Rheumatoid Arthritis in Men: Psychological Effects and Gaps in Self-Management

Gender differences in the manifestation of common chronic diseases such as cardiovascular, lung, and various autoimmune diseases are well documented.^1-3 However, clinical management of these conditions generally does not take gender into consideration. The long-term management of chronic diseases is primarily focused on self-management, and support interventions, such as the Stanford Chronic Disease Self-Management Program,⁴ are increasingly used to help individuals better manage their disease. The program addresses several areas, including physical and psychological effects of chronic disease (focusing on fatigue, pain, depression, and frustration), well-being (focusing on physical exercise, good nutrition, and appropriate medications), and effective communication with family, friends, and health professionals.⁴ 

Although studies are limited, there is evidence to support some benefit of the Stanford Chronic Disease Self-Management Program in improving health outcomes. For example, a systematic review of 10 studies involving 6074 people with various chronic diseases, including arthritis and pain, chronic respiratory diseases, depression, diabetes, heart disease, and stroke, evaluated the effectiveness of self-management support interventions compared with usual care.⁵ Overall, the study found modest, short-term improvements in pain, disability, fatigue, depression, health distress, self-rated health, and health-related quality of life. The study also found increased participation in physical exercise, stress or pain reduction techniques, and communication with their healthcare provider. The study, however, did not stratify the data by gender, and given the gender difference of chronic diseases, it is not clear whether the study results are representative of both men and women or biased by underrepresentation of one gender. At this time, there is insufficient evidence from the available studies to be able to conclusively determine whether self-management support interventions show larger, similar, or smaller effects in men compared with women.⁶

A meta-analysis that assessed the effectiveness of self-management support, stratified by sex, found that when data consisted of men only, physical activity interventions had greater effects on health-related quality of life, depression, anxiety, and fatigue outcomes compared with interventions that included education, peer support, or healthcare practitioner monitoring and feedback.⁶ Interestingly, analysis that included a mixed group of men and women found that physical activity, as well as education or peer support-based interventions, had some positive benefit in men, although the effect was small to moderate, but reached statistical significance.⁶ These results highlight differences in healthcare needs and support between men and women. In fact, a study conducted in Europe concluded that men’s health lags behind that of women, and the increasing recognition of gender-specific health needs has led to calls for tailored and targeted healthcare interventions in men.⁷ However, how chronic diseases specifically affect men and how such diseases are self-managed is not well known. Indeed, self-management is one area in which gender differences are likely to exist, and based on the available studies, it is possible that men may not fully benefit from self-management programs.⁶

Rheumatoid arthritis (RA) is one such chronic disease with known gender differences. Prevalence statistics show that RA is more common in women, and the majority of studies exploring the effect of RA and self-management interventions are biased toward women.⁸ There is a dearth of literature focused specifically on men. As a consequence, how RA specifically affects men, and how men self-manage RA, is poorly understood. A recent study found that the effect of RA in men goes beyond the physical manifestations and challenges. Psychological effect related to the perception of masculinity and ability to maintain the role of a breadwinner was highlighted in a study by Flurey and colleagues.⁹ The study also highlighted the lack of focus in the available literature on the effect of chronic illness on masculine identity, which, according to Fluery, should be taken into consideration when designing self-management services for men with long-term conditions such as RA.⁹ A narrative review by Flurey and colleagues explored gender differences on the psychological effect of RA, coping, and self-management.⁸ Quality of life, work disability, sexual activity, and emotional distress were affected differently in men compared with women.⁸ For example, with respect to quality of life, a greater effect on social activities was reported by men compared with a greater effect on emotional state reported by women.⁸ Compared with women, men reported greater distress if they have to stop work because of their disease, suggesting that loss of work was more emotionally stressful for men compared with women.⁸ Flurey and colleagues also found that coping and self-management of RA differed between men and women, reporting that the coping strategies and self-management techniques used by men are limited, less diverse, and have fewer support networks compared with women.⁸

The available literature, supported by studies such as those by Flurey and colleagues⁸ and Galdas and colleagues,⁶ exposes the limitations of current self-management programs and highlights the need for the development of tailored interventions that better meet the needs of men to better self-manage their RA. Clearly, additional research is needed to address several unanswered questions. For example, a need for consideration of gender differences in study design and analysis to provide more consistent reporting of outcomes by gender. In addition, there is a need for studies to improve understanding of the specific interventions that are acceptable and accessible to men for the self-management of chronic diseases such as RA. Finally, there is a need for studies to explore gender-specific interventions and models of service delivery that are most effective in providing self-management support to men. Until more research emerges to provide specific guidance, healthcare practitioners need to recognize the psychological effect of RA on men, with a consideration to tailor self-management support to include physical activity, with elements of education, and peer support-based interventions.

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References

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4. US Centers for Disease Control and Prevention. Chronic Disease Self-Management Program (CDSMP). https://www.cdc.gov/arthritis/marketing-support/1-2-3-approach/docs/pdf/provider_fact_sheet_cdsmp.pdf. Accessed December 13, 2018.
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