E LS QUATRE RITUALS D ’ ANÀLIS

The association between PPC and clinical variables (co-morbidities of RA, fatigue, pain and physical health function), have been addressed as below.

4.3.1.1. Common co-morbidities

Approximately two thirds of the current study’s participants stated that they have other health conditions. These are mainly osteoarthritis, osteoporosis and fibromyalgia. Some earlier researchers have reported on other health conditions, with 80.0% involving individuals with RA. For instance, Petri et al. (2010) and Michaud and Wolfe (2007) reported that the rate of osteoporosis is nearly twice as much in people with RA. However, those people with other long term physical or mental health conditions that might have influenced the present findings were screened, as reported in the method section.

4.3.1.2. Fatigue

It was initially expected that PPC would be negatively correlated with fatigue, as there is evidence of the multidimensional action of the fatigue through physiological and psychological pathways, as explained by Louati & Berenbaum, (2015). The findings from the current research highlight the important role of fatigue in relation to PPC, as greater fatigue is significantly associated with decreasing levels of PPC.

In addition, in a follow up analysis, the study aimed to investigate the differences in the study variables for fatigue, concerning the level of PPC scores based on the SLQ-38 scores. In the process, it has been examined whether there is a significant difference between those whose scores are lower than the SLQ-38 mean, compared to those who attained the SLQ-38 mean. This suggests that fatigue would have had a significant impact on the level of PPC on the SLQ-38 scores at the SLQ-38 mean and one SD level, signifying that those people with lower fatigue might experience more PPC. On the whole, the findings indicate that people who scored higher in their level of PPC were more able to control their fatigue, possibly through their self-efficacy-pain ability. This means that there might be many factors that can

explain this variation, however, the model includes overall well-being, sense of coherence and resilience, RA duration and fatigue, which may explain 14.3% of it; among this value, fatigue can be explained by only 0.02% of the variation. Thus, there must be other variables that have an effect as well.

It is worth noting that some previous studies have confirmed that fatigue, pain and depression are often associated with a complex and dynamic mechanism concerning psychosocial factors and RA illness beliefs (i.e., Dures et al., 2013). In addition, some earlier studies (i.e., Repping-Wuts et al., 2008) suggest that the severity of fatigue could minimise the perceived ability to cope with RA. In line with these findings, the current research supports the study hypothesis and suggests that effective coping strategies, in particular cognitive reframing, are positively related to lower levels of fatigue and also higher levels of PPC. This might be due to the impact of self-efficacy-pain ability, which may assist in minimising the influence of RA fatigue. The second possibility is the impact of a combination of other factors, for example, psychological well-being and the level of coping strategies, in particular the cognitive reframing capacity, as this might help in reducing the level of fatigue. Thus, the suggestion is that the changes in the levels of fatigue are possibly as a result of a collaboration of other factors, including psychological well- being, lower pain experience, and longer RA duration. However, this research is a preliminary exploration and the current thesis did not measure fatigue at the baseline, thus it can be assumed that this finding might be due to the nature of the study when considering the level of fatigue. In addition, the influence of the combination of these factors to reduce fatigue is in doubt. Therefore this could be another interesting topic to be explored in the future.

Alternatively, some previous studies show that higher levels of fatigue are linked to more severe mental health problem in people with RA (i.e., Pollard et al., 2006; Munsterman et al., 2013). In what follows, the present study suggesting that lower levels of fatigue are associated with poorer pain experience, which might contribute towards enhancing psychological well-being and utilising effective coping strategies to handle the RA burden, which might lead to increasing the level of PPC experienced by individuals with RA. Thus, PPC is positively connected to lower levels of fatigue and pain and not psychological symptoms such as depression and the level of tension. The lack of information in this area

could be addressed in future research, so that these findings can assist in moving toward developing a range of applications to effectively meet the needs of people with RA.

4.3.1.3. Pain

This study primarily predicted that PPC is negatively correlated with ratings of arthritis pain scores, yet the study hypothesis has not been confirmed. Nevertheless, in a later analysis, the thesis aimed to examine the difference of the pain on the level of PPC scores based on the SLQ-38 scores. Thus, the thesis has examined whether there is a significant difference between those whose scores are lower the SLQ-38 mean compared to those who attained the SLQ-38 mean. This shows more severe RA pain might be controlled only at higher levels of PPC, over two SD, suggesting that those diagnosed with RA are differ in their level of PPC if they experience more pain. However, in this case, other variables might assist in decreasing the level of pain experienced due to the higher level of psychological well-being; higher level of self-efficacy pain control and the lower fatigue experienced.

Previous research has shown an association between self-efficacy and changes in daily pain (Brekke et al., 2001), fatigue (Barlow et al., 2002) and well-being (Cross, March, Lapsley, Byrne, & Brooks, 2006). The self-efficacy-pain scenario emphasises thatif people with RA believe that they are capable of controlling their pain, they are more able to organise and accomplish the action necessary to achieve this and control their pain. In addition, if they expect positive outcomes (self-efficacy expectation, i.e., controlling their pain), they are more likely to control their pain (outcome expectation, Bandura, 1977). Besides experiencing higher pain, RA might interfere with other social roles, for instance house holding (Hirsh et al., 2006), leading to poorer quality of life (Olofesson et al., 2013) and experiencing higher levels of psychosocial distress (Evans et al., 2005). In this case, the research has shed light on the significant role of PPC in mediating the association between arthritis, self-efficacy pain and psychological well-being. The more people with RA can manage the impact of pain, perhaps through self-efficacy pain ability, the more psychologically well they are and PPC. Hence, future research might consider self-efficacy pain beliefs as a core concept in self-management programmes to identify those positive beliefs that can influence pain management in individuals with RA.

4.3.1.4. Physical health function

This research hypothesis was that the level of PPC on the SLQ negatively correlates with the total physical health factor scores. The physical health function included the rate of

mobility; walking bending; hand and finger function and arm function scores on the AIMS- 2. The assumption was that individuals with RA commonly live with lots of stress due to the unpredictability of the condition and experiencing lots of pain. This might cause a person to lose the ability to function as normal, which might lead to depression and anxiety. However, an unexpected finding was that there was no significant relationship between PPC and physical health function. The reason for this result might be because the content of the AIMS-2 focuses largely on function and the essential tasks of everyday living, for instance writing with the hands and being able to walk around the house. Thus, one of the reasons for this finding is that this cohort was initially healthy enough to be able to handle their daily tasks. The reasons for this suggestion is that this data has been collected based on the information received from those who were unpaid volunteers, either from ARP or NRAS organisations, thus the cohort might underrepresent the population, so the existing findings might not address some aspects of the population; therefore, the findings should be considered with caution. Although it is critical to consider a representative sample, it is common and not always possible to consider the databases’ combined demographic data from an entire RA population; however, this finding provides some evidence for future studies to investigate the point further. Another suggestion is that the study did not measure physical health function at the baseline because of the nature of the study with its cross- sectional design, so it can be assumed that this finding might be due to the nature of the study when measuring the physical health factors. Thus, the present findings may flag up that further researchers should investigate this by conducting prospective studies, as data about possible elements is collected in advance and then compared to see if it differs at baseline when considering the same elements, which would assist in examining the field in more depth.

4.3.2. Psychosocial factors associated with Positive Psychological Change in people