Acceptability and usability of ‘One Key Question’® in Australian primary health care

Keywords: communication, general practice, One Key Question®, preconception, pregnancy intention, pre-pregnancy, primary care, screening.

A recent report investigating the impact of unintended conceptions in Australia found that 40% of pregnancies are unintended (Organon and HTAnalysts 2022). As a result, many are entering pregnancy without the benefits of behavioural or lifestyle changes that can improve maternal and neonatal outcomes. Preconception care consists of interventions that aim to identify and modify the biomedical, behavioural and social risks to a woman’s health prior to conception (Moore et al. 2017). Such interventions include the use of folate supplementation to prevent neural tube defects (De-Regil et al. 2010) and the tight control of blood sugar levels in women with diabetes around the time of conception to reduce the risk of fetal congenital abnormalities (Fraser and Lawlor 2014; Genuis and Genuis 2016). Of increasing importance is the optimisation of pre-pregnancy maternal weight to improve the general health and wellbeing of the mother and to decrease the risk of an adverse pregnancy outcome, including miscarriage, stillbirth and fetal abnormality (Schummers et al. 2015). Important too are the longer-term impacts on the child’s health and obesity (Drake and Reynolds 2010), leading the World Health Organization to name preconception care as one of the six strategies to reduce childhood obesity (World Health Organization 2016).

Due to these potential health benefits of preconception care for mothers and babies, the Royal Australian College of General Practitioners (RACGP) has recommended preconception care as an important preventive care healthcare strategy (RACGP 2016). Indeed, primary care is uniquely placed to reduce unintended pregnancies by improving use of contraception in women not wanting to conceive and by counselling women about preconception care should they wish to receive it. Interventions such as the use of folic acid supplementation prior to conception will have a positive benefit on fetal development (Wilson et al. 2015). However, numerous barriers to implementation of preconception care have been identified in this setting, including time constraints, a lack of women being identified as actively planning for pregnancy, and a lack of resources for assisting in the delivery of preconception care guidelines (Mazza et al. 2013). Several enablers have been suggested to enhance the delivery of preconception care, including clinical practice guidelines and checklists.

One tool, developed by the Oregon Foundation for Reproductive Health (Bellanca and Hunter 2013; Allen et al. 2017), the ‘One Key Question®’ (OKQ®) facilitates pregnancy intention screening in the non-pregnant population. The OKQ® simplifies the process for practitioners by encouraging them to routinely ask women of reproductive age ‘Would you like to become pregnant in the next year?’. The clinician documents one of four responses: Yes; I’m OK either way; I’m not sure; or No; and depending on this answer, the clinician then follows up with information and advice around preconception care or contraceptive methods (see Fig. 1). The OKQ® thus offers the opportunity to embed a discussion on reproductive planning into primary care consultations and potentially overcome the barrier of women not presenting for preconception care. This tool has been evaluated in several studies in the United States (Ferketa et al. 2022; Stulberg et al. 2019) that have explored clinician and patient perspectives, but the OKQ® has never been tested in the Australian context. The aim of this study was to assess the acceptability and usability of the OKQ® implemented in an Australian general practice setting from the perspective of women and the general practitioner (GP).

Fig. 1.  One Key Question®. LARC, Long Active Reversible Contraceptive.

We undertook a pilot study consisting of quantitative and qualitative components that explored the acceptability and usability of the OKQ® among patients and GPs in primary care in Australia. A survey-based quantitative approach was used in this pilot study to maximise patient encounters and subsequently the strength of any conclusions drawn about patient and GP perspectives regarding the acceptability and usability of the OKQ®. Qualitative interviews with all participating GPs were conducted after the completion of the quantitative component of the study to gain overall insights of how GPs found using the OKQ®. This is compared to the case-by-case analysis of a specific patient interaction, which is what the quantitative GP survey provided. GPs’ thoughts on the delivery of preconception care was also asked to provide context to the space in which the OKQ® would be used.

The OKQ® tool, developed by the Oregon Foundation for Reproductive Health, is now registered as a product by Power to Decide (Power to Decide 2022) who provide training in the use and application of the tool. Although the clinicians in this study did not undergo the certified training that is recommended prior to use, the leadership team at Power to Decide granted permission for the authors to use the tool for the purposes of this pilot study.

This study took place in two primary care general practices in urban Sydney between September 2019 and December 2019. One site was a mixed billing practice (private and public) in the inner-city where some patients (those on low income or government benefits) were charged only the amount of the government rebate, and others were charged above this and had out-of-pocket expenses. The other site in Sydney’s south-east only charged patients the cost of the government rebate (‘bulk-billing’) so there were no additional costs to the patients.

All GPs working at the two study sites were eligible to participate. GP participants at both sites who provided informed consent were educated on the recruitment process (Fig. 2). Any woman aged 18–40 years who presented for a consultation (regardless of the reason for presentation) and who had sufficient English-language skills could be asked the OKQ® at the discretion of the clinician. Following the consultations, GPs were asked about how they felt about asking the OKQ®, how it was received, its ease of use and whether it led to a change in medication. Their responses were recorded on a paper-based survey after each patient consultation (Appendix 1).

Fig. 2.  Study process.

All female patients aged between 18 and 40 years, presenting for a consultation at either site, were eligible for inclusion. The population from which the patients were drawn were inner-city with a higher socioeconomic status (SES) for the mixed billing practice, and suburban with a lower SES for the bulk-billing practice. Patients who had insufficient English-language skills to understand the written study information were excluded from the study. Patients were not informed about the trial implementation of the tool as it was deemed an important part of routine health care.

After their consultation with the GP, patients were informed that the study investigator (JF) was on site to discuss the study. Patients were asked whether they would be willing to allow their consultation to be included in the research. All patients were provided with a participant information sheet and consent form, which permitted inclusion of the appointment interaction, and they were also requested to complete a short survey. All 56 patients who were asked the OKQ® by their GP agreed to meet with the study investigator and subsequently provided informed consent to participate in the study. The patients proceeded with the paper-based patient survey of their experience of the OKQ® (see Appendix 2). The survey asked whether they had been previously asked about their pregnancy intentions, whether they were happy to discuss their reproductive plans and whether they considered it relevant to the current consultation or to their health in general. Their feelings about a pregnancy in the next 12 months were also recorded. Patients were informed that they were free to opt out of the study and not have their consultation included.

Descriptive statistics of median and percentages were used describe the usability and acceptability of the OKQ® tool by patients and GPs.

At the end of the recruitment period, all of the participating GPs took part in face-to-face semi-structured interviews with JF (see Appendix 3). In these interviews, GPs were asked, among a range of questions, to describe some of the challenges in delivering preconception care, to identify the patient factors or other factors that prompt them to discuss pregnancy planning with patients, whether they felt patients were aware of preconception care, whether the OKQ® will be a useful tool and how they perceived patients’ reactions to be being asked the OKQ®. The interviews ranged in length from 8 min and 20 s, to 16 min and 35 s.

After the recordings were de-identified, they were transcribed by an external provider. The interview transcript data were extracted by JF using descriptive coding, and coded transcripts were reviewed independently by two team members (JF and ED). Both researchers used Braun and Clarke’s (2006) reflexive thematic analysis to organise and agree on the codes into themes. The initial themes were reviewed and subsequently defined by the research team.

I, the study investigator (JF), was a General Practice registrar during the data collection period. Since finishing data collection, I have completed General Practice training and am a clinical and academic GP with an interest in women’s health. I conducted all the interviews. Although some GPs were previously known to me prior to the study, as they were experienced practitioners, I felt they could choose whether to provide consent to participate in the study freely.

As a doctor who strongly believes in the importance of women’s health and preconception care, I was aware throughout the interviews that my context influenced my interviewing technique and the GPs’ perceptions. I knew that many GPs were committed to the delivery of preconception care, but that there were likely barriers that separated the ‘ideal’ from the ‘real world’ practice. The most challenging aspect of reflective practice was to allow the GPs to describe their experiences using the OKQ® without exaggeration for my benefit. To help mitigate my influence, I would re-read the semi-structured interview schedule prior to each interview and facilitate the GP participant to do most of the talking.

Ethical approval was granted by the University of Sydney Human Research Ethics Committee, Number 2019/402. Research was undertaken with appropriate informed consent of participants.

In total, 56 patients and 10 GPs were recruited across the two sites. As all patients were female aged between 18 and 40 years, no additional demographics were collected to maintain confidentiality in this pilot study. More patients (70%) were recruited from the bulk-billing site. Six of the 10 GPs were female, with five GPs recruited from each study site (Table 1).

Table 1.  Participant demographics.

Of the 56 patient participants when asked the OKQ® ‘Would you like to become pregnant in the next year?’, 19 (33.9%) said ‘yes’, 22 (39.3%) said ‘no’, nine (16.1%) said ‘not sure’ and six (10.7%) said ‘I’m ok either way’.

Half (n = 28; 50%) of the patient participants reported being asked previously of their pregnancy plans prior to the research consultation with the clinician (Table 2). Regarding being asked in the study consultation, almost all participants (55, 98.2%) reported being happy to discuss their pregnancy intentions and regarded it as relevant to their general health.

Table 2.  Participant patient responses.

The survey of the GPs demonstrated that over three-quarters (n = 44; 78.4%) felt comfortable or somewhat comfortable asking the OKQ® and almost (n = 40; 70%) as many regarded the OKQ® as very easy or easy to use (Table 3). GPs reported that asking the OKQ® increased the length of consultation time in two-thirds of consults, but of these consults, the median time that was added to the consult was only 2 min, with the maximum being 20 min and the minimum being 1 min.

Table 3.  General practitioner responses.

The aim of this study was to assess the acceptability and usability of the OKQ® implemented in an Australian general practice setting from the perspective of patients and GPs. The following results explore the perspectives of the GPs and their perceptions of their patients’ perspectives through the constructed themes. (Table 3).

Broaching the issue of reproductive life planning was experienced as less challenging than the practitioners anticipated. Indeed, using the OKQ® was generally found to be easy and did not arouse practitioner discomfort.

I actually found it pretty straightforward. I haven’t come across any major barriers or complications or awkward impact or anything like that. (GP6, female, aged 30–39 years)

I found it really easy. (GP4, female, aged 40–49 years)

Asking the OKQ® often required an introduction and was deemed easier to pose in consultations where there was a clear link between the reason for presentation, like contraceptive discussions or cervical screening tests, or in general health checks.

I probably would use it more so when they come in for a preventative health reason like for their pap smear or ‘Hey I’m just coming in for a general health check.’ …if they’re coming in for preventative health, it’s a good place to use it. (GP10, Female, aged 30–39 years)

In other consults, GPs often found framing the OKQ® a useful way to introduce preconception care discussions into the consult without seeming too jarring. Framing was frequently discussed by GPs and was seen to increase the OKQ®’s ease of use. Framing methods were varied, but often included a brief spiel about how the GP was asking all relevant patients the OKQ® or explained some of the rationale behind the OKQ®.

So, in general, if it was framed in an appropriate way, it was fairly routine and unobtrusive. (GP2, Male, aged 20–29 years)

I think I said, ‘I’m also just asking all patients…around your age this sort of question as a preventative health screening. Are you planning on having children in the next 12 months?’ (GP10, Female, aged 30–39 years)

A second theme constructed was that GPs felt that patient acceptability of being asked the OKQ® was higher than anticipated. There was caution among some of the GPs prior to commencing the study that patients may feel awkward being asked the OKQ®, or that even in a worst-case scenario, it may negatively affect the ongoing patient–doctor relationship. All GPs felt that patients were open to being asked the OKQ®, even if it was not directly relevant to their presenting problem.

I don’t think they had any problem with me asking them. (GP4, Female, aged 40–49 years)

Women in general seem to respond reasonably even [if] asked out of the blue. (GP2, Male, aged 20–29 years)

I think most of them accept the fact that doctors were all asking [OKQ®] and they are quite happy about giving the information…I don’t think anybody actually gets upset. Most of them seem to be quite tolerant and able to discuss the issues. (GP5, Male, aged 80–89 years)

This sense that the OKQ® was generally well received and, indeed, more acceptable than GPs had anticipated meant that they were encouraged to use the question going forward.

I must admit, before I did this, I thought that it was a little bit uncomfortable... it was surprisingly quite comfortable and people very open about it. And so I think now I’ve actually changed my view of it, I think that I will use it. (GP9, Female, aged 30–39 years)

The third key theme was the identification of common barriers to using the OKQ®, and more generally to delivering preconception care. Time constraints were acknowledged as an important issue in asking the OKQ® because its use would often require follow-on questions. Additionally, it was felt that the discussion may be regarded as inappropriate in the patient’s presenting circumstances.

I mean there’s just so many things to talk about and this is, I guess, another one of those things we probably should bring up on a regular basis but just don’t. (GP3, Male, aged 40–49 years)

You can’t rush them. Once you put the question in, you’ve got to give them enough time. And if you are not prepared to give them enough time and you’re rushing to see your next patient, you better not ask them. (GP5, Male, aged 80–89 years)

The perceived acuity of the patient’s presenting complaint, and the presence of a more emergent issue deterred GPs from asking the OKQ®. GPs used their judgement to decide if the patient would feel comfortable with the question during that particular consultation interaction, and also whether there was time to discuss the issues that emerged from the conversation.

I see a lot of [people with] mental health [issues] and so I’m very conscious with some of the people that I see where there are lots of issues which are going on that sometimes it’s about what they can handle in terms of distress management and that was not going to be on that priority list at that time. (GP8, Female, aged 40–49 years)

The constructed themes support the quantitative data; that is, the OKQ® is easy for GPs to use and is deemed acceptable by both GPs and patients.

This pilot study revealed that patient participants generally found the screening tool to be acceptable and that it was applicable to their general health. The minority were surprised to be asked this, and indeed, half the sample reported a previous conversation with their GP about their plans for pregnancy. Clinicians were mostly comfortable using the tool, and the mean time it added to the consultation was 2 min. In the qualitative data, clinicians revealed the ways in which they framed the question in order for it to seem more routine and increase the perceived acceptability of asking the OKQ® to their patients. The clinicians found using the OKQ® easy, informative and were planning on continuing its use.

Our study is unique in exploring both provider and patient perspectives. Previous studies from the United States have focussed on either the patient experience or clinician-identified facilitators and barriers to the OKQ® implementation (Song et al. 2021; Ferketa et al. 2022). In a recent study, patient satisfaction before and after the OKQ® implementation was reported to increase (Song et al. 2021). In a study across an obstetrics and gynaecology clinic and a family medicine clinic, clinicians identified the simplicity of the tool and its alignment with the clinic goals to be facilitators of the OKQ® implementation, but raised concerns about the impact on clinic workflow (Ferketa et al. 2022). A further study sought to assess the impact the integration of the OKQ® into the Electronic Medical Record (EMR) of an urban community health centre had on rates of contraceptive and preconception counselling. The researchers found that the rates of contraceptive counselling and long-acting reversible contraceptive (LARC) recommendations increased, but the rates of preconception counselling did not (Stulberg et al. 2019).

All of the GPs in the study acknowledged the opportunistic nature of preconception care and spoke of the difficulties providing preconception care to patients who were not aware of the importance and recommendation of pre-pregnancy interventions. A number of the GPs felt that having an evidence-based tool, like the OKQ®, had the potential to promote the delivery of preconception care to their patients. This promotion would also be furthered by endorsement and backing from the two colleges responsible for overseeing general practice in Australia – the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine.

Other studies have examined the use of tools to enhance reproductive life planning. One study involved a randomised controlled trial comparing the use of the ‘Family Planning quotient’, another method of measuring desired fertility, to the OKQ®, finding that both tools were equally reported as being useful by two-thirds of women for communicating reproductive goals to healthcare providers. The healthcare providers reported less utility, with a half or less stating the tools helped to focus their counselling (Baldwin et al. 2018). The authors point out that an individual’s reproductive life goals are much more complicated than the responses elicited at one point in time. Further, it remains unknown if tools such as the OKQ® have the potential to lead to behaviour change and impact on population health outcomes, such as unplanned pregnancy and interconception care and birth spacing.

In this study, we provided GPs with the OKQ® without the formal training recommended by the Power to Decide (Power to Decide 2022). The organisation that has trademarked the OKQ® offers a 4- to 6-h online certification training course that teaches providers to initiate the conversation about pregnancy desires. However, when we devised this study, we were unaware of this requirement. Fortunately, the team at Power to Decide still permitted us to pilot the tool. Another limitation is that we did not record the extent to which the clinician applied the tool in detail, such as follow up with those not wanting to get pregnant with a discussion around contraception.

This study thus provides encouraging preliminary data about the acceptability and usability of the OKQ® without training in an Australian general practice setting. Future research could further explore how best to implement the OKQ® into Australian clinical practice. It would be important to assess the impact of the OKQ® on preconception care and contraception counselling and uptake.

The data that support this study will be shared upon reasonable request to the corresponding author.

The authors declare no conflicts of interest.

This research project is supported by the Royal Australian College of General Practitioners, with funding from the Australian Government under the Australian General Practice Training program.