Barriers to self-management of paediatric eczema in primary care: GP and parent factors

Problem

Eczema is a common childhood condition characterised by exacerbations and remissions. The majority are treated in primary care by self-management with topical treatments – emollients and topical corticosteroids (TCS). Treatment adherence in primary care is poor and is the main reason for poor clinical outcomes. Until now we have had limited understanding of clinicians’ perspectives on eczema management, and how this reflects or conflicts with the experiences & opinions of parents.

Approach

As part of a project to develop written action plans for children with eczema, we conducted semi-structured in-depth interviews with: 11 parents of children who have eczema (children participated in two interviews) 21 primary care clinicians (GPs, practice nurses, health visitors and pharmacist); 5 secondary care clinicians (dermatologists and community and hospital based dermatology nurses); and 4 stakeholders (nursery nurses and members of eczema charity organisations) across the UK. We also held one mixed participant focus group with another planned. The data are being analysed using a thematic approach.

Findings

The main emerging barriers to self-management are: 1) Parental beliefs: parents often talked about the cause of eczema and a ‘cure’, yet few parents or primary care clinicians reported receiving or providing education about these aspects of the condition. 2) Parental underuse and/or incorrect use of emollients and steroids, was often discussed by the clinicians. The reasons for this may include lack of advice about treatment application, parent dislike of particular treatments and conflicting advice mainly around steroid use (discussed across all participant groups), parental fear of TCS (reported among the parents and clinicians), and lack of GP confidence in prescribing higher potency potent TCS (as reported by the GPs themselves). 3) Recording and recalling treatments: parents reported difficulty in remembering the names of treatments which makes re-ordering prescriptions and recalling ineffective treatments difficult. Also, GPs reported not keeping full records on why treatments were stopped. 4) Dissonance between the GP and parent perspectives frequently emerged, in particular around emollient advice, the quantity of emollient prescribed, views of eczema severity and the role of allergy. 5) Parent perception of GP attitude towards eczema was a commonly voiced frustration among parents, where they often felt that eczema was not taken seriously by GPs.

Consequences

Managing eczema can be a frustrating and confusing experience for parents and clinicians, as a consequence of a complex interplay of parent and clinician factors, exacerbated by a disparity between parents and GPs around treatment and cause. We have identified a need for training initiatives that focus on patient education and managing clinician-patient dissonance. In the context of the wider study, written action plans have the potential to address some of these barriers to self-management.