Abstract
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Purpose
This pilot study aimed to develop and conduct an initial evaluation of a self-care improvement program for older school-aged children with atopic dermatitis (AD).
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Methods
A quasi-experimental, non-equivalent control group pretest-posttest design was used with 20 children in grades 4–6 diagnosed with AD. The experimental group (n=12) received a 5-week Information-Motivation-Behavioral Skills (IMB)-based program, which included five 40-minute sessions for children and one 50-minute session for mothers. The control group (n=8) received usual care. Data was collected at baseline, immediately after the intervention, and 4 weeks post-intervention. Outcome variables included AD knowledge, motivation for AD self-care, self-efficacy for managing AD, self-care behaviors, and AD severity. Generalized estimating equations were used for analysis.
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Results
Time-by-group interaction effects were observed for AD knowledge (p<.001), personal motivation (p=.011), self-efficacy (p=.034), self-care behaviors (p=.027), and AD severity (p=.039). Improvements in knowledge, motivation, and self-efficacy persisted through follow-up, while changes in self-care behaviors and AD severity were significant only at posttest.
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Conclusion
This study provides preliminary evidence that an IMB-based self-care program can improve knowledge, motivation, and self-efficacy in children with AD, leading to better self-care behaviors and reduced symptom severity. These findings support the feasibility and potential usefulness of a structured, theory-based intervention. Further fully powered trials are needed to confirm effectiveness and identify strategies for maintaining long-term outcomes.
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Key words: Atopic dermatitis; Children; Health education; Self care
INTRODUCTION
Atopic dermatitis (AD) is a common chronic inflammatory skin disease in children, marked by itching and eczematous lesions. Reported prevalence varies widely depending on the survey method. In South Korea, the lifetime prevalence among school-aged children is 25%–29% [
1], and the current prevalence is 4.43%, with a continuing upward trend [
2]. Children with AD have reduced quality of life because of skin damage and pruritus, may develop negative body image due to visible lesions, and can become targets of peer teasing [
3]. Parents of children with AD often experience stress and depression because of the high demands of care [
4] and may have difficulty forming positive parent–child relationships while managing dietary restrictions and discouraging scratching behavior [
3].
Uncontrolled AD increases the risk of allergic rhinitis and asthma, emphasizing the need for active treatment and management. Essential management strategies include keeping skin clean and moisturized with proper bathing and emollient use, reducing exposure to irritants, and removing aggravating factors [
5,
6]. Although the prevalence of severe AD is rising among children in the Republic of Korea, only 1.10% of diagnosed cases are classified as severe, with most cases being mild to moderate [
2]. Mild to moderate AD can be managed effectively with topical corticosteroids, topical immunomodulators, basic skin care, and other topical treatments [
5]. Nevertheless, many patients continue to experience worsening symptoms, pruritus, and sleep disturbance due to non-adherence to treatment and inappropriate symptom management, which negatively affect the quality of life of both children and their families [
3,
7]. Therefore, interventions to promote sustained self-management and appropriate medication use are needed.
Psychological and educational interventions improve AD management in children [
8]. In Korea, policy-level initiatives have been introduced since the Ministry of Health and Welfare announced a comprehensive plan for AD and asthma prevention and management in 2007. For example, the Seoul Metropolitan Government has conducted camps for children with AD [
9] and implemented school-based health management programs [
10]. Atopic and Asthma-Friendly Schools have also been established to support children with AD. However, as of 2023, only 736 of approximately 6,000 elementary schools nationwide were designated as Atopic and Asthma-Friendly Schools, indicating limited implementation of AD management for school-aged children [
11]. In addition, designated schools continue to face challenges because of insufficient education and limited support [
10].
Individualized educational opportunities remain limited, and when available, are usually directed toward parents rather than children [
12]. Because AD often develops during infancy, parental management—especially by mothers as primary caregivers—is crucial. As the disease becomes chronic, mothers report increased caregiving burdens due to persistent symptoms [
13]. Managing AD requires comprehensive daily management, including diet, hygiene, and environmental factors. As children grow older and become more independent, parental control over these aspects becomes more difficult. Teaching children age-appropriate self-care skills and enabling them to perform these behaviors is essential for controlling symptoms and reducing caregiver burden. Improving treatment adherence among children with AD and their parents requires educating children about self-care, as they must apply medication independently and actively participate in management [
7].
As children’s cognitive development advances, they gain the ability to understand their health status and practice self-care behaviors [
14]. Late school-age children begin to develop the skills needed to understand and manage their health conditions [
15], making this a critical period to establish self-care behaviors for AD.
Unlike existing programs that primarily provide environmental support or parent-focused education, this pilot study developed and implemented a child-centered AD self-care program to promote management behaviors and reduce symptoms in late school-age children. The study aimed to evaluate the program’s feasibility and preliminary effects, providing initial evidence of its applicability and informing future fully powered trials.
1. Conceptual Framework
This study’s conceptual framework is based on the Information-Motivation-Behavioral Skills (IMB) model, which includes information, motivation, behavioral skills, health behaviors, and health outcomes [
16]. Although several theories explain health behaviors in children, the IMB model is widely used for pediatric conditions such as obesity management and diabetes self-management and is recognized as a practical framework for supporting sustained behavioral change [
17,
18]. Because AD management requires children to perform daily behavioral tasks (e.g., medication application, moisturizing, symptom monitoring), the IMB model offers a coherent structure to address the main factors influencing effective self-care in this group.
In this framework, information refers to children’s knowledge about AD, motivation reflects their attitudes toward disease management and perceived maternal support, and behavioral skills indicate their self-efficacy in managing the condition. Health behaviors refer to adherence to recommended management practices, and health outcomes are measured by the severity of AD symptoms.
2. Study Objectives
This study aims to develop and implement a self-care program to improve children’s knowledge, motivation, and self-efficacy in managing AD. The program also provides parental education to increase social motivation and supportive involvement. The program is expected to promote children’s self-care behaviors and reduce the severity of their AD symptoms (
Figure 1).
METHODS
Ethical statements: This study received approval from the Institutional Review Board of Seoul National University (IRB No. 2406/001-010). All participants provided informed consent.
1. Study Design
This study followed the Intervention Mapping (IM) protocol [
19], a systematic methodological framework that guides the development of self-care programs for older school-aged children with AD. To assess feasibility and examine preliminary effects, the study used a quasi-experimental pre–posttest design. Reporting adhered to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines [
20].
Participants were elementary school students in grades 4–6 with AD who voluntarily agreed to participate after recruitment through promotional materials at elementary schools, community child centers, and online communities. Eligibility criteria included: (1) students in grades 4–6 diagnosed with AD by a physician who had experienced symptoms for more than 6 months (including periods of exacerbation and remission). Exclusion criteria were: (1) children diagnosed with severe AD who were receiving hospital-based care or injection therapy; (2) children participating in other AD management programs provided by external institutions during the study period; and (3) children who had difficulty communicating in Korean or completing the study questionnaires.
A total of 22 children were screened for eligibility through offline and online recruitment channels. One child was excluded for not meeting the inclusion criteria, and one declined participation. The remaining 20 children provided informed consent and were enrolled in the study. Recruitment occurred from May 2024 to January 2025, and outcome data were collected from July 2024 to March 2025. Participants were assigned to the experimental or control group based on availability and preference because of feasibility constraints. To reduce potential selection bias, both groups were recruited during the same period using identical recruitment materials and eligibility criteria. All participants received the same explanation, consent procedures, and assessment schedule.
Pilot studies typically assess feasibility rather than detect statistically powered effects and often include 10–30 participants per group [
21]. Methodological guidance also indicates that 12 participants per group is a reasonable minimum for estimating variance parameters when planning future trials [
22]. In this study, 12 children enrolled in the experimental group and eight in the control group. There were no dropouts, so 20 participants were included in the analysis. Although the final sample size reflects recruitment challenges in the community setting, it aligns with recommended ranges for exploratory pilot studies.
This study developed a self-care behavior promotion program for children with AD using IM, a systematic framework for designing theory- and evidence-based health promotion interventions [
19]. IM offers a structured, stepwise process that links interventions to identified needs and theoretical models.
IM includes six steps: (1) assessing health problems and needs (logic model of the problem), (2) defining program outcomes and objectives, (3) selecting theoretical methods and practical strategies, (4) designing and producing program components, (5) planning program adoption and implementation, and (6) developing an evaluation plan. Each step builds on the previous one, connecting health behavior determinants to intervention strategies. This process increases transparency in decision-making and ensures that interventions are evidence-based, contextually appropriate, and feasible.
IM has been widely applied to various populations and health issues. Previous studies have shown that IM is effective for promoting health behaviors and self-care practices in children [
19], making it suitable for this study. Although the IM process is complex and time-consuming, it is valued for improving the systematicity, transparency, and effectiveness of interventions [
19]. In the context of AD, where management involves pharmacological treatment, consistent skin care, and trigger avoidance, IM offers a strong framework to integrate these practices with strategies that enhance children’s knowledge, motivation, and behavioral skills, while including parental support. Therefore, this study used the six IM steps to systematically develop a self-care promotion program for late school-aged children with AD.
1) Step1: logic model of the problem
In the first stage, health problems and contributing factors were identified. A literature review examined barriers to managing AD symptoms and established program goals based on these needs. Factors influencing health were classified as personal or environmental.
Personal factors mainly included insufficient self-care behaviors, which are central to managing chronic conditions [
23]. AD management consists of three core components: pharmacological treatment, skin care, and trigger avoidance, along with the essential task of breaking the itch–scratch cycle by controlling pruritus [
6]. Without consistent use of these behaviors, effective control of AD is not possible. According to the IMB model, inadequate practical knowledge about AD management, low motivation for self-care, and insufficient behavioral skills may all contribute to poor self-care among children.
Environmental factors primarily involved barriers faced by mothers, who play a critical role in shaping children’s health behaviors. Families often lacked an integrated, long-term approach to management. They typically received medication-focused care without comprehensive guidance on daily environmental control or skin care, and management was rarely maintained during periods of improvement, despite the relapsing–remitting nature of AD. In Korea, most pediatric AD patients are treated in dermatology clinics, where care is mainly pharmacological and less emphasis is placed on environmental, or avoidance strategies compared to pediatric or allergy clinics [
12].
Second, reluctance to use topical corticosteroids was a major barrier. Concerns about side effects often led to steroid phobia, and misconceptions about the relapsing–remitting course of AD created unrealistic expectations of a complete cure [
7,
12]. As a result, many patients and caregivers viewed corticosteroids as temporary solutions and avoided their appropriate use [
7,
24].
Third, difficulty establishing trust with healthcare providers hindered effective management. Limited consultation time restricted opportunities for structured education [
24]. Consequently, caregivers often turned to the internet, where a nationwide survey found that most AD-related Korean websites offered anecdotal, experience-based content with little evidence-based information. This led to misconceptions about steroid use and frequent adoption of unproven complementary and alternative therapies [
25]. Caregivers often placed more trust in personal accounts than in professional recommendations, resulting in reliance on unproven treatments and inappropriate management practices.
2) Step 2: program outcomes and objectives
In the second step, specific performance objectives (POs) that individuals and their environment must achieve to meet the program goals were identified, and detailed change objectives were developed for each PO. These change objectives were linked to determinants influencing behavioral or environmental change and organized in a matrix format [
19].
The main goal of this program was to alleviate AD symptoms in children. Based on the Step 1 needs assessment, four POs were established: (PO1) treating AD with medication, (PO2) caring for skin with a shower and moisturizer, (PO3) ceasing or reducing scratching, and (PO4) identifying and avoiding triggers of AD.
Change objectives were then formulated using the IMB model as the theoretical framework, resulting in a matrix of behavioral determinants. In this framework, children’s information, personal motivation, and behavioral skills were categorized as personal factors, while social motivation was classified as an environmental factor (
Table 1).
3) Step 3: program design
In the third stage, the program was developed by identifying theoretical methods to achieve change and selecting practical strategies for their application [
19]. Using the IMB model, a matrix was created to guide strategies for improving children’s knowledge, attitudes, and behavioral skills. Based on this matrix, theoretical methods from the IM framework—such as advance organizers, persuasive communication, reinforcement, guided practice, goal setting, individualization, consciousness-raising, and self-monitoring of behavior—were selected [
19], with habit reversal added as an additional behavioral strategy [
26]. These methods were then translated into practical strategies and integrated into key program components, including group education sessions, in-class activities, and workbook-based home activities to promote self-care behaviors in children with AD.
4) Step 4: program production
In the fourth step, the intervention content and materials were developed. The program consisted of 5 weekly sessions, structured according to previous research. Evidence does not confirm the effectiveness of a single brief educational session, indicating that a multi-session program addressing comprehensive AD management is preferable [
8]. Studies providing educational interventions in multiple sessions reported 4–12 sessions [
8,
27].
The number of sessions for this program was determined by reviewing the essential content needed to meet the POs identified in Steps 1 and 2. Three core components of AD management [
6]—pharmacological treatment, skin care, and trigger avoidance—were each addressed in separate sessions. An introductory session was included to provide foundational knowledge and improve children’s understanding of AD and its chronic, relapsing–remitting nature. Stress management was also added as a dedicated session because psychological stress is a well-established factor that worsens symptoms, affects scratching behavior, and disrupts treatment adherence [
8]. Based on these factors, the program was organized into 5 weekly themes: understanding AD, medication treatment, skin care through bathing and moisturizing, avoidance therapy to identify and manage triggers, and stress management.
Session duration was set based on feasibility and developmental appropriateness for children in grades 4–6. As one elementary school class period lasts 40 minutes, each session matches this length. Sessions followed a three-part structure: introduction, development, and conclusion. At the beginning of each session, children’s AD symptoms were assessed, and results from the previous week’s home activities were shared. The previous session’s content was reviewed before introducing the new topic.
Educational materials for children and mothers were prepared separately as PowerPoint slides and compiled into booklets. A workbook supported both in-class and home activities, aligned with the session schedule. It summarized key management points and included structured exercises, such as creating daily AD care schedules, recording symptoms, and practicing daily self-care. The workbook also included an AD management diary to encourage children to continue self-monitoring after completing the program.
Although the program primarily focused on educating children, mothers play a key role in managing their children’s health. Therefore, one session targeted mothers to help them support their children’s use of program content at home.
To ensure content appropriateness, the program materials were refined through scholarly review during development. The overall structure and educational content were based on existing literature and theoretical frameworks, with iterative revisions to improve clarity and developmental suitability for school-aged children. A child psychiatric nurse reviewed the stress-management session (week 5), advising on the appropriateness and organization of the content. These scholarly and clinical inputs supported the clinical relevance and clarity of the educational materials. The program was pilot tested with one child and two mothers to assess the appropriateness of its content and vocabulary. Revisions were made based on feedback, and the final version of the program was refined.
5) Step 5: program implementation plan
This study received approval from the Institutional Review Board of Seoul National University. Because the program targeted children with AD living in the community, participants were recruited through elementary schools, community child centers, and online parenting communities. In schools and community child centers, the researcher explained the study purpose to institution heads, who then distributed recruitment notices to children and their parents. In online communities, the researcher posted the recruitment notice directly.
The researcher who developed the program delivered the intervention. To improve accessibility, most child sessions were conducted online, with only the first and final sessions held in person. Each child session lasted 40 minutes and was conducted in small groups of two to four participants. The mothers’ program included a single 50-minute one-on-one online session.
To reduce participant dropout, the researcher made intentional efforts to build rapport and maintain engagement. During the initial in-person session, the researcher explained the study’s purpose and significance to both children and their mothers to strengthen their understanding of the program’s value and establish trust. Throughout the 5-week program, reminder messages were sent before each session, including brief feedback on the child’s participation in the previous session and a summary of the goals for the upcoming week. These strategies aimed to sustain motivation and ensure consistent participation during the intervention period.
6) Step 6: evaluation plan
To evaluate the program’s effectiveness, participants were assigned to either an experimental group that participated in the program or a control group that continued their usual care. Because AD symptoms fluctuate between exacerbation and remission, immediate intervention was provided when children expressed willingness to participate, as they were likely experiencing symptoms at that time. Since participants were recruited from the community rather than specific institutions, immediate intervention was also expected to reduce withdrawal.
A non-equivalent control group pre–post design was used. Outcome variables were measured at 3 times: before the intervention, immediately after the program, and 4 weeks post-intervention to assess the sustainability of the effects. Changes in outcome variables over time were compared between the experimental and control groups.
4. Measurements
1) General characteristics
General characteristics for both children and their mothers were assessed based on prior studies and confirmed through maternal responses. Children’s characteristics included age, gender, time of diagnosis, types of medications currently used, identified allergens, and presence of other allergic diseases. Maternal characteristics included age, education level, employment status, history of AD, presence of other allergic diseases, prior education about AD, and use of complementary and alternative therapies.
2) Atopic dermatitis knowledge
Children’s knowledge of AD was measured using the tool developed by Kim and Choi [
28] for mothers of children with AD. The instrument includes 21 items in five domains: overview, skin care, medication, diet, and daily life. To reduce bias, some items are negatively worded, and an “I don’t know” option is available. Each correct answer receives 1 point; incorrect or “I don’t know” responses receive 0, resulting in a total score range of 0–21. Higher scores reflect greater knowledge of AD. Cronbach’s α was 0.65 at development and 0.66 in this study.
3) Atopic dermatitis self-care motivation
Children’s motivation for AD self-care was measured using a researcher-developed tool based on previous AD studies [
29]. The tool assessed personal motivation (attitudes toward self-care) and social motivation (perceived maternal support) using a 5-point Likert scale. Four pediatric nursing professors and one school health teacher at an Atopic Dermatitis and Asthma Safe School evaluated content validity, and all items met the required threshold. Although no formal pilot test was conducted, two elementary school children (grades 4–6) confirmed the vocabulary was appropriate. After removing items that reduced reliability, the final tool included two personal motivation items and six social motivation items. Cronbach’s α was 0.61 and 0.82, respectively.
4) Self-efficacy in managing atopic dermatitis
Children’s self-efficacy in managing AD was measured using a modified version of the Parental Self-Efficacy with Eczema Care Index (PASECI [
30]), which had been translated into Korean and validated by Lee et al. [
31]. The original PASECI, designed to assess parental efficacy in caring for a child’s eczema, consists of 29 items in four domains: medication management, symptom management, communication with healthcare professionals, and managing personal challenges. For this study, the instrument was adapted for children’s direct use. With permission from the original developers, the domains of communication with healthcare professionals and managing personal challenges were removed because they are specific to caregivers. The remaining 12 items from the medication management and symptom management domains were reworded to reflect the child’s perspective (e.g., changing “I help my child…” to “I can…”). Each item was rated on a scale from 0 (“not at all”) to 10 (“very confidently”), with total scores ranging from 0 to 120. Higher scores indicated greater self-efficacy. Cronbach’s α was 0.91 and 0.87 in the original study, and 0.82 and 0.86, respectively, in this study.
5) Atopic dermatitis self-care behaviors
Children’s AD self-care behaviors were assessed using a structured questionnaire adapted from previous studies [
9] and AD management guidelines [
6]. The questionnaire included items on moisturizer use, showering, coping with itching, and adherence to six management guidelines. Four pediatric nursing professors and one school health teacher at an Atopic Dermatitis and Asthma Safe evaluated content validity, and all items met the acceptable threshold. Although no formal pilot test was conducted, two elementary school children (grades 4–6) confirmed that the vocabulary was appropriate. Higher scores indicate better self-care behaviors for AD.
6) Atopic dermatitis severity
Children’s AD severity was assessed using the Scoring Atopic Dermatitis (SCORAD) index [
32]. SCORAD is widely used for consistent evaluation of disease severity by both specialists and trained non-specialists. The tool measures objective symptoms (extent and severity of skin lesions) and subjective symptoms (itching and sleep disturbance). Lesion severity is rated from 0 (none) to 3 (severe) for six features: erythema, edema, oozing/crusting, excoriations, lichenification, and dryness. Subjective symptoms are scored from 0 to 10 for both itching and sleep loss. Total scores of 0–14 indicate mild, 15–40 moderate, and 41 or higher severe AD. Higher scores indicate greater symptom severity.
The data were analyzed using IBM SPSS ver. 29.0 (IBM Corp.). Descriptive statistics (frequency, percentage, mean, and standard deviation) summarized participants’ general characteristics. The Shapiro-Wilk test assessed the normality of outcome variables. Baseline homogeneity between the experimental and control groups was examined using the chi-square test or Fisher’s exact test for categorical variables. For continuous variables, independent t-tests were used when the normality assumption was met, and the Mann-Whitney U test was used when the assumption was not met. Because this was a pilot study with a small sample size, generalized estimating equations (GEE) were used to examine differences in dependent variables between the two groups over time. GEE was chosen because it accommodates repeated measures data without requiring normality assumptions.
RESULTS
1. General Characteristics and Homogeneity Test of Variables
Twenty participants were included: 12 in the experimental group and eight in the control group. The mean age was 10.58 years in the experimental group and 10.38 years in the control group. The mean duration of AD diagnosis was 8.04 years in the experimental group and 9.13 years in the control group. At the time of the study, six participants (50.0%) in the experimental group and 6 (75.0%) in the control group were receiving medication. Among participants with identified allergens, 10 (83.3%) were in the experimental group and 5 (62.5%) were in the control group. For those with concomitant allergic diseases, 10 (83.3%) were in the experimental group and 6 (75.0%) were in the control group. Prior education on AD management from mothers was reported by five participants (41.7%) in the experimental group and 4 (50.0%) in the control group. The main sources of information about AD were healthcare facilities and the internet. No significant baseline differences were found in general characteristics (
Table 2) or outcome variables (
Table 3), confirming group homogeneity before the intervention.
1) Atopic dermatitis knowledge
Testing the difference in changes in AD knowledge scores between the experimental and control groups over time showed a significant interaction between time and group (χ
2=20.43,
p<.001), indicating preliminary positive effects of the program. The exploratory effect size for the pre–post change was Cohen’s d=1.27. Parameter estimates showed that the intervention had a significant effect at both the post-intervention (
p<.001) and follow-up (
p<.001) assessments (
Table 4).
2) Atopic dermatitis self-care motivation
Motivation scores showed a significant time-by-group interaction (χ
2=8.36,
p=.015). The exploratory effect size for the pre–post change was Cohen’s d=0.06. In the personal motivation subdomain, a significant interaction effect was also observed (χ
2=9.00,
p=.011), with intervention effects significant at both posttest (
p=.018) and follow-up (
p=.003). In contrast, no significant interaction was found for social motivation (χ
2=2.37,
p=.306), indicating that the intervention did not significantly affect children’s perceptions of maternal support (
Table 4).
3) Self-efficacy in managing atopic dermatitis
Self-efficacy scores showed a significant time-by-group interaction (χ
2=6.77,
p=.034). The exploratory effect size for the pre–post change was Cohen’s d=1.10. Parameter estimates indicated that the intervention group had significantly higher self-efficacy at both posttest (
p=.012) and follow-up (
p=.022) assessments (
Table 4).
4) Atopic dermatitis self-care behavior
A significant time-by-group interaction was found for self-care behaviors (χ
2=7.23,
p=.027). The exploratory effect size for the pre–post change was Cohen’s d=0.37. Intervention effects were significant at posttest (
p=.008) but not at follow-up (
p=.071), indicating that improvements in self-care behaviors were not sustained (
Table 4).
5) Atopic dermatitis severity
Severity scores showed a significant time-by-group interaction (χ
2=6.48,
p=.039). The exploratory effect size for the pre–post change was Cohen’s d=0.51, indicating a moderate effect. Parameter estimates indicated that symptom severity decreased significantly in the intervention group at posttest (
p=.011); however, this effect was not maintained at follow-up (
p=.204) (
Table 4).
DISCUSSION
This pilot study developed and implemented a self-care behavior promotion program for late school-aged children with AD and discusses both the program’s development and its potential effects. The intervention was systematically designed using the IMB model and the IM framework to ensure a theory-based, structured approach. This is important because patient education in AD is often inadequate; although guidelines emphasize education [
6], clinicians usually have limited time to provide it [
24], and only about 40% of patients receive any self-management training [
12]. The program aimed to address this gap by offering dedicated, out-of-clinic education. It engaged children as active participants in their care and included education for their mothers. The program set clear behavioral objectives and change strategies based on the literature, which helped children gain knowledge, build motivation, and practice self-care skills. Although preliminary, these findings indicate that focusing on the child as an emerging self-manager may be a feasible way to support autonomy and adherence in this age group.
After the 5-week program, children in the experimental group showed preliminary improvements compared with the control group across several outcomes. Knowledge, personal motivation, and self-efficacy increased and remained higher at follow-up. Self-care behaviors and symptom severity improved immediately after the program, but these improvements were not sustained at follow-up.
Increased disease knowledge in the experimental group is consistent with previous evidence that educational and psychological interventions improve understanding and management of AD, especially among adult patients and caregivers [
8]. However, even young patients can learn about their condition when given age-appropriate instruction [
14]. This study demonstrates the value of age-appropriate education for improving children’s knowledge of AD. In addition, greater knowledge can lead to more positive illness perceptions and a stronger sense of control over the disease [
33], which are linked to better management behaviors and improved quality of life [
25,
34]. Future interventions should continue to involve children directly to further strengthen their disease-related knowledge.
Motivation is crucial for translating knowledge into action [
16]. In this study, personal motivation increased significantly, but social motivation did not. While an IMB-based program for adolescents with diabetes improved both types of motivation [
18], our program led to gains only in personal motivation. Persuasive communication that highlighted the importance of regular self-care and provided positive reinforcement for symptom control may have strengthened children’s personal motivation. However, the lack of change in social motivation indicates that the indirect approach to involving mothers—through education and weekly updates—was not enough for children to perceive greater support. Social motivation refers to perceived social support that encourages individuals to perform health-promoting behaviors. Because school-age children have limited autonomy in managing their health [
35], relying only on their efforts may not be sufficient. Previous studies show that involving parents with children can provide more consistent reinforcement and shared understanding during interventions [
8]. Therefore, future programs should include strategies to strengthen social motivation, such as parent–child joint sessions, extending education to other family members involved in daily care, and helping children develop skills to request support appropriately.
Self-efficacy in managing AD also showed preliminary improvement, consistent with caregiver education programs that enhanced parental efficacy [
8]. The step-by-step practice in our program and the children’s repeated successful experiences likely contributed to these gains. Notably, the improvement in self-efficacy was sustained at follow-up, possibly because children recognized that their actions directly affected their symptoms, which reinforced their confidence. Because self-efficacy is a strong predictor of adherence, this lasting improvement is a particularly meaningful outcome.
Self-care behaviors improved in the experimental group in the short term. This is notable because baseline adherence among participants was already relatively high, likely to reflect increased public awareness of AD care in recent years. Despite this, the program still led to further gains, indicating that even families already practicing basic skin care can benefit from a structured educational intervention. These findings align with previous research show that structured education and support improve daily management [
9] and emphasize the need for continued interventions to optimize adherence.
Another short-term outcome was the reduction in eczema severity in the experimental group compared with controls immediately after the intervention. Previous education programs for AD have primarily focused on parents or adult patients [
8,
27], but our findings show that direct education for children can also produce measurable clinical benefits. Because AD severity is closely linked to quality of life [
3,
4], the short-term symptom improvement observed in this study is significant.
However, at follow-up, the intervention group’s improvement in self-care behaviors had decreased, and AD severity scores had increased, indicating that some initial benefits were not maintained. This suggests that ongoing reinforcement is necessary to sustain symptom control. Several factors may explain these results. First, children may have found it difficult to maintain daily routines. Although self-efficacy remained relatively stable, motivation declined slightly, which may have reduced adherence. Second, the relapsing nature of AD likely contributed, as families may have relaxed management when symptoms improved, possibly believing the condition was cured [
12]. This highlights the importance of emphasizing the chronic nature of AD and the need for continuous care. Additionally, a small improvement in the control group’s behaviors—despite no intervention—suggests that researcher contact and study participation alone may have encouraged positive changes. Overall, periodic booster sessions, digital reminders, or scheduled follow-up contacts may be needed to support ongoing adherence and achieve long-term symptom reduction.
This study has several limitations. First, it used a quasi-experimental design rather than a randomized design, which may have introduced selection bias and allowed awareness of group assignment to influence outcomes. Second, the small sample size limited statistical power and generalizability; because this was a pilot study, results from inferential statistical analyses should be interpreted with caution. Third, some outcomes were measured with researcher-developed or adapted instruments that showed modest internal consistency, suggesting limited measurement precision. Finally, because the researcher who delivered the intervention also conducted outcome assessments, assessment bias due to non-blinding is possible.
Given the pilot nature of this study, future research should use randomized controlled trials with larger, more diverse samples, validated and standardized measures, and independent evaluators to improve objectivity. Assessing parent-related outcomes, such as parental knowledge and supportive behaviors, would also help clarify the family’s role in children’s self-care. Despite these limitations, the findings provide preliminary evidence that a theory-driven, child-focused intervention can improve self-care and offer clinical benefits for school-aged children with AD. The systematic development and successful implementation of this program present a model for future interventions aiming to empower young patients with chronic conditions.
CONCLUSION
This study developed and pilot-tested a 5-week, theory-based self-care promotion program for late school-aged children with AD. Based on the IMB model and the IM framework, the program aimed to improve children’s knowledge, motivation, and self-efficacy, and to reduce symptoms. The findings show preliminary improvements in knowledge, personal motivation, and self-efficacy. However, increases in self-care behaviors and reductions in symptom severity appeared only immediately after the program and were not sustained at follow-up. These results indicate a need for strategies to support long-term adherence and ongoing symptom management.
The study also demonstrates the program’s feasibility and acceptability, as all participants completed the program and engaged actively in each session. The focus on developmentally appropriate education and child participation supports the program’s practical use in community-based settings.
Nevertheless, limitations—including the quasi-experimental design, small sample size, use of non-standardized tools for some measures, and the lack of blinding—should be acknowledged. To address these limitations, future research should use randomized controlled trial designs, enroll a sufficiently large sample to allow rigorous hypothesis testing, and use validated measurement tools and independent evaluators to improve objectivity and reduce potential bias.
In conclusion, although exploratory, this study provides preliminary insights indicating that school-aged children may benefit from systematic, theory-driven interventions that promote self-care in AD. The program and its development process offer a foundational framework for future fully powered trials, supporting the advancement of interventions to improve self-management and quality of life among children with chronic conditions.
ARTICLE INFORMATION
Figure 1.Conceptual framework of this study.
Table 1.Matrix of performance objectives and change objectives to promote atopic dermatitis self-care behaviors
|
Performance objectives |
Personal determinant |
Environmental determinant |
|
Information |
Personal motivation |
Behavioral skills |
Social motivation |
|
PO1. Treating atopic dermatitis with medication |
CO1.1.1. Understanding types of medications for AD and their uses |
CO1.2.1. Expecting symptom control with medication |
CO1.3.1. Differentiating prescribed medications |
CO1.4.1. Supervising medication use |
|
CO1.1.2. Understanding topical steroid ointment use |
CO1.2.2. Monitoring skin condition for early detection of flares |
CO1.3.2. Applying appropriate amount of steroid ointment to affected areas |
CO1.4.2. Encouraging correct use of medication |
|
PO2. Taking care of skin with a shower and moisturizer |
CO2.1.1. Understanding the purpose of showering and moisturizer use |
CO2.2.1. Intending to shower once daily |
CO2.3.1. Choosing appropriate body wash and moisturizers |
CO2.4.1. Encouraging daily showering |
|
CO2.1.2. Knowing proper showering methods |
CO2.2.2. Intending to apply moisturizer at least twice daily |
CO2.3.2. Controlling shower water temperature |
CO2.4.2. Encouraging frequent moisturizer use |
|
CO2.1.3. Knowing moisturizer selection and application |
|
CO2.3.3. Carrying and reapplying moisturizer as needed |
|
|
PO3. Ceasing or reducing scratching |
CO3.1.1. Knowing consequences of scratching such as secondary infections |
CO3.2.1. Intending to stop scratching behavior |
CO3.3.1. Choosing alternative behaviors when itching occurs |
CO3.4.1. Presenting alternative behaviors to reduce scratching |
|
CO3.1.2. Knowing alternative itch-relief behaviors |
CO3.4.2. Providing positive feedback for reduced scratching |
|
PO4. Identifying and avoiding the triggers of atopic dermatitis |
CO4.1.1. Knowing AD triggers |
CO4.2.1. Intending to identify and avoid triggers |
CO4.3.1. Identifying AD triggers |
CO4.4.1. Helping children identify and avoid triggers |
|
CO4.1.2. Knowing stress management techniques |
CO4.2.2. Intending to practice stress reduction techniques |
CO4.3.2. Practicing stress reduction techniques |
CO4.4.2. Encouraging practice of stress reduction techniques |
Table 2.Baseline homogeneity of general characteristics
|
Characteristic |
Experimental groups (n=12) |
Control groups (n=8) |
t/z/χ2
|
p
|
|
Child |
|
|
|
|
|
Age (yr) |
10.58±0.79 |
10.38±0.74 |
–0.55a)
|
.624 |
|
Gender |
|
|
0.30b)
|
.670 |
|
Male |
6 (50.0) |
3 (37.5) |
|
|
|
Female |
6 (50.0) |
5 (62.5) |
|
|
|
Duration of AD diagnosis (yr) |
8.04±2.82 |
9.13±2.76 |
1.24a)
|
.238 |
|
Current AD symptoms |
|
|
1.94b)
|
.482 |
|
Improved |
5 (41.7) |
5 (62.5) |
|
|
|
Unchanged |
5 (41.7) |
1 (12.5) |
|
|
|
Worsened |
2 (16.7) |
2 (25.0) |
|
|
|
AD medications |
|
|
1.25b)
|
.373 |
|
Yes |
6 (50.0) |
6 (75.0) |
|
|
|
No |
6 (50.0) |
2 (25.0) |
|
|
|
Known allergens |
|
|
1.11b)
|
.603 |
|
Yes |
10 (83.3) |
5 (62.5) |
|
|
|
No |
2 (16.7) |
3 (37.5) |
|
|
|
Comorbid allergic conditions |
|
|
0.21b)
|
.999 |
|
Yes |
10 (83.3) |
6 (75.0) |
|
|
|
No |
2 (16.7) |
2 (25.0) |
|
|
|
Mother |
|
|
|
|
|
Age (yr) |
40.83±4.04 |
42.50±3.02 |
–0.99 |
.334 |
|
Educational level |
|
|
1.48b)
|
.495 |
|
High school |
2 (16.7) |
0 (0.0) |
|
|
|
≥University |
10 (83.3) |
8 (100.0) |
|
|
|
Employment status |
|
|
1.25b)
|
.373 |
|
Yes |
6 (50.0) |
6 (75.0) |
|
|
|
No |
6 (50.0) |
2 (25.0) |
|
|
|
Subjective economic status |
|
|
0.82b)
|
.999 |
|
High |
2 (16.7) |
1 (12.5) |
|
|
|
Medium |
9 (75.0) |
7 (87.5) |
|
|
|
Low |
1 (8.3) |
0 (0.0) |
|
|
|
Diagnosis of allergic diseases |
|
|
0.56b)
|
.648 |
|
Yes |
4 (33.3) |
4 (50.0) |
|
|
|
No |
8 (66.7) |
4 (50.0) |
|
|
|
Previous AD educational experience |
|
|
0.14b)
|
.999 |
|
Yes |
5 (41.7) |
4 (50.0) |
|
|
|
No |
7 (58.3) |
4 (50.0) |
|
|
|
Sources of information on ADc)
|
|
|
1.52b)
|
.822 |
|
Healthcare facilities |
10 (83.3) |
6 (75.0) |
|
|
|
Internet |
10 (83.3) |
5 (62.5) |
|
|
|
Books |
2 (16.7) |
2 (25.0) |
|
|
|
Personal contacts |
3 (25.0) |
2 (25.0) |
|
|
|
Experience with alternative therapies |
|
|
1.05b)
|
.537 |
|
Yes |
1 (8.3) |
2 (25.0) |
|
|
|
No |
11 (91.7) |
6 (75.0) |
|
|
Table 3.Baseline homogeneity of outcome variables
|
Variable |
Experimental groups (n=12) |
Control groups (n=8) |
t/z |
p
|
|
Atopic dermatitis knowledge |
9.58±2.75 |
10.38±3.70 |
1.01a)
|
.343 |
|
Atopic dermatitis self-care motivation |
32.25±7.03 |
35.00±3.82 |
–1.00 |
.328 |
|
Personal motivation |
8.25±1.96 |
9.63±0.74 |
2.88a)
|
.089 |
|
Social motivation |
24.00±5.24 |
25.38±3.58 |
–0.65 |
.527 |
|
Self-efficacy in managing atopic dermatitis |
81.25±24.85 |
73.25±22.80 |
0.43 |
.476 |
|
Atopic dermatitis self-care behaviors |
12.50±3.85 |
13.63±1.77 |
–0.77 |
.462 |
|
Atopic dermatitis severity |
26.58±8.20 |
24.21±13.48 |
0.49 |
.629 |
Table 4.Comparison of dependent variables between the experimental and control groups
|
Variable |
Pre |
Post |
Follow-up |
χ2
|
p
|
Effect sizea)
|
|
G |
T |
G×T |
G |
T |
G×T |
|
Atopic dermatitis knowledge |
|
|
|
2.55 |
22.55 |
20.43 |
.110 |
<.001 |
<.001 |
1.27 |
|
Exp. (n=12) |
9.58±0.76 |
14.50±0.62 |
14.08±0.62 |
|
|
|
|
|
|
|
|
Con. (n=8) |
10.38±1.22 |
10.50±1.43 |
10.13±1.68 |
|
|
|
|
|
|
|
|
Atopic dermatitis self-care motivation (total) |
|
|
|
0.58 |
2.20 |
8.36 |
.810 |
.333 |
.015 |
0.06 |
|
Exp. (n=12) |
32.25±1.94 |
34.83±1.60 |
34.92±1.56 |
|
|
|
|
|
|
|
|
Con. (n=8) |
35.00±1.26 |
34.50±1.80 |
34.00±1.26 |
|
|
|
|
|
|
|
|
Atopic dermatitis self-care motivation (personal) |
|
|
|
0.07 |
1.07 |
9.00 |
.788 |
.587 |
.011 |
0.21 |
|
Exp. (n=12) |
8.25±0.54 |
9.33±0.18 |
9.33±0.27 |
|
|
|
|
|
|
|
|
Con. (n=8) |
9.63±0.25 |
9.00±0.47 |
8.63±0.47 |
|
|
|
|
|
|
|
|
Atopic dermatitis self-care motivation (social) |
|
|
|
0.05 |
2.71 |
2.37 |
.824 |
.258 |
.306 |
0.00 |
|
Exp. (n=12) |
24.00±1.45 |
25.50±1.53 |
25.58±1.36 |
|
|
|
|
|
|
|
|
Con. (n=8) |
25.38±1.19 |
25.50±1.44 |
25.38±1.00 |
|
|
|
|
|
|
|
|
Self-efficacy in managing atopic dermatitis |
|
|
|
10.22 |
5.07 |
6.77 |
.001 |
.079 |
.034 |
1.10 |
|
Exp. (n=12) |
81.25±6.87 |
98.75±4.46 |
103.83±3.99 |
|
|
|
|
|
|
|
|
Con. (n=8) |
73.25±7.54 |
72.25±6.67 |
69.50±7.23 |
|
|
|
|
|
|
|
|
Atopic dermatitis self-care behavior |
|
|
|
0.54 |
24.82 |
7.23 |
.817 |
<.001 |
.027 |
0.37 |
|
Exp. (n=12) |
12.50±1.06 |
15.58±0.67 |
15.75±0.67 |
|
|
|
|
|
|
|
|
Con. (n=8) |
13.63±0.58 |
14.38±0.75 |
15.13±0.96 |
|
|
|
|
|
|
|
|
Atopic dermatitis severity |
|
|
|
0.10 |
22.22 |
6.48 |
.757 |
<.001 |
.039 |
0.51 |
|
Exp. (n=12) |
26.58±2.27 |
17.21±1.74 |
19.23±2.79 |
|
|
|
|
|
|
|
|
Con. (n=8) |
24.21±4.46 |
22.45±3.63 |
20.30±3.69 |
|
|
|
|
|
|
|
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