Barriers and facilitators to potential nationwide implementation of fertility health awareness strategies in young married couples in Singapore: an implementation study

Globally, the total fertility rate has declined over the years, partly attributable to limited public awareness of age-related fertility decline. To address this, we conducted an effectiveness-implementation hybrid type I, three-arm, open-label randomised clinical trial (RCT) to evaluate the effects of fertility health screening (FHS) and fertility awareness tools (FAT) on knowledge, attitudes, and practices related to childbearing. This study reports the implementation outcomes, barriers, and facilitators to potential nationwide implementation of these two interventions. The study comprised a three-arm RCT and a qualitative component involving individual semi-structured interviews conducted from January 2021 to March 2024. Eligible participants were married, childless heterosexual couples with a female partner aged between 25 and 34 years. Healthcare professionals (HCPs) who implemented the interventions, along with purposively selected couples, participated in the interviews. The interview guide was based on the Consolidated Framework for Implementation Research. Interviews were audio-recorded, transcribed, and analysed using thematic analysis. Completion of each FHS component was verified against medical records, and data used to inform cost was collected via a productivity loss survey and Time Driven Activity Based Costing. A total of 778 heterosexual couples were randomised in this three-arm RCT. Of these, 29 couples and 20 HCPs took part in the interviews. FHS was perceived as valuable for family planning, while views on FAT were mixed. Both interventions demonstrated high fidelity. HCPs spent a median of 219 min delivering FHS, which costs on average $83.36 per couple. Each couple also incurred a median total cost of productivity loss and transportation of $663.55 over all FHS visits. Key facilitators of FHS were the use of evidence-based testing and professional guidance, whereas resource and time constraints were notable barriers. Key barriers for FAT included the lack of content novelty and access to health screening though its structured design was a facilitator. Both FHS and FAT were deemed acceptable and feasible by couples and HCPs. Cost and staffing emerged as significant barriers to broader implementation and scalability. These findings offer insights into translating educational and fertility awareness interventions into practice and guiding future nationwide and international implementation efforts.