Evaluation of the expert patient panlar self-management program in rheumatoid arthritis. A pilot study in Argentina, Colombia and Panamá.
- Carlo VCaballero Uribe MD
- PriscilaTorres
https://doi.org/10.46856/grp.10.e194
Cite as:
Arrighi, E., León Aguila, A. P., Caballero-Uribe, C. V., Soriano, E. R., Cabrera Correal, M. C., Vazquez, N., Pereira, D., Giraldo, E., Ferreyra Garrot, L., Moreno Del Cid, I. Y., Leal, M. O., Salas Siado, J. A., Rodríguez Sotomayor, J. J., Fernández, A., Torres, P., Gómez, S. M., Vilches, S., Jordán, M. C., Pinzón, E., Ochoa G, G. S., & Suárez, D. Evaluation of the expert patient panlar self-management program in rheumatoid arthritis. A pilot study in Argentina, Colombia and Panamá. Global Rheumatology. Vol 5/ Ene - Jun [2024]. Available from: https://doi.org/10.46856/grp.10.e194
Tabla 1 - Características sociodemográficas de los participantes
Tabla 2 - Descripción de los participantes, según países, diagnóstico, comorbilidades y tratamiento
Tabla 3 - Niveles de calidad de vida QOLD5
Tabla 4 - Hábitos de vida
Tabla 5 - Toma de decisiones y adherencia al tratamiento
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Evaluation of the expert patient panlar self-management program in rheumatoid arthritis. A pilot study in Argentina, Colombia and Panamá.
Introduction: Education is a cornerstone of the comprehensive management of patients living with rheumatic and musculoskeletal diseases (RMSDs). It allows them to optimize their self-care for health maintenance.
The objective of this study was to assess the effectiveness of the PANLAR Patient Expert (PE) program in optimizing self-care skills for physical activity, healthy eating, communication with professionals, therapeutic adherence and decision making.
Material and Methods: This is a pre-post pilot study whose objective was to assess the effect of the educational intervention on health outcomes. The PE PANLAR program was delivered in Argentina, Colombia and Panama during 2022 to a sample of 80 patients and their caregivers. To assess the effect of the educational intervention, a self-administered questionnaire was administered before and after the intervention that included the QOLD5 for ESRD validated in Spanish and the adaptation of the INDEC questionnaire on healthy lifestyle habits. Means, standard deviations, percentages and Student's t-test for related samples were calculated.
Results: Improvements were observed in eating habits, physical exercise, alcohol consumption and weight control. Patients perceived improvements in aspects of their quality of life (general health, mobility, activities of daily living, personal care, anxiety and depression). In addition, evolution in the physician-patient relationship and adherence to treatment.
Conclusions: The program generated positive changes in healthy lifestyle habits and disease management skills in a short period of time, so its use is recommended as part of standardized treatment for RMSDs.
Rheumatic and musculoskeletal diseases (RMDs) represent a group of conditions that affect the musculoskeletal system and connective tissue, with a multifactorial and often autoimmune origin (1). These diseases display various demographic, genetic, and clinical profiles, triggering pain, chronic inflammation, fatigue, suffering, and functional impairments, which may lead to disability, reduced quality of life, and high healthcare costs (2, 3, 4).
A progressive 2- to 4-fold increase in their prevalence has been observed over the past 40 years, depending on ethnicity, lifestyle, and socioeconomic characteristics (1, 5). The prevalence in the region ranges from 17% to 50%, with rheumatoid arthritis (RA) affecting between 0.9% and 1.6% of the population, and osteoarthritis being the most common (6, 7, 8).
As a result, the high prevalence of RMDs makes them a public health issue, generating a significant economic impact, accounting for between 1% and 3% of the gross domestic product in developed countries (9). Additionally, only 56% of patients living with RA in Latin America have access to full healthcare coverage. This is compounded by an insufficient number of rheumatologists—mostly concentrated in major cities—a limited healthcare network, and a reduced budget for education and research (10).
Education must be a cornerstone of comprehensive patient management, serving as a first-line treatment to optimize self-care levels and thereby maintain health status and quality of life (11, 12, 13). Positive changes have been demonstrated in 77% to 87% of studies on patient education in RA (14). Short-term improvements have been documented in knowledge, coping, pain, physical function, disability, and depression in patients with inflammatory arthritis such as RA and ankylosing spondylitis (11, 13). For this reason, self-care has become a key non-pharmacological strategy for disease management, enabling patients to take an active role in managing their condition and overall health.
Acquiring self-care skills allows for effective management of the practical, physical, and psychological challenges of the disease and serves as a strategy to address limitations within the healthcare system regarding chronic disease management (15, 12).
Self-care programs began in the 1990s with Dr. Kate Lorig at Stanford University. Based on their positive outcomes, randomized clinical trials started to be conducted worldwide, showing improvements in patients’ quality of life and reductions in healthcare costs (16, 17, 18). Consequently, the UK government conducted cost-effectiveness studies and, based on the evidence, began offering these courses free of charge to people living with chronic diseases and their caregivers. Results have shown a decrease in hospital readmissions, fewer emergency room visits, and improved treatment adherence, among other outcomes (19, 20).
Enhancing self-efficacy is one of the cornerstones for achieving behavioral change and is one of the main theories supporting these types of programs (21). It involves the knowledge and skills needed, along with the motivation and confidence to achieve a series of health-related goals, particularly for managing pain, stress, and emotional well-being (22, 23, 24). It also includes setting change goals, problem-solving, and interactive dynamics with facilitators, one of whom is a patient (25, 26).
Patient education has been officially recommended as part of the standard treatment strategy for RMDs by the European Alliance of Associations for Rheumatology (EULAR) task force, and it is one of the strategic actions included in the Patient Needs Manifesto for RMDs published by the Pan American League of Associations for Rheumatology (PANLAR) in the region (27, 28).
The PANLAR Patient Expert (PE) program originates from an adaptation of Stanford University’s self-care program and the successful implementation of these courses in Spain for over 10 years (29). Its main goal is to foster self-care skills in people living with RMDs to promote healthier behaviors, including increased physical activity, healthy eating, improved communication with healthcare providers, treatment adherence, and shared decision-making in health.
The relevance of this study lies primarily in generating valid and reliable evidence on the effectiveness of the PE program in a population that has been scarcely studied in Latin America—adults with RMDs. In terms of its social relevance, the main beneficiaries of this study are the patients living with these diseases and their families. However, the study results are also expected to be of interest to healthcare professionals working in this field. Lastly, with regard to its broader implications, demonstrating the benefits of the PE program may provide scientific evidence to support the replication of this type of program for other patient groups and caregivers.
OBJECTIVE
To evaluate the effectiveness, in terms of health outcomes, of the PE PANLAR self-care program for people living with RMDs in Argentina, Colombia, and Panama.
Regarding the design, this is a non-randomized, pre-post intervention repeated measures study, aimed at evaluating the effect of the educational intervention on health outcomes.
2.1 Intervention
PE is a training program led by two facilitators known as Expert Patients (EPs). One is a patient and the other a healthcare professional; both completed specific training. These two facilitators deliver the training to a group of approximately 12 to 16 participants, including patients and caregivers (16, 17, 18).
Patients with RMDs attended a 2½-hour interactive workshop once a week for six weeks to learn: problem-solving, decision-making, and other techniques to manage common issues faced by people with chronic illnesses. In a typical workshop, participants set a realistic goal for the upcoming week and develop an action plan to achieve that goal. The sessions were led by paired trainers (one patient and one healthcare professional). Following a structured manual detailing activities, methodology, and resources, the sessions addressed shared decision-making, pain management, and emotional regulation.
2.2 Instrument
A self-administered questionnaire was used, which included the QOLD5 for RMDs validated in Spanish, and an adapted version of the INDEC questionnaire on healthy lifestyle habits. This included items assessing the extent to which some habits increased, such as vegetable, fruit, and physical activity intake, or others decreased, such as salt, alcohol, and tobacco consumption.
2.3 Procedure
This pilot pre-post study evaluates the impact of an educational intervention on participants recruited through patient organizations and social media invitations. Participants completed a questionnaire before and after the intervention, with full knowledge of the study’s objective and confidentiality guarantees, and gave their consent.
2.4 Data Analysis
SPSS Statistics-25 software (IBM SPSS Inc., Chicago, IL, USA) was used to analyze the data. Descriptive statistical analyses were conducted, including mean calculations, standard deviations, and percentages; and inferential statistical analyses, such as the Student's t-test for related samples. The latter was used to identify whether the differences between the means of the studied variables were statistically significant (p<0.05) before and after the intervention.
In November 2019, the train-the-trainers program was carried out in Panama with the participation of three countries selected after an open call to scientific societies across the Pan-American region. A total of 16 participants were trained: 8 rheumatologists from the Panamanian Society of Rheumatology, the Argentine Society of Rheumatology, and the Colombian Society of Rheumatology; and 8 leaders from patient organizations that are part of the Pan-American Network of Rheumatic Patient Associations (RED ASOPAN). During the training, pairs consisting of a healthcare professional and a patient were trained to follow a training manual detailing the course’s activities and methodology. With these tools, they returned to their countries to implement the course for patients with rheumatic and musculoskeletal diseases (RMDs).
In 2022, after the restrictions caused by the COVID-19 pandemic, participant recruitment began in each country. A convenience sampling method was used, and recruitment was carried out through invitations from patient organizations in each country and announcements on social media.
The sample included 78 participants, all of whom were people living with RMDs. Although the program was open to caregivers, very few were included in the sample (3.6%) and were therefore excluded from the analysis.
The average age was 57.26 years (SD = 11.78), with 95% women and 5% men. The sample included residents from Argentina (46.25%), Colombia (18.75%), and Panama (35%). Of the participants, 63.75% belonged to a patient association, and 36.25% had done or were currently engaged in volunteer work. Sociodemographic characteristics are shown in Table 1, and information on diagnosis, comorbidities, and treatments is presented in Table 2, with data disaggregated by country.
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3.1 Quality of Life Analysis
After participating in the program, improvements were observed in patients' perceptions of their quality of life, particularly in the areas of mobility, ability to carry out daily activities, self-care, and levels of anxiety and depression. In addition, they reported changes in their general health (see Table 3).
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In relation to quality of life, patients who had been living with these conditions for more than 10 years experienced significant improvements in the mobility dimension, showing fewer problems after the intervention (M1=1.60 vs. M2=1.36; t=2.370, df=49, p=0.022, d=0.49). Improvements were also observed in the health dimension of quality of life in the subgroup with education up to completed secondary school and more than 10 years living with the condition, showing fewer problems after participating in the expert patient program (M1=3.68 vs. M2=3.16; t=2.727, df=18, p=0.014, d=0.79).
3.2 Lifestyle Habits
Various aspects were analyzed, such as the consumption of fruits, vegetables, meat, fish, salt, alcohol, tobacco, and physical activity (see Table 4). In general, an improvement in eating habits was observed, with an increase in the consumption of fruits, vegetables, and meats, both in frequency and portion sizes. An improvement was also noted in the habit of reading salt or sodium content labels. Alcohol consumption decreased among patients, although the majority of the sample were already non-smokers, so no significant changes were observed in tobacco use (97.5% non-smokers).
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These dietary changes, which are key to maintaining healthy lifestyle habits, were accompanied by an increase in physical activity and a reduction in sedentary behavior—changes that were statistically significant (p<0.05). Additionally, there was an increase in actions taken by patients to maintain their weight (from 60% before the intervention to 72.55% after) and to lose weight (from 46.25% to 48.75%). These changes are notable, especially considering that 18.75% were overweight or obese.
In the subgroup of patients with lower education levels and more than 10 years living with the condition, improvements in dietary habits were observed. The number of fruit servings consumed increased (M1=1.42 vs. M2=2.26; t=-2.650, df=18, p=0.016, d=0.72), as did the frequency of fish consumption (M1=0.79 vs. M2=1.52; t=-2.689, df=18, p=0.015, d=0.83) after participating in the expert patient program, with statistically significant improvements (p<0.05).
3.3 Decision-Making and Adherence
Patients felt they improved their skills in asking questions to healthcare professionals, participated in decision-making, and remembered to take their medication after the intervention (see Table 5).
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3.4 Program Evaluation by Patients
Approximately 80% of the patients evaluated the program positively, considering that it met their expectations, provided them with self-care tools, and improved their lifestyle habits.
As mentioned at the beginning of this paper, RDs and ARDs represent a public health problem due to their prevalence and significant economic impact (9). This situation becomes even more complex in the Latin American region due to limited access to comprehensive health coverage, the low availability of rheumatologists, a limited healthcare network, and a reduced budget for education and research (10).
This is one of the first studies to measure the effect of the educational intervention of the PE PANLAR self-care program, specifically for rheumatic diseases. The possibility of conducting this type of research, which provides valuable and relevant information on opportunities for improvement in patients' quality of life and overall well-being, is of great importance. It is worth highlighting that this pilot program included the participation of three Latin American countries—Argentina, Colombia, and Panama—with a broad representation of diseases from the RD and ARD groups. This becomes a strength of the study in terms of the representativeness of the sample achieved. Another distinctive aspect of the PE PANLAR program is that it followed the recommendations developed by EULAR for patient education in three fundamental points: the courses are taught by a trained professional and patient; the change objectives to improve self-care are identified by the patients themselves, granting them an active role in their care; and finally, the program uses an interactive, in-person learning methodology with high participation from attendees (28, 31, 32, 34).
Regarding lifestyle habits, previous studies have shown that education leads to substantial changes in the adoption of healthy habits related to diet, incorporation of physical activity, and better management of complications derived from the disease (34, 35). Participants stated that after the intervention, they were also able to take actions to control their weight, which are habits typically difficult for patients to achieve, as well as incorporating physical activity and reducing sedentary behavior (36, 37). The self-care tools taught in the course offer participants cognitive and behavioral strategies to better manage emotions, increasing their self-esteem and self-confidence (38, 39).
Concerning skills related to active participation during consultations with specialists, shared decision-making skills, and treatment adherence, a marked improvement and impact on self-efficacy was recorded. Therefore, patients with greater confidence are better equipped to make informed decisions about their health (40).
Regarding the study’s limitations, although improvements were recorded in most of the dimensions evaluated, the measurement of quality of life through the EQ-5D instrument does not appear to be sensitive enough to detect statistically significant changes in such a short period of time (41, 42). Another limitation of this study is related to the use of a convenience sample, with a predominance of female participants (95%) and few caregivers (3.6%), which led to the exclusion of caregivers from the analysis. The improvements recorded across all areas only reached statistical significance in the case of the incorporation of physical activity.
Through the present study, it was evidenced that the PE PANLAR program enabled patients with RD and MSCs to take a more active role in managing their health. They acquired healthier eating habits, increased the frequency of physical exercise, reduced alcohol consumption, and took more measures to control their weight. Patients reported improvements in several aspects of their quality of life after participating in the program. They referred to improvements in their general health and in aspects related to their mobility, their ability to perform daily activities, personal care, and their levels of anxiety and depression. Moreover, the PE PANLAR program appears to have an impact beyond the patient with RD and MSCs, as changes were observed in aspects related to the doctor-patient relationship and treatment adherence. These results are extremely encouraging, considering that self-care has become a fundamental non-pharmacological strategy for disease control.
The PANLAR PE course is a recommended strategy that should be considered as an integral part of the standardized treatment for RD and MSCs, as it promotes positive changes in self-care within a short period of time. PE PANLAR has a positive influence on behavior change related to the adoption of healthy lifestyle habits and disease self-management skills, presenting itself as a low-cost and effective strategy.
As future lines of research, it is suggested to replicate PE PANLAR in other countries in the region and among caregiver populations. In addition, it would be interesting for future studies to increase the proportion of men in the sample.
Dr. Carlo V. Caballero-Uribe, MD, MSc, PhD, declares that he is Editor-in-Chief of the journal Global Rheumatology.
The remaining authors declare no conflicts of interest.
1. Chopra A, Abdel-Nasser A. Epidemiology of rheumatic musculoskeletal disorders in the developing world. Best Pract Res Clin Rheumatol. 2008 Aug;22(4):583-604. doi: 10.1016/j.berh.2008.07.001. Disponible en: https://pubmed.ncbi.nlm.nih.gov/18783739/
2. Caballero VC. Artritis reumatoide como enfermedad de alto costo. Rev.Colomb.Reumatol. 2004 Sept;11(3): 225-231. Disponible en: https://www.academia.edu/2823129/Artritis_reumatoide_como_enfermed ad_de_alto_costo
3. Londoño J, Peláez-Ballestas I, Cuervo F, Angarita I, Giraldo R, Rueda JC, Ballesteros JG, Baquero R, Forero E, Cardiel M, Saldarriaga E, Vásquez A, Arias S, Valero L, González C, Ramírez J, Toro C & Santos AM. Prevalencia de la enfermedad reumática en Colombia, según estrategia COPCORD-Asociación Colombiana de Reumatología. Estudio de prevalencia de enfermedad reumática en población colombiana mayor de 18 años. Revista Colombiana de Reumatología. 2018;25(4): 245-256. https://doi.org/10.1016/j.rcreu.2018.08.003. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0121-81232 018000400245
4. Schoels M, Wong J, Scott DL, Zink A, Richards P, Landewé R, Smolen JS, Aletaha D. Economic aspects of treatment options in rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis. 2010 Jun;69(6):995-1003. doi: 10.1136/ard.2009.126714. Disponible en: https://ard.bmj.com/content/69/6/995.citation-tools
5. Harkness EF, Macfarlane GJ, Silman AJ, McBeth J. Is musculoskeletal pain more common now than 40 years ago?: Two population-based cross-sectional studies. Rheumatology (Oxford). 2005 Jul;44(7):890-5. doi: 10.1093/rheumatology/keh599. Disponible en: https://pubmed.ncbi.nlm.nih.gov/15784630/
6. COPCORD. Information [Internet]. COPCORD. s.f. [citado 24 noviembre 2022]. Disponible en: http://copcord.org/information.asp
7. Chopra A. The COPCORD world of musculoskeletal pain and arthritis. Rheumatology (Oxford). 2013 Nov;52(11):1925-8. doi: 10.1093/rheumatology/ket222. Disponible en: https://pubmed.ncbi.nlm.nih.gov/23843110/
8. Londoño, John, et al. "Prevalencia de la enfermedad reumática en Colombia, según estrategia COPCORD-Asociación Colombiana de Reumatología. Estudio de prevalencia de enfermedad reumática en población colombiana mayor de 18 años." Revista colombiana de reumatología 25.4 (2018): 245-256. Disponible en: https://www.elsevier.es/es-revista-revista-colombiana-reumatologia-374- articulo-prevalencia-enfermedad-reumatica-colombia-segun-S01218123 18300951
9. Sokka T, Kautiainen H, Pincus T, Toloza S, da Rocha Castelar Pinheiro G, Lazovskis J, Hetland ML, Peets T, Immonen K, Maillefert JF, Drosos AA, Alten R, Pohl C, Rojkovich B, Bresnihan B, Minnock P, Cazzato M, Bombardieri S, Rexhepi S, Rexhepi M, Andersone D, Stropuviene S, Huisman M, Sierakowski S, Karateev D, Skakic V, Naranjo A, Baecklund E, Henrohn D, Gogus F, Badsha H, Mofti A, Taylor P, McClinton C, Yazici Y. Disparities in rheumatoid arthritis disease activity according to gross domestic product in 25 countries in the QUEST-RA database. Ann Rheum Dis. 2009 Nov;68(11):1666-72. doi: 10.1136/ard.2009.109983. Disponible en: https://ard.bmj.com/content/68/11/1666
10. Pineda C, Caballero-Uribe CV. Challenges and opportunities for diagnosis and treatment of rheumatoid arthritis in Latin America. Clin Rheumatol. 2015 Mar;34 Suppl 1(Suppl 1):S5-7. doi: 10.1007/s10067-015-3019-6. Disponible en: https://link.springer.com/article/10.1007/s10067-015-3019-6
11. Escorcia ME, Osorio HJ, Pérez CA, Thulcán MC, Caballero Uribe CV, Borda Pérez M. Efectividad de una intervención educativa en pacientes con artritis reumatoide. Hospital Universidad del Norte. Barranquilla. Abril-Mayo de 2005. Rev.Colomb.Reumatol. 2006 Mar;13( 1 ):11-19. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0121-81232 006000100002
12. Nikiphorou E, Santos EJF, Marques A, Böhm P, Bijlsma JW, Daien CI, Esbensen BA, Ferreira RJO, Fragoulis GE, Holmes P, McBain H, Metsios GS, Moe RH, Stamm TA, de Thurah A, Zabalan C, Carmona L, Bosworth A. 2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis. Ann Rheum Dis. 2021 Oct;80(10):1278-1285. doi: 10.1136/annrheumdis-2021-220249. Disponible en: https://pubmed.ncbi.nlm.nih.gov/33962964/
13. Zangi HA, Ndosi M, Adams J, Andersen L, Bode C, Boström C, van Eijk-Hustings Y, Gossec L, Korandová J, Mendes G, Niedermann K, Primdahl J, Stoffer M, Voshaar M, van Tubergen A; European League Against Rheumatism (EULAR). EULAR recommendations for patient education for people with inflammatory arthritis. Ann Rheum Dis. 2015 Jun;74(6):954-62. doi: 10.1136/annrheumdis-2014-206807. Disponible en: https://pubmed.ncbi.nlm.nih.gov/25735643/
14. Nadrian H, Morowatisharifabad MA, Bahmanpour K. Development of a Rheumatoid Arthritis Education Program using the PRECEDE_PROCEED Model. Health Promot Perspect. 2011 Dec 20;1(2):118-29. doi: 10.5681/hpp.2011.013. Disponible en: https://pubmed.ncbi.nlm.nih.gov/24688908/
15. Luo, W., Zhang, X. , Ren, K. . Self-Management in Patients with Rheumatoid Arthritis. In: Mohammed, R. H. A. , editor. Rheumatoid Arthritis - Other Perspectives towards a Better Practice [Internet]. London: IntechOpen; 2020 [cited 2022 Nov 25]. doi: 10.5772/intechopen.91047. Disponible en: https://www.intechopen.com/chapters/71618
16. 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 Apr;36(4):439-46. doi: 10.1002/art.1780360403. Disponible en: https://onlinelibrary.wiley.com/doi/10.1002/art.1780360403
17. Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on patients with chronic disease. Eff Clin Pract. 2001 Nov-Dec;4(6):256-62. Disponible en: https://pubmed.ncbi.nlm.nih.gov/11769298/
18. Lorig KR, Ritter PL, Laurent DD, Plant K. The internet-based arthritis self-management program: a one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Rheum. 2008 Jul 15;59(7):1009-17. doi: 10.1002/art.23817. Disponible en: https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.23817
19. Bauer, C & May, U. Self-Care in Europe: Economic and Social Impact on Individuals and Society. Bruselas, Bélgica: Association of the European Self-Care Industry. 2021. Disponible en: https://aesgp.eu/content/uploads/2022/01/AESGP-Summary-Report-Self- Care-in-Europe-Economic-and-Social-Impact-on-Individuals-and-Society. pdf
20. van Eijck, L., Restrepo, L. & Amesz, B. The health-economic benefits of self-care in Europe. A potential to rethink its position in the healthcare system. Vintura. 2020. Disponible en: https://assets.gskstatic.com/corporate/Health-Economic-Study/GSK_rep ort_summary-FINAL.pdf
21. Bandura, A., & Walters, R. H. Social learning theory (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall. 1977. Disponible en: https://www.semanticscholar.org/paper/SOCIAL-LEARNING-THEORY-Al bert-Bandura-Englewood-247-boone-Reilly/5dd3cb1ca57ae11d393c945e 51d10f0b110450e4
22. Riemsma RP, Taal E, Rasker JJ. Group education for patients with rheumatoid arthritis and their partners. Arthritis Rheum. 2003 Aug 15;49(4):556-66. doi: 10.1002/art.11207. Disponible en: https://pubmed.ncbi.nlm.nih.gov/12910564/
23. Bandura A. Cultivate Self-efficacy for Personal and Organizational Effectiveness. En: E.A. Locke, editor. Handbook of Principles of Organizational Behavior: Indispensable Knowledge for Evidence-Based Management. John Wiley & Sons, Ltd, 2012. p. 179-200. Disponible en: https://onlinelibrary.wiley.com/doi/10.1002/9781119206422.ch10
24. Doumen M, De Cock D, Pazmino S, Bertrand D, Joly J, Westhovens R, Verschueren P. Treatment response and several patient-reported outcomes are early determinants of future self-efficacy in rheumatoid arthritis. Arthritis Res Ther. 2021 Oct 27;23(1):269. doi: 10.1186/s13075-021-02651-3. Erratum in: Arthritis Res Ther. 2021 Nov 15;23(1):285. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8549201/
25. van Riel PLCM, Zuidema RM, Vogel C, Rongen-van Dartel SAA. Patient Self-Management and Tracking: A European Experience. Rheum Dis Clin North Am. 2019 May;45(2):187-195. doi: 10.1016/j.rdc.2019.01.008. Disponible en: https://pubmed.ncbi.nlm.nih.gov/30952392/
26. Niedermann K, de Bie RA, Kubli R, Ciurea A, Steurer-Stey C, Villiger PM, Büchi S. Effectiveness of individual resource-oriented joint protection education in people with rheumatoid arthritis. A randomized controlled trial. Patient Educ Couns. 2011 Jan;82(1):42-8. doi: 10.1016/j.pec.2010.02.014. Disponible en: https://pubmed.ncbi.nlm.nih.gov/20451345/
27. Arrighi E, León AP, Caballero-Uribe CV, Soriano ER, Torres P, Pereira, D. Manifiesto Panamericano sobre las Enfermedades Reumáticas: La Perspectiva de los Pacientes. Global Rheumatology. 2022 Feb. Disponible en: https://globalrheumpanlar.org/manuscrito-articulo-original/manifiesto-pan americano-sobre-las-enfermedades-reumaticas-la
28. Zangi HA, Ndosi M, Adams J, Andersen L, Bode C, Boström C, van Eijk-Hustings Y, Gossec L, Korandová J, Mendes G, Niedermann K, Primdahl J, Stoffer M, Voshaar M, van Tubergen A; European League Against Rheumatism (EULAR). EULAR recommendations for patient education for people with inflammatory arthritis. Ann Rheum Dis. 2015 Jun;74(6):954-62. doi: 10.1136/annrheumdis-2014-206807. Disponible en: https://pubmed.ncbi.nlm.nih.gov/25735643/
29. Nuño-Solinis R, Rodríguez-Pereira C, Piñera-Elorriaga K, Zaballa-González I, Bikandi-Irazabal J. Panorama de las iniciativas de educación para el autocuidado en España. Gac Sanit. 2013 Ago;27( 4 ): 332-337. Disponible en: https://pubmed.ncbi.nlm.nih.gov/23465729/
30. Richardson, G., Kennedy, A., Reeves, D., Bower, P., Lee, V., Middleton, E., ... & Rogers, A. (2008). Cost effectiveness of the Expert Patients Programme (EPP) for patients with chronic conditions. Journal of Epidemiology & Community Health, 62(4), 361-367. Disponible en: https://pubmed.ncbi.nlm.nih.gov/18339831/
31. Sharpe L, Schrieber L. A blind randomized controlled trial of cognitive versus behavioral versus cognitive-behavioral therapy for patients with rheumatoid arthritis. Psychother Psychosom. 2012;81(3):145-52. doi: 10.1159/000332334. Disponible en: https://pubmed.ncbi.nlm.nih.gov/22398880/
32. Grønning K, Skomsvoll JF, Rannestad T, Steinsbekk A. The effect of an educational programme consisting of group and individual arthritis education for patients with polyarthritis--a randomised controlled trial. Patient Educ Couns. 2012 Jul;88(1):113-20. doi: 10.1016/j.pec.2011.12.011. Disponible en: https://pubmed.ncbi.nlm.nih.gov/22277625/
33. El Miedany Y, El Gaafary M, El Arousy N, Ahmed I, Youssef S, Palmer D. Arthritis education: the integration of patient-reported outcome measures and patient self-management. Clin Exp Rheumatol. 2012 Nov-Dec;30(6):899-904. Disponible en: https://pubmed.ncbi.nlm.nih.gov/22992291/
34. Barlow JH, Turner AP, Wright CC. A randomized controlled study of the Arthritis Self-Management Programme in the UK. Health Educ Res. 2000 Dec;15(6):665-80. doi: 10.1093/her/15.6.665. Disponible en: https://pubmed.ncbi.nlm.nih.gov/11142075/
35. Hosseini Z, Najafi P, Mohseni S, Aghamolaei T, Dadipoor S. The effect of a theory-based educational program on southern Iranian prisoners' HIV preventive behaviors: a quasi-experimental research. BMC Public Health. 2022 Jul 14;22(1):1342. doi: 10.1186/s12889-022-13763-z. Disponible en: https://pubmed.ncbi.nlm.nih.gov/35836148/
36. Bliddal H, Leeds AR & Christensen, R. Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons–a scoping review. Obesity reviews. 2014;15(7): 578-586. Disponible en: https://www.researchgate.net/publication/261770975_Osteoarthritis_obesity_and_weight_loss_Evidence_hypotheses_and_horizons_-_a_scoping_review
37. Mayoux-Benhamou A, Giraudet-Le Quintrec JS, Ravaud P, Champion K, Dernis E, Zerkak D, Roy C, Kahan A, Revel M, Dougados M. Influence of patient education on exercise compliance in rheumatoid arthritis: a prospective 12-month randomized controlled trial. J Rheumatol. 2008 Feb;35(2):216-23. Disponible en: https://pubmed.ncbi.nlm.nih.gov/18085742/
38. Radford S, Carr M, Hehir M, Davis B, Robertson L, Cockshott Z, Tipler S, Hewlett S. 'It's quite hard to grasp the enormity of it': perceived needs of people upon diagnosis of rheumatoid arthritis. Musculoskeletal Care. 2008 Sep;6(3):155-67. doi: 10.1002/msc.132. Disponible en: https://pubmed.ncbi.nlm.nih.gov/18649347/
39. Hammond A, Young A, Kidao R. A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis. Ann Rheum Dis. 2004 Jan;63(1):23-30. doi: 10.1136/ard.2002.001511. Disponible en: https://pubmed.ncbi.nlm.nih.gov/14672887/
40. Masiero S, Boniolo A, Wassermann L, et al. Effects of an educational–behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial. Clinical Rheumatology. 2007;26:2043-50. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747567/pdf/IJCBNM-6-1 2.pdf
41. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003 Aug;26(1):1-7. doi: 10.1207/S15324796ABM2601_01. Disponible en: https://pubmed.ncbi.nlm.nih.gov/12867348/
42. Keefe FJ, Lefebvre JC, Kerns RD, Rosenberg R, Beaupre P, Prochaska J, Prochaska JO, Caldwell DS. Understanding the adoption of arthritis self-management: stages of change profiles among arthritis patients. Pain. 2000 Sep;87(3):303-313. doi: 10.1016/S0304-3959(00)00294-3. Disponible en: https://pubmed.ncbi.nlm.nih.gov/10963910/