Rheumatol Int (2014) 34:1085–1093
DOI 10.1007/s00296-013-2938-2
Original Article
Association between helplessness, disability, and disease activity
with health‑related quality of life among rheumatoid arthritis
patients in a multiethnic Asian population
Yu Heng Kwan · Ee Tzun Koh · Khai Pang Leong ·
Hwee‑Lin Wee · On behalf of the Tan Tock Seng
Rheumatoid Arthritis Study Group ·
Received: 19 July 2013 / Accepted: 27 December 2013 / Published online: 9 January 2014
© Springer-Verlag Berlin Heidelberg 2014
Abstract  To investigate the association between help-
lessness, disability, and disease activity with health-
related quality of life (HRQoL) in a multiethnic cohort
of rheumatoid arthritis (RA) patients in Singapore. This
cross-sectional study was conducted at Tan Tock Seng
Hospital, Department of Rheumatology, Allergy and
Immunology, from October 2010 to October 2011. All
patients fulfilled the American College of Rheumatology
1987 criteria for RA. Socio-demographics, clinical, and
patient-reported outcome (PRO) variables were collected.
HRQoL outcomes were Short Form 36 (SF-36) physi-
cal and mental component summary (PCS and MCS)
scores and Short Form 6 Dimensions (SF-6D) utilities.
Stepwise multiple linear regression analyses were per-
formed using HRQoL outcomes as dependent variables
in separate models and with adjustment for helplessness
(Rheumatology Attitudes Index, RAI), disability (Health
Assessment Questionnaire, HAQ), and disease activity
(Disease Activity in 28 joints) followed by socio-demo-
graphic, clinical, and PRO variables. Complete data were
provided by 473 consenting subjects [mean (SD) age:
60.02 (11.04) years, 85 % female, 77 % Chinese]. After
adjustment for all measured covariates, only RAI and
HAQ scores remained significantly associated with SF-
36 MCS (β: −0.9, p < 0.001; β: −7.0, p < 0.001) and SF-
6D utilities (β: −0.005, p < 0.001; β: −0.081, p < 0.001),
Y. H. Kwan · H.-L. Wee (*) 
Department of Pharmacy, Faculty of Science, National University
of Singapore, 18 Science Drive 4, Singapore 117543, Republic
of Singapore
e-mail: phawhl@nus.edu.sg
E. T. Koh · K. P. Leong 
Department of Rheumatology, Allergy and Immunology, Tan
Tock Seng Hospital, Singapore, Republic of Singapore
respectively, while only HAQ scores were significantly
associated with SF-36 PCS (β: −7.7, p < 0.001). Inter-
ventions to address the sense of helplessness and to pre-
vent or reduce disability could improve HRQoL of RA
patients.
Keywords  Quality of life · Rheumatoid arthritis ·
Singapore · Factors · Psychosocial techniques
Introduction
Rheumatoid arthritis (RA) is a chronic debilitating disease
with an estimated 1 % prevalence in the population [1].
Health-related quality of life (HRQoL) is a multidimen-
sional measure of a patient’s well-being, including physical
well-being, social well-being, emotional well-being, and
functional abilities [2]. The course of RA results in finan-
cial burdens and drastic psychosocial and physical changes
to the patients, thus affecting their HRQoL [3]. In recent
years, there has been a shift of focus from traditional indi-
cators of disease activity and prognosis to a more holistic
measure of patient outcome using HRQoL instruments [4].
Furthermore, it has been shown that current efficacy end-
points such as joint counts and laboratory tests, such as
C-reactive protein, are poorer predictors of overall HRQoL
of patients compared with patient-reported outcomes
(PRO) [5].
Although there are several studies on the HRQoL of RA
patients in North Asia, Europe, and Northern America [6–
13], the findings from these populations may not be read-
ily generalizable to Southeast Asia, as HRQoL is heavily
influenced by cultural, economic, and social issues [14].
For example, depressed elderly Asians residing in Canada
and the United States were significantly more likely to
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1086
report more external locus of control and self-blaming attri-
butions than depressed Caucasians [15], and this may alter
the relationship between sense of helplessness and HRQoL
among Asians. Furthermore, there is a dearth of literature
on RA patients in Southeast Asia and existing studies have
their limitations. The study by Sadamoto et al. [11] uti-
lized the Lorish’s face scale which is not widely used in
clinical practice or research, while the studies by Kojima
et al. [13] and Linde et al. [10] involved subjects with lower
disease activity, who are not representative of the general
RA patient population. Studies by Standfield et al. [12]
and Cho et al. [8] may not have accounted for all possi-
ble confounding factors, as acknowledged by the authors.
Hence, our study is likely to fill a gap in the current litera-
ture by studying the relationships between sense of help-
lessness, disability, and disease activity and HRQoL in RA
patients in Singapore, an island city state in Southeast Asia.
We hypothesized that subjects with a higher sense of help-
lessness would report poorer mental and overall HRQoL
while those with greater disability or higher disease activity
would report poorer physical, mental, and overall HRQoL
as measured by the SF-36 and the Short Form 6 Dimen-
sions (SF-6D).
Methods
Patients and data collection
A cross-sectional study involving RA patients from the
Department of Rheumatology, Allergy and Immunology at
Tan Tock Seng Hospital (TTSH) was carried out from Octo-
ber 2010 to October 2011. All patients fulfilled the Ameri-
can College of Rheumatology (ACR) 1987 criteria for RA
[16]. This study was approved by the Institutional Review
Board, and all subjects provided written informed consent.
Clinical variables were scored by the attending rheuma-
tologists. Socio-demographic and PRO variables were col-
lected using a set of self-administered and pre-tested Eng-
lish and Chinese language questionnaires. For a very small
group of subjects who can understand but cannot read, the
survey was interviewer-administered. Socio-demographic
variables collected included gender, age, race, educa-
tion level, and marital status. Clinical variables included
the number of comorbidities, duration of morning stiff-
ness, ACR functional status, physician’s global assessment
(DGA, higher score indicates poorer disease status) of RA,
RA disease activity in 28 joints (DAS28) [17], and medi-
cations. PRO variables included patient’s global assess-
ment of RA activity and pain intensity on visual analog
scale (0–100 mm, higher value denoting worse PGA and
greater pain intensity), HAQ (range 0–3) [18, 19], RAI
(range 15–75) [20], SF-36 [21, 22], and SF-6D [23, 24] for
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Rheumatol Int (2014) 34:1085–1093
assessment of functional status, helplessness, and quality of
life, respectively.
RAI
RAI is a 15-item self-administered survey to measure the
sense of helplessness which may arise due to the unpre-
dictable nature of the rheumatic disease [20]. The RAI was
previously found to exhibit good psychometric properties
in Singapore. The response options range from 1 (strongly
disagree) to 5 (strongly agree) [25] with reversed scor-
ing for nine questions. The total RAI score ranges from
15 to 75 with higher scores indicating a greater sense of
helplessness.
SF‑36
The SF-36 is a self-reported generic HRQoL survey that
has also been used widely in Singapore [26]. It comprises
eight health domains including physical functioning, physi-
cal role functioning, emotional role functioning, bodily
pain, general health, vitality, social functioning, and mental
health. The eight domains may be further collapsed into the
physical component summary (PCS) and the mental com-
ponent summary (MCS) scores [21]. PCS and MCS are
norm-based scores with a mean of 50 and standard devia-
tion of 10, with higher scores indicating better HRQoL.
This means that someone with a score of 40 is one standard
deviation below the average score of the Singapore general
population while someone with a score of 60 is one stand-
ard deviation above the average score of the Singapore
general population. A difference of 5 points [26] is usually
defined as the minimally important difference (MID) but
MID of 3 points has also been suggested [22].
SF‑6D
The SF-6D is a preference-based HRQoL questionnaire
derived from the SF-36 [23] and comprises six single-
item dimensions including physical function, role limita-
tion, social function, pain, mental health, and vitality. The
response option for each item ranges from 4 to 6 levels,
thus describing 18,000 possible health states. The utility
scores of SF-6D range from 0.30 to 1.00 with a score of
1.00 designated perfect health and a score of 0.3 represent-
ing the worst possible health state. A MID of 0.041 for SF-
6D has been proposed [24].
Statistical analyses
Descriptive statistics was presented and stratified by gen-
der and race. Mean and standard deviations (SD) were pre-
sented. Differences between genders were assessed using
Rheumatol Int (2014) 34:1085–1093 1087

chi-squared test for categorical variables and Student’s t
test or Mann–Whitney U test for normally and non-nor-
mally distributed continuous variables, respectively. Differ-
ences between races were assessed using Chi-squared test
for categorical variables and analysis of variance (ANOVA)
or Kruskal–Wallis test for normally and non-normally dis-
tributed continuous variables, respectively.
Univariable regression analyses were conducted, and
only variables that had p values less than 0.1 were included
in the subsequent multiple linear regression analyses. Step-
wise multiple linear regression analyses were performed
with SF-36 PCS, SF-36 MCS, and SF-6D utility scores
as dependent variables in separate models. Given that we
hypothesized that helplessness, functional status, and dis-
ease activity are associated with HRQoL outcomes, we
introduced RAI, HAQ, and DAS28 scores separately as
independent variables one at a time to each of the three
dependent variables (model series 1). Only the variable(s)
that has/have statistically significant association(s) with
the dependent variable is/are retained in the next series of
model. In model series 2, socio-demographic covariates
such as age, gender, race, marital status, and education
level were added to the variables that were statistically sig-
nificant in model series 1. In model series 3, clinical covari-
ates such as ACR functional class status, DGA, number
of medications, number of comorbidities, and duration of
morning stiffness were added to model series 2. In model
series 4, PRO covariates such as PGA and pain intensity
were added to model series 3. To avoid multicollinearity in
the model, a variable is only included if the variance infla-
tion factor is less than 10 [27]. Adjusted R2 was used to
compare across the models.
All statistical analyses were carried out using STATA
SE version 12.1 for Windows (StataCorp, College Station,
TX).
Results
Subjects
Of the 708 subjects recruited, 198 subjects did not
have complete HRQoL data, 22 subjects did not have
complete socio-demographic, clinical, and other PRO
data, and 15 subjects who were not ethnically Chi-
nese, Malay, or Indian were excluded (Fig. 1). Sub-
jects that were excluded had better General Health
Assessment (GHA) (3.02 ± 12.57 vs. 9.72 ± 19.09,
p < 0.0001), shorter morning stiffness (4.42 ± 21.56 vs.
12.74  ± 49.86, p  = 0.0169), better PGA (6.15 ± 18.22
vs. 22.04 ± 26.58, p < 0.0001), and better pain score
(4.09 ± 14.58 vs. 14.26 ± 22.59, p < 0.0001) than those
included. Characteristics of the 473 subjects who pro-
vided complete data for analyses are described in Table 1.
Stratified descriptive analyses for gender and race are
reported in Tables 1 and 2, respectively. Compared with
female subjects, male subjects are more likely to be mar-
ried (88 vs. 69 %, p = 0.007), to have completed second-
ary or higher education (71 vs. 53 %, p  = 0.001), to be
smokers (24 vs. 2 % p < 0.001), to have higher number of
comorbidities (2.90 ± 2.03 vs. 2.36 ± 1.80, p = 0.041),
and to have normal ACR functional status (72 vs. 69 % in
ACR category I, p  = 0.010). There were no gender dif-
ferences in any of the PRO.

Fig. 1  Patient exclusion chart.

HRQoL health-related quality
October 2010-October 2011
of life, DGA physician’s global
assessment, PGA patient’s
global assessment, PRO patient-
reported outcomes, HAQ Health
Assessment Questionnaire, RAI
rheumatology attitudes index,
ACR American College of
Rheumatology
Recruitment
N=708
198 subjects with missing HRQoL data
7 subjects with missing education level data
Complete HRQoL data
1 subject with missing morning stiffness data
N=510
1 subject with missing DGA data
1 subject with missing PGA data
2 subjects with missing HAQ score
8 subjects with missing RAI score
Complete HRQoL and 2 subjects with missing ACR functional status
covariate data
N=488

15 subjects who were not Chinese, Malays or

Indians
Exclusion of other races
N=473

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1088 Rheumatol Int (2014) 34:1085–1093

Table 1  Socio-demographics, Feature Total (N = 473) Mean ± SD (%) p value

clinical, and PRO variables in
overall population and between Male (N = 70) Female (N = 403)
genders
Socio-demographic variables
Age (years) 60.02 ± 11.04 62.26 ± 10.33 59.63 ± 11.12 0.066
Race
 Chinese 366 (77) 50 (72) 316 (78) 0.092
 Malay 47 (10) 12 (17) 35 (9)
 Indian 60 (13) 8 (11) 52 (13)
Marital status
 Single 64 (13) 4 (6) 60 (15) 0.007*
 Married 339 (71) 62 (88) 277 (69)
 Widowed 51 (11) 4 (6) 47 (12)
 Divorced 19 (4) 0 (0) 19 (4)
Educational level
 No formal education 91 (19) 9 (13) 82 (20) 0.001*
 Primary 121 (25) 11 (16) 110 (27)
 Secondary 193 (41) 33 (47) 160 (40)
 Polytechnic/pre-U 46 (10) 15 (21) 31 (8)
 Tertiary education 22 (5) 2 (3) 20 (5)
Clinical variables
ACR functional status
 I Normal 326 (69) 50 (72) 276 (69) 0.010*
Data shown as mean ± SD or  II Limited in social activities 112 (24) 10 (14) 102 (25)
n (%)  III Limited in vocational activities 26 (5) 9 (13) 17 (4)
HRQoL health-related quality  IV Wheelchair or bedridden 9 (2) 1 (1) 8 (2)
of life, Pre-U A-Levels, DGA 3.60 ± 7.89 4.17 ± 6.96 3.51 ± 8.04 0.266
DGA physician’s global
assessment, PGA patient’s Number of medications 3.80 ± 1.71 3.74 ± 1.77 3.81 ± 1.70 0.774
global assessment, PRO patient- Number of comorbidities 2.43 ± 1.84 2.90 ± 2.03 2.36 ± 1.80 0.041*
reported outcomes, HAQ Health Minutes of morning stiffness 12.74 ± 49.86 11.98 ± 47.44 12.92 ± 50.44 0.258
Assessment Questionnaire, RAI
DAS28 score 2.32 ± 0.86 2.45 ± 0.96 2.30 ± 0.84 0.261
Rheumatology Attitudes Index,
DAS28 disease activity in 28 PRO variables
joints, SD standard deviation, PGA 22.04 ± 26.58 23.91 ± 28.38 21.71 ± 26.27 0.615
ACR American College of Pain intensity 14.27 ± 22.59 13.37 ± 19.99 14.42 ± 23.03 0.772
Rheumatology, PCS physical
component summary, MCS HAQ score 0.29 ± 0.49 0.28 ± 0.43 0.30 ± 0.50 0.889
mental component summary, RAI score 35.90 ± 6.65 36.64 ± 6.14 35.77 ± 6.73 0.216
RA rheumatoid arthritis, SF-36 SF-36 PCS 49.32 ± 10.16 50.13 ± 9.80 49.18 ± 10.22 0.287
Short Form 36, SF-6D Short SF-36 MCS 53.70 ± 12.99 53.25 ± 12.77 53.78 ± 13.04 0.872
Form 6 dimensions
SF-6D index 0.81 ± 0.12 0.81 ± 0.13 0.81 ± 0.12 0.937
* p < 0.05

Among the ethnic groups, Indian subjects are least likely
to be married (72 vs. 75 vs. 68 % for Chinese, Malay, and
Indian, respectively, p  = 0.003) and most likely to have
normal ACR functional status (69 vs. 57 vs. 75 % for Chi-
nese, Malay, and Indian, respectively, p = 0.030).
Univariable association of RAI, HAQ, and DAS28 scores
with SF‑36 PCS, SF‑36 MCS, and SF‑6D scores (Table 3)
RAI score was statistically significant across all HRQoL
outcomes without adjustment for covariates (p < 0.001).
Every unit increase in RAI will result in a 0.5-point
decrease in SF-36 PCS, 1.3-point decrease in MCS, and
0.010-point decrease in SF-6D.
DAS28 score was statistically significant across all
HRQoL outcomes without adjustment for covariates
(p < 0.001). Every unit increase in DAS28 score will result
in 3.0-point decrease in SF-36 PCS, 4.4-point decrease in
SF-36 MCS, and 0.040-point decrease in SF-6D.
HAQ score was statistically significant across all
HRQoL outcomes without adjustment for covariates
(p < 0.001). Every unit increase in HAQ score will

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Rheumatol Int (2014) 34:1085–1093 1089

Table 2  Socio-demographics, clinical, and PRO variables in overall population and among races
Feature Mean ± SD (%) p value
Total (N = 473) Chinese (N = 366) Malay (N = 47) Indian (N = 60)

Socio-demographic variables
Age (years) 60.02 ± 11.04 60.44 ± 11.21 58.92 ± 9.99 58.28 ± 10.06 0.425
Gender
 Male 70 (15) 50 (14) 12 (26) 8 (13) 0.092
 Female 403 (85) 315 (86) 35 (74) 52 (87)
Marital status
 Single 64 (13) 55 (15) 1 (2) 8 (14) 0.003*
 Married 339 (71) 263 (72) 35 (75) 41 (68)
 Widowed 51 (11) 40 (11) 5 (11) 6 (10)
 Divorced 19 (4) 8 (2) 6 (12) 5 (8)
Educational level
 No formal education 91 (19) 75 (21) 7 (15) 9 (15) 0.201
 Primary 121 (25) 91 (25) 11 (24) 19 (32)
 Secondary 193 (41) 140 (38) 26 (55) 27 (45)
 Polytechnic/pre-U 46 (10) 40 (11) 3 (6) 3 (5)
 Tertiary education 22 (5) 20 (5) 0 (0) 2 (3)
Clinical variables
ACR functional status
 I Normal 326 (69) 254 (69) 27 (57) 45 (75) 0.028*
 II Limited in social activities 112 (24) 87 (24) 15 (32) 10 (17)
 III Limited in vocational activities 26 (5) 21 (6) 4 (9) 1 (1)
 IV Wheelchair or bedridden 9 (2) 4 (1) 1 (2) 4 (7)
DGA 3.60 ± 7.89 3.54 ± 7.89 4.13 ± 7.35 3.60 ± 8.42 0.485
Number of medications 3.80 ± 1.71 3.77 ± 1.70 4.11 ± 1.54 3.72 ± 1.83 0.414
Number of comorbidities 2.43 ± 1.84 2.39 ± 1.85 2.34 ± 1.59 2.80 ± 1.96 0.334
Minutes of morning stiffness 12.74 ± 49.86 12.77 ± 48.98 8.93 ± 31.29 15.83 ± 65.85 0.874
DAS28 score 2.32 ± 0.86 2.30 ± 0.86 2.37 ± 0.74 2.39 ± 0.97 0.604
PRO variables
PGA 22.04 ± 26.58 21.92 ± 26.01 22.09 ± 27.57 22.75 ± 29.52 0.936
Pain intensity 14.27 ± 22.59 14.03 ± 21.96 11.13 ± 21.13 18.18 ± 26.92 0.216
HAQ score 0.29 ± 0.49 0.28 ± 0.48 0.35 ± 0.45 0.36 ± 0.57 0.177
RAI score 35.90 ± 6.65 35.92 ± 6.55 35.26 ± 6.30 36.30 ± 7.56 0.781
SF-36 PCS 49.32 ± 10.16 49.62 ± 10.32 47.62 ± 9.86 48.83 ± 9.34 0.127
SF-36 MCS 53.70 ± 12.99 53.60 ± 13.32 53.91 ± 11.81 54.15 ± 11.97 0.980
SF-6D utilities 0.81 ± 0.12 0.81 ± 0.12 0.80 ± 0.12 0.82 ± 0.11 0.913

Data shown as mean ± SD or n (%)

HRQoL health-related quality of life, Pre-U A-Levels, DGA physician’s global assessment, PGA patient’s global assessment, PRO patient-
reported outcomes, HAQ Health Assessment Questionnaire, RAI rheumatology attitudes index, DAS28 disease activity in 28 joints, SD stand-
ard deviation, ACR American College of Rheumatology, PCS physical component summary, MCS mental component summary, RA rheumatoid
arthritis, SF-36 Short Form 36, SF-6D Short Form 6 Dimensions
* p < 0.05

result in an 8.2-point decrease in SF-36 PCS, 12.7-point
decrease in SF-36 MCS, and 0.118-point decrease in
SF-6D.
Out of the three HRQoL outcomes, SF-36 MCS, com-
pared with SF-36 PCS and SF-6D, showed the strongest
association with RAI, HAQ, and DAS28 scores.
Multivariable regression analysis of RAI, HAQ, DAS28,
socio‑demographic, clinical, and PRO factors with HRQoL
outcomes (Table 4)
Table 4 lists the results of stepwise multiple linear regres-
sion analysis of factors affecting HRQoL outcomes. For

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Table 3  Univariable association between RAI, HAQ, and DAS28
scores on HRQoL outcomes
Model SF-36 PCS SF-36 MCS SF-6D
series 1 Regression Regression Regression
coefficient coefficient coefficient (×10−2)
RAI score −0.5*** −1.3*** −1.0***
DAS28 score −3.0*** −4.4*** −4.0***
HAQ score −8.2*** −12.7*** −11.8***
HRQoL health-related quality of life, HAQ Health Assessment Ques-
tionnaire, RAI rheumatology attitudes index, DAS28 disease activity
in 28 joints, PCS physical component summary, MCS mental com-
ponent summary, SF-36 Short Form 36, SF-6D Short Form 6 Dimen-
sions
*** p < 0.001
SF-36 PCS as the dependent variable, DAS28, HAQ, and
RAI scores accounted for 20 % of the variance in SF-36
PCS. Adding the socio-demographic, clinical, and PRO
covariates contributed an additional 2, 1, and 6 %, respec-
tively, accounting for a total of 29 %. In the final multivari-
able regression model, HAQ score (β: −6.0, p < 0.001) and
pain intensity (β: −0.1, p < 0.001) were significantly asso-
ciated with SF-36 PCS.
Using SF-36 MCS as the dependent variable, the
DAS28, HAQ, and RAI explained 49 % of the variance.
Adding the socio-demographic, clinical, and PRO covari-
ates explained an additional 3, 2, and 4 %, respectively,
of the variance, accounting for a total of 58 %. In the final
multivariable regression model, HAQ score (β: −7.0,
p < 0.001), RAI score (β: −0.9, p < 0.001), ACR functional
status class IV (β: 8.0, p < 0.05), pain intensity (β: −0.1,
p < 0.001), and PGA (β: −0.1, p < 0.01) were significantly
associated with SF-36 MCS.
Using SF-6D as the dependent variable, the DAS28,
HAQ, and RAI score accounted for 40 % of the variance.
Adding the socio-demographic, clinical, and PRO covari-
ates explained an additional 3, 2, and 5 %, respectively,
accounting for a total of 50 %. In the final multivariable
regression model, HAQ score (β: −0.081, p < 0.001), RAI
score (β: −0.005, p < 0.001), pain intensity (β: −0.001,
p < 0.001), and PGA (β: −0.001, p < 0.05) were signifi-
cantly associated with SF-6D.
Discussion
In this study, among multiethnic Southeast Asian patients
with RA, as hypothesized, sense of helplessness and dis-
ability are inversely associated with the HRQoL of RA
patients. Furthermore, helplessness was more strongly
associated with mental HRQoL than with physical HRQoL
[28]. Therefore, clinicians may consider emphasizing
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Rheumatol Int (2014) 34:1085–1093
self-management skills so as to improve the mental HRQoL
of RA patients [29]. Interestingly, our hypothesis with
regard to disease activity was not supported by our findings.
We observed that there was initially an association
between disease activity and HRQoL but this was abol-
ished after adjusting for PRO covariates in PCS and SF-
6D. In MCS, the association was abolished after adjusting
for clinical variables. The observation that PRO covariates
explain much of the association between disease activ-
ity and HRQoL would suggest that it might be feasible to
replace the cumbersome DAS28 measurements with sim-
pler PRO tools.
Our study supported the hypothesis that RA patients
with higher HAQ have lower HRQoL. This relationship
was strong across all three HRQoL measures: SF-36 PCS,
SF-36 MCS, and SF-6D. This finding is consistent with
other studies and supports the recommendation that meas-
uring disability be made part of daily clinical practice [9].
In fact, among all independent variables, regression coef-
ficients were the largest for HAQ (6.0 points with SF-36
PCS, 7.0 points with SF-36 MCS, and 0.081 points with
SF-6D) and exceeded the minimal clinically important dif-
ference for all three measures. The relationship of pain was
also seen across all three HRQoL measures. This was con-
sistent with the published literature although it was not in
our original hypotheses [30, 31].
In this study, we demonstrated that RAI, HAQ, and
DAS28 scores were more strongly associated with SF-
36 MCS than with SF-36 PCS and SF-6D. The HAQ is a
generic measure that was designed to assess the difficulty
in performing activities of daily living. It is interesting
that it should be more strongly correlated with MCS com-
pared with PCS as there is a published study that showed a
stronger association with PCS than MCS [32]. We observed
that RA has a greater impact on PCS (49.32 ± 10.16) than
MCS (53.70 ± 12.99). It appears that a more refined RA-
specific measure of physical functioning may be needed if
the impact of RA on physical functioning is to be fully cap-
tured. While the SF-36 may suffice, a RA-specific measure
may be more sensitive and responsive compared with the
generic SF-36.
As SF-6D is an overall measure of HRQoL, it is not sur-
prising that the factors associated with SF-6D scores reflect
a combination of factors associated with PCS and MCS.
Limitations
There are several limitations in our study. First, the cross-
sectional design does not allow us to draw any causal rela-
tionship between the factors and HRQoL. However, this
study provides the basis for a future prospective, longitudi-
nal study to identify predictors of HRQoL in RA. Second,
our subjects were recruited from a tertiary care setting;
 Table 4  Stepwise, multivariable association between RAI, HAQ, DAS28 scores, socio-demographic, clinical, and psychosocial variables on HRQoL outcomes
Covariates SF-36 PCS SF-36 MCS SF-6D
Regression coefficient Regression coefficient Regression coefficient (×10−2)

Model 1P Model 2P Model 3P Model 4P Model 1 M Model 2 M Model 3 M Model 4 M Model 1D Model 2D Model 3D Model 4D

Step 1—helplessness, disease disability, and disease activity

RAI score −0.2** −0.2** −0.2** −0.1 −1.1*** −1.0*** −1.0*** −0.9*** −0.7*** −0.7*** −0.7*** −0.5***
HAQ score −6.4*** −6.3*** −7.7*** −6.0*** −6.3*** −7.1*** −9.0*** −7.0*** −7.1*** −7.8*** −9.8*** −8.1***
DAS28 score −1.7** −1.6** −1.8** −0.4 −1.3* −1.0* −0.8 1.1 −1.6** −1.4** −1.4** 0.2
Step 2—adjust for socio-demographic covariates
Rheumatol Int (2014) 34:1085–1093

Age (years) 0.0 0.0 −0.1 0.1* 0.1 0.1 0.1* 0.1 0.1
Gendera
If male 2.5 2.3 2.0 −0.4 −0.1 −0.3 1.5 1.0 0.6
Raceb
If Malay −2.1 −2.2 −2.6 0.2 0.3 −0.1 −0.2 −0.1 −0.5
If Indian −0.3 −0.3 0.0 1.7 1.1 1.2 2.1 1.7 1.9
Marital statusc
If married −0.6 −0.7 −0.6 0.3 0.4 0.5 −0.7 −0.4 −0.3
If widowed 0.8 0.9 1.0 −0.7 0.2 0.2 −0.3 0.7 0.7
If divorced 1.8 1.7 2.8 −0.3 −0.5 0.7 −0.3 −0.3 1.0
Educational leveld
If primary −0.8 −0.9 −0.5 −0.9 −0.6 −0.2 0.7 0.8 1.2
If secondary −1.4 −1.3 −1.0 −1.8 −1.5 −1.2 −1.1 −0.9 −0.5
If polytechnic/ −4.5* −4.3* −3.8 −3.4 −3.0 −2.7 −3.7 −3.0 −2.5
pre-U
If tertiary educa- −0.7 −0.6 −0.1 −5.5* −4.7 −4.3 −2.1 −1.6 −1.3
tion
Step 3—adjust for clinical covariates
ACR functional statuse
If class II 0.5 −0.4 −1.1 −2.0 −0.4 −1.3
If class III 2.8 2.5 2.7 2.4 3.6 3.4
If class IV 5.3 2.4 11.4 8.0* 7.5 4.4
DGA 0.0 0.0 0.0 0.0 0.0 0.0
Medicationsf
 ≥4 Medications 0.6 1.0 −1.1 −0.7 −1.1 −0.7
Comorbiditiesg
 ≥2 comorbidi- −0.4 −1.0 1.3 0.8 1.9 1.2
ties
Minutes of morn- 0.0 0.0 0.0 0.0 0.0 0.0
ing stiffness

13
1091

1092 Rheumatol Int (2014) 34:1085–1093

thus, our findings may not be generalizable to patients

HRQoL health-related quality of life, HAQ Health Assessment Questionnaire, RAI rheumatology attitudes index, DAS28 disease activity in 28 joints, DGA physician’s global assessment, PGA
patient’s global assessment, Pre-U A-Levels, ACR American College of Rheumatology, PRO patient-reported outcomes, PCS physical component summary, MCS mental component summary,
Models 1, 2, 3, and 4 refer to addition of independent variables (HAQ, RAI, and DAS28 in step 1), adjustment for socio-demographic covariates (step 2), adjustment for clinical covariates (step
Model 4D

−0.1***
with milder conditions who are being followed up in the

−0.1*

0.50
primary care setting. Nonetheless, we observed that the
HAQ and DAS28 scores of our population are lower than
many published overseas studies. Third, we did not observe
Model 3D

any significant association between the number of comor-

0.45
0.05
bidities and HRQoL outcomes, and this may suggest that
Regression coefficient (×10−2)

alternative approaches to account for comorbidities should

be explored [33]. Last, this study did not capture socio-
Model 2D

3), and adjustment for PRO covariates (step 4), respectively. Models P, M, and D refer to using SF-36 PCS, MCS, and SF-6D as dependent variables, respectively
economic status data. Nonetheless, previous studies have
0.43
0.02

shown that beta coefficient associated with socioeconomic

status tends to be smaller than with comorbidities [7, 34].
The study sample was restricted to subjects with com-
Model 1D

plete HRQoL, socio-demographic, clinical, and PRO data.

SF-6D

0.40
0.03

The individuals excluded had better GHA, PGA, and pain

score with shorter duration of morning stiffness. This may
limit the generalizability of our data, and additional studies
Model 4 M

−0.1***

focusing on this group of excluded subjects may need to be

−0.1**

0.58

conducted.
Model 3 M

Reference group: a Female, b Chinese, c Single, d No formal education, e Class I, f <4 medication, g <2 comorbidities

Conclusions
0.54
0.04

We found that RAI and HAQ scores, but not DAS28 scores,
are significantly associated with HRQoL of RA patients in
Model 2 M

Incremental adjusted R2 reflects the additional amount of variance explained by the additional variables

Singapore. Greater emphasis on managing disability and

0.52
0.02
Regression coefficient

providing psychosocial support should supplement clinical

management so that HRQoL of RA patients can improve
and better treatment outcomes achieved.
SF-36 MCS

Model 1 M

0.49
0.03

Acknowledgments This study is supported by a Grant from the

National Healthcare Group (NHG)-SIG/PTD/06044.
Model 4P

−0.1***
0.29
0.0

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