'It's quite hard to grasp the enormity of it': perceived needs of people upon diagnosis of rheumatoid arthritis

Candidacy 2.0 (CC) - an enhanced theory of access to healthcare for chronic conditions: lessons from a critical interpretive synthesis on access to rheumatoid arthritis care

BACKGROUND

The Dixon-Woods et al. Candidacy Framework, a valuable tool since its 2006 introduction, has been widely utilized to analyze access to various services in diverse contexts, including healthcare. This social constructionist approach examines micro, meso, and macro influences on access, offering concrete explanations for access challenges rooted in socially patterned influences. This study employed the Candidacy Framework to explore the experiences of individuals living with rheumatoid arthritis (RA) and their formal care providers. The investigation extended to assessing supports and innovations in RA diagnosis and management, particularly in primary care.

METHODS

This systematic review is a Critical Interpretive Synthesis (CIS) of qualitative and mixed methods literature. The CIS aimed to generate theory from identified constructs across the reviewed literature. The study found alignment between the seven dimensions of the Candidacy Framework and key themes emerging from the data. Notably absent from the framework was an eighth dimension, identified as the "embodied relational self." This dimension, central to the model, prompted the proposal of a revised framework specific to healthcare for chronic conditions.

RESULTS

The CIS revealed that the eight dimensions, including the embodied relational self, provided a comprehensive understanding of the experiences and perspectives of individuals with RA and their care providers. The proposed Candidacy 2.0 (Chronic Condition (CC)) model demonstrated how integrating approaches like Intersectionality, concordance, and recursivity enhanced the framework when the embodied self was central.

CONCLUSIONS

The study concludes that while the original Candidacy Framework serves as a robust foundation, a revised version, Candidacy 2.0 (CC), is warranted for chronic conditions. The addition of the embodied relational self dimension enriches the model, accommodating the complexities of accessing healthcare for chronic conditions.

TRIAL REGISTRATION

This study did not involve a health care intervention on human participants, and as such, trial registration is not applicable. However, our review is registered with the Open Science Framework at https://doi.org/10.17605/OSF.IO/ASX5C .

Experiences of individuals with rheumatoid arthritis interacting with health care and the use of a digital self-care application: a qualitative interview study

OBJECTIVES

Over the last few decades, there have been significant improvements in the treatment of rheumatoid arthritis (RA), with the development of new treatments and guidelines for teamwork and patient self-care and access to digital tools. This study aimed to explore the experiences of individuals with RA interacting with healthcare. It also looked at how a self-care application, an educational programme called the 'healthcare encounter', improved patient-doctor communication.

DESIGN

Semistructured interviews were conducted, and qualitative content analysis was performed.

SETTING

The potential participants, individuals with established, or under investigation for, RA diagnosis at rheumatology clinics in Sweden, were asked to participate in the study via a digital self-care application called the Elsa Science Self-care app.

PARTICIPANTS

Ten interviews were performed with participants from nine clinics following a meeting with the rheumatologist or other healthcare personnel between September 2022 and October 2022. Phrases, sentences or paragraphs referring to experiences from healthcare meetings and opinions about the digital programme were identified and coded. Codes that reflected similar concepts were grouped; subcategories were formulated, and categories were connected to their experiences and opinions.

RESULTS

Among our participants, three main categories emerged: the availability of healthcare, individual efforts to have a healthier life and personal interaction with healthcare. Participants described that the 'healthcare encounter' educational programme can be a source of information, which confirms, supports and creates a sense of control.

CONCLUSION

The participants valued being seen and taking part in a dialogue when they had prepared themselves (observed symptoms over time and prepared questions). The implementation of digital self-care applications might need to be incorporated into the healthcare setting, so that both the patients and the healthcare personnel have a shared understanding. Collaboration is essential in this context.

Peer Support in Rheumatic Diseases: A Narrative Literature Review

Rheumatic diseases are a group of chronic conditions that are associated with significant morbidity, impaired physical function, psychosocial stress, and cost to the healthcare system. Peer support interventions have been shown to have a positive impact on health outcomes in several chronic conditions, but no review has specifically assessed the impact of peer support on rheumatic conditions. The aim of this narrative literature review was to understand how peer support has been applied in the field of rheumatology, with a specific focus on the impact of observational and randomized studies of direct peer support interventions on various outcome measures across rheumatic conditions. We also examined studies exploring patient attitudes and preferences toward peer support. The majority of studies included focused on peer support in rheumatoid arthritis and systemic lupus erythematosus. Generally, patients across the spectrum of rheumatic disease perceive peer support as a useful tool. Peer support interventions, while highly variable, were generally associated with positive impacts on health-related quality of life metrics (both perceived and measured), although these differences were not always statistically significant. Important limitations include variability in study design, selection bias among study participants, and short follow-up periods across most peer support interventions.

Self-management support needs of patients with inflammatory arthritis and the content of self-management interventions: a scoping review

BACKGROUND

Self-management skills can empower a person to manage the physical, psychological, and social impact of a health condition. However, the components of self-management interventions differ widely between studies and interventions. By performing a scoping review, we aimed to describe patients' self-management needs and how health professionals (HPs) can provide effective self-management support to patients with inflammatory arthritis (IA).

OBJECTIVES

1) to identify the evidence for self-management support needs of patients with IA, and 2) to identify the content (theory/theoretical approach, mode of delivery, duration and frequency) of self-management interventions that target patients with IA.

METHODS

In May 2021, we performed a systematic literature search (from 2000 onward) in five databases (CINAHL (Ebsco), Cochrane Library, Embase (Ovid), Medline (Ovid) and PsycINFO (Ovid)) regarding self-management in patients with IA.

RESULTS

Out of 11,748 records identified, we included 31 articles describing patients' support needs and 33 articles describing the content of self-management interventions. Patients' support needs were sorted into six topics: 1) disease impact and the pharmacological treatment, 2) care continuity and relations with HPs, 3) the importance of non-pharmacological treatment, 4) the need for support from family and friends, 5) support needs related to work issues, and 6) contextual preferences for self-management support. The theory/theoretical approach, mode of delivery, duration and frequency varied widely and were often unclearly or insufficiently described. In addition, the self-management concept was scarcely - or not - defined in the included articles. The identified topics for support needs were compared with the described content in the included articles. Only a few self-management interventions focused on patients' need for support in relation to work, and to family and friends.

CONCLUSION

HPs provided self-management support to patients with IA in various ways, but there were gaps between the patients' support needs and the identified interventions. In developing self-management interventions, the self-management concept needs to be defined and a clear theory is required to support the development of the intervention. Future studies should seek to investigate various modes of delivery, frequency and duration, to develop effective interventions that meet patients' support needs.

Newly diagnosed with inflammatory arthritis (NISMA)-development of a complex self-management intervention

BACKGROUND

Patients newly diagnosed with inflammatory arthritis (IA) request regular consultations and support from health professionals to manage physiological, emotional, and social challenges. Evidence suggests that providing a tailored multi-component self-management program may benefit disease management. However, there is a lack of evidence of effective interventions with multiple components targeting the needs of this group. Therefore, the aim of this study was to develop a self-management intervention targeting newly diagnosed patients with IA, following the Medical Research Council (MRC) framework for developing complex interventions.

METHODS

The development of the complex self-management intervention covered three steps. First, the evidence base was identified through literature reviews, in which we described a preliminary nurse-led intervention. Secondly, we chose Social Cognitive Theory as the underlying theory along with Acceptance and Commitment Theory to support our communication strategy. Thirdly, the preliminary intervention was discussed and further developed in workshops to ensure that the intervention was in accordance with patients' needs and feasible in clinical practice.

RESULTS

The developed intervention comprises a 9-month nurse-led intervention (four individual and two group sessions). A physiotherapist and an occupational therapist will attend the group sessions along with the nurse. All sessions should target IA-specific self-management with a particular focus on medical, role, and emotional management.

CONCLUSION

Through the workshops, we involved all levels of the organization to optimize the intervention, but also to create ownership and commitment, and to identify barriers and shortcomings of the preliminary intervention. As a result, from the existing evidence, we believe that we have identified effective mechanisms to increase self-management in people newly diagnosed with IA. Further, we believe that the involvement of various stakeholders has contributed significantly to developing a relevant and feasible intervention. The intervention is a nurse-led complex self-management intervention embedded in a multidisciplinary team (named NISMA). The intervention is currently being tested in a feasibility study.

Design and development of an e-learning patient education program for self-management support in patients with rheumatoid arthritis

Objective

To develop an e-learning education program targeting patients with rheumatoid arthritis.

Methods

The development process involved content specification and creative design. It was theoretically framed within theories of multimedia learning and entertainment-education and empirically based on evidence of patient education in rheumatoid arthritis and focus group discussions with stakeholders. We conducted a feasibility test among ten patients to assess the acceptability and usability of the program, and to identify areas to be adjusted.

Results

The following themes for educational needs were found in focus group discussions: "Knowledge of rheumatoid arthritis," he disease course and prognosis," "Medical treatment," "A new life situation" and "Daily life with rheumatoid arthritis." Based on this, an e-learning program covering the disease course, examinations, treatment, and daily life, was created. It combines animations, videos, podcasts, text, speech, and tests. Test persons found the program feasible-that is, clear in content and easy to understand with a suitable pace and coherence between graphics, speech, and text.

Conclusion

This e-learning program is based on solid theoretical knowledge that meets users' needs and is easy to use.

Innovation

This study contributes to the innovation of health care by the development of a new digital tool for patient education.

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with patients' perspectives

OBJECTIVES

To explore patients' agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA).

METHODS

This mixed-method survey collected data using snowball sampling. The survey had been translated into 20 languages by local healthcare professionals, researchers and patient research partners. It explored the degree to which patients with IA agreed with each recommendation for PE (0=do not agree at all and 10=agree completely) and their rationale for their agreement level in free text questions. Descriptive statistics summarised participants' demographics and agreement levels. Qualitative content analysis was used to analyse the free text data. Sixteen subcategories were developed, describing the reasons for agreement or disagreement with the recommendations, which constituted the categories.

RESULTS

The sample comprised 2779 participants (79% female), with a mean (SD) age 55.1 (13.1) years and disease duration 17.1 (13.3) years. Participants strongly agreed with most recommendations (median 10 (IQR: 9-10) for most recommendations). Reasons for agreement with the recommendations included the benefit of using PE to facilitate collaborative care and shared decision making, the value of flexible and tailored PE, and the value of gaining support from other patients. Reasons for disagreement included lack of resources for PE, not wanting information to be tailored by healthcare professionals and a reluctance to use telephone-based PE.

CONCLUSION

The EULAR recommendations for PE have been disseminated among patients with IA. Overall, agreement levels were very high, suggesting that they reflect patients' preferences for engaging in collaborative clinical care and using PE to facilitate and supplement their own understanding of IA. Reasons for not completely agreeing with the recommendations can inform implementation strategies and education of healthcare professionals.

'More than just chitchat': a qualitative study concerning the need and potential format of a peer mentor programme for patients with early rheumatoid arthritis

Background

Patients recently diagnosed with rheumatoid arthritis (RA) have specific educational and supportive needs. These could partly be addressed with mentoring by other patients living with RA. This qualitative study explores stakeholder perceptions towards peer mentoring in early RA care.

Methods

Two focus groups with patients with early RA (n=10), one with patient organisation representatives (n=5), one with rheumatologists (n=8) and one with rheumatology nurses (n=5) were held. Two patient research partners supported analysis and interpretation.

Results

Four overarching themes were found: added value, experience with peer mentoring, concerns and need in daily care. Patients and patient organisation representatives confirmed the potential of peer mentoring especially regarding sensitive topics not easily discussed with professionals. Patients felt it could provide additional understanding and recognition. Nurses and rheumatologists were less convinced of the added value of peer mentoring because patients never mentioned it and they were concerned about the loss of control over correct information provision. The need for peer mentoring was perceived as person and disease phase-dependent and should therefore be optional, rather than a care standard. The requirements for a peer mentorship programme remained challenging to define for stakeholders. However, all expressed the need for supervision by healthcare professionals and that peer mentors should be carefully selected, educated and matched to newly diagnosed patients.

Conclusion

Peer mentoring and its implementation remain vague concepts, especially for healthcare providers. However, patients are interested in mentoring by peers, and the current results may support in effectively implementing such programmes early in the disease.

What do patients prefer? A multinational, longitudinal, qualitative study on patient-preferred treatment outcomes in early rheumatoid arthritis

OBJECTIVES

To explore treatment outcomes preferred by patients with early rheumatoid arthritis (RA) and how these change throughout the early disease stage across three European countries.

METHODS

A longitudinal, qualitative, multicentre study was conducted in Belgium, the Netherlands and Sweden. 80 patients with early RA were individually interviewed 3-9 months after treatment initiation and 51 of them participated again in either a focus group or an individual interview 12-21 months after treatment initiation. Data were first analysed by country, following the Qualitative Analysis Guide of Leuven (QUAGOL). Thereafter, a meta-synthesis, inspired by the principles of meta-ethnography and the QUAGOL, was performed, involving the local research teams.

RESULTS

The meta-synthesis revealed 11 subthemes from which four main themes were identified: disease control, physical performance, self-accomplishment and well-being. 'A normal life despite RA' was an overarching patient-preferred outcome across countries. Belgian, Dutch and Swedish patients showed many similarities in terms of which outcomes they preferred throughout the early stage of RA. Some outcome preferences (eg, relief of fatigue and no side effects) developed differently over time across countries.

CONCLUSIONS

This study on patient-preferred outcomes in early RA revealed that patients essentially want to live a normal life despite RA. Our findings help to understand what really matters to patients and provide specific insights into the early stage of RA, which should be addressed by clinicians of different disciplines from the start of treatment onwards.

A sanctuary from everyday life: rheumatology patients' experiences of in-patient multidisciplinary rehabilitation - a qualitative study

PURPOSE

To explore how rheumatology patients experience the personal impact of an inpatient rehabilitation stay and to elucidate the impact of contextual factors on the outcome.

METHODS

Exploratory qualitative individual interviews were conducted with 15 rheumatology patients (73% female) who had completed a two-week inpatient rehabilitation stay. Data collection, analysis and interpretation of data were performed within a phenomenological-hermeneutic framework inspired by Paul Ricoeur's interpretative philosophy.

RESULTS

The analysis derived one core theme, A sanctuary from everyday life, and five subthemes: (1) Being seen, heard and acknowledged as an equal and whole person; (2) Professional care and compassion; (3) Social relations and interactions between patients; (4) Individual rehabilitation, but challenges regarding shared decision making; and (5) Rehabilitation as a personal process but problems with coherence and transferability of learning to everyday life.

CONCLUSION

Patients experience inpatient rehabilitation as a sanctuary, in the following three ways; through individually planned multidisciplinary interventions at the hospital; recognition and compassion from the multidisciplinary staff and through social relationships and interactions with fellow patients. There is a need for improved coordination across primary and secondary health care, to ease coherence and transfer of learning to the patients' everyday lives.IMPLICATIONS FOR REHABILITATIONPatients can find peace and energy to care for themselves because they are away from everyday life when admitted for inpatient multidisciplinary rehabilitation.Patients need to be prepared for shared decision-making in order to be able to participate in formulating personal and meaningful goals for rehabilitation.There is a need for awareness of organisational and life transitions, to secure transfer of elements from the rehabilitation stay to the patient's everyday life.Rehabilitation professionals should be aware of the significance of fellow patients and facilitate and support the patient-patient relationships.

Educational needs of patients with rheumatic and musculoskeletal diseases attending a large health facility in Austria

INTRODUCTION

Patient education is an important part of the management of rheumatic and musculoskeletal diseases. Given that patients with diverse diseases do not have the same needs, it is crucial to assess the educational requirements of targeted groups to provide tailored educational interventions. The aim of our study was to assess educational needs of a large cohort of patients with different rheumatic and musculoskeletal diseases attending a health facility in Austria.

METHODS

We assessed educational needs, via an online survey of patients with fibromyalgia (FMS), rheumatoid arthritis (RA), and ankylosing spondylitis (AS) recruited from an Austrian health-care facility, using the Austrian version of the Educational Needs Assessment Tool (OENAT).

RESULTS

For our sample of 603 patients, AS (62%), RA (15%), and FMS (24%), there were no educational need differences for the domains of movements, disease process, and self-help measures. Patients with FMS had less need for pain management education and greater need for education about feelings, than other disease groups. Patients with RA had a greater need for education related to treatments than other groups, and patients with AS had a greater need for treatment education than patients with FMS. Patients with AS reported greater need for support system education than other patient groups.

CONCLUSION

Educational needs vary by disease groups, suggesting that health-care professionals should assess disease-specific needs for education to provide optimal assistance in disease management for patients.

Appropriating and asserting power on inflammatory arthritis teams: A social network perspective

Background

Therapeutic interventions for people with inflammatory arthritis (IA) increasingly involve multidisciplinary teams and strive to foster patient‐centred care and shared decision making. Participation in health‐care decisions requires patients to assert themselves and negotiate power in encounters with clinicians; however, clinical contexts often afford less authority for patients than clinicians. This disadvantage may inhibit patients' involvement in their own health care.

Objective

To identify communication attributes, IA patients use to influence and negotiate their treatment with members of their health‐care network.

Method

A qualitative social network approach was used to analyse data from a larger study that investigated IA patients' overall experiences of multidisciplinary care. Fourteen patients with IA attended individual semi‐structured interviews. Researchers used thematic analysis to identify patterns of assertiveness and influence in the data.

Results

Participants experienced loss of identity, control and agency in addition to the physical symptoms of IA. However, they had a sense of personal responsibility for managing their health care. Perceptions of health‐care team support enhanced patients' influence in treatment negotiations. Notably, there appeared to be an underlying tension between being empowered or disempowered.

Discussion and conclusions

The findings have significant implications for treatment decision communication approaches to IA care. A social network perspective may provide a pathway for clinicians to better understand the complexities of communication with their patients. This approach may reduce unequal power dynamics that occur within clinician/patient interactions and afford people with IA agency, control and affirmation of identity within their health‐care network.

Efficacy of a Web-Based Self-Management Enhancing Program for Patients with Rheumatoid Arthritis: Explorative Randomized Controlled Trial

Background

Web-based self-management enhancing programs have the potential to support patients with rheumatoid arthritis (RA) in their self-management; for example, improve their health status by increasing their self-efficacy or taking their prescribed medication. We developed a Web-based self-management enhancing program in collaboration with RA patients and professionals as co-designers on the basis of the intervention mapping framework. Although self-management programs are complex interventions, it is informative to perform an explorative randomized controlled trial (RCT) before embarking on a larger trial.

Objective

This study aimed to evaluate the efficacy of a Web-based self-management enhancing program for patients with RA and identify outcome measures most likely to capture potential benefits.

Methods

A multicenter exploratory RCT was performed with an intervention group and a control group. Both groups received care as usual. In addition, the intervention group received 12 months of access to a Web-based self-management program. Assessment occurred at baseline, 6 months, and 12 months. Outcome measures included self-management behavior (Patient Activation Measurement, Self-Management Ability Scale), self-efficacy (Rheumatoid Arthritis task-specific Self-Efficacy, Perceived Efficacy in Patient-Physician Interaction), general health status (RAND-36), focus on fatigue (Modified Pain Coping Inventory for Fatigue), and perceived pain and fatigue (Numeric Rating Scales). A linear mixed model for repeated measures, using the intention-to-treat principle, was applied to study differences between the patients in the intervention (n=78) and control (n=79) groups. A sensitivity analysis was performed in the intervention group to study the influence of patients with high (N=30) and low (N=40) use of the intervention.

Results

No positive effects were found regarding the outcome measurements. Effect sizes were low.

Conclusions

Based on these results, it is not possible to conclude on the positive effects of the intervention or to select outcome measures to be regarded as the primary/main or secondary outcomes for a future trial. A process evaluation should be performed to provide more insight into the low compliance with and effectiveness of the intervention. This can determine for whom this sort of program will work and help to fine-tune the inclusion criteria.

Trial Registration

Netherlands Trial Register NTR4871; https://www.trialregister.nl/trial/4726

Patient-perceived health service needs in inflammatory arthritis: A systematic scoping review

BACKGROUND

Care that is patient-centred is more likely to be sustainable and associated with improved health outcomes. This approach to care requires an understanding of patients' health service needs, yet few studies have directly investigated the perceived health service needs of people with inflammatory arthritis.

OBJECTIVES

To systematically identify the existing literature relating to patient perceived health service needs for inflammatory arthritis.

METHODS

A systematic review of MEDLINE, EMBASE, CINAHL, and PsycINFO was conducted (1990-2016). Studies examining patients' perceived needs relating to health services for inflammatory arthritis were identified. Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Findings were collated and categorized thematically.

RESULTS

In total, 27 of 1405 (16 qualitative, 9 quantitative, and 2 mixed-methods) studies were relevant. The main areas of perceived need related to (1) Communication: consumers wanted clear, empathic communication, and to be involved with decision-making. (2) Characteristics of ongoing care: adequate consultation length with continuity and timely care were valued. (3) Factors influencing care-seeking included individual attitudes, disease severity, finances and family expectations. (4) Allied health and complementary and alternative medicines (CAM) were perceived as useful by many. The reporting of CAM use to doctors was variable, with several factors contributing to under-reporting.

CONCLUSIONS

This review identified patients' perceived needs for better communication with their health providers, the heterogeneity of influences determining when care is sought and preferences regarding non-pharmacologic therapies. Aligning patients' perceived needs with evidence-based therapy for people with inflammatory arthritis will be important in optimizing patient outcomes.

Educational needs in patients with spondyloarthritis in Sweden - a mixed-methods study

BACKGROUND

There is a demand for a flexible and individually tailored patient education to meet patients' specific needs and priorities, but this area has seldom been studied in patients with spondyloarthritis (SpA), a family of inflammatory rheumatic diseases. The aim of the present study was to identify needs and priorities in patient education in patients with SpA. A second aim was to investigate patients' experiences and preferences of receiving patient education.

METHODS

Data collection included a questionnaire survey with the Educational Needs Assessment Tool (ENAT) and interviews, using a mixed-methods design. Patients were identified through a specialist clinic register. Descriptive data are presented as mean with standard deviation, or frequencies. Chi-square test and independent-samples t-test were used for group comparisons. A manifest qualitative conventional content analysis was conducted to explore patients' experiences and needs in patient education, based on two focus groups (n = 6) and five individual interviews.

RESULTS

Almost half (43%) of the 183 SpA patients had educational needs, particularly regarding aspects of self-help, feelings, and the disease process. More educational needs were reported by women and in patients with higher disease activity, while duration of disease did not affect the needs. The qualitative analysis highlighted the importance of obtaining a guiding, reliable, and easily available patient education for management of SpA. Individual contacts with healthcare professionals were of importance, but newer media were also requested.

CONCLUSION

There are considerable educational needs in patients with SpA, and education concerning self-help, feelings, and the diseases process were raised as important issues. Healthcare professionals need to consider the importance of presenting varied formats of education based on the experiences and preferences of patients with SpA.

[EULAR recommendations for patient education of people with inflammatory arthritis. Translation and evaluation in Germany]

In 2015 EULAR published recommendations for patient education of people with inflammatory arthritis. The recommendations included two superior principles and eight recommendations based on the level of evidence and expert knowledge. The German translation of the recommendations was evaluated by 15 German experts. Experts graded the strength of the recommendations (SOR) on an 11 point numerical rating scale (from 0 = no agreement to 10 = total agreement). The mean score was 8,8 ± 0,49.

Patient goals in rheumatoid arthritis care: A systematic review and qualitative synthesis

OBJECTIVE

During the clinical encounter, rheumatoid arthritis (RA) patient goals for care often go unexplored. The aim of the present systematic review was to identify needs, goals and expectations of RA patients in order better to guide systematic elicitation of patient goals in clinical encounters.

METHODS

An academic librarian searched MEDLINE, PsychINFO and the Cochrane Library using a specialized algorithm developed to identify articles about patient goals for RA care. Investigators screened search results according to prespecified inclusion criteria and then reviewed included articles and synthesized the evidence qualitatively, utilizing an inductive approach.

RESULTS

A total of 909 titles were retrieved in the literature search, of which 871 were excluded after a title/abstract screen. Of the remaining 38, 22 papers were included in the final review. Investigators identified four major themes in the literature: (a) the bodily experience of RA; (b) achieving normalcy and maintaining wellness; (c) social connectedness and support; and (d) interpersonal and healthcare system interactions.

CONCLUSION

Patients' goals when receiving care for RA are multidimensional and span several facets of everyday life. Goals for RA care should be collaboratively developed between patients and providers, with particular attention to the patient's life context and priorities.

What do we know about rheumatoid arthritis patients' support needs for self-management? A scoping review

BACKGROUND

Self-management support is essential to perform self-management behavior. To provide this support in an effective way, insight in the needs for self-management support is necessary.

OBJECTIVE

To give an overview of self-management support needs from the perspective of rheumatoid arthritis patients to help nurses to improve self-management.

DESIGN

We conducted a scoping review for the period of January 2002 to May 2013 using the following inclusion criteria: (1) studies on adult patients aged 18 years and older, (2) studies from the perspective of rheumatoid arthritis patients, (3) studies reporting results on support needs, and (4) empirical studies using any design.

DATA SOURCES

We searched in PubMed, CINAHL, and PsycINFO.

REVIEW METHODS

Following the steps of a scoping review, we (1) identified the research question, (2) identified relevant studies, (3) selected studies, (4) charted the data, and (5) collated, summarized, and reported results. We incorporated the optional sixth step of consultation of a multidisciplinary panel of professionals and patients to validate our findings.

RESULTS

Seventeen articles were included. Our review shows that rheumatoid arthritis patients have informational, emotional, social and practical support needs. We found an information need for various topics, e.g. exercises and medication. Patients express a need for emotional support in daily life, given through other RA patients, colleagues and supervisors and nurses. For information needs, emotional and social support it is important that it is tailored to the individual needs of the patient.

CONCLUSION

The most important support needs for self-management mentioned by rheumatoid arthritis patients are more informational, social and practical support and emotional support. Considering patients' perspective as a starting point for delivering support for self-management can lead to the development of nursing interventions tailored to the needs of rheumatoid arthritis patients.

EULAR recommendations for patient education for people with inflammatory arthritis

Objectives

The task force aimed to: (1) develop evidence-based recommendations for patient education (PE) for people with inflammatory arthritis, (2) identify the need for further research on PE and (3) determine health professionals’ educational needs in order to provide evidence-based PE.

Methods

A multidisciplinary task force, representing 10 European countries, formulated a definition for PE and 10 research questions that guided a systematic literature review (SLR). The results from the SLR were discussed and used as a basis for developing the recommendations, a research agenda and an educational agenda. The recommendations were categorised according to level and strength of evidence graded from A (highest) to D (lowest). Task force members rated their agreement with each recommendation from 0 (total disagreement) to 10 (total agreement).

Results

Based on the SLR and expert opinions, eight recommendations were developed, four with strength A evidence. The recommendations addressed when and by whom PE should be offered, modes and methods of delivery, theoretical framework, outcomes and evaluation. A high level of agreement was achieved for all recommendations (mean range 9.4–9.8). The task force proposed a research agenda and an educational agenda.

Conclusions

The eight evidence-based and expert opinion-based recommendations for PE for people with inflammatory arthritis are intended to provide a core framework for the delivery of PE and training for health professionals in delivering PE across Europe.

Self-management support from the perspective of patients with a chronic condition: a thematic synthesis of qualitative studies

BACKGROUND

Receiving adequate support seems to be crucial to the success of self-management. Although different empirical studies separately examined patients' preferences for self-management support (SMS), an overview is lacking.

OBJECTIVE

The aim of this qualitative review was to identify patients' needs with respect to SMS and to explore by whom this support is preferably provided.

SEARCH STRATEGY

Qualitative studies were identified from Embase, MEDLINE OvidSP, Web of science, PubMed publisher, Cochrane central, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO.

INCLUSION CRITERIA

Articles needed to meet all of the following criteria: (i) focuses on self-management, (ii) concerns adult patients with rheumatic diseases (rheumatoid arthritis and fibromyalgia), a variant of cancer or chronic kidney disease, (iii) explores support needs from the patients' perspective, (iv) uses qualitative methods and (v) published in English.

DATA EXTRACTION AND SYNTHESIS

A thematic synthesis, developed by Thomas and Harden, was conducted of the 37 included studies.

MAIN RESULTS

Chronic patients need instrumental support, psychosocial support and relational support from health-care professionals, family/friends and fellow patients to manage the chronic condition. Relational support is at the centre of the support needs and fuels all other types of support.

DISCUSSION AND CONCLUSIONS

Patients do not self-manage on their own. Patients expect health-care professionals to fulfil a comprehensive role. Support needs can be knitted together only when patients and professionals work together on the basis of collaborative partnership. Dynamics in support needs make it important to regularly assess patient needs.

Patient preferences for psychological support in inflammatory arthritis: a multicentre survey

OBJECTIVES

Inflammatory arthritis (IA) can lead to anxiety, depression, pain and fatigue. Psychological support can improve quality of life and self-management; and European and American guidelines recommend support be offered. This study examined patient views on psychological support for their IA.

METHODS

A questionnaire designed by researchers, patient partners and clinicians was administered to 2280 patients with IA.

RESULTS

1210 patients responded (53%): 74% women; mean age 59 years (SD 12.7); patient global 5 (2.3); disease duration <5 years (41%), 5-10 (20%), >10 (39%). Only 23% reported routinely being asked about social and emotional issues by a rheumatology professional, but 46% would like the opportunity to discuss psychological impact. If offered, 66% of patients reported they would use a self-management/coping clinic (63% pain management, 60% occupational therapy, 48% peer support groups, 46% patient education, 46% psychology/counselling). Patients want support with managing the impact of pain and fatigue (82%), managing emotions (57%), work and leisure (52%), relationships (37%) and depression (34%). Preferences are for support to be delivered by the rheumatology team (nurse 74%, doctor 55%) and general practitioners (GPs) (51%). Only 6% of patients stated that social and emotional issues were not relevant.

CONCLUSIONS

Demand for psychological support is high; however, less than a quarter of patients reported being asked about social and emotional issues, suggesting a gap between needs and provision. The preference is for delivery from rheumatology clinicians and GPs, and research should establish whether they have the skills and resources to meet patients' needs.

'What I want clinicians to know'--experiences of people with arthritis

AIM

To explore the perceptions and experiences of people with osteoarthrits (OA) and rheumatoid arthritis (RA) regarding the knowledge and skills they want nurses and allied health professionals (AHPs) to have to manage their care needs.

METHOD

Two condition-specific focus groups were conducted in London with five people with OA and eight people with RA in January 2011. A semistructured interview guide was used. The focus groups were audiotaped and the transcripts analysed using content analysis.

RESULTS

Shared and condition-specific themes were identified. The shared themes were: living with pain; the need for self-management; and meaningful consultation. The condition-specific themes were: no experts in OA; and wanting to talk in the RA participants.

CONCLUSION

People with OA and RA wanted nurses and AHPs to listen, empathise and help them to manage their condition, especially the pain. Participants with RA would value psychological support. We need to ensure that nurses and AHPs have the knowledge and skills to address these needs.

Redefined by illness: meta-ethnography of qualitative studies on the experience of rheumatoid arthritis

PURPOSE

To synthesize published qualitative studies concerning the lived experience of rheumatoid arthritis (RA). To compare the conceptual features of qualitative studies covering two different time periods.

METHODS

In 2002, 24 items published 1975-2001 were identified in comprehensive literature searches and assessed by multiple reviewers. In 2010, the first author found 28 articles published 2002-2009 in a simple search of the Medline database and synthesized them alone. Articles were synthesized using meta-ethnography.

RESULTS

Both syntheses found that the main symptoms of RA are variable and unpredictable. However, in the first synthesis a sociological model dominated where RA was seen as an assault on self-identity with devastating social consequences. The main concepts were biographical disruption, role incompetence and the dread of dependency on others. In the second synthesis, the findings produced a model for health care practitioners tied to perceptions of control and incorporating a career-adaptation model of the experience of RA.

CONCLUSIONS

We recommend that future synthesizers and primary qualitative health researchers focus more on non-hospital based populations and non-English language articles or study participants. The implications for rehabilitation follow from reflecting the findings of the synthesis against existing psychological models of coping and adaptation in RA. Implications for Rehabilitation Coping and adaptation are biographical processes, although the relative importance of active "disease mastery" versus more passive "getting used to it" is unclear. The uncertainty and fluctuating nature of symptoms and disease course presents existential challenges for people with RA in relation to maintaining physical functioning and social roles. Within a social model of disability, these findings point to potential intervention sites in society and relationships that would benefit people living with RA.

Validation of the brief International Classification of Functioning, Disability, and Health (ICF) core set for hand conditions

STUDY DESIGN

Cross-sectional multi-centre study.

INTRODUCTION

The ICF Core Sets for Hand Conditions (HC) have been developed to describe functioning of patients with HC.

PURPOSE OF THE STUDY

To study the content validity of the Brief ICF Core Set for HC.

METHODS

Patients with HC were interviewed using the Comprehensive ICF Core Set for HC. ICF categories that best explained variation in patients' general health were identified using multiple regression methods.

RESULTS

Overall, 12 of the 23 ICF categories of the Brief ICF Core Set could be validated. Our analyzes further revealed that the categories "b134 Sleep functions", "s830 Structure of nails", "e225 Climate" as well as categories referring to "e4 Attitudes" also deserve consideration when assessing functioning in patients with HC.

CONCLUSIONS

Clinicians are encouraged to complement the Brief ICF Core Set for HC by adding sleep functions, structure of nails, climate and attitudes, especially when following patients over time.

LEVEL OF EVIDENCE

Level 3.

It means everything: continuing normality of everyday life for people with rheumatoid arthritis in early remission

OBJECTIVE

The aim of this follow-up study was twofold: firstly, to explore how people who were clinically regarded to be in a state of remission experienced their everyday lives with rheumatoid arthritis (RA); secondly, to explore the experiences of people in early remission with healthcare provision and their perceived support needs.

METHODS

Two focus group interviews were conducted with 11 participants in total. Interview data were analysed using content analysis methods.

RESULTS

All participants felt that they were able to continue their normal everyday activities at home, at leisure and at work. They were also able to maintain their normal roles. Continuing the normality of everyday life seemed to be the most important defining variable for experiencing being in remission. Support needs were directly related to the participants' positive experiences of actual support from the healthcare providers and were related to the continuity of the care provider, coherence, being taken care of, having a personal and trusting relationship with the health professionals and being properly informed about RA and how to manage it.

CONCLUSION

The participants wanted to concentrate on wellness and tended to avoid thinking of possible side effects, being chronic ill and the development of RA in the future.

Everyday life with rheumatoid arthritis and implications for patient education and clinical practice: a focus group study

OBJECTIVES

This study aimed to explore how everyday life is affected by rheumatoid arthritis (RA), in order to inform patient education and clinical practice and generate further research.

METHODS

Six focus group interviews were conducted with, in total, 32 participants. Interview data were analysed using content analysis methods.

RESULTS

The study showed that RA affected almost every aspect of participants' everyday lives, particularly self-identity, social relationships, work and relationships with health and social care professionals. A small number of the participants did not have these experiences, due to receiving fast diagnosis and effective medical treatment.

CONCLUSION

The findings point to a need to increase knowledge about RA, support symptom management and reduce the physical, social and psychological challenges posed by RA in everyday life. An individualized and engaged approach to patient education, taking the individual experiences as the point of departure, is suggested. The results indicate directions for further research. The general implications for patient education that emerge from this study might not address the support needs of those who did not experience significant changes in everyday life. A more detailed and in-depth understanding about living with RA in the first years after diagnosis would provide a valuable supplement to the many retrospective studies, and useful knowledge in the design of patient education tailored to those who are newly diagnosed with RA.

'It's more scary not to know': a qualitative study exploring the information needs of patients with systemic lupus erythematosus at the time of diagnosis

OBJECTIVES

To identify the information needs of patients newly diagnosed with systemic lupus erythematosus (lupus), to inform the design of a future education package.

METHODS

Focus groups were conducted in seven rheumatology centres in the UK with 43 purposively selected participants. Data were subjected to thematic inductive analysis.

RESULTS

The first major theme, 'Impact of early information', describes how for many individuals information was scant and, as most had little prior knowledge of lupus, the information was difficult to absorb, leaving them with feelings of fear and confusion. 'Information received versus information sought' (theme 2) describes how few participants felt they had received clear, consistent information. For most, information was felt to be insufficient, forcing them to seek it elsewhere, which, if unsuitable, resulted in further distress. 'Early education needs' (theme 3) reflects that patients would rather be informed of potential problems than remain naïve. Patients felt that receiving a comprehensive information pack as an adjunct to verbal information from their clinician would be helpful, along with rapid access to knowledgeable professionals when they were ready to ask questions about their lupus.

CONCLUSIONS

Participants stated information and support currently provided at diagnosis is inadequate for their needs. They would like detailed information, provided through a variety of formats. Crucially this should be supported by professionals and available at whatever point in the patient's journey they want to access such discussions .The challenge is for health professionals to meet these needs in the most beneficial and cost effective way.

Development of the International Classification of Functioning, Disability and Health core sets for hand conditions--results of the World Health Organization International Consensus process

PURPOSE

A formal decision-making and consensus process was applied to develop the first version of the International Classification on Functioning, Disability and Health (ICF) Core Sets for Hand Conditions.

METHOD

To convene an international panel to develop the ICF Core Sets for Hand Conditions (HC), preparatory studies were conducted, which included an expert survey, a systematic literature review, a qualitative study and an empirical data collection process involving persons with hand conditions. A consensus conference was convened in Switzerland in May 2009 that was attended by 23 healthcare professionals, who treat hand conditions, representing 22 countries.

RESULTS

The preparatory studies identified a set of 743 ICF categories at the second, third or fourth hierarchical level. Altogether, 117 chapter-, second-, or third-level categories were included in the comprehensive ICF Core Set for HC. The brief ICF Core Set for HC included a total of 23 chapter- and second-level categories.

CONCLUSIONS

A formal consensus process integrating evidence and expert opinion based on the ICF led to the formal adoption of the ICF Core Sets for Hand Conditions. The next phase of this ICF project is to conduct a formal validation process to establish its applicability in clinical settings.

Physical activity coaching of patients with rheumatoid arthritis in everyday practice: a long-term follow-up

OBJECTIVES

To investigate the long-term effects on perceived general health, disease activity, pain, activity limitation and cognitive behavioural factors of a one-year coaching programme performed in ordinary physical therapy practice to promote the adoption of health-enhancing physical activity in patients with early rheumatoid arthritis (RA).

METHODS

A total of 228 patients with early RA, from 10 rheumatology clinics in Sweden, were randomly assigned to an intervention group (IG; n = 94) or a control group (CG; n = 134). The IG was coached by physical therapists during the first year to adopt health-enhancing levels of physical activity (30 minutes/day, moderately intensive, ≥ 4 days/week). No coaching was given during the subsequent year between post-intervention and follow-up. Follow-up assessment consisted of a postal questionnaire on physical activity and of visual analogue scales for ratings of general health perception and pain. The Health Assessment Questionnaire Disability Index (HAQ) and the Disease Activity Score in 28 joints (DAS 28) were collected at regular medical check-ups.

RESULTS

Sixty-five (69%) participants in the IG and 92 (69%) in the CG completed the entire study period by filling in the follow-up questionnaire on physical activity two years after baseline. The intervention seemed to lack any significant influence on long-term outcome. However, different patterns of change in physical activity behaviour were observed in the two groups.

CONCLUSIONS

No long-term improvement in perceived general health or other outcomes were found in the follow-up. This may partly be because the intervention lacked several important behavioural elements for physical activity maintenance.

Indicators of need for occupational therapy in patients with chronic pain: occupational therapists' focus groups

This study explores occupational therapists' (OT) perceptions of indicators for occupational therapy interventions among patients with chronic pain. An exploratory design was applied to six focus groups of OTs (n = 25) for data collection. Analysis was performed using content analysis through identification of meaning units, codes, categories and themes. Limitations of occupational performance was a major theme that included participant restrictions caused by physical, emotional and environmental barriers. Five subthemes of need were identified: 1) pain behaviour that prevented engagement in activities; 2) lack of knowledge about pain mechanisms and strategies to deal with pain; 3) occupational imbalance in work, leisure and home; 4) emotional stress and depression due to pain; and 5) physical or environmental strain resulting in limitations in occupational performance. Because of the variety and the diverse trends of approaches towards interventions for patients with chronic pain that exist in different cultures and settings, this study should be replicated in other contexts to increase the transferability of the findings.

'Your whole life, your whole world, it changes': partners' experiences of living with rheumatoid arthritis

OBJECTIVES

Research suggests that rheumatoid arthritis (RA) can have a negative psychosocial impact on partners, as well as patients. However, until now there has been very little in-depth qualitative research in this area. The aim of this study was to explore the experiences of partners of people with RA.

METHODS

Semi-structured interviews were conducted with a heterogeneous sample of eight partners of people with RA (six men, two women, age range 48-73 years). Transcripts were analysed thematically.

RESULTS

Five overarching themes emerged: psychological burden in partners was substantial, as they experienced frustration and distress at watching their partner suffer and tried to protect their spouse from emotional and physical distress. 'It's a restricted life': partners reported having to cut back on previously enjoyable shared activities and had difficulty making future plans. Adjusting lives: partners had to make considerable adjustments to many aspects of their lives, and had adopted practical and psychological ways to cope. 'It's a joint approach': many partners discussed adopting a joint approach to managing the RA. Met and unmet support needs varied considerably, and many partners felt that a joint approach to treatment taken by health professionals is needed, which involves and recognizes their role.

CONCLUSIONS

Partners of people with RA are vital to the patients' disease management, but the data show that many carry a substantial psychosocial burden. Healthcare professionals should be aware of this, so that couples coping with RA can be better supported.

Exploring indicators for pain rehabilitation: a Delphi study using a multidisciplinary expert panel

OBJECTIVE

Lack of referral guidelines can cause delayed or even non-existent rehabilitation for chronic pain patients. Indicators signalling the need for interventions could counteract this delay for pain rehabilitation and thereby prevent deteriorating patient health. This study aimed to explore the indicators of need for pain rehabilitation using a multidisciplinary expert panel working with pain rehabilitation.

METHODS

A three-round Delphi study was conducted with a multidisciplinary expert panel (n = 23), each representing one pain rehabilitation unit in Sweden. The expert panel produced indicators, which were then ranked using a four-point Likert scale.

RESULTS

Twenty multi-faceted indicators for pain rehabilitation were identified. A major part concerned patient problems with activity level, catastrophizing, coping, existential problems, fear avoidance, high pain rating, medication, mental health, motivation, no pain relief, pain spread/increase, psychosocial problems combined with activity problems, psychosocial problems, recovery, and reduced physical function. Furthermore, indicators concerned demographic factors, sick leave, situation in primary health care and work. Finally, tacit knowledge was pointed out as an indicator. The results support previous research but also bring out less quantifiable indicators, such as relying on tacit knowledge while assessing a patient's need for rehabilitation.

CONCLUSION

The indicators for pain rehabilitation were comprehensive, pointing out that needs assessment is complex. Despite reaching consensus on 19 out of 20 indicators, further research is needed to deepen knowledge in this area and to secure a fair assessment of a patient's need for pain rehabilitation.