1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information


To conduct a systematic review to identify and describe the scope and nature of the research evidence on the effectiveness of interventions to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis (OA) as an example of a common chronic disease.


We searched electronic databases from 1950 through February 2010 and grey literature for relevant articles using any study design. Studies with interventions designed explicitly to improve health care quality or reduce disparities in the care of disadvantaged adult populations with OA and including an evaluation were eligible. We used the PROGRESS-Plus framework to identify disadvantaged population subgroups.


Of 4,701 citations identified, 10 met the inclusion criteria. Eight were community based and 6 targeted race/ethnicity/culture. All 10 studies evaluated interventions aimed at people with OA; 2 studies also targeted the health care system. No studies targeted health care providers. Nine of 10 studies evaluated arthritis self-management interventions; all showed some benefit. Only 1 study compared the difference in effect between the PROGRESS-Plus disadvantaged population and the relevant comparator group.


There are few studies evaluating the effectiveness of interventions to improve health care quality in disadvantaged populations with OA. Further research is needed to evaluate interventions aimed at health care providers and the health care system, as well as other patient-level interventions. Gap intervention research is also needed to evaluate whether interventions are effective in reducing documented health care inequities.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information

Individuals living in high-income countries are among the healthiest populations in the world. However, the opportunity to be healthy varies by degree of social advantage, with the poor and vulnerable bearing an unequal burden of chronic disease (1, 2), a pattern of health inequity that is even more pronounced in low- and middle-income countries (3, 4). Health care, another important determinant of health, is also distributed inequitably around the world (5–11). Disparities (or inequalities) in the diagnosis of disease and in the use of medical or surgical interventions that are not only unnecessary and avoidable, but also unfair and unjust, have been termed health care inequities (12).

Evidence of disparities in health and health care is remarkably consistent across a range of diseases, including osteoarthritis (OA). We chose to focus our review on OA as the exemplar chronic disease rather than including all chronic conditions, as OA has several features that constitute a good prototype. OA is among the leading causes of chronic musculoskeletal pain and disability worldwide (13, 14), contributing to 3.4% and 1.7% of the total disease burden in the developed and developing world, respectively (15). This burden is expected to increase, largely due to the obesity epidemic and an aging population. Moreover, OA affects as many as 30% of people ages >65 years (16). Both the prevalence and severity of this disease are disproportionately higher among persons with a lower socioeconomic status (SES) (17–24), nonwhite ethno-racial groups (21, 25, 26), and in women, compared with men, even after adjustment for lifestyle risk factors for OA, such as obesity (11, 24, 27, 28). In addition, using the PROGRESS-Plus framework (29, 30) (Table 1) to identify populations vulnerable to health and health care disparities, there is substantial international evidence of disparities in OA, as shown in Table 2. Disadvantaged population subgroups include those living in the inner-city or rural areas, specific ethno-racial groups, women, those with a lower SES, and individuals ages 80 years and older, given that most people with OA are older adults.

Table 1. Multidimensional components affecting health and health care equity according to the PROGRESS-Plus framework (29, 30)
Dimensions of health and health care inequalitiesDescription
Place of residenceRural, urban, inner city
Race/ethnicity/cultureRacial, ethnic, cultural background
OccupationProfessional, skilled, unemployed, etc.
Gender/sexWomen or men, female or male
ReligionReligious background
EducationYears of education or level attained, literacy, etc.
Socioeconomic statusIncome, type of housing, single-parent family
Social capital and networksMarried or common-law partner, formal or informal neighborhood, or community supports
 AgeAge range
 DisabilityPeople with physical, mental, or emotional disabilities, disability insurance recipients
 Sexual orientationHeterosexual, gay, lesbian, bisexual, transgender
Table 2. International evidence of multidimensional components affecting health and health care equity in OA*
  • *

    OA = osteoarthritis; TJA = total joint arthroplasty; TKA = total knee arthroplasty.

Place of residenceUS, Russia, AustraliaHigher prevalence of OA in rural vs. urban population (19, 24, 81, 82)
Race, ethnicity, cultureUSHigher prevalence of OA (21, 25, 26) and lower rates of TJA among African Americans (22, 25, 33, 35) and Hispanics (34) compared with whites
Higher OA-associated mortality and severity among racial and ethnic minorities compared with whites (83)
Higher complication rate following TJA among African Americans compared with whites (84)
OccupationCanada, France, RussiaHigher prevalence and severity of OA among unemployed (18), nonprofessional occupations (85), and blue-collar workers (86) vs. employed, professional occupations, and all other workers, respectively
Gender, sexCanada, China, Australia, SpainHigher prevalence of OA (24, 27, 28, 87), lower rate of TJA, and greater unmet need for TJA among women (11) compared with men
Women, compared with men, have a greater reliance on the use of acetaminophen, suggesting that pain due to OA may be undertreated among women (88)
The odds of an orthopedic surgeon recommending TKA to a man was 22 times that for a woman, and the odds of a family physician recommending TKA to a man was 2 times that for a woman (46)
Women receive TJA at a more advanced stage of OA and so benefit less (89, 90)
EducationUS, Canada, Finland, Italy, Denmark, UK, The Netherlands, Belgium, France, Spain, AustraliaHigher prevalence and severity of OA (17–19, 21, 23, 24), lower rates of TJA (33), and greater unmet need for TJA among people with lower education (36) vs. those with a higher education
Advice, instruction, and monitoring of exercise less comprehensive in people with a lower education vs. those with a higher education (32)
Socioeconomic statusUS, Canada, UK, AustraliaHigher prevalence and severity of OA (17–21, 24), lower rates of TJA (33, 91, 92), and greater unmet need for TJA among people with lower income (36) vs. those with higher income
Social capital and networksUSIndividuals without a partner less likely to consult an orthopedic surgeon for TJA than those with a partner (51)
AgeUSIndividuals ages ≥80 years less likely to consult an orthopedic surgeon for TJA than younger individuals (51)

The greater severity of OA in disadvantaged population subgroups is due not only to disparities in access to care but also to disparities in the actual delivery of care. For example, among individuals with hip and knee OA, those with lower education were less likely to receive advice on exercise (31), or when it was received, it was delivered in a less comprehensive manner compared to those with a higher education (32). Furthermore, despite a higher prevalence of disabling OA among vulnerable populations, disparities in the rates of use of total joint arthroplasty (TJA) have been observed by sex (11), race/ethnicity/culture (22, 25, 33–35), and SES (33, 36). Because TJA is a highly efficacious treatment for relieving pain and restoring function (37), disparities in the use of TJA are a major concern.

Barriers to and mediators of equitable health care are multifactorial, and they include health insurance (38), financial resources (38), geographic proximity to care (39), transportation (39), patient-level factors such as patient preferences and health literacy (40–44), physician-level factors such as cultural competence and bias (9, 43, 45, 46), and patient–physician interaction (47, 48). In addition, both patients and physicians may be influenced by the community in which they live and the health care system (49).

There is an increased global recognition of the importance of developing interventions that are effective in reducing disparities in health care (5). Interventions can be aimed at people with the disease (e.g., improving self-care management), health care providers (e.g., cultural competency training), the health care system (e.g., changing the roles of health care providers), and/or the population (e.g., mass media campaigns). To our knowledge, there is no systematic review on what works to reduce disparities in OA care of disadvantaged populations. The objective of this systematic review was to identify and describe the scope and nature of the research evidence on the effectiveness of interventions designed to improve health care quality or reduce disparities in the care of disadvantaged populations with OA. We also sought to identify interventions that may be worthy of future evaluation among disadvantaged populations with OA.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information

Study design.

We conducted a systematic review of the literature using formal methods of literature identification, selection of relevant articles, data abstraction, and quality assessment. We then assessed the scope and nature of the available research literature. This “scoping review” differed from an in-depth systematic review in that: 1) hand searching was not conducted, 2) there was no contact with the study authors, and 3) there was no attempt to combine the results in a meta-analysis.

Search strategy.

The search strategy was developed by one of the authors (CMB) and reviewed by an information scientist (50). We searched electronic databases, including Medline (1950 to February 2010) and EMBase, PsycINFO, and the BIREME set of databases (1980 to February 2010), for relevant articles. The Medline search strategy, which formed the basis for the search strategies for the other electronic databases, is shown in Supplementary Appendix A (available in the online version of this article at

We searched the following grey literature: 1) abstracts from the 2004 and 2008 Osteoarthritis Research Society International scientific meetings (online at and the 2006–2009 American College of Rheumatology Annual Scientific Meetings (online at, 2) the ProQuest Dissertations & Theses database, and 3) Google (online at by using a few key concepts such as “disparities and arthritis interventions.” We also scanned the references of included original articles, review articles, and articles with a focus on disparities in OA that were identified in our electronic search.

Inclusion criteria.

We included studies with interventions targeting disadvantaged adult populations with OA. The study population had to be a disadvantaged population such as those living in the inner-city or rural areas, specific ethno-racial groups, women, and those with a lower SES. Among individuals with OA, those ages 80 years and older are also considered a disadvantaged population subgroup (51). Studies evaluating whether arthritis self-management programs (ASMPs) are effective or culturally acceptable to Chinese patients in Hong Kong (52), for example, would be excluded because they would not be considered a disadvantaged population. For studies that included a mixed population of arthritis, at least 50% of the study population had to have OA; studies were included even if results were not presented separately. We defined an intervention as any treatment, program, or approach that was designed explicitly to improve health care quality or reduce disparities in care. Studies had to report the evaluation of the intervention in terms of health outcomes (e.g., pain) or intermediate outcomes (e.g., knowledge). All study designs and articles written in all languages were included.

At least 2 reviewers (CMB, MLW, or VW) independently screened the titles and abstracts of all of the citations retrieved by the search strategy to identify articles potentially meeting the inclusion criteria. When reviewers agreed that an article was eligible or a decision regarding eligibility could not be made because of insufficient information, the article was retrieved for full-text review. When reviewers disagreed on eligibility, the remaining team members were consulted and disagreements were resolved by consensus.

Data abstraction.

We developed a data abstraction form to: 1) confirm eligibility for full article review, 2) record study and participant characteristics, and 3) abstract the relevant data regarding the intervention. The form was developed through an iterative process that included reviewing relevant data collected by similar previous systematic reviews, consultation with the team, and pilot testing. We used a serial review process such that a primary reviewer (EM) completed the data abstraction forms and a second reviewer (ZA), after reading the article, checked each item on the form for completeness and accuracy. Any differences between the primary and secondary reviewers were resolved by consensus and, when necessary, through discussion with a third reviewer (CMB).

For each eligible study, we abstracted data regarding the targeted disadvantaged population according to the PROGRESS-Plus framework (30) (Table 1), PROGRESS-Plus factors described at baseline, study objective, study design and whether there was a control or comparator group, study population, and intervention description, including intervention target, type, setting, measured outcomes, and findings.

Quality assessment.

We used the criteria by Jadad et al (53) to assess the methodologic quality of all of the randomized controlled trials. We did not assess blinding because the types of interventions being studied could not be blinded. We used the Newcastle-Ottawa Scale (54) to assess the quality of the nonrandomized studies. This 8-item scale uses a star system (maximum of 9 stars) to evaluate nonrandomized studies regarding 3 criteria: patient selection (4 stars), comparability of study groups (2 stars), and outcome assessment (3 stars). Studies that achieve a rating of 6 stars or higher are considered to be of good quality.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information

Literature search and review process.

Results of the literature search and review process are summarized in Figure 1. Of the 4,701 citations identified through search processes, 4,066 qualified for title and abstract review. Of these, 115 citations were identified as potentially eligible and were retrieved for full article review. After review, 105 were excluded for the following reasons: there was no intervention (n = 62), they did not specify the disadvantaged population being studied (n = 27), the study population did not meet the criteria of at least 50% of people with OA (n = 6), the intervention was not designed to improve health care quality or reduce disparities in care (n = 6), there were no original data (n = 3), or there was no evaluation of the intervention (n = 1). Ten articles (55–64) met the inclusion criteria.

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Figure 1. Summary of the literature search and review for eligible articles (the numbers indicate citations or articles at each step).

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Description of studies.

Key study characteristics of the included studies are summarized in Table 3. All of the studies were published between 1989 and 2009, were conducted in the US, and the sample sizes ranged from 32 to 921 participants. The disadvantaged population in 6 studies (59–64) was defined by race/ethnicity/culture, 2 studies (55, 57) included rural or inner-city patients, 1 (56) included a low SES population, and 1 (58) compared men and women. Five studies included only those with OA (56–58, 60, 62), whereas for the others, at least 50% of the study participants had OA (55, 59, 61, 63, 64). Only 4 of the studies (58, 59, 63, 64) were randomized controlled trials. Most studies were community based, with 2 (57, 62) based in hospital clinics.

Table 3. Characteristics of the 10 studies evaluating interventions to improve health care quality for disadvantaged populations with OA*
Author, year (ref.)PROGRESS-Plus factorTarget of the interventionType of interventionIntervention descriptionStudy design/comparison/quality assessmentSetting of interventionStudy populationImpact of intervention (+/0/− outcome)
  • *

    OA = osteoarthritis; TKA = total knee arthroplasty; BA = before/after study (no control group); S = patient selection (nonrandomized studies; 4 items, maximum of 1 star for each); C = comparability of study groups (nonrandomized studies; 1 item, maximum 2 stars); O = outcome assessment (nonrandomized studies; 3 items, maximum of 1 star for each); ASMP = arthritis self-management program; RCT = randomized controlled trial; HMO = Health Maintenance Organization; CCT = controlled clinical trial; HAQ = Health Assessment Questionnaire; QWB = quality of well-being; AIMS2-SF = Arthritis Impact Measurement Scales 2 Short Form; HS = home study; SG = small group; CBA = controlled before/after study; SASMP = Spanish ASMP; SAEP = Spanish Arthritis Empowerment Program; ASHC = Arthritis Self-Help Course; CDSMP = Chronic Disease Self-Management Program.

Weng et al, 2007 (62)Race/ethnicity/culture (African American men)People with OA and the health care systemVideo patient decision aidDuring race-specific group meetings, patients viewed a video patient decision aid about knee OA treatment options and were provided a personalized arthritis report that presented predicted post-TKA outcomesBA vs. white men S***, C, O**Hospital outpatient clinic; Veterans Administration hospital in Los Angeles, CaliforniaN = 102 men (54 African American, 48 white), mean age 62 yrsKnowledge about treatment options and post-TKA expectations for pain and function improved (+)
Gallagher et al, 1997 (58)Gender/sex (women)People with OAASMP/social support4 groups all attend 10 weekly meetings and 10 monthly meetings: 1) social support only (focus on coping with OA), 2) ASMP, 3) combination 1 and 2, or 4) control (did not meet or receive any information)RCT vs. men 2/5 Jadad scoreCommunity based; members of a large HMON = 90 in each group, mean age 69 yrs, 64% women, 94% white, 74% married, 75% retired, majority were middle class and educated with 1–2 yrs of collegeAnxiety decreased in 2 and 3; helplessness decreased in 1, 2, and 3, but not control. Interventions equally effective for men and women. Trend for men to have higher quality of well-being scores than women. Women were more likely than men to contact their HMO by phone. (+)
Mazzuca et al, 1997 (57)Place of residence (inner city)People with OA and the health care systemASMP/reinforcement followup callsIndividualized 30–60-minute instruction based on needs by an arthritis nurse specialist under the supervision of a rheumatologist. An adjunct to primary care, emphasizing nonpharmacologic management of joint pain, preservation of function by problem solving, and practice of principles of joint protection over a 12-month period. Brief telephone contact to ensure compliance with self-care recommendations. Control: attention control group viewed a 20-minute slide presentation designed for the general public and received telephone contact (only to encourage continued participation).CCT vs. attention control group S****, C**, O**Hospital outpatient clinic; Regenstrief Health Center, Indiana University Medical Center, IndianaN = 105 intervention, n = 106 control; mean age 63 yrs, 85% women, 97% <$20,000 income, 69% African American, 73% live alone, mean 9.7 yrs of formal education, 85% unemployed or retiredResting knee pain decreased at 1 yr, improved function at 4 mos but not 12 mos, no improvement: pain with walking, overall joint pain (HAQ), general health status (QWB) (+/0)
Taylor et al, 2004 (60)Race/ethnicity/culture (African Americans)People with OAASMP1-day educational symposium about OA and self-management delivered by speakers who are experts in the field of arthritis careBA S***, C, O*Community based; predominantly African American community in a large urban cityN = 32, 91% women, mean age 72 yrs, 100% African American, 61% living alone, 59% widowed, 54% diagnosed with OA by their provider, 46% self-reported OAKnowledge and use of self-management methods increased; 3 mos after all AIMS2-SF subscales of affect, symptoms of pain and stiffness, and function decreased (+)
Bill-Harvey et al, 1989 (56)Socioeconomic status (low-literacy patients)People with OAASMP10-hour group self-management program tailored to low-literacy patients taught by trained indigenous instructors. The 6-wk series of classes were activity centered and stressed the importance of learning by doing using “hands-on” demonstrations and providing ample time to master a skill.BA S***, C, O*Community based; inner-city neighborhoods in Hartford, ConnecticutN = 76, low income, mean age 73 yrs, 96% women, 66% African American, 34% white, 58% less than ninth-grade educationKnowledge, exercise behavior, attitude toward OA improved. Trend toward improvement in function. Use of adaptive equipment (raised toilet seats, reaches, and canes) increased. In open-ended questions participants indicated improved self-help skills, knowledge about medicines, and social support. (+)
Goeppinger et al, 1989 (55)Place of residence (rural patients)People with OAASMP“Bone Up On Arthritis” participants randomized to 1 of 3 groups: HS, SG, or control. HS and SG covered the same content in 6 lessons using an illustrated booklet written at a sixth-grade reading level. HS lessons were mailed to participants along with audiotapes with instructions provided by the narrator and reinforced by “testimonials” of persons with OA. SGs held at community sites (e.g., churches, libraries) included an informal 2-hour class led by trained community leaders. Control group delayed treatment (participants chose HS or SG at 4 mos).CBA vs. delayed treatment control group S****, C**, O*Community based; residents of 1 of 9 rural counties in VirginiaN = 121 HS, n = 100 SG, n = 153 control; mean age 62 yrs, 87% women, 96% white, mean 12.3 yrs of school, 70% married, 40% homemakers, 32% retired, 28% employed, 77% with OABoth HS and SG improved arthritis knowledge, self-care behavior, perceived helplessness, and pain, compared with the control group. SG was more effective in improving pain and depression at 4 mos, whereas HS was more effective in maintaining improvement in perceived helplessness at 12 mos. (+)
Lorig et al, 1999 (59)Race/ethnicity/culture (Spanish-speaking community)People with OAASMPSASMP culturally adapted from the English ASMP. 12-hour program conducted in Spanish by trained lay leaders in 2-hour sessions over 6 wks. Participants randomized to 1 of 2 groups: 1) SASMP or 2) control group (delayed treatment; participants offered SASMP at 4 mos).RCT vs. delayed treatment control group 2/5 Jadad scoreCommunity based; predominantly Spanish-speaking community with program taught in churches and neighborhood centersN = 219 SASMP, n = 112 control; mean age 63 yrs, 85% women, 48% ≤6 yrs of education, 100% Spanish speaking (50% of Mexican origin), 50% with OAAt 4 mos, SASMP improved exercise behavior, function, pain, self-efficacy compared to control but no effect on self-rated health, depression, and no. of physician visits. At 1 yr, SASMP improved exercise behavior, function, pain, self-efficacy, depression, and self-rated health compared to baseline, but no effect on no. of physician visits. (+/0)
Wong et al, 2004 (61)Race/ethnicity/culture (Spanish-speaking community)People with OAASMPSAEP culturally adapted from the Stanford ASHC. 12-hour program given in 2-hour sessions over 6 wks, led by a facilitator (promotora) certified by the Arthritis Foundation of Southern California Chapter.BA S***, C, O**Community based; schools and churches (attention given to transportation and scheduling needs) in Orange County, California; family/friends encouraged to accompany themN = 141 low-income, indigent, migrant laborers; mean age 51 yrs, 92% women, 55% sixth-grade education or less, 100% Spanish speaking (84% of Mexican origin), 58% married, 60% had no medical insurance, 81% with OASAEP improved self-efficacy, self-care behavior, arthritis knowledge, pain compared to baseline. Small improvements in function using a modified HAQ reported. (+)
Goeppinger et al, 2009 (64)Race/ethnicity/culture (Spanish-speaking community)People with OAASMPMail-delivered SASMP tool kit culturally adapted for English- or Spanish-language skills and a range of literacy levels. Tool kit contained 1) a “self-test” to help participants determine how arthritis affects their lives and self-tailor the use of the tool kit; 2) information sheets on Working with Your Doctor and the Health Care System; 3) information sheets on the ASMP: action planning, problem solving, deciding on treatment options, individualizing exercise; 4) The Arthritis Helpbook or Como Convivir Con Sur Artritis; 5) audio relaxation and exercise CDs; and 6) an audio CD of all printed material. Participants were randomized to 1 of 2 groups: 1) SASMP tool kit or 2) control group (delayed treatment; participants sent the tool kit at 4 mos).RCT vs. English-speaking community 2/5 Jadad scoreCommunity based; Stanford University coordinated the Spanish-language arm of the study and the University of North Carolina at Chapel Hill coordinated the English arm of the study; single mailing to participant's homes; all contact with patients using a toll-free telephone numberN = 458 tool kit group (164 Spanish, 294 English), n = 463 control group (171 Spanish, 261 English); mean age 54 yrs, 85% women, 50% married, mean education 14 yrs in both groups, although Spanish speakers had 2–3 yrs less; 51% with OATool kit improved health status, health behavior, self-efficacy compared with control. No change in health care utilization, including no. of physician and emergency department visits, hospitalizations, and nights spent in hospitals. Results similar for Spanish-speaking and English-speaking participants. (+/0)
Goeppinger et al, 2007 (63)Race/ethnicity/culture (African Americans)People with OAASMPASHC and CDSMP were culturally adapted for use with African Americans, emphasizing faith and spirituality. Both are 12-hour programs administered in an SG workshop format in 2-hour sessions over 6 wks, led by trained laypersons with chronic disease. Both use efficacy-enhancing strategies of skill mastery, problem solving, and social persuasion, and include content on exercise, depression, fatigue management, healthy eating, medication management, and working with health professionals. ASHC does not include content on advance directives, better breathing, or communication strategies; CDSMP does not include content on arthritis pain management, energy conservation, sleep, or making nontraditional treatment decisions. Workshops were randomized to ASHC or CDSMP; participants were assigned to a workshopRCT vs. CDSMP 3/5 Jadad scoreCommunity based; 12 counties in eastern North Carolina with African American populations exceeding the state average of 22%; programs taught in schools and churchesN = 416 (82% African American) enrolled: 231 (208 African American) to ASHC, 185 (157 African American) to CDSMP; mean age 64 yrs, 82% women, mean 12 yrs of education, 42% married, mean 4.2 chronic diseases, at least 50% with OAAt 4 mos, ASHC improved self-efficacy, self-reported general health, exercise behavior. CDSMP improved self-reported general health; trend toward improvements in health distress, function, cognitive symptom management, exercise behavior. At 12 mos, the results for both programs were minimal. (+/0)

Methodologic quality.

Four of the 10 studies (58, 59, 63, 64) were described as randomized controlled trials; the randomization process was described and appropriate in only the study by Goeppinger et al (63). All 4 studies had a description of the withdrawals and dropouts, although only 1 study (64) gave reasons for withdrawals and dropouts, in addition to the total numbers. All 4 studies provided a thorough description of the intervention. None of the randomized controlled trials blinded treatment allocation. The other 6 studies were nonrandomized studies; 2 studies (55, 57) achieved a rating of 6 stars or higher primarily because they included a control group.

Intervention methods.

All 10 studies evaluated interventions targeting people with OA. Nine of the studies evaluated ASMPs (1 study [58] had a support group to help cope with OA as an additional component of the intervention) and 1 (62) used a video patient decision aid. The 2 hospital-based studies (57, 62) also targeted the health care system, as both involved changes in health care provider roles. For 1 study (57), an arthritis nurse specialist provided individualized arthritis self-care instruction to inner-city patients based on their needs. This study used reinforcement as an additional system-level intervention; followup telephone calls to ensure compliance with self-care recommendations were made by the arthritis nurse specialist and primary care physician 1 week and 1 month after the initial instruction, respectively. The second study (62) used a video patient decision aid about knee OA treatment options and a personalized arthritis report describing a patient's current symptoms compared with average preoperative total knee arthroplasty (TKA) symptoms and predicted TKA outcomes. None of the studies targeted the provider.

All of the studies provided patient education as the main intervention, including content on one or more of the following: OA as a disease, pain management, exercise, healthy eating, preservation of function, practice of principles of joint protection, depression, fatigue management, sleep, nonpharmacologic management of joint pain, medication management, surgical treatment options, coping strategies, communication strategies, working with health professionals, and when to use the health care system. The Spanish Arthritis Empowerment Program that was culturally adapted from the Stanford Arthritis Self-Help Course emphasized empowerment, including learning how to gain access to health care, finding appropriate physician care, and communicating more effectively with physicians (61). These educational interventions used a variety of delivery methods, including didactic lectures, skill building, problem solving, health behavior learning by doing using “hands-on” demonstrations, family member or friend participation, individualized assessment, printed material, and audiotapes or CDs (with audio versions of printed material or testimonials of persons with OA).

Six of the 10 studies (55, 56, 59, 61, 63, 64) described cultural tailoring of the arthritis self-management interventions to meet the needs of the targeted disadvantaged population. Some described using a participatory action research approach by working with members of the targeted community to evaluate the cultural acceptability of the program, focus groups to conduct needs assessments (e.g., to assess health literacy levels) or to field test revised content and delivery methods, and community leaders to arrange workshops at acceptable times and places and sometimes lead or co-lead workshops. One study (63) targeting African Americans built on cultural beliefs by emphasizing faith, spirituality, and mutual support in program curricula. The other 5 studies considered the literacy (55, 56) and language (59, 61, 64) of the populations. For low literacy, adaptations included rewriting material at a sixth-grade reading level or having activity-centered classes stressing the importance of learning by using “hands-on” demonstrations and providing ample time to master a skill. The ASMP by Lorig et al (59) and Stanford's Arthritis Self-Help Course (61) were both culturally adapted for the Spanish-speaking community, which included many immigrants with lower education levels. These programs are not mere translations of the English versions, but rather important cultural adaptations of concepts, content, and process that were made based on needs assessments of Spanish-speaking people with OA gathered from focus groups.

Effectiveness of interventions.

The 10 studies fell into 2 categories. Targeted intervention research (n = 9) includes studies that target disadvantaged population subgroups with the greatest health care needs. The intervention typically has been shown to improve health care quality for a heterogeneous and often more advantaged population. The study is an evaluation of the effectiveness of the intervention to improve the health care quality of disadvantaged populations. In some cases, the intervention has been tailored to meet the needs of the “hard to reach” disadvantaged population. The study may involve comparisons with: 1) the individuals being studied as their own control (i.e., before/after study), 2) members of the same PROGRESS-Plus disadvantaged population acting as a control group, or 3) a relevant comparator group.

Gap intervention research (n = 1) includes studies that are designed to reduce the health care inequity gap. These studies include many of the features of targeted intervention research; however, to belong in this category, the study objective must clearly state that the purpose is to evaluate whether the intervention (one that has the potential to “level the playing field”) reduces disparities in access to care, health care utilization, or health care outcomes of the targeted disadvantaged population. The evaluation of the effectiveness of the intervention must include comparing the difference in effect between the PROGRESS-Plus disadvantaged population subgroup and relevant comparator group.

Nine of 10 studies (55–61, 63, 64), considered targeted intervention research, evaluated arthritis self-management interventions. All 9 studies reported positive results supporting the use of arthritis self-management as an intervention to improve health care quality of disadvantaged populations with OA. The authors of these studies reported improvements in the participants' knowledge of OA and self-management options, self-help skills, exercise behavior, cognitive symptom management, self-efficacy, depression, perceived helplessness, disability, pain at rest, pain when walking, overall joint pain, general health status, and the use of adaptive equipment. Seven (55–57, 59–61, 63) of these studies compared the disadvantaged population to a pretest or control group. One study (63) was the first to document the benefits of ASMPs for African Americans, acknowledging the programs' potential in reducing health care disparities. However, rather than comparing the difference in effect between the African Americans and a relevant comparator group (i.e., whites), the authors compared African Americans to all participants (including the African American participants).

Although 2 (58, 64) of the 9 targeted intervention studies compared the difference in effect between the disadvantaged population and more advantaged population subgroups, neither cited an evaluation of whether the intervention reduced the health care inequity gap as a study objective. The first study (58) compared the effectiveness of an ASMP or a social support group or a combined intervention of the two between women and men. The authors found that all 3 interventions were equally effective for men and women in decreasing helplessness levels and that the education-only and combination groups were equally effective for men and women in decreasing anxiety levels, but that men, compared with women, experienced greater improvements in the quality of well-being, self-efficacy, and depression. The second study (64) examined differences in health status, health behavior, arthritis self-efficacy, and health care utilization between Spanish-speaking and English-speaking participants who were mailed an arthritis self-management tool kit. The authors found no difference in the effectiveness of the tool kit between the two groups and concluded that all of the tool kit participants experienced positive results for all outcomes but health care utilization, which was unaffected.

Only the study by Weng et al (62) would be considered gap intervention research. This study evaluated the effectiveness of a video patient decision aid in improving knowledge about treatment options for OA and post-TKA expectations for pain and physical function in African American men compared with white men, with the goal of reducing disparities in knowledge and expectations between the two groups. Knowledge and expectations about TKA improved among African American patients, whereas outcomes for white patients remained largely unchanged. Although expectations about TKA outcomes remained poor for both groups, they concluded that the video patient decision aid reduced disparities in knowledge and expectations between the two groups, which may in turn reduce disparities in TKA utilization.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information

Few studies have evaluated the effectiveness of interventions designed to improve health care quality in disadvantaged populations with OA, even though the prevalence and severity of OA disproportionately affect these groups. We found only 10 studies that met our inclusion criteria and assessed interventions in disadvantaged populations with OA. All of the interventions were designed primarily to target those with the condition, while 2 simultaneously targeted the health care system. No studies targeted health care providers.

Gap intervention research evaluating whether an intervention is effective in reducing documented health care disparities is also lacking. Only one study in this review compared the effectiveness of the intervention by comparing the difference in effect for the PROGRESS-Plus disadvantaged population with the relevant comparator group (62). Some (43, 65) have called for appropriate study designs when evaluating interventions, including the use of control groups whenever possible. Studies should continue to use a control group that gets no intervention to guard against a placebo effect that may be present in these interventions.

All of the studies reviewed here provided patient education as the main intervention method and all but one evaluated arthritis self-management interventions. There is substantial evidence on the effectiveness of ASMPs in more advantaged populations with OA (66); these same programs are also effective in improving the health care quality of disadvantaged people with OA. However, even if ASMPs work, we do not know if they work as well as they do in more advantaged populations. Most studies evaluating ASMPs were conducted to extend their reach to, and evaluate their benefit in, disadvantaged populations with OA, but made no comparison with the more advantaged population. One study compared the improvement in health care quality between Spanish-speaking and English-speaking participants who were mailed a tool kit of arthritis self-management material, but did not specifically address the question of whether the intervention could reduce disparities in care (64).

Much of the positive impact of the ASMPs that were evaluated is likely attributable to the cultural tailoring of these programs to meet the needs of the targeted disadvantaged population. Needs assessments with representatives from the disadvantaged group, community involvement, and the training of lay leaders to deliver the intervention were frequently part of developing the intervention. Tailoring was for African American (63) and Hispanic cultures (59, 61, 64) and low literacy and other social contextual barriers (e.g., lack of transportation) affecting inner-city (56) and rural patients (55). Given the fact that disadvantaged populations do not receive potentially effective interventions until they reach 25% of the total population with the disease (67), culturally tailoring programs appears to be an effective strategy on how to extend their reach to those most in need.

Our review identifies important gaps in knowledge and a focus for future research. None of the identified studies evaluated interventions targeting health care providers, and few targeted the health care system. This is despite evidence to suggest that provider behavior during the clinical encounter and the operation of health care systems contribute substantially to health care inequities (38, 45, 46). Furthermore, there is some evidence that provider- and system-level interventions improve health care quality of disadvantaged populations in other clinical areas (e.g., diabetes mellitus, cancer screening) (68, 69). We need to evaluate interventions targeted at health care providers that have the potential to reduce disparities in the care of people with OA. Potential interventions include increasing their awareness of health care inequities as an important public health problem and of conscious and/or unconscious biases toward vulnerable populations that may be influencing their clinical decision making (70, 71), providing them with cultural competence training (72), and improving their shared decision-making skills (73) to improve the clinical encounter. Potential system-level interventions include increasing the diversity of the health care provider workforce (74) and changes to physician reimbursement that grant physicians more time and, in turn, cognitive resources needed to overcome unconscious biases (45). Population-level interventions may also be worthy of future evaluation. Coined as “self-management education en masse,” mass media campaigns can reach large numbers of people simultaneously, including disadvantaged populations who might be difficult to reach, through traditional health care delivery (75, 76).

Different interventions at multiple levels may be required to narrow the health care inequity gap in OA. In addition, researchers need to work together to develop strategies to overcome existing barriers to conducting research in hard to reach population subgroups, including patients' mistrust of the health care system and their perceptions of exploitation and lack of benefit in participating in research, health care providers' lack of familiarity with disadvantaged populations (43), and lack of funding (69). The World Health Organization's call for a global commitment to address health care disparities (5) serves to highlight that funding research in this area should become an important priority. All 10 studies included in our review were conducted in the US. An increased global recognition of the importance of reducing health care disparities provides a reason for optimism that in time, this research will take place in other countries.

This review has several limitations. First, as we only included published studies, there is a possibility of publication bias, particularly as all 10 reported a positive impact from the interventions studied. However, publication bias was reduced by our grey literature search. Second, as our systematic review was a scoping review, there was no attempt to combine the results in a meta-analysis. Even so, the small number of articles meeting the inclusion criteria could not be combined due to the heterogeneity of populations, interventions, and outcomes. Third, we employed the PROGRESS-Plus framework in our scoping review to identify populations vulnerable to disparities in OA care (30); although this framework has not been published in a peer-reviewed journal, it is considered an improved version of the published PROGRESS framework. Finally, although we limited our review of interventions to disadvantaged populations with OA, we are not advocating a disease-by-disease approach. We also recognize that in some disadvantaged populations with arthritis, a definitive diagnosis of OA may not always be possible due to limited resources (77–79). Given that research on interventions to address health care disparities is the “least mature area within the scientific study of health disparities” (80) in all fields of medicine, a systematic review of interventions for all chronic diseases using the PROGRESS-Plus framework may have resulted in a higher yield and increased our knowledge of effective interventions. As noted earlier, we chose to focus our review on OA as the exemplar chronic disease rather than including all chronic conditions, as OA contributes significantly to the global burden of chronic disease (15) and there is substantial international evidence of health care inequity in OA and a disproportionately higher prevalence and severity of OA in a number of vulnerable populations. We believe that it is likely that interventions shown to be effective in reducing inequities in one chronic condition will be similarly effective in others.

In conclusion, there are several arthritis self-management interventions targeting disadvantaged people with OA that are effective in improving health care quality, but there is a lack of studies evaluating interventions targeting health care providers and the health care system. Population-level interventions, such as mass media campaigns that prime the population, could augment the effectiveness of promising provider- and system-level interventions. To reduce health care disparities in the care of disadvantaged populations with OA, we need to understand what works and in whom. Gap intervention research is important if we are to discern not only what interventions improve health care quality, but also what works to reduce disparities in access to care, health care utilization, and health care outcomes of disadvantaged populations with OA. We may need to “glocal,” i.e., “think globally and act locally,” to tackle disparities in health care by looking to other countries and other clinical areas for potential interventions and then culturally tailor and test the interventions locally in our communities.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Borkhoff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Borkhoff, Wieland, Myasoedova, Welch, Hawker, Li, Buchbinder, Beaton, Cardiel, Gabriel, Guillemin, Bombardier, Hajjaj-Hassouni, Tugwell.

Acquisition of data. Borkhoff, Wieland, Myasoedova, Welch.

Analysis and interpretation of data. Borkhoff, Wieland, Myasoedova, Ahmad, Welch, Hawker, Li, Buchbinder, Ueffing, Beaton, Gabriel, Adebajo, Tugwell.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information

The authors would like to thank Jessie McGowan, information scientist, for generously assisting with reviewing the literature search strategy.


  1. Top of page
  2. Abstract
  8. Acknowledgements
  10. Supporting Information
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