# | Challenge | TDF Domain | Underlying determinant of the Challenge |
---|---|---|---|
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 |