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LETTER TO EDITOR
Ahead of print publication  

Impact of household dynamics and familial support in influencing beliefs toward medications in patients with rheumatoid arthritis


 Department of Medicine, Royal College of Surgeons in Ireland, Dublin 2, D02 YN77, Ireland

Date of Submission03-Sep-2020
Date of Acceptance24-Sep-2020

Correspondence Address:
Ahmad Saud,
Mailbox 280 Bachelors Walk Apartments, Dublin 1, D01 C603
Ireland
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_244_20



How to cite this URL:
Saud A. Impact of household dynamics and familial support in influencing beliefs toward medications in patients with rheumatoid arthritis. Indian J Rheumatol [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=326158



Dear Editor,

We read with great interest the article reporting the personal views on rheumatoid arthritis specific medication of Indian patients with very early rheumatoid arthritis.[1] After obtaining responses from recently diagnosed patients by means of the Beliefs about Medicines Questionnaire (BMQ) and categorizing them into one of four categories (accepting, ambivalent, indifferent, or skeptical), the authors concluded that while the vast majority (>95%) believe that, generally, medications are overused and cause harm, the views on rheumatoid arthritis-specific medications were one of indifference in 242 of the 250 (96.8%) patients. The study also states that patient characteristics such as sex, age, educational status, occupation, or income do not show correlation with the patients' beliefs. While the article records patient baseline characteristics such as age, sex, educational status, occupation, or income, we feel it overlooks one crucial social dynamic that may possibly contribute to the unexpected finding of indifference toward rheumatoid arthritis medications found in the study, which is the household situation of the patient and whether they are single and living alone, living with a family (including extended families), or living in a long-term care home. Examining the correlation between household status (living alone, living with family, or living in a long-term care home) and responses to the questionnaire can shed light on the unexpected results of this study.

A recent UN report states that in Asian countries, including India, over 50% of households are multi-generational.[2] This is in stark contrast to the United States and UK where multigenerational households account for under 16% of all households. In light of this, we present the idea that the relatively common social dynamic of Indian culture, one of individuals living with an extended family provides sufficient social support in catering to the activities of daily living (ADL) for the rheumatoid arthritis patient, so-much-so that the perceived need for rheumatoid arthritis specific medicines decreases. This may be a reason for low specific necessity and concern scores for rheumatoid arthritis medications in this relatively young sample population who are more likely to be living with families compared to an elderly cohort who may more likely be living alone or in long-term care homes.[3]

A study done on patient attitudes toward medicine deprescription by Reeve et al. showed that when given the option to reduce their medication, 92% of outpatients opted for medications to be deprescribed.[4] However, surprisingly, when views were obtained from nursing home patients, only 79% were in favor of having their medicines deprescribed.[5] This suggests that nursing home residents feel more reliant on their medications compared to the general population presenting from the community. If this is the case, then it will be worthwhile for the authors of this study to have a look at and record the household dynamics of the 250 patient cohorts. Given that the patient sample of this study was relatively young (mean age 47.6 ± 13.4 years), we would not expect the patients to be in long-term care homes but rather living with families and having this familial support present may have led to the low specific concern and medicine necessity scores as they would not have become reliant on solely medication to help them function in their immediate environments.

Another study conducted in a sample of diabetic patients in India showed that there was a positive, statistically significant association between good family support and self-management.[6] Similarly, rheumatoid arthritis patients with strong familial support may feel that they can self-manage the condition and hence not consider medication a necessity. However, studies on the level of familial support of patients with early rheumatoid arthritis in India are scarce, and hence, we humbly request the editor to assist in highlighting the lack of focused research directed toward this area by means of publishing our letter. It would indeed be worthwhile to look at the association of the BMQ scores and level of familial support available in the management of daily activities for rheumatoid arthritis patients. We would expect that rheumatoid arthritis patients would not be as concerned or view medications as something necessary when there is familial support available to help them perform ADL, and in contrast, we would expect to find individuals living alone or in long-term care facilities to be more reliant on, and approving of, medications and hence report a higher necessity rating on the BMQ due to the lack of direct familial support. Until such household dynamics are examined, we may be missing out on the key to unlocking the code to patient beliefs on medicine and consequently, adherence to important medication required for rheumatoid arthritis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ahmed S, Mahapatra A, Behera B, Padhan P. Beliefs and outlook toward medications in Indian patients with very early rheumatoid arthritis: Cross sectional survey. Indian J Rheumatol 2020;1-6. doi: 10.4103/injr.injr_3_20. [Last accessed 2020 Sep 06].   Back to cited text no. 1
    
2.
United Nations. Patterns and Trends in Household Size and Composition: Evidence from a United Nations Dataset. Department of Economic and Social Affairs Population Division 2019. Available from: https://www.un.org/en/development/desa/population/publications/pdf/ageing/household_size_and_composition_technical_report.pdf. [Last accessed on 2020 Sep 01].  Back to cited text no. 2
    
3.
Jadhav A, Sathyanarayana KM, Kumar S, James KS. Living Arrangements of the Elderly in India: Who Lives Alone and what are the Patterns of Familial Support? Session 301: Living Arrangement and its Effect on Older People in Ageing Societies. IUSSP; 2013.  Back to cited text no. 3
    
4.
Reeve E, Wiese MD, Hendrix I, Roberts MS, Shakib S. People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to deprescribe. J Am Geriatr Soc 2013;61:1508-14.  Back to cited text no. 4
    
5.
Kalogianis MJ, Wimmer BC, Turner JP, Tan EC, Emery T, Robson L, et al. Are residents of aged care facilities willing to have their medications deprescribed? Res Social Adm Pharm 2016;12:784-8.  Back to cited text no. 5
    
6.
Ravi S, Kumar S, Gopichandran V. Do supportive family behaviors promote diabetes self-management in resource limited urban settings? A cross sectional study. BMC Public Health 2018;18:826.  Back to cited text no. 6
    




 

 
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