Table 5 List of the three most substantive gaps, challenges and barriers identified, with results of their secondary analysis using TDF domains

1

Challenges in overcoming patient barriers and resistance

"1 – Knowledge"

Lack of knowledge of tools to facilitate patient – provider communication

"2 – Skills"

Lack of communication skills

"4 - Beliefs about Capabilities"

Lack of confidence

"5 – Optimism"

Underestimation of impacts of miscommunications

"6 - Beliefs about Consequences"

2

Challenges with the treatment decision-tree

"1 – Knowledge"

Extent to which short-term adverse side-effects compare to long term benefits of treatment in patients with AGHD

"2 – Skills"

Challenge in balancing long term benefits of treatment with short-term adverse effects

"4 - Beliefs about Capabilities"

Confidence issues

"9 – Goals"

Prioritization between proximal goal of avoiding side effects and distal goal of avoiding long-term consequences of disorder

"10 - Memory, Attention, and Decision Processes"

Specific challenges in the clinical reasoning process

3

Challenges associated with the transition from childhood to teen years, to adulthood

"1 – Knowledge"

Consequences of inappropriate cessation of GH therapy

"2 – Skills"

Lack of skills in addressing compliance during teenage years

"3 - Social/Professional Role and Identity"

Lack of clarity on which tests should be done at primary care levels and which ones should be done by specialists

"4 - Beliefs about Capabilities"

General pediatricians preferring to refer because of lack of confidence

"6 - Beliefs about Consequences"

Underestimation of impact of growth hormone treatment cessation

"11 - Environmental Context and Resources"

Lack of adult-treating endocrinologists forcing pediatric endocrinologists to keep patients under their management longer