1. Introduction
Rheumatic diseases, such as rheumatoid arthritis (RA), spondyloarthritis (SpA), and systemic lupus erythematosus (SLE), are characterized by joint inflammation and other systemic manifestations that lead to functional disability and impaired quality of life [
1]. The therapeutic objectives in affected patients include not only reducing inflammatory activity, but also improving quality of life and participation in social activities [
2,
3]. Previous studies have shown that participation in social activities is closely related to better quality of life and well-being [
4].
Patients with rheumatic disease have a reduced capacity for participating in social activities in various settings [
5]. Such social isolation may be associated with mood disorders and reduced social satisfaction [
6]. Furthermore, the poor visibility of rheumatic symptoms (i.e., pain, stiffness, and fatigue) means that patients are excluded from social exchanges and stigmatized [
5,
7]. Van Genderen et al. observed that patients with SpA were less satisfied with their interpersonal relationships and leisure interests than controls [
8]. Similarly, patients with RA more frequently experience negative sensations with respect to social skills, such as sadness, frustration, and defenselessness [
9]. In patients with SLE, loss and uncertainty have been reported to be the two main sensations with respect to social relationships [
10]. The first refers to different types of loss—for example, physical ability, appearance, independence, and family balance. In this sense, it is important to note that concerns associated with body image mainly affect self-esteem and social withdrawal in affected patients [
11].
However, it is not easy to provide a general measurement of participation in social activities, since this area encompasses a wide variety of domains [
12]. One of the most widely used tests for the evaluation of participation in social activities is the Patient-Reported Outcomes Measurement Information Systems (PROMIS) Ability to Participate in Social Roles and Activities v2.0 Short-Form (8 items, PROMIS-APS), which has been shown to have adequate measurement properties [
13]. While PROMIS-APS has been used in patients with musculoskeletal disorders [
14,
15], it has not been specifically evaluated in patients with inflammatory rheumatic diseases. Similarly, no attempts have been made to determine other social factors associated with impaired ability to participate in social activities, since social support is a reasonable treatment goal in interventions that seek to improve psychological well-being in persons with conditions that are associated with disability. Likewise, although these problems are common to all rheumatic diseases, they are experienced differently and affect each type of disease in a different way [
16]. In fact, a study comparing social involvement in rheumatic diseases found the greatest degree of involvement in systemic autoimmune diseases such as SLE [
5]. However, no comparisons have been made of patients with different inflammatory rheumatic diseases. Therefore, the objectives of our study were to describe the ability to participate in social activities in patients with rheumatoid arthritis compared with SpA and SLE, and likewise to identify the factors involved.
3. Results
We recruited 151 patients between June and November 2019: 50 (33.1%) with RA, 51 (33.8%) with SpA, and 50 (33.1%) with SLE. All the patients completed the questionnaires, and no data were missing.
3.1. Patient Characteristics
The main patient characteristics are shown by group in
Table 1. Patients with SLE had a mean age of around 47 years, which was slightly lower than those with RA and SpA (
p = 0.010). There were more women in the RA group (90.0%) and SLE group (96.0%) than in the SpA group (50.0%) (
p < 0.001). There were no differences in educational level or socioeconomic level between the groups. Most participants had a basic educational level and a socioeconomic level of €1000–1500 per month.
The most frequent comorbid conditions overall were visual impairment (23/151; 15.2%), anxiety (20/151, 13.2%), and depression (according to the clinical history, 21/151, 13.9%). Patients with SLE were more frequently diagnosed with depression (p = 0.065) and anxiety (p = 0.027) and less frequently with arthritis (p < 0.001).
A total of 98/151 patients had a history of peripheral arthritis (64.9%) at the time of the evaluation. The mean DAS28 score in patients with RA indicated low disease activity, the mean BASDAI in patients with SpA was 4, and the mean SLEDAI score was around 5 in patients with SLE. No patients with SpA had psoriasis. The main clinical characteristics of patients with SLE are shown in
Supplementary Table S1.
3.2. Ability to Participate in Social Activities
The mean PROMIS scores for ability to participate in social activities were very similar between the groups, except for poorer mobility in patients with RA and SpA than in those with SLE (
p = 0.017) (
Table 2).
3.3. Factors Associated with Ability to Participate in Social Activities for the Whole Sample of Patients with Rheumatic Disease
Table 3 shows the results of the multivariable linear regression analysis (dependent variable: ability to participate in social activities) for the 151 patients with rheumatic diseases included in the study.
The ability to participate in social activities for all the patients with rheumatic diseases was independently associated with age and the PROMIS items social satisfaction, mobility, depression, and company. Consequently, levels of participation in social activities increased by a mean of 0.07 units per year of age, 0.25 units for each point increase in social satisfaction, 0.15 units for each point increase in mobility, and 0.17 units for each point increase in company; however, the score decreased by 0.17 units for each point increase in depression.
3.4. Factors Associated with the Ability to Participate in Social Activities in the Three Groups of Patients
We subsequently ran three separate multivariable linear regression models to identify factors associated with the ability to participate in social activities for each of the groups individually.
Following this approach, we observed that in patients with RA, the ability to participate in social activities was independently associated with satisfaction with social roles, mobility, less social isolation, instrumental support, and lower inflammatory activity according to DAS28 (
Table 4). Furthermore, in patients with SpA, the ability to participate in social activities was independently associated with satisfaction with social roles, less frequent depression, company, and lower inflammatory activity according to BASDAI (
Table 5). Lastly, in patients with SLE, the ability to participate in social activities was associated with social satisfaction, mobility, and emotional support (
Table 6).
4. Discussion
Social participation is thought to be a major factor in several health domains (i.e., cardiovascular, neuroendocrine, and immune function) and in the maintenance of health in the general population and in patients with rheumatic diseases [
27]. In the general population, reduced ability to participate in social activities is associated with greater mortality, morbidity, and poorer quality of life [
28]. We evaluated the ability to participate in social activities (PROMIS-APS) in patients with three rheumatic diseases and its association with other social variables and clinical factors. We found that, despite the epidemiological and clinical differences between the three diseases, abnormalities in patients’ ability to participate in social activities were very similar, and the mean scores of the PROMIS-APS in these three rheumatic diseases were much lower than those of the reference population and patients with other musculoskeletal conditions [
29] Likewise, we did not observe differences in the PROMIS score for social activities in the different settings, except for mobility, which was less affected in patients with SLE. The greater impairment in mobility observed in patients with RA and SpA could be associated with older age and more frequent arthritis than in patients with SLE. In this sense, our data are consistent with those of other authors, who report poorer health-related quality of life and physical functioning in patients with RA and SpA than in those with SLE [
30,
31,
32].
On the other hand, we found that improved PROMIS scores for social satisfaction, mobility, company, older age, and lower frequency of depression were independently associated with the ability to participate in social activities (PROMIS-APS). While these aspects have not been evaluated in this type of patient, other studies on patients with musculoskeletal and neuromuscular involvement revealed that participation, as assessed using the PROMIS questionnaire, is associated with better quality of life, greater social satisfaction, and less frequent depression [
4,
29]. As for age, we found that older patients were more able to participate in social activities. In this sense, whereas adult patients with rheumatic diseases were particularly worried about how their disease could limit their ability to work and their professional goals, adolescents expressed their frustration with differences in the way they were treated by teachers and companions, with the result that this could further affect their participation in social activities [
19].
Our study also revealed that participation in social activities by patients with RA and SpA was negatively associated with inflammatory activity, as measured using DAS28 and BASDAI, respectively. This finding is consistent with those of other studies of RA, which found an association between increased inflammatory activity and pain, anxiety, depression, and quality of life [
33]. In SpA, inflammatory activity measured using the BASDAI was also associated with greater depression, anxiety, and sleep disorders [
3]; therefore, control of inflammation could improve these psychological factors, even participation in social activities. However, this does not seem to be the case in patients with SLE, since we found no association between SLEDAI values and participation in social activities; associations were found only for satisfaction with social roles, mobility, and emotional support. In this sense, one study attempted to evaluate various psychopathological factors and personality dimensions in patients with SLE and found negative correlations for mental health, emotional support, vitality, and perception of general health. Similarly, the authors did not find correlations between any of the clinical variables (SLICC, SLEDAI, or disease duration) and dimensions of quality of life, mental health, and depression [
34]. These findings emphasize the importance of analyzing patients’ subjective perceptions of their disease, its impact on their lives, and their symptoms.
Our study was subject to a series of limitations. First, its cross-sectional design prevented us from establishing causality. However, it did enable us to fulfill the primary objective. Second, the PROMIS-APS questionnaire has not yet been validated for rheumatic diseases, although it has proven successful in patients with musculoskeletal conditions; in addition, the reference for PROMIS is the US population and, in our study, was the Spanish population [
14,
15]. Furthermore, the association between the PROMIS-APS questionnaires and the corresponding scores for participation in different social activities indicates that they are valid instruments. In addition, our study included patients whose understanding and command of the Spanish language was similarly reasonable between the three groups.
5. Conclusions
In conclusion, we observed that patients with RA, SpA, and SLE had the same ability to participate in social activities and the three groups of patients had scores below those of the reference population. In addition, we found that the ability to participate in social activities was affected by psychosocial factors (satisfaction, mobility, company, depression) and clinical factors (age and inflammatory activity). It would be interesting to perform interventional studies on these psychosocial factors and inflammatory activity in order to improve participation in social activities and patient quality of life.