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Research Letters |

Maternal Adherence Factors in the Treatment of Pediatric Atopic Dermatitis FREE

Sarah D. Fenerty, BS; Jenna L. O’Neill, MD; Cheryl J. Gustafson, MD; Steven R. Feldman, MD, PhD
[+] Author Affiliations

Author Affiliations: Center for Dermatology Research, Departments of Dermatology (Ms Fenerty and Drs O’Neill, Gustafson, and Feldman), Pathology (Dr Feldman), and Public Health Sciences (Dr Feldman), Wake Forest University School of Medicine, Winston-Salem, North Carolina.


JAMA Dermatol. 2013;149(2):229-231. doi:10.1001/2013.jamadermatol.253.
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Published online

Effective control of atopic dermatitis in children requires frequent use of treatment, but adherence to topical treatment in this population is abysmal.1 Caregiver involvement plays a crucial role in treatment. Mothers are frequently the primary caregivers and often control medication administration.

While much of the data on adherence to topical treatment regimens for chronic skin disease come from adult studies,2,3 adult impediments to adherence might also apply to mothers in the treatment of their children: inconvenience of use, time constraints, unclear or complex instructions, and fear of adverse effects. We sought to gain a better understanding of the poorly characterized maternal factors that affect medication use through a qualitative study to identify factors that influence mothers' medication administration in the management of pediatric atopic disease.

Data for this study were collected as part of a larger investigation examining mothers' willingness to participate in research studies. Data were initially collected from 20 mothers of children 5 years or younger in 5 counties across North Carolina through a site-based recruitment strategy with the goal of obtaining a representative, nonrandom sample that included a range of racial, ethnic, and income groups. We analyzed data from 12 participants whose children had a diagnosis of atopic dermatitis, asthma, or both. In-depth, semistructured interviews lasting approximately 1 to 2 hours were conducted, and subjects were asked open-ended questions regarding the effects of the atopic condition and attitudes towards treatment.

The transcribed interviews then underwent content analysis by at least 2 members of the research team assigning content using the qualitative software package ATLAS.ti, version 5.5.4 A coding dictionary was developed based on review of transcribed interviews. Coded categories relevant to adherence included (1) alternative treatments; (2) effect of disease on children; (3) effect of disease on mothers; (4) the physician-patient relationship; (5) physician's attitudes; (6) ideal treatments; (7) prescriptions; (8) reminders; and (9) treatment effect. The Wake Forest University Health Sciences institutional review board approved the study protocol.

We identified 5 thematic domains affecting treatment adherence: (1) convenience of medication use; (2) effect of disease and medication use on the lives of patients and caregivers; (3) caregiver education; (4) parent-physician relationship; and (5) alternative treatments (Table 1). Ease of use was commonly mentioned as an important consideration (Table 2) and was determined by the number of doses required per day, route of administration, ability of the child to self-administer, and willingness of the child to participate in uncomfortable treatments. The importance of convenience was emphasized by participants' perceptions of the ideal treatment: simple administration, infrequent dosing, and rapid results.

Table Graphic Jump LocationTable 1. Maternal Comments on Thematic Domains Affecting Treatment Adherence
Table Graphic Jump LocationTable 2. Salient Maternal Comments Concerning Ease of Use

Four mothers expressed open concern about potential adverse effects of steroids and believed that steroids might pose a greater risk than the disease. Most denied that difficulty remembering to give medications was a factor in adherence, but tying administration to routine daily activities was identified as a key to routine administration. Understanding the disease and its management eased parental anxiety and reinforced the necessity of treatment.

Parent-physician interactions were critical in shaping mothers' attitudes toward treatment; factors that contributed to a favorable experience were physician communication skills, length of time physicians spent with patients, and expediency of scheduling appointments and receiving treatment. When mothers perceived that physicians did not consider parental input in designing treatment plans, there was decreased motivation for adherence. Follow-up improved willingness to continue seeking treatment.

Most of the mothers denied seeking or accepting treatment recommendations from family, friends, and nonmedical sources, although many reported receiving unsolicited advice from family members and friends.

Making the diagnosis of atopic dermatitis and prescribing appropriate topical treatments are necessary but not sufficient for effective management of the disease. In addition, addressing the poor adherence that is common in this condition is critical. Because caregivers tend to be intimately involved in the treatment, the treatment plan should address caregivers' concerns. Prescribing once-a-day treatments, providing adequate instructions (concerning the disease, its treatment, and why the treatment is needed5), and tying the treatment to an existing element of the family routine (such as bathing or brushing teeth) may be helpful.

While topical corticosteroids are the first-line treatment for atopic dermatitis, apprehension regarding adverse effects of steroid use is common.3 Projecting a caring attitude, engendering trust, and building a strong caregiver-physician relationship may help overcome fear of adverse effects and promote better adherence. Close follow-up, at least until initial control of the disease is achieved, may further enhance adherence and outcomes.6

Correspondence: Dr Feldman, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 (sfeldman@wfubmc.edu).

Accepted for Publication: August 2, 2012.

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Feldman. Acquisition of data: O’Neill and Feldman. Analysis and interpretation of data: Fenerty, Gustafson, and Feldman. Drafting of the manuscript: Fenerty and O’Neill. Critical revision of the manuscript for important intellectual content: Fenerty, Gustafson, and Feldman. Administrative, technical, and material support: Feldman. Study supervision: Feldman.

Conflict of Interest Disclosures: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, LP. Dr Feldman has received research, speaking, and/or consulting support from Galderma, Abbott Labs, Warner Chilcott, Leo, Amgen, Astellas, Centocor, National Biological Corporation, and Stiefel/GSK; he also Feldman owns stock in the patient satisfaction website www.DrScore.com.

Funding/Support: This study was supported in part by National Institutes of Health grant R21 AI 70687.

Role of the Sponsors: The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; or in the preparation, review, or approval of the manuscript.

Additional Contributions: Chaya R. Spears, MA, and Thomas A. Arcury, PhD, assisted with this article.

Krejci-Manwaring J, Tusa MG, Carroll C,  et al.  Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis.  J Am Acad Dermatol. 2007;56(2):211-216
PubMed   |  Link to Article
Feldman SR, Horn EJ, Balkrishnan R,  et al; International Psoriasis Council.  Psoriasis: improving adherence to topical therapy.  J Am Acad Dermatol. 2008;59(6):1009-1016
PubMed   |  Link to Article
Brown KK, Rehmus WE, Kimball AB. Determining the relative importance of patient motivations for nonadherence to topical corticosteroid therapy in psoriasis.  J Am Acad Dermatol. 2006;55(4):607-613
PubMed   |  Link to Article
van Scheppingen C, Lettinga AT, Duipmans JC, Maathuis CGB, Jonkman MF. Main problems experienced by children with epidermolysis bullosa: a qualitative study with semi-structured interviews.  Acta Derm Venereol. 2008;88(2):143-150
PubMed   |  Link to Article
Robinson JK, Turrisi R, Mallett KA,  et al.  Efficacy of an educational intervention with kidney transplant recipients to promote skin self-examination for squamous cell carcinoma detection.  Arch Dermatol. 2011;147(6):689-695
PubMed   |  Link to Article
Sagransky MJ, Yentzer BA, Williams LL, Clark AR, Taylor SL, Feldman SR. A randomized controlled pilot study of the effects of an extra office visit on adherence and outcomes in atopic dermatitis.  Arch Dermatol. 2010;146(12):1428-1430.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Maternal Comments on Thematic Domains Affecting Treatment Adherence
Table Graphic Jump LocationTable 2. Salient Maternal Comments Concerning Ease of Use

References

Krejci-Manwaring J, Tusa MG, Carroll C,  et al.  Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis.  J Am Acad Dermatol. 2007;56(2):211-216
PubMed   |  Link to Article
Feldman SR, Horn EJ, Balkrishnan R,  et al; International Psoriasis Council.  Psoriasis: improving adherence to topical therapy.  J Am Acad Dermatol. 2008;59(6):1009-1016
PubMed   |  Link to Article
Brown KK, Rehmus WE, Kimball AB. Determining the relative importance of patient motivations for nonadherence to topical corticosteroid therapy in psoriasis.  J Am Acad Dermatol. 2006;55(4):607-613
PubMed   |  Link to Article
van Scheppingen C, Lettinga AT, Duipmans JC, Maathuis CGB, Jonkman MF. Main problems experienced by children with epidermolysis bullosa: a qualitative study with semi-structured interviews.  Acta Derm Venereol. 2008;88(2):143-150
PubMed   |  Link to Article
Robinson JK, Turrisi R, Mallett KA,  et al.  Efficacy of an educational intervention with kidney transplant recipients to promote skin self-examination for squamous cell carcinoma detection.  Arch Dermatol. 2011;147(6):689-695
PubMed   |  Link to Article
Sagransky MJ, Yentzer BA, Williams LL, Clark AR, Taylor SL, Feldman SR. A randomized controlled pilot study of the effects of an extra office visit on adherence and outcomes in atopic dermatitis.  Arch Dermatol. 2010;146(12):1428-1430.
PubMed   |  Link to Article

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