Straiton Diondra, Frost Kyle, Ingersoll Brooke
Michigan State University.
Implement Res Pract. 2023 Jan-Dec;4. doi: 10.1177/26334895231153631. Epub 2023 Feb 15.
Parent coaching is an evidence-based practice for young autistic children, but it is underutilized in lower-resourced community settings like the Medicaid system (Straiton et al., 2021b). Clinicians often struggle to implement parent coaching with low-income and marginalized families (Tomczuk et al., 2022), but little is known about which factors influence clinician decision making processes about providing parent coaching to this population.
This qualitative analysis used the framework method and thematic analysis. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework (Aarons et al., 2011) to identify factors in the clinical decision-making process that community providers use when offering parent coaching to families of Medicaid-enrolled autistic children. Interviews with 13 providers and a focus group with 13 providers were analyzed.
The following themes emerged: 1) Policies drive provider task priorities and affect competing demands; 2) Providers are more likely to use parent coaching when agency leaders monitor parent coaching benchmarks, though this is rarely done; 3) Logistical factors like scheduling and treatment location affect perceived feasibility of using parent coaching; 4) Previous experience or coursework in parent coaching and/or family systems supports the quality of parent coaching implementation; 5) Provider perceptions of "parent readiness" are initially indicated by overt expressions of parent interest.
In the absence of outer-context and inner-context policies, providers have more decision-making power to offer parent coaching based on their own judgements and preferences, which may result in fewer families being offered parent coaching and increased bias related to which families are offered this service. State-, agency-, and clinician-level recommendations are provided for increasing equitable provision of this evidence-based practice for autism.
家长指导是针对自闭症幼儿的一种循证实践，但在医疗补助系统等资源匮乏的社区环境中未得到充分利用（斯特雷顿等人，2021b）。临床医生在为低收入和边缘化家庭实施家长指导时常常面临困难（托姆楚克等人，2022），但对于哪些因素会影响临床医生针对这一人群提供家长指导的决策过程，我们知之甚少。
本定性分析采用框架法和主题分析法。我们使用探索、准备、实施和维持（EPIS）框架（阿伦斯等人，2011）来确定社区提供者在为参加医疗补助计划的自闭症儿童家庭提供家长指导时，临床决策过程中的影响因素。对13名提供者进行了访谈，并对13名提供者组成的焦点小组进行了分析。
出现了以下主题：1）政策驱动提供者的任务优先级并影响相互竞争的需求；2）当机构领导监督家长指导基准时，提供者更有可能使用家长指导，不过这种情况很少发生；3）诸如安排时间表和治疗地点等后勤因素会影响使用家长指导的感知可行性；4）在家长指导和/或家庭系统方面的先前经验或课程作业有助于提高家长指导实施的质量；5）提供者对“家长准备情况”的认知最初通过家长兴趣的公开表达体现出来。
在缺乏外部环境和内部环境政策的情况下，提供者有更多决策权根据自己的判断和偏好提供家长指导，这可能导致接受家长指导的家庭减少，以及在提供这项服务的家庭选择上出现更多偏见。针对如何更公平地为自闭症提供这种循证实践，我们提出了州、机构和临床医生层面的建议。
