For the past 2 decades, community-based, person-focused intervention programs have provided opportunities for people with arthritis to increase their levels of physical activity, but true population-based approaches are just beginning to emerge. Although many authors appear to use the terms community- and population-based interchangeably, these terms actually reflect different dimensions of an intervention. Sharpe has provided a heuristic framework for conceptualizing community-based interventions (1). Community-based can be used to describe the setting or context of an intervention (the where of the intervention), whereas population-based can refer to the body of potential participants, which may be the entire population or a defined subgroup (the who of the intervention). As Sharpe described, community-based interventions may be population-based or more individually focused. Green and Kreuter clarify that a population-based approach must go beyond people who appear for treatment or turn out for an educational event (2). For the purpose of our discussion, we define a population-based intervention as one designed to reach out to most members of a defined population. Interest in population-based approaches for arthritis has been fueled by the publication of the National Arthritis Action Plan: A Public Health Strategy (NAAP), which catalyzed the public health system's interest in arthritis and emphasized population-based approaches (3), and the recognition that person-focused, community-based programs, such as many of those reviewed by Boutaugh (4), are unlikely to reach large portions of the 70 million Americans with arthritis (5).
Minor et al have shown that people with arthritis benefit from both structured exercise and the more broadly defined physical activity (which includes daily activities of moderate intensity such as walking, raking leaves, or washing the car); and person-focused, community-based programs have been developed by the Arthritis Foundation and others (6, 7). However, little is know about effective population-based approaches to increase physical activity among persons with arthritis (PWA). The NAAP calls for the development of such population-based efforts (3).
We will briefly review the NAAP and the Centers for Disease Control and Prevention (CDC) Arthritis Program that emerged from Congressional support of NAAP. We also will highlight physical activity initiatives being developed by the CDC and state health departments.
National Arthritis Action Plan: A Public Health Strategy
In response to a growing recognition of the magnitude of the problem and the significant impact of arthritis on quality of life, CDC, the Association of State and Territorial Health Officials, and the Arthritis Foundation led the development of the NAAP. NAAP was released in 1999 with the support of over 90 additional organizations. NAAP blends the perspectives, values, and resources of both the public health and arthritis communities into a strategic plan that guides the use of the nation's public health resources and proposes strategies for a coordinated approach—at national, state, and local levels—to reduce the burden of arthritis in the United States. This framework embraces classic public health values: to emphasize primary, secondary, and tertiary prevention; to use and expand the science base; to seek social equity; and to work through partnerships. The goals of NAAP are outlined in Table 1.
|•To establish a solid scientific base of knowledge on the prevention of arthritis and related disability.|
|•To increase awareness of arthritis, its impact, the importance of early diagnosis and appropriate management, and effective prevention strategies.|
|•To implement effective programs to prevent the onset of arthritis and its related disability.|
|•To achieve the arthritis-related objectives included in Healthy People 2010.|
The NAAP framework organizes strategies into 3 broad sections; each section contains strategies that address physical activity. The Surveillance, Epidemiology, and Prevention Research section recommends expanding arthritis-related public health science, which includes monitoring trends in physical activity among PWA, and evaluating the efficacy of physical activity interventions. The Communication and Education section focuses on increasing awareness and understanding of arthritis, its impact, and management among the general public, PWA and their families, and health professionals. It includes strategies that address the need to communicate the importance of physical activity in managing pain and disability. The Programs, Policies, and Systems section outlines strategies to create arthritis programs in public health agencies and to develop and disseminate evidence-based interventions, including physical activity interventions, to reduce the impact of arthritis.
CDC–State Health Department Arthritis Programs
Following the release of NAAP, Congress, for the first time, appropriated funds in fiscal year 1999 for CDC to initiate a public health response to arthritis. The core activities of the resulting arthritis program focus on 3 key areas: strengthening the public health science; fostering the development of state arthritis programs; and developing intervention activities to reduce the burden of arthritis.
Strengthening arthritis public health science
Consistent with NAAP, public health science activities focus on surveillance, epidemiology, and prevention research. CDC has revised the surveillance methods used to estimate the prevalence of arthritis. This revision includes revamping the arthritis surveillance questions and ensuring a comparable core of questions between the National Health Interview Survey, used for national prevalence estimates, and the Behavioral Risk Factor Surveillance Survey (BRFSS), used for state-level estimates. The revised surveillance questions, developed in consultation with a panel of arthritis and public health experts, have been cognitively tested and are currently being validated. BRFSS also includes questions on physical activity. The CDC Arthritis Program provided a standard analysis of physical activity data among persons with and without arthritis to all states that used the Arthritis questions in the 2000 and 2001 BRFSS; state health departments can use these analyses to help tailor their physical activity interventions. CDC also funds a variety of extramural prevention research projects, including a project to develop and test materials (workbook and videotape) designed to teach strength training to older adults with osteoarthritis.
State arthritis programs
In 1999, CDC funded the development of arthritis programs in 37 states. Twenty-nine of these states received modest, 2-year grants (approximately $60,000) to establish the basic public health foundation necessary to support a state arthritis program. These states were asked to develop partnerships with their local Arthritis Foundation chapter and other partners, to develop a state arthritis plan, and to gather state-specific surveillance data to monitor the number and characteristics of PWA in the state. Eight other states, each of which had a more developed foundation to address arthritis, received larger, 4-year grants (approximately $300,000) to strengthen their public health infrastructure for arthritis and to pilot test interventions to reduce the impact of arthritis. In 2001, CDC funded 21 states (average award $120,000); this group included states that had previously received $60,000 and states with no previous arthritis funding from CDC. In 2002, an additional 7 states were funded at the $120,000 level. In 2002, a total of 36 states (28 at $120,000 and 8 at $320,000) received CDC funding.
CDC, in collaboration with the state arthritis programs, developed a public health framework for arthritis programs (Table 2). This framework promotes a common approach and ensures that all programs consistently focus on persons affected by arthritis and aim to improve the quality of life of those affected by arthritis. The program framework outlines long-term goals, short-term goals, and desired immediate program effects, which include increasing participation in self-management programs such as physical activity interventions.
|Persons affected by arthritis|
|Diagnosed arthritis, symptoms of arthritis or chronic joint symptoms|
|Overall Program Goal|
|To increase the quality of life among persons affected by arthritis|
|•Increase awareness of the signs, symptoms, and management options of/for arthritis|
|•Increase awareness of the need for early diagnosis and appropriate management|
|•Increase inclusion of self management as part of routine medical care for arthritis|
|•Increase participation in self management programs among persons with arthritis|
|•Increase early diagnosis and appropriate management|
|•Improve/increase self management attitudes and behaviors among persons with arthritis|
|•Decrease pain and disability among persons with arthritis|
|•Improve physical, psychosocial, and work function among persons with arthritis|
The CDC Arthritis Program plays a key role in implementing NAAP by developing health communications, health education, and health care system interventions to be used by state arthritis programs and their partners to address arthritis in their state. Several of these population-based approaches will be reviewed.
The CDC Arthritis Program has developed an integrated public health approach to address arthritis, to both monitor the burden of arthritis and foster programs to reduce that burden. CDC's surveillance, epidemiology, and prevention research efforts are oriented toward expanding arthritis-related public health science to inform public health practice, and state arthritis programs and other activities of the CDC Arthritis Program are guided by the public health science base.
Emerging population-based approaches to increase physical activity
CDC health communications campaign
Within CDC, health communications is defined as “The study and use of communication strategies to inform and influence individual and community decisions that enhance health” (8). Health communications strategies are capable of reaching broad segments of the population, but have not been widely used in arthritis. CDC has developed a health communications campaign specifically designed to increase physical activity among PWA. Health communications is most effective when both the messages and delivery channels are tailored to a specific target audience. CDC used extensive formative research (29 focus groups of PWA, 24 in-depth interviews with PWA, 19 interviews with primary care physicians [PCPs], a literature search, and a review of other arthritis-related media coverage and environmental trends) to segment the target audience and identify appropriate messages, materials, and distribution channels. CDC's campaign targets white and African American adults aged 45–64 years, with a high school education or less and income below $35,000, whose arthritis has begun to affect or threatens to affect their valued life roles. Campaign objectives are to 1) increase knowledge of the benefits of physical activity and appropriate physical activity for persons with arthritis; 2) strengthen beliefs about the importance of physical activity for arthritis management; 3) increase person's with arthritis confidence in their ability to do regular, moderate physical activity; and 4) increase trial attempts of physical activity.
The formative research, which demonstrated that pain relief was the most attention-grabbing and motivating benefit to promote, led to the campaign themeline, “Physical Activity. The Arthritis Pain Reliever.” This themeline is executed in radio scripts, a countertop brochure holder and campaign-specific brochures, 4 print public service announcements, and 2 posters. Campaign materials emphasize the importance of accumulating 30 minutes of moderate physical activity (such as walking, riding a bike, or swimming) at least 3 days per week. (An arthritis-specific physical activity recommendation, which has not yet been empirically tested, should be the subject of further research. This communications message was based on the physical activity clinical trials that use a three-day per week protocol.) Formative research demonstrated that the concept of doing physical activity in 10 minute increments made physical activity more feasible for PWA; this concept is included in campaign materials as well. The campaign is being pilot tested in 6 states in 2002 and it will be ready for general distribution in 2002. Approximately half of the CDC-funded state arthritis programs will use these materials in the next 2 years. Within Sharpe's heuristic typology, this health communications campaign would likely be considered a community-based risk factor reduction program with a population-based approach.
Health system quality improvement initiative
Another population-based approach to increasing physical activity among PWA can occur in the clinical care arena. American College of Rheumatology guidelines for the management of osteoarthritis of the hip and knee identify nonpharmacologic modalities, including aerobic, strengthening, and range-of-motion exercise, as integral to management (9). However the focus group and PCP interviews conducted for the health communications campaign revealed that although both patients and providers reported that exercise is often mentioned during the clinical visit, little or no specifics are given. Most PCPs reported that medications comprise their first line of treatment, and that they had little time for the level of detail required to give specific exercise instructions. While physicians appear to recognize that exercise or physical activity is important for arthritis management, at present they do not have the time, and may not have the knowledge, to provide appropriate physical activity instruction.
The need to improve clinical care delivery is not unique to arthritis. The current delivery system, created when acute infectious diseases dominated care needs, is ill suited to meet the needs of patients with chronic disease (10). In the 1990s, development and implementation of guidelines were initially seen as a way to improve the quality of care (11). However, these guidelines have focused primarily on changing individual provider behaviors and have had limited success. On the basis of a review of guideline implementation literature and staff interviews, Solberg concluded that it is “more effective to create systems that support the desired clinical behavior than to focus on changing the behavior of individual physicians” (11). Consequently, CDC is pilot testing a systems-change approach to improving the quality of arthritis care, in collaboration with the Robert Wood Johnson Foundation funded Improving Chronic Illness Care Program at Group Health Cooperative of Puget Sound (ICIC) and the Arthritis Foundation.
ICIC has pioneered a comprehensive, system-change approach to quality improvement in chronic illness care by combining the system changes suggested by their Chronic Care Model with rapid cycle quality improvement methodology developed by the Institute for Healthcare Improvement (12). This approach has been successfully used for diabetes, congestive heart failure, asthma, and depression. The Chronic Care Model specifies that productive interactions between activated patients (e.g., patients who actively manage their condition) and prepared practice teams produce optimal functional and clinical outcomes; system changes are required to create these productive interactions. This model identifies 5 areas of system change: decision support (such as guidelines or best practices), self management support (such as collaborative goal setting and self management education), clinical information systems (including a registry to identify appropriate patients and a clinical reminder system), alternative models of care delivery (such as group clinical visits, telephone care) and community linkages (physical activity programs in the community) (11). System changes in these areas are likely to improve patient-provider interaction and patient outcomes.
To identify characteristics that define high quality arthritis care, a necessary precursor to a quality improvement initiative, ICIC convened a panel of clinical arthritis experts and primary care providers. Among 10 recommended change concepts or critical elements of high quality arthritis care, 2 were specific to physical activity: routine assessment of physical activity and endurance and routine referral to specific exercise/endurance programs or resources. By implementing these changes, health systems should be able to increase physical activity among the PWA in their system.
Although clinical care is frequently delivered individually, this system change strategy is a population-based approach. A cornerstone of this quality improvement strategy is to create a registry or listing of all the patients in the health system with appropriate arthritis diagnoses. By using this registry, it is possible to focus interventions not just on those patients who may appear in the clinical setting for arthritis care, but all patients in the system who have the targeted diagnoses. System changes focused on ensuring routine assessment of physical activity and referral to physical activity resources could serve to increase physical activity among the entire arthritis population in participating health systems.
This health system quality improvement initiative is being pilot tested by the Florida and Missouri Departments of Health with local health system partners. Further dissemination of this approach will depend on the results of this pilot test.
Community-based physical activity promotion
At least 24 of the CDC-funded state arthritis programs are pilot testing community-based physical activity interventions. One such intervention is “It's your Life. Join the Movement,” which the Georgia State Department of Human Resources, Division of Public Health is testing. This program uses a person-to-person modeling and support approach to increase physical activity among 450 PWA in a west Georgia health district. “It's your Life” aims to increase the proportion of Georgians with arthritis who know that appropriate regular physical activity can reduce pain and other symptoms and improve quality of life, and who use physical activity as a part of their arthritis management plan. A team of community leaders, staff of the health district, the local branch of the Arthritis Foundation, and the Area Agency on Aging led the program development. Three counties in west Georgia were selected for the pilot project, representing urban, small town, and rural populations.
The intervention uses “team captains” to each recruit 10 PWA to participate in 10-week sessions in which they must self-report their physical activity levels. Team captains and participants receive support from county-based “group leaders,” community champions who serve as spokespersons and cheerleaders for the intervention. Team captains make periodic phone calls to their team members and are supplied with educational materials on the benefits of physical activity for arthritis and tips on living actively with arthritis. Occasional group sessions are held as well. Participants complete program activity logs periodically throughout the program. Evaluation consists of pre, midpoint, and postparticipation surveys of health status and physical activity. The pilot test is designed to determine if this intervention results in lessened pain, increased mobility, and enhanced quality of life. Results will guide decision-making about state-wide implementation.
Another community-based intervention, which compares the effects of several different modes of promoting physical activity, is being tested by the California Department of Health Services Arthritis Program. Four communities, each from a different broadcast market, are involved in the pilot test. Site A receives the “Physical Activity. The Arthritis Pain Reliever.” health communications campaign. Site B receives the “Physical Activity. The Arthritis Pain Reliever.” health communications campaign paired with a community-based physical activity intervention such as Georgia's “It's Your Life. Join the Movement” program sponsored by a local health department. Site C receives the local, community-based intervention alone; and Site D receives neither the CDC health communications campaign nor the community-based intervention. Population-based community surveys will be used to assess changes in physical activity, perceived importance of physical activity in managing arthritis, and willingness to participate in physical activity.
The development and publication of the National Arthritis Action Plan: A Public Health Strategy catalyzed federal and state public health efforts to reduce the burden of arthritis by developing public health programs. Overall, the CDC and CDC-funded state arthritis programs aim to increase the quality of life among persons affected by arthritis by decreasing pain and disability, and increasing function. Increasing self management beliefs and behaviors, such as being physically active, is core to achieving the goals of these programs. As the public health system has mobilized to address arthritis, several population-based approaches have begun to emerge, including health communications campaigns, changing health systems to routinely assess and address physical activity among PWA, and community-based approaches to increase physical activity. These population-based approaches are being pilot tested to determine which, if any, will be successful in increasing physical activity among PWA. It is likely that no single approach will be effective for all people with arthritis, and a wide array of population-based approaches will be necessary.
Implications for physical activity recommendations
Hootman et al report that nearly 31% of PWA are inactive (13). It is clear that persons PWA need to increase their physical activity, and that positive health benefits, such as decreasing pain and increasing function, will result if they are able to do so (14). Population-based approaches to increasing physical activity among PWA have begun to emerge, but it is premature to formulate recommendations on the use of these specific approaches. However, other recommendations are clear. Population-based approaches to increase physical activity among PWA are likely to involve many organizations, including public health agencies, clinical care providers, community organizations, and others. Although general physical activity messages and programs in the community may reach PWA, tailored messages and programs will also be beneficial. We have reviewed a health communications strategy (i.e., the CDC campaign “Physical Activity. The Arthritis Pain Reliever.”), a strategy to improve care for PWA (i.e., the health systems quality improvement initiative), and community-based strategies in Georgia and California to increase physical activity. A multitude of strategies will likely be required to meet the diverse needs of PWA; further development of population-based approaches, in addition to those that have emerged, remains a high priority. In addition, physical activity research findings must be translated into public health practice that effectively mobilizes PWA to increase their levels of physical activity.
Recommendations for future research
In general, physical activity recommendations are based on Physical Activity and Health: A Report of the Surgeon General, which recommends that Americans perform 30 minutes of moderate physical activity per day, most days of the week for general health benefits (12). Although some organizations have further specified “most days of the week” to be 4 or 5 days per week or more, no scientific evidence on which to base arthritis-specific recommendations has accumulated. There is little evidence on the safety of 5 to 7 day per week programs for people with arthritis, nor evidence on which to base recommendations that address other arthritis-relevant outcomes such as pain, disability, and quality of life. A clarification of physical activity frequency, intensity, and duration recommendations specifically for arthritis is needed.
The best ways to reach and motivate large population groups and which populations respond best to which types of interventions need to be determined. For example, in health communications, what messages reach which audiences? How should messages and delivery channels change to reach specific subpopulations, such as older adults, Hispanic Americans, and Asian Americans with arthritis? In the clinical care arena, what other avenues are available to incorporate strategies that enhance physical activity promotion in primary care? How do primary care providers assess physical activity levels or endurance in their brief clinical visits?
Community-based approaches are ripe with research opportunities as well. In addition to the evaluation of programs like the Arthritis Foundation's PACE (People with Arthritis Can Exercise) and aquatics programs (4), other interventions, including interventions that promote physical activity beyond the level promoted in Arthritis Foundation programs, should be explored. Further research should also address the feasibility of local interventions (e.g., promoted and conducted by local health departments), potential combinations among programs (e.g., programs addressing nutrition or other chronic diseases), and community characteristics that may moderate or mediate the effectiveness of interventions. Very little work has focused on policy and environmental physical activity interventions for PWA. Unique environmental barriers for people with arthritis may exist. Interorganizational partnerships will also be needed, but more research should be done to determine what constitutes effective partnerships and how to deliver physical activity interventions with partners, both health-related and otherwise. Finally, measurement of physical activity remains a problem. How to best monitor levels of physical activity among PWA should be determined, as well as whether current measures are sensitive enough to detect community- and population-level change.
In summary, the area of population-based approaches to increasing physical activity among PWA is rich with research opportunities. However, all of this research will need to build from evidence-based, arthritis-specific recommendations on the frequency, intensity, and duration of physical activity that is safe and effective for PWA. Determining these recommendations is the cornerstone for all future population-based approaches.