Joint Bone Spine 77 (2010) 405–410

Review

Characteristics and development of therapeutic patient education in rheumatoid

arthritis: Analysis of the 2003–2008 literature
Maria Grazia Albano a , Janine-Sophie Giraudet-Le Quintrec b , Cyril Crozet c , Jean-François d’Ivernois c,∗
a
Medical Education Center, University of Foggia, Foggia, Italy
b
Hôpital Cochin, AP–HP, University Paris-VI, 75679 Paris cedex 14, France
c
Laboratoire de pédagogie de la santé EA 3412, faculté de médecine, université Paris-XIII, 74, rue Marcel-Cachin, 93017 Bobigny cedex, France

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this study is to point out the recent characteristics and developments of therapeutic
Accepted 25 January 2010 patient education (TPE) in rheumatoid arthritis through an analysis of the international articles published
Available online 8 April 2010
from 2003 to 2008.
Method: Studies were selected from major databases, using the following keywords: rheumatoid arthritis,
Keywords: patient education, self-management, programs. Three authors independently reviewed each study and
Rheumatoid arthritis
selected the data using the patient education research categories (PERC). Articles consistently related to
Therapeutic patient education
patient education in rheumatoid arthritis (37 among 109) were included.
Self-management
Programs Results: The selected articles have been published in 23 scientific journals. The majority of them concern
Review of literature TPE for adult patients with rheumatoid arthritis. TPE is delivered in several structures and group education
represents the most widespread educational strategy mainly provided by a multiprofessional team. There
are two types of programs: educational, aiming to make the patient competent in the daily management
of his disease and psycho-educational ones, aiming to improve coping and to decrease stress, anxiety and
depression. Twenty-eight studies show the effectiveness of TPE on the basis of bio-clinical, educational,
psychosocial, economical criteria, but the majority of these positive results are observed in short-term.
Barriers to TPE are linked to cultural and socio-economic factors.
Conclusion: A large number of studies still assess the positive effects of TPE. Nowadays, the problems of
short-term efficacy of TPE and the cultural and social barriers to this practice have become a major issue
for research.
© 2010 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.

1. Introduction In Europe, these therapeutic patient education (TPE) programs,

Rheumatoid arthritis (RA) requires multidisciplinary care and
patient empowerment. Patient education is recognized as an
important component of active management programs for RA. Edu-
cational strategies may range from the provision of information, as
in usual care, to the use of cognitive-behavioural strategies as in
educational programs.
The United States (US) pioneering work has explored the most
effective way to enable people to self-manage effectively their
long-term condition by the development of the Chronic Disease
Self-Management Program (CDSMP), a key contributor to the body
of knowledge. The CDSMP is a six-week, lay-led, self-management
skills training course for generic long-term physical conditions with
evaluations suggesting improved outcomes and some cost reduc-
tions for chronic care [1,2].
∗ Corresponding address.
E-mail address: ivernois@smbh.univ-paris13.fr (J.-F. d’Ivernois).
usually led by health professionals, aim to improve compliance
to specific therapies. However, there is evidence to suggest that
this type of approach does not necessarily lead to improved health
outcomes unless individuals are empowered to take over aspects
of self-management that are the traditional province of health
professionals, such as therapeutic adjustments to medication. The
obstacles reported by professionals that need to be overcome are
limited available time, lack of recovery and inadequate staff train-
ing.
Conflicting results have been obtained concerning the impact
of these educational programs on short- or long-term evaluations,
patient knowledge, habits, coping strategies, anxiety, quality of life,
health, and costs. The clinical significance of the benefits of patient
education and the relationship between changes in behaviour and
changes in health outcomes remain unclear. Short-term effects
in program targets are generally observed, whereas long-term
changes in health status are not convincingly demonstrated. More
questions rose about the efficacy of arthritis self-management pro-
grams.

1297-319X/$ – see front matter © 2010 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jbspin.2010.01.010
406 M.G. Albano et al. / Joint Bone Spine 77 (2010) 405–410
Riemsma et al.’s meta-analysis on the effects of patient edu-
cation for RA (on 31 studies) showed that the benefits of such
education were small and short-lived [3]. This paper demonstrated
significant effects of patient education at first follow-up for scores
on disability, joint counts, patient global assessment, psychologi-
cal status, and depression. A trend favouring patient education was
found for scores on pain. Physician global assessment was not taken
into account in any of the included studies. No significant effect
was found concerning anxiety and disease activity. There was no
evidence for long-term benefits of TPE.
However, until now the majority of the reviews of literature
[4–10] on patient education in rheumatic diseases focus on its effi-
cacy and there is a lack of analysis on how the patients are educated
and evaluated, on what the trends of the research in this field are.
Therefore, the purpose of our study is to give a detailed and precise
picture of what has recently been done in RA therapeutic patient
education, to analyze the characteristics and development of TPE
as described in the international literature from 2003 to 2008.
2. Methods
Studies were selected from several databases: Medline, Pubmed,
EMBASE, ERIC, Cochrane central database, PsycInfo, NHS Eco-
nomic Evaluations database, AMED, CINAHL, Science Citation
Index, Psychology and Behaviour Sciences Publications using the
following keywords: rheumatoid arthritis, patient education, self-
management, programs.
The term “patient education” was used as key word rather than
“Therapeutic Patient Education” because it is still mostly used in sci-
entific studies, even if in 1998 the WHO has proposed to substitute
it with the term “Therapeutic Patient Education”. We added the key
word “self-management program” because this term is commonly
used in the American literature instead of “patient education” and
the key word “program” because our objective was to analyze
structured and organized patient education activities instead of
informal one. Three authors independently reviewed each study
and collected the data using the same categories of analysis. This
checklist, named PERC (Patient Education Research Characteris-
tics), was related to: authors’ country, type of study (i.e.: evaluation
study, randomized control trial, review, meta-analysis. . .), research
duration, patients’ characteristics (i.e.: sex, age. . .), professional
categories of educators (i.e.: doctors, nurses. . .), setting of educa-
tion (i.e.: hospital, primary health care. . .), educational strategies
(i.e.: group, individual, self-learning. . .), evaluation criteria (i.e.:
bio-clinical, educational, psychosocial, economic).
Thirty-seven articles on 112 (33%) consistently related to patient
education have been selected among which 33 on patient education
in rheumatoid arthritis, seven on osteoarthritis and one on inflam-
matory arthritis in general (some studies on education in RA also
deal with OA and on inflammatory arthritis).
The articles were selected on the following criteria:
• articles describing or analyzing structured/organized patient
education programs or activities rather than informal educational
interventions or transmission of information to the patients;
• articles centered on patient education in RA rather than papers
focusing on treatment and follow-up strategies of RA or concern-
ing medical or continuing education of health care providers on
RA.
Publications written into English, French and German were
included. This study encompasses studies published from 2003 to
2008.
3. Results
3.1. Journal
The 37 articles identified (on a total of 112) in 11 data bases have
been published in 23 scientific journals that we classified into seven
categories: journals of rheumatology: nine (20 articles), journals of
patient education: one (two articles), nursing journals: four (six
articles), journals of rehabilitation and occupational therapy: three
(three articles), journals of psychology and behavioural medicine:
four (four articles), journals of clinical medicine (two articles).
3.2. Country of publication
The researchers are from 14 countries; Europe totalizes 29 arti-
cles, North America four articles (two USA and two Canada) and
three articles issued from Asia (two China, one Australia), one arti-
cle from South America (Brazil). We have not found publications
from Eastern Europe or Africa. The research teams of Western
Europe that published the most about the period considered are
from UK (14 articles), France (four articles), The Netherlands (four
articles).
3.3. Types of study
Among the 37 articles, 29 [7,11–38] are evaluation studies; some
of them are multicenter studies [11,12,16,22,29], other are prospect
trials [13,15,27] or randomized studies [13–15,19,20,25,29,36–38].
Many evaluation studies [9,13,15,20,23,29,30,34,37,38] last 1 year;
some others last from 1 to 9 months [11,18,19,24–26,32,35,36] and
two more than 5 years [16,27], the remaining being interviews or
tests without follow-up.
The reviews of literature are seven [4–10], among which one
[7] is a meta-analysis. Moreover, four articles [6,8,27,39] include
recommendations.
Two more studies deal with the validation of questionnaires
[17,26].
The analysis of the main purpose of each
article stresses this trend: 16 studies (43.2%)
[5,7,9,11,13,15,19,20,23,24,29,30,32,36–38] are intended to
demonstrate the effectiveness of TPE, this efficacy being divided
into short-term efficacy: 10 studies [7,9,11,13,19,20,24,25,30,36]
and short-term and long-term (More than 1 year) efficacy: seven
studies [7–9,15,19,37,38].
More specifically, four studies [8,22,25,29] focus on the role of
the partner as support for the patient, seven articles concern the
evaluation of self-efficacy [11,22,36–38] and coping [10,35], four
the educative role of the nurse in rheumatology [18,34,39,40], two
concern the evaluation of the compliance to treatment [13,9], two
studies [27,29] the training of patient educators, two [12,16] focus
on the evaluation of accessibility to TPE programs, two on the
validation of questionnaires [17,26] and one [14] on the identifi-
cation of cultural, psychological and social barriers to TPE, one on
the comparison between the efficacy of TPE in osteoarthritis and
rheumatoid arthritis programs [31], one on the evaluation of health
literacy [21], one on the evaluation of training educators programs
[33].
Other publications concern the self-management strategies:
one [23], the readability of documentation: two [14,21], the eval-
uation of TPE by patients: two [28,31], and recommendations for
education of patients: one [6].
3.4. Patients
A total of 9955 patients were included in this research. The
majority of the studies concern adult patients: 7528 in total (75.6%),
 M.G. Albano et al. / Joint Bone Spine 77 (2010) 405–410
2357 (23.7%) elderly patients and 70 (0.7%) adolescents. The great
majority of adults and elderly patients are women (71.5%). This is
related to the fact that most of the studies (30 studies) concern RA,
out of seven dealing with both OA and RA.
3.5. Settings of TPE (n = 27 studies)
The studies show a variety of settings and health personnel
involved in the TPE programs. The hospital is the main setting
for therapeutic education: it is represented in 17 studies (63%),
whereas four publications indicate that TPE is delivered in arthritis
centers [18,21,30,35]; other studies indicate that TPE is delivered
in camps [32], ambulatory [20] and primary care and community-
based settings [4], during home visits [20], through health networks
[30].
3.6. Educational strategies (n = 37 studies)
Among a wide variety of formats, group education (20 studies,
54%) represents the most widespread educational strategy, some-
times making use of problem solving (six studies); five studies
deal with face-to-face education. Self-learning is also used as edu-
cational strategy; it is carried out through printed materials (13
studies), including the use of a mind map (one study), web (one
study), video (one study), computer instruction (one study). Other
papers mentioned strategies like telephone coaching (two studies),
counselling interventions accompanied by information sessions
(three studies).
3.7. Content and duration of the programs (n = 26 studies)
As pointed out by Niederman et al. [9], two types of
TPE programs can be observed in rheumatology: “educa-
tional programs (aiming at increasing knowledge and improv-
ing performance) and psycho-educational programs (combin-
ing teaching intervention activities to improve coping and
change behaviour)”. The following topics are taught in the
“educational programs”: basic knowledge (cited in 16 stud-
ies [7,9,10,11,15,19,20,26–30,34,36–38]), self-management (cited
in nine studies [16,26,27,29,30,34,36–38]) physical activity
(cited in 14 studies [7,9,11,13,15,20,26,27,29–31,36–38]), pain
evaluation, control and management (cited in 16 studies
[5,7,9–11,15,19,20,26,27,29,30,36–39]), joint protection (cited in
13 studies [4,7,9–11,15,19,26,31,33,36–38]), decision versus cri-
sis (cited in two studies [7,26]), diet (cited in three studies
[7,10,15]), footwear [11], assistive devices [15,30], sexual issues
[11], complementary therapies [10,11], RHU services [10,11],
leisure [10,30], daily activities and work (cited in seven studies
[7,10,13,19,20,29,37]).
The “psycho-educational programs” focus on: stress manage-
ment (cited in seven studies [7,10,11,15,20,36,37]), relaxation
(cited in nine studies [11,15,19,20,26,29,36–38]), anxiety and
depression (cited in seven studies [7,9,10,19,20,29,36]), social func-
tioning and social activities (cited in five studies [7,9,10,20,32]),
doctor–patient communication (cited in three studies [10,29,30]).
One study deals with the training of educators and health care
providers change of practice [33].
Fourteen studies among 37 (37.8%) have specified the number
of sessions and the duration or the TPE programs. The number of
sessions varies from one to 12 (mean: 5.7); each one can last from
1 to 3 hours. The duration of the programs varies from one ses-
sion (1 week) to 36 weeks (mean: 4.7 weeks), involving one to 12
patients per session (mean: 7).
407
3.8. Educator
Only 17 studies among 37 (45.9%) indicate the categories of
health care providers delivering education; 12 studies precise that
education is ensured by a multiprofessional team, as recommended
by the WHO [41]. Nurses are most often cited: in 15 studies,
including clinical rheumatology specialized nurses (three studies).
Rheumatologists (11 studies), occupational therapists (11 stud-
ies), and physiotherapists (11 studies) come in second position,
followed by dietetics (four studies) and social workers (four stud-
ies), rehabilitation specialists (three studies), psychologists (three
studies), pharmacists (one study), podiatrists (one study) and kine-
siologists (one study). Two studies mention the participation of
expert patients [7,39].
3.9. How effective is TPE?
Arguments for the effectiveness of TPE were found in 28 stud-
ies. We have classified them into four categories: arguments based
on bio-clinical, educational, psychosocial, economic criteria. Since
most studies report multiple results, we present them as number of
citations found in the studies rather than in percentages (Table 1).
3.9.1. Bio-clinical criteria
Seventeen studies have evaluated bio-clinical effects after TPE.
The positive effects pointed out in 14 studies are: reduction of
pain (cited in six studies [4,7,25,27,29,32,36–38]) (at short-term),
and of disability [4,7,27,36,38]. Other studies indicate less fatigue
[5,13,29,30] and a reduction of the disease activity score [25]. A
better functional status is observed in five studies [4,25,30,32,36].
Physical activity score is increased in four studies [13,15,20,36], as
well as mobility and dexterity in one study [25]. On the other hand,
four studies [9,19,24,29] have found no or limited effect on health
status after attending TPE programs.
3.9.2. Educational criteria
Educational criteria have been considered in 23 studies; 19
among them demonstrate the effectiveness of TPE. In this cate-
gory, elements related to the acquisition of knowledge and skills
and changes in patients’ health behaviours due to TPE can be found.
The development of self-management skills is reported in 14
studies [4,9,13,15,19,20,23–25,27,30,36–38], resulting particularly
in pain evaluation, control and management [19,24,25,36–38],
increased physical activity [9,13,20,24], relaxation [15,20].
Increased patients’ knowledge about arthritis, mainly at short-
term, is emphasized by 11 studies [9,14,15,19,26,27,30,36–38,40].
One study [26] stresses the importance of patients, pre-knowledge
on their disease in gaining knowledge after education and two oth-
ers [14,21] show the relationship between health literacy, reading
comprehension and consequent acquisition of knowledge: “people
having limited health literacy even simple written instructions
or prescription labels may not understand even simple written
instructions or prescription labels” [21]. Finally, some authors [14]
conclude: “poor readers have poor educational attainment and
poor knowledge acquisition”.
Eight studies [12,15,19,20,32,36–38] put into evidence the sat-
isfaction of patients towards the education received.
3.9.3. Psychosocial criteria
Results differ: among the 22 studies demonstrating the effec-
tiveness of TPE based on psychosocial criteria, some show no
positive results (six studies) and some others even negative
effects (two studies). The improvement observed generally con-
cerns self-efficacy (function/ pain/ other symptoms): 11 studies
[9,11,19,22,24,29,30,35–38], coping: six studies [9,10,15,23,25,35],
reduction of depression: four studies [7,14,25,35] and anxiety:
408 M.G. Albano et al. / Joint Bone Spine 77 (2010) 405–410

Table 1
Evaluation criteria of TPE effectiveness.

Bio-clinical criteria Educational criteria Psychosocial criteria Economical criteria

Improvement in 14 studies Improvement in 19 studies Improvement in 22 studies

Reduction of Increase of Self-efficacy No better use the of

Pain [4,7,25,27,29,32,36–38] Self-management skills
[4,9,13,15,19,20,23–25,27,30,36–38]
Disability [4,7,27,36–38] Knowledge
[9,14,15,19,26,27,30,36–38,40]
Fatigue [5,13,29,30] Satisfaction vs education
[12,15,19,20,32,36–38]
Disease activity score [25] Physical activity
[9,13,20,24]
Pain evaluation, control
and management [19,24,25]
Better Relaxation [15,20]
Functional status [4,25,30,32,36]
Physical activity score [13,15,20,36]
Mobility and dexterity [25]
Limited or no effect on
Health status [9,19,24,29]
(function/pain/other health care system [24,20]
symptoms)
[9,11,19,22,24,29,30,35–38]
Coping [9,10,15,23,25,35] Reduction of the number
of visits to the GP [30]
Psychological status
[7,9,13,25]
Compliance to treatment
and physical activity
[13,42,43]
Health-related behaviours
[20,29]
Motivation [22]
Well-being [30]
Treatment credibility [29]
Optimism [20]
Trust in educators [29]
Social functioning [32]
Peer support networks [32]
Reduction of
Depression [7,14,25,35]
Anxiety [14,25,30,35]
Perceived
limitation/dependence [25]

No improvement in
Depression [9,15,19,20]
Coping [19,20,29]
Anxiety [9,15,19]
Social functioning [20,29]
Self-efficacy [20]
Well-being [29]
Social support [10]

four studies [14,25,30,35]. Therapeutic education programs also
have positive influence on: compliance to treatment and physi-
cal activity [13,42,43], motivation [22], well-being [30], treatment
credibility [29], optimism [20], trust in educators [29], social func-
tioning [32]; for adolescents, the programs offer an opportunity
to develop informal peer support networks and to built friendship
[32]; a decrease in perceived limitation/dependence is also shown
[25]. Psychological status is improved in four studies [7,9,13,25].
Health-related behaviours are more frequently adopted [20,29].
On the other hand, some of these studies show no improvement
in self-efficacy [20], coping [19,20,29], depression [9,15,19,20], anx-
iety [9,15,19], well-being [29], social functioning [20,29], social
support [10]. Other studies bring contrasted results: for exam-
ple, the partner support can be positive [22] or have no influence
[25], meanwhile partner participation to the education program
has been shown to have negative effects: decrease in self-efficacy
and increased fatigue of the patient [29]; feeling of helplessness
may be improved by TPE [27] or remain unchanged [9].
3.9.4. Economical criteria
Economical criteria are taken into account by only three stud-
ies: one demonstrates the reduction of the number of visits to the
general practitioner after education [30], two others that educated
patients do not better use the health care system [24,20].
3.10. Obstacles to TPE
Several publications deal with the problem of obstacles to TPE.
Eleven studies among the 37 (29.7%) we have analyzed focus
on this topic. The majority of them concern the cultural barri-
ers, demonstrating that low cultural level, limited health literacy
and poor reading comprehension create serious difficulties to the
patients, preventing them to fully benefit of the TPE programs
[14,16,17,20,21,26,29,30]. One publication [20] underlines that the
economic conditions make TPE more or less efficient: in this study,
the more economically privileged patients obtain better effects
after education.
It also has been pointed out that unfavourable psychological
conditions (depression, anxiety, helplessness) can constitute obsta-
cles to a good self-management of the disease that TPE try to
overcome.
Another kind of obstacle to an efficient TPE may result from
the “educational conservatism” of the health care providers when
educating patients, mainly the adolescents. In the study of Kyngas
[28], 40 teenagers from Finland with different chronic conditions,
including RA, criticize individual routine educational programs: “an
education based on the professional knowledge of the physician
and nurses rather than the needs of adolescents (. . .); it appears not
compatible with the developmental level of the adolescent, run in
inappropriate setting, without written material, nor use of modern
technologies (computer, internet)”.
On the opposite, active participative group education for RA
adolescents may result in satisfaction, friendship and subsequent
development of informal peer support even through text messag-
ing [32]. In fact, changes in educational practice are difficult to reach
among health care providers, particularly the shift from individual
to small group education, mainly because it requires training and
greater organizational support [33,34].
 M.G. Albano et al. / Joint Bone Spine 77 (2010) 405–410
Some more frequent barriers to change TPE practices are limited
human resources, scarce time and difficulties in funding programs
costs [32].
4. Discussion
Our study is based on the analysis of patient education experi-
ences in RA and takes as reference and conceptual framework the
1998 WHO definition of “therapeutic patient education”: a pro-
cess “designed to train patients in the skills of self-managing or
adapting treatment to their particular chronic disease and in coping
processes and skills. Therapeutic patient an education is educa-
tion managed by health care providers trained in the education of
patients and designed to enable a patient (or a group of patients and
families) to manage the treatment of their condition and prevent
avoidable complications while maintaining or improving quality
of life. Its principal purpose is to produce a therapeutic effect addi-
tional to that of all other interventions (pharmacological, physical
therapy, etc.)” [41].
It was difficult to compare the results of all the analyzed stud-
ies because of differences in population selection, in sources of
information, in educational programs (often even not detailed)
and educators, in outcome measures and follow-up periods. There
were biases in recruitment (RA and OA) because some relevant
studies on education in RA also deal with OA, a bias in random-
ization, in patients’ degree of motivation, in the dimension of
the groups (sometimes quite small), in drop out rates. Even if a
larger number of studies could have been obtained through the
questioning of the databases with other key words as, for exam-
ple: “patient instruction”, “patient teaching”, “patient information”,
“patient counselling”, we discarded these terms because they do
not fit directly with the WHO definition of “therapeutic patient
education” which also radically differs from the one of “rehabili-
tation”.
Moreover, the interpretation of results was also difficult
because disease and treatment (corticosteroids, biotherapies,
methotrexate. . .) are different for each patient and this background
may influence the outcomes.
A lot of interventions resulted in an increase of patient knowl-
edge about arthritis and in the use of exercise and sometimes
coping strategies compared with control group that received no
intervention. However, few educational programs were effective
on patient’s pain, fatigue, functional status, anxiety/depression, and
health behaviours beyond that of exercise in most of the studies.
In fact, pain is subjective, emotion-dependant and difficult to
evaluate. The lack of efficacy of patient education trials is probably
due in part to subjective impact of chronic pain which interferes
with enjoyment of life, sleep, work, relationships with friends and
family (sexual relations) and accomplishment of everyday tasks
and hobbies. Ongoing pain can cause weakness feeling and depres-
sion.
This controversy highlights some of the challenges in apply-
ing outcomes measurements to educational or psycho-educational
interventions. Like drugs, such programs often work less well in the
real world than in developmental trials.
As we observed in a recent review on TPE studies in diabetology
[44], there is generally a lack of description of several elements of
the educational programs.
The analysis of the recent literature we carried out in this arti-
cle shows that educational objectives of the programs are rarely
specified, a description of the educational strategies used is sel-
dom given (small group education is mostly cited without further
details), the educational diagnosis is never mentioned, although we
know that it should be systematically conducted in order to adjust
the educational intervention on the patients’ real needs (patient-
centered education) [45]. Moreover, a limited variety of modern
409
teaching methods seems to be used (problem solving, simulations,
web, mind maps, computer assisted instruction), cited in only eight
articles.
Previous knowledge on the disease is evaluated in few studies
but suggestions on how to overcome the constraints deriving from
cultural barriers to TPE are seldom given.
The review of literature of Niedermann et al. [9] and the meta-
analysis of Riemsma et al. [7] conclude both that TPE shows more
short-term effects than long-term ones. This issue is largely dis-
cussed by the authors. However, this could be also explained by
the fact that a large majority (70.5%) of the studies is quantitative,
using standardized tests, scales or validated questionnaires while
there is a lack of qualitative researches (23.5%) using interviews or
in depth questionnaires that would probably add relevant infor-
mation about patients’ perception on the long-term efficacy of TPE.
Moreover, the concept of continuity in patient education does not
seem to be developed and perhaps therefore follow-up sessions,
refreshing courses and recycling activities are not run. This itera-
tive education (mid- and long-term TPE), strongly recommended
by some national health authorities [46], could help the patient
in maintaining his knowledge, competences, coping behaviours
through the time.
RA is known to have an unpredictable course and prognosis and
“negative psychosocial impact” [8]. The aim of the educational pro-
grams is to mitigate the negative psychosocial effect of this illness
and to transfer to the patient the competences he needs to delay
its evolution.
Therefore, evaluation protocols used by the authors to mea-
sure the effectiveness of various TPE strategies focus on bio-clinical
criteria (pain, disability, health/functional status, fatigue, mobility,
plasma viscosity, DAS 28. . .), on psychosocial (coping, depression,
anxiety, social functioning, self-efficacy. . .) and educational criteria
(self-management behaviours, knowledge, need of external help,
satisfaction vs TPE. . .), taking into account not only the changes
concerning the disease but also the patients’ psychological life. In
fact, we found that the evaluation studies tend to refer more to the
psychological criteria (26 criteria) than to the bio-clinical (13 cri-
teria) and educational (13 criteria) or economical (three criteria)
ones.
Although TPE, as defined by the WHO [41], aims to enable
patients to acquire the knowledge and the understanding of their
disease, the studies we analyzed do not tell us enough about how
patients explain themselves the complex physiopathology of RA,
which reasoning process they activate and finally, how their under-
standing of the disease contributes to therapeutic compliance. This
could lead to further research.
Our study confirms that TPE is multidisciplinary, since it asso-
ciates several categories of health professionals, first and foremost
among them nurses. The importance of a pedagogical training
for this personnel is highlighted by few papers. Moreover, only
two studies [7,35] refer to patients as educators of other patients,
despite the fact that nowadays peer teaching is carried out in sev-
eral contexts (patients’ groups, Internet forums, “e-patients”. . .)
and for several chronic diseases being considered by WHO [47] as
an efficient contribution to TPE.
A significant limitation of our study is linked to the fact that it
focuses on 5 years of publications. Despite the analysis over such a
relatively short period may be insufficient to show durable orien-
tations, limiting therefore the generalization of findings, it permits
to indicate the main characteristics and development of research
in the field of TPE in rheumatology.
5. Conclusion
Our study confirms that TPE in rheumatology, delivered through
educational or psycho-educational programs, is effective in terms
410 M.G. Albano et al. / Joint Bone Spine 77 (2010) 405–410
of acquired knowledge, competencies and psychological improve-
ment, whereas it brings fewer changes in health status and social
well-being. The positive results are more frequently observed in
short-term than in long-term; therefore, we questioned whether
this could be due to the lack of qualitative researches exploring
patients’ perceptions about the benefits they feel long after having
attended TPE programs.
It also seems that the concept and practice of continuing patient
education are still not enough developed.
We have found that in the last 5 years the barriers to TPE are
linked to different factors: economical, psychological and mainly
cultural (poor health literacy). The relative “traditionalism” of the
educational methods used in most of the programs, as far as we can
deduce because of the lack of precision in the descriptions of these
programs, can also be considered one more obstacle.
On the other hand, the studies we have examined do not show
a deep interest in the learning process of the patient, in how he
understands the educational messages and lastingly acquires the
competencies he needs.
Similarly, the new role of the patients (for example, the “teach-
ing role” of patient’s associations, the peer teaching. . .) in TPE does
not appear to have been until now a significant area of investigation.
There is a need for further research in all these fields.
Conflict of interest statement
There are no conflict of interest related to the manuscript.
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