Patient education and self-management in the rheumatic diseases: a self-efficacy approach

The Effects of Patient Education on Psychological Status and Clinical Outcomes in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

Background

Rheumatoid arthritis (RA) is a common systemic inflammatory autoimmune disease. The disease has a serious impact on mental health and requires more effective non-pharmacological interventions.

Objective

This study aims to systematically evaluate the effectiveness of patient education on psychological status and clinical outcomes in rheumatoid arthritis.

Methods

This systematic review and meta-analysis was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Library, EMBASE database, and Web of Science database were screened for articles published until November 2, 2021. Randomized controlled trials (RCTs) of patient education for RA were included. Outcomes measures included pain, physical function, disease activity, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anxiety, depression, Arthritis Self-Efficacy (pain, other symptoms, total), and General health. For each outcome, standardized mean differences or mean differences and 95% confidence intervals (CIs) were calculated.

Results

A total of 24 RCTs (n = 2,276) were included according to the inclusion and exclusion criteria. Meta-analysis revealed a statistically significant overall effect in favor of patient education for physical function [SMD = -0.52, 95% CI (-0.96, -0.08), I 2 = 93%, P = 0.02], disease activity [SMD = -1.97, 95% CI (-3.24, -0.71), I 2 = 97%, P = 0.002], ASE (pain) [SMD = -1.24, 95% CI (-2.05, -0.43), I 2 = 95%, P = 0.003], ASE (other symptoms) [SMD = -0.25, 95% CI (-0.41, -0.09), I 2 = 25%, P = 0.002], ASE (total) [SMD = -0.67, 95% CI (-1.30, -0.05), I 2 = 90%, P = 0.03], and general health [SMD = -1.11, 95% CI (-1.36, -0.86), I 2 = 96%, P < 0.00001]. No effects were found for anxiety [SMD = 0.17, 95% CI (-0.64, 0.98), I 2 = 82%, P = 0.68], depression [SMD = -0.18, 95% CI (-0.52, 0.15), I 2 = 52%, P = 0.28], pain [SMD = -0.37, 95% CI (-0.80, 0.05), I 2 = 89%, P = 0.08], and CRP [SMD = -0.27, 95% CI (-0.57, 0.02), I 2 = 0%, P = 0.07].

Conclusions

Patient education may be effective in improving clinical outcomes and psychological status in patients with rheumatoid arthritis. Considering the methodological limitations of the included RCTs, more high-quality and large-sample RCTs are needed to confirm this conclusion in the future.

Systematic Review Registration

http://www.crd.york.ac.uk/prospero, identifier: CRD42021250607.

EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

OBJECTIVE

To develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA).

METHODS

An EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A-D: A typically consistent level 1 studies and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0-10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members.

RESULTS

Two overarching principles and 11 PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4-9.6).

CONCLUSIONS

These PtCs for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research.

Evaluation of an ankylosing spondylitis education and self-management program: Beneficial effects on ankylosing spondylitis specific outcomes

BACKGROUND

Self-management programs have demonstrated significant health benefits in people with musculoskeletal diseases.

AIM

To examine the benefits of a tailored ankylosing spondylitis self-management program (ASSMP) delivered by trained health professionals for people with ankylosing spondylitis (AS) relative to health status, quality of life and disease activity.

METHODS

ASSMP was developed within a continuous quality improvement framework following a needs assessment and focus group discussions. Formal feedback from the group after each 6 week program cycle group by questionnaire helped refine the ASSMP. Patient health status, quality of life and disease activity were assessed at multiple time points up to 12 months.

RESULTS

Fifty-five percent were female; mean age 48.5 ± 15.2 years. Median time to AS diagnosis was 4 years (interquartile range: 1-10). AS disease activity Bath Ankylosing Spondylitis Global Score scores improved at 3, 6 and 12 months (P < .001). Bath Ankylosing Spondylitis Disease Activity Index improved at 6 weeks and was sustained at 3, 6 and 12 months (P < .001). The Ankylosing Spondylitis Quality of Life improved at 3, 6 and 12 months (P < .001). Bath Ankylosing Spondylitis Functional Index improved by 12 months (P < .001). Participants reported less nocturnal back pain at 6 months and was sustained at 12 months (P < .001). Patients Global Disease Activity improved by 6 months (P = .012), Multi-Dimensional Assessment of Fatigue and a Global Fatigue Index at 6 months (P = .003), Hospital Anxiety and Depression Scale - Anxiety at 12 months (P = .001), Evaluation Ankylosing Spondylitis Quality of Life at 6 months (P = .001) and Pain Self-Efficacy Questionnaire at 12 months (P = .002).

CONCLUSION

This ASSMP demonstrated significant and sustained benefit in symptoms, disease activity measures and quality of life in a condition that results in significant impairment, disability and poorer quality of life. The cost effectiveness and benefit of this program should be tested.

Effectiveness of preoperative group education for patients with colorectal cancer: managing expectations

PURPOSE

To evaluate the potential beneficial effect of preoperative face-to-face group education after colonic surgery in a pre-existing ERAS pathway environment.

METHODS

Patients were randomized to cohorts for 3 weeks to either the standard preoperative counseling by the colorectal surgeon and the nurse practitioner (control group) or to the additional group education (intervention group). Patients scored EORTC-QLQ-info25 after the preoperative information was completed and the EORTC-QLQ-30 and EORTC-QLQ-29 prior to surgery and 1, 3, and 6 months after surgery.

RESULTS

A significantly better level of information was scored considering the expectations and patient involvement in the intervention group. This coincided with a significant reduction of the in-hospital stay, enhanced return to the preoperative global health status, and persistent improved body image after surgery.

CONCLUSION

By investing in the preoperative group education patients develop more realistic expectations resulting in a perceived improved quality of life and body image 1 month after operation coinciding with a statistically significant reduction in duration of in-hospital stay in this study.

Video-based learning versus traditional lecture-based learning for osteoporosis education: a randomized controlled trial

BACKGROUND

Patient education about osteoporosis is an important component of osteoporosis treatment.

AIM

To compare the effectiveness of osteoporosis education between video-based learning and traditional lecture-based learning.

METHODS

Participants who attended the Outpatient Department of Siriraj Hospital during June 2017 to November 2017 were recruited. Ten-question pre- and post-tests were used to evaluate participant osteoporosis knowledge. After finishing the pre-test, patients were randomized to receive osteoporosis education via either traditional lecture-based or video-based learning for 25 min. After the training, patient questions about the subject matter were answered, and then the post-test was administered. Change in score was compared between groups using non-inferiority test at a non-inferiority margin of - 1.

RESULTS

Of 413 participants, 207 and 206 people were allocated to the lecture-based group and the video-based group, respectively. There were no significant differences in baseline characteristics, change in score between pre-test and post-test, or change in score between pre-test and retention test between groups. Non-inferiority test revealed the change in score after video-based learning to be non-inferior to traditional lecture-based learning at a difference of > - 1, α = 0.05 (p < 0.001).

DISCUSSION

Video-based osteoporosis education can be used as part of a fracture liaison service to provide essential information about osteoporosis to both patients and caregivers. Video-based education is an efficient and effective tool that will reduce dependency on clinicians to provide lecture-based osteoporosis instruction.

CONCLUSIONS

Since video- and lecture-based education were found to be equally effective, a standard package for both education techniques should be developed and implemented for all patients.

Effects of a six-week mobile app versus paper book intervention on quality of life, symptoms, and self-care in patients with fibromyalgia: a randomized parallel trial

BACKGROUND

The ProFibro application (app) was developed as a Mobile Health resource to promote self-care in fibromyalgia management.

OBJECTIVE

This study aimed to assess the effects of the use of the ProFibro app for six weeks compared to the use of a traditional paper book of similar content to improve health-related quality of life, symptoms, and self-care agency in individuals with fibromyalgia.

METHODS

Forty individuals with fibromyalgia were included in this randomized, single-blind, parallel trial. One group received intervention content using the ProFibro app on a smartphone while the other received similar information using a paper book. Participants were assessed at baseline and after six weeks. The primary outcome was the Revised Fibromyalgia Impact Questionnaire. Secondary outcomes were Widespread Pain Index, Pain Visual Analog Scale, Symptom Severity Scale, and Appraisal of Self-Care Agency Scale - Revised.

RESULTS

No differences in changes were found between groups at the end of the treatment for any outcome. Both groups showed improvements in symptom severity.

CONCLUSIONS

The use of the ProFibro app for six weeks was not more effective than the use of a traditional paper book with similar content for health-related quality of life, symptoms, or self-care agency in individuals with fibromyalgia. Both groups showed improvements from baseline on severity of symptoms, suggesting that the self-care program using a mobile app or a paper book may be beneficial for individuals with fibromyalgia.

Validation of the Chinese version of joint protection self-efficacy scale in patients with rheumatoid arthritis

OBJECTIVE

To develop and validate the Chinese version of the Joint Protection Self-Efficacy Scale (CJP-SES) in patients with rheumatoid arthritis (RA) in China.

METHOD

(1) Translation of the original German/English version JP-SES and cultural adaptation into the Chinese language; (2)Validation of the CJP-SES with the Chinese versions of the Arthritis Self-Efficacy Scale-8 (ASES-8), the Laffrey Health Conception Scale (LHCS), 10-item Perceived Efficacy in Patient-Physician Interactions Scale (PEPPI-10), Disease Activity Score-28 (DAS-28) and Health Assessment Questionnaire (HAQ). Instrument measurement included reliability testing, item generation, construct validity, test-retest reliability, and correlation with other measurements. Confirmatory factor analysis was applied to determine construct validity and internal consistency. One hundred fifteen patients with RA were investigated.

RESULT

Finally, 105 RA patients were included in the analysis. Confirmatory factor analysis demonstrated fit for a unidimensional model of the JP-SES. Additionally, the scale showed internal consistency (Cronbach's α coefficient 0.922), kappa coefficient (0.653), and test-retest reliability (ICC = 0.94). Weak correlations with other scores for the other instruments, such as the Chinese version of ASES-8 (0.263) and PEPPI-10 (0.326). Correlation with duration (0.274), moderate correlation with BMI (- 0.438) and DAS-28 (- 0.493), and strong correlation with HAQ (- 0.644) were found in this research.

CONCLUSION

This is the first study to adapt and validate the JP-SES into Chinese for use in patients with RA. Our research showing that the CJP-SES has a good construct validity, internal consistency, and test-retest reliability. This scale can help doctors and nurses to assess the self-efficacy of patients with RA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: TJYY-YLS-036.

Use of the Orem self-care model on pain relief in women with rheumatoid arthritis: a randomized trial

Background and aim

Self-care is an important tool in controlling pain in patients with rheumatoid arthritis. The aim of this study was to determine the use of the Orem self-care model on pain relief in patients with rheumatoid arthritis.

Methods

This was a clinical trial performed on 60 patients with rheumatoid arthritis who referred to a rheumatology clinic in Karaj during 2013–2015 (30 patients in the control group and 30 patients in the intervention group), convenience sampling was done and subjects were divided into two groups randomly. Data collecting tools were a demographic questionnaire which consisted of 19 questions and the Numeric Pain Rating Scale. The data result was analyzed by SPSS version 19, using independent-samples t-test and Chi square test. P-value of less than 0.05 was considered significant.

Results

The mean age was 44.63±10.65 years, 90% were married and 35% had a high school diploma. The results showed a significant difference in three measures of pain in the intervention group (p=0.001), while in the control group, this difference was not significant (p=0.59).

Conclusion

According to the results, the Orem self-care model is effective in reducing pain in patients with rheumatoid arthritis Therefore, applying the Orem self-care model is recommended to promote and maintain self-care behavior in patients with rheumatoid arthritis.

Trial registration

The trial was registered at the Iran Registry of Clinical Trials (http://en.irct.ir) with code IRCT2014052517840N1.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Does the Comprehensive ICF Core Set for Rheumatoid Arthritis Capture Occupational Therapy Practice? A Content-Validity Study

Background. The ICF Core Sets for rheumatoid arthritis (RA) constitute an application of the International Classification of Functioning, Disability and Health (ICF). Purpose. To explore whether the ICF Core Sets for RA include the areas of functioning and environmental factors that are typically treated by occupational therapists in their clinical everyday practice with clients with RA. Methods. In a three-round survey occupational therapists were asked about their intervention goals when treating clients with RA. The identified goals were grouped into goal classes that were then linked to the ICF. Results. 41 occupational therapists in nine countries named 533 intervention goals that were grouped into 48 goal classes and then linked to ICF categories of all ICF components. The goal classes self-confidence, relaxation and psycho-social well-being are not represented in the Comprehensive ICF Core Set for RA. Conclusion. The validity of the ICF Core Set for RA from the perspective of occupational therapists was largely confirmed.

The educational needs of people with systemic sclerosis: a cross-sectional study using the Dutch version of the Educational Needs Assessment Tool (D-ENAT)

The Dutch Educational Needs Assessment Tool (D-ENAT) systematically assesses educational needs of patients with rheumatic diseases. The present study aims to describe the educational needs of Dutch patients with systemic sclerosis (SSc). The D-ENAT was sent to 155 SSc patients registered at the outpatient clinic of a university hospital. The D-ENAT consists of 39 items in seven domains. “Each domain has different number of items therefore we normalized each domain score: (domain score/maximum) × 100) and expressed in percentage to enable comparisons between domains.” A total D-ENAT score (0–156) is calculated by summing all 39 items. In addition, age, disease duration, gender, educational level, present information need (yes/no) and information need (1–4; wanting to know nothing–everything) were recorded. Univariate regression analysis was used to examine factors associated with the D-ENAT scores. The response rate was 103 out of 155 (66 %). The mean % of educational needs scores (0–100 %; lowest–highest) were 49 % for “D-ENAT total score,” 46 % for “Managing pain,” 41 % for “Movement,” 43 % for “Feelings,” 59 % for “Disease process,” 44 % for “Treatments from health professionals,” 61 % for “Self-help measures” and 51 % for “Support systems.” No associations between the D-ENAT total score and age, disease duration, gender and educational level were found. The D-ENAT demonstrated its ability to identify educational needs of Dutch SSc patients. SSc patients demonstrated substantial educational needs, especially in the domains: “Disease process” and “Self-help measures.” The validity and practical applicability of the D-ENAT to make an inventory of SSc patients’ educational needs require further investigation.

Evaluation of a disease specific rheumatoid arthritis self-management education program, a single group repeated measures study

BACKGROUND

Rheumatoid Arthritis is a progressive and disabling disease, predicted to increase in prevalence over the next 50 years. Self-management is acknowledged as an integral part in the management of chronic disease. The rheumatoid arthritis specific self-management program delivered by health professionals was developed by Arthritis Western Australia in 2006. The purpose of this study was to determine whether this program would achieve early benefits in health related outcomes, and whether these improvements would be maintained for 12 months.

METHODS

Individuals with rheumatoid arthritis were referred from rheumatologists. Participants with co-existing inflammatory musculoskeletal conditions were excluded. All participants completed a 6-week program. Assessments occurred at baseline (8 weeks prior to intervention), pre-intervention, post-intervention, and 6 and 12 month follow ups. Outcomes measured included pain and fatigue (numerical rating scale, 0-10), depression and anxiety (hospital anxiety and depression questionnaire), health distress, and quality of life (SF-36 version 2).

RESULTS

There were significant improvements in mean [SD] fatigue (5.7 [2.4] to 5.1 [2.6]), depression (6.3 [4.3] to 5.6 [3.9]) and SF-36 mental health (44.5 [11.1] to 46.5 [9.5]) immediately following intervention, with long term benefits for depression (6.3 [4.3] to 4.9 [3.9]), and SF-36 subscales mental health (44.5 [11.1] to 47.8 [10.9]), role emotional (41.5 [13.2] to 46.5 [11.8]), role physical (35.0 [11.0] to 40.2 [12.1]) and physical function (34.8 [11.5] to 38.6 [10.7]).

CONCLUSION

Participants in the program recorded significant improvements in depression and mental health post-intervention, which were maintained to 12 months follow up.

Social persuasion in rheumatology: a randomized trial of testimonials on television in the rheumatology clinic waiting room to increase attendance for multidisciplinary education

Multidisciplinary self-management programs are important in inflammatory arthritis as adjunctive treatment. Patients often have excuses as to why they do not attend these programs. The purpose of this study was to determine whether an intervention of televised testimonials from rheumatologists and allied health professionals increases attendance at a multidisciplinary education day for rheumatology patients seen in a large university hospital clinic. This was an RCT of intervention: playing televised interviews in the waiting room where rheumatology patients were seen versus no TV. There was a total of 6 months (3 months with and 3 without the televised interview playing). All eligible patients who attended the rheumatology outpatient clinic were then tracked to determine whether they attended a subsequent education day over the next 10 months. The sample size was calculated to have a 15% increase in attendance at the education days. There was a 20% increase in attendees at the multidisciplinary education days for patients who saw the televised testimonials. Sixty-three patients who viewed the testimonials (2.17% of 2,908) attended the education day compared to 39 who did not receive the intervention (1.80% of 2,168); however, the increase was not statistically significant (p = 0.36). Attendance of eligible patients increased using televised testimonials; however, the increase was not significant as the rates of attendance were still very low in both groups. Many eligible patients did not attend the program. Other interventions are necessary to encourage attendance in a multidisciplinary program.

Marital quality and self-efficacy: influence on disease management among individuals with rheumatoid arthritis

Individuals with rheumatoid arthritis (RA) struggle to maintain improved functional ability and reduced pain levels. Health education emphasizing self-efficacy helps individuals to adjust with the disease outcome and progression. As a basis to develop comprehensive evidence-based patient education programs, the aim of the study was to examine the role of marriage as a predictor of pain and functional self-efficacy among individuals with RA. Review of the regression analysis did not provide support for the relationships between marital quality and self-efficacy. Relationships were not observed between marital quality, length of marriage, and self-efficacy as predicted by the first hypothesis. Additional regression analysis examination found that marital quality, length of marriage, pain, and health assessment together reported significant variance in self-efficacy. However, only health assessment significantly predicted self-efficacy. Other nonexamined variables could have influenced the independent marital quality effects. Future longitudinal studies with larger sample sizes can further validate the current findings.

The role of goal management for successful adaptation to arthritis

OBJECTIVE

Persons with polyarthritis often experience difficulties in attaining personal goals due to disease symptoms such as pain, fatigue and reduced mobility. This study examines the relationship of goal management strategies - goal maintenance, goal adjustment, goal disengagement, goal reengagement - with indicators of adaptation to polyarthritis, namely, depression, anxiety, purpose in life, positive affect, participation, and work participation.

METHODS

305 patients diagnosed with polyarthritis participated in a questionnaire study (62% female, 29% employed, mean age: 62 years). Hierarchical multiple-regression-analyses were conducted to examine the relative importance of the goal management strategies for adaptation. Self-efficacy in relation to goal management was also studied.

RESULTS

For all adaptation indicators, the goal management strategies added substantial explained variance to the models (R(2): .07-.27). Goal maintenance and goal adjustment were significant predictors of adaptation to polyarthritis. Self-efficacy partly mediated the influence of goal management strategies.

CONCLUSION

Goal management strategies were found to be important predictors of successful adaptation to polyarthritis. Overall, adjusting goals to personal ability and circumstances and striving for goals proved to be the most beneficial strategies.

PRACTICE IMPLICATIONS

Designing interventions that focus on the effective management of goals may help people to adapt to polyarthritis.

Readability of patient education materials available at the point of care

BACKGROUND

Many patient education materials (PEMs) available on the internet are written at high school or college reading levels, rendering them inaccessible to the average US resident, who reads at or below an 8(th) grade level. Currently, electronic health record (EHR) providers partner with companies that produce PEMs, allowing clinicians to access PEMs at the point of care.

OBJECTIVE

To assess the readability of PEMs provided by a popular EHR vendor as well as the National Library of Medicine (NLM).

DESIGN

We included PEMs from Micromedex, EBSCO, and MedlinePlus. Micromedex and EBSCO supply PEMs to Meditech, a popular EHR supplier in the US. MedlinePlus supplies the NLM. These PEM databases have high market penetration and accessibility.

MEASUREMENTS

Grade reading level of the PEMs was calculated using three validated indices: Simple Measure of Gobbledygook (SMOG), Gunning Fog (GFI), and Flesch-Kincaid (FKI). The percentage of documents above target readability and average readability scores from each database were calculated.

RESULTS

We randomly sampled 100 disease-matched PEMs from three databases (n = 300 PEMs). Depending on the readability index used, 30-100% of PEMs were written above the 8(th) grade level. The average reading level for MedlinePlus, EBSCO, and Micromedex PEMs was 10.2 (1.9), 9.7 (1.3), and 8.6 (0.9), respectively (p ≤ 0.000) as estimated by the GFI. Estimates of readability using SMOG and FKI were similar.

CONCLUSIONS

The majority of PEMS available through the NLM and a popular EHR were written at reading levels considerably higher than that of the average US adult.

Unmet information needs about the delivery of rheumatology health care services: a survey among patients with rheumatoid arthritis

OBJECTIVE

To measure patient-perceived knowledge and information need regarding regional health care services and their determinants among 400 patients with rheumatoid arthritis (RA) and to identify the preferred method of information provision.

METHODS

Postal survey on knowledge and information need (content and accessibility) of 18 regional health care services and preferences for the mode of delivery of information. Logistic regression analyses determined which factors were associated with insufficient knowledge and information need.

RESULTS

Two-hundred and thirty-seven (94%) patients reported insufficient knowledge about the contents and 235 (94%) about the accessibility of at least one health care services, whereas 172 patients (69%) reported an information need about the content and 154 (61%) on the accessibility. Age was significantly associated with knowledge whereas both age and physical functioning were significantly associated with information need. Seventy-nine percent of the patients mentioned written information, 21% the Internet and 12% personal contact with a professional as a preferred method of information delivery.

CONCLUSION

Many RA patients reported a lack of knowledge or information need concerning the contents and accessibility of regional health care services.

PRACTICE IMPLICATIONS

Active strategies to provide practical information about health care services are needed for RA patients.

[Contribution of nurse-led clinics in the management of the patient with rheumatoid arthritis]

The goal of a nurse-led clinic in the management of rheumatoid arthritis patients is to promote patient independence. Patient education and empowerment are efficacious tools for achieving this. The main nursing care roles are vigilance of physical symptoms, drug toxicity and co-morbidities; management of physical and psychological symptoms; to provide continuity of care. There is evidence supporting the effectiveness of nurse-led clinics and the economic benefits related to it.

Translating patient education theory into practice: developing material to address the cardiovascular education needs of people with rheumatoid arthritis

OBJECTIVE

This paper describes the rationale and design of a theory-informed patient education programme addressing cardiovascular disease for people with rheumatoid arthritis (RA) to illustrate how theory can explicitly be translated into practice.

METHODS

A steering group of rheumatologists and psychologists was convened to design the programme. The Common Sense Model, the Theory of Planned Behaviour and the Stages of Change Model were used to underpin the topics and activities in the programme. User involvement was sought. The programme was formatted into a manual and the reading age of the materials was calculated.

RESULTS

A small group 8-week programme was designed. The structure of the patient education programme, including topics, underlying psychological theory as well as behaviour change techniques, is described.

CONCLUSION

This patient education programme addresses a currently unmet educational need for patients with RA and uses theory to design, not just evaluate, the programme. This will allow both enhanced interpretation of the results when the programme is implemented and replication by other units if successful.

PRACTICE IMPLICATIONS

The actual design and detail of education programmes merit wider dissemination to facilitate progress in the process of development and application.

Self-efficacy as an outcome measure and its association with physical disease-related variables in persons with rheumatoid arthritis: a literature review

BACKGROUND

Studies have demonstrated a positive impact of patient education on self-efficacy in persons with rheumatoid arthritis (RA). However, the relationship between self-efficacy, physical disease-related variables and educational interventions has not yet been reviewed.

AIM

The aims of this study, in relation to persons with RA, were: 1) to provide an overview of the existing research into the association between self-efficacy and physical disease-related variables and, with this knowledge, 2) to provide an overview of the existing research on the effect of different types of educational interventions on self-efficacy.

METHOD

A systematic literature search was performed using eight databases, based on the terms 'rheumatoid arthritis' AND 'self-efficacy'. In total, 74 studies reporting associations between self-efficacy and physical disease-related variables and using self-efficacy as an outcome measure in educational interventions were included.

RESULTS

The scores obtained by the most commonly used questionnaire, the Arthritis Self-Efficacy Scale (ASES), was highly associated with physical disability, pain, fatigue and disease duration. If educational activities had a positive impact on self-efficacy, disease-related variables usually improved as well. Evidence is scarce as to whether disease-related variables affect patients' self-efficacy or vice versa and whether individual consultations can affect patients' self-efficacy.

CONCLUSION

The scores attained by the ASES is highly associated with physical disease-related variables. This relationship requires further research using a specific study design to restrict bias when evaluating the impact of interventions on self-efficacy in persons with RA. Research is needed on whether individual consultations can affect patients' self-efficacy. Disease-related variables do not affect the Rheumatoid Arthritis Self-Efficacy (RASE) questionnaire but this needs further exploration.

Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis: a randomized controlled study

BACKGROUND

Evidence supports the use of educational and physical training programs for people with rheumatoid arthritis (RA).

OBJECTIVE

The purpose of this study was to evaluate the effects of a group-based exercise and educational program on the physical performance and disease self-management of people with RA.

DESIGN

This was a randomized controlled trial.

SETTING

The study was conducted at a rehabilitation center in the Netherlands.

PARTICIPANTS

Thirty-four people diagnosed with RA participated in the study. Participants were randomly assigned to either an intervention group (n=19) or a waiting list control group (n=15).

INTERVENTION

The intervention in this study was an 8-week, multidisciplinary, group therapy program for people with RA, consisting of physical exercise designed to increase aerobic capacity and muscle strength (force-generating capacity) together with an educational program to improve health status and self-efficacy for disease-self-management.

MEASUREMENTS

The main outcome measures were maximum oxygen uptake (Vo(2)max), muscle strength of the elbow and knee flexors and extensors, health status, and perceived self-efficacy. All data were recorded before intervention in week 1, after intervention in week 9, and at follow-up in week 22.

RESULTS

The intervention group showed significant improvement (12.1%) in Vo(2)max at week 9 compared with the control group (-1.7%). Although significant within-group changes were found over time for muscle strength of the upper and lower extremities and health status that favored the intervention group, no between-group changes were found regarding these outcomes.

LIMITATIONS

An important limitation was the small number of participants included in our study, which may have resulted in a lack of power.

CONCLUSIONS

The present group-based exercise and educational program for people with RA had a beneficial effect on aerobic capacity but not on muscle strength, health status, or self-efficacy.

Improving the quality of rheumatoid arthritis patients' education using written information

OBJECTIVE

The objective of this study was to evaluate whether the quality of patient education could be improved by using written education materials.

METHODS

Seventy-five inpatients with rheumatoid arthritis (RA) were provided with individual education sessions during their inpatient stay. The education sessions were supported with written educational materials. A patient education quality instrument was used to assess the sufficiency and implementation of the education and the readiness of nurses and doctors to deliver the education. A Mann-Whitney U-test and content analysis was used to analyse the data.

RESULTS

There was a statistically significant difference in the sufficiency of education concerning the disease, medication and treatment after the revised material was introduced (p < 0.005). The quality of interaction improved significantly during the intervention (p = 0.004). The strengths of the education included individual treatment, two-way interaction, the opportunity to receive patient education and its sufficiency.

CONCLUSION

Clear, readable and understandable written education material improved the quality of the education of RA patients in terms of implementation, sufficiency and the readiness of nurses and doctors to deliver the education.

Effectiveness of individual resource-oriented joint protection education in people with rheumatoid arthritis. A randomized controlled trial

OBJECTIVE

the modern joint protection (JP) concept for people with rheumatoid arthritis (RA) is an active coping strategy to improve daily tasks and role performance by changing working methods and using assistive devices. Effective group JP education includes psycho-educational interventions. The Pictorial Representation of Illness and Self Measure (PRISM) is an interactive hands-on-tool, assessing (a) the individual's perceived burden of illness and (b) relevant individual resources. Both issues are important for intrinsic motivation to take action and change behaviour. This study compared individual conventional JP education (C-JP) with PRISM-based JP education (PRISM-JP).

METHODS

an assessor-blinded multicentre randomized controlled trial, including four JP education sessions over 3 weeks, with assessments at baseline and 3 months.

RESULTS

in total 53 RA patients participated. At 3 months, the PRISM-JP (n=26) participants did significantly better compared to the C-JP participants (n=27) in JP behaviour (p=0.02 and p=0.008 when corrected for baseline values), Arthritis Self-efficacy (ASES, p=0.015) and JP self-efficacy (JP-SES, p=0.047). Within-group analysis also showed less hand pain (p<0.001) in PRISM-JP group.

CONCLUSION

PRISM-JP more effectively supported learning of JP methods, with meaningful occupations, resource activation and self-efficacy acting as important mediators.

PRACTICE IMPLICATIONS

PRISM improved patient-clinician communication and is feasible for occupational therapy.

Being an outpatient with rheumatoid arthritis--a focus group study on patients' self-efficacy and experiences from participation in a short course and one of three different outpatient settings

BACKGROUND

A Danish study compared three different outpatient settings for persons with rheumatoid arthritis (RA). All participants completed a short course before random allocation to one of three groups. A third of the patients continued with planned medical consultations. A third was allocated to a shared care setting with no planned consultations. The final third was allocated for planned nursing consultations every 3 months. Little knowledge exists of patients' experiences at different outpatient settings.

AIMS

(1) To explore the patients' experiences of participation in the course and one of the three different outpatient settings and (2) to explore whether some of these experiences can explain possible changes in self-efficacy beliefs.

METHOD

In total six focus group interviews were carried out with 33 participants from the three settings. The interviews and the analysis were inspired by phenomenological philosophy.

RESULTS

On the short course the participants felt understood, gained new insights and some changed behaviours after attendance. Important themes in experiences from the three outpatient settings were: (1) continuity and relationships with health professionals, (2) a need for others to take control, and (3) contact with health professionals. SPECIFIC FINDINGS: The nursing consultations were experienced as less factual and less authoritarian than the medical consultations. The participants in the shared care setting had a lack of confidence in the GP's competence to manage their RA. However, they felt responsible for taking action in case of a flare up. The study provided opportunities to enhance the participants' self-efficacy beliefs.

CONCLUSION

When planning follow-up care, the focus needs to be on continuity, the interpersonal relationship and easy access to health professionals with thorough knowledge of RA. A short course and consultations with nurses and hospital doctors can enhance patients' self-efficacy and thereby strengthen their confidence to assess and manage their own disease.

Can the application of control theory assist patient management in rheumatoid arthritis?

Supporting patient self-management is an important part of the care of patients with rheumatoid arthritis (RA) but patients vary in their capacity and willingness to manage their illness and may feel overwhelmed by the challenge of controlling the impact on their life. This paper discusses the value and importance of control theory and how it might be applied to enhance patients' self-management. Not only does it offer a means of identifying those who might have greatest difficulty in managing their illness, but it also points the way to effective interventions.

Development and psychometric properties of a joint protection self-efficacy scale

INTRODUCTION

Self-efficacy is one of the most powerful determinants of behaviour change. To increase effectiveness of joint protection (JP) education, it may be important to address perceptions of JP self-efficacy directly. The aim of this study was to develop a scale to measure JP self-efficacy (JP-SES) in people with rheumatoid arthritis (RA).

METHODS

Instrument development included item generation, construct validity, and reliability testing. Rasch analysis was applied to determine construct validity and the revised JP-SES was tested again to confirm validity and establish test-retest reliability and internal consistency.

RESULTS

A total of 46 items were generated by literature review, occupational therapists, and people with RA. After semi-structured interviews and field-testing with RA participants, a 26-item questionnaire draft was constructed and tested. Rasch analysis to determine construct validity reduced the JP-SES to 13 items with good overall fit values. Rasch analysis of confirmatory validity resulted in a final 10-item version of the JP-SES. Test-retest results supported the validity of the scale, with high internal consistency (α = 0.92) and good test-retest reliability (r(s) = 0.79; p < 0.001).

CONCLUSIONS

The JP-SES is a valid and reliable scale to assess perceived ability of people with RA to apply JP methods. The JP-SES could help stimulate the use of efficacy-enhancing methods in JP education.

Measuring educational needs among patients with rheumatoid arthritis using the Dutch version of the Educational Needs Assessment Tool (DENAT)

The Educational Needs Assessment Tool (ENAT) was developed in the United Kingdom (UK) to systematically assess the educational needs of patients with arthritis. The aim of the present study was to describe the educational needs of Dutch patients with rheumatoid arthritis (RA) by using the Dutch version of the ENAT (DENAT). The original UK version of the ENAT, comprising 39 items grouped into seven domains, was translated into Dutch according to international guidelines for cross-cultural translation and adaptation. The DENAT was then sent to a random sample of 319 RA patients registered at the outpatient clinic of a university hospital. For each domain (score range 1–5, equalling low–high educational needs), a median score with the inter-quartile range was computed. The Kruskal–Wallis test was used to determine possible associations between educational needs and age, disease duration, gender and educational background. The response rate was 165 out of 319 (52%). The median educational needs scores were 2.5 for “managing pain”, 3.0 for “movement”, 2.0 for “feelings”, 4.0 for “arthritis process”, 4.0 for “treatments from health professionals”, 3.5 for “self-help measures” and 2.5 for “support systems”. Lower age and shorter disease duration were associated with more educational needs in the domain “support systems”. In addition, younger patients had more educational needs regarding managing pain and feelings than older patients. There were no associations between gender or educational background and educational needs. The DENAT has demonstrated its ability to identify individual educational needs of Dutch patients with RA. The lower age and shorter disease duration were associated with more educational needs. The practical applicability of the DENAT needs further research.

[Patient education in rheumatologic care--a review]

Patient education is a medical intervention for patients with chronic diseases to increase knowledge of their disease, self-efficacy, self-management and consumer behaviour. The goal is to improve their disease outcome, social participation and quality of life. This article reviews concepts, modalities and knowledge on effectiveness of patient education. The results of different studies in different rheumatic diseases on efficacy will be summarized including a small number of cost-benefit analyses. Most studies report on significant and relevant improvements of knowledge, self-efficacy and health status. With respect to disease specific outcomes low to moderate effect sizes with a short duration have been observed. Especially good results have been reported when physical training or other methods of rehabilitation were included. There are marked improvements in consumer behaviour of health measures and sickness leave. A better understanding of information needs and baseline characteristics of patients is necessary to develop more appropriate educational interventions focussed on relevant outcomes that can be improved by educational measures.

Cost-effectiveness of intensive exercise therapy directly following hospital discharge in patients with arthritis: results of a randomized controlled clinical trial

OBJECTIVE

To estimate the cost-utility and cost-effectiveness of a 3-week intensive exercise training (IET) program directly following hospital discharge in patients with rheumatic diseases.

METHODS

Patients with arthritis who were admitted to the hospital because of a disease activity flare or for elective hip or knee arthroplasty were randomly assigned to either the IET group or usual care (UC) group. Followup lasted 1 year. Quality-adjusted life years (QALYs) were derived from Short Form 6D scores and a visual analog scale (VAS) rating personal health. Function-related outcome was measured using the Health Assessment Questionnaire, the McMaster Toronto Arthritis (MACTAR) Patient Preference Disability Questionnaire, and the Escola Paulista de Medicina Range of Motion scale (EPMROM). Costs were reported from a societal perspective. Differences in costs and incremental cost-effectiveness ratios (ICERs) were estimated.

RESULTS

Data from 85 patients (50 IET and 35 UC) could be used for health-economic analysis. VAS personal health-based QALYs were in favor of IET. Function-related outcome showed statistically significant improvements in favor of IET over the first 6 months, according to the MACTAR (P < 0.05) and the EPMROM (P < 0.01). At 1-year followup, IET was euro718 less per patient. The ICER showed a reduction in mean total costs per QALY. In 70% of cases the intervention was cost-saving.

CONCLUSION

IET results in better quality of life at lower costs after 1 year. Thus, IET is the dominant strategy compared with UC. This highlights the need for implementation of IET after hospital discharge in patients with arthritis.

Theory-based programme development and evaluation in physiotherapy

PURPOSE

Programme evaluation has been defined as "the systematic process of collecting credible information for timely decision making about a particular program." Where possible, findings are used to develop, revise, and improve programmes. Theory-based programme development and evaluation provides a comprehensive approach to programme evaluation.

SUMMARY OF KEY POINTS

In order to obtain meaningful information from evaluation activities, relevant programme components need to be understood. Theory-based programme development and evaluation starts with a comprehensive description of the programme. A useful tool to describe a programme is the Sidani and Braden Model of Program Theory, consisting of six programme components: problem definition, critical inputs, mediating factors, expected outcomes, extraneous factors, and implementation issues. Articulation of these key components may guide physiotherapy programme implementation and delivery and assist in the development of key evaluation questions and methodologies. Using this approach leads to a better understanding of client needs, programme processes, and programme outcomes and can help to identify barriers to and enablers of successful implementation. Two specific examples, representing public and private sectors, will illustrate the application of this approach to clinical practice.

CONCLUSIONS

Theory-based programme development helps clinicians, administrators, and researchers develop an understanding of who benefits the most from which types of programmes and facilitates the implementation of processes to improve programmes.

Does the Comprehensive ICF Core Set for rheumatoid arthritis capture occupational therapy practice? A content-validity study

BACKGROUND

The ICF Core Sets for rheumatoid arthritis (RA) constitute an application of the International Classification of Functioning, Disability and Health (ICF).

PURPOSE

To explore whether the ICF Core Sets for RA include the areas of functioning and environmental factors that are typically treated by occupational therapists in their clinical everyday practice with clients with RA.

METHODS

In a three-round survey occupational therapists were asked about their intervention goals when treating clients with RA. The identified goals were grouped into goal classes that were then linked to the ICF.

RESULTS

41 occupational therapists in nine countries named 533 intervention goals that were grouped into 48 goal classes and then linked to ICF categories of all ICF components. The goal classes self-confidence, relaxation and psycho-social well-being are not represented in the Comprehensive ICF Core Set for RA.

CONCLUSION

The validity of the ICF Core Set for RA from the perspective of occupational therapists was largely confirmed.

Effects of an educational-behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial

The aim of this study was to asses the effects on pain, disability, and health status of an educational-behavioral joint protection program in a group of moderate-severe rheumatoid arthritis (RA) patients. Eighty-five subjects with RA in treatment with anti-tumor necrosis factor alpha (TNFalpha) drugs (infliximab) were enrolled into the study and randomized into either an experimental group (46, EG) or a control group (39, CG). We organized four EG meetings, which included information on pathophysiology and evolution of RA, joint protection during normal activities of daily living, suggestions on how to adapt the surrounding environment, and self-learning exercises to perform at home. Sociodemographic characteristics and degree of knowledge of the disease, measured by the Health Service Interview (HSI), were recorded at baseline. The outcome measures included the Visual Analogue Scale (VAS), the Arthritis Impact Measurement Scale 2 (AIMS2), and the Health Assessment Questionnaire (HAQ), which were administered at the beginning and end of the trial. Thirty-six patients from the EG (7 men and 29 women; mean age 54.2 years) and 34 from the CG (6 men and 28 women; mean age 52.2 years) completed the trial. No statistical differences in baseline evaluations were found between the two groups. According to the answers given on the HSI, the majority of our patients had poor knowledge of RA and its consequences. After a mean time of 8 months, the patients receiving educational training displayed a significant decrease, compared to the CG, in the VAS (p = 0.001), HAQ (p = 0.000), and physical (p =0.000), symptoms (p = 0.049), and social interaction (p = 0.045) scores on the AIMS2, but not in other items. Our study showed that 8 months after attending an educational-behavioral joint protection program, subjects with moderate-severe RA presented less pain and disability and thus an enhanced health status. This approach may efficiently complement drug therapy in these patients.

Validation of the comprehensive international classification of functioning, disability and health core set for rheumatoid arthritis: the perspective of physical therapists

BACKGROUND AND PURPOSE

The Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Rheumatoid Arthritis (RA) represents the typical spectrum of problems in the functioning of patients with RA. The objective of this study was to validate this ICF Core Set from the perspective of physical therapists.

METHODS

Physical therapists were asked about their intervention goals in a 3-round Delphi survey. Intervention goals were compiled, and the physical therapists were asked whether they considered the goal classes to be relevant. The goal classes then were linked to the ICF.

RESULTS

A total of 82 physical therapists in 12 countries named 562 intervention goals. A total of 45 goal classes covering all ICF components were identified. The goal classes addressing muscle tone, balance and coordination, and psychological distress were not represented in the ICF Core Set for RA.

DISCUSSION AND CONCLUSION

The validity of the ICF Core Set for RA was largely supported. However, some categories currently not covered by the ICF Core Set for RA will need to be investigated further.

Successfully living with chronic arthritis

The treatment and care of patients with rheumatoid arthritis (RA) is complex and various health professionals with different areas of expertise may be involved. The objective of this article is to review the treatments and their efficacy as provided by health care professionals in RA care. The requirements for further research in this area are formulated. To achieve better effects of treatment it is necessary to improve the coordination of services as provided by the different specialists. The important roles of the patients themselves in the care and management of the disease are emphasized, as well as the roles of the informal caregivers such as a spouse or other family members and friends and the role of patient societies. The possible role of the International Classification of Functioning, Disability and Health (ICF) to improve the communication and facilitate the coordination among health professionals and between patients and health professionals is mentioned. The topics presented in this article may encourage further discussion and research, particularly concerning the effects of the treatments as provided by allied health professionals. Health professionals play an important role in the life of patients with rheumatic disorders, in all the domains of the ICF: body functions and structure, activities (action by an individual) and participation (involvement in a life situation). Health professionals in rheumatology can make the difference in the lives of RA patients and their families.

Contribution of Partner Support in Self-Management of Rheumatoid Arthritis Patients. An Application of the Theory of Planned Behavior

The aim of this exploratory study was to test the applicability of a model derived from the Theory of Planned Behavior on self-management. In this model social support from the partner, attitude and self-efficacy are determinants of intention, and intention and self-efficacy are determinants of self-management. We tested the model on rheumatoid arthritis patients who have a partner, using regression analyses and structural equation models. Partner support and attitude partly explained the variance in intention. Intention in turn partly explained the variance in self-management. Self-efficacy showed a tendency to positively affect intention and self-management. The present study provided moderate support for the use of the constructs and ideas derived from the Theory of Planned Behavior-attitude, social support, self-efficacy, and intention-in predicting and explaining self-management.

Educating patients: self-management approaches

PURPOSE

To review and evaluate approaches to educating patients with fibromyalgia syndrome (FMS).

METHODS

A narrative literature review was undertaken to summarize the published literature on patient education for FMS patients.

RESULTS

A number of studies contain specific education strategies while others are combined with exercise or movement therapies or cognitive-behavioural therapy.

CONCLUSIONS

Self-efficacy provides an effective theoretical model from which to understand how patients change as a result of education strategies that focus on self-management. Programmes that combine education with cognitive-behavioural techniques and exercise are most effective in enhancing self-efficacy and decreasing symptoms of FMS.

Caregiving burden and psychiatric morbidity in spouses of persons with mild cognitive impairment

BACKGROUND

While the deleterious psychosocial and mental health effects of dementia caregiving are firmly established, very little is known about the burdens or psychiatric outcomes of providing care to a spouse with less severe cognitive impairment, such as mild cognitive impairment (MCI). We characterized the nature and level of caregiver burden and psychiatric morbidity in spouses of persons diagnosed with MCI.

METHODS

Interview assessments were completed on a cohort of 27 spouses of persons with a recent diagnosis of MCI. Patient medical records were reviewed to collect information regarding the MCI patient's medical history.

RESULTS

Respondents endorsed elevated levels of both task-related responsibilities and subjective caregiver burden. Depression and anxiety symptom levels also showed some elevations. Measures of caregiver burden were significantly associated with depression and anxiety levels. In particular, even after controlling for demographic risk factors for distress, nursing task burden was correlated with elevated depressive symptoms, and greater lifestyle constraints were correlated with higher anxiety levels.

CONCLUSIONS

Although caregiver burden and psychiatric morbidity levels were lower than those typically observed in family dementia caregiving samples, our findings suggest that MCI caregivers have already begun to experience distress in association with elevated caregiving burden. These individuals may be ideal targets for selective preventive interventions to maximize their psychological well-being as caregiving burdens related to their spouses' cognitive impairment increase.