Psychological and educational interventions to reduce arthritis disability

Cross-culture adaptation and validation of English version of Rheumatoid Arthritis Knowledge Assessment Scale (RAKAS) in patients with rheumatoid arthritis

AIM

To carry out cross-culture adaptation and validation of the English version of Rheumatoid Arthritis Knowledge Assessment Scale (RAKAS) in patients with rheumatoid arthritis (RA).

METHODS

A cross-sectional study was conducted for 2 months in 2 tertiary care hospitals in Karachi, Pakistan. Sample size was calculated based on item-subject ratio. The translation was carried out using standard procedures for translation and cross-culture adaptation. The validation process included estimation of discrimination power, item difficulty index, factorial, convergent, construct and known group validities and reliability. Reliability of the scale was estimated using Kuder-Richardson Formula 20 and a value of σ²  ≥ 0.6 was acceptable. SPSS v23, Remark Classic OMR v6 software and MedCalc Statistical Software v16.4.3, were used to analyze the data. The study was approved by the relevant ethics committee (IRB#NOV:15).

RESULTS

The mean score was 7.68 ± 2.52 (95% CI: 7.31-8.05) for 177 patients. The σ²  = 0.601, that is, >0.6, test-retest reliability ρ = .753, P < .05. The average discrimination power = 47.27, average Item Difficulty Index = 0.557. The fit indices were acceptable in a range that established its factorial validity and average factor loading was ≥0.7 which established convergent validity. A significant association (χ²  = 33.074, P < .01) between score interpretation and previous counseling by pharmacists established its construct validity. A significant association (χ²  = 19.113, P < .05) between score interpretation and patient occupation established known group validity.

CONCLUSION

The English version of RAKAS was deemed a reliable and validated tool to measure knowledge about disease in Pakistani patients with RA.

Development and validation of a novel rheumatoid arthritis knowledge assessment scale in Pakistani patients with rheumatoid arthritis

AIM

Rheumatoid arthritis (RA) is a chronic progressive disabling disease that mainly affects joints. Studies documenting Pakistani patients' knowledge regarding RA disease are lacking and there is a need for such endeavor. The purpose of this study was to develop and validate a novel research tool to document patient knowledge about RA disease.

METHODS

A novel research instrument known as the rheumatoid arthritis knowledge assessment scale (RAKAS) which consisted of 13 items, was formulated by a rheumatology panel and used for this study. This study was conducted in rheumatology clinics of three tertiary care hospitals in Karachi, Pakistan. The study was conducted in March-April 2018. Patients were recruited using a randomized computer-generated list of appointments. Sample size was calculated based on item-to-respondent ratio of 1:15. The validities, factor structure, sensitivity, reliability and internal consistency of RAKAS were assessed. The study was approved by the institutional Ethics Committee.

RESULTS

A total of 263 patients responded to the study. Content validity was 0.93 and response rate was 89.6%. Factor analysis revealed a 3-factor structure. Fit indices, namely normed fit index (NFI), Tucker Lewis index (TLI), comparative fit index (CFI) and root mean square of error approximation (RMSEA) were calculated with satisfactory results, that is, NFI, TLI and CFI > 0.9, and RMSEA < 0.06. Internal consistency (α) was 0.62, that is, acceptable. All items had a high discrimination index, that is, >19 and difficulty index <0.95. Sensitivity and specificity of RAKAS were above 90%. The tool established construct and known group validities.

CONCLUSION

A novel tool to document disease knowledge in patients with RA was formulated and validated.

Health-related quality of life in systemic lupus erythematosus: a longitudinal study on the impact of problematic support and self-efficacy

Objectives: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which can affect any organ in the body, reducing patients' health-related quality of life (HR-QOL). Psychosocial research on SLE is quite recent and is mostly based on qualitative and cross-sectional evidence. Some studies suggest that a protective role is played by perceived self-efficacy in the management of the disease, while a detrimental role is played by problematic social interactions. Methods: In a longitudinal study, we tested the independent contribution of self-efficacy and problematic social support, in predicting patients' HR-QOL after 11 months. An online questionnaire was completed by 162 participants with SLE, the second questionnaire after 11 months. Results: Controlling for corticosteroids and hydroxychloroquine use, self-efficacy in the management of the disease at Time 1 showed a significant and positive effect on HR-QOL at Time 2, while problematic social support (denying/uninformed) showed a negative effect. Conclusions: HR-QOL of SLE patients is influenced by self-efficacy in the management of the disease and problematic support. Specific attention should be paid to the quality of patients' social relationships and their perceived efficacy in the management of the disease in focused interventions as in daily clinical practice.

Coping self-efficacy as a mediator between catastrophizing and physical functioning: treatment target selection in an osteoarthritis sample

The purpose of this study was to assess the relative effects of coping self-efficacy and catastrophizing on physical functioning. Over a 9-month period, studying changes in self-efficacy as possible mediator between catastrophizing changes and physical functioning changes might provide evidence for the most promising treatment target. Data came from a randomized, longitudinal controlled trial comparing exercise, self-management and the two combined to treat 254 individuals with early knee osteoarthritis. A secondary analysis using a bootstrapped linear mixed-effects mediational model produced estimates of both the direct and indirect effects. Results indicated that self-efficacy partially mediated the effect between catastrophizing and physical functioning suggesting that self-efficacy was the more direct treatment target compared to catastrophizing. Treatments targeting both self-efficacy and catastrophizing may have greater impact on physical functioning compared to treatments that focus on only one.

Expectations of recovery from revision knee replacement

OBJECTIVE

To evaluate outcome expectations of patients undergoing revision total knee replacement (TKR) and to examine personal factors, patient functioning, previous experiences with knee replacement surgery, concerns about surgery, and general health as predictors of expectations.

METHODS

Revision TKR patients (n = 184, 54% women; mean age 69 years) completed a questionnaire up to 2 weeks before surgery. This included demographics, experience with previous knee surgery, concerns about surgery, the Life Orientation Test (LOT), the Arthritis Helplessness Scale, the Western Ontario and McMaster Universities Osteoarthritis Index, and a rating of overall health. Outcome expectations were evaluated as 5 questions assessing global benefit; relief of pain; ease of disability; expectations of having complications; and whether the person expected to be fully recovered from surgery in <6 months, 6-12 months, >12 months, or did not expect to recover. Predictors of each of the 5 outcome expectations were evaluated using univariable and multivariable regression analyses.

RESULTS

Expectations are a multidimensional construct (Cronbach's alpha = 0.63). Expectation of global benefit of surgery was high, but was lower for benefits related to ease of pain and improved function. Concerns about surgery were a consistent predictor of all expectation outcomes in multivariable modeling. When concerns about surgery and general health were entered into the model as an interaction with expectation of recovery time as the outcome, past experience (P = 0.05), pain (P = 0.03), LOT (P = 0.03), and interaction between concerns about surgery and general health were significant predictors.

CONCLUSION

Clinicians need to understand and help patients shape appropriate expectations for recovery from revision TKR.

A randomized clinical trial of a psychoeducational intervention to improve outcomes in systemic lupus erythematosus

OBJECTIVE

In a cross-sectional study, we previously identified 2 potentially modifiable risk factors for adverse outcomes in systemic lupus erythematosus (SLE): self-efficacy and social support. The goal of this study was to evaluate in a randomized controlled trial a theory-based intervention to improve patient self-efficacy and partner support to manage SLE.

METHODS

Patients with SLE ages 18 years and older who met the American College of Rheumatology criteria and were able to identify a partner (spouse or family member) were recruited from 2 academic medical centers and randomized into an experimental group or a control group. Patients in the experimental group and their partners received an intervention designed to enhance self-efficacy, couples communication about lupus, social support, and problem solving, in the form of a 1-hour session with a nurse educator followed by monthly telephone counseling for 6 months. Patients in the control group and their partners received an attention placebo, including a 45-minute video presentation about lupus, and monthly telephone calls. Measures of physical and mental health status, disease activity, and psychosocial factors were collected at baseline, 6 months, and 12 months. The effect of the intervention on physical and mental health and disease activity at 6 and at 12 months was modeled with linear regression and adjusted for baseline health status, disease activity, sociodemographic factors, treatment change, and psychosocial factors.

RESULTS

One hundred twenty-two patients (plus their partners) were enrolled and randomized as follows: 64 to the experimental intervention and 58 to the attention control group. The participants were predominantly white, approximately half were college educated, and the groups were balanced for sociodemographic factors. At 6 months, significantly higher scores for couples communication (P = 0.01) and problem-focused coping (P = 0.03) were seen in the experimental group compared with the control group. At 12 months (6 months after the intervention ended), social support was higher (4.4 versus 4.1; P = 0.03), self-efficacy was higher (7.2 versus 6.2; P = 0.02), couples communication was higher (3.5 versus 3.1; P = 0.03), and fatigue was lower (5.1 versus 6.3; P = 0.02) in the experimental group compared with the control group. Global mental health status at 12 months, as measured by the Short Form 36 survey, was 69 points in the experimental group compared with 58 points in the control group (P = 0.04). In multivariate models, adjusting for baseline covariates, scores for couple communication (P = 0.01) were significantly higher at 6 months, and scores for self-efficacy (P = 0.004) and global mental health status (P = 0.03) were significantly higher at 12 months in the experimental group compared with the control group, and the mean score for global physical function was higher by 7 points, which was a clinically meaningful change (P = 0.2). The mean score for fatigue was also significantly lower in the experimental group than in the control group (P = 0.05). SLE disease activity was unchanged by this intervention.

CONCLUSION

This randomized, controlled trial of a theory-based educational intervention in SLE demonstrated significantly higher scores for couple communication, self-efficacy, and mental health status, and lower fatigue scores in the experimental group compared with the control group. Because couple communication and self-efficacy appear to be modifiable risk factors, they may also be potential targets in more disadvantaged populations.

The Impact of Disease Activity on the Quality of Life, Mental Health Status, and Family Dysfunction in Colombian Patients With Rheumatoid Arthritis

This study investigated the relationship between activity of disease, mental health status, quality of life, and family dysfunction in northwestern Colombian patients with rheumatoid arthritis (RA). Seventy-nine patients completed a 2-phase study that included physical examination (objective measurement of disease activity according to adapted American College of Rheumatology criteria) and a pretested questionnaire that sought information on helplessness, disability, depression, anxiety, quality of life, arthritis self-efficacy for pain, and other symptoms, as well as family dysfunction and socioeconomic status. Nineteen patients (24%) had active RA, 48 (61%) had moderately active RA, and 12 (15%) were in remission. Symptoms of depression, helplessness, disability, pain, anxiety, lower quality of life, and self-efficacy were associated with RA activity regardless of age, sex, and duration of the disease. Symptoms of depression were directly correlated with anxiety, helplessness, pain, and disability and inversely correlated with quality of life and self-efficacy. Although family dysfunction was present in 39% of patients, no associations between family dysfunction, activity of RA, mental health variables, socioeconomical status or quality of life were observed. These results indicate that RA activity significantly influences mental health status and quality of life in this population. Accordingly, a holistic conception of therapy should guide the treatment of patients with RA.

Stimulating active coping in patients with rheumatic diseases: a systematic review of controlled group intervention studies

Teaching patients with rheumatic diseases to cope actively with their problems may increase the social support they receive and, also, the quality of their lives. In this paper, a systematic review of coping interventions for people with rheumatic diseases is described. Fourteen controlled trials were selected. Effects on quality of life have been measured in 13 studies of which 6 found positive effects. Effects on social support have been found in one of four studies investigating this variable. Coping has been measured in three studies with effects found on active coping in one study. There is a need for well-designed research on the effects of active coping in people with rheumatic diseases, as this may open new perspectives in patient education.

Use of cognitive-behavioural arthritis education programmes in newly diagnosed rheumatoid arthritis

OBJECTIVE

To identify the effect of attending a cognitive-behavioural arthritis education programme on the health status of participants with newly diagnosed rheumatoid arthritis (RA) compared with a control group.

DESIGN

Randomized controlled trial.

SETTING

Hospital based.

SUBJECTS

Newly diagnosed with RA.

INTERVENTION

Participation in either a cognitive-behavioural arthritis education programme or a standard arthritis education programme (control group). Sessions for both groups lasted for 2 hours per week for four weeks. Subjects were examined at home by an assessor blinded to group allocation, prior to and three and six months following attendance.

OUTCOME MEASURES

The main outcome measure was the Physical Function subscale of the Arthritis Impact Measurement Scale Two. Other outcome measures included erythrocyte sedimentation rate (ESR), joint count scores, assessments of pain and psychological status.

RESULTS

Fifty-four subjects (mean time since diagnosis 4.5 months) took part. Baseline analysis revealed that the control group had significantly better levels of functional ability (U = 185; p = 0.009) and lower levels of helplessness (U = 168; p = 0.002) prior to intervention. This difference remained unchanged three months later. Six months following the intervention no significant differences were noted between the groups for any measure of health status. There were no significant changes in health status over time in either group.

CONCLUSION

Attending a cognitive-behavioural arthritis education programme had no significant effect on the health status of individuals newly diagnosed with RA. The move to early use of these programmes should be examined further, with a larger sample size and longer duration of follow-up.

Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial

Recent developments in chronic pain research suggest that effectiveness of cognitive-behavioral therapy (CBT) may be optimized when applying early, customized treatments to patients at risk. For this purpose, a randomized, controlled trial with tailor-made treatment modules was conducted among patients with relatively early rheumatoid arthritis (RA disease duration of <8 years), who had been screened for psychosocial risk profiles. All participants received standard medical care from a rheumatologist and rheumatology nurse consultant. Patients in the CBT condition additionally received an individual CBT treatment with two out of four possible treatment modules. Choice of treatment modules was determined on the basis of patient priorities, which resulted in most frequent application of the fatigue module, followed by the negative mood, social relationships and pain and functional disability modules. Analyses of completers and of intention-to-treat revealed beneficial effects of CBT on physical, psychological and social functioning. Specifically, fatigue and depression were significantly reduced at post-treatment and at the 6-month follow-up in the CBT condition in comparison to the control condition, while perceived support increased at follow-up assessment. In addition, helplessness decreased at post-treatment and follow-up assessment, active coping with stress increased at post-treatment, and compliance with medication increased at follow-up assessment in the CBT condition in comparison to the control condition. Results indicate the effectiveness of tailor-made CBT for patients at risk in relatively early RA, and supply preliminary support for the idea that customizing treatments to patient characteristics may be a way to optimize CBT effectiveness in RA patients.

Patient education for adults with rheumatoid arthritis

BACKGROUND

Because of the unpredictability people with arthritis face on a daily basis, patient education programmes have become an effective complement to traditional medical treatment giving people with arthritis the strategies and the tools necessary to make daily decisions to cope with the disease.

OBJECTIVES

To assess the effectiveness of patient education interventions on health status in patients with rheumatoid arthritis.

SEARCH STRATEGY

We searched MEDLINE, EMBASE and PsycINFO and the Cochrane Controlled Trials Register. A selection of review articles (see references) were examined to identify further relevant publications. There was no language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCT's) evaluating patient education interventions that included an instructional component and a non-intervention control group; pre- and post-test results available separately for RA, either in the publication or from the studies' authors; and study results presented in full, end-of-study report.

MAIN RESULTS

Twenty-four studies with relevant data were included. We found significant effects of patient education at first follow-up for scores on disability, joint counts, patient global assessment and psychological status. Physician global assessment was not assessed in any of the included studies. The two separate dimensions of psychological status: anxiety and depression showed no significant effects, nor did the dimensions of pain and disease activity. At final follow up no significant effects of patient education were found.

REVIEWER'S CONCLUSIONS

Patient education as provided in the studies reviewed here had moderate short-term effects on patient global assessment, and small short-term effects on disability, joint counts and psychological status. There were no long-term benefits.

The psychology of rheumatic diseases

Most chronic rheumatological disorders require major psychological adaptation, and levels of psychological distress among those with rheumatological disease have been found to be higher than in the general population. Research suggests that the relationship between disease severity, disablement and psychological well-being is not simple. This chapter highlights the complex nature of this relationship and will indicate, in particular, how psychological factors can impact on patients' perceptions of their symptoms and physical functioning. Psychological concepts that may mediate between the disease and its consequences are also discussed. A range of psychosocial interventions have been developed for individuals with rheumatological disorders. Most have related to rheumatoid arthritis, and although their primary focus has usually been on alleviating pain and improving physical functioning, this chapter examines their impact on psychological well-being. It also discusses a number of methodological issues that need to be addressed in this area of work.

An evaluation of a psychotherapeutic group intervention for persons having difficulty coping with musculoskeletal disorders

This study evaluated an 8-9 week psychotherapeutic group program designed to help people cope with the difficulties and changes that arise when living with musculoskeletal (MSK) disorders. Also examined were individual differences in client expectations about the benefits of the groups. Participants were 64 community-dwelling adults who completed questionnaires at the beginning, end, and three months after their final group session. Outcomes were mastery, coping efficacy, helplessness, self-acceptance and depression. Significant changes from pre- to post-intervention were found in mastery, depression, and coping-efficacy with effect sizes of .50 or greater. Individuals who had concerns or reservations about participating in the groups gained from the intervention in the same ways as others who were more positive at the outset of the groups.

Risk factors for early work disability in systemic lupus erythematosus: results from a multicenter study

OBJECTIVE

To study the risk factors for early work disability in systemic lupus erythematosus (SLE).

METHODS

A sample of 159 SLE patients who had been employed at some time since diagnosis was drawn from a multicenter study of outcome in SLE. Disease activity, organ damage, education, income, source of health insurance, and work-related factors were measured in a standardized interview. Work disability was defined by patient self-report of not working because of SLE. The outcome measure was current work status. Seven patients were excluded from the analysis because their choice not to work was unrelated to SLE.

RESULTS

An average of 3.4 years after diagnosis, 40% had quit work completely, and job modification was substantial. Univariate analysis (chi-square and t-test) showed that significant predictors of early work disability included having a high school education or less, receiving Medicaid or having no health insurance, having a job which required more physical strength, having an income below poverty level, and having greater disease activity at diagnosis. In multivariate models, significant predictors were education level (P = 0.0004), higher physical demands of the job (P = 0.0028), and higher disease activity at diagnosis (P = 0.0078). Race, sex, cumulative organ damage at diagnosis, and disease duration were not significant.

CONCLUSION

Early work disability in SLE is strongly associated with some sociodemographic factors that might be amenable to intervention.

Coordinated individual education with an arthritis passport for patients with rheumatoid arthritis

OBJECTIVE

To evaluate the effects of a program for individual education in combination with the use of an arthritis passport.

METHODS

We studied 3 groups of patients with rheumatoid arthritis. The first experimental group received educational materials and followed the program under the guidance of their regular providers of health care whose activities were coordinated through arthritis passports. The second experimental group only received education materials; the control group received only usual care.

RESULTS

There were no effects on self-efficacy expectations, knowledge, health status, or behavior in either experimental group. Opinions of general practitioners, physiotherapists, and visiting nurses concerning the arthritis passport were very positive, but rheumatologists' opinions were not. Opinions on coordination of care were more positive among the physiotherapists of the experimental group.

CONCLUSIONS

Individual education for patients with rheumatoid arthritis by health care providers during routine consultations, as implemented in this program, had no effect on self-efficacy expectations, knowledge, health status, or health behavior. Likewise, the distribution of educational materials by itself without the involvement of health care providers had no effect. The use of the arthritis passport improved coordination of care, especially for physiotherapists.

A practical guide to patient education and information giving

Patient education is accepted as an essential component in the management of rheumatoid arthritis (RA) and this chapter provides an overview of patient education for practising clinicians. It includes an explanation of the need for patient education including the results of studies into what patients already know. The effectiveness of patient education and its benefits to patients are discussed in the light of recent research, reviews and meta-analyses. Alternative methods of delivering patient education are compared including, one-to-one teaching, opportunity education, group teaching and self-management programmes. Topics for inclusion in education programmes are suggested and the merits of written literature, audio-visual and computer assisted learning are explained. Practical guidance is given on methods of ensuring that written information is readily understandable by patients, including the use of readability formulae.

An instrument for reviewing the effectiveness of health education and health promotion

It has been difficult to make a balanced appraisal of the effectiveness of an intervention in the area of health education/health promotion. This is mainly due to the different methods used for analyzing the effect studies. Therefore, the Netherlands Institute for Health Promotion and Disease Prevention, in cooperation with TNO Prevention and Health, has developed a review instrument which enables a standardized analysis of health education/health promotion effect studies to be conducted. The review instrument distinguishes eight themes, which are subdivided into total of 39 multiple-choice questions. Answering these questions yields insight not only into the methodological quality and the effect of a certain intervention, but also into the process by which this effect was achieved. During the development stages of the instrument many experts were consulted. It became clear that the instrument is a useful and manageable instrument for conducting reviews. Based on the information in these reviews we get more detailed insight into the effectiveness of health education/health promotion and into how it can be further improved.

The arthritis knowledge questionnaire. A test for measuring patient knowledge of arthritis and its self-management

OBJECTIVE

To develop a questionnaire for measuring patients' knowledge about arthritis and its self-management.

METHODS

An initial item pool of 175 multiple-choice questions was developed, based on the Stanford Arthritis Self-Management Program and on basic medical knowledge about arthritis and its management. A rheumatologist, psychologist, physiotherapist, and several lay individuals assessed the questions for content validity, breadth of coverage, and face validity. Patients assessed the questions for comprehensibility. Four subject groups with varying knowledge levels were recruited to answer the entire set of questions. Item analysis was undertaken to develop parallel forms of subtests so that repeated assessments could be undertaken.

RESULTS

The final instrument, the Arthritis Knowledge Questionnaire, consists of 2 tests, each comprising 3 subtests: self-management (15 items), arthritis in general (15 items), and rheumatoid arthritis (11 items).

CONCLUSION

We present psychometric evidence that these parallel forms provide highly reliable and valid estimates of knowledge concerning arthritis and arthritis self-management.