Efficacy of Integrative Body-Mind-Spirit Group Intervention for Parents of Children With Eczema: A Randomized,Wait-List Controlled Clinical Trial

Abstract

Objectives:

This randomized controlled trial evaluated the effects of a psychosocial intervention developed based on the Integrative Body-Mind-Spirit (IBMS) model that aimed to enhance the well-being of parents of children with eczema.

Methods:

Ninety-one families were randomly allocated to either the six-session intervention group (n = 48) or the wait-list control group (n = 43) and completed the randomized trial. For both groups, a range of psychosocial outcome measures were taken before the intervention (T₀), postintervention (T₁), and 6 weeks after the intervention (T₂).

Results:

Relative to the control group, the intervention group was significantly improved over time in their levels of perceived stress, depression, and a number of holistic well-being measures, including nonattachment, afflictive ideation, and general vitality.

Discussion:

The results provided empirical support for an IBMS-informed psychosocial intervention in reducing stress and depression and enhancing well-being among parents of children with eczema.

Keywords

eczema psychosocial intervention stress depression well-being

Atopic dermatitis, commonly known as eczema, is a chronic skin disease with pruritic inflammation, which creates a worldwide public health problem. Prevalence in children is 15%–30%, while in adults, it can be up to 10% (Archer, 2013; Fortson et al., 2017). Noticeably, 45% of patients start to experience eczema during their early infancy, that is, from their first 6 months of life, 60% grow out of the symptoms when they reach their teens, while about half continue to persist into adulthood (Archer, 2013; Ring, 2016)(Archer, 2013 #1). In view of the growing trend and the frequent outbreak of childhood eczema in the industrialized and developed countries, a recent research study proposed to identify the prevalence of the disease in Hong Kong based on the International Study of Asthma and Allergies in Childhood survey (Fung & Lo, 2000; S. L. Lee et al., 2017). From this, it is predicted that the local prevalence of eczema will significantly increase especially for children in primary schools, which will eventually introduce a substantial health and economic burden for the children, their parents, and their communities (El-Heis et al., 2017; S. L. Lee et al., 2017).

Previous studies indicated that not only will children with eczema (hereafter “children” unless otherwise specified) suffer from daytime tiredness, diminished self-esteem, emotional distress, irritability, and psychological disturbance (Archer, 2013; Maksimović et al., 2012; Ring, 2016), their parents who are their primary caregivers (hereafter “parents” unless otherwise specified) can also experience interruption of daily routines, poor physical condition, emotional instability, and reduction of social activities (Andersson et al., 2016; Carmen et al., 2018; Ho et al., 2010). Although eczema is not considered a life-threatening disease, the incurable and lifelong nature of the unbearable itch may introduce emotional and psychological challenges to patients and family members, especially children and their parents (Andersson et al., 2016; Carmen et al., 2018; Fortson et al., 2017; Ho et al., 2010; Kelsay et al., 2010; Maksimović et al., 2012).

Parental stress of children with eczema generally comes from the feelings of uncontrollability and unpredictability in the caregiving process. Repeated failure of treatment episodes and the endless struggle through various treatment alternatives can trigger emotional distress (El-Heis et al., 2017; Santer, 2014). However, it is also common for parents to internalize their stress and feelings because emotional support from family members can rarely be attained, particularly in light of tension among family members due to their diversified opinions in handling the problem (Neill et al., 2013). In addition, the inflamed and reddish skin can easily lead to social stigmatization for the children, which can further induce negative emotions for their parents (Meyer et al., 2014). Furthermore, the unpredictable nature of the disease can also seriously affect family daily routines and the social life of the parents. The combined effect of these risk factors can eventually propel parents toward a deterioration of mental health. In most circumstances, parents consider their primary role as caregivers for their children, and their own well-being is set aside and given a lower priority.

It is crucial to identify the type of guidance and support that parents require. Although literature suggests that some nonpharmacological training programs have been developed for parents of children with eczema, most of them focus on treatment compliance and symptom management, while the well-being of parents is seldom mentioned (Ersser et al., 2014; Farasat, 2014). Regarding the psychosocial needs of the parents, it is important to address their emotional needs arising from caregiving and build up their capacity in order to deal with their caregiving stress and accommodate the enduring nature of the eczema of their children. Among various types of intervention models, psychological group counseling has been considered as one of the most effective strategies in supporting the parents with caretaking roles. During group experience, parents’ caregiving experience can be normalized and they can learn new ways of coping from group members with similar experience (Leung & Chan, 2015; Rashid, 2015; Rentala et al., 2015).

In terms of nonpharmacological treatment options, various psychosocial therapy approaches have been developed. Research studies found that psychological interventions reduce severity and itching intensity for eczema patients, but more vigorous empirical evidence is still required (Chida et al., 2007). Cognitive behavioral therapy was found to improve the psychological functioning of eczema patients, even if the severity of the disease remained the same (Wittkowski & Richards, 2007). However, the small sample sizes of various research studies (Wittkowski & Richards, 2007) may limit the generalizability of their findings.

Psychological interventions for eczema patients were first developed in the 1980s, and structural education programs have been developed in the past two decades (Chida et al., 2007; Staab et al., 2006). These included cognitive behavioral therapy, stress management, behavioral therapy, brief dynamic psychotherapy, autogenic training, and aromatherapy (Chida et al., 2007). In the present literature, there is still a paucity of evidence-based and theory-based psychological and educational intervention for children with eczema and their parents. Wenninger et al. (2000) developed a Berlin Parental model for the management of children with eczema. The result was inconclusive, although some improvement in quality of life (QoL) and coping skills of parents was found. In addition, other programs have also been found to be useful only in improving the severity of children’s skin conditions and pruritus intensity (Blessmann Weber et al., 2008; Staab et al., 2006; Weisshaar et al., 2008). Kupfer et al. (2010) later modified the Berlin model and created a more comprehensive structured parent–child education program, but the result only revealed certain psychological benefits and the overall effectiveness of the program was still uncertain. The Eczema Education Programme for parents was recently launched (Ersser et al., 2013), but evidence on parental satisfaction was inconclusive (Jackson et al., 2014).

Although research findings have supported parental training for managing childhood eczema as an effective adjunct to conventional dermatological intervention, these programs were restricted to addressing compliance to treatment procedures, use of emollients, and topical medication with little intervention on the psychosocial impact of the disease. The psychosocial distress and needs of parents were not properly addressed and remain under-researched (Farasat, 2014).

It is believed that parents of children with eczema can be empowered in terms of physical, psychological, and social well-being, which are crucial for improving their QoL in the caregiving process. This study adopts a strength-based social work approach, an Integrative Body-Mind-Spirit (IBMS) model (C. L. W. Chan et al., 2000; M. Y. Lee et al., 2018), which aims to enhance the holistic well-being of the parents of children with eczema (Fung et al., 2019). We hypothesize that the holistic well-being of the parents of children with eczema will be significantly improved by the intervention based on IBMS model.

Method

Participants

Parents of children with eczema aged from 6 to 11 years (primary school students) were recruited through social media, agency newsletter, website postings, and referrals from community health-care providers. Participants who were interested could elect to complete a brief online survey, which included medical history regarding the skin condition of the children. Eligible participants were invited to attend a pregroup interview, where informed consent was obtained and self-administered questionnaire was completed. The pregroup interviews were conducted by experienced social workers.

The children should be between the ages of 6 and 11, which is the age range of the primary school students in the location of the research study. The child should be between the ages of 6 and 11 (primary school students). Besides, the child should be clinically diagnosed with eczema only with no other major chronic diseases. The parent should be either the father or mother of the child with eczema and has a key role in taking care of the child for at least 6 months. Finally, all participants should be able to express themselves in Cantonese.

Sample Size Calculation

We determined the desired sample size of the study by power analysis (Faul et al., 2007). With reference to other similar studies conducted by the team, this research study was expected to have a moderate effect size of around .25. Taking the assumption of .8 as power, .05 as significance criterion, and .5 as the correlation among repeated measures (analysis of variance, repeated measures, and between factors), a total of 86 participants were needed in total as calculated by the statistical software G-Power Version 3.1.9.2. Assuming an attrition rate of 10%, the total number of participants was expected to be 96 (i.e., 48 in each group).

Design

This is a randomized, wait-list controlled clinical trial. After obtaining participants’ informed consent and getting the baseline measurement completed, participants were randomly assigned to either an intervention group (IG) or a wait-list control group (WLCG). The randomization was conducted by using a random number generator in Excel. Allocation of intervention was revealed to the research coordinators, group leaders, and participants after completing the basement measurements.

Participants of the IG were asked to complete questionnaires at three time points at baseline (T₀), after the six-session psychosocial intervention (T₁), and 6 weeks after the psychosocial intervention (T₂). Participants of the WLCG were asked to complete questionnaires at baseline (T₀), 6 weeks after T₀, and at 12 weeks’ follow-up (T₃). After the T₁, participants of WLCG received the six-session psychosocial intervention for the sake of ethical consideration. Figures 1 and 2 show the process flow of this study based on the Consolidated Standards of Reporting Trials guideline (Reveiz & Krleža-Jerić, 2010).

Figure 1.

Schematic model of the intervention.

Figure 2.

Consolidated Standards of Reporting Trials workflow of the study.

Psychosocial Intervention

A psychosocial intervention program based on the IBMS protocol was customized for parents of children with eczema. The program consisted of six 3-hr consecutive weekly sessions. IBMS intervention approach was an empirically supported social work intervention model, which adopted a strength-based perspective in patient empowerment. It focused on the interplay between exercise, emotions and physical well-being, the spiritual transformation of traumatic experiences, and the acceptance of adversity through the philosophical concepts of forgiveness and letting go (C. L. W. Chan et al., 2000; M. Y. Lee et al., 2018). This integrated Eastern health practices with meaning-making and body techniques (C. L. W. Chan et al., 2006; C. L. W. Chan & Yan, 2015; Leung & Chan, 2015; M. Y. Lee et al., 2018; Leung et al., 2009) provided a set of physical exercises that lead to explicit articulation in spiritual transformation through suffering and pain under a meaning-oriented framework (C. L. W. Chan et al., 2006; C. L. W. Chan & Ho, 2012; Tang et al., 2007). The model aimed to empower individuals to regain their self-healing capabilities, maintain harmony, and balance at intrapersonal, interpersonal, and transpersonal levels (Ng et al., 2006). It also affirmed the importance of the discovery of meaning especially in adverse life situations and has developed meaning-focused measurements (T. H. Y. Chan et al., 2007). The details of the intervention program can be found in protocol paper previously published by the research team (Fung et al., 2019). The customized IBMS protocol for this research study has also been registered in the Clinical Trials Centre of The University of Hong Kong with registration number HKUCTR-2234 (www.hkuctr.com).

Fidelity of IBMS

To ensure the competence and adherence concern in the current clinical trial, experienced social workers and counselors who have received standardized professional training on IBMS intervention model conducted the intervention program. The training involved 3 full-day sessions with didactic teaching on the theoretical underpinnings of IBMS as well as practice training and experiential learning of the IBMS-informed techniques. Intervention fidelity to the protocol was monitored by completion of session-specific checklists of all required IBMS activities. The checklist would be reviewed and completed by the implementer of the program and would be returned to the research team for further examination. On-site supervision was provided by IBMS trainers to address clinical concerns.

Ethical Consideration

The objectives and the procedure in the study were clearly explained to all participants, and written informed consent was collected from them before data collection. Participation was entirely voluntary, and participants had the right to terminate their participation at any time during the study without any negative consequences. Ethical approval was obtained as per the standard procedure indicated by the Human Research Ethics Committee of The University of Hong Kong (www.rss.hku.hk/integrity/ethics-compliance/hrec,reference:EA1612023).

Measurements

The selection of measurement tools was based on (a) the relevancy of the scales with the primary and secondary outcomes of this study, (b) psychometric properties of the scales, (c) availability of the validated scales in the Chinese version, and (d) license to use of the scales. Five scales were selected for this study:

Holistic Well-Being Scale (HWS) was developed based on the conceptualization of well-being and spirituality, which comprised two aspects of spiritual dimensions (affliction and equanimity) and seven subscales (HWS Nonattachment, HWS Afflictive Emotion, HWS Afflictive Sensation, HWS Afflictive Ideation, HWS Mindful Awareness, HWS General Vitality, and HWS Spiritual Self-Care) with reported Cronbach’s αs (internal consistency reliability) ranging from .670 to .892 (C. H. Y. Chan et al., 2014).

Perceived Stress Scale (PSS) with reported Cronbach’s α (internal consistency reliability) of .84 was used to measure the stress exerted by parents (Cohen et al., 1983).

Patient Health Questionnaire 9 (PHQ-9) with reported Cronbach’s α (internal consistency reliability) of .89 was used to measure the depression levels of the parents (Kroenke et al., 2001).

Generalized Anxiety Disorder Scale 7 (GAD-7) with reported Cronbach’s α (internal consistency reliability) of .92 was used to measure the anxiety level of the parents (Spitzer et al., 2006).

Dermatitis Family Impact (DFI) with reported Cronbach’s α (internal consistency reliability) of .85 was developed by Lawson et al. (1998) to measure the effect of childhood atopic dermatitis on family function.

Data Analysis

Demographic characteristics of the participants were first analyzed using χ² tests of independence and independent samples t test. Baseline data (T₀) on the mean scores for all the outcome variables (and their subscales if applicable) were then examined between the IG and control group.

The general linear model (GLM) for repeated measures was used to evaluate the changes in the outcome variables at three time points (before intervention: T₀, immediately after intervention: T₁, and 6 weeks after intervention: T₂). The GLM was first performed for the outcome variables to identify the within-subject main effect (Time) and the interaction effect between the group across the time line (Time × Attended Group). Pairwise comparisons among the mean scores at the three time points in the IG were then conducted.

Result

Demographics

During the recruitment period (50 days), 222 potential families were recruited by the nine service centers. After the initial screening process, 59 families were excluded due to duplication of application, failure to meet inclusion criteria (e.g., children were not within the age range of the study, children had skin disease but not eczema), or declining to participate after knowing the details of the program. Subsequently, 163 families were randomized into the IG and control group. However, after randomization, 50 families declined to participate due to the conflict with their schedules. As a result, 113 families (58 in IG and 55 in control group) were able to complete the initial assessment (T₀). During the intervention period, 10 families (6 in IG and 4 in control group) decided to quit the program due to other commitments, and 12 families (4 in IG and 8 in control group) failed to complete the follow-up assessment (T₁ and T₂). Finally, data from 91 families (48 in IG and 43 in control group) were collected for analysis. In view of the original recruitment estimation of 86 families (43 in IG and 43 in control group), the existing sample size should be able to provide a reasonable justification for the effect size (.25) and power (.8) of the study.

Table 1 summarizes the characteristics of the demographic variables. The average age of the parents was 41 (IG: 41.52; control group: 41.07), and most of them were female (IG: 91.67%; control group: 83.72%). More than half of them were employed on a full-time basis (IG: 54.17%; control group: 60.47%), while one third of them were homemakers (IG: 33.33%; control group: 32.56%). Around three quarters of them have received either secondary or tertiary education (IG: 84.78%; control group: 72.09%). Most parents were married/cohabited (IG: 89.58%; control group: 95.35%), and half of them had no religion (IG: 50%; control group: 55.81%). No specific pattern in family monthly income could be observed, although it was noted that seven families in the control group were recorded with a relatively high income (>HK$80,000).

Table 1.

Demographic Characteristics of Participants.

Demographic Items	Intervention Group		Control Group		p Value
Demographic Items	n	%	n	%	p Value
Gender
Male	4	8.33	7	16.28	.246
Female	44	91.67	36	83.72	.246
Employment
Full time	26	54.17	26	60.47	.412
Part time	5	10.42	2	4.65
Retired	0	0.00	1	2.33
Homemaker	16	33.33	14	32.56
Unemployed	1	2.08	0	0.00
Education level
Primary	2	4.17	0	0.00	.171
Secondary	19	39.58	17	39.53
Tertiary	20	41.67	14	32.56
Postgraduate	7	14.58	12	27.91
Marital status
Single	1	2.08	1	2.33	.41
Married/cohabited	43	89.58	41	95.35
Divorced/separated	2	4.17	1	2.33
Widowed	2	4.17	0	0.00
Religion
No religion	24	50.00	24	55.81	.683
Catholic	5	10.42	4	9.30
Christian	14	29.17	11	25.58
Buddhism	4	8.33	3	6.98
Others	1	2.08	1	2.33
Family income (in HK$)
<10,000	2	4.17	0	0.00	.225
10,000–19,999	9	18.75	4	9.30
20,000–29,999	10	20.83	8	18.60
30,000–39,999	7	14.58	6	13.95
40,000–49,999	6	12.50	4	9.30
50,000–59,999	4	8.33	4	9.30
60,000–69,999	3	6.25	2	4.65
70,000–79,999	1	2.08	2	4.65
>80,000	1	2.08	7	16.28
No answer	5	10.42	6	13.95

χ² tests of independence were performed for the nominal and ordinal demographic variables (gender, employment status, education level, marital status, religion, and family income) between the participants in the intervention and control groups. No significant difference was found between the two groups in terms of gender, χ²(1) = 1.348, p = .246, employment status, χ²(4) = 3.959, p = .412, education level, χ²(3) = 5.005, p = .171, marital status, χ²(3) = 2.885, p = .41, religion, χ²(5) = 3.113, p = .683, and family income, χ²(8) = 10.601, p = .225. An independent samples t test was performed on the mean scores of age. No significant difference was found in age between the IG (M = 41.52, SD = 5.57) and control group (M = 41.07, SD = 5.28), t(86) = 0.388, p = .699.

Furthermore, independent samples t test was performed to compare the mean scores of all the outcome variables between the IG and the control group before the intervention was conducted. No significant difference was identified. In general, there was no significant difference in the demographic characteristics and the baseline result of the outcome variables between the IG and the control group.

GLM and Post Hoc Analysis

The GLM for repeated measures was used to evaluate the changes in the outcome variables at three time points (before intervention: T₀, immediately after intervention: T₁, and 6 weeks after intervention: T₂). GLM was first performed for the outcome variables to identify the interaction effect between the group across the time line (Time × Group). Post hoc pairwise comparisons with t tests among the mean scores at the three time points in the IG and the control group were then conducted to help interpret any significant interactions found. The GLM results and that of the post hoc t tests can be found in Table 2.

Table 2.

Changes in Outcome Measures Over Time for the Intervention and Control Groups.

Outcome Measures/Group	T₀	T₁	T₂	Time × Group		(T₁ − T0)		(T₂ − T₁)		(T₂ − T₀)
Outcome Measures/Group	M (SD)	M (SD)	M (SD)	F(2, 178)	$η_{p}^{2}$	t	d	t	d	t	d
Perceived Stress (PSS)
Intervention	22.1 (4.3)	18.7 (5.0)	19.3 (5.8)	4.13*	.044	−4.56***	−.73	0.76	.11	−2.99**	−.55
Control	21.7 (4.3)	21.3 (4.6)	20.5 (4.8)	4.13*	.044	−0.53	−.09	−1.32	−.17	−2.15*	−.26
Depression (PHQ-9)
Intervention	7.3 (4.3)	4.7 (3.7)	5.8 (4.1)	8.59***	.088	−5.62***	−.65	2.89**	.28	−3.60**	−.36
Control	6.6 (5.4)	6.7 (5.5)	6.8 (5.8)	8.59***	.088	0.36	.02	0.05	.02	0.36	.04
Anxiety (GAD7)
Intervention	6.2 (4.2)	4.7 (3.7)	5.5 (4.1)	0.94	.010	−3.10**	−.38	2.00	.20	−1.65	−.17
Control	6.5 (5.0)	5.7 (5.4)	6.6 (5.8)	0.94	.010	−1.39	−.15	2.91**	.16	0.17	.02
Family Function (DFI)
Intervention	14.5 (6.5)	10.3 (5.6)	10.5 (5.5)	1.60	.018	−5.07***	−.69	0.45	.04	−5.31***	−.66
Control	16.8 (5.4)	4.0 (5.8)	12.6 (5.7)	1.60	.018	−4.60***	−.50	−2.28*	−.24	−6.63***	−.76
Afflictive Emotion (HWS)
Intervention	24.3 (9.9)	24.3 (8.4)	24.6 (8.7)	0.55	.006	−0.57	.00	0.33	.04	−0.27	.03
Control	22.8 (8.7)	24.6 (8.4)	24.9 (9.2)	0.55	.006	0.64	.21	0.41	.03	1.01	.23
Afflictive Sensation (HWS)
Intervention	24.3 (8.6)	21.8 (8.3)	22.2 (7.8)	1.15	.013	−2.24*	−.30	0.37	.05	−2.04*	−.26
Control	22.8 (10.5)	22.3 (9.6)	22.4 (10.3)	1.15	.013	−0.43	−.05	0.17	.01	−0.36	−.04
Afflictive Ideation (HWS)
Intervention	13.3 (7.9)	12.4 (7.5)	12.8 (6.9)	3.97*	.043	−1.13	−.12	0.56	.06	−0.61	−.07
Control	11.1 (5.6)	13.0 (5.8)	12.9 (6.8)	3.97*	.043	2.44*	.33	−0.16	−.02	2.20*	.29
Nonattachment (HWS)
Intervention	32.1 (8.9)	33.4 (6.6)	33.8 (6.7)	4.43*	.047	1.35	.17	0.50	.06	1.43	.22
Control	34.4 (7.6)	32.5 (7.6)	32.6 (7.5)	4.43*	.047	−2.59*	−.25	0.03	.01	−1.93	−.24
Mindful Awareness (HWS)
Intervention	29.8 (5.3)	29.7 (4.9)	29.3 (5.1)	2.51	.027	−1.16	−.02	−0.57	−.08	−0.57	−.10
Control	30.5 (4.6)	28.5 (4.5)	28.1 (5.0)	2.51	.027	−3.12**	−.44	−0.66	−.08	−3.34**	−.50
General Vitality (HWS)
Intervention	23.3 (6.7)	25.1 (6.6)	24.9 (6.9)	3.39*	.037	2.45*	.27	−0.43	−.03	2.23*	.24
Control	24.3 (7.3)	23.9 (6.9)	24.1 (7.3)	3.39*	.037	−0.85	−.06	0.36	.03	−0.29	−.03
Spiritual Self-Care (HWS)
Intervention	18.4 (4.8)	18.9 (4.6)	18.6 (4.6)	0.85	.010	0.77	0.11	−.44	−.07	0.31	.04
Control	17.6 (4.9)	17.3 (3.9)	16.7 (4.8)	0.85	.010	−0.59	−0.07	−.87	−.14	−1.45	−.19

Note. M = mean; SD = standard deviation; $η_{p}^{2}$ = partial eta squared; d = Cohen’s d; PSS = Perceived Stress Scale; PHQ-9 = Patient Health Questionnaire 9; GAD7 = Generalized Anxiety Disorder Scale 7; DFI = Dermatitis Family Impact; HWS = Holistic Well-being Scale.

*p < .05. **p < .01. ***p < .001.

The results of the GLM revealed that there was a significant interaction effect for perceived stress as measured by PSS, F(2, 178) = 4.13, p = .018, $η_{p}^{2} = .044$ . Post hoc t tests suggested that the IG, but not the controlled group, underwent a significant reduction in perceived stress from T₀ to T₁, t(48) = −4.56, p < .001. Cohen’s effect size value (d = −0.73) suggested a moderate to high practical significance. This reduction remained significant at follow-up (T₂), t(48) = −2.99, p = .004, with a moderate Cohen’s effect size (d = −0.55), although at this point, the control group showed a more modest but significant reduction in this measure, t(46) = −2.15, p = .037, with a small to moderate Cohen’s effect size (d = −0.26).

A significant interaction effect was also detected for the levels of depression as measured by PHQ-9, F(2, 178) = 8.59, p < .001, $η_{p}^{2} = .088$ . Post hoc t tests revealed that the IG underwent a significant reduction in depression from T₀ to T₁, t(48) = −5.62, p < .001. Cohen’s effect size value (d = −0.65) suggested a moderate to high practical significance. There was a significant (partial) rebound from T₁ to T₂, t(48) = 2.89, p = .006, with a small to moderate Cohen’s effect size (d = 0.28), but a significant overall reduction from T₀ to T₂, t(48) = −3.60, p =.001, with a small to moderate Cohen’s effect size (d = −0.36) could be identified. The control group, on the other hand, did not undergo any significant changes across time in this measure.

As for anxiety as measured by GAD-7, GLM did not detect a significant Time × Group interaction effect. However, post hoc comparisons indicate that the IG underwent a significant reduction in this measure from T₀ to T₁, t(48) = −3.10, p = .003, with a small to moderate Cohen’s effect size (d = −0.38), whereas the control group underwent a significant increase in anxiety from T₁ to T₂, t(46) = 2.91, p = .006, with a small Cohen’s effect size (d = 0.16).

Family function as measured by DFI did not exhibit a significant Time × Group interaction effect in the GLM. Post hoc analysis, however, suggested that both the intervention and the control groups underwent significant overall reduction in this measure from T₀ to T₂, t(46) = −5.31, p < .001, with a moderate to large Cohen’s effect size (d = −0.66), and t(46) = −6.63, p < .001, with a moderate to large Cohen’s effect size (d = −0.76), respectively.

There was no significant interaction effect detected for HWS Afflictive Sensation. However, post hoc comparisons indicated that the IG underwent a significant decrease in this measure across time between the period of T₀ and T₁, t(46) = −2.24, p = .03, with a small to moderate Cohen’s effect size (d = −0.3) as well as the period between T₀ and T₂, t(46) = −2.04, p = .047, with a small Cohen’s effect size (d = −0.26).

A significant Time × Group interaction effect for HWS Afflictive Ideation by GLM, F(2, 178) = 3.97, p = .021, $η_{p}^{2} = .043$ . Post hoc comparisons showed that the control group, but not the IG, underwent a significant increase in this measure between T₀ and T₁, t(46) = 2.44, p = .019, with a small to moderate Cohen’s effect size (d = 0.33) and that this effect was largely maintained at follow-up (T₂), t(46) = 2.20, p = .033, with a small Cohen’s effect size (d = 0.29).

GLM also found a significant Time × Group interaction effect for HWS Nonattachment, F(2, 178) = 4.43, p = .013, $η_{p}^{2} = .047$ . Post hoc analysis revealed that the control group, but not the IG, underwent a significant increase in this measure from T₀ to T₁, t(46) = −2.59, p = .013, with a small Cohen’s effect size (d = −0.25).

There was no significant interaction effect detected for HWS Mindful Awareness. Nonetheless, post hoc comparisons indicated that the control group, but not the IG, underwent a significant decrease in this measure across time between the period of T₀ and T₁, t(46) = −3.12, p = .003, with a moderate Cohen’s effect size (d = −0.44) as well as the period between T₀ and T₂, t(46) = −3.34, p = .002, with a moderate Cohen’s effect size (d = −0.50).

As for HWS General Vitality, GLM revealed that there was a significant Time × Group interaction, F(2, 178) = 3.39, p = .036, $η_{p}^{2} = .037$ . Post hoc comparisons showed that the IG, but not the control group, underwent a significant increase in this measure between T₀ and T₁, t(48) = 2.45, p = .018, with a small Cohen’s effect size (d = 0.27) and between T₀ and T₂, t(48) = 2.23, p = .031, with a small Cohen’s effect size (d = 0.24). Finally, as for HWS Afflictive Emotion and Spiritual Self-Care, neither GLM nor post hoc t tests detected any significant effects.

Discussion and Application to Practice

The customized IBMS intervention program could effectively improve the holistic well-being (HWS, reduce stress level (PSS), and reduce depression (PHQ-9) of the parents of children with eczema. The results of this study implied the importance of psychosocial therapy in eczema caregiving and generated a new nonpharmacological perspective in eczema management in addition to the conventional treatment approaches.

Contemporary findings from the literature suggested that parents of children with eczema have suffered from various kinds of psychological and social distress in the caregiving process. Although parental training was found to be an effective adjunct to conventional intervention programs on symptom management, there was little focus on the psychosocial impacts of the disease for parent–child dyads, and the well-being of parents has thus inadvertently been understated. Further empirical evidence on the effectiveness of existing education programs for parents was required and that more attention should be given to improving the mental health of parents.

In this study, result of the outcome variables indicated that the IBMS intervention program could effectively improve the parental condition in a number of areas including holistic well-being (HWS), stress levels (PSS), and depression levels (PHQ-9). To date, this is possibly the first psychosocial research study that assisted parents to acquire the necessary skills to enhance their own physical, mental, and spiritual conditions and to improve their holistic well-being in the caregiving process. The customized IBMS protocol successfully engendered change for parents toward the direction of a life with reduced stress and depression and better holistic well-being. The results from the intervention program also provided strong evidence on the effectiveness of psychosocial therapy in eczema control, which can in turn identify new direction for managing the disease to compliment conventional treatment approaches. This is a unique and crucial finding in this study, especially when treatment of eczema has typically been considered from a pharmacological perspective.

Traditionally, eczema was treated as a “disease of a child” that required substantial medication and treatment, and the caregiving journey of the parents could be disturbing and unsettling. However, the results of this research study have shown that eczema could also be considered as a “condition of a family” that required proper management starting from the psychological perspective of the parents. This shift of paradigm has created a new dimension in the current social work practices as well as family counseling approaches. In addition to the conventional pharmacological treatment provided by medical professionals, social workers could play a key role in improving the holistic well-being of the parents by implementing IBMS intervention approach, which would eventually enhance parent–child relationship and increase the resilience of the family in adverse condition (M. Y. Lee et al., 2018; Ruckstaetter et al., 2017).

Nevertheless, some parents also argued that eczema could sometimes be improved “naturally” without going through any specific treatment procedures. The necessity of psychosocial intervention was therefore questionable. Nevertheless, the impact of eczema on the psychosocial well-being of both parents and their children was frequently understated (Ersser et al., 2014; Farasat, 2014), perhaps due to the lack of awareness of people in mental health when managing eczema. The feelings of shame and guilt of parents were not easily identified and measured, but the implications could be disastrous to parent–child relationships (Cohen-Filipic & Bentley, 2015; Ruckstaetter et al., 2017; Tangney, 2002). The outbreak of eczema was multifaceted, and some parents suggested that it was unpredictable but could sometimes be seasonal and have certain patterns (e.g., during school examination periods or change in the weather). While childhood eczema in a mild form of severity may be controlled through regular application of ointments or medication, the chance of childhood eczema in a moderate or severe form being improved “naturally” was unlikely. A long-term treatment process would easily generate psychological stress for parents that should surely be carefully attended.

Furthermore, it is important to define what intervention protocol would be applicable for different groups of participants. Baseline data analysis in this study suggested that parents who were divorced/separated and widowed required more attention and support, and the parents of female children expressed more worries and had greater difficulty relaxing. These groups of parents should receive more attention in future intervention programs. The protocol should be customized to address the psychological and emotional issues encountered by these parents. Regarding the gender of parent participants, although no statistically significant difference was found on the outcome variables between the two gender groups, only 12% of participants (11 of 91) in this program were male parents, so more investigation is required in future studies to identify any gender-specific needs. Future studies should also consider the developmental stages of children in different age ranges, and the protocol should be adjusted accordingly.

Literature suggested that there was a significant correlation in QoL between parents and their children (Dodington et al., 2013; Kelsay et al., 2010). While a reduction in the QoL of children due to the symptoms of eczema tended to negatively affect the well-being of their parents, an improvement in the QoL of children would also result in an enhancement of the well-being of parents. Similarly, this might imply that if the well-being of parents could be improved effectively, the QoL of children would also eventually be enhanced. Indeed, recent studies have suggested that parental stress may increase the risk of childhood eczema, which created a cyclic effect between parents and children (C. L. W. Chang et al., 2016; Elbert et al., 2017; Wang et al., 2016). Furthermore, providing social support for parents can also reduce the outbreak of childhood eczema (Letourneau et al., 2017). However, by emphasizing the psychosocial intervention for the parent–child dyads, there was no intention to downplay the importance of the medical treatment process taken by the children. Parents should continue to seek medical advice, and pharmacological treatment should not be stopped. Nevertheless, physical health was only one of the six dimensions of QoL, and other dimensions including living environments, social relationships, mental health, level of independence, and spiritual life should not be inadvertently neglected (The WHOQOL, 1998). Therefore, improving QoL did not necessarily imply an improvement in physical symptoms only. Indeed, some parents commented that after attending the program, they and their children were more confident and skillful in facing the challenges brought about by eczema, even if the skin condition remained the same.

Nevertheless, severity of the eczema was not considered in this study, which might involve different kinds of caregiving activities and hence implied variations in parental attitude, behavior, and perception on caregiving burden and stress. This study only focused on parents of children between the ages of 6 and 11 (primary school students). Parental stress in taking care of children with eczema in other age ranges should not be understated.

Supplemental Material

Supplemental Material, CONSORT-2010-Checklist-MS-Word_eczema_paper - Efficacy of Integrative Body-Mind-Spirit Group Intervention for Parents of Children With Eczema: A Randomized, Wait-List Controlled Clinical Trial

Supplemental Material, CONSORT-2010-Checklist-MS-Word_eczema_paper for Efficacy of Integrative Body-Mind-Spirit Group Intervention for Parents of Children With Eczema: A Randomized, Wait-List Controlled Clinical Trial by Yat-Lui Fung, Hiu-Tin Leung, Celia H. Y. Chan, Bobo H. P. Lau and Cecilia L. W. Chan in Research on Social Work Practice

Footnotes

Acknowledgments

We thank the staff of The Hong Kong Society for Rehabilitation and The Boys’ and Girls’ Clubs Association of Hong Kong for their contributions to implementing intervention program in this project.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: UBS Optimus Foundation.

ORCID iD

Yat-Lui Fung

Hiu-Tin Leung

Supplemental Material

Supplemental material for this article is available online.

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