Background
The theoretical domains framework
Clinical background of the needs assessment
Methods
Sampling and inclusion criteria
Recruitment and ethical considerations
Qualitative data collection
Broad domains of qualitative exploration | Example of exploratory qualitative questions (no precise behaviors targeted) | Example of themes emerging from qualitative data (i.e., behaviors to be further investigated) |
---|---|---|
Diagnosis | What challenges do you experience in screening and diagnosing growth disorders? | Screening and management of GH deficiency |
Diagnosis of GH excess | ||
Treatment | What type of challenges (if any) do you experience in your treatment choices? | Treatment criteria and guideline application in PGD |
Multi-modal therapy for GH excess | ||
Clinical decision-making regarding the choice of treatment in acromegaly | ||
Management | What (if any) are your challenges in effectively managing or monitoring your patients with growth disorders? | Ensuring smooth transition of care from childhood to adulthood |
Referrals from primary care pediatricians to Pediatric Endocrinologists |
Quantitative data collection
Category | Examples of questions | Scale anchors | Examples of items |
---|---|---|---|
a) current level of knowledge, skill, and confidence | Please select the number that best describes how you currently evaluate your level of [knowledge/confidence/skill] concerning each issue. | 1 = low; 5 = high | The usefulness of using priming substances in GH stimulation test |
Considering all co-morbidities in the selection of a treatment plan | |||
b) desired level of knowledge, skill, and confidence with regards to their role | Please indicate what you think is the required level of [knowledge/confidence/skill] with regards to your role in the care for patients with [GH deficiency/GH excess/PGD] | 1 = low; 5 = high | |
Negotiating patients’ resistance to daily injection treatment | |||
c) perception of barriers to optimal care | Please indicate to what extent you think each of the following is a barrier for you in providing optimal care to patients [GH deficiency/GH excess/PGD]. | 1 = not a barrier; 5 = a major barrier | Worries about possible long-term side-effects of growth hormone therapy |
Patients’ resistance to daily injections | |||
d) clinical behaviors and attitudes | Please indicate to what extent you are following each clinical practice behavior in providing care to patients with [GH deficiency/GH excess/PGD] | 1 = almost never; 5 = almost always | I generally avoid using growth hormone stimulation tests because I have no confidence in their value |
When I propose a treatment to a patient, I discuss the potential impact on his/her quality of life |
Analysis plan
Post-hoc categorization of needs assessment findings using the TDF
Linking of needs assessment findings to behavior change techniques, through the TDF
Results
Sample size and demographics
Healthcare Providers | Phase 1: Qualitative (n = 30) | Phase 2: Quantitative (n = 195) | TOTAL (n = 225) |
---|---|---|---|
Specialty
| |||
Endocrinologists | 8 | 112 | 120 (53.3%) |
Pediatric Endocrinologists | 12 | 41 | 53 (23.6%) |
General Pediatricians | 10 | 42 | 52 (23.1%) |
Gender
| |||
Men | 20 | 108 | 128 (57.1%) |
Women | 10 | 86 | 96 (42.9%) |
Region
| |||
Northeast | 13 | 53 | 66 (29.3%) |
Midwest | 6 | 43 | 49 (21.8%) |
South | 5 | 59 | 64 (28.4%) |
West | 6 | 40 | 46 (20.4%) |
Practice setting
| |||
Solo or group practice | 20 | 144 | 164 (72.9%) |
Community hospital or clinic | 6 | 27 | 33 (14.7%) |
Government hospital | 0 | 11 | 11 (4.9%) |
Academic Medical Center | 4 | 5 | 9 (4.0%) |
Other | 0 | 8 | 8 (3.6%) |
Years of practice
| |||
0-5 years of practice | 1 | 35 | 36 (16.0%) |
6-10 years | 3 | 41 | 44 (19.6%) |
11-20 years | 13 | 71 | 84 (37.3%) |
21-30 years | 10 | 38 | 48 (21.3%) |
More than 30 years | 3 | 10 | 13 (5.7%) |
Practice location
| |||
Urban | 10 | 92 | 102 (45.3%) |
Suburban | 18 | 93 | 111 (49.3%) |
Rural | 2 | 10 | 12 (5.3%) |
Patients & Caregivers
| |||
Adult patients with GH deficiency | 5 | N/A | 5 (35.7%) |
Caregivers of child with growth disorder | 9 | 9 (64.3%) | |
Gender
| |||
Male | 1 | N/A | 1 (7.7%) |
Female | 13 | 13 (92.3%) | |
Age of child
| |||
Age of child = 0–6 years old | 1 | N/A | 1 (11.1%) |
Age of child = 7–12 years old | 4 | 4 (44.4%) | |
Age of child = 13–18 years old | 4 | 4 (44.4%) | |
Region
| |||
Northeast | 1 | N/A | 1 (7.7%) |
Midwest | 1 | 1 (7.7%) | |
South | 6 | 6 (42.9%) | |
West | 6 | 6 (42.9%) |
Identified gaps, challenges and barriers in the needs assessment
# | Challenge | AGHD | Acromegaly | PGD | TDF Domains* |
---|---|---|---|---|---|
1 | Challenges communicating with patients, especially in overcoming patients’ barriers and resistances | X | X | X | 1, 2, 4, 5, 6 |
2 | Challenges with the treatment decision-tree | X | X | — | 1, 2, 4, 9, 10 |
3 | Challenges associated with the transition from childhood to teen years, to adulthood | — | — | X | 1, 2, 3, 4, 6, 11 |
4 | Insurance companies processes interfere with clinical decisions | X | X | X | 11 |
5 | Use of appropriate materials to support patient education | X | X | X | 1, 11 |
6 | Referrals between general pediatricians and pediatric endocrinologists (timeliness, appropriate pre-testing) | — | — | X | 1, 4, 6 |
7 | Perceptions of GH therapy | X | — | — | 6 |
8 | Lack of clarity in roles and responsibilities | X | X | X | 3 |
9 | Application of diagnostic tests | X | — | X | 2, 4 |
10 | Lack of screening by primary care | — | X | — | 6 |
11 | Identifying tests needed for at risk co-morbidities | — | — | X | 2, 6 |
12 | Presenting Treatment as optional | X | — | — | 6 |
13 | Inconsistencies between labs (system) | X | X | X | 11 |
Categorization of educational and performance gaps by TDF
# | Challenge | TDF Domain | Underlying determinant of the Challenge |
---|---|---|---|
1 | Challenges in overcoming patient barriers and resistance | "1 – Knowledge" | Lack of knowledge of tools to facilitate patient – provider communication |
"2 – Skills" | Lack of communication skills | ||
"4 - Beliefs about Capabilities" | Lack of confidence | ||
"5 – Optimism" | Underestimation of impacts of miscommunications | ||
"6 - Beliefs about Consequences" | |||
2 | Challenges with the treatment decision-tree | "1 – Knowledge" | Extent to which short-term adverse side-effects compare to long term benefits of treatment in patients with AGHD |
"2 – Skills" | Challenge in balancing long term benefits of treatment with short-term adverse effects | ||
"4 - Beliefs about Capabilities" | Confidence issues | ||
"9 – Goals" | Prioritization between proximal goal of avoiding side effects and distal goal of avoiding long-term consequences of disorder | ||
"10 - Memory, Attention, and Decision Processes" | Specific challenges in the clinical reasoning process | ||
3 | Challenges associated with the transition from childhood to teen years, to adulthood | "1 – Knowledge" | Consequences of inappropriate cessation of GH therapy |
"2 – Skills" | Lack of skills in addressing compliance during teenage years | ||
"3 - Social/Professional Role and Identity" | Lack of clarity on which tests should be done at primary care levels and which ones should be done by specialists | ||
"4 - Beliefs about Capabilities" | General pediatricians preferring to refer because of lack of confidence | ||
"6 - Beliefs about Consequences" | Underestimation of impact of growth hormone treatment cessation | ||
"11 - Environmental Context and Resources" | Lack of adult-treating endocrinologists forcing pediatric endocrinologists to keep patients under their management longer |
Challenges in overcoming patient barriers and resistance
TDF Domain | Identified challenges (underlying determinant) | Techniques Recommendations (All other techniques are in the "agreed non-use" category)
|
---|---|---|
1 - Knowledge | Challenges in overcoming patient barriers and resistance (Lack of knowledge of tools to facilitate patient – provider communication) | Agreed use: Information regarding behavior, outcome |
Uncertain: goal/target specified: behavior or outcome//Persuasive communication | ||
Challenges with the treatment decision-tree (Extent to which short-term adverse side-effects compare to long term benefits of treatment in patients with AGHD) | Disagreement: Personalized message//Homework | |
Challenges associated with the transition from childhood to teen years, to adulthood (Consequences of inappropriate cessation of GH therapy) | ||
2 -Skills | Challenges in overcoming patient barriers and resistance (Lack of communication skills) | Agreed use: goal/target specified: behavior or outcome//Monitoring//Self-monitoring//rewards & incentives//Graded tasks//problem-solving, decision-making, goal-setting//Rehearsal//Modeling, demonstration of behavior//Homework//perform behavior in different settings//problem-solving |
Challenges with the treatment decision-tree (balancing long term benefits of treatment with short-term adverse effects) | ||
Challenges associated with the transition from childhood to teen years, to adulthood (Lack of skills in addressing compliance during teenage years) | Uncertain: Stress management//Planning, implementation | |
Disagreement: Coping skills//Role-play//Feedback//Shaping of behavior | ||
3 - Social/Professional Role and Identity | Challenges associated with the transition from childhood to teen years, to adulthood (Lack of clarity on which tests should be done at primary care levels and which ones should be done by specialists) | Agreed use: Social process of encouragement, pressure, support |
Uncertain: Contract//rewards & incentives//problem-solving, decision-making, goal-setting//Role-play//Environmental changes//Persuasive communication//Personalized message//feedback | ||
Disagreement: Information regarding behavior, outcome//Modeling, demonstration of behavior//Cognitive restructuring | ||
4 - Beliefs about Capabilities | Challenges in overcoming patients’ barriers and resistances (Lack of confidence) | Agreed use: Self-monitoring//Graded tasks//problem-solving, decision-making, goal-setting//Social process of encouragement, pressure, support//Feedback//self-talk//Motivational interviewing |
Challenges with the treatment decision-tree (Lack of confidence) | ||
Challenges associated with the transition from childhood to teen years, to adulthood (General pediatricians preferring to refer because of lack of confidence) | Uncertain: Monitoring//rewards & incentives//Coping skills//Rehearsal//Stress management//Information regarding behavior, outcome//Personalized message//Experiential//Use of imagery//perform behavior in different settings//Shaping of behavior//Relapse prevention//Identify-prepare for difficult situations, problems | |
Disagreement: - | ||
5 - Optimism | Challenges in overcoming patients’ barriers and resistances (Underestimation of impacts of miscommunications) | Agreed use: Self-monitoring//Graded tasks//problem-solving, decision-making, goal-setting//Social process of encouragement, pressure, support//Feedback//self-talk//Motivational interviewing |
Uncertain: Monitoring//rewards & incentives//Coping skills//Rehearsal//Stress management//Information regarding behavior, outcome//Personalized message//Experiential//Use of imagery//perform behavior in different settings//Shaping of behavior//Relapse prevention//Identify-prepare for difficult situations, problems | ||
Disagreement: Role-Play//Persuasive communication//Modeling, demonstration of behavior//Homework//Personal experiments//Cognitive restructuring | ||
6 - Beliefs about Consequences | Challenges in overcoming patients’ barriers and resistances (Underestimation of impacts of miscommunications) | Agreed use: Self-monitoring//Persuasive communication//Information regarding behavior, outcome//Feedback |
Challenges associated with the transition from childhood to teen years, to adulthood (Underestimation of impact of growth hormone treatment cessation) | Uncertain: Monitoring//rewards & incentives//Role-play//Personalized message//Personal experiments | |
Disagreement: goal/target specified: behavior or outcome//Homework//Motivational interviewing//Cognitive restructuring | ||
9 - Goals | Challenges with the treatment decision-tree (prioritization between proximal goal of avoiding side effects and distal goal of avoiding long-term consequences of disorder) | Agreed use: Social process of encouragement, pressure, support//Modeling, demonstration of behavior |
Uncertain: Monitoring//rewards & incentives//Role-play//persuasive communication//homework | ||
Disagreement: Contract | ||
10 - Memory, Attention, and Decision Processes | Challenges with the treatment decision-tree (Specific challenges in the clinical reasoning process) | Agreed use: Self-monitoring//Planning, implementation//Prompts, triggers, cues |
Uncertain: Monitoring//rewards & incentives//Graded tasks//problem-solving, decision-making, goal-setting//stress management//Rehearsal//Personalized message//Personal experiments//feedback//self-talk//use of imagery//perform behavior in different settings//Time management | ||
Disagreement: Environmental changes | ||
11 - Environmental Context and Resources | Challenges associated with the transition from childhood to teen years, to adulthood (Lack of adult-treating Endocrinologists forcing Pediatric Endocrinologists to keep patients under their management longer) | Agreed use: Environmental changes |
Uncertain: Prompts, triggers, cues | ||
Disagreement: - |