SEARCH

SEARCH BY CITATION

Keywords:

  • Rheumatoid arthritis;
  • Spouses;
  • Patient education;
  • Self management

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Objective

To determine the effects of group education followed by booster sessions for people with rheumatoid arthritis (RA), and to determine whether participation of a significant other influenced the effects.

Methods

A total of 218 RA patients, each of them with a partner, took part in the study. Two-thirds of the patients received a 5-week group self-management education program, with booster sessions after 3, 6, and 9 months; half of them received the intervention with a partner, and half without. One-third of the patients received the same educational materials without group sessions. Data were collected 1 week before the group sessions began and 2, 6, and 12 months later. The assessments included health behavior, arthritis self-efficacy, health status, and social interactions.

Results

After 12 months, self-efficacy scores for coping with other symptoms were significantly higher for patients participating in the group education without a partner and significantly lower for patients participating in the group education with a partner. Fatigue increased in patients participating in the group education with a significant other and decreased in patients participating in the group education without a significant other. No other effects were found on health status, health behavior, or social interactions.

Conclusion

Our findings suggest that participation of a significant other in psychoeducational programs does not have only positive effects. Instead of stimulating patients to adopt beneficial health behaviors and increase their self-efficacy expectations, participation of a significant other led in our program to decreases in self-efficacy and increased fatigue, whereas patients participating in group education without partners showed increases in self-efficacy and decreased fatigue. Booster sessions did not seem to influence results.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Rheumatoid arthritis (RA) is a chronic, disabling disease characterized by chronic inflammation of joints, in most patients resulting in progressive joint destruction with deformities and various degrees of incapacitation (1). Disease activity can vary considerably, even from day to day. The unpredictable and painful course of the disease causes a lot of stress for patients, which has great impact on their quality of life (2).

People with arthritis can play an important part in the management of their disease. Patient education can help them to develop the necessary self-management skills and prepare them to make decisions about adjustments in their treatment regimen (3, 4). Several studies have shown that patient education can increase knowledge and lead to improvements in self management practices and health status (3, 5–10). However, a review of group education for RA patients showed that benefits were limited. Group education interventions for RA patients less often showed beneficial effects on health behavior and physical and psychosocial health status than group interventions for populations with mixed rheumatic diseases (10). This is in line with a recent Cochrane systematic review of 39 randomized clinical trials of patient education for people with RA (11). Small short-term effects (5–13% improvement) were found on patient global assessment, disability, joint counts, and psychological status. No significant short-term effects were found on pain, disease activity, anxiety, and depression; no long-term benefits were found. Effects on health behavior were not evaluated in this review. To explore what types of educational interventions are effective for RA patients and which factors can improve the benefits, the causal relationships between intervention and outcome should be clarified. Therefore, it is necessary to investigate factors that may facilitate or mediate these beneficial effects (3, 4, 6, 7, 9, 10, 12).

An important factor in behavioral change is perceived self-efficacy. Perceived self-efficacy can be defined as “people's judgements of their capabilities to organize and execute courses of action required to attain designated types of performances. It is concerned not with the skills one has but with judgements of what one can do with whatever skills one possesses” (13). In a previous study, we found that among patients with RA, perceived self-efficacy is an important determinant of compliance with health recommendations and of such health outcomes as pain and disability (14). Other studies have also found associations between perceived self-efficacy and health status among arthritis patients (9, 15–18). The Arthritis Self-Management Program (ASMP) developed by Kate Lorig and colleagues has been shown to result in increased knowledge, more consistent performance of health practices, and reductions in pain (12, 19, 20). Reductions in pain and in number of visits to physicians persisted up to 4 years after participation in the ASMP, despite the increasing physical disability of the patients (21). Lorig et al (17) showed that both perceived self-efficacy and health outcomes improved during the course of the ASMP and that the improvements were significantly correlated.

For patients with RA, who often are dependent to some extent on spouses, partners, or close relatives for the fulfillment of daily tasks, developing adequate self management behavior is a process that involves social interaction. The perceptions of the patients' spouses or other close relatives of the capacities of the patient to cope with the consequences of the disease may be an important factor in that process (4, 13). The performance of adequate self management depends in part on the support patients receive from their spouses or close relatives. The active participation of family members of arthritis patients in self-management education programs may positively influence their opinions with regard to the patients' capacities. In the ASMP, patients can participate with a family member if they wish, but there has been no report of whether such participation leads to any additional benefits.

The effects of psychoeducational interventions for arthritis patients on physical and psychosocial health status rarely are maintained over long intervals (9, 10). One possibility to improve the long-term effects of psychoeducational interventions is the inclusion of booster sessions held every few months after the initial educational intervention (10).

Taal et al (22) have developed and evaluated a Dutch self-management program for RA patients that was based on Bandura's self-efficacy theory (13) and the ASMP (19). This program has been evaluated and showed positive effects on knowledge, outcome expectations, perceived self-efficacy with respect to function, the practice of relaxation and physical exercises, self-management behavior, joint tenderness, and self reported disability (22). After 14 months, there were still effects on knowledge, the practice of physical exercises, and self-efficacy, but any other effects were not maintained over 14 months. In this study, it was also examined whether the participation of spouses in educational group sessions for RA patients led to additional beneficial effects (23). Data were collected from 27 RA patients who participated in the group education program at baseline, after 6 weeks, 4 months, and 14 months. Spouses were invited to participate. The spouses of 10 patients participated in the group sessions. Statistically significant beneficial effects of spouse's participation were found on social support, self-efficacy, practice of endurance exercises, and self-management activities. However, the study population was small, and spouse participation was not experimentally manipulated. It was concluded that spouse participation may improve effects of patient education but further methodologically sound studies on this topic were needed.

We have developed a revised Dutch arthritis self-management group education program in which RA patients can participate with a significant other (in most cases the spouse). Furthermore, 3 booster sessions after 3, 6, and 9 months were included in the program to improve long-term effects. The goal of the program was to strengthen self-efficacy and self-management behavior with respect to pain and other physical and psychosocial consequences of RA. The emphasis was on learning and applying skills. The main differences between the original Dutch program and the revised program were that booster sessions were included; patients participating alone and patients participating with a significant other were randomly assigned to separate conditions; all significant others were asked to fill out questionnaires; and RA patients were not referred to a physiotherapist for an individual exercise program. The development of an individual exercise program was part of the program itself.

The primary aims of this study were to assess the effects of participation in the psychoeducational group program and the effects of participation of patients' significant others on RA patients' self-efficacy and health behavior; and the long-term maintenance of short-term effects by booster sessions.

It is expected that changes in self-efficacy and health behavior will eventually lead to changes in health status (pain, disability, psychological well being). Furthermore, we expected that participation of significant others would improve the social interactions between patients and their significant others, and that patients would perceive improved support from them.

Secondary aims of our study were to assess the effects of participation in the program on RA patients' health status (pain, disability, fatigue, psychological well being) and perceived social support and overprotection.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

The group program

The program consisted of 5 weekly 2-hour group sessions for 8 patients, with or without a significant other. The program included 3 2-hour booster sessions after 3, 6, and 9 months. Each group had 2 trained leaders: a specialized arthritis nurse and a nurse with experience in working with RA patients. To ensure treatment integrity and adequate execution of the program, the leaders received 2 days of training and a teaching manual. This manual contained detailed instructions for the administration of the various parts of the group education in each session. The various parts of the program and the instructions for administration were discussed extensively with the group leaders during the 2 days of training. Patients received a program book with information on the sessions, a self-help guide, various brochures on RA, and an audiotape with relaxation exercises.

The program included the following components:

Contracting, goal setting, and feedback

Contracts and goal setting were systematically used to stimulate the practicing of exercises at home. At the end of every session, patients stated their goal for the next week in a written contract. At the beginning of every next session, feedback was given. Results of and problems with contracts were discussed. Patients were encouraged to solve problems themselves. Significant others who participated in the group education program also wrote contracts for themselves at the end of every session, and patients and significant others were stimulated to support each other with the fulfillment of the contracts

Self management and problem solving

Participants received the explanation that self-management often means solving of problems one has due to the disease, like pain or functional impairments. Problem solving techniques were exercised. Patients received homework instructions on problem solving

Information on RA and treatment

Minimal facts were taught during sessions, but sources were mentioned for further information and written materials on RA were handed out. Patients were instructed how to read this information and, for example, guidelines were given to evaluate different methods of treatment, including complementary medicine

Pain management and relaxation

Information was given about the relationships between pain, muscle tension, stress, and depression and cognitive methods of pain management. Extensive information was given on relaxation as a method of pain management. During every session, relaxation exercises were practiced and patients were advised to perform these exercises at home using the audiotape they received. During all sessions, exercises were practiced based on Jacobson's progressive relaxation (24). With this method, muscles were alternately tightened and relaxed, thus one learns how it feels to be relaxed and to be tense, and how one can induce relaxation. In session 5, this exercise is extended with guided imagery, a kind of daydream where patients are asked to imagine that they are in a beautiful flower garden

Physical exercises

Information was given on exercises and patients were encouraged to exercise at home

Communication skills

Patients were given insight in communication processes. Furthermore, problems in doctor–patient communication were discussed

Coping with depression

Methods were discussed to cope with depression and how to cope with feelings associated with life-threatening conditions. It was emphasized to maintain social contacts and daily activities

Booster sessions

In the booster sessions, the accomplishments of goals and problems during the past 3 months were discussed and feedback was given. In each booster session some topics were reiterated, a relaxation exercise was practiced, goals were set for the coming months, and contracts were written

Respondents and procedure

Our study was performed with 218 RA patients, selected from the outpatient clinics of all 7 rheumatologists from 2 hospitals in the province of Twente, the Netherlands. First, all outpatients in Twente satisfying at least 4 of the 1987 American College of Rheumatology (ACR, formerly American Rheumatism Association) criteria for RA (25) were selected from the Standard Diagnosis Register of rheumatic diseases in the Netherlands (26). They were asked by their rheumatologists to participate in a study on education for arthritis patients. Patients were only allowed to participate in the study if their significant other was also willing to participate in the study. The exclusion criteria were: residence in a nursing home and age younger than 20 years or older than 70 years. Out of 825 RA patients, 238 returned a form stating that they agreed to participate. These participants were randomly assigned to 3 groups. Seventy-nine respondents were allocated to the education group with participation of their significant other (GESO); 80 respondents were allocated to the education group for patients only (GE); and 79 respondents were allocated to the control group receiving the self-help guide without group session (C). A composite questionnaire was posted to each participating patient. Four respondents were unable to find time for the education program, 5 were admitted to hospital when the education program started, and 11 did not want to fill out the questionnaire. A total of 218 respondents returned the questionnaires at baseline

Measures

Patients were asked to fill out questionnaires and to come to the hospital for clinical measures. The questionnaires were administered at 4 moments: before the intervention, immediately after the intervention, and after 6 and 12 months. The clinical measures were administered at 3 moments: before the intervention, after 6 months, and after 12 months.

Primary outcome measures were self-efficacy and health behavior.

Self efficacy

A Dutch version of the Arthritis Self-Efficacy Scale (17, 22) was used to measure patient's perceived ability to perform specific behaviors aimed at controlling disability, pain, and other symptoms associated with arthritis. It has 3 subscales: self-efficacy related to physical function (9 items); self-efficacy related to coping with pain (5 items); and self-efficacy related to coping with other symptoms such as depression, fatigue, and frustration (6 items). The 3 subscales had good internal consistency (α = 0.90, 0.84, and 0.88, respectively). Items were completed by indicating to what extent one agreed with the statements given on a 5-point scale, where 1 = thoroughly disagree and 5 = thoroughly agree. Mean scores for the 3 scales were calculated

Health behavior

Health behavior was assessed by asking patients how often (number of times per week and minutes per session) they performed relaxation exercises, physical exercises, or other physical activities such as swimming, walking, or bicycling. In this study, the third category is described as endurance exercises and results are expressed in minutes per week.

Self-management activities were measured with 7 items (e.g., “If you have pain, do you try to alleviate it by doing a relaxation exercise?”) to be answered on 5-point scales ranging from never (= 1) to always (= 5) (Cronbach's alpha = 0.63). A mean score for this scale was calculated.

To measure the degree to which people use active coping strategies, we used 2 scales from the Dutch CORS (Coping with Rheumatoid Stressors) (27). For active coping with limitations, we used the scale creative solutions (8 items; α = 0.95). Active coping with pain was assessed with the scale diverting attentions (8 items; α = 0.94). Response categories ranged from seldom or never (= 1) to very often (= 4). For both scales, a mean score has been calculated.

Secondary outcomes were health status and social interactions.

Health status

Disease activity was calculated by the disease activity score (DAS28) (28), comprising the erythrocyte sedimentation rate (Westergren method), number of tender joints, and number of swollen joints (total of 28 joints), and a visual analog scale (VAS) for general health status (range 0–100). The DAS28 ranges from 0 to 10, where 0 represents the lowest level of disease activity and 10 the highest. Joint counts were assessed by a physiotherapist who was blinded regarding subjects' treatment condition assignments.

To measure functional limitations, we used the combined physical function scale of the Dutch Arthritis Impact Measurement Scales 2 (Dutch-AIMS2) (29, 30). The physical function scale of the Dutch-AIMS2 comprises 6 subscales: mobility (5 items, α = 0.80); walking and bending (5 items, α = 0.73); hand and finger (5 items, α = 0.86); arm function (5 items, α = 0.83); self-care tasks (4 items, α = 0.85); and household tasks (4 items, α = 0.83). All items have 5 response categories ranging from every day to never or always to never. To obtain a subscale score, the scores on the individual items were first added together. The result was then converted into a score ranging from 0 to 10, where 0 represents good health and 10 poor health. The score for the overall physical function scale was the average of the scores for the subscales.

Pain was measured using the pain scale from the Dutch-AIMS2; this scale comprises 5 items, with each 5 response categories, ranging from every day to never. The scale showed good internal consistency (α = 0.84). To obtain a subscale score, the scores on the individual items were first added together. The result is then converted into a score ranging from 0 to 10, where 0 represents no pain and 10 severe pain.

To measure the psychological well being of patients, we used the affect scale of the Dutch-AIMS2. The scale comprised 2 subscales, level of tension (anxiety, α = 0.88) and mood (depression, α = 0.72). To obtain a subscale score, the scores on the individual items were first added together. The result was then converted into a score ranging from 0 to 10, where 0 represents good mental health and 10 poor mental health. The score for the overall affect scale was the average of the scores for the subscales.

Severity of fatigue was measured using a double-anchored VAS. The question read, “How tired were you on average during the past week due to your arthritis?” The range of the scale was 0 (not tired at all) to 100 (very tired) (31).

Social interactions

To measure perceived social support from the participating significant other, we used a Dutch translation of a scale developed by Revenson et al (32, 33). This scale includes 4 subscales measuring positive aspects of social support and 1 subscale measuring problematic aspects of social support. The first 4 are emotional support (5 items, e.g., “How often does your partner listen to you?” α= 0.88), esteem support (3 items, e.g., “How often does your partner make you feel you have something positive to contribute to others?” α = 0.81), informational support (5 items, e.g., “How often does your partner give you information or advice if you want it?” α = 0.84), and tangible support (3 items, e.g., “How often does your partner do small favors for you, e.g., picks up groceries or watches the children?” α = 0.86).

The subscale measuring problematic aspects of social support comprises 4 items (e.g., “Does it happen that your partner tries to change the way you are coping with your illness in a way you don't like?” α = 0.87). Response categories for all support scales ranged from seldom or never (= 1) to often (= 4). For all support scales a mean score has been calculated.

Another aspect of problematic social support is overprotection. This was measured using a self-developed scale comprising 4 statements (e.g., “My partner takes work off my hands that I can do myself”, α = 0.87). Each statement had 5 possible responses ranging from totally agree to totally disagree. The scores range from 1 (little overprotection) to 5 (very much overprotection).

Treatment credibility

To assure that the 2 education groups (GESO and GE) were equally credible, several questions were included in the questionnaire administered directly after the intervention. Patients in the 2 education groups were asked to judge the entire group program and the group sessions on 5-point scales regarding the following 5 aspects: bad/good; incomprehensible/comprehensible; not instructive/instructive; incomplete/complete; not useful/useful. Mean scores were calculated for these scales (α = 0.82 and α = 0.79, respectively). Furthermore, patients were asked to indicate to what extent they agreed with the following 2 statements on a 5-point scale ranging from thoroughly disagree (= 1) to thoroughly agree (= 5): By participating in the group sessions I'm now more able to manage the consequences of my arthritis. I would advise other people with RA to participate in this group program.

To ensure that the self-help guide was judged equally credible in all 3 groups (GESO, GE, and C) patients in all 3 groups were asked to judge the self-help guide on 5-point scales regarding 4 aspects: incomprehensible/comprehensible; not instructive/instructive; incomplete/complete; not useful/useful. A mean score was calculated for this scale (α = 0.73). Also, patients in all 3 groups were asked to indicate to what extent they agreed with the following 2 statements on a 5-point scale ranging from thoroughly disagree (= 1) to thoroughly agree (= 5): By reading the self-help guide, I'm now more able to manage the consequences of my arthritis. I would advise other people with RA to read the self-help guide.

Group leader competence

To evaluate group leaders' competence, patients in the 2 educational groups were asked to rate the group leaders on 5-point scales regarding 5 aspects: incredible/credible; incompetent/competent; demotivating/motivating; not convincing/convincing; bad/good. A mean score was calculated for this scale (α = 0.91).

Statistics

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS for Windows 8.0; SPSS, Chicago, IL). Data were analyzed on an intention-to-treat basis.

To test whether the educational group with participation of a significant other was as credible as the educational group for patients only, Mann-Whitney U tests were applied on the credibility questions. To assess whether all 3 groups judged the self-help guide as equally credible, Kruskal-Wallis tests were applied. To evaluate group leaders' competence, mean scores were calculated for the competence measure and differences between the 2 educational groups were tested with a Mann-Whitney U test.

Differences at baseline between the 3 conditions were analyzed with univariate analyses of variance (one way) for rational variables and chi-square tests for ordinal variables. Variables that did not have a normal distribution (relaxation exercise, physical exercise, endurance exercise, problematic support, and overprotection) were first transformed into variables with a normal distribution by means of a logarithmic or exponential transformation. For relaxation exercise, normalization did not succeed due to extreme skewness. Differences at baseline for this variable were analyzed with a nonparametric test (Kruskal-Wallis). The level of significance for these analyses was set at P < 0.01.

Differences at baseline between patients who completed the 12-month study and patients who had dropped out of the study between baseline and 12 months were analyzed with chi-square tests for ordinal variables, t-tests for rational variables with a normal distribution, and a Mann-Whitney U test for relaxation exercises. The level of significance for these analyses was set at P < 0.01.

Effects after 2, 6, and 12 months were analyzed with analysis of covariance, with baseline scores of the outcome variable and variables with significant (P < 0.01) differences at baseline as covariates. When the F test result was significant, post-hoc multiple comparisons were calculated for the differences between all 3 experimental groups. When any of the assumptions for performing parametric analysis of covariance (homogeneity of variance and parallelism of regression) were violated, we performed nonparametric analysis of covariance (34, 35). Residuals are calculated by multiple linear regression analysis with the outcome variable of interest as dependent variable and the covariates as independent variables. The residuals are then used as data points in a nonparametric Kruskal-Wallis test. When this test result was significant, differences between all 3 experimental groups were tested with a nonparametric Mann-Whitney test. For relaxation exercises, change scores were calculated between baseline and posttests. Differences in gain scores between the 3 groups were analyzed with the nonparametric Kruskal-Wallis test.

The significance level for all effect analyses in this study were set at P < 0.05 after adjustment for multiple testing by the Holm procedure (36, 37).

Ethics

The ethics committee of the Medisch Spectrum Twente Hospital in Enschede, The Netherlands, approved the study.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Background characteristics

There were no significant differences in background characteristics between patients in the 3 groups (Table 1).

Table 1. Background characteristics of RA patients in 3 conditions*
 GESO (n = 71)GE (n = 71)C (n = 76)Total
  • *

    RA = rheumatoid arthritis; GESO = group education with a significant other; GE = group education without a significant other; C = controls.

Sex, female, %58666262
Education
 Lower, %27102220
 Medium, %46445147
 Higher, %27472734
 No. missing134
Marital status, married, %93908790
Comorbidities, none, %42585853
Age, mean ± SD, years57.2 ± 10.355.1 ± 10.357.0 ± 8.356.4 ± 9.6
Disease duration, mean ± SD, years12.1 ± 9.311.7 ± 11.111.4 ± 8.911.7 ± 9.8

Most patients participated in the study with their spouse (88%). The other patients participated with a close relative (10%) or a good friend (2%). Of the significant others, 46% were female. Their highest level of education completed was primary school for 17%, junior vocational school for 51%, and 32% had been educated to senior vocational school level or higher. The mean (±SD) age of the significant others was 55.1 years (± 11.4 years) with a range between 17 and 78 years.

Treatment credibility and competence of group leaders

Patients in all groups had a positive judgment about the credibility of the group program and the self-help guide (Table 2), and there were no significant differences in the mean scores between the groups. The group leaders were judged to be highly competent and not significantly different by the patients in both educational groups (mean score = 4.3 in both educational groups).

Table 2. Credibility of group education programs and self help guide in 3 conditions*
 GESOGEC
  • *

    Scores range from 1 (negative) to 5 (positive). There were no significant differences between groups tested with Mann-Whitney U tests (group program) or Kruskal-Wallis tests (self-help guide). See Table 1 for definitions. The group leaders were judged to be highly competent and not significantly different by the patients in both educational groups (mean score = 4.3 in both educational groups).

Group program
 Judgment entire group program3.84.0
 Judgment group sessions3.94.0
 By participating in the group sessions I'm now more able to manage the consequences of my arthritis3.33.6
I would advise other people with RA to participate in this group program4.14.4
Self-help guide
 Judgment self-help guide4.24.24.3
 By reading the self-help guide I'm now more able to manage the consequences of my arthritis3.53.63.8
I would advise other people with RA to read the self-help guide4.54.54.7

Baseline scores on outcome measures

Scores at baseline on self-efficacy, health behavior, health status, and social aspects for each of the 3 conditions are presented in Table 3. There were significant differences between the 3 groups for coping with pain (F[2,205] = 5.38, P = 0.005) and perceived problematic support (F[2,211] = 5.22, P = 0.006). Control respondents used significantly more active coping resources in coping with pain (P = 0.004) and perceived significantly more problematic social support (P = 0.005) compared with RA patients participating in the group education with their significant others.

Table 3. Baseline mean scores and standard deviations of patients with rheumatoid arthritis in 3 conditions*
 GESO mean (SD) (n = 71)GE mean (SD) (n = 71)C mean (SD) (n = 76)All mean (SD)
  • *

    DAS28 = disease activity score; AIMS2 = Arthritis Impact Measurement Scales 2; VAS = visual analog scale. See Table 1 for additional definitions.

  • P < 0.01.

Self efficacy
 Function3.6 (1.1)3.8 (1.1)3.7 (1.1)3.7 (1.1)
 Pain3.1 (0.9)3.2 (1.0)3.4 (0.9)3.2 (0.9)
 Other symptoms3.6 (0.9)3.6 (0.8)3.8 (0.8)3.7 (0.8)
Behavior
 Endurance exercises210.0 (189.4)287.8 (281.2)279.9 (254.0)261.2 (247.6)
 Physical exercises19.1 (37.9)29.9 (61.5)34.5 (136.5)28.0 (90.8)
 Relaxation exercises5.2 (14.7)23.9 (69.3)8.2 (24.4)12.5 (43.7)
 Self management3.6 (0.5)3.8 (0.6)3.7 (0.5)3.7 (0.6)
 Coping with limitations2.4 (0.7)2.5 (0.7)2.5 (0.6)2.4 (0.7)
 Coping with pain2.0 (0.6)2.2 (0.6)2.4 (0.6)2.2 (0.6)
Social interactions
 Emotional support3.3 (0.6)3.2 (0.6)3.1 (0.7)3.2 (0.6)
 Esteem support3.0 (0.7)2.9 (0.8)2.8 (0.7)2.9 (0.7)
 Informative support2.7 (0.7)2.7 (0.7)2.7 (0.7)2.7 (0.7)
 Tangible support3.3 (0.7)3.3 (0.7)3.2 (0.7)3.2 (0.7)
 Problematic support1.5 (0.5)1.6 (0.4)1.8 (0.7)1.6 (0.6)
 Overprotection1.8 (0.9)1.7 (0.8)1.8 (0.9)1.8 (0.9)
Health status
 DAS284.4 (1.2)3.7 (1.2)3.9 (1.4)4.0 (1.3)
 AIMS2—physical2.6 (1.6)2.4 (1.7)2.4 (1.5)2.5 (1.6)
 AIMS2—pain5.4 (1.7)5.2 (2.3)5.4 (2.2)5.3 (2.1)
 AIMS2—affect3.1 (1.4)3.2 (1.5)3.1 (1.4)3.1 (1.4)
 VAS—fatigue38.6 (20.8)43.9 (24.3)40.8 (21.9)41.1 (22.4)

Between baseline and the 12-month evaluation, 37 patients (17%) dropped out of the study. At baseline, there were no significant differences between patients who completed the 12-month study and the dropouts.

Effects on self-efficacy and health behavior

After 2 and 6 months there were no significant effects on any measures of self-efficacy or health behavior, the primary outcome measures in our study (Table 4). At 6 months, there was only a trend for the practice of physical exercises (F[2,156] = 5.16, P = 0.06). Patients in both educational groups practiced physical exercises for more minutes per week than at baseline, and controls practiced less.

Table 4. Mean changes with standard deviations at 2 months, 6 months, and 12 months for primary outcomes (self-efficacy, behavior) in 3 conditions*
  GESOGECP
Δmean (SD)Δmean (SD)Δmean (SD)
  • *

    Number of subjects participating at the 2-month evaluation were GESO = 61, GE = 58, C = 73; at the 6-month evaluation: GESO = 56, GE = 58, C = 71; and at the 12-month evaluation: GESO = 54, GE = 57, C = 70. See Table 1 for definitions.

  • P values are significance levels after Holm adjustment for multiple testing from analyses of covariance on mean scores at 2, 6, and 12 months with baseline scores of outcome variable, coping with pain, and problematic support as covariates. Means in the same row that share subscripts differ at P < 0.05 after Holm adjustment for multiple testing in post hoc comparisons.

  • Nonparametric analysis of covariance was applied.

  • §

    Differences between groups in changes from baseline were analyzed with the nonparametric Kruskal-Wallis test.

Self-efficacy function2 months0.0 (0.5)0.0 (0.5)0.0 (0.5)>0.1
 6 months0.0 (0.6)0.0 (0.5)0.0 (0.6)>0.1
 12 months0.0 (0.7)0.0 (0.7)0.0 (0.7)>0.1
Self-efficacy pain2 months0.1 (0.7)0.0 (0.7)0.1 (0.8)>0.1
 6 months0.0 (0.7)0.3 (0.7)0.0 (0.8)>0.1
 12 months0.0 (0.7)0.3 (0.7)0.1 (0.8)0.06
Self-efficacy other symptoms2 months0.0 (0.6)0.0 (0.7)0.0 (0.7)>0.1
 6 months0.0 (0.7)0.2 (0.6)0.0 (0.6)>0.1
 12 months−0.2ab (0.7)0.3ac (0.7)0.0bc (0.7)0.000
Endurance exercises2 months−10.0 (148.6)−11.8 (248.8)64.8 (299.5)>0.1
 6 months6.3 (326.6)−71.6 (253.7)−3.4 (321.8)>0.1
 12 months−22.9 (135.4)−40.5 (272.6)−14.8 (213.5)>0.1
Physical exercises2 months3.6 (28.2)12.6 (31.9)−0.5 (84.2)>0.1
 6 months11.6 (48.4)14.7 (36.0)−3.4 (95.6)0.06
 12 months1.4 (35.8)9.6 (34.5)−2.8 (77.2)>0.1
Relaxation exercises2 months15.3 (36.0)1.9 (87.5)15.8 (105.4)>0.1§
 6 months2.3 (21.2)5.5 (62.1)4.7 (32.7)>0.1§
 12 months6.2 (31.3)2.6 (55.7)2.4 (27.0)>0.1§
Self management2 months0.2 (0.5)0.0 (0.4)0.1 (0.4)>0.1
 6 months0.2 (0.5)0.1 (0.6)0.0 (0.4)>0.1
 12 months0.0 (0.6)0.2 (0.5)0.1 (0.5)>0.1
Coping with limitations2 months0.1 (0.5)0.1 (0.6)0.1 (0.5)>0.1
 6 months0.0 (0.6)0.2 (0.5)0.0 (0.5)>0.1
 12 months0.1 (0.6)0.0 (0.6)0.0 (0.5)>0.1
Coping with pain2 months0.1 (0.6)0.1 (0.5)0.0 (0.6)>0.1
 6 months0.0 (0.6)0.2 (0.5)0.0 (0.6)>0.1
 12 months0.2 (0.6)0.1 (0.5)0.0 (0.6)>0.1

We did find a significant long-term effect after 12 months on self-efficacy other symptoms (F[2,155] = 9.58, P = 0.000). All differences between the 3 groups were significant (P < 0.05) in post hoc comparisons. Self-efficacy scores for coping with other symptoms improved in patients participating in the group education without a significant other and decreased in patients participating in the group education with their significant others, whereas control respondents had approximately the same scores as at baseline. There was a trend at 12 months for self-efficacy pain (F[2,156] = 5.06, P = 0.06). Self-efficacy scores increased in patients participating in group education without their significant others, whereas controls and patients participating in group education with their significant others had approximately the same scores as at baseline.

Effects on health status

After 2, 6, and 12 months there were no significant effects on disease activity (DAS28), physical function, pain, or affect (Table 5). At 6 months, there was a trend for fatigue (χ2 = 8.71, P = 0.07). Respondents participating in the group education with their significant others increased in levels of fatigue compared with both other groups. At 12 months, there was a significant effect on fatigue (χ2 = 12.15, P = 0.01). Differences between patients participating in the group education with their significant others and patients participating in the group education without their significant others (Z = 3.50, P = 0.001) and between patients participating in the group education with their significant others and controls (Z = 2.39, P = 0.04) were significant. Fatigue increased in patients participating in the group education with their significant others and decreased in patients participating in the group education without their significant others. Controls had approximately the same levels of fatigue as at baseline.

Table 5. Mean changes with standard deviations at 2 months, 6 months, and 12 months for disease activity and health status in 3 conditions*
  GESOGECP
Δmean (SD)Δmean (SD)Δmean (SD)
  • *

    Number of subjects participating at the 2-month evaluation were GESO = 61, GE = 58, C = 73; at the 6-month evaluation: GESO = 56, GE = 58, C = 71; and at the 12-month evaluation: GESO = 54, GE = 57, C = 70. See Table 1 for definitions.

  • P values are significance levels after Holm adjustment for multiple testing from analyses of covariance on mean scores at 2, 6, and 12 months with baseline scores of outcome variable, coping with pain, and problematic support as covariates. Means in the same row that share subscripts differ at P < 0.05 after Holm adjustment for multiple testing in post hoc comparisons.

  • Nonparametric analysis of covariance was applied.

DAS286 months−0.4 (1.1)0.0 (0.8)−0.2 (1.3)>0.1
 12 months−0.1 (1.0)0.0 (1.1)0.3 (1.3)>0.1
Physical function2 months−0.3 (0.7)−0.2 (0.7)−0.1 (0.8)>0.1
 6 months−0.2 (0.9)0.0 (0.8)−0.1 (0.9)>0.1
 12 months0.1 (1.2)−0.1 (0.8)0.0 (1.1)>0.1
Pain2 months−0.4 (1.5)−0.3 (1.8)−0.3 (1.5)>0.1
 6 months−0.4 (1.8)−0.5 (1.6)−0.3 (2.0)>0.1
 12 months0.0 (1.8)−0.4 (1.5)−0.4 (0.8)>0.1
Affect2 months0.0 (1.0)−0.1 (1.0)0.0 (1.0)>0.1
 6 months−0.3 (0.8)−0.2 (1.5)0.0 (1.0)>0.1
 12 months0.1 (1.3)−0.3 (1.3)−0.2 (1.0)>0.1
Fatigue2 months5.5 (17.4)−3.7 (17.0)−0.1 (19.8)>0.1
 6 months5.8 (20.6)−2.7 (21.5)0.6 (22.4)0.07
 12 months8.1ab (18.5)−4.8a (16.5)0.8b (20.5)0.01

Effects on social interactions

At 2, 6, and 12 months there were no significant effects on any measures of perceived positive and problematic support and overprotection (Table 6).

Table 6. Mean changes with standard deviations at 2 months, 6 months, and 12 months for social interactions in 3 conditions*
  GESOGECP
Δmean (SD)Δmean (SD)Δmean (SD)
  • *

    Number of subjects participating at the 2-month evaluation were GESO = 61, GE = 58, C = 73; at the 6-month evaluation: GESO = 56, GE = 58, C = 71; and at the 12-month evaluation: GESO = 54, GE = 57, C = 70.

  • values are significance levels after Holm adjustment for multiple testing from analyses of covariance on mean scores at 2, 6, and 12 months with baseline scores of outcome variable, coping with pain, and problematic support as covariates.

  • Nonparametric analysis of covariance was applied.

Emotional support2 months0.0 (0.5)0.0 (0.4)0.0 (0.5)>0.1
 6 months0.0 (0.4)0.0 (0.5)−0.1 (0.6)>0.1
 12 months0.0 (0.5)−0.1 (0.4)0.0 (0.5)>0.1
Esteem support2 months−0.2 (0.7)0.0 (0.7)0.0 (0.7)>0.1
 6 months0.0 (0.5)0.0 (0.7)0.0 (0.7)>0.1
 12 months0.0 (0.7)−0.2 (0.7)−0.1 (0.6)>0.1
Informational support2 months0.0 (0.7)0.0 (0.5)0.0 (0.5)>0.1
 6 months−0.1 (0.6)−0.2 (0.6)−0.2 (0.7)>0.1
 12 months−0.1 (0.6)−0.2 (0.7)−0.1 (0.6)>0.1
Tangible support2 months0.0 (0.7)−0.1 (0.5)−0.2 (0.6)>0.1
 6 months−0.1 (0.5)−0.1 (0.6)−0.1 (0.6)>0.1
 12 months0.0 (0.7)−0.2 (0.7)−0.1 (0.6)>0.1
Problematic support2 months0.0 (0.5)0.0 (0.3)−0.2 (0.7)>0.1
 6 months0.0 (0.6)−0.1 (0.4)−0.2 (0.8)>0.1
 12 months0.0 (0.7)0.0 (0.4)−0.2 (0.7)>0.1
Overprotection2 months0.2 (1.0)0.0 (0.9)−0.1 (0.8)>0.1
 6 months0.3 (1.0)0.0 (0.8)0.0 (0.8)>0.1‡
 12 months0.0 (0.9)0.0 (0.9)0.0 (0.8)>0.1

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

In this study we investigated the effects of a psychoeducational group program, followed by booster sessions, on health behavior, self-efficacy, health outcomes, and perceived social support of arthritis patients, and whether participation of a significant other influenced these effects. We expected that participation of significant others would lead to improved effects.

Our study showed limited effects of group education. Long-term effects after 6 and 12 months were found only for self-efficacy and fatigue. No effects were found on other aspects of health status, health behavior, and social interactions. This is in line with reviews of patient education for people with RA that showed, in general, that patient education has limited effects on physical and psychosocial health status and health behavior (10, 11). In earlier evaluations of the ASMP, both in The Netherlands (22) and in the United States (17, 19, 21) much more effects of group education were found.

Differences with the earlier Dutch study were the selection criteria: in the earlier study respondents were taking second-line medication for at most 8 years and their age was between 21 and 65 years. Therefore, respondents were more homogeneous and in better health compared with the current study. Also, in the earlier Dutch study, patients were referred to a physiotherapist for an individual exercise program, in the current program this was taught during the group sessions. Differences with the American studies may also be explained by the inclusion criteria. In the American studies, respondents were recruited through public service announcements. Therefore they were probably in better health and more motivated. Furthermore, not only people with RA participated in the American studies but also people with other rheumatic diseases; most participants were people with osteoarthritis. The American program was led by peer lay leaders, while health professionals led our program. Lay leaders may have been more stimulating or convincing, although Lorig et al found no differences when they examined the effects of lay leaders compared with professional leaders (38).

The limited effects of group education did not seem to be caused by low treatment integrity or low competence and performance of group leaders. Adequate execution of the program was assured by providing the group leaders a teaching manual with detailed instructions for the administration of the various parts of the group education in each session. Also, the various parts of the program and the instructions for administration were discussed extensively with the group leaders during 2 days of training. The patients in both educational groups judged the group leaders to be highly competent.

Contrary to what we expected, participation of significant others did not lead to improved effects. Instead of stimulating patients to adopt beneficial health behaviors and increase their self-efficacy expectations, participation of a significant other led in our program, in the long run, to decreases in self-efficacy for coping with other symptoms. Patients participating in group education without their partners showed increases in self-efficacy for coping with other symptoms. Also, fatigue increased in patients participating in the group education with a significant other and decreased in patients participating in the group education without a significant other. These effects were only found at 12 months and not directly after the intervention. This might indicate that the effects could have been due to chance or a confounder that was not accounted for in the analysis. However, the effects at 12 months were significant after controlling for multiple testing. If we calculate effect sizes (mean difference in changes from baseline between the groups divided by the pooled baseline standard deviation), we find effect sizes of 0.56 for self-efficacy and 0.53 for fatigue compared with education with a significant other, and 0.38 for self-efficacy and 0.26 for fatigue compared with the control group. These effect sizes are larger than the mean effect sizes that are found in the recent Cochrane systematic review of patient education for people with RA (significant effect size ranged from 0.14 for joint counts to 0.26 for patient global assessment) (11). Therefore, it is unlikely that the effects found were due to chance.

Differences in outcome between study groups can be caused by differences in treatment credibility between these groups. In this study, this seems not to be the case, as there were no differences in credibility judgments between the groups.

Ours is not the only psychoeducational program for arthritis patients in which family members can participate (19, 20, 39–47), but only 3, to the best of our knowledge, have evaluated the effects of such participation. Potts and Brandt (42) evaluated an educational support program for RA patients, which consisted of 4 weekly group sessions. They had anticipated that patients who were accompanied by family members would show greater improvement in their perceptions of their families' attitudes and behavior, but the results did not support this. Participation in the support groups increased patients' knowledge, but there was no change in their compliance with health recommendations or coping abilities. The sessions consisted of unstructured discussions, and the sessions did not include practical exercises.

Radojevic et al (47) considered the possible effects of involving a family member in their evaluation of the effects of a cognitive behavioral program for the enhancement of pain management skills on pain, psychological status, and disease activity in RA patients. Patients were randomly assigned to 1 of 4 groups. Patients in the first group received behavior therapy with family support, in which patients were taught coping skills and family members learned how to assist them with coping. Patients in the second group also received behavior therapy but family members did not participate. Together with members of their families, the third group attended 4 sessions in which videotaped information on RA was presented and discussed. This group education with family support did not include training of behavioral skills. The fourth group served as the control group and did not participate in any form of behavior therapy or education. After the interventions, the patients who had received behavior therapy with family support achieved significantly greater reductions in joint swelling and numbers of swollen joints than did the patients in the other 3 groups. Furthermore, the discussion groups with family support (which did not include training of behavioral skills) did not prove to be more effective than the control group with no treatment in promoting clinical gains.

Keefe et al (39) evaluated the effects of a spouse-assisted pain coping skills training (CST) intervention on pain, psychological disability, physical disability, pain coping, and pain behavior in patients with osteoarthritis of the knees. Their data analysis revealed that at the completion of treatment, patients in the spouse-assisted CST condition and patients who received CST without spouse involvement had significantly better scores on most outcome variables compared with patients in the arthritis education-spousal support control condition. Although results in the spouse-assisted CST condition were better than in the CST condition without spouse involvement, these differences were not significant.

The participation of family members did not enhance any of the beneficial effects of either unstructured group discussions (42) or educational sessions without skills training (47). A beneficial effect of spouse participation is only seen in programs that have included a strong behavioral component (39, 47).

Our program also included skills training in which the accompanying significant others actively participated. Unfortunately, we could not reproduce the beneficial effects of spouse involvement in behavioral therapy. On the contrary, we found that involvement of significant others lowered the effects of patients participating in patient education programs. However, in our program significant others were not taught principles of reinforcement and skills designed to reinforce adaptive pain coping of the patient, and there was no specific attention for family and marital relationships and the effects of arthritis on these relationships, as was done in the behavioral interventions of Radojevic et al (47) and Keefe et al (39).

The most appropriate way to evaluate the effect of booster sessions is by comparing groups of patients that participate in booster sessions with groups that do not participate in booster sessions. To do this we would have needed almost twice as many patients participate in the study, which was not feasible. Instead, we choose to offer booster sessions to all patients that participated in group education. Short-term effects are rarely maintained over long intervals. So, if we would find that short-term effects were maintained or enhanced after 12 months, this indicated that the booster sessions were effective in maintaining or enhancing treatment gains. The effects of booster sessions were not as apparent as we expected. Because we did not find any short-term benefits, it is not surprising that we found little effects after 12 months. Although there were positive effects after 12 months on fatigue and self-efficacy for patients participating without significant others, there were no significant effects after 12 months on scores of behavior, social interactions, physical health, pain, or affect. This indicates that booster sessions are not very effective in enhancing the effects of patient education.

In group psychoeducational programs, arthritis patients are often recommended to have their spouses participate in the group sessions. Our study shows that this is not always good advice; participation of significant others can lead to deleterious effects. Further investigations are necessary to establish under what conditions participation of significant others will be effective. Studies by Radojevic et al (47) and Keefe et al (39) suggest that participation of family members will only have beneficial effects when attention is paid to the effects of arthritis on the family relationships and when these family members are trained specific skills to reinforce adaptive behavior of the patients.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

We wish to thank all our respondents. We also gratefully acknowledge the cooperation of our group education leaders: Ms. G. te Nijenhuis, Ms. L. Korvemaker, Ms. E. van Gessel, and Ms. A. Wilmink from Thuiszorg Enschede-Haaksbergen; Ms. M. Konink from Medisch Spectrum Twente; Ms. M. Kleine Schaars, Ms. M. Boerrigter, Ms. T. Buitenhuis, and Ms. K. Jansen from Thuiszorg Centraal Twente; Ms. R. Droogendijk, Ms. G. van Hulten, Ms. A. de Wilde, and Ms. M. Segerink from Thuiszorg Noord West Twente; and Mr. B. Pigge from Twenteborg Ziekenhuis. We also gratefully acknowledge the cooperation of the rheumatologists: H. J. Bernelot Moens, MD, J. J. M. Festen, MD, C. J. Haagsma, MD, M. W. M. Kruijsen, MD, M. A. F. J. van de Laar, MD, and J. C. M. Oostveen, MD. We would like to thank Ms. W. Burke (UK) for correcting the English.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  • 1
    Rasker JJ, Cosh JA. Course and prognosis of early rheumatoid arthritis. Scand J Rheumatol 1989; 79 Suppl: 4556.
  • 2
    Taal E, Seydel ER, Rasker JJ, Wiegman O. Psychosocial aspects of rheumatic diseases: introduction. Patient Educ Couns 1993; 20: 5561.
  • 3
    Lorig K, Konkol L, Gonzalez V. Arthritis patient education: a review of the literature. Patient Educ Couns 1987; 10: 20752.
  • 4
    Taal E, Rasker JJ, Wiegman O. Patient education and self management in the rheumatic diseases: a self-efficacy approach. Arthritis Care Res 1996; 9: 22938.
  • 5
    Mullen PD, Laville EA, Biddle AK, Lorig K. Efficacy of psychoeducational interventions on pain, depression and disability in people with arthritis: a meta-analysis. J Rheumatol 1987; 14: 339.
  • 6
    Kirwan JR. Patient education in rheumatology. Curr Opin Rheumatol 1990; 2: 3369.
  • 7
    McCracken LM. Cognitive-behavioral treatment of rheumatoid arthritis: a preliminary review of efficacy and methodology. Ann Behav Med 1991; 13: 5765.
  • 8
    Hawley D. Psycho-educational interventions in the treatment of arthritis. Baillieres Clin Rheumatol 1995; 9: 80323.
  • 9
    Keefe FJ, van Horn Y. Cognitive behavioral treatment of rheumatoid arthritis pain: maintaining treatment gains. Arthritis Care Res 1993; 6: 21322.
  • 10
    Taal E, Rasker JJ, Wiegman O. Group education for rheumatoid arthritis patients. Semin Arthritis Rheum 1997; 26: 80516.
  • 11
    Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient education for adults with rheumatoid arthritis (Cochrane review). In: The Cochrane library, Issue 2. Oxford: Update Software; 2002.
  • 12
    Goeppinger J, Lorig K. Interventions to reduce the impact of chronic disease: community-based arthritis patient education. Annu Rev Nurs Res 1997; 15: 10122.
  • 13
    Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood (NJ): Prentice-Hall; 1986.
  • 14
    Taal E, Rasker JJ, Seydel ER, Wiegman O. Health status, adherence with health recommendations, self-efficacy and social support in patients with rheumatoid arthritis. Patient Educ Couns 1993; 20: 6376.
  • 15
    Shoor SM, Holman HR. Development of an instrument to explore psychological mediators of outcome in chronic arthritis. Trans Assoc Am Phys 1984; 97: 32531.
  • 16
    O'Leary A, Shoor S, Lorig K, Holman HR. A cognitive behavioral treatment for rheumatoid arthritis. Health Psychol 1988; 7: 52744.
  • 17
    Lorig K, Chastain R, Ung E, Shoor S, Holman HR. Development and evaluation of a scale to measure the perceived self-efficacy of people with arthritis. Arthritis Rheum 1989; 32: 3744.
  • 18
    Schiaffino KM, Revenson TA, Gibofsky A. Assessing the impact of self-efficacy beliefs on adaptation to rheumatoid arthritis. Arthritis Care Res 1991; 4: 1507.
  • 19
    Lorig K, Lubeck D, Kraines RG, Seleznick M, Holman HR. Outcomes of self-help education for patients with arthritis. Arthritis Rheum 1985; 28: 6805.
  • 20
    Lorig K, Seleznick M, Lubeck D, Ung E, Chastain RL, Holman HR. The beneficial outcomes of the arthritis self-management course are not adequately explained by behavior change. Arthritis Rheum 1989; 32: 915.
  • 21
    Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis Rheum 1993; 36: 43946.
  • 22
    Taal E, Riemsma RP, Brus HLM, Seydel ER, Rasker JJ, Wiegman O. Group education for patients with rheumatoid arthritis. Patient Educ Couns 1993; 20: 17787.
  • 23
    Taal E, Rasker JJ, Wiegman O, Brus HLM, Riemsma RP. Spouse participation in group self-management education for patients with rheumatoid arthritis. Scand J Rheumatol 1994; 97 Suppl: 24.
  • 24
    Jacobson E. Progressive relaxation. Chicago: University of Chicago Press; 1938.
  • 25
    Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: 31524.
  • 26
    Miedema HS, van der Linden SM, Rasker JJ, Valkenburg HA. National database of patients visiting rheumatologists in The Netherlands: the standard diagnosis register of rheumatic diseases: a report and preliminary analysis. Br J Rheumatol 1998; 37: 55561.
  • 27
    Van Lankveld WGJM. Coping with chronic stressors of rheumatoid arthritis [thesis]. Nijmegen: KUN; 1993.
  • 28
    Prevoo MLL, Van't Hof MA, Kuper HH, Van Leeuwen MA, Van de Putte LBA, van Riel PLCM. Modified disease activity scores that include twenty-eight-joint counts, development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995; 38: 448.
  • 29
    Meenan RF, Mason JH, Anderson JJ, Guccione AA, Kazis LE. AIMS2: the content and properties of a revised and expanded Arthritis Impact Measurement Scales Health Status Questionnaire. Arthritis Rheum 1992; 35: 110.
  • 30
    Riemsma RP, Taal E, Rasker JJ, Houtman PM, van Paassen HC, Wiegman O. Evaluation of a Dutch version of the AIMS2 (Dutch-AIMS2) in patients with rheumatoid arthritis. Br J Rheumatol 1996; 35: 75560.
  • 31
    Riemsma RP, Rasker JJ, Taal E, Griep EN, Wouters JM, Wiegman O. Fatigue in rheumatoid arthritis: the role of self-efficacy and problematic social support. Br J Rheumatol 1998; 37: 10426.
  • 32
    Revenson TA, Schiaffino KM, Majerovitz SD, Gibofsky A. Social support as a double-edged sword: the relation of positive and problematic support to depression among rheumatoid arthritis patients. Soc Sci Med 1991; 33: 80713.
  • 33
    Riemsma RP, Taal E, Rasker JJ, Bruyn GAW, van Paassen HC, Wiegman O. Problematic and positive support in relation to depression in people with rheumatoid arthritis. J Health Psychol 2000; 2: 22130.
  • 34
    Tsutokawa RK, Hewett JE. Quick test for comparing two populations with bivariate data. Biometrics 1977; 33: 2159.
  • 35
    Hewett JE, Johnson JC. Appropriate use of covariate analyses in arthritis research: Symposium at 33rd National Scientific meeting of the Association of Rheumatology Health Professionals; November 812, 1998, San Diego.
  • 36
    Holm S. A simple sequentially rejective multiple test procedure. Scand J Stat 1979; 6: 6570.
  • 37
    Aickin M, Gensler H. Adjusting for multiple testing when reporting research results: the Bonferroni vs Holm methods. Am J Public Health 1996; 86: 7268.
  • 38
    Lorig K, Feigenbaum P, Regan C, Ung E, Chastain RL, Holman HR. A comparison of lay-taught and professional-taught arthritis self-management courses. J Rheumatol 1986; 13: 7637.
  • 39
    Keefe FJ, Caldwell DS, Baucom D, Salley A, Robinson E, Timmons K, et al. Spouse-assisted coping skills training in the management of osteoarthritis knee pain. Arthritis Care Res 1996; 9: 27991.
  • 40
    Kaye RL, Hammond AH. Understanding rheumatoid arthritis: evaluation of a patient education program. JAMA 1978; 239: 24667.
  • 41
    Gross M, Brandt KD. Educational support groups for patients with ankylosing spondylitis: a preliminary report. Patient Couns Health Educ 1981; 3: 612.
  • 42
    Potts M, Brandt KD. Analysis of education-support groups for patients with rheumatoid arthritis. Patient Couns Health Educ 1983; 4: 1616.
  • 43
    Berg CE, Alt KJ, Himmel JK, Judd BK. The effects of patient education on patient cognition and disease-related anxiety. Patient Educ Couns 1985; 7: 38994.
  • 44
    Bradley LA, Turner RA, Young LD, Agudelo CA, Anderson KO, McDaniel LK. Effects of cognitive-behavioral therapy on pain behavior of rheumatoid arthritis (RA) patients: preliminary outcomes. Scand J Behav Ther 1985; 14: 5164.
  • 45
    Bradley LA, Young LD, Anderson KO, Turner RA, Agudelo CA, McDaniel LK, et al. Effects of psychological therapy on pain behavior of rheumatoid arthritis patients. Arthritis Rheum 1987; 30: 110514.
  • 46
    Goeppinger J, Arthur MW, Baglioni AJ Jr, Brunk SE, Brunner CM. A reexamination of the effectiveness of self-care education for persons with arthritis. Arthritis Rheum 1989; 32: 70616.
  • 47
    Radojevic V, Nicassio PN, Weisman MH. Behavioral intervention with and without family support for rheumatoid arthritis. Behav Ther 1992; 23: 1330.