Can knowledge mobilisation through understanding and amending lay and clinician mindlines improve the experience of eczema treatment in primary care? An ethnographic study.
Eczema is a common, chronic skin condition which impacts significantly on quality of life and is commonly managed in primary care. Previous research has found that consultations about eczema are often perceived as unsatisfactory for both clinicians and patients. Non-adherence to prescribed treatments is the leading cause of treatment failure and results from the high demands of applying topical treatments but also lack of information and conflicting advice from health professionals. Providing evidence-based treatment appears to be a challenge for health professionals managing eczema. Knowledge mobilisation (KM) is a deliberative effort to move the right knowledge to where it is most useful. One approach to KM is influencing mindlines “collectively reinforced, internalised tacit guidelines” which underpin day-to-day practice. This study examined how eczema specific mindlines are developed by lay people (patients and parents), and clinicians in order to identify areas of synergy and dissonance prior to developing strategies for improvement.
Ethnographic observation (>250 hours) in one general practice and pharmacy and interviews with people with eczema and those who care for them (general practitioners, nurses, health visitors, pharmacy staff) (n=32) were conducted in central England in 2017. Following ethnographic data analysis further lay and clinician interviews (n=50) verified understanding and interpretation of mindlines.
Clinician data indicates eczema specific mindlines are relatively static as perceived need and incentives to amend them is minimal. Three themes were identified: beliefs about eczema, eczema knowledge and approaches to self-management. Clinicians consistently believed that most eczema is a minor, simple to treat condition which is not a high priority. Practice is largely based on tacit knowledge and experience and is constrained by local prescribing guidance. Self-management is expected but not often explicitly facilitated.Lay data revealed four themes: doctor knows best; not worth bothering the doctor; I need to manage this myself and how I know what to do. These themes were linked to four broad typologies of approaches to eczema management: content to self-manage; content to accept clinician management; self-managing by default and those referred to secondary care. Key areas of synergy were caution in the prescription and use of topical steroids and a reactive, ‘trial and error’ approach to management. Dissonance was most marked between clinician’s perception of eczema as a minor condition which is simple to treat and lay perspectives in the ‘self-managing by default’ category who were identified as being most receptive to new knowledge.
The outstanding challenge is to find strategies to revise or modify these mindlines by adding reliable and useful knowledge and by erasing outdated or inaccurate information. Further work will now use co-creative methods aimed at influencing clinician and ‘self-managing by default’ patients in parallel with the intention of improving consultation experiences and self-management practices.