Abstract
Background:
Nurses can play a significant role to provide care to millions of patients with dermatophytosis and scabies. Thus, the study was undertaken to assess the effectiveness of task sharing with nurses for the diagnosis of dermatophytosis and scabies.
Material and Method:
An interventional trial was conducted in two periurban communities of Chandigarh which were randomized to experimental and control groups. Survey Performa was used to identify patients already diagnosed with dermatophytosis and scabies. However, teleconsultation with the dermatologist was done for patients presenting with signs and symptoms for the confirmation of diagnosis. Nurse led intervention which included health education and counselling about prevention and management of dermatophytosis and scabies, i.e., its signs and symptoms, medication adherence, lifestyle modification, hygiene practices, application of medicine to treat scabies was given to intervention group participants with the help of booklet and flash cards. The control group received usual care. Endline assessment was done at 8th week to assess the effect of intervention on medication adherence, quality of life, and self-reported cure rates. The trial was also registered under the Clinical Trials Registry-India with the CTRI no. CTRI/2022/07/043856.
Results:
The results revealed significant difference in the medication adherence among participants in experimental (20.51 ± 09.04) and control groups (28.56 ± 9.46) at the endline assessment. The mean score of quality of life (13.16 ± 7.30) was significantly lower than in experimental and control groups (18.83 ± 7.30) indicating better quality of life. There was significant difference in the self-reported cure rate among experimental and control group.
Conclusion:
The study concluded that task sharing was effective in improving quality of life, medication adherence, hygiene practices, and self-reported cure rate among patients with dermatophytosis and scabies.
Keywords: Dermatophytosis, medication adherence, nurse led intervention, quality of life, scabies
INTRODUCTION
Dermatophytosis and scabies are widespread throughout the world and are more severe in tropical nations. Although they are contagious and simple to treat, the widespread prevalence and high cost of treatment represent a serious public health concern and pose a significant financial burden on patients in tropical nations like India.[1] The prevalence of dermatophytosis and scabies ranges from 36.6 to 78.4% and 0.2% to 71%, respectively, in India.[2] Overall disease burden, as measured in DALYs, was 501.91 per 100,000 from skin and subcutaneous disease conditions in 2019.[3] High burden of these diseases,[4] presence of stigma, and lack of human resources, particularly dermatologists, make it challenging to provide care to these patients. Task sharing and shifting are effective strategies to address these shortages. Nurses are successfully doing task sharing in the area of noncommunicable diseases.[5,6,7,8,9] However, their role in the skin diseases is limited, especially in low and middle income countries.[10] Hence, the study was undertaken to assess the effectiveness of nurse led intervention on management of dermatophytosis and scabies in selected communities of Chandigarh.
METHODS
The study was an interventional trial conducted in two periurban communities of Chandigarh. Two periurban communities of UT Chandigarh, i.e. Dhanas and Dadu Majra Colony, were selected conveniently and randomized into experimental and control groups. Survey performa was used to identify patients already diagnosed with dermatophytosis and scabies. However, teleconsultation with the dermatologist was done for patients presenting with signs and symptoms (itching, lesions, irritation, ring-shaped rashes, scaly skin, and redness) suggestive of dermatophytosis and scabies for the confirmation of diagnosis. After the teleconsultation, patients were also sent to skin OPD, PGIMER, Chandigarh, if required. Inclusion criterion of the study was patients diagnosed with dermatophytosis and scabies. However, patients with severe secondary bacterial infections and terminally ill patients were excluded.
Primary outcome of the study was medication adherence, quality of life, self-reported cure rates, and hygiene practices.
Sample size calculation was done considering the present medication adherence rate of 12% among patients with dermatophytosis and scabies (pilot study data) at 5% level of significance and 80% power. We considered 30% increase in the adherence rate as clinically significant. Hence, with the effect size of 0.3 and attrition rate of 5%, the sample size calculated was 50 in each group. Considering the prevalence of skin conditions as 4.1%,[11] we recruited all the patients of dermatophytosis and scabbles from the two periurban communities of Chandigarh.
Tools used for data collection were interview schedule compromised of sociodemographic profile, clinical profile, and self-reported cure. Standardized tools were used to assess medication adherence (adherence to refill medication adherence scale, ARMS). It is a four point Likert type scale with total of 12 items. Scoring is done as follows: all the time = 3, most of the time = 2, some of the time = 1, and never = 0. A total score of less than 12 indicate better adherence and score more than 12 indicate nonadherence.[12]
Quality of life was measured by using DLQI. It is a questionnaire which designed to measure the health-related quality of life of adult patient suffering from skin disease. The DLQI consists of 10 questions concerning patient, perception of the impact of skin diseases on different aspects of their health-related quality of life over the last week. Each question is scored from 0 to 3, resulting in a possible score range from 0 (no impact of skin disease on quality of life) to 30 (meaning maximum impact on quality of life): interpretation of DLQI scores (0–1), no effect at all on patients’ life (2–5), small effect at all on patients’ life (6–10), moderate effect at all on patients’ life (11–20), very large effect at all on patients’ life (21–30), and extremely large effect at all on patients’ life.[13]
Hygiene practices were assessed using a checklist. Items included in the checklist were related to hand washing, hair wash, changing undergarments, feet wash, changing clothes, towel wash, removal of dead skin/nails cutting, application of oil, cream on body, and sharing of personal clothes. Validation of the tool was done with the help of experts in the field of nursing, dermatology, and community medicine.
Nurse led intervention refers to set of protocols to identify and educate patient on treatment adherence, quality of life and hygiene and prevention of Dermatophytosis and scabies. It was developed by investigator and validated by experts. Patient information booklet and flashcards were developed as a part of a package. It included the information related to signs and symptoms, prevention and treatment of fungal infection which included health education, counselling, medication adherence, lifestyle modification, hygiene practices, application of medicine to treat scabies, yoga. The package was delivered by a trained nurse in the form of health education and counselling.
Follow ups were done at 2nd, 4thand 6th week for the participants in the intervention group to reinforce medication adherence, hygienic practices, and life style modification. Control group received usual care. Endline assessment was done at the 8th week in both the group. Data collection was done over a period of 3 months from July2022 to September 2022.
Ethical approval for the study was obtained from the Institute Ethics Committee of PGIMER Chandigarh with reference number INT/IEC/2022/SPL-221 on 21/03/2022. The trial was also registered under the Clinical Trials Registry- India with the CTRI no. CTRI/2022/07/043856.
RESULTS
A total of 36884 population was surveyed from 8062 households in two peri-urban communities (experimental-19249 and control group- 17635) of Chandigarh. Overall prevalence of dermatophytosis and scabies was 3 (95% CI 2.2- 3.9) and 3.1 (95% CI 2.4- 4.0) per 1000 population in experimental and control group respectively. After assessing for inclusion and exclusion criteria a total of 62 and 54 patients were included in experimental and control group respectively [Figure 1]. Socio-demographic profile of patients revealed that mean age of participants was 36.50 ± 19.0 years and 37.43 + 14.8 years in the experimental group andcontrol group respectively. Nearly two third of the participants (62.9%) in experimental groupwere females and nearly half (48.1%) in control groupwere males. Study participants in experimental and control group were homogenous in terms of age, gender, caste, education, occupation [Table 1].
Figure 1.
Flow diagram showing enrollment, allocation and follow-up process with the respective patient numbers and reasons for exclusion
Table 1.
Sociodemographic profile of patients with dermatophytosis and scabies in control and experimental groups
|
n=116 | |||
|---|---|---|---|
| Variables | Experimental group n=62 f (%) | Control group n=54 | P |
| AGE (In years) ** | |||
| 16-35 | 44 (71.0) | 25 (46.3) | 0.05 |
| 36-45 | 10 (16.1) | 17 (31.5) | |
| 46-60 | 02 (03.2) | 04 (07.4) | |
| Above 60 | 06 (09.7) | 08 (14.8) | |
| Gender | |||
| Male | 23 (37.1) | 26 (48.1) | 0.11 |
| Female | 39 (62.9) | 28 (51.9) | |
| Marital Status | |||
| Never married | 32 (51.6) | 15 (27.8) | 0.09 |
| Ever married* | 30 (48.4) | 39 (53.7) | |
| Religion | |||
| Hindu | 48 (77.4) | 53 (98.1) | 0.04 |
| Sikh | 10 (16.1) | 01 (01.9) | |
| Muslim | 04 (06.5) | --- | |
| Education | 0.95 | ||
| No formal education | 10 (16.1) | 08 (14.8) | |
| Primary school | 07 (11.3) | 05 (09.3) | |
| Middle school | 10 (16.1) | 06 (11.1) | |
| Matriculation | 15 (24.2) | 16 (29.6) | |
| Senior secondary (10+2) | 14 (22.6) | 14 (25.9) | |
| Graduate and above | 06 (09.7) | 05 (09.3) | |
| Occupation | 0.07 | ||
| Employed | 29 (46.8) | 16 (29.6) | |
| Housewife | 23 (37.1) | 18 (33.3) | |
| Non-government employee | 04 (06.5) | 10 (18.5) | |
| Retired | 06 (09.7) | 08 (14.8) | |
| Unemployed | -- | 02 (03.7) | |
| Socioeconomic status (As per Modified BG Prasad classification May 2021) | |||
| Upper class ((≥7863) | 21 (33.9) | 04 (07.4) | 0.04 |
| Upper middle class (3931-7862) | 31 (50.0) | 32 (59.3) | |
| Lower middle class (2359-3930) | 06 (09.7) | 14 (25.9) | |
| Upper lower class (1179-2358)/Lower class* (<1179) | 04 (06.4) | 04 (07.4) | |
Note : Percentages in brackets represents column-wise percentages
Clinical profile of patients revealed that 77.4% of patients in experimental group and 75.9% in control group were already diagnosed with dermatophytosis and scabies. Rest of the patients were diagnosed through teleconsultation. Mean duration of illness for dermatophytosis among already diagnosed patients was (3.96 ± 3.44 months) and (4.49 ± 5.0 months) for the experimental and control group respectively. However mean duration of illness for scabies among already diagnosed patients was (1.37 ± 2.49) months and (3.07 ± 3.72) months for the experimental and control group respectively.
In this study 62.9% from experimental group and 61.1% control group were diagnosed at health and wellness centre. Majority of the study participants 77.4% from experimental group and 76% from control group were taking allopathy treatment [Table 2]. Mean difference of medication adherence and quality of life score [Table 3] revealed no significant difference at baseline among experimental and control group participants, however, end line assessment revealed the significant difference between group.
Table 2.
Clinical profile of patient with dermatophytosis and scabies in control and experimental groups
|
n=98 | |||
|---|---|---|---|
| Variables | Experimental n=62 | Control group n=54 | P |
| Dermatophytosis (n=42) | |||
| Already diagnosed | 31 (50.0) | 23 (42.6) | 0.704 |
| Diagnosed through teleconsultation | 11 (17.7) | 05 (09.3) | |
| Scabies (n=20) | |||
| Already diagnosed | 17 (27.4) | 18 (33.3) | |
| Diagnosed through teleconsultation | 03 (04.8) | 08 (14.8) | |
| Duration of illness among already diagnosed with dermatophytosis | (n=31) | (n=23) | |
| 6 months | 19 (30.6) | 09 (16.7) | 0.41 |
| 6-1 year | 06 (09.7) | 11 (20.4) | |
| above 1 year | 06 (09.7) | 03 (04.8) | |
| Duration of illness among already diagnosed with scabies | (n=17) | (n=18) | |
| 6 months | 14 (22.6) | 15 (24.8) | 0.54 |
| 6-1 year | 03 (04.8) | 03 (04.8) | |
| above 1 year | -- | --- | |
| Place of diagnosis | (n=48) | (n=54) | |
| Health and wellness center | 39 (62.9) | 33 (61.1) | 0.91 |
| GMSH sec 16 | 06 (09.7) | 04 (07.4) | |
| PGIMER, Chandigarh | 03 (04.8) | 04 (07.4) | |
| Type of Treatment for already diagnosed (n=48) | |||
| Ayurveda Medicine | 05 (08.1) | 03 (05.6) | 0.007 |
| Allopathy | 48 (77.4) | 41 (76.0) | |
| Over the counter medication | 09 (14.5) | 11 (20.4) | |
| Signs and Symptoms among teleconsultation patients | (n=14) | (n=13) | |
| Redness | 10 ((16.2) | 08 (14.9) | 0.78 |
| Itching | 14 (22.6) | 13 (24.1) | 0.92 |
| Ring shaped rashes | 11 (17.7) | 05 ((09.3) | 0.06 |
| Dry skin | 07 (11.3) | 08 ((14.9) | 6.554 (5) 0.23 |
*Mean duration of illness (5.34±2.64 months) in experimental group. *Mean duration of illness (7.56±3.40 months) in control group
Table 3.
Mean difference of medication adherence and quality of life scores at baseline and endline among experimental and control groups
| Variables | Baseline |
Endline |
||||||
|---|---|---|---|---|---|---|---|---|
| Experimental Mean±SD |
Control Mean±SD |
Mean difference | P | Experimental Mean±SD |
Control Mean±SD |
Mean difference | P | |
| Medication adherence (ARMS Scale) | 28.56±9.46 | 28.06±7.77 | 0.5±1.69 | <0.75 | 20.52±9.04 | 31.26±13.29 | 10.74±4.25 | <0.001 |
| Quality of life (DLQI Scale) | 17.84±5.70 | 19.87±6.42 | 2.03±0.72 | <0.74 | 13.16±7.11 | 18.83±7.30 | 5.14±0.19 | <0.001 |
Statistically significant values are highlighted in bold
Mean change from baseline to endline assessment for medication adherence and quality of life was statistically significant only in intervention group. Cohen d was calculated to measure the effect size. Experimental group showed larger effect size as compared to control group for both medication adherence and quality of life [Table 4].
Table 4.
Mean change in the medication adherence and quality of life scores at baseline and endline among intervention and comparison groups
| Variables | Baseline Mean±SD |
Endline Mean±SD |
Mean Change Mean±SD |
P | Cohens d. |
|---|---|---|---|---|---|
| Medication adherence | |||||
| Intervention group | 28.56±9.46 | 20.52±09.04 | 8.04±0.42 | <0.001 | 0.86 |
| Comparison Group | 28.06±7.77 | 31.26±13.29 | 03.2±5.52 | <0.12 | 0.29 |
| Quality of life | |||||
| Intervention group | 17.84±5.70 | 13.16±7.15 | 4.24±1.45 | <0.001 | 0.72 |
| Comparison Group | 19.87±6.42 | 18.83±7.30 | 1.04±0.88 | <0.35 | 0.15 |
Statistically significant values are highlighted in bold
There was no significant difference in the level of medication adherence among control and experimental groups at baseline assessment. However, at endline assessment 51.6% of the participants in the experimental group and 24.1% in the control group had better adherence and the difference was statistically significant [Table 5].
Table 5.
Comparison on level of medication adherence and quality of life among patients in experimental and control groups at baseline assessment and endline assessment as assessed by ARMS scale and DLQI scale
| Interpretation of score | Baseline |
P | Endline |
P | ||
|---|---|---|---|---|---|---|
| Control Group n=54 (%) | Experimental Group n=62 (%) |
Control Group n=54 (%) |
Experimental Group n=62 (%) |
|||
| Medication adherence | 0.99 | <0.001 | ||||
| Better Adherence (12) | 09 (16.7) | 14 (22.6) | 13 (24.1) | 32 (51.6) | ||
| Non-Adherence (>12) | 45 (83.3) | 48 (77.4) | 41 (75.9) | 30 (48.4) | ||
| Quality of life | <0.001* | |||||
| 0-1=NO effect at all on patients’ life | --- | -- | 0.74 | -- | -- | |
| 2-5=small effect on patients’ life | --- | -- | 05 (09.3) | 02 (03.2 | ||
| 6-10=moderate effect on patients’ life’ | 02 (03.7) | 06 (09.7 | 04 (07.4) | 28 (45.2) | ||
| 11-20=very large effect on patient life | 27 (50.0) | 41 (66.1) | 28 (51.9) | 24 (38.7) | ||
| 21-30=extremely large effect on patients’ life | 25 (46.3) | 15 (24.2) | 17 (31.5) | 08 (12.9) | ||
Statistically significant values are highlighted in bold
Regarding self- reported cure rates, 43.5% and 16.7% in the experimental and control group respectively reported as being completely cured from the infection. Whereas 9.7% in experimental and 20.3% in the control group reported no change in the symptoms. Hygiene practices revealed that higher percentageof participants in experimental group as compared to control group, who were able to maintain hygiene such as hand washing, hair wash, changing undergarments, feet wash, changing clothes, application of oil and cream on the body, towel wash, reducing in sharing personal clothes, removal of dead skin frequency after the nurse led intervention.
DISCUSSION
Dermatophytosis and scabies can significantly affect quality of life by reducing social contacts and independence.[14] Nonadherence to treatment leads to poor clinical outcomes and increase in morbidity along with unnecessary expenditures on health care.[15,16] Nurses can play an important role in providing counselling and health education to improve quality of life and treatment adherence, among these patients. Although task shifting is only occasionally used in dermatology, the literature makes clear that it is both necessary and effective.[1] Hence, the present study was undertaken.
The overall prevalence of superficial fungal infection in this study was 3.1 per 1000 population and 3 per 1000 population in experimental and control groups, respectively. The findings of the study were consistent with previous study finding reported in Iran and Turkey by Işil İnanir and Sanei et al. 3.1 and 3.8.[17,18] The finding of our study inconsistent with the study done by Adefemi et al. where the prevalence rate among patient with dermatophytosis was 5.0.[19] This difference might be due to the variation in the study population, and the sample size might be another possible reason for the variation between the present and previous studies.
The mean age of the participants in the present study was 33.38 ± 15.78 years. The cause of this could be related to the age group’s higher degree of physical activity, which causes excessive sweating that encourages the growth of dermatophytes. The results of this study are in consonance with the study done by Jagadeesan et al.[20] in Kochi where they showed that majority of patients were in the age between 21 and 39 years.
Medication nonadherence is associated with poorer health outcomes.[21] Findings of the present study revealed that 77.4% participants were nonadherent toward their treatment. The results of our study contrast with those of Jagadeesan et al. and Tsunemi et al. conducted in Kochi, Japan, where adherence rates among patients with dermatophytosis were 33.6% and 59.6%, respectively.[20,22] This disparity may stem from the shorter data collection period and difficulties accessing treatment, which posed significant challenges.
Quality of life is defined as an individual’s perception of his life in relation to his culture and values system in which he lives in relation to his goals, expectations, standards, and concerns. The DLQI scores of the present study were higher than those reported by Mushtaq et al. and Narang et al.[16,23] where the mean score of overall quality of life was 13.41 ± 7.56 and 13.41 ± 7.53, respectively. In present study, it was 17.84 ± 5.70. In addition, the findings of the present study revealed that 45.2% of participants had moderate effect and 38.7% of participants had large effect on patient quality of life as per the DLQI scale. This study aligns with Morales et al., who reported a mean DLQI score of 15.78 ± 6.26.[24] In contrast, our findings differ from those of Varshney et al. (mean score 14.48 ± 5.18) and Bashir et al. (mean score 13.93 ± 6.26), where 47.5% had large effect on patient life.[25,26] The discrepancies may be attributed due to different time period and setting, technique of the sampling technique used between our study and theirs.
Task shifting and task sharing is one of the effective strategies, and[11] implementing task-shifting and empowering nurses are essential policy changes that could effectively address and bridge this gap in primary healthcare services, contributing significantly to achieving the Sustainable Development Goals and universal health coverage.[27]
In the present study, the nurse led interventions had significant effect in improving the quality of life and medication adherence with the mean change of 13.16 ± 7.11 and 20.51 ± 9.04, respectively. The results of the present study are consistent with another study by Mushtaq et al. and Narang et al.[16,23] which concluded that counselling intervention was effective in improving the quality of life, treatment adherence, and hygiene practices among patient with superficial fungal infection.
Nurse-led interventions for managing dermatophytosis and scabies in subcenters and villages can significantly enhance public health outcomes. These interventions leverage the accessibility and trustworthiness of nurses in local communities, providing timely and effective treatment for these common skin conditions. Nurses, equipped with the right training, can diagnose and treat tinea and scabies, educate patients about hygiene and preventive measures, and monitor treatment adherence, thereby reducing transmission rates. Such decentralized healthcare models improve access to care, especially in remote areas, and alleviate the burden on higher-level health facilities. This approach not only addresses immediate health concerns but also fosters long-term community health resilience by empowering local healthcare providers and improving overall health literacy.
CONCLUSION
The study concluded that nurse-led intervention scabies were effective in improving quality of life, medication adherence, and hygiene practices among patients with dermatophytosis and scabies.
Ethical approval
The study was approved by the Institutional Ethics Committee, PGIMER, Chandigarh.
Conflict of interest
There is no conflict of interest
Funding Statement
Nil.
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