A mixed methods study exploring the barriers and facilitators of screening for autism spectrum disorder in Oman

Background: Within the routine practice, specific screening for autism spectrum disorder (ASD) has been recommended, in order to facilitate early intervention and improve outcomes. Despite the substantial advantages of this process, it has also presented a variety of challenges, across clinical settings, which have not yet been explored sufficiently. There is little information available to support the introduction of ASD screening in Oman. Research is required to identify the potential facilitators of and barriers to ASD screening in Oman, prior to the implementation of a screening programme, to ensure its successful introduction. Method: An exploratory mixed-methods design was adopted, in two sequential phases. Phase 1 involved two focus group discussions, with seven nurses and six GPs, from primary health care (PHC) settings in Oman. The participants were recruited using a purposive and snowballing technique. The discussions were audio-taped and transcribed verbatim. Framework Analysis was used to identify recurrent themes within and across groups. Data from the focus groups was then used to inform the development of a questionnaire, which was piloted on a sub-sample of volunteers from both groups. Phase two (quantitative phase) comprised of sending the final draft of the questionnaire to a random sample of primary health care providers (PHPs) (n=571) across Oman. The returned data was analysed statistically with the software program SPSS (Statistical Package for Social Sciences version 22.0). The Social Ecological Model (SEM) was then applied to interpret the final data from both phases and to draw conclusions. Results: Qualitative data analysis revealed five themes, which voiced the major challenges facing ASD screening in Oman, as well as highlighting a few facilitators. The findings revealed that both nurses and GPs believed that introducing screening for ASD would be a positive step. However, they felt overwhelmed by their responsibilities and believed that their workplaces lacked the necessary infrastructure. Practitioners’ awareness of ASD services was identified as poor, as were the essential skills required for undertaking screening. Additionally, limited public awareness of ASD and a strong interest in traditional medicine, as well as the social stigma attributed to ASD, were thought to create barriers to screening. The groups also discussed their preference for a clear, simple, paper-based questionnaire, supported with guidance and researcher availability to reward their willingness to participate. The findings from the focus group informed the development of a 38-item questionnaire to explore the potential barriers to and facilitators of the introduction of ASD screening in Oman. The questionnaire was short so that it could be completed within 15 minutes. Five hundred and seventy-one questionnaires were sent to a random sample of PHP providers across Oman. Of those, five hundred and sixteen questionnaires were returned, in phase 2 (response rate 90.37%). The quantitative results of this phase were congruent with the qualitative findings, in that they suggested a deficit in the knowledge of professionals, among both older respondents and nurse respondents. In addition, a lack of resources, time constraints, workload issues and staff shortages were highlighted. The respondents also emphasised the ambiguity surrounding their role and the lack of guidance on protocols to identify or refer suspected cases. This was compounded by a lack of public awareness and knowledge of ASD identification and its potential causes, as well as the attributed social stigma. Conclusions: The root challenges and potential facilitators for screening for ASD were examined, through the SEM. Challenges were addressed and resolved across three levels (intrapersonal, organisational, and community). At the intrapersonal level, more training and knowledge regarding ASD is required. Organisations need to implement a clear protocol, to guide the process, with greater coordination and collaboration among services. A country-wide awareness campaign, targeting social issues, may reduce the stigma and improve the uptake of screening.