The Use of Avoidance, Adjustment, Interaction and Acceptance Strategies to Handle Participation Restrictions Among Swedish Men with Early Rheumatoid Arthritis

Patient and Healthcare Provider Experience With Rheumatoid Arthritis in Northern Ontario, Canada: A Qualitative Descriptive Study

BACKGROUND

Rheumatoid arthritis (RA) is a disabling common chronic inflammatory joint disease. In Ontario, the burden is higher in those aged 65 and older, in females, and in northern communities. This study examined patient disease impact and healthcare provider access and satisfaction as well as provider satisfaction, patient experience and educational suggestions.

METHODS

Semi-structured interviews and reflexive thematic analysis were used.

RESULTS

Interviews occurred with: (1) 18 Northern (N) Ontario patients, (2) 6 N Ontario family physicians, (3) 6 N Ontario pharmacists and (4) a rheumatologist and 4 advanced clinical practitioners in arthritis care (ACPACs) who treat N Ontario patients. Patients emphasised the need to: (1) act on early symptoms, (2) self-advocate, (3) attract more N Ontario rheumatologists, (4) educate the public, (5) recognise that medication can change over time and (6) pace physical tasks. Satisfaction was expressed with providers. Family physicians mentioned the need to: (1) be front-line educators, (2) commence initial treatment, (3) enhance undergraduate medical curricula and (4) require rheumatology rotations. Pharmacists expressed: (1) acting as patient educators, (2) assisting with insurance plans, (3) encouraging family physicians to commence treatment, (4) monitoring medication interactions and (5) professional collaboration. The ACPACs and rheumatologist stressed the value of: (1) patient advocates, (2) family physicians initiating treatment, (3) pharmacists monitoring for drug interactions, (4) expanding undergraduate medical school rheumatology curricula and (5) accessing local care.

CONCLUSION

Additional patient and public education are needed. Enhancing undergraduate and graduate medical school rheumatology curricula, rotations, continuing rheumatology education and interprofessional collaboration were recommended.

A dyadic exploration of support in everyday life of persons with RA and their significant others

BACKGROUND

Support from significant others is important for participation in everyday life for persons with rheumatoid arthritis (RA). Meanwhile, significant others also experience limitations.

AIMS

To explore how support is expressed by persons with RA and significant others, and how support relates to participation in everyday life of persons with RA.

MATERIAL AND METHODS

Sixteen persons with RA and their significant others participated in individual semi-structured interviews. The material was analyzed using dyadic analysis.

RESULTS

Persons with RA and significant others reported that RA and support had become natural parts of everyday life, especially emotional support. The reciprocal dynamics of support were also expressed as imperative. Also, support from people outside of the dyads and well-functioning communication facilitated everyday life.

CONCLUSIONS

Significant others and the support they give are prominent factors and facilitators in everyday life of persons with RA. Concurrently, the support persons with RA provide is important, along with support from outside of the dyads.

SIGNIFICANCE

The results indicate that the interaction between persons with RA and the social environment is central to gain insight into how support should be provided for optimal participation in everyday life. Significant others can preferably be more involved in the rehabilitation process.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

"My role as a parent, to me, it has narrowed" the impact of early inflammatory arthritis on parenting roles: a qualitative study

PURPOSE

To explore the impact of early inflammatory arthritis on participation in parenting roles.

MATERIALS AND METHODS

Twenty-four individuals (20 female) aged between 32 and 62 years with early inflammatory arthritis (<2 years duration) and who were parents of dependent children (≤21 years) were interviewed. A qualitative description study design was used, and thematic analysis methodologies were employed in the data analysis.

RESULTS

Parenting roles were significantly impacted in early disease and extensive parenting restrictions were identified regardless of age and gender. Physical symptoms hampered "everyday mammy activities." Parent-child interactions were altered by the emotional impact of early arthritis including low mood and irritability. Participants emphasised remorse at the negative impact of their arthritis on their children's childhood. Parent-role identity and parents' perception of how they were viewed by their children were negatively impacted by early disease with considerable self-imposed pressure to shield children from the consequences of arthritis. A forced "role switch" requiring relinquishing of some parenting tasks was identified as an unwanted burden associated with inflammatory arthritis.

CONCLUSION

Inflammatory arthritis has a negative impact on parenting which is present from disease onset. Understanding factors which influence parenting with arthritis is important to identify appropriate healthcare interventions.Implications for rehabilitationAn early diagnosis of inflammatory arthritis is synonymous with considerable challenges in performing parenting tasks and activities which are present despite early medical management and drug therapy.Physical and psychosocial sequelae of early inflammatory arthritis result in restrictions in the execution of parenting activities and are accompanied by a forced "role switch".The disease impact on parenting differs in early and established inflammatory arthritis and requires distinct healthcare approaches and interventions to adequately address the needs.Parent role identity and perceived lack of control are intrinsically linked to the degree of perceived negative impact on parenting and these factors should be considered in the design and evaluation of appropriate healthcare interventions for this population.

'You don't want to be seen as a burden' experiences of working with early inflammatory arthritis: a qualitative study

PURPOSE

To describe the impact of early inflammatory arthritis on work participation.

MATERIALS AND METHODS

Thirty individuals (24 women) of working age (age 18-69 years) with inflammatory arthritis (<2 years duration) who were in paid employment or fulltime education were interviewed using qualitative description methodology. Data was analysed using thematic analysis.

RESULTS

Half of participants (n = 15) reported work disability within the first two-years of diagnosis. Five descriptive themes were identified that explained the early impact of IA on participation in paid employment. These themes were: (i) altered capacity for work; (ii) work comes first; (iii) the invisible burden; (iv) the disclosure effect; and (v) a reconstructed work future.

CONCLUSION

The scale of early work disability appears to be higher than previously understood. Although early medical intervention has improved disease management, significant work-based restrictions requiring intervention remain. Internalised and invisible work-related anxieties present early in the disease and need to be acknowledged and addressed by healthcare providers.IMPLICATIONS FOR REHABILITATIONEarly inflammatory arthritis causes significant challenges in work ability, and early work-based participation restrictions are present despite early use of drug therapy.Assessment of the client's subjective experience, including understanding the invisible burden, is an important aspect in determining the types of work interventions required.Disclosure of diagnosis in the work environment is associated with anxiety and fear, however, disclosure is influential in supporting capacity to retain work participation and should be included in work interventions.Routine healthcare should include early interventions to address work-based restrictions and supporting work retention to avoid work disability.

Renegotiating dimensions of the self: A systematic review and qualitative evidence synthesis of the lived experience of self-managing rheumatoid arthritis

BACKGROUND

As chronic illnesses, such as rheumatoid arthritis (RA), place an increased burden on health-care systems, the ability of individuals to self-manage these diseases is crucial.

OBJECTIVE

To identify and synthesize the lived experience of self-management described by adults living with RA.

DESIGN

A systematic search of five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and ASSIA) was undertaken to identify relevant studies. Data were extracted and quality-assessed using CASP guidelines. A meta-synthesis was conducted based on Thomas and Harden's thematic synthesis approach.

RESULTS

The search identified 8423 publications. After removing duplicates, 6527 records remained of which 32 studies met the inclusion criteria. Quality of studies was moderate to high, yet a considerable lack of reflection on researcher bias was evident. Our analysis identified 28 dimensions of self-management RA across six domains: (a) cognitive-emotional, (b) behavioural, (c) social, (d) environmental, (e) physical and (f) technological. Cognitive-emotional experiences dominated the analysis. Renegotiating 'the self' (self-concept, self-esteem, self-efficacy) was a key focus of self-management among individuals with RA.

CONCLUSION

Our findings highlight the focus of 'the self' as a central concern in the self-management of RA. Standardized self-management programmes may primarily focus on disease management and daily functioning. However, we suggest that personal biographies and circumstances should move to the fore of self-management support.

REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews 2018: CRD42018100450.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement was not explicit in this review. However, three authors provided a patient perspective on the self-management of arthritis and autoimmune disease.

Time to update the ICF by including socioemotional qualities of participation? The development of a "patient ladder of participation" based on interview data of people with early rheumatoid arthritis (the Swedish TIRA study)

Purpose: The aim of was to identify and illustrate in what situations and with what qualities people with early RA experience participation in every day's life.Methods: Fifty-nine patients (age 18-63 years) were interviewed; 25 men and 34 women. Content analysis was used to identify meaning units that were sorted based on the type of situations described and later on, categories based on quality aspects of participation were developed.Results: Participation was described as: 1. being part of a group, where a sense of belonging arose. 2. In doing activities with others for example at work or in leisure. 3. When sharing everyday chores and responsibilities for example in domestic duties. 4. When experiencing influence on actions such as when being asked for opinions on how to conduct a specific task. 5. When having the possibility to give direction of goals in rehabilitation, or elsewhere. 6. When sharing decision making and experiencing a high degree of influence in the situation.Conclusions: Participation from an individual's perspective is about belonging and having influence that mediates a positive feeling of being included and that you matter as a person. The results are important when using participation as a goal in clinical care. It is important to expand participation beyond the definitions in ICF and guidelines to include the patients' socio-emotional participation in order to promote health.Implications for rehabilitationFacilitation of participation in daily activities is an important part of rehabilitation.Participation is expressed as determined by a person's unique life circumstances often in engagement with others.It is important to expand participation beyond the definitions in ICF and guidelines to include the patients' socio-emotional participation in order to promote health.Collected information about socioemotional participation can serve as a starting point for interventions aimed at the patient's social environment and also provide support for health professions how to involve significant others in the rehabilitation.

Coping Strategies, Psychological Impact, and Support Preferences of Men With Rheumatoid Arthritis: A Multicenter Survey

Objective

To investigate the existence and distribution of 2 typologies (termed “factors”) of men with rheumatoid arthritis (RA) identified through our previous Q‐methodology study (n = 30) in a larger sample of men with RA, and whether differences in psychosocial impact or support preferences exist between the 2 factors, and between men and women with RA.

Methods

A postal survey was sent to 620 men with RA from 6 rheumatology units across England, and the support preferences section of the survey was given to 232 women with RA.

Results

A total of 295 male patients (47.6%) and 103 female patients (44.4%) responded; 15 male participants had missing data, and thus 280 were included in the analysis. Of these, 61 (22%) were assigned to factor A (“accept and adapt”), 120 (35%) were assigned to factor B (“struggling to match up”), and 99 (35%) were unassigned. The two factors differed significantly, with factor B reporting more severe disease, less effective coping strategies, and poorer psychological status. For support, men favored a question and answer session with a consultant (54%) or specialist nurse (50%), a website for information (69%), a talk by researchers (54%), or a symptom management session (54%). Overall, women reported more interest in support sessions than men, with ≥50% of women reporting interest in nearly every option provided.

Conclusion

Some men accept and adapt to their RA, but others (43%) report severe disease, less effective coping, and poor psychological status. Men's preferences for support are practical, with a focus on expanding their knowledge.

Women's situation-specific strategies in managing participation restrictions due to early rheumatoid arthritis: A gender comparison

INTRODUCTION

The present study explored how women describe their use of situation-specific strategies when managing rheumatoid arthritis (RA). The aim was also to compare women's strategies with those of men, and see the extent to which they used the same strategies.

METHODS

The data were collected using semi-structured interviews based on the critical incident technique. The sample consisted of women with early rheumatic arthritis (n = 34), and the results were compared with data reported in a previous study on men (n = 25) from the same cohort. The patient-described participation restrictions due to RA were firstly linked to the domains of the International Classification of Functioning, Disability and Health (ICF). The different strategies used were then categorized. The study was approved by the Research Ethics Committee of the Faculty of Health Sciences, Linköping University, Sweden.

RESULTS

The study found that women used four situation-specific strategies: adjustment, avoidance, interaction and acceptance. The same strategies had been found previously in interviews with men with RA. Women and men used these strategies to a similar extent in the ICF domains of mobility; major life arenas; domestic life; interpersonal interactions and relationships; and community, social and civic life. However, some differences were found, relating to the reported activities in self-care and domestic life, in which women reported using strategies to a greater extent than men.

CONCLUSIONS

Women and men used four types of situation-specific strategies in managing RA; adjustment, avoidance, interaction and acceptance. These situation-specific strategies provide useful knowledge, in terms of multidisciplinary rehabilitation and for patients' significant others.

Identifying different typologies of experiences and coping strategies in men with rheumatoid arthritis: a Q-methodology study

OBJECTIVE

To identify typologies of experiences and coping strategies of men with rheumatoid arthritis (RA).

DESIGN

Q-methodology (a qualitative and quantitative approach to grouping people according to their subjective opinion). Men with RA sorted 64 statements relating to their experience of living with RA according to level of agreement across a normal distribution grid. Data were examined using Q-factor analysis.

SETTING

Rheumatology outpatient departments in the UK.

PARTICIPANTS

30 of 65 invited men with RA participated in this study (46%).

RESULTS

All participants ranked highly the need to be well informed about their medication and the importance of keeping a positive attitude. 2 factors describing the experiences and coping strategies of male patients living with RA were identified: factor A: 'acknowledge, accept and adapt' (n=14) take a proactive approach to managing the impact of RA and find different ways of doing things; while factor B: 'trying to match up to a macho ideal' (n=8) are determined to continue with their pre-RA lives, and therefore push themselves to carry on even if this causes them pain. They are frustrated and angry due to the impact of RA but they internalise this rather than directing it at others.

CONCLUSIONS

While some men adapt to their RA by renegotiating their masculine identity, others struggle to relinquish their traditional masculine roles. Further research is needed to identify whether the finding that there are 2 distinct groups of men with RA can be generalised, and if so whether the differences can be explained by clinical, social or psychological factors, which may inform different therapeutic approaches.