Primary Health Care Management of Childhood Atopic Eczema

Background

20-30% of the world’s population suffers from allergic diseases and places a high burden on health services (Pawankar, Baena-Cagnani, Bousquet, Canonica, Cruz, Kaliner & Lanier, 2008: S4).. In a study conducted by The World Allergy Organization Speciality and Training Council it was found that the majority of allergic patients are seen by non-allergy-trained health workers (Warner, Kaliner, Crisci, Del Giacco, Frew, Lui, Maspero, Moon, Nakagawa, Potter, Lanny, Rosenwasser, Singh, Valovirta & Van Cauwenberge, 2006). This situation is also true for South Africa (Potter, Warner, Pawankar, Kaliner, Del Giacco & Rosenwasser, 2009: 150). Primary health care (PHC) is the entrance point for patients into the public health system of South Africa. Research question: How can the PHC clinician, as part of a multi-disciplinary team manage childhood atopic eczema (CAE)?

Method

This study consisted of three phases.

One:

A qualitative, contextual, explorative, descriptive design with an embedded single case study was used. The case: public health service of Gauteng central district. Embedded units: parents of children 0-14 years with atopic eczema, who at some stage visited a primary health care facility to seek help for their children; specialists in the paediatric-dermatology-outpatient unit of a tertiary hospital, treating children 0-12, suffering from atopic eczema referred by the primary health care clinicians, and PHC clinicians in clinics employed by the provincial health department or the local authority who treated (drug and/or non-drug) children 0-12, suffering from atopic eczema. Ethical clearance was obtained from the university, the Health departments of Gauteng and city of Johannesburg, as well as the tertiary hospital,

Data was collected using semi-structured interviews, focus group interviews, direct observations, field notes and document analysis. Questions asked in interviews: How is it for you to manage CAE? How do you see the role of PHC clinicians regarding the management of CAE? Data was collected until saturation occurred and analysed using Tesch’s eight steps for open coding. Data saturation occurred after ten individual interviews with parents, five individual interviews with specialists, four individual and three focus group interviews with primary health care clinicians, 88 hours of direct observation and analysis of 33 patient records.

Two:

A conceptual framework for PHC management of CAE was developed, using The six aspects of Dickoff, James and Wiedenbach’s (1968: 425) survey list are:

1. Who or what performs the activity? (agent)

2. Who or what is the recipient of the activity?

3. In what context is the activity performed?

4. What is the endpoint of the activity? (Outcome)

5. What is the guiding procedure, technique or protocol of the activity?

6. What is the energy source for the activity? (dynamics)

Three:

The third phase was a quantitative phase. Based on first two phases, using the AGREE II Instrument, a validated and widely used instrument for clinical guideline development and evaluation (Brouwers, Kho, Browman, Cluzeau, Feder, Fervers, Hanna, & Makarski, 2010), evidence based PHC management guidelines for CAE were developed and validated. The AGREE II Instrument indicated six domains for the development of high quality clinical practice guidelines namely: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence (Brouwers et al, 2010). The guidelines sent for validation to the experts and stakeholders,

Results

CAE has a physical, emotional and social impact on parents, children and health care workers. Management challenges regarding the PHC management of CAE, including difficulty in assessment and diagnosis, ineffective and insufficient drug management availability, low knowledge levels of PHC clinicians, the need for health education, lack of clear treatment protocols as well as an ineffective referral system  were identified. Recommendations to address these challenges were identified from the collected data. Evidence based guidelines, based on the findings in phase one and the conceptual framework in phase two, following the AGREE II Instrument, were developed and validated.

Conclusion

Effective management of CAE can significantly reduce the impact of CAE. Implementation of the guidelines will need the support from district/sub-district management teams and nurse educators to address the identified challenges. The focus for the presentation will be the evidence based guidelines, focusing on the assessment and diagnosis of childhood atopic eczema as well as the step wise approach management thereof on the primary health care level.