Abstract of the dissertation entitled A parental education program for the management of atopic dermatitis in children Submitted by Kong Wing Yin For the Degree of Master of Nursing at The University of Hong Kong in August 2015 In the pediatric ward of a major public hospital in Hong Kong, around 5% of patients admitted were due to eczema. Among them, 30% had poor disease control with repeated admissions. Some studies showed that nurse-led parental education in eczema can lead to better disease management, but it has not been considered in the local setting. Despite a systematic review was conducted, there has been subsequently new evidence that urges for an updated evaluation. Therefore, this dissertation aims to systematically review the up-to-date evidence on the effectiveness of parental education program in reducing the severity of eczema, develop an evidence-based guideline for the program, assess the implementation potential, and plan for a pilot and an evaluation of the program. A systematic search of British Nursing Index, PubMed, CINHAL and PsyInfo
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Abstract of the dissertation entitled
A parental education program for the management
of atopic dermatitis in children
Submitted by
Kong Wing Yin
For the Degree of Master of Nursing
at The University of Hong Kong
in August 2015
In the pediatric ward of a major public hospital in Hong Kong, around 5% of
patients admitted were due to eczema. Among them, 30% had poor disease control
with repeated admissions. Some studies showed that nurse-led parental education in
eczema can lead to better disease management, but it has not been considered in the
local setting. Despite a systematic review was conducted, there has been subsequently
new evidence that urges for an updated evaluation. Therefore, this dissertation aims to
systematically review the up-to-date evidence on the effectiveness of parental
education program in reducing the severity of eczema, develop an evidence-based
guideline for the program, assess the implementation potential, and plan for a pilot
and an evaluation of the program.
A systematic search of British Nursing Index, PubMed, CINHAL and PsyInfo
identified 5 randomized controlled trials (RCTs) that assessed the effectiveness of
parental program in reducing severity of eczema in children. Using the Scottish
Intercollegiate Guidelines Network (SIGN) checklist, three of them had high
methodological quality, and two had acceptable quality. Four studies reported
parental education reduced severity of eczema. Thus, it was considered as sufficient
evidence that supported the implementation of parental education program in
reducing severity of eczema. An evidence-based guideline for parental education was
then developed. The local setting shared similar characteristics with the selected
studies in terms of the eligible participants and settings. It also had the staff
supportive to the change with available resources. Moreover, there would be an
annual cost saving of around HK$650,000. Hence, the proposed education program is
feasible and transferable to the local setting.
Training of staff will be made in one month before embarking on a 3-month pilot
study on ten eczematous patients. Then, a 5-month evaluation study on eczematous
patients would be commenced. The primary outcome is the severity of eczema, while
the secondary outcomes are patient’s satisfaction, frontline staff workload and morale,
admission rate and attendance rate at specialty outpatient clinic, and the cost of
innovation. Finally, the primary and secondary outcomes would be evaluated in order
to identify the effectiveness of the program.
A parental education program for the management
of atopic dermatitis in children
by
Kong Wing Yin
B.Nurs. H.K.U.
A dissertation submitted in partial fulfillment of the requirements for
the Degree of Master of Nursing
at The University of Hong Kong
August 2015
i
Declaration
I declare that this dissertation thereof represents my own work, except where due
acknowledge is made, and that it had not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a
degree, diploma or other qualifications.
Signed ______________________________________
Kong Wing Yin
ii
Acknowledgements
I would like to express my sincere gratitude to my supervisor, Dr. Daniel Yee-Tak
Fong, Associate Professor, for his generous guidance, enlightenment and patience in
directing me to the right track throughout the dissertation process.
I would also like to thank the staff of the School of Nursing for their assistance and
teaching in my master study.
Finally, I must express my immense gratitude and appreciation to my dear family,
classmates, friends and colleagues for their love, support and encouragement
throughout my study.
iii
Table of Contents
Declaration ................................................................................................................................ i
Acknowledgements .................................................................................................................. ii
Table of Contents .................................................................................................................... iii
List of Appendices....................................................................................................................iv
2.1.1 Identification of Study ........................................................................................................................... 9
2.1.2 Criteria for selecting studies for review ..................................................................................... 10
2.1.3 Data Extraction ..................................................................................................................................... 11
2.2.2 Characteristics of the Studies .......................................................................................................... 13
2.2.2.1 Study Types .......................................................................................................................................... 13
2.3.2 Synthesis of data ................................................................................................................................... 21
Chapter 3. Translation and Application .............................................................................. 25
3.2.1 Comparison of Setting and Audience ........................................................................................... 25
3.2.2 Philosophy of Care ............................................................................................................................... 27
3.2.3Number of clients benefit from the Innovation ........................................................................ 27
3.2.4 Time for Implementation and Evaluation ................................................................................. 27
3.3 Feasibility 28
3.3.1 Freedom on implementation ........................................................................................................... 28
3.3.2 Interference of Staff Functions ....................................................................................................... 29
3.3.3 Administrative Support ..................................................................................................................... 30
3.3.4 Consensus among the Staff and Administrators ..................................................................... 31
3.3.5 Risk of Friction ....................................................................................................................................... 32
3.3.6 Skills of Adopting the Innovation .................................................................................................. 32
3.3.7 Equipment and Facilities .................................................................................................................. 33
3.3.8 Staff Training ......................................................................................................................................... 33
3.3.9 Measuring tool for evaluation ........................................................................................................ 33
4.2.4 Data Collection ...................................................................................................................................... 45
4.2.5 Data Evaluation .................................................................................................................................... 45
4.3 Evaluation Plan 46
4.3.1 Objectives of Evaluation Plan ......................................................................................................... 46
4.3.2.3 System Outcomes .............................................................................................................................. 48
4.3.3 Nature and Number of Clients to be involved .......................................................................... 49
4.3.4 Timing and Frequency of Data Collection ................................................................................. 50
4.3.5 Data Analysis .......................................................................................................................................... 51
4.3.6 Basis for Recommendation of Nurse-‐led Education Program to Eczematous
Williams, Hywel C. "Atopic dermatitis." New England Journal of Medicine352.22
(2005): 2314-2324.
57
Appendices
Appendix 1a: Systemic Search Strategies & Results
British Nursing
Index
CIHNAL PubMed PsyInfo
Search Data 15/8/2014 15/8/2014 15/8/2014 15/8/2014
“educational or educating or education”
and “atopic dermatitis or eczema” and
“Child or childhood or children or
pediatric or pediatric”.
37 26 651 32
Search by titles 3 0 71 4
Search by abstract 1 0 17 0
Manually Remove duplicated & final
number selected
5
58
Appendix 1b: PRIMSA Flowchart
59
Appendix 2: Table of Evidence
Bibliographic citation/Study design
Patient characteristics Intervention(s) Comparison Length of follow up
Outcome measures Effect Size (Intervention vs control)
M.Futamua et al. 2013 / RCT
59 children age 6months -‐ 6years with moderate to severe AD and their mothers 19 Male (IG) 22 Male (CG) 10Female(IG) 8 Female (CG) Mean age: 2.2 years (IG) 2.6 years (CG) (Range:0.5 – 5.7) Mean total eczema score 40.2(IG) 42.0 (CG)
2-‐day parental education program (PEP) comprising 3 lectures (1PA +2NP)+ practical sessions + a group discussion Continued conventional treatment for 6 months (n=29)
Booklet + conventional treatment (n=30)
3 months 6 months
Primary outcome: (1) Evaluation of severity of eczema
using SCORAD at 6 months (Range: 0 – 103)
(2) 1. Change in symptoms scores
(Range 0-‐10)
2. Amount (Grams) of corticosteroid used
3. Parental QoL by DFI questionnaires (range 0 – 30)
4. Change in parental anxiety regarding the use of corticosteroids in children (Score1=No Anxiety -‐ score 5=Very anxious)
(1) -‐10 (p=0.012)
(2)
1. -‐1.3 (p=0.056) 2. No significant
difference 3. -‐2.1 (p=0.111) 4. 3months:
p=0.02 6months:p=0.02
60
M. Griollo, et al, 2006/ Longitudinal RCT
61 pediatric patients (0 -‐16 years) diagnosed with Atopic eczema from the metropolitan area of Adelaide (1) 35 boys & 26 girls (2) Mean age= 4.3 years (Range: 4months to 13 years) (3) Mean SCORAD= 50.97 (IG) 47.7 (CG) (4) Baseline mean DFI= 11.09 (IG) 10.86 (CG) (5) Mean CDLQI= 8.1 (IG) 9.69 (CG) (6) Mean IDQOL= 11 (IG) 8.63 (CG)
2-‐hour education workshop -‐Basic Information of eczema -‐Practical session -‐Sharing session Normal management regimen (n=32)
Routine education medical consultation and management (n=29)
(3) Wk 4: No sig difference Wk 12: -‐3.74 (p=0.004)
(4) No significant difference
61
E. Moore et al.,2009/ RCT ++
182 patients new referral for the management of eczema at Royal children’s Hospital in Melbourne (1) 30 boys (IG) 24 boys (CG) 19 girls (IG) 26 girls (CG) (2) Mean age= 3.3 years 2.8 years (IG) 3.75 years (CG) (Range: 0-‐16) (3) Baseline mean SCORAD= 38 (IG) 42 (CG)
Nurse-‐led eczema workshop (n=80) -‐Referral to dermatologist -‐Eczema booklets + cards -‐ Practical session on application -‐Written management plan
Dermatologist-‐led clinic (n=85) -‐Prescription -‐Eczema booklets +cards -‐Educational video Management plan
4 week Follow-‐up
Primary outcome: (1) Severity of eczema as
determined by scores of SCORAD (Range: 0 – 103)
(1) -‐9.93 (P<0.001)
Kupfer et al., 2010 /RCT
185 aged 8 -‐12 years and their parents
6 weekly 2 hours group session (n=102)
Control group Same education program received at 1 year follow up (n=83)
1 year follow-‐up
(1) Differences between training group and control group in coping behavior of children (COPEKI) and parental disease management (FEN)
(2) Changes in training group and control group concerning the psychological variables not due to changes in somatic severity
204( 5 months -‐12 years) suffered from moderate to severe AD (SCORAD > 20 points)at least 4 months
(1) Mean age: 2.7(IG) 3.4 years(CG)
(2) SCORAD index=44(IG) 42(CG)
(3) Duration of disease 2.1(IG) 2.4(CG)
Intervention group parental training 6 group session of 2hour each -‐Presentation of information -‐Experience sharing -‐Practical session (n=93)
Control Group no training (n=111)
1 year follow-‐up
(1) Severity of eczema (SCORAD) (Range 0 – 103)
(2) Treatments costs
(3) QoL (4) Coping strategies
(1) -‐4 (p=0.43)
(2) 92 vs 54 -‐38 (p=0.043)
(3) p=0.016 alpha level set as 0.01 after correction for the number of scales
(4) p=0.013 alpha level set as 0.01 after correction for the number of scales
63
D. Stabb et al., 2006 / Multi-‐centered, RCT
Parents of children with AD 3months-‐18years (1) 3months – 7 years
143Male (IG) 127 Male (CG) 131Female (IG) 117 Female (CG) 8-‐12 years 41 Male (IG) 40 Male (CG) 61 Female(IG)43Female (CG) 13-‐18 years 29 Male (IG)18 Male (CG) 41Female (IG) 32Female (CG) (2 ) Mean age: 3months – 7 years 2.4 (IG) 2.4(CG) 8-‐12 years 9.5(IG) 9.5(CG) 13-‐18 years 14.9(IG) 14.8(CG) (3)Total severity score
Group session of standardized intervention program for AD once weekly for 6 weeks 2hrs each 3months – 7 years receive education+ sessions based ib previously reported work 8-‐12 years separate educational session 13-‐18 years educational sessions tailored to their needs Personal experience sharing Practical session (n=496)
no education (n= 496)
12 months (1) Severity of eczema: By scoring of atopic dermatitis scale (SCORAD) (0-‐103)
(2) Subjective severity: QoL for parents of affected children< 13 years old (Range :0-‐20)
(3) QoL 5 subscales: 1. Psychosomatic wellbeing 2. Effects on social life 3. Confidence in medical
treatment 4. Emotional coping 5. Acceptance of disease
Appendix 3: Quality Assessment of Selected Studies
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
M Futamura et al. (2013) Effects of a Short-Term Parental Education Program on Childhood Atopic
Dermatitis: A Randomized Controlled Trial, Pediatric Dermatology Vol. 30 no.438-443
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question
Yes R
Can’t say £
No £
1.2 The assignment of subjects to treatment groups is randomised. -Use of computer-generated randomisation list with a block size of eight.
Yes R
Can’t say £
No £
1.3 An adequate concealment method is used.
-Adequate concealment method is used by each patient is picking up a
paper from a total of eight pieces of paper, half of which were labeled
parental education program and half control in a sealed box
Yes R
Can’t say £
No £
1.4 Subjects and investigators are kept ‘blind’ about treatment
allocation. Analyses performed before un-blinding of treatment
allocation
-uses digital photographs as they could conceal group allocation and time
of assessment from the objective scorer.
Yes R
Can’t say £
No £
1.5 The treatment and control groups are similar at the start of the trial.
-Well match and shown in table 2 but no p-value was shown.
Yes R
Can’t say □
No £
1.6 The only difference between groups is the treatment under
investigation.
Yes R
Can’t say £
No £
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes R
Can’t say £
No £
66
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
1 in IG lost follow up 2 in CG lost to follow up
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes £
Can’t say £
No £
Does not apply
R
1.10 Where the study is carried out at more than one site, results are
comparable for all sites
Yes £
Can’t say £
No £
Does not apply
R
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows.
High quality (++)R
Acceptable (+)£
Unacceptable – reject 0 £
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Yes
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
67
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
Grillo,2006, Pediatric atopic eczema : The impact of an Educational Intervention Pediatric Dermatology,
2006, Vol.23(5), pp.428-436
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes R
Can’t say £
No £
1.2 The assignment of subjects to treatment groups is randomised. -A random number generator was used to place the participants into either the intervention group or control group.
Yes R
Can’t say £
No £
1.3 An adequate concealment method is used.
-Insufficient detail in concealment allocation was provided.
Yes £
Can’t say R
No £
1.4 Subjects and investigators are kept ‘blind’ about treatment
allocation.
- They are receiving the education program, they cannot be blinded.
- Blinding is unclear for the assessor.
Yes R
Can’t say £
No £
1.5 The treatment and control groups are similar at the start of the trial. Yes £
Can’t say P
No £
1.6 The only difference between groups is the treatment under
investigation.
Yes R
Can’t say £
No £
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes R
Can’t say £
No £
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
>80% follow-up 3 lost contact
68
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes £
Can’t say *
No £
Does not apply
R
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes £
Can’t say £
No £
Does not apply
R
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
High quality (++)£
Acceptable (+) R
Unacceptable – reject 0 £
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Yes
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
69
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
Moore et al.(2009) Eczema workshops reduce severity of childhood atopic eczema, Australasian Journal of
Dermatology, 2009, Vol.50(2), pp.100-106
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes R
Can’t say £
No £
1.2 The assignment of subjects to treatment groups is randomised. -They are randomised in block of 10 using (Stata Crop)statistical software.
1.4 Subjects and investigators are kept ‘blind’ about treatment
allocation.
-Complete blinding cant be made, minimized by 10 blinded assessment
and assessors. Inter-rater reliability established using Lin concor-dance.
Yes R
Can’t say £
No £
1.5 The treatment and control groups are similar at the start of the trial.
Yes R
Can’t say □
No £
1.6 The only difference between groups is the treatment under
investigation.
Yes R
Can’t say £
No £
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
-All outcome listed
Yes R
Can’t say £
No £
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
13 patiemts lost to follow up >80% follow up
70
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes £
Can’t say R
No £
Does not apply
£
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes R
Can’t say R
No £
Does not apply
£
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
High quality (++)R
Acceptable (+)£
Unacceptable – reject 0 £
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Yes
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
yes
71
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
D. Staab et al., (2002) Evaluation of a parental training program for the management of childhood atopic
dermatitis. Pediatric Allergy and Immunology, 2002, Vol.13(2), pp.84-90
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
Yes R
Can’t say £
No £
1.2 The assignment of subjects to treatment groups is randomised. Not stated
Yes £
Can’t say R
No £
1.3 An adequate concealment method is used.
Not stated
Yes £
Can’t say R
No £
1.4 Subjects and investigators are kept ‘blind’ about treatment
allocation.
-Cant be blinded as the questionnaires answered by the parents which they
know which group they were in
Yes £
Can’t say £
No R
1.5 The treatment and control groups are similar at the start of the trial.
-No significant difference in any of socio-economic parameters
Yes R
Can’t say □
No £
1.6 The only difference between groups is the treatment under
investigation.
Yes R
Can’t say £
No £
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes R
Can’t say £
No £
1.8 What percentage of the individuals or clusters recruited into each
treatment arm of the study dropped out before the study was
completed?
77% follow-up IG 66% follow-up CG
72
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes £
Can’t say
No R
Does not apply
£
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes £
Can’t say £
No £
Does not apply
R
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise bias?
Code as follows:
High quality (++)£
Acceptable (+)R
Unacceptable – reject 0 £
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the statistical
power of the study are you certain that the overall
effect is due to the study intervention?
Yes
2.3 Are the results of this study directly applicable to the
patient group targeted by this guideline?
Yes
73
S I G N
Methodology Checklist 2: Controlled Trials
Study identification (Include author, title, year of publication, journal title, pages)
D.Staab, (2006),Age related, structured educational programmes for the management of atopic dermatitis in
children and adolescents: multicentre, randomised controlled trial. Apr 22;332(7547):933-8
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and clearly focused question.
YesR No £
1.2 The assignment of subjects to treatment groups is randomised. - Randomization was carried out by an independent study centre by computer-generated numbers.
Yes R
Can’t say £
No £
1.3 An adequate concealment method is used.
-The randomization code was concealed in closed envelopes.
Yes R
Can’t say £
No £
1.4 Subjects and investigators are kept ‘blind’ about treatment
allocation.
-Blinding is impossible for the participants who provide most of the
outcome measure by answering questionnaires. Trainers cannot be
blinded.
-The scoring of the AD severity assessors are not involved in the
intervention.
Yes £
Can’t say £
No R
1.5 The treatment and control groups are similar at the start of the trial.
well covered
Yes R
Can’t say □
No £
1.6 The only difference between groups is the treatment under
investigation.
Yes R
Can’t say £
No £
1.7 All relevant outcomes are measured in a standard, valid and reliable
way.
Yes R
Can’t say £
No £
1.8 What percentage of the individuals or clusters recruited into each Overall follow up rate is 83%
74
treatment arm of the study dropped out before the study was
completed?
The dropout rate was 17% (10% in intervention group, 24% in control group)
1.9 All the subjects are analysed in the groups to which they were
randomly allocated (often referred to as intention to treat analysis).
Yes £
Can’t say R
No £
Does not apply
£
1.10 Where the study is carried out at more than one site, results are
comparable for all sites.
Yes R
Can’t say £
No £
Does not apply
£
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
High quality (++) R
Acceptable (+)£
Unacceptable – reject 0 £
2.2 Taking into account clinical considerations, your
evaluation of the methodology used, and the
statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Yes
2.3 Are the results of this study directly applicable to
the patient group targeted by this guideline?
Yes
75
Appendix 4: Estimated Set-Up Cost of the Parental Education Program of Management of Eczema (1st – 2nd Year) Items Cost
Personal Cost
Program Team Members Preparation of presenting materials and booklet Work meeting Introductory session Program Session Follow Up Data analysis Nursing Staff training $234 (max RN pay) x 500 hours
$117,000
Medical Introductory Training 30 Medical Officer x 1 hour $464 x 30 hours
$13,920
Nursing Introductory Training
80 Registered Nurse x 1 hour $234 x 80 hours
$18,720
Compensatory Nursing Staff for Program Team Members
$ 234 x 500 hours $117,000
Direct Program Cost
Printing & Photocopying
$5000
Stationery $500
Promotion $1000
Total Set Up Cost $273,140
76
Appendix 5 : Estimated Operation Cost of the Parental Education Program of
Management of Eczema (3rd year onward)
Items Cost
Personal Cost
Program Team Leader Meetings
Introductory session
Data Analysis
Writing Reports
$234 x 50 hours
$11,700
Program Team Members Meetings
Introductory sessions
Running program
Follow-‐up session
$234 x 250 hours
$58,500
Compensatory Nursing
Staff
$234 x 300 hours $70,200
Direct Program Cost
Printing & photocopying $2500
Stationery $500
Total Running Cost $143,400
77
Appendix 6: Evidence-based Guideline of Parental Education Program for
Eczematous Children
An Evidence-‐Based Guideline of Parental Education Program
for Eczematous Children
June 2015
78
Introduction:
It is an evidence-‐based eczema education program for reducing the severity of
eczema in children. The purpose of this guideline is to develop an organized
education program in helping parents of eczematous children to obtained the
knowledge and acquire the skills in managing eczema. It is developed based on
the evidence on the reviewed studies which was graded by the Level of
evidence( SIGN, 2012a) and the recommendations provided in this guideline are
developed from the selected studies and graded according to the Grades of
Recommendation (SIGN , 2012). The in-‐charge nurses should stop this program
if any adverse events occur and should document clearly with the reason.
Rationale of the Guideline
1. To maintain the consistency of nurses in holding the education program on
management of eczema in children
2. To increase nurses’ confidence in holding the parental education program
Objectives of the Parental Education Program
1. To improve confidence and to enhance the skills of parents of eczematous
children in management of eczema
79
2. To improve the severity of skin condition of eczematous children
3. To decrease the admission rate and follow-‐up frequency
Target Group
The targeted participants are parent of children diagnosed as eczema or with a
history of eczema aged between 0 – 18 years old children.
Content of the Program
The education program is organized by five registered nurses who have more
than 5 years experience in pediatric.
Pediatricians and nurses in Pediatric and Adolescent Medicine will refer the
eligible participants and their parents to the parental education program.
The education program lasts for three hours. Follow up will be one month,
three month, six month and one year. The basic information about eczema will
be given in presentation in the first 45 minutes. The remaining time will be run
in form of a group discussion.
80
The schedule of the program
Time Content Aims
30 minutes Presentation
Ø Introduction of the education
program
Ø Basic epidemiology of atopic eczema
Ø Signs and symptoms of atopic eczema
Ø Triggering factors
Ø Basic skin care
- To understand the basic
knowledge of atopic
eczema
90 minutes Group Discussion
Ø Self introduction
Ø Sharing of own experience (e.g.
when and how was it found?
Treatment undertaking? Allergens?
Technique of dealing with itching
behavior? )
- To develop a supportive
and friendly atmosphere
- To learn the different
approaches in tackling
eczema from each others
81
60 minutes Demonstration on treatment application
Return Demonstration
- To develop and strengthen
the skills of wet wrapping
- To learn the common
mistakes in wet wrapping
skills from each others
82
Recommendations
Recommendation 1.0 Recruitment
1.1 The target population would be pediatric diagnosed with atopic eczema
and their parents. The patient should aged from 0-‐18 years old that
includes in-‐patients and outpatients. (Grade A)
All the participants in the selected studies were under 18 years old and their
parents. Both parents and some children who are capable in self-‐management
are also encouraged to join the program. (Futamura et al., 2013; Grillo et al.,
2006; Moore et al., 2009; Stabb et al., 2002; Stabb et al., 2006).(1+, 1+, 1++, 1+,
1++)
Recommendation 2.0 Implementation of the management of eczema
education program
2.1 The education should be conducted in the outpatient clinic. (Grade A)
The program should conduct in the outpatient clinic so as to facilitate the
interdisciplinary communication and can provide a spacious activity room and
staffs at outpatient clinic are experienced in giving primary health education
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program.(Futamura et al., 2013; Grillo et al.,2006; Moore et al.,2009). (1+,
1+,1++)
2.2 The eczema workshop is suggested to be carried out in a group basis.
(Grade A)
All education program in all selected studies include group session. (Futamura
et al., 2013; Grillo et al., 2006; Moore et al., 2009; Stabb et al., 2002; Stabb et al.,
2006). (1+, 1+, 1++, 1+, 1++). It allows them to share their personal experience
and understand more about the obstacles when managing eczema. Therefore, it
is desirable to carry out the sharing session in a group basis.
2.3 Practical session on wet wrapping and cream application skills should
be included in the program. (Grade A)
Application of treatment such as cream or wet wrapping is demonstrated and
re-‐turn demonstration on trying out the newly learned skills is also encouraged
under a nurse supervision so as to improve the treatment outcome (Futamura et
al., 2013; Grillo et al., 2006; Moore et al., 2009; Stabb et al., 2002; Stabb et al.,
2006).(1+, 1+, 1++, 1+, 1++).
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Recommendation 3.0 Evaluation and Follow-‐up
3.1 It is suggested to evaluate the program by measuring SCORAD of the
clients at baseline before the program and after the program in order to
evaluate the change in SCORAD. (Grade A)
All the studies measure the baseline SCORAD at follow-‐up session and
calculate the change in severity after the program so as to evaluate the efficacy of
the proporsed program. (Futamura et al., 2013; Grillo et al., 2006; Moore et al.,
2009; Stabb et al., 2002; Stabb et al., 2006).(1+, 1+, 1++, 1+, 1++).
3.2 The length of follow-‐up is set to be one month and 3 month and one
year. (Grade A)
The length of follow up cannot be too long because the dropout rate is high
especially if the participants are in the control group which are having no
intervention. Among all selected studies, only one (Stabb et al., 2002) shown
more than 20% of dropout rate as the first follow-‐up is conducted at one year
after the education program.
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References
Futamura, Masaki, et al. "Effects of a Short-Term Parental Education Program on Childhood Atopic Dermatitis: A Randomized Controlled Trial." Pediatric
dermatology 30.4 (2013): 438-443.
Moore, Elizabeth J., et al. "Eczema workshops reduce severity of childhood atopic
eczema." Australasian journal of dermatology 50.2 (2009): 100-106.
Grillo, Marianne, et al. "Pediatric atopic eczema: the impact of an educational