Researchers identified themes, which were organized according to the outer setting, inner setting, and intervention characteristics CFIR domains. Table 1 shows the frequency of codes within each domain.
Table 1
Frequency of code by CFIR domain
CFIR domain | Total # mentions | # providers mentioned |
Outer setting | 71 | 16 |
Inner setting | 115 | 16 |
Intervention characteristics | 89 | 16 |
Outer Setting
The outer setting domain has constructs that refer to factors outside of the organization. The patients’ needs and resources (i.e., the extent to which patient’s needs are known by the organization) was a salient theme. Providers reported the challenges with working families who would struggle to have time to attend EBPIs
“Basically, the barriers are… cultural and socioeconomic and just again a lot of people
have jobs, and it’s hard… working full time and taking care of your family, carving out time to go to a class about something can be difficult” (Participant 6).
“I think unfortunately, parents don’t always put enough weight into how they can help their kids through these tough things and um for a number of reasons because they’re busy with other kids, because they have to work two jobs, because they’re caring for another parent or a parent of theirs. A resource of time is such a limitation for so many families.” (Participant 11)
Providers also described barriers surrounding the availability of and distance to providers:
“There’s a lack of services… There’s just not enough providers for the load of patients that need help… I mean, you can’t get in. It takes 5–6 months to see someone sometimes… By that time, parents lose interest sometimes or they problem solve it themselves. You have to be exceptionally motivated and organized from a parent’s standpoint to navigate all of the resources that parents have to access. And sometimes if you are in a lower socioeconomic status or if you’re in a state where you’re just trying to get food on the table for your family, the time it might take to access resources can be overwhelming.” (Participant 10)
Inner Setting
Providers repeatedly expressed interest in offering a program to support parents, including offering office space during working hours or making it available on evenings/weekends
“We all see it as a huge issue with our families who cope with that. We’d be willing to kind of make moves or bends to accommodate them.” (Participant 11)
“I've been hoping to do something like this at some point in time from this office because we have a space that is easy to get to, could be open in the afternoon or evening hours, when families would be available. I really think it's a need that pediatricians can fill, but we're very busy people and can't really do it during the daylight hours. But if there are other folks like yourself or other social workers or folks who've had training in some of these techniques to teach parents, what I envision is… more after hours or evening kind of sessions... But our office could be available for that. We have that big room that you were sitting in. But we also have sort of our lunchroom that's in the back that could be set up for a group discussion.”(Participant 15)
Physicians also explained that the pediatric primary care setting is a convenient location and a “safe space,” where physicians are trusted sources of information.
“Our parents have developed a big trust in us as physicians… And, I think with that trust if we have someone in our practice, they would feel that it was a unified, it’s not somebody else, dealing somewhere else, that there might be communication, there might be a safe place to, they might have more confidence in seeing someone in the practice” (Participant 2).
Despite the enthusiasm, EBPIs seemed to be of low relative priority; providers emphasized the limited resources available for parents both within the pediatric primary care setting as well as in the community as a whole. Though some primary care offices offered resources for parents, such as recommended reading materials or additional consultations, many providers described them as insufficient for addressing parents’ concerns:
“There’s not enough. I think they [existing resources] are very helpful, but there’s just not enough. They are sometimes hard to plug the parents into...Sometimes the counselors or the psychologists, they’re full, the waiting time is long, so it’s not that easy… They’re not as available as we need them to be” (Participant 7).
Intervention characteristics
Cost of the intervention was a major theme; however cost, along with other themes on social determinants of health are reported elsewhere (28). The other main theme identified was related to the intervention’s adaptability. Although providers felt that an EBPIs are needed and would be welcomed by parents, they acknowledged the relative complexity of many EBPIs. Some suggested having fewer sessions, while others recommended decreasing the length of each session.
“I think that for some problems, just a one-time visit might be enough... Other times, the parents may welcome a more intensive repetitive program, if that makes sense. It depends on the problem, right? So it would be nice to have either one of those… But we know, let's say with anxiety, cognitive behavioral therapy takes many visits to teach them what to do, because they didn't get there overnight. It'll take a while to fix it.” (Participant 16)
Providers focused on the strategies to deliver the interventions. To increase convenience, they suggested in-home visits or offering the program in a community-based setting.
“Well, proximity is important. Location, location, location. The closer it is to people, the more likely they are to go… Whether that be a church, whether it be a community center, it would be allowing you to do this” (Participant 16).
Providers also emphasized the importance of thinking about who would deliver the EBPI. Psychologists, social workers, and peers (i.e., another parent) were suggested as viable options, but greater emphasis was placed on the interventionist’s personality and approachability.
“I think if it's convenient and the person's helpful, I don't think you need a PhD to counsel a family through some behavioral problems” (Participant 14).
There were mixed ideas regarding the intervention’s delivery format. Some providers suggested a group format to encourage feelings of support and camaraderie. Others recommended a one-on-one format to allay concerns about stigma and judgment.
“And people might have fears about strangers, if it’s in a group setting for example, a parenting class with ten strangers. They may feel uncomfortable or they don’t want to feel stupid. They don’t want to look like they don’t know how to take care of… their own child and they don’t want to show up because it implies that ya know that they’re not a good parent… So they might not want to come if it’s in a group setting.” (Participant 6)
“Well, I think one-on-one helps a lot, but I think also, a small group, I think also helps some parents to realize, ‘okay, they’re going through the same thing. It’s not just me.’” (Participant 7)
Providers recognized the need for this type of program as a treatment and as a preventative approach.
“I think that it's one of the most important things to do in life is to be a parent and the frustrating, challenging aspect of it is that no one gets training in it, right? I mean, we take time to teach people how to drive cars, we take time to teach people education at school. And you learn lots of facts and how to think and how to speak in front of a group and things like that. But you don't really learn how to be a parent and yet the impacts of it are huge… So I think it would be a great thing to try to find a way to support families and parents with all the complexity that they have to deal with… It would be really helpful to have better answers or better training for those families, ideally, ahead of time… So it's not just about intervening when there's a problem, although that can happen. It would be great to train people to know how to take care of their child, how to parent their child, I guess. You know how to take care of them, you know how to put their diaper on and stuff like that. It's more than that.” (Participant 15)