Clin Rheumatol DOI 10.1007/s10067-015-2896-z
ORIGINAL ARTICLE
Sociodemographic factors associated with functional disability in outpatients with rheumatoid arthritis in Southwest China Shangping Zhao & Yanling Chen & Hong Chen
Received: 12 September 2014 / Revised: 29 January 2015 / Accepted: 4 February 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract With the rising number of patients with rheumatoid arthritis (RA), there is a limited understanding about sociodemographic factors that influence functional disability in Chinese patients. In order to provide more targeted interventions to improve health-related quality of life (HRQoL) for patients with RA, we conducted a cross-sectional study to investigate the level and influencing factors of functional disability. Convenient samples were collected in outpatients with RA from a rheumatological center in southwest China from September to December 2013. Data were collected by printed questionnaires, and functional disability was measured by the Health Assessment Questionnaire Disability Index (HAQDI). The results showed that 58.48 % of 607 outpatients had functional disability. Patients from rural residents, with lower household income and lower education level, were significantly associated with worse functional disability. Multivariate regression findings showed that pain, age, disease duration, total cost for treatment, and frequency of hospitalization were positively associated with functional disability. Meanwhile, subjective and available social support was the protective predictors for functional disability. The results suggested that systematic intervention and therapies should be provided as early as possible. Patients and health care providers should promote the awareness of the importance of accessible health education in early intervention of RA. Besides, pain management and social support are encouraged to postpone the proS. Zhao : H. Chen (*) West China School of Nursing & Department of Nursing, West China Hospital, Sichuan University, No. 37, Guoxuexiang, Wuhou District, Chengdu, Sichuan 610041, People’s Republic of China e-mail: [email protected] Y. Chen Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No. 37, Guoxuexiang, Wuhou District, Chengdu, Sichuan 610041, People’s Republic of China
cess of disability of patients and improve the HRQoL. Lastly, but not least, prevention and intervention of RA should be incorporated into public health education. Keywords Chinese . Disease duration . Functional disability . Household income . Pain . Rheumatoid arthritis . Social support
Introduction Rheumatoid arthritis (RA) is a chronic, autoimmune, inflammatory, and progressive disease that is complicated by functional disability and mental disturbance [1, 2]. A systematic review showed that the prevalence of RA in Chinese people was about 0.42 % [3]. Similarly, China Health Statistical Digest (2012) reported that RA was the fourth common chronic disease in China with a morbidity rate of 1.02 % [4]. Even worse, the incidence of functional disability in RA can reach up to 20 % within 1 year and 60 % within 10 years [5]. With the rapidly increasing disease burden of RA around the world [6], preventing functional disability is an urgent mission for both patients and health care providers. However, both of them ignored or despised the factors related to functional disability in the clinical practice [7, 8]. No conclusive therapies have been shown to prevent disability nowadays, even though therapies and disease activity had significant effect on disability. Worse physical function may be associated with sociodemographic factors such as elder age, longer disease duration, a lower education level, being single, and female [9, 10]. Functional disability was also positively associated with pain intensity and fatigue severity and negatively correlated with social support [11–13]. Studies of RA-related functional disability in developed countries reported some controversial conclusions on sociodemographic factors probably for different socioeconomic status and
Clin Rheumatol
ethnicity. In addition, as functional disability negatively affects health-related quality of life (HRQoL) [14], it is important to promote patients’ self-protection awareness of RA. Since there is a limited understanding about the sociodemographic factors especially in residence, household income, cost of therapy, and social support, which may associated with functional disability in Chinese patients with RA, we aimed to describe the level of functional disability and to identify the sociodemographic factors of functional disability in this population. Having an improved understanding of sociodemographic factors, health care providers may be able to provide individualized and specific interventions for maximally improving the HRQoL of patients.
Demographic data
Material and methods
Demographic variables that had possible correlation with functional disability were collected. General data include age, gender, marital status (single, married, divorced, or widowed), education level (primary school or below, junior high school, senior high school, or college or above), and residence (urban, suburban, or rural). Financial data included household income monthly per capita (HIMPC, $), total cost of therapy (TCT, money self-estimated spending on RA treatment till study enrollment including medication, hospitalization, and other non-surgery treatment but without surgery) and medical payment approaches (self paying, medical insurance, or new rural cooperative medical insurance (NRCM)). Disease-related data included disease duration (months between diagnosis by physician and study enrollment) and frequency of hospitalization.
Study design
Social support
The study was a cross-sectional survey. West China Hospital Medical Ethics Committee approved the study. All patients provided written informed consent before their participation in the study.
Social support was assessed by the Social Support Rating Scale (SSRS) [16]. The SSRS includes ten items in objective support (three items), subjective support (four items), and available social support (four items). The total score ranges from 12 to 66. Cronbach’s α of the total SSRS and its subscales were 0.896, 0.849, 0.825, and 0.833, respectively [17]. Higher scores indicate higher social support.
Patients Patients were recruited by convenience sampling from the Rheumatic Outpatient Clinic of West China Hospital Sichuan University, a rheumatologic center in southwest China (Chengdu, China). Individuals who met the diagnosis of the 1987 American College of Rheumatology revised criteria by their rheumatologist [15], were 18 years old or above, had no mental illness and severe cognitive impairment, and had no difficulty in communicating were included. Excluded criteria included having other diseases or surgery which significantly affect physical function (e.g., other severe osteoarthritis, paralysis, or joint replacement experience) or unwilling to participate.
Assessment methods Printed questionnaires were distributed to patients at their routine outpatient visit from September to December 2013. Six research assistants (RAs) received training before the data collection and collected the questionnaire via a face-to-face interview. They assisted the collection process and answered questions under a unified explanation of questionnaire. Patients completed questionnaire independently. RAs checked the accuracy and completeness of the questionnaires immediately after patients finished it.
Pain and fatigue Pain and fatigue were assessed by Visual Analog Scale (VAS), which was widely used in arthritis researches [18, 19]. VAS ranges from 0 (no pain/fatigue) to 10 (extremely pain/fatigue as it cannot endure) to rate the average severity of RA-related pain/fatigue experienced in the previous week. Score 1 to 3, 4 to 6, and 7 to 10 indicate mild, moderate, and severe pain, respectively [20]. Severe fatigue is rated as score higher than 5 [21]. Functional disability Health Assessment Questionnaire Disability Index (HAQ-DI) measured the functional disability of RA, including 20 items from eight dimensions: dressing and grooming, arising, eating, walking, hygiene, reaching, gripping, and other activities [22]. HAQ-DI describes the disability of rheumatic disease patients widely in the preceding week with satisfying reliability and validity [23, 24]. Scores are rated by patients on a 4-point Likert scale where 0=without any difficulty, 1=with some difficulty, 2=with much difficulty, and 3=unable to do. Score was from 0 to 3. Higher score of HAQ-DI reflects worse function. Any score higher than 0 is regarded as functional disability. Score 0 to 1 (0
ORIGINAL ARTICLE
Sociodemographic factors associated with functional disability in outpatients with rheumatoid arthritis in Southwest China Shangping Zhao & Yanling Chen & Hong Chen
Received: 12 September 2014 / Revised: 29 January 2015 / Accepted: 4 February 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract With the rising number of patients with rheumatoid arthritis (RA), there is a limited understanding about sociodemographic factors that influence functional disability in Chinese patients. In order to provide more targeted interventions to improve health-related quality of life (HRQoL) for patients with RA, we conducted a cross-sectional study to investigate the level and influencing factors of functional disability. Convenient samples were collected in outpatients with RA from a rheumatological center in southwest China from September to December 2013. Data were collected by printed questionnaires, and functional disability was measured by the Health Assessment Questionnaire Disability Index (HAQDI). The results showed that 58.48 % of 607 outpatients had functional disability. Patients from rural residents, with lower household income and lower education level, were significantly associated with worse functional disability. Multivariate regression findings showed that pain, age, disease duration, total cost for treatment, and frequency of hospitalization were positively associated with functional disability. Meanwhile, subjective and available social support was the protective predictors for functional disability. The results suggested that systematic intervention and therapies should be provided as early as possible. Patients and health care providers should promote the awareness of the importance of accessible health education in early intervention of RA. Besides, pain management and social support are encouraged to postpone the proS. Zhao : H. Chen (*) West China School of Nursing & Department of Nursing, West China Hospital, Sichuan University, No. 37, Guoxuexiang, Wuhou District, Chengdu, Sichuan 610041, People’s Republic of China e-mail: [email protected] Y. Chen Department of Rheumatology and Immunology, West China Hospital, Sichuan University, No. 37, Guoxuexiang, Wuhou District, Chengdu, Sichuan 610041, People’s Republic of China
cess of disability of patients and improve the HRQoL. Lastly, but not least, prevention and intervention of RA should be incorporated into public health education. Keywords Chinese . Disease duration . Functional disability . Household income . Pain . Rheumatoid arthritis . Social support
Introduction Rheumatoid arthritis (RA) is a chronic, autoimmune, inflammatory, and progressive disease that is complicated by functional disability and mental disturbance [1, 2]. A systematic review showed that the prevalence of RA in Chinese people was about 0.42 % [3]. Similarly, China Health Statistical Digest (2012) reported that RA was the fourth common chronic disease in China with a morbidity rate of 1.02 % [4]. Even worse, the incidence of functional disability in RA can reach up to 20 % within 1 year and 60 % within 10 years [5]. With the rapidly increasing disease burden of RA around the world [6], preventing functional disability is an urgent mission for both patients and health care providers. However, both of them ignored or despised the factors related to functional disability in the clinical practice [7, 8]. No conclusive therapies have been shown to prevent disability nowadays, even though therapies and disease activity had significant effect on disability. Worse physical function may be associated with sociodemographic factors such as elder age, longer disease duration, a lower education level, being single, and female [9, 10]. Functional disability was also positively associated with pain intensity and fatigue severity and negatively correlated with social support [11–13]. Studies of RA-related functional disability in developed countries reported some controversial conclusions on sociodemographic factors probably for different socioeconomic status and
Clin Rheumatol
ethnicity. In addition, as functional disability negatively affects health-related quality of life (HRQoL) [14], it is important to promote patients’ self-protection awareness of RA. Since there is a limited understanding about the sociodemographic factors especially in residence, household income, cost of therapy, and social support, which may associated with functional disability in Chinese patients with RA, we aimed to describe the level of functional disability and to identify the sociodemographic factors of functional disability in this population. Having an improved understanding of sociodemographic factors, health care providers may be able to provide individualized and specific interventions for maximally improving the HRQoL of patients.
Demographic data
Material and methods
Demographic variables that had possible correlation with functional disability were collected. General data include age, gender, marital status (single, married, divorced, or widowed), education level (primary school or below, junior high school, senior high school, or college or above), and residence (urban, suburban, or rural). Financial data included household income monthly per capita (HIMPC, $), total cost of therapy (TCT, money self-estimated spending on RA treatment till study enrollment including medication, hospitalization, and other non-surgery treatment but without surgery) and medical payment approaches (self paying, medical insurance, or new rural cooperative medical insurance (NRCM)). Disease-related data included disease duration (months between diagnosis by physician and study enrollment) and frequency of hospitalization.
Study design
Social support
The study was a cross-sectional survey. West China Hospital Medical Ethics Committee approved the study. All patients provided written informed consent before their participation in the study.
Social support was assessed by the Social Support Rating Scale (SSRS) [16]. The SSRS includes ten items in objective support (three items), subjective support (four items), and available social support (four items). The total score ranges from 12 to 66. Cronbach’s α of the total SSRS and its subscales were 0.896, 0.849, 0.825, and 0.833, respectively [17]. Higher scores indicate higher social support.
Patients Patients were recruited by convenience sampling from the Rheumatic Outpatient Clinic of West China Hospital Sichuan University, a rheumatologic center in southwest China (Chengdu, China). Individuals who met the diagnosis of the 1987 American College of Rheumatology revised criteria by their rheumatologist [15], were 18 years old or above, had no mental illness and severe cognitive impairment, and had no difficulty in communicating were included. Excluded criteria included having other diseases or surgery which significantly affect physical function (e.g., other severe osteoarthritis, paralysis, or joint replacement experience) or unwilling to participate.
Assessment methods Printed questionnaires were distributed to patients at their routine outpatient visit from September to December 2013. Six research assistants (RAs) received training before the data collection and collected the questionnaire via a face-to-face interview. They assisted the collection process and answered questions under a unified explanation of questionnaire. Patients completed questionnaire independently. RAs checked the accuracy and completeness of the questionnaires immediately after patients finished it.
Pain and fatigue Pain and fatigue were assessed by Visual Analog Scale (VAS), which was widely used in arthritis researches [18, 19]. VAS ranges from 0 (no pain/fatigue) to 10 (extremely pain/fatigue as it cannot endure) to rate the average severity of RA-related pain/fatigue experienced in the previous week. Score 1 to 3, 4 to 6, and 7 to 10 indicate mild, moderate, and severe pain, respectively [20]. Severe fatigue is rated as score higher than 5 [21]. Functional disability Health Assessment Questionnaire Disability Index (HAQ-DI) measured the functional disability of RA, including 20 items from eight dimensions: dressing and grooming, arising, eating, walking, hygiene, reaching, gripping, and other activities [22]. HAQ-DI describes the disability of rheumatic disease patients widely in the preceding week with satisfying reliability and validity [23, 24]. Scores are rated by patients on a 4-point Likert scale where 0=without any difficulty, 1=with some difficulty, 2=with much difficulty, and 3=unable to do. Score was from 0 to 3. Higher score of HAQ-DI reflects worse function. Any score higher than 0 is regarded as functional disability. Score 0 to 1 (0
