Epinephrine auto-injector use in adolescents at risk of anaphylaxis: a qualitative study in Scotland, UK

Abstract

Background: Adolescents with severe allergies are at particular risk of severe and fatal anaphylactic reactions. Epinephrine (adrenaline) is known to be under-utilized by teenagers.

Objective: We sought to gain knowledge of adolescents' attitudes towards and experience of epinephrine auto-injectors in order to inform improvements in patient education.

Methods: A qualitative study of adolescents in Scotland, UK with a history of anaphylaxis and their parents. In-depth interviews explored adolescents' accounts of anaphylactic reactions, including issues related to using epinephrine auto-injectors. Focus groups with adolescents and parents were used to discuss interventions to improve adolescent self-management of anaphylaxis.

Results: Twenty-six adolescents and 28 parents were interviewed. Eight adolescents and 10 parents participated in separate focus groups. Most adolescents had not used the auto-injector in an anaphylactic emergency. We identified multi-faceted barriers to use, including: failure to recognize anaphylaxis; uncertainty about auto-injector technique and when to administer it; fear of using the auto-injector. Most adolescents reported carrying auto-injectors some of the time, though several found this inconvenient due to the size; only one reported non-use of an auto-injector because it had not been carried.

Conclusion and clinical relevance: Adolescents and parents reported under-use of epinephrine auto-injectors. Carriage is insufficient to ensure that auto-injectors are used. Barriers to use are multiple and complex, and unlikely to be overcome using simple educational interventions. Auto-injector training currently offered is often inadequate preparation for an emergency. A more comprehensive approach is needed, addressing the psychosocial dimensions of anaphylactic emergencies as well as treatment. Training should ideally be provided by specialist allergists or nurses, but can also be provided and reinforced in primary care.