Racial differences in self-reported pain and function among individuals with radiographic hip and knee osteoarthritis: the Johnston County Osteoarthritis Project.

OBJECTIVE: This study compared pain and function among African Americans and Caucasian with radiographic hip and/or knee osteoarthritis (OA), controlling for radiographic severity and other patient characteristics. METHODS: Participants were 1368 individuals (32% African American) from the Johnston County Osteoarthritis Project with only knee OA, only hip OA, and both knee and hip OA. Linear regression models examined racial differences in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores and pain and function subscales, adjusting for radiographic severity, age, gender, education, body mass index (BMI), depressive symptoms, and WOMAC pain (last variable in models of function). RESULTS: Among those with only knee OA, African Americans had significantly worse mean WOMAC total scores than Caucasian (32.8 vs 24.3, P<0.001), and worse pain and function scores (P<0.001). Racial differences in WOMAC total, pain, and function scores persisted when controlling for radiographic severity and demographic factors but were not significant when also controlling for BMI and depressive symptoms. In models of WOMAC function, pain was the most strongly associated variable and substantially reduced the association of race with function. There were no racial differences in WOMAC scores among those with only hip OA or with both knee and hip OA. CONCLUSION: Among participants with knee OA, racial differences in pain and function may be explained by BMI and depressive symptoms, and racial differences in function may also be largely influenced by pain. Improving management of weight and depressive symptoms may be key steps toward reducing racial disparities in knee OA symptoms.

Patient perceptions about illness self-management in ANCA-associated small vessel vasculitis.

OBJECTIVES: To characterize patient perceptions, related to eight self-management behaviours relevant for adults with ANCA-associated small vessel vasculitis (ANCA-SVV), and to determine if these perceptions were associated with performance of each behaviour. METHODS: Adults with ANCA-SVV (n = 202) completed a self-administered questionnaire that assessed eight self-management behaviours (adherence to recommendations for medication, health service use, diet, exercise, infection avoidance and symptom monitoring; prompt reporting of symptoms and side effects; and adjusting activities in response to symptoms), perceptions about these behaviours, socio-demographics, clinical factors and social desirability bias. Descriptive statistics were generated to characterize patients' perceptions about difficulty of, importance of, and specific barriers to performing each behaviour. Regression analyses explored whether these variables were associated with performing each behaviour, controlling for potential confounders. RESULTS: With few exceptions, higher perceived importance and lower perceived difficulty of each behaviour were associated with more frequent performance of the behaviour. For each behaviour, several specific barriers were frequently endorsed by patients and a number of these were associated with lower levels of self-management. CONCLUSION: This study reveals that patient perceptions about the illness and its treatment influence ANCA-SVV self-management. Perceived barriers to medication, health services, diet and exercise adherence were similar to those in other illnesses. This study also provides insight into barriers experienced by patients in performing behaviours (infection avoidance, symptom monitoring, reporting symptoms and side-effects and adjusting activities) not often previously studied. How the identification of these barriers can help inform future interventions for ANCA-SVV patients is to be discussed.

Development of a health status measure for older African-American women with type 2 diabetes.

OBJECTIVE: To develop a health status measure in older African-American women with type 2 diabetes. RESEARCH DESIGN AND METHODS: African-American women, age > or =40 years with type 2 diabetes, were recruited from central North Carolina to participate in three sequential phases: 1) Seven focus groups were convened and transcripts evaluated to generate questions and identify plausible domains; 2) Ten one-on-one cognitive response interviews were performed to ensure clarity and cultural appropriateness of the questions; and 3) 217 women participated in psychometric evaluation to establish the internal consistency and validity of the instrument. RESULTS: Three broad categories--mental, physical, and social well-being--captured important issues generated during the focus groups. "My diabetes" was added during the cognitive response interviews as a way of separating the impact of diabetes from coexisting issues that affect health status. The response option was changed from a six- to a four-point Likert scale to accommodate subject preference. Using principal components and subsequent promax rotation, we identified two hierarchical domains (mental and social well-being) and a physical symptom index. The internal consistency (Cronbach's alpha) of the mental and social well-being subscales are 0.83 and 0.93, respectively. A priori hypothesized correlations between subscales along with each subscale and glycated hemoglobin, diabetes duration, physical activity, and a perceived health competence scale helped establish the construct validity of the instrument. CONCLUSIONS: A culturally appropriate disease-specific health status measure for older African-American women with type 2 diabetes has been developed. We have established the internal consistency, construct validity, and factor analytic properties of the measure. This measure should prove useful for investigators who seek a health status instrument that addresses issues germane to African-American women with type 2 diabetes.

Older Medicare enrolees' choices for insured services.

OBJECTIVES: The Medicare Trust Fund is expected to be bankrupt in the next decade, thus threatening the viability of the Medicare Program. We have ascertained what Medicare enrollees' priorities for insured services would be, and why, if it were fiscally necessary to limit Medicare benefits to maintain the viability of the Program. DESIGN: A cross-sectional survey using anonymous, inperson interviews and an innovative instrument to elicit choices. SETTING: General Internal Medicine outpatient clinic at a university teaching hospital. PARTICIPANTS: One hundred five adults, 65 years of age and older, who had primary care physician visits between July and September 1995. MEASUREMENTS: Desire to personally select insurance benefits, insurance benefit choices, and the reasons for selection or rejection of benefits. RESULTS: Subjects of various educational and economic backgrounds were able to carry out the selection process with relative case, and four-fifths of respondents preferred to make their own choices about insured services. The most frequently selected services were hospitalization, outpatient care, prescription drugs, eye care, and home care, in descending order. Subjects selected 52 different combinations of services. Only 2% of respondents picked the current Medicare service package. The reasons given for selection varied by service; cost and current or anticipated need for a service were the most frequently cited forces driving the choices made. CONCLUSION: These data suggest that Medicare enrollees prefer some element of choice about their health insurance coverage. Their choices vary widely and differ from the current Medicare package.

Interactive computer technology for skin cancer prevention targeting children.

BACKGROUND: Computer technology has become an integral part of health care, yet there have been few studies exploring the use of multimedia technology in the prevention of cancer, especially targeting children. OBJECTIVE: The aims of this study were to develop and evaluate a new multimedia computer program for the primary prevention of skin cancer among a childhood population. DESIGN AND PARTICIPANTS: An interactive CD-ROM program was developed, then pilot tested in a public elementary school in rural North Carolina. This intervention trial involved 8 third- and fourth-grade classes (N = 209 students), randomized into 3 groups: computer intervention, standard teacher-led intervention, and controls. MAIN OUTCOME MEASURES: Students were tested using pre- and postintervention surveys that measured knowledge, attitudes, and self-reported behaviors. A 7-month follow-up survey was performed. RESULTS: There was a significant increase in postintervention knowledge for the computer group when compared to either the teacher-led or control groups (mean scores out of 100: 75.2, 59.5, 55.0, respectively; p < 0.001). Attitudes about suntanning demonstrated a significant difference between the 3 groups (mean scores out of 100: 64.0, 53.0, 48.6, respectively; p = 0.002). There were slight improvements in the behavioral scores, especially among the computer group, but the overall differences were not significant. Similar overall results were found for the long-term follow-up survey, except that attitudes about suntanning no longer demonstrated a significant difference. CONCLUSION: These results indicate that this new educational tool is an effective way to introduce health education programs for young children in typical classroom settings. This prototype may serve as a model for the development of future preventive school-based programs, including applications to other conditions associated with high-risk behaviors among children.

Do people with rheumatoid arthritis develop illness-related schemas?

OBJECTIVE: To assess, using both qualitative/inductive and quantitative data, whether people with rheumatoid arthritis (RA) have schemas related to arthritis. METHODS: Themes identified from interview and focus group transcripts were used to develop 1) questionnaire items, and 2) statements participants were asked to recall during home interviews. Two hundred one people with RA completed questionnaires and recall tasks of the type used in cognitive research, followed 10 days later by another recall assessment by telephone. RESULTS: Qualitative methods, item-level questionnaire data, and category-level recall data yielded convergent results supporting 4 final categories: mastery, support, loss of independence, and depression. Regression analyses indicated that category of earlier recollections predicted subsequent recollections assessed via phone. CONCLUSIONS: Results from widely different methods offer at least partial support for arthritis schemas and suggest that the concepts identified are meaningful to patients as well as to researchers.

Effect of satisfaction with one's abilities on positive and negative affect among individuals with recently diagnosed rheumatoid arthritis.

OBJECTIVE: The purpose of this study was to examine the effect that self-evaluation processes have on psychologic well-being among individuals with rheumatoid arthritis (RA). METHODS: The study used a longitudinal research design with 4 data collection points. Participants were 227 adults with recently diagnosed RA. Data were collected via mailed questionnaire and telephone interview. Two dimensions of psychologic well-being were assessed--positive affect and negative affect. RESULTS: We found that, among participants who viewed the abilities being evaluated as very important, greater satisfaction at time 1 was associated with less negative affect at time 2 and time 4. Satisfaction was not associated with positive affect at any of the time points, however. CONCLUSION: Study findings indicate that dissatisfaction with illness-related abilities can exacerbate psychologic distress. The findings also highlight the need for research examining the role that positive affect plays in adaptation to RA.

Correlates of changes in mood following a mood induction in osteoarthritis patients.

OBJECTIVE: To determine the relationship of mood management skills, and affective and cognitive states to changes in moods following mood induction among people with osteoarthritis. METHODS: After completing questionnaires, participants underwent a negative mood induction. Momentary moods were assessed prior to, immediately following, and several minutes after the mood induction. RESULTS: A specific mood management skill, mood clarity, consistently predicted changes in positive mood following the mood induction: people who scored high on mood clarity experienced less diminution in positive affect. In contrast, changes in negative affect were unrelated to mood management skills. However, people who scored higher on measures of depressive symptoms and pessimism rebounded from the negative induced mood less strongly than others. CONCLUSION: Positive and negative emotional states operate largely independently and are differentially influenced by mood clarity, depressive symptoms, and pessimism. High levels of mood clarity may be adaptive in illnesses such as osteoarthritis because negative affective experiences that may be unavoidable need not preclude positive affective states.

Using a short food frequency questionnaire to estimate dietary calcium consumption: a tool for patient education.

OBJECTIVE: To develop a short food frequency questionnaire (FFQ) assessing calcium intake and a prediction equation for estimating total calcium intake from the short FFQ. METHODS: Data were collected from 536 women via mailed questionnaires at 3 time points. Stepwise regression analyses were used to identify those foods and beverages included in the Black Health Habits and History Questionnaire (HHHQ) that explained the most variance in participants' dietary calcium intake. A prediction equation was developed to estimate total calcium intake based only on information from the foods/beverages identified. RESULTS: Calcium obtained from 15 foods/beverages explained 97.2% of the variance in total calcium intake. The mean absolute difference between total calcium intake estimated from the 15 foods/beverages and the full HHHQ was less than 50 mg at each time point. CONCLUSION: Findings suggest that a short FFQ can provide estimates of total dietary calcium consumption comparable to the full Block HHHQ.

Appraisal of and coping with arthritis-related problems in household activities, leisure activities, and pain management.

PURPOSE: We examined whether or not there are systematic differences in how people appraise different types of illness-related problems and in how they cope with these problems. METHODS: Two hundred thirty-five adults with recently diagnosed rheumatoid arthritis completed a mailed questionnaire followed by a telephone interview. A series of stress appraisal and coping variables were assessed in relation to three areas: household activities, leisure activities, and pain management. RESULTS: Pain differed significantly from household and leisure activities with regard to several appraisal and coping variables. Participants reported the least control over problems with pain, while attaching the most importance to pain control. Leisure activities also stood out as unique on several variables. Participants perceived greater ability and were more satisfied with their ability in relation to leisure activities. CONCLUSION: These findings show that, at least early in the disease, appraisal and coping strategies differ across the areas of household activities, leisure activities, and pain management.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior.

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Arthritis and perceptions of quality of life: an examination of positive and negative affect in rheumatoid arthritis patients.

The utility of measuring both positive and negative affective states for assessing rheumatoid arthritis (RA) patients was examined in 3 independent samples of male and female RA patients (Sample A: 179 women, 48 men; Sample B: 177 women, 24 men; Sample C: 134 women, 38 men). Confirmatory factor analyses of each sample indicated that positive and negative affect constituted separate, negatively correlated factors. The relations among disease variables, coping, and affects were consistent with a model in which coping mediates the relationship between disease variables and positive and negative affect. Patients with higher pain and limitation from RA had higher levels of maladaptive coping, and maladaptive coping was associated with lower positive affect and higher negative affect. Those RAs with higher activity limitation also reported less adaptive coping, which was associated with less positive affect.

A brief dietary assessment to guide cholesterol reduction in low-income individuals: design and validation.

Low-income Americans are at greatest risk for coronary heart disease. Dietary assessment methods are needed that can efficiently and effectively guide diet counseling to reduce serum cholesterol in this population. The Dietary Risk Assessment is a brief food frequency questionnaire designed to guide an intervention program for cholesterol reduction. It can easily be administered and scored in 10 to 15 minutes by persons who are not trained in nutrition. The assessment is culturally specific for a low-income southern population, identifies positive as well as problematic dietary behaviors, is easily interpreted, and measures potential barriers to dietary change. The assessment was validated against 3 days of dietary recall data in a sample of 42 low-income individuals recruited from the waiting room of an ambulatory care clinic. A Keys score, which measures the serum-cholesterol-raising potential of the diet, was calculated for each patient from their recall data. The Keys and Dietary Risk Assessment scores were significantly correlated (r = .60, P less than .001). We conclude that the Dietary Risk Assessment can rank individuals by level of dietary atherogenic risk adequately to guide a dietary treatment program for low-income patients, an underserved population with a high prevalence of diet-induced elevations in serum cholesterol.

Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults.

OBJECTIVE: To evaluate the effectiveness of computer-tailored newsletter interventions in improving the number and variety of fruits and vegetables eaten by adults. DESIGN: The 4-group randomized trial with pre- and postintervention measures consisted of a control group and 3 intervention groups receiving nontailored newsletters, computer-tailored newsletters, or tailored newsletters with tailored goal-setting information. Intervention groups received 1 newsletter each month for 4 months. SUBJECTS: Baseline surveys were completed by 710 health maintenance organization clients. Postintervention surveys administered 6 months after baseline were completed by 573 participants (80.8%). INTERVENTION: All newsletters contained strategies for improving fruit and vegetable consumption. Tailored newsletters used computer algorithms to match a person's baseline survey information with the most relevant newsletter messages for promoting dietary change. MAIN OUTCOME MEASURES: Daily intake and weekly variety of fruits and vegetables were measured using a food frequency questionnaire. STATISTICAL ANALYSES PERFORMED: Analysis of covariance and Tukey's honestly significant difference test were used to assess differences in the number and variety of fruits and vegetables consumed among intervention groups. RESULTS: For persons completing postintervention surveys (n = 573), all 3 newsletter groups had significantly higher daily intake and variety scores compared with the control group. Although there was a trend of improved intake and variety with each added newsletter element, there were no significant differences at follow-up among the newsletter groups. CONCLUSIONS: Newsletters can be effective in improving the fruit and vegetable consumption of adults. In this study, a computer-tailoring system did not significantly enhance the effect of the nutrition newsletters on fruit and vegetable intake.

Perception of contingency and mental retardation.

It is argued that the general learning difficulties exhibited by mentally retarded persons are similar in many respects to the learning difficulties of nonretarded persons who are in a state of learned helplessness (Seligman, 1975) or who are external in locus of control orientation. It is suggested that studies of locus of control and learned helplessness as theoretical constructs both directly concern the perceiving of relationships between behavior and outcomes, and that a systematic investigation of perception of contingency might increase our understanding of some of the learning difficulties of mentally retarded persons. An overview is given of the results of the few studies that have addressed perception of contingency and mental retardation, and suggestions for future research are offered.

Reproductive decisions of women at risk for acquiring HIV infection.

Approximately 1 to 1.5 million people in the United States are infected with HIV. The incidence of HIV is increasing among women and children. Little information exists regarding the determinants of reproductive decisions of women at risk of HIV infection. This study investigated the correlates of reproductive decisions using data from the National AIDS Demonstration and Research Projects funded by the National Institutes on Drug Abuse. Subjects for this study were 1,921 women. HIV serostatus, AIDS knowledge, and perceived risk for getting AIDS were not associated with the reproductive decisions. Major correlates of reproductive decisions were age, ethnicity, and the number of children living with the women. Pregnancy, 6 months after the baseline interview, was associated with intention to become pregnant at baseline. In addition age and education level were significant predictors of self-reported pregnancy at follow-up.

Effects of educational materials concerning osteoporosis on women's knowledge, beliefs, and behavior.

PURPOSE: This study examined the effects of brief written educational materials on osteoporosis-related knowledge, beliefs, and behaviors. The study also examined whether observed effects varied as a function of one's stage in the precaution adoption process. DESIGN: The study used an experimental research design. SETTING: Participants were identified from North Carolina driver's license records. SUBJECTS: Of the 1476 women in the initial sample, 536 (36.3%) enrolled in the study and 307 completed all follow-up assessments. INTERVENTION: Participants were randomly assigned to one of four groups. One group received an information packet containing general information about osteoporosis. One group received an action plan packet containing instructions on how to increase one's level of exercise and calcium intake. One group received both packets. The final group received neither packet. MEASURES: Primary study variables were beliefs related to osteoporosis, calcium, and exercise; osteoporosis knowledge; calcium and exercise stage; calcium intake; and exercise level. RESULTS: Overall, receipt of the information packet was associated with changes in knowledge and beliefs (F[18,283] = 2.11, p < .01) irrespective of participants' stage of change. No effects on behavior were observed. CONCLUSIONS: These findings suggest that brief written educational materials can facilitate knowledge and belief change but that they do not promote behavior change. The generalizability of these findings is limited by the low study response rate.

Nutrition education for cardiovascular disease prevention among low income populations--description and pilot evaluation of a physician-based model.

Low income Americans are at greatest risk for coronary heart disease but have least access to health promotion programs for life style modification. Primary care physicians may represent one of the few sources of preventive care available to the poor. However, the majority of physicians feel unprepared to help patients achieve dietary change, and few existing nutrition intervention programs address the special needs of low literacy populations. The Food for Heart Program was developed to facilitate dietary counseling experienced by primary care physicians who care for low literacy patients and to overcome barriers to behavior change faced by patients. The program consists of three components: (1) a validated dietary risk assessment that rapidly identifies atherogenic eating habits and requires no nutritional expertise to administer or interpret, (2) a structured diet treatment program that is culturally specific for a southern patient population and links practical behavior change recommendations with results of the diet assessment, and (3) a system for monitoring and reinforcement that prompts physicians to review progress, reinforce prior messages, and reward positive change. Behavior change theory is used to guide the intervention and readability of the material has been assessed at the 5-6th grade level. An evaluation study of the Food for Heart Program suggests that it has a positive impact on physician counseling and that patients are responding favorably to these efforts.

Psychological distress among survivors of burn injury: the role of outcome expectations and perceptions of importance.

This study examined factors associated with psychologic distress among survivors of burn injury. The study tested hypotheses derived from Scheier and Carver's model of behavioral self-regulation and focused on two primary predictor variables: expectations concerning rehabilitative outcomes and the importance attached to those outcomes. The study used a cross-sectional research design. Two hundred sixteen people who had sustained major or moderate thermal burn injuries within 2 years of study entry served as subjects. Data were collected via mailed questionnaire and chart review. Consistent with study hypotheses, we found that participants who had low expectations for further improvement but who attached high importance to the need for improvement exhibited the most psychologic distress. Study findings lend support to Scheier and Carver's model and suggest that application of this model within the context of burn rehabilitation may increase our understanding of the rehabilitation process. Directions for future theory-based research are discussed.