A Model of Factors Predicting Delayed Access to Healthcare Services among People with Rheumatoid Arthritis: A Cross-Sectional Study
DOI:
https://doi.org/10.60099/prijnr.2026.277188Keywords:
Delayed access, Health literacy, Healthcare services, Help-seeking behavior, Illness perception, Rheumatoid arthritisAbstract
Delayed access to healthcare services among people with rheumatoid arthritis remains a critical challenge, which may increase the risks of disability and reduce quality of life. Timely initiation of disease-modifying anti-rheumatic drugs within the first 12 weeks is the therapeutic window of opportunity essential for preventing long-term disease progression. However, evidence explaining the determinants of delayed access in Asian contexts remains limited. This study aimed to design and test a causal model of factors predicting delayed access to healthcare services among people who have rheumatoid arthritis in Northern Vietnam. A detailed cross-sectional study was conducted among 308 adults with rheumatoid arthritis between June and September 2023. Data were collected using the Demographic and Clinical Questionnaire, the Health Literacy Short Form-12 items (HL-SF12), the Brief Illness Perception Questionnaire (BIPQ), and the General Help-Seeking Questionnaire (GHSQ). Structural equation modeling was used to examine the relationships between variables and identify predictors of delayed access to care.
Delayed access was highly prevalent, with 91% of participants experiencing delays of three months or longer before receiving treatment. The final model explained 9.6% of the variance in delayed access. Health literacy and help-seeking behaviors demonstrated small but statistically signif icant total effects in reducing delay. A strong negative relationship was observed between health literacy and help-seeking behaviors. The model’s limited explanatory power highlights the need to enhance its predictive capabilities by adding more factors or variables before further testing. Nursing interventions and practice should broaden strategies beyond individual behaviors to address structural, cultural, and service barriers, thereby improving equity and the timeliness of care.
References
National Institute for Health and Care Excellence (NICE). Rheumatoid arthritis in adults: management (NG100). London: NICE; 2018. Updated 2020. Reviewed 2024. Available from: https://www.nice.org.uk/guidance/ng100
Almutairi K, Nossent J, Preen D, Keen H, Inderjeeth C. The global prevalence of rheumatoid arthritis: a metaanalysis. based on a systematic review. Rheumatol Int. 2021;41(5):863-77. doi: 10.1007/s00296-020-04731-0.
Ma Y, Chen H, Lv W, Wei S, Zou Y, Li R, et al. Global, regional and national burden of rheumatoid arthritis from 1990 to 2021, with projections of incidence to 2050: a systematic and comprehensive analysis of the Global Burden of Disease study 2021. Biomark Res. 2025;13(1):47. doi: 10.1186/s40364-025-00760-8.
Hsieh PH, Wu O, Geue C, McIntosh E, McInnes IB, Siebert S. Economic burden of rheumatoid arthritis: a systematic review of literature in biologic era. Ann Rheum Dis. 2020;79(6):771-7. doi: 10.1136/annrheumdis2019-216243.
Radu AF, Bungau SG. Management of rheumatoid arthritis: an overview. Cells. 2021;10 (11):2857. doi: 10.3390/cells10112857.
Naeem F, Khan SEA, Saeed MA, Farman S. Diagnostic and therapeutic delay in rheumatoid arthritis patients: impact on disease outcome. Pak J Med Sci. 2021;37(4): 1001-7. doi: 10.12669/pjms.37.4.3471.
Lee J, Martindale J, Makris UE, Singh N, Yung R, Bynum JPW. Initiation of disease-modifying antirheumatic drugs in older medicare beneficiaries with new diagnosis of late-onset rheumatoid arthritis. ACR Open Rheumatol. 2023;5(12):694-700. doi: 10.1002/acr2.11625.
Butt NI, Waris B, Waris U. Delayed diagnosis and treatment of rheumatoid arthritis: a preventable path to disability. Am J Diagn Imaging. 2025;11(4).50-3. doi: 10.5455/ajdi.20250531043655.
Ester M, White K, Dhiman K, Zafar S, Subdar S, Zimmermann GL, et al. A theory of change for patientinitiated follow-up care in rheumatoid arthritis. BMC Rheumatol. 2025;9(1):31. doi: 10.1186/s41927-025-00481-3.
Kirik A, Şahin N, Baykul M, Bodur H, Güler T, Çevik R, et al. Low vaccination rates and awareness status in patients with rheumatoid arthritis: a nationwide cross-sectional survey study. Rheumatol Int. 2025;45(5):116. doi: 10.1007/s00296-025-05870-y.
Javaid U, Mahmud TH, Rasheed A, Javaid AUR, Riaz S, Zohaib A. Factors leading to diagnostic and therapeutic delay of rheumatoid arthritis and their impact on disease outcome. Cureus. 2023;15(1):e34481. doi:10.7759/cureus.34481.
Alanazi F, Abdulaziz S, Alghanim K, Alhamzi H, Alrayes H. Diagnostic delay in rheumatoid arthritis patients: a multi-centric study conducted in Saudi Arabia. Ann Rheumatol Autoimmun. 2025;5(1):26-30. doi: 10.4103/ ara.ara_3_25.
Sacilotto NC, Giorgi RDN, Vargas-Santos AB, de Albuquerque CP, Radominski SC, Pereira IA, et al. Real - rheumatoid arthritis in real life - study cohort: a sociodemographic profile of rheumatoid arthritis in Brazil. Adv Rheumatol. 2020;60(1):20. doi:10.1186/ s42358-020-0121-5.
Hathaway EC, Lee J, Wojeck RK. Socioeconomic disparities associated with healthcare utilization among adults with rheumatoid arthritis. Nurs Res. 2023;72(3):167-74. doi: 10.1097/NNR.0000000000000638.
Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. doi: 10. 1186/1471-2458-12-80.
Broadbent E, Petrie KJ, Main J, Weinman J. The Brief Illness Perception Questionnaire. J Psychosom Res. 2006; 60(6):631-7. doi: 10.1016/j.jpsychores.2005.10.020.
Nguyen T, Cao HTK, Quach DN, Le KK, Au SX, Pham ST, et al. The Vietnamese Version of the Brief Illness Perception Questionnaire and the Beliefs about Medicines Questionnaire: translation and cross-cultural adaptation. Trop Med Int Health. 2019;24(12):1465-74. doi: 10.1111/tmi.13312.
Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013; 12:18. doi: 10.1186/1475-9276-12-18.
Andersen RM, Davidson PL. Improving access to care in America: individual and contextual indicators. In: Andersen RM, Rice TH, Kominski EF, editors. Changing the U.S. health care system: key issues in health services, policy, and management. 3rd ed. San Francisco (CA): JosseyBass; 2007. pp. 3–31.
Hajek A, Kretzler B, König HH. Determinants of healthcare use based on the Andersen Model: a systematic review of longitudinal studies. Healthcare (Basel). 2021;9(10):1354. doi: 10.3390/healthcare9101354.
Nakajima A, Sakai R, Inoue E, Harigai M. Geographic variations in rheumatoid arthritis treatment in Japan: a nationwide retrospective study using the national database of health insurance claims and specific health checkups of Japan. Mod Rheumatol. 2022;32(1):105-13. doi: 10.1080/14397595.2021.1910615.
Gorter A, Bakker MM, Ten Klooster PM, Boonen A, Vonkeman HE. The impact of health literacy: associations with disease activity and medication prescription in patients with rheumatoid arthritis. Rheumatology (Oxford). 2023; 62(10):3409-15. doi: 10.1093/rheumatology/kead094.
Simons G, Belcher J, Morton C, Kumar K, Falahee M, Mallen CD, et al. Symptom recognition and perceived urgency of help-seeking for rheumatoid arthritis and other diseases in the general public: a mixed method approach. Arthritis Care Res (Hoboken). 2017;69(5):633-41. doi: 10.1002/acr.22979.
Ohta R, Sano C. Factors affecting the duration of initial medical care seeking among older rural patients diagnosed with rheumatoid arthritis: a retrospective cohort study. BMC Rheumatol. 2024;8(1):23. doi: 10.1186/s41927-024-00392-9.
Jain A, Joseph S, James J, James TS, Kumar K, Raza K, et al. Delay in diagnosis of rheumatoid arthritis: reasons and trends over a decade. Rheumatol Int. 2023;43(3): 503–8. doi: 10.1007/s00296-022-05187-0.
Duong TV, Nguyen TTP, Pham KM, Nguyen KT, Giap MH, Tran TDX, et al. Validation of the Short-Form Health Literacy Questionnaire (HLS-SF12) and its determinants among people living in rural areas in Vietnam. Int J Environ Res Public Health. 2019;16(18):3346. doi: 10.3390/ijerph16183346.
Lindgren LH, de Thurah A, Thomsen T, Hetland ML, Aadahl M, Vestergaard SB, et al. Sociodemographic and clinical variables associated with negative illness perception in patients newly diagnosed with rheumatoid arthritis, axial spondyloarthritis, or psoriatic arthritis-a survey based cross-sectional study. Rheumatol Int. 2024;44(6):1119-31. doi: 10.1007/s00296-024-05553-0.
Wilson CJ, Deane FP, Ciarrochi JV, Rickwood D. Measuring help-seeking intentions: properties of the General Help Seeking Questionnaire. Can J Counsel. 2005;39(1):15-28. Available from: https://ro.uow.edu.au/hbspapers/1527
Brooke P, Bullock R. Validation of a 6 item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry. 1999;14(11):936-40. PMID: 10556864.
Kline RB. Principles and practice of structural equation modeling. 4th ed. New York: Guilford Press; 2016.
United Nations. Provisional guidelines on standard international age classification [Internet]. New York: United Nations; 1982 [cited 2025 Aug 1]. Available from: https://unstats.un.org/unsd/publication/SeriesM/SeriesM_74e.pdf
Ozolins U, Hale S, Cheng X, Hyatt A, Schofield P. Translation and back-translation methodology in health research - a critique. Expert Rev Pharmacoecon Outcomes Res. 2020;20(1):69-77. doi: 10.1080/14737167.2020.1734453.
Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35(6):382-5. PMID: 3640358.
Fazaa A, Bettaieb H, Sellami M, Miladi S, Ouenniche K, Souebni L, et al. Journey of rheumatoid arthritis patients in Tunisia: from symptoms to treatment. Arch Rheumatol. 2021;37(1):85-93. doi: 10.46497/ArchRheumatol.2022.8469.
Saraiva L, Duarte C. Barriers to the diagnosis of early inflammatory arthritis: a literature review. Open Access Rheumatol. 2023;15:11-22. doi: 10.2147/OARRR.S282622.
Tsai TY, Podgorski A, Al-Heilfi A, Hassett G, Gorelik A, Buchbinder R, et al. Health literacy of rheumatology patients in three clinics in Australia and its association with sociodemographic and clinical characteristics. Rheumatol Adv Pract. 2024;8(4):rkae113. doi: 10.1093/rap/rkae113.
Pedersen S, Nielsen B, Assmann M, Hauge E, de Thurah A. Early diagnosis of rheumatoid arthritis: associations between patients’ perceptions of initial symptoms and the timing of seeking help from the general practitioner. Scand J Rheumatol. 2025;54(4):242-51. doi: 10.1080/03009742.2025.2464457.
Patierno C, Fava GA, Carrozzino D. Illness denial in medical disorders: a systematic review. Psychother Psychosom. 2023;92(4):211-26. doi: 10.1159/000531260.
Mosleh S, Alnajar M, Darawad M. The impact of illness perception on delay in seeking medical help in patients with acute chest pain: a cross-sectional study in the United Arab Emirates. Open Nurs J. 2023;17: e18744 3462303130. doi: 10.2174/18744346-v17-e230407-2022-181.
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