OBJECTIVES: In a previously published Delphi exercise the European Pediatric Dialysis Working Group (EPDWG) reported widely variable counteractive responses to COVID-19 during the first week of statutory public curfews in 12 European countries with case loads of 4-680 infected patients per million. To better understand these wide variations, we assessed different factors affecting countermeasure implementation rates and applied the capability, opportunity, motivation model of behaviour to describe their determinants. DESIGN: We undertook this international mixed methods study of increased depth and breadth to obtain more complete data and to better understand the resulting complex evidence. SETTING: This study was conducted in 14 paediatric nephrology centres across 12 European countries during the COVID-19 pandemic. PARTICIPANTS: The 14 participants were paediatric nephrologists and EPDWG members from 12 European centres. MAIN OUTCOME MEASURES: 52 countermeasures clustered into eight response domains (access control, patient testing, personnel testing, personal protective equipment policy, patient cohorting, personnel cohorting, suspension of routine care, remote work) were categorised by implementation status, drivers (expert opinion, hospital regulations) and resource dependency. Governmental strictness and media attitude were independently assessed for each country and correlated with relevant countermeasure implementation factors. RESULTS: Implementation rates varied widely among response domains (median 49.5%, range 20%-71%) and centres (median 46%, range 31%-62%). Case loads were insufficient to explain response rate variability. Increasing case loads resulted in shifts from expert opinion-based to hospital regulation-based decisions to implement additional countermeasures despite increased resource dependency. Higher governmental strictness and positive media attitude towards countermeasure implementation were associated with higher implementation rates. CONCLUSIONS: COVID-19 countermeasure implementation by paediatric tertiary care centres did not reflect case loads but rather reflected heterogeneity of local rules and of perceived resources. These data highlight the need of ongoing reassessment of current practices, facilitating rapid change in 'institutional behavior' in response to emerging evidence of countermeasure efficacy.

Department of Pediatric Nephrology Hôpital Femme Mère Enfant Hospices Civils de Lyon Lyon France

Department of Pediatric Nephrology KfH Children's Kidney Center Marburg Germany

Department of Pediatric Nephrology Medical University of Gdansk Gdansk Poland

Department of Pediatric Nephrology Mitera Children's Hospital Athens Greece

Department of Pediatric Nephrology University Hospital Motol Prague Czech Republic

Department of Pediatric Nephrology University Hospital Vall d'Hebron Barcelona Spain

Department of Pediatric Nephrology Utoped Universitair Ziekenhuis Gent Ghent Belgium

Dialysis Unit Department of Pediatrics IRCCS Giannina Gaslini Genoa Italy

Division of Nephrology and Vascular Biology Research Center Beth Israel Deaconess Medical Center Department of Medicine Harvard Medical School Boston Massachusetts USA

Division of Pediatric Nephrology and Gastroenterology Department of Pediatrics and Adolescent Medicine Comprehensive Center for Pediatrics Medical University of Vienna Vienna Austria

Division of Pediatric Nephrology Gazi University Faculty of Medicine Ankara Turkey

Ludwig Boltzmann Institute Digital Health and Patient Safety Medical University of Vienna Wien Austria

Ludwig Boltzmann Institute for Arthritis and Rehabilitation Vienna Austria

Pediatric Center Institute of Clinical Medicine Vilnius University Vilnius Lithuania

Pediatric Nephrology Center for Child and Adolescent Medicine Heidelberg University Heidelberg Germany

Pediatric Nephrology Dialysis and Transplant Unit La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico Milano Italy

Renal Unit UCL Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health London UK

Research Platform Data Science University of Vienna Vienna Austria

Section for Outcomes Research Center for Medical Statistics Informatics and Intelligent Systems Medical University of Vienna Vienna Austria

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