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Keywords:

  • Empowerment;
  • Spanish language;
  • Arthritis;
  • Self management

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Objective

To evaluate the effectiveness of the Spanish Arthritis Empowerment Program as presented by the Arthritis Foundation, Southern California Chapter, in Orange County, California.

Methods

Participants with arthritis (n = 141) enrolled in the program between October 1999 and May 2001. All materials were in Spanish. Written pretest, 6-week posttest, and 6-month followup tests measured pain rating, self-report joint counts, function (modified Health Assessment Questionnaire [mHAQ]), self efficacy, self-care behavior, and arthritis knowledge.

Results

Mean age was 51 years, 92% were female, 84% were born in Mexico, 55% had sixth grade education or less, and 60% had no medical insurance. Of the 141 participants, 118 completed 6-month followup testing. Repeated-measures analysis of variance showed significant improvement from pretest to 6-month followup in pain (6.0 versus 3.4); self efficacy (5.5 versus 8.4), self-care behavior (1.7 versus 4.9), arthritis knowledge (1.6 versus 4.5), and general health (2.1 versus 2.5), all at P < 0.001. Small improvement was reported in mHAQ (0.56 versus 0.50; P = 0.024).

Conclusion

The Spanish Arthritis Empowerment Program was successfully disseminated. Significant improvements in self efficacy and in arthritis symptoms were maintained at the 6-month followup.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

The role of arthritis patients as informed participants in their health care has become increasingly important. Patients with higher education levels tend to be more proactive in their health care and have better outcomes (1). To improve patient education in arthritis, several programs were developed, including the Stanford Arthritis Self-Help Course (ASHC) in 1979, which produced improvements in self efficacy and pain reduction (2) that were sustained at 4 years (3), and helped reduce health care costs and hospitalization (3–5). The cornerstone of the self-management program was found to be the self-efficacy component rather than knowledge or behavior modification (6, 7). A meta-analysis of self-help programs further demonstrated the effectiveness of the group-education approach (8). In a recent study of patients recruited from primary care practices, however, equivalent gains were made by patients attending group classes and controls who were instructed to read the class book (9).

The Stanford ASHC was recently adapted to meet the needs of the growing Spanish-speaking community that includes many immigrants with lower education levels. The Spanish adaptation of the ASHC was shown to improve exercise, disability, pain, and self efficacy after 4 months, and to maintain improvements after 1 year (10). The Orange County branch of the Arthritis Foundation, Southern California Chapter was licensed by Stanford University to present the Spanish ASHC as the Spanish Arthritis Empowerment Program (SAEP). The purpose of the present study is to evaluate whether the SAEP was successfully disseminated to another region of California and was effective among the low-income, indigent, and migrant laborers with arthritis in its Hispanic community.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Subjects.

The Orange County branch of the Arthritis Foundation, Southern California Chapter, recruited participants using a variety of strategies, including flyers, community presentations, word-of-mouth, and referrals from bilingual physicians and clinics. The Arthritis Foundation developed partnerships with existing local Hispanic community services to publicize the SAEP and to recruit participants. Community-based organizations, schools, and churches provided classroom space as well as opportunities for recruitment.

Participants in the SAEP classes included persons with arthritis as well as family members and friends who accompanied them. Class participants were excluded from the data analysis if they did not have arthritis, were younger than 18 years, were repeating the class, or if they declined to complete the initial survey.

Arthritis self-management program course and manual.

The SAEP consisted of 6 weekly sessions, each ∼2 hours long, led by a facilitator (promotora) certified by the Arthritis Foundation. The content of class sessions followed a standardized protocol in an interactive discussion format. The SAEP materials as developed by Stanford University included a book, 2 audiotapes (for relaxation and exercise), and an illustrated booklet of exercise routines (10, 11). The program is not a direct translation from English into Spanish, but rather reflects important cultural adaptations of concepts, content, and process. The program used techniques to enhance self efficacy and included discussion about different types of physicians providing arthritis care in the United States and how to access health care. Transportation and scheduling needs of participants were met by presenting classes at 10 community locations in the morning, afternoon, or some evenings.

Evaluation measures and test administration.

Pretest measures included patient demographics (age, sex, education level, current employment status, occupation, marital status, health insurance, country of birth, language preference). Health status measures included a general health rating from the Short Form 36 (12), pain rating (10-point scale) with numbers and verbal descriptors (13), the modified Health Assessment Questionnaire (mHAQ) (14), and self-report joint counts using mannequin diagrams to indicate 50 tender joints and 48 swollen joints (excluding hips) (15). Collected health care information included the total number of physician visits in the past 4 months, the number of visits to a general practitioner and to an arthritis specialist, and their arthritis diagnosis, if known. Self efficacy was measured with 8 questions from the arthritis self-efficacy scale (10). Ratings of effects of arthritis on sleep, daily activities, and depression were obtained using 10-point numerical scales with verbal descriptors. Self-care behavior and arthritis knowledge were assessed using 4-choice multiple choice questions. Self-care behavior included use of exercise, relaxation, energy conservation techniques, coping skills, and communication (8 questions). Arthritis knowledge included types of arthritis, proper medication use, and diet (7 questions). Outcome measures at posttest and 6-month followup were the same as at pretest. The pretest questionnaire was administered at the first class meeting, the posttest at the last class meeting, and assistance was given for those with difficulty reading. The followup was mailed to participants ∼6 months from enrollment; if it was not returned, staff interviewed participants by telephone to complete it.

Data analysis.

Repeated-measures analyses of variance (ANOVA) compared pretest to posttest outcomes (F-test) on the whole sample (n = 141) and were also done with planned contrasts to compare pretest with posttest and 6-month followup measures among patients who completed all 3 questionnaires (n = 118). Where appropriate, nonparametric Wilcoxon's sign-rank test for 2 related samples (Z-statistic) compared pretest to posttest, and pretest to 6-month followup. The Friedman test, a nonparametric repeated-measures equivalent to ANOVA, compared pretest, posttest, and 6-month followup for outcomes with nonnormal distributions. Linear regression analyses were done on change in outcome measures (disease activity, function, health) from pretest to 6-month followup to identify significant predictors of improvement. Secondary analyses were done to compare those lost to followup at 6 months (n = 23) with those who completed the protocol (n = 118) to discover if differences in baseline characteristics or in the instructional process (e.g., attendance, instructor, and site) may have contributed to dropout.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Participants in the SAEP classes were enrolled between October 1999 and May 2001. Of 216 people who enrolled in classes, 23 did not have arthritis, 9 were repeating, 16 were family members, and the remaining 168 were eligible for the study. Of those 168 eligible, 141 (84%) graduated and completed both pretest and posttest evaluations; 118 (83.7%) of these persons completed the 6-month followup evaluation. The 23 cases lost to followup were similar to the 118 who completed followup on all demographic characteristics. However, 22 of those lost to followup were from 1 site, suggesting an administrative or data collection problem.

Mean age of study participants (n = 141) was 50.7 years (SD 14.4) and 92.2% were women. Other characteristics of study participants are presented in Table 1. Approximately 80.9% had a noninflammatory type of arthritis, including osteoarthritis and low back pain, and 19.1% likely had inflammatory arthritis, including rheumatoid arthritis, lupus, and gout, as determined by patient self report of physician diagnosis of arthritis and mannequin joint count and pattern. However, only 6% had previously seen a rheumatologist regarding their arthritis.

Table 1. Baseline participant characteristics (n = 141)
CharacteristicPercentage
Nation of origin 
 Mexico84.3
 Central America10.0
 South America5.0
 Caribbean/Cuba0.7
Education, years 
 09.2
 1–645.4
 7–1239.0
 13 or more6.4
Medical insurance 
 None59.6
 Private30.5
 Medicare4.9
 Medi-Cal5.0
Employment status 
 Housewife51.8
 Full/part time32.6
 Seeking work5.7
 Retired4.3
 Disabled3.5
 Other2.1
Language spoken 
 Spanish only60.0
 Spanish with some English40.0
Marital status 
 Married58.3
 Divorced/separated17.7
 Widowed11.3
 Single/other12.7
Current source of medical care 
 Private doctor/clinic41.8
 County hospital/clinic25.5
 Other12.0
 Do not receive regular medical care20.6
Occupation (current or former) 
 Homemaker24.1
 Manufacturing/laborer22.7
 Service work (housekeeper, childcare)18.4
 Clerical/sales4.9
 Technical/professional2.8
 None reported26.2

Significant improvement was seen from pretest to posttest in measures of disease activity using repeated-measures ANOVA (n = 141). The largest improvement was seen in the pain rating mean ± SD, which decreased from 5.6 ± 2.7 to 4.3 ± 2.5 (P = 0.0001). The patient self-reported tender and swollen joint counts decreased from a mean of 8.6 to 7.1 (P = 0.002) and 3.7 to 2.8 joints (P = 0.043), respectively. Function (mHAQ) did not significantly change from pretest (mean 0.52) to posttest (mean 0.51; P = 0.73). Patients reported significant improvement in mean pretest to posttest ratings (on a 0 to 10 scale) of arthritis impact on sleep impairment (4.1 to 3.1; P < 0.0001), daily activity impairment (4.8 to 3.4; P < 0.0001), and depression (4.6 to 3.8; P = 0.002).

Followup surveys were completed by 118 of the 141 program participants 6 months after enrollment. As shown in Table 2, the improvements at posttest were maintained at the 6-month followup. Although mHAQ was not significantly different from pretest to posttest, significant improvement was seen after 6 months. Overall, after 6 months, 0.9% rated their general health as excellent, 8.5% as very good, 31.4% good, 55.9% fair, and 3.3% poor. General health mean ± SD rating improved significantly from pretest (2.1 ± 0.7) to 6-month followup (2.5 ± 0.7; Z = 4.63, P < 0.0001); 33.9% improved, 60.2% remained the same, and only 5.9% reported worse health than at pretest.

Table 2. Repeated-measures analyses of variance comparing pretest to posttest and to 6-month followup (n = 118)*
MeasurePretest Mean ± SDPosttest Mean ± SD6-Month follow-up Mean ± SDRepeated-measures planned contrasts
Pre–postPre–6-month
FPFP
  • *

    VAS = visual analog scale; mHAQ = modified Health Assessment Questionnaire.

Disease activity measures       
 Pain (0–10 VAS)5.99 ± 2.604.51 ± 2.513.44 ± 2.1349.18<0.0001146.46<0.0001
 Tender joints (0–50)9.22 ± 10.847.51 ± 9.706.72 ± 8.139.070.00310.070.002
 Swollen joints (0–48)4.11 ± 8.513.13 ± 6.292.18 ± 5.323.360.0699.990.002
 mHAQ (0–3)0.564 ± 0.6880.539 ± 0.6330.499 ± 0.6081.630.2055.210.024
Arthritis health measures (0–10 VAS,  10 is worst)       
 Sleep impairment4.25 ± 3.763.09 ± 3.392.39 ± 2.7127.25<0.000153.67<0.0001
 Depression4.75 ± 3.613.97 ± 3.292.96 ± 2.848.130.00538.47<0.0001
 Daily activity impairment5.05 ± 3.613.50 ± 3.162.49 ± 2.4430.63<0.000188.10<0.0001
Self-management measures (0 is worst)       
 Self efficacy (0–10)5.53 ± 3.577.84 ± 1.878.35 ± 1.5757.10<0.000179.82<0.0001
 Self-care behavior (0–8)1.73 ± 1.404.07 ± 1.564.92 ± 1.50249.6<0.0001397.5<0.0001
 Arthritis knowledge (0–7)1.62 ± 1.594.42 ± 1.534.49 ± 1.31198.8<0.0001209.8<0.0001

Stepdown linear regression analyses were done on 7 outcome variables to identify significant predictors of improvement (Tables 3 and 4). Dependent variables were change scores (pretest – 6-month), with positive scores indicating improvement. The pretest measure corresponding to each change score was included in the regression model for each outcome variable because it was expected that the greater the problem at pretest, the greater the improvement can be at followup. Self-management outcomes related to program content, e.g., self-efficacy score and self-care behavior and arthritis knowledge score at 6-month followup, were included as predictors of disease activity and arthritis health improvement. The mean ± SD number of physician visits in the 4 months prior to the pretest was 1.14 ± 1.9 and in the 4 months prior to the 6-month followup was 1.85 ± 1.5. The increase in physician visits was mainly due to 54 of 67 persons with no visits at pretest who then went to see a physician for their arthritis after the SAEP. Number of physician visits between posttest and 6-month followup was included in the regression model to see how physician visits contributed to improvement.

Table 3. Summary of regression models for each dependent variable (n = 118)*
Dependent variable improvement scoreR2Adjusted R2FPConstant + predictors included in each stepwise regression model
  • *

    mHAQ = modified Health Assessment Questionnaire.

Pain improvement0.5090.50159.67<0.0001Constant = −6.057 + pain (pretest) + efficacy (6 months)
No. tender joints improvement0.5240.51241.88<0.0001Constant = −1.348 + no. tender joints (pretest) + inflammatory + no. physician visits
No. swollen joints improvement0.8060.802238.5<0.0001Constant = −0.631 + no. swollen joints (pretest) + inflammatory
Impaired sleep improvement0.5930.58254.40<0.0001Constant = −2.622 + sleep (pretest) + efficacy (6 months) + pain (6 months)
Depression improvement0.6120.60158.83<0.0001Constant = −3.569 + depression (pretest) + efficacy (6 months) + pain (6 months)
Impaired daily activity improvement0.6840.67680.97<0.0001Constant = −5.430 + daily activity (pretest) + efficacy (6 months) + pain (6 months)
mHAQ improvement0.3410.32218.61<0.0001Constant = 0.116 + mHAQ (pretest) + no. physician visits (6 months) + pain (6 months)
Table 4. Regression coefficients (B) and significance levels for predictors*
Dependent variablePretest measureEfficacy (6 months)Self-care behavior/ knowledge (6 months)No. physician visits (6 months)Inflammatory arthritisPain rating (6 months)
BPBPBPBPBPBP
  • *

    mHAQ = modified Health Assessment Questionnaire.

Pain improvement0.678<0.00010.543<0.00010.0270.713−0.0480.489    
No. tender joints improvement0.639<0.00010.0030.964−0.0010.992−0.7920.037−7.650.001  
No. swollen joints improvement0.886<0.00010.0460.299−0.0510.224−0.0580.185−14.13<0.0001  
Impaired sleep improvement0.638<0.00010.3350.0110.0220.742−0.0060.924  −0.3010.003
Depression improvement0.719<0.00010.4210.0040.0710.2800.0180.773  −0.461<0.0001
Impaired daily activity improvement0.763<0.00010.583<0.0001−0.1040.077−0.0640.250  −0.2170.020
mHAQ improvement0.293<0.00010.1420.1570.1010.215−0.0360.034  −0.044<0.0001

The pretest measure was the best predictor of improvement score for each outcome (e.g., for pain improvement, pretest pain rating was the first predictor to enter the stepdown regression model with B = 0.678, P < 0.0001). After the pretest score, self efficacy was a significant predictor of improvement in 4 of 7 outcome variables (P < 0.0001) except the tender and swollen joint count and mHAQ scores. Having a type of inflammatory arthritis (by self report) was predictive of less improvement in number of tender and swollen joints (B = –7.65 and –14.13, respectively). Number of physician visits entered the regression model for improvement in tender joints and mHAQ. However, B was –0.792 for tender joints and –0.036 for mHAQ, suggesting higher improvements in tender joint count and mHAQ were related to fewer physician visits. Similarly, patients with lower improvement, e.g., worsening tender joint count or mHAQ score, had more physician visits. Pain rating entered the regression models for ratings of arthritis effect on sleep, mood, and daily activity, suggesting that pain is an important component of these outcomes. Attendance was very good; 52.5% attended all 6 classes, 39% attended 5, and the remaining 8.5% attended 4 of 6 classes. Attendance was not a significant predictor for any outcome measures.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

The SAEP as presented by the Arthritis Foundation, Southern California Chapter, in Orange County produced significant improvements in patient arthritis knowledge, self efficacy, general health, and arthritis symptoms from pretest to posttest, which were maintained over the 6-month followup period. Physical function (measured by the mHAQ) did not change from pretest to posttest, but showed improvement after 6 months. Similar findings were shown by Lorig et al (10) among Spanish-speaking patients in the Stanford area of northern California. Their sample was also predominantly from Mexico, with 46% having <7 years of education.

In contrast, Solomon et al (9) found no significant difference between intervention patients attending ASHC classes and controls who were given the ASHC book to read, and overall no significant changes from baseline to followup. These contrasting findings may be due to differences in the respective samples. Their English-speaking participants were recruited from a physician-hospital network, were older than our sample (mean age 68 years), 96% white, and well educated (29% of intervention and 49% control groups were college graduates). Many may have already been knowledgeable about pain control and coping skills at baseline. Moreover, all were under physician's care and 39% of intervention and 53% of controls were treated by a rheumatologist. Our sample had similar levels of pain and disability, but was on average 18 years younger and less well educated (55% had <7 years of education), with only 6% reporting care by a rheumatologist. Additional studies, including randomized controlled trials among various populations and settings, are needed to better target the ASHC to participants most likely to benefit.

Components of best practices in arthritis care should include effective patient education, such as the SAEP, which emphasizes empowerment and self-efficacy skills in coordination with appropriate physician care for arthritis. These components are difficult to achieve in lower-educated, indigent populations with less access both to health information and health care. The SAEP empowered participants by improving self-management measures (self efficacy, self-care behavior, and arthritis knowledge), which contributed to the significant improvements in measured outcomes at 6-month followup. Empowerment may include self-management skills as well as learning how to gain access to health care, finding appropriate physician care, and communicating more effectively with their physicians. As evidenced by the linear regression models to predict change in tender joint count and mHAQ, patients with worsening scores tended to have an increased number of physician visits, suggesting that the SAEP may have empowered them to seek physician care as appropriately indicated.

In summary, the Spanish Arthritis Empowerment Program was successfully disseminated and implemented in a lower-educated Spanish-speaking population in Southern California. Participants improved their self-management skills, knowledge of arthritis, appropriate seeking of health care for arthritis, and implemented changes in self-care behavior related to arthritis.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

We gratefully acknowledge invaluable assistance from Erika Vertiz (program coordinator), Julie Bevan, MD, and Virginia Gonzalez, MPH.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
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