Several themes emerged from the data analysis of the interviews. These themes included: (1) Social-level barriers and facilitators from the perspectives of clients and healthcare provider; (2) structural-level barriers and facilitators related to both internal and external organizational environments; and (3) intervention-related barriers and facilitators. The following sections describe these themes in detail and substantiate them using in-depth quotes taken verbatim from the participants within the study.
1. SOCIAL-LEVEL BARRIERS AND FACILITATORS
Items were coded as social-level if they assessed barriers/facilitators that represent the social context in which the organization is located. This theme has been emerged from two aspects of clients and healthcare providers who implement the ADHD program. In the following, we will first explain barriers and facilitators on behalf of clients and then, barriers and facilitators on behalf of healthcare providers.
1-1 Social-level barriers on behalf of clients
Parents of children with ADHD seem to harbour a lack of acceptance or distrust in the quality of General Practitioners [GPs] working within basic-level hospitals when seeking help in treating their child’s mental health challenges. This lack of acceptance exists even when physicians within these hospitals are wholly qualified and trained to treat such health challenges. Instead, parents often actively seek the help of specialists within third-level hospitals. As one of the participants said: “…, if basic doctors [GPs] are trained, they may gain some knowledge about ADHD… But the question is whether the patient would like to see them…”. In addition, several participants indicated that there exists an overall lack of “parents' education” on the importance of the psychological health of their children. This parental lack of education translates to a lack of screening for mental health disorders in child populations as a whole. Finally, from a logistical standpoint, participants identified geographic location and/or “traveling” as a real barrier to healthcare access. Some patients have to travel a long distance to see a specialist which is not “convenient” and “feasible” for them. Whereas if the patients’ treatment was stable, they would rather to “choose a place close to home to get the medication”. The long line-ups often required of patients seeking healthcare treatment was similarly seen as a barrier to specialist access: “...there [at the basic level hospitals] is no need [for patients] to queue up [compare to a third level hospital]…”.
Overall, with regards to social-level barriers that pertain to the Chinese clients in the implementation of our study, lack of acceptance or distrust in the quality of physicians working at the basic-level hospital, a lack of parental education, and burdensome logistical barriers were chiefly identified.
1-2 Social-Level facilitators on behalf of clients
In addition to the social-level barriers identified by participants within the focus groups, several key facilitators were discussed to enable implementation of this project.
To begin, participants indicated that the mandate and goals of the project are highly in line with the social demands within a Chinese healthcare context which facilitates the overall acceptability of the project. Given that in the previous section, travel time and long wait times were an identified barrier to healthcare access, participants indicated that this project would help address this issue. Specifically, adopting a shared-care approach would promote the visiting of GPs at basic level hospitals and subsequently translate into lowered costs and faster patient turn-around. Mentioned during one of the focus groups: “It's quite easy to see a doctor in our hospital [basic level hospital]… there is a certain discount for taking medications from basic hospitals…and there is no need to queue up … So, the patients may go there”. Furthermore, this project would promote the education of parents, teachers, and classmates of children within ADHD, allowing for greater assistance for identification and management of children with ADHD. As one of the participants mentioned, “… it is necessary to provide education in this area. One is education for parents and the other is education for teachers”.
Developing a working partnership between GPs, specialist, teachers, and decision makers have been mentioned recurrently as another facilitator during the focus groups. One of the research participants went so far as to indicate that: “The biggest highlight of this project is that to integrate different parts together. Working together to get the task done instead of fighting alone individually. Personally, I think that is the biggest highlight”.
A final facilitator to social-level implementation involves the potential assessment of the acceptability of this sort of project from the patients’ perspective: “This project includes some interview, and will also ask about patients’ opinions, then … modifying the referral scheme [based on patients’ feedback]. Incorporating patients’ feedback can increase the chance of sustainability of the project”.
To conclude, the Client’s social-level facilitators comprise of this project having a resonating mandate, beliefs that adopting a shared care approach would help with wait times and access to health services, promote education of parents and teachers of children with ADHD, develop a working partnership , and the ability to potentially assess of the acceptability of this project from the perspective of patients.
1-3 Social-Level Barriers on behalf of healthcare providers
Similar to social level-barriers identified by participants regarding clients, themes related to barriers faced by healthcare providers were identified. For example, in China, specialists are often the ones responsible for the training of GPs. However, given an already heavy workload and related time limitations, some of these specialists are often unable or unwilling to provide the necessary mental health training for GPs “especially when it is very likely to be a long-term thing”. As one of the participants mentioned, “So, we’re …really intense with the time issue… How can I do it well, on the premise of not delaying my current work is a real challenge”.
Not all physicians are allowed to prescribe stimulant medication for patients with a mental health diagnosis like ADHD. As such, participants indicated that there is a need for a streamlined “prescription certification for mental stimulants” in order to properly and succinctly treat their patients. Related to this issue is a lack of clarity with regards to legal scopes of practice. Several participants indicated that they had major concerns related to the possibility of practicing beyond their scope of practice when treating patients with mental health challenges. For example: “…For general practitioners, it is indeed a problem to practice beyond the scope, as a “specialist”. So, in this part, I think we need to get it approved legally”.
Finally, the qualifications of physicians from hospital to hospital, and from specialty to specialty are very different. For example, a basic level hospital may only consist of “undergraduate” and GPs while a third level hospital may house several specialists: “The qualifications of doctors at different levels are quite different… some doctors at the basic hospitals are undergraduate, some are even not”. As such, an additional barrier in order to implement the project is the heterogeneity of practitioners; physicians that often come from differing backgrounds elicit a wide range of training needs in order to properly diagnose and manage patients. This situation makes the training needs of physicians in differing hospitals’ levels complex.
In summary, the social-level barriers experienced by healthcare providers that could hinder implementation encompass issues related to training such as time constrain and heavy workload of specialists, barriers to proper prescription certifications, and the varying qualifications held by physicians within differing hospitals which provoke a wide range of training needs.
1-4 Social-level facilitators on behalf of healthcare providers
The facilitators pertaining to healthcare providers in the implementation of this project were discussed at length by participants. In general, the physicians participated within the focus groups had a high degree of confidence and interest in the success of the project. For example, a participant indicated that: “I give a score of 9 [out of 10 for success of the project]…I can even give 9.5, based on history, and the scientific nature of the project, as well as social needs”. Similarly, the compatibility of the project was seen to be highly in line with participants’ own values and goals which can facilitate the successful implementation and high sustainability of the project. Participants often indicated that they had expectations and believed that the project would greatly “make improvement of medical treatment” within a Chinese context which is in line with the healthcare providers’ own goals and values.
2. STRUCTURAL-LEVEL BARRIERS AND FACILITATORS
Item were coded as structural level if they assess barriers/facilitators that represent the organizations in which the new ADHD program is being implemented, and legal entity other than organizations where this program is being implemented. In the following, first the internal organization barriers and facilitators and then, the external organization barriers and facilitators have been explained.
2-1 Internal organizational barriers
Spoken of at length, participants identified several key barriers that they felt related to the internal organization of their respective hospitals that could affect the implementation of the ADHD Shared Care Pathways program within a Chinese context. Both general practitioners and specialists indicated that in order for this project to be successful, barriers related to lack of support on behalf of leaders at hospitals from all levels would need to be addressed. For example, participants indicated that a lack of internal policies that would ultimately support this new program could serve as a barrier to implementation: “…and, we also need their support… Whether the leaders of these hospitals support this kind of work also matters, which need communication and coordination”.
On a related note, a lack of financial and human resources (technical and administrative staff) would greatly hinder implementation: “we should have the resources from our hospital… I don't know what the situation of the basic hospital is…Do they have enough personnel? … To ensure we can do our work well, we must have policies and financial expenditures.”
Finally, participants indicated that a lack of a proper referral system, that would refer patients from primary to specialized hospitals, was a definite barrier to project implementation: “The current referral system is still very imperfect…the problem is that the patients in Third Grade hospital are not transferred here [the basic level hospital]…”. Therefore, there is a need to design a proper referral system between hospitals where the project will be implemented.
To conclude, internal organizational barriers identified by participants in both focus groups included a lack of organizational support, lack of financial and human resources, and an unclear or lack of an appropriate patient referral system.
2-2 Internal organizational facilitators
The compatibility of the project was seen as a major facilitator given the organizational culture present within many of the participating hospitals: “According to the history, it [the designated hospital's culture and values] is matched [with the current project]”.One of the participants explained that the culture of their hospital supports innovation, and that’s the reason for this compatibility. As was elaborated by another participants: “… I think there should be no problem in the aspect of culture… In fact, in terms of our values and culture, we serve the general population and definitely can provide such services for children.”
Some of the Chinese hospitals that were represented by the focus group participants have ongoing connections within their communities, including their local school systems which increase the chance of success in implementation of the project. Such connections were indicated by almost all participants: “In fact, I think, especially in psychiatry, we have done some services in schools, including primary and secondary schools, and we also have certain communication with schools.”
2-3 External organizational barriers
External organizational barriers were identified in the form of lack of support on behalf of municipal and state governments. Namely, participants indicated that a lack of government-level policies that would ultimately enable the implementation of this project (and others like it) was a definite barrier:
“Some of the slogans we have been spoken for 10 years did not solve the problem, and some of the medical staff have changed careers…That's why I emphasized that in this process, we should let the decision makers [at the governmental level] participate and let them have a look at the actual situation. Otherwise, doctors in the top hospitals are too burdened to think or study at all”.
2-4 External organizational facilitators
Many external organization facilitators were discussed by the participants from both focus group locations. For example, participants indicated that the mandate of the project was highly compatible with the needs of current Chinese “medical triage” practices and the current “direction of medical development”, particularly in Beijing. Similarly, the project was seen to be highly compatible with the “management system of the Haidian district”.
Participants named a hospital in Beijing that has been relatively successful in the grading diagnosis, and treatment of patients by expert medical teams: :“ I know they have expert teams …such as for depression, ADHD, etc...the number of outpatients of their attending doctors is relatively large… Top experts have to be recommended level by level...”. Since a proper patient referral system was identified as a barrier to the treatment of patients within the designated hospitals in the current study, the use of the aforementioned hospital’s patient referral model was suggested as a possible facilitator in this project.
3. INTERVENTION-RELATED BARRIERS AND FACILITATORS
Item were coded as intervention-level if they assess barriers/facilitators that represent aspects of the proposed ADHD Shared Care Pathways program that will be implemented. In the following, first the barriers and then facilitators related to this theme have been explained.
3-1 Intervention-related barriers
The participants indicated the need for a detailed outline of the proposed program. Herein, participants wanted details on all internal procedures, especially as they pertain to the referral system. As highlighted by one of the participants: “For example, this kid has been treated, but he has relapse later. Under this situation… should we tell the child to go to the specialist directly, or wait for the specialist to come over?”. Another participants mentioned: “But we should discuss what you [GPs] come to us [Specialist][to receive training] for, and what tasks you [GPs] need to solve after you go back [to your hospital]”.
Related to this aforementioned barrier, participants indicated that the program outline should consider the reality or context of China’s current healthcare setting. For example, this program should take into account the lack of specialists available who can provide training for GPs: “I'm also thinking about the time issue if I'm going to do something really detailed. Because there are so many things in hand…”.
The final barrier applies to the current design of the training phase of the program. One of the participants feel that online training may not be sufficient for their needs: “In the past, there was such [online] training because of the inconvenient transportation. But the effect of the training was not very good”. The lack of additional in-person training and/or online exams could hinder the training of those involved in the project.
Overall, intervention-related barriers encompassed a lack of a detailed program outline, a lack of specialists who can provide training, and the possibility that current training approach may be inadequate.
3-2 Intervention-related facilitators
A significant number of facilitators that were identified within this study applied to the intervention. To begin, participants described the scientific and rigorous design of the project very acceptable for stakeholders in China. As was elucidated: “the design of this research is very rigorous…there are very rigorous qualitative research methods… Through such a model, once established, it must be very scientific, effective and generalizable”.
Related to one of the above-mentioned barriers, participants indicated that a series of exams, designed for the online course, would increase the overall effectiveness of the training: “We can add in exams. So online training plus exams, some tasks and so on. This will be better”. Further related to the training aspect of this intervention, a proper amount of time allocated to specialists to prepare the courses (in the cases that they train GPs) would greatly contribute to the effectiveness of training provided by them, and dividing the training tasks among differing specialists would reduce the overall burden associated with meeting training goals.
Another suggested facilitator to the project would be ensuring that the assessment questionnaires are short and/or simple and that the project is completed in small, adaptive parts; much like a pilot: “But I still have some ideas. Don't do too much at one time, because I think starting from one point, then after you have accumulated enough experience and made some improvement, you can slowly move on”. Having a clearly stated end-goal for the project would also contribute to the sustainability and overall longevity of the project.
In conclusion, the intervention-related facilitators that were discussed by participants included the strong scientific foundations that make up this study, the allocation of adequate time to prepare training, the potential of proper training assessment tools, ensuring that the questionnaires/assessments used during the study do not overwhelm participants, and having a clearly-stated end goal for the project.