Background
National Health Service (2016) stated that atopic eczema (atopic dermatitis) is more prevalent amongst children and often developing just before their first birthday. Nevertheless, atopic eczema can develop for the first time at any age, even in adults. Knott (2015) highlight that atopic eczema is very prevalent in developing countries, affecting approximately 20% of children; as well as, around 80% of children under the age of 5 years are affected by atopic eczema.
NHS (2016) advise that atopic eczema is usually a long- term condition; however, in some children it may improve or even clear up totally as they become older. (Knott 2015) suggest that atopic eczema is a chronic inflammatory skin condition that are characterised by dry patches, red, itchy, sore and sometime broken skin. Atopic eczema can affect any area of the body, typically the extents of the creases, amongst the elbow and area behind the knees.
Frowen et al (2010) states that the source of atopic eczema is of genetic predisposition, which is frequently connected to other atopic diseases such as asthma and hay- fever allergy. The cause is complex and multifactorial- nevertheless the main underlying factor is a defective skin barrier.
Whilst Smith 2017 argues that atopic eczema occurs due to immune dysregulation and abnormality in the permeability in the skin barrier function. Where by filaggrin mutations are found abnormal high permeability of epidermal skin layer improved water loss
National Institute for health and care excellence (2017) highlight that atopic eczema are best managed with regular application of emollient cream, as a moisturising treatment; while mild to moderate eczema can be treated with 1% hydrocortisone cream not including the face and genitals area
Methods
Following the conclusion of the chosen topic a research question was developed by means of using the PICO formation. In PICO the P is for population-the question was identified as under 5 years old Children with atopic eczema. I is for intervention –Emollient or hydrocortisone cream. The C is for counter-intervention- no counter intervention. The O is for outcome- treatment compliance (Craig and Smith 2012).

Table 1- PICO analysis
Population Intervention Counter- intervention Outcome
under 5 years old Children with atopic eczema Emollient or Hydrocortisone cream No comparison treatment adherence

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The formulated PICO clinical question was- Parents and carers perception to adherence in applying Emollients cream to under 5 years old children with atopic eczema?
To locate a suitable research paper that would answer the chosen clinical question. Three electronic databases were chosen to search. Ovid Medline 1946 to March 2018; this database was chosen due to its contains the largest amount of literature on biomedical sciences and health. This database is updated weekly as well as it hosts numerous international journals, these studies are relevant to uses in the United Kingdom (Melnyk & Fineout-Overholt 2011). CINAHL database was chosen due to its being a large nursing database of allied health journals, dissertations and books which are updated weekly with the most recent articles and journals since 1981 to March 2018, (Melnyk & Fineout-Overholt 2011). This database cover researches studies on atopic eczema that are relevant for the chosen clinical question. EMBASE was chosen due to its consists of journals that are not available on the other databases. Also, EMBASE is of European focused and contains large numbers of literature resource on biomedicine and drugs research relating to clinical nursing practice since 1974 to March 2018, (Goyal 2013).
Brooker and Waugh (2013) proposed that index term also termed as medical subject headings (Mesh). The database search was carried out using the index terms search to find suitable articles that are classified by the database as the primary topic in the article (Craig and Smyth 2012. All the articles where Atopic dermatitis is the primary focus would be indexed as atopic dermatitis. So, the index term “atopic dermatitis” would fall into such group and the database search would show all such articles.
The index term search was equally completed on all the other components of the research question- Emollient cream, treatment adherence and compliance.
Brooker and Waugh (2013) proposed that free text terms are the expansion of a list of words that describe each section of the search question into more detail. However, free text search is very sensitive, and the outcome could result in retrieving high volume of articles where the search term only produces a minor segment. So, articles which may not have been indexed properly would likewise be classify (Craig and Smyth 2012). Differences search terms were used, so that important articles would not be missed for example, atopic eczema is also known as atopic dermatitis. Truncation terms was used to search, since it provides plurals ending of the same word terms; this is a way of not having to type out numerous terms. The Truncation symbol used was the $ at the end of the words to find different dissimilarity such as Bab$ would classify baby or babies (Godshall 2016).
Godshall (2016) proposed that the Boolean search operator describes logical relationships amongst terms in a search. Boolean operators search terms is OR, and AND to find articles consisting all the terms required to answer the clinical question (Craig and Smyth 2012). The terms documented under were atopic dermatitis Or atopic eczema children$ Or atopic dermatitis Infant$ Or eczema Bab$. The linking word used here was OR this was used to locate articles covering unique terms would be located. The terms were used under Intervention and Outcome AND joint the search terms together so that articles that contain all of them are classified- Atopic dermatitis, atopic eczema children$, hydrocortisone cream$ and treatment adherence.
Davies (2014) highlight points to consider in efficient search strategy like inclusion
and exclusion criteria. Inclusion criteria looks at research that published in English and within 10 years as only the most recent and up to date research are to consider. Whilst exclusion looks at research published more than 10 years as well as articles published in other language.
To find the research paper a thorough search was concluded to locate the right article that would answer the clinical question see facet analysis below in table 2

Tablet 2-facet analysis with search plan
Population Intervention Counter- intervention Outcome
Facet-analysis
Atopic dermatitis
Or Emollient cream
Or No comparison Treatment
Adherence
Atopic eczema children$
Or Hydrocortisone cream$
Or No comparison
Or
Atopic dermatitis
Infant$
Or
Eczema
Bab$ Hydrocortisone lotion$ No comparison Compliance

During the database search, 3 research papers were identified to be relevant to answer the clinical question. One research study was chosen: Santer et al (2016) ”Parents’ and carers’ views about emollients for childhood eczema: qualitative interview study” the study is qualitative studies that explore parents and carers views, experiences and understanding of the use of leave on emollients treatments of children with eczema. Nevertheless, there was poor adherence. The study draws on two study group with different knowledges of eczema education and support giving a diversity of views and understandings.
Table 3 findings
Databases searched Number of hits Studies relevant to the question Study designs
Ovid Medline 5 1 Qualitative interview study
CINAHL 9 1 Qualitative study
Embase 6 1 Qualitative interview study

Critical appraisal
The chosen paper by Santer et al (2016) is a qualitative interview study, which clearly focused on parents and carers of child with eczema. This study is a Qualitative research, studying the effectiveness and acceptability of leave-on emollients treatment as an intervention for childhood eczema. Therefore, it would deem as appropriate for the research topic. Additionally, it draws on two study groups with different experiences of child eczema with different educational background and support, giving the diverse of views and understandings of child with eczema.
The researcher looks at non-adherence of long- term leave-on emollients treatments for childhood eczema in 0 to 5 years; how it thought to be a barrier to effective treatment of eczema. Corkin (2012) suggest that poor adherence to treatment can occur due to misunderstanding of topical preparations.
Keele (2011) argue that all research studies have imperfection; so, it is necessary to critically evaluate the research process and finding, as well as consider their strength and weakness before considering any changes in practice. The qualitative research checklist, Critical Appraisal Skills Programme (2013) will be used to appraise the selected research paper. In study 1 population, staff from six general practices in the south of England search database looking for carers/parents with young children under 5 years with eczema and invite them through post, to participate in a develop web-based self-care support study as an intervention for eczema treatment. Invites were sent to 289 homes; so, 70 participants respond, 33 participants said their child eczema was no longer a problem, 3 participants declined for various reasons and 6 participants were not contactable; 28 participants. All participants in studies were parents of children with eczema (CASP 2013). Researcher purposively sampled participants from a numbers of parental and child ages and differing geographical areas. Knowledgeable consent was sought previously to the interviews, which were semi-structured and followed an interview guide Interviews lasted 30–60 min, taking place in contributors’ homes besides for one in which the participant chose to be interviewed at her health centre.
In study 2 the researcher state that participants were chosen from lower socioeconomic background of a range of ages and geographical areas. The interviews were carried out in the form of a feasibility trial that randomised participants into three sub- groups. Which suggest that participant was unaware of what treatment the other groups would receive (CASP 2013). The web-based intervention contained information about rationale for emollient use, videos on emollient use and a ‘2-week challenge’ for carers to use emollients frequently and judge the difference for themselves (CASP 2013). This information was clearly presented to participant. Out of 143 participant who take part in the study only 82 agreed to give feedback. Due to the high drop-out in giving back feedback. The feedback result was based on genuine accuracy (CASP 2013).
Santer et al (2016) highlight that some parents hold mixed feeling and caution about applying emollients to their child as they feel it unnatural or it contain too many chemicals. Whilst other says the child skin becomes used to the emollients as well as the emollients lose their effectiveness if used frequently. Others states that leave on emollients did not work and they sting her child (CASP 2013). These views from some of the parents clearly suggest that adherence to emollients as an intervention in eczema treatment will encounter challenge in clinical practice. Bass et al (2015) proposed that poor adherence is a major problem that affecting treatment outcome. Santer et al (2016) suggest that previously research study proposed that some carers have concern about the used of topical corticosteroids, but this research study highlight that carers/ parents of eczema not only have concern about the use of corticosteroid; but they also have concern about the use of emollients treatment in child eczema (CASP 2013). Therefore, its is necessary for clinical practitioner to inform and demonstrate to carers of eczema child how to use emollients treatment.
Since patients who are well informed will understand the important of treatment adherence (Falvo 2011).
The ?ndings are supported by having been drawn from two study groups with different knowledges of eczema education and support, highlighting that carers who had received self-care support seemed happier to use emollients in the long term (CASP 2013).

Implementation plan
Sexton (2011) argues that constructive implementation is like limitless family therapy. Should other proposal come to light to back- up the need to change practice and implement a new one. potential barriers to implementation are required to be identified and addressed (Melnyk and Morrison-Beedy 2012).
Barriers recognised could include not having enough time to undertake any research, lack of support from colleagues and management, lack of experience/knowledge or working in environment resisting (Timmins et la 2012).To overcome these barriers, the individual initiating the implementation of new practise need to believe that the change can be achieved and share this vision with other which in turn can then lead to organisational change (Menlyk and fineout-overholt,2012)
Lewin’s model is a theoretical model that could be used to facilitate change in current practise. This model based on three of change: unfreeze, change and freeze (Connelly 2008). This high prevalence in vitamin D deficiency in breastfed babies was identified as an initial problem and the need to address it arose which in turn would act as the motivation factor for the change (the unfreeze stage). Health practitioners would need to understand the need for the purposed change e.g. mothers not willing to supplement their babies directly. The change stage practitioner are being taught about the new practices. They would need to understand the vitamin D transfer from mothers to babies and how much the mothers need to take in order for it to be effective. During the last the last stage the new practise of encouraging mother to take 6100 IU per day of Vit D supplement becomes a standard care which will be a subject of regular reviews (Baker2013).

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