Remote Delivery of the Chronic Pain Self-management Program Using Self-directed Materials and Small-group Telephone Support: A Pilot Study.

A remote (telephone and tool kit) chronic pain program was studied using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. This 6-week pilot took place in underserved communities in Cleveland, Ohio. We determined reach by the diversity of the population, nearly 50% Black and mostly low income. Effectiveness over 7 weeks was shown with validated instruments (depression, pain, sleep, quality of life, self-rated health, and self-efficacy). Changes in pain, depression, and self-efficacy were significant. (p < .01). Remote implementation was accomplished by sending participants a box of materials (book, exercise and relaxation CDs, a self-test, and tip sheets). Participants also participated in peer-facilitated, weekly, scripted telephone calls. Maintenance was demonstrated as the study site has offered nine additional programs with more plan. In addition, 60 additional organizations are now offering the program. This proof-of-concept study offers an alternate to in-person chronic pain self-management program delivery.

Development and Evaluation of the Eight-Item Caregiver Self-Efficacy Scale (CSES-8).

BACKGROUND AND OBJECTIVES: This paper describes the development and evaluation of a short caregiving self-efficacy measure. The self-administered 8-item Caregiver Self-Efficacy Scale (CSES-8) was developed to reflect components of typical caregiver support interventions and to be practical for inclusion in future self-efficacy and caregiving research. RESEARCH DESIGN AND METHODS: We administered the CSES-8 in 2 samples: participants in an intervention for caregivers of persons with cognitive disabilities, and a voluntary online survey for caregivers of adults. We evaluated the completion rate, item-scale correlations, reliability, descriptive statistics, and preliminary construct validity of the CSES-8 in both samples, and sensitivity to change in the intervention sample. RESULTS: The intervention caregivers' sample (N = 158) was 85% female (mean age = 65 years). The online survey sample (N = 138) was 90% female (mean age = 78). In both samples, the CSES-8 had excellent internal consistency reliability (.89 and .88) and good distribution with sufficient variability to detect change. Test-retest reliability was good in the online sample (.73). As evidence of construct validity, most hypotheses were confirmed in both samples. The CSES-8 was sensitive to change at 6 months for caregivers in the intervention program (p < .001). DISCUSSION AND IMPLICATIONS: The CSES-8 is short, comprehensive with respect to common components of interventions to improve caregivers' quality of life, and sensitive to change. It can serve a useful role exploring mechanisms by which caregiver intervention studies work, and it can be helpful in examining whether self-efficacy mediates the effect of these interventions on various outcomes such as psychological well-being.

Effects of COVID-19 on Informal Caregivers and the Development and Validation of a Scale in English and Spanish to Measure the Impact of COVID-19 on Caregivers.

To understand how the COVID-19 pandemic has affected caregivers, we assessed its perceived impact on caregiving through a new measure: the Caregiver COVID-19 Limitations Scale (CCLS-9), in Spanish and English. We also compared levels of caregiver self-efficacy and burden pre-COVID-19 and early in the pandemic. We administered surveys via internet to a convenience sample of caregivers in January 2020 (pre-pandemic, n = 221) and in April-June 2020 (English, n = 177 and Spanish samples, n = 144) to assess caregiver self-efficacy, depression, pain, and stress. We used the early pandemic surveys to explore the validity of the CCLS-9. The pre-COVID-19 survey and the April English surveys were compared to determine how the COVID-19 pandemic affected caregivers. The CCLS-9 had strong construct and divergent validity in both languages. Compared to pre-COVID-19, caregiver stress (p = .002) and pain (p = .009) were significantly greater early in COVID-19, providing evidence of its validity. COVID-19 added to caregiver stress and pain.

Building Better Caregivers: A Pragmatic 12-Month Trial of a Community-Based Workshop for Caregivers of Cognitively Impaired Adults.

Building Better Caregivers (BBC), a community 6-week, peer-led intervention, targets family caregivers of those with cognitive impairments. BBC was implemented in four geographically scattered areas. Self-report data were collected at baseline, 6 months, and 1 year. Primary outcome were caregiver strain and depression. Secondary outcomes included caregiver burden, stress, fatigue, pain, sleep, self-rated health, exercise, self-efficacy, and caregiver and care partner health care utilization. Paired t tests examined 6 month and 1-year improvements. General linear models examined associations between baseline and 6-month changes in self-efficacy and 12-month primary outcomes. Eighty-three participants (75% of eligible) completed 12-month data. Caregiver strain and depression improved significantly (Effect Sizes = .30 and .41). All secondary outcomes except exercise and caregiver health care utilization improved significantly. Baseline and 6-month improvements in self-efficacy were associated with improvements in caregiver strain and depression. In this pilot pragmatic study, BBC appears to assist caregivers while reducing care partner health care utilization. Self-efficacy appears to moderate these outcomes.

A Diabetes Self-Management Program: 12-Month Outcome Sustainability From a Nonreinforced Pragmatic Trial.

BACKGROUND: Diabetes self-management education has been shown to be effective in controlled trials. The 6-week Better Choices, Better Health-Diabetes (BCBH-D) self-management program was also associated with an improvement in health outcomes in a 6-month translation study. OBJECTIVE: The objective of this study was to determine whether a national translation of the BCBH-D self-management program, offered both Web-based and face-to-face, was associated with improvements in health outcomes (including HbA1c) and health behaviors (including recommended medical tests) 1 year after intervention. METHODS: Web-based programs were administered nationally, whereas face-to-face workshops took place in Atlanta, Indianapolis, and St Louis. Self-report questionnaires were either Web-based or administered by mail, at baseline and 1 year, and collected health and health-behavior measures. HbA1c blood samples were collected via mailed kits. A previous 6-month study found statistically significant improvements in 13 of 14 outcome measures, including HbA1c. For this study, paired t test compared baseline with 1-year outcomes. Subgroup analyses determined whether participants with specific conditions improved (high HbA1c, depression, hypoglycemia, nonadherence to medication, no aerobic exercise). The percentage of participants with improvements in effect size of at least 0.4 in at least 1 of the 5 measures was calculated. RESULTS: A total of 857 participants with 1-year data (69.7% of baseline participants) demonstrated statistically significant 1-year improvements in 13 of 15 outcome measures; 79.9% (685/857) of participants showed improvements in effect size of 0.4 or greater in at least 1 of the 5 criterial measures. CONCLUSIONS: Participants had small but significant benefits in multiple measures. Improvements previously noted at 6 months were maintained or amplified at 1 year.

Benefits of Diabetes Self-Management for Health Plan Members: A 6-Month Translation Study.

BACKGROUND: Diabetes self-management education has been shown to be effective in controlled trials. However, few programs that meet American Association of Diabetes Educators standards have been translated into widespread practice. OBJECTIVE: This study examined the translation of the evidence-based Better Choices, Better Health-Diabetes program in both Internet and face-to-face versions. METHODS: We administered the Internet program nationally in the United States (n=1010). We conducted face-to-face workshops in Atlanta, Georgia; Indianapolis, Indiana; and St. Louis, Missouri (n=232). Self-report questionnaires collected health indicator, health behavior, and health care utilization measures. Questionnaires were administered on the Web or by mail. We determined hemoglobin A1c (HbA1c) from blood samples collected via mailed kits. Paired t tests determined whether changes between baseline and 6 months differed significantly from no change. Subgroup analyses determined whether participants with specific conditions benefited (high HbA1c, depression, hypoglycemia, nonadherence to medication taking, and no aerobic exercise). We calculated the percentage of participants with improvements of at least 0.4 effect size in at least one of the 5 above measures. RESULTS: Of the 1242 participants, 884 provided 6-month follow-up questionnaires. There were statistically significant improvements in 6 of 7 health indicators (including HbA1c) and in 7 of 7 behaviors. For each of the 5 conditions, there were significant improvements among those with the condition (effect sizes 0.59-1.1). A total of 662 (75.0%) of study participants improved at least 0.4 effect size in at least one criterion, and 327 (37.1%) improved in 2 or more. CONCLUSIONS: The Diabetes Self-Management Program, offered in two modes, was successfully disseminated to a heterogeneous national population of members of either insured or administered health plans. Participants had small but significant benefits in multiple measures. The program appears effective in improving diabetes management.

Characteristics of the Spanish- and English-Language Self-Efficacy to Manage Diabetes Scales.

PURPOSE: The purpose of this study was to examine the characteristics of the Spanish-language diabetes self-efficacy scale (DSES-S) and the English-language version (DSES). METHODS: This study consists of secondary data from 3 randomized studies that administered the DSES-S and DSES at 2 time points. The scales consist of 8 Likert-type 10-point items. Principal component analysis was applied to determine if the scales were unitary or consisted of subscales. Univariate statistics were used to describe the scales. Sensitivity to change was measured by comparing randomized treatment with control groups, where the treatment included methods designed to enhance self-efficacy. General linear models were used to examine the association between the scales and the 8 medical outcomes after controlling for demographic variables. RESULTS: Principal component analysis indicated that there were 2 subscales for both versions: self-efficacy for behaviors and self-efficacy to manage blood levels and medical condition. The measures had similar means across the 3 studies, high internal consistent reliability, values distributed across the entire range, and they showed no evidence of floor effects and little evidence of ceiling effects. The measures were sensitive to change. They were associated with several health indicators and behaviors at baseline, and changes were associated with changes in health measures. CONCLUSIONS: The self-efficacy measures behaved consistently across the 3 studies and were highly reliable. Associations with medical indicators and behaviors suggested validity, although further study would be desirable to compare other measures of self-efficacy for people with type 2 diabetes. These brief scales are appropriate for measuring self-efficacy to manage diabetes.

Can a Box of Mailed Materials Achieve the Triple Aims of Health Care? The Mailed Chronic Disease Self-Management Tool Kit Study.

Not all patients with chronic conditions are able or willing to participate in small-group or Internet self-management programs. Based on the Arthritis Mailed Took Kit Program and the Chronic Disease Self-Management Program, a mailed Chronic Disease Self-Management Tool Kit, delivered in a onetime mailing, was developed as an alternative mode of delivery. Kits were mailed to a national sample of 255 participants with varying chronic conditions and evaluated in a longitudinal (6-month) trial. Outcomes reflected the triple aims of health care. At 6 months, participants demonstrated better health care indicators, better health indicators, and less health care utilization. There were significant improvements in two health care indicators and six health indicators and reductions in physician visits. Follow-up response rate was high (85%). There were no significant baseline differences between responders and nonresponders. Subgroup analyses were performed for a number of subgroups, including those with arthritis (58%) and/or depression (43%), and for African Americans (14%). Subgroups demonstrated improvements equal to or better than the overall group. The Mailed Chronic Disease Self-Management Tool Kit represents a third mode, along with small groups and Internet, of delivering self-management patient education, and appears to contribute to meeting the triple aims of health care for those who actively chose this mode of delivery.

Dissecting an online intervention for cancer survivors: four exploratory analyses of internet engagement and its effects on health status and health behaviors.

The Internet has been used extensively to offer health education content and also for social support. More recently, we have seen the advent of Internet-based health education interventions that combine content with structured social networking. In many ways this is the Internet equivalent to small group interventions. While we have some knowledge about the efficacy of these interventions, few studies have examined how participants engage with programs and how that might affect outcomes. This study seeks to explore (a) the content of posts and (b) the nature of participant engagement with an online, 6-week workshop for cancer survivors and how such engagement may affect health outcomes. Using methodologies related to computational linguistics (latent Dirichlet allocation) and more standard statistical approaches, we identified (a) discussion board themes; (b) the relationship between reading and posting messages and outcomes; (c) how making, completing, or not completing action plans is related to outcome; and (d) how self-tailoring relates to outcomes. When considering all posts, emotional support is a key theme. However, different sets of themes are expressed in the first workshop post where participants are asked to express their primary concern. Writing posts was related to improved outcomes, but reading posts was less important. Completing, but not merely making, action plans and self-tailoring are statistically associated with future positive health outcomes. The findings from these exploratory studies can be considered when shaping future electronically mediated social networking interventions. In addition, the methods used here can be used in analyzing other large electronically mediated social-networking interventions.

The English and Spanish Self-Efficacy to Manage Chronic Disease Scale measures were validated using multiple studies.

OBJECTIVES: Self-efficacy theory, as developed by Bandura, suggests that self-efficacy is an important predictor of future behavior. The Chronic Disease Self-Management Program was designed to enhance self-efficacy as one approach to improving health behaviors and outcomes for people with varying chronic diseases. The six-item Self-Efficacy to Manage Chronic Disease Scale (SEMCD) and the four-item Spanish-language version (SEMCD-S) were developed to measure changes in self-efficacy in program participants and have been used in a numerous evaluations of chronic disease self-management programs. This study describes the development of the scales and their psychometric properties. STUDY DESIGN AND SETTING: Secondary analyses of questionnaire data from 2,866 participants in six studies are used to quantify and evaluate the SEMCD. Data from 868 participants in two studies are used for the SEMCD-S. Subjects consisted of individuals with various chronic conditions, who enrolled in chronic disease self-management programs (either small group or Internet based). Subjects came from United States, England, Canada, Mexico, and Australia. Descriptive statistics are summarized, reliability tested (Cronbach alpha), and principal component analyses applied to items. Baseline and change scores are correlated with baseline and change scores for five medical outcome variables that have been shown to be associated with self-efficacy measures in past studies. RESULTS: Principal component analyses confirmed the one-dimensional structure of the scales. The SEMCD had means ranging from 4.9 to 6.1 and the SEMCD-S 6.1 and 6.2. Internal consistency was high (Cronbach alpha, 0.88-0.95). The scales were sensitive to change and significantly correlated with health outcomes. CONCLUSION: The SEMCD and SEMCD-S are reliable and appear to be valid instruments for assessing self-efficacy for managing chronic disease. There was remarkable consistency across a range of studies from varying countries using two languages.

The components of action planning and their associations with behavior and health outcomes.

BACKGROUND: Based on the works of Kiesler and Bandura, action plans have become important tools in patient self-management programs. One such program, shown effective in randomized trials, is the Internet Chronic Disease Self-Management Program. An implementation of this program, Healthy Living Canada, included detailed information on action plans and health-related outcome measures. METHODS: Action plans were coded by type, and associations between action plans, confidence in completion and completion were examined. Numbers of Action Plans attempted and competed and completion rates were calculated for participants and compared to six-month changes in outcomes using regression models. RESULTS: Five of seven outcome measures significantly improved at six-months. A total of 1136 action plans were posted by 254 participants in 12 workshops (mean 3.9 out of 5 possible); 59% of action plans involved exercise, 16% food, and 14% role management. Confidence of completion was associated with completion. Action plan completion measures were associated with improvements in activity limitation, aerobic exercise, and self-efficacy. Baseline self-efficacy was associated with at least partial completion of action plans. DISCUSSION: Action planning appears to be an important component of self-management interventions, with successful completion associated with improved health and self-efficacy outcomes.

Effectiveness of the chronic disease self-management program for persons with a serious mental illness: a translation study.

Evaluation of evidence-based interventions in new settings and new populations is the hallmark of successful translation. We evaluated the Chronic Disease Self-Management Program in persons with serious mental illness who were receiving care through Michigan Community Mental Health Services (N = 139). At 6-months, participants demonstrated improvements in health indicators (fatigue, quality of life, sleep, depression, health distress, and days health bad) and health behaviors (medical adherence and communication with doctor). The program was successfully administrated in a "real world" setting and continues to be used. In addition, the program appears to be an effective resource for people with serious mental illness.

Effects of chronic disease self-management programs for participants with higher depression scores: secondary analyses of an on-line and a small-group program.

Depression often accompanies chronic illness. Study aims included determining (1) the level of current depression (Patient Health Questionnaire (PHQ)-8 ≥ 10) for two sets of Chronic Disease Self-Management Programs (CDSMP) participants; (2) if depression or other outcomes improved for those with PHQ-8 ≥ 10; and (3) if outcomes differed for participants with or without depression. This study utilized longitudinal secondary data analysis of depression cohorts (PHQ-8 ≥ 10) from two independent translational implementations of the CDSMP, small-group (N = 175) and Internet-based (N = 110). At baseline, 27 and 55  % of the two samples had PHQ-8 10 or greater. This decreased to 16 and 37  % by 12  months (p < 0.001). Both depressed and non-depressed cohorts demonstrated improvements in most 12-month outcomes (pain, fatigue, activity limitations, and medication adherence). The CDSMP was associated with long-term improvements in depression regardless of delivery mode or location, and the programs appeared beneficial for participants with and without depression.

Successes of a national study of the Chronic Disease Self-Management Program: meeting the triple aim of health care reform.

BACKGROUND: Emerging health care reform initiatives are of growing importance amidst concerns about providing care to increasing numbers of adults with multiple chronic conditions. Evidence-based self-management strategies are recognized as central to managing a variety of chronic diseases by improving the medical, emotional, and social role management demands of chronic conditions. OBJECTIVES: To examine the effectiveness of the Chronic Disease Self-Management Program (CDSMP) among a national sample of participants organized around the Triple Aim goals of better health, better health care, and better value in terms of reduced health care utilization. RESEARCH DESIGN: Utilizing data collected from small-group CDSMP workshops, baseline, 6-month, and 12-month assessments were examined using 3 types of mixed-effects models to provide unbiased estimates of intervention effects. SUBJECTS: Data were analyzed from 1170 community-dwelling CDSMP participants. MEASURES: Triple Aim-related outcome measures: better health (eg, self-reported health, pain, fatigue, depression), better health care (eg, patient-physician communication, medication compliance, confidence completing medical forms), and better value [eg, reductions in emergency room (ER) visits and hospitalizations in the past 6 mo]. RESULTS: Significant improvements for all better health and better health care outcome measures were observed from baseline to 12-month follow-up. The odds of ER visits significantly reduced from baseline to 12-month follow-up, whereas significant reductions in hospitalization were only observed from baseline to 6-month follow-up. CONCLUSIONS: This National Study of CDSMP (National Study) demonstrates the successful translation of CDSMP into widespread practice and its potential for helping the nation achieve the triple aims of health care reform.

Effectiveness of a generic chronic disease self-management program for people with type 2 diabetes: a translation study.

PURPOSE: The purpose of the study was to determine the feasibility and efficacy of a generic chronic disease self-management program for people with type 2 diabetes. METHODS: English-speaking adults with type 2 diabetes who were part of a larger US national translation study of the Stanford Chronic Disease Self-Management Program (CDSMP) were invited to be part of the current study. In addition to completing self-report questionnaires, participants submitted blood samples at baseline, 6 months, and 12 months. Of the 114 participants, half had A1C values between 6% and 6.9% and half had values of 7.0% or more. RESULTS: Adults with diabetes successfully participated in CDSMP workshops in a community health setting. Participants demonstrated statistically significant improvements in health indicators and behaviors but no reductions in health care utilization. Participants with A1C of 7% and above had A1C reductions at 6 months, with smaller reductions at 12 months. Those with baseline A1C less than 7% had no changes in A1C at 6 or 12 months. CONCLUSIONS: The results suggest that the CDSMP is a useful and appropriate program for lowering A1C among those with A1C above 7% and for improving health status for people with diabetes, regardless of their A1C.

Coding and evaluating facilitator posts for an online cancer survivor workshop.

One-hundred and forty-five people attended six online cancer survivor workshops. Each workshop was monitored by two facilitators, who generated a total of 1,537 online posts. The authors developed a scheme for coding facilitator posts, combining grounded codes with categories developed by Spiegel and Classen for coding therapist responses in cancer support groups. Participants received a mean of 10.6 facilitator posts. Improvement in two health outcomes (practice of mental relaxation and illness intrusiveness) were significantly correlated with supportive posts and total number of posts. The coding scheme was easily applied and appears reliable. The data suggests that more facilitation is better.

The South Australia health chronic disease self-management Internet trial.

OBJECTIVES: To evaluate the effectiveness of an online chronic disease self-management program for South Australia residents. METHOD: Data were collected online at baseline, 6 months, and 12 months. The intervention was an asynchronous 6-week chronic disease self-management program offered online. The authors measured eight health status measures, seven behaviors, and four utilization measures; self-efficacy; and health care satisfaction. RESULTS: Two hundred fifty-four South Australian adults with one or more chronic conditions completed baseline data. One hundred forty-four completed 6 months and 194 completed 1 year. Significant improvements (p < .05) were found at 6 months for four health status measures, six health behaviors, self-efficacy, and visits to emergency departments. At 12 months, five health status indicators, six health behaviors, self-efficacy, and visits to emergency departments remained significant. Satisfaction with health care trended toward significance. DISCUSSION: The peer-led online program was both acceptable and useful for this population. It appeared to decrease symptoms, improve health behaviors, self-efficacy, and reduce health care utilization up to 1 year. This intervention also has large potential implications for the use of a public health education model for reaching large numbers of people. It demonstrates that an Internet self-management program, which includes social media, can reach rural and underserved people as well as be effective and reduce health care costs. If this intervention can be brought to scale, it has the potential for improving the lives of large numbers of people with chronic illness. It represents a way the medical care and public health sectors can interact.

Moderators of chronic disease self-management programs: who benefits?

BACKGROUND: The Stanford University Chronic Disease Self-Management Program (CDSMP) has resulted in moderate beneficial outcomes in randomized controlled trials. A study of a modified CDSMP in England suggested that younger participants, those with lower initial self-efficacy and those with greater depression benefited most from the program. DESIGN: Using data from previous CDSMP programs in English and Spanish, we examined whether there were statistically significant interactions between baseline statuses (demographic, disease and health status variables) and randomization (intervention or usual-care control) in estimating 6-month changes in health status (health distress, activity limitation/role function, self-efficacy and self-reported general health). If an interaction was found, post hoc examinations of the relationships between the baseline variables and outcomes determined the directions of the relationships. RESULTS: Six moderating variables were found in the original English-language CDSMP and three in the Spanish program. Each moderator was specific to only one outcome within only one of the two studies. CONCLUSION: There were no consistent moderating effects across four outcomes and two programs and little evidence to suggest that any groups should be targeted for program recruitment. The CDSMP appears to remain useful to a wide range of people with chronic illness.

Online diabetes self-management program: a randomized study.

OBJECTIVE: We hypothesized that people with type 2 diabetes in an online diabetes self-management program, compared with usual-care control subjects, would 1) demonstrate reduced A1C at 6 and 18 months, 2) have fewer symptoms, 3) demonstrate increased exercise, and 4) have improved self-efficacy and patient activation. In addition, participants randomized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement. RESEARCH DESIGN AND METHODS: A total of 761 participants were randomized to 1) the program, 2) the program with e-mail reinforcement, or 3) were usual-care control subjects (no treatment). This sample included 110 American Indians/Alaska Natives (AI/ANs). Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups. RESULTS: At 6 months, A1C, patient activation, and self-efficacy were improved for program participants compared with usual care control subjects (P < 0.05). There were no changes in other health or behavioral indicators. The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects. The subgroup with initial A1C >7% demonstrated stronger improvement in A1C (P = 0.01). At 18 months, self-efficacy and patient activation were improved for program participants. A1C was not measured. Reinforcement showed no improvement. CONCLUSIONS: An online diabetes self-management program is acceptable for people with type 2 diabetes. Although the results were mixed they suggest 1) that the program may have beneficial effects in reducing A1C, 2) AI/AN populations can be engaged in and benefit from online interventions, and 3) our follow-up reinforcement appeared to have no value.

Mail-delivered arthritis self-management tool kit: a randomized trial and longitudinal followup.

OBJECTIVE: To determine the effectiveness of an intervention Tool Kit of arthritis self-management materials to be sent once through the mail, and to describe the populations reached. METHODS: Spanish speakers (n = 335), non-Hispanic English-speaking African Americans (n = 156), and other non-Hispanic English speakers (n = 404) were recruited separately and randomized within each of the 3 ethnic/racial categories to immediately receive the intervention Tool Kit (n = 458) or to a 4-month wait-list control status (n = 463). At the end of 4 months, controls were sent the Tool Kit. All subjects were followed in a longitudinal study for 9 months. Self-administered measures included health status, health behavior, arthritis self-efficacy, medical care utilization, and demographic variables. Using analyses of covariance and t-tests, analyses were conducted for all participants and for Spanish- and English-language groups. RESULTS: At 4 months, comparing all intervention subjects with randomized wait-list controls, there were significant (P < 0.01) benefits in all outcomes except medical care utilization and self-rated health. The results were maintained at 9 months compared with baseline. On average, the Tool Kit reached persons ages 50-56 years with 12-15 years of schooling. There were few differences between English- and Spanish-language participants in either the effectiveness or reach variables. CONCLUSION: A mailed Arthritis Self-Management Tool Kit proved effective in improving health status, health behavior, and self-efficacy variables for up to 9 months. It also reached younger persons in both English- and Spanish-language groups and Spanish speakers with higher education levels than previous studies of the small-group Arthritis Self-Management Program.