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Stronger family relationships predict positive health outcomes: a relationship that is partially due to the range of emotional, practical and informational support that families can provide. Yet not all families possess these resources. A survey study in a disadvantaged community in Nottingham, UK ( N = 142) demonstrated that family identification positively predicts ability to cope with financial stress, but that this relationship is moderated by whether family support is present or absent. Semi-structured interviews with 10 members of different families from the same community shed further light upon the nature of this relationship: individuals report that they tend to turn to their family rather than friends or community services in times of financial hardship, even though their family are unlikely to be able to support them effectively, and that this is often due to feelings of embarrassment or finance-related stigma. Our findings highlight the complex role that families can play in finance-related issues, as well as the need to encourage individuals to seek financial support from sources which provide effective (rather than emotionally comfortable) assistance.

Objectives There is increasing interest in prediction and prevention of RA. It is important to understand the views of those at risk to inform the development of effective approaches. First-degree relatives (FDRs) of RA patients are at increased risk of RA. This study assessed predictors of their interest in predictive testing for RA. Methods Questionnaires were completed by RA patients (provided with their questionnaire by a healthcare professional) and their FDRs (provided with their questionnaire by their RA proband). FDR surveys assessed interest in taking a predictive test, demographic variables, perceived RA risk, attitudes about predictive testing, autonomy preferences, illness perceptions, avoidance coping and health anxiety. Patient surveys included demographic variables, disease impact, RA duration and treatment. Ordinal logistic regression examined the association between FDRs’ characteristics and their interest in predictive testing. Generalized estimating equations assessed associations between patient characteristics and FDRs’ interest in predictive testing. Results Three hundred and ninety-six FDRs responded. Paired data from the RA proband were available for 292. The proportion of FDRs interested in predictive testing was 91.3%. Information-seeking preferences, beliefs that predictive testing can increase empowerment over health and positive attitudes about risk knowledge were associated with increased interest. Beliefs that predictive testing could cause psychological harm predicted lower interest. Patient characteristics of the proband were not associated with FDRs’ interest. Conclusions FDRs’ interest in predictive testing for RA was high, and factors associated with interest were identified. These findings will inform the development of predictive strategies and informational resources for those at risk.

Background Rheumatoid arthritis (RA) is a chronic inflammatory arthritis which can cause joint damage and reduced quality of life. Early treatment of RA within 3 months of symptom onset is associated with improved clinical outcomes. However, this window of opportunity is often missed. One important factor that contributes to treatment delay is that patients with symptoms of RA often delay consulting their general practitioner (GP). Previous research indicates that patients with inflammatory arthritis are likely to visit pharmacies for advice before consulting their GP. Therefore, pharmacists are well positioned to identify patients with symptoms of early inflammatory arthritis and sign post them appropriately. This research examines community pharmacy staff’s knowledge, perceptions and approaches to management of patients presenting with symptoms of RA in order to identify training needs and other opportunities for intervention to enhance the role of pharmacy staff in the pathway to care. Methods Semi-structured interviews were conducted with 19 community pharmacy staff with varying roles in the West Midlands, UK, during a 12 month period (2017–2018). The interviews were audio-recorded, transcribed and analyzed using thematic analysis facilitated by NVivo 12. Results Community pharmacy staff (including pharmacists, pharmacy managers, technicians, dispensers and pre-registration pharmacists) had a range of knowledge and differing perceptions of RA and what action should be taken when patients present with symptoms of RA. These can be grouped into four themes: (1) Variations in perceptions and knowledge about RA. (2) The role of the pharmacy in increasing public awareness about RA. (3) The role of the pharmacy staff in facilitating access to the GP. (4) Practical considerations for pharmacy based interventions. Conclusion Amongst community pharmacy staff, there is wide variation in the understanding of RA and the importance of early treatment. This study identifies opportunities for enhanced training of community pharmacists and other pharmacy staff in relation to inflammatory arthritis as well as other pharmacy-based interventions, such as public awareness campaigns about RA and other musculoskeletal conditions. This could result in enhanced signposting to rapid GP consultation for inflammatory symptoms and reduced treatment delay.

Background It has been well documented that patients with symptoms of RA often wait for a long time before consulting their GP. This delay is one of the main reasons why only a minority of RA patients are treated within the 3-month therapeutic window of opportunity. In previous research we have shown that people often do not perceive the initial symptoms of RA to be serious or worthy of urgent medical attention. 40% of respondents to a large-scale survey said they would visit a pharmacy for advice before or instead of visiting a GP following the onset of RA symptoms. Therefore, pharmacy staff appear to be well placed to signpost patients with suspect symptoms towards GP consultation. The current research explores the knowledge and perceptions of RA in a range of pharmacy staff and their views on identifying patients with inflammatory symptoms who would benefit from a GP consultation. This information could identify training needs and opportunities for positive intervention. Methods We conducted semi-structured qualitative interviews (face to face or by telephone) with pharmacy staff. Audio recordings of the interviews were transcribed, and the data were analysed by thematic analysis facilitated by NVIVO. Results A total of 19 pharmacy staff (10 males, 9 females) aged between 22 and 56 were interviewed. Interviewees had a variety of roles within the pharmacy including pharmacist or preregistration pharmacist and pharmacy assistants. Interviewees worked at either a (small) chain pharmacy or an independent pharmacy. Accurate knowledge of RA, the seriousness of the disease and knowledge of the importance of early treatment varied greatly amongst staff impacting on their advice given to patients. Further, although many pharmacy staff said they would suggest a GP visit if someone presented with joint swelling, pain and stiffness, others would advise self-management first and only suggest a GP visit if symptoms did not improve. Pharmacy staff indicated that although they felt that they were ideally placed to signpost people to appropriate care, there was a need for additional training (e.g. on how to identify synovial swelling on inspection of the hand joints) in order for them to distinguish the symptoms of inflammatory arthritis from those of non-inflammatory conditions and suggest appropriate care. Conclusion These interviews suggest that although some pharmacy staff already play a role in accurately signposting people with RA towards a GP visit others need further training. This training should enable them to confidently recognise the symptoms signs of RA and other Musculoskeletal conditions and understand that RA is a serious condition that needs rapid disease modifying treatment initiation and consequently that people need to see their GP promptly. Disclosures G. Simons None. G. Mahoney None. N. Wyatt None. R.J. Stack None. K. Raza Grants/research support; KR has received speaker fees/ honoraria from Abbvie, Sanofi, Lilly, UCB, BMS, Pfizer, Janssen and research grant funding from Pfizer Inc. M. Falahee None.

Objective: Clinical outcomes in Rheumatoid arthritis (RA) are improved if the disease is treated early. However, treatment is often significantly delayed as a result of delayed help seeking by patients who fail to recognise its symptoms or the need for rapid medical attention. We conducted two studies to investigate the role of symptom recognition in help-seeking for the symptoms of RA and compared this with angina and bowel cancer. Methods: We conducted a qualitative interview study with 31 individuals and a postal survey of 1088 members of the general public (all without RA). Both studies used vignettes describing the symptoms of RA, bowel cancer and angina. Participants made causal attributions and rated the perceived seriousness of the symptoms and the urgency with which they would seek medical help if confronted with these symptoms. Results: Only a small proportion of participants in both studies recognised the symptoms of RA, whereas the symptoms of bowel cancer and angina were readily recognised by many participants and considered to be more serious and to require more rapid medical attention (Z values of 14.7 to 34.2, p

Family financial stress research has typically examined negative effects of deprivation on mental health, which in turn erode financial coping. While this work acknowledges family support’s role in buffering these effects, it has typically overlooked how family identification can act to structure the experience of, and response to, economic challenge. We adopt a Social Identity approach, arguing that family identification predicts increased social support and improved well-being, which predicts more effective coping with financial problems. We explore this in two community surveys (N = 369; N = 187). In the first we show that stronger family identification and support predict better well-being, which predicts better evaluation of economic coping. In the second we replicate these findings, and also show that the relationship between well-being and financial distress is fully mediated by perceptions of ‘Collective Family Financial Efficacy’. These findings point to a more positive understanding of how family cohesion can promote mental well-being/resilience.

Objective The aim was to explore the perceptions of rheumatology health-care professionals (HCPs) of interacting with patients of South Asian origin attending early inflammatory arthritis clinics. Methods We used face-to-face semi-structured interviews, designed in partnership with a clinician partner, to interview 10 HCPs involved in the running of early inflammatory arthritis clinics across seven centres in the UK. Data were recorded, transcribed by an independent company and analysed using inductive thematic analysis. Results Three emerging themes were identified that characterized consulting experiences of HCPs: varied approaches were used in early inflammatory arthritis clinic; the challenges for rheumatology HCPs in managing and delivering information to patients of South Asian origin in early inflammatory arthritis clinics; and moving towards good practice, the views on managing future patients of South Asian origin in early inflammatory arthritis clinics. Overall, HCPs found that they required additional skills to support the engagement and management for patients of South Asian origin living with inflammatory arthritis. The HCPs felt that they were less effective in addressing self-management issues for this patient group, and they found it difficult to determine adherence to medication. In such consultations, HCPs perceived that their own limitation of inadequate training contributed towards poor consultations. Conclusion For the first time, our data demonstrate that the management of patients of South Asian origin in early inflammatory arthritis clinics is under-served. To address this, HCPs have identified training needs to improve knowledge and skills in engaging with and supporting patients of South Asian origin. These findings provide a good direction for future research.

Objective The aim was to explore how UK South Asian patients living with RA interact with health care professionals and experience receiving health information in an early inflammatory arthritis clinic. Methods A semi-structured interview schedule, designed in conjunction with a patient partner, was used for face-to-face interviews. South Asian participants with RA were recruited from Central Manchester University Hospitals National Health Service Foundation Trust. Data were recorded and transcribed by an independent company. Data were analysed using inductive thematic analysis. Results Fifteen participants were interviewed. Three predominant themes emerged around participants’ experiences and interaction with health care professionals in early inflammatory arthritis clinic. First, ‘the personal experiences of RA and cultural link to early inflammatory arthritis clinic’, where participants described the impact of RA as individuals and their altered roles within their cultural setting. Second, ‘experiences of interacting and receiving information in the early inflammatory arthritis clinic’, where participants described their limited engagement with health care professionals and the quality of information discussed in the clinic. Third, ‘views on future content for early inflammatory arthritis clinics’, where participants highlighted new innovative ideas to build on current practice. Conclusion We believe this to be the first study to generate insight into the experiences of South Asian patients of interacting with health care professionals while attending an early inflammatory arthritis clinic. Policy directives aimed at improving access to services and delivery of information for ethnic minority groups in early inflammatory arthritis clinics should include consideration of the different roles of cultures. Professionals should be cognizant of the factors that drive health inequalities and focus on improving service delivery.

ObjectiveTo investigate delays from symptom onset to rheumatology assessment for patients with a new onset of rheumatoid arthritis (RA) or unclassified arthritis.MethodsNewly presenting adults with either RA or unclassified arthritis were recruited from rheumatology clinics. Data on the length of time between symptom onset and first seeing a GP (patient delay), between first seeing a general practitioner (GP) and being referred to a rheumatologist (general practitioner delay) and being seen by a rheumatologist following referral (hospital delay) were captured.Results822 patients participated (563 female, mean age 55 years). The median time between symptom onset and seeing a rheumatologist was 27.2 weeks (IQR 14.1–66 weeks); only 20% of patients were seen within the first 3 months following symptom onset. The median patient delay was 5.4 weeks (IQR 1.4–26.3 weeks). Patients who purchased over-the-counter medications or used ice/heat packs took longer to seek help than those who did not. In addition, those with a palindromic or an insidious symptom onset delayed for longer than those with a non-palindromic or acute onset. The median general practitioner delay was 6.9 weeks (IQR 2.3–20.3 weeks). Patients made a mean of 4 GP visits before being referred. The median hospital delay was 4.7 weeks (IQR 2.9–7.5 weeks).ConclusionThis study identified delays at all levels in the pathway towards assessment by a rheumatologist. However, delays in primary care were particularly long. Patient delay was driven by the nature of symptom onset. Complex multi-faceted interventions to promote rapid help seeking and to facilitate prompt onward referral from primary care should be developed.

Treating patients with rheumatoid arthritis (RA) within three months of symptom onset leads to significantly improved outcomes. However, many people delay seeking medical attention. In order to understand the reasons for this delay, it is important to have a thorough understanding of public perceptions about RA. The current study investigated these perceptions using the Self-Regulation Model (SRM) as a framework to explain how health behaviour is influenced by illness perceptions (prototypes) through qualitative interviews with 15 members of the public without RA. Interviews were audio-recorded, transcribed and analysed using framework analysis based on SRM illness perceptions. Both accurate and inaccurate perceptions about the identity, causes, consequences, controllability and timeline of RA were identified. This highlights opportunities to enhance public knowledge about RA. These findings further support the utility of exploring prototypical beliefs of illness, suggesting their potential role in influencing help-seeking behaviours and identifying probable drivers/barriers to early presentation. © 2016 The Authors Musculoskeletal Care Published by John Wiley & Sons Ltd.

Background:There is considerable interest within the medical research community in the identification of individuals at risk of developing rheumatoid arthritis (RA), to identify those who may benefit from preventive interventions. However, it is important to understand the views of those who may be candidates for such predictive tests, to inform the development of effective approaches. First degree relatives (FDRs) of patients with RA are at an increased risk of developing RA. RA patients can provide access to FDRs. Qualitative investigations have explored the views of these groups about predictive testing for RA1,2, but quantitative approaches are needed to develop a robust understanding.Objectives:To identify predictors of interest in predictive testing for FDRs and patients, and to assess the likelihood of patients communicating information about RA risk to their FDRs.Methods:Surveys were completed by 482 RA patients and 397 of their FDRs. Patients were invited to complete the survey and to provide another to their relatives. Spearman’s Rank Correlations were used to assess relationships between interest in predictive testing/ likelihood of risk communication and potential predictor variables.Results:FDRs had a median age of 41 years, 64% were female. 57% were definitely interested and 36% were probably interested in taking a predictive test for RA. Several predictors were found to be associated with interest (table 1).Table 1.Spearman’s correlations for relatives’ and patients’ interest in predictive testing. After applying a Bonferonni adjustment, p values were taken as statistically significant at p≤0.003.FDRsPatientsPredictors of interest in predictive testingrsPrsPBrief Illness Perception Questionnaire0.110.030.090.05 Consequences0.16*0.002*0.100.03 Timeline0.090.07-0.050.28 Personal control-0.030.59-0.020.68 Treatment control-0.020.760.020.74 Identity0.090.090.120.01 Concern0.21*0.16* Coherence0.110.030.0070.88 Emotional0.120.020.110.02Information Seeking0.35*0.22*Decision making-0.050.330.070.13Health literacy0.030.520.020.62Health numeracy-0.060.23-0.020.72Brief Avoidance Coping Questionnaire0.120.02-0.010.76Optimism0.060.26-0.070.12Health anxiety0.16*0.001*--Perceived risk0.37*--Rheumatoid Arthritis Impact of Disease--0.050.31– not applicablePatients had a median age of 65 years, 71% were female. 47% were definitely interested and 30% were probably interested in their children taking a predictive test. Several predictors were found to be associated with interest (table 1). On a Likert scale from extremely unlikely (0) to extremely likely (4), most patients indicated that they were likely to communicate RA risk information to their children (median score=3).Conclusion:Interest in predictive testing for RA was high amongst FDRs, and factors including information seeking preference, RA risk perception, concern about RA, perceived consequences of RA and health anxiety were significantly associated with interest. Patients were also willing to communicate information about RA risk to their children. These findings increase understanding of perceptual variation in those at risk of RA, and will inform the development of information to support decision making in individuals considering predictive tests and preventive interventions. We are currently extending this preliminary analysis by building multivariate models incorporating a range of attitudes about predictive testing, assessing predictors of patients’ likelihood of communicating to their FDRs about risk, and the relationship between patients’ and FDRs’ responses.References:[1]Stack RJ et al. BMJ open. 2016; 6(6):e010555.[2]Falahee M et al. Arthritis care & research. 2017; 69(10):1558-65.Acknowledgments:This work was supported by Versus Arthritis; Grant reference: 21560.Disclosure of Interests:Imogen Wells: None declared, Gwenda Simons: None declared, Rebecca Stack: None declared, Christian Mallen Grant/research support from: My department has received financial grants from BMS for a cardiology trial., Peter Nightingale: None declared, Karim Raza Grant/research support from: KR has received research funding from AbbVie and Pfizer, Consultant of: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Speakers bureau: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, M. Falahee: None declared

Objective: Little is known about the experiences, values and needs of people without arthritis who undergo predictive biomarker testing for the development of rheumatoid arthritis (RA). Our study aimed to explore the perspectives of these individuals and describe their information needs.\ud \ud Methods: A qualitative, multicenter interview study with a thematic analysis was conducted in Austria, Germany and the UK. Individuals who underwent predictive biomarker testing for RA and had a positive test result, but no diagnosis of any inflammatory joint disease, were interviewed. Participants included patients with arthralgia and asymptomatic individuals. Information and education needs were developed from the qualitative codes and themes using the Arthritis Educational Needs Assessment Tool (ENAT) as a frame of reference.\ud \ud Results: Thematic saturation was reached in 34 individuals (76% female; 24 [71%] with arthralgia and 10 [29%] asymptomatic individuals). Thirty‐seven codes were summarized into four themes, namely (i) decision making around whether to undergo initial predictive testing, (ii) willingness to consider further predictive tests and/or (iii) preventive interventions, including medication and (iv) varying reactions after receiving a positive test result. Individuals with arthralgia were more likely to be willing to take preventive action, undergo further testing, and experience psychological distress than asymptomatic individuals. All participants expressed the need for tailored, lay‐understandable information.\ud \ud Conclusion: Individuals at risk of RA are currently the subjects of research aimed at developing better predictive strategies and preventive approaches. Their perceptions and needs should be addressed to inform the future development of interventions combined with education.

Background Rheumatoid arthritis (RA) should be treated with DMARDs in its earliest stages to reduce the likelihood of permanent joint damage and disability1. This therapeutic window is often missed. One important cause is delayed help seeking by patients themselves2. Qualitative work with members of the public has previously identified a number of potential causes for this delay3. Objectives To quantify and extend the findings of existing qualitative research investigating factors which impact on speedy help seeking for symptoms of RA. Methods A survey of members of the public without a diagnosis of inflammatory arthritis assessed the speed with which they would seek medical attention if they were to experience symptoms of RA (stiffness, pain and joint swelling). It explored factors which might impact on the speed with which help would be sought, including: self-management of symptoms; barriers to and drivers of help seeking and information seeking. Results 1088 people (788 females; 9 undisclosed) aged between 18 and 96 years completed the survey. 48% indicated that they would seek help quickly for RA symptoms, however 63% would delay seeing their GP in order to try to self-manage the symptoms. Most intended to self-manage with over the counter medication (e.g. ibuprofen), massaging the joint or exercising. Barriers endorsed included difficulty getting a GP appointment (39%); fear of wasting the GP’s time (34%) and being busy with family/work (37%). Drivers (>90%) included worsening of symptoms, inability to work, struggling to do usual activities, symptoms spreading to other parts of the body or inability to self-manage symptoms. Most participants would seek out information prior to seeking medical attention for the symptoms. Sources of information frequently endorsed were: Internet (74%); relatives/friends (49%); someone with a joint problem (41%) and pharmacists (37%). Conclusions Less than half of the current sample would seek help quickly for the symptoms of RA. Several barriers and drivers identified in qualitative research3 were endorsed by the survey sample making them valid targets for interventions Most participants would further seek out information about the symptoms prior to seeking medical attention and their preferred sources of information such as the internet or the pharmacist should be used in these targeted interventions. References [1] Raza K, Filer A. The therapeutic window of opportunity in rheumatoid arthritis: does it ever close?Ann Rheum Dis2015;74:793–4. [2] Stack RJ, et al. Patient delays in seeking help at the onset of rheumatoid arthritis: the problem, its causes and potential solutions. Aging Health2013;9:425–35. [3] Simons G, et al. A qualitative investigation of the barriers to help-seeking among members of the public presented with symptoms of new-onset rheumatoid arthritis. J. Rheumatol2015;42:585–92. Acknowledgements This research was supported by The Dunhill Medical Trust (grant number R226/1111) and the National Institute for Health Research, through the Primary Care Research Network. CDM is funded by the NIHR CLAHRC West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice (NIHR-RP-2014–04–026). KR is funded by the Birmingham NIHR BRC. The authors would like to thank the patient research partners who have been involved in the project. Disclosure of Interest None declared

Early intervention following the onset of chronic illnesses such as rheumatoid arthritis, lupus and Sjogren’s syndrome can improve disease prognosis, reduce illness related disability and improve patient quality of life. Therefore, it is vital that the time between symptom onset and treatment is short, however, many patients experience long delays. The period of time between an individual’s first detection of a bodily change and the first consultation with a healthcare professional is known as patient delay, while the time between first consultation and been referred to a rheumatologist for treatment is known as healthcare professional delay. Patient delay can be attributed to a range of barrier to consultation, these include contextual barriers (e.g. geographical location, financial barriers and availability of health services), individual barriers (e.g. demographic characteristics and health literacy) the nature of symptom onset (e.g. intermittent symptoms or the experience of a symptoms commonly associated with many conditions such as fatigue) and psychological barriers (e.g. perceptions of illness, the normalising symptoms interpretation of symptoms and fear and worries about wasting the doctor’s time). Many interventions to reduce patient delay focus on educating the public about the typical symptoms associated with a specific illnesses in the hope that greater awareness will lead to better recognition of early symptoms. These interventions are based on the premise that the general public may hold misrepresentative stereotypes of what it is like to experience an illness or may even have no stereotypical belief (also known as a prototypical belief) to compare their current symptoms to. There is very little evidence about the evolution of early symptoms over time and how patients appraise these early symptoms and then decide to seek help. Furthermore, the non-specific nature of early symptoms for many rheumatological conditions can also be a significant barrier to patients recognising that symptoms are indicative of a chronic illness. For example, patients may attribute symptoms to stress, ageing or a temporary condition and actively choose not to seek help. Therefore, we must explore patients beliefs about symptom experience and not just focus on their beliefs about specific illnesses. Understanding early symptom presentation and the way that early symptoms are interpreted by patient is important for the development of robust help seeking interventions. However, interventions to promote prompt help-seeking based on symptom presentation must also take in to account for contextual, individual and psychological barriers which may interact with individual perceptions of early symptoms. Understanding the factors which lead to patient delays and healthcare professional delays across rheumatological conditions can ensure that interventions to reduce delay are developed using a robust evidence base. Evidence based interventions such be multifaceted and may include the development of public health information (e.g posters, tv campaigns etc), the development of robust online information and challenging mis-information online, addressing health inequalities which may lead to delay (e.g. increasing the accessibility of health services and promoting health literacy in hard-to-reach communities) and developing educational information for healthcare professionals. Disclosure of Interest None declared

Single parent families are at high risk of financial hardship which may impact on psychological wellbeing. This study explored the impact of financial hardship on wellbeing on fifteen single parents. Semi-structured interviews were conducted and analysed using constructivist thematic analysis. Participants described food and fuel poverty, and the need to make sacrifices to ensure that children's basic needs were met. In some cases, participants went without food and struggled to pay bills. Isolation, anxiety, depression, paranoia, and suicidal thoughts were described . However, participants reported that psychological services not able to take the needs of single parents into account. Support for single parents must acknowledge the impact of social circumstances and give more consideration economic drivers of distress.

Background\ud Rheumatoid arthritis (RA) has articular and non-articular manifestations. Early, intensive treatment has substantial benefit for both. This requires patients be identified as soon as symptoms develop.\ud \ud Objectives\ud To determine whether selected signs and symptoms can be identified in the primary care records of patients prior to a formal diagnosis of RA being made and, if so, how early they can be identified.\ud \ud Methods\ud A case-control study was constructed within the UK Clinical Practice Research Datalink (CPRD). 3577 individuals with ‘definite’ RA, were matched to 14,287 individuals without inflammatory arthritis. An index date was established (i.e., date general practitioner (GP) first appeared to suspect RA). Rates of consultation and consultations for suspected early RA symptoms were compared in cases and controls in the two years prior to the index date using conditional logistic regression, adjusted for number of consultations.\ud \ud Results\ud The mean (standard deviation) age of participants was 58.8 (14.5) years and 66.8% were female. Rates of any consultation were significantly higher in RA cases than in controls for at least two years prior to the index date. Cases were more likely to have a pre-diagnosis coded consultation for joint, and particularly hand symptoms (aOR 11.44 (9.60, 13.63)), morning stiffness (8.10 (3.54, 18.5)), carpal tunnel syndrome (4.57 (3.54, 5.88)) and other non-articular features.\ud \ud Conclusions\ud In patients who develop RA, GP consultation rates are higher for at least two years prior to the first recorded suspicion of RA. This study highlights symptoms that should raise a GP's index of suspicion for RA.

Objectives: To explore the impact on daily life of symptoms experienced by those with systemic autoimmunity associated with rheumatoid arthritis (RA). Methods: Fifteen people took part in focus groups to explore the impact of symptoms on daily life. Results: Core themes included: 1) physical impact of limited hand function and mobility; 2) psychological distress experienced included a fear of symptoms progressing into RA, uncertainty about the future, feelings of despair, shame and frustration. Conclusion: People with arthralgia at risk of developing RA experienced considerable physical and psychological impact of symptoms. Greater consideration should be given to the needs of people at risk of developing RA.

Objectives To explore how social interactions at the onset of rheumatoid arthritis (RA) influence help-seeking behaviour from the perspectives of those with RA and their significant others (family and friends). Methods Nineteen semi-structured qualitative interviews were undertaken with people recently diagnosed with RA and their significant others. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Results Significant others’ initial appraisals of symptoms led them to provide practical support with daily activities rather than advice to seek help. People with RA described difficulties in communicating the severity of their symptoms and often attempted to hide their symptoms from others. Significant others also reacted negatively, expressing disbelief and dismissing symptoms. On occasion, early symptoms were even described as the catalyst for the breakdown of relationships. On reflection, significant others expressed guilt about their initial reactions and wished that they had recognized the need for intervention earlier. When symptoms had advanced and were more obvious, significant others often strongly advised that help should be sought and, in some cases, physically escorted the patient to their medical appointment. In many instances, people with RA described significant others as the catalyst for eventually seeking help. Conclusions Significant others play an important role in influencing help-seeking behaviour; this has implications for theoretical models of help-seeking and the development of help-seeking interventions. A negative consequence of social interactions resulted from a lack of understanding and knowledge about RA among significant others, highlighting the need for greater public awareness about the early symptoms of RA. Statement of contribution What is already known on this subject? At the onset of rheumatoid arthritis (RA) people often delay in seeking help, leading to poor clinical outcomes. Previous research has highlighted the role of personal interpretations of symptoms in help seeking. However, little is known about the social context of help-seeking decisions and role of social networks in influencing help-seeking behaviour. What this study adds? This study highlights the importance of social interactions at the onset on RA from multiple perspectives (i.e., those with RA, their family and friends) Family and friends played a critical role at symptom onset, and help-seeking was found to be both facilitated and hindered by social networks. It is vital that help-seeking campaigns and theoretical models give more weight to the role of social interactions in encouraging help-seeking behaviour.

Objectives: To describe the development and assess the psychometric properties of the novel 'Symptoms in Persons At Risk of Rheumatoid Arthritis' (SPARRA) questionnaire in individuals at risk of rheumatoid arthritis (RA) and to quantify their symptoms.Methods: The questionnaire items were derived from a qualitative study in patients with seropositive arthralgia. The questionnaire was administered to 219 individuals at risk of RA on the basis of symptoms or autoantibody positivity: 74% rheumatoid factor and/or anticitrullinated protein antibodies positive, 26% seronegative. Validity, reliability and responsiveness were assessed. Eighteen first degree relatives (FDR) of patients with RA were used for comparison.Results: Face and content validity were high. The test-retest showed good agreement and reliability (1 week and 6 months). Overall, construct validity was low to moderate, with higher values for concurrent validity, suggesting that some questions reflect symptom content not captured with regular Visual Analogue Scale pain/well-being. Responsiveness was low (small subgroup). Finally, the burden of symptoms in both seronegative and seropositive at risk individuals was high, with pain, stiffness and fatigue being the most common ones with a major impact on daily functioning. The FDR cohort (mostly healthy individuals) showed a lower burden of symptoms; however, the distribution of symptoms was similar.Conclusions: The SPARRA questionnaire has good psychometric properties and can add information to currently available clinical measures in individuals at risk of RA. The studied group had a high burden and impact of symptoms. Future studies should evaluate whether SPARRA data can improve the prediction of RA in at risk individuals.

Background: The availability of tests to predict the risk of developing chronic diseases is increasing. The identification of individuals at high risk of disease can trigger early intervention to reduce the risk of disease and its severity. In order for predictive tests to be accepted and used by those at risk, there is a need to understand people's perceptions of predictive testing. Method: A meta-synthesis of qualitative research that explored patient and public perceptions of predictive testing for chronic inflammatory diseases was conducted. Studies were coded by researchers and patient research partners, and then organised into common themes associated with the acceptability or use of predictive testing. Results: Perceived barriers to predictive testing were identified, including a concern about a lack of confidentiality around the use of risk information; a lack of motivation for change; poor communication of information; and a possible impact on emotional well-being. In order to reduce these barriers, the literature shows that a patient-centred approach is required at each stage of the testing process. This includes the consideration of individual needs, such as accessibility and building motivation for change; readily available and easy to understand pre and post-test information; support for patients on how to deal with the implications of their results; and the development of condition specific lifestyle intervention programmes to facilitate sustainable lifestyle changes. Conclusion: Patients and members of the public had some concerns about predictive testing; however, a number of strategies to reduce barriers and increase acceptability are available. Further research is required to inform the development of a resource that supports the individual to make an informed decision about whether to engage in a predictive test, what test results mean, and how to access post-test support.

Background People at risk of developing rheumatoid arthritis (RA) may be candidates for interventions aimed at preventing RA development [1]. The identification of such “at risk” populations includes testing for genetic and other (e.g. autoantibody) biomarkers. However, little is known about the people9s perspectives on these tests, how they react and cope when identified as being a person “at risk” and what their unmet needs are. Objectives To expore the perceptions about RA and predictive testing and to understand the various reactions and coping strategies used when identified as being at risk of developing RA from the perspective of those directly concerned. Methods As part of the EuroTEAM project, a qualitative interview study with people who were informed of being at risk of developing RA was conducted. An interview schedule was developed and pilot-tested. Interviews were audio-recorded, transcribed verbatim and analyzed using thematic analysis. Results A total of 34 individuals (with rheumatoid factor and/or ACPA positive) already informed of being at risk of developing RA participated in the study, from Austria (n=15), Germany (n=15), and the UK (n=4). In Vienna, people who had been tested within an expanded health exam participated in this study. In Birmingham and Erlangen, people with arthralgia were recruited from the outpatient clinics. Analysis of the interview data revealed five overarching themes related to predictive testing in the context of RA (Figure). There were differences between the perceptions of althralgia patients and asymptomatic individuals. People suffering from pain were much more frightened and worried when informed of being at risk of developing RA. As a consequence, they modified their lives in a larger extent and had greater knowledge about RA than those without any symptoms who were rather surprised, kept calm and hardly changed their lifestyle after being tested positive. Allmost all participants in this study would appreciate precise predictive tests in the context of RA. However, more than half of them would refuse synovial biopsy (even if this could help quantify risk more accurately) or preventive medication. Recommendations for an improved procedure of predictive testing in the field of RA were given, which could promote uptake of preventive strategies. Conclusions Participants showed large differences in views about predictive testing in the context of RA risk and offered specific suggestions that should be incorporated into service design and delivery in the context of future predictive testing programmes. These findings may also be relevant to prediction and prevention in the context of other diseases where multiple genetic risk factors interact with environmental risk factors to drive disease development. References van Steenbergen, H.W., T.W. Huizinga, and A.H. van der Helm-van Mil, The preclinical phase of rheumatoid arthritis: what is acknowledged and what needs to be assessed? Arthritis Rheum, 2013. 65(9): p. 2219–32. Disclosure of Interest None declared

This abstract presents reflections on recruiting and involving South Asian patients with rheumatoid arthritis (RA) in research; it draws on the first author9s experiences of leading a qualitative study which explored South Asian patients9 perceptions of communicating the risk of developing RA with relatives. RA is a chronic inflammatory condition that may lead to long-term disability and co-morbidities. First-degree relatives are at increased risk. Access to this group is dependent on the co-operation of patients with RA; it is therefore important to understand patients9 perceptions of risk and their willingness to communicate risk with relatives. Fifteen patients of South Asian origin were recruited in a secondary rheumatology clinic. Participants were also approached to act as patient research partners (PRPs) and help with interpreting and validating the data. We adopted a culturally competent approach: cultural competency entails understanding that socio-cultural factors influence patient participation in research and ensures that these influences do not become a basis for exclusion. South Asian groups are frequently considered ‘hard to reach’ – a label which suggests a lack of engagement on their part rather than institutional barriers. The conventional approach, commonly adopted by qualitative researchers, can serve to exclude people by, for example, including only people who speak English. As a researcher from a South Asian background, the author found her shared identity, languages and experiences helped to facilitate recruitment, build rapport and involve participants as PRPs.

The aim of this study was to explore symptoms and symptom development during the earliest phases of RA in patients with seropositive arthralgia and patients newly diagnosed with RA.Interviews were conducted with 15 seropositive patients (anti-CCP positive, and often with arthralgia) and 11 newly presenting RA patients [classified according to the 2010 ACR/European League Against Rheumatism (EULAR) criteria]. Feedback procedures shared the experiences of seropositive arthralgia patients with early RA patients and vice versa. Data were analysed using thematic analysis.Symptoms common to both groups included joint pain, psychological distress, muscle cramps, abnormal skin sensations, stiffness, loss of motor control, weakness, fatigue and sleeping difficulties. Also, patterns of symptom evolution and the order of symptom development were described. Seropositive arthralgia patients described pain as annoying, while RA patients described how the severity of pain intensified before diagnosis, to the point where symptoms were psychologically distressing. Patients with seropositive arthralgia described reddening of the skin and burning sensations that they felt were indicative of the onset of swelling. Intense pain appeared to precede the onset of swelling for those with RA, which was often palindromic and travelled between joints until it later became persistent.This study highlights the breadth of symptoms that constitute the earliest phases of RA. Further research is needed to develop measures of symptom patterns and clusters to allow the predictive utility of symptoms to be assessed and to allow the integration of aspects of the patient's history into evidence-based investigative and management algorithms for use in primary and secondary care.

Objective Understanding the features and patterns of symptoms that characterize the earliest stages of rheumatoid arthritis (RA) is of considerable importance if patients are to be identified and started on treatment early. However, little is known about the characteristics of symptoms at the onset of a disease that eventually progresses to RA. Methods A systematic review of qualitative peer-reviewed publications was conducted to identify the earliest symptoms associated with the onset of RA. A total of 1,736 abstracts were searched to identify relevant publications. Twenty-six publications were identified, assessed for quality, and subjected to analysis informed by thematic and grounded theory frameworks. Results Several interacting themes describing the early symptoms of RA were identified, including swelling, pain and tenderness, stiffness, fatigue and weakness, and the emotional impact of symptoms. For each symptom, different and evolving intensities were described; in some cases, patterns of symptom onset and symptom complexes at the onset of RA were highlighted. Importantly, this review has emphasized major deficiencies in the literature. None of the studies reviewed originally aimed to explore symptoms at RA onset (often discussions about symptom onset were secondary to the study's primary aim). Also, many of the articles identified sampled people diagnosed with RA many years previously, making their recollection of symptoms at onset less reliable. Conclusion In order for clinicians to fully understand the earliest phases of disease, the nature of symptoms at onset needs to be understood. The current work represents a useful starting point, but this area needs further qualitative investigation, followed by quantitative explorations of symptom clusters and their associated features.

Advances in genomic technologies and a growing trend towards stratified and preventive approaches to medicine mean that increasing numbers of individuals may have access to information about their genetic makeup, and their risk of developing diseases. This is likely to impact on healthcare professionals involved in the delivery of genetic tests, or in supporting patients who are affected by a disease with a genetic risk factor. It is therefore important to understand health-care professionals’ perceptions about providing these services, and how they feel about communicating information about genetic risk to patients. This paper provides a systematic review and metasynthesis of qualitative research exploring healthcare professionals’ perceptions of genetic risk in the context of predictive genetic testing for chronic disease. Healthcare professionals expressed a range of reservations about the utility of predictive testing in this context. Professionals judged patients’ understanding of risk information to be limited and subject to bias and a range of sociocultural influences. Concerns about the psychosocial impact of genetic risk information were frequently cited, both in relation to individual patients and the wider impact on their families and communities. The need for provision of multidisciplinary support was described. The concept of responsibility was also an important theme. Healthcare professionals recognized the responsibility that accompanies risk knowledge, and that ultimately this responsibility lies with the patient, not the provider. Our analysis suggests that professionals’ evaluation of the utility of predictive genetic testing is influenced not only by resource deficits, but may also be interpreted as a response to challenging ethical and social issues associated with genetic risk, that are not well aligned with current medical practice.

To understand the perspectives of patients with rheumatoid arthritis (RA) about the risk of their relatives developing RA in the future, and about communicating with their relatives concerning risk and its modulation.Twenty-one RA patients took part in semistructured interviews.Participants reported willingness to communicate with relatives about their risk of developing RA, but described choosing which relatives to communicate with, on the basis of the relatives' perceived receptivity to such risk information. Participants described the potential for risk information to cause negative emotions. Some participants did not consider RA to be hereditable, and few reported smoking as a risk factor. Patients described a lack of public awareness about the causes of RA and the negative impact that RA has on the quality of life. Awareness of this negative impact was identified as an important driver for predictive and preventive strategies. Participants held positive perceptions of predictive testing for RA, though the results of predictive tests were conceptualized as having a high degree of accuracy. Negative views of predictive testing were associated with an appreciation of the probabilistic nature of risk information. Participants felt that their relatives would prefer lifestyle modification over medication as a risk reduction strategy.Information about risk factors for RA, and the potential impact of RA on the quality of life, is needed to support family communication about RA risk. Management of expectations is needed in relation to the probabilistic nature of risk information, and appropriate support should be provided for negative psychological outcomes.

Clinical outcomes in rheumatoid arthritis (RA) are improved if the disease is treated early. However, treatment is often significantly delayed as a result of delayed help-seeking by patients who fail to recognize its symptoms or the need for rapid medical attention. Two studies were conducted to investigate the role of symptom recognition in help-seeking for the symptoms of RA, and compared this to symptom recognition and help-seeking in angina and bowel cancer.A qualitative interview study with 31 individuals and a survey of 1,088 members of the general public (all without RA) were conducted. Both studies used vignettes describing the symptoms of RA, bowel cancer, and angina. Participants made causal attributions and rated the perceived seriousness of the symptoms and the urgency with which they would seek medical help if confronted with these symptoms.Only a small proportion of participants in both studies recognized the symptoms of RA, whereas the symptoms of bowel cancer and angina were readily recognized by many participants and considered to be more serious and to require more rapid medical attention (Z = 14.7-34.2, P 0.001).Accurate symptom attribution and the perception that symptoms are indicative of a serious underlying condition are both important drivers for rapid help-seeking. In the case of angina and bowel cancer, recent campaigns have promoted not only recognition of symptoms and their seriousness, but also emphasized the consequences of not seeking timely help. Our results suggest that these consequences should also be addressed in any public health campaign for RA.

A systematic review of qualitative peer-reviewed publications was conducted to identify drivers of and barriers to help-seeking behaviour in adults with new-onset rheumatoid arthritis (RA). 1058 abstracts were searched to identify relevant publications. 21 relevant publications were identified assessed for quality and subjected to analysis informed by thematic and grounded theory frameworks. Several interacting themes were identified including the early experience of symptoms in relation to disease prototypes, minimising the impact of symptoms, speaking to others, gathering information and seeking alternative treatments, and issues related to accessing health services and attitudes towards healthcare professionals. Many people suggested that they had little knowledge of RA before diagnosis, believing RA to be a mild condition that affected older people. These misperceptions made correct symptom interpretation unlikely. Normalising and ignoring symptoms led people to delay in help-seeking. However, when symptoms impacted on daily activities help was usually sought. Individual interpretations of symptoms are both drivers of and barriers to help seeking. Targeted public health interventions are required to inform symptom interpretation and reduce delays.

Objectives The family members of patients with rheumatoid arthritis (RA) are at increased risk of developing RA and are potential candidates for predictive testing. This study explored the perceptions of first-degree relatives of people with RA about being at risk of RA and engaging in predictive testing. Methods# 34 first-degree relatives (siblings and offspring) of patients with RA from the UK, Germany and Austria participated in semistructured interviews about their perceptions of RA risk and the prospect of predictive testing. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Results First-degree relatives were aware of their susceptibility to RA, but were unsure of the extent of their risk. When considering their future risk, some relatives were concerned about the potential impact that RA would have on their lives. Relatives were concerned that knowing their actual risk would increase their anxiety and would affect decisions about their future. Also, relatives were concerned about the levels of uncertainty associated with predictive testing. Those in favour of knowing their future risk felt that they would need additional support to understand the risk information and cope with the emotional impact of this information. Conclusions# Identifying individuals at risk of RA may allow targeted interventions to reduce the risk and consequence of future disease; however, relatives have concerns about predictive testing and risk information. The development of strategies to quantify and communicate risk needs to take these views into account and incorporate approaches to mitigate concerns and minimise the psychological impact of risk information.

Background: Type 2 diabetes is associated with cardiovascular disease, and patients with both conditions are prescribedcomplex medication regimens. Aim: The aim was to develop a reliable and valid measure of attitudes associated with the prescription and management ofmultiple medicines in patients with Type 2 diabetes and cardiovascular disease. Methods: Principal component analysis (PCA) and Cronbach alpha assessed the reliability of the Attitudes about ComplexTherapy Scale (ACTS). Examinations of relationships with related measures inform concurrent validity. Questionnaireswere sent to a cross-sectional sample of 480 people prescribed multiple medicines for co-morbid Type 2 diabetes. Results: Cronbach alpha was 0.76, indicating the scale had good internal reliability. PCA rotated a four factor model accountingfor 37% of the variance. Four subscales identified; 1. Concerns about multiple medicines and increasing numbersof medicines; 2.Anxiety over missed medicines; 3. Desires to substitute medicines and reduce the number of medicines prescribed and; 4. Perceptions related to organising and managing complex therapy. The ACTS showed significant relationshipswith measures of anxiety, depression, general beliefs about medicines and self-efficacy. Also, the ACTS significantlycorrelated with adherence to medicines, showing good predictive validity. Conclusion: The ACTS was designed to assess negative attitudes towards complex therapy and multiple medication management.This tool could aid prescribing decisions and may identify people who are intentionally non-adherent to all orsome of their medicines.

Perceptions Of Testing To Predict Future Development Of Rheumatoid Arthritis Among The First-Degree Relatives Of People With Rheumatoid Arthritis : A Qualitative Exploration

Objective.Treating patients with rheumatoid arthritis (RA) within 3 months of symptom onset leads to significantly improved clinical outcomes. However, many people with RA symptoms wait a long time before seeking medical attention. To develop effective health interventions to encourage people to seek help early, it is important to understand what the general public knows about RA, how they would react to the symptoms of RA, and what might delay help-seeking.Methods.Qualitative interviews were conducted with 38 members of the general public (32 women) without any form of inflammatory arthritis about their perceptions of RA symptoms and decisions to seek help were they to experience such symptoms. The interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.Results.A number of barriers and drivers to help-seeking were identified and grouped into 5 themes: perceived causes of symptoms; factors related to presentation, location, and experience of symptoms; perceived effect of symptoms on daily life; self-management of symptoms; and general practitioner-related drivers and barriers.Conclusion.To our knowledge, our study is the first to investigate barriers to and drivers of help-seeking in response to the onset of RA symptoms in individuals without a diagnosis of RA. It has revealed a number of additional factors (e.g., the importance of the location of the symptoms) besides those previously identified in retrospective studies of patients with RA. Together with the data from previous research, these findings will help inform future health interventions aimed at increasing knowledge of RA and encouraging help-seeking.

Letter to the editor

BACKGROUND: Early treatment for rheumatoid arthritis (RA) is vital. However, people often delay in seeking help at symptom onset. An assessment of the reasons behind patient delay is necessary to develop interventions to promote rapid consultation. OBJECTIVE: Using a mixed methods design, we aimed to develop and test a questionnaire to assess the barriers to help seeking at RA onset. DESIGN: Questionnaire items were extracted from previous qualitative studies. Fifteen people with a lived experience of arthritis participated in focus groups to enhance the questionnaire's face validity. The questionnaire was also reviewed by groups of multidisciplinary health-care professionals. A test-retest survey of 41 patients with newly presenting RA or unclassified arthritis assessed the questionnaire items' intraclass correlations. RESULTS: During focus groups, participants rephrased questions, added questions and deleted items not relevant to the questionnaire's aims. Participants organized items into themes: early symptom experience, initial reactions to symptoms, self-management behaviours, causal beliefs, involvement of significant others, pre-diagnosis knowledge about RA, direct barriers to seeking help and relationship with GP. The test-retest survey identified seven items (out of 79) with low intraclass correlations which were removed from the final questionnaire. CONCLUSION: The involvement of people with a lived experience of arthritis and multidisciplinary health-care professionals in the preliminary validation of the DELAY (delays in evaluating arthritis early) questionnaire has enriched its development. Preliminary assessment established its reliability. The DELAY questionnaire provides a tool for researchers to evaluate individual, cultural and health service barriers to help-seeking behaviour at RA onset.

Objective. To explore general practitioners’ (GPs’) perspectives on public health campaigns to encourage people with the early symptoms of rheumatoid arthritis (RA) to seek medical help rapidly. Design. Nineteen GPs participated in four semi-structured focus groups. Focus groups were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results. GPs recognised the need for the early treatment of RA and identified that facilitating appropriate access to care was important. However, not all held the view that a delay in help seeking was a clinically significant issue. Furthermore, many were concerned that the early symptoms of RA were often non-specific, and that current knowledge about the nature of symptoms at disease onset was inadequate to inform the content of a help-seeking campaign. They argued that a campaign might not be able to specifically target those who need to present urgently. Poorly designed campaigns were suggested to have a negative impact on GPs’ workloads, and would “clog up” the referral pathway for genuine cases of RA. Conclusions. GPs were supportive of strategies to improve access to Rheumatological care and increase public awareness of RA symptoms. However, they have identified important issues that need to be considered in developing a public health campaign that forms part of an overall strategy to reduce time to treatment for patients with new onset RA. This study highlights the value of gaining GPs’ perspectives before launching health promotion campaigns.

Rheumatoid arthritis (RA) is a chronic inflammatory disease for which early treatment is vital to limit long-term joint damage. However, individuals often delay seeking medical help at the onset of RA symptoms. The early interpretation of symptoms and the process of making sense of symptoms impacts on both help-seeking decision-making and self-management. Furthermore, the general public’s perceptions and knowledge of RA may also affect the way that symptoms are interpreted. Examining the psychology behind early-symptom interpretation, the barriers to help-seeking behavior and investigating the public’s understanding of RA, can help us understand how decisions are made and guide us in developing interventions that encourage individuals to seek help promptly at the onset of RA.