Exploring Potentially Modifiable Factors That Influence Treatment Non-Adherence Amongst Pediatric Growth Hormone Deficiency: A Qualitative Study

Figures & data

Table 1 Sample Characteristics

Participant #	Parent Gender	Parent Age (Years)	Child Gender	Child Age	Treatment Duration
P1	Female	44	Male	9 years 2 months	2 years
P2	Female	50	Male	8 years 11 months	3 years
P3	Female	48	Female	6 years 4 months	3 months
P4	Female	44	Male	10 years 4 months	3 years 2 months
P5	Female	39	Male	9 years 7 months	4 years
P6	Female	34	Male	10 years 7 months	1 year
P7	Female	47	Female	7 years 8 months	2 years 3 months
P8	Female	47	Male	11 years 8 months	6 years
P9	Female	45	Female	6 years 2 months	10 months
P10	Female	47	Male	8 years 8 months	2 months
P11	Female	58	Female	9 years 5 months	3 years
P12	Female	51	Female	9 years 9 months	4 years 6 months
P13	Female	36	Male	4 years 11 months	2 years 6 months
P14*	Female	51	Male	10 years 8 months	3 years 6 months
P15*	Male	47

Notes: * P14 and P15 were the mother and father of the same child. One interview was conducted with both participants present; each participant contributed to the interview.

Table 2 Themes Mapped Onto the COM-B Framework as Potentially Modifiable Determinants of Non-Adherence to rhGH Treatment Amongst Pediatric GHD

Capability	Opportunity	Motivation
An individual’s physical and psychological capability to engage in and perform a behavior.	All factors lying outside the individual that can either prompt or prevent the performance of a behavior.	An individual’s brain processes that can either energize and direct or inhibit a behavior.
Physical Capability	Physical Opportunity	Reflective Motivation
Physical skill, strength or stamina.	Opportunity afforded by the environment involving time, resources, locations, cues, physical 'affordance'.	Reflective processes involving plans (self-conscious intentions) and evaluations (beliefs about what is good and bad).
Administration Technique - Poor administration technique (skill)	Device Issues - Device difficulties Discomfort and pain associated with daily injection - Discomfort and pain associated with daily injection [child] Interference of treatment* - Interference of injection on daily life (eg timing of injection)	Treatment Concerns - Concern with treatment side effects - Fear of long-term effect of treatment - Dissatisfaction with effectiveness of treatment Administration Anxieties - Worry of administering the daily injection (eg administration skill, use of needle) - Guilt of administering the injection (ie causing pain to child) Interference of treatment* - Interference of injection on daily life (eg timing of injection)
Psychological Capability	Social Opportunity	Automatic Motivation
Knowledge or psychological skills, strength or stamina to engage in the necessary mental processes.	Opportunity afforded by interpersonal influences, social cues and cultural norms that influence the way we think about things.	Automatic processes involving emotional reactions, desires (wants and needs), impulses, inhibitions, drive states and reflex responses.
Lack of knowledge and understanding - Lack of knowledge and understanding of the condition Forgetting to administer injection - Active forgetting, eg due to travel or social activities - Passive forgetting, eg accidental	Challenge to administer injection to child - Challenge to administer injection to child (due to child reluctance, non-cooperation or refusal) Lack of HCP Information input - Lack of information provided about the nature of condition [HCP] Poor HCP-parent/caregiver communication - Poor listening and understanding of concerns [HCP] - Reluctance to discuss worries with HCP [parent] Disruption to treatment regimen and scheduling issues - Being away from home [social events, travelling, school trips, overnight sleepovers] - Illness [child]