Knowledge and selected variables as determinants of the quality of life and general health of patients with rheumatoid arthritis

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Introduction
The quality of life is a multidimensional concept, varying over time, and takes into account an objective and subjective assessment of life in physical, psychological and social terms.One of the chronic diseases which results in the reduction of the quality of life is rheumatoid arthritis (RA), one of the most aggressive and most common rheumatic diseases.This is a condition causing chronic inflammation of the bone-joint system, and the result of this process is a permanent deformation of bones and joints along with their damage.
2][3] Progressive disability is associated with the loss of productivity, financial burden on the patient's family and the impossibility of earning money.Patients are often not prepared to change their way of life, which is the reason why it is important to make them aware of the significance of active cooperation in therapy.This applies especially to regular exercise at home, adapted to current capabilities, which helps to reduce the motor dysfunction, and the use of dietary therapy. 4ne of the main problems of people w ith R A is pain,which undoubtedly is reflected in the mental condition of the patient and their social functioning.][7] The need to undertake educational activities aimed at patients with rheumatoid arthritis comes from the currently biggest challenge of contemporary medicine referring to all chronic diseases -failure in following the therapy guidelines. 8,9nowledge about the disease is the key to achieve the maximum effects of treatment and one of the ways to prevent the consequences of improperly treated disease. 10,11t is also essential to enable the patient, through counseling and retraining, to get a suitable employment opportunity, which is the basis for developing an active attitude to life and regaining independence in the later stages of the disease.It is also relevant in the process of accepting the disability and feeling satisfaction from life. 12e solution may be the improvement of the therapeutic relationship between the therapeutic team and the patient in order to increase the efficiency of the treatment through better knowledge about the disease, and to reduce the impact of the disease on the mental condition of the patient. 13

Material and methods
The study included 270 patients diagnosed with rheumatoid arthritis, treated at the Department of Rheumatology and Internal Medicine (Table 1).
The author's questionnaire, International Questionnaire SF-36 questionnaire, and the General Health Questionnaire GHQ-30 were used to collect the study data.
The author's questionnaire allowed us to gather basic information about the study group and to assess the level of knowledge about RA. 14 Questionnaire SF-36 estimated the areas included in a wide approach to health definition, covering 8 competent scales defining physical and mental aspects of the quality of life. 15These are: • physical functioning -PF; • mental health -MH; • social functioning -SF; • role physical -RP; • role emotional -RE; • vitality -VT; • general health -GH; • bodily pain -BP, Factors of the quality of life were estimated on the basis of the system SF-36, which allowed us to estimate 8domains of life and to calculate on their grounds the level of physical and mental activities depicting the general condition of a patient.The level of physical and mental activities was calculated using the norms assumed for the USA because there are no norms created for Poland and accepted by the QualityMetric, Inc.
Five scales (PF, RP, BP, SF, RE) describe the state of a person's functioning as a lack of limitations or disability.Three of the above mentioned scales (PF, RP, BP) reflect most accurately the physical condition of a patient, but it should be noted that each of them refers to a different aspect thereof.PF measures the constraints of daily physical activity, RP includes limitations in life, while BP focuses on the pain and the resultant limitations in everyday life.
The most useful in the presentation of the mental functioning of a patient are SF and RE.Their maximum results (100 points) indicate the lack of physical and emotional problems.
Other scales such as MH, VT and GH are bipolar, i.e., they measure both the positive and the negative picture of a patient.For the MH scale, the scoring in the middle of the range (50 points) means the lack of restrictions caused by personal or emotional problems.In the case of achieving the maximum score, it indicates frequently recurring feelings of happiness and peace.
The changes in the physical and mental well-being are detected by VT and GH scales.The middle score on the VT scale means no symptoms of fatigue or exhaustion, while the maximum (100 points) indicates additionally constantly occurring feeling of energy.The middle and higher scores on the GH scale confirm general health. 14eneral Health Questionnaire (GHQ) by David Goldberg is a screening tool used to assess non-specific psychiatric morbidity.The authors of the Polish version of GHQ-30 are Krzysztof Małyszczak and Stanisław Sidorowicz. 16The test assesses the current psychiatric condition and is used to identify the cases which are at a significant likelihood of developing disorders.The overall score of the questionnaire is influenced by individual sensibility, a way of going through and feeling during the course of disease.Therefore it is believed that using GHQ can also help to measure the condition of mental disorder and a subjective evaluation of its consequences, which is called a non-specific psychiatric morbidity.This study used a version of the questionnaire with 30 questions (GHQ-30).The maximum score a patient can get is 30 points.The threshold of 5 points provides a basis for the identification of persons with mental disorders.The study used a scoring method by Goldberg: 0-0-1-1.The questionnaire can be treated, on one hand, as a 1-dimensional tool; on the other hand, it would be reasonable to isolate specific factors, which are called: anxiety and depression, interpersonal relations and general functioning.
The statistical analysis was performed using the program STATISTICA v. 10 PL with the application of Student's t-test and χ 2 test.The level of significance was set at p = 0.05.

Results
The analysis of the study material showed that there were no statistically significant differences in particular domains of the SF-36 questionnaire in terms of gender (Table 2).
A multiple regression analysis of the impact of independent variables on the quality of life in patients with RA has yielded the following results: • the level of physical functioning (PF) is positively affected by active professional work (p = 0.002), higher education (p = 0.004) and the acquisition of knowledge about the disease from friends (p = 0.01), and is negatively affected by age (p = 0.001), lack of education (p = 0.004), low subjective state of knowledge about the disease (p = 0.004) and poor subjective health (SF-36) (p < 0.001) (Table 3); • limited activity due to physical health (RP) is mostly influenced by the interpersonal relationships (GHQ-30) (p = 0.002), the general level of health (GHQ-30) (p = 0.001) and subjective health condition (SF-36) (p < 0.001); • the level of pain (BP) depends on interpersonal relationships (GHQ-30) (p = 0.019), the general health (GHQ-30) (p < 0.001) and subjective health status (SF-36) (p = 0.004); • the general perception of health (GH) is positively influenced by the acquisition of knowledge from nurses (p = 0.02), and is negatively affected by age (p = 0.005) and the presence of RA history in the family (p = 0.001) (Table 4); • the level of vitality (VT) is positively influenced by the acquisition of knowledge from a physiothera- ) and a low level of health according to GHQ-30 (p < 0.001).The analysis of the study material obtained from the GHQ-30 questionnaire showed that particular domains did not show any statistically significant differences in terms of gender (Table 6).
A multiple regression analysis of the impact of independent variables on the health levels in RA patients has yielded the following results: • symptoms of anxiety and depression are negatively affected by the occurrence of disease (RA) in the family, rare medical consultations and a feeling that life is not worth living; • interpersonal relationships are positively influenced by higher education (p = 0.036), place of residence -a city (p = 0.009) and a shorter duration of disease -1-3 years (p = 0.001), and are negatively affected by a positive family history of RA (p = 0.026) and a feeling that life is not worth living (p < 0.001); • general functioning is positively inf luenced by a higher education (p = 0.002) and reading books about the disease (p = 0.0011), whereas it is negatively affected by age (p = 0.004), the presence of the disease in the family (p = 0.012) and a feeling that life is not worth living (p < 0.001); • general health (GHQ-30) is positively affected by education (p = 0.003), place of residence -a city (p = 0.013), active professional work (p = 0.001), whereas it is negatively affected by a positive family history of RA (p = 0.002), frequent stays in the hospital (p = 0.008) and poor subjective health status (p < 0.001) (Table 7).

Discussion
A crucial element in the treatment and rehabilitation of patients with rheumatoid arthritis should be the analysis of quality of life.Due to the fact that it is a chronic, progressive and still incurable disease, care should be taken to improve the viability of patients by means of a thorough examination of the factors that impair their quality of life.In addition, continuously developing knowledge on the quality of life of patients with RA should help to eliminate the factors that have the most negative impact on the various spheres of life of such patients.
8][19][20][21][22][23][24] The lower number of points in the PCS domain in comparison to the MCS domain may indicate that RA affects more the physical than the mental sphere as indicated by other authors. 21,23,2423][24][25][26][27][28][29][30][31] Studies conducted by many authors have shown that poorer functioning of the respondents in the physical sphere is conditioned by the duration of the disease. 18,24,26,28,30Studies by Baloglu et al. and Wisłowska et al.  did not confirm this dependence. 20,31In our study, the worse results in the PF domain and the PCS scale were related to age of the respondents, which has also been indicated by other authors. 20,23,31It was also shown that people who subjectively assessed their health as poor had a lower perception of the quality of their lives in the domains of physical activity (PF, RP and BP) as well.
The literature highlights the fact that quality of life is modified by patients' convictions about their health, which is reflected in the results of our own study, where people with poor subjective health condition were characterized by greater limitations of activity due to physical health and lower general health (GHQ-30). 30he studies by van Vilsteren et al. concluded that patients suffering from RA with low quality of life are characterized by decreased productivity. 26Our study showed that economic activity has a positive effect on the general health level according to GHQ-30.
Factors such as higher education and living in a city also had a positive effect on general health (GHQ-30).
The results obtained from the SF-36 questionnaire and GHQ-30 revealed the occurrence of symptoms such as anxiety and depression and a decreased quality of life in the MCS domain.Rheumatoid arthritis is undoubtedly a disease which leaves permanent consequences of a psychological nature, especially in the emotional area, and affects quality of life. 17,20,29There are many premises suggesting that personal predispositions of a patient, their competence and approach to the disease may have a considerable influence on the further course of the disease and its prognoses.According to Abu Al-Fadl et al. and Maiden et al., during the treatment of patients with RA, more attention should be paid to the identification of symptoms of depression because the emotional condition affects the quality of life of patients and treatment outcomes. 17,32requent contact with the members of the therapeutic team and obtaining accurate information positively affected the selected domains (GH, VT, RE, MCS) in RA patients, which was presented for the first time in our study and proves the need for providing informational and emotional support by the members of the therapeutic team.
It was also shown that interpersonal relationships affected activity limitations due to physical health (RP), the level of pain (BP) and the level of social functioning (SF).This means that people with satisfying relationships with others less frequently experienced limitations in the sphere of physical activity and experienced less pain, and better functioned in the society.Mäkeläinen et al. attempted to find an answer to the question if there is a dependence between the level of knowledge in 252 patients with rheumatoid arthritis and their physical functioning. 33The studies did not reveal a correlation between the level of knowledge of patients and their physical functioning in everyday life.The autors' own study showed, however, that the level of knowledge about the disease affected the SF domain in the SF-36 questionnaire.
The evaluation of quality of life has an enormous significance in economic analyses.Financing health care, costs of treatment, its effectiveness are the leading subjects.We need to find an answer to the question if the treatment means applied for this purpose correlate with the effects, patient satisfaction and the level of quality of life. 34he quality of life of patients suffering from rheu- matoid arthritis is determined by psycho-physical activities and many other factors.It is promising that there are more and more studies on the quality of life in rheumatoid diseases.The conducted research and the results of our own study showed that the International Questionnaire -SF-36 and the General Health Questionnaire GHQ-30 are good tools to assess the quality of life in patients with rheumatoid arthritis and help to identify therapeutic strategies aimed at minimizing the deficits in the area of emotional support and education in patients with RA. 23,31,35

Conclusions
Physical activity of patients with rheumatoid arthritis depends on their age and subjective health condition.General health (GHQ-30) in patients with rheumatoid arthritis is influenced by education, place of residence, professional work, family history of RA and subjective health status.Frequent contact and accurate information obtained from the members of the therapeutic team has a positive effect on the selected domains of quality of life in patients with RA.The SF-36 scale and the GHQ-30 questionnaire may be used at the time of hospitalizations at the rheumatoid ward as methods of detecting patients with possible risk of emotional disorders and disorders in social functioning.

Table 1 .
Characteristics of the study group (data was presented as mean ±SD).

Table 2 .
The analysis of factors related to quality of life -SF-36

Table 6 .
The analysis of data obtained from the General Health Questionnaire -GHQ-30