Size

Age Range

Method of Data Collection

Results

Limitations

Sellgren, Ekvall, Tomson, (2006), Sweden

Qualitative, explorative and descriptive design

492

20 – >60 years

Questionnaire

Managers and their subordinates have vastly different opinions related to production and relation orientation

Low response rate
Dropout rate
Female predominance

Discussion:

This critical literature review focused on an appraisal of research examining the factors of leadership that nurses perceive as influential on staff morale. Even though numerous research articles have concentrated on nursing leadership and nurse performance, fewer studies have explored nurses’ perceptions of these leadership factors.

A total of 13 methodologically sound studies reflect the small group of studies that advance our understanding of factors that nurses perceive to affect their morale and capability to function satisfactorily by delivering solid care to their patients. The revolution of staff morale embarks on a transformation of organisational culture that empowers nurse leaders and employs mutual decision making to establish environments where the autonomy and satisfaction of nurses can prosper (Bormann & Abrahamson, 2014).

Autonomy was a theme identified in five out of thirteen studies as being a factor that influences nursing morale. In possessing the choice to impact results and suggest and participate in activities devoid of being required to obtain authorisation, nurses use their critical thinking abilities, clinical skills, and knowledge effectively which is associated with positive patient outcomes and effective nursing results. Nurses who feel trusted, respected, and as though they are a respected and valued team member, they feel inspired to practice autonomously (Brunetto et al., 2011). The need for professional development was one of the concepts also identified in five of the studies critiqued. This shows that nurses possess the desire to improve professionally, and to advance and develop their practice. This also reveals the nurses’ need for additional independence and accountability (Morsiani, et al., 2017). Empowered staff was the most predominant aspect of leadership across all of the articles and was mentioned in eight out of thirteen studies. When nurse leaders communicate assurance in their employee’s capability to function at an elevated standard, staff experience a sense of feeling empowered to perform as they experience appreciation within the workplace. Nurses are stimulated to perform as there is extra rationale and significance to their job when they realise they are empowered team members. Empowered staff are more highly committed to their organisation (Dahinten et al., 2014). Transformational Leadership was an emerging theme in five out of thirteen studies. The aspects of transformational leadership can act as a model for nursing leaders and managers to support them in adjusting their managerial characteristics to enhance the standards of morale and career fulfilment in staff nurses. Due to the convolution and magnitude of the subject of staff morale, it is necessary to declare it as a strategic priority by nursing directors (Morsiani et al., 2017). Communication was identified as a key theme in six out of thirteen studies. Robust communication between nurses and their leaders is beneficial in developing trusting rapports, resulting in efficient nurse function, which optimises care of patients via teamwork and collaboration. Open communication lines, such as open-door policies, also appreciate contributing to decision-making practices concerning nurse managers and their employees (Saleh et al., 2018). Each of these five factors of leadership affect the elements of job satisfaction, motivation, organisational commitment, morale, and retention. If the factors of leadership, previously mentioned, are absent or are not implemented, each of these elements are affected in a negative manner.

The strengths in the included studies were the verification of existing knowledge, the contribution of new knowledge, advocation of the significance of leaders to assume the transformational leadership style, the research has linked poor morale and dissatisfaction to lower standards of patient care and negative outcomes for patients (O’Donnell et al., 2012). Bormann and Abrahamson’s (2014) findings correlate with previous research results in substantiating that the transformational leadership style has a certain affect in the nursing workplace. The questionnaire used by Sellgren et al. (2006) was advantageous as both construct and predictive validity were demonstrated and important connections between staff who rated the same manager (Sellgren et al., 2006). Dahinten et al. (2014) showed remarkable results given the amount of time to complete the follow-up. The large number of respondents, in the quantitative survey that was completed in the research undertaken by Mannix et al. (2015), who reported anecdotal information, enhanced the study (Mannix et al, 2015). Reliability levels for influences associated with factors of leadership were acceptable.

The most common weaknesses in the studies related to low response rates, sampling sizes, dropout rates, and study design. Data could have been more rigorous if sample sizes were larger, however, small sample sizes are not uncommon in nursing populations. Only three studies collected data across more than one site, the remaining ten were collected from a single site, resulting in lower heterogeneity in the resulting samples. Three studies did not include complete sets of demographics. Method bias is obvious in four out of the 13 studies, as self-rating is not objective (Lornudd et al., 2015). There is also a female predominance which is reflective of the current global nursing workforce demographic, as ninety percent of the nursing population is female (Fischer, 2017).

Published literature, to date, implies that leadership methods which acknowledge and appreciate nurse contributions are successful. Regardless of the substantial studies on leadership styles and methods, and staff results, numerous unanswered queries persist. It is imperative that organisations produce positive results and outcomes for their patients. Additionally, it is vital for staff to be employed in healthy, supportive workplaces. Consequently, additional study on leadership practices that influence nurses’ proficiencies to accomplish those organisational goals should be investigated. Given that the current healthcare system is constantly excessively burdened, and staff and managers are obliged to respond to the stresses of their organisation, studies that investigate and connect the factors include nursing leadership, nurse performance, and organisational goals must likewise be ongoing. Non-positivist studies would provide improved transparency and vigour to the current research available. Additional thought-provoking and beneficial studies might comprise of research that addresses what nurses interpret as their responsibility in performance versus what nursing managers expect of them.

Conclusion:

The aim of this critical literature review was to identify and explore the factors of leadership that influence the morale of nurses. The factors identified were autonomy, professional development, empowering staff, communication and transformational leadership. In applying these factors to daily practice, nurse leaders and managers can successively increase morale, job satisfaction, organisational commitment, motivation and retention. Furthermore, through practicing of all these components, patient care and outcomes are improved, and organisational performance improves. The literature has highlighted that the extrinsic factors, leadership traits and management styles, fears about job security, and excessive workload, are what reduce staff morale, whereas the intrinsic factors, feeling valued and respected, having good relationships with colleagues, and giving good patient care, appear to enhance staff morale.

It is recommended that additional study on leadership practices that influence nurses’ proficiencies to accomplish organisational goals should be investigated. Given that the current healthcare system is constantly excessively burdened, and staff and managers are obliged to respond to the stresses of their organisation, studies that investigate and connect the factors include nursing leadership, nurse performance, and organisational goals must likewise be ongoing. Non-positivist studies would provide improved transparency and vigour to the current research available and supplement quantitative measurements of morale. Additional thought-provoking and beneficial studies might comprise of research that addresses what nurses interpret as their responsibility in performance versus what nursing managers expect of them. These proposed further studies may enhance strategic development criteria at the organisational, profession and government stages and planning for personnel, and by understanding the key variables that impact nursing morale, managers will be able to develop appropriate workplace strategies.

Maintaining leadership modifications to affect levels of morale in a work environment is superior to an employee’s fundamental fulfilment with and efficiency in their role. Given the ongoing and cumulative expectations being placed on the nursing workforce, and the essential functions that they perform in the delivery of superior standards of care, it is imperative that the issue of staff morale should be acknowledged as a strategic directive by nursing managers and hospital directors, and continued efforts are made to decrease turnover and increase morale and job satisfaction within the nursing population so that the vocation can keep hold of an elevated standard of nurses into the future.

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Sveinsdóttir, H., Ragnarsdóttir, E. D., & Blöndal, K. (2016). Praise matters: The influence of nurse unit managers’ praise on nurses’ practice, work environment and job satisfaction: A questionnaire study.
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International Journal of Qualitative Methods, 1–15. https://doi.org/10.1177/160940690900800401

 

MARKED ASSIGNMENT 2 FEEDBACK COMMENTS USING ASSIGNMENT 2 MARKING RUBRIC

Research Question 2 (2%)

The RQ is Included with formatting and is suitably focused and structured. It is worthwhile for a critical literature review

 

Database and search strategy as per templates 7 (11%):

You have included a sufficient number of databases with justification. You have included some required search terms/MeSH, database thesauri compatible terms and free text/Boolean operators, wildcards & truncations/Use of search period etc. There is scope for some more clarity in your explanation. 

The table is correctly labelled with the title above the table There are some minor amendments you can make to improve the accuracy of your search strategy and the transparency/reproducibility of the method.

Definition & justification of inclusion criteria 2 (4%)

You have included study designs aligned with your criteria, the nature/type of intervention/outcome (where applicable), participants and settings, and publication type and language. But your explanation and justification are a little confusing.

Explanation and rationale for the first cull, based on titles/abstracts 1.5 (3%)

Some room for improving the explanation/rationale of the number of duplicates, and number of articles rejected

Explanation and rationale of a second cull 1.5 (3%)

Some room for improving the explanation/rationale of the number of excluded papers. The excluded studies are grouped by reason for exclusion. But you need to provide some examples of what has been excluded.

Modified PRISMA flow diagram 3 (3%)

You have included a correctly labelled, logical, clear, and accurate diagram.

Writing, structure, format 1 (2%), and APA 7th edition referencing 1  (2%)

You have met the word limit, with clear, succinct and grammatically correct writing  based on APA 7th format (with only minor errors). You have made good use of all three templates. All needed citations are included and all references are based on APA 7th format but there are some unnecessary citations. You could also provide more details about the articles you excluded.

·
Please make sure to thoroughly read assessment 2 feedback and incorporate it into assessment 3. It is difficult to increase grades from one assessment to the next if the marker feedback is not attended to.

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/locate/ijns

Barriers and facilitators to the provision of preconception care by healthcare
providers: A systematic review

Joline Goossensa,1, Marjon De Roosea,1, Ann Van Heckea,b, Régine Goemaesa,
Sofie Verhaeghea,c,2, Dimitri Beeckmana,d,⁎,2

aUniversity Centre for Nursing & Midwifery, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, UZ 5K3, De Pintelaan 185, B-9000
Ghent, Belgium
bNursing Science, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium
c VIVES University College, Department Health Care, Wilgenstraat 32, B-8800 Roeselare, Belgium
d School of Health Sciences, Faculty of Health & Medical Sciences, Duke of Kent Building, University of Surrey Guildford Surrey, GU2 7XH, United Kingdom

A R T I C L E I N F O

Keywords:
Health knowledge, attitudes, practice
Health personnel
Preconception care
Review
Socio-Ecological Model (SEM)

A B S T R A C T

Background: Healthcare providers play an important role in providing preconception care to women and men of
childbearing age. Yet, the provision of preconception care by healthcare providers remains low.
Objectives: To provide an overview of barriers and facilitators at multiple levels that influence the provision of
preconception care by healthcare providers.
Design: A mixed-methods systematic review.
Data sources: PubMed, Web of Science, CINAHL, The Cochrane Library, and EMBASE were systematically
searched up to April 27, 2017. The search strategy contained MeSH terms and key words related to pre-
conception care and healthcare providers. Reference lists of included studies and systematic reviews on pre-
conception care were screened.
Review methods: Publications were eligible if they reported on barriers and facilitators influencing the provision
of preconception care by healthcare providers. Data were extracted by two independent reviewers using a data
extraction form. Barriers and facilitators were organized based on the social ecological model. The methodo-
logical quality of included studies was evaluated using the Critical Appraisal Skills Programme Qualitative
checklist for qualitative studies, the Quality Assessment Tool for quantitative studies, and the Mixed Methods
Appraisal Tool for mixed methods studies.
Results: Thirty-one articles were included. Barriers were more reported than facilitators. These were situated at
provider level (unfavourable attitude and lack of knowledge of preconception care, not working in the field of
obstetrics and gynaecology, lack of clarity on the responsibility for providing preconception care) and client
level (not contacting a healthcare provider in the preconception stage, negative attitude, and lack of knowledge
of preconception care). Limited resources (lack of time, tools, guidelines, and reimbursement) were frequently
reported at the organizational and societal level.
Conclusions: Healthcare providers reported more barriers than facilitators to provide preconception care, which
might explain why the provision of preconception care is low. To overcome the different client, provider, or-
ganizational, and societal barriers, it is necessary to develop and implement multilevel interventions.

What is already known about the topic?

• Healthcare providers play an important role in the uptake of pre-
conception care.

• The provision of preconception care is low and offered on an ad hoc basis.

What this paper adds

• There are several barriers and facilitators at client, provider, orga-
nizational, and societal level that influence the provision of pre-
conception care by healthcare providers.

https://doi.org/10.1016/j.ijnurstu.2018.06.009
Received 8 January 2018; Received in revised form 8 June 2018; Accepted 15 June 2018

⁎ Corresponding author at: De Pintelaan 185, B-9000 Ghent, Belgium.

1 These authors contributed equally to this work and shared the first authorship.
2 These authors contributed equally to this work and shared the last authorship.

E-mail address: Dimitri.Beeckman@UGent.be (D. Beeckman).

International Journal of Nursing Studies 87 (2018) 113–130

0020-7489/ © 2018 Elsevier Ltd. All rights reserved.

T

http://www.sciencedirect.com/science/journal/00207489

https://www.elsevier.com/locate/ijns

https://doi.org/10.1016/j.ijnurstu.2018.06.009

https://doi.org/10.1016/j.ijnurstu.2018.06.009

mailto:Dimitri.Beeckman@UGent.be

https://doi.org/10.1016/j.ijnurstu.2018.06.009

http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2018.06.009&domain=pdf

• Most barriers were situated at client and provider level.

• Lack of clarity on the responsibility for the provision of PCC was one
of the most reported barriers in the provision of PCC.

1. Introduction

The improvement of maternal health and the reduction of child
mortality remain global health objectives, and are two health targets of
the Sustainable Development Goals for 2030 that build on the
Millennium Development Goals (United Nations, 2015). Despite a
substantial reduction of the global maternal and child mortality be-
tween 1990 and 2015, efforts remain necessary to further improve
maternal and newborn health, and reduce maternal mortality and
preventable deaths of newborns (United Nations, 2015). One strategy
towards ending preventable maternal and child mortality could be fo-
cusing on preconception care (PCC) as many adverse reproductive
outcomes including pregnancy losses, congenital disorders, and low
birth weight are associated with preventable preconception risk factors
(Johnson et al., 2006; World Health Organization, 2012). Preconcep-
tion care can be defined as “the provision of biomedical, behavioural
and social health interventions to women and couples before concep-
tion occurs, aimed at improving maternal and child health outcomes in
both the short and long term” (World Health Organization, 2012, p.
36). PCC is an umbrella term that refers to health promotion, risk as-
sessment, and the initiation of interventions to target risk factors with a
potential influence on pregnancy outcomes (Johnson et al., 2006). Key
domains of PCC include family planning; nutrition and physical ac-
tivity; tobacco, alcohol and substance use; occupational and environ-
mental exposures; family history and genetic risks; infectious diseases
and immunization; medical and psychosocial conditions; and medica-
tions (Johnson et al., 2006). Given the potential benefits of PCC to
improve pregnancy outcomes, several prominent international organi-
zations including the Centers for Disease Control and Prevention (CDC),
American College of Obstetricians and Gynecologists (ACOG), and
World Health Organization (WHO), recommend PCC for all women and
men of childbearing age (Jack et al., 2008; Johnson et al., 2006; World
Health Organization, 2012). Nevertheless, the use of PCC remains low
in couples who are planning a pregnancy (Stephenson et al., 2014). To
illustrate, a UK study of Stephenson et al. (2014) found that 63% of the
pregnant women with a planned pregnancy reported to take folic acid
before pregnancy, and 48% of the smokers and 41% of the drinkers
reduced or stopped before conceiving. In addition, research suggests
that only 25%–39% of the couples consulted a healthcare professional
before conception (Poels et al., 2017a, 2017b). A systematic review of
Poels et al. (2016) revealed several barriers to women’s use of PCC,
including lack of awareness and unfamiliarity with the concept of PCC,
not fully planning their pregnancy, women’s wish for secrecy, perceived
absence of risks, and perceived sufficient knowledge. In addition, sev-
eral provider characteristics were identified as possible influencing
factors for PCC use, such as provider attitudes and communication with
providers (Poels et al., 2016). This suggests that healthcare providers
(HCPs) may have an important influence on couples’ use of PCC. Yet,
the provision of PCC by HCPs is low with mainly providing PCC on an
opportunistically rather than on a routine basis (Shawe et al., 2014).

Given the role of HCPs in promoting and providing PCC, an ex-
ploration of associated factors and underlying processes of the provi-
sion of PCC is needed. Factors influencing the provision of PCC are
often complex due to the multifactorial and multilevel character
(Eldredge et al., 2016; McLeroy et al., 1988). Understanding facilitators
and barriers to providing PCC is essential as it can inform intervention
development and strategies to improve PCC uptake and delivery
(Eldredge et al., 2016). A literature review is one of the first steps in the
development of these interventions and strategies (Eldredge et al.,
2016).

To the authors’ knowledge, only few systematic reviews were con-
ducted on the topic of PCC, including a literature review on the

effectiveness of preconception care (Korenbrot et al., 2002), research
regarding preconception health behaviours (Toivonen et al., 2017), and
factors related to the use of preconception care by women (Delissaint
and McKyer, 2011; Poels et al., 2016). Curtis et al. (2006) and Steel
et al. (2016) performed a systematic review on clinical practice of HCPs
with regard to PCC guidelines, and healthcare professionals’ attitudes
and experience of preconception care service delivery, respectively. Our
study built on this previous work (Curtis et al., 2006; Steel et al., 2016),
and aimed to provide an overview of factors identified as barriers and
facilitators at multiple levels that influence the provision of PCC by
HCPs.

2. Methods

A mixed-methods systematic review was conducted based on
PRISMA guidelines (Moher et al., 2010).

2.1. Search strategy

Five electronic databases were searched for studies published up to
April 27, 2017: PubMed, Web of Science (WoS), Cumulative Index to
Nursing and Allied Health Literature (CINAHL), The Cochrane Library,
and EMBASE. The search strategy was developed based on literature
scoping preconception care, and several discussions with methodolo-
gical experts. The search strategy consisted of combining MeSH terms
and key words for two concepts: “preconception care” AND “healthcare
provider” (See Table 1). In order to improve the sensitivity of the search
strategy, terms referring to nurses/midwives and physicians (physi-
cians, GPs, Obstetricians, gynecologists) were added as synonyms of the
concept “healthcare provider”. Reference lists of included studies and
systematic reviews on preconception care (Curtis et al., 2006; Steel
et al., 2016) were also screened to identify additional studies. Authors
of relevant conference abstracts were also contacted to identify addi-
tional studies.

Table 1
Search strategy with MeSH terms and key words.

Boolean operator ‘OR’1 Boolean operator ‘OR’1

MeSH Terms Preconception Care AND Health Personnel
Nurses
Midwifery
General Practitioners
Physicians

Key words Pre conception* Healthcare Provider*
Preconception* Health care Provider*
Prepregnan* Healthcare professional*
Pre pregnancy Health care professional*
Pre-pregnancy Nurse*
Periconception* Midwife*
Peri conception* Midwives
Peri-conception Physician*
Before pregnancy Obstetrician*
Internatal* Gynaecologist*
Interpregnan* Gynecologist*
Inter pregnancy General practitioner*
Inter-pregnancy
Interconception*
Inter conception*
Inter-conception
Pregestation*
Pre gestation*
Pre-gestation*
Intergestation*

1 All the MeSH terms and key words in this column were combined with
Boolean operator ‘OR’.

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

114

2.2. Eligibility criteria

Studies written in English, French, German, and Dutch were in-
cluded if they met the following eligibility criteria: (1) Participants: all
healthcare providers including physicians, midwives, and nurses; (2)
Outcomes: perceived barriers and facilitators to provide PCC in general
or one aspect of PCC, such as folic acid supplementation or genetic
carrier screening; (3) Design: quantitative, qualitative, and mixed
methods research. Quantitative studies were excluded if only de-
scriptive statistics were performed. Studies were also excluded if they

only focused on barriers and enablers to implementing a nationwide
PCC program, because these might be different from factors related to
direct care provision.

2.3. Study selection

Three reviewers (JG, RG, and MD) independently screened a se-
lection of titles and abstracts. Differences in assessment were discussed
between the reviewers until consensus was reached. In case of dis-
agreement between reviewers, a fourth independent reviewer (DB) was

Fig. 1. Decision flowchart for identified studies.

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

115

involved. An interrater agreement of 99.7% between the reviewers on
title and abstract screening was obtained. Two reviewers (JG and MD)
screened the remaining references and full texts.

2.4. Quality assessment

To assess the methodological quality of the included studies, we
used the Critical Appraisal Skills Programme (CASP) Qualitative
checklist developed by the Public Health team in Oxford for qualitative
studies (Critical Appraisal Skills Programme, 2017; Milne et al., 1995),
the Quality Assessment Tool developed by Vyncke et al. (2013) for
quantitative studies, and the Mixed Methods Appraisal Tool (MMAT) –
version 2011 developed by Pluye et al. (2009) for mixed methods
studies. The methodological quality was assessed by one reviewer (MD)
and 10% of the articles were double checked by a second reviewer (JG).
Differences in assessment between the two reviewers were discussed
until consensus was reached. No studies were excluded based on the
methodological quality.

2.5. Data extraction and synthesis

Data from each study was extracted by two independent reviewers
(MD and JG). A data extraction form was used to extract data, which
included study aim, content of PCC provision, study design, country
and health setting, data collection methods, study population char-
acteristics, and factors associated with providing PCC. The associated
factors were classified into barriers (-) and facilitators (+) for the
provision of preconception care, and were organized based on the social
ecological model (SEM) (McLeroy et al., 1988). The SEM is a theory-
based framework for understanding the dynamic and multifaceted in-
terplay between individual and environmental factors that impact be-
haviours (McLeroy et al., 1988). The SEM acknowledges that individual
behaviour is shaped through multilevel factors including the individual,
interpersonal, organizational, community, and societal level (McLeroy
et al., 1988). In the present study we included four levels of influence:
provider (individual characteristics and biologically determined fac-
tors), client (women’s and couples’ characteristics, and the character-
istics of the provider-client relationship), organizational (policies,
formal and informal structures, and rules in healthcare organizations),
and societal (local and national laws and policies). Due to heterogeneity
in methodology and content of PCC, results were synthesized descrip-
tively and no meta-analysis was performed.

3. Results

3.1. Selection of articles

A total of 14,003 records were identified through database
searching. Duplicates (n=1969) were excluded. The remaining articles
(n=12,034) were screened on title, abstract, and full text respectively,
and assessed for eligibility according to the pre-determined selection
criteria (n= 117). Twenty-eight articles met all inclusion criteria, and
the snowball method added three more articles (Fig. 1).

3.2. Study characteristics

Table 2 presents an overview of the study characteristics, barriers
and facilitators influencing the provision of PCC.

All included research articles (n=31) were published in English
between 2003 and 2017. This review discussed 17 quantitative studies
(including 16 cross-sectional study designs (Abu-Hammad et al., 2008;
Baars et al., 2004; Bonham et al., 2010; Burris and Werler, 2011; Heyes
et al., 2004; Morgan et al., 2004, 2006; Parker et al., 2010; Poppelaars
et al., 2004; Power et al., 2013; Tough et al., 2007, 2004; Tough et al.,
2008, 2006; van Voorst et al., 2016; Williams et al., 2006), one trans-
verse correlational study design (Miranda et al., 2003), 13 qualitative

studies (Archibald et al., 2016; Bortolus et al., 2017; Chuang et al.,
2012; Coll et al., 2016; M’Hamdi et al., 2017; Mazza et al., 2013;
McClaren et al., 2008; McPhie et al., 2016; Mortagy et al., 2010;
Ojukwu et al., 2016; Poels et al., 2017a, 2017b; Schwarz et al., 2009;
Stephenson et al., 2014), and one mixed method design (Fieldwick
et al., 2017). The studies were conducted in a variety of settings, in-
cluding general / university / public / private hospitals, private prac-
tices, and primary care settings in the field of obstetrics and gynae-
cology, paediatrics, midwifery, and family practice in particular. The
majority of the studies were conducted in the USA (n=10) (Bonham
et al., 2010; Burris and Werler, 2011; Chuang et al., 2012; Coll et al.,
2016; Morgan et al., 2004, 2006; Parker et al., 2010; Power et al., 2013;
Schwarz et al., 2009; Williams et al., 2006), the Netherlands (n=5)
(Baars et al., 2004; M’Hamdi et al., 2017; Poels et al., 2017a, 2017b;
Poppelaars et al., 2004; van Voorst et al., 2016), Canada (n=4) (Tough
et al., 2007, 2004; Tough et al., 2008, 2006), the UK (n=4) (Heyes
et al., 2004; Mortagy et al., 2010; Ojukwu et al., 2016; Stephenson
et al., 2014), and Australia (n= 4) (Archibald et al., 2016; Mazza et al.,
2013; McClaren et al., 2008; McPhie et al., 2016). Sample size, referring
to the total number of healthcare providers included, ranged from
small-scale studies (n=7) to large-scale studies (n= 2101).

Thirteen publications focused on general PCC (Bortolus et al., 2017;
Chuang et al., 2012; Heyes et al., 2004; M’Hamdi et al., 2017; Mazza
et al., 2013; Morgan et al., 2006; Ojukwu et al., 2016; Parker et al.,
2010; Poels et al., 2017a, 2017b; Power et al., 2013; Stephenson et al.,
2014; Tough et al., 2006; van Voorst et al., 2016), six studies on pre-
conception genetic screening (e.g. cystic fibrosis carrier screening,
fragile X syndrome) (Archibald et al., 2016; Baars et al., 2004; Bonham
et al., 2010; McClaren et al., 2008; Morgan et al., 2004; Poppelaars
et al., 2004), four studies on preconception folic acid supplementation
(and multivitamins) (Abu-Hammad et al., 2008; Burris and Werler,
2011; Miranda et al., 2003; Williams et al., 2006), three studies on
preconception alcohol use (e.g. abstinence, foetal alcohol spectrum
disorder prevention) (Tough et al., 2007, 2004, 2008; Williams et al.,
2006), one study on weight management (McPhie et al., 2016), and one
study on teratogenic medications (Schwarz et al., 2009). Few publica-
tions focused on PCC in specific subpopulations e.g. women with dia-
betes (n=1) (Mortagy et al., 2010), HIV-infected women (n= 1) (Coll
et al., 2016), and women suffering from overweight or obesity (n=1)
(Fieldwick et al., 2017).

3.3. Methodological quality of the studies included

A summary of the quality assessment of the included quantitative
studies is displayed in Supplementary file 1, in Supplementary file 2 for
studies with a qualitative approach, and in Supplementary file 3 for
mixed methods studies. In general, the overall methodological quality
of the quantitative studies was weak to moderate. A considerable risk of
selection bias was present in half of these studies. Five studies men-
tioned the potential influence of confounding factors (Baars et al., 2004;
Bonham et al., 2010; Burris and Werler, 2011; Morgan et al., 2006;
Tough et al., 2004). Data collection methods were evaluated as mod-
erately valid and/or reliable in only two studies (Baars et al., 2004;
Miranda et al., 2003). Few studies reported on power calculation
(n= 4), and nine articles did not report on how they handled missing
data (Baars et al., 2004; Heyes et al., 2004; Miranda et al., 2003;
Morgan et al., 2004, 2006; Poppelaars et al., 2004; Power et al., 2013;
Tough et al., 2007; van Voorst et al., 2016). However, in all studies, the
main results of statistical analysis were unambiguously reported, the
statistical methods were appropriate, and the results-section reported
on all outcomes measures mentioned in the method-section.

With regard to the qualitative studies, the articles generally showed
good methodological quality. All qualitative studies had a clear state-
ment of aims, an appropriate methodology and data collection, an ap-
propriate recruitment strategy, a clear statement of findings, and were
considered to be valuable research. Nevertheless, in one study (McPhie

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

116

Ta
bl
e
2

St
ud

y
ch

ar
ac
te
ri
st
ic
s,

ba
rr
ie
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an
d
fa
ci
lit
at
or
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in
fl
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nc
in
g
th
e
pr
ov

is
io
n
of

pr
ec
on

ce
pt
io
n
ca
re
.

St
ud

y
(1
)
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ud

y
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m

(2
)
C
on

te
nt

of
PC

C
St
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si
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(1
)
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ou

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ea
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in
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D
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co

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M
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Fa

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(+

)
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la
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to
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od

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va
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)
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pr
im

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ph

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in
pr
ac
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Pr
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id
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:

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kn
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(+

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(2
00

4)
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)
To

ex
am

in
e
th
e
op

in
io
n
of

ph
ys
ic
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on
PC

ge
ne

ti
c
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in
g
&

to
ex
am

in
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fa
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s
ar
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w
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fi
br
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th
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N
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lf
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n
=

49
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pa

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id
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ti
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PC
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(+

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on

ta
ct

w
it
h
pr
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ar
y
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re

te
am

s
af
te
r
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nc
ep

ti
on

(-
):
un

pl
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s
(-
),
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s
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to

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-)

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n
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00

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)
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s

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%

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ge
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1y

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39

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rs

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38

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li
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t:

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am

ily
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rt
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s
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t
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or
e
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pe

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)

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ro
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ss
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n/

sp
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lt
y:

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bG

yn
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>

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yn

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nl
y
(+

)
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rg
an

iz
at
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na

l:
/

So
ci
et
al
:
/

Po
pp

el
aa

rs
et

al
.

(2
00

4)

(1
)
To

de
te
rm

in
e
th
e
at
ti
tu
de

s
of

po
te
nt
ia
l
pr
ov

id
er
s
to
w
ar
ds

PC
cy
st
ic

fi
br
os
is

ca
rr
ie
r
sc
re
en

in
g
(2
)
PC

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ic

fi
br
os
is

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ie
r
sc
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en

in
g

C
ro
ss
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al
,

qu
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ve

(1
)
th
e
N
et
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rl
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ds
(2
)
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om

m
un

it
y
H
ea
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Se
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e
(C

H
S)
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en
er
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ce

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lf
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dm

in
is
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qu
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5
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Ps

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d
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3%
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m
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A
ge
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5y
(2
9–

63
)

Y
ea
rs

in
pr
ac
tic

e:
/

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li
en

t:
/

Pr
ov

id
er
:

•H
ig
h
pe

rc
ei
ve

d
se
ve

ri
ty

of
cy
st
ic

fi
br
os
is

(+
)

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ei
ng

no
nr
el
ig
io
us

co
m
pa

re
d
to

re
fo
rm

ed
(+

)

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ow

pe
rc
ei
ve

d
ba

rr
ie
rs

(+
)

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ig
h
pe

rc
ei
ve

d
te
st

se
ns
it
iv
it
y
(+

)
O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

(c
on

tin
ue
d
on

ne
xt

pa
ge
)

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

117

Ta
bl
e
2
(c
on

tin
ue
d)

St
ud

y
(1
)
St
ud

y
ai
m

(2
)
C
on

te
nt

of
PC

C
St
ud

y
de

si
gn

(1
)
C
ou

nt
ry

(2
)
H
ea
lt
h
se
tt
in
g

D
at
a
co

lle
ct
io
n
m
et
ho

ds
St
ud

y
po

pu
la
ti
on

M
ea
n
±

SD
Fa

ct
or
s
as
so
ci
at
ed

w
it
h
pr
ov

id
in
g
(+

)
or

no
t

pr
ov

id
in
g
(-
)
PC

C
in

re
la
ti
on

to
le
ve

l
w
it
hi
n
so
ci
o-

ec
ol
og

ic
al

m
od

el

To
ug

h
et

al
.

(2
00

4)
(1
)
To

de
sc
ri
be

ch
ar
ac
te
ri
st
ic
s
of

ph
ys
ic
ia
ns

w
ho

re
co

m
m
en

d
al
co

ho
l

ab
st
in
en

ce
du

ri
ng

pr
eg

na
nc

y
w
it
h

re
ga

rd
to

kn
ow

le
dg

e
of

FA
S
an

d
PC

co
un

se
lli
ng

st
ra
te
gi
es

(2
)
PC

al
co

ho
l
ab

st
in
en

ce

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
C
an

ad
a

(2
)
Fa

m
ily

pr
ac
ti
ce
,

ob
st
et
ri
cs
/
gy

na
ec
ol
og

y
pr
ac
ti
ce
s,

m
id
w
if
er
y

na
ti
on

w
id
e

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

10
90

O
bG

yn
s,

fa
m
ily

ph
ys
ic
ia
ns

an
d
m
id
w
iv
es
;5

18
%

fe
m
al
e

A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•P
er
ce
iv
ed

la
ck

of
cl
ie
nt

in
te
re
st

(-
)

•B
el
ie
vi
ng

th
at

cl
ie
nt
s
ar
e
in
te
re
st
ed

in
di
sc
us
si
ng

al
co

ho
l
us
e
(+

)
Pr

ov
id
er
:

•P
ro
fe
ss
io
n/

sp
ec
ia
lit
y:

Fa
m
Ph

ys
(+

)
>

m
id
w
iv
es

an
d
ob

st
et
ri
ci
an

s

•R
ol
e:

be
lie

vi
ng

in
ha

vi
ng

a
ro
le

to
m
an

ag
e
cl
ie
nt
s
in

th
e
ar
ea

of
al
co

ho
l
us
e
(+

-)

•K
no

w
le
dg

e
(+

)

•O
bt
ai
ni
ng

in
fo
rm

at
io
n
fr
om

m
ed

ic
al

jo
ur
na

ls
(+

)

•A
w
ar
en

es
s:
be

lie
vi
ng

th
at

th
er
e
is
so
lid

in
fo
rm

at
io
n

ab
ou

t
al
co

ho
l
us
e
(+

)
O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

M
or
ga

n
et

al
.

(2
00

6)
(1
)
To

de
sc
ri
be

O
bG

yn
s’
op

in
io
ns

of
PC

C
(2
)
PC

C
in

ge
ne

ra
l

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
U
SA

(2
)
O
bG

yn
pr
ac
ti
ce
s

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

57
9
O
bG

yn
s;

46
.1
%

fe
m
al
e

A
ge

:4
7.
3y

±
0.
39

Y
ea
rs

in
pr
ac
tic

e:
15

.2
2y

±
0.
41

C
li
en

t:

•F
re
qu

en
cy

w
it
h
w
hi
ch

cl
ie
nt
s
re
po

rt
ed

ly
pr
es
en

t
fo
r
PC

C
(+

)
Pr

ov
id
er
:

•O
pi
ni
on

s
re
ga

rd
in
g
PC

C
:d

efi
ni
ng

PC
C
as

ro
ut
in
e

(+
)
⬄

de
fi
ni
ng

PC
C
as

sp
ec
ia
liz

ed
(-
),
ag

re
e
th
at

PC
C
is

im
po

rt
an

t/
po

si
ti
ve

/
hi
gh

pr
io
ri
ty

(+
)

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

To
ug

h
et

al
.

(2
00

6)
(1
)
To

de
te
rm

in
e
th
e
PC

pr
ac
ti
ce
s

am
on

g
O
bG

yn
s
an

d
fa
m
ily

ph
ys
ic
ia
ns

in
C
an

ad
a

(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
C
an

ad
a

(2
)
Fa

m
ily

pr
ac
ti
ce
,

ob
st
et
ri
cs

&
gy

na
ec
ol
og

y
na

ti
on

w
id
e

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

96
5
fa
m
ily

ph
ys
ic
ia
ns

&
O
bG

yn
s;

50
.6
%

fe
m
al
e
Y
ea
rs

in
pr
ac
tic

e:
/

Y
ea
rs

gr
ad

ua
te
d:

≥
22

y:
27

.4
%
,1

2
–

21
y:

31
.6
%
,≤

11
y:

41
.0
%

C
li
en

t:
/

Pr
ov

id
er
:

•P
ro
fe
ss
io
n/

sp
ec
ia
lit
y:

O
bG

yn
s
(+

)
>

Fa
m
Ph

ys
fo
r

di
sc
us
si
ng

Pa
p
te
st
in
g
&

pr
eg

na
nc

y
re
la
te
d
is
su
es

in
cl
ud

in
g
fo
lic

ac
id
,s

m
ok

in
g,

dr
ug

us
e,

se
xu

al
ab

us
e)
;F

am
Ph

ys
>

O
bG

yn
s
to

di
sc
us
s
m
en

ta
l

he
al
th
,d

ep
re
ss
io
n,

w
or
kp

la
ce

st
re
ss

•G
en

de
r:

fe
m
al
e
(+

)
>

m
al
e
ph

ys
ic
ia
ns

to
di
sc
us
s

9
or

m
or
e
PC

an
d
he

al
th

pr
om

ot
io
n
to
pi
cs

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

W
ill
ia
m
s
et

al
.

(2
00

6)
(1
)
To

as
se
ss

he
al
th
ca
re

pr
ov

id
er
s

kn
ow

le
dg

e
an

d
pr
ac
ti
ce
s
re
ga

rd
in
g
FA

us
e
fo
r
ne

ur
al

tu
be

de
fe
ct

pr
ev

en
ti
on

(2
)
PC

FA
us
e

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
U
SA

(2
)
O
bG

yn
an

d
Fa

m
/G

en
pr
ac
ti
ce

se
tt
in
gs

Te
le
ph

on
e
su
rv
ey

(n
ot

va
lid

at
ed

)
n
=

11
11

ph
ys
ic
ia
ns

(O
bG

yn
s
an

d
Fa

m
/G

en
)
an

d
no

n-
ph

ys
ic
ia
ns

(p
hy

si
ci
an

as
si
st
an

ts
,
nu

rs
e

pr
ac
ti
ti
on

er
,c

er
ti
fi
ed

nu
rs
e
m
id
w
iv
es

an
d
re
gi
st
er
ed

nu
rs
es
);
60

%
fe
m
al
e

A
ge
:7

6%
< 55 y Y ea rs in pr ac tic e: 39 % ov er 20 y in pr ac ti ce C li en t: / Pr ov id er : •P ro fe ss io n/ sp ec ia lit y: pr ov id er s in O bG yn se tt in gs (+ ) >

Fa
m
/G

en
se
tt
in
gs
;n

ur
se

pr
ac
ti
ti
on

er
s
in

O
bG

yn
se
tt
in
g
(+

)
w
er
e
m
os
t
lik

el
y
to

ta
lk

ab
ou

t
FA

an
d
fa
m
/g

en
ph

ys
ic
ia
ns

le
as
t
lik

el
y

•P
ro
vi
de

r
pe

rs
on

al
ly

to
ok

m
ul
ti
vi
ta
m
in

(+
)

•L
ow

er
in
co

m
e
cl
ie
nt
s
(+

)

•P
ra
ct
ic
es

co
ns
is
te
d
of

at
le
as
t
10

%
m
in
or
it
ie
s
(+

)

•G
en

de
r:

fe
m
al
e
pr
ov

id
er

(+
)

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

(c
on

tin
ue
d
on

ne
xt

pa
ge
)

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

118

Ta
bl
e
2
(c
on

tin
ue
d)

St
ud

y
(1
)
St
ud

y
ai
m

(2
)
C
on

te
nt

of
PC

C
St
ud

y
de

si
gn

(1
)
C
ou

nt
ry

(2
)
H
ea
lt
h
se
tt
in
g

D
at
a
co

lle
ct
io
n
m
et
ho

ds
St
ud

y
po

pu
la
ti
on

M
ea
n
±

SD
Fa

ct
or
s
as
so
ci
at
ed

w
it
h
pr
ov

id
in
g
(+

)
or

no
t

pr
ov

id
in
g
(-
)
PC

C
in

re
la
ti
on

to
le
ve

l
w
it
hi
n
so
ci
o-

ec
ol
og

ic
al

m
od

el

To
ug

h
et

al
.

(2
00

7)
(1
)
To

ex
am

in
e
if
ph

ys
ic
ia
n
kn

ow
le
dg

e
an

d
pr
ac
ti
ce
s
re
la
te
d
to

FA
SD

an
d
it
s

pr
ev

en
ti
on

va
ry

ba
se
d
on

th
e

pr
op

or
ti
on

of
N
at
iv
e/

A
bo

ri
gi
na

l
pa

ti
en

ts
se
rv
ed

(2
)
PC

FA
SD

pr
ev

en
ti
on

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
C
an

ad
a

(2
)
Fa

m
ily

pr
ac
ti
ce
,O

bG
yn

pr
ac
ti
ce
s,

pa
ed

ia
tr
ic
s

na
ti
on

w
id
e

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

17
00

O
bG

yn
s,

fa
m
ily

ph
ys
ic
ia
ns
,

pa
ed

ia
tr
ic
ia
n;

/
A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•E
th
ni
ci
ty

(+
-)
:p

hy
si
ci
an

s
ca
ri
ng

fo
r
a
gr
ea
te
r

pr
op

or
ti
on

of
N
at
iv
e/
A
bo

ri
gi
na

l
cl
ie
nt
s
w
er
e
le
ss

lik
el
y
to

di
sc
us
s
fo
lic

ac
id
,b

ut
m
or
e
lik

el
y
to

ro
ut
in
el
y
in
qu

ir
e
ab

ou
td

ri
nk

in
g
pr
io
r
to

pr
eg

na
nc

y
aw

ar
en

es
s

Pr
ov

id
er
:
/

O
rg
an

iz
at
io
na

l:

•L
ac
k
of

ti
m
e
(-
)
(d
es
cr
ip
ti
ve

re
su
lt
)

•P
oo

rl
y
fo
rm

at
te
d
in
fo
rm

at
io
n
(-
)
(d
es
cr
ip
ti
ve

re
su
lt
)

So
ci
et
al
:/

A
bu

-H
am

m
ad

et
al
.

(2
00

8)

(1
)
To

ev
al
ua

te
pr
im

ar
y
ca
re

ph
ys
ic
ia
ns
’k

no
w
le
dg

e
an

d
at
ti
tu
de

s
re
ga

rd
in
g
FA

su
pp

le
m
en

ta
ti
on

fo
r

ch
ild

be
ar
in
g
w
om

en
(2
)
PC

FA
su
pp

le
m
en

ta
ti
on

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
Is
ra
el

(2
)
Th

e
la
rg
es
t
he

al
th
ca
re

pr
ov

id
er

or
ga

ni
za
ti
on

in
Is
ra
el

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

87
pr
im

ar
y
ca
re

ph
ys
ic
ia
ns
;6

1.
5%

A
ge
:4

7.
3y

±
7.
8y

Y
ea
rs

in
pr
ac
tic

e:
18

.7
y
±

8.
7

C
li
en

t:

•E
th
ni
ci
ty
:J

ew
is
h
>

Be
do

ui
n
(+

-)
Pr

ov
id
er
:

•C
er
ti
fi
ca
ti
on

:u
nc

er
ti
fi
ed

>
bo

ar
d-
ce
rt
ifi
ed

(+
-)

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

M
cC

la
re
n
et

al
.

(2
00

8)
(1
)
To

ex
pl
or
e
pe

rs
pe

ct
iv
es

of
th
e

V
ic
to
ri
an

co
m
m
un

it
y
re
ga

rd
in
g
ca
rr
ie
r

sc
re
en

in
g
fo
r
cy
st
ic

fi
br
os
is

pr
io
r
to

off
er
in
g
sc
re
en

in
g

(2
)
PC

ge
ne

ti
c
ca
rr
ie
r
sc
re
en

in
g
fo
r

cy
st
ic

fi
br
os
is

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
A
us
tr
al
ia

(2
)
G
Ps

of
pr
ac
ti
ce
s
in

th
e

lo
ca
l
m
et
ro
po

lit
an

M
el
bo

ur
ne

ar
ea
,h

os
pi
ta
l,

pr
en

at
al

cl
in
ic
s,

U
ni
ve

rs
it
y

of
M
el
bo

ur
ne

Se
m
i-
st
ru
ct
ur
ed

fo
cu

s
gr
ou

p
in
te
rv
ie
w
s
&

in
di
vi
du

al
in
te
rv
ie
w
s

n
=

12
he

al
th

pr
ov

id
er
s

(m
id
w
iv
es
,s

oc
ia
l
w
or
ke

r
ph

ys
io
th
er
ap

is
ts
,
ge

ne
ti
c
co

un
se
llo

r,
ob

st
et
ri
ci
an

s
G
Ps
);
/

A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•T
he

po
te
nt
ia
l
ps
yc
ho

so
ci
al

im
pa

ct
fo
r
cl
ie
nt
s:

st
ig
m
a
an

d
st
re
ss

on
re
la
ti
on

sh
ip
s
(-
)

•N
ot

th
in
ki
ng

ab
ou

t
ha

vi
ng

ch
ild

re
n
(-
)

Pr
ov

id
er
:

•P
er
so
na

la
tt
it
ud

e
to
w
ar
ds

off
er
in
g
ca
rr
ie
r
sc
re
en

in
g

to
cl
ie
nt
s
(+

-)

•H
av

in
g
ex
pe

ri
en

ce
w
it
h
di
sc
us
si
ng

po
te
nt
ia
li
m
pa

ct
an

d
ac
ce
pt
ab

ili
ty

of
a
sc
re
en

in
g
pr
og

ra
m
m
e
fo
r

th
ei
r
cl
ie
nt
s
(+

)
O
rg
an

iz
at
io
na

l:

•T
im

e
co

ns
tr
ai
nt
s
al
re
ad

y
pr
es
en

t
in

co
ns
ul
ta
ti
on

s
(-
)

So
ci
et
al
:
/

To
ug

h
et

al
.

(2
00

8)
(1
)
To

de
te
rm

in
e
w
he

th
er

di
ff
er
en

ce
s

ex
is
t
be

tw
ee
n
ru
ra
l
an

d
ur
ba

n
he

al
th
ca
re

pr
ov

id
er
s
in

kn
ow

le
dg

e
of
,

at
ti
tu
de

s
ab

ou
ta

nd
aw

ar
en

es
s
of

FA
SD

di
so
rd
er
s
an

d
PC

co
un

se
lli
ng

(2
)
FA

SD
pr
ev

en
ti
on

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
C
an

ad
a

(2
)
Fa

m
ily

pr
ac
ti
ce
,

ob
st
et
ri
cs

&
gy

na
ec
ol
og

y,
pa

ed
ia
tr
ic
s,

ps
yc
hi
at
ry
,

m
id
w
if
er
y
na

ti
on

w
id
e

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

21
01

O
bG

yn
s,

fa
m
ily

ph
ys
ic
ia
ns
,

ps
yc
hi
at
ri
st
s
pa

ed
ia
tr
ic
ia
ns
,
m
id
w
iv
es
;

49
.0
%

fe
m
al
e

A
ge
:
< 40 y: 31 % , 40 -4 9y :3 4% , 50 - 57 y: 25 % , ≥ 60 y: 10 % Y ea rs in pr ac tic e: / Y ea rs gr ad ua te d: ≥ 42 y: 2% ;2 2– 41 y: 39 % ; 12 –2 1y : 31 % ;≤ 11 y: 28 % C li en t: / Pr ov id er : •B el ie ft ha t cl ie nt s al re ad y ha d go od in fo rm at io n on al co ho l us e (- ) (d es cr ip ti ve re su lt ) •P ro fe ss io n/ sp ec ia lit y: ur ba n pr ov id er s w er e m or e lik el y to di sc us s fo lic ac id (+ ) >

ru
ra
l
pr
ov

id
er
s;

no
di
ff
er
en

ce
s
re
ga

rd
in
g
ot
he

r
PC

to
pi
cs

O
rg
an

iz
at
io
na

l:

•L
ac
k
of

ti
m
e
(-
)
(d
es
cr
ip
ti
ve

re
su
lt
)

•I
nf
or
m
at
io
n
no

t
in

a
us
ef
ul

fo
rm

at
(-
)
(d
es
cr
ip
ti
ve

re
su
lt
)

So
ci
et
al
:/

(c
on

tin
ue
d
on

ne
xt

pa
ge
)

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

119

Ta
bl
e
2
(c
on

tin
ue
d)

St
ud

y
(1
)
St
ud

y
ai
m

(2
)
C
on

te
nt

of
PC

C
St
ud

y
de

si
gn

(1
)
C
ou

nt
ry

(2
)
H
ea
lt
h
se
tt
in
g

D
at
a
co

lle
ct
io
n
m
et
ho

ds
St
ud

y
po

pu
la
ti
on

M
ea
n
±

SD
Fa

ct
or
s
as
so
ci
at
ed

w
it
h
pr
ov

id
in
g
(+

)
or

no
t

pr
ov

id
in
g
(-
)
PC

C
in

re
la
ti
on

to
le
ve

l
w
it
hi
n
so
ci
o-

ec
ol
og

ic
al

m
od

el

Sc
hw

ar
z
et

al
.

(2
00

9)
(1
)
To

id
en

ti
fy

w
ha

t
pr
im

ar
y
ca
re

pr
ov

id
er
s
pe

rc
ei
ve

as
ba

rr
ie
rs

to
an

d
po

te
nt
ia
l
fa
ci
lit
at
or
s
of

pr
ov

id
in
g

co
un

se
lli
ng

to
w
om

en
of

ch
ild

be
ar
in
g

ag
e
w
he

n
te
ra
to
ge

ni
c
m
ed

ic
at
io
ns

ar
e

pr
es
cr
ib
ed

(2
)T

er
at
og

en
ic

m
ed

ic
at
io
ns

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
U
SA

(2
)
4
cl
in
ic
al

se
tt
in
gs

in
Pi
tt
sb
ur
gh

,
Pe

nn
sy
lv
an

ia

Fo
cu

s
gr
ou

p
in
te
rv
ie
w
s

n
=

48
pr
im

ar
y
ca
re

pr
ov

id
er
s

(a
ca
de

m
ic

an
d
co

m
m
un

it
y-
ba

se
d

cl
in
ic
ia
ns
,
ph

ar
m
ac
is
ts
,
nu

rs
es
,

ph
ys
ic
ia
ns
,c

lin
ic
al

fa
cu

lt
y
an

d
tr
ai
ne

es
);
88

%
fe
m
al
e

A
ge
:4

9y
±

9
Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•C
on

ce
rn

th
at

cl
ie
nt
s
an

xi
et
y
re
la
te
d
to

in
fo
rm

at
io
n

ab
ou

t
te
ra
to
ge

ni
c
ri
sk

w
ill

le
ad

to
m
ed

ic
at
io
n
no

n-
us
e
(-
)

•W
om

en
ha

vi
ng

di
ffi
cu

lt
y
of

vo
lu
nt
ee
ri
ng

in
fo
rm

at
io
n
ab

ou
t
th
ei
r
pr
eg

na
nc

y
in
te
nt
io
n
(-
)

Pr
ov

id
er
:

•P
ro
fe
ss
io
na

l
re
sp
on

si
bi
lit
y/

ro
le

(+
)

•D
iffi

cu
lt
y
id
en

ti
fy
in
g
cl
ie
nt
s’
pr
eg

na
nc

y
in
te
nt
io
ns

/
no

t
ro
ut
in
el
y
as
ki
ng

cl
ie
nt
s’
pr
eg

na
nc

y
in
te
nt
io
ns

(-
)

O
rg
an

iz
at
io
na

l:

•L
im

it
ed

cl
in
ic
al

ti
m
e
&

co
m
pe

ti
ng

m
ed

ic
al

pr
io
ri
ti
es
.D

is
cu

ss
io
ns

ab
ou

t
te
ra
to
ge

ni
c
ri
sk
s
of

m
ed

ic
at
io
n
ar
e
co

m
pl
ex
,a

nd
th
us
,t
im

e
co

ns
um

in
g

(-
)

•D
iffi

cu
lt
y
fi
nd

in
g
cl
in
ic
al
ly

re
le
va

nt
in
fo
rm

at
io
n
on

m
ed

ic
at
io
ns
’t
er
at
og

en
ic
it
y
(-
)

•A
ss
is
ta
nc

e
in

id
en

ti
fy
in
g
m
ed

ic
at
io
ns

th
at

po
se

te
ra
to
ge

ni
c
ri
sk
s
(+

)
(e
.g
.o

nl
in
e
re
fe
re
nc

es
,

co
m
pu

te
ri
ze
d
de

ci
si
on

su
pp

or
t)

•A
ss
is
ta
nc

e
in

id
en

ti
fy
in
g
w
om

en
’s
pr
eg

na
nc

y
in
te
nt
io
ns

(+
)

So
ci
et
al
:

•L
ac
k
of

re
im

bu
rs
em

en
t
fo
r
ti
m
e
sp
en

t
co

un
se
lli
ng

(-
)

•A
cc
es
s
to

ed
uc

at
io
na

l
m
at
er
ia
ls

fo
r
cl
ie
nt
s
(+

)
Bo

nh
am

et
al
.

(2
01

0)
(1
)
To

as
se
ss

th
e
in
fl
ue

nc
e
of

pa
ti
en

t
ch

ar
ac
te
ri
st
ic
s
on

de
ci
si
on

s
to

off
er

pr
ec
on

ce
pt
io
n
ge

ne
ti
c
sc
re
en

in
g

(2
)
PC

ge
ne

ti
c
sc
re
en

in
g

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
U
SA

(2
)
G
en

er
al

pr
ac
ti
ce

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

96
8
fa
m
ily

ph
ys
ic
ia
ns
;3

2.
7%

fe
m
al
e

A
ge
:4

5.
6y

Y
ea
rs

in
pr
ac
tic

e:
/

Y
ea
rs

si
nc
e
re
si
de
nc
y
co
m
pl
et
io
n:

< 5y : 19 % , 5y -1 5y :3 6% , >

15
y:

45
%

C
li
en

t:

•R
ac
e:

be
in
g
bl
ac
k
(+

)

•F
em

al
e
ge

nd
er

(+
)
(b
la
ck

cl
ie
nt
)

•A
ge

(+
)
(d
es
cr
ip
ti
ve

re
su
lt
)

Pr
ov

id
er
:

•W
or
k
ex
pe

ri
en

ce
:c

om
pl
et
in
g
re
si
de

nc
y
le
ss

th
an

15
ye

ar
s
ea
rl
ie
r
(+

)
(b
la
ck

cl
ie
nt
)

•W
or
ki
ng

in
a
un

iv
er
si
ty
,t
ea
ch

in
g,

or
re
si
de

nc
y

tr
ai
ni
ng

en
vi
ro
nm

en
t
(+

)
(b
la
ck

cl
ie
nt
)

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

Pa
rk
er

et
al
.

(2
01

0)
(1
)
To

as
se
ss

pe
rc
ep

ti
on

s
of

th
e

im
po

rt
an

ce
of

PC
C
an

d
fa
ct
or
s

aff
ec
ti
ng

th
e
w
ill
in
gn

es
s
of

ST
D

co
un

se
llo

rs
to

in
te
gr
at
e
PC

C
in

ST
D

cl
in
ic
s.

(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
U
SA

(2
)
ST

D
cl
in
ic
s

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

14
0
ST

D
co

un
se
llo

rs
;
/

A
ge

:/
Y
ea
rs

in
pr
ac
tic

e:
2-
5y

:2
1%

,
6-
10

y:
48

%
,

≥
10

y:
31

%

C
li
en

t:
/

Pr
ov

id
er
:

•G
oo

d
or

ex
ce
lle

nt
kn

ow
le
dg

e
of

PC
C
(+

)

•H
ig
he

r
le
ve

l
of

re
sp
on

si
bi
lit
y
(+

)

•M
or
e
ye

ar
s
of

w
or
k
ex
pe

ri
en

ce
(+

)

•C
om

in
g
fr
om

ar
ea
s
w
it
h
hi
gh

le
ve

ls
of

m
or
bi
di
ty

(+
)

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

(c
on

tin
ue
d
on

ne
xt

pa
ge
)

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

120

Ta
bl
e
2
(c
on

tin
ue
d)

St
ud

y
(1
)
St
ud

y
ai
m

(2
)
C
on

te
nt

of
PC

C
St
ud

y
de

si
gn

(1
)
C
ou

nt
ry

(2
)
H
ea
lt
h
se
tt
in
g

D
at
a
co

lle
ct
io
n
m
et
ho

ds
St
ud

y
po

pu
la
ti
on

M
ea
n
±

SD
Fa

ct
or
s
as
so
ci
at
ed

w
it
h
pr
ov

id
in
g
(+

)
or

no
t

pr
ov

id
in
g
(-
)
PC

C
in

re
la
ti
on

to
le
ve

l
w
it
hi
n
so
ci
o-

ec
ol
og

ic
al

m
od

el

M
or
ta
gy

et
al
.

(2
01

0)
(1
)
To

ex
pl
or
e
th
e
pe

rs
pe

ct
iv
e
of

G
Ps

an
d
se
co

nd
ar
y
ca
re

he
al
th

pr
of
es
si
on

al
s
on

th
e
ro
le

of
G
Ps

in
de

liv
er
in
g
PC

to
w
om

en
w
it
h
di
ab

et
es

(2
)G

en
er
al

PC
to

w
om

en
w
it
h
di
ab

et
es

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
U
K

(2
)
D
iv
er
se

se
t
of

G
P

pr
ac
ti
ce
s
an

d
1
Lo

nd
on

te
ac
hi
ng

ho
sp
it
al

Se
m
i-
st
ru
ct
ur
ed

in
te
rv
ie
w
s

n
=

15
G
Ps

an
d
se
co

nd
ar
y
he

al
th
ca
re

pr
of
es
si
on

al
s;

/
A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:
/

Pr
ov

id
er
:

•I
nt
er
es
t
in

di
ab

et
es

ca
re

(+
)

•P
ro
fe
ss
io
na

l
re
sp
on

si
bi
lit
y/

ro
le
:
la
ck

of
a
de

fi
ne

d
G
P
ro
le

in
PC

C
(-
)

•A
w
ar
en

es
s
th
ro
ug

h
on

go
in
g
ed

uc
at
io
n
an

d
tr
ai
ni
ng

(+
)

O
rg
an

iz
at
io
na

l:

•L
ac
k
of

cl
ea
r
di
vi
si
on

of
re
sp
on

si
bi
lit
y
an

d
-la

bo
ur

re
ga

rd
in
g
di
ab

et
es

ca
re

pr
ac
ti
ce
s
be

tw
ee
n
pr
im

ar
y

an
d
se
co

nd
ar
y
ca
re

(-
)

•P
ra
ct
ic
e
pr
ot
oc

ol
s
re
ga

rd
in
g
PC

C
(+

)
So

ci
et
al
:

•L
ac
k
of

cl
ea
r
gu

id
el
in
es

on
ho

w
to

pr
ov

id
e
PC

C
an

d
w
he

n
to

m
ak

e
re
fe
rr
al
s
(-
)

•E
vi
de

nc
e-
ba

se
d
in
fo
rm

at
io
n
on

PC
be

ne
fi
ts

(+
)

•A
cc
es
s
to

cl
ie
nt

in
fo
rm

at
io
n
le
afl

et
s
(+

)
Bu

rr
is

an
d

W
er
le
r

(2
01

1)

(1
)
To

de
te
rm

in
e
w
he

th
er

m
ed

ic
al

pr
ov

id
er
s
or
de

r
fo
lic

ac
id

or
fo
lic

ac
id
–

co
nt
ai
ni
ng

m
ul
ti
vi
ta
m
in
s
fo
r
th
ei
r
no

n-
pr
eg

na
nt

fe
m
al
e
pa

ti
en

ts
of

ch
ild

be
ar
in
g
ag

e
(2
)
PC

FA
an

d
m
ul
ti
vi
ta
m
in
s

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
U
SA

(2
)
N
on

-f
ed

er
al
ly

offi
ce

ba
se
d
ph

ys
ic
ia
n
pr
ac
ti
ce

an
d
no

n-
fe
de

ra
l
ho

sp
it
al
s

A
na

ly
si
s
of

da
ta

fr
om

tw
o
da

ta
so
ur
ce
s
N
A
M
C
S
an

d
N
H
A
M
C
S

n
=

46
34

pr
ev

en
ti
ve

vi
si
ts

of
no

n-
pr
eg

na
nt

w
om

en
A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•A
ge

(+
);
w
om

en
ag

es
30

-3
4

>
w
om

en
ag

ed
15

-1
9

or
40

-4
4

•R
ac
e/
et
hn

ic
it
y
(+

):
ra
ce

ot
he

r
th
an

w
hi
te
,b

la
ck

or
H
is
pa

ni
c

•I
ns
ur
an

ce
st
at
us

(+
):
M
ed

ic
ai
d
>

pr
iv
at
e

in
su
ra
nc

e
or

ot
he

r
Pr

ov
id
er
:

•P
ro
fe
ss
io
n/

sp
ec
ia
lit
y:

(+
):

O
bG

yn
s
>

no
n-
O
bG

yn
s

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

C
hu

an
g
et

al
.

(2
01

2)
(1
)
To

ex
am

in
e
pr
im

ar
y
ca
re

ph
ys
ic
ia
ns
’p

er
ce
pt
io
ns

of
ba

rr
ie
rs

to
pr
ev

en
ti
ve

re
pr
od

uc
ti
ve

he
al
th
ca
re

(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
U
SA

(2
)
So

lo
pr
iv
at
e
pr
ac
ti
ce
s

an
d
ho

sp
it
al
-o
w
ne

d
m
ul
ti
sp
ec
ia
lt
y
gr
ou

ps
in

ru
ra
l
ce
nt
ra
l
Pe

nn
sy
lv
an

ia

Se
m
i-
st
ru
ct
ur
ed

te
le
ph

on
e

an
d
fa
ce
-t
o-
fa
ce

in
te
rv
ie
w
s

n
=

19
ru
ra
l
pr
im

ar
y
ca
re

ph
ys
ic
ia
ns
;

47
.4
%

fe
m
al
e

A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
21

y
(1
–3

8)

C
li
en

t:

•N
ot

in
it
ia
ti
ng

di
sc
us
si
on

s
ab

ou
t
pr
eg

na
nc

y
pl
an

ni
ng

be
ca
us
e
of

in
di
ff
er
en

ce
to

fa
m
ily

pl
an

ni
ng

(-
)

Pr
ov

id
er
:

•P
ro
fe
ss
io
na

lr
es
po

ns
ib
ili
ty
/r
ol
e:

be
lie

f
th
at

it
is

no
t

th
e
pr
im

ar
y
ca
re

ph
ys
ic
ia
n’
s
ro
le

to
in
it
ia
te

an
d

di
sc
us
s
pr
eg

na
nc

y
pl
an

ni
ng

an
d
PC

C
(-
)

•P
C
C
is

no
pr
io
ri
ty

(-
)

•F
ee
lin

g
un

ce
rt
ai
n
w
ha

t
th
ey

co
ul
d
off

er
(-
)

O
rg
an

iz
at
io
na

l:

•L
ac
k
of

ti
m
e
(-
)

•A
la
ck

of
lo
ca
l
sp
ec
ia
lis
ts
:l
ac
k
of

ac
ce
ss

to
ob

st
et
ri
ci
an

s
w
it
h
tr
ai
ni
ng

in
m
an

ag
in
g
hi
gh

-r
is
k

pr
eg

na
nc

ie
s
w
ho

m
ay

as
si
st

PC
C
,o

r
en

do
cr
in
ol
og

is
ts

w
ho

m
ay

as
si
st

w
it
h
m
an

ag
em

en
t

of
di
ab

et
es

(-
)

So
ci
et
al

•R
ur
al

co
m
m
un

it
y
no

rm
s
(-
):
e.
g.

ac
ce
pt
in
g

un
in
te
nd

ed
pr
eg

na
nc

ie
s,

ea
rl
y
ch

ild
be

ar
in
g,

la
rg
e

fa
m
ili
es
…

(c
on

tin
ue
d
on

ne
xt

pa
ge
)

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

121

Ta
bl
e
2
(c
on

tin
ue
d)

St
ud

y
(1
)
St
ud

y
ai
m

(2
)
C
on

te
nt

of
PC

C
St
ud

y
de

si
gn

(1
)
C
ou

nt
ry

(2
)
H
ea
lt
h
se
tt
in
g

D
at
a
co

lle
ct
io
n
m
et
ho

ds
St
ud

y
po

pu
la
ti
on

M
ea
n
±

SD
Fa

ct
or
s
as
so
ci
at
ed

w
it
h
pr
ov

id
in
g
(+

)
or

no
t

pr
ov

id
in
g
(-
)
PC

C
in

re
la
ti
on

to
le
ve

l
w
it
hi
n
so
ci
o-

ec
ol
og

ic
al

m
od

el

M
az
za

et
al
.

(2
01

3)
(1
)
To

ex
am

in
e
th
e
ba

rr
ie
rs

an
d

en
ab

le
rs

to
th
e
de

liv
er
y
an

d
up

ta
ke

of
PC

C
gu

id
el
in
es

fr
om

G
Ps
’p

er
sp
ec
ti
ve

us
in
g
th
eo

re
ti
ca
l
do

m
ai
ns

re
la
te
d
to

be
ha

vi
ou

r
ch

an
ge

(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
A
us
tr
al
ia

(2
)
D
iv
er
se

pr
ac
ti
ce

se
tt
in
gs

Fo
cu

s
gr
ou

p
in
te
rv
ie
w
s

n
=

22
G
Ps
;5

9.
1%

fe
m
al
e
A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•N
ot

pr
es
en

ti
ng

at
PC

st
ag

e
(-
):
un

aw
ar
e
of

av
ai
la
bi
lit
y
an

d
im

po
rt
an

ce
of

PC
C
(-
)

•N
ot

w
ill
in
g
to

sp
en

d
m
or
e
ti
m
e
an

d
m
on

ey
fo
r

m
ul
ti
pl
e
co

ns
ul
ta
ti
on

s
(-
)

Pr
ov

id
er
:

•P
er
ce
pt
io
n
of

ha
vi
ng

no
op

po
rt
un

it
y
to

de
liv

er
PC

C
(-
)

•B
el
ie
fs

ab
ou

t
eff

ec
ti
ve

ne
ss

PC
C
:d

ou
bt
s
re
ga

rd
in
g

eff
ec
ti
ve

ne
ss

of
fo
lic

ac
id

in
pr
ev

en
ti
ng

N
TD

’s
(-
)

•O
th
er

co
m
pe

ti
ng

pr
ev

en
ti
ve

ca
re

pr
io
ri
ti
es

(b
el
ie
vi
ng

in
a
po

te
nt
ia
l
in
cr
ea
se

in
bu

rd
en

on
cl
in
ic
s
if
th
e
nu

m
be

r
of

PC
C
co

ns
ul
ta
ti
on

s
w
as

in
cr
ea
se
d
(-
)

O
rg
an

iz
at
io
na

l:

•T
im

e
lim

it
s
on

co
ns
ul
ta
ti
on

(-
)

•G
P
an

d
cl
ie
nt

re
so
ur
ce
s
fo
r
PC

C
:L

ac
k
of

re
so
ur
ce
s

(-
);
av

ai
la
bi
lit
y
of

PC
C
re
so
ur
ce
s
(e
.g
.c

he
ck
lis
ts
/

cl
ie
nt

br
oc

hu
re
s/

ha
nd

ou
ts
/
w
ai
ti
ng

ro
om

po
st
er
s)

(+
)

•L
im

it
ed

ac
ce
ss

to
in
di
vi
du

al
G
Ps

(e
.g
.l
on

g
w
ai
ti
ng

lis
t)

(-
)

•L
im

it
ed

nu
m
be

r
of

G
Ps

w
ill
in
g
to

de
liv

er
PC

C
(-
):

po
te
nt
ia
l
de

la
y
fo
r
cl
ie
nt
s

•P
ot
en

ti
al

bu
rd
en

on
cl
in
ic
s
if
PC

C
co

ns
ul
ta
ti
on

s
in
cr
ea
se
d
(-
)

So
ci
et
al
:

•L
ac
k
of

G
P
&

cl
ie
nt

re
so
ur
ce
s
(e
.g
.e

vi
de

nc
e
ba

se
d

w
eb

si
te
s)

fo
r
PC

C
(-
)

Po
w
er

et
al
.

(2
01

3)
(1
)
To

as
se
ss

ba
rr
ie
rs

to
an

d
qu

al
it
y
of

pr
ec
on

ce
pt
io
n,

pr
en

at
al

an
d
po

st
na

ta
l

ca
re

fo
r
di
ab

et
ic

w
om

en
by

ob
st
et
ri
ci
an

-g
yn

ae
co

lo
gi
st
s

(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
an

ti
ta
ti
ve

(1
)
U
SA

(2
)
Pr
iv
at
e
gr
ou

p,
pr
iv
at
e

so
lo
,
ac
ad

em
ic
,h

os
pi
ta
l-

ow
ne

d
se
tt
in
gs

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

)
n
=

51
0
O
bG

yn
s,

/
A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
17

.5
±

1.
5
y.

C
li
en

t:

•H
ea
lt
h
st
at
us
:i
f
a
cl
ie
nt

ha
d
di
ab

et
es
,
ph

ys
ic
ia
ns

w
er
e
m
or
e
lik

el
y
to

as
k
ab

ou
tp

re
gn

an
cy

pl
an

s
(+

)
(d
es
cr
ip
ti
ve

re
su
lt
)

•A
ct
iv
e
de

si
re

fo
r
ch

ild
re
n
(+

)
(d
es
cr
ip
ti
ve

re
su
lt
)

Pr
ov

id
er
:

•P
ro
fe
ss
io
n/

sp
ec
ia
lit
y:

M
at
er
na

l-f
oe

ta
l
m
ed

ic
in
e

sp
ec
ia
lis
t
(+

)
>

no
n-
M
at
er
na

l-f
oe

ta
l
m
ed

ic
in
e

sp
ec
ia
lis
t

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:/

St
ep

he
ns
on

et
al
.

(2
01

4)

(1
)
To

as
se
ss

th
e
vi
ew

s
an

d
en

ga
ge

m
en

t
of

he
al
th

pr
of
es
si
on

al
s

w
it
h
PC

C
(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
U
K

(2
)
A
ll
se
tt
in
gs

re
la
te
d
to

ge
ne

ra
l
pr
ac
ti
ce
,
ob

st
et
ri
cs

&
gy

na
ec
ol
og

y,
m
id
w
if
er
y,

se
xu

al
&

re
pr
od

uc
ti
ve

he
al
th

Te
le
ph

on
e
in
te
rv
ie
w
s

n
=

21
co

ns
ul
ta
nt
s
in

O
bG

yn
,

m
id
w
iv
es
,G

Ps
,c

om
m
un

it
y
ba

se
d

co
ns
ul
ta
nt
s
(o
r
cl
in
ic
al

le
ad

s)
in

se
xu

al
an

d
re
pr
od

uc
ti
ve

he
al
th
,s

ex
ua

l
he

al
th

sp
ec
ia
lis
t
nu

rs
e;

/
A
ge
:
< 30 y: 28 % ,3 0- 34 y: 41 % ,3 5+ y: 31 % Y ea rs in pr ac tic e: / C li en t: •U np la nn ed pr eg na nc ie s (- ) •A w ar en es s (+ ) Pr ov id er : •P ro fe ss io na l re sp on si bi lit y/ ro le : PC C is so m eo ne el se ’s re sp on si bi lit y (- ) •K no w le dg e (+ -) •C on fi de nc e (+ ) •L ac k of in te re st (- ) O rg an iz at io na l: / So ci et al : •C on st ra in ed re so ur ce s (- ) •F in an ci al in ce nt iv es fo r de liv er y of PC C (+ ) (c on tin ue d on ne xt pa ge ) J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130 122 Ta bl e 2 (c on tin ue d) St ud y (1 ) St ud y ai m (2 ) C on te nt of PC C St ud y de si gn (1 ) C ou nt ry (2 ) H ea lt h se tt in g D at a co lle ct io n m et ho ds St ud y po pu la ti on M ea n ± SD Fa ct or s as so ci at ed w it h pr ov id in g (+ ) or no t pr ov id in g (- ) PC C in re la ti on to le ve l w it hi n so ci o- ec ol og ic al m od el A rc hi ba ld et al . (2 01 6) (1 ) To ex pl or e st ak eh ol de r vi ew s ab ou t off er in g po pu la ti on -b as ed ge ne ti c ca rr ie r sc re en in g fo r fr ag ile X sy nd ro m e (2 ) PC ge ne ti c ca rr ie r sc re en in g fo r fr ag ile X sy nd ro m e C ro ss -s ec ti on al , qu al it at iv e (1 ) A us tr al ia (2 ) / Se m i- st ru ct ur ed in te rv ie w s & fo cu s gr ou ps n = 81 he al th pr ov id er s (G Ps , ph ys io th er ap is ts nu rs es ,m id w iv es , sp ee ch pa th ol og is ts ,O bG yn s, ps yc ho lo gi st s, su pp or t w or ke rs , pa ed ia tr ic ia ns , cl in ic al ge ne ti ci st s an d co un se llo rs , m ed ic al sc ie nt is ts ,o cc up at io na l th er ap is ts ); / A ge :/ Y ea rs in pr ac tic e: / C li en t: •L ac k of kn ow le dg e an d aw ar en es s (- ) •T he po te nt ia lt o in cr ea se an xi et y at a st re ss fu lt im e (- ) Pr ov id er : •L ac k of kn ow le dg e an d aw ar en es s (- ) •S up po rt fr om he al th ca re pr ov id er s (+ ) O rg an iz at io na l: •R ed uc ed ti m e fo r de ci si on -m ak in g (- ) •L im it ed re pr od uc ti ve op ti on s (- ) •L im it ed ti m e av ai la bl e to pr ov id e pr et es t co un se lli ng (- ) •A se le ct iv e ap pr oa ch to off er in g sc re en in g (- ) •T ra in ed an d qu al ifi ed ca re pr ov id er s to off er th e te st (+ ) •S uffi ci en t re so ur ce s fo r m an ag in g te st -p os it iv e re su lt s (+ ) So ci et al : •D ev el op m en t of pr ot oc ol s an d gu id el in es (+ ) •E co no m ic ev al ua ti on s (+ ) C ol l et al . (2 01 6) (1 ) Ex pl or in g kn ow le dg e, at ti tu de an d pr ac ti ce s am on g he al th ca re pr ov id er s re ga rd in g PC C , sa fe r co nc ep ti on an d pr eg na nc y am on g H IV -i nf ec te d w om en (2 ) PC C am on g H IV -i nf ec te d w om en C ro ss -s ec ti on al , qu al it at iv e (1 ) U SA (2 ) U rb an So ut h Fl or id a – pu bl ic an d pr iv at e ho sp it al s K ey in fo rm an t in te rv ie w s n = 14 nu rs e pr ac ti ti on er s ph ys ic ia ns , ph ys ic ia n as si st an ts , an d pr ov id in g O bG yn an d H IV ca re ;/ A ge :/ Y ea rs in pr ac tic e: / C li en t: •L ac k of kn ow le dg e (- ) •W om en do no t br in g up th e to pi c du e to st ig m as su rr ou nd H IV -i nf ec te d w om en ’s de si re s fo r ch ild re n (- ) an d un pl an ne d pr eg na nc y (- ) Pr ov id er : •C om pe ti ng m ed ic al pr io ri ti es (- ) •F ai lu re to ad dr es s fe rt ili ty de si re s (- ) •L im it ed kn ow le dg e/ un de rs ta nd in g of PC is su es (- ) O rg an iz at io na l: •T im e co ns tr ai nt s (- ) •L ac k of pr ov id er re so ur ce s fo r H IV -in fe ct ed w om en (- ) So ci et al : / M cP hi e et al . (2 01 6) (1 ) To id en ti fy ba rr ie rs to pr ov id in g pr ec on ce pt io n w ei gh t m an ag em en t (2 ) PC w ei gh t m an ag em en t C ro ss -s ec ti on al , qu al it at iv e (1 ) A us tr al ia (2 ) / Se m i- st ru ct ur ed ph on e in te rv ie w n = 20 he al th pr ov id er s w it h ex pe rt is e in m at er na l an d ch ild he al th (p ri m ar y he al th pr ac ti ti on er s, m id w iv es , st ak eh ol de rs w or ki ng in he al th po lic y, he al th ca re m an ag em en t, pr ev en ti ve he al th ); / A ge :/ Y ea rs in pr ac tic e: / C li en t: •L ac k of aw ar en es s of th e im po rt an ce of PC he al th an d w ei gh t: es pe ci al ly w om en w ho ar e no t pl an ni ng on be co m in g pr eg na nt (- ) •U np la nn ed pr eg na nc ie s (- ) Pr ov id er : •P ro fe ss io na lr es po ns ib ili ty /r ol e: co nfl ic tin g id ea s ab ou tw ho sh ou ld be re sp on si bl e fo rp ro vi di ng PC C (- ) •S en si ti ve na tu re of th e to pi c (- ) •L ac k of co nfi de nc e to ha nd le se ns it iv e co nv er sa ti on s (- ) •L im ite d ac ce ss to w om en of ch ild be ar in g ag e w ho pl an to co nc ei ve :m is co nc ep tio n ab ou t pr ev al en ce of un pl an ne d pr eg na nc ie s an d im po ss ib le to de te rm in e w hi ch w om en w ill be co m e pr eg na nt an d w he n (- ) O rg an iz at io na l: •N o sc op e in th ei r ro le or th e cu rr en t he al th ca re sy st em (e .g .d ue to ti m e co ns tr ai nt s) (- ) So ci et al : •N o sc op e in th ei r ro le or th e cu rr en t he al th ca re sy st em (e .g .d ue to ti m e co ns tr ai nt s) (- ) (c on tin ue d on ne xt pa ge ) J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130 123 Ta bl e 2 (c on tin ue d) St ud y (1 ) St ud y ai m (2 ) C on te nt of PC C St ud y de si gn (1 ) C ou nt ry (2 ) H ea lt h se tt in g D at a co lle ct io n m et ho ds St ud y po pu la ti on M ea n ± SD Fa ct or s as so ci at ed w it h pr ov id in g (+ ) or no t pr ov id in g (- ) PC C in re la ti on to le ve l w it hi n so ci o- ec ol og ic al m od el O ju kw u et al . (2 01 6) (1 ) To ex am in e G Ps kn ow le dg e, at ti tu de s, an d vi ew s to w ar ds pr ec on ce pt io n he al th an d ca re in th e ge ne ra l pr ac ti ce se tt in g (2 ) G en er al PC C C ro ss -s ec ti on al , qu al it at iv e (1 ) U K (2 ) G en er al pr ac ti ce s In di vi du al se m i- st ru ct ur ed in te rv ie w s N = 7 G Ps ;4 2. 8% fe m al e A ge :/ ye ar s in pr ac tic e: 13 .7 y C li en t: •L ac k of at te nd an ce fo r he al th ca re be fo re pr eg na nc y (- ): un pl an ne d pr eg na nc ie s, et hn ic po pu la ti on s •L ac k of kn ow le dg e (- ) •L ac k of pe rc ei ve d ne ed (- ) Pr ov id er : •L ac k of m ot iv at io n (- ) •‘N an ny st at e’ in di ca ti ng pe rs on al be ha vi ou r (- ) O rg an iz at io na l: •L ac k of ti m e (- ) •F in an ci al co ns tr ai nt s (- ) So ci et al :/ va n V oo rs t et al . (2 01 6) (1 ) To as se ss cu rr en t ac ti vi ti es , pe rc ep ti on s an d pr er eq ui si te s fo r de liv er y of PC C (2 ) G en er al PC C C ro ss -s ec ti on al , qu an ti ta ti ve (1 ) th e N et he rl an ds (2 ) pr im ar y ca re se tt in g Se lf -a dm in is te re d qu es ti on na ir e (n ot va lid at ed ) n = 69 9 G Ps an d m id w iv es ;6 9. 6% fe m al e A ge :4 1y (2 3– 66 ) Y ea rs in pr ac tic e: / C li en t: •M en ti on in g de si re to be co m e pr eg na nt (+ ) (d es cr ip ti ve re su lt ) •A ft er m is ca rr ia ge (+ ) (d es cr ip ti ve re su lt ) •A pp ar en t ri sk fo r ad ve rs e re pr od uc ti ve ou tc om es (+ ) (d es cr ip ti ve re su lt ) •P os tn at al ch ec k- up (+ ) (m id w iv es – de sc ri pt iv e re su lt ) •P re sc ri pt io n m ed ic at io n, di sc us si ng co nt ra ce pt io n an d fo llo w -u p ch ro ni c di se as e (+ ) (G Ps – de sc ri pt iv e re su lt ) Pr ov id er : •P ro fe ss io n/ sp ec ia lit y: G Ps (+ ) >

m
id
w
iv
es

in
pe

rf
or
m
in
g
PC

C
co

ns
ul
ta
ti
on

;
m
id
w
iv
es

>
G
Ps

in
as
se
ss
in
g
PC

C
ri
sk

fa
ct
or
s

•P
er
ce
pt
io
ns

(-
):
PC

C
on

ly
fo
r
w
om

en
w
it
h
hi
gh

ri
sk
s,

PC
C
m
ed

ic
al
is
ed

pr
ec
on

ce
pt
io
n
pe

ri
od

,P
C
C

w
it
ho

ut
w
om

en
as
ki
ng

fo
r
it
w
as

ob
je
ct
io
na

bl
e

(d
es
cr
ip
ti
ve

re
su
lt
s)

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:/

Fi
el
dw

ic
k
et

al
.

(2
01

7)
(1
)
To

ex
pl
or
e
th
e
kn

ow
le
dg

e
an

d
pr
ac
ti
ce

of
G
Ps

re
ga

rd
in
g
PC

an
d

ge
st
at
io
na

l
w
ei
gh

t
m
an

ag
em

en
t

(2
)
PC

w
ei
gh

t
m
an

ag
em

en
t
(i
n
w
om

en
ha

vi
ng

ov
er
w
ei
gh

t,
ob

es
it
y
or

w
om

en
w
ho

ex
ce
ss

ge
st
at
io
na

l
w
ei
gh

t
ga

in
)

C
ro
ss
-s
ec
ti
on

al
,

m
ix
ed

m
et
ho

ds
(1
)
N
ew

Ze
al
an

d
(2
)
/

Se
lf
-a
dm

in
is
te
re
d

qu
es
ti
on

na
ir
e
(n
ot

va
lid

at
ed

),
co

ns
is
ti
ng

of
cl
os
ed

-e
nd

ed
qu

es
ti
on

s
(q
ua

nt
it
at
iv
e)

an
d

an
op

en
qu

es
ti
on

(q
ua

lit
at
iv
e)

n
=

20
0
G
Ps
;/

A
ge
:
< 30 y: 2% ,3 0- 39 y: 26 % ,4 0- 49 y: 23 % , 50 -5 9y :3 5% , 60 + y: 15 % Y ea rs in pr ac tic e: < 4y :1 1% ,4 -9 y: 20 % , 10 -1 5y :1 7% , >

15
y:

52
%

C
li
en

t:

•H
ea
lt
h
st
at
us
:G

Ps
m
or
e
of
te
n
di
sc
us
s
w
ei
gh

t
m
an

ag
em

en
tw

it
h
ov

er
w
ei
gh

to
r
ob

es
e
w
om

en
(+

)
(d
es
cr
ip
ti
ve

re
su
lt
);
if
w
om

en
pr
es
en

t
pr
ec
on

ce
pt
io
n,

it
is

of
te
n
re
la
te
d
to

in
fe
rt
ili
ty

(+
)

•R
ar
el
y
pr
es
en

ti
ng

fo
r
PC

C
(-
)

Pr
ov

id
er
:

•L
ac
k
of

op
po

rt
un

it
y
to

pr
ov

id
e
PC

C
(-
)

•L
ac
k
of

aw
ar
en

es
s:
no

tk
no

w
in
g
w
ha

t
PC

C
in
vo

lv
es

an
d
th
e
be

ne
fi
ts

of
PC

in
te
rv
en

ti
on

s
in

ov
er
w
ei
gh

t
an

d
ob

es
e
w
om

en
(-
)

O
rg
an

iz
at
io
na

l:
/

So
ci
et
al
:
/

(c
on

tin
ue
d
on

ne
xt

pa
ge
)

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

124

Ta
bl
e
2
(c
on

tin
ue
d)

St
ud

y
(1
)
St
ud

y
ai
m

(2
)
C
on

te
nt

of
PC

C
St
ud

y
de

si
gn

(1
)
C
ou

nt
ry

(2
)
H
ea
lt
h
se
tt
in
g

D
at
a
co

lle
ct
io
n
m
et
ho

ds
St
ud

y
po

pu
la
ti
on

M
ea
n
±

SD
Fa

ct
or
s
as
so
ci
at
ed

w
it
h
pr
ov

id
in
g
(+

)
or

no
t

pr
ov

id
in
g
(-
)
PC

C
in

re
la
ti
on

to
le
ve

l
w
it
hi
n
so
ci
o-

ec
ol
og

ic
al

m
od

el

M
’H
am

di
et

al
.

(2
01

7)
(1
)
To

ex
am

in
e
he

al
th
ca
re

pr
of
es
si
on

al
s’
vi
ew

s
of

th
ei
r
ro
le

an
d

re
sp
on

si
bi
lit
ie
s
in

pr
ov

id
in
g
PC

C
an

d
id
en

ti
fy

ba
rr
ie
rs

th
at

aff
ec
t
th
e

de
liv

er
y
an

d
up

ta
ke

of
PC

C
(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
Th

e
N
et
he

rl
an

ds
(2
)
O
ne

un
iv
er
si
ty

ho
sp
it
al

(s
pe

ci
al
is
ts
),
G
P
an

d
m
id
w
if
er
y
pr
ac
ti
ce
s

Se
m
i-
st
ru
ct
ur
ed

in
te
rv
ie
w
s

n
=

20
m
id
w
iv
es
,G

Ps
,s

pe
ci
al
is
ts
;/

A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•U
nf
am

ili
ar
it
y
w
it
h
PC

C
(-
)

•L
im

it
ed

aw
ar
en

es
s
ab

ou
t
im

po
rt
an

ce
of

PC
C
(-
)

•L
ow

so
ci
oe

co
no

m
ic

w
om

en
ar
e
ha

rd
es
t
to

re
ac
h
(-
)

•N
ot

w
ill
in
g
to

in
ve

st
ti
m
e
an

d
eff

or
t
(-
)

Pr
ov

id
er
:

•U
nf
am

ili
ar
it
y
w
it
h
PC

C
(-
)

•L
ac
k
of

kn
ow

le
dg

e
of

PC
C
(-
)

•E
th
ic
al

ba
rr
ie
rs

(-
):
te
ns
io
n
be

tw
ee
n
pe

rs
on

al
be

lie
fs

ab
ou

t
pr
eg

na
nc

y
an

d
th
e
w
el
lb
ei
ng

of
th
e

fu
tu
re

ch
ild

on
th
e
on

e
ha

nd
⬄

th
e
pr
of
es
si
on

al
re
sp
on

si
bi
lit
y
to

pr
ov

id
e
th
e
be

st
ca
re

po
ss
ib
le

fo
r

cl
ie
nt
s
w
hi
le

re
sp
ec
ti
ng

th
e
re
pr
od

uc
ti
ve

au
to
no

m
y

of
th
e
fu
tu
re

pa
re
nt
s
on

th
e
ot
he

r
ha

nd
O
rg
an

iz
at
io
na

l:

•T
im

e
co

ns
um

in
g
(-
):
PC

C
is

a
ne

w
fo
rm

of
ca
re
,a

su
bs
ta
nt
ia
l
am

ou
nt

of
ri
sk

fa
ct
or
s
sh
ou

ld
be

ad
dr
es
se
d,

co
m
pe

ti
ng

pr
ev

en
ti
ve

ca
re

w
hi
ch

al
so

ne
ed

s
to

be
de

liv
er
ed

•P
oo

r
or

la
ck

of
co

m
m
un

ic
at
io
n
be

tw
ee
n
di
ff
er
en

t
he

al
th
ca
re

di
sc
ip
lin

es
th
at

off
er

PC
C
(-
)

So
ci
et
al
:

•N
o
fi
na

nc
ia
l
co

m
pe

ns
at
io
n
(-
):
la
ck

of
a
fe
e
in

co
m
bi
na

ti
on

w
it
h
la
bo

ur
in
te
ns
iv
en

es
s

Po
el
s
et

al
.

(2
01

7a
,

20
17

b)

(1
)
To

id
en

ti
fy

bo
tt
le
ne

ck
s
an

d
so
lu
ti
on

s
fo
r
th
e
de

liv
er
y
of

PC
C
fr
om

a
H
C
pr
ov

id
er
s’
pe

rs
pe

ct
iv
e

(2
)
G
en

er
al

PC
C

C
ro
ss
-s
ec
ti
on

al
,

qu
al
it
at
iv
e

(1
)
Th

e
N
et
he

rl
an

ds
(2
)
/

Pa
ra
lle

l
gr
ou

p
se
ss
io
ns

n
=

30
he

al
th

pr
ov

id
er
s

(g
yn

ae
co

lo
gi
st
s,

m
id
w
iv
es
,p

re
ve

nt
iv
e

ch
ild

he
al
th
ca
re
,f
er
ti
lit
y
sp
ec
ia
lis
ts
,

m
at
er
ni
ty

ca
re
,G

Ps
,d

ie
ti
ci
an

,
ph

ys
io
th
er
ap

is
ts
,
pa

ti
en

t
ad

vo
ca
cy
,

m
un

ic
ip
al

po
lic

y
offi

ce
r;

/
A
ge
:/

Y
ea
rs

in
pr
ac
tic

e:
/

C
li
en

t:

•L
ac
k
of

at
te
nd

an
ce

fo
r
he

al
th
ca
re

be
fo
re

pr
eg

na
nc

y
du

e
to

un
aw

ar
en

es
s
(-
)
an

d
po

or
un

de
rs
ta
nd

in
g
of

pe
rs
on

al
ri
sk
s
(-
)

•H
ig
h-
ri
sk

gr
ou

ps
(l
ow

so
ci
oe

co
no

m
ic

st
at
us
,n

on
–

w
es
te
rn

et
hn

ic
it
y
or

liv
in
g
in

de
pr
iv
ed

ar
ea
s)

du
e

to
ig
no

ra
nc

e,
la
ck

of
se
lf
-k
no

w
le
dg

e
an

d
in
ad

m
is
si
bi
lit
y
fo
r
PC

in
fo
rm

at
io
n
(-
)

Pr
ov

id
er
:

•R
ol
e/
re
sp
on

si
bi
lit
y:

un
cl
ea
r
w
ho

sh
ou

ld
be

th
e

en
ti
tl
ed

pr
ov

id
er

fo
r
PC

C
(-
)

•P
ro
fe
ss
io
n/

sp
ec
ia
lit
y:

m
id
w
iv
es

le
ss

ac
ce
ss

to
w
om

en
w
it
h
ch

ild
be

ar
in
g
pl
an

s,
bu

tm
os
tw

ill
in
g
to

pr
ov

id
e
PC

C
;G

Ps
ha

ve
m
or
e
ac
ce
ss

to
w
om

en
w
it
h

ch
ild

be
ar
in
g
pl
an

s,
bu

t
le
ss

in
te
re
st
ed

in
pr
ov

id
in
g

PC
C

•L
ac
k
of

aw
ar
en

es
s
an

d
kn

ow
le
dg

e
(-
)

•N
ot

be
in
g
co

nv
in
ce
d
of

th
e
im

po
rt
an

ce
,
ne

ed
,

be
ne

fi
ts

an
d
effi

ca
cy

of
PC

C
(-
)

•L
ac
k
of

ex
pe

ri
en

ce
(-
)

O
rg
an

iz
at
io
na

l:

•R
ol
e/
re
sp
on

si
bi
lit
y:

un
cl
ea
r
w
ho

sh
ou

ld
be

th
e

en
ti
tl
ed

pr
ov

id
er

fo
r
PC

C
(-
)

•P
C
C
co

ns
ul
ts
ar
e
ti
m
e
co

ns
um

in
g
(t
im

e
co

ns
tr
ai
nt
s)

(-
)

•L
im

it
ed

co
lla

bo
ra
ti
on

an
d
re
fe
rr
al
s
be

tw
ee
n

he
al
th
ca
re

pr
ov

id
er
s
w
it
h
re
ga

rd
to

PC
C
du

e
to

la
ck

of
aw

ar
en

es
s
of

PC
C
an

d
ex
is
ti
ng

te
ns
io
n
be

tw
ee
n

di
ff
er
en

t
he

al
th
ca
re

di
sc
ip
lin

es
(-
)

(c
on

tin
ue
d
on

ne
xt

pa
ge
)

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

125

et al., 2016), the presence of an appropriate design could not be eval-
uated. Three articles did not sufficiently report on rigorousness of the
data analysis (Bortolus et al., 2017; McClaren et al., 2008; Stephenson
et al., 2014). Only two research articles clearly considered the re-
lationship between the researcher and the participants (McPhie et al.,
2016; Poels et al., 2017a, 2017b). Ethical issues were inadequately
discussed in four qualitative studies (Chuang et al., 2012; McClaren
et al., 2008; Mortagy et al., 2010; Stephenson et al., 2014).

One article with a relevant mixed method design, integrating both
qualitative and quantitative data, was included (Fieldwick et al., 2017).
Nevertheless, the study inappropriately considered the limitations of
this integration. The qualitative part was based on relevant data
sources, and an adequate data analysis process. The relation between
the findings and the context as well as the researchers’ influence were,
however, inadequately considered. The quantitative part was char-
acterized by inappropriate measurements, and the absence of an ac-
ceptable response rate. The sampling strategy was found to be relevant,
and the presence of a representative sample could not be evaluated.

3.4. Provider factors as facilitators or barriers to the provision of PCC

Most provider facilitators and barriers were related to the profes-
sional responsibility. Being confused about who should (be the entitled
provider to) deliver PCC was a frequently reported barrier (Bortolus
et al., 2017; Chuang et al., 2012; Heyes et al., 2004; Mortagy et al.,
2010; Poels et al., 2017a, 2017b; Stephenson et al., 2014; Tough et al.,
2004). Conversely, the belief that having a responsibility in PCC fa-
cilitated the provision of PCC (Parker et al., 2010; Tough et al., 2004).

The intention to provide PCC appeared to depend on the HCPs’
profession or specialty, although research findings were often incon-
sistent. HCPs in obstetrics and gynaecology (ob/gyn) practice settings,
including obstetrician–gynaecologists (Burris and Werler, 2011;
Morgan et al., 2004; Williams et al., 2006), maternal-foetal medicine
specialists (Power et al., 2013), and midwives (Poels et al., 2017a,
2017b) tended to be more involved in PCC compared with HCPs in
non–ob/gyn practice settings such as gynaecologists only (Burris and
Werler, 2011; Morgan et al., 2004) and general practitioners (Poels
et al., 2017a, 2017b; Williams et al., 2006). Some studies, however,
observed a greater PCC–engagement among family physicians in com-
parison with midwives and obstetricians (Tough et al., 2004; van Voorst
et al., 2016). In addition, the intention to provide PCC seemed to de-
pend on which PCC aspect was dealt with. Obstetrician-gynaecologists
seemed to discuss Pap testing and pregnancy related issues (including
folic acid, smoking, drug use, sexual abuse) more frequently than family
physicians, while family physicians tended to handle mental health,
depression, and workplace stress related topics more often (Tough
et al., 2006). Midwives seemed to assess PCC risk factors more regularly
compared with general practitioners (Poels et al., 2017a, 2017b).
Moreover, nurse practitioners in ob/gyn settings were most likely to
talk about folic acid while family physicians were least likely to discuss
the topic (Williams et al., 2006).

Having good knowledge on PCC was also identified as one of the
main facilitators to provide PCC (Archibald et al., 2016; Coll et al.,
2016; M’Hamdi et al., 2017; Miranda et al., 2003; Parker et al., 2010;
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J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

126

specialized rather than routine care was also a barrier for the provision
of PCC (Morgan et al., 2006). One study identified lack of motivation as
a barrier (Ojukwu et al., 2016). Being interested or not might have a
stimulating (Mortagy et al., 2010) or restraining influence (Stephenson
et al., 2014) on the provision of PCC.

The HCP’s perception of having no opportunity to deliver PCC was also
found to be a considerable barrier for the provision of PCC (Fieldwick
et al., 2017; Mazza et al., 2013). Some professionals experienced a
limited access to women of childbearing age who plan to conceive
(McPhie et al., 2016). Competing priorities (e.g. medical, preventive)
might also discourage professionals to engage in PCC (Coll et al., 2016;
Mazza et al., 2013).

Some studies cited communication problems as a barrier. HCPs might
experience some difficulties in addressing the topic of pregnancy in-
tentions or fertility desires (Coll et al., 2016; Schwarz et al., 2009), or
did not routinely ask clients for it (Schwarz et al., 2009). The sensitive
nature of the topic also seemed to prevent professionals in beginning a
PC-conversation with their clients (McPhie et al., 2016), which may be
attended by a lack of confidence (McPhie et al., 2016). Having good or a
lack of confidence (Chuang et al., 2012; Stephenson et al., 2014), as
well as having more or less (years of work) experience in providing PCC
(Bonham et al., 2010; McClaren et al., 2008; Morgan et al., 2004; Poels
et al., 2017a, 2017b) were also found to be either a facilitator or bar-
rier. Moreover, lack of training seemed to hamper HCPs (Heyes et al.,
2004).

Several articles mentioned that a HCP’s workplace influences the
provision of PCC; those working in a university, teaching, or residency
training environment (Bonham et al., 2010), and coming from areas
with high levels of morbidity (Parker et al., 2010) were more likely to
engage in PCC. Urban providers tended to discuss folic acid more often
than providers in rural areas (Tough et al., 2008). Another facilitating
factor was having clients of high risk groups; healthcare providers seeing
lower income clients, and whose practice consisted of at least 10%
minorities tended to be more inclined to provide PCC (Williams et al.,
2006). Two studies found a positive association between female pro-
fessionals and the provision of PCC (Heyes et al., 2004; Tough et al.,
2006).

The following facilitating HCP factors were mentioned in only one
study: provider who personally took multivitamin (Williams et al.,
2006); being nonreligious compared to reformed (Poppelaars et al.,
2004); obtaining information from medical journals (Tough et al.,
2004); support from other healthcare providers (Archibald et al., 2016);
and being uncertified (Abu-Hammad et al., 2008). Experiencing ethical
barriers (M’Hamdi et al., 2017) was considered to be an additional
barrier related to the provision of PCC.

3.5. Client factors as facilitators or barriers to the provision of PCC

A total of 14 studies identified contact with clients only after con-
ception as the main barrier for HCPs to deliver PCC. This implies clients
who do not present (whether consciously or not e.g. due to being
unaware of availability and importance of PCC) at preconception stage
(Fieldwick et al., 2017; Mazza et al., 2013; Ojukwu et al., 2016; Poels
et al., 2017a, 2017b), and those having unplanned pregnancies (Coll
et al., 2016; Heyes et al., 2004; McPhie et al., 2016; Ojukwu et al.,
2016; Stephenson et al., 2014). The aforementioned barrier also implies
communication difficulties; the perception that clients are not thinking
about having children (McClaren et al., 2008) or do not (want to) in-
itiate discussions about pregnancy planning or preconception health,
dissuaded HCPs from providing PCC (Bortolus et al., 2017; Chuang
et al., 2012; Heyes et al., 2004; Schwarz et al., 2009). By contrast, client
request (Morgan et al., 2004, 2006), and mentioning the desire to be-
come pregnant (Morgan et al., 2004; Power et al., 2013; van Voorst
et al., 2016) incited HCPs to offer PCC.

Several barriers related to the client’s personal attitude, seemed to
negatively influence the degree to which HCPs are willing to provide

PCC, including clients who are not willing to invest time, money, and
effort in preconception consultations (M’Hamdi et al., 2017; Mazza
et al., 2013), not interested in discussing PCC-related topics (Tough
et al., 2004), perceiving PCC as less needed (Ojukwu et al., 2016) or
important (Heyes et al., 2004), and less attending for healthcare before
pregnancy due to poor understanding of personal risks (Poels et al.,
2017a, 2017b).

The client’s lack of knowledge on PCC was considered as another
impeding factor (Archibald et al., 2016; Coll et al., 2016; Ojukwu et al.,
2016). Healthcare providers also seemed to be susceptible to the extent
to which clients are aware of PCC or otherwise. While awareness can be
seen as a facilitating factor (Stephenson et al., 2014), the client’s lack of
or limited awareness about the availability and importance of PCC were
identified as discouraging factors in the provision of PCC (Archibald
et al., 2016; M’Hamdi et al., 2017; Mazza et al., 2013; McPhie et al.,
2016; Poels et al., 2017a, 2017b).

Furthermore, HCPs mentioned the negative influence of the client’s
status, especially those belonging to high risk groups (e.g. low socio-
economic status, living in deprived areas) (M’Hamdi et al., 2017).
Those clients might be hardest to reach due to lack of self-knowledge,
ignorance, and inadmissibility for preconception information (M’Hamdi
et al., 2017; Poels et al., 2017a, 2017b). The client’s ethnicity or race
might either hamper or stimulate HCPs to provide PCC. Healthcare
providers were more likely to discuss preconception-related topics if
their clients were Jewish (Abu-Hammad et al., 2008), if the client’s race
was black (Bonham et al., 2010), or other than white, black or Hispanic
(Burris and Werler, 2011). Physicians caring for Indigenous clients were
more likely to inform their clients about drinking prior to pregnancy
(Tough et al., 2007). One study identified a non-western ethnicity as a
possible barrier for HCPs (Poels et al., 2017a, 2017b).

Several studies named the potential psychosocial impact for clients as a
discouraging factor for HCPs to provide PCC, including the potential to
increase anxiety (related to specific information, e.g. teratogenic risk of
certain medications) (Archibald et al., 2016; Schwarz et al., 2009), as
well as the potential to cause stress on relationships (McClaren et al.,
2008). Existing stigmas among clients might also hamper HCPs to in-
itiate PCC (Coll et al., 2016; McClaren et al., 2008). However, other
articles found that the client’s health status may trigger HCPs to discuss
PCC-related topics. A family history of cystic fibrosis, having a partner
who has cystic fibrosis or is a known carrier (Morgan et al., 2004),
suffering from diabetes (Power et al., 2013) or a chronic disease (van
Voorst et al., 2016), having experienced a miscarriage (van Voorst
et al., 2016), having infertility problems (Fieldwick et al., 2017), taking
medicines (e.g. contraception) (van Voorst et al., 2016), or having
overweight or obesity (Fieldwick et al., 2017) were mentioned as fa-
cilitating factors.

The following facilitating client factors were mentioned in only one
or two studies: the client’s insurance status (Burris and Werler, 2011),
gender (i.e. female clients) (Bonham et al., 2010), and age (Bonham
et al., 2010; Burris and Werler, 2011).

3.6. Organizational factors as facilitators or barriers to the provision of PCC

The main organizational factors were related to resources. Especially
lack of time was found to be a major barrier for HCPs to provide PCC
(Archibald et al., 2016; Bortolus et al., 2017; Chuang et al., 2012; Coll
et al., 2016; Heyes et al., 2004; M’Hamdi et al., 2017; Mazza et al.,
2013; McClaren et al., 2008; McPhie et al., 2016; Ojukwu et al., 2016;
Poels et al., 2017a, 2017b; Schwarz et al., 2009; Tough et al., 2007,
2008). Those time constraints refer to e.g. the decision-making process
(Archibald et al., 2016), the provision of pretest counselling (Archibald
et al., 2016), and other competing preventive care which also needs to
be delivered (M’Hamdi et al., 2017). HCPs in the study of McPhie et al.
(2016) considered limited available time as the reason why there is no
scope for PCC in both their role and the current healthcare system.
Other resource-related barriers were lack of money (Heyes et al., 2004;

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

127

Ojukwu et al., 2016), lack of space (Heyes et al., 2004), lack of client /
provider resources for PCC (Coll et al., 2016; Mazza et al., 2013), and
lack of manpower (Heyes et al., 2004). The latter includes a limited
number of general practitioners (willing) to deliver PCC (Mazza et al.,
2013), and a lack of (access to) local specialists or general practitioners
(e.g. long waiting list) (Chuang et al., 2012; Mazza et al., 2013). Con-
versely, the availability of PCC resources (e.g. checklists, client bro-
chures, handouts, waiting room posters), as well as trained and quali-
fied care providers were identified as organizational facilitators
(Archibald et al., 2016; Mazza et al., 2013; Schwarz et al., 2009).

HCPs tended to be less inclined to provide PCC if there was poorly
formatted information (Tough et al., 2007, 2008), or if they experienced
difficulties in finding clinically relevant information (e.g. on medica-
tions’ teratogenicity) (Schwarz et al., 2009). Disposing of the necessary
aids regarding PCC (e.g. online references, computerized decision
support, practice protocols), however, stimulated HCPs to engage in
PCC (Mortagy et al., 2010; Schwarz et al., 2009).

Besides the potential negative influence of resource- and informa-
tion-related factors, a lack of clear division of responsibility concerning
PCC was regarded as another barrier; some HCPs still found it unclear
who should be the entitled provider for PCC (Mortagy et al., 2010; Poels
et al., 2017a, 2017b). HCPs also mentioned that PCC (consultations)
might cause burden on organizational level owing to e.g. an added
workload (Heyes et al., 2004; Mazza et al., 2013).

Only Baars et al. (2004) identified the provision of genetic coun-
selling in an HCP’s own practice as an facilitating factor on organiza-
tional level. Limited reproductive options, a selective approach to of-
fering screening (Archibald et al., 2016), limited collaboration and
referrals between HCPs regarding PCC, and existing tension between
different healthcare disciplines (Poels et al., 2017a, 2017b) were
identified once as organizational factors that discourage HCPs to pro-
vide PCC.

3.7. Societal factors as facilitators or barriers to the provision of PCC

Societal barriers and facilitators were particularly related to the
availability of resources, guidelines, and reimbursement. The degree to
which HCPs are triggered to deliver PCC seemed to depend on having
access to educational materials for clients (e.g. information leaflets) and
professional resources (e.g. evidence based websites) or not (Mazza
et al., 2013; Mortagy et al., 2010; Schwarz et al., 2009; Stephenson
et al., 2014). HCPs need a society in which client information and
evidence-based guidelines for PCC are available (Heyes et al., 2004;
Mortagy et al., 2010) and being developed (Archibald et al., 2016). A
lack of PCC-related tools and guidelines were seen as discouraging
factors to provide PCC (Mortagy et al., 2010; Poels et al., 2017a,
2017b). Being reluctant to provide PCC can also be attributed to fi-
nancial constraints, including the absence of a costing structure (Poels
et al., 2017a, 2017b), and the lack of a financial compensation for PCC
(M’Hamdi et al., 2017; Schwarz et al., 2009). A society that equips fi-
nancial incentives, by contrast, might entice HCPs into providing PCC
to their clients (Stephenson et al., 2014). In the study of Archibald et al.
(2016) HCPs also identified the performance of economic evaluations of
PCC as a facilitating factor.

The following additional societal barriers were mentioned in only
one study: rural community norms (e.g. accepting early childbearing,
unintended pregnancies) (Chuang et al., 2012), poor or lack of com-
munication between different healthcare disciplines that offer PCC
(M’Hamdi et al., 2017), lack of formal professional education on PCC
(Poels et al., 2017a, 2017b), lack of overview of collaboration partners
(Poels et al., 2017a, 2017b), and the organization of the current
healthcare system (e.g. time constraints) (McPhie et al., 2016).

4. Discussion

The aim of this review was to provide an overview of barriers and

facilitators that could influence the provision of PCC by HCPs. Thirty-
one studies were included in this review. Findings of this review suggest
that the provision of PCC is influenced by several client, provider, or-
ganizational, and societal factors. Most of the factors influencing the
provision of PCC were identified as barriers, which might explain why
the provision of PCC is low. The majority of the reported barriers were
situated at client level (e.g. not contacting a HCP in the preconception
stage, negative attitude and lack of knowledge of PCC), and HCP level
(e.g. unfavourable attitude and lack of knowledge of PCC, not working
in the field of obstetrics and gynaecology, and lack of clarity on the
responsibility for the provision of PCC). The aforementioned barrier
was one of the most reported barriers in the provision of PCC (Bortolus
et al., 2017; Chuang et al., 2012; Heyes et al., 2004; M’Hamdi et al.,
2017; McPhie et al., 2016; Mortagy et al., 2010; Poels et al., 2017a,
2017b; Schwarz et al., 2009; Stephenson et al., 2014; Tough et al.,
2004). Several studies found that HCPs perceive PCC as the responsi-
bility of other HCPs rather than their own responsibility. This lack of
clarity of responsibility can be explained by the fact that PCC is still an
emerging topic. In 2006, the Centers for Disease Control and Prevention
(CDC) were one of the first to develop recommendations to improve
preconception health and care (Johnson et al., 2006). Since then, more
attention has been given to PCC with an increased research activity and
development of national and global guidelines (Jack et al., 2008; Shawe
et al., 2014; World Health Organization, 2012). However, there is still a
lack of clarity regarding who should provide PCC. Most studies and
guidelines recommend a shared responsibility between all healthcare
providers who have contact with women, from obstetricians/gynae-
cologists to general practitioners, paediatricians, family practice phy-
sicians, midwives, nurses, (advanced) midwife/nurse practitioners, and
so on, which may reduce the sense of individual responsibility and ef-
forts (Johnson et al., 2006; Shawe et al., 2014).

Another frequently reported barrier was the lack of client initiative
in the preconception stage to discuss pregnancy planning or pre-
conception health due to unplanned pregnancies and lack of awareness
(Bortolus et al., 2017; Chuang et al., 2012; Coll et al., 2016; Fieldwick
et al., 2017; Heyes et al., 2004; Mazza et al., 2013; McPhie et al., 2016;
Morgan et al., 2004; Ojukwu et al., 2016; Poels et al., 2017a, 2017b;
Schwarz et al., 2009; Stephenson et al., 2014; van Voorst et al., 2016).
The perception of women as main initiators of a dialogue about preg-
nancy planning and preconception health may result from the belief
that PCC is the responsibility of others, including women’s responsi-
bility (Goossens et al., 2014). Another explanation is that HCPs hesitate
to pose personal questions about women’s reproductive plans because
they belief these questions are sensitive or embarrassing. Yet, literature
suggests that the majority of clients appreciate a discussion about their
reproductive plans and health (Stern et al., 2013). In addition, the re-
search of Wendt and colleagues suggests that women may experience
difficulties in raising a conversation about sexual health issues them-
selves, and therefore, would find it easier if a HCP would initiate a
dialogue about these matters (Wendt et al., 2007).

Limited resources were frequently reported barriers at the organi-
zational and societal level. At the organizational level, lack of time was
found to be a major barrier for the provision of PCC. Previous research
also identified lack of time and heavy workload as one of the most
important factors that prevented HCPs from providing health promo-
tion and prevention (Luquis and Paz, 2015). A study in six European
countries found that mean consultation length in general practices was
10.7 min (Deveugele et al., 2002). Given the restricted amount of time,
the opportunities to discuss preconception health promotion may be
limited, as physicians need to spend their time discussing more urgent
care issues. A possible solution to lack of physician time is to use a
team-based PCC approach in which midwives and nurses, and health
educators are responsible for general preconception health promotion,
and advanced nurse/midwife practitioners and physicians address the
more complicated cases.

Lack of reimbursement for PCC, tools and guidelines were the main

J. Goossens et al. International Journal of Nursing Studies 87 (2018) 113–130

128

societal barriers for the provision of PCC. These barriers were also
frequently reported in other studies on factors influencing the provision
of preventive health services and health promotion (Luquis and Paz,
2015). Clear evidence-based guidelines, and education materials and
tools might support the provision of PCC.

This systematic review has some limitations. First, a number of
methodological issues and potential biases were identified in the in-
cluded studies. More than half of the quantitative studies had a con-
siderable risk of selection bias due to low response rates (Bonham et al.,
2010; Fieldwick et al., 2017; Tough et al., 2007, 2004; Tough et al.,
2008, 2006; van Voorst et al., 2016) and convenience sampling
(Miranda et al., 2003). Furthermore, only two quantitative studies used
a validated and reliable data collection method (Baars et al., 2004;
Miranda et al., 2003), and only Morgan et al. (2004, 2006) and Tough
et al. (2006, 2008) performed a sample size or power calculation. Some
of the qualitative studies had a relatively small and heterogeneous
sample of HCPs (Bortolus et al., 2017; Coll et al., 2016; Mortagy et al.,
2010; Ojukwu et al., 2016), and a rather short interview duration (Coll
et al., 2016; McPhie et al., 2016). In addition, the authors critically
considered their role as researcher and the potential bias and influence
during the data collection in only two qualitative studies (McPhie et al.,
2016; Poels et al., 2017a, 2017b). The aforementioned methodological
concerns may affect the validity of the study findings. Second, physi-
cians (e.g. GPs and obstetricians-gynaecologist) were overrepresented
in this review with 14 studies focusing on physicians only (Abu-
Hammad et al., 2008; Baars et al., 2004; Bonham et al., 2010; Burris
and Werler, 2011; Chuang et al., 2012; Fieldwick et al., 2017; Mazza
et al., 2013; Miranda et al., 2003; Morgan et al., 2004, 2006; Ojukwu
et al., 2016; Power et al., 2013; Tough et al., 2007, 2006), and 16
studies included both physicians and non-physicians healthcare provi-
ders (e.g. midwives and nurses) (Archibald et al., 2016; Bortolus et al.,
2017; Coll et al., 2016; Heyes et al., 2004; M’ Hamdi et al., 2017;
McClaren et al., 2008; McPhie et al., 2016; Mortagy et al., 2010; Poels
et al., 2017a, 2017b; Poppelaars et al., 2004; Schwarz et al., 2009;
Stephenson et al., 2014; Tough et al., 2004, 2008; van Voorst et al.,
2016; Williams et al., 2006). Because most findings relate to physicians,
findings might be less generalizable to non-physician healthcare pro-
viders including midwives and nurses. It is possible that nurses and
midwives experience other barriers and facilitators influencing the
provision of preconception care. In addition, due to heterogeneity in
study characteristics, including content of PCC (PCC in general or a
specific care domain), target population (general population or sub-
groups of the population), study country, and healthcare setting, find-
ings may be less generalizable to a broader context. Third, this het-
erogeneity in methodology and content of PCC made it impossible to
perform a meta-analysis, which would have allowed us to learn more
about associated factors of the provision of PCC. Finally, we did not
search for grey literature. Therefore, it is possible that some studies
might have been missed due to publication bias.

To overcome the different client, provider, organizational, and so-
cietal barriers, it is necessary to develop and implement multilevel in-
terventions (Eldredge et al., 2016). At the client level, developing and
implementing preconception mass media campaigns with e.g. posters,
leaflets, TV spots, mobile applications, and evidence-based websites
could improve people’s attitude, awareness, and knowledge about
preconception health (Poels et al., 2017a, 2017b; Toivonen et al.,
2017). However, this does not guarantee a preconception lifestyle
change (Delissaint and McKyer, 2011; Toivonen et al., 2017). There-
fore, it is important to gain insight in which determinants are associated
with the intention to prepare for pregnancy (Toivonen et al., 2017). The
study of intentions to prepare for pregnancy may also be more en-
lightening than measuring knowledge or attitude alone to assess the
effectiveness of a preconception campaign (Toivonen et al., 2017). In
addition, most preconception interventions focus on women only
(Toivonen et al., 2017). Yet, preconception health is considered as a
shared responsibility between women and men, therefore, future

research should target both future parents (Toivonen et al., 2017). At
provider level, there is a need to define the role and responsibility of the
different HCPs in providing PCC. A team-based PCC approach with
general PCC provided by nurses and midwives, and specialized in-
dividual PCC provided by advanced nurse/midwife practitioners and
physicians should be further explored. In addition, further research
should be undertaken to investigate barriers and enablers to provide
PCC among non-physician HCPs (e.g. midwives, nurses, health educa-
tors) as none of the included studies focused solely on factors influen-
cing the provision of PCC by these HCPs. At organizational level, our
findings suggest that the development of education materials and tools
could facilitate the provision of PCC. The Reproductive Life Plan (RLP),
a tool for reproductive health promotion across the life span, might be a
feasible tool for promoting reproductive and preconception health in
primary care settings, such as student health centres, STD clinics, and
community health centres (Stern et al., 2013). Preconception inter-
ventions should also be delivered through non-medical channels, for
example, through school-based education programs. By integrating
preconception health and care in existing sexual health education, the
vast majority of the population could be reached. At societal level, the
provision of preconception care can be encouraged by developing clear
evidence-based guidelines and reimbursing PCC.

Funding

This work was supported by The Research Foundation – “Flanders
(FWO) (grant number G058113N)”.

Appendix A. Supplementary data

Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.ijnurstu.2018.06.009.

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http://refhub.elsevier.com/S0020-7489(18)30147-0/sbref0210

http://refhub.elsevier.com/S0020-7489(18)30147-0/sbref0210

http://refhub.elsevier.com/S0020-7489(18)30147-0/sbref0215

http://refhub.elsevier.com/S0020-7489(18)30147-0/sbref0215

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https://sustainabledevelopment.un.org/post2015/transformingourworld

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Barriers and facilitators to the provision of preconception care by healthcare providers: A systematic review

What is already known about the topic?

What this paper adds

Introduction

Methods

Search strategy

Eligibility criteria

Study selection

Quality assessment

Data extraction and synthesis

Results

Selection of articles

Study characteristics

Methodological quality of the studies included

Provider factors as facilitators or barriers to the provision of PCC

Client factors as facilitators or barriers to the provision of PCC

Organizational factors as facilitators or barriers to the provision of PCC

Societal factors as facilitators or barriers to the provision of PCC

Discussion

Funding

Supplementary data

References

TUTORIAL – ASSIGNMENT 3

no 
systematic reviews are allowed (nor literature reviews, or meta-analyses) because these are all studies based on “secondary data” which you have all excluded from your searches.

And a few final reminders about A3.

What to include in the data extraction table? Please be advised that there can be a lot of variations in the data extraction table – this does not mean a lack of consistency, but rather different approaches in data extraction, based on the context/nature of the studies. However, there are some key sections that need to be provided regardless of the designs (the first 4 key points).

These are:

1. Author, year, country

2. Study Aim/s – different studies may conceptualise their study aims differently, for example, aims/objectives/research question/hypothesis and/or outcome measures, or sometimes simply discussing the relationships between variables (X impacting Y or correlation between X & Y).

3. Study design (including population/sample, data collection, and analysis) – please be advised that you can separate these via columns, or integrate all of these together.

4. Results/key findings – I suggest providing bullet points to be punchy and informative, rather than too many details.  

5. Strengths and limitations (optional) – No study is perfect, and there are limitations, so understanding the limitations assists in improving them in future studies. Statements around strengths and weaknesses can be generally found in the discussion section. Sometimes papers directly use these statements (e.g., in this paper, we have highlighted X & Y; the strengths of this paper are X & Y…) – Sometimes there can be only indications!

Rephrasing & citation of the data extraction table – No need to rephrase the table, however, if you aim to 
publish it in the future, it needs to be rephrased, later on. Also, no need to reference/cite every column of the table, if you only mention the name/s of authors in the first column, that is sufficient, as it indicates that the rest of the info in that row is related to the same author. 

Data extraction table for quantitative and qualitative studies – The quantitative versus qualitative data can be extracted in either one table or two tables separately.

Rephrasing – NO need to rephrase any sections of assignments 1 and 2, when incorporating in assignment 3, as at the end, these 3 tasks will be one piece of work, as a review paper. However, make sure to rephrase the rest (e.g., finding, discussion, conclusion).

Different papers from the same authors – Studies from the same authors can be included. Researchers can have multiple publications out of the same research project, as it may not be possible to provide all the findings in one paper.

Statistics – Numbers related to statistics and decimals need to be written in numbers… Please see this link for further information on the “numbers & statistics guide” 

https://apastyle.apa.org/instructional-aids/numbers-statistics-guide

Please see below some of our recent review papers (mainly scoping reviews), providing further full examples of data extraction tables – you can have access to these studies via the library. As you can see there are variations across different papers. 
Please be advised that you would NOT lose any scores if you have flexibility in your data extraction table, as far as you provide the four key sections highlighted above.

Obieche, O., Lee, M., & Salehi, N. (2021). Exploring attitudes towards smoking behaviour and cessation among hospitalised smokers via a socio-ecological framework: A scoping review. 
Addictive Behaviors, 
122, 107040–107040. 

https://doi.org/10.1016/j.addbeh.2021.107040

Visser, A., Lee, M., Barringham, T., & Salehi, N. (2021). Out of tune: Perceptions of, engagement with, and responses to mental health interventions by professional popular musicians—A scoping review. 
Psychology of Music, 30573562110194–. 

https://doi.org/10.1177/03057356211019477

Mathews, S. B., Mozolic-Staunton, B., Jefford, E., & Salehi, N. (2020). Canadian Occupational Performance Measure and Early Intervention: A Scoping Review. 
Journal of Occupational Therapy, Schools & Early Intervention, 
13(4), 353–373. 

https://doi.org/10.1080/19411243.2020.1744210

Cornelius, J., Doran, F., Jefford, E., & Salehi, N. (2020). Patient decision aids in clinical practice for people with diabetes: a scoping review. 
Diabetology International, 
11(4), 344–359. 

https://doi.org/10.1007/s13340-020-00429-7

Salehi, A., Ehrlich, C., Kendall, E., & Sav, A. (2019). Bonding and bridging social capital in the recovery of severe mental illness: a synthesis of qualitative research. 
Journal of Mental Health (Abingdon, England), 
28(3), 331–339. 

https://doi.org/10.1080/09638237.2018.1466033

Salehi, A., Frommolt, V., & Coyne, E. (2019). Factors affecting provision of care services for patients with cancer living in the rural area: An integrative review. 
The Australian Journal of Cancer Nursing, 
20(1), 3–13. 

https://doi.org/10.33235/ajcn.20.1.3-13

Sav, A., Salehi, A., Mair, F. S., & McMillan, S. S. (2017). Measuring the burden of treatment for chronic disease: implications of a scoping review of the literature. 
BMC Medical Research Methodology, 
17(1), 140–140. 

https://doi.org/10.1186/s12874-017-0411-8

Udovicich, A., Foley, K. R., Bull, D., & Salehi, N. (2020). Occupational therapy group interventions in oncology: A scoping review. 
American Journal of Occupational Therapy, 
74(4), 7404205010p1-7404205010p13.

Note on assignment 2 correction/feedback

Please, you can adjust where you use, Cochrane library for your review searching,  google scholar as a database to ..

The Academic Search Planner, CINAHL, MedLine, ProQuest, and Scopus electronic data bases

please do NOT…, Cochrane library for your review searching,  google scholar as a database t

24

A Critical Review of Self-care for Emotional Distress Among Young Adults

Student’s Name

Institutional Affiliation

Course Details

Instructor’s Name

Date

Self-care for Emotional Distress Among Young Adults

Introduction

Problem Statement

Emotional distress is a prevalent mental health concern in adolescence, a crucial stage in constructing social and personal identity. According to Jorm & Kitchener (2021), 44% of Australians had experienced a mental health problem in the previous twelve months of 2021. More women than men, with 45% and 43% respectively, had experienced psychological problems in their lifetimE (Jorm & Kitchener, 2021). People between 16 and 24 years were 40% more likely to have experienced mental health symptoms in the previous 12 months than those between 75 and 85 years, who were at least 4%. This demonstrates that adolescent Australians are at increased risk of developing mental health problems (Jorm & Kitchener, 2021).

Adolescents are vulnerable to anxiety, depression, and negative moods and tend to have negative attitudes toward seeking professional assistance (Vazquez‐Ortiz et al., 2020). Evidence demonstrates a strong relationship between self-care strategies like a healthy diet, weight management, sleep, and coping strategies, and reducing depressive symptoms. Other possible depression protective factors include self-disclosure to parents, dating during adolescence, sport, physical activity, and relationship with positive peers.

Various lay care strategies outside the professional care boundaries can help address youths’ emotional distress. These strategies can include social support, self-care, informal care, or self-help, all of which cover a broad range of practices. Moreover, studies find spirituality, structured routine, and creative activities as important in reducing emotional distress (Bemme & Kirmayer, 2020). A self-care model in mental health is grounded on the inclusive use of other concepts like self-management, recovery, and self-help. The model demonstrates a reciprocal relationship with self-care behaviors, self-care support, and well-being and functioning: studies recommend self-care strategies as critical for people with mental health problems (Ziede & Norcross, 2020). The study will analyze self-care strategies among young people and adolescents diagnosed with depression or with perceived depressive distress in Australia. The paper will consider resources and activities young people care utilize to alleviate, control, and resolve their circumstances of distress without professional services intervention.

The Systematic Review Type

Experiential (qualitative) reviews are the most suitable for the study as it concentrates on analyzing people’s experiences and social phenomena (Munn et al., 2019). The reviews focus on the engagement between the intervention and participants and describe a suitable intervention for addressing particular problems like emotional distress. The mnemonic PICo can be utilized for question development guidance. The review will assist in establishing suitable self-care strategies and their effectiveness in reducing emotional distress in young people and adolescents.

The Structured Question

What are the effective self-care strategies for reducing emotional distress among youths and adolescents diagnosed with depression or perceived depressive distress in Australia?

The Question Format

Among youths and adolescents with depression (P), what are the self-care strategies (I), compared to no intervention (C ), that are effective in reducing emotional distress (O)? The population for the study is young people diagnosed with depression, and the intervention is self-care strategies like relaxation, naturopathy, and medication. The comparison is no intervention, while reducing distress is the outcome. The self-care strategies are to be compared to no intervention to measure their effectiveness in reducing emotional distress among adolescents and young adults suffering from depression.

Justification of Question Format

The adopted question is suitable for the study as it allows diverse research and testing through literature drawn from diverse areas of mental health. Using the PICo format breaks down the question to better understand the problem of interest, intervention, and population to retrieve the best evidence for the study (Kang et al., 2019). The format allows for the effective extraction of relevant research literature as it breaks down the research question into keywords and phrases for the study. Feeding relevant words and phrases into databases makes it easy to extract all the relevant articles relevant to the subject of interest. Research is a process, and getting the right literature establishes a solid foundation for the study, therefore creating room for reliable, valid, and generalization study findings.

Method

The research used the Academic Search Planner,

CINAHL

, MedLine, ProQuest, and

Scopus

electronic databases CINAHL and Searched Premier electronic databases that are accessible through the university’s library to conduct a systematic literature search. The above databases are acknowledged internationally to be part of the most reliable sources of information on health and medical studies (Bartels, 2013). The databases above allowed for obtaining around 10 million peer-reviewed journals since they were employed as they were without pre-set filters. The following key terms were used during the literature search: Youths, Adolescents, Depression, Self-care, Reduce, and Emotional distress. Boolean operators accompanied the above words. The Boolean operators primarily used in the above search include

AND

and

OR

. The search terms were similar across all databases. Secondary and grey sources were excluded from the search. The search strategy, database, keywords, and the number of articles generated are indicated in Table 1. Table 1. Databases and Keywords Used to Identify Sources for the Literature Review

Database

Search terms

No. articles

Scopus

Adolescents [MeSH] OR “teenagers” OR “young adults” OR “young people” OR “teens” OR “young individuals” OR “juvenile.”

N =13

AND

depression [MesH] OR stress [MesH] OR despondency [MesH] OR unhappiness [MesH] OR sadness [MesH]

OR

“self-care” OR “self-management” OR “self-rehabilitation.”

Limiters:

2017-2023, type of publication (Peer-reviewed journal articles), English language, type of study design (systematic reviews, randomized control trials, meta-analyses, or cohort studies).

CINAHL

Adolescents [MeSH] OR “teenagers” OR “young adults” OR “young people” OR “teens” OR “young individuals” OR “juvenile.”

N = 131

AND

depression [MesH] OR stress [MesH] OR despondency [MesH] OR unhappiness [MesH] OR sadness [MesH]

OR

“self-care” OR “self-management” OR “self-rehabilitation.”

Limiters:

2017-2023, type of publication (Peer-reviewed journal articles), English language, type of study design (systematic reviews, randomized control trials, meta-analyses, or cohort studies).

COCHRANE Library

Adolescents [MeSH] OR “teenagers” OR “young adults” OR “young people” OR “teens” OR “young individuals” OR “juvenile.”

N =145

AND

depression [MesH] OR stress [MesH] OR despondency [MesH] OR unhappiness [MesH] OR sadness [MesH]

OR

“self-care” OR “self-management” OR “self-rehabilitation.”

Limiters:

2017-2023, type of publication (Peer-reviewed journal articles), English language, type of study design (systematic reviews, randomized control trials, meta-analyses, or cohort studies).

Academic Premier Search

Adolescents [MeSH] OR “teenagers” OR “young adults” OR “young people” OR “teens” OR “young individuals” OR “juvenile.”

N =138

AND

depression [MesH] OR stress [MesH] OR despondency [MesH] OR unhappiness [MesH] OR sadness [MesH]

OR

“self-care” OR “self-management” OR “self-rehabilitation.”

Limiters:

2017-2023, type of publication (Peer-reviewed journal articles), English language, type of study design (systematic reviews, randomized control trials, meta-analyses, or cohort studies).

Total records identified after database searching

N = 552

Total records after duplicates removed

N =105

The literature search was restricted to sources authored in the past five years to ensure the currency and relevance of data gathered from the sources. The participants in the literature were limited to teenagers aged between 13 and 17 since that is the age bracket when adolescents and teenagers are trying to define themselves and develop their values and goals. The articles were from peer-reviewed journals since they offer more reliable information because they are reviewed and acknowledged by relevant scholars and bodies (Bartels, 2013). The publications were published in the English language to guarantee reliability and comprehensive understanding. The sources were randomized control trials, meta-analyses, or cohort studies because they offer a comprehensive analysis of the issue under study. Sources were published within the past five years to ensure currency hence the relevancy of the materials to the current study (Bartels, 2013).

The exclusion criteria included articles published more than five years ago to avoid extracting outdated study findings. Current studies give current and well-updated information that is applicable to address current problems effectively. Articles not published in English were excluded to allow a wide audience considering the English language is spoken and understood globally. English is the official language in most countries across the world; therefore, choosing articles published in the language would make the work reach and be applied by a wider population. Sources whose participants did not fall in the 13-25 years bracket were as well excluded because this is the age where most adolescents fall, and using an older population would allow contradicting results as the study would be using the wrong study population. Additionally, only peer-reviewed articles were used because journals analyze them well to ensure they meet standards of valid and reliable scientific research. Peer-reviewed articles go through a thorough critique process to ensure they have the right information and follow the appropriate study methodology. This is an important consideration when choosing study articles to guarantee reliable, valid, and generalizable study findings.

The above search yielded around 552 articles. After the removal of duplicate sources (447 articles), the remaining 105 articles were assessed against the inclusion criteria. Another 66 articles were rejected because they were not freely accessible to readers and required an access fee. The remaining 39 sources were screened for inclusion in the current study. An additional 27 journals were rejected for different reasons; for instance, the study methodology needed to be stronger to appeal to all criteria. For example, a small sample size meant that the final results could not be generalized (Lakens, 2022). The articles were a generalized pilot study with a sub-standard methodology. Additionally, some sources mainly employed secondary information sources in their data. Finally, the report cumulatively deviated from the research scope, population, or sample set. The remaining 12 articles that met the inclusion criteria included five controlled trials, three randomized controls, and four cross-sectional studies. These articles are relevant to effectively answering the research question, “What are the effective self-care strategies for reducing emotional distress among youths and adolescents diagnosed with depression or perceived depressive distress in Australia?”

Figure 1: PRISMA Flow Diagram

Potentially relevant articles identified through database searching (n = 522)

Articles after duplicates removed (n =105)

Screening

Articles excluded after assessing titles/abstract, based on inclusion/exclusion criteria (n=66)

Eligibility
Full-text articles assessed for eligibility (n = 39)

Articles excluded after full-text assessment, based on inclusion/exclusion criteria (n=27)

Additional studies identified through
citation chaining (n =0)

Articles excluded after full-text assessment, based on inclusion/exclusion criteria (n=0)

Included
Total papers included (n =12)

Reports excluded for other reasons (n=27)
i. Reason 1 The study methodology was not strong enough to appeal to all criteria. For example, a small sample size meant that the final results could not be generalized.
ii. The article was a generalized pilot study with a low-quality methodology
iii. The source mainly used secondary sources of information in its data
iv. The article generally deviated from the research scope, population, or sample set.

The type of the paper included [e.g., Cluster-randomized trial (n =3) and (n=4) cross-sectional studies.

The type of the paper included: controlled trials (n =5)

A PICo format is adopted to assist in searching for the right information, as it breaks the study question in an easy-to-understand way (Kang et al., 2019). PICo question provides keywords and phrases for searching the right study literature for the study. The PICo for this project is “Among youths and adolescents with depression 
(P), what are the self-care strategies 
(I), compared to no intervention 
(C ), that are effective in reducing emotional distress 
(O)?” The population for the study is young people diagnosed with depression, and the intervention is self-care strategies like relaxation, naturopathy, and medication. The comparison is no intervention, while reducing distress is the outcome. The format allows the researcher to extract detailed literature for the study subject thoroughly.

Results

           The final set included 12 study articles published between 2019 and 2023; three were conducted in Australia, one in Uganda, two in Iran, four in the United States, one in Syria, and one in China. The research articles reflected on various self-care strategies to reduce emotional distress among young adults and adolescents. The participants’ demographics were reported in all twelve study articles. The articles balanced gender in their sampling. Male young adults are the most affected by emotional distress compared to females in the majority of the studies. The twelve selected study articles included five controlled trials, three randomized controls, and four cross-sectional studies.

Table 2. Results Table

Author/Year/Country

Study Design

Sample Size

Age Range

Data Collection Method

Results

Limitations

Downie, G. A., Mullan, B. A., Boyes, M. E., & McEvoy, P. M. (2021). Australia

Controlled Trial

167

18-24

Surveys

Self-care strategies are effective in addressing emotional distress among young adults with type 1 diabetes.

Validity of results require multiple sites, which the study lacked.

Akhtar, A., Giardinelli, L., Bawaneh, A., Awwad, M., Naser, H., Whitney, C., … & STRENGTHS Consortium. (2020). Syria

Randomized controlled trial

480

18 years and above

Interviews

Group problem management plus (gPM+) is effective in treating emotional distress

The study involved participants aged 18 years and above, which may not reflect realities among adolescent population.

Bai, C. F., Cui, N. X., Xu, X., Mi, G. L., Sun, J. W., Shao, D., … & Cao, F. L. (2019). United States

Cluster randomized controlled trial

189

234

Questionnaire

Brief mindfulness is found effective in improving sleep quality and reducing depression.

Inlucion criteria opened room for bias as those with limited education were excluded. The study included females only.

Tol, W. A., Leku, M. R., Lakin, D. P., Carswell, K., Augustinavicius, J., Adaku, A., … & van Ommeren, M. (2020). Uganda

Parallel-group cRCT

613

–

Focus group

Self-help Plus intervention reduced significantly reduced emotional distress within 3 months.

The study included female participants only, therefore cannot be generalized to the entire population.

Tonsing, K. N., & Tonsing, J. C. (2022). United States

Cross-sectional study

210 

18 years and above

Survey questionnaires

Positive coping interventions help cope and reduce emotional distress and academic demands’ pressure.

Behavior cannot be analysed over a longer time period.

Tonsing, K. N., & Tonsing, J. C. (2022). United States

Cross-sectional study

251

Average of 23 years

Questionnaires

Perceived support is inversely related with depressive symptoms. Social support is a critical resource among the university students to prevent distress.

The study received no funding, affecting its ability to effectively gather more information

Reiszadeh, I., Abolhassani, S., Masoudi, R., & Kheiri, S. (2022). Iran

Cluster randomized controlled trial

66 

–

Survey questionnaire

Self-care interventions are effective in improving the quality of life, and reducing fatique

The study used a small sample size, therefore limiting generalization of the study findings across wider population.

Shrestha, M., Ng, A., Paudel, R., & Gray, R. (2021). Australia

 Cross-sectional observational study

17,319

–

Survey questionnaire

Adherence to physical activity and healthy diet reduces emotional distress among diabetic patients

Participants were adults, which may not reflect reality in young adults population.

Chen, C., Zhang, Y., Zhao, Q., Wang, L., An, Y., & Fan, X. (2022). China

Cross-sectional study

296

40 years and above

Self-reported questionnaires

Self-care confidence and social connectedness improves emotional well-being.

Participants were adults, which may not reflect reality in young adults population

Moench, J., & Billsten, O. (2021). United States

Controlled Trial

34

—

Questionnaires and interveiew

STEP is effective in decreasing depressive symptoms.

The sample size was small, limiting the findings’ generalizability.

de Lorena, S. B., Duarte, A. L., Bredemeier, M., Fernandes, V. M., Pimentel, E. A., Marques, C. D., & Ranzolin, A. (2022). Australia

Controlled Trial

45

–

Interveiews, observation, questionnaire

Physical activity, emphasizing on stretching boost emotional well-being

A small sample size may not generate valid, and generalizable results.

Farshi, N., Hasanpour, S., Mirghafourvand, M., & Esmaeilpour, K. (2020). Iran

Controlled Trial

76

–

Questionnaire 

Self-care enhances quality of life and anxiety among women suffering from endomettiosis.

The sample size was small.

Six articles were guided by framework, model, or theory, with some study articles using more than theories. This is substantial because theories, models, and frameworks justify developing a hypothesis and pragmatically examining the relationship among concepts and variables. Four different data collections were used, with some articles using two or more data collection methods. Three study articles conducted interviews; two used focus groups, six utilized questionnaires, and one used surveys. Twenty-three instruments were used to measure mental distress levels, depression, and self-care strategies. Likert scales were utilized to examine how subjects rated their response to statements: The scales are used to gather participants’ feelings, opinions, and attitudes on self-care interventions (Dye et al., 2020). The responses are assigned scores and measured subsequently.
The analysis of most articles showed an attitude among adolescents to seek assistance in their social networks and rely on other self-care strategies to reduce emotional distress (Farshi et al., 2020). The resources and actions adolescents utilize are summarized into ten groups and grouped into four main areas for four analytical purposes. The first significant area involves resources for reinforcing adolescents individually in their life cycle phase, in that their objective is maintaining personal autonomy to resolve conflict. Some socialization of problems with friends was established as the primary motive for emotional stress; thus, distress may originate from the social context, and solutions can only come from the context.
The second area involves parents and teachers who provide particular support in the form of unconditional love, expressed through parenting to young adults during self-care (Reiszadeh et al., 2022). Attention from parents and teachers entails that adolescents are accompanied into their future. The area can include a girlfriend-boyfriend relationship because it provides trust and affection as support to cope with adverse situations. The third area concerns taking mental distress beyond close social networks, directing stress caused by the unfortunate case in a spot, physical activity, and conversation with close and trusted relatives (Reiszadeh et al., 2022). The last identified area outlines self-care approaches that connect the adolescent’s external and internal worlds through artistic and sensory expression.
Eight of the twelve studies believe adolescents express concern about maintaining self-control and personal autonomy when looking for assistance with emotional distress. The perspective comes when they consider seeking solutions to their problem themselves and within themselves (Tonsing & Tonsing, 2022). For adolescents, this represents maintaining individuality and strengthening. Among young people, mobilizing personal resources take varying connotations. Some young adults express the need to move and act themselves, believing that no one else can assist them out of their situation. Others seek to empty their distress to acquire the desired happiness from within themselves. One article utilizes the silence metaphor to describe this internalization process of addressing emotional distress (Tonsing & Tonsing, 2022). The article believes that when an individual experiences silence and breaks away from all noise backgrounds, such an individual realizes their situation and is aware of areas of change or improvement. Being silent assist people in becoming alone with themselves, creating room to solve their distress. This intervention can be utilized anytime and place where one wants. Writing is found to be another self-care strategy some adolescents use to determine the internal communication process to express their personal experiences. The young adult can write things down and see the best way to react.
Adolescents feel they can only depend on themselves when their mental health worsens. In most cases, young adults tend to ask for assistance from others when they cannot resolve their distressing issue with their resources or have no option (Nguyen et al., 2021). Additionally, interventions for addressing adversity situations may go beyond personal resources. As times pass, young adults cannot live with their problems; therefore, they can share their experiences. When adolescents opt to come out of themselves, they socialize in a friendship context, where distress originates for most young people. Encouraging and talking to others is among the primary resources young people can use to face the adverse situation. Adolescents consider their friends the primary psychological source in daily life, especially during distressing situations (Ren et al., 2021). Some of the activities young adults share with their friends include watching movies, walking, and having coffee, all of which help them let off steam, seek understanding, and grow trust. Friends play a critical role in cheering them up and assisting them in regaining confidence and overcoming emotional distress.
The presence of individuals close to the adolescents’ adult world, their knowledge, unconditional love, and trust places them as a critical support resource for adolescents facing emotional distress (Cho, 2021). For some young adults, sports serve as a way to expand their social networks and establish support outside of family and friendship circles (Bang & Park, 2020). Team sports bring a sense of belonging and identity, eventually boosting adolescents’ self-esteem (Bruno et al., 2021). Other self-care strategies identified in some study articles include artistic, creative, and sensory activities like music and reflexology.

Discussion

The two articles provide a critical summary of the effectiveness of self-care interventions in dealing with distress, especially among young adults and adolescents. The majority of the studies demonstrate different self-care resources adolescents and young adults can utilize to cope with situations of anxiety and depressive distress. Three studies, Farshi et al. (2020), Shrestha et al. (2021), and Reiszadeh et al. (2022, show ten main resources categorized into four areas covering various levels and possible therapeutic pathways adolescents take, depending on whether they suffer from self-perceived distress, formal diagnosis, and control group case.
The adolescents’ narrative shows the experience of distress as their fault and responsibility. Most participants expressed their ability to resolve emotional distress through their resources. Self-care strategies for reducing distress ranges from sociability expressed relationship with parents, families, friends, and older adults, to individuality, group membership like drama, sports, and bands, or even other self-care intervention like meditation, relaxation, and laughter (Gibson & Trnka, 2020). Additionally, young adults can rely on homeopathy, naturopath, and reflexology (Cowie & Myers, 2021). The adolescents’ self-sufficiency perception reinforces the use of different lay resources.
Most articles agree that young adults prefer seeking assistance from family and friends to cope with distressing events. The findings confirm the findings of other studies that discussing or talking with a close friend or maintaining contact with social networks helps young adults reduce depressive symptoms. Some articles, however, consider the conviction by young people that they can resolve mental health problems on their own as a severe hindrance to seeking professional assistance. Other studies believe that young adults prefer support networks because they are easy and readily available. Additionally, the interventions reduced the risk of stigmatization experienced when seeking professional help from health facilities and professionals. Adolescents see family and social networks as another link between the adult and the immediate world (Bang et al., 2020). Moreover, young people rely on networks to establish suitable care and attention consistent with their lay strategies of problem-solving and personal autonomy.
The young people’s choice of lay care approaches should be seen as a social reality that brings an understanding of how young people cope with distressing situations (Wickström & Lindholm, 2020). The frequency with which the adolescents refer to terms like understanding, presence, and trust to describe the relationship or expect from parents, friends, teachers, or relatives show such to be desirable characteristics in the person with whom the young adults share their stress. Additionally, this demonstrates the need for adolescents to establish an intersubjective and dialogic encounters with one another to regain their mental health. The articles show to reveal this relationship as grounded on the peace of mind and understanding to express their pain.
Young adults expect to be listened to and given emotional support and let them talk without hurting their autonomy and self-esteem. The emphasis from the young adults on “being there” show how much they value their local-subjective world in handling emotional distress. Moreover, one article articles describe brief mindfulness as effective in improving sleep quality and reducing depression (Downie et al., 2021). Mindfulness and meditation have been relied upon for stress management in various settings, including workplaces, hospitals, and personal levels, during distressful events. According to Farshi et al. (2020), self-care enhances the quality of life and anxiety among women suffering from endometriosis. Most self-care strategies, including regular physical exercise, can greatly enhance an individual’s mood and mental health (Butler et al., 2019). Eating healthy foods such as fruits and vegetables and staying hydrated can boost one’s well-being. Additionally, Chen et al. (2022), self-care confidence and social connectedness improve emotional well-being among young adults, who greatly value the role played by parents, teachers, friends, and relatives in relieving the distress they get during their lifetime.
All the twelve studies selected for the project used scientific research methodology and complied with the necessary ethical standards for the studies. Strict adherence to the research guidelines and methods guarantees valid, reliable, and widely generalizable study findings that correctly reflect the reality of the population from which the sample is drawn (Bruno et al., 2021). However, some articles used a small sample size which can affect the results’ generalizability. But generally, the study findings remarkably confirmed and agreed with past findings. The findings can form a strong literature foundation for future research on the effectiveness of self-care strategies in addressing emotional distress. Additionally, the provided evidence in the studies can serve as a base for developing effective evidence-based practice (EBP) interventions to address different nursing and healthcare problems.

Conclusion

Emotional distress is a prevalent mental health concern in adolescence and young adults because they are at a critical phase in constructing social and personal identities. Adolescents are vulnerable to anxiety, depression, and negative moods and tend to have negative attitudes toward seeking professional assistance. Various lay care strategies outside the professional care boundaries can help address youths’ emotional distress. These strategies can include social support, self-care, informal care, or self-help, all of which cover a broad range of practices. Moreover, studies find spirituality, structured routine, and creative activities as important in reducing emotional distress. The population for the study is young people diagnosed with depression, and the intervention is self-care strategies like relaxation, naturopathy, and medication. The comparison is no intervention, while reducing distress is the outcome. The self-care strategies are to be compared to no intervention to measure their effectiveness in reducing emotional distress among adolescents and young adults suffering from depression.
The research used the Academic Search Planner, CINAHL, MedLine, ProQuest, and Scopus electronic databases CINAHL and Search Premier electronic databases that are accessible through the university’s library to conduct a systematic literature search. The final set included 12 study articles published between 2019 and 2023; three were conducted in Australia, one in Uganda, two in Iran, four in the United States, one in Syria, and one in China. The twelve selected study articles included five controlled trials, three randomized controls, and four cross-sectional studies. The analysis of most articles shows an attitude among adolescents to seek assistance in their social networks and rely on other self-care strategies as an option to reduce emotional distress. The resources and actions adolescents utilize are summarized into ten groups and grouped into four main areas for four analytical purposes. The first significant area involves resources for reinforcing adolescents individually in their life cycle phase. The second area involves parents and teachers who provide particular support in the form of unconditional love, expressed through parenting to young adults during the process of self-care. The third area concerns taking mental distress beyond close social networks, directing stress caused by the distressing situation in a spot, physical activity, and conversation with close and trusted relatives. The last identified area outlines self-care approaches that connect the adolescent’s external and internal worlds through artistic and sensory expression. All the twelve studies selected for the project used scientific research methodology and complied with the necessary ethical standards for the studies. However, some articles used a small sample size which can affect the results’ generalizability. Generally, the study findings greatly confirmed and agreed with past study findings. The findings can form a strong literature foundation for future research on the effectiveness of self-care strategies in addressing emotional distress.

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