RA = rheumatoid arthritis; OA = osteoarthritis.
Critical review of arthritis self-management strategy use
Version of Record online: 7 OCT 2003
Copyright © 2003 by the American College of Rheumatology
Arthritis Care & Research
Volume 49, Issue 5, pages 724–731, 15 October 2003
How to Cite
Keysor, J. J., DeVellis, B. M., DeFriese, G. H., DeVellis, R. F., Jordan, J. M., Konrad, T. R., Mutran, E. J. and Callahan, L. F. (2003), Critical review of arthritis self-management strategy use. Arthritis & Rheumatism, 49: 724–731. doi: 10.1002/art.11369
- Issue online: 7 OCT 2003
- Version of Record online: 7 OCT 2003
- Manuscript Accepted: 6 JAN 2003
- Manuscript Received: 19 JUL 2001
- National Institute on Arthritis and Musculoskeletal Disease. Grant Number: 5-P60-AR30701-18
- National Institute on Arthritis and Musculoskeletal Disease Predoctoral
- Arthritis Foundation Dissertation Award
- University of North Carolina Center on Aging Pilot
- US Department of Education. Grant Number: #H133B990005
Notions of self care and self management of common, but serious, health conditions were once viewed with skepticism by clinicians. However, over time, enlightened health care professionals have come to embrace the idea of informed, participative collaboration with patients as a key strategy for enhancing the effectiveness of clinical diagnostic and therapeutic interventions (1). Although these ideas are being absorbed into mainstream contemporary medicine and health care, our understanding of the range of self-initiated actions consumers use and the factors related to use of these actions is inadequate.
Sobel (2) suggests that self care is the “hidden” health care system and that self care, rather than primary, secondary, or tertiary care, comprises the majority of health care. Others suggest that self-management activities are determinants of well being, potentially intervening between health status and health outcomes (3–5). If these assertions are true, we must have a clear understanding of the factors related to and outcomes associated with strategy use so people with chronic conditions can be guided in effective self-management practices.
The terms self management and self care, often used interchangeably among lay and professional persons, are broadly defined as the activities people engage in to promote health and/or manage chronic conditions (6–9). These activities are usually self initiated and often undertaken with little to no supervision from health care professionals. For this article we use both phrases (self care and self management) to refer to the wide range of activities people use to promote personal health and to detect, prevent, and treat common health problems.
The use of self-initiated actions to manage arthritis conditions is well recognized in the scientific literature and among health care providers. Applying the above definition of self management to arthritis, a variety of strategies could be used to manage the symptoms and consequences of the disease, such as taking medication, exercising, wearing splints or braces, taking herbs or supplements, or seeking care from alternative care providers. Two review articles by Ernst (10, 11) show that use of complementary and alternative strategies is common but variable among people with rheumatic disease, with most people using at least 1 type of complementary therapy (e.g., special diets, jewelry, vitamins, herbs, prayer, relaxation, or massage). Little is known, however, about the broad range of strategies that could be used to manage arthritis, the degree to which people with arthritis use various strategies, and factors related to use of specific strategies. The purpose of this article is to address these gaps in the scientific literature.
The Medline database was used to identify studies that met the following criteria: 1) study participants were from a rheumatology clinical practice or were community-dwelling adults who reported arthritis, rheumatoid arthritis (RA), osteoarthritis, or chronic musculoskeletal joint problems; 2) specific self-management strategy use or categories were assessed (e.g., heat, lotions, exercise, rest, dietary practices, herbs and supplements, or alternative care provider); and 3) frequency of use and/or sociodemographic or clinical disease-related correlates of strategy use were reported. Sociodemographic factors included age, sex, marital status, educational attainment, ethnicity, and income or social status; disease-related factors included functional status, pain, disease severity (e.g., joint involvement or number of symptoms), disease duration, and comorbidity.
The search was limited to articles published in English between 1980 and January 2002. The terms, “self-care” or “self-management” were combined into 1 search strategy and the terms “arthritis,” “rheumatoid arthritis,” “osteoarthritis,” or “musculoskeletal” were combined into another search strategy. The 2 search strategies then were combined to capture self-management practices among persons with chronic arthritis and musculoskeletal problems. Additional searches were performed for the terms “complementary or alternative medicine,” “joint protection,” or “adaptive equipment” in combination with the arthritis and musculoskeletal terms specified above. The bibliographies of articles thus identified were scanned for further relevant publications. Studies examining self-management strategy use specifically for fibromyalgia and systemic lupus erythematosus were excluded because these conditions usually do not manifest with chronic joint problems.
Study design, ascertainment and frequency of strategy use, and sociodemographic and clinical disease-related correlates of strategy use were assessed for each study that met inclusion criteria. Frequency of strategy use was reported as “recent use” (i.e., strategy used within the past 6 months) and “ever use” (i.e., use within the past year or in previous years). Demographic and disease-related correlates of strategy use were summarized by reporting significant associations (P ≤ 0.05).
To further structure our review, frameworks described by DeFriese et al (7) and Norburn et al (12) were adopted. Seven broad categories representing different types of arthritis self-management strategies were identified: 1) topical treatments (e.g., lotions, ointments, oils, heat, and cold), 2) activity-related strategies (e.g., exercise, activity modification, assistive device use, joint protection behaviors, or environmental changes), 3) dietary practices (e.g., eating or avoiding special foods, taking supplements or herbs, drinking or avoiding alcohol), 4) mind-body practices (e.g., relaxation, prayer, talking with others, positive thinking, and meditation), 5) alternative and complementary practitioners (ACPs; e.g., chiropractors, acupuncturists, or massage therapists), 6) home remedies (e.g., household oils such as WD-40, motor oil, snake venom, bee sting, or special jewelry), and 7) conventional medical care (e.g., prescribed and over-the-counter medications or use of health care services).
Nineteen studies met inclusion criteria (Table 1), all were cross-sectional (4, 13–31). All but 1 study used self-report surveys to ascertain strategy use; 1 study used self-report diaries and surveys to ascertain strategy use (31).
|Gray (13)||Australian community-dwelling adults with self-reported arthritis (n = 76)|
|Kronenfeld and Wasner (14)||Consecutive in-patient and out-patient rheumatology clinic patients, most with RA or OA (n = 98)|
|Cassidy et al (15)||Randomly selected patients with physician-diagnosed RA (n = 100)|
|Struthers et al (16)||Patients with physician diagnosed RA (n = 199)|
|Coulton et al (17)||Community-living elders with self-reported joint problems (n = 317)|
|Davis et al (18)||Patients with physician diagnosed RA or OA and 3 months self-reported pain (n = 82)|
|Cronan et al (19)||Community-dwelling adults with self-reported OA (n = 382)|
|Hampson et al (20, 21)||Patients with physician-diagnosed OA for at least 1 year (n = 61)|
|Boisset and Fitzcharles (22)||Consecutive rheumatology outpatients (n = 235)|
|Arcury et al (23)||Rural community-living adults with physician-diagnosed arthritis (n = 219)|
|Katz (4)||Consecutive patients with physician-diagnosed RA from randomly selected rheumatologic practices (n = 471)|
|Hammond (24)||Patients with physician-diagnosed RA (n = 41)|
|Ramos-Remus et al (25)||Consecutive patients from rheumatology clinical practices in Mexico (n = 250)|
|Rao et al (26)||Consecutive patients from rheumatology practices (n = 232)|
|Anderson et al (27)||Random sample of patients seen at least once during 1997 in rheumatology and geriatric practices (n = 176)|
|Aceves-Avila et al (28)||Consecutive patients from rheumatology practices in Mexico (n = 247)|
|Kaboli et al (29)||Random sample of community-dwelling adults 65 years old or older with self-report physician-diagnosed arthritis (n = 480)|
|McDonald-Miszczak et al (30)||Community-dwelling adults 50 years or older who self report arthritis randomly selected via random-digit dialing (n = 377)|
|Ramsey et al (31)||Community-dwelling adults 55 years or older with physician-diagnosed OA from a randomized clinical trial of water aerobics (n = 122)|
Frequency of strategy use
Special dietary practices and use of herbs and supplements were most frequently examined, with approximately 60% of the studies assessing these strategies (see Table 2). Lotions, heat, exercise, rest, relaxation, and special jewelry were examined in at least 40% of the studies; use of splints and joint protection strategies, massage, prayer, coping, chiropractic care, and any ACP were examined in 25% of the studies. The least frequently examined strategies were activity modification, the application of cold or ice, acupuncture, some of the stress and mind-body strategies, and some of the home remedies, with less than 25% of the studies examining these strategies.
|Self-management strategy||Ever use, % (reference; specific strategy)||Recent use, % (reference, specific strategy)|
|Heat (applied or not specified)||49 (4); 66 (43); 70 (18); 71 (23)||38 (17); 40 (20); 47 (23)|
|Hot shower, bath, spa||4 (29); 63 (4); 71 (18)||29 (19); 34 (17)|
|Cold||22 (18)||4 (17)|
|Lotions, oils, and ointments||21 (26); 26 (25); 36 (23; lotions); 38 (29); 66 (25); 81 (14, 23; ointments)||11 (26); 18 (23; lotions); 30 (19); 52 (23; ointments)|
|Exercise||56 (24); 74 (4); 75 (23); 78 (18)||33 (19); 63 (23); 65 (20; range of motion); 68 (30); 74 (17); 92 (20; gentle activity)|
|Rest||62 (23); 71 (43); 89 (4); 90 (18)||29 (30); 33 (19); 59 (23); 60 (17); 65 (20)|
|Modify activity||22 (24); 62 (4)||15 (17)|
|Splints/braces, joint protection||29 (18); 38 (4); 44 (24)||3 (17); 5 (20; splints); 35 (20; joint protection)|
|Special diets (avoid or eat special foods)||7 (29; special diet); 13 (22); 20 (26; special diet); 25 (26; vinegar drinks); 28 (4; avoid foods); 33 (16; special diet); 34 (18; avoid foods); 46 (15; cod liver oil); 49 (23; special foods); 54 (14; specific diets); 60 (15; dietary modifications)||2 (17; special foods); 5 (17; avoid foods); 12 (26); 26 (23); 32 (30)|
|Supplements or herbs||4 (25; shark cartilage); 4 (29; herbs); 16 (26; minerals or megavitamins); 18 (25; garlic); 22 (26; supplements); 25 (14); 29 (26; herbs); 38 (4; supplements, vitamins, and special foods); 44 (25; vitamins); 74 (25; herbs)||1 (27; shark cartilage); 4 (17); 5 (27; grape seed); 5 (27; cranberry or ginkgo); 5 (27; glucosamine); 9 (26; minerals and megavitamins); 11 (26; supplements); 12 (26; herbs); 18 (17; herbs); 27 (19; vitamins); 31 (20); 47 (27; vitamins); 51 (28)|
|Alcohol||15 (23; whiskey); 1 (17); 6 (30; reduce intake)||5 (23; whiskey)|
|Stress and mind-body|
|Prayer/spiritual||5 (26); 37 (23; church services); 38 (15; religious services); 39 (22; prayer, meditation, relaxation); 42 (29); 92 (23; prayer)||2 (17); 2 (26); 31 (23; religious services); 44 (19); 92 (23; prayer)|
|Relaxation or meditation||5 (29); 10 (29); 21 (4); 32 (43); 38 (18)||1 (17); 33 (19); 40 (21)|
|Diverting attention||3 (23; special trips); 12 (14; special trips); 72 (4); 79 (18)||1 (23; special trips); 10 (17)|
|Social support||60 (18); 66 (4)||28 (30)|
|Stress control||31 (4); 44 (18)||43 (30)|
|Support or self-help groups||6 (4; support group); 8 (4; self help group); 15 (18)||6 (30)|
|Alternative and complementary care|
|ACP*||13 (22); 25 (13); 28 (29); 28 (15); 36 (14)|
|Chiropractor||20 (25); 26 (29); 31 (26)||7 (26)|
|Acupuncture||3 (29); 7 (26); 7 (15); 11 (16); 14 (25)||1 (26)|
|Massage||17 (25); 26 (4); 46 (18)||9 (17); 1 (19); 35 (21)|
|Homeopathist||<1 (29); 1 (15)|
|Jewelry||<1 (22); 5 (29); 12 (25); 28 (23); 29 (26); 37 (15); 38 (14); 38 (16)||4 (23); 6 (26); 10 (17)|
|Household motor oils||5 (25); 17 (23; WD-40); 18 (23; turpentine)||3 (23; WD-40); 7 (23; turpentine); 9 (17)|
|Snake venom/bee sting||3 (25); 7 (23)||2 (23)|
Frequencies of use between and within the “recent” versus “ever” timeframes were varied. In most instances, people were less likely to have used a strategy when strategy use was assessed within the past 6 months than when assessed within the past year or longer. This conclusion is consistent with those determined by others (23, 26), that people with arthritis may try various strategies but are less likely to continue them.
Heat, rest, and exercise were used by the majority of participants in the studies, although frequency of use and ascertainment of strategy varied. In Katz's study (4), 49% of the respondents applied heat to parts of their body and 63% used a heated pool, tub, or shower. Arcury et al (23) reported 71% of the participants used heat (unspecified) and Davis et al (18) found that 70% of participants applied heat to painful areas. Ascertainment of exercise also differed among the studies; prevalence of use estimates were varied. In the studies reporting the highest rates of exercise, participants were asked about their use of “exercise as tolerated” (18), “exercise” (23), and “gentle activity” (20, 21). Cronan et al (19), reporting the lowest frequency of exercise, asked participants about use of “exercise or swimming not prescribed.”
Findings related to use of rest and lotions and ointments were similar to heat and exercise: frequency estimates varied and so did ascertainment. In the study that reported the highest use of topical applications, participants were from a southern community and were specifically asked about the use of “ointments-liniments” (23). Lower estimates were found when use of lotions, creams, or oils was assessed (23, 25, 26). The highest rates of the use of rest as a self-management strategy were ascertained by questions relating to “rest,” “resting,” or “used rest” (4, 18, 23); the lowest estimates of rest were reported when the use of rest was assessed in a more restrictive manner, such as “bed rest” (19) or “resting more” (30).
Use of activity modification practices and joint protection strategies was examined in only 5 studies; results indicated that these strategies were not commonly used. One study reported that 35% of the participants used joint protection principles within the past 6 months (20), but other studies reported that fewer than 15% used joint protection activities or braces or splints (17, 20).
Dietary practices were examined frequently and assessed in many different ways (see Table 2). Generally, about one-third of the participants used these strategies. Some studies examined the use of specific herbs or supplements, such as shark cartilage or glucosamine (25, 27), garlic (25), grape seed (27), or ginkgo (27), although most assessed the general use of herbs or supplements (4, 14, 17, 19, 25–27, 29). In addition, 1 assessment included special foods with supplements and herbs (4).
Spiritual and relaxation practices (including prayer and meditation) were fairly common, although estimates ranged from 5% (26, 29) to as high as 92% (23). Spiritual practices included attending church or religious services and engaging in prayer. In 2 studies (15, 23), approximately 40% of the participants reported using church services as a self-management practice; whereas in one study, 92% of the participants used prayer (23).
ACP use was usually assessed within the past year or longer; only a few studies assessed current use of ACP. Although estimates varied, approximately 25% of the participants used some type of ACP. Chiropractors and massage therapists were the ACPs most frequently seen; acupuncturists and homeopathists were least frequently seen.
Of the home remedies, special jewelry was the most frequently used strategy; however, in 3 studies, fewer than 10% of the participants used special jewelry for their arthritis within the past 6 months. Studies showed that less than 20% of the participants had tried household oils, such as WD-40, turpentine, and other motor oils. Estimates of use within the past month were lower: 3% used WD-40 and 7% used turpentine (23).
The following strategies were reported only in 1 study and were, therefore, not listed in Table 2: assistive devices (24), environmental changes (30), positive thinking (23), natural healing (26), spiritual healing (26), hypnotism (29), energy healer (29), reflexology (25), dimethyl sulfoxide (17), quit or decrease tobacco use (30), mothballs (23), special clothing (23), orthopedic shoes (17), biofeedback (18), and transcutaneous electrical nerve stimulation (18).
In summary, much of the literature focused on use of topical treatments, diet, alternative care strategies, exercise, and rest. Use of activity modification practices and joint protection strategies was not examined often, despite the potential benefit and long-term importance of these strategies on health outcomes of people with chronic joint problems. Furthermore, people do not seem to be using these strategies to a great degree.
Correlates of strategy use
In Table 3, the sociodemographic and disease-related correlates of strategy use are summarized. Because few studies reported these correlations, only patterns and trends are reported. Functional status was the only disease-related factor examined often enough to identify patterns and trends. Correlations between disease severity, disease duration, comorbidity, and pain with self-management strategies were not reported because the relations were not examined frequently enough to identify any patterns or trends.
|Topical treatments||Activity-related strategies||Dietary practices||Stress and mind-body practices||Alternative care providers||Folk lore/home remedies|
|Age||Heated pool (Y; 18)||Bracing (Y; 18)||Eat or avoid foods||Stress control (Y; 18)||Massage (Y; 18)||Turpentine (23)|
|Apply heat (18, 23)||Exercise (18, 23)||(14, 18, 23)||Support (18)||Alternative care providers (14, 29, 31)||WD-40 (23)|
|Apply cold (18)||Rest (18, 23)||Vitamins (14)||Distraction (18)||Jewelry (14, 23)|
|Lotion (14, 23)||Whiskey (23)||Relaxation (18)|
|Positive thinking (23)|
|Sex||Heat (M; 23)||Rest (F; 23)||Whiskey (M; 23)||Prayer (F; 23)||Alternative care providers (14, 29, 31)||Turpentine (23)|
|Lotions (F; 23)||Eat or avoid foods (14, 23)||Positive thinking (23)||WD-40 (23)|
|Lotions (14)||Vitamins (14)||Trips (14)||Jewelry (14, 23)|
|Race||Heat (W; 23)||Rest (W; 23)||Eat or avoid foods (14, 23)||Prayer (AA; 23)||Alternative care providers (14)||Turpentine (23)|
|Lotions (AA; 23)||Rest (4, 17)||Vitamins (14)||Positive thinking (W; 23)||WD-40 (23)|
|Lotions (14)||Whiskey (23)||Trips (14)||Jewelry (14, 23)|
|Education||Apply heat (4)||Exercise (4)||Eat or avoid foods (4)||Support (4)||Massage (4)||Jewelry (14)|
|Heated pool (4)||Rest (4)||Eat or avoid foods (14)||Stress control (4)||Alternative care providers (14, 22, 29, 31)|
|Heat (22)||Joint protection (4)||Vitamins (14)||Relaxation (4)|
|Lotions (14)||Change routine (4)||Supplements (4) Herbs (22, 28)||Distraction (4) Support (4) Self-help (4)|
|Trips (14, 22)|
|Socioeconomic||Heat (Lower; 22)||Eat or avoid foods (14)||General stress (22)||Alternative care providers (14, 22, 29, 31)||Jewelry (14)|
|status||Lotions (14)||Vitamins (14, 22)||Trips (14)|
|Functional||Heat (23)||Rest (23)||Eat or avoid foods (23)||General stress (14, 23)||Alternative care providers (14, 31)||WD-40 (23)|
|status||Lotions (14, 23)||Whiskey (23)||Jewelry (23)|
|Eat or avoid foods (14)||Turpentine (23)|
|Vitamins (14)||Jewelry (14)|
Dietary practices, alternative care, or home remedies, generally, were not related to sociodemographic factors, although there were a few exceptions. Katz (4) reported that people with RA who had more educational attainment were more likely to avoid certain foods and use massage compared with people with fewer years of education, even after adjusting for age, sex, race, marital status, income, comorbidity, disease duration, arthritis, number of painful joints, presence of severe fatigue, and functional status. Most studies examining these relationships, however, found no differences in strategy use. This discrepancy may be due to variability in the way educational attainment was operationalized. Katz categorized education into 6 groups: 0–8 years of education, 9–11 years, 12 years, 13–15 years, 16 years, or 17 or more years of education, but other researchers used educational attainment as a continuous variable. Sex differences were found with the use of alcohol: men were more likely to use whiskey than women (23). Ethnic differences were also found: African Americans were more likely to use turpentine than whites (23). Regarding physical functioning, findings were inconsistent. One study showed that people with worse physical functioning were more likely to eat special foods, drink whiskey, use WD-40, or wear special jewelry (23); however, another study found no relationship between functional status and use of similar dietary strategies or home remedies (14).
Regarding topical treatments, age and functional status, generally, were not related to use of heat or lotions. In 1 study, however, which dichotomized people as age 50 years of age or younger and over 50, the younger aged adults were more likely to use a heated pool than the older adults. Findings for sex, race, education, and income were mixed. Men, whites, and those with more income and more years of educational attainment were more likely to use heat (4, 22, 23); women and African Americans were more likely to use lotions (23). On the other hand, 2 studies showed no differences in use of topical treatments by sex, race, education, or income (14, 22).
Activity-related strategies were examined in only a few of the studies, thus, our interpretations are limited. Generally, age and education were not related to exercise, rest, or activity modification practices, although Davis et al (18) found that people who were younger were more likely to use braces or splints. Findings with sex and race were inconsistent. Women and people who were white were more likely to rest than were men or African Americans (23). On the other hand, no association was found in 2 other studies (4, 17).
Stress and mind-body practices were not related to age, socioeconomic status, or functional status, except in 1 study (18) that showed younger adults were more likely to engage in stress control practices. However, there were some associations between stress and mind-body practices and sex, race, and educational attainment, though only a few studies examined these relations. Katz (4) found that people with more educational attainment were more likely to attend support groups, use stress control strategies, and use relaxation strategies than were people with fewer years of education. Women and African Americans were more likely to use prayer and church services compared with men and people who were white; and whites were more likely to use positive-thinking strategies (23).
In sum, we found no conclusive evidence relating sociodemographic and disease-related factors to self-management strategy use. Some positive associations were found between sex, race, and functional status and use of topical treatments, activity-related strategies, stress and mind-body practices, and folklore strategies. Age, education, and income were generally not related to strategy use. These findings, at least in part, are supported by studies that show sociodemographic factors contribute only a small amount of variance to self-management strategy use (12, 13, 19, 30, 32, 33).
The primary aims of this study were 1) to identify the range of strategies that people with arthritis or chronic joint problems used to manage their condition, and 2) to examine the sociodemographic and disease-related factors associated with use of these self-management strategies. Ascertainment of strategy use was remarkably varied among the studies, with no 2 studies examining arthritis self-management strategy use in the same manner. The range of self-initiated strategies used to manage arthritis symptoms and consequences varied and included conventional and unconventional activities. No conclusive evidence relating sociodemographic and disease-related factors to self-management strategy use was found.
These findings may be explained by 2 factors: 1) a lack of clearly defined and consistent conceptual framework, and 2) methodologic limitations in studies. None of the studies used the same conceptual framework to identify and define strategies or categories of use; only 2 used a theoretical framework to guide the examination of correlates of strategy use (17, 30). A clear conceptual framework for arthritis self management—i.e., identify and define relevant categories or domains—would enable researchers to more easily compare study findings and assess arthritis self-management behaviors. Without a clear, conceptual framework, assessment of the broad range of self-management strategy use is unstructured, potentially misleading, and difficult to duplicate. The conceptual framework of DeFriese and colleagues (7, 34) and the 1 proposed in this article could be useful in identifying the broad range of arthritis self-management strategies and defining categories.
In addition to using conceptual frameworks to assess self-management strategy use, conceptual frameworks could guide research examining the determinants of self-management behaviors. The Behavioral Model of Health Service Utilization (35–37) and the Health Belief Model (38) were used in 2 studies of this review to guide the examination of arthritis self-management strategy use. Using Andersen's model as a framework, Coulton et al (17) showed that pain and number of chronic conditions (identified as need factors in Andersen's model) were the strongest correlates of self-management strategy use, after adjusting for demographic factors. Similar findings were reported in 2 other studies of self-management practices among elderly persons (32, 33), suggesting that disease-related factors explained a larger part of the variance in strategy use than sociodemographic factors.
Likewise, using the Health Belief Model as a framework, McDonald-Miszczak et al (30) found that among 377 community-dwelling adults 50 years of age or older, perceived seriousness and self-rated health status were associated with self-care behaviors after adjusting for sociodemographic factors, disease-related factors, and health care utilization. Peoples' perceptions, therefore, may influence the strategies they use to manage their conditions. The self-regulation model (SRM) of Leventhal et al (39–41) provides such a framework for understanding how people interpret health threats and how these interpretations influence self-management activities. In the SRM, cognitive representations of and emotional responses to disease states are viewed as proximal determinants of the actions people take to enhance their health and to prevent, treat, and rehabilitate from illness.
Despite a substantial amount of research on illness representations among people with arthritis, few studies have examined the relation of these factors to the use of specific strategies people use to cope with arthritis conditions. Using this framework, if people with arthritis interpret pain and fatigue as problematic, they may take actions to decrease these symptoms by avoiding activity, resting, or taking herbs or supplements; however, if someone interprets these symptoms as a consequence of lack of exercise, he or she might start or increase exercise activity.
Methodologic differences also may explain the inconsistencies found in the articles. Some of the inconsistencies could be due to how self-management strategy use was ascertained, whether confounding factors were included in modeling strategies, and differences in sample characteristics. As shown in the Results section, ascertainment of strategy use varied markedly. In some instances when strategies were very general, such as “exercised” or “rested,” estimates of use were high. On the other hand, when very specific strategies were assessed, such as “bed rest” or “cod liver oil,” use estimates were lower. Differences in ascertainment of strategy use may explain a substantial amount of the variance in prevalence estimates. In addition, because many of the strategies were assessed globally, exercise for example, we do not know whether people using these strategies engaged in the appropriate type of exercise, safely performed the exercise (e.g., minimizing abnormal joint forces), or exercised long enough to have any health benefit. A clear conceptual framework of arthritis self-management categories or domains should enable researchers to develop better assessment instruments.
Some of the discrepancies in the correlates of strategy use may be due to differences in analytic approaches. For example, several differences were found between whites and African Americans in relation to use of medications, rest, spiritual practices, and household oils in a large representative sample from a rural southern community; however, socioeconomic factors were not adjusted in these models, which may in part explain the ethnic differences. In the study reported by Coulton et al (17), several ethnic differences were found in univariate models; however, when models were adjusted for socioeconomic factors and physical disability, the associations between race and self-management strategy use were no longer significant.
Furthermore, because all studies in this review were cross-sectional, we are unable to ascertain whether such factors as functional status or pain influenced strategy choice and use. In a longitudinal study on self-management among community-dwelling elders, elderly persons who reported consistent joint pain and stiffness (arthritis-related symptoms) at 4 time points over 27 months were more likely to use self-management strategies than were persons who reported inconsistent symptoms (joint pain or stiffness 3 or fewer times over a 27-month interval) (42). Symptom recurrence over time, therefore, seemed to be related to self-management practices, potentially supporting the SRM approach of Leventhal et al to illness interpretation and self-management behaviors.
There are limitations to our approach to this article. First, it was difficult to classify some findings using our classification scheme, and as a result we may have obscured some findings. Although we tried to establish clear and reliable guidelines for interpreting the data, other researchers may not agree with our classification framework. Nonetheless, a wide range of strategies was used, many inconsistencies were present, ascertainment of strategy use varied, and few studies reported specific relations between sociodemographic and disease-related factors and use of our self-management categories. Second, we found only 19 articles meeting our criteria. The findings are, therefore, limited to trends and patterns and should be interpreted with caution. There is great interest among health professionals regarding the strategies people use to manage arthritis; however, those who have studied these behaviors among persons with arthritis have approached these issues in an ad hoc manner, using highly idiosyncratic measures resulting in primarily descriptive information and many inconsistent findings. We do not know whether use of various self-management strategies is influenced by episodes of acute pain or discomfort; functional loss; cultural factors; or intentional, preventive, precautionary measures. Lastly, we know very little about the levels of knowledge, skills, or experience with these self-management strategies that are required to practice them with any likelihood of realizing a therapeutic effect.
We thank Dr. Shannon Currey for her contributions to the North Carolina Musculoskeletal Health Project and Dr. Alan Jette for his comments on this article.
- 7Self-care and quality of life in old age. In: AbelesRP, GiftHC, OryMG, editors. Aging and quality of life. New York: Springer; 1994. p. 99–117., , , , .
- 8Introduction: the nature, extent, and modifiability of self-care behaviors in later life. In: OryMG, DeFrieseGH, editors. Self-care in later life. New York: Springer; 1998. p. xv–xxvi., , .
- 34Informal and formal health care systems serving older persons. In: OryMG, AbelesRP, LipmanPD, editors. Aging, health, and behavior. Newbury Park (CA): Sage Publications; 1992. p. 57–82., .
- 35Behavioral model of families' use of health services. Chicago: University of Chicago; 1968..
- 38Public participation in medical screening programs: a sociopsychological study. Washington (DC): US Government Printing Office; 1958..
- 40Are there differences in perceptions of illness across the lifespan? In: PetrieKJ, WeinmanJA, editors. Perceptions of health and illness. Amsterdam: Harwood Academic Publishers; 1997. p. 77–102., .
- 41Enhancing self-care research: exploring the theoretical underpinnings of self-care. In: OryMG, DeFrieseGH, editors. Self-care in later life. New York: Springer; 1998. p. 118–41., , .