According to the Arthritis Society, Rheumatoid Arthritis (RA) is an inflammatory autoimmune disease that can affect multiple joints in the body. The immune system, which normally functions to protect our bodies against infections, mistakenly attacks the lining of the bodies’ joints thus causes pain, stiffness and swelling. If this inflammation continues it can get aggressive and lead to damaging of the joints. This inflammation can further affect other organs such as the nerves, eyes, skin, lung or even the heart (“What is Rheumatoid Arthritis”, 2018).
In Canada, approximately one in every 100 adults have RA, this is roughly 300,000 Canadians (“What is Rheumatoid Arthritis”, 2018). During a population-based cohort study conducted in Ontario from 1996 to 2010 it was found that one percent of the adult population has RA, with around twice as many women being affected compared to men. In 1996, the number of patients living with RA in Ontario was 42,734 this number has more than doubled to 97,499 patients in 2010 (Widdifield et al., 2014).
Below is a video provided by 3D4Medical provides a description of RA.
Source: [3D4Medical]. (2017, February 2). What is Rheumatoid Arthritis? [Video File]. Retrieved from https://www.youtube.com/watch?v=RauJmjLH-hQ
There are many factors that impact the development of RA that go beyond the individual. According to Theory at a Glance: A Guide for Health Promotion Practice, “contemporary health promotion involves more than simply educating individuals about health practices. It includes efforts to change organizational behaviour, as well as the physical and social environment of communities…health promotion programs that seek to address health problems across this spectrum employ a range of strategies, and operate on multiple levels” (“Therapy at a Glance”, 2005). Identifying these multiple levels of influence can allow for an understanding of “how social relationships produce health behaviours that in turn may result in pathophysiological manifestations of disease” (Galea, 2015). A model that can be used to evaluate the factors that influence RA is the Social Ecological Model (SEM) of health.
The Social Ecological Model
The SEM of health is described as a, “theory-based framework for understanding the multifaceted and interactive effects of personal and environmental factors that determine behaviours, and for identifying behavioural and organizational leverage points and intermediaries for health promotion within organizations " (“Model 1: What are the Social Ecological Model”, 2004).This model emphasizes the interactions between and the interdependences of factors that are within and across all levels of a health problem by highlighting the interactions of individuals with their physical and socio-cultural environments (“Therapy at a Glance, 2005"). The model consists of five hierarchical levels which are the: individual level, interpersonal level, community level, organizational level as well as the policy/ enabling environment level (“Model 1: What are the Social Ecological Model”, 2004). The individual level includes individual characteristics that influence behaviour; the interpersonal level includes interpersonal processes and primary groups. Next is the organizational level which consists of rules, regulations policies and informal structures which constrain or promote recommended behaviours. Then the community level which is comprised of social networks and norms, or standards, which exist as formal or informal among individuals, groups and organizations. Lastly, the policy/enabling environment level which includes local, state and federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control and management (“Therapy at a Glance”, 2005).
Figure 1 and Table 1 shows a visual of the SEM along with a detailed description of each level
Figure 1. Social Ecological Model
Source: “Social Ecological Model”. (2011). Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion. Retrieved from http://www.cdc.gov/cancer/crccp/sem.htm.
Table 1. A Description of Social Ecological Model (SEM) Leve
Source: “Model 1: What are the Social Ecological Model (SEM), Communication for Development (C4D)?”. (2004). Unicef. Retrieved from https://www.unicef.org/cbsc/files/MNCH_Guide_Module_1.docx
Applying the SEM to RA
Below is a breakdown of each level within the SEM and the factors which influences RA.
Individual Level
Inheritance: According to the U.S. National Library of Medicine, it is indicated that although the inheritance pattern of RA is unclear due to many genetic and environmental factors that appear to be involved, having a close relative with RA likely increases a person’s risk of developing the condition (“Rheumatoid Arthritis, 2018).
Genetic Changes: There are a variety of genes studied as risk factors for RA, most of which are known or suspected to be involved in immune system function. The variations in the gene called Human Leukocyte Antigen (HLA), specifically the HLA-DRB1 gene (“Rheumatoid Arthritis, 2018). The U.S. National Library of Medicine indicates, “the proteins produced from the HLC genes help the immune system distinguish the body’s own proteins from proteins made by foreign invaders (such as viruses and bacteria). Changes in other genes appear to have a smaller impact on a person’s overall risk of developing the condition” (“Rheumatoid Arthritis, 2018).
Age: Although any one can get RA at any age, the risk does increase with one’s age. RA commonly develops between the ages of 40 and 60 years (“What is Rheumatoid Arthritis”, 2018).
Sex: RA affects woman two to three times more often then it does men (“What is Rheumatoid Arthritis”, 2018).
Hormone: As there is a significant proportion of woman who develop RA compared to men, experts feel that there is a strong link between female hormonal changes and the onset of RA symptoms. With a decrease of pregnancy hormones, estrogen and progesterone levels in woman as they age, this hormonal shift could be a potential disease trigger (“Rheumatoid Arthritis Facts and Statistics, 2016).
Interpersonal Level
Lifestyle
Smoking: The Rheumatoid Arthritis Support Network expresses that smoking is the most strongly associated risk factor for the onset of RA in patients (“Rheumatoid Arthritis Facts and Statistics”, 2016). It was found that, “a history of smoking is said to increase the risk of developing RA by as much as 2.4%. The risk factor of smoking is most strongly associated with seropositive RA patients – those who test positive for anti-CCP (cyclic citrullinated peptide) (“Rheumatoid Arthritis Facts and Statistics”, 2016).
History of Life Birth: The Centers for Disease Control and Prevention indicate that, “woman who have never given birth may be at greater risk of developing RA (“Rheumatoid Arthritis”, 2017).
Obesity: The risk of developing RA can increase with being obese. Studies concluded that the more overweight a person was, the higher they chances/ risks of developing RA became (“Rheumatoid Arthritis”, 2017).
Periodontal Disease: tooth loss, which is a marker for periodontal (gum) disease may predict RA and its severity. The more teeth lost is associated with a greater risk of RA (“Rheumatoid Arthritis and Gum Disease”, 2018).
Environment:
Virus/ Bacteria: There are several microorganisms implicated in the development of RA, this is based on the higher titres of the relevant antibodies in patients with RA. One of the possibilities is that these microorganisms trigger the development of RA in individuals what carry genetic susceptibility factors to the disease (Tobon, Youinou & Saraux, 2010). Some of the infectious agents that are reported to trigger RA include: Human parvovirus B19; Rubella virus; Human retrovirus 5; Alphaviruses; Hepatitis B Virus; Mycoplasma; Mycobacterium Tuberculosis; and Escherichia Coli (Tobon et al., 2010).
Urbanization: In the study The Environment, Geo-Epidemiology and Autoimmune Disease: Rheumatoid Arthritis, it was observed that the prevalence of RA is higher among individuals living in an urban rather than a rural environment (Tobon et al., 2010).
Exposures: The Arthritis Foundation indicates that research has shown air pollution, insecticides and occupational exposures to mineral oil and silica may play a role in one’s risk for RA (“Rheumatoid Arthritis Causes”, 2018).
Smoking: According to the Center for Disease Control and Prevention, one study found that, “children whose mothers smoked had double the risk of developing RA as adults (“Rheumatoid Arthritis”, 2017).
Organizational Level
The Arthritis Society of Ontario provides a variety of support and education and rehabilitation programs for individuals with RA and other forms of arthritis (Arthritis Society, 2018). These programs include services such as: client-centered rehabilitation services; consultation and guidance on arthritis self-management in the home, workplace and community; and individual and group education sessions (Arthritis Society, 2018). “Through the Ontario Drug Benefit Program (ODB) the Ministry of Health and Long Term Care covers most of the cost of prescription drug products listed in the OBD formulary” (Arthritis Society, 2018). As there are different medications associated with the treatment of RA, under section 8 of the ODB if a new drug that is not yet listed on the ODB formulary is needed, your physician (under exceptional circumstances) may request special coverage (Arthritis Society, 2018).
Community Level
According to the Government of Canada, there are many myths associated with arthritis such as: arthritis is an old’s persons disease; arthritis is just a normal part of aging; arthritis isn’t a serious condition, its just minor aches and pains, and that it is best to ignore it; there is nothing that can be done for arthritis, you just have to learn to live with it; and joint with arthritis should be rested (Government of Canada, 2018). This can be associated with the lack of individuals understanding the importance of getting tested for RA. As well as taking appropriate precautions to prevent the disease. Lastly, if the disease is diagnosed, possible lack in the understanding of importance in treatment options and self-management (Government of Canada, 2018).
Policy/ Enabling Environment Level
Healthy People 2020: This federal initiative has a goal of preventing illness and disability related to arthritis as well as other rheumatic conditions, osteoporosis and chronic back conditions (“Arthritis, Osteoporosis, and Chronic Back Conditions”, 2018). The Healthy People 2020 also has initiatives for promoting health for all through a healthy environment (“Environmental Health”, 2018). The government of Canada also has The Canada’s Food Guide and The Canada’s Physical Activity Guide to Healthy Active Living with the goals of making healthy food choices as well as developing a healthy, well-being and quality of life through being physically active respectively (Government of Canada. 2018).
Conclusion
In concludes, there are several factors that influence RA, which go beyond the individual simply being diagnosed. The SEM allows for the understanding of these factors by breaking down the multiple levels of influence that affect an individual and can result in the pathophysiological manifestation of the disease (Galea, 2015). This model can help aid in the awareness of what affects the development of RA thus improving preventative measures.
References:
“Arthritis, Osteoporosis, and Chronic Back Conditions”. (2018). Office of Disease Prevention and Health Promotion. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/Arthritis-Osteoporosis-and-Chronic-Back-Conditions
Arthritis Society. (2018).
“Environmental Health”. (2018). Office of Disease Prevention and Health Promotion. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health
Galea, S. (2015). The Determination of Health Across the Life Course and Across Levels of Influence. Boston University School of Public Health. Retrieved from https://www.bu.edu/sph/2015/05/31/the-determination-of-health-across-the-life-course-and-across-levels-of-influence-2/
Government of Canada. (2018).
“Model 1: What are the Social Ecological Model (SEM), Communication for Development (C4D)?”. (2004). Unicef. Retrieved from https://www.unicef.org/cbsc/files/MNCH_Guide_Module_1.docx
Tobon, G.J., Youinou, P., & Saraux. A. (2010). The Environment, Geo-Epidemiology, and Autoimmune Disease: Rheumatoid Arthritis. Elsevier, 9 (5); A288-292. Retrieved from https://0-www-sciencedirect-com.aupac.lib.athabascau.ca/science/article/pii/S1568997209001979?ticket=ST-710649-N0ccOGeAWOl5pMaqK1Hr-cas
“Rheumatoid Arthritis”. (2017). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html
“Rheumatoid Arthritis”. (2018). U.S. National Library of Medicine – Genetics Home Reference. Retrieved from https://ghr.nlm.nih.gov/condition/rheumatoid-arthritis#inheritance
“Rheumatoid Arthritis Causes”. (2018). Arthritis Foundation. Retrieved from https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/causes.php
“Rheumatoid Arthritis and Gum Disease”. (2018). Arthritis Foundation. Retrieved from https://www.arthritis.org/living-with-arthritis/comorbidities/gum-disease/ra-and-gum-disease.php
“Rheumatoid Arthritis Facts and Statistics”. (2016). Rheumatoid Arthritis Support Network. Retrieved from https://www.rheumatoidarthritis.org/ra/facts-and-statistics/
“Social Ecological Model”. (2011). Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion. Retrieved from http://www.cdc.gov/cancer/crccp/sem.htm.
“Theory at a Glance: A Guide for Health Promotion Practice”. (2005). U.S. Department of Health and Human Services- National Institutes of Health. Retrieved from http://website.aub.edu.lb/fhs/heru/Documents/heru/resources/pdf/TheoryataGlance.pdf
“What is Rheumatoid Arthritis”. (2018). Arthritis Society. Retrieved from https://www.arthritis.ca/about-arthritis/arthritis-types-(a-z)/types/rheumatoid-arthritis
Widdifield, J., Paterson, J.M., Bernatsky, S., Tu, K., Throne, J.C., Ahluwalia, V., … Bombardier, C. (2014). Ontario Study Finds The Number of Rheumatoid Arthritis Patients Has More Than Doubled in 15 Years. Institute for Clinical Evaluative Sciences. Retrieved from https://www.ices.on.ca/Newsroom/News-Releases/2014/Ontario-study-finds-the-number-of-rheumatoid-arthritis-patients-has-more-than-doubled-in-15-years
[3D4Medical]. (2017, February 2). What is Rheumatoid Arthritis? [Video File]. Retrieved from https://www.youtube.com/watch?v=RauJmjLH-hQ
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