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

Multiple sclerosis and identity: a mixed-methods systematic review

PURPOSE

This systematic review addressed the following topics: (1) psychometric measures used to evaluate the identity/self in MS patients; (2) impact of MS on the identity/self of patients; (3) relationships between the identity/self and the adjustment to MS.

METHOD

Five electronic databases were searched for all peer-reviewed empirical studies published up to April 2024 (PROSPERO CRD42023485972). Studies were eligible if they included MS patients and examined identity/self through quantitative, qualitative, or mixed-method study design. MMAT (Mixed Method Appraisal Tool) checklist was used to assess the quality of included studies. After conducting narrative synthesis (quantitative studies) and thematic synthesis (qualitative studies), an integration was undertaken following a convergent segregated approach.

RESULTS

Forty-three studies were included (13 quantitative, 26 qualitative, and four mixed methods). Studies used measures of "self" to refer to specific domains, and of "identity" to highlight the individual's uniqueness and continuity of experience over time. MS causes a loss of various aspects of self (physical, working, family, and social self) and identity discontinuity. Maintaining a positive self-concept and integrating MS into one's identity are associated with better adjustment to MS.

CONCLUSION

Clinicians should consider the centrality of identity redefinition for the promotion of MS patients' adjustment to the illness.

Experiences of Nurses Regarding Self-Care: A Qualitative Systematic Review and Meta-Synthesis

Nurses are susceptible to burnout, making it crucial for them to engage in self-care. This review consolidated the experiences of nurses regarding self-care. Seven electronic databases were searched from inception till October 2024: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, and ProQuest Dissertations and Theses Global. The enhancing transparency in reporting the synthesis of qualitative research statements and Sandelowski and Barroso's guidelines guided this review. Quality appraisal of included studies was conducted using the Critical Appraisal Skills Program tool. Data were thematically synthesized. Confidence in review findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach. Three main themes were identified from the 24 included studies: (1) Being a nurse: An occupational hazard towards self-care, (2) Catalyst towards self-care, and (3) Call to action. Nurses' poor engagement in self-care practices were due to work-related challenges (e.g., working hours), poor self-care awareness, and negative influence from their colleagues and leaders. Conversely, nurses were motivated to engage in self-care when they received encouragement from their peers and leaders.

The impact of living with multiple long-term conditions (multimorbidity) on everyday life - a qualitative evidence synthesis

BACKGROUND

Multiple long-term conditions (MLTCs), living with two or more long-term conditions (LTCs), often termed multimorbidity, has a high and increasing prevalence globally with earlier age of onset in people living in deprived communities. A holistic understanding of the patient's perspective of the work associated with living with MLTCs is needed. This study aimed to synthesise qualitative evidence describing the experiences of people living with MLTCs (multimorbidity) and to develop a greater understanding of the effect on people's lives and ways in which living with MLTCs is 'burdensome' for people.

METHODS

Three concepts (multimorbidity, burden and lived experience) were used to develop search terms. A broad qualitative filter was applied. MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (EBSCO), CINAHL (EBSCO) and the Cochrane Library were searched from January 2000-January 2023. We included studies where at least 50% of study participants were living with three or more LTCs and the lived experience of MLTCs was expressed from the patient perspective. Screening and quality assessment (CASP checklist) was undertaken by two independent researchers. Data was synthesised using an inductive approach. PPI (Patient and Public Involvement) input was included throughout.

RESULTS

Of 30,803 references identified, 46 met the inclusion criteria. 31 studies (67%) did not mention ethnicity or race of participants and socioeconomic factors were inconsistently described. Only two studies involved low- and middle-income countries (LMICs). Eight themes of work were generated: learning and adapting; accumulation and complexity; symptoms; emotions; investigation and monitoring; health service and administration; medication; and finance. The quality of studies was generally high. 41 papers had no PPI involvement reported and none had PPI contributor co-authors.

CONCLUSIONS

The impact of living with MLTCs was experienced as a multifaceted and complex workload involving multiple types of work, many of which are reciprocally linked. Much of this work, and the associated impact on people, may not be apparent to healthcare staff, and current health systems and policies are poorly equipped to meet the needs of this growing population. There was a paucity of data from LMICs and insufficient information on how patient characteristics might influence experiences. Future research should involve patients as partners and focus on these evidence gaps.

Interdisciplinary Rheumatoid Arthritis Research and Patient Care: An Introduction and Critique of the Biopsychosocial Model of Disease Experience in Rheumatoid Arthritis

INTRODUCTION

Rheumatoid arthritis (RA), a debilitating autoimmune disease, affects approximately 78 million people globally. RA is often managed solely by rheumatology providers, but an interdisciplinary approach to RA may be the key to improving health equity and outcomes. An interdisciplinary model is an important step towards this goal. The Biopsychosocial Model of Disease Experience in RA (BDRA) is a conceptual approach that considers individual disease determinants in interdisciplinary research and care.

OBJECTIVE

To introduce and critique the evidence-based, interdisciplinary BDRA.

METHODS

Engel's Biopsychosocial Model of Health (BMH) and the Revised Symptom Management Conceptual Model (RSMCM) were blended in the BDRA. A literature search of articles published prior to December 2021 was completed using "disease exacerbation," "disease improvement," and "disease activity" in RA. Results were categorized as biological, psychological, and social determinants of disease activity in RA. These biopsychosocial factors alter biological function and result in the individual RA experience. Model development and critique were completed using guidelines established by Walker and Avant.

CONCLUSION

The BDRA is a visual depiction of RA biopsychosocial factors, disease activity, and individual experience. This model can guide interdisciplinary research and patient care, in efforts to improve RA health equity and rates of sustained remission.

How do patients with rheumatoid arthritis perceive their self-care and self-care support? A mixed-method study

AIM

To explore self-care and needs and preferences towards tailored self-care support of patients with rheumatoid arthritis at the outpatient clinic.

DESIGN

A sequential explanatory mixed method design.

METHODS

The Self-Care of Chronic Illness Inventory questionnaire, two focus groups and six semi-structured interviews were conducted between November 2021 and April 2023. Questionnaires of 107 patients were descriptively analysed. Subsequently, 11 patients and 2 healthcare professionals participated in the focus groups and 6 patients in the interviews, which were thematically analysed.

RESULTS

Quantitative and qualitative data corresponded and showed that patients perform various self-care activities at an adequate level and have strategies to exert control and reduce symptoms. One key theme emerged: 'Not only being the person with rheumatoid arthritis' (RA) as patients primarily aim to get on with their lives. Nine subthemes covered self-care activities for maintaining health including staying physically active, finding the right medication and dose and adapting their diet. Patients differed in how they self-monitored their symptoms. Recognizing symptoms and finding strategies to manage symptoms included the process of body listening in which patient seek and try different strategies to find what works for them and incorporate routines. Patients experienced positive effects of a warm or cold environment. Patients felt the need for practical and emotional support from others and preferred having credible information.

CONCLUSION

Patients perform adequate self-care including a diversity of self-care activities to get on with their lives and have strategies to reduce and control the symptoms and impact of RA.

IMPLICATIONS

Tailoring self-care support to patients' individual needs and preferences is necessary to help patients cope with the erratic nature of the disease and maintain their quality of life. Healthcare providers need to provide practical and emotional support and use credible information to allow patients to make self-care decisions to manage their lives.

REPORTING METHODS

Quantitative finding are reported according to the STROBE guidelines and qualitative finding are reported according to the COREQ guidelines.

WHAT DOES THIS PAPER ADD

Patients perform various self-care activities at an adequate level and have strategies to exert control and reduce symptoms. Patients primarily aim to continue their lives and not being seen as the person with rheumatoid arthritis. Healthcare professionals need to provide practical and emotional support and use credible information to inform patients' self-care decision-making.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The Impact of Occupational Therapy on the Self-Management of Rheumatoid Arthritis: A Mixed Methods Systematic Review

OBJECTIVE

To determine the impact of occupational therapy (OT) on the self-management of function, pain, fatigue, and lived experience for people living with rheumatoid arthritis (RA).

METHODS

Five databases and gray literature were searched up to June 30, 2022. Three reviewers screened titles and abstracts, with two independently extracting and assessing full texts using the Cochrane risk of bias (quantitative) and Critical Appraisal Skills Programme (qualitative) tools to assess study quality. Studies were categorized into four intervention types. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) (quantitative) and GRADE- Confidence in Evidence from Reviews of Qualitative research (qualitative) were used to assess the quality of evidence for each intervention type.

RESULTS

Of 39 eligible papers, 29 were quantitative (n = 2,029), 4 qualitative (n = 50), and 6 mixed methods (n = 896). Good evidence supports patient education and behavior change programs for improving pain and function, particularly group sessions of joint protection education, but these do not translate to long-term improvements for RA (>24 months). Comprehensive OT had mixed evidence (limited to home OT and an arthritis gloves program), whereas limited evidence was available for qualitative insights, splints and assistive devices, and self-management for fatigue.

CONCLUSION

Although patient education is promising for self-managing RA, no strong evidence was found to support OT programs for self-managing fatigue or patient experience and long-term effectiveness. More research is required on lived experience, and the long-term efficacy of self-management approaches incorporating OT, particularly timing programs to meet the individual's conditional needs (i.e., early or established RA) to build on the few studies to date.

Experiences of individuals with rheumatoid arthritis interacting with health care and the use of a digital self-care application: a qualitative interview study

OBJECTIVES

Over the last few decades, there have been significant improvements in the treatment of rheumatoid arthritis (RA), with the development of new treatments and guidelines for teamwork and patient self-care and access to digital tools. This study aimed to explore the experiences of individuals with RA interacting with healthcare. It also looked at how a self-care application, an educational programme called the 'healthcare encounter', improved patient-doctor communication.

DESIGN

Semistructured interviews were conducted, and qualitative content analysis was performed.

SETTING

The potential participants, individuals with established, or under investigation for, RA diagnosis at rheumatology clinics in Sweden, were asked to participate in the study via a digital self-care application called the Elsa Science Self-care app.

PARTICIPANTS

Ten interviews were performed with participants from nine clinics following a meeting with the rheumatologist or other healthcare personnel between September 2022 and October 2022. Phrases, sentences or paragraphs referring to experiences from healthcare meetings and opinions about the digital programme were identified and coded. Codes that reflected similar concepts were grouped; subcategories were formulated, and categories were connected to their experiences and opinions.

RESULTS

Among our participants, three main categories emerged: the availability of healthcare, individual efforts to have a healthier life and personal interaction with healthcare. Participants described that the 'healthcare encounter' educational programme can be a source of information, which confirms, supports and creates a sense of control.

CONCLUSION

The participants valued being seen and taking part in a dialogue when they had prepared themselves (observed symptoms over time and prepared questions). The implementation of digital self-care applications might need to be incorporated into the healthcare setting, so that both the patients and the healthcare personnel have a shared understanding. Collaboration is essential in this context.

Physical Exercise and Occupational Therapy at Home to Improve the Quality of Life in Subjects Affected by Rheumatoid Arthritis: A Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that affects synovial membranes and typically causes joint pain and swelling. The resulting disability of RA is due to the erosion of cartilage and bone from the inflamed synovial tissue. Occupational therapy is a strategy and technique to minimize the joints' fatigue and effort. At the same time, physical exercise reduces the impact of systemic manifestations and improves symptoms in RA. This study investigates the role of a 30-day joint economy intervention (integration of physical exercise and occupational therapy) at home on the quality of life of subjects with RA.

METHODS

One hundred and sixty outpatients with RA were enrolled in a single-center trial with PROBE design and were divided into the intervention group (IG), which combined joint protection movements and physical exercise to maintain muscle tone at home, and the control group (CG). Both groups included 80 patients. In all patients, data from the disease activity score (DAS 28), health assessment questionnaire (HAQ), and short-form health survey (SF-12) "Italian version" were collected. In addition, to IG, a brochure was distributed, and the joint economy was explained, while to CG, the brochure only was distributed. The comparison between groups was made using Fisher's exact test for contingency tables and the z-test for the comparison of proportions. The non-parametric Mann-Whitney U test was used to compare quantitative variables between groups. The Wilcoxon signed-ranked test was used for post-intervention versus baseline comparisons.

RESULTS

Among the recruited patients, 54% were female. The mean age was 58.0 (42.4-74.7) for the CG and 54.0 (39.7-68.3) for the IG. Patients included in the IG had a higher cumulative illness rating scale for the evaluation of severity and comorbidity index (2.81 vs. 2.58; 2.91 vs. 2.59, respectively), as well as morning stiffness (33.8 vs. 25.0), even if not significant compared with CG patients. Our results indicate that, after 30 days of joint economy intervention at home, the DAS28 erythrocyte sedimentation rate (esr) and DAS28 C-reactive protein (crp), HAQ, and SF-12 mental component score were significantly improved (p = 0.005, p = 0.004, p = 0.009, and p = 0.010, respectively).

CONCLUSIONS

Our findings show that the combination of physical exercise and occupational therapy positively affects patients' quality of life with RA considering disease activity, global health status, and mental health.

Assessment of self-esteem and community integration in spondyloarthritis

INTRODUCTION

The aim of this study was to identify the associated factors with lower self-esteem and restriction in community reintegration in SpA patients.

METHODS

This study was a cross-sectional study including SpA patients (ASAS criteria) aged 18-50 years. The level of self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES). The Reintegration to Normal Living Index (RNLI) evaluated the degree of reintegration to normal social activities. Anxiety, depression, and fibromyalgia were screened by the Hospital Anxiety and Depression Scale (HADS)-A, HADS-D, and FiRST, respectively. Statistical analysis was performed.

RESULTS

A total of 72 patients were enrolled (sex-ratio=1.88), with median (IQR) age of 39 years (28.25-46). Median (IQR) disease duration was 10 (6-14) years. Median (IQR) BASDAI and ASDAS were 3 (2.1-4.7) and 2.7 (1.9-3.48), respectively. Anxiety symptoms were screened in 10% of SpA patients, depression in 11%; and fibromyalgia in 10%. Median (IQR) RSES and RNLI scores were 30 (23.25-34), and 83 (53.25-93.25), respectively. Multivariate regression analysis identified the domain (work) of pain interference, VAS pain, HAD anxiety, PGA, marital status, and morning stiffness as factors associated with lower self-esteem. Restriction in the reintegration community was predicted by the presence of IBD, VAS pain, FIRST, deformity, enjoyment of life, and HAD depression.

CONCLUSION

Pain intensity and interference, deformities, extra-articular manifestations, and deterioration of mental health were associated with low self-esteem and severe restriction in community reintegration among patients with SpA rather than inflammatory parameters.

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.

The role of occupational therapy for the self-management of rheumatoid arthritis: A protocol for a mixed methods systematic review

BACKGROUND

Occupational therapists can support people with rheumatoid arthritis to self-manage their disease symptoms and engage in daily activities. This protocol reports a review to broaden understanding of what is known about the role of occupational therapy in the self-management of rheumatoid arthritis.

METHODS

Studies involving adults with rheumatoid arthritis, having participated in self-management involving occupational therapy, will be included. Patient involvement will help develop the search strategy by identifying patient-centred interventions and outcomes to complement those identified by researchers. An electronic search will be performed using several bibliographic databases, including grey literature from subject-specific, health-related, and social care databases. Searches will run from the database inception until the date that the search is conducted (December 2021-May 2022). Retrieved studies will be de-duplicated, and the remaining titles and abstracts will be screened by three reviewers. Full texts of all eligible studies will be independently reviewed by the reviewers to select papers for data extraction and quality assessment. Outcomes are function, pain, fatigue and lived experience. For quantitative studies, data will be synthesised using descriptive statistics in text and tables, whereas for qualitative studies, data will be synthesised using thematic synthesis.

DISCUSSION

This review will synthesise current evidence on how occupational therapy can help the self-management of rheumatoid arthritis. It will include evidence of best practice, including advice, education and training provided by occupational therapists. These findings can inform future research and the selection of strategies to promote quality of life for people with rheumatoid arthritis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022302205.

Exploring the physical, psychological and social well-being of people with rheumatoid arthritis during the coronavirus pandemic: a single-centre, longitudinal, qualitative interview study in the UK

OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune, inflammatory, systemic condition that requires specific drug treatment to suppress disease activity and prevent joint deformity. To manage the ongoing symptoms of joint pain and fatigue patients are encouraged to engage in self-management activities. People with RA have an increased incidence of serious illness and mortality, with the potential to impact on quality of life. This study explored patients' experiences of living with RA on physical, psychological and social well-being as well as their ability to employ self-management skills during the coronavirus pandemic.

DESIGN

Qualitative, longitudinal (baseline, 16 September to 23 November 2020 and after 2-4 months, 11 January to the 17 January 2021), semistructured telephone interviews.

SETTING

A rheumatology service based in a community hospital.

PARTICIPANTS

15 adults with RA.

MAIN OUTCOMES

Data were analysed using interpretative phenomenological analysis.

RESULTS

Five themes were identified that related to impact on (1) fear: the dominant emotion, (2) social connections and work practices, (3) physical health, (4) identity and (5) self-management as a coping mechanism. The overriding emotion was one of fear, which remained high throughout both interviews. The negative impact on social well-being increased as the pandemic progressed. Conversely, physical health was not affected at either time point, although participants reported difficulty in interpreting whether physical symptoms were attributable to their RA or COVID-19. Recognition of increased vulnerability led to a reassessment of self-identity; however, respondents reported using previously learnt self-management techniques to cope in the context of the pandemic.

CONCLUSIONS

The main impact was on emotional and social well-being. Levels of fear and vulnerability which affected self-identity remained high throughout the pandemic and the impact on social well-being increased over time. Physical health remained largely unaffected. Self-management skills were used to maintain a sense of well-being.

"My Pain Is Unbearable…I Cannot Recognize Myself!" Emotions, Cognitions, and Behaviors of People Living With Musculoskeletal Disorders: An Umbrella Review

OBJECTIVE

To summarize (1) the emotions, cognitions, and behaviors of people who are living with musculoskeletal disorders related to symptoms and (2) the interactions of emotions, cognitions, and behaviors with the person's environment (family, social, and work roles).

DESIGN

An umbrella review of qualitative research syntheses and meta-summaries (metasynthesis, meta-ethnographies, meta-aggregation, meta-summary).

LITERATURE SEARCH

We searched CINAHL, EMBASE, PsycARTICLES, PsycEXTRA, PsycINFO, PubMed, and PubPsych from database inception to January 2021. We also searched gray literature via Open Grey and Google Scholar.

STUDY SELECTION CRITERIA

We included qualitative evidence syntheses evaluating adults with musculoskeletal disorders, based on the multidimensional diagnostic criteria for acute and chronic pain. Emotions, cognitions, and behaviors were the phenomenon of interest.

DATA SYNTHESIS

We developed 3 categories of themes ([1] emotions, [2] cognitions, and [3] behaviors) for each objective. We selected the 3 most common emotions, cognitions, and behaviors that appear as themes in our narrative synthesis.

RESULTS

We included 20 qualitative evidence syntheses that retrieved 284 original qualitative studies. Despair, distress, and fear were the main emotions reported by people living with musculoskeletal disorders. The alterations of the self and how people described their symptoms, what caused them, and how the symptoms impacted their lives were the most common cognitions. Cognitive strategies (ie, acceptance) and perceptions about social support emerged. People often used passive behaviors (eg, social isolation or hiding symptoms) to cope with the challenges that arose related to musculoskeletal symptoms. However, some people actively faced their symptoms, planning their activities or practicing them despite their symptoms.

CONCLUSION

Clinicians who support people living with musculoskeletal disorders should consider (1) assessing other emotions than pain-related fear (eg, despair and distress), (2) observing their cognitive responses (ie, acceptance), and (3) evaluating what type of behaviors people use (eg, active or passive). J Orthop Sports Phys Ther 2022;52(5):243-261. doi:10.2519/jospt.2022.10707.

The chronic disease Self-Management Programme: A phenomenological study for empowering vulnerable patients with chronic diseases included in the EFFICHRONIC project

Introduction

The Chronic Disease Self‐Management Programme (CDSMP) has resulted in improved health outcomes for patients. However, research has focused mainly on those with chronic conditions and has not extensively explored prevention programmes targeting individuals with specific vulnerability profiles.

Aim

This study aimed to understand the effects of the CDSMP on the lived experience of vulnerable patients included in the EFFICHRONIC project in France, based on their needs and expectations before and after participation.

Methods

We conducted a qualitative phenomenological semio‐pragmatic study based on 37 in‐depth interviews with 20 patients (20 before/17 after CDSMP).

Results

By transforming existential dimensions (identity, relationship with others and bodily experience), chronic illness generates new needs in the vulnerable person. By resonating with the expectations and needs of participants, the CDSMP induces motivation and a sense of belonging to a community of peers. It has enabled the participants to become actors of their own health until empowerment. Although some limitations are reported, the programme has awakened a desire in the participants to take better care of their health and to develop personal skills with, for some, a desire to become involved in health education.

Conclusion

Our phenomenological approach highlighted the resonance between the programme (its design and implementation) and the lived experience of patients, as an effective element of empowerment. This necessitates training the facilitators to elicit the lived experience of patients. Furthermore, as a patient‐centred approach is required, the facilitators need to learn how to adapt the design of the programme to the singularity of the patient.

Patient or Public Contribution

Patients provided the data that were collected through in‐depth interviews, and their experiences before and after the programme were analysed.

Patient Empowerment and Associations with Disease Activity and Pain-Related and Lifestyle Factors in Patients With Rheumatoid Arthritis

BACKGROUND

Empowerment is important to patients with rheumatoid arthritis (RA) because most care is in the form of self-management. The aim was to study levels of empowerment and associated variables in patients with RA and to investigate longitudinal clinical data in patients with low and high empowerment.

METHODS

A postal survey was sent in 2017 to patients with RA from the BARFOT (Better Anti-Rheumatic Pharmacotherapy) cohort that included questions about disease activity, pain-related factors, lifestyle habits, and contained the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23). The 844 patients who answered the SWE-RES-23 made up the cohort of the present study. Differences in level of empowerment between groups (low, moderate, and high empowerment) were analyzed with ANOVA. Logistic regression analysis was used to study variables associated with low empowerment. Thirdly, we performed comparisons in longitudinal data (15 years) of disease activity, pain, and physical function between the three empowerment groups (low, moderate, and high empowerment).

RESULTS

Patients with low empowerment (n = 282) were significantly older, more often women, and reported worse pain-related factors and physical function and lower moderate and vigorous physical activity compared with those with high empowerment (n = 270). An analysis of longitudinal data found that patients with low empowerment had worse pain and physical function at all time points.

CONCLUSION

Patients with low empowerment have more pain-related symptoms, poorer physical function, and are less physically active. To promote patient empowerment in rehabilitation interventions it is important to identify and support self-management.

Identification of Five Quality Needs for Rheumatology (Text Analysis and Literature Review)

Background: While the use of the term "quality" in industry relates to the basic idea of making processes measurable and standardizing processes, medicine focuses on achieving health goals that go far beyond the mere implementation of diagnostic and therapeutic processes. However, the quality management systems used are often simple, self-created concepts that concentrate on administrative processes without considering the quality of the results, which is essential for the patient. For several rheumatic diseases, both outcome and treatment goals have been defined. This work summarizes current mainstreams of strategies with published quality efforts in rheumatology. Methods: PubMed, Cochrane Library, and Web of Science were used to search for studies, and additional manual searches were carried out. Screening and content evaluation were carried out using the PRISMA-P 2015 checklist. After duplicate search in the Endnote reference management software (version X9.1), the software Rayyan QCRI (https://rayyan.qcri.org) was applied to check for pre-defined inclusion and exclusion criteria. Abstracts and full texts were screened and rated using Voyant Tools (https://voyant-tools.org/). Key issues were identified using the collocate analysis. Results: The number of selected publications was small but specific (14 relevant correlations with coefficients >0.8). Using trend analysis, 15 publications with relative frequency of keywords >0.0125 were used for content analysis, revealing 5 quality needs. The treat to target (T2T) initiative was identified as fundamental paradigm. Outcome parameters required for T2T also allow quality assessments in routine clinical work. Quality care by multidisciplinary teams also focusing on polypharmacy and other quality aspects become essential, A global software platform to assess quality aspects is missing. Such an approach requires reporting of multiple outcome parameters according to evidence-based clinical guidelines and recommendations for the different rheumatic diseases. All health aspects defined by the WHO (physical, mental, and social health) have to be integrated into the management of rheumatic patients. Conclusion: For the future, quality projects need goals defined by T2T based initiatives in routine clinical work, secondary quality goals include multidisciplinary cooperation and reduction of polypharmacy. Quality indicators and standards in different health systems will provide new information to optimize patients' care in different health systems.

(In)Visible illness: A photovoice study of the lived experience of self-managing rheumatoid arthritis

BACKGROUND

Chronic illnesses, such as Rheumatoid Arthritis (RA), are a growing burden on health care systems worldwide. Self-management emphasises the patient's central role in managing their illness. This is pertinent given the majority of care is provided by the individual themselves; yet how individuals make sense of self-management in everyday life is largely unseen.

OBJECTIVE

The purpose of this study was to capture the strengths and concerns of individuals with RA in self-managing their illness, raise awareness of their lived experience and spark a dialogue among stakeholders.

METHODS

A community-based participatory approach, Photovoice, was adopted. A purposive sample of participants were tasked with taking photographs to represent the challenges and solutions to living with RA. Group workshops and semi-structured interviews were conducted to facilitate reflection, dialogue and analysis. Data analysis followed Braun and Clarke's thematic analysis. Public exhibitions were held throughout the Autumn of 2019.

RESULTS

Eight women and three men (n = 11) across suburban and urban regions of Ireland were recruited (mean age 57 years, disease duration 4-21 years). Participants identified four main themes which reflected the lived experience of self-managing RA: (i) I'm Here but I'm Not, (ii) Visible Illness, (iii) Medicine in All its Forms, (iv) Mind Yourself. These themes captured the challenge of reduced agency, limited contribution and participation, and a complex relationship between visible and invisible illness. Solutions focused on improving psychological and emotional resilience, particularly through personal reflection and increased agency.

CONCLUSIONS

Our findings suggest that RA is experienced as a fluid relationship between states of masking and surfacing of illness shaped by contextual and situational factors. Photovoice was a highly effective tool to capture and communicate this complexity. Supporting increased agency among individuals with RA to control the (in)visibility of illness and disability can inform the development of future self-management support.

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.