Life stories of people with rheumatoid arthritis who retired early: how gender and other contextual factors shaped their everyday activities, including paid work

Significant others in inflammatory arthritis: roles, influences, and challenges-a scoping review

Improving self-management in individuals with inflammatory arthritis (IA) is crucial for effective disease management. However, current recommendations primarily focus on interventions for the diagnosed individuals, overlooking the potential impact of their significant others on their self-management abilities. This review aims to fill this gap by identifying and mapping relevant research employing both qualitative and quantitative design to provide a broader understanding of the potential of significant others in relation to IA management. We examined studies published from 2007 to 2024 that explore our research questions using electronic databases and grey literature searches. Two independent reviewers meticulously screened and categorized the studies based on a developed framework employing basic content analysis. Out of 20.925 studies, 43 were included: 22 quantitative studies (including 1 educational trial), 20 qualitative studies, and 1 mixed-methods study. Our analysis of the included studies revealed that significant others predominantly provided practical and emotional support and could positively or negatively influence the person with IAs self-management abilities. Additionally, significant others reported their own feelings of emotional distress and expressed the need for knowledge, skills and social support enabling them to provide better support while taking care of them self. Greater focus on the significant others of those diagnosed with IA in their provision of support to this patient group may both improve the people with IA self-management skills and address significant others' reported needs. Future studies should explore the impact of such initiatives through randomized controlled trials.

Tailoring Rheumatoid Arthritis Treatment through a Sex and Gender Lens

Rheumatoid arthritis (RA) occurs more frequently in women than in men, and the studies that have addressed clinical and prognostic differences between the sexes are scarce and have contradictory results and methodological problems. The present work aims to evaluate sex- and gender-related differences in the clinical expression and prognosis of RA as well as on the impact on psychosocial variables, coping behavior, and healthcare use and access. By identifying between sex differences and gender-related outcomes in RA, it may be possible to design tailored therapeutic strategies that consider the differences and unmet needs. Being that sex, together with age, is the most relevant biomarker and health determinant, a so-called personalized medicine approach to RA must include clear guidance on what to do in case of differences.

Chew-Graham C, Paskins Z. Exploring the treatment burden of disease-modifying anti-rheumatic drug monitoring in people with rheumatoid arthritis

Objectives

People with RA taking DMARDs require safety monitoring to identify potential side effects. The aim of this study was to explore the perspectives of patients and family members on DMARD monitoring and how the associated treatment burden could be minimized to optimize concordance and safety.

Methods

Thirteen adults with RA on DMARDs and three family members participated in semi-structured telephone interviews between July 2021 and January 2022. Data were analysed using a framework method. Findings were discussed with a group of stakeholders to develop implications for practice.

Results

Two main themes were identified: (i) making sense of drug monitoring; and (ii) work involved in drug monitoring. Participants perceived DMARDs as necessary to reduce symptoms, with drug monitoring providing an opportunity for a holistic assessment of wellbeing. Participants expressed a preference for face-to-face consultations, which allowed them to share their concerns, rather than remote, often transactional, care. The limited availability of convenient appointment times, travel requirements and parking increased the work involved for patients and family members.

Conclusion

Drug monitoring was accepted as a necessity of DMARD treatment, but increased the work for people with RA related to organizing and attending appointments. The potential for treatment burden needs to be assessed proactively by clinicians when a DMARD is commenced. Where identified, strategies for minimizing the treatment burden can form part of a shared management plan, including the offer of regular contact with health professionals, with an emphasis on person-centred care.

Work disability and rheumatoid arthritis: Predictive factors

BACKGROUND

Rheumatoid arthritis is often associated with work disability, a term used to describe the inability to be or to remain employed. Work disability is a common implication of rheumatoid arthritis.

OBJECTIVE

This review aims to identify and analyze the predictive factors of work disability among patients with rheumatoid arthritis, as well as to group these factors into broader categories, based on the most current studies in this field.

METHODS

An electronic search was conducted using Google Scholar, MEDLINE and PsycINFO databases. Eighty-six international journal articles were finally selected.

RESULTS

The results suggest that occupational, personal, medical and societal factors are the main predictive categories of work disability for people with rheumatoid arthritis.

CONCLUSIONS

Medical progress has had a positive effect on the development and the rates of work disability among patients with RA. Work disability is, however, not only defined by medical factors. Occupational, personal and societal factors interact with each other and affect the development of work disability in RA. The results of this review emphasize the need for medical and vocational therapy interventions, social support and state policies that target the work status of patients with RA. Future holistic research approaches to the field are required for a complete picture and concrete solutions with the aim of keeping patients with RA employed.

Clinical relevance of activities meaningful to parents of preterm infants with very low birth weight: A focus group study

Introduction

Parents have a major impact on the outcome of health care of preterm infants. Parents’ engagement in meaningful activities could have an impact on their own health and wellbeing and therefore be relevant in neonatal intensive care. The aim of this study was to explore meaningful activities of parents of very low birth weight (VLBW) preterm infants with the purpose to further the understanding of their clinical relevance and to foster their consideration in clinical practice and research of neonatal intensive care.

Methods

A total of 36 parents of preterm infants born prior to complete 37 weeks of gestation with VLBW (≤1.500 grams) were asked to participate in a focus group interview. Interview transcripts were used to analyse the content of the focus group interviews using meaning condensation method by Steinar Kvale.

Results

Thirty-six parents participated in a total of twelve focus groups. Parents reported that the meaning of certain activities changed due to preterm birth. Meaningful activities, like bathing the baby and gardening, could foster a transition from a feeling of parental immaturity to a feeling of maturity, following health care instructions to possessing health care skills, and a functioning-only state to a balance of activities.

Conclusions

In neonatal intensive care, nurses contribute to delivering parental education and thereby facilitate experiences of being a mature parent and of possessing health care skills. Occupational therapy could be used to help re-engage in meaningful activities and maintain a balance of activities in parents of VLBW preterm infants.

Patients' Attitudes and Experiences of Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis and Spondyloarthritis: A Qualitative Synthesis

OBJECTIVE

Nonadherence to disease-modifying antirheumatic drugs (DMARDS) in rheumatoid arthritis (RA) and spondyloarthritis (SpA) results in increased disease activity and symptoms and poorer quality of life. We aimed to describe patients' attitudes and experiences of DMARDs in RA and SpA to inform strategies to improve medication adherence.

METHODS

Databases (MEDLINE, Embase, PsycINFO, and CINAHL) were searched to January 2016. Thematic synthesis was used to analyze the findings.

RESULTS

From 56 studies involving 1,383 adult patients (RA [n = 1,149], SpA [n = 191], not specified [n = 43]), we identified 6 themes (with subthemes): intensifying disease identity (severity of sudden pharmacotherapy, signifying deteriorating health, daunting lifelong therapy), distressing uncertainties and consequences (poisoning the body, doubting efficacy, conflicting and confusing advice, prognostic uncertainty with changing treatment regimens), powerful social influences (swayed by others' experiences, partnering with physicians, maintaining roles, confidence in comprehensive and ongoing care, valuing peer support), privilege and right of access to biologic agents (expensive medications must be better, right to receive a biologic agent, fearing dispossession), maintaining control (complete ownership of decision, taking extreme risks, minimizing lifestyle intrusion), and negotiating treatment expectations (miraculous recovery, mediocre benefit, reaching the end of the line).

CONCLUSION

Patients perceive DMARDs as strong medications with alarming side effects that intensify their disease identity. Trust and confidence in medical care, positive experiences with DMARDS among other patients, and an expectation that medications will help maintain participation in life can motivate patients to use DMARDs. Creating a supportive environment for patients to voice their concerns may improve treatment satisfaction, adherence, and health outcomes.

'Everyone assumes a man to be quite strong': Men, masculinity and rheumatoid arthritis: A case-study approach

Current literature has overlooked the impact of chronic illness on masculine identity. We therefore aimed to investigate the impact of rheumatoid arthritis (a long term condition, affecting more women than men) on masculine identity. Six focus groups with 22 men with rheumatoid arthritis (RA) (data reported elsewhere) followed by five one-to-one interviews with men (English, mean age: 59 years) sampled to reflect a heterogeneous experience of life with RA based on knowledge gained from the focus groups. Transcripts were analysed using thematic analysis and are presented as individual case studies. Whilst the case studies provide five distinct experiences, common themes can be drawn across them, such as the importance of paid work. The men needed to renegotiate their masculine identity to deal with their RA. Two dealt with this by pushing through pain to retain masculine activities, two replaced masculine roles they could no longer do with other roles, and one rejected masculinity completely. Men with long term conditions may need to re-write their masculinity scripts to enable them to accept and adapt to their condition. However, some men struggle with this, which should be taken into consideration when designing self-management services for men with long term conditions.

Men, rheumatoid arthritis, psychosocial impact and self-management: A narrative review

Rheumatoid arthritis is a chronic disease affecting fewer men than women. We systematically reviewed the literature on impact and self-management of rheumatoid arthritis in men. A total of 28 papers were included and grouped into two categories: psychosocial impact of rheumatoid arthritis, and coping and self-management. This review finds gender differences relating to quality of life, work, distress, self-management, coping and support. We conclude that there is a dearth of literature focussing on rheumatoid arthritis in men only, and mixed gender studies include insufficient men to draw strong conclusions about men. Thus, further research is needed to understand the support needs of men with rheumatoid arthritis in depth.

Impairment in the activities of daily living in older adults with and without osteoporosis, osteoarthritis and chronic back pain: a secondary analysis of population-based health survey data

BACKGROUND

Independence in performing activities of daily living (ADLs) is a central aspect of functioning. Older adults frequently experience impairments and limitations in functioning in various life areas. The aim of this survey was to explore the limitations in the ADLs in older adults in a population-based survey in Austria.

METHOD

A population-based cross-sectional study in 3097 subjects aged ≥65 years who were included in the Austrian health interview survey was performed. Descriptive statistics were used to calculate frequencies of problems in the ADLs. A principal component analysis was applied to analyze the main dimensions of 19 ADL items. Binary logistic regression models were used with the ADL dimensions as the dependent variables and osteoarthritis, chronic back pain, osteoporosis, sex, education level, anxiety or depression, age and pain intensity as independent variables.

RESULTS

People with musculoskeletal conditions were significantly more often affected by ADL problems than people without these diseases. The ADL domain which caused problems in the highest proportion of people was "doing heavy housework" (43.9 %). It was followed by the ADL domains "bending or kneeling down" (39.3 %), "climbing stairs up and down without walking aids" (23.1 %), and "walking 500 m without walking aids" (22.8 %). The principal components analysis revealed four dimensions of ADLs: (1) intense "heavy burden" ADLs, (2) basic instrumental ADLs, (3) basic ADLs and (3) hand-focused ADLs. The proportion of subjects who had problems with the respective dimensions was 58.2, 29.2, 23.0, and 9.2 %. Anxiety/depression (greatest effect), followed by the chronic musculoskeletal disease itself, female sex, higher age and pain intensity were significant predictors of ADL problems.

CONCLUSION

This population-based survey indicates that older people have considerable ADL problems. More attention should be paid to the high impact of pain intensity, anxiety and depression on ADLs.

Initial evidence for the link between activities and health: Associations between a balance of activities, functioning and serum levels of cytokines and C-reactive protein

Growing evidence shows interrelations of psychological factors, neurological and immunological processes. Therefore, constructs like a balance of activities, the so called "occupational balance", could also have biological correlates. The aim of this study was to investigate potential associations between occupational balance, functioning, cytokines and C-reactive protein (CRP) in patients suffering from a chronic inflammatory disease like rheumatoid arthritis (RA) and healthy people. Moreover, we wanted to explore potential differences in gender and employment status. A descriptive study in patients with RA and healthy people was conducted using the Occupational Balance-Questionnaire (OB-Quest) and the Short-Form 36 Health Survey (SF-36). Serum levels of cytokines, such as interleukin 6 (IL-6) and 8 (IL-8), interferon alpha (INFα), tumour necrosis factor alpha (TNFα), rheumatoid factor (RF) and of CRP were measured. Descriptive statistics, as well as Mann-Whitney U tests and Spearmen's rank correlation coefficients (rs) were calculated. One-hundred-thirty-two patients with RA and 76 healthy people participated. Occupational balance was associated with functioning, cytokines and CRP. The strongest associations were identified in the unemployed healthy-people sample with cytokines and CRP being within the normal range. For example, the OB-Quest item challenging activities was associated with IL-8 (rs=-0.63, p=0.04) and the SF-36 sub-scale bodily pain was associated with IFNα (rs=-0.69, p=0.02). The items rest and sleep (rs=-0.71, p=0.01) and variety of different activities (rs=-0.74, p<0.01) correlated with the SF-36 sub-scale social functioning. Employed and unemployed people differed in their age and CRP levels. Additionally, gender differences were found in two OB-Quest items in that fewer women were able to adapt their activities to changing living conditions and fewer men were overstressed. In conclusion, we found preliminary biological evidence for the link between occupation and health in that the concepts encompassed in the construct of occupational balance were associated with functioning, cytokines and CRP.

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

OBJECTIVES

Living with a chronic disease means learning to live under new circumstances and involves a continuous adaptation to new ways of living. There is increasing knowledge about how people cope with stressful life events and adapt to new life situations. Approximately a third of patients diagnosed with rheumatoid arthritis (RA) are men; however, few studies have described the needs and experiences of men living with RA. The aim of the present study was to explore men's strategies for handling challenges related to participation in everyday life.

METHODS

The present study was associated with the prospective Swedish multicentre early arthritis project (given the Swedish acronym TIRA), which, in 2006-2009, included patients with early RA, contemporarily treated, with a mean disease duration of three years. From this cohort, 25 men, aged 20-63 years, were recruited consecutively. Data were collected in individual interviews, using the critical incident technique. The strategies for dealing with the challenges of RA in everyday life were analysed and categorized using content analysis.

RESULTS

Men with RA described four types of strategy for dealing with participation restrictions in everyday life: (i) Adjustment strategies - adjust behaviour, movements, medication, equipment and clothing to find new ways to conduct tasks or activities; (ii) Avoidance strategies - avoid activities, movements, social contacts and sometimes medication; (iii) Interaction strategies - say no, ask for help and work together to handle participation restrictions; and (iv) Acceptance strategies - learn to accept RA, with the pain, the slower work pace and the extended time needed.

CONCLUSIONS

According to men's lived experiences, a combination of strategies was used to deal with RA, depending on the situation and the experienced restriction. The results provided an understanding of how men with RA manage their disease, to reduce physical, social and emotional challenges. This knowledge may be used further to develop multi-professional interventions and patient education tailored to men with RA.

Social participation in early and established rheumatoid arthritis patients

PURPOSE

The aim of the study was to examine whether rheumatoid arthritis (RA) patients with different levels of restriction in social participation differ in disease related as well as psychosocial variables and whether a similar pattern can be found among early and established RA patients.

METHOD

Two samples of RA patients with early (n = 97; age = 53 ± 12.3 years; disease duration = 2.8 ± 1.2 years; 76% women) and established (n = 143; age = 58 ± 10.3 years; disease duration = 16.1 ± 3.6 years; 86% women) were collected. The pattern of differences for the patients with different level of participation restriction (no restriction, mild, moderate or high restriction) was explored by the Jonckheere-Terpstra test.

RESULTS

Significant differences were found between patients with different levels of social participation restrictions in both samples in pain, fatigue, functional disability, anxiety, depression and mastery. Generally, it was found that patients with higher restrictions experienced more pain and fatigue, more anxiety and depression and reported lower mastery. Similar pattern of differences concerning disease activity and self-esteem was found mainly in the established group.

CONCLUSIONS

The study shows that the level of perceived restrictions in social participation are highly relevant regarding the disease related variables such as pain, fatigue and functional disability as well as psychological status and personal resources in both early and established RA.

IMPLICATIONS FOR REHABILITATION

Supporting involvement and participation of individuals with rheumatoid arthritis is important for decreasing the impact of RA symptoms on everyday life. Recognition and empowerment of individual resources such a mastery and self-esteem of RA patients could be beneficial for overcoming restrictions in participation.

Exploring preferences for domain-specific goal management in patients with polyarthritis: what to do when an important goal becomes threatened?

Usually priorities in goal management—intended to minimize discrepancies between a given and desired situation—are studied as person characteristics, neglecting possible domain-specific aspects. However, people may make different decisions in different situations depending on the importance of the personal issues at stake. Aim of the present study therefore was to develop arthritis-related vignettes to examine domain-specific goal management and to explore patients’ preferences. Based on interviews and literature, situation-specific hypothetical stories were developed in which the main character encounters a problem with a valued goal due to arthritis. Thirty-one patients (61 % female, mean age 60 years) evaluated the face validity of the newly developed vignettes. Secondly, 262 patients (60 % female, mean age 63 years) were asked to come up with possible solutions for the problems with attaining a goal described in a subset of the vignettes. Goal management strategies within the responses and the preference for the various strategies were identified. The 11 developed vignettes in three domains were found to be face-valid. In 90 % of the responses, goal management strategies were identified (31 % goal maintenance, 29 % goal adjustment, 21 % goal disengagement, and 10 % goal re-engagement). Strategy preference was related to domains. Solutions containing goal disengagement were the least preferred. Using vignettes for measuring domain-specific goal management appears as valuable addition to the existing questionnaires. The vignettes can be used to study how patients with arthritis cope with threatened goals in specific domains from a patient’s perspective. Domain-specific strategy preference emphasizes the importance of a situation-specific instrument.

Men's experiences of living with ankylosing spondylitis: a qualitative study

BACKGROUND

The majority of patients with ankylosing spondylitis (AS) are male, although potential gender differences have not been investigated in relation to disease management. Moreover, men's perceptions of experiencing AS have not been reported in the literature.

AIMS

This study sought to develop an understanding of how men experience AS and the challenges related to living with AS as a chronic disease.

METHODS

A purposive sample of 13 men diagnosed with AS, with a median age of 44 years (range 32-58) was recruited from a rheumatology outpatient clinic. The median duration of disease was 12 years (range 0.3-28 years), and the median time from the first symptom to final diagnosis was seven years (range 2-20 years). Semi-structured interviews were conducted using an interview guide, and the interviews were analysed using content analysis inspired by Graneheim qualitative methodology.

RESULTS

The analysis revealed four categories: (1) 'Approaching a diagnosis'; (2) 'Ill in a social context'; (3) 'Challenged as a man'; and (4) 'The importance of remaining physically well'. Based on these categories, the overall category of 'An invisible companion for life' emerged, which captures the experience of living with an invisible, life-long disease.

CONCLUSIONS

These findings demonstrate that AS impacts men's perceptions of themselves as men, relationships as a partner and father, social lives, and masculine identity. Physical activity was highlighted as an important part of being a man, and not being able to exercise challenged the men's masculine identity.

Emotions related to participation restrictions as experienced by patients with early rheumatoid arthritis: a qualitative interview study (the Swedish TIRA project)

Psychological distress is a well-known complication in rheumatoid arthritis (RA), but knowledge regarding emotions and their relationship to participation restrictions is scarce. The objective of the study was to explore emotions related to participation restrictions by patients with early RA. In this study, 48 patients with early RA, aged 20-63 years, were interviewed about participation restrictions using the critical incident technique. Information from transcribed interviews was converted into dilemmas and linked to International Classification of Functioning, Disability, and Health (ICF) participation codes. The emotions described were condensed and categorized. Hopelessness and sadness were described when trying to perform daily activities such as getting up in the mornings and getting dressed, or not being able to perform duties at work. Sadness was experienced in relation to not being able to continue leisure activities or care for children. Examples of fear descriptions were found in relation to deteriorating health and fumble fear, which made the individual withdraw from activities as a result of mistrusting the body. Anger and irritation were described in relation to domestic and employed work but also in social relations where the individual felt unable to continue valued activities. Shame or embarrassment was described when participation restrictions became visible in public. Feelings of grief, aggressiveness, fear, and shame are emotions closely related to participation restrictions in everyday life in early RA. Emotions related to disability need to be addressed both in clinical settings in order to optimize rehabilitative multi-professional interventions and in research to achieve further knowledge.

Health determining concepts important to people with Crohn's disease and their coverage by patient-reported outcomes of health and wellbeing

BACKGROUND AND AIMS

Busy clinical settings often restrict the possibility to focus on concepts that determine health in a positive way, commonly assessed by using patient-reported outcomes (PROs). We aimed to explore which determinants of health (DHs) are important to people with Crohn's disease (CD), to understand possible gender differences and to analyze whether these DHs are covered by PROs used in CD.

METHODS

Two systematic literature reviews were done to identify relevant DHs and clinically relevant PROs. We conducted a qualitative narrative biographical study and mapped the patients' experiences to concepts that determine health in a positive way. Experiences, DHs and the items of the PROs were compared by the WHO International Classification of Functioning, Disability and Health (ICF) as a common framework.

RESULTS

15 people with CD with a median age of 46 years (IQR 34-60) and median disease duration of 15 years (IQR 8-30) participated. Self-efficacy, social support, job satisfaction and occupational balance were mentioned most frequently. While participation appeared to have greater meaning to men, appreciation and resilience seemed to be more important for women. Of 18 PROs the Perceived Stress Questionnaire (PSQ), the Inflammatory Bowel disease - Self-efficacy scale (IBD-SES), the Life Orientation Test - Revised (LOT-R) and the Patient Activation Measure 13 (PAM-13) cover most DHs.

CONCLUSIONS

This is the first study elaborating the coverage of patient's perspective by commonly used PROs in CD. The findings could support health professionals to focus on DHs in people with CD in clinical practice and research.