Teresa J. Brady

Intervention Programs for Arthritis and Other Rheumatic Diseases

Disability reduction or prevention programs for people with arthritis and other rheumatic conditions reduce long-term pain and disability but reach only a fraction of their target audience. Few public health professionals are aware of these programs or their benefits. The objective of this study is to review and describe packaged (ready-to-use) arthritis self-management education and exercise/physical activity programs that have had at least preliminary evaluation. Nine intervention programs (five self-management education programs, and four exercise/physical activity programs met study criteria). Several of the packaged arthritis interventions reviewed help people with arthritis and other rheumatic conditions maximize their abilities and reduce pain, functional limitations, and other arthritis-related problems. Other packaged interventions show promise in reducing pain, disability, and depression and in increasing self-care behaviors, but they need to be evaluated more extensively.

A Meta-Analysis of Health Status, Health Behaviors, and Health Care Utilization Outcomes of the Chronic Disease Self-Management Program

Introduction The Chronic Disease Self-Management Program (CDSMP) is a community-based self-management education program designed to help participants gain confidence (self-efficacy) and skills to better manage their chronic conditions; it has been implemented worldwide. The objective of this meta-analysis was to quantitatively synthesize the results of CDSMP studies conducted in English-speaking countries to determine the program’s effects on health behaviors, physical and psychological health status, and health care utilization at 4 to 6 months and 9 to 12 months after baseline. Methods We searched 8 electronic databases to identify CDSMP-relevant literature published from January 1, 1999, through September 30, 2009; experts identified additional unpublished studies. We combined the results of all eligible studies to calculate pooled effect sizes. We included 23 studies. Eighteen studies presented data on small English-speaking groups; we conducted 1 meta-analysis on these studies and a separate analysis on results by other delivery modes. Results Among health behaviors for small English-speaking groups, aerobic exercise, cognitive symptom management, and communication with physician improved significantly at 4- to 6-month follow-up; aerobic exercise and cognitive symptom management remained significantly improved at 9 to 12 months. Stretching/strengthening exercise improved significantly at 9 to 12 months. All measures of psychological health improved significantly at 4 to 6 months and 9 to 12 months. Energy, fatigue, and self-rated health showed small but significant improvements at 4 to 6 months but not at 9 to 12 months. The only significant change in health care utilization was a small improvement in the number of hospitalization days or nights at 4 to 6 months Conclusion Small to moderate improvements in psychological health and selected health behaviors that remain after 12 months suggest that CDSMP delivered in small English-speaking groups produces health benefits for participants and would be a valuable part of comprehensive chronic disease management strategy.

Anxiety and depression among US adults with arthritis: prevalence and correlates.

There has been limited characterization of the burden of anxiety and depression, especially the former, among US adults with arthritis in the general population. The study objective was to estimate the prevalence and correlates of anxiety and depression among US adults with doctor‐diagnosed arthritis.

A randomized controlled trial of the people with arthritis can exercise program: Symptoms, function, physical activity, and psychosocial outcomes

OBJECTIVE To evaluate the basic 8-week People with Arthritis Can Exercise (PACE) program for improvements in primary (symptoms, functioning, level of physical activity) and secondary (psychosocial) outcomes. METHODS A total of 346 individuals with self-reported arthritis from 18 sites participated in a randomized controlled trial of PACE. Outcomes were measured at baseline and 8 weeks. The intervention group completed self-reported assessments at 3 and 6 months. Two-level multiple linear regression models were estimated to calculate adjusted outcome means in the intervention and control groups. A mixed-effects repeated-measures model was used to calculate adjusted means in the intervention group at 3 and 6 months. Both intent-to-treat (ITT) and as-treated (AT) analyses were conducted. RESULTS At 8 weeks, the intervention group had improvements in the following outcomes: 2 symptom outcomes (pain, fatigue) and 1 psychosocial outcome (self-efficacy for managing arthritis) in the ITT analyses; 1 symptom outcome (pain), 1 function outcome (chair stands), and 1 psychosocial outcome (self-efficacy for arthritis management) in the AT analyses. In addition, completers who attended>or=9 classes had improvements in 3 symptom outcomes (pain, fatigue, stiffness), 2 function outcomes (10-pound lifts, chair stands), and 1 psychosocial outcome (self-efficacy for arthritis management) at 8 weeks. Relative to baseline, PACE participants maintained significant improvements in symptoms at 6 months, but declined in function and self-efficacy for exercise. CONCLUSION If adults with arthritis attend a majority of PACE classes, they may expect improvements in symptoms, self-efficacy for arthritis management, and upper and lower extremity function. Achieving sustained improvement in outcomes may require continued participation in PACE.

Serious Psychological Distress in U.S. Adults with Arthritis

AbstractBACKGROUND: Arthritis and mental health disorders are leading causes of disability commonly seen by health care providers. Several studies demonstrate a higher prevalence of anxiety and depression in persons with arthritis versus those without arthritis. OBJECTIVES: Determine the national prevalence of serious psychological distress (SPD) and frequent anxiety or depression (FAD) in adults with arthritis, and in adults with arthritis, identify risk factors associated with SPD. METHODS: Cross-sectional data from the 2002 National Health Interview Survey, an in-person household interview survey, were used to estimate the prevalence of SPD and FAD in adults with (n=6,829) and without (n=20,676) arthritis. In adults with arthritis, the association between SPD and sociodemographic, clinical, and functional factors was evaluated using multivariable logistic regression. RESULTS: The prevalence of SPD and FAD in adults with arthritis is significantly higher than in adults without arthritis (5.6% vs 1.8% and 26.2% vs 10.7%, P<.001, respectively). In adults with arthritis, SPD was significantly associated with younger age, lower socioeconomic status, divorce/separation, recurrent pain, physical inactivity, having functional or social limitations, and having comorbid medical conditions. Adults aged 18 to 44 years were 6.5 times more likely to report SPD than those 65 years or older, and adults with recurrent pain were 3 times more likely to report SPD than those without recurrent pain. CONCLUSIONS: Serious psychological distress and FAD affect persons with arthritis and should be addressed in their treatment. Younger adults with arthritis, and those with recurrent pain or either functional or social limitations, may be at higher risk for SPD.

A Public Health Approach to Addressing Arthritis in Older Adults: The Most Common Cause of Disability

Arthritis is highly prevalent and is the leading cause of disability among older adults in the United States owing to the aging of the population and increases in the prevalence of risk factors (e.g., obesity). Arthritis will play a large role in the health-related quality of life, functional independence, and disability of older adults in the upcoming decades. We have emphasized the role of the public health system in reducing the impact of this large and growing public health problem, and we have presented priority public health actions.

Public health interventions for arthritis: expanding the toolbox of evidence-based interventions.

BACKGROUND Since 1999, the Centers for Disease Control and Preventions (CDC) Arthritis Program has worked to improve the quality of life for people with arthritis, in part by funding state health departments to disseminate physical activity (PA) and self-management education (SME) interventions. Initially, only one SME and two PA interventions were considered evidence-based and appropriate for people with arthritis. The purposes of this article are to describe the processes and criteria used to screen new or existing intervention programs and report the results of that screening, including an updated list of recommended intervention programs. METHODS A series of three sets of screening criteria was created in consultation with subject matter experts: arthritis appropriateness, adequacy of the evidence base, and implementability as a public health intervention. Screening interventions were categorized as Recommended, Promising Practices, Watch List, Future Possibility, or Unlikely to Meet criteria based on how well the intervention met the screening criteria. RESULTS A total of 15 packaged PA interventions and six SME interventions were screened. Three PA and three SME interventions met all three sets of criteria and were added to the list of recommended public health interventions for use by CDC-funded state arthritis programs. An additional two SME interventions are developing the infrastructure for public health dissemination and were categorized as Promising Practices, and six PA interventions have evaluations underway and are on the Watch List. CONCLUSIONS The CDC Arthritis Program identified arthritis-appropriate interventions that can be used effectively and efficiently in public health settings to improve the quality of life of people with arthritis. The screening criteria used offer a guide to intervention developers on necessary characteristics of interventions for use in public health settings. The expanded menu of interventions is beneficial to clinical care and public health professionals and, ultimately, to people with arthritis.

Vital Signs: Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation — United States, 2013–2015

Background In the United States, doctor-diagnosed arthritis is a common and disabling chronic condition. Arthritis can lead to severe joint pain and poor physical function, and it can negatively affect quality of life. Methods CDC analyzed 2013–2015 data from the National Health Interview Survey, an annual, nationally representative, in-person interview survey of the health status and behaviors of the noninstitutionalized civilian U.S. adult population, to update previous prevalence estimates of arthritis and arthritis-attributable activity limitations. Results On average, during 2013–2015, 54.4 million (22.7%) adults had doctor-diagnosed arthritis, and 23.7 million (43.5% of those with arthritis) had arthritis-attributable activity limitations (an age-adjusted increase of approximately 20% in the proportion of adults with arthritis reporting activity limitations since 2002 [p-trend <0.001]). Among adults with heart disease, diabetes, and obesity, the prevalences of doctor-diagnosed arthritis were 49.3%, 47.1%, and 30.6%, respectively; the prevalences of arthritis-attributable activity limitations among adults with these conditions and arthritis were 54.5% (heart disease), 54.0% (diabetes), and 49.0% (obesity). Conclusions and Comments The prevalence of arthritis is high, particularly among adults with comorbid conditions, such as heart disease, diabetes, and obesity. Furthermore, the prevalence of arthritis-attributable activity limitations is high and increasing over time. Approximately half of adults with arthritis and heart disease, arthritis and diabetes, or arthritis and obesity are limited by their arthritis. Greater use of evidence-based physical activity and self-management education interventions can reduce pain and improve function and quality of life for adults with arthritis and also for adults with other chronic conditions who might be limited by their arthritis.

Measures of self‐efficacy: Arthritis Self‐Efficacy Scale (ASES), Arthritis Self‐Efficacy Scale‐8 Item (ASES‐8), Children's Arthritis Self‐Efficacy Scale (CASE), Chronic Disease Self‐Efficacy Scale (CDSES), Parent's Arthritis Self‐Efficacy Scale (PASE), and Rheumatoid Arthritis Self‐Efficacy Scale (RASE)

Enhancing self-efficacy has become an essential feature of many arthritis management interventions because of its robust relationships with health behaviors and health status. Empirical studies document that self-efficacy predicts health behaviors such as physical activity, eating behaviors, and pain coping strategies (1). In rheumatoid arthritis and osteoarthritis, self-efficacy has also been correlated with measures of health status such as daily pain and mood ratings (2), pain, stiffness, function, and physical and mental well-being (3); it has also been correlated with changes in pain, function, and depression (4). Adherence with medications and other health recommendations has also been associated with self-efficacy (5,6). In addition to evidence that self-efficacy is associated with health behaviors, current and future health status, and adherence to health recommendations, the fact that self-efficacy can change through efficacy-enhancing interventions makes it a rich target of arthritis interventions (1). Self-efficacy, defined in Bandura’s seminal 1977 article as “the conviction that one can successfully execute the behavior required to produce the outcomes” (7), was hypothesized to influence whether a behavior was initiated and sustained despite obstacles or adverse experiences, and to influence the level of effort invested in the behavior. Bandura’s definition of self-efficacy evolved slightly over time; in his 1997 publication, Bandura defined self-efficacy as “belief in one’s capability to organize and execute the courses of action required to produce given attainments” (8). Bandura has consistently described self-efficacy as domain specific and distinct from other constructs in social learning theory such as outcome expectations, defined as a person’s estimate that a given behavior will lead to certain outcomes (7). Self-efficacy beliefs are also conceptualized as distinct from actual ability to perform a task (e.g., can I ride a bicycle), actual task performance (e.g., do I ride a bicycle), or intention to perform task (e.g., do I intend to ride a bicycle) (8,9). These different types of beliefs are clearly distinguished in Gecht et al’s survey of exercise beliefs and habits among people with arthritis (10). In that survey, respondents were asked about their self-efficacy expectations regarding exercise (“If I want to exercise, I know I can do it”), and their outcome expectations regarding exercise (“regular exercise will probably make my arthritis worse in the future”); they were also asked to report their actual behavior (how often they did specific exercises in the past 2 weeks). Self-efficacy theory hypothesizes that both efficacy expectations and outcome expectations influence whether or not an individual will initiate and sustain a specific behavior (7). Gecht et al found that positive outcome expectations and self-efficacy for exercise were associated with participation in exercise (10). Conversely, self-efficacy theory predicts that if a patient believes that they can exercise (self-efficacy expectation) but also believes that exercise will be harmful for their arthritis (outcome expectation), the patient would be less likely to exercise than if they expected positive outcomes from exercise (7). Social learning theory suggests that it is important for clinicians and others hoping to help a person adopt health behaviors to understand both whether the person believes they can perform the behavior, and whether they believe that behavior will lead to positive outcomes. Outcome expectations have received very little attention in arthritis-related research, but self-efficacy has been measured extensively (11). This review focuses on self-efficacy measures in the domain of arthritis management, and measures frequently used in arthritis management intervention studies (i.e., Arthritis Self-Efficacy Scales [12], Rheumatoid Arthritis Self-Efficacy Scale [13]). One nonarthritis specific measure, the Chronic Diseases Self-Efficacy Scale The findings and conclusions herein are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Teresa J. Brady, PhD: Centers for Disease Control and Prevention, Atlanta, Georgia. Address correspondence to Teresa J. Brady, PhD, Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS K-51, Atlanta, GA 30341. E-mail: Tob9@cdc.gov. Submitted for publication March 29, 2011; accepted in revised form July 20, 2011. Arthritis Care & Research Vol. 63, No. S11, November 2011, pp S473–S485 DOI 10.1002/acr.20567

Monitoring healthy people 2010 arthritis management objectives: education and clinician counseling for weight loss and exercise.

PURPOSE Our goal was to monitor the progress of 3 Healthy People 2010 (HP2010) objectives encouraging self-management education and clinician counseling for weight loss and physical activity among adults with doctor-diagnosed arthritis. METHODS Using the national 2002 and 2006 National Health Interview Survey (NHIS) and state-based 2003 and 2007 Behavioral Risk Factor Surveillance System (BRFSS), we estimated the change in proportion of persons counseled for each objective, overall and by selected characteristics. RESULTS Nationally, the proportion of overweight and obese adults with doctor-diagnosed arthritis who were counseled by their clinician to lose weight to lessen their arthritis symptoms increased significantly from 35.0% (95% confidence interval [CI], 32.8%–37.2%) in 2002 to 41.3% (95% CI, 38.7%–44.0%) in 2006 but have yet to reach the 2010 target of 46%. There was no change in the proportion of adults with doctor-diagnosed arthritis who had ever taken a self-management education class (approximately 11%) or who had been counseled to engage in physical activity (approximately 52%), whose targets for 2010 are 13% and 67%, respectively. States had variable findings. CONCLUSIONS Nationally, significant progress has been made by clinicians for weight counseling of overweight and obese adults with doctor-diagnosed arthritis but not for the other 2 arthritis management objectives. Because clinician counseling can have important effects on the latter, this discrepancy suggests a need to focus on barriers to physician counseling for these outcomes.