The educational needs of patients with undifferentiated spondyloarthritis: Validation of the ENAT questionnaire and needs assessment.

OBJECTIVES: The aim of the present study was to validate the Swedish version of the educational needs assessment tool (SwENAT) in undifferentiated spondyloarthritis (USpA) and use it to study the educational needs of patients with USpA. METHODS: This was a cross-sectional study, recruiting a random sample of patients with USpA from a hospital register in Sweden. Educational needs data were collected, together with disease activity and function indices (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] and Bath Ankylosing Spondylitis Functional Index [BASFI]). Rasch analysis was utilized to evaluate the construct validity, internal consistency and unidimensionality of the SwENAT before studying differences in educational needs between patient subgroups (gender, age and disease severity). RESULTS: Complete responses were obtained from 77 patients (48 women), with a mean age (standard deviation [SD]) of 50 (12) years, a disease duration of 16 (11) years, a BASDAI score of 4.9 (1.9) and a BASFI score of 3.1 (2.3). The SwENAT satisfied the requirements of the Rasch model (χ2 = 11.488; p = 0.119), including strict unidimensionality. Overall, the mean (SD) SwENAT score was 86 (32). Women reported higher needs than men in the domains of pain (mean [SD] 13.1 [6.8] versus 10.1 [6.0]; p = 0.05); movement (mean [SD] 13.0 [5.5] versus 9.9 [5.7]; p = 0.02) and self-help (mean [SD] 17.0 [5.8] versus 14.1 [5.0]; p = 0.03). Higher disease activity (BASDAI >4) was associated with higher educational needs (mean [SD] 92.6 [31.9] versus 73.7 [29.4]; p = 0.02). CONCLUSIONS: These data suggest that the SwENAT is valid in USpA. Women and patients with higher disease activity are more likely to have high levels of educational needs, so special attention and strategies to target patient education are warranted.

Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study.

AIMS: To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer. METHODS: This multicentre, prospective, observational study reviewed participants' data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants' notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence. RESULTS: In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06). CONCLUSIONS: Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers.

Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial.

OBJECTIVES: The Educational Needs Assessment Tool (ENAT) is a self-completed questionnaire, which allows patients with arthritis to prioritise their educational needs. The aim of this study was to evaluate the effects of needs-based patient education on self-efficacy, health outcomes and patient knowledge in people with rheumatoid arthritis (RA). METHODS: Patients with RA were enrolled into this multicentre, single-blind, parallel-group, pragmatic randomised controlled trial. Patients were randomised to either the intervention group (IG) where patients completed ENAT, responses of which were used by the clinical nurse specialist to guide patient education; or control group (CG) in which they received patient education without the use of ENAT. Patients were seen at weeks 0, 16 and 32. The primary outcome was self-efficacy (Arthritis Self Efficacy Scale (ASES)-Pain and ASES-Other symptoms). Secondary outcomes were health status (short form of Arthritis Impact Measurement Scale 2, AIMS2-SF) and patient knowledge questionnaire-RA. We investigated between-group differences using analysis of covariance, adjusting for baseline variables. RESULTS: A total of 132 patients were recruited (IG=70 and CG=62). Their mean (SD) age was 54 (12.3) years, 56 (13.3)  years and disease duration 5.2 (4.9) years, 6.7 (8.9) years for IG and CG, respectively. There were significant between-group differences, in favour of IG at week 32 in the primary outcomes, ASES-Pain, mean difference (95% CI) -4.36 (1.17 to 7.55), t=-2.72, p=0.008 and ASES-Other symptoms, mean difference (95% CI) -5.84 (2.07 to 9.62), t=-3.07, p=0.003. In secondary outcomes, the between-group differences favoured IG in AIMS2-SF Symptoms and AIMS2-SF Affect. There were no between-group differences in other secondary outcomes. CONCLUSIONS: The results suggest that needs-based education helps improve patients' self-efficacy and some aspects of health status. TRIAL REGISTRATION NUMBER: ISRCTN51523281.

CROSS-CULTURAL VALIDATION OF THE PORTUGUESE VERSION OF THE EDUCATIONAL NEEDS ASSESSMENT TOOL (PortENAT).

OBJECTIVES: To undertake a cross-cultural adaptation and validation of the educational needs assessment tool (ENAT) into Portuguese. METHODS: The first phase of this research (cross-cultural adaptation) utilised a well-established translation method comprising five sequential steps: forward-translation, synthesis of translations, back-translation, expert committee and field-testing of the adapted version. The second phase involved collecting data from 123 patients and subjecting them to Rasch analysis for validity testing including cross-cultural invariance. RESULTS: The translation and field-testing phase went smoothly giving rise to minor adjustments in the phrasing of some items. The preliminary analysis of the 39 items, revealed some deviations from the model with the overall item-person interaction fit statistics 2(df) = 56.025 (39), p = 0.038. Significant item-item correlations caused artificial inflation of the internal consistency, therefore violating the model assumption of local independence of items. To correct this, all locally dependent items were then grouped into their respective domains, creating a 7 testlet-scale which demonstrated a good fit to the Rasch model, 2(df) = 2.625 (7), p = 0.917 and internal consistency PSI = 0.975. Analysis of the pooled (Portuguese and the English) data revealed cross-cultural DIF, requiring adjustments in two testlets: 'treatments' and 'support' which ensured cross-cultural equivalence. CONCLUSIONS: This study confirms the Portuguese ENAT is a robust unidimensional tool with which to assess the educational needs of Portuguese people with RA. Cross-cultural adjustments are required only if the data from Portugal and the UK are pooled or compared. The tool is now available for use in clinical practice and research.

Measuring educational needs among patients with systemic lupus erythematosus (SLE) using the Dutch version of the Educational Needs Assessment Tool (D-ENAT).

OBJECTIVE: The Educational Needs Assessment Tool (ENAT) was developed in the United Kingdom (UK) to systematically assess the educational needs of patients with rheumatic diseases. The aim of the present study was to describe the educational needs of Dutch patients with systemic lupus erythematosus (SLE) by means of a Dutch version of the ENAT (D-ENAT). METHODS: The D-ENAT was sent to a random sample of 244 SLE patients registered at the outpatient clinic of a university hospital. D-ENAT consists of 39 items in seven domains. The D-ENAT domain scores range from 0-16 to 0-28 (higher scoring equals higher educational needs) depending of the number of items in the domain. A total D-ENAT score (0-156) is calculated by summing all 39 items. In addition, age, disease duration, gender, educational level, present information need (yes/no) and the extent of information need (1-4: nothing-everything) were recorded. Univariate regression analysis was used to examine the D-ENAT's potential determinants. RESULTS: The response rate was 122 out of 244 (50%). The mean (% of maximum score) educational needs scores were 56% for 'D-ENAT total score', 62% for 'Self-help measures', 60% for 'Disease process', 58% for 'Feelings', 56% for 'Treatments', 50% for 'Movement', 49% for 'Support systems' and 46% for 'Managing pain'. Being female was significantly associated with higher scoring on the D-ENAT total score (ß 23.0; 95% CI 5.9, 40.3). CONCLUSION: SLE patients demonstrated substantial educational needs, especially in the domains: 'Self-help measures', 'Disease process' and 'Feelings'. The validity and practical applicability of the D-ENAT to make an inventory of SLE patients' educational needs requires further investigation.