An over-view of barriers to effective gout care: An implication for change in general practice

Abstract

Title. An Over-View of barrier to effective gout care: an implication for a change in general practice.

Aim. To explore the barriers to effective gout care in the community.

Background. Lay perspectives on gout care are a barrier to improved health outcome, proper utilization of health services and resources. If patients’ perspectives are not understood by health professionals, the prevalence of gout will continue rising, leading to irreversible joint damage and risks of developing chronic kidney and heart diseases.

Design. A narrative review.

Data sources. Key texts and information of patients’perspective and beliefs on gout care was sourced from health institutions, focus groups, surveys, policy documents, medical and nursing studies from PubMed, ProQuest, Mediline, CINAHL and SCOPUS data bases (1997-2012).

Review methods. A narrative review involving reading, analyzing and critiquing of the research findings was used to synthesize the material and come up with a convincing, cohesive and interesting story on patients’ perception in regards to gout

Results. A total of 31 papers were identified in the research addressing the proper management and care of gout in Western world and Australasian countries. The main themes identified in the studies were: patients’ beliefs as a barrier to treatment adherence, gout on the rise, gout is poorly managed, lack of universal gout guidelines, misperception of the disease by health professionals and doctor-patient relationships.

Conclusion. There is evidence that issues of beliefs and cultures have a strong influence on gout care. The way forward is to urge governments and health professionals to develop better understandings of groups vulnerable to gout understand and interpret their diseases.

Keywords: patients’perspective,perception,experience,international,gout, doctor-patient relationship, compliance, rheumatology nursing. Gout in New Zealand.

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Introduction

Palscual & Sivera( 2007 defines gout as one of the commonest form of inflammatory arthritis in people over the age of 45 years affecting lower joints particularly the metatarsalphalangeal(MTP) joint in approximately 50% of cases. The disease results from accumulation of monosodium urate crystals into joint structures and periarticular sites forming tophi as one of the complications. It is characterized by acute attacks of a painful, swollen joint with redness of the skin over the joint. If untreated or poorly managed, it can cause disabling and poor quality of life (Pascual & Sivera 2007, Susan et al. 2011, Howard et al. 2011 Smith et al. 2011).

The prevalence of gout was higher in western countries and Australasia than in Africa. The United States of America(USA) has more than 6.1 million people with living gout and the number is expected to rise (Charles 2010,Smith et al. 2011).The rise in gout is attributed to acquired conditions for example, cytotoxic drugs, hypertension, alcohol use, obesity, myloproliferative disorders, consumption of fructose, metabolic syndromes and lifestyle habits. These conditions either change the nucleic acid or affect the elimination of uric acid by the renal system predisposing the subjects to gout (Smith et al. 2011).

Men were more affected (0.7%) than women (0.1%).This is because men have less uricosuric(protective) effect of estrogen than women who have higher estrogen levels. But after menopause, women have increased risks of developing gout when estrogen levels are depleted ( Zycowcz &Michael 2010).

Zycowcz & Michael (2010) discovered that 90% of men between the ages of 40 and 50 were diagnosed with gout in USA and black men were more affected than other races. This was attributed to genetic factors, hypertension and indiscriminate use of diuretics.

Despite of the high prevalence, gout has been sub optimally managed internationally. Neogi(2006) was convinced that one in five people with gout do not consult a doctor while one in four people with gout have received inappropriate treatment. This was due to a substantial gap in accessing knowledge about causes and management of gout, lay people perceived gout as part of punishment for previous life so seeking treatment was not a priority. Those who seek treatment become discouraged and dissatisfied with the long period of time for the treatment to take effect. As a result, most of them do not continue taking the medication. If the trend is not corrected, it will have a negative impact on the quality of lives for many people living with gout (Donovan 2009, Spencer et al. 2012).

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The review

Aim

The aim of the review was to explore the knowledge and lay perception of gout on the disease and to determine its impact on lifestyle and barriers to treatment.

Design

A narrative review was undertaken by adopting Moher et al’s(2009) flow diagram used by many authors to report a wide range of reviews to ‘ identify, select and critically appraise relevant research for eligibility and synthesized in either qualitative or quantitative form and integrate all results into one review’. Generic search terms were used to capture related information and finally narrowed to specific terms as discussed below.

Methods

A search was conducted from cross-sectional studies in PubMed, ProQuest Medical CINAHL, COCHRANE and SCOPUS data bases for research papers published from 1997-2012 in English. Seminal content on lay perspective and rheumatology nursing were also scrutinized. Work colleagues and organization with specific skills and interest were contacted for their contribution. The search terms used were ‘gout care’, ‘lay/patients perspectives’, ‘perception and experience’. Hand searches of quality material regarding patient’s perception on gout were also undertaken, but yielded irrelevant information to answer the search question, so they were excluded.

The rest of the content was analyzed for terms relevant to the Western countries but discussed more in relation to New Zealand perspective. Quality appraisal was applied to evaluate whether the content was cogent to support the argument for the themes selected (Kirkevold 1997, Mays et al. 2005).

The approach was based on Moher et al’s (2009) methodology stating that, complex concepts should be drawn from different sources of literature, synthesized and presented into simple and understandable concept (Kirkevold 1997, Mays et al. 2005).

Synthesis

The synthesis of this review involved reading, arguing, interpreting, justifying and then writing to come up with a convincing and cohesive story for readers and stakeholders.

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A total of 31 papers were identified in the research addressing patients’ perspective on gout care verses health care professionals views in western countries. The main themes identified in the studies were: patients’ beliefs as a barrier to treatment adherence, gout on the rise, gout is poorly managed, lack of universal gout guidelines, misperception of the disease by health professionals and doctor-patient relationships.

Findings

Lay perspectives

Many patients perceive gout as self-inflicting disease, part of punishment for their actions in early life or as part of aging, and seeking early treatment meant ‘giving in or letting the gout win’(Donovan 1991, p.418).Although Donovan’s article was published in 1991,its still relevant to this over-view. There is also a misperception among people with gout and the wider public that gout was not a chronic illness. They believe that gout was present during an attack only; therefore they do not need taking long-term treatment (Ministry of Health 2012).

For hundreds of years, the public’s perception has been that gout was caused by indulging in alcohol, eating rich food and drinking port wine (HyunSoo et al. 2011). So, many of them do not want to be known that they suffer from gout and coming to the hospital will be a disgrace to the family. Others believe that gout runs in families and was not curable, so they consult the ‘elders’ to perform some rituals or church leaders to intercede on their behalf. Far (2004, p.633) describes this as “intrinsic religiosity” where a person believes in his or her region as the organizing principle and motivating force of their life. They seek medical care last.

Some believe that natural or herbal remedies were better than empirical medicine. Patients are threatened by media reports that colchicine was highly toxic to the body and cause side effects such as nausea, vomiting and diarrhea. But people do not know that natural remedies can make gout worse if not taken carefully for example, vitamin C can lower uric acid but increases the risk of kidney stones that may affect elimination of uric acid(Long et al.2001,Dubchak & Falasca 2010).

People with lower health literacy scores believe that gout medications increase gout attacks in the first few months of commencing treatment. During the course, they stop taking it thinking they were not working. However, this may be avoided by starting at a lower dose and then increase it over time (Nean &Hammond 2005).

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Maori and Pacific peoples believe that stopping eating sea food or drinking alcohol will completely make them stay free from gout symptoms. This belief is not supported scientifically studies. Restricting or eating low purine foods will only reduce an attack but not eliminate gout (Dubchak & Falasca 2010).

The general public feel that physicians were not confident in diagnosing gout and do not commence (ULT) in time. Sometimes physicians do not prescribe the right doses, leaving many sufferers inadequately treated (Martini et al. 2012). The Lacet report (2008) attributed this to lack of a consistence in universal treatment guidelines for GPs and physicians. The Ministry of Health New Zealand(2012) has published a review summary of work done by workbase in conjunction with the Maori Gout Group, Arthritis New Zealand(Greater Auckland Branch),Lean Te Karu(Clinical pharmacist) and Ng’ati Porou Hauora on how to help health professionals and patients with gout to better understand and manage gout effectively (http://www.health.govt.nz/publication/review-health-education-resources-gout-medication-summary-report-ministry-health). In this report, the Maori Gout Action Group recommended the Workbase team to encourage doctors use the ‘Manakau DHB’s starting on allopurinol’ resource and develop a list of messages that was essential in addressing the problem at hand.

Though studies have sighted lay beliefs and culture as the main barrier to effective treatment, Martin et al (2012) argues that it is the health professionals who have forgotten how to effectively manage the disease correctly. Recent studies indicate that more than 80% of doctors were managing gout incorrectly. There is an urgent need to implement strategies to manage gout efficiently and effectively.

One of the strategies is to focus on doctor-patient relationships, to engage and educate the patients on how the medicine works in a simplified language that they were able to understand. Most often, patients were forced to comply with the instruction given, without exploring their illness perceptions systemically to elicit some of the concerns they may have for example, financial or family responsibilities. It was important for health professionals to understand that patients weigh the cost of medicine against the benefits of treatment (Harrold et al. 2010). Nean &Hammond (2005) believe that if patients’ concerns were listened to and take appropriate measures, it will have great influence on treatment adherence. Ahlemen et al (2004) and Kitson et al (2012) advocate a change in the model of care, from routine to individualized or patient-centered care. This model of care has many advantages; it brings forth the understanding of patients’ perspective, uniqueness, shared understanding of the problem at hand and how it can be solved, get them involved in decision-making and take their own responsibility over their conditions. This was supported by Boon (2012,

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p.17) who stated “as we seek improving health outcomes and health styles to reduce the risk and cost of chronic illness, the consumer is a critical stakeholder and must become an engaged partner. Even the most capable and caring of clinicians cannot unilaterally improve a patient’s health. It is a team effort among providers, caregivers, patients and health plans.”

Why should we care about gout?

Current studies report that gout was on the increase and will continue rising, costing many Western countries billions of dollars (Lee et al. 2009).

The prevalence rate was estimated at two percent per annum, America being on the lead. And the most affected populations were people over the age of 65 years. The driving factors in the increase was, people were living longer, high rate of indiscriminate prescription of diuretics and low-usage of acetylsalicylic acid by health professionals, obesity, hypertension, end-stage renal disease, diabetes and other metabolic syndromes. Lee et al (2009) discusses that although there was a high prevalence of gout in USA and other western countries, not many studies have been carried out to examine the impact of gout on the health-related quality of life (HRQoL) a phenomenal theory that examines the physical, psycho-social cornerstone of health. Recent case-studies carried out in United Kingdom (UK), USA and Europe demonstrated that patients with gout had a lower HRQoL affecting their daily work, recreational activities and employability (Lee et al. 2009,Dubchak & Falasca 2010).The Physical Summary of the SF-36(PCS) was approximately 10 points lower than the general population.

New Zealand statistics

A study carried out by Access Economics (2010) reported that there were approximately 650,335 New Zealanders living with arthritic conditions, including gout. The report stated that the expected demographic aging of the New Zealand population living with arthritic conditions over the next ten years would be higher. It was then estimated that it would increase four-fold to (4.1%) by the age of 75 years ( Dubchak & Falasca 2010). The most affected populations in New Zealand were, Maori and Pacific peoples(especially males), people living in low socioeconomically deprived areas and those aged over 65 years(medication summary report ministry health,2011).

In Arthritis New Zealand (2010) survey, it was noted that the general perceptions and impact of gout in New Zealand was potentially the same as discussed internationally. Patients did not think gout was a chronic disease, but assumed that it was caused by

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dietary factors. Understanding of the condition was associated with treatment adherence and high literacy levels, while severity of pain and lack of information was viewed as a negative illness perception (Dalbeth et al. 2011).

With that misperception, patients developed other strategies to cope with the condition for example, change jobs, set priorities and ask for help from friends and relatives. Donavan (1991) noted that women go into ‘denial phase’ by ignoring medical advice to rest even when they were in severe pain. Others tried alternative treatment such as applying fish oil and cold ice packs to affected joints, go for acupuncture therapy, take ‘special diets and formulation’ as per advice from relatives, friends and promotional magazines. They completely do away with empirical medicine. These beliefs have great influence on their behavior and decision –making (Donovan 2009).

On the other hand, Donovan & Blake (2002) noted that patients weigh up cost and benefits of options available to them before they could select the suitable one. Some patients may not take medical advice to rest because it makes them stiff. Others may reject the advice because of family responsibilities for example, looking after a sick or demanding child or worried of long period of taking medication and side effects of the drugs. They would prefer home remedies to pharmacological therapy because they believe that they were free from side effects (Zychowicz & Michael 2011). The authors emphasize that lay perceptions, personal and social inclination within the environment they live in were crucial to decision-making. This was thought to contribute to the high percentage of poor compliance. Therefore it is prudent to elicit lay beliefs so as to understand the reasons for non-adherence to treatment.

When Neame & Hammond (2005) investigated 344 people on what they belied about treatment adherence by utilizing the social cognition theory of health, it was interesting to learn patients’ views on this subject. About 74.3% maintained that medication was necessary for their health while 47.4% were concerned with potential adverse effects of taking medication while the majority (80%) expressed concerns about the long-term side effects of taking ULT. The other concerns raised were fear of becoming dependent on taking medication. The study highlighted patients’ concerns and why adverse effects led to non-adherence to treatment.

Compliance

Many studies have the assumption that non-compliance was as a result of patients’ ignorance on the causes, treatment, prevention and self-management of the condition. Donovan & Blake (2002) concluded that between one third and one half of all patients were non-compliant. But other studies have suggested different reasons why non-

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compliance was high in many patients for example, patients carry out the ‘cost-benefit’ analysis of every treatment, balancing up benefits of costs or risks of each treatment against the benefits of taking medication. Therefore patients’ personal and social circumstances contributed to their decision-making. But doctors and other health professionals would see this as an irrational act.

The global consensus on lack of knowledge and understanding of the causes and treatment of gout was high. Patients did not know that gout was curable by simply adhering to lifestyle changes and taking ULT (Spenser et al. 2011).

Donovan & Blake (2002) give a practical solution to the waste of resources inherent to poor compliance; ‘it is not worth while trying to increase patient compliance only but, adopt a more open, co-operative doctor-patient relationships in engaging them’. Boon (2012) stresses the importance of engaging the patient and the family if we want to improve their health outcomes and healthier lifestyles to reduce the risks and cost of gout.

If patients were educated on the causes and the complications, many of them would comply with the treatment. A study conducted on 60 gout patients in Korea (HyuSoo et al.2008) showed that patients who knew the causes and the importance of treatment were compliant with the treatment than those who were ignorant about the causes and treatment regimen. The author therefore recommended that the only best intervention in improving treatment compliance was to focus on “physician-patient relationships” in the consulting rooms to understanding a disease rather than focusing them to comply.

Sub optimal treatment

Most of the studies indicate that inappropriate treatment of acute gout still continues even among physicians. Unfortunately, the misconception and lack of knowledge among rheumatologist and general practitioners on diagnosis of gout and the recommended management guidelines still abound. Dubchack & Falasca(2010) reports that 43 out of 159 patients with gout that visited a physician received potentially inappropriate treatment while ten received a definite inappropriate treatment. Inappropriate treatment means prescribing “ULT in acute gout without having used it before prophylactically”. This has led to poor management of the disease (Spencer et al. 2011).

In addition, lay people rated rheumatologist low in knowledge about the disease and its management. Pascual & Francis (2007) found out that rheumatologists had no interest or priority in taking care of patients with gout, the diagnosis was based on clinical ground and most of the patients managed by the GPs who were not specialized in that field. The shift of responsibility was a reflection of inadequate training in their school

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curriculum. A positive attitude of rheumatologist was essential in providing evidence-based approach in managing gout just like any other conditions. Pascal and Francis (2007) found it irresponsible for a highly sought professional to subject patients to an excruciating pain throughout their lives. The traditional thoughts that gout was out of fashion should not continue weighing heavily on suboptimal treatment of gout.

Smith et al (2011) proves that most patients were treated with non-steroidal anti-inflammatory drugs (NSAIDS) for a longer period of time than the recommended duration of seven to ten days. NSAIDS are given as first-line treatment to relieve acute symptoms and they have less adverse effects than allopurinol and colchicine. Smith et al (2011) reports that higher doses of colchicine (1.2 mg) may potentially lead to diarrhea, so caution should be exercised by adjusting dosages.

To prevent recurrence and chronic stage of gout, allopurinol 100-600mg is recommended. Allopurinol inhibits uric acid production in the body. Probenecide is another ULT that is administered three times a day. It improves kidney’s ability to eliminate uric acids. And the most common side effects are diarrhea, hypersensitivity, vomiting and renal complications. Patients were not willing to take ULT because of the adverse effects. Most of the patients prefer home remedies, massage and physiotherapy sessions to ULT (Long et al. 2001, Neame & Hammond 2005,HyuSoo et al. 2011).

Pharmaceutical industry

There have been very little efforts made to develop more drugs that have less adverse effects. Charles (2010), states that very few new drugs, Febuxostat have been developed since 1960 that are used internationally. In addition, pharmaceutical companies do not regard gout as equally important as other condition for example, rheumatoid arthritis. This gives an impression that gout was not on their priority list (Richette, 2012).

This has increased the poor compliance on patients taking the ULT for example colchicine, allopurinol and probenecide. Interestingly, the treatment for gout has not been optimized because many health professionals do not differentiate between acute gout and hyperuricaemia( Dalbeth et al.2011,Zychowicz & Michael 2011 ).

Doctor-patient relationship

As mentioned earlier in this over-view paper, it has been discovered that when patients visit the consultants for the first time, they have the highest expectation to receive right information. Most of them go back home disappointed. The physicians bore them with the routine physical examination and ask closed questions that were not helpful to

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patients. A study carried out by Donovan (1991) in two British hospitals on 54 patients with gout who visited the rheumatologist reported that 29 Patients were satisfied, 10 patients were dissatisfied with the consultation while 13 were very happy about everything. Generally most of them stated that the consultation were too short and could not have chance to express their feelings, the doctors rushed them through the routine questions such that they could not feel relaxed and comfortable (Bensing et al. 2011). In another study (Lee et al. 2011) physicians rated the patients’ pain as less severe than the patients. The discrepancy in assessing pain led to lower level of satisfaction.

Those who managed to go for subsequent visits, found the attitudes of the physicians uncomfortable. Physicians were not listening to the patients’ complaints on the severity of pain. They were given the same prescriptions and no further testes were carried out. Those patients went back home disappointed and did not return for further follow up. Such attitudes scare away patients and may lead to complication and distrust of empirical treatment. Long et al(2001) and moore(2007)suggest that physicians need to promote doctor-patient relationship in order to improve health outcomes. Liv Tveit (2011) recommends that using Habermas’ theory of patient-centred approach creates a good relationship and personalized care. This is a practical guidance for doctors to invest in long-term relationships with clients. Patients will have increased confidence, become more knowledgeable and participate fully in managing their conditions (LivTveit et al. 2011, Boon 2012).

Discussion

Impact of gout

Lay perspectives and beliefs on management and care of gout covering a wide spectrum of gout patients in Western and Australasian countries, is a challenge to the general practice. This over-view was aimed at evaluating why lay perspective was a barrier to good health outcomes and adhering to treatment regimens. The limitations were that not much information has been published in many journals. Yet gout has a significant impact on people living with acute and chronic gout. The quality of life seems to be lower because these subjects are always in pain, leading to reduced activities and may have disability for life (Winnard et al. 2008, Smith et al. 2011). Severe gout is associated with poor and lower health related quality of life in those that experience frequent gout

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flares. Smith et al (2011) elaborates that these subjects experience less social functioning abilities compared with their counterparts who suffer from other conditions such as, rheumatoid arthritis, diabetes, hypertension, asthma and angina.

Importance of health education

The over-view has highlighted some concerns of poor adherence to medication regimes aimed at preventing gout and manage the pain of gout flares. Smith et al (2011) demonstrated that ‘patient’s education must stress on the importance of strict compliance with ULT medication regimens even when patients may not feel the need for taking medication due to some beliefs or lack of education on the importance of taking medication. It has been observed that 75% of patients taking UTL have adherence gap in completing treatment in their first year. This may lead to poor health and quality of life.

Better health, as defined by World Health Organization (2007 ) can be improved only when gout centers were established in regional centers, where physician trainees, GPs, patients and their families could access information in an effort to improve the wellbeing of people with gout(Smith et al.2011).

The ministry of health has empowered the Royal New Zealand College of GPs to employ and provide ongoing training and guidance in the provision of quality health services to the general public. It is hoped that gout will receive attention and be placed on priority list. As mentioned earlier, patients with gout have received suboptimal treatment including significant delays in commencing ULT, inappropriate use of colchicine, NSAIDs and allopurinol resulting in patients losing confidence and trust in empirical medicine (Smith et al.2011).This practice can be corrected by establishing a regional/hospital-wide protocol that will assist GPs and Physicians to manage both acute and chronic gout universally (Smith et al.2011, Ministry of Health 2012).

To close the knowledge gap and clear the myths about gout, the Ministry of Health has recommended stakeholders to improve people’s health literacy skills. The populations that were mostly affected are the Maori and Pacific peoples. Most of them have poor health literacy skills, ranging between one and two on a five-point scale. People on level three were deemed to have skills that can enable them carry out their daily living activities. Contrary to this, 75% of the Maori and 86% of Pacific peoples have low numeracy skills. This entails that gout education must be used to build the health literacy skills and knowledge. Numeracy skills will help people with gout understand their uric acid levels and uric targets, monitor their fluid intake and right food portions,

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manage multiple medications and doses. Furthermore, health literacy will make it easier for them to search for information on the web (Ministry of health 2010).

The Ministry of health emphasizes the need to provide gout resources in simple but well-presented text highlighting key messages on how their bodies process food and eliminates waste (uric acid), importance of continuing medication in the absence of symptoms, some food to be avoided and change of life style. Māori and Pacific peoples have a poor compliancy in taking gout treatment, particularly in the long term (Ministry of health 2012).

Possibilities/recommendations for future research

The information gathered and differing reports will form a basis for further research and come up with the best solution to help people with gout understand that gout was a serious condition that was treatable and can only be well managed with appropriate use of ULT (Pascual & Sivera 2007, Spenser et al.2011). There is still need to research on effective communication skills between health professionals and patients in the management of gout focusing on patient-centered approach, lifestyle counseling as a practical tool in engaging with the patients and their families (Ahlemen et al. 2004, Walseth et al. 2011).

Implication for policy and practice

This over-view has highlighted some strategies that can be used to elicit the causes of non-compliance and dispel the misperceptions among patients with gout and the wider population. Introducing nurse-led specialist clinics would improve the quality of life for patients with gout. Hill (1997) demonstrates how a nurse practitioner in the rheumatology department managed an outpatient in parallel with a consultant rheumatologist seeing over 80% of patient without the recourse to medical advice. The patients suffered less pain, were all knowledgeable about their conditions and more satisfied with the service than the consultant’s patients. This shows how nurses have a strong focus in their educational roles than the doctors. Moore (2008) also highlighted positive results in some hospitals in Nepal region of North Korea. Patients were followed up by telephone calls and discussions, creating trust and nurse-patient relationship.

Providing education to patients is a cornerstone for effective management of acute gout and improved patients’ compliancy (Pascual & Sivera 2007). In the above example, working in partnership with patients and local gout groups would be an appropriate strategy that will substantially close existing gaps in accessing knowledge about gout and its management (Martin et al. 2010). The onus is now with governments and

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ministry of health to invest more funds in setting up gout specialist clinics if they want to close the knowledge gap that has existed for many years.

Web-based self- management program

This is another strategy that is becoming user friendly in managing gout in many countries. HyunSoo et al (2011) demonstrated that developing a “web-based self-management program proved to work well and provided gout related information on overview of gout, causes, risk factors, symptoms, prognosis, treatments and complication.” The program was developed in such a way that it was applicable to each stage to ensure there was validity in its evaluation. The stages were based on analysis, design, development, implementation and evaluation (based on needs assessment of 60 patients with gout. The information and websites were analyzed by utilizing a systematic review. This program was aimed at improving self-management abilities on a daily basis (HyunSoo et al. 2011).

This is the modern tool in managing chronic gout in the medical and nursing settings. It facilitates social interactions among peers and health providers (Shigaki et al. 2008). HyunSoo et al (2008) urges that web-based gout program has been proven to increase treatment compliance by more than 50% in patients with gout. This is because information related to gout was easily found and patients were encouraged to share personal experiences with other peers and health professionals.

Ahlmen et al (2004) demonstrated that participants were free to discuss disabilities caused by gout not only physically but also emotionally. Participants found it comforting to use other network members’ experiences as a positive move in the right perspective and encouraged them to continue taking ULT treatment. Support from fellow network members, health professionals and the positive environment in the rheumatology clinic strengthened them psychologically and increased their confidence in managing their conditions well. One of them stated, “When you get support, it gives you a boost and you can manage more” (Ahlmen et al. 2004, p.107).

The Arthritis New Zealand in conjunction with the Ministry of Health have developed “web-based patient information resources” in educating patients on gout conditions (http://www.healthnavigator.org.nz http://nlm.nih.gov/medlineplus; Warrant of fitness-Gout (series 5, Episode 11) found on youtube(www.youtube.com),

http://www.health.govt.nz/about-ministry/leadership-ministry/clinical-groups/national-renal-advisory-board).

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This new concept was also adopted in Korea, where 13 gout websites were developed to provide information to patients on definition, causes, symptoms, risk factors, complications, diagnostic tests, treatment and self-management strategies. Websites that were for the purpose of advertising were excluded (HyunSoo et al, 2008).People with gout were encouraged to explore these resources so that they were enlighten about their conditions.

Conclusion

The world-wide misconceptions of gout and lack of knowledge among health professionals and patients on the causes, diagnosis, prevention and management is a great concern that needs to be addressed immediately. Policies and programs need to be developed to improve the quality of life as defined in the New Zealand Health Strategy (2000). Education is one of the components that is lacking in patients with gout.

Teaching patients on the disease profile and treatment will unlock their pre-conceived beliefs. Therefore, health professionals need to be up to date with gout information, prioritizing and targeting it to the needs of specific population. It must be in plain and simple language, shorter, consistence and accurate to avoid confusing them. This will improve patient engagement and possibly increase compliance.

In addition, patients must have health literacy skills in order to understand the disease profile and treatment regimens. Since most New Zealanders have poor health literacy (particularly the old people, Maori, Pacific, other ethnic groups and those in low income brackets), health professionals must develop a health resource that will share vital information, and empower them with the most important concepts and knowledge that will be used to develop their understanding of the condition and treatment to attain and lead a better and productive life.

Acknowledgements

I would like to thank Dr Annemarie Jetel for her research knowledge,support and encouragement that inspired me to persevere and complete this assignment.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

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No conflict of interest has been declared by the author

Appendix 1

Summary Statement

Why is this review needed?

To create awareness of the impact of gout on quality of life on patients with gout.

To provide a working document for health professionals.

To narrow the knowledge gap that exists between lay people and health practitioners.

What are the three key findings?

Patients are ignorant of the consequences of not taking treatment

Gout is sub-optimally treated and pharmaceutical companies were biased in discovering new treatment.

Stake holders to review health education resources on gout medication

How should the findings be used to influence policy/practice/research and education?

The prevalence of gout is on the increase and if not treated will cost governments billions of dollars.

Providing education and creating doctor patient focus groups will give autonomous to patients and manage their conditions well at home.

Develop web-based patient information resources that are easy to understand and follow.

Appendix 2

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Format guide:

Name of the Journal: http://www.journalofadvancednursing.com

Word limit: 5000 words or fewer (excluding the abstract,apeendix, references and summary statement).

References: Unlimited.

Abstract: Up to 250 words, structured.

Reference style-Harvard

NOTE: Due to time contraint, I did not indent the references

Reference:

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Ahlme M, Nordenskiold B, Archenholtz B, Thyberg I, Ronnqvist R, Linden L , Andersson AK &Mannerkorpi(2005) Rheumatology outcome: the patients’perspective. Rheumatolgy journal, 44(1)105-110.

Arthritis New Zealand. (2010).Enabling better quality of life.

Bensing JM, Deveugele M, Moretti F, Fletcher I, Van Vliet L, Van Bogaet M & Rimondini M(2011)How to make the medical consultation more successful from a patient’s perspective? Tips for doctors and patients from lay people in United Kingdom,Italy,Belgium and the Netherlands.Patient Educ Couns.84(3):287-93.

Boon A(2012).Excellent through Patient and Family Centred Care. Health quality & safety commission New Zealand.

Bijsterbosch J, Scharloo M, Visse AW, Meulenbelt I, Huizinga TW, Kaptein AA & Kloppenburg M(2009).Illness perception in patients with osteoarthritis: change over time association with disability. Arthritis Rheumatology15;61(8),1054-61.

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