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Wilkin K, Evans S, Van Niekerk L, Romano D, Fuller-Tyszkiewicz M, Knowles S, Chesterman S, Raven L, Mikocka-Walus A. Moving Towards Acceptance and Values: A Qualitative Study of ACTforIBD Compared to IBD Psychoeducation. J Clin Psychol Med Settings 2024; 31:245-257. [PMID: 38347385 PMCID: PMC11102374 DOI: 10.1007/s10880-023-09999-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 05/20/2024]
Abstract
The current study explored perspectives of those with inflammatory bowel disease (IBD) and comorbid anxiety and/or depression on a hybrid acceptance and committment therapy (ACT) intervention, compared to an active control. This qualitative study was nested within a randomized controlled trial (RCT) where an experimental group received an 8-week blended delivery ACTforIBD intervention (four sessions telehealth, four sessions pre-recorded self-directed), while an active control group received a psychoeducation program of similar intensity. Semi-structured interviews were conducted post-intervention and at a 3-month follow-up. Themes were interpreted using reflexive thematic analysis. Twenty individuals participated; ten in each condition. Seven themes were constructed, including three shared themes between groups: I Am Worth Advocating For, Present Moment Is My Biggest Ally, and Ambivalence About Self-Directed Modules. Two themes were identified for the ACTforIBD group: Symptoms Are Going to Happen and Moving Toward Values while two themes identified from the ActiveControl group were: Reset and Refresh and It's Ok to Say No. Acceptance and values modules from ACTforIBD were perceived as useful in reducing psychological distress for those with IBD, while the ActiveControl group felt their program affirmed existing effective coping strategies. Access to external resources for self-directed modules and networking may increase engagement with content long term.
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Affiliation(s)
- Kathryn Wilkin
- School of Psychology, Deakin University, Geelong, Melbourne, VIC, Australia
| | - Subhadra Evans
- School of Psychology, Deakin University, Geelong, Melbourne, VIC, Australia
| | - Leesa Van Niekerk
- School of Psychological Sciences, University of Tasmania, Churchill Avenue, Sandy Bay, Hobart, TAS, Australia
| | - Daniel Romano
- School of Psychology, Deakin University, Geelong, Melbourne, VIC, Australia
| | | | - Simon Knowles
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Susan Chesterman
- School of Psychology, Deakin University, Geelong, Melbourne, VIC, Australia
| | - Leanne Raven
- Crohn's & Colitis Australia, Melbourne, VIC, Australia
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Radford SJ. The impact of Inflammatory Bowel Disease related fatigue on Health-Related Quality of Life: a qualitative semi-structured interview study. J Res Nurs 2022; 27:685-702. [PMID: 36530749 PMCID: PMC9755563 DOI: 10.1177/17449871211061048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023] Open
Abstract
Background Fatigue is a frequently reported symptom of Inflammatory Bowel Disease (IBD), having a negative impact on Health-Related Quality of Life (HRQoL). Patients' experiences of this have not been researched in IBD. Methods Semi-structured interviews were conducted with adults with Crohn's Disease from out-patient clinics in the United Kingdom. Interviews were audio-recorded and transcribed verbatim, then analysed using thematic analysis. Results Fourteen participant interviews were conducted. Three key themes were identified: 1) 'The new normal' established through adaptation and acceptance; 2) 'Energy as a resource' describing attempts to better manage fatigue through planning and prioritising tasks; 3) 'Keeping healthy' encompasses participants' beliefs that 'good health' allows better management of fatigue. Conclusion Participants establish a 'new' normality, through maintaining the same or similar level of employment/education activities. However, this is often at the expense of social activities. Further research is required to explore patient led self-management interventions in IBD fatigue.
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Affiliation(s)
- Shellie J Radford
- Senior Research Nurse, Nottingham Digestive Diseases Centre, School of Medicine, The University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, GI and Liver Theme, University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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3
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Coates E, Wickramasekera N, Barr A, Shackley P, Lee M, Hind D, Probert C, Sebastian S, Totton N, Blackwell S, Bedford H, Dames N, Lobo A. Patient preferences and current practice for adults with steroid-resistant ulcerative colitis: POPSTER mixed-methods study. Health Technol Assess 2022; 26:1-118. [PMID: 36305390 PMCID: PMC9638891 DOI: 10.3310/rhxr5192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Corticosteroids are a mainstay of the treatment of moderately severe relapses of ulcerative colitis, yet almost 50% of patients do not respond fully to these and risk prolonged steroid use and side effects. There is a lack of clarity about the definitions of steroid resistance, the optimum choice of treatment, and patient and health-care professional treatment preferences. OBJECTIVES The overall aim of this research was to understand how steroid-resistant ulcerative colitis is managed in adult secondary care and how current practice compares with patient and health-care professional preferences. DESIGN A mixed-methods study, including an online survey, qualitative interviews and discrete choice experiments. SETTING NHS inflammatory bowel disease services in the UK. PARTICIPANTS Adults with ulcerative colitis and health-care professionals treating inflammatory bowel disease. RESULTS We carried out a survey of health-care professionals (n = 168), qualitative interviews with health-care professionals (n = 20) and patients (n = 33), discrete choice experiments with health-care professionals (n = 116) and patients (n = 115), and a multistakeholder workshop (n = 9). The interviews with and survey of health-care professionals showed that most health-care professionals define steroid resistance as an incomplete response to 40 mg per day of prednisolone after 2 weeks. The survey also found that anti-tumour necrosis factor drugs (particularly infliximab) are the most frequently offered drugs across most steroid-resistant (and steroid-dependent) patient scenarios, but they are less frequently offered to thiopurine-naive patients. Patient interviews identified several factors influencing their treatment choices, including effectiveness of treatment, recommendations from health-care professionals, route of administration and side effects. Over time, depending on the severity and duration of symptoms and, crucially, as medical treatment options become exhausted, patients are willing to try alternative treatments and, eventually, to undergo surgery. The discrete choice experiments found that the probability of remission and of side effects strongly influences the treatment choices of both patients and health-care professionals. Patients are less likely to choose a treatment that takes longer to improve symptoms. Health-care professionals are willing to make difficult compromises by tolerating greater safety risks in exchange for therapeutic benefits. The treatments ranked most positively by patients were infliximab and tofacitinib (each preferred by 38% of patients), and the predicted probability of uptake by health-care professionals was greatest for infliximab (62%). LIMITATIONS The survey and the discrete choice experiments with patients and health-care professionals are limited by their relatively small sample sizes. The qualitative studies are subject to selection bias. The timing of the different substudies, both before and during the COVID-19 pandemic, is a potential limitation. CONCLUSIONS We have identified factors influencing treatment decisions for steroid-resistant ulcerative colitis and the characteristics to consider when choosing treatments to evaluate in future randomised controlled trials. The findings may be used to improve discussions between patients and health-care professionals when they review treatment options for steroid-resistant ulcerative colitis. FUTURE WORK This research highlights the need for consensus work to establish an agreed definition of steroid resistance in ulcerative colitis and a greater understanding of the optimal use of tofacitinib and surgery for this patient group. A randomised controlled trial comparing infliximab with tofacitinib is also recommended. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 41. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Amy Barr
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Phil Shackley
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew Lee
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher Probert
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Shaji Sebastian
- Hull University Teaching Hospitals NHS Foundation Trust, Hull, UK
| | - Nikki Totton
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | | | - Alan Lobo
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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4
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Keefer L, Bedell A, Norton C, Hart AL. How Should Pain, Fatigue, and Emotional Wellness Be Incorporated Into Treatment Goals for Optimal Management of Inflammatory Bowel Disease? Gastroenterology 2022; 162:1439-1451. [PMID: 34995528 DOI: 10.1053/j.gastro.2021.08.060] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/10/2021] [Accepted: 08/14/2021] [Indexed: 12/16/2022]
Abstract
Early diagnosis and the optimal control of inflammation, with a continuous cycle of assessment, treatment, monitoring, and adjustment of therapy, is best practice for the management of inflammatory bowel disease. However, patients express frustration with ongoing challenging symptoms, often discordant with inflammation, including abdominal pain, fatigue, depression, anxiety, and emotional wellness; these are often not optimally addressed by inflammatory bowel disease clinicians due to lack of time or resources. This review will highlight the burden of these symptoms and issues, suggest ways of assessing these in clinical practice, highlight the importance of acknowledging and validating the symptoms and issues with patients, reassuring them that they are being heard, and discuss different possible models of service delivery for psychosocial support, from fully integrated gastropsychology models to referral pathways that optimize community support. We suggest the importance of the treat-to-target concept, where the target is not only control of inflammation but also emotional wellness.
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Affiliation(s)
- Laurie Keefer
- Department of Medicine-Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Alyse Bedell
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois
| | - Christine Norton
- Florence Nightingale School of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Ailsa L Hart
- IBD Unit, St Mark's, The National Bowel Hospital, London, United Kingdom
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Silke L, Kirresh O, Sturt J, Lempp H. Development of the Rheumatoid Arthritis Distress Scale (RADS): a new tool to identify disease-specific distress in patients with Rheumatoid Arthritis. BMC Rheumatol 2021; 5:51. [PMID: 34782021 PMCID: PMC8594165 DOI: 10.1186/s41927-021-00220-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background Patients with Rheumatoid Arthritis (RA) may experience psychological distress (depression, anxiety) in addition to their physical symptoms. People with RA may also experience disease-specific distress (DSD), related to the specific burden of living with their life-long condition. DSD is a patient reported outcome in several long-term conditions, including type 1 and 2 diabetes. The aims of this study were to determine whether DSD is experienced by people with RA, and if so, develop a Patient Reported Outcome Measure (PROM) to assess for DSD in people with RA. Methods A five-phased qualitative study was conducted which consisted of a secondary data analysis of 61 interviews of people with rheumatological disease (Phase 1), validation of findings via a Patient and Public Involvement (PPI) group of people with RA (n = 4) (Phase 2), item generation for a PROM (Phase 3) and establishing face and content validity of the PROM via PPI group (n = 4) and individual cognitive interviews (n = 9) of people with RA respectively (Phase 4 and 5). The final PROM was presented at a Patient Education Evening for patients with long-term rheumatological conditions, including RA, and carers. Results Five themes of rheumatological disease distress emerged from Phase 1, which were validated in the Phase 2 PPI group. After Phases 3–5, the Rheumatoid Arthritis Distress Scale (RADS) was formed of 39 items and 3 supplementary questions. Overall participants reported the content of the RADS to be clear and relevant, and that DSD is a valid concept in RA, distinct from other entities like clinical depression or anxiety. Conclusions DSD appears to be an important concept in RA. The 39-item RADS demonstrates acceptable face and content validity in this patient group. Further psychometric testing is needed. The RADS may be a useful tool for healthcare professionals to identify RA distress.
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Affiliation(s)
- Linda Silke
- Outpatient Physiotherapy Department, Mile End Hospital, Bancroft Rd, London, E1 4DG, UK.
| | - Othman Kirresh
- Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, Waterloo, London, SE1 8WA, UK
| | - Heidi Lempp
- Department of Inflammation Biology, Faculty of Life Sciences and Medicine, Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10, Cutcombe Road, London, SE5 9RJ, UK
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Whelan K, Murrells T, Morgan M, Cummings F, Stansfield C, Todd A, Sebastian S, Lobo A, Lomer MCE, Lindsay JO, Czuber-Dochan W. Food-related quality of life is impaired in inflammatory bowel disease and associated with reduced intake of key nutrients. Am J Clin Nutr 2021; 113:832-844. [PMID: 33677550 DOI: 10.1093/ajcn/nqaa395] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) may impact the extent to which food, eating, and drinking bring satisfaction and enjoyment to peoples' lives, and this may impact dietary intake. The prevalence of an impaired food-related quality of life (FR-QoL), its associated factors, and its impact on diet have not been explored. OBJECTIVES To measure the prevalence and nature of the burden of impaired FR-QoL in people with IBD, the factors associated with these, and their associations with nutrient intake. METHODS We recruited 1576 outpatients with IBD (≥16 years old) in person from 7 IBD centers across the United Kingdom. Patients completed validated questionnaires to measure their FR-QoL, quality of life (QoL), distress, fatigue, anxiety, and depression. Dietary intake was recorded using the European Prospective Investigation into Cancer FFQ. A health professional recorded disease activity, Montreal classification, blood results, BMI, and malnutrition risk. FR-QoL was regressed onto explanatory variables using univariable and multivariable analyses. RESULTS Data from 1221 patients were available (77.4% response; Crohn's disease, 65%; ulcerative colitis, 35%). The FR-QoL mean (± SD) score was 80.8 ± 26.9, with wide ranges (minimum, 29; maximum, 145). Following multivariable regression, the strongest associations with FR-QoL were the number of recent disease flares (5 flares β = -12.7; P < 0.001), the IBD-specific QoL (β = 0.33; P < 0.001), and IBD-related distress (β = -0.26; P < 0.001). Patients with poorer FR-QoL had lower intakes of fiber (nonstarch polysaccharide; Q1 to Q5 difference = 2.1 g/d; 95% CI: 0.4-3.8; P = 0.048), calcium (192.6 mg/d; 95% CI: 112.5-272.6; P < 0.001), phosphorus (167 mg/d; 95% CI: 58-276; P = 0.041), and magnesium (34.4 mg/d; 95% CI: 9.3-59.4; P = 0.041). CONCLUSIONS Impaired FR-QoL is prevalent in IBD and is associated with recurrent disease flares, a reduced IBD-specific QoL, and greater IBD-related distress. A poorer FR-QoL was associated with lower intakes of key nutrients of importance to IBD, including those relating to gut health and bone mineralization.
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Affiliation(s)
- Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, United Kingdom
| | - Trevor Murrells
- Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, United Kingdom
| | - Myfanwy Morgan
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
| | - Fraser Cummings
- University Southampton Hospital National Health Service (NHS) Foundation Trust, Southampton, United Kingdom
| | | | - Anne Todd
- NHS Forth Valley, Forth Valley Royal Hospital, Larbert, United Kingdom
| | - Shaji Sebastian
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
- Hull York Medical School, Hull, United Kingdom
| | - Alan Lobo
- Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, United Kingdom
| | - Miranda C E Lomer
- Department of Nutritional Sciences, King's College London, London, United Kingdom
- Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - James O Lindsay
- Bart's Health NHS Trust, London, United Kingdom
- Queen Mary University of London, Blizard Institute, London, United Kingdom
| | - Wladyslawa Czuber-Dochan
- Department of Nutritional Sciences, King's College London, London, United Kingdom
- Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, United Kingdom
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Abstract
Inflammatory bowel disease (IBD) is associated with significant psychological comorbidities, with associated impacts on patient quality of life, disease course, and health care costs. The present article reviews the latest evidence on the etiology of psychological comorbidities in IBD, with a focus on shared inflammatory pathways. The current state of practice in managing and understanding psychological comorbidities from the perspective of both gastroenterology practice and psychological treatment is reviewed, with a focus on evidence-based treatments shown to be effective in managing depression, anxiety, stress, and improving IBD-related health outcomes.
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8
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Ilias T, Bungau S, Tit DM, Maghiar D, Hocopan C, Brata R, Bratu OG, Negrut N, Diaconu C, Fratila O. Psychosocial profile of the patients with inflammatory bowel disease. Exp Ther Med 2020; 20:2493-2500. [PMID: 32765741 DOI: 10.3892/etm.2020.8816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/28/2020] [Indexed: 12/12/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic, disabling entity of unknown aetiology, with negative impact on the patient's life, including psychological patterns. This study assessed multiple psychosocial factors (satisfaction with life, coping mechanisms, emotional profile, mental recognition of the disease and cognition schemes related to patients' demographic characteristics, clinical picture, form and duration of the disease, therapeutic plans) in IBD patients vs. a healthy group. This non-interventional study comprised 60 participants who attended for medical advice/check-up as an ambulatory visit or during hospitalization. The patients completed questionnaires after receiving explanations from the psychologist. Statistical analyses (Kolmogorov-Smirnov test, Independent-Samples t-test, One-Way ANOVA and Post Hoc Multiple Comparisons) were conducted using IMB for the Social Sciences (SPSS), version 20 (P≤0.05). IBD patients (G1) are more hostile when compared to the healthy group (G2). Those who experience abdominal pain are more likely to use active coping mechanisms and those who experience fatigue are more likely to use acceptance, emotional venting, behavioural disengagement and mental disengagement. G1 have higher levels of others-downing vs. G2. Regarding negative emotions, IBD patients generally experience more negative emotions compared to healthy participants (who have higher levels of life satisfaction). Regarding the perception of illness, there are no differences between patients in terms of illness coherence, personal or treatment control, consequences, timeline, or emotional representations. Results indicate that psychological factors and different characteristics of IBD patients play a relevant role in the way these patients deal with their disease.
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Affiliation(s)
- Tiberia Ilias
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
| | - Delia Mirela Tit
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
| | | | - Cristian Hocopan
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Roxana Brata
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Ovidiu Gabriel Bratu
- Clinical Department 3, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Nicoleta Negrut
- Department of Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Camelia Diaconu
- Department 5, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, 041914 Bucharest, Romania
| | - Ovidiu Fratila
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
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Kitchen H, Farrar M, Al-zubeidi T, Pegram H, Hunter T, Naegeli AN, Delbecque L, Jairath V. Patient's Perspective on Disease Burden, Remission Definition, and Symptoms Associated With Treatment Seeking: A Qualitative Study in Adult and Adolescent Patients With Crohn's Disease. CROHN'S & COLITIS 360 2020; 2:otaa033. [PMID: 36777302 PMCID: PMC9802196 DOI: 10.1093/crocol/otaa033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Indexed: 11/14/2022] Open
Abstract
Background Disease burden, a definition of remission, and symptoms that drive treatment seeking were explored in a Crohn's disease (CD) population. Methods A qualitative semistructured interview guide was developed, informed by published literature. Clinicians identified adolescents and adult patients with CD. Face-to-face interviews were audio-recorded and transcribed. Two rounds of interviews were conducted with patients. Transcripts were analyzed using thematic methods facilitated by ATLAS.ti. Results Twenty-four patients participated in the first round of interviews (n = 16 adults, mean age 50.3 years; n = 8 adolescents, mean age 15.6 years). Abdominal pain (n = 24), urgent bowel movements (n = 24), diarrhea (n = 23), and frequent bowel movements (n = 21) were the most frequently reported symptoms. CD affected patients' physical functioning, daily activities, emotional wellbeing, social functioning, work/education, and relationships. No major difference in disease burden was observed between adolescents and adults. Twenty-three patients (96%) reported they would seek or had sought medical treatment for at least one symptom including abdominal pain (n = 19), diarrhea (n = 12), and blood in stools/rectal bleeding (n = 9). On a 0-10 scale (0 = no symptom and 10 = symptom at its worst possible), most patients (87%, 20/23) answered they would seek/had sought treatment when the symptom's severity was at least 7. In the second round of interviews (n = 6 adults, mean age 51.5 years), 5/6 patients described that they did not require a complete absence of abdominal pain or loose/watery stools to consider their CD to be in remission. Conclusions CD is associated with substantial disease burden. Worsening of some symptoms drives treatment seeking. To some patients, remission is not defined as a complete absence of symptoms.
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Affiliation(s)
- Helen Kitchen
- Clinical Outcomes Assessment, DRG Abacus, Manchester, UK,Address correspondence to: Helen Kitchen, MSc, DRG Abacus, The Lexicon, Mount Street, Manchester M2 5NT ()
| | - Mallory Farrar
- Global Patient Outcomes-Real World Evidence, Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | - Hannah Pegram
- Clinical Outcomes Assessment, DRG Abacus, Manchester, UK
| | - Theresa Hunter
- Global Patient Outcomes-Real World Evidence, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - April N Naegeli
- Global Patient Outcomes-Real World Evidence, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Laure Delbecque
- Patient-Focused Outcomes Center of Expertise, S.A. Eli Lilly Benelux N.V., Brussels, Belgium
| | - Vipul Jairath
- Division of Gastroenterology, Western University & London Health Sciences Centre, London, Ontario, Canada
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Radford SJ, McGing J, Czuber-Dochan W, Moran G. Systematic review: the impact of inflammatory bowel disease-related fatigue on health-related quality of life. Frontline Gastroenterol 2020; 12:11-21. [PMID: 33489066 PMCID: PMC7802486 DOI: 10.1136/flgastro-2019-101355] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Fatigue is frequently reported in inflammatory bowel disease (IBD) and impacts on health-related quality of life (HRQoL). HRQoL has not been systematically reviewed in IBD fatigue. AIM To investigate what impact IBD fatigue has on HRQoL in adults with IBD. METHODS Systematic searches (CINAHL, EMBASE, PsychINFO, Medline) were conducted on 25 September 2018, restricted to 'human', 'adult', 'primary research' and 'English language'. Search terms encompassed concepts of 'fatigue', 'IBD' and 'HRQoL'. A 5-year time limit (2013-2018) was set to include the most relevant publications. Publications were screened, data extracted and quality appraised by two authors. A narrative synthesis was conducted. RESULTS Eleven studies were included, presenting data from 2823 participants. Fatigue experiences were significantly related to three HRQoL areas: symptom acceptance, psychosocial well-being and physical activity. Patients reporting high fatigue levels had low symptom acceptance. Psychosocial factors were strongly associated with both fatigue and HRQoL. Higher social support levels were associated with higher HRQoL. Physical activity was impaired by higher fatigue levels, lowering HRQoL, but it was also used as a means of reducing fatigue and improving HRQoL. Quality appraisal revealed methodological shortcomings in a number of studies. Notably, use of multiple measures, comparison without statistical adjustment and fatigue and HRQoL assessment using the same tool were some of the methodological shortcomings. CONCLUSION Psychosocial factors, symptom management and acceptance and physical activity levels have significant impact on HRQoL. Results support application of psychosocial or exercise interventions for fatigue management. Further exploration of HRQoL factors in IBD fatigue is required, using validated fatigue and HRQoL measures. PROSPERO REGISTRATION NUMBER CRD42018110005.
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Affiliation(s)
- Shellie Jean Radford
- Nottingham Digestive Diseases Centre, University of Nottingham, University Park Campus, Nottingham, UK,NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jordan McGing
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Wladyslawa Czuber-Dochan
- Florence Nightingale school of Nursing, Midwifery and Pallative care, King's College London, London, UK
| | - Gordon Moran
- Nottingham Digestive Diseases Centre, University of Nottingham, University Park Campus, Nottingham, UK,NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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11
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Artom M, Czuber-Dochan W, Sturt J, Proudfoot H, Roberts D, Norton C. Cognitive-behavioural therapy for the management of inflammatory bowel disease-fatigue: a feasibility randomised controlled trial. Pilot Feasibility Stud 2019; 5:145. [PMID: 31890258 PMCID: PMC6905023 DOI: 10.1186/s40814-019-0538-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 11/28/2019] [Indexed: 02/08/2023] Open
Abstract
Background Fatigue is the third most prevalent symptom for patients with inflammatory bowel disease (IBD), yet optimal strategies for its management are unclear. Treatment protocols for fatigue in other conditions have been based on cognitive-behavioural models. Targeting cognitions, emotions and behaviour related to fatigue through cognitive-behavioural therapy (CBT) may be a viable option to improve fatigue and quality of life (QoL) in IBD. Methods This single centre, two-arm, feasibility randomised controlled trial (RCT) aimed to assess the feasibility and initial estimates of potential efficacy of a CBT intervention for the management of IBD-fatigue. Feasibility, acceptability and initial estimates of potential efficacy outcomes were collected through self-report measures and semi-structured interviews. Participants were recruited from one tertiary referral centre. Intervention Group 1 received a CBT manual for fatigue, one 60-min and seven 30-min telephone sessions with a therapist over 8-weeks. Control Group 2 received a fatigue information sheet without therapist support. A nested qualitative study evaluated patients’ and therapists’ experiences, and IBD-healthcare professionals’ (HCPs) perceptions of the intervention. Results Eighty-nine participants were assessed for eligibility. Of these, 31 of the 70 eligible participants consented to participate (recruitment rate of 44%). Of the 15 participants randomised to the intervention group, 13 (87%) started it and 10 (77% of those who started) completed all 8 sessions. Follow-up questionnaires were completed by 22 (71%) participants at 3 months, 14 (45%) at 6 months and 12 (39%) at 12 months’ follow-up. The intervention was acceptable to participants and feasible for therapists to deliver. HCPs reported that the intervention would be applicable, but time, finance and training constraints limit its implementation. Initial estimates of potential efficacy with complete case analysis showed a reduction in fatigue and an increase in QoL at 3, 6 and 12 months post-randomisation. Conclusions A full-scale effectiveness RCT testing CBT for IBD-fatigue is feasible and is potentially worthwhile with some changes to the protocol. However, given the small numbers, further pilot work is warranted before a full-scale RCT. Trial registration Registration Trial ISRCTN 17917944, Registered 2 September 2016
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Affiliation(s)
- Micol Artom
- 1Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK
| | - Wladyslawa Czuber-Dochan
- 1Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK
| | - Jackie Sturt
- 1Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK
| | - Hannah Proudfoot
- 2Tobacco & Alcohol Research Group, University College London, London, UK
| | - Danniella Roberts
- 1Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK
| | - Christine Norton
- 1Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK
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12
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Polak EJ, O'Callaghan F, Oaten M. Perceptions of IBD within patient and community samples: a systematic review. Psychol Health 2019; 35:425-448. [PMID: 31538517 DOI: 10.1080/08870446.2019.1662014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: Inflammatory bowel disease (IBD) is a chronic, gastrointestinal condition that involves a range of debilitating bowel symptoms. Adjustment to living with IBD can be negatively impacted by maladaptive cognitive and behavioural factors (e.g. negative illness representations and repressing emotions). Patient samples also report negative reactions from the general public and such perceptions can further negatively impact people living with IBD. Therefore, we aimed to systematically review literature investigating the illness perceptions, perceived stigmatisation, and negative emotional reactions toward IBD within patient and community samples. We also aimed to review how these factors impact those living with IBD (i.e. adjustment, psychological health). Design: A range of databases (e.g. Psych INFO, PubMed) were searched over two years. One reviewer individually screened titles and abstracts using the specified inclusion criteria, and this process was repeated by a second reviewer. Subsequently, the full text articles were screened and data were extracted for the 82 articles that satisfied the inclusion criteria. Following data extraction, a narrative synthesis was conducted.Results: The review of 82 studies suggested that negative illness perceptions are linked to poorer psychosocial outcomes, that patient samples frequently anticipate stigmatisation, fear relating to bowel accidents was the most common emotion reported, and that the general public direct little enacted stigma towards IBD.Conclusion: For people living with IBD: (i) poorer psychological adjustment was reported by those who held more negative perceptions and reactions toward their illness; and (ii) their concerns regarding public perceptions of IBD warrants further empirical attention. Results emphasise the importance of targeting perceptions, and facilitating education and adaptive responding during treatment.
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Affiliation(s)
- Elia-Jade Polak
- School of Applied Psychology, Griffith University, Gold Coast, QLD, Australia
| | - Frances O'Callaghan
- School of Applied Psychology, Griffith University, Gold Coast, QLD, Australia
| | - Megan Oaten
- School of Applied Psychology, Griffith University, Gold Coast, QLD, Australia
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13
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Knisely MR, Conley YP, Szigethy E. Cytokine Genetic Variants and Health-Related Quality of Life in Crohn's Disease: An Exploratory Study. Biol Res Nurs 2019; 21:544-551. [PMID: 31272196 DOI: 10.1177/1099800419860906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Crohn's disease (CD) is an inflammatory condition that has deleterious effects on patients' health-related quality of life (HRQoL). Demographic, clinical, and psychosocial factors contribute to variability in HRQoL; however, the influence of genetic variations related to altered inflammatory responses in individuals with CD is unknown. This exploratory study compared HRQoL scores across genotypes of functional genetic polymorphisms in cytokine candidate genes among individuals with CD. METHOD This study used data and blood samples collected in a parent study in 39 patients with CD aged 15-30 years. Participant reports of HRQoL were collected using the Shortened Inflammatory Bowel Disease Questionnaire (SIBDQ). Genetic data were collected for 18 functional polymorphisms in eight cytokine candidate genes. SIBDQ scores were compared among genotypes using one-way, between-subjects analysis of variance. RESULTS SIBDQ scores differed across genotypes as follows: for IL-1R2 rs4141134 scores differed for total SIBDQ (p = .004) and systemic (p = .011), emotion (p = .038), and social domains (p = .025); for IL-10 rs1878672, scores differed for total SIBDQ (p = .031) and social domain (p = .008); for NFKB2 rs1056890, scores differed for social domain (p = .041); for TNF-α rs1800629, scores differed for total SIBDQ (p = .001) and bowel (p = .026), systemic (p = .014), and social domains (p = .045). CONCLUSIONS Findings on differences in SIBDQ scores across functional genetic polymorphisms in cytokine genes suggest potential mechanisms that contribute to variability in HRQoL in adolescents and young adults with CD.
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Affiliation(s)
| | - Yvette P Conley
- 2 School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.,3 Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eva Szigethy
- 4 Department of Gastroenterology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,5 Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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14
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Dibley L, Czuber-Dochan W, Woodward S, Wade T, Bassett P, Sturt J, Norton C. Development and Psychometric Properties of the Inflammatory Bowel Disease Distress Scale (IBD-DS): A New Tool to Measure Disease-Specific Distress. Inflamm Bowel Dis 2018; 24:2068-2077. [PMID: 29788323 DOI: 10.1093/ibd/izy108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) imposes a heavy psychosocial burden, with many patients reporting anxiety, depression, and distress. In diseases such as diabetes, disease-specific distress is associated with concordance with treatments and disease control. IBD distress, distinct from anxiety and depression, is evident in people with IBD. We aimed to develop a questionnaire for assessing IBD-specific distress, validate this against a gold standard distress measure for diabetes, and demonstrate the difference between anxiety, depression, and distress. METHODS The 94-item IBD Distress Scale (IBD-DS) was developed through secondary analysis of 3 qualitative data sets from previous IBD studies. Items were then refined through cognitive interviews in 2 stages (n = 15, n = 3). Three supplementary unscored questions were added to enable patients to identify their overall level of distress, their perceived level of disease activity, and their 3 most distressing issues. Subsequently, the 55-item IBD Distress Scale was subjected to test-retest. Two hundred seventy-five people received the test draft IBD-DS, and 168 responded (60.4%). Of these, 136 (82%) returned the retest draft of IBD-DS 3 weeks later. After analysis, further item reduction was informed by response rates, kappa values, and correlation coefficients, and test-retest was repeated. One hundred fifty-four people received the test final 28-item IBD-DS, and 123 people responded (58.8%). Of these, 95 (77%) returned the retest final IBD-DS. RESULTS The 94 items were reduced to 28 items. Good intraclass correlation (ICC) was found between test-retest scores on 72 complete data sets with unchanged disease status (ICC, 0.92; 95% confidence interval, 0.88-0.95). Cronbach's alpha was 0.95, indicating excellent internal consistency. Factor analysis indicated scoring the items as a single domain (score range, 0-168). CONCLUSION The final IBD-DS performs well and offers a tool for assessing IBD-specific distress.
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Affiliation(s)
- Lesley Dibley
- Faculty of Education and Health, University of Greenwich, London, United Kingdom.,Bart's Health NHS Trust, London, United Kingdom
| | - Wladyslawa Czuber-Dochan
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Sue Woodward
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Tiffany Wade
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Paul Bassett
- Independent Statistician, Amersham, United Kingdom
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
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15
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Kluthe C, Isaac DM, Hiller K, Carroll M, Wine E, van Manen M, Huynh HQ. Qualitative Analysis of Pediatric Patient and Caregiver Perspectives After Recent Diagnosis With Inflammatory Bowel Disease. J Pediatr Nurs 2018; 38:106-113. [PMID: 29357985 DOI: 10.1016/j.pedn.2017.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 11/06/2017] [Accepted: 11/20/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE A diagnosis of a chronic illness is a life-altering experience for a child and his or her family. The purpose of this study was to elicit children and parent perspectives following a diagnosis of Inflammatory Bowel Disease (IBD). DESIGN & METHODS A qualitative description design was employed. Eighteen patients were recruited from a Pediatric IBD Clinic in Western Canada. Interviews were used to gather perceptions, opinions, and attitudes from children and their parents. Transcriptions of the interviews were analyzed using a qualitative content analysis. RESULTS Four themes were identified: perspective of diagnosis, roles in care and decision-making, sharing the diagnosis, and treating the disease. Children and parents expressed varied emotions in response to diagnosis. Families articulated the desire to become more active members in the decision-making process on treatment choices. While using conventional medical therapy was seen as an appropriate choice for short-term therapy, many parents hoped that more non-conventional and alternative therapies could be used in the future. CONCLUSION Healthcare providers need to provide excellent education on the disease process, treatment options, and the use of CAM therapy in IBD, while at the same time supporting children and parent's voices in treatment decisions. PRACTICE IMPLICATIONS Improvement strategies need to be implemented to allow families to feel that they have a voice when making decisions regarding treatment options. Families need to be educated and supported on the use of CAM therapies in IBD.
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Affiliation(s)
- Cheryl Kluthe
- Edmonton Pediatric Inflammatory Bowel Disease Clinic (EPIC), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - D M Isaac
- Edmonton Pediatric Inflammatory Bowel Disease Clinic (EPIC), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Kaitlynd Hiller
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew Carroll
- Edmonton Pediatric Inflammatory Bowel Disease Clinic (EPIC), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Eytan Wine
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michael van Manen
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Hien Quoc Huynh
- Edmonton Pediatric Inflammatory Bowel Disease Clinic (EPIC), Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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16
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Reigada LC, Moore MT, Martin CF, Kappelman MD. Psychometric Evaluation of the IBD-Specific Anxiety Scale: A Novel Measure of Disease-Related Anxiety for Adolescents With IBD. J Pediatr Psychol 2017; 43:413-422. [DOI: 10.1093/jpepsy/jsx121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/05/2017] [Indexed: 12/24/2022] Open
Affiliation(s)
- Laura C Reigada
- Department of Psychology, City University of New York at Brooklyn College
| | | | - Christopher F Martin
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill
| | - Michael D Kappelman
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill
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17
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Patient Health Communication Mediating Effects Between Gastrointestinal Symptoms and Gastrointestinal Worry in Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:704-711. [PMID: 28394807 DOI: 10.1097/mib.0000000000001077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND To investigate the effects of patient health communication regarding their inflammatory bowel disease (IBD) to their health care providers and significant others in their daily life as a mediator in the relationship between gastrointestinal symptoms and gastrointestinal worry in pediatric patients. METHODS The Pediatric Quality of Life Inventory Gastrointestinal Symptoms, Gastrointestinal Worry, and Communication Scales, and Pediatric Quality of Life Inventory 4.0 Generic Core Scales were completed in a 9-site study by 252 pediatric patients with IBD. Gastrointestinal Symptoms Scales measuring stomach pain, constipation, or diarrhea and patient communication were tested for bivariate and multivariate linear associations with Gastrointestinal Worry Scales specific to patient worry about stomach pain or bowel movements. Mediational analyses were conducted to test the hypothesized mediating effects of patient health communication as an intervening variable in the relationship between gastrointestinal symptoms and gastrointestinal worry. RESULTS The predictive effects of gastrointestinal symptoms on gastrointestinal worry were mediated in part by patient health communication with health care providers/significant others in their daily life. In predictive models using multiple regression analyses, the full conceptual model of demographic variables, gastrointestinal symptoms (stomach pain, constipation, or diarrhea), and patient communication significantly accounted for 46, 43, and 54 percent of the variance in gastrointestinal worry (all Ps < 0.001), respectively, reflecting large effect sizes. CONCLUSIONS Patient health communication explains in part the effects of gastrointestinal symptoms on gastrointestinal worry in pediatric patients with IBD. Supporting patient disease-specific communication to their health care providers and significant others may improve health-related quality of life for pediatric patients with IBD.
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18
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Artom M, Czuber-Dochan W, Sturt J, Murrells T, Norton C. The contribution of clinical and psychosocial factors to fatigue in 182 patients with inflammatory bowel disease: a cross-sectional study. Aliment Pharmacol Ther 2017; 45:403-416. [PMID: 27868215 DOI: 10.1111/apt.13870] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 07/19/2016] [Accepted: 10/29/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fatigue is a frequently reported and predominant symptom experienced by patients with inflammatory bowel disease (IBD) and its impact has been associated with poorer quality of life (QoL). The complex interplay between disease-related variables and potentially modifiable psychosocial factors in IBD-fatigue has yet to be unravelled. AIM To evaluate the contribution of clinical, sociodemographic and psychosocial factors to the severity and impact of IBD-fatigue and QoL. METHOD In a cross-sectional study, 182 patients with IBD were recruited from three tertiary referral hospitals' out-patient clinics in London. Fatigue was assessed utilising the Inflammatory Bowel Disease-Fatigue Scale (IBD-F), the Multidimensional Fatigue Inventory (MFI); and QoL by the Inflammatory Bowel Disease Questionnaire (IBDQ). Patients completed self-report questionnaires evaluating emotional, cognitive and behavioural factors potentially correlated with fatigue. Sociodemographic data were collected. Disease-related and laboratory data were retrieved from patients' hospital electronic medical records. RESULT In hierarchical regression models, disease activity was the only clinical factor consistently associated with severity and impact of fatigue and QoL (P = 0.01). More negative fatigue perceptions were significantly associated with greater IBD-F1 scores (P = 0.01). When controlling for clinical factors (disease activity and anti-TNF therapy), negative perceptions of fatigue, and all-or-nothing and avoidance behaviours explained an additional 41% of the variance in fatigue impact (IBD-F2). CONCLUSIONS Apart from disease activity, emotional and behavioural factors and patients' negative fatigue perceptions may be key factors to be addressed. Further exploration of these factors in longitudinal and intervention studies may help to develop effective models of fatigue management.
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Affiliation(s)
- M Artom
- King's College London, Florence Nightingale Faculty of Nursing & Midwifery, London, UK
| | - W Czuber-Dochan
- King's College London, Florence Nightingale Faculty of Nursing & Midwifery, London, UK
| | - J Sturt
- King's College London, Florence Nightingale Faculty of Nursing & Midwifery, London, UK
| | - T Murrells
- King's College London, Florence Nightingale Faculty of Nursing & Midwifery, London, UK
| | - C Norton
- King's College London, Florence Nightingale Faculty of Nursing & Midwifery, London, UK.,Imperial College Healthcare NHS Trust, London, UK
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