Views of oral antibiotics and advice seeking about acne: a qualitative study of online discussion forums

Current Utilization of Qualitative Methodologies in Dermatology: A Scoping Review

The focus of this review was to determine how qualitative methods are used in dermatology research and whether published manuscripts meet current standards for qualitative research. A scoping review of manuscripts published in English between January 1, 2016 and September 22, 2021 was conducted. A coding document was developed to collect information on authors, methodology, participants, research theme, and the presence of quality criteria as outlined by the Standards for Reporting Qualitative Research. Manuscripts were included if they described original qualitative research about dermatologic conditions or topics of primary interest to dermatology. An adjacency search yielded 372 manuscripts, and after screening, 134 met the inclusion criteria. Most studies utilized interviews or focus groups, and researchers predominantly selected participants on the basis of disease status, including over 30 common and rare dermatologic conditions. Research themes frequently included patient experience of disease, development of patient-reported outcomes, and descriptions of provider and caregiver experiences. Although most authors explained their analysis and sampling strategy and included empirical data, few referenced qualitative data reporting standards. Missed opportunities for qualitative methods in dermatology include examination of health disparities, exploration of surgical and cosmetic dermatology experiences, and determination of the lived experience of and provider attitudes toward diverse patient populations.

Eczema Care Online: development and qualitative optimisation of an online behavioural intervention to support self-management in young people with eczema

OBJECTIVES

To describe the development of Eczema Care Online (ECO), an online behaviour change intervention for young people with eczema (phase I); and explore and optimise the acceptability of ECO among this target group using think-aloud interviews (phase II).

METHODS

Theory-based, evidence-based and person-based approaches to intervention development were used. In phase I, a qualitative systematic review and qualitative interviews developed an in-depth understanding of the needs and challenges of young people with eczema. Guiding principles highlighted key intervention design objectives and features to address the needs of this target group to maximise user engagement. Behavioural analysis and logic modelling developed ECO's hypothesised programme theory. In phase II, qualitative think-aloud interviews were carried out with 28 young people with eczema and the intervention was optimised based on their feedback.

RESULTS

The final intervention aimed to reduce eczema severity by supporting treatment use (emollients, topical corticosteroids/topical calcineurin inhibitors), management of irritants/triggers, emotional management and reducing scratching. Generally, young people expressed positive views of intervention content and design in think-aloud interviews. Quotes and stories from other young people with eczema and ECO's focus on living with eczema (not just topical treatments) were valuable for normalising eczema. Young people believed ECO addressed knowledge gaps they had from childhood and the safety information about topical corticosteroids was reassuring. Negative feedback was used to modify ECO.

CONCLUSIONS

A prototype of the ECO intervention was developed using rigorous and complementary intervention development approaches. Subsequent think-aloud interviews helped optimise the intervention, demonstrated ECO is likely to be acceptable to this target group, and provided support for our guiding principles including key design objectives and features to consider when developing interventions for this population. A randomised controlled trial and process evaluation of the intervention is underway to assess effectiveness and explore user engagement with the intervention's behavioural goals.

Supporting Self-management Among Young People With Acne Vulgaris Through a Web-Based Behavioral Intervention: Development and Feasibility Randomized Controlled Trial

BACKGROUND

Acne is a common skin condition that is most prevalent in young people. It can have a substantial impact on the quality of life, which can be minimized with the appropriate use of topical treatments. Nonadherence to topical treatments for acne is common and often leads to treatment failure.

OBJECTIVE

The aim of this study is to develop a web-based behavioral intervention to support the self-management of acne and to assess the feasibility of recruitment, retention, and engagement of users with the intervention.

METHODS

The intervention was developed iteratively using the LifeGuide software and following the person-based approach for intervention development. The target behavior was appropriate use of topical treatments. Barriers and facilitators identified from the qualitative research and evidence from the wider literature were used to identify techniques to improve and promote their use. Young people with acne aged 14-25 years who had received treatment for acne in the past 6 months were invited to participate through mail-out from primary care practices in the South of England in a parallel, unblinded randomized trial. Participants were automatically randomized using a computer-generated algorithm to usual care or to usual care plus access to the web-based intervention. Usage data was collected, and a series of questionnaires, including the primary outcome measure for skin-specific quality of life (Skindex-16), were collected at baseline and at the 4- and 6-week follow-ups.

RESULTS

A total of 1193 participants were invited, and 53 young people with acne were randomized to usual care (27/53, 51%) or usual care plus intervention (26/53, 49%). The response rate for the primary outcome measure (Skindex-16) was 87% at 4 weeks, 6 weeks, and at both time points. The estimate of mean scores between groups (with 95% CI) using linear regression showed a trend in the direction of benefit for the web-based intervention group in the primary outcome measure (Skindex-16) and secondary measures (Patient Health Questionnaire-4 and the Problematic Experiences of Therapy Scale). Intervention usage data showed high uptake of the core module in the usual care plus web-based intervention group, with 88% (23/26) of participants completing the module. Uptake of the optional modules was low, with less than half visiting each (myth-busting quiz: 27%; living with spots or acne: 42%; oral antibiotics: 19%; what are spots or acne: 27%; other treatments: 27%; talking to your general practitioner: 12%).

CONCLUSIONS

This study demonstrated the feasibility of delivering a trial of a web-based intervention to support self-management in young people with acne. Additional work is needed before a full definitive trial, including enhancing engagement with the intervention, recruitment, and follow-up rates.

TRIAL REGISTRATION

ISRCTN 78626638; https://tinyurl.com/n4wackrw.

Views and experiences of people with acne vulgaris and healthcare professionals about treatments: systematic review and thematic synthesis of qualitative research

OBJECTIVES

The objective of this study was to systematically review and synthesise qualitative papers exploring views and experiences of acne and its treatments among people with acne, their carers and healthcare professionals (HCPs).

DESIGN

Systematic review and synthesis of qualitative papers.

METHODS

Papers were identified through Medline, EMBASE, PubMed, PsychINFO and CINAHL on 05 November 2019, forward and backward citation searching, Google Scholar and contacting authors. Inclusion criteria were studies reporting qualitative data and analysis, studies carried out among people with acne, their carers or HCPs and studies comprising different skin conditions, including acne. The title and abstracts of papers were independently screened by three researchers. Appraisal was carried out using the adapted Critical Appraisal Skills Programme tool. Thematic synthesis was used to synthesise findings.

RESULTS

A total of 20 papers were included from six countries. Papers explored; experiences living with acne, psychosocial impact of acne, views on causation of acne, perceptions of acne treatments, ambivalence and ambiguity in young people's experience of acne and HCPs' attitudes towards acne management. Findings suggest that people often viewed acne as short-term and that this had implications for acne management, particularly long-term treatment adherence. People often felt that the substantial impact of acne was not recognised by others, or that their condition was 'trivialised' by HCPs. The sense of a lack of control over acne and control over treatment was linked to both psychological impact and treatment adherence. Concerns and uncertainty over acne treatments were influenced by variable advice and information from others.

CONCLUSIONS

People need support with understanding the long-term management of acne, building control over acne and its treatments, acknowledging the impact and appropriate information to reduce the barriers to effective treatment use.

PROSPERO REGISTRATION NUMBER

CRD42016050525.

Understanding farmers' naturalistic decision making around prophylactic antibiotic use in lambs using a grounded theory and natural language processing approach

The routine use of antibiotics for prevention of disease in neonatal lambs has been highlighted as inappropriate, yet research suggests that many farmers in the UK still carry out this practice. The aim of the study was to understand farmers' naturalistic decision-making around prophylactic antibiotic use in lambs. Data from 431 posts by 133 different users of an online discussion forum were analysed quantitatively using natural language processing and qualitatively using a grounded theory approach. Results from the qualitative analysis identified five categories that influenced farmers risk perceptions around prophylactic antibiotic use in lambs: anticipated regret, negative emotions and experiential avoidance; economic considerations; farmer identity; perception of capability; and perception of social judgement. Natural language processing analysis of the posts by the study group were compared to posts on topics unrelated to antibiotic use by control groups from the same forum to understand the underlying style and tone within the text. Analytical thinking and authenticity scores were significantly lower in the study group compared to the control groups (P < 0.01). Words relating to cognitive processes were significantly higher in the study group compared to the control groups (P < 0.01). Results of the qualitative and quantitative analysis were integrated to assess the fit of the data and enhance findings from either method alone. The key findings were the identification of reasons why farmers used antibiotics prophylactically in neonatal lambs. Farmers disassociated the use of oral antibiotics in neonatal lambs from other types of antibiotics within sheep farming. Farmers used the concept of luck and uniqueness to justify their prophylactic antibiotic use. This may explain farmers' low analytical thinking scores as this reflects a more personal style of thinking as farmers express their thoughts on antibiotic use on an individual basis. Farmers' felt that they did not have the capabilities to control neonatal disease without antibiotics during busy periods and this was exacerbated by external economic constraints. For farmers' who used antibiotics for therapeutic use, fear of social judgement was an important factor in their perceptions of risk around antibiotic use. The high frequency of negations and conjunctions suggested feelings of moral duty. As such, antibiotic use has developed into a symbol of their good farming identity which conflicted with the identity held by those who used antibiotics prophylactically. These results can be used to inform knowledge exchange around prophylactic antibiotic use in lambs to improve antibiotic stewardship in the sheep farming sector.

Young people's perceptions of acne and acne treatments: secondary analysis of qualitative interview data

Background

Acne vulgaris is a common skin condition affecting approximately 95% of adolescents to some extent. First‐line treatments are topical preparations but nonadherence is common. A substantial proportion of patients take long courses of oral antibiotics, associated with antibiotic resistance.

Objectives

This study aimed to explore young people's views and experiences of acne and its treatments.

Methods

We report a secondary thematic analysis of interview data collected by researchers in the Health Experiences Research Group (HERG), University of Oxford. A total of 25 transcripts from young people aged 13–24 years with acne were included.

Results

Acne is often perceived as a short‐term self‐limiting condition of adolescence and this appears to have implications for seeking treatment or advice. Participants widely perceived topical treatments as being ineffective, which seemed related to unrealistic expectations around speed of onset of action. Many participants felt they had tried all available topical treatments, although were unsure what was in them or unaware of differences between cosmetic and pharmaceutical treatments. They had concerns around how to use topicals ‘properly’ and how to avoid side‐effects. They were also concerned about the side‐effects or necessity of oral treatments, although few seemed aware of antibiotic resistance.

Conclusions

People with acne need support to manage their condition effectively, particularly a better understanding of different topicals, how to use them and how to avoid side‐effects. Unrealistic expectations about the onset of action of treatments appears to be a common cause of frustration and nonadherence. Directing people towards accessible evidence‐based information is crucial.

What's already known about this topic?

There is a common perception that acne is a short‐term condition that will resolve without treatment.

Previous research has shown that nonadherence to topical treatments is common and that oral antibiotics are the most commonly prescribed treatment for acne in the U.K.

Further research is needed to understand how young people perceive acne treatments and the implications of this for treatment adherence and self‐management.

What does this study add?

People often said they had tried all available topical preparations for acne, but seemed confused between cosmetic and pharmaceutical treatments.

People seemed unsure how to use topical treatments ‘properly’ or how to avoid side‐effects. This was rarely discussed with health professionals.

People's perception of acne as a short‐term condition appeared to influence their expectations around onset of action of treatment and their views about its effectiveness and necessity.

What are the clinical implications of the work?

The perception of acne as a short‐term condition has implications for self‐management and motivation to seek and adhere to treatments.

Providing advice about onset of action of treatments and how to prevent side‐effects is crucial, including directing people towards accessible, written, evidence‐based information.

People's confusion about the different topical treatments available may be alleviated by such information, or by encouraging photos or other recordings of treatments tried and for how long.

Linked Comment: Prior. Br J Dermatol 2020; 183:208–209.

Linked Comment: Prior. Br J Dermatol 2020; 183:208–209.

Plain language summary available online

Public understanding and use of antibiotics in England: findings from a household survey in 2017

OBJECTIVES

To describe public understanding and use of antibiotics.

DESIGN

Ipsos MORI Capibus survey of randomly-selected households.

SETTING

England, January-April 2017.

PARTICIPANTS

2283 adults (≥15 years) including 777 parents of children <5 years old.

DATA COLLECTION AND ANALYSIS

The main survey was undertaken in January 2017 (n=1691); data from an additional sample of parents were collected in April 2017 (n=592). Analyses were weighted to obtain estimates representative of the population.

MAIN OUTCOME MEASURES

Responses to questions about antibiotics (awareness and perceptions), recent illness (expectations and experience), delayed and leftover antibiotics, and child illness stratified by demographic and socioeconomic characteristics.

RESULTS

Most respondents (83% (1404/1691)) recognised that antibiotics kill bacteria/treat bacterial infections, but a sizeable minority (35% (592/1691)) thought that antibiotics kill viruses/treat viral infections. Overall levels of understanding have not changed substantially since similar surveys in 2003 and 2008/2009. One sixth of respondents who were prescribed antibiotics reported having leftovers (14% (64/498)) and 33% (22/64) kept these for possible future use. 1.3% of all respondents (23/1691) reported taking left-over antibiotics in the past year and 1.6% (26/1691) reported taking antibiotics obtained without a prescription. Higher social grade and educational qualifications were strongly positively associated with antibiotic knowledge; youngest (15-24 years), oldest (65 +years) and black, Asian and minority ethnic adults were less knowledgeable. Among 1319 respondents who had an infection or antibiotics within the past year, 43% (568/1319) said that they had not received any advice or information about antibiotics.

CONCLUSIONS

Despite many campaigns, public understanding of antibiotics in England continues to combine correct basic knowledge held by most people with less prevalent but persistent and potentially harmful misunderstandings. These could be addressed through active provision of advice and information during primary and secondary care consultations and more effective public health interventions.

Update in the management of acne in adolescence

PURPOSE OF REVIEW

This review will update the pediatric provider on recent data on the pathogenesis and treatment of acne in adolescent patients. A special focus was made to summarize recent guidelines and fill in several identified practice gaps.

RECENT FINDINGS

Our understanding of the pathogenesis of acne is greatly expanding and data is emerging to tie diet, particularly the role of IGF-1 with inflammation in acne. Additionally, stronger recommendations to limit antibiotic usage in acne are being made worldwide. Although retinoids are considered the base of most effective acne treatment strategies, data suggests that all providers need to emphasize their importance in maintenance of acne.

SUMMARY

An effective acne management strategy targets multiple pathogenic factors in acne, using a retinoid as the foundation. Systemic antibiotics for moderate-to-severe acne should be used for acute management, then discontinued at 3-4 months, while maintaining on topical treatments. If therapy is ineffective, alternate treatments, such as combined oral contraceptives in females or isotretinoin, should be promptly employed to prevent prolonged psychological impact and cutaneous scarring.

'Disease, illness, affliction? Don't know': Ambivalence and ambiguity in the narratives of young people about having acne

The popular characterisation of acne as a mundane and insignificant feature of adolescence sits at odds with academic studies showing the detrimental impacts of the condition on people of various ages. Drawing from in-depth qualitative interviews with 13- to 25-year olds living in England, this article will consider some of the tensions between two messages about acne through the ambiguities in young people's narratives. Consistent with existing literature on skin conditions and visual differences more broadly, participants in the study recounted ways in which acne negatively shaped their lives socially and emotionally. However, there were topics around which participants' accounts held nuances and complications, in relation to: understandings held about acne causes; uncertainty as to whether acne was a medical concern/problem; and comparisons to other people's acne or broader health experiences. In attending to these aspects, this article will explore how different and potentially conflicting meanings are negotiated by young people, producing ambiguous and ambivalent experiential accounts about living with acne.