Impact of Stressful Climates on Provider Perceptions of Integrated Behavioral Health Services in Pediatric Primary Care: An Exploratory Study

J Dev Behav Pediatr. 2019 Dec;40(9):686-695. doi: 10.1097/DBP.0000000000000712.


Objective: Pediatric primary care providers (PCPs) work in challenging environments and are increasingly called to implement complex interventions, such as behavioral health (BH) service integration. We explore how perceived stressful practice climates (1) change over time in and (2) influence provider perceptions of collaborative care versus usual care, 2 models of integrated BH care.

Methods: Secondary exploratory analysis using hierarchical linear modeling was performed on an 18-month cluster-randomized trial of 8 pediatric primary care practices to Doctor-Office Collaborative Care (DOCC), where an on-site care manager delivered BH services in coordination with PCPs, or Enhanced Usual Care (EUC), where a care manager facilitated referrals to local BH providers. Various indicators of PCP perceptions of BH services, including satisfaction with practice, burdens and beliefs regarding psychosocial problems, and effectiveness in treating behavioral problems, were assessed as outcomes. Moderators were 2 domains of stressful climates, role conflict and role overload.

Results: Role conflict and role overload stayed stable in both conditions. Role conflict strengthened the positive effect of DOCC on PCP perceived effectiveness in treating behavioral problems (β [SE], 0.04 [0.02]; p = 0.04) and improvement in managing oppositional/aggressive behavior (0.02 [0.01]; p = 0.02). Role overload strengthened the positive effect of DOCC on PCP-perceived improvement in managing attention-deficit hyperactivity disorder (0.03 [0.01]; p = 0.01). Stressful climates did not influence perceptions for EUC providers.

Conclusions: Providers experiencing more stressful practice climates developed more positive perceptions of collaborative care. This may encourage stressed providers to make effective practice changes and promote practice integration of BH services.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Attitude of Health Personnel*
  • Child
  • Child Health Services* / organization & administration
  • Delivery of Health Care, Integrated* / organization & administration
  • Humans
  • Mental Health Services* / organization & administration
  • Occupational Stress*
  • Organizational Culture*
  • Primary Health Care* / organization & administration