Facilitating implementation of an evidence-based method to assess the mental health of 3–5-year-old children at Child Health Clinics: A mixed-methods process evaluation

Abstract

Background A number of instruments for identifying mental health problems in children are available, but there is limited knowledge about how to successfully implement their use in routine practice. The Strengths and Difficulties Questionnaire (SDQ) is an instrument with sound psychometric properties. Because using multi-informant SDQs when assessing young children has been emphasized, parent-and preschool teacher reports on the SDQ were introduced at Child Health Clinics in a Swedish municipality. This paper aimed to describe a facilitation programme developed to support the introduction of SDQ in clinical practice and evaluate how nurses perceived the facilitation strategies used. Moreover, the dose (delivery) and reach (response rate and population coverage) of the questionnaires were assessed. Methods The mixed-methods process evaluation was guided by Moore et al.'s framework. Process data were excerpted from monitoring data, the trial database, research group documents, study materials, group interviews with nurses, and a survey on nurses' opinions and experiences of the screening method and the implementation process. Data were analysed using descriptive statistics and qualitative content analysis. Results Facilitation strategies used included: educational meetings, educational outreach visits, newsletters, facilitative administrative support, and adaptations made in procedures and materials when required. Although nurses described a variety of barriers at the organisational and individual level, they were in favour of using the SDQ in clinical practice and emphasised the importance of the facilitation strategies used for its implementation. While dose levels (77-91%) indicated that nurses essentially delivered the intervention as intended, parental response rates remained between 54 and 63% and population coverage at around 50%, throughout the intervention period.

Parental sociodemographic characteristics and mental health referrals by nurses in Swedish child health centres

“…A new procedure to collect parent and teacher SDQs before 3‐ to 5‐year‐old's routine CHC visit was introduced 19 . Given that normative SDQ data for Swedish children aged 3‐5 years were not available when data were collected, SDQ scores could not be used to determine whether a child should be considered as symptomatic.…”

“…Questionnaires were also available in English, Arabic and Somali. The total participation rate in the Focus study was 48% in study year 1 (2013–2014), 45% in study year 2 (2014–2015) and 51% in study year 3 (2015–2016) 19 . Ethics approval for the Focus study was provided by the Regional Ethical Review Board (Dnr 2012/437).…”

“…In 2013, a structured method was introduced in a trial for CHC nurses to assess children's mental health problems through parent and teacher SDQ reports. 19,20 Because national SDQ norms were missing when the trial was launched, nurses were instructed to use a non-score-based method to interpret the parent and teacher SDQ assessments. The nonscore-based method (described in the Methods section) developed by the trial researchers aimed to guide the nurse's referral decisionmaking by providing information about which children might need further evaluation.…”

“…The Strengths and Difficulties Questionnaire (SDQ) 18 is a well‐known and much evaluated instrument to identify children who may have mental health problems or are at risk of mental health problems. In 2013, a structured method was introduced in a trial for CHC nurses to assess children's mental health problems through parent and teacher SDQ reports 19,20 . Because national SDQ norms were missing when the trial was launched, nurses were instructed to use a non‐score‐based method to interpret the parent and teacher SDQ assessments.…”

Experiences of Norwegian child and school health nurses with the “Starting Right™” child health assessment innovation: a qualitative interview study

“…For example, another study conducted in Finland using online tools determined the utility and appropriateness of a mental health screening tool (strength and difficulties questionnaire, SDQ), as well as how to overcome barriers to support parents and develop competence among CSHNs [ 8 ]. In a Swedish project nurses preferred using SDQ to assess mental health of children in child health clinics, but emphasized the importance of reducing individual and organizational level barriers [ 9 ]. In addition, systematically collecting data on the development and health of children can facilitate the distribution of services to geographical areas with the highest need for follow-up [ 10 ].…”