Discussion
There were significant correlations between AD severity, caregiver
illness perceptions, QoL and SE. Timeline cyclical (whether the AD was
believed to be re-occurring) did not significantly correlate with any
other variable. This was unexpected as AD can be chronic and
episodic.2 This non-significance could be explained by
varying item agreement within the timeline cyclical subscale. For
example, in an AD adult population, agreement with an IPQ-R item which
refers to symptoms changing daily, was significantly lower than other
items that are explicitly cyclical.27 Building on
existing evidence,16,27 this study found stronger
correlations between QoL, emotional representations and consequences
than between AD severity and QoL. This suggests that caregiver QoL may
be impacted more by a caregiver’s emotional response to their child’s AD
and their perceptions of its consequences on the child’s life than
severity of the AD.
When asked about causal beliefs 68% of participants in this study
believed their child’s AD was hereditary. There is a direct link between
cause and control factors28 and ‘hidden causes’ under
which genetic/biologic factors are classified are considered the least
controllable compared to environmental or behavioural
causes.29 This implies that parents who believe their
child’s AD is hereditary may feel they have less control over it,
thereby lowering their SE.
The hierarchical regression model found that caregiver illness
perceptions (consequences, emotional representations and identity), AD
severity, and SE predicted 72% of the variance in caregiver QoL. Adding
SE at the third step did not explain additional variance. These results
might suggest that SE is not a significant predicter of QoL which
contrasts with existing research.12,13 A probable
explanation is that the lack of additional variance explained by SE is
due to multicollinearity, as SE is correlated with, and mediates,
illness perceptions. In order to explore this a separate simple linear
regression was run with just SE as the predictor, where it was able to
explain 25% variance in QoL.
The importance of SE is further shown in the results of the mediation
analysis, where SE mediated between all illness perceptions and QoL,
except emotional representations. SE was found to fully mediate the
relationship between caregiver views on chronicity, illness coherence
and identity and QoL. This implies that the effect of these illness
perceptions on QoL within those models was transmitted entirely through
SE and so SE rather than these illness beliefs may be better targeted in
interventions aimed at improving QoL. SE did not mediate between
emotional representations and QoL, and therefore interventions should
also focus on negative emotions such as fear anger and depression. Not
only were negative emotions linked to reduced QoL but can also cause
individuals to underestimate their ability thereby reducing
SE.30
This study has a number of limitations. The mediation and hierarchical
regression models leave a proportion of variance unexplained. Unexplored
predictors could include coping strategies, and anxiety and depression,
which are common in caregivers of children with
AD.9,31 Whilst the current study’s mediation models
are rudimentary and oversimplify the mechanisms between illness
perceptions and self-efficacy, the results offer preliminary support to
the integration of the CSM and SE models. More variables included and
controlled for in future longitudinal research would allow for a more
thorough examination of the causal mechanisms.
Overall, the study’s results imply that SE, emotional representations
and perceptions of consequences are the most important variables to
target to improve caregiver QoL. The findings emphasise the need for
psychological assessment and treatment of caregivers to be embedded in
the dermatological treatment pathway and have several implications.
Clinicians need to be aware that caregivers can be less capable of
managing their child’s condition if they perceive the consequences more
negatively and struggle emotionally. By assisting caregivers to gain a
realistic understanding of the consequences and causes of their child’s
AD, clinicians may be able to reduce the negative emotional impact. The
findings provide a foundation for future interventions targeting these
modifiable variables to support better QoL in caregivers who, in turn,
can provide optimum care to their children living with AD.