The Role of Self-Efficacy in Self-Management of Atopic Dermatitis

As atopic dermatitis (AD) is increasing in prevalence, so is the suffering that accompanies it.^1-3 AD affects up to 13% of children in the United States and up to 20% worldwide.^4,5 Due to its impact on sleep and social and intellectual development, AD can diminish the quality of life in children and families. AD is a multibillion-dollar problem to society, with an estimated direct cost of $314 million per year in the United States.^2,6-8 Combating the burden of this disease requires a multipronged approach, but complex treatment plans often compromise adherence to treatment. 

Much research has been done to better understand the pathophysiology of AD and to develop better treatments. Research on the factors that affect patients’ adherence to treatment has the potential to vastly improve patients’ outcomes and to do so quickly and at low cost. Models that describe the factors that affect patients’ adherence are being developed. A key factor in these models is self-management, a promising strategy that combines patient education and psychological support to actively engage patients in their health care. 

Self-management is a patient’s ability to manage symptoms, treatments, and physical and psychological consequences associated with a chronic condition. Since patients, not providers, are responsible for day-to-day disease management, patients must be more actively involved in their care through self-management. Evidence suggests that self-management interventions effectively increase patient knowledge, symptom management, and health status.⁹ Self-management may help bridge the gap between patients’ needs and the ability of health care to meet those needs. 

There is increasing interest in developing self-management interventions for patients with AD.^10-12 Since AD can be disabling to patients and families, educational and psychological support of the patient and caregiver are essential components of disease management. Educational interventions teach parents to better understand the need for medical interventions and effective disease management. The content of educational interventions may include disease information, treatment instructions, management, and prevention strategies. Approaches include pamphlets, workshops, programs, online video education, and Web-based interventions.^13-16 However, interventions solely based on education are unlikely to bring about health behavior change.¹⁶ 

Successful educational interventions improve participant’s motivation, familial shared decision-making, development of problem-solving skills, goal setting, action plans, and self-efficacy. Self-efficacy is the extent to which a person is able to successfully initiate and complete actions needed to achieve a specific outcome.¹⁷ Self-efficacy influences how individuals approach goals, tasks, and challenges. Individuals with high self-efficacy tend to be more confident in confronting challenging tasks, while individuals with low self-efficacy tend to avoid challenges altogether.¹⁷ Interventions that strengthen a patient’s self-efficacy result in positive changes in health behaviors and improved health outcomes.^11,18,19 There are 4 key sources of self-efficacy: mastery, vicarious experience, verbal persuasion, and emotional regulation.

Many existing educational programs for chronic conditions are based on social learning theory.²⁰ This approach has been applied to adult psoriasis patients with promising results. The intervention consisted of 4 components based on the 4 sources of self-efficacy: a nurse-led group learning experience, supporting written and audiovisual material, a follow-up telephone consultation, and a relaxation resource. While intervention participants had a modest reduction in psoriasis severity, there was insufficient power to detect significance. 

Interventions to evaluate and promote parental self-efficacy have been applied to AD.^10-12 The Parental Self-Efficacy with Eczema Care Index (PASECI) is a validated tool to measure parental self-efficacy in managing childhood eczema.^11,12 The PASECI was used as a pre- and post-intervention tool in evaluating an Eczema Education Programme (EEP). The EEP intervention was based on the self-efficacy construct and consisted of a nurse-led session designed to generate group interaction, provide opportunities for shared learning, and mutual support.²¹ The EEP intervention enhanced the PASECI score of participants, meaning increased self-efficacy in managing eczema and symptoms.¹¹ A web-based education program similarly increased the self-efficacy of mothers.¹⁰  

While intervention programs can build up parental self-efficacy in treating AD, other factors can erode it. Child behavior problems, parental depression and stress, parenting conflict, and relationship dissatisfaction were all associated with lower self-efficacy and less success in performing AD management tasks. Parents reporting lower self-efficacy performed AD management tasks less competently compared with patients with higher self-efficacy.²² Further research into self-efficacy will help researchers plan patient education programs, measure the impact of patient education programs, and detect individual differences in self-efficacy between patients.

Interventions to promote self-management and self-efficacy may provide immediate practical strategies to improve patient adherence and therefore treatment outcomes for children living with AD.  A common goal of self-management is to increase patients’ involvement in care, thereby promoting better patient adherence. Improved self-efficacy and self-management enables patients to take control of their case and disease, which may lead to better health outcomes and reduced health care costs.²³ For AD patients and parents to achieve the best results from medical therapies, providers need to better understand and conduct more investigation into self-management and self-efficacy. 

Dr Cline is with the Center for Dermatology Research in the department of dermatology at Wake Forest School of Medicine in Winston-Salem, NC.

Dr Masicampo is with the department of psychology at Wake Forest University in Winston-Salem, NC.

Dr Feldman is with the Center for Dermatology Research and the Department of Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.

Disclosure: Dr Feldman has received research, speaking, and consulting support from a variety of companies including Galderma, GSK/Stiefel, Almirall, Leo Pharma, Baxter, Boeringer Ingelheim, Mylan, Celgene, Pfizer, Ortho Dermatology, Taro, Abbvie, Astellas, Janssen, Lilly, Merck, Novartis, Regeneron, Sanofi, Novan, Parion, Qurient, National Biological Corporation, and Sun Pharma. He is founder and majority owner of www.DrScore.com and founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment. 

Drs Cline and Masicampo report no relevant financial relationships.