The Impact of Occupational Therapy on the Self-Management of Rheumatoid Arthritis: A Mixed Methods Systematic Review

OBJECTIVE

To determine the impact of occupational therapy (OT) on the self-management of function, pain, fatigue, and lived experience for people living with rheumatoid arthritis (RA).

METHODS

Five databases and gray literature were searched up to June 30, 2022. Three reviewers screened titles and abstracts, with two independently extracting and assessing full texts using the Cochrane risk of bias (quantitative) and Critical Appraisal Skills Programme (qualitative) tools to assess study quality. Studies were categorized into four intervention types. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) (quantitative) and GRADE- Confidence in Evidence from Reviews of Qualitative research (qualitative) were used to assess the quality of evidence for each intervention type.

RESULTS

Of 39 eligible papers, 29 were quantitative (n = 2,029), 4 qualitative (n = 50), and 6 mixed methods (n = 896). Good evidence supports patient education and behavior change programs for improving pain and function, particularly group sessions of joint protection education, but these do not translate to long-term improvements for RA (>24 months). Comprehensive OT had mixed evidence (limited to home OT and an arthritis gloves program), whereas limited evidence was available for qualitative insights, splints and assistive devices, and self-management for fatigue.

CONCLUSION

Although patient education is promising for self-managing RA, no strong evidence was found to support OT programs for self-managing fatigue or patient experience and long-term effectiveness. More research is required on lived experience, and the long-term efficacy of self-management approaches incorporating OT, particularly timing programs to meet the individual's conditional needs (i.e., early or established RA) to build on the few studies to date.

Decision-Making Around COVID-19 Public Health Measures and Implications for Self-Care Activities: Experiences of Persons With Rheumatoid Arthritis

OBJECTIVE

We aimed to advance understanding of how persons with rheumatoid arthritis (RA) experience decision-making about adopting public health measures during the COVID-19 pandemic.

METHODS

Persons living with RA partnered throughout this nested qualitative study. One-to-one semistructured telephone interviews were conducted with participants with RA between December 2020 and December 2021. They were strategically sampled from a randomized controlled trial that was underway to test a physical activity counseling intervention. Analysis was guided by reflexive thematic analysis.

RESULTS

Thirty-nine participants (aged 26-86 years; 36 women) in British Columbia, Canada were interviewed. We developed three themes. Participants described how their decision-making about public health measures related to 1) "upholding moral values of togetherness" because decisions were intertwined with moral values of neighborliness and reciprocity. Some adapted their self-care routines to uphold these moral values; 2) "relational autonomy-supports and challenges," because they sometimes felt supported and undermined in different relational settings (eg, by family, local community, or provincial government); and 3) "differing trust in information sources," in which decisions were shaped by the degree of faith they had in various information sources, including their rheumatologists.

CONCLUSION

Across themes, experiences of decision-making about public health measures during the pandemic were embedded with moral concepts of solidarity, autonomy, and trust, with implications for how persons with RA chose and sustained their self-care activities. Insights gained help sensitize researchers and clinicians to moral issues experienced by persons with RA, which may inform support for self-care activities during and after the pandemic.

Effect of digital monitoring and counselling on self-management ability in patients with rheumatoid arthritis: a randomised controlled trial

OBJECTIVES

To assess a remote physiotherapist (PT) counselling intervention using self-monitoring tools for improving self-management ability, physical activity participation, and health outcomes in people with rheumatoid arthritis (RA).

METHODS

Eligible participants were randomly assigned to receive group education, a Fitbit®, a self-monitoring app, and PT counselling phone calls (Immediate Group). The Delayed Group received a monthly e-newsletter until week 26, and then the intervention. The primary outcome was Patient Activation Measure (PAM-13). Participants were assessed at baseline, 27 weeks (the primary end point) and 53 weeks. Secondary outcomes included disease activity, pain, fatigue, depression, sitting/walking habits, daily physical activity time, and daily awake sedentary time. Generalized Linear Mixed-effect Models (GLMMs) were used to assess the effect of the intervention on the change of each outcome measure from the initiation to 27 weeks after the intervention.

RESULTS

Analysis included 131 participants (91.6% women; 80.2% completed during the COVID-19 pandemic). The mean change of PAM-13 at 27 weeks was 4.6 (SD = 14.7) in the Immediate Group vs -1.6 (SD = 12.5) in the Delayed Group. The mean change in Delayed Group at 53 weeks (after the 26-week intervention) was 3.6 (SD = 14.6). Overall, the intervention improved PAM-13 at 27 weeks post-intervention from the GLMM analysis (adjusted coefficient: 5.3; 95% CI: 2.0, 8.7; p = <0.001). Favourable intervention effects were also found in disease activity, fatigue, depression, and self-reported walking habit.

CONCLUSION

Remote counselling paired with self-monitoring tools improved self-management ability in people with RA. Findings of secondary outcomes indicate that the intervention had a positive effect on symptom management.

Beyond dyadic communication: Network of communication in inflammatory arthritis teams

OBJECTIVE

To explore how communication is perceived and care is negotiated amongst IA healthcare teams by drawing on the perspectives of each team member.

METHOD

This analysis drew on data from an ongoing three-year study exploring team-based IA care. We interviewed 11 participants including two men with IA and their family care providers and healthcare providers. We used a three-staged analytic process and integrated broad tenets of social network theory to understand the relational dimensions of team members experiences.

RESULT

Analysis revealed three themes regarding communication and care: (1) seeking/sharing information, (2) striving to coordinate unified care, and (3) providing patients a voice.

DISCUSSION

This study emphasizes the importance of understanding team dynamics beyond the dyad of patient and care provider. Negotiating power and decision-making in IA care is a dynamic process involving shifting levels of responsibility amongst a care team. Communication-based strategies that extend dyadic interactions may enhance teamwork and health outcomes in chronic conditions.

The role of occupational therapy for the self-management of rheumatoid arthritis: A protocol for a mixed methods systematic review

BACKGROUND

Occupational therapists can support people with rheumatoid arthritis to self-manage their disease symptoms and engage in daily activities. This protocol reports a review to broaden understanding of what is known about the role of occupational therapy in the self-management of rheumatoid arthritis.

METHODS

Studies involving adults with rheumatoid arthritis, having participated in self-management involving occupational therapy, will be included. Patient involvement will help develop the search strategy by identifying patient-centred interventions and outcomes to complement those identified by researchers. An electronic search will be performed using several bibliographic databases, including grey literature from subject-specific, health-related, and social care databases. Searches will run from the database inception until the date that the search is conducted (December 2021-May 2022). Retrieved studies will be de-duplicated, and the remaining titles and abstracts will be screened by three reviewers. Full texts of all eligible studies will be independently reviewed by the reviewers to select papers for data extraction and quality assessment. Outcomes are function, pain, fatigue and lived experience. For quantitative studies, data will be synthesised using descriptive statistics in text and tables, whereas for qualitative studies, data will be synthesised using thematic synthesis.

DISCUSSION

This review will synthesise current evidence on how occupational therapy can help the self-management of rheumatoid arthritis. It will include evidence of best practice, including advice, education and training provided by occupational therapists. These findings can inform future research and the selection of strategies to promote quality of life for people with rheumatoid arthritis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022302205.

'Make the Most of the Situation'. Older Adults' Experiences during COVID-19: A Longitudinal, Qualitative Study

The COVID-19 pandemic restrictions have been associated with increased social isolation and reduced participation in older adults. This longitudinal qualitative study drew on life course theory to analyse data from a series of four sequential semi-structured interviews conducted between May 2020-February 2021 with adults aged 65+ (n = 12) to explore older adults' experiences adjusting to the COVID-19 pandemic. We identified three themes: (1) Struggling 'You realize how much you lost' describes how older adults lost freedoms, social connections and activities; (2) Adapting 'whatever happens, happens, I'll do my best', revealing how older adults tried to maintain well-being, participation and connection; and (3) Appreciating 'enjoy what you have', exploring how older adults found pleasure and contentment. Engagement in meaningful activities and high-quality social interactions supported well-being during the COVID-19 pandemic for older adults. This finding highlights the need for policies and services to promote engagement during longstanding global crises.

Ethical issues experienced by persons with rheumatoid arthritis in a wearable-enabled physical activity intervention study

Introduction

Using wearables to self‐monitor physical activity is a promising approach to support arthritis self‐management. Little is known, however, about the context in which ethical issues may be experienced when using a wearable in self‐management. We used a relational ethics lens to better understand how persons with rheumatoid arthritis (RA) experience their use of a wearable as part of a physical activity counselling intervention study involving a physiotherapist (PT).

Methods

Constructivist grounded theory and a relational ethics lens guided the study design. This conceptual framework drew attention to benefits, downsides and tensions experienced in a context of relational settings (micro and macro) in which participants live. Fourteen initial and eleven follow‐up interviews took place with persons with RA in British Columbia, Canada, following participation in a wearable‐enabled intervention study.

Results

We created three main categories, exploring how experiences of benefits, downsides and tensions when using the intervention intertwined with shared moral values placed on self‐control, trustworthiness, independence and productivity: (1) For some, using a wearable helped to ‘do something right’ by taking more control over reaching physical activity goals. Some, however, felt ambivalent, believing both there was nothing more they could do and that they had not done enough to reach their goal; (2) Some participants described how sharing wearable data supported and challenged mutual trustworthiness in their relationship with the PT; (3) For some, using a wearable affirmed or challenged their sense of self‐respect as an independent and productive person.

Conclusion

Participants in this study reported that using a wearable could support and challenge their arthritis self‐management. Constructing moral identity, with qualities of self‐control, trustworthiness, independence and productivity, within the relational settings in which participants live, was integral to ethical issues encountered. This study is a key step to advance understanding of ethical issues of using a wearable as an adjunct for engaging in physical activity from a patient's perspective.

Patient or Public Contribution

Perspectives of persons with arthritis (mostly members of Arthritis Research Canada's Arthritis Patient Advisory Board) were sought to shape the research question and interpretations throughout data analysis.

Networks of Care: A Social Network Perspective of Distributed Multidisciplinary Care for People With Inflammatory Arthritis

OBJECTIVE

To explore how multidisciplinary inflammatory arthritis (IA) care is accessed from the perspectives of people with IA and their health care network members.

METHODS

In this phenomenological study, we used purposive sampling to recruit patients with IA for less than 5 years and age of more than 18 years who spoke English and reported two or more health care network members. We conducted one-to-one interviews with patients and their health care network members. Data were analysed using a social network perspective.

RESULTS

We interviewed 14 patient participants and 19 health care network members comprising health care providers and informal caregivers. An overarching theme of whole person (holistic) IA care was identified, with the following two broad multifaceted subthemes: 1) connected networks and whole person care and 2) network disconnect and disrupted access to care. The first subtheme notes how access to health care providers and social support was fundamental to holistic care and how care was facilitated by communication pathways that promoted care. The second subtheme illustrates impediments to access, including appointment time pressures, inadequacies in communication delivery modes, and family physicians' unfamiliarity with rheumatology care. Inequities in care were also reported.

CONCLUSION

Participants shared a goal of whole person care. Although health care networks included multiple disciplines, they did not always provide coordinated multidisciplinary care. Communication modes, linkages between network actors, and organizational structures governed the flow of information and resources through networks and influenced access to equitable whole person care. The development of health care system structures to support the flow of information and resource transfer is needed to promote network collaboration and equitable access to resources.

Experiences of Wearable Technology by Persons with Knee Osteoarthritis Participating in a Physical Activity Counseling Intervention: Qualitative Study Using a Relational Ethics Lens

Background

Current evidence indicates physical activity wearables could support persons with knee osteoarthritis (OA) to be more physically active. However, recent evidence also identifies some persons with arthritis experience guilt or worry while using a wearable if they are not as active as they feel they should be. Questions remain around how persons with knee OA experience benefits or downsides using a wearable in their everyday lives. Better understanding is needed if wearables are to be incorporated in arthritis self-management in ethically aware ways.

Objective

Using an ethics lens, we aimed to describe a range of experiences from persons with knee OA who used a wearable during a physical activity counseling intervention study.

Methods

This is a secondary analysis of qualitative interviews nested within a randomized controlled trial. Guided by phenomenography, we explored the experiences of persons with knee OA following participation in a physical activity counseling intervention that involved using a Fitbit Flex and biweekly phone calls with a study physiotherapist (PT) in an 8-week period. Benefits or downsides experienced in participants’ relationships with themselves or the study PT when using the wearable were identified using a relational ethics lens.

Results

Interviews with 21 participants (12 females and 9 males) aged 40 to 82 years were analyzed. Education levels ranged from high school graduates (4/21, 19%) to bachelor’s degrees or above (11/21, 52%). We identified 3 categories of description: (1) participants experienced their wearable as a motivating or nagging influence to be more active, depending on how freely they were able to make autonomous choices about physical activity in their everyday lives; (2) some participants felt a sense of accomplishment from seeing progress in their wearable data, which fueled their motivation; (3) for some participants, sharing wearable data helped to build mutual trust in their relationship with the study PT. However, they also expressed there was potential for sharing wearable data to undermine this trust, particularly if this data was inaccurate.

Conclusions

Findings provide an early glimpse into positive and negative emotional impacts of using a wearable that can be experienced by participants with knee OA when participating in a randomized controlled trial to support physical activity. To our knowledge, this is the first qualitative study that uses a relational ethics lens to explore how persons with arthritis experienced changes in their relationship with a health professional when using a wearable during research participation.

Occupational Science Concepts Essential to Occupation-Based Practice: Development of Expert Consensus

IMPORTANCE

What occupational science (OS) knowledge may be essential to occupational therapy practice has not been systematically explored.

OBJECTIVE

To identify and gain expert consensus on OS concepts viewed as essential to occupational therapy practice.

DESIGN

A complex, convergent mixed-methods Delphi design with an international panel of OS experts randomly assigned to two parallel groups. In Round 1, each group generated OS concepts; in Rounds 2 and 3, they rated the degree to which each concept was essential to occupational therapy. Data were analyzed separately for each group. A fourth round combined the two groups and used carefully merged concept definitions from both groups to validate consensus on essential concepts arising from the prior rounds.

PARTICIPANTS

Fifty-two nominated experts from 22 countries who met a priori criteria participated in the 14-mo study.

RESULTS

Of 62 experts invited, 52 (Group A = 24, Group B = 28) participated in the first round, and 42 (81%) completed the full-group final round. Eleven concepts met the consensus threshold (≥70%) established for the study. Additional analysis compared parallel- and full-group results to carefully discern conceptual similarities and differences, especially with near-consensus concepts.

CONCLUSIONS AND RELEVANCE

Substantial expert agreement was established for several OS concepts viewed as essential, providing a basis for future studies to refine the concepts for occupational therapy education and practice. What This Article Adds: The results of this research provide a systematically derived preliminary basis for selecting OS content for occupational therapy educational programs and preliminary concepts for organizing OS knowledge germane to occupational therapy practice.

Experiences of self-care during the COVID-19 pandemic among individuals with rheumatoid arthritis: A qualitative study

Objectives

This study aimed to explore the impact of the coronavirus disease 2019 (COVID‐19) pandemic on self‐care of individuals living with rheumatoid arthritis (RA).

Methods

Guided by a constructivist, qualitative design, we conducted one‐to‐one in‐depth telephone interviews between March and October 2020 with participants with RA purposively sampled for maximum variation in age, sex and education, who were participating in one of two ongoing randomized‐controlled trials. An inductive, reflexive thematic analysis approach was used.

Results

Twenty‐six participants (aged 27–73 years; 23 females) in British Columbia, Canada were interviewed. We identified three themes: (1) Adapting to maintain self‐care describes how participants took measures to continue self‐care activities while preventing virus transmissions. While spending more time at home, some participants reported improved self‐care. (2) Managing emotions describes resilience‐building strategies such as keeping perspective, positive reframing and avoiding negative thoughts. Participants described both letting go and maintaining a sense of control to accommodate difficulties and emotional responses. (3) Changing communication with health professionals outlined positive experiences of remote consultations with health professionals, particularly if good relationships had been established prepandemic.

Conclusion

The insights gained may inform clinicians and researchers on ways to support the self‐care strategies of individuals with RA and other chronic illnesses during and after the COVID‐19 pandemic. The findings reveal opportunities to further examine remote consultations to optimize patient engagement and care.

Patient or Public Contribution

This project is jointly designed and conducted with patient partners in British Columbia, Canada. Patient partners across the United Kingdom also played in a key role in providing interpretations of themes during data analysis.

Fatherhood Experiences of Men With Inflammatory Arthritis: A Preliminary Grounded Theory

OBJECTIVE

Minimal prior research has examined the impact of inflammatory arthritis (IA) on men's perspectives on parenting. We aimed to describe fathering roles and experiences, the effect of IA on parenting activities, and strategies used by fathers with IA to fulfill this role.

METHODS

A grounded theory approach guided data gathering and analysis. Nine men with IA, parenting at least 1 child age <19 years, were recruited through rheumatology practices, therapy clinics, and social media. Each engaged in 1 in-depth personal interview. Transcripts were analyzed using inductive and iterative steps to identify key themes and a preliminary explanatory framework of fathering experiences of men with IA.

RESULTS

All men were married, ages 31-62 years, with 1 to 5 children ages 6 months to 28 years. "Being an involved father" describes participants' perspectives on fulfilling their role as hands-on parents, role models, and financial providers. "Taking ownership" explains how participants managed daily life, comprising 2 subthemes, "taking care of yourself," using strategies like exercise and communicating with loved ones, and "redefining yourself," a process of adapting to reframed identity and lifestyle adjustments. "Accessing support" indicates men who felt well-supported by social networks (most critically their wives), health care providers, and informational and educational resources.

CONCLUSION

This small, grounded theory study offers an enriched understanding of fatherhood experiences of men with IA. When social, practical, and educational supports are in place, these men found parenting joyful and rewarding. Despite task limitations, their perspectives on being involved fathers was unrestricted by arthritis.

Exploring the associations among occupational balance and health of adults with and without inflammatory arthritis

OBJECTIVE

Occupational balance is a person's subjective perception of the amount and variation of their everyday activities. Evidence suggests an association between occupational balance and health. However, the impact of arthritis on occupational balance and its association with health is unclear. This exploratory study examined associations between occupational balance and measures of health, and between-group differences, in adults with and without inflammatory arthritis (IA).

METHODS

In a cross-sectional study, participants completed the Occupational Balance Questionnaire (OBQ11), SF-36 Health Survey (Physical and Mental Component Scores) and provided demographic information. Telomere lengths were analyzed from dried blood spots.

RESULTS

143 adults participated (67 with IA, 76 healthy comparison (HC) group). Occupational balance was higher in the HC group than the IA group (mean difference = 3.5, 95% CI = 1.0, 5.9, p = 0.01), but this difference was not statistically significant when adjusted for physical health. The association between occupational balance and physical health was stronger in the IA group (R² = .17, p = .001) than in the HC group (R² = .05, p = .05). Occupational balance was associated with mental health (R² = .26, p < .001) but not associated with telomere length (R² = .02, p = .24).

CONCLUSION

Occupational balance is associated with mental health for all participants and associated with physical health and disease activity in participants with IA. Attention to assessment of and strategies for improving occupational balance in rehabilitation practice and arthritis self-management programs may contribute to sustaining physical and mental health.

The Perspectives of Persons with Arthritis on the Use of Wearable Technology to Self-Monitor Physical Activity: A Qualitative Evidence Synthesis

OBJECTIVE

We aim to broaden understanding of the perspectives of persons with arthritis on their use of wearables to self-monitor physical activity, through a synthesis of evidence from qualitative studies.

METHODS

We conducted a systematic search of 5 databases (including Medline, CINAHL, and Embase) from inception to 2018. Eligible studies qualitatively examined the use of wearables from the perspectives of persons with arthritis. All relevant data were extracted and coded inductively in a thematic synthesis.

RESULTS

Of 4358 records retrieved, 7 articles were included. Participants used a wearable during research participation in 3 studies and as part of usual self-management in 2 studies. In remaining studies, participants were shown a prototype they did not use. Themes identified were: 1) Potential to change dynamics in patient-health professional communication: Articles reported a common opinion that sharing wearable data could possibly enable them to improve communication with health professionals; 2) Wearable-enabled self-awareness; a benefit or downside?: There was agreement that wearables could increase self-awareness of physical activity levels, but perspectives were mixed on whether this motivated more physical activity; 3) Designing a wearable for everyday life: Participants generally felt the technology was not obtrusive in their everyday lives, but it was speculated certain prototypes may embarrass or stigmatize persons with arthritis.

CONCLUSION

Themes hint toward an ethical dimension, as participants perceive their use of wearables may positively or negatively influence their capacity to shape their everyday self-management. We suggest ethical questions pertinent to the use of wearables in arthritis self-management for further exploration.

Men and Women's Occupational Activities and the Risk of Developing Osteoarthritis of the Knee, Hip, or Hands: A Systematic Review and Recommendations for Future Research

Objective

To systematically review the evidence for an increased risk of osteoarthritis in the hip, knee, hand, wrist, finger, ankle, foot, shoulder, neck, and spine related to diverse occupational activities of men and women and to examine dose‐response information related to the frequency, intensity, and duration of work exposures and the risk of osteoarthritis (OA).

Methods

Established guidelines for systematic reviews in occupational health and safety studies were followed. MEDLINE, Embase, CINAHL, and Cochrane Library were searched from inception to December 2017. Studies were reviewed for relevance, quality was appraised, and data were extracted and synthesized.

Results

Sixty‐nine studies from 23 countries yielded strong and moderate evidence for lifting, cumulative physical loads, full‐body vibration, and kneeling/squatting/bending as increasing the risks of developing OA in men and women. Strong and moderate evidence existed for no increased risk of OA related to sitting, standing, and walking (hip and knee OA), lifting and carrying (knee OA), climbing ladders (knee OA), driving (knee OA), and highly repetitive tasks (hand OA). Variability in dose‐response data resulted in an inability to synthesize these data.

Conclusion

Evidence points to the potential for OA occupational recommendations and practice considerations to be developed for women and men. However, research attention is needed to overcome deficits in the measurement and recall of specific work activities so that recommendations and practice considerations can provide the specificity needed to be adopted in workplaces.

Effects of a 12-Week Multifaceted Wearable-Based Program for People With Knee Osteoarthritis: Randomized Controlled Trial

BACKGROUND

Current guidelines emphasize an active lifestyle in the management of knee osteoarthritis (OA), but up to 90% of patients with OA are inactive. In a previous study, we demonstrated that an 8-week physiotherapist (PT)-led counseling intervention, with the use of a Fitbit, improved step count and quality of life in patients with knee OA, compared with a control.

OBJECTIVE

This study aimed to examine the effect of a 12-week, multifaceted wearable-based program on physical activity and patient outcomes in patients with knee OA.

METHODS

This was a randomized controlled trial with a delay-control design. The immediate group (IG) received group education, a Fitbit, access to FitViz (a Fitbit-compatible app), and 4 biweekly phone calls from a PT over 8 weeks. Participants then continued using Fitbit and FitViz independently up to week 12. The delay group (DG) received a monthly electronic newsletter in weeks 1 to 12 and started the same intervention in week 14. Participants were assessed in weeks 13, 26, and 39. The primary outcome was time spent in daily moderate-to-vigorous physical activity (MVPA; in bouts ≥10 min) measured with a SenseWear Mini. Secondary outcomes included daily steps, time spent in purposeful activity and sedentary behavior, Knee Injury and OA Outcome Score, Patient Health Questionnaire-9, Partners in Health Scale, Theory of Planned Behavior Questionnaire, and Self-Reported Habit Index.

RESULTS

We enrolled 51 participants (IG: n=26 and DG: n=25). Compared with the IG, the DG accumulated significantly more MVPA time at baseline. The adjusted mean difference in MVPA was 13.1 min per day (95% CI 1.6 to 24.5). A significant effect was also found in the adjusted mean difference in perceived sitting habit at work (0.7; 95% CI 0.2 to 1.2) and during leisure activities (0.7; 95% CI 0.2 to 1.2). No significant effect was found in the remaining secondary outcomes.

CONCLUSIONS

A 12-week multifaceted program with the use of a wearable device, an app, and PT counseling improved physical activity in people with knee OA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02585323; https://clinicaltrials.gov/ct2/show/NCT02585323.

Effectiveness of an online self-management tool, OPERAS (an On-demand Program to EmpoweR Active Self-management), for people with rheumatoid arthritis: a research protocol

Background

Active self-management is a process where patients are fully engaged in managing their health in daily life by having access to contextualized health data and tailored guidance to support a healthy lifestyle. This study aims to determine whether an e-health intervention that incorporates symptom/disease activity monitoring and physical activity counselling can improve self-management ability in patients with rheumatoid arthritis (RA).

Methods

The ‘Empowering active self-management of arthritis: Raising the bar with OPERAS (an On-demand Program to EmpoweR Active Self-management)’ project is a randomized controlled trial that uses a delayed control design. One hundred thirty-four participants with RA will be randomly assigned to start the intervention either immediately (immediate group) or 6 months later (delayed group). The intervention involves (1) use of a Fitbit-compatible web app to record and monitor their RA disease activity, symptoms, and time spent on physical activity and a Fitbit; (2) group education and individual counselling by a physiotherapist (PT); and (3) six phone calls with a PT. The primary outcome measure is self-management ability measured by the Patient Activation Measure. Secondary outcome measures include disease status, fatigue, pain, depressive symptoms, and characteristics of habitual behavior and also time spent in physical activity and sedentary activity with a wearable multi-sensor device (SenseWear Mini). After the 6-month intervention, we will interview a sample of participants to examine their experiences with the intervention.

Discussion

The results of this study will help to determine whether this technology-enhanced self-management intervention improves self-management ability and health outcomes for people living with RA. A limitation of this study is that participants will need to self-report their symptoms, disease status, and treatment use through questionnaires on the OPERAS web app. The user-friendly interface, reminder emails from the research staff, and tailored guidance from PTs will encourage participants to actively engage with the app.

Trial registration

Date of last update in ClinicalTrials.gov: January 2, 2019. ClinicalTrials.gov Identifier: NCT03404245.

Using Physical Activity Trackers in Arthritis Self-Management: A Qualitative Study of Patient and Rehabilitation Professional Perspectives

OBJECTIVE

To compare and contrast the perspectives of patients with arthritis and those of rehabilitation professionals regarding starting and sustaining use of physical activity trackers (PATs).

METHODS

We conducted focus group sessions with patients, physiotherapists, and occupational therapists in Ontario, Alberta, or British Columbia, Canada. To be eligible, patients must have self-reported a diagnosis of inflammatory or osteoarthritis. Rehabilitation professionals reported that at least 40% of their caseload was dedicated to arthritis care. Participants had any level of experience with PATs. A thematic analytic approach was used.

RESULTS

The following 3 themes were identified: 1) anticipating sharing objective measures of physical activity. Participants agreed that use of PATs had the potential to improve consultations between patients with arthritis and rehabilitation professionals but were uncertain how to achieve this potential; 2) perceived or experienced barriers to start or continue using a PAT. Participants shared doubts about whether existing PATs would meet specific needs of patients with arthritis and expressed concerns about possible negative impacts; and 3) bolstering motivation? Although there was agreement that use of PATs could bolster the motivation of patients who were already active, patients and rehabilitation professionals had different opinions regarding whether use of PATs alone would motivate patients to start increasing activity levels.

CONCLUSION

Our study highlights similarities and differences between the perspectives of patients and rehabilitation professionals regarding the potential value and risks of integrating PATs into arthritis self-management. Despite agreement about the potential of PATs, participants were uncertain how to effectively incorporate these tools to enhance patient-clinician consultations and had differing views about whether use of PATs would support a patient's motivation to be active.

"I just love it": Avid knitters describe health and well-being through occupation

BACKGROUND.

Examining craft-based occupations is necessary to explicate the relationship between occupation and well-being.

PURPOSE.

This study aimed to understand the role of knitting in the lives of passionate knitters and their experience of how knitting contributes to health, well-being, and occupational identity.

METHOD.

Principles of phenomenology guided interviews with 21 knitting-guild members (with and without health conditions) and observations at seven guild meetings as well as guided the data analysis. Eight interviewees and 24 additional guild members confirmed key findings in writing.

FINDINGS.

Five main themes capture how knitting (a) "makes me happy," (b) is "the mental challenge I need," (c) is "a hobby that joins" through social connections and skill development, (d) sustains identity such that "I can't imagine life without knitting," and (e) is a creative outlet "reflecting my personality."

IMPLICATIONS.

This in-depth description of how knitters experience their craft in daily life bolsters the philosophical assumption that favoured occupations have the power to promote health and well-being.

Patient Perspectives on the Challenges and Responsibilities of Living With Chronic Inflammatory Diseases: Qualitative Study

Background

Collectively, chronic inflammatory diseases take a great toll on individuals and society in terms of participation restrictions, quality of life, and economic costs. Although prior qualitative studies have reported patients’ experiences and challenges living with specific diseases, few have compared the consequences of disease management in daily life across different types of inflammatory diseases in studies led by patient partners.

Objective

The aim of this study was to identify the significant consequences of inflammatory arthritis, psoriasis, and inflammatory bowel diseases on daily life and explore commonalities across diseases.

Methods

A cross-sectional Web-based survey was designed by patient research partners and distributed by patient awareness organizations via their social media channels and by sharing a link in a newspaper story. One open-ended item asked about burdens and responsibilities experienced in daily life. Informed by narrative traditions in qualitative health research, we applied a thematic content analysis to participants’ written accounts in response to this item. This is an example of a study conceived, conducted, and interpreted with patients as research partners.

Results

A total of 636 Canadians, with a median age band of 55-64 years, submitted surveys, and 80% of the respondents were women. Moreover, 540 participants provided written substantive responses to the open-ended item. Overall, 4 main narratives were generated: (1) daily life disrupted; (2) socioeconomic vulnerabilities; (3) stresses around visible, invisible, and hiding disabilities; and (4) actions aimed at staying positive. Ways in which participants experienced social stigma, pain and fatigue, balancing responsibilities, and worries about the future appeared throughout all 4 narratives.

Conclusions

People living with chronic inflammatory diseases affecting joints, skin, and the digestive tract report important gaps between health, social, and economic support systems that create barriers to finding the services they need to sustain their health. Regardless of diagnosis, they report similar experiences navigating the consequences of lifelong conditions, which have implications for policy makers. There is a need for outcome measures in research and service delivery to address patient priorities and for programs to fill gaps created by the artificial administrative separation of health services, social services, and income assistance.

Development and pre-testing of the Patient Engagement In Research Scale (PEIRS) to assess the quality of engagement from a patient perspective

OBJECTIVES

To develop and examine the content and face validity of the Patient Engagement In Research Scale (PEIRS) for assessing the quality of patient engagement in research projects from a patient partner perspective.

METHODS

Our team of researchers and patient partners conducted a mixed qualitative and quantitative study in three phases. Participants were English-speaking adult patients (including informal caregivers, family members, and friends) with varying experiences as partners in research projects in Canada. 1) Questionnaire items were generated following thematic analysis of in-depth interviews and published literature. 2) A three-round e-Delphi survey process via email correspondence was undertaken to refine and select the items for a provisional PEIRS. 3) Two rounds of cognitive interviewing elicited participants' understanding and opinions of each item and the structure of the PEIRS.

RESULTS

One hundred and twenty items were generated from 18 interviews and organized across eight themes of meaningful engagement of patients in health research to form an initial questionnaire. The e-Delphi survey and cognitive interviewing each included 12 participants with a range of self-reported diseases, health-related conditions, and use of healthcare services. The e-Delphi survey yielded a 43-item provisional PEIRS. The PEIRS was then reduced to 37 items organized across seven themes after 1) refinement of problems in its instructions and items, and 2) the combining of two themes into one.

CONCLUSIONS

We developed a 37-item self-reported questionnaire that has demonstrated preliminary content and face validity for assessing the quality of patient engagement in research.

Measuring occupational balance and its relationship to perceived stress and health: Mesurer l'équilibre occupationnel et sa relation avec le stress perçus et la santé

BACKGROUND

There is an assumption that occupational balance is integrally related to health and well-being.

PURPOSE

This study aimed to investigate test-retest reliability of the English-translated Occupational Balance Questionnaire (OBQ), its relationship to measures of health (Short Form Health Survey-36 Version 2.0 [SF-36v2]) and stress (Perceived Stress Scale-10; PSS-10), and demographic differences in OBQ scores in Canadian adults.

METHOD

Test-retest reliability (2 weeks) was assessed using intraclass correlation (ICC) coefficients. Online surveys from 86 adults were analyzed using descriptive, correlational, and t test statistics.

FINDINGS

OBQ test-retest reliability was ICC = 0.74 (95% CI [0.34, 0.90]; p = .003) when excluding an influential case ( n = 20). OBQ correlations with PSS-10 were r = -.72; with SF-36v2 Mental Component Score, r = .65; and with Physical Component Score, r = .31; all p < .001. Age and gender had no impact on OBQ scores.

IMPLICATIONS

Findings help elucidate relationships among health, stress, and occupational balance; however, further psychometric testing is warranted before using OBQ for clinical purposes.

eHealth Technologies, Multimorbidity, and the Office Visit: Qualitative Interview Study on the Perspectives of Physicians and Nurses

Background

eHealth is a broad term referring to the application of information and communication technologies in the health sector, ranging from health records to telemedicine and multiple forms of health education and digital tools. By providing increased and anytime access to information, opportunities to exchange experiences with others, and self-management support, eHealth has been heralded as transformational. It has created a group of informed, engaged, and empowered patients as partners, equipped to take part in shared decision making and effectively self-manage chronic illness. Less attention has been given to health care professionals’ (HCPs) experiences of the role of eHealth in patient encounters.

Objective

The objective of this study was to examine HCPs’ perspectives on how eHealth affects their relationships with patients living with multiple chronic conditions, as well as its ethical and practical ramifications.

Methods

We interviewed HCPs about their experiences with eHealth and its impact on the office visit. Eligible participants needed to report a caseload of ≥25% of patients with multimorbidity to address issues of managing complex chronic conditions and coordination of care. We used a semistructured discussion guide for in-depth interviews, and follow-up interviews served to clarify and expand upon initial discussions. Constant comparisons and a narrative approach guided the analyses, and a relational ethics conceptual lens was applied to the data to identify emergent themes.

Results

A total of 12 physicians and nurses (6 male, 6 female; median years of practice=13) participated. eHealth tools most frequently described were Web-based educational resources for patients and Web-based resources for HCPs such as curated scientific summaries on diagnostic criteria, clinical therapies, and dosage calculators. Analysis centered on a grand theme of the two-way conversation between HCPs and patients, which addresses a general recentering of the ethical relationship between HCPs and patients around engagement. Subthemes explain the evolution of the two-way conversation, and having, using, and supporting the two-way conversation with patients, primarily as this relates to achieving adherence and health outcomes.

Conclusions

Emerging ethical concerns were related to the ambiguity of the ideal of empowered patients and the ways in which health professionals described enacting those ideals in practice, showing how the cultural shift toward truly mutually respectful and collaborative practice is in transition. HCPs aim to act in the best interests of their patients; the challenge is to benefit from emergent technologies that may enhance patient-HCP interactions and effective care, while abiding by regulations, dealing with the strictures of the technology itself, and managing changing demands on their time.

A technology-enabled Counselling program versus a delayed treatment control to support physical activity participation in people with inflammatory arthritis: study protocol for the OPAM-IA randomized controlled trial

Background

Being physically active is an essential component of successful self-management for people with inflammatory arthritis; however, the vast majority of patients are inactive. This study aims to determine whether a technology-enabled counselling intervention can improve physical activity participation and patient outcomes.

Methods

The Effectiveness of Online Physical Activity Monitoring in Inflammatory Arthritis (OPAM-IA) project is a community-based randomized controlled trial with a delayed control design. We will recruit 130 people with rheumatoid arthritis or systemic lupus erythematosus, who can be physically active without health professional supervision. Randomization will be stratified by diagnosis. In Weeks 1-8, participants in the Immediate Group will: 1) receive education and counselling by a physical therapist (PT), 2) use a Fitbit and a new web-based application, FitViz, to track and obtain feedback about their physical activity, 3) receive 4 biweekly follow-up calls from the PT. Those in the Delayed Group will receive the same program in Week 10. We will interview a sample of participants about their experiences with the intervention. Participants will be assessed at baseline, and Weeks 9, 18 and 27. The primary outcome measure is time spent in moderate/vigorous physical activity in bouts of ≥ 10 min, measured with a portable multi-sensor device in the free-living environment. Secondary outcomes include step count, time in sedentary behaviour, pain, fatigue, mood, self-management capacity, and habitual behaviour.

Discussion

A limitation of this study is that participants, who also administer the outcome measures, will not be blinded. Nonetheless, by customizing existing self-monitoring technologies in a patient-centred manner, individuals can be coached to engage in an active lifestyle and monitor their performance. The results will determine if this intervention improves physical activity participation. The qualitative interviews will also provide insight into a paradigm to integrate this program to support self-management.

Trial registration

Date of last update in ClinicalTrials.gov: September 18, 2015. ClinicalTrials.gov Identifier: NCT02554474.

An empirically based conceptual framework for fostering meaningful patient engagement in research

Background

Patient engagement in research (PEIR) is promoted to improve the relevance and quality of health research, but has little conceptualization derived from empirical data.

Objective

To address this issue, we sought to develop an empirically based conceptual framework for meaningful PEIR founded on a patient perspective.

Methods

We conducted a qualitative secondary analysis of in‐depth interviews with 18 patient research partners from a research centre‐affiliated patient advisory board. Data analysis involved three phases: identifying the themes, developing a framework and confirming the framework. We coded and organized the data, and abstracted, illustrated, described and explored the emergent themes using thematic analysis. Directed content analysis was conducted to derive concepts from 18 publications related to PEIR to supplement, confirm or refute, and extend the emergent conceptual framework. The framework was reviewed by four patient research partners on our research team.

Results

Participants’ experiences of working with researchers were generally positive. Eight themes emerged: procedural requirements, convenience, contributions, support, team interaction, research environment, feel valued and benefits. These themes were interconnected and formed a conceptual framework to explain the phenomenon of meaningful PEIR from a patient perspective. This framework, the PEIR Framework, was endorsed by the patient research partners on our team.

Conclusions

The PEIR Framework provides guidance on aspects of PEIR to address for meaningful PEIR. It could be particularly useful when patient‐researcher partnerships are led by researchers with little experience of engaging patients in research.

Ascribing Meaning to Occupation: An Example From Healthy, Working Mothers

Ascribing meaning to occupation is a multifaceted process. Understanding this process is illusive, yet fundamental to theory and practice. The objective is to describe the meaning that mothers ascribe to their occupations. A secondary analysis was conducted with data from a convenience sample of 35 Israeli mothers, ages 25 to 45 years. Data were collected using the Occupational Performance History Interview as part of a larger study. Interviews were transcribed verbatim and content analysis applied. Two main categories emerged: the meaning of "giving" (investing values) and the meaning of "receiving" (ensuring needs are met). Values such as responsibility require mothers to do occupations they find less desirable than others associated with the mothering role. The study illustrates how values and needs are intertwined to contribute to the meaning of occupation. Moreover, meaningful occupations can be undesirable but doing them arises from the values that drive mothers to fulfill this role.

What telomeres say about activity and health: A rapid review: Ce que les télomères révèlent au sujet de l'activité et de la santé : revue rapide

BACKGROUND.

Empirical studies on occupation as a determinant of health could be advanced with research incorporating biological measures of health. Telomere length and telomerase function are promising biomarkers of the interaction of genetics, lifestyle, and behaviour; however, they have not been used in occupational therapy research.

PURPOSE.

This paper reviews current evidence on the role of physical and mindfulness activities in sustaining telomeres. The findings are applied to the study of occupation, health, and aging.

METHOD.

A rapid review was conducted with an evidence synthesis of 23 studies published from 2008 to 2014.

FINDINGS.

Mindfulness activities may preserve telomeres, slow cell senescence and death, and sustain health through mediating life stressors. Inconsistencies exist for the effect of physical activities on telomeres.

IMPLICATIONS.

Similar research examining a range of occupations may help to identify the health-promoting benefits of occupation and inform lifestyle interventions.

Understanding the Experiences of Rural Community-Dwelling Older Adults in Using a New DVD-Delivered Otago Exercise Program: A Qualitative Study

Background

The home-based Otago Exercise Program (OEP) has been shown to reduce the occurrence of falls in community-dwelling seniors. A new OEP DVD was recently developed for people living in rural communities to be used with minimal coaching by a physical therapist.

Objective

This study aimed to understand older adults’ experiences using the DVD-delivered OEP and explore barriers and facilitators to implementing the DVD-delivered OEP from the participants’ perspectives.

Methods

Rural community-dwelling older adults (75 years and older) who participated in a six-month DVD-delivered OEP study were invited to participate in this qualitative study. Two small group interviews were initially conducted to explore the breadth of participants’ experiences with the program. These were followed by semi-structured individual interviews to gain an in-depth understanding of these experiences. An inductive constant comparison analysis of the transcripts was performed. To ensure methodological rigor, field notes, journaling, and an audit trail were maintained, supplemented by peer-review.

Results

Of 32 eligible participants, five participated in group interviews and 16 in individual interviews. Three themes emerged. Theme 1, The OEP DVD—useful training tool but in need of more pep, represented participants’ experiences that the DVD provided important guidance at program onset, but was too slow and low-energy for longer-term use. Theme 2, Gaining control over one’s exercise regimen, but sometimes life gets in the way of staying active, described participants’ appreciation of the program’s flexibility, but personal health concerns and everyday lives posed challenges to adhering to the program. Theme 3, Social creatures—wanting greater human connection during exercise, described how some participants desired further social interactions for enhancing motivation and receiving guidance.

Conclusions

Individuals should be encouraged to refer to the OEP user manual or DVD as needed and engage friends and family in exercises. The importance of exercise even when living with health problems should be raised at program onset, and participants should be supported in working through challenging issues. Health professionals should work with individuals to integrate the program with their everyday activities.

eHealth, Participatory Medicine, and Ethical Care: A Focus Group Study of Patients' and Health Care Providers' Use of Health-Related Internet Information

Background

The rapid explosion in online digital health resources is seen as transformational, accelerating the shift from traditionally passive patients to patients as partners and altering the patient–health care professional (HCP) relationship. Patients with chronic conditions are increasingly engaged, enabled, and empowered to be partners in their care and encouraged to take responsibility for managing their conditions with HCP support.

Objective

In this paper, we focus on patients’ and HCPs’ use of health-related Internet information and how it influences the patient-HCP relationship. In particular, we examine the challenges emerging in medical encounters as roles and relationships shift and apply a conceptual framework of relational ethics to examine explicit and nuanced ethical dimensions emerging in patient-HCP interactions as both parties make increased use of health-related Internet information.

Methods

We purposively sampled patients and HCPs in British Columbia, Canada, to participate in focus groups. To be eligible, patients self-reported a diagnosis of arthritis and at least one other chronic health condition; HCPs reported a caseload with >25% of patients with arthritis and multimorbidity. We used a semistructured, but flexible, discussion guide. All discussions were audiotaped and transcribed verbatim. Elements of grounded theory guided our constant comparison thematic analytic approach. Analysis was iterative. A relational ethics conceptual lens was applied to the data.

Results

We recruited 32 participants (18 patients, 14 HCPs). They attended seven focus groups: four with patients and three with rehabilitation professionals and physicians. Predominant themes to emerge were how use of health-related Internet information fostered (1) changing roles, (2) patient-HCP partnerships, and (3) tensions and burdens for patients and HCPs.

Conclusions

Relational aspects such as mutual trust, uncertainty, and vulnerability are illuminated in patient-HCP interactions around health-related Internet information and the negotiated space of clinical encounters. New roles and associated responsibilities have key ethical dimensions that make clear the changes are fundamental and important to understand in ethical care. When faced with tensions and burdens around incorporating health-related Internet information as a resource in clinical encounters, participants described a particular ambivalence illustrating the fundamental changes being negotiated by both patients and HCPs.

Women's accounts of help-seeking in early rheumatoid arthritis from symptom onset to diagnosis

BACKGROUND

As interest in gender and health grows, the notion that women are more likely than men to consult doctors is increasingly undermined as more complex understandings of help seeking and gender emerge. While men's reluctance to seek help is associated with practices of masculinities, there has been less consideration of women's help-seeking practices. Rheumatoid arthritis (RA) is a chronic disease that predominantly affects women and requires prompt treatment but considerable patient-based delays persist along the care pathway. This paper examines women's accounts of help seeking in early RA from symptom onset to diagnosis.

METHODS

We conducted in-depth interviews with 37 women with RA <12 months in Canada. Analysis was based on a constant comparison, thematic approach informed by narrative analysis.

RESULTS

The women's accounts featured masculine practices associated with men's help-seeking. The women presented such behaviours as relational, e.g. rooted in family socialisation and a determination to maintain roles and 'normal' life.

DISCUSSION

Our findings raise questions about how far notions of gender operate to differentiate men and women's help seeking and may indicate more similarities than differences. Recognising this has implications for policy and practice initiatives for both men and women.

Striking a balance: work-health-personal life conflict in women and men with arthritis and its association with work outcomes

PURPOSE

To examine men and women's perceptions of inter-role balance/imbalance in work, arthritis, and personal roles and its association with demographic, health and employment factors, including job stress, career satisfaction, job disruptions, absenteeism and perceived productivity losses.

METHODS

Participants were employed, aged ≥40 years and diagnosed with osteoarthritis or inflammatory arthritis. They were recruited through community advertising and rheumatology clinics in two Canadian provinces. Respondents completed a 35-45 min telephone interview and a 20-min self-administered questionnaire assessing role perceptions [(arthritis negatively impacts work (A → W); work/personal life negatively impact arthritis (W/P → A); work as a positive role (W +))], demographic, health and work context information. Analyses included exploratory factor analysis and multivariate regressions.

RESULTS

Findings revealed similarities between men (n = 104) and women (n = 248) in health, work and role perceptions, although women reported more benefits of working with arthritis (W+) than men. Some gender differences were found in factors associated with inter-role perceptions highlighting the importance of children, fatigue, unpredictable work hours, job control, and workplace activity limitations. Role perceptions were associated with work outcomes but only one perception, W/P → A, interacted with gender. Among men, greater perceptions that work and personal demands interfered with managing arthritis were associated with more job disruptions.

CONCLUSIONS

This study revealed negative and positive inter-role perceptions related to working with a chronic illness and associations with work outcomes. It highlights potentially modifiable factors that could assess risk and inform interventions to improve role balance and working experiences.

"Employment and arthritis: making it work" a randomized controlled trial evaluating an online program to help people with inflammatory arthritis maintain employment (study protocol)

BACKGROUND

Arthritis and musculoskeletal conditions are the leading cause of long-term work disability (WD), an outcome with a major impact on quality of life and a high cost to society. The importance of decreased at-work productivity has also recently been recognized. Despite the importance of these problems, few interventions have been developed to reduce the impact of arthritis on employment. We have developed a novel intervention called "Making It Work", a program to help people with inflammatory arthritis (IA) deal with employment issues, prevent WD and improve at-work productivity. After favorable results in a proof-of-concept study, we converted the program to a web-based format for broader dissemination and improved accessibility. The objectives of this study are: 1) to evaluate in a randomized controlled trial (RCT) the effectiveness of the program at preventing work cessation and improving at-work productivity; 2) to perform a cost-utility analysis of the intervention.

METHODS/DESIGN

526 participants with IA will be recruited from British Columbia, Alberta, and Ontario in Canada. The intervention consists of a) 5 online group sessions; b) 5 web-based e-learning modules; c) consultations with an occupational therapist for an ergonomic work assessment and a vocational rehabilitation counselor. Questionnaires will be administered online at baseline and every 6 months to collect information about demographics, disease measures, costs, work-related risk factors for WD, quality of life, and work outcomes. Primary outcomes include at-work productivity and time to work cessation of > 6 months for any reason. Secondary outcomes include temporary work cessation, number of days missed from work per year, reduction in hours worked per week, quality adjusted life year for the cost utility analysis, and changes from baseline in employment risk factors. Analysis of Variance will evaluate the intervention's effect on at-work productivity, and multivariable Cox regression models will estimate the risk of work cessation associated with the intervention after controlling for risk factors for WD and other important predictors imbalanced at baseline.

DISCUSSION

This program fills an important gap in arthritis health services and addresses an important and costly problem. Knowledge gained from the RCT will be useful to health care professionals, policy planners and arthritis stakeholders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01852851; registered April 13, 2012; first participant randomized on July 6, 2013.

Association between self-efficacy and participation in community-dwelling manual wheelchair users aged 50 years or older

BACKGROUND

Self-efficacy with using a wheelchair is an emerging construct in the wheelchair-use literature that may have implications for the participation frequency in social and personal roles of wheelchair users.

OBJECTIVES

The aim of this study was to investigate the direct and mediated effects of self-efficacy on participation frequency in community-dwelling manual wheelchair users aged 50 years or older.

DESIGN

A cross-sectional study was conducted.

METHODS

Participants were community-dwelling wheelchair users (N=124), 50 years of age or older (mean=59.7 years), with at least 6 months of experience with wheelchair use. The Late-Life Disability Instrument, the Wheelchair Use Confidence Scale, the Life-Space Assessment, and the Wheelchair Skills Test-Questionnaire Version measured participation frequency, self-efficacy, life-space mobility, and wheelchair skills, respectively. Multiple regression analyses with bootstrapping were used to investigate the direct and mediated effects. The International Classification of Functioning, Disability and Health was used to guide the analyses.

RESULTS

Self-efficacy was a statistically significant determinant of participation frequency and accounted for 17.2% of the participation variance after controlling for age, number of comorbidities, and social support. The total mediating effect by life-space mobility, wheelchair skills, and perceived participation limitations was statistically significant (point estimate=0.14; bootstrapped 95% confidence interval=0.04, 0.24); however, the specific indirect effect by the wheelchair skills variable did not contribute to the total effect above and beyond the other 2 mediators. The mediated model accounted for 55.0% of the participation variance.

LIMITATIONS

Causality cannot be established due to the cross-sectional nature of the data, and the self-report nature of our data from a volunteer sample may be influenced by measurement bias or social desirability, or both.

CONCLUSION

Self-efficacy directly and indirectly influences the participation frequency in community-dwelling manual wheelchair users aged 50 years or older. Development of interventions to address low self-efficacy is warranted.

Rating of Everyday Arm-Use in the Community and Home (REACH) scale for capturing affected arm-use after stroke: development, reliability, and validity

Objective

To develop a brief, valid and reliable tool [the Rating of Everyday Arm-use in the Community and Home (REACH) scale] to classify affected upper limb use after stroke outside the clinical setting.

Methods

Focus groups with clinicians, patients and caregivers (n = 33) and a literature review were employed to develop the REACH scale. A sample of community-dwelling individuals with stroke was used to assess the validity (n = 96) and inter-rater reliability (n = 73) of the new scale.

Results

The REACH consists of separate scales for dominant and non-dominant affected upper limbs, and takes five minutes to administer. Each scale consists of six categories that capture ‘no use’ to ‘full use’. The intraclass correlation coefficient and weighted kappa for inter-rater reliability were 0.97 (95% confidence interval: 0.95–0.98) and 0.91 (0.89–0.93) respectively. REACH scores correlated with external measures of upper extremity use, function and impairment (rho = 0.64–0.94).

Conclusions

The REACH scale is a reliable, quick-to-administer tool that has strong relationships to other measures of upper limb use, function and impairment. By providing a rich description of how the affected upper limb is used outside of the clinical setting, the REACH scale fills an important gap among current measures of upper limb use and is useful for understanding the long term effects of stroke rehabilitation.

Usability testing of ANSWER: a web-based methotrexate decision aid for patients with rheumatoid arthritis

BACKGROUND

Decision aids are evidence-based tools designed to inform people of the potential benefit and harm of treatment options, clarify their preferences and provide a shared decision-making structure for discussion at a clinic visit. For patients with rheumatoid arthritis (RA) who are considering methotrexate, we have developed a web-based patient decision aid called the ANSWER (Animated, Self-serve, Web-based Research Tool). This study aimed to: 1) assess the usability of the ANSWER prototype; 2) identify strengths and limitations of the ANSWER from the patient's perspective.

METHODS

The ANSWER prototype consisted of: 1) six animated patient stories and narrated information on the evidence of methotrexate for RA; 2) interactive questionnaires to clarify patients' treatment preferences. Eligible participants for the usability test were patients with RA who had been prescribed methotrexate. They were asked to verbalize their thoughts (i.e., think aloud) while using the ANSWER, and to complete the System Usability Scale (SUS) to assess overall usability (range = 0-100; higher = more user friendly). Participants were audiotaped and observed, and field notes were taken. The testing continued until no new modifiable issues were found. We used descriptive statistics to summarize participant characteristics and the SUS scores. Content analysis was used to identified usability issues and navigation problems.

RESULTS

15 patients participated in the usability testing. The majority were aged 50 or over and were university/college graduates (n = 8, 53.4%). On average they took 56 minutes (SD = 34.8) to complete the tool. The mean SUS score was 81.2 (SD = 13.5). Content analysis of audiotapes and field notes revealed four categories of modifiable usability issues: 1) information delivery (i.e., clarity of the information and presentation style); 2) navigation control (i.e., difficulties in recognizing and using the navigation control buttons); 3) layout (i.e., position of the videos, text, diagrams and navigation buttons); 4) aesthetic (i.e., the colour, look and feel of the online tool).

CONCLUSIONS

Although the SUS score indicated high usability before and after major modification, findings from the think-aloud sessions illustrated areas that required further refinement. Our results highlight the importance of formative evaluation in usability testing.

Exploring eHealth Ethics and Multi-Morbidity: Protocol for an Interview and Focus Group Study of Patient and Health Care Provider Views and Experiences of Using Digital Media for Health Purposes

BACKGROUND

eHealth is a broad term referring to the application of information and communication technologies in the health sector, ranging from health records to medical consultations (telemedicine) and multiple forms of health education, support, and tools. By providing increased and anytime access to information, opportunities to exchange experiences with others, and self-management support, eHealth has been heralded as transformational. It has the potential to accelerate the shift from traditional "passive patient" to an informed, engaged, and empowered "patient as partner," equipped to take part in shared decision-making, and take personal responsibility for self-managing their illness.

OBJECTIVE

The objective of our study is to examine how people with chronic illness use eHealth in their daily lives, how it affects patient-provider relationships, and the ethical and practical ramifications for patients, providers, and service delivery.

METHODS

This two-phase qualitative study is ongoing. We will purposively sample 60-70 participants in British Columbia, Canada. To be eligible, patient participants have to have arthritis and at least one other chronic health condition; health care providers (HCPs) need a caseload of patients with multi-morbidity (>25%). To date we have recruited 36 participants (18 patients, 18 HCPs). The participants attended 7 focus groups (FGs), 4 with patients and 3 with rehabilitation professionals and physicians. We interviewed 4 HCPs who were unable to attend a FG. In phase 2, we will build on FG findings and conduct 20-24 interviews with equal numbers of patients and HCPs (rehabilitation professionals and physicians). As in the FGs conducted in phase I, the interviews will use a semistructured, but flexible, discussion guide. All discussions are being audiotaped and transcribed verbatim. Constant comparisons and a narrative approach guides the analyses. A relational ethics conceptual lens is being applied to the data to identify emergent ethical issues.

RESULTS

This study explores ethical issues in eHealth. Our goal is to identify the role of eHealth in the lives of people with multiple chronic health conditions and to explore how eHealth impacts the patient role, self-managing, and the patient-HCP relationship. The ethical lens facilitates a systematic critical analysis of emergent ethical issues for further investigation and pinpoints areas of practice that require interventions as eHealth develops and use increases both within and outside of the clinical setting.

CONCLUSIONS

The potential benefits and burdens of eHealth need to be identified before an ethical framework can be devised.

Choosing where to put your energy: a qualitative analysis of the role of physical activity in the lives of working adults with arthritis

OBJECTIVE

Research points to many potential benefits of physical activity (PA) for those with arthritis. However, PA has not typically been examined within the context of other life roles. This study examined the perceptions of PA among individuals managing arthritis in addition to employment and other role demands.

METHODS

Eight focus groups were conducted with 24 women and 16 men (age range 29-72 years) who were currently or recently employed (within 2 years) and had osteoarthritis or inflammatory arthritis. Participants were recruited from community newspaper advertisements, rheumatology clinics, and arthritis groups. Discussions were audiotaped and transcribed. Transcripts were analyzed using qualitative content analysis.

RESULTS

All groups discussed the impact of arthritis on a range of PAs. Overall, participants discussed PA as positively influencing their health and well-being. Yet, several overarching themes highlighted the complexity of PA, including 1) PA as a potential cause of arthritis; 2) the reciprocal impact of arthritis on PA and PA on arthritis; 3) physical and psychological benefits and harms of PA, such as difficulty making PA decisions when living in pain or when faced with episodic symptoms; 4) perceived choices about engagement in PA (e.g., role overload); and 5) social support.

CONCLUSION

The relationships among work, health, and other roles were complex. Competing demands, pain, energy, episodic symptoms, support, and decisions to disclose one's illness at work influenced PA. Changes to PA not only affected physical health but also people's self-identity. PA interventions may be improved by taking into account the demands of multiple life roles.

A qualitative interview study: patient accounts of medication use in early rheumatoid arthritis from symptom onset to early postdiagnosis

OBJECTIVE

To examine accounts of medication use in participants with early rheumatoid arthritis (RA) from symptom onset to early postdiagnosis.

DESIGN

Qualitative study with in-depth, personal interviews.

PARTICIPANTS

37 women and one man, aged 30-70s, with a diagnosis of RA <12 months.

MAIN OUTCOME MEASURE

Participants' experiences and feelings of medication use in early RA.

SETTING

British Columbia, Canada.

RESULTS

Medications were central to how people managed symptoms and disease. Two main themes were identified, showing that optimum medication use was hampered, and how this related to delayed diagnosis and effective care. The first theme, 'paradox of prediagnosis reliance on over the counter (OTC) medications', describes how people's self-management with OTC medications was 'effective'. Participants relied extensively on OTC medications for pain relief and to maintain 'normal life'. However, as this contributed to delayed medical consultation, diagnosis and effective treatment, OTC medication was also potentially detrimental to disease outcome. The second theme, 'ambivalence around prescription medications post diagnosis', describes how adherence was hindered by patient beliefs, priorities and ambivalence towards medications.

CONCLUSIONS

This study highlights how people use medications in early RA and contributes to a better understanding of medication use that may transfer to other conditions. Given the drive towards active self-management in healthcare and patients' ambivalence about using strong medications, an in-depth understanding of how these combined factors impact patient experiences will help healthcare providers to support effective medication practices. The reported extensive reliance on OTC medications may speak to a care gap needing further investigation in the context of health behaviours and outcomes of patient self-management.

Physical effect of work on healthy individuals: implications for FCE testing

OBJECTIVE

The objective of this study was to assess the effect of time of day and job type on performance of three functional capacity evaluation measures in healthy (asymptomatic) adults. It was queried whether or not a healthy population of adults would demonstrate a change in physical performance ability, when re-tested at the end of their work day.

SETTING

A convenience sample of 50 healthy adults (19-62 years, 66% male) was used from six work sites in an urban area.

DESIGN

Same day pre-test and post-test testing was performed, implementing use of three commonly used functional capacity tests: Jamar dynamometer grip strength test, Turning sub-test of the Complete Minnesota Dexterity Test, and the 50-foot walk test.

METHODS

The study compared morning and afternoon test scores, and using t-tests, assessed the effect of job type (sedentary, light, medium, heavy) on performance using ANOVA.

RESULTS

All three measures improved from morning to afternoon; differences were statistically significant for 50-foot walk (mean=0.2 sec, p=0.02) and manual dexterity (mean=5 sec, p< 0.001). Job type had a significant effect on dexterity.

CONCLUSIONS

Late day performance did not show any significant decline in this sample of healthy adults, and in fact tended to improve or stay relatively stable. Therefore, clinicians who perform functional capacity evaluations should consider alternative explanations for late-day functional declines observed in injured patients. These findings, combined with other test results, may assist clinicians with disability determination.

Association between mobility, participation, and wheelchair-related factors in long-term care residents who use wheelchairs as their primary means of mobility

OBJECTIVES

To explore how wheelchair-related factors, mobility, and participation are associated in a sample of long-term care residents who use wheelchairs as their primary means of mobility.

DESIGN

Cross-sectional survey.

SETTING

Eleven residential care facilities in the lower mainland of British Columbia, Canada.

PARTICIPANTS

One hundred forty-six self-responding residents and 118 proxy respondents: mean age 84 (range 60-103). Most were female (69%), and a small proportion (9%) drove a power wheelchair.

MEASUREMENTS

The Nursing Home Life Space Diameter Assessment was used to measure resident mobility, and the Late Life Function and Disability Instrument: Disability Component was used to measure participation frequency in daily activities.

RESULTS

Path analysis indicated that wheelchair-related factors were associated with participation frequency directly and indirectly through their relationship with mobility. The final model explained 46% of the variance in resident mobility and 53% of the variance in resident participation frequency. Wheelchair skills, which include the ability to transfer in and out of and propel a wheelchair, were important predictors of life-space mobility and frequency of participation, and life space mobility was a significant predictor of frequency of participation. Depression was associated with poorer wheelchair skills and mobility and less-frequent participation. Counterintuitively, perceived environmental barriers were positively associated with frequency of participation.

CONCLUSION

The findings suggest that, by addressing wheelchair-related factors, resident's mobility and participation may be improved, but the efficacy of this approach needs to be confirmed experimentally.

Grey spaces: the wheeled fields of residential care

Many individuals living in residential care use a wheelchair as their primary means of mobility. Although studies have documented challenges encountered by residents in these facilities, few have addressed the role that wheelchairs, as potential enablers and barriers to mobility and participation, play in their lives. To better understand residents' experiences, an ethnographic study was conducted drawing on Bourdieu's theoretical constructs of capital, field, and habitus. Participant observations were conducted at two facilities, and residents, family members and staff took part in in-depth individual interviews. Our analysis revealed three themes. Ready to roll detailed how residents used wheelchairs as a source of comfort and means for expanding their social space, while staff could use them as a means to move and control some residents. Squeaky wheels described how residents solicited assistance from staff and family amid having to wait to perform activities of daily living. In, out and about revealed diversity in the places residents went, spaces they shared and the social activities in which they engaged inside and outside their residential facilities. The study findings emphasise how wheelchairs constitute capital that governs many fields of practice for residents and staff and suggest how practice and policy might be adjusted.