Rheumatoid Arthritis Community

Community Impact on Patient Care

As mentioned above, there are numerous community resources and community health professionals for rheumatoid arthritis patients, such as PT, OT, The Arthritis Society, patient education groups, vocational rehabilitation groups, workplace programs, and physical exercise group facilities. Patients find considerable comfort and benefit in being introduced to rheumatoid arthritis support groups such as The Arthritis Society (TAS). Such societies allow health management to attend to all aspects of a patient’s needs, and to adopt a holistic approach. It provides a variety of treatments and education programs, such as the Arthritis Self-Management Program, Joints in Motion Training Team and “Ask an Expert” Sessions. Their website is also an exceptional resource to patients (arthritis.ca). Patient education groups, which were provided by the TAS through hospitals are very helpful, and our patient was enthusiastic to attend these. Furthermore, the notion that, increased access to information for rheumatoid arthritis patients must always be beneficial has been challenged recently (31). Easy access and a surfeit of information, such as the Internet, can result in misinformation of patients, which can mislead patients, as well as terrify them. This highlights the need for a close professional relationship between the team and the patient, as well as the role of TAS, which provides a tremendous amount of support and information to the community, as well as online. This information is consistently reviewed and accurate. An Arthritis Bookstore online is also provided. We recommended this to our patient who has utilized the TAS and their website extensively.

Moreover, our patient was encouraged to attend weekly sessions of a physical exercise group, which are organized within the rehabilitation unit of the hospital in order to maintain joint condition and mobility. It is a public-funded rehabilitation program which offers outpatient community-based services. Furthermore, outpatient PT, and a fitness centre and aquatics program were recommended. Individual treatment services provided by PT were crucial and involved job coaching, work conditioning, wellness programs and psychological consultation. As our patient lived alone in a private household, PT and OT assessments were essential. Functional abilities evaluation, job site assessment, physical demands analysis, and home site assessments were done.

Although there were monthly waiting lists for these multidisciplinary programs and services, the patient had tremendous financial supports and an extensive employee benefits program. As such, her employment benefits from Nortel, in addition to substantial private funds, provided her access to numerous services immediately, without any time limitations or restrictions. Funds were also available for non-medically supported services and resources, such as Acupuncture and Naturopathic medicine which the patient found helpful. In contrast to patients with a lower socioeconomic status (SES), resource availability was not a problem for our patient. The availability of numerous services, such as PT, was very accessible through private funds and a strong benefits program. Not only were waitlists avoided, but the time of therapy was much more extensive and beneficial. This patient could take advantage of all the resources available in the community, and has significantly benefited.  

Considering her work, the patient works for Nortel and has been unable to resume work for numerous months. She is trying to follow a vocational rehabilitation program; however, she is aware that her work, as well as getting to work, which is a one hour commute on the public transit system, has become physically too heavy. The patient has described that her workplace, Nortel, has a flexible work program that allows ill patients to have flexible work hours, as well as work at home. This will be of great benefit to her.

It is well documented, that before the industrial revolution, there have been limited, if any cases of rheumatoid arthritis. An examination, which occurred in the United Kingdom (UK), of over 800 medieval skeletons, failed to show any evidence of rheumatoid arthritis 33,34. In contrast, the present day UK population has a 1.16% prevalence of rheumatoid arthritis in females and 0.44% in males33. Moreover, in African populations, there is a higher prevalence of rheumatoid arthritis in people from an urban rather than a rural environment, and that these people suffer more severe disease (35). These studies suggest that environmental factors are important in rheumatoid arthritis.

Our patient has had numerous environmental factors in her local community impact on the severity of her disease and its progression, as well as possibly contributing to its cause. These same factors also impend her ability to cope with rheumatoid arthritis and overcome its difficulties. These include psychosocial factors, such as living alone, with no supports in a low socioeconomic status community with an increased crime rate and poor public transportation/transit. Poor mechanical/ergonomic factors within the community, often pose difficulties for independent arthritic patients to commute within buses and walk the distances to bus stops. Urban noise contributes to the patients’ poor sleep, and urban pollution predisposes an immunosuppressed patient to toxins and infection. Furthermore, hygiene becomes an issue, as the patient is independent but does not have the capabilities of cleaning and maintaining a two-storey home. Mechanical/ergonomic factors will be crucial to assess and improve within the patient’s house and workplace environment.  Infection, moisture and dust may become common problems and will predispose her to numerous future co-morbidities that are commonly associated with rheumatoid arthritis, such as recurrent infections. Moreover, nutrition and diet may become a problem, as cooking and shopping may pose difficulties to the patient.  

It has been previously described that stress from life events may contribute to the onset and worsening of rheumatoid arthritis (36). “Matrimonial quarrels, problems at work and/or economic problems” during the 5-year period preceding the rheumatoid arthritis symptoms and diagnosis, were significantly associated with the onset of rheumatoid arthritis compared to controls (37). Moreover, poor social environmental factors and medical status have been associated with the onset of other autoimmune disorders, such as psoriasis. The impact of psychological influences on hormonal and immunological changes within the human body has been postulated to be the mechanism possibly underlying the cause of rheumatoid arthritis (36). It is therefore crucial to prevent any further stressors from worsening a patients rheumatoid arthritis through appropriate allocation of health resources and supports, and advocating for appropriate workplace environments and economic supports.

The association between low socioeconomic status and poorer health outcomes in arthritis is also well established. Interestingly, recent reports suggest that community social determinants (eg, the socioeconomic environment of an individual’s community) may be also associated to health outcomes in arthritis. The association of community social determinants with health outcomes however, appears to be independent of an individual’s socioeconomic status (38). The socioeconomic context of communities may affect the environment to which all residents are exposed, irrespective of their own individual socioeconomic status. This can occur two ways; indirectly through shaping an individuals’ educational attainment, job prospects, and income level, or directly, by affecting the social, service and physical environments. These upstream determinants related to the community, include place of residence, work environment, and the wider social and economic policies of society. Indicators associated with a worse clinical outcome in rheumatoid arthritis in poorer neighborhoods included unemployment, poor education, overcrowding and no access to a vehicle (38). In our patient, no access to a vehicle, and a poor social, service and physical environment in her neighborhood, place her at a disadvantaged situation to access support. Economic support and an improved social infrastructure could greatly benefit this community through physician advocacy.

There are numerous actions that the physician along with the community, allied health care workers and/or through a broader public health initiative can accomplish, to make contributions to environmental issues within this community. Physicians can advocate for their patients during the development of public policy. Lobbying all levels of government through physician-based associations, such as the Canadian and Ontario Medical Associations to develop policies for improved community and work environments, such as making public transit more accessible to patients with arthritis who are not candidates for wheeltrans, can be very effective. Our patient had difficulties with transportation within her community. Greater access to transportation, and user-friendly buses, trains and sidewalks for patients with arthritis would be beneficial. In addition, physicians can advocate for more community supports for patients with arthritis, as well as making the government more aware of the prevalence and complexities of arthritis and their patients’ needs. Participation in societies, such as Doctors for the Environment39, can create large, influential societies that can create the needed voice for the environment from physicians. These societies can effectively educate other physicians on environmental issues, and prepare spokespersons to comment on the health implications of their own community issues. National interventions could possibly include legislation against the use of pesticides and ozone depleting chemicals, and the preservation of parks and recreational areas.

Primary prevention efforts have the potential to reach large and diverse groups of people, especially when used early in life (eg, talks at schools to prevent air pollution and increase awareness on pesticide use). Different factors and strategies can be used to address and implement issues in different settings, such as in the community, schools, or clinical setting, in order to improve and benefit a community and its environment. Primary prevention can take place at numerous different levels (40).             

Physicians should advocate for easily accessible educational and treatment programs, and support for patients with arthritis. Greater access to treatment programs will facilitate the identification and treatment of RA individuals, in addition to patients with other rheumatic diseases. In many cases, newly immigrated families or individuals who come to Canada, usually speak little English, except for their children, and are unknowledgeable about the health care system and what it has to offer. The provision of information regarding available community supports, and health care programs in primary care offices and community clinics which offer support, advice, and direction to access other regional and health care services and supports is crucial in a physician. Information can be provided in different forms, such as multilingual pamphlets and posters, or through direct one-to-one discussions at routine visits with patients or parents. Furthermore, a discussion of environmental issues within the community would be beneficial with these opportunities. A knowledgeable physician that can direct his or her patients to these community and health care services can be an asset to patients.

Finally, community-level programs, which can be integrated with the school system, clinics, local media and religious, youth, and parenting organizations, can be the most influential mode of support and change, and can provide the opportunity to create a synergistic effect among the many different levels and agents of change in the community and its’ environment (14). In addition, greater access to education and treatment programs for patients and families, will facilitate the identification and treatment of rheumatoid arthritis early, and also prevent relapses and life-threatening consequences.

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