Table 1:
Demographic characteristic of paediatricians, parents and adolescents
Demographic Characteristics
|
Paediatricians
(n=14)
|
Parents
(n=22)
|
Adolescents
(n=4)
|
Gender (female /male)
|
3/11
|
19/3
|
2/2
|
Age range in years
|
n.a.
|
32-49
|
14-17
|
Age of the child (<14 years) Mean (range)
|
n.a.
|
7.1 (3-14)
|
n.a.
|
Diagnosis of the child / adolescent
- Head and somatoform abdominal pain
- Developmental disorder of speech & language
- Non-organic enuresis
- Conduct disorder
- Combination of two
- None of them/ do not know
|
n.a.
|
3
5
4
5
5
-
|
1
-
-
1
-
2
|
Highest educational qualification
|
n.a.
|
|
n.a.
|
- University degree
|
|
6
|
Higher education entrance qual.
|
|
5
|
- Intermediate secondary school
|
|
6
|
- Secondary school
|
|
4
|
- Other
|
|
1
|
School currently attended by children
|
n.a.
|
n.a.
|
|
- University of applied sciences
|
1
|
- Intermediate secondary school
|
3
|
Migration background
|
n.a.
|
5
|
0
|
Population size of place of residence
|
|
|
|
Major city (> 100,000)
|
8
|
7
|
4
|
Medium sized town (>20,000)
|
4
|
4
|
-
|
Small town (> 5,000)
|
2
|
8
|
-
|
Country town (≤ 5,000)
|
-
|
2
|
-
|
n.a.
|
-
|
1
|
-
|
Description of study participants
Eleven of the 14 interviewed paediatricians were male. Eight practices were located in a major city, six were located in a small or medium-sized town. Duration of interviews was eleven minutes on average (range: 5–23).
Regarding parents, in total 19 mothers (age range 32–49) and three fathers (age range 39–47) were interviewed. Number of children per family ranged from one to three. In five families, the child had a migration background. Migration background was defined based on information about the country of birth of the child and the country of birth and nationality of the parents (children and adolescents who had immigrated from another country and had at least one parent not born in Germany and/or of non-German citizenship) (25). The majority of the families (n = 12) were inhabitants of a small (> 5.000) or medium-sized town (> 20.000). Seven families were residents of a major city (> 100.000 inhabitants). Average duration of interviews with parents was 18 minutes (range: 4–46), with adolescents thirteen minutes (range: 3–17).
Metacodes and subcodes
Based on the results of the exploratory interviews with HC developers, we defined four metacodes “acceptance”, “facilitators”, “barriers” and “aims”. For these, we defined 17 subcodes for paediatricians and 13 subcodes for parents/adolescents. All metacodes and subcodes are shown in Fig. 1. In order to facilitate reading, following short forms are used: “DEV” (HC developers), “PAED” (paediatricians), “PAR” (parents) and “ADOL” (adolescents).
Metacode “Acceptance”
All DEV stated that the aim of the programme was to facilitate diagnosis and treatment of MPH in primary paediatric care to reduce the need for referrals. While this intention was generally well received among colleagues, they also reported rejection and indifference in the beginning among their ranks. PAED perceived their own competence for children with MHP as improved.
I simply can’t imagine general routine work without it anymore. (Transcription of Interview partner D5 (DEV), p. 1, lines 14–20)
PAED also had the impression that PAR did not care about being in a specific programme, but appreciated their increased efforts.
They are happy when the medical conditions we are dealing here with (…) can be treated in the practice of their confidence on an outpatient and on-site basis. (Transcription of Interview partner D5 (DEV), p. 3, lines 86–91)
Accordingly, PAR and ADOL reported that they did not realize that there was a programme specifically designed for their needs.
Metacode “Facilitators”
DEV stated that flexibility and operability of the programme were planned and implemented right from the start.
We deliberately designed it so simply that everyone can easily cope with it. (Transcription of Interview partner D13 (DEV), p. 3, line 116)
PAED appreciated the additional allocation of resources as a token of trust and valuation.
The fact that the health insurance company recognizes that the basic providers such as a paediatrician can provide some of these specific things and that it is rewarded. (Transcription of Interview partner D14 (PAED), p. 3, lines 71–73)
Repeatedly, PAED reported that the material provided by HC was helpful and facilitated diagnosis and decision-making. They also appreciated the continuing training opportunities.
It allows and structures the approach, may it be in the diagnostics itself in the practice, but also for the diagnosis and, finally, in the decision whether we want and we are able to continue the treatment in the practice. (Transcription of Interview partner D14 (PAED), p. 1, lines 12–16)
PAR and ADOL felt that their PAED allocated a large part of his consultation time to their problems. This was perceived as an indication of high quality of care. PAR mostly reported that they trusted their PAED even with more sensitive issues. Quality of communication and being included in the decision process were appreciated.
I am very satisfied, got a lot of advice and I think, if I go there again now and say: "Well, it has not worked yet", I will be well advised again. At the moment, I cannot think of a better way. (Transcription of Interview partner P13 (PAR), p. 9, lines 348–351)
Interaction between care providers, e.g. between PAED and speech therapists, was positively noted.
It was very uncomplicated. Maybe because of the cooperation of the paediatrician with the speech therapist, that they are so well connected (…) that worked just fine. (Transcription of Interview partner P19 (PAR), p. 9, lines 310–312)
Metacode “Barriers”
Although substantial financial resources were allocated through the programme, PAED still perceived their opportunities for interaction with the patients as limited. Time and budgetary restrictions were still reported as major barriers to success. Also, as HC is only one of many managed care contracts PAED reported feeling overwhelmed.
That would be a reason why, also as a health coach, I would refer him or them, because at the moment I can’t. (Transcription of Interview partner D13 (DEV), p. 3, lines 92–95)
DEV admitted that a realistic resource estimate should be made before the enrolment of a patient into the HC. PAED reported that it was still difficult to refer patients, and that parents might have problems to follow-up on that referral.
We have too little time to monitor what we recommend to parents (…) This happens very often, that the advice comes to nothing (Transcription of Interview partner D10 (PAED), p. 2, lines 46–51)
We detect children with MHP but it still takes far too long until they receive therapy. (Transcription of Interview partner D13 (DEV), p. 6, lines 205–213)
PAED perceived distinct social disparities, and cultural and linguistic barriers which could not be resolved by the programme. Also, they felt that parents would not necessarily trust their expertise for sensitive issues in MHP.
(…) then the same things will get way more complicated and difficult. (Transcription of Interview partner D5 (DEV), p. 6, lines 194–196)
Many of them like to see us as a cough-runny-nose-flu-doctor only. (Transcription of Interview partner D14 (PAED), p. 3, lines 73–74)
PAR reported feeling reluctant about contacting a physician for MHP of their children, either because this might be too trivial for the paediatrician, or because more specialised help would be needed. However, PAR also reported that they had delayed consulting the PAED because they had underestimated the problems.
Until now we did not suffer so much. I’ve always thought it would get better somehow. (Transcription of Interview partner P20 (PAR), p. 3, lines 103–109)
PAR explained this by their impression that the PAED acted stressed and in a rush. In this vein, PAED were perceived as hardly encouraging and not participative in treatment decisions, withholding treatment options or disregarding parents’ concerns. One mother felt that she was not sufficiently empowered to support her child’s therapy more actively.
When you have a problem, you need to convince the doctors to support you. (Transcription of Interview partner P14 (PAR), p. 1, lines 16–17)
PAR reported problems with secondary and tertiary care, namely long waiting lists for specialist appointments, long distances to the next specialised clinic, limited prescription options of the PAED, and a general lack of insurance coverage for many treatment options. Recommendations were perceived as not compatible with the daily life of a family.
As a working mother with two children who are at school, it is not always easy to implement all supporting measures at home right away. (Transcription of Interview partner P14 (PAR), p. 5, lines 164–166)
Metacode “Aims”
DEV and PAED underlined the need for improved interdisciplinary networking. DEV also mentioned conflicts with specialist care providers and proposed establishing mandatory care pathways. Several detailed recommendations for programme improvement were made, e.g., to facilitate prescription, and to add options to directly strengthen the resources of families (e.g. assistant at home, language support).
…the involvement of other professional groups, for example remedial teacher or people from the sports sector and to involve them early on. (Transcription of Interview partner D7 (DEV), p. 3, lines 99–102)
Care assistants could actually do home visits and have a look at the situation there. (Transcription of Interview partner D3 (PAED), p. 3, lines 106–108)
PAED proposed still higher reimbursement of their services and improved quality control of HC. Universal coverage by all statutory health insurance funds was mentioned.
It should be adequately remunerated and it has to be quality assured. (Transcription of Interview partner D2 (PAED), p. 2 and p3, lines 60–61)
Our goal and our hope are that at some time all insurances will take over this service and will also take for granted that they are responsible for MHP. (Transcription of Interview partner D5 (DEV), p. 6, lines 207–210)
Generally, PAR/ADOL felt sufficiently supported. However, PAR proposed to improve access to services, e.g. by allowing telephone consultations, a better communication between providers, and a more convenient localisation of specialised services.
Specialists for both of these topics are spread quite widely over the country. You really need a connection on site and if there were more cooperation with the paediatricians, that would be great. (Transcription of Interview partner P17 (PAR), p. 11, lines 326–333)
PAR proposed to involve other health professionals such as midwives and alternative practitioners into the programme. Opening treatment options e.g. to include homeopathy, and financial aids were additionally mentioned.