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The SLQ-38, (Sodergren et al., 2002) has the larger coverage of positivity compared to the Perceived Benefit Scale (PBS). The SLQ-38 (Sodergren et al., 2002) is a generic scale of positivity compared to the BF scale which has been adapted for the cancer patients (Cruess et al., 2000).The PTGI focused on the event and not illness, while the SLQ-38 is based on the illness. Compared to the modified version of the BF scale used in Japan’s study (Sato et al., 2008), the SLQ seems to be ideal, due to the cultural issues. The Satisfaction with Illness

Scale (Hyland & Kenyon, 1992) could be considered as an old version of the SLQ-38 (Sodergren et al., 2002).This was confirmed by one of the authors of the scale, Professor Hyland, when he was contacted by email in 2014 before making a decision about the proper scale. Moreover, SLQ has been recommended by Joseph & Linley, (2012) where they confirmed that ‘a wider pool of measures is available for assessing the potential for positive outcomes of negative events that are often more specifically tied to a particular stressor, such as illness, Silver Lining Questionnaire (Joseph & Linley, 2012, P.22); Finally, most recently some of the investigators have used the SLQ to assess positive change in other chronic health conditions, for example, a sample of 85 patients with Myocardial Infarction (Maqsood, Jabeen, & Khatoon, 2013) and a sample of patients with cancer eight years post- diagnosis (Bride et al., 2008). All in all, SLQ was preferred for use in assessing PPC in people with RA for the purpose of the current thesis.

There is rising agreement that generic, as well as disease-specific tools, must be employed to measure the disease process, its impact and to allow for comparisons between disease conditions and therapeutic findings (Danao, Padilla, & Johnson, 2001). The sub-aims for this thesis were: to explore factors connected with PPC in people living with RA. For example, this thesis was intended to examine the association between clinical variables used, such as pain, and PPC in people living with RA, thus a range of reliable and validated measures was considered which is addressed below.

The Arthritis Impact Measurement Scales-2 (AIMS-2; Meenan, Mason, Andersson, Guccione, & Kazis, 1992) is an arthritis specific questionnaire which assesses physical, emotional and social well-being using 12 domain scales: mobility level, walking and bending, hand and finger function, arm function, self-care, household tasks, social activities, support from family and friends, arthritis pain, work, level of tension, and mood (Szende et al., 2003). Out of 12, this thesis chose some of the AIMS-2 subscales to assess functional state. These were: mobility level (i.e., support getting around the house), walking and bending (i.e., stairs climbing), hand and finger function (i.e., handwriting) and arm function (i.e., brushing). In addition, mental health symptoms were explored via level of tension and mood (depression) sub- scales. Other domains are described in the methods section.

Fatigue in people with RA may be caused by a dynamic relationship between some clinical (i.e., inflammation, pain, disability) and psychosocial factors (i.e., coping, mood, illness beliefs), which may differ within individuals and over a period of disease (Hewlett et al.,

2011). The Bristol Rheumatoid Arthritis Fatigue Scales (BRAFs) are employed to measure fatigue in RA patients. The scale was produced in the Rheumatology Department at Bristol, UK.

Bandura defined self-efficacy as: one’s judgement of their capabilities of what a person can do with whatever skill she/he possesses (Bandura, 1986; Brekke et al., 2001). This judgement is based on some major resources of information, for example; modelling, social persuasion, mastery experiences and psychological state (Brekke et al., 2001; Lomi & Nordholm, 1992). There is evidence that examining the level of self-efficacy and health related to the disease may be important in people with RA (Brekke et al., 2001; Aldwin, Levenson, Tedeschi, & Calhoun, 2004). The present thesis chose to include pain and other symptoms on the sub-scale of the Arthritis Self-Efficacy Scale to examine self-efficacy in people with RA (Aldwin et al., 2004).

RA is a chronic, progressive (and in the long run) debilitating health problem worldwide, to be so ignored (Danao, et.al., 2001). Previous studies have found that RA is associated with decreased levels in QoL (Carpenter, Stoner, Schmitz, McGregor, & Doorenbos, 2014). Danao, et.al., (2001) proposed a list of various elements relevant to the QoL: physical ability, pain, interaction with family and friends, support from family and friends, mood, tension, arthritis, and health (Danao, et.al., 2001). This was examined by the Quality of Life-Rheumatoid Arthritis Scale (QoLRA; Danao, et.al., 2001, English version).

Some theories suggested that the emotional responses and coping efforts determine people’s explanations of the distress and how they respond to it, in terms of their attempts to relieve, fix or resolve the challenging conditions (Park, 2010). As such, the coping strategies mainly emphasize the importance of the meaning of the stressor and how each individual responds to the stressful events (Park, 2010). Therefore, coping strategies are assessed by the Rheumatoid Arthritis Questionnaire (C-RAQ; Englbrecht et al., 2012). The questionnaire comprises the following coping domains: cognitive reframing, distancing, emotional expression, and active problem solving (Newth & DeLongis, 2004).

Psychological well-being has been conceptualized as incorporating of six dimensions: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, self-acceptance (Ryff & Keyes, 1995). Psychological Well-Being Scales (PWB; Ryff & Keyes, 1995) were used to examine psychological well-being.

Dealing with stress is an inevitable part of life. How individuals cope with these troubles can play a main role in their long-term psychological consequences. Antonovsky, (1993) introduced the concept of Sense of Coherence in reference to a person’s viewpoint of life in a way that makes coping with stress easier. The ability to cope with stress has been described as resilience (Luthar & Cicchetti, 2000). The short-form of the Sense of Coherence (SOC; Antonovsky, 1987) was used to inspect a person’s ability to manage stressful conditions such as dealing with RA. (See chapter two, method section, for more details).