Knowledge, attitudes and behaviour in everyday life with chronic hand eczema: a qualitative study

Health Literacy and Associated Factors in Subjects with Hand Eczema: A Dutch Population-based Study

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Chronic hand eczema in Europe: Patient experiences and perspectives (CHEPEP) in qualitative interviews

BACKGROUND

Chronic hand eczema (CHE) is a very common skin disease among the European population. It causes itch and pain and, in more severe cases, seriously impairs hand functioning at work and in private life.

OBJECTIVES

To explore perspectives of people with lived experience on CHE-related problems, wishes and goals.

METHODS

Following a qualitative approach, we conducted topic-guided interviews in five European countries and applied template analysis to identify recurrent themes among patients with CHE.

RESULTS

We interviewed 60 patients in seven outpatient dermatological and occupational medicine clinics in Croatia, Denmark, Germany, the Netherlands and Spain. Five main themes were identified: (1) knowledge about the disease and its course, (2) preventive behaviour, (3) hand eczema therapy, (4) impact on everyday life and (5) attitudes towards CHE and healthcare. Participants did not feel well informed about CHE, especially about causes, triggers and treatment options. Preventive measures were experienced as more or less effective but also cumbersome. Experiences with therapy were diverse. Treatment satisfaction depended on the results and on the perceived support from the treatment teams. Participants found it important to be taken seriously, to receive practical advice, to try out additional treatments or examinations, find new hope and have occupational perspectives. They wished that others could better understand the physical and emotional burden of CHE. Patient support groups were not mentioned. Participants found it important to learn to take care of themselves and accept life with CHE.

CONCLUSIONS

Due to its annoying symptoms, high visibility and impaired functioning at work and in private life, CHE has a high emotional and social impact. Some people may require support to learn coping with CHE and its prevention. Patients wish for information about causes and triggers. They value physicians who listen to them and keep looking for solutions.

Illness Perceptions of Patients with Occupational Skin Diseases in a Healthcare Centre for Tertiary Prevention: A Cross-Sectional Study

Objectives: To investigate the illness perceptions of patients with occupational skin diseases (OSDs). Design: Cross-sectional study. Setting: Specialised healthcare centre for inpatient and outpatient individual prevention in occupational dermatology in Germany. Participants: A total of 248 patients with hand eczema (55.2% female; average age: 48.5 years, SD: 11.9) were included in the final analyses. Measures: A modified and recently validated version of the 'Revised Illness Perception Questionnaire' (IPQ-R) was used to assess illness perceptions. Severity of skin disease was evaluated with the Patient-Oriented Eczema Measure (POEM), the Osnabrueck Hand Eczema Severity Index (OHSI), and a single, self-reported global item. The Erlangen Atopy Score (EAS) was used for atopy screening. Results: We found strong illness identity, high emotional impact, and long timeline beliefs, meaning that study participants perceive their OSD on the hands as a highly symptomatic, emotionally burdening, and chronic condition. Results suggest that hand eczema has a major impact on how participants manage their own lives, particularly during everyday life and occupational activities. Study participants predominantly identified irritant or sensitising substances and activities at work as well as skin protection regimes as causes of their disease. Conclusions: Healthcare workers should consider the illness perceptions as well as the disease burden of patients with an OSD on the hands in clinical practice. Multi-professional approaches to patient care should be sought. Illness perception in (occupational) dermatological patients should be the subject of further research.

Illness perceptions of occupational hand eczema in German patients based on the common-sense model of self-regulation: A qualitative study

BACKGROUND

Occupational skin diseases (OSD) in the form of hand eczema (HE) are a common work-related disease. Illness perceptions as presented in Leventhal's Common-Sense Model (CSM) are important for patients' self-management of diseases. Understanding these illness perceptions is essential for patient communicating. No quantitative or qualitative studies which investigated subjective illness perceptions in patients with occupational HE utilized the CSM as theoretical framework. The Objective of this study is to investigate illness perceptions of patients with occupational hand eczema (HE) using the CSM.

METHODS

We applied an exploratory qualitative approach and conducted purposive sampling. Thirty-six patients with occupational HE were interviewed using an interview guide based on the dimensions of the CSM, including coherence and emotional representation. All participants participated in a three-week inpatient program at a clinic specialized on occupational dermatology. One interview had to be excluded before analysis, since one participant's diagnosis was retrospectively changed from ICD to tinea and hence did not match the inclusion criteria. Thirty-five interviews were transcribed verbatim and analyzed. Data was analyzed deductively and inductively using qualitative text analysis. MAXQDA 2018 (Verbi, Berlin, Germany), a software for qualitative data analysis, was applied for coding and summarizing of results. All dimensions of the CSM were explored for occupational HE.

RESULTS

Several sub-categories could be identified. Participants named a variety of causes in different areas (e. g. external irritants and other hazardous factors, psycho-social factors, allergies, having a 'bad immune system' or lifestyle). The great impact of the disease on the participants' life is shown by the wide range of consequences reported, affecting all areas of life (i. e. psychological, physical, occupational, private). Considering coherence, an ambivalence between comprehensibility and non-comprehensibility of the disease is apparent.

DISCUSSION

The complexity of illness perceptions presented in this paper is relevant for those involved in HE patient education and counseling, e. g, health educators, dermatologists, and, occupational physicians. Future research might further investigate specific aspects of illness perceptions in patients with occupational HE, especially considering the complexity of coherence and overlapping dimensions (i. e. emotional representation and psychological consequences).

Patients' perspectives on quality of care for chronic hand eczema: a qualitative study

Background

Hand eczema (HE) has a significant impact on patients’ quality of life and work‐related activities. However, little is known about the patients' perspectives on quality of care for HE.

Objectives

To evaluate the patient perspective of the HE care process in a tertiary referral center.

Methods

Qualitative, semi‐structured focus groups were carried out, recorded, transcribed, and analysed using an inductive‐deductive thematic approach.

Results

Fifteen patients participated in four focus groups. Time and attention, together with being listened to and understood by the health care professional, were the most important aspects of care for HE mentioned by participants. Other aspects of care that were regarded as important were that diagnoses, causes and follow‐up of HE were not always clear to the participant; more psychosocial support was needed, and that participants experienced frequent changes in doctors. Information provided by nurses was valuable, but more individualized advice was needed.

Conclusions

To better meet the needs of patients, more explanation should be given about the causes of HE and the final diagnosis. Besides focusing on the treatment, it is also important to focus on its impact on the patient and options for psychosocial and peer support should be discussed. Furthermore, the beneficial role of the specialized nurse as part of integrated care was emphasized.

The Sociotype of Dermatological Patients: Assessing the Social Burden of Skin Disease

Skin diseases can be the cause of a significant psychosocial burden. However, tools to screen for social interaction difficulties and diminished social networks that affect the wellbeing and mental health of the individual have not been sufficiently developed. This study is based on the sociotype approach, which has recently been proposed as a new theoretical construct implemented in the form of an ad hoc questionnaire that examines the social bonding structures and relational factors. A pilot study was conducted in Alcañiz Hospital (Spain), with a study population of 159 dermatology patients. The results showed that in both subjective estimates concerning family, friends, work, and acquaintances, and in quantitative aspects, such as social contacts, duration of conversations, and moments of laughter, there were significant differences between the sample regarding diagnostic severity, dermatological diseases, and gender. The sociotype questionnaire (SOCQ) is a useful tool to screen for social difficulties in dermatological patients.

Illness perceptions of adults with eczematous skin diseases: a systematic mixed studies review

BACKGROUND

Eczematous skin diseases, e.g., atopic dermatitis or contact dermatitis, are associated with a high disease burden, a significant impact on quality of life and a higher risk for anxiety and depression. Therefore, coping strategies are of interest. In order to understand coping processes, it is necessary to examine the patients' perspectives on their illness. The aim of this systematic mixed studies review is to investigate the illness perceptions of patients with eczematous skin diseases to get a better understanding of their coping processes.

METHODS

We performed a systematic literature search in PubMed, The Cochrane Library, PsycInfo, PSYNDEX, CINAHL, Web of Science, and Scopus until February 20, 2019. Both qualitative and quantitative studies were included in the review. Two independent reviewers conducted data extraction and carried out a narrative synthesis. We assessed study quality with the Mixed Methods Appraisal Tool.

RESULTS

Three qualitative and four quantitative studies were included in the systematic review. We found different methodological approaches for investigating illness perceptions: guided interviews, focus group interviews as well as standardized questionnaires, e.g., the Brief Illness Perception Questionnaire. All studies report suspected causes of the skin disease, such as endogenous and exogenous causes (namely, psychological or occupational factors). We found long timeline beliefs as well as various perceived and experienced social, economic, and psychological consequences. Our analysis reveals complex emotional representations in patients with eczematous skin diseases, in particular impairment of emotional well-being, and feelings of shame or helplessness. Qualitative and quantitative data were predominantly complementary and convergent.

CONCLUSION

Patients with eczematous skin diseases have complex illness representations regarding their disease. These representations interrelate with the coping behavior of patients. Therefore, medical professionals should consider them for counseling and treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2018 CRD42018109217 .

Supporting self-care for eczema: protocol for two randomised controlled trials of ECO (Eczema Care Online) interventions for young people and parents/carers

INTRODUCTION

Eczema care requires management of triggers and various treatments. We developed two online behavioural interventions to support eczema care called ECO (Eczema Care Online) for young people and ECO for families. This protocol describes two randomised controlled trials (RCTs) aimed to evaluate clinical and cost-effectiveness of the two interventions. METHODS AND ANALYSIS: Design: Two independent, pragmatic, unmasked, parallel group RCTs with internal pilots and nested health economic and process evaluation studies. Setting: Participants will be recruited from general practitioner practices in England. Participants: Young people aged 13-25 years with eczema and parents and carers of children aged 0-12 years with eczema, excluding inactive or very mild eczema (five or less on Patient-Oriented Eczema Measure (POEM)). Interventions: Participants will be randomised to online intervention plus usual care or to usual eczema care alone. Outcome measures: Primary outcome is eczema severity over 24 weeks measured by POEM. Secondary outcomes include POEM 4-weekly for 52 weeks, quality of life, eczema control, itch intensity (young people only), patient enablement, health service and treatment use. Process measures include treatment adherence, barriers to adherence and intervention usage. Our sample sizes of 303 participants per trial are powered to detect a group difference of 2.5 (SD 6.5) in monthly POEM scores over 24 weeks (significance 0.05, power 0.9), allowing for 20% loss to follow-up. Cost-effectiveness analysis will be from a National Health Service and personal social service perspective. Qualitative and quantitative process evaluation will help understand the mechanisms of action and participant experiences and inform implementation.

ETHICS AND DISSEMINATION

The study has been approved by South Central Oxford A Research Ethics Committee (19/SC/0351). Recruitment is ongoing, and follow-up will be completed by mid-2022. Findings will be disseminated to participants, the public, dermatology and primary care journals, and policy makers.

TRIAL REGISTRATION NUMBER

ISRCTN79282252.

Care and treatment needs of immunosuppressive therapy patients with warts and impact on everyday life: a qualitative study

INTRODUCTION

Patients receiving immunosuppressive therapy have an increased risk of developing verrucae vulgaris (warts). They often suffer from dissemination of numerous warts, complicated by low treatment response and long-term treatment. How patients experience these challenges is not well characterized. The aim of this study was to explore how patients on immunosuppressive therapy experience everyday life with warts on the hands and feet, and their needs related to care and treatment.

METHODS

The study took a phenomenological-hermeneutic approach. Semi-structured interviews were conducted with 10 adults. Data were analyzed using the thematic analysis described by Braun and Clark.

RESULTS

Warts on the hands and feet impact everyday life and cause feelings of stigma and pain. Patients request treatment and hope to be cured although the prospects are poor. Self-treatment is experienced as a burden, because of the need for more specific information about and skills to treat the warts, and because individual patients' resources are not considered. Patients experience a lack of care continuity.

CONCLUSIONS

Patients request a person-centred care and treatment approach, to establish a relationship with health care professionals. Establishing care continuity might reduce patients' treatment-related insecurity.

Protocol for the development of a core domain set for hand eczema trials

BACKGROUND

Clinical hand eczema trials measure a variety of outcome domains to determine the success of interventions. This considerably limits the comparability and overall confidence in the study results, and thereby the strength of recommendations for clinical practice.

OBJECTIVES

The Hand Eczema Core Outcome Set (HECOS) initiative aims to develop a core outcome set (COS) for the standardized evaluation of interventions in future hand eczema trials and reviews. This COS will define the minimum that should be measured and reported in controlled and randomized-controlled trials of therapeutic hand eczema interventions. The objective of this protocol is to specify the methods to develop a core domain set.

METHODS

In Phase 1, a list of candidate domains will be derived from a systematic literature review concerning previously measured outcomes in hand eczema trials, from qualitative patient interviews and from expert interviews. In Phase 2, a consensus study about core domains will be conducted by an online 3-round Delphi survey and a face-to-face meeting, applying predefined consensus criteria. HECOS involves hand eczema and methods experts as well as patients and further stakeholders with an interest in the initiative.

OUTLOOK

When a set of core domains has been defined, HECOS is going to identify appropriate outcome measurement instruments in a development process that will be detailed in another protocol. The COS will considerably enhance the methodological quality, comparability and usefulness of hand eczema trials for clinical decision-making and the development of new therapeutic options for hand eczema, and also reduce the effort of planning, conducting, and reporting individual hand eczema studies, reviews and meta-analyses.

Development of a Conceptual Model of Chronic Hand Eczema (CHE) Based on Qualitative Interviews with Patients and Expert Dermatologists

INTRODUCTION

Chronic hand eczema (CHE) is a relapsing inflammatory dermatologic disease. Signs and symptoms can have a significant impact on patients' health-related quality of life (HRQoL). The aim of this study is to characterize the core signs, symptoms and impacts of CHE to develop a conceptual model.

METHODS

A structured literature search and qualitative interviews with 20 adult CHE patients in the US and 5 expert dermatologists were conducted to explore the patient experience of CHE signs, symptoms and impacts. Findings were used to support the development of a conceptual model.

RESULTS

There was a paucity of CHE qualitative research in the literature, supporting the need for the prospective qualitative research. The primary signs and symptoms identified from the literature review and interviews included itch, dryness, cracking, pain, thickened skin and bleeding. The most salient impacts included embarrassment and appearance concerns, frustration, impacts on work and sleep disturbance. Saturation was achieved for all signs, symptoms and impact concepts.

CONCLUSIONS

Findings from this literature review and in-depth qualitative interviews supported the development of a comprehensive conceptual model documenting the signs, symptoms and impacts relevant to CHE patients. Such a model is of considerable value given the lack of existing studies in the literature focused on the qualitative exploration of the CHE patient experience. Limitations included the patient sample being only from the US and not including some CHE subtypes.

'It's like the bad guy in a movie who just doesn't die': a qualitative exploration of young people's adaptation to eczema and implications for self-care

BACKGROUND

Eczema is a common childhood inflammatory skin condition, affecting more than one in five children. A popular perception is that children 'outgrow eczema', although epidemiological studies have shown that, for many, eczema follows a lifelong episodic course.

OBJECTIVES

To explore the perceptions of young people about the nature of their eczema and how these perceptions relate to their self-care and adapting to living with eczema.

METHODS

This is a secondary inductive thematic analysis of interviews conducted for Healthtalk.org. In total 23 interviews with young people with eczema were included. Of the 23 participants, 17 were female and six male, ranging from 17 to 25 years old.

RESULTS

Participants generally experienced eczema as an episodic long-term condition and reported a mismatch between information received about eczema and their experiences. The experience of eczema as long term and episodic had implications for self-care, challenging the process of identifying triggers of eczema flare-ups and evaluating the success of treatment regimens. Participants' experiences of eczema over time also had implications for adaptation and finding a balance between accepting eczema as long term and hoping it would go away. This linked to a gradual shift in treatment expectations from 'cure' to 'control' of eczema.

CONCLUSIONS

For young people who continue to experience eczema beyond childhood, a greater focus on self-care for a long-term condition may be helpful. Greater awareness of the impact of early messages around 'growing out of' eczema and provision of high-quality information may help patients to manage expectations and support adaptation to treatment regimens. What's already known about this topic? There is a common perception that people 'grow out of' eczema, but for many people eczema follows a lifelong episodic course. Qualitative work has shown that parents can find that being told their child will grow out of eczema is dismissive, and that they have difficulty with messages about 'control not cure' of eczema. It is unclear how young people perceive their eczema and the implications of this perception for their adaptation and self-care. What does this study add? The message that many people 'grow out of' eczema has a potentially detrimental effect for young people where the condition persists. This has implications for young people's perceptions of their eczema, their learning to self-care and how they adapt to living with eczema and eczema treatments. What are the clinical implications of this work? Clinicians need to promote awareness among young people that eczema is a long-term episodic condition in order to engage them with effective self-care. Young people transitioning to self-care need evidence-based information that is specific and relatable to them.

The psychosocial burden of hand eczema: Data from a European dermatological multicentre study

BACKGROUND

The essential physical role, visibility and social importance of the hands place a major psychological burden on patients with hand eczema.

OBJECTIVES

The aim of this study was to identify the psychological, social and clinical characteristics of patients with hand eczema, in particular the prevalences of depression, anxiety, suicidal ideation, and comorbidities.

MATERIALS AND METHODS

Data on patients with hand eczema were analysed from a large European multicentre study conducted with dermatology outpatients from 13 countries. Groups of patients and controls were compared to analyse the psychological burden of hand eczema.

RESULTS

Female patients with hand eczema had higher Hospital Anxiety and Depression Scale (HADS) scores for anxiety (n = 86, median = 7.0) than controls (n = 900, median = 5.0, P = .02), and for depression (median = 4.0) than controls (3.0, P < .001). Patients with high suicidal ideation, with low socioeconomic status and who were widowed or divorced were more likely to fulfil the HADS criteria for anxiety [odds ratio (OR) > 1, P = .038, P < .001, and P < .001, respectively]. The median Dermatology Life Quality Index score was 7.0 (n = 68).

DISCUSSION

This study identifies a specific psychological burden experienced by hand eczema patients, highlighting the need for focused psychosocial interventions. Physicians in particular should be aware of the need to identify anxiety and depression in female patients.

Experiences of stigma over the lifetime of people with xeroderma pigmentosum: A qualitative interview study in the United Kingdom

This study explored experiences of stigma in 25 adults with xeroderma pigmentosum. Analysis of semi-structured interviews revealed the changing nature of stigma over the lifetime. Bullying occurred in childhood, whereas adults were questioned about both their photoprotection and skin damage, often resulting in internalised feelings of stigma. Resilience and rejection of feelings of stigma increased with age and experiences of stigma differed across cultures. Findings indicate a need to develop social skills training to help people reject feelings of stigma. Future research should explore perspectives of families, friends and formal institutions and their potential to cause or reduce feelings of stigma.

Parents' and carers' views about emollients for childhood eczema: qualitative interview study

OBJECTIVE

Leave-on emollients form the mainstay of eczema treatment, but adherence is poor. We aimed to explore parents'/carers' views on effectiveness and acceptability of leave-on emollients for childhood eczema through secondary analysis of data from 2 qualitative data sets.

SETTING

Study 1 recruited through mail-out from 6 general practices in southern England. Study 2 recruited from a feasibility trial of an intervention to support eczema self-care in 31 practices in the same area.

PARTICIPANTS

Study 1 included 28 interviews with carers of children aged ≤5 years with eczema. Study 2 included 26 interviews with carers of children aged ≤5 years with eczema.

METHODS

Interviews followed semistructured guides: study 1 explored carers' understandings around eczema treatments in order to develop a web-based self-care support intervention; study 2 explored carers' understandings of eczema and eczema treatments after using the intervention. Interviews were carried out face to face or by telephone, audio-recorded and transcribed. Secondary analysis of data from both studies focused on views and experiences of emollient use. Data were analysed using an inductive thematic approach facilitated by NVivo V.10 software.

RESULTS

In study 1, most participants felt emollients improved eczema but held mixed views about long-term use to prevent flare-ups. In study 2, where carers had used the web-based intervention, all participants held positive views about long-term emollient use. In both studies, participants expressed a range of preferences about emollient 'thickness'; some felt that 'thick' emollients (ointments) were most effective, while others found these difficult to use. Carers described a process of 'trial and error', trying emollients suggested by professionals, friends and family, or bought over-the-counter. Carers expressed a need for understanding differences between products and their effective use.

CONCLUSIONS

Providing a rationale for long-term emollient use and choice of emollients could help improve adherence and help families gain more rapid control of eczema.

User evaluation of patient counselling, combining nurse consultation and eHealth in hand eczema

BACKGROUND AND OBJECTIVE

This study reports the findings from a user evaluation of a counselling programme for hand eczema patients in which face-to-face encounters were supplemented with user access to a new website.

PATIENTS AND METHODS

Patients treated for hand eczema in two different settings were included consecutively. Website utilization was examined by use of the transaction log. Comparisons were made between participants who used the website and those who did not. The patients' perspectives were explored by the use of interviews.

RESULTS

Among potential website users (n = 140), 88 patients (63%) had an average of 5.1 site visits. At follow-up, the website users had improved more in quality of life (p = 0.014), current burden of disease (p = 0.053), and itching (p = 0.042). The website users reported more changes in habits than did the non-website users (p = 0.024). No differences in clinical severity of hand eczema were found. The interviewees were generally satisfied with the counselling and the website. The strict log-on procedures were considered to be an obstacle to using the site. The consecutive inclusion of participants was considered to be a barrier to engagement in the dialogue forum.

CONCLUSIONS

The website users benefited from the website, although this was not substantiated by clinical measurements. The trial design partly hampered website utilization. An initial feasibility study could have been warranted.

Barriers and facilitators in the implementation of recommendations for hand eczema prevention among healthcare workers

Background

Evidence‐based recommendations are available for the prevention of hand eczema among healthcare workers. However, the implementation of these recommendations is not always successful.

Objectives

To identify barriers and facilitators in the implementation of recommendations for the prevention of hand eczema among healthcare workers alongside a randomized controlled trial.

Methods

A qualitative study was performed in which 19 healthcare workers were interviewed. The interview transcripts were open coded and also coded by means of a template by two researchers to identify relevant barriers and facilitators.

Results

Most barriers and facilitators reported for the recommendations were found at the level of the innovation (e.g. the recommendations), whereas for the guideline as a whole, multiple levels (socio‐political, organization, user, and facilities) were identified.

Conclusions

To enhance the implementation of recommendations for the prevention of hand eczema in a healthcare setting, having knowledge about these recommendations seems to be an important first step. In addition, maintaining the attention of the subject, testing the products beforehand and close collaboration with the infection control department might enhance implementation. Furthermore, it is important that the recommendations fit in with the work of the healthcare workers. When the implementation of the recommendations is prepared, these points should be taken into account.