Social interactions at the onset of rheumatoid arthritis and their influence on help-seeking behaviour: A qualitative exploration

It Is Like a Puppet Show-Experiences of Rheumatoid Arthritis Among Adult Chinese: A Qualitative Study

Rheumatoid arthritis results in progressive destruction of the joints. However, descriptions of patient's experiences with the disease are limited. This qualitative study aimed to explore patients' personal experiences with rheumatoid arthritis in Taiwan. Face-to-face interviews were conducted with 30 patients from January to May 2019; interview data were analyzed with content analysis. Most participants were female (90%); their mean age was 57 years. Three main categories emerged from analysis of the data: "physical suffering," "limitations of abilities," and "coexisting with the disease." Physical suffering was due to personal lifelong hardships from chronic pain and stiffness. Limitations of abilities occurred from loss of physical function and limited social life, due to participants discomfort with joint deformities and their appearance to others. Participants coexisted with the disease by making changes in their outlook and comparing their lives with others in order to gain a positive perspective.

'Lost time'. Patients with early inflammatory/rheumatoid arthritis and their experiences of delays in Primary Care

BACKGROUND

Early referral forms a crucial part in early inflammatory/rheumatoid arthritis (EI/RA) recovery. Delayed decisions to refer can lead to severe incapacity and emotional distress for individuals and family and feelings of lost time. How patients with EI/RA experience early referral decisions in Primary Care is an under explored area and warrants further investigation.

AIM

To explore how patients newly diagnosed with EI/RA experienced their early contacts with Primary Care as they negotiated their journey through the referral process into secondary care.

DESIGN AND SETTING

Qualitative face-to-face interviews with newly diagnosed EI/RA patients.

METHODS

In-depth semi-structured interviews were conducted to explore patients' experiences of referral from first symptoms to General Practitioner referral. All participants were interviewed within 2 weeks of being diagnosed in Secondary Care. Data analysis was conducted using interpretative phenomenological analysis.

FINDINGS

All participants in this study described having experienced struggles with their navigation through Primary Care towards diagnosis and specialist EI/RA services. This struggle comprised five key elements: 'family persuasion', 'lack of continuity in care', 'pushing for referral', 'strained relations' and 'lost time'.

CONCLUSION

The delays experienced by patients when attempting to reach an early referral decision in Primary Care cause frustration for those presenting with EI/RA, partly because they do not feel heard. There is a significant impact on patients and their families when referral to specialist care is delayed.

What Factors Influence Symptom Reporting and Access to Healthcare During an Emerging Infectious Disease Outbreak? A Rapid Review of the Evidence

During any emerging infectious disease outbreak, people with symptoms of the illness are asked to report to a health service immediately to facilitate contact tracing. Several factors may influence a person's willingness to report symptoms and their ability to access healthcare services. Understanding these factors has become urgent during the COVID-19 pandemic. To determine which factors influence symptom reporting during an emerging infectious disease outbreak, we conducted a rapid review of the evidence. Studies included in the review were based on primary research, published in a peer-reviewed journal, written in English, included factors associated with symptom reporting or accessing healthcare, and were related to a major public health incident involving an infectious disease outbreak. Five themes were identified as facilitators of symptom reporting or accessing healthcare: accurate and informative communication about the disease and the need to seek help, symptom severity, concern about disease exposure, ease of access to healthcare facilities, and relationship with the healthcare provider. Seven themes were identified as barriers to symptom reporting or accessing healthcare: lack of knowledge of the disease and its treatment, fear of the disease and fear of subsequent treatments or requirements, stigmatization attached to having a disease, invasion of privacy, low concern about symptoms, economic consequences of disease diagnosis, and challenges related to attending a healthcare facility. For contract tracing services to be effective, members of the public need to have the capability, opportunity, and motivation to use them. The themes identified should be used to evaluate information provided to the public to ensure as many people as possible with relevant symptoms report them to a healthcare provider.

"To be lonely in your own loneliness": The interplay between self-perceived loneliness and rheumatoid arthritis in everyday life: A qualitative study

OBJECTIVE

Loneliness has a negative impact on physical health, and rheumatoid arthritis symptoms can lead to social isolation. However, there is a lack of research exploring patients' perspectives on self-perceived loneliness in everyday life with rheumatoid arthritis. The purpose of this study was to gain insight into the meaning and importance of self-perceived loneliness among adult patients diagnosed with rheumatoid arthritis.

METHODS

This study was designed as a qualitative, exploratory interview study using a narrative framework. Semi-structured interviews were conducted with Danish adults with rheumatoid arthritis. All interviews were recorded, transcribed verbatim, and analyzed within a narrative thematic framework.

RESULTS

Ten women and seven men were interviewed, aged between 18 and 73 years and a disease duration between 6 months and 40 years. Three themes were identified during the analysis: (1) explanations of loneliness in everyday life with rheumatoid arthritis, (2) disclosing or disguising loneliness, and (3) feelings of loneliness in social life.

CONCLUSION

The findings from this study show that loneliness can be burdensome when living with RA. Narratives of loneliness can be hard for patients to disclose, so health care practitioners should take responsibility for legitimizing this subject. A narrative approach in consultations may be helpful to support patients and to encourage a dialogue about loneliness in everyday life with rheumatoid arthritis.

Delay in seeking medical help in patients with rheumatoid arthritis in India: A qualitative study

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disease with varied articular and extra-articular manifestations. In developing countries such as India patients with RA often delay seeking medical advice which may impact prognosis and disease burden.

AIM

To explore perceptions and experiences of patients living in India in seeking medical help for their RA symptoms.

METHODS

Clinician-diagnosed RA participants from different socioeconomic backgrounds were interviewed using a semi-structured topic guide. Participants were purposively selected and interviewed following an iterative approach. All interviews were recorded and transcribed by an independent company and analyzed using a thematic framework. Findings were reported in accordance with consolidated criteria for reporting qualitative research guidelines.

RESULTS

Twenty participants (13 male, 7 female) with median age 40 years (35.7-46.5) were recruited. Three overarching themes demonstrating participants' experiences and reasons for delay in seeking medical help were identified. (1) "Symptoms perspectives and delay in participants' journey" narrated participants' experiences of having RA symptoms, how these were perceived, rationalized and led to delay. (2) "Participants' experience of the healthcare system" illustrated delay in referral, reaching diagnosis and treatment initiation highlighting their experiences with the health system. (3) "Recommendations for improving care" where participants made recommendations for reducing the delay at local and national levels.

CONCLUSION

This is the first qualitative study which explored perceptions and experiences of RA patients in India resulting in delay. Improved provision of rheumatology care, effective referral system and greater involvement of government at local and national levels are needed to improve the delay in seeking medical help for Indian patients.

Development and formative evaluation of patient research partner involvement in a multi-disciplinary European translational research project

PLAIN ENGLISH SUMMARY

Patient and public involvement (PPI) improves the quality of health research and ensures that research is relevant to patients' needs. Though PPI is increasingly evident in clinical and health services research, there are few examples in the research literature of effective PPI in translational and laboratory-based research. In this paper, we describe the development and evaluation of PPI in a multi-centre European project (EuroTEAM - Towards Early biomarkers in Arthritis Management) that included both translational and laboratory-based and psychosocial research. We found that although most PPI in EuroTEAM was centred around the psychosocial research, there were examples of PPI in the laboratory studies. As the project evolved, researchers became better at accommodating PPI and identifying PPI opportunities. It was generally agreed that PPI had a positive impact on the project overall, particularly on public engagement with the research. We concluded that the inclusion of both psychosocial and laboratory-based research in the same project facilitated PPI across all aspects of the research. In future projects, we would try to specify individual PPI activities in more detail at the project-planning stage, and better accommodate patient partners who are not native speakers of English.

ABSTRACT

Background Patient and public involvement (PPI) enhances research quality and relevance and is central to contemporary health policy. The value of PPI has been recognised in rheumatology research, though there are limited examples of PPI in basic and translational science. The EU FP7 funded 'EuroTEAM' (Towards Early biomarkers in Arthritis Management) project was established to develop biomarker-based approaches to predict the future development of rheumatoid arthritis and incorporated psychosocial research to investigate the perceptions of 'at risk' individuals about predictive testing, and to develop informational resources about rheumatoid arthritis (RA) risk. Patient involvement was central to EuroTEAM from the inception of the project. The objective of this paper is to describe the development of PPI in EuroTEAM, formatively assess the impact of PPI from the perspectives of researchers and patient research partners (PRPs), reflect on successes and lessons learned, and formulate recommendations to guide future projects.Methods Two mixed-methods surveys (for PRPs and researchers) and a teleconference were undertaken to assess the impact of PPI on individual work packages and on EuroTEAM overall.Results There was consensus about the positive impact of PPI on the research and on the experiences of those involved. In particular, the positive impact of PPI on the personal development of researchers, and on effective public engagement with EuroTEAM research were highlighted. Researchers described adapting their practice in future projects to facilitate PPI. Spin-off projects and ongoing collaborations between PRPs and researchers reflected the value of PPI to participants. PPI was more frequently integrated in psychosocial research, though examples of PPI in laboratory/translational science were also described. PRPs asked for more opportunities to contribute meaningfully to basic scientific research and for more extensive feedback on their contributions.Conclusions The findings were used to formulate recommendations to guide effective involvement of patients in future similar projects, including identifying specific training requirements for PRPs and researchers, the identification of PRP focused tasks/deliverables at the project planning stage, and supporting access to involvement for all PRPs. Importantly, the distinctive multidisciplinary approach of EuroTEAM, incorporating both basic science and psychosocial research, facilitated patient involvement in the project overall.

The perspective of patients with early rheumatoid arthritis on the journey from symptom onset until referral to a rheumatologist

Objective

Timely treatment of patients with early RA (ERA) favours a beneficial disease outcome. However, individuals often delay their contact with a health-care professional (HCP) after ERA-related symptom onset. The aim of this study was to investigate the perspective of patients on the journey of a patient from RA symptom onset until referral to a specialist.

Methods

A subgroup of patients with ERA from the Care in ERA (CareRA) trial were interviewed retrospectively to discuss their initial ERA-related experiences preceding diagnosis, using a bespoke assessment form. The first section of the form focused on initial symptoms and help-seeking behaviour by the patients. The second part probed the actions of the HCPs consulted. Additional notes derived from the patient stories were analysed thematically.

Results

Among 94 patients, pain (97%), swelling (73%) and stiffness (52%), typically in multiple joints, were reported as initial ERA symptoms. The general practitioner (GP) was generally the first HCP to be contacted (87%). Frequently reported reasons to visit an HCP were intense pain (90.4%) and difficulties in performing daily activities (69%). In 44.1% of patients, the HCP suspected ERA at the first visit. Approximately 25% of patients needed more than five visits before detection of ERA. GPs mainly referred patients to rheumatologists (71%). Thematic analysis uncovered that multiple HCPs were often involved in the journey to RA detection and referral.

Conclusion

Pain is the most commonly reported initial symptom of ERA and the main reason to visit an HCP, usually a GP. These GPs play a pivotal role in early detection and correct referral. Furthermore, the journey of a patient seems complex, often with multiple HCPs being involved.

Delays between the onset of symptoms and first rheumatology consultation in patients with rheumatoid arthritis in the UK: an observational study

OBJECTIVE

To investigate delays from symptom onset to rheumatology assessment for patients with a new onset of rheumatoid arthritis (RA) or unclassified arthritis.

METHODS

Newly presenting adults with either RA or unclassified arthritis were recruited from rheumatology clinics. Data on the length of time between symptom onset and first seeing a GP (patient delay), between first seeing a general practitioner (GP) and being referred to a rheumatologist (general practitioner delay) and being seen by a rheumatologist following referral (hospital delay) were captured.

RESULTS

822 patients participated (563 female, mean age 55 years). The median time between symptom onset and seeing a rheumatologist was 27.2 weeks (IQR 14.1-66 weeks); only 20% of patients were seen within the first 3 months following symptom onset. The median patient delay was 5.4 weeks (IQR 1.4-26.3 weeks). Patients who purchased over-the-counter medications or used ice/heat packs took longer to seek help than those who did not. In addition, those with a palindromic or an insidious symptom onset delayed for longer than those with a non-palindromic or acute onset. The median general practitioner delay was 6.9 weeks (IQR 2.3-20.3 weeks). Patients made a mean of 4 GP visits before being referred. The median hospital delay was 4.7 weeks (IQR 2.9-7.5 weeks).

CONCLUSION

This study identified delays at all levels in the pathway towards assessment by a rheumatologist. However, delays in primary care were particularly long. Patient delay was driven by the nature of symptom onset. Complex multi-faceted interventions to promote rapid help seeking and to facilitate prompt onward referral from primary care should be developed.

Significant others' influence on participation in everyday life - the perspectives of persons with early diagnosed rheumatoid arthritis

Purpose: To describe the meaning of significant others in relation to participation in everyday life of persons with early diagnosed rheumatoid arthritis (RA).Materials and methods: Fifty-nine persons participated in this interview study. Inclusion criteria were three years' experience of diagnosis and being of working age. Semi-structured interviews were conducted using critical incident technique (CIT), and the material was analysed using content analysis.Results: Four categories were revealed: (1) My early RA causes activity adaptations for us all, referring to the person and significant others modifying activities. (2) Making the significant others balance between shortfalls and participation, where the participants distinguished between needing help and feeling involved in activities. (3) Physical interactions with significant others, referring to both the problematic and manageable impact RA could have on body contact. (4) Emotions in relation to activities with others, where participants described feelings of failing others, and anxiety about future activities.Conclusions: For persons with early diagnosed RA, significant others can be both hindering and facilitating for participation in everyday life. As a clinical implication, it is valuable to identify how significant others can be involved in the rehabilitation process, to enhance participation in everyday life early in the disease process.Implications for rehabilitationSignificant others of persons with rheumatoid arthritis can facilitate as well as hinder participation in everyday life, even early in the disease process.It is important to include the significant others in the rehabilitation process of persons with early diagnosed rheumatoid arthritis.It is of great importance to identify when and how significant others can be facilitators of participation in everyday life for persons with early rheumatoid arthritis.To make it easier for significant others to facilitate participation, there is a need for the healthcare system to explore ways to support significant others with easily accessible information about early rheumatoid arthritis.

Enhancing Screening Systems to Facilitate Hearing-Healthcare Access: A Qualitative Study

BACKGROUND

Although hearing loss is a common health issue, hearing healthcare (HHC) is poorly accessed. Screening to identify hearing loss is an important part of HHC access, specifically for those who screen positive for hearing loss and would benefit from seeing a HHC provider. New technologies can be automated to provide information and recommendations that are tailored to the needs of individual users, potentially enhancing rates of HHC access after positive screens. A greater understanding of the facilitators of postscreening HHC access that could be leveraged in such systems is needed.

PURPOSE

The purpose of this project was to identify facilitators of postscreening HHC access that can be used in automated screening systems.

RESEARCH DESIGN

This qualitative study used focus groups (FGs) to understand perceived barriers, perceived benefits, and potential cues to action, as informed by the Health Belief Model, for accessing HHC after use of automated hearing screening systems.

STUDY SAMPLE

Fifty individuals participated in one of seven FGs. FGs were conducted separately with three types of stakeholders: four FGs included adults who reported some degree of perceived hearing loss and had recently completed a hearing screening; two FGs included adults who had recently sought HHC for the first time because of hearing loss; and one FG involved significant others/family members of individuals with hearing loss.

DATA COLLECTION AND ANALYSIS

FGs were 60-90 minutes in length and were led by a trained facilitator following a discussion guide. A research audiologist was present at each FG and served as a notetaker. FGs were recorded and transcribed by research team members, and transcripts were then coded in an iterative process by multiple team members. Qualitative content analysis was used to reduce data and to identify salient themes and subthemes, following an inductive approach. We focused on identifying themes that were related to facilitators of HHC access after positive screens for hearing loss and, separately, potential enhancements to automated hearing screening systems that would leverage these facilitators to improve HHC access.

RESULTS

We identified five key themes related to HHC access after a positive screen for hearing loss, along with ideas for enhancing automated hearing screening systems based on these themes. The themes included knowledge, trust, access, quality of life, and interpersonal influence.

CONCLUSIONS

The results of our work help inform the development of innovative hearing screening systems that can be automated to leverage individual facilitators of HHC access.

The Impact of Financial Hardship on Single Parents: An Exploration of the Journey From Social Distress to Seeking Help

Single parent families are at high risk of financial hardship which may impact on psychological wellbeing. This study explored the impact of financial hardship on wellbeing on 15 single parents. Semi-structured interviews were conducted and analysed using constructivist thematic analysis. Participants described food and fuel poverty, and the need to make sacrifices to ensure that children's basic needs were met. In some cases, participants went without food and struggled to pay bills. Isolation, anxiety, depression, paranoia, and suicidal thoughts were described. However, participants reported that psychological services not able to take the needs of single parents in to account. Support for single parents must acknowledge the impact of social circumstances and give more consideration economic drivers of distress.

The pathway to consultation for rheumatoid arthritis: exploring anticipated actions between the onset of symptoms and face-to-face encounter with a healthcare professional

Background

When people first experience symptoms of rheumatoid arthritis (RA) they often delay seeking medical attention resulting in delayed diagnosis and treatment. This research assesses behaviours people might engage in prior to, or instead of, seeking medical attention and compares these with behaviours related to illnesses which are better publicised.

Methods

Thirty-one qualitative interviews with members of the general public explored intended actions in relation to two hypothetical RA vignettes (with and without joint swelling) and two non-RA vignettes (bowel cancer and angina). The interviews were audio-recorded and transcribed. Analysis focused on intended information gathering and other self-management behaviours in the interval between symptom onset and help-seeking.

Results

Participants were more likely to envision self-managing symptoms when confronted with the symptoms of RA compared to the other vignettes. Participants would look for information to share responsibility for decision making and get advice and reassurance. Others saw no need for information seeking, perceived the information available as untrustworthy or, particularly in the case of bowel cancer and angina, would not want to delay seeking medical attention. Participants further anticipated choosing not to self-manage the symptoms; actively monitoring the symptoms (angina/ bowel cancer) or engaging in self-treatment of symptom(s).

Discussion

These results help define targets for interventions to increase appropriate help-seeking behaviour for people experiencing the initial symptoms of RA, such as educational interventions directed at allied healthcare professionals from whom new patients may seek information on self-management techniques, or the development of authoritative and accessible informational resources for the general public.

Moderating role of self-efficacy on the associations of social support with depressive and anxiety symptoms in Chinese patients with rheumatoid arthritis

PURPOSE

Rheumatoid arthritis (RA) is significantly associated with depression and anxiety. Social support and self-efficacy are the coping resources of psychological distress. However, little research is available on the interaction of social support and self-efficacy in RA patients. This study aimed to identify the prevalence of depressive and anxiety symptoms and to examine whether or not self-efficacy moderates the associations of social support with depressive and anxiety symptoms in Chinese RA patients.

METHODS

A multicenter, cross-sectional study was conducted in northeast of China from December 2014 to January 2016. A total of 297 RA patients completed the Center for Epidemiologic Studies Depression Scale, Zung Self-Rating Anxiety Scale, Multidimensional Scale of Perceived Social Support and General Self-Efficacy Scale. The associations of social support, self-efficacy and social support × self-efficacy interaction with depressive and anxiety symptoms were examined by hierarchical regression analysis. If the interaction was statistically significant, simple slope analysis was conducted.

RESULTS

The prevalence of depressive symptoms was 58.2%, while 47.5% RA patients had anxiety symptoms. Social support and social support × self-efficacy interaction were significantly associated with depressive symptoms. Social support, self-efficacy and their interaction were significantly associated with anxiety symptoms. The association between social support and depressive symptoms was gradually reduced in the low (1 standard deviation [SD] below the mean, B=-0.614, β=-0.876, P<0.001), mean (B=-0.395, β=-0.563, P<0.001) and high (1 SD above the mean, B=-0.176, β=-0.251, P=0.002) groups of self-efficacy. For anxiety symptoms, the association was also gradually reduced in the low (B=-0.527, β=-0.774, P<0.001), mean (B=-0.288, β=-423, P<0.001) and high (B=-0.049, β=-0.071, P=0.447) groups of self-efficacy.

CONCLUSION

There was a high prevalence of depressive and anxiety symptoms in Chinese RA patients. Self-efficacy could attenuate the associations of social support with depressive and anxiety symptoms. Adequate social support and self-efficacy intervention should be provided to alleviate psychological distress.