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Socio-demographic and psychosocial predictors of rheumatoid arthritis health outcome

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Socio-demographic and psychosocial predictors of rheumatoid arthritis health outcome
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  109 articles Volume 10 No. 4 December 2004 - SAJP Socio-demographic and psychosocial predictors of rheumatoid arthritis health outcome Pamela Naidoo, MA(Clin Psych), DPhil Department of Psychology, University of the WesternCape Graham C Lindegger, MA(Clin Psych), PhD School of Psychology, University of KwaZulu-Natal,Pietermaritzburg Girish M Mody, MB ChB, MRCP, FCP, MD, FRCP Department of Rheumatology, Nelson R Mandela Schoolof Health Sciences, University of KwaZulu-Natal, Durban Rheumatoid arthritis (RA) is a systemic autoimmune disorderof unknown aetiology, which is disabling and chronic. Thesynovial membranes of multiple joints are usually affected,with the formation of chronic synovitis leading to bone andcartilage damage. 1 The most common outcome of the estab-lished disease is the progressive development, in varyingdegrees, of joint destruction, deformity and disability. The pri-mary cause of RA is unknown and it has, therefore, beendescribed as ‘one of modern medicine's major enigmas’. 2 There has been a proliferation of studies from developedcountries on the medical and psychological aspects of RA,and more recently on the psychoneuroimmunological aspectsof the disease. RA is a chronic and disabling disease withserious clinical, psychosocial and economic effects. Despiteinvestigation into ways of improving the quality of life of indi-viduals with RA, it is difficult to contain the overall cost of thisdebilitating disease. One possible explanation for not beingable to control the economic effects of the disease rests onthe unclear aetiology of RA. Attempts to prevent the diseasefrom manifesting have been futile thus far. Consequently, thecost of the disease to the individual, his or her workplace andto the health care system remains high.Most RA research in South Africa is medically based 3,4 com- Objectives . To investigate the psychosocial aspects ofrheumatoid arthritis (RA) and to determine the predictors ofRA health outcome in a low socio-economic group ofclinic-based adult RA patients. Design . This was a cross-sectional study. Clinic-basedadult RA patients were subjected to a series of self-administered questionnaires to assess their experience ofthe disease. Coping, social support, causal attribution,cognitive illness representation, pain and functional statuswere assessed. Joint status, which indicated the degree ofseverity of joint inflammation for each RA patient, wasassessed by a rheumatologist. Subjects . The sample consisted of 186 RA patients with amean age of 49.51 years and a mean duration of RA of10.80 years. Outcome measures . Health status measures defined bypain and functional status, and joint status. Results . Psychological factors, especially coping, weremore significant predictors of self-report of pain andfunctional status than socio-demographic factors. Bothsocio-demographic factors and psychological factors(especially coping) were found to be significant predictorsof swollen and tender joint status. Conclusion and recommendations . As a psychologicalfactor, coping emerged as a consistent predictor of bothself-report of pain and functional status, and swollen andtender joint status. It is recommended that to enhance thequality of life of RA patients and improve their healthstatus, the impact of psychosocial factors such as the wayin which patients cope with their disease status, must beconsidered. Further, it is recommended that healthprofessionals collaborate not only in attempting to refinethe theoretical conceptualisation of RA, but also indevising holistic and multidisciplinary care for individualsafflicted with the disease.  110 articles pared with international research trends in the area of chron-ic illness. International research has become increasinglyfocused on the importance of both socio-demographic andpsychosocial factors in disease outcome. 5 This South Africanstudy appears to be the first to conduct a comprehensiveinvestigation into the way in which psychosocial factors areassociated with socio-demographic factors, disease factors,and health-related quality of life. A sample obtained from adeveloping country such as South Africa, with its uniquesociological patterns around family structure, cultural prac-tices, religious beliefs and economic disparity between dif-ferent groups of people, differs from a sample based in adeveloped country such as North America.Psychosocial and biomedical disease factors often accountfor variance in disease outcome. Although results from studieshave varied, general support has been found for the disease-course hypothesis that takes into account the psychologicalresponse to RA experience. For example, there is often apoor correlation between disease status and disability in RApatients. 6 Frequently, patients with severe RA as measured byclinical assessments including X-rays and other radiographicmeasures, experience mild disability, whereas patients withmild disease present with severe disability. 7 It is important,therefore, to identify other variables responsible for affectingthe variability in the health outcome measures of thesepatients. Psychological factors such as coping, social sup-port, causal attribution, and cognitive illness representationare known to impact on health outcome. 8 The aim of this study was to investigate the predictive value ofboth socio-demographic and psychosocial factors in RAhealth outcome. Methods This was a cross-sectional study. A purposive or judgementalnon-probability sampling method 9 was used to obtain a sam-ple of RA patients. One hundred and eighty-six adult femaleand male RA patients were selected over an 18-month periodfrom the outpatient rheumatology clinic at King Edward VIIIHospital, Durban. Permission to conduct the study was obtained from the rele-vant authorities at the University of KwaZulu-Natal’s Nelson RMandela School of Health Sciences and King Edward VIIIHospital. Approval from the Ethics Committee at the medicalschool was also obtained. Only two rheumatologists from the Department ofRheumatology were responsible for medically examining thesubjects and confirming a diagnosis of RA, which ensuredthat there was consistency in applying the relevant medicalcriteria in diagnosing RA, and in assessing the extent towhich each subject was functionally impaired (disabled as aresult of RA).The clinical records were reviewed before the patients wereenrolled in the study. The rheumatologists at the clinicassessed patients who had been previously diagnosed withRA, and who were able to read in English. The rheumatolo-gist reviewed the clinical records of the patients, once again,to determine whether these patients fulfilled the AmericanRheumatism Association (ARA) 10 criteria for the diagnosis ofRA. To ensure a valid and reliable sample only those patientswho fulfilled the criteria were approached to participate inthe study. Patients with a co-existing serious medical or psy-chiatric condition were excluded. The purpose of the studyand the requirements were discussed in detail with thepatients and once their informed consent was obtained theywere enrolled as participants. Participants were alsoinformed of their right to withdraw from the study.Information pertaining to the subjects’ socio-demographic sta-tus, criteria in accordance with the American College ofRheumatology 11 disease activity measures, assessment offunction, and psychological measures were obtained andrecorded. The classification of the patients’ functional statusaccording to the ARA revised criteria was also recorded(class I - class IV). 11 Senior nursing sisters were responsible for the collection ofblood samples from each patient. These were then forward-ed to the hospital laboratory for analysis. Once the resultswere obtained they were interpreted and noted by the tworheumatologists involved in the study. A series of questionnaires were administered to the subjects.A semi-structured interview also formed part of the assessmentprocedure. A nursing sister at the rheumatology clinic actedas an interpreter for black patients who felt they couldexpress an idea or thought more clearly in an indigenous lan-guage such as Zulu or Xhosa. A detailed biographical inven-tory was administered and the actual number of years of RAwas recorded. Psychosocial measures and health outcomemeasures were also obtained. Volume 10 No. 4 December 2004 - SAJP  111 articles The psychosocial measures included the London Coping withRheumatoid Arthritis Questionnaire (LCRAQ), a 36-item ques-tionnaire based on a Likert-type format, 12 the Illness SpecificSocial Support Scale (IS-SSS) used to assess the construct ofproblematic support and positive social support in individualswith RA, 13 and causal attribution and cognitive illness repre-sentation. A semi-structured questionnaire was devised toassess the causes that RA patients attribute to their diseaseand to assess RA patients' cognitive illness representations.‘Open-ended’ responses were obtained to ascertain thecausal attribution subjects made at the time of disease onsetand at the time the study was conducted.Measures of health outcome included measures of pain andfunctional status. Joint status was retained as a separate mea-sure. Pain was measured using the Visual Analogue Scale(VAS) 14 and the Arthritis Impact Measurement Scale 2(AIMS2), 15 a pain subscale. Disability was measured usingthe VAS, AIMS2, and the Stanford Health AssessmentQuestionnaire (HAQ). 16  Joint status was measured using the28-joint count. 17 The individual measures of pain and functional assessmentmeasures (namely measures of disability and joint count) inthis study were factor analysed, and two measures emerged.The first was the measure of pain and disability, and the sec-ond was the 28-joint count measure. Pain and disability, adependent variable (DV) in this study, was therefore retainedas a single measure in the statistical analyses. Results The age range of this hospital-based outpatient clinic samplewas 20 - 80 years, with a mean age of 49.51 years and astandard deviation (SD) of 10.86 years. The mean number of years of RA was 10.80 (SD 7.96). As shown in Table I, themajority of participants were women (87.1%), a little morethan half the sample (54.8%) had never been married, themajority (81.2%) had at least a senior primary or high schooleducation, most participants were not engaged in paid work activities, and well over half the subjects reported a monthlyhousehold income of less than R1 000. Most participantsidentified themselves as being either Hindu or Christian. IndianSouth Africans comprised 65.6% of the sample. In order to test the hypotheses, the data were statisticallyanalysed using the SPSS statistical programme. 18 Correlational analysis was used to test the linear relationshipsbetween the socio-demographic variables, psychosocial vari-ables and health outcome of RA patients. Hiearchical multi-ple regression analysis was used to test the health-sustainingfunction of psychosocial factors (referred to as the direct-effects hypothesis). 19 Volume 10 No. 4 December 2004 - SAJP Table I. Frequencies and percentages of the demographicvariables Demographic variablesFrequencyPercentage (%)Age (yrs)20 - 29115.930 - 392111.340 - 495429.050 - 596937.1≥ 60 3116.7Marital statusMarried4524.2Never married10254.8Widowed2614.0Separated or divorced137.0SexMale2412.9Female16287.1Educational levelNo formal schooling2211.81 - 3 years of junior school42.24 - 6 years senior primary school2614.01 - 3 years of high school7138.24 - 6 years of high school5429.0Tertiary education94.8Employment statusEmployed4423.7Not engaged in paid work activities14276.3Monthly household income < R100010958.6R1 000 - R2 0005831.2R2 000 - R6 000168.6> R6 00031.6Religion Christian8646.2Hindu8244.1Muslim179.1Racial classificationBlack6434.4Indian12265.6Total 186100  112 articles Interrelationship between socio-demographicand health outcome variables The strength of the relationships between the independentvariables (IVs) age, sex, educational level, employment sta-tus, income, duration and race, and dependent variables(DVs) self-report of pain and functional status, swollen andtender joint status, is presented in Table II. While it can beargued that the correlations between the IVs and DVs (asshown in Tables II and III) are small the results are neverthe-less a true reflection of the analysis of the data, whichdeserves to be reported. However, these figures must beinterpreted with caution because they reflect statistical signifi-cance and may not have practical value. A significant positive relationship was found betweenemployment status and self-report of pain and functional sta-tus ( r  =0.25). RA patients in this study who were notengaged in paid work activities experienced higher levels ofpain and poorer functional status. Significant negative rela-tionships were found between monthly household incomeand self-report of pain and functional status ( r = –0.27), andrace and self-report of pain and functional status ( r = –0.16).The first reported significant negative correlation indicatesthat subjects who earned more had less pain and better func-tional status, and the second significant negative correlationindicates that subjects of Indian srcin experienced less painand better functional status.Significant positive relationships were found betweenemployment status and swollen and tender joint status ( r  =0.17), and age and swollen and tender joint status( r  =0.22), indicating that those subjects not engaged in paidwork activities, as well the older RA subjects had poor jointstatus (i.e. higher scores on the measure for swollen and ten-der joint status). Interrelationship between the psychologicaland health outcome variables The strength of the relationships between the psychosocialvariables and DVs is presented in Table III. The values presented in Table III show that there are no asso-ciations between both positive social support and problemat-ic support and each of the dependent variables. This unusualfinding is contrary to what has been reported in the literatureabout the direct effect of social support on health status.Social support has been associated with increased psycho-logical well-being and better functional status in chronically illindividuals. 20 Volume 10 No. 4 December 2004 - SAJP Table II. Pearson’s product-moment correlation coefficients(zero order  r  ) between independent and dependent vari-ables and marital status and religion are represented usingF-values from analysis of variance (ANOVA) Self-report of painSwollen and and functionaltender jointstatusstatusIVsZero order (  r  )Zero order (  r  )Age0.100.22*Sex0.060.09Education level– 0.12– 0.08 Employment status0.25 † 0.17*Income – 0.27 †  – 0.05Duration0.02– 0.06Race– 0.16*– 0.12Marital statusF(3.186)=2.86*F(3.186)=0.003ReligionF(2.186)=3.39*F(2.186)=2.66 * p < 0.05† p < 0.01F-values are presented from the ANOVAs for marital status and religion. Table III. Pearson’s product-moment correlation coefficients(  r  ) between psychological variables and health outcomevariables, and causal attribution at the time of onset of RA(CA_O) and causal attribution at the time the study wasconducted (CA_R) are represented using F-values fromANOVAs Self-report ofSwollen andPsychosocial pain andtender jointvariables functional statusstatusZero order (  r  )Zero order(  r  )Total coping– 0.30*– 0.12Proactive coping – 0.21*– 0.12Negative-internal coping – 0.39*– 0.27*Positive-interactive coping – 0.20*– 0.03Network support_A– 0.090.001Network support_B– 0.060.05Control internal 0.22*0.16 † Control external 0.16 † 0.15 † Causal attribution_OF(2.186) = 0.10F(2.186) = 0.55Causal attribution_RF(2.186) = 0.21F(2.186) = 0.67 * p < 0.01† p < 0.05F-values are presented for causal attribution at the time of onset of RA(CA_O) and causal attribution at the time the study was conducted(CA_R).Network support: _A = positive support and network support; _B = negativesupport.  113 articles There were significant positive correlations between internalcontrol ( r = 0.22), external control ( r = 0.16) and self-reportof pain and functional status. This result indicates that subjectswho believed that they had the ability to control the disease as well as those who believed that RA can only becontrolled by factors outside the individual had increased levelsof pain and poorer functional status.Significant negative correlations were found between total cop-ing and self-report of pain and functional status ( r = –0,30), proactive coping and self-report of pain and func-tional status ( r = –0.21), negative-internal coping and self-reportof pain and functional status ( r = –0.39); and positive-interactivecoping and self-report of pain and functional status ( r = – 0.20).These associations indicate that increased ability to cope withRA was related to lower scores on pain and functional status. Inaddition, proactive and positive-interactive coping styles of thesubjects were related to decreased levels of pain and better func-tional status. Finally, a somewhat contradictory finding indicatesthat a negative-internal coping style was associated with lowerpain scores and better functional status.As shown in Table III, significant positive relationships were foundbetween internal control and swollen and tender joint status ( r =0.16) and external control and swollen and tender joint status ( r  = 0.15). Although these findings indicate small but significantcorrelations, it demonstrates that despite the subjects’ belief thatthey are able to control the disease they still have increased jointinvolvement. In addition, those subjects who believed factors out-side the individual played a greater role in controlling the dis-ease also had increased joint involvement. Psychological con-trol, therefore, may not be as significant as biological factorsduring symptom flare-ups, or it is possible that psychological fac-tors played a role in an unexpected direction. Whether there is aperception of greater internal or external control in this sampledid not make a difference to joint involvement.The only significant correlation with coping variables was foundbetween negative-internal coping and joint status ( r = –0.27)indicating that an increased negative style of coping was asso-ciated with poor joint status. Multivariate analysis Multivariate analysis was conducted to construct predictive mod-els of the factors that contribute to each of the DVs associatedwith RA, namely self-report of pain and functional status, andswollen and tender joint status. A hierarchical method of analysiswas employed whereby the variance associated with factorswhich deemed causally prior, which have been termed IVs, waspartialled out before the effect of other psychological variableswas examined. A mixture of analysis of variance and hierarchi-cal multiple regression analysis 21 was used to isolate the predic-tors of each of the two DVs, namely pain and functional status. Atwo-step procedure was used to develop a model for eachdependent variable. Step one All the IVs found to be significantly related to the DV in the bivari-ate analysis were entered into the regression analysis, and astepwise procedure was employed to determine which variableremained in the final model. Step two All the psychological variables found to be significantly related tothe DV in the bivariate analysis were entered into the regressionanalysis next, as a set, after the IV. A stepwise procedure wasemployed once again to determine which variable remained inthe final model.By means of this two-stage process it was possible to developpredictive models for each DV, where the psychological vari-ables were only entered once the variance for the socio- demo-graphic variables had already been partialled out. There was one minor difficulty in developing the models. Therewere two sets of categorical variables among both the IVs (mari-tal status and religion) and the psychological variables (CA_Oand CA_R — causal attributions made by the subjects at the timeof onset of the disease and causal attributions made at the timethe study was conducted, respectively) which could not simply beentered into the regression analysis. On completion of step one,regression residuals were computed, and these were used asDVs in two one-way ANOVAS, to determine whether marital sta-tus and religion were also significant predictors. In no instanceswere these found to be significant. The results of the first analysis are reported in Table IV. The results of the multiple regression analyses for each of the DVsare presented below. Regression models Predictive model one: self-report of pain and func-tional status The partial correlations (partial r  ) presented in Table IV indicatewhich socio-demographic and psychological variables are sig- Volume 10 No. 4 December 2004 - SAJP
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