Background
Methods
Design
Conceptual framework of the study: Lazarus stress model
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Cognitive Evaluation: process that determines the consequences that a particular event will generate in an individual.
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Values: Values convey what is important for the individual and determine what is at stake in a particular stressing situation.
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Emotions: Lazarus enumerates the following emotions: anger, envy, jealousy, anxiety-horror, guilt, shame, relief, hope, sadness-depression, gratefulness, compassion, happiness-joy, pride and love [27].
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Beliefs: cognitive configurations created individually or culturally shared. They are pre-existing notions of reality that can be used as a perceptual lens.
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Coping Strategies: constantly changing cognitive and behavioural efforts developed to manage specific external and/or internal demands that are evaluated as excessive or overwhelming for the resources of the individual.
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Social Support: coping resource whereby we have somebody that provides emotional, informative and/or tangible support.
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Participants: The study included symptomatic knee OA patients, with clinical and radiographic OA grades 1–3 in the Kellgren-Lawrence classification, selected from four primary health care centres (PHCC) in Barcelona. Participants were recruited by the general practitioners in each PHCC between February and April 2015.
Sampling and participant selection strategy
Techniques to generate information
Code | Gender | Age (years) | Years since onset knee osteoarthritis | Employment status | Household size | Relevant health problems |
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M1_CR | Female | 60 | 16 | Housewife | Partner | Haemophilia and Depression |
H2_CR | Male | 84 | 14 | Retired (building) | Partner | Silicosis, vascular problem in one leg |
H3_CR | Male | 58 | 20 | Disabled (graphic design) | Partner | Pain in lower limbs |
H4_SA | Male | 85 | 6 | Retired (factory) | Alone (widower) | Diabetes, bladder cancer (operated) |
M5_U | Female | 66 | 16 | Disabled (cleaning) | Alone (divorced) | Polyarthritis, anxiety |
M6_U | Female | 62 | 15 | Housewife | Partner | Polyarthritis, anxiety symptoms, high blood pressure |
M7_U | Female | 67 | 5 | Retired | Partner | Knee prosthesis, carpal tunnel |
M8_VR | Female | 75 | 3 | Housewife | Grandson | Knee prosthesis and breast cancer |
M9_VR | Female | 83 | <1 | Housewife | Alone (widow) | High blood pressure |
M10_VR | Female | 67 | 17 | Retired | Alone (single) | Diabetes and depression |
Data analysis
Results
Experiences and perceptions of informants
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Information-education on knee osteoarthritisSome participants reported that the information was mostly provided by their family doctors, who explained the repercussions of knee OA, the progression of the disease and also provided some advice. However, a participant told that sometimes she did not understand the information provided. Others were not satisfied with the information received, in particular by specialists; they considered that it amounted practically to nothing and that the interaction was limited to prescribing painkillers and to referring them for diagnostic tests.Do you feel that the professionals of the health centre have provided enough information on knee osteoarthritis?. . No, they just prescribe painkillers. And I cannot take strong painkillers because I have a large hernia and they prescribe paracetamol, which is useless. M9_VRNone of the participants received materials on these issues, and some said it would be useful for them to have this information although they did not specify which type of materials they expected. The patients’ expectations aimed to obtain more information on their condition, prognosis and treatment”.
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Professional advice on diet and weightAdvice on losing weight was mentioned by most participants. Informants are aware that they are overweight, they know which food they should eat to lose weight and the benefits of weight loss. Some explained that they take care of their weight, but that putting on weight comes very easy to them. They find it difficult to modify behaviours, mainly because of lack of discipline and because of the food they love. They emphasized the difficulty of sustaining a healthy weight, they had lost weight with the help of dieticians, endocrinologists and acupuncture and have again put it on.“…I’m very strict …You tell me “take this list: Monday this, Tuesday that,..” and I will do it… don’t give me anything ambiguous for me to plan between 5 possible first courses, 5 possible second courses.. no. H4_SASome had received leaflets about diets to help them achieve weight loss.
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Professional advice on physical activityParticipants explained that health professionals tell them to walk. They explained that they like it and they walk even if it is difficult, because if they move they feel better.Some receive positive feedback for exercising in water to reduce impact on the joints,“Aguagym? Yesyesyes, it’s wonderful. I go twice a week, and then I feel so relaxed, because I leave the swimming pool, I have a shower…and such, I then feel so relaxed …” M1_CRand others use the stationary bicycle. They explained that they would feel more motivated if they could exercise in a group.
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Experiences with the different treatments providedInformants mentioned painkillers and non-steroidal anti-inflammatory agents, usually prescribed by health professionals. They are anxious about the side effects of these medications.“I avoid taking pills…I have some, in case one day it hurts too much….” M5_UDepending on the situation, they choose to take paracetamol, NSAIDs, sometimes with a “gastric protection agent”, or bear the pain without taking any tablets.Gels and creams are well accepted by participants, but they complained that the public health system does not cover this type of treatment; they also complain about (the) long waiting times for local injections.Some participants had also had physiotherapy with mostly positive results on the short and medium term. In general, they complained about the long waiting lists to access these services.One informant explained a positive experience with magnesium supplements. They did not comment on the opinions of professionals on alternative therapies.Two participants have a knee prosthesis and they evaluate them positively. Most consider that prosthesis is the best option in the long term although they leave it for when their condition is unsustainable. The youngest participants explained that in this case the health professionals recommend to wait and to bear the condition. Two participants expressed the need for research in this area.“in November 2011 they were about to give me a prosthesis, I had the day of admission, for the operation and everything, but in the preoperative stage, the last person you talked to is the anaesthetist, and he really scared me he told me you are very young and the average duration of the prosthesis is 10 years, and there is more rejection in the second…and I didn’t do it,” H3_CR“Well, if some people need the operation, they don’t want to suffer more then, explain, tell him to not be afraid, that the operation no no… My experience of the operation is very positive…” M8_VR
“I have to do the shopping, I have to do the housework to my family” M7_U
“I feel bad when I eat something forbidden”. M6_U
“… Terrible, terrible. But in 1998 it was less painful, I think that because I still had my house and was busy with my children, but since I came here, in 2001, uyy, this has been terrible” M10_VR
“ until now I went swimming, but lately I had to quit due to family problems, I don’t have time ” “I know many thin women that have bad arthritis” M6_U
“… For me it’s not a trauma or anything, people should see that … people are very nosey, they like to ask; there she is with the bad knee.. you have to explain, otherwise …” M1_CR
“And most of all not being in much pain, because I have things to do, … help my daughter, … help my mother…”. M1_CR
“Being busy the whole day!! I spend cleaning … cleaning here and there… It does not even hurt.. M10_VR
“It makes me sad because it limits me, it limits me a lot, I cannot do what I would do”. M8_VR
“I had my mother sitting in a chair for many years as a result of arthrosis. That’s what I fear most” M8_VR
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Beliefs on painTo some, physiotherapy helps them feel less pain. However, others explain that it is of no use to them.“No… Because when I’m doing physiotherapy it hurts even more, and when physiotherapy finishes it goes on hurting. It doesn’t work for me”. M1_CRPatients believe that physiotherapy is useful when they are doing it and are aware that when they stop physiotherapy the pain comes back. Only one participant explained that he consistently practices the exercises daily because he believes that it is key to improve pain. For some, the pain of knee OA hinders the practice of physical activity because of the belief that it can increase the pain.Another shared belief on pain is “that it must be borne”, possibly related to some Judeo-Christian values of sacrifice, be it as acceptance (coping strategy) or some resignation (negative emotion).To cope with pain, patients choose as a first option looking for distractions, secondly they prefer to bear it and lastly they take medication.
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Beliefs on dietParticipants are aware of the association overweight– pain. The impossibility of losing weight is one of the most common beliefs amongst women with knee OA. They attribute this impossibility to menopause, age and other factors unrelated to the quality and amount of food intake. Anxiety surrounding food is another factor related to the difficulty in losing weight. Most participants believe that the dieting recommendations are not effective for their particular case. They pointed out that the leaflets with standard advice are of no use to them.“He gave me some paper, but I don’t follow it because it’s bad for me. However, him and another one have insisted that I should not put on weight ” M5_U
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Beliefs on PAParticipants believe that PA is positive. When they are more active they feel better and their mood improves. The most common PA are walking and Aqua gym.“In water you can do any exercise” “outside water no”. M1_CRThe main limitations for being physically active were knee pain and in some cases negative emotions.
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Beliefs on OAParticipants explain that OA is a chronic disease and that professionals have told them that it cannot be cured. Beliefs on the possibilities of a cure for knee OA emerge in the interviews, whereas at a conscious level participants are aware that no cure exists yet. However, they mention hope and the need to find a curative treatment.“I think that everything but death has a cure”. M10_VRPatients need to translate the medical indications into something practical in their daily lives. Resignation when faced with knee OA has a strong emotional impact and generates sadness, anger and anxiety. Some patients talked about acceptance with a resigned face and non-verbal signs of negative emotions.
“I spoil myself with a latte”. M8_VR“I wake up around 10 a.m. First thing I drink lukewarm water with lemon, eh, I have breakfast after half an hour, and I make my beds, clean the floor, sweep the apartment, I do, I prepare lunch.. and in the afternoon I get out. ” H3_CR“Mm.. little things, then you understand, how can I explain it.. look, right now I’m enjoying the tablet and my husband with the ball and me with the tablet is no problem at all ” M6_U.“I get it out of my mind” (referring to the disease of the daughter). M8_VR
“If you accept it your attitude changes” H3_CR
“When it’s very painful I take ibuprofen or naproxen”. M7_U“Walking at my pace is very relaxing for me”. H3_CR“And I rub it with wasps’ poison” M8_VR“ if you join a gym, whether you believe it or not it’s super positive for the brain ” M10_VR)
II-Recommendations for the design of the coaching psychology intervention (Table 2)
Barriers in the management of knee osteoarthritis | |
Result | Contributions |
Difficulty for translating theory into practice | Strategies and techniques to take action |
Difficulties in sustaining a healthy diet | Indications and recommendations for a healthy diet |
To facilitate simple menus | |
To facilitate healthy menus | |
Techniques to control stress (anxiety) | |
Motivation strategies to implement a healthy diet and make it sustainable over time | |
Pain associated with physical activity | Techniques to manage pain |
Indications and recommendations to carry out physical activity | |
Motivation strategies to start and sustain physical activity | |
Fear | Strategies to overcome fears |
Facilitators in the management of knee osteoarthritis | |
Result | Contributions |
Holistic Vision | Holistic vision focused on individual needs |
Lack of individualisation | Taking into account the person within the group |
Physiotherapy to reduce pain | Include physiotherapy exercises in the intervention |
Strategies to sustain the practice of these exercises | |
They would like to have more information | To provide information on the disease, its repercussions and advice on how to live with it |
Learning to say “no” | Assertiveness strategies |
Social support | To offer space for participants to talk about their particular situation |
To offer the possibility of continuity of contact between participants at the end of the intervention (WhatsApp, phone, etc.) | |
Self-care | To provide strategies for the patient to have time for him/herself |
Learning to calm down | Strategies to control stress |
Mindfulness | |
Breathing and relaxation techniques | |
Acceptance | Work with acceptance and differentiating it from resignation |
Values | The patients’ most important values will be used to motivate and to generate change in the participants (family, autonomy, discipline) |
Reference framework
“To help us know what’s in there, in this neighbourhood there is nothing to do. Things like aqua gym and such” M7_U
“I’m happy, because it’s working well with the doctor, and now with you, and if there are things to do for no, to slow down a bit the arthritis, then fantastic…·”. M7_U
Contents/components
“We need to cheer up people that feels down, teach them that they have to move even if they are in pain. Because I also have pain, eh?” M8_VR
Use of TICs
“Whatsapp yes. My friend in Italy, I will show you, that I have a friend in Italy, that friend I mentioned from Italy. Whatsapp yes and gmail too… Let’s see, Nicoletta… Every day or every night, “good night”, “”, “bon giorno” “#italiano#” “#italiano#”. M5_U.