Introduction
Recent advancements in medicine and the positive effects of these advancements on encouraging longer life expectancies have led to a rapid increase in the incidence of chronic diseases (Malm et al., 2016). Consequently, long-term self-care by patients, in addition to treatment by doctors, is important to successful disease management (Malm et al., 2016; McDonald et al., 2012).
Rheumatoid arthritis, an autoimmune disease of unknown cause, is the second most prevalent type of chronic arthritis, after osteoarthritis (McDonald et al., 2012; Uhm et al., 2012). Rheumatoid arthritis is characterized by the inflammation of symmetrical joints and mainly causes joint deformity and dysfunction (Okumus et al., 2013; Uhm et al., 2012). The prevalence of rheumatoid arthritis ranges from 0.5% to 1.0% worldwide (Bae, 2010; Evans et al., 2013). It primarily affects persons between 35 and 45 years old, with a prevalence among women that is two to three times higher than among men (Bae, 2010). The reason rheumatoid arthritis is more likely to occur in women is likely due to factors including heredity, immunity, stress, female hormones, pregnancy, and childbirth (Bae, 2010; Ostlund, Bjork, Valtersson, & Sverker, 2015). However, the exact mechanism has not yet been identified (Ostlund et al., 2015), making complete recovery difficult and continuous care mandatory (Bae, 2010; Malm et al., 2016). Continuous self-control and self-care of related symptoms are necessary (Bae, 2010; Ostlund et al., 2015). Symptoms of rheumatoid arthritis include general discomfort as well as localized symptoms such as joint pain, morning stiffness, edema, and fatigue (Kojima et al., 2009; Uhm et al., 2012; Yoo, 2013). In particular, the inability to perform activities of daily living (ADLs) is mostly due to persistent pain, stiffness, and joint deformity (Malm et al., 2016; Meade, Sharpe, Hallab, Aspanell, & Manolios, 2013). In addition, this disease manifests as a hand or systemic dysfunction due to somatic symptoms, which affect the daily life and emotions of the patient and lead to disorders affecting social life and housekeeping and to isolation (Kojima et al., 2009; Ostlund et al., 2015). Women with rheumatoid arthritis feel more subjective pain than men (Ostlund et al., 2015; Yoo, 2013). This may be because they perform unique roles such as housework and childcare, which are known to strain the joints, even after being diagnosed with the disease (I. O. Hwang & Kim, 2004; Yoo, 2013). Furthermore, the uncertain course of the disease in terms of its continued progression even with the constant use of steroids and disease-modifying antirheumatic drugs results in poor personal self-care such as the self-interruption of hospital treatment or reliance on folk remedies for pain control (Hwang et al., 2002; Yacoub, Amine, Laatiris, & Hajjaj-Hassouni, 2011; Yoo, 2013). Therefore, identifying self-care competence and improving the ability to perform self-care in women with rheumatoid arthritis should be the basis for the planning of nursing intervention strategies (Hwang & Kim, 2004; Okumus et al., 2013; Ovayolu, Ovayolu, & Karadag, 2012).
Self-care competence consists of knowledge, skills, attitudes, and beliefs that enable individuals to carry out health activities to maintain life, health, and well-being (Meade et al., 2013; Renpenning, SozWiss, Denyes, Orem, & Taylor, 2011). Basic life activities (ADLs/self-care activities such as cooking, repositioning, and walking) and social adaptation are essential for women with rheumatoid arthritis. The self-care activities required for daily living, interpersonal relationships, occupational maintenance, adaptation skills, and self-help management education are more important than drug treatment (Ovayolu et al., 2012; Renpenning et al., 2011).
The concept of self-care competence is a very important factor in women with rheumatoid arthritis (Meade et al., 2013; Ostlund et al., 2015). Various studies on self-care competence in patients with chronic diseases have been conducted recently in areas such as kidney transplantation (Sim & Son, 2012), hemodialysis (Park & Lee, 2010), geriatric musculoskeletal diseases (Nam & Sung, 2014), diabetes (Sohn & Yang, 2013), chronic obstructive pulmonary disease (Yildirim, Asilar, Bakar, & Demir, 2013), and chemotherapy (Kawasaki, Uchinuno, Arao, Kobayashi, & Otsuka, 2011). The few studies that have been conducted on patients with rheumatoid arthritis have shown that women are more sensitive than men in feeling role conflicts and in physical and psychological problems. The number of studies that have sought to determine the factors that influence self-care competence is insufficient. The factors influencing self-care competence of Korean women with rheumatoid arthritis that were used in this study were ADLs, pain, uncertainty, self-esteem, age, level of education, and duration of disease. They were selected based on the findings of previous research (Hwang & Kim, 2004; Kojima et al., 2009; Nam & Sung, 2014; Oh & Kim, 2004; Ovayolu et al., 2012; Uhm et al., 2012; Yacoub et al., 2011; Yoo, 2004). These factors affect the self-care competence of Korean women with rheumatoid arthritis as independent factors.
The aims of this study were to (a) identify the general characteristics of study participants, (b) examine self-care competence in Korean women with rheumatoid arthritis and related factors, (c) examine the correlations between the self-care competence in this population and related factors, and (d) examine the significant factors that influence self-care competence in this population.
Methods
Participants
A cross-sectional descriptive design was employed. Participants included 132 women aged 20 years and older who were visiting rheumatoid arthritis outpatient clinics at hospitals in Seoul and Gyeonggi-do, South Korea. Convenience sampling was primarily used in selecting participants. The eligibility criteria included being 20 years of age or older, visiting a rheumatoid arthritis outpatient clinic at a hospital in the target areas, having awareness of the study purpose and willingness to participate, and being able to communicate verbally in Korean. No special exclusion criteria were applied. One hundred thirty of the 140 distributed questionnaires (96.43%) were returned. Because of incomplete data in several of the questionnaires, the data from 132 questionnaires were included in the final data set. Sample size adequacy (N = 115) using F test and G*Power 3 analysis software was estimated based on an alpha level of .05, a medium effect size of 0.15, and a power of 0.85 (Faul, Erdfelder, Lang, & Bunchner, 2007). Therefore, the sample size was adequate.
Measures
The study questionnaire was designed to measure general characteristics, self-care competence, ADLs, pain, uncertainty, and self-esteem. General characteristics consisted of 13 items, including age, education, religion, marital status, economic status, exercise, smoking, drinking, duration of disease, morning stiffness, concomitant diseases, prior hospitalization, and current medication.
The Self-as-Carer Inventory, developed by Geden and Taylor (1991), was revised and implemented in this study to assess self-care competence. This inventory includes 34 questions that are scored on a 6-point Likert scale. Possible scores range between 34 and 204, with higher scores associated with higher competence in self-care. The reliability of the instrument used in this study was a Cronbach's [alpha] of .87.
The Korean Activities of Daily Living scale, developed by Katz, Ford, Moskowitz, and Jackson (1963), was revised and utilized in this study to quantify the ADLs of the participants. This scale includes seven questions that are scored on a 3-point Likert scale. Possible scores range between 7 and 21, with higher scores associated with a higher degree of dependence. The reliability of the instrument used in this study was a Cronbach's [alpha] of .84.
Pain was measured using the Visual Analogue Scale. Scale items are scored using a scale ranging from 0 to 10, with 0 representing no pain and 10 representing the most pain. Although it is subjective, it is widely used and is considered a valid measuring tool for assessing level of pain (Chao et al., 2007).
The Mishel Uncertainty in Illness Scale-Community Form developed by Mishel (1981) was revised and used to measure uncertainty in this study. This scale consists of 23 questions that are scored using a 5-point Likert scale. Possible scores range between 23 and 115, with higher scores associated with a greater level of uncertainty. The reliability of the instrument used in this study was a Cronbach's [alpha] of .86.
The Self-esteem Scale developed by Rosenberg (1962) was revised and applied to measure degree of self-esteem. This scale includes 10 questions that are scored using a 5-point Likert scale. Possible scores range between 10 and 50, with higher scores associated with higher self-esteem. The reliability of the instrument used in this study was a Cronbach's [alpha] of .89.
Data Collection
Hospitals with rheumatoid arthritis outpatient clinics were visited to obtain permission to include their premises in this study. Researchers then reached out to prospective study participants and discussed with them the study purpose, the details of their participation, and the survey that would be used to gather data. The authors received completed, written consent forms from those who volunteered to participate. The surveys were given only to those who sent in their consent forms, and the surveys were retrieved from the participants after completion. The survey was constructed as a self-reporting questionnaire that was administered by the researchers. The average time to complete the survey was 20 minutes. The period of data collection was from January to March 2015.
Data Analysis
The collected data were analyzed using SPSS Version 21.0 statistical software (IBM, Armonk, NY, USA). The general characteristics of the participants and the levels of study variables were examined using descriptive statistics (frequency, percentage, mean, and standard deviation). Correlations among the study variables related to self-care competence were probed using the Pearson correlation coefficient. Moreover, multiple regression analysis was used to investigate the factors that influenced their self-care competence.
Ethical Considerations
The institutional review board of a university in Seoul, South Korea, approved this study (KHSIRB-14-083RA). Participants were briefed that their involvement in the study would be voluntary and that they could withdraw their commitment at any time. They were also told that the information that they provided would remain anonymous and confidential. The researchers then obtained the completed, written consent forms from the selected study participants.
Results
General Characteristics of Study Participants
The average age of the participants was 43.60 years. The largest age group was 30-39 years (37.9%). Over half (52.2%) of the participants had a college or higher level of education, followed by a high school education (30.3%). Most were married (79.5%) and of a moderate economic status (72.7%), exercised 1-2 days per week (51.7%), did not smoke (90.2%), and drank alcohol (95.5%). Moreover, over one third (38.7%) of the participants had been diagnosed for a period of 6 months to 3 years. Furthermore, most had morning stiffness (84.1%), concomitant diseases (79.6%), and prior hospitalization experience (62.1%) and were currently taking medications (75.8%; Table 1).
Factors Related to Self-Care Competence
The mean score of the participants for self-care competence was 121.91 (+/- 21.51), indicating a slightly higher level of self-care competence; the mean score for routine activities was 10.76 (+/- 1.64), showing a low level of dependence in daily life activities; the mean score for severity of pain was 4.38 (+/- 1.98), exhibiting a slightly low level of pain; the mean score for uncertainty was 72.50 (+/- 11.63), demonstrating a high level of uncertainty; and the mean score for self-esteem was 35.53 (+/- 6.47), indicating a high level of self-esteem.
Correlations Among the Factors Related to Self-Care Competence
In terms of the correlations between self-care competence and related factors, the analyses of ADLs (r = .246, p = .042) and self-esteem (r = .446, p < .001) showed a positive correlation, whereas the analyses of pain (r = -.357, p < .001) and uncertainty (r = -.548, p < .001) showed negative correlations (Table 2).
Multiple Regression Analysis of Factors of Influence for Self-Care Competence
The test that was conducted on the assumptions of the regression analysis showed that all of the assumptions coincided with the required assumptions of the regression equations. First, there were no multicollinearity problems (Durbin-Watson value = 1.737, tolerance limit = 0.229-0.857, variance inflation factor = 1.116-1.629). All of the independent variables were shown to be independent of one another (correlations among study variables: from -.548 to .446), and the normality of the error term and homoscedasticity were satisfactory, supporting the assumption of model linearity.
Second, multiple regression analyses of ADLs, pain, uncertainty, and self-esteem were conducted using demographic variables, including participant age, educational level, and duration of disease, to identify the key factors behind the level of self-care competence. The analyses proved that the prediction model for self-care competence in Korean women with rheumatoid arthritis was significant (F = 21.744, p < .001). The value of the adjusted R2 was .401, corresponding to an explanatory power of 40.1%. The factors found to impact most significantly on self-care competence were uncertainty ([beta] = -.43) and self-esteem ([beta] = .26; Table 3).
Discussion
This study found a middle level of self-care competence among study participants. In the study by Park, Nam, and Baek (2000), which investigated rheumatoid arthritis using the same scale, the mean score for self-care competence was 134.62 points, which was higher than that of this study. This may be because the study of Park et al. included both men and women, whereas this study was conducted exclusively on women. Women with rheumatoid arthritis are known to have a tendency to prioritize their family's health over their own health because of their home-based housework and childcare duties (Meade et al., 2013; Yoo, 2013). In other words, women are more sensitive to physical and psychological health than men, so they must pay more attention to their own health. However, because of their dual roles of being both a spouse and a parent, they prioritize their family's health over their own health and have reduced self-care competence. Low self-care competence has been associated with poor self-care behaviors (Meade et al., 2013; Yoo, 2013). Previous studies of the self-care competence of patients with diseases other than rheumatoid arthritis that used the same scale found mean scores of 135.32 for patients with degenerative arthritis (Lee, 2003), 142.09 for hemodialysis patients (Yang, Ji, Kim, Yeom, & Kweon, 2014), and 143.55 for patients with osteoarthritis (Nam & Sung, 2014), which were all higher than those for the participants in this study. This suggests that women with rheumatoid arthritis have lower self-care competence than patients with other chronic diseases (e.g., osteoarthritis and degenerative arthritis) and patients undergoing hemodialysis.
The average level of ADLs in the participants was slightly higher than average. The percentile score was lower (26.74) in a previous study of patients with rheumatoid arthritis that used a different scale (Uhm et al., 2012). The results of this study contrast with the results of past studies, as patients with rheumatoid arthritis in the latter have generally had a lower level of ADLs. In Uhm et al. (2012), subjects aged 60 years or older accounted for 48.1% of the sample, although the mean age of this study was 30-40 years (37.9% of the sample). It is thought that the younger the age, the higher the level of ADLs. Multiple studies using the same scale should be conducted for an accurate comparison.
The mean pain score for participants, measured using the Visual Analogue Scale, was slightly lower than average. In Uhm et al. (2012), who measured pain using the same scale in patients with rheumatoid arthritis, showed a percentile score of 33.94. Meanwhile, Nam and Sung (2014), who measured the pain of patients with osteoarthritis, showed a percentile score of 56.60. In the studies of Lee (2003) and Oh and Kim (2004), which measured the pain of patients with arthritis, the percentile scores were both 56.60. These results indicate that most patients with arthritis, including rheumatoid arthritis, have an average pain score of 4-6 of 10 points, suggesting that these patients continue to have uncontrolled pain despite using a combination of drug and nondrug treatments for pain management. In particular, Yacoub et al. (2011) reported that women with rheumatoid arthritis feel more severe subjective pain when no family member or spouse is able to take care of them. For this reason, self-care is required.
The mean score for uncertainty in this study was higher than average. Yoo (2004) measured uncertainty in patients with rheumatoid arthritis using a different scale and showed a percentile score of 58.58, which was lower than that in this study. The mean age of the subjects in Yoo's (2004) study was 43.37 years, which is similar to that of this study, which is 43.60 years. This study targeted women only, but Yoo (2004) included men and women at a ratio of 1:3. Gender composition is considered to have made a difference. In addition, the mean duration of the disease was 6 months to 3 years (38.7%) in this study and over 7 years in Yoo's (2004) study. Uncertainty seems to be lower when the duration of the disease is less because the patients cannot predict the period of adaptation and the future course of the disease. The percentile score for uncertainty in this study was higher than that of patients with cancer (57.10) and patients with diabetes (57.17) in prior studies. This may be because the prognosis and progression of rheumatoid arthritis, which is an immunological disease, are more uncertain than those of other chronic diseases in which symptoms are consistently manifested. Furthermore, the unpredictable nature of the degree and extent of pain, deformity, and other symptoms of rheumatoid arthritis makes it very difficult to create an effective treatment plan. Therefore, strategies to reduce uncertainty by developing various nursing intervention programs to reduce anxiety and pain are required.
In this study, self-esteem was found to be higher than average. Hwang and Kim (2004) measured self-esteem using the same scale in patients with rheumatoid arthritis and yielded a similar level of self-esteem, with an average rating of 3.41. However, the average rating of self-esteem in patients with chronic arthritis in Oh and Kim (2004) was 3.37, which is slightly lower than that in this study. The reason for this is that the subjects with chronic arthritis in Oh and Kim's study accounted for 39.3% of the subjects who were 60 years old or older, indicating that most of the sample comprised elderly people. The joints of elderly subjects have worn out, and they find it difficult to recover. Self-esteem decreases as inpatient treatments become more frequent. However, rheumatoid arthritis also had a high prevalence in the younger age group in this study, and their discomfort may be lessened with proper control of the pain. As a result, self-esteem was high in the younger age group.
In examining the correlations between the factors affecting the self-care competence of the participants, higher self-care competence was associated with higher ADLs and self-esteem and lower pain and uncertainty. These results were consistent with the results of Oh and Kim (2004), Yoo (2004), and Uhm et al. (2012). Self-care competence in Korean women with rheumatoid arthritis is necessary for them to lead independent lives (Malm et al., 2016; Okumus et al., 2013; Yoo, 2013). Self-care competence is related to ADLs, self-esteem, pain, and uncertainty and will increase when these factors are controlled.
The factors with the greatest influence on self-care competence included uncertainty and self-esteem, with these two variables explaining 40.1% of self-care competence in the participants. The above results showed that both decreased uncertainty because of health problems such as illness or injury and improved self-esteem have an important influence on self-care competence. Self-care competence is the ability to practice self-care and refers to goal-oriented behaviors. Self-care competence increased when the uncertainty of the participants decreased, which subsequently improved their self-esteem. Therefore, it is necessary to reduce uncertainty and improve self-esteem to enhance the self-care competence of women with rheumatoid arthritis.
Limitations
The generalizability of the results of this study is limited because the data were collected using a convenience sampling approach. The participants were women aged 20 years or older who were visiting rheumatoid arthritis outpatient clinics at hospitals in Seoul and Gyeonggi-do, South Korea. However, the characteristics of the population in other areas or regions of the country may differ.
Conclusions
The results of this study showed that the self-care competence of women with rheumatoid arthritis was correlated with ADLs, pain, uncertainty, and self-esteem. In particular, uncertainty and self-esteem were identified as the most influential factors, explaining 40.1% of total self-care competence. The results of this study can help establish a strong foundation for formulating concrete nursing interventions to enhance the self-care competence of Korean women with rheumatoid arthritis. Moreover, nursing interventions are requisite to improving the self-care competence of this population. Furthermore, the findings of this study may be used as basic data for the development of nursing intervention programs and nursing strategies to improve the self-care competence of Korean women with rheumatoid arthritis. The insights provided by this study support the development of advanced standards for providing care and for the nursing practice in general. In addition, the findings contribute to the expansion of scholarly knowledge on this subject. In the future, it will be necessary to conduct experiments to develop nursing intervention programs and to verify their effectiveness with regard to self-care competence by increasing the number of variables beyond the four that were used in this study.
Acknowledgments
The authors are grateful to all of the subjects who participated in the study.
References