Moving from identifying to addressing health disparities: A public health perspective†
The findings and conclusions in this article are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.
This special themed issue of Arthritis Care & Research provides a valuable overview of the current state of the scientific study of health disparities in rheumatology. Several articles, such as the study by Lee and colleagues on the association of African American race/ethnicity and low bone mineral density (1), help us identify or quantify health disparities. Other articles, such as the systematic review by Kane et al of studies on disparities in total knee replacements (2) and the study by Fernández et al of ethnic disparities in systemic lupus erythematosus (3), help us understand some of the factors contributing to health disparities.
However, as recognized by Fernández et al (3), identifying and understanding health disparities is not enough. We also need to investigate interventions to address health disparities—currently the least mature area within the scientific study of health disparities in rheumatology. Only one article in this issue, the study by Weng and colleagues on the use of an educational video as a decision aid in total knee replacement (4), examines an attempt to address a known health disparity. As a field, we must expand our efforts to actively address disparities in health behavior and status if we are to improve the quality of life of all persons with arthritis.
Both clinical and public health interventions can be used to reduce health disparities. Clinic-based interventions, such as the total knee replacement decision aid used by Weng et al, reach persons with arthritis individually. Public health approaches, which are designed to improve the health and quality of life of broader segments of the population, need to reach larger population groups. One promising public health approach, health communications campaigns, has been used by the Centers for Disease Control and Prevention (CDC) Arthritis Program to address health disparities related to physical activity among individuals with arthritis.
Disparities in Disease Impact and Physical Activity Among Persons With Arthritis
According to national data from 2002, approximately 21% of US adults report doctor-diagnosed arthritis (5). Of these, more than one-third report activity limitations attributable to arthritis, and nearly one-third of working-age adults report work limitations attributable to the disease (5). Minority populations bear a disproportionate amount of the burden associated with arthritis. Blacks and whites have a similar prevalence of arthritis, but blacks have a higher proportion of arthritis-attributable activity limitations and work limitations and severe pain. Hispanics have a lower prevalence of arthritis than whites, but a higher proportion of Hispanics report arthritis-attributable work limitations and severe pain (5).
Physical activity and exercise have been shown to significantly reduce pain and improve physical and psychological function (6); they are cornerstones of nonpharmacologic management of rheumatoid arthritis and osteoarthritis of the hip and knee (7, 8). However, individuals with arthritis are more likely to be inactive than those without arthritis, and the rate of inactivity is higher among minority and disadvantaged populations. Approximately 44% of adults with arthritis, but only 36% of adults without arthritis, are inactive (9). Approximately 41% of whites with arthritis, but 55% of blacks and 58% of Hispanics with the disease, are inactive. Activity levels also diminish with decreasing levels of education: among persons with arthritis, only 31% of those educated beyond high school, but 54% of those with a high school education or less, are inactive. The CDC Arthritis Program's health communications campaign was designed to address these disparities in disease impact and physical inactivity.
Using Health Communications Campaigns to Promote Physical Activity
Health communications campaigns are organized and purposeful efforts to use mass media channels to communicate with, persuade, and influence a population or a large population segment to consider, adopt, or change to more health-enhancing practices (10). However, to be effective, health communications campaigns must be designed to be meaningful and accessible to the target audience. Audience research is needed to determine the messaging, motivating concepts, types of materials, and delivery channels that will reach the target audience.
The initial CDC Arthritis Program communications campaign targeted adults with arthritis ages 45–64 years (to create a more homogeneous group) and persons of lower education and income levels because of the greater disease impact among that population. Because early audience research indicated that white and black men and women responded to the same messages and motivating concepts, these populations were all targeted in this initial campaign. Within these populations, individuals who had begun to experience some limitations from their arthritis were targeted because audience research indicated that persons with arthritis pay little attention to their arthritis until it begins to affect, or threatens to affect, valued life activities.
Key findings from the extensive audience research used to develop this initial campaign (29 focus groups and 24 individual interviews with the target audience, and 16 interviews with primary care physicians) are summarized in Table 1 (11). Based on this audience research, a mass media campaign was designed around the tag line “Physical Activity. The Arthritis Pain Reliever.” Campaign materials (which included radio spots, brochures and countertop brochure holders, and print advertisements and posters) were selected with the understanding that because the target audience was unlikely to seek arthritis information, materials needed to be placed where individuals with arthritis would encounter them in the course of their daily lives.
Table 1. Key findings of Centers for Disease Control and Prevention-sponsored initial formative research with white and black adults with arthritis from lower socioeconomic levels (11)
|White and black adults with arthritis from lower socioeconomic levels:|
| 1. Prefer nonpharmacologic interventions (but physicians believe patients prefer medications).|
| 2. Believe exercise could be helpful, but do not receive specific instructions from their physicians (physicians agree).|
| 3. Are motivated primarily by the idea of pain relief.|
| 4. Attend to their arthritis when it begins to affect, or threatens to affect, valued life roles.|
| 5. Do not seek out health information but welcome it when they encounter it.|
A posttest-only community-based telephone survey was used to evaluate the pilot test of the Pain Reliever campaign. Pilot test data from 4 sites indicated that the campaign reached the target audience, increased knowledge about physical activity, and stimulated an increase in physical activity (Table 2) (12).
Table 2. Results of pilot testing of 2 health communications campaigns developed by the Centers for Disease Control and Prevention Arthritis Program (15)*
|Read/heard about relieving arthritis pain with physical activity/using exercise to beat arthritis in the past month||50||67|
|Agree that physical activity/exercise can be helpful even if done 10 minutes at a time||92||88|
|Increased physical activity/exercise in last month in response to something they heard or read||20||27|
Addressing Diverse Audiences Through Health Communications Campaigns
Health communications campaigns need to be designed to resonate with their specific target audience, and a campaign designed for one audience may not be effective with another. To reach a new audience, an existing campaign may need to be modified slightly, or a whole new campaign may need to be created. Modest modifications in the Pain Reliever campaign were needed to expand its audience. After the campaign was released, some organizations desired to target adults older than 45–64 years. Eighteen in-depth interviews were used to test the campaign materials for appropriateness with an older adult audience. Findings indicated that although most of the messages resonated with persons of lower income between the ages of 65 and 70 years, the senior adult audience interpreted the messages more literally. For example, the senior adult audience responded negatively to advertisements with the headline “Reduce arthritis pain? It's not such a big stretch” because in their experience, “It IS a big stretch.” The senior adult audience also preferred materials that had the same headline (“Don't sit still for arthritis pain”) rather than materials with a mixture of headlines used with the younger audience (13). Campaign materials were revised for the senior adult audience so that all materials had the same headline.
More substantial changes were needed to create a campaign to reach Spanish-speaking Hispanic adults with arthritis. Although the Hispanic audience had some commonalities with the black/white audience, such as similar barriers to exercise and similar aversions to medications, the two audiences also had substantive differences. Specifically, the concept most likely to motivate the English-speaking white/black audience to take action was pain relief (11). The most motivating concept for this Spanish-speaking Hispanic audience was gaining control (14). The English-speaking audience preferred the term physical activity to exercise, which had negative connotations of being a boring chore. The Spanish-speaking audience preferred the term exercise because it implied planned, sustained, and intentional activity (14). As did the English-speaking older adult audience, the Spanish-speaking Hispanic audience preferred concrete messages and concepts and graphics that were close to their personal experiences.
These conceptual and linguistic preferences were incorporated into a Spanish-language health communications campaign with a tagline that reflected the priority of gaining control: “Buenos Dias, Artritis. Hoy no nos venceras” (“Good Morning, Arthritis. You will not beat us today”). Campaign materials were similar to those for the English campaign (radio, brochures, and print advertisements) but also included billboards and bus shelter placards because formative research findings indicated that the Spanish-speaking population used mass transit frequently. Pilot testing of the Buenos Dias, Artritis health communications campaign at 4 sites revealed results very similar to those for the Pain Reliever campaign; each demonstrated awareness of the campaign message, knowledge about physical activity, and an increase in physical activity (see Table 2) (15).
Rheumatology as a field is making progress in identifying disparities in health status and behavior and in understanding contributing factors. Yet we need to move beyond identifying and understanding to actually addressing these disparities. Interventions to reduce health disparities (or, more desirably, to raise the disadvantaged population to the level of the advantaged population) need to be developed and implemented at the individual level (e.g., clinical treatment) and population level. One promising population-based approach to addressing these disparities is health communications campaigns. Mass-media health communications campaigns complement clinical interventions and can be useful tools in the effort to eliminate health disparities. Because effective campaigns are based on a clear understanding of the messages and message channels likely to reach and motivate a specific target audience, they are well suited for addressing the unique needs of disadvantaged populations.