Comparisons of Body Image Perceptions of a Sample of Black and White Women with Rheumatoid Arthritis and Fibromyalgia in the US.

OBJECTIVE: To explore the disease-related, body image (BI) perceptions of women diagnosed with, rheumatoid arthritis (RA) and fibromyalgia (FM). METHODS: A purposive sample of twenty-seven females participated in individual semi-structured phone interviews to elicit BI perceptions relative to pain, activity limitations and coping measures. Sessions were digitally recorded, transcribed verbatim, and content analyzed. RESULTS: Body image perceptions relative to 5 major themes emerged in the analysis. They focused on Pain, Disease Impact on Physical and Mental Function, Weight, Diseased-Induced Fears and, Coping measures. Pain was a common experience of all participants. Other troubling factors verbalized by participants included dislike and shame of visibly affected body parts, and disease-induced social, psychological and physical limitations. RA participants thought that manifested joint changes, such as swelling and redness, undergirded their prompt diagnosis and receipt of health care. Contrarily, women with fibromyalgia perceived that the lack of visible, disease-related, physical signs led to a discounting of their disease, which led to delayed health care and subsequent frustrations and anger. All but one participant used prayer and meditation as a coping measure. CONCLUSION: The body image perceptions evidenced by the majority of participants were generally negative and included specific focus on their disease-affected body parts (e.g. joints), mental function, self-identity, health care experiences, activity limitations and overall quality of life. Given the global effect of RA and FM, assessment and integration of findings about the BI perceptions of individuals with FM and RA may help define suitable interdisciplinary strategies for managing these conditions and improving participants' quality of life.

Individual and community socioeconomic status: impact on mental health in individuals with arthritis.

To examine the impact of individual and community socioeconomic status (SES) measures on mental health outcomes in individuals with arthritis, participants with self-reported arthritis completed a telephone survey assessing health status, health attitudes and beliefs, and sociodemographic variables. Regression analyses adjusting for race, gender, BMI, comorbidities, and age were performed to determine the impact of individual and community level SES on mental health outcomes (i.e., Medical Outcomes Study SF-12v2 mental health component, the Centers for Disease Control and Prevention Health-Related Quality of Life Healthy Days Measure, Center for Epidemiological Studies Depression [CES-D] scale). When entered singly, lower education and income, nonmanagerial occupation, non-homeownership, and medium and high community poverty were all significantly associated with poorer mental health outcomes. Income, however, was more strongly associated with the outcomes in comparison to the other SES variables. In a model including all SES measures simultaneously, income was significantly associated with each outcome variable. Lower levels of individual and community SES showed most consistent statistical significance in association with CES-D scores. Results suggest that both individual and community level SES are associated with mental health status in people with arthritis. It is imperative to consider how interventions focused on multilevel SES factors may influence existing disparities.

Evaluation of active living every day in adults with arthritis.

BACKGROUND: Adults with arthritis can benefit from participation in physical activity and may be assisted by organized programs. The purpose of this study was to evaluate the effectiveness of a 20-week behavioral lifestyle intervention, Active Living Every Day (ALED), for improvements in primary outcomes (physical activity levels, aerobic endurance, function, symptoms). METHODS: A 20-week randomized controlled community trial was conducted in 354 adults. Outcomes were assessed at baseline and 20 weeks in the intervention and wait-list control groups. The intervention group was also assessed at 6 and 12 months. Mean outcomes were determined by multilevel regression models in the intervention and control groups at follow-up points. RESULTS: At 20 weeks, the intervention group significantly increased participation in physical activity, and improved aerobic endurance, and select measures of function while pain, fatigue and stiffness remained status quo. In the intervention group, significant improvements in physical activity at 20 weeks were maintained at 6 and 12 months, and stiffness decreased. CONCLUSIONS: ALED appears to improve participation in physical activity, aerobic endurance, and function without exacerbating disease symptoms in adults with arthritis.

Independent associations of socioeconomic factors with disability and pain in adults with knee osteoarthritis.

BACKGROUND: The purpose of this study is to explore the relationship between function, pain and stiffness outcomes with individual and community socioeconomic status (SES) measures among individuals with radiographic knee osteoarthritis (rOA). METHODS: Cross-sectional data from the Johnston County Osteoarthritis Project were analyzed for adults age 45 and older with knee rOA (n = 782) and a subset with both radiographic and symptomatic knee OA (n = 471). Function, pain and stiffness were measured using the Western Ontario and McMasters Universities Index of Osteoarthritis (WOMAC). Individual SES measures included educational attainment (<12 years, ≥12 years) and occupation type (managerial, non-managerial), while community SES was measured using Census block group poverty rate (<12%, 12-25%, ≥25%). SES measures were individually and simultaneously examined in linear regression models adjusting for age, gender, race, body mass index (BMI), occupational physical activity score (PAS), comorbidity count, and presence of hip symptoms. RESULTS: In analyses among all individuals with rOA, models which included individual SES measures were observed to show that occupation was significantly associated with WOMAC Function (ß =2.91, 95% Confidence Interval (CI) = 0.68-5.14), WOMAC Pain (ß =0.93, 95% CI = 0.26-1.59) and WOMAC Total scores (ß =4.05, 95% CI = 1.04-7.05), and education was significantly associated with WOMAC Function (ß =3.57, 95% CI = 1.25-5.90) and WOMAC Total (ß =4.56, 95% CI = 1.41-7.70) scores. In multivariable models including all SES measures simultaneously, most associations were attenuated. However, statistically significant results for education remained between WOMAC Function (ß =2.83, 95% CI = 0.38-5.28) and WOMAC Total (ß =3.48, 95% CI = 0.18-6.78), as well as for the association between occupation and WOMAC Pain (ß =0.78, 95% CI = 0.08-1.48). In rOA subgroup analyses restricted to those with symptoms, we observed a significant increase in WOMAC Pain (ß =1.36, 95% CI = 0.07-2.66) among individuals living in a block group with poverty rates greater than 25%, an association that remained when all SES measures were considered simultaneously (ß =1.35, 95% CI = 0.06-2.64). CONCLUSIONS: Lower individual and community SES are both associated with worse function and pain among adults with knee rOA.

Associations of educational attainment, occupation, and community poverty with hip osteoarthritis.

OBJECTIVE: To examine cross-sectional baseline data from the Johnston County Osteoarthritis Project for the association between individual and community socioeconomic status (SES) measures with hip osteoarthritis (OA) outcomes. METHODS: We analyzed data on 3,087 individuals (68% white and 32% African American). Educational attainment and occupation were used as individual measures of SES. Census block group household poverty rate was used as a measure of community SES. Hip OA outcomes included radiographic OA and symptomatic OA in one or both hip joints. Multivariable logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for the association of each hip OA outcome with each SES variable separately, and then with all SES measures simultaneously. Associations between hip OA outcomes and SES variables were evaluated for effect modification by race and sex. RESULTS: Living in a community of high household poverty rate showed independent associations with hip radiographic OA in one or both hips (OR 1.50, 95% CI 1.18-1.92) and bilateral (both hips) radiographic OA (OR 1.87, 95% CI 1.32-2.66). Similar independent associations were found between low educational attainment among those with symptomatic OA in one or both hips (OR 1.44, 95% CI 1.09-1.91) or bilateral symptomatic OA (OR 1.91, 95% CI 1.08-3.39), after adjusting for all SES measures simultaneously. No significant associations were observed between occupation and hip OA outcomes, nor did race or sex modify the associations. CONCLUSION: Our data provide evidence that hip OA outcomes are associated with both education and community SES measures, associations that remained after adjustment for covariates and all SES measures.

What community resources do older community-dwelling adults use to manage their osteoarthritis? A formative examination.

Community resources can influence health outcomes, yet little research has examined how older individuals use community resources for osteoarthritis (OA) management. Six focus groups were conducted with 37 community-dwelling older adult African Americans and Caucasians who self-reported OA and resided in Johnston County, North Carolina. Descriptive analyses and qualitative constant comparison methodology revealed individuals use local recreational facilities, senior centers, shopping centers, religious organizations, medical providers, pharmacies and their social network for OA management. Participants also identified environmental characteristics (e.g., sidewalk conditions, curb-cuts, handicapped parking, automatic doors) that both facilitated and hindered use of community resources for OA management. Identified resources and environmental characteristics were organized around Corbin & Strauss framework tasks: medical/behavioral, role, and emotional management. As older Americans live with multiple chronic diseases, better understanding of what community resources are used for disease management may help improve the health of community-dwelling adults, both with and without OA.

Coping with prescription medication costs: a cross-sectional look at strategies used and associations with the physical and psychosocial health of individuals with arthritis.

BACKGROUND: Prescription medication costs increase financial burden, often leading individuals to engage in intentional nonadherence. Little is known about what specific medication cost-coping strategies individuals with arthritis employ. PURPOSE: The purposes of this study are (1) to identify characteristics of individuals with arthritis who self-report prescription medication cost-coping strategies and (2) to examine the association between medication cost-coping strategies and health status. METHODS: Seven hundred twenty-nine people self-reporting arthritis and prescription medication use completed a telephone survey. Adjusted regression models examined medication cost-coping strategies and five health status outcomes. RESULTS: Participants reported engaging in cost-coping strategies due to medication costs. Those borrowing money had worse psychosocial health and greater disability; those with increasing credit card debt reported worse physical functioning, self-rated health, and greater helplessness. Medication underuse was associated with worse psychosocial health, greater disability, and depressive symptoms. CONCLUSION: Individuals with arthritis use multiple strategies to cope with medication costs, and these strategies are associated with adverse physical and psychosocial health status.

Methodological tips for overcoming formative evaluation challenges: the case of the Arthritis Foundation Walk With Ease program.

Formative evaluation is an effective first step in guiding program improvement by identifying participant preferences and yielding information pertinent to making program decisions. As program evaluators working with service providers are increasingly encouraged to adopt evidence-based health promotion programs, a discrete set of real-world recommendations may help extend the use of this methodology to respond to community-specific contexts and improve health impact. This article describes the authors' step-by-step process of conducting a formative evaluation of the Arthritis Foundation Walk With Ease (WWE) program. Data collection targets (leaders, coordinators, and participants in the original program and leaders and participants in the revised piloted program) as well as methods (written surveys, focus groups, structured telephone interviews, and expert reviews) were triangulated. The authors describe the challenges they faced and conclude with practical methodological recommendations about managing time and resources, communications with respondents, and accountability systems for organizing triangulated data.

The association of disability and pain with individual and community socioeconomic status in people with hip osteoarthritis.

OBJECTIVE: To examine associations between disability and socioeconomic status (SES) in persons with hip radiographic OA (rOA) or symptomatic OA (sxOA) in the Johnston County Osteoarthritis Project. METHODS: Cross-sectional analyses were conducted on individuals with hip rOA (708) or sxOA (251). rOA was defined as Kellgren-Lawrence ≥ 2. Educational attainment (<12 years or ≥12 years) and occupation (managerial or non-managerial) were individual SES measures. Census block group poverty rate (<12%, 12-25%, ≥25%) was the community SES measure. Disability was measured by the HAQ-DI and the WOMAC (function, pain, total). Covariates included age, gender, race, BMI, and presence of knee symptoms. Analyses examined associations of disability with each SES effect separately, followed by multivariable analyses using all SES variables, adjusting for covariates. RESULTS: In models with single SES variables adjusted for covariates, WOMAC scores were associated significantly (p<0.05) with low educational attainment and non-managerial occupation in rOA and sxOA. HAQ was significantly associated with low educational attainment in rOA and sxOA and with high community poverty in rOA. In models including all SES variables, the patterns of association were similar although with diminished significance. There was indication that education was more strongly associated with HAQ and WOMAC function, while occupation was more strongly associated with WOMAC pain. CONCLUSION: Our data provide evidence that individual SES is an important factor to consider when examining disability and pain outcomes in older adults with hip OA.

Associations of educational attainment, occupation and community poverty with knee osteoarthritis in the Johnston County (North Carolina) osteoarthritis project.

INTRODUCTION: The purpose of this study was to examine data from the Johnston County Osteoarthritis (OA) Project for independent associations of educational attainment, occupation and community poverty with tibiofemoral knee OA. METHODS: A cross-sectional analysis was conducted on 3,591 individuals (66% Caucasian and 34% African American). Educational attainment (< 12 years or ≥12 years), occupation (non-managerial or not), and census block group household poverty rate (< 12%, 12 to 25%, > 25%) were examined separately and together in logistic models adjusting for covariates of age, gender, race, body mass index (BMI), smoking, knee injury and occupational activity score. Outcomes were presence of radiographic knee OA (rOA), symptomatic knee OA (sxOA), bilateral rOA and bilateral sxOA. RESULTS: When all three socioeconomic status (SES) variables were analyzed simultaneously, low educational attainment was significantly associated with rOA (odds ratio (OR) = 1.44, 95% confidence interval (CI) 1.20, 1.73), bilateral rOA (OR = 1.43, 95% CI 1.13, 1.81), and sxOA (OR = 1.66, 95% CI 1.34, 2.06), after adjusting for covariates. Independently, living in a community of high household poverty rate was associated with rOA (OR = 1.83, 95% CI 1.43, 2.36), bilateral rOA (OR = 1.56, 95% CI 1.12, 2.16), and sxOA (OR = 1.36, 95% CI 1.00, 1.83). Occupation had no significant independent association beyond educational attainment and community poverty. CONCLUSIONS: Both educational attainment and community SES were independently associated with knee OA after adjusting for primary risk factors for knee OA.

Racial/Ethnic differences in quality of life for people living with arthritis who see a primary care physician.

OBJECTIVE: Previous research suggests that insufficient access to health care may contribute to health disparities in arthritis-related outcomes. The purpose of this article is to document whether racial disparities in health status, health-related quality of life (HRQOL), and activity limitations exist for individuals living with arthritis who have access to a primary care physician. METHODS: Cross-sectional survey data were collected in 2005 and 2008 from individuals seeking care at 11 family practice clinics in North Carolina. Participants self-reported their arthritis status, health status, physical and mental HRQOL, and activity limitations. Analysis of variance was used to determine whether there were differences in demographic and clinical characteristics of White (n= 405), Black (n = 244), and Latino (n = 100) participants who self-reported arthritis. Linear regressions determined whether race/ethnicity was significantly associated with HRQOL and activity limitations; whereas, logistic regression determined whether the odds of poor health were higher for Black and Latino participants, controlling for age, gender, body mass index, marital status, and number of comorbid conditions. RESULTS: Over 50% of participants reported fair/poor health status and more than 8 days of poor physical and mental health and 6 days of activity limitations during the past month. Latino participants were more likely to report fair/poor health status and fewer activity limitations than Whites or Blacks, whereas Black participants reported fewer days of poor mental health. CONCLUSION: Despite access to a primary care physician, racial/ethnic disparities exist. Future research should explore the underlying reasons for the persistence of these disparities.

Evaluation of group and self-directed formats of the Arthritis Foundation's Walk With Ease Program.

OBJECTIVE: To evaluate the effects of a revised 6-week walking program for adults with arthritis, Walk With Ease (WWE), delivered in 2 formats, instructor-led group or self-directed. METHODS: In an observational pre-post study design, 462 individuals with self-reported arthritis selected either a group format (n = 192) or a self-directed (n = 270) format. Performance and self-reported outcomes were assessed at baseline and at 6 weeks. Self-reported outcomes were assessed at 1 year. Adjusted mean outcome values for group and self-directed participants were determined using regression models, adjusting for covariates. RESULTS: At 6 weeks, significant adjusted mean improvements (P < 0.05) were seen for nearly all self-report and performance measures in both formats. Modest to moderate effect sizes (ES) were seen for disability (ES 0.16-0.23), pain, fatigue, and stiffness (ES 0.21-0.40), and helplessness (ES 0.24-0.28). The Arthritis Self-Efficacy (ASE) pain and symptom scales had modest improvements (ES 0.09-0.21). The performance measures of strength (ES 0.29-0.35), balance (ES 0.12-0.36), and walking pace (ES 0.12-0.32) all showed modest to moderate improvements. No adverse events were reported for either format. At 1 year, both formats showed modest improvement in ASE pain, but there were 5 outcomes where self-directed participants showed significant improvement, while the group participants did not. CONCLUSION: The revised WWE program decreases disability and improves arthritis symptoms, self-efficacy, and perceived control, balance, strength, and walking pace in individuals with arthritis, regardless of whether they are taking a group class or doing the program as self-directed walkers. At 1 year, some benefits are maintained, particularly among the self-directed. This is a safe, easy, and inexpensive program to promote community-based physical activity.

Independent and combined influence of homeownership, occupation, education, income, and community poverty on physical health in persons with arthritis.

OBJECTIVE: To examine the independent and combined influence of individual- and community-level socioeconomic status (SES) measures on physical health status outcomes in people with self-reported arthritis. METHODS: From 2004-2005, 968 participants completed a telephone survey assessing health status, chronic conditions, community characteristics, and sociodemographic variables. Individual-level SES measures used included homeownership, occupation (professional or not), educational attainment (less than high school, high school degree, and more than high school), and income (<$15,000, $15,000-$45,000, and >$45,000). Community poverty (2000 US Census block group percentage of individuals living below the poverty line [low, medium, and high]) was used as a community-level SES measure. Outcomes were physical functioning (Medical Outcomes Study Short Form 12 version 2 physical component summary [PCS]), functional disability (Health Assessment Questionnaire [HAQ]), and the Centers for Disease Control and Prevention (CDC) Health-Related Quality of Life (HRQOL) Healthy Days physical and limited activity days, and were analyzed via multivariable regressions. RESULTS: When entered separately, all individual-level SES variables were significantly (P < 0.01) associated with poorer PCS, HAQ, and CDC HRQOL scores. A higher magnitude of effect was seen for household income, specifically <$15,000 per year in final models with all 4 individual SES measures and community poverty. The magnitude of effect for education is reduced and marginally significant for the PCS and number of physically unhealthy days. No effects were seen for occupation, homeownership, and community poverty. CONCLUSION: Findings confirm that after adjusting for important covariates, lower individual- and community-level SES measures are associated with poorer physical health outcomes, while household income is the strongest predictor (as measured by both significance and effect) of poorer health status in final models. Studies not having participant-reported income available should make use of other SES measures, as they do independently predict physical health.

Associations of perceived neighborhood environment on health status outcomes in persons with arthritis.

OBJECTIVE: To examine the association between 4 aspects of perceived neighborhood environment (aesthetics, walkability, safety, and social cohesion) and health status outcomes in a cohort of North Carolinians with self-reported arthritis after adjustment for individual and neighborhood socioeconomic status covariates. METHODS: In a telephone survey, 696 participants self-reported ≥1 types of arthritis or rheumatic conditions. Outcomes measured were physical and mental functioning (Short Form 12 health survey version 2 physical component and mental component summary [MCS]), functional disability (Health Assessment Questionnaire), and depressive symptomatology (Center for Epidemiologic Studies Depression Scale scores <16 versus ≥16). Multivariate regression and multivariate logistic regression analyses were conducted using Stata, version 11. RESULTS: Results from separate adjusted models indicated that measures of associations for perceived neighborhood characteristics were statistically significant (P ≤ 0.001 to P = 0.017) for each health status outcome (except walkability and MCS) after adjusting for covariates. Final adjusted models included all 4 perceived neighborhood characteristics simultaneously. A 1-point increase in perceiving worse neighborhood aesthetics predicted lower mental health (B = -1.81, P = 0.034). Individuals had increased odds of depressive symptoms if they perceived lower neighborhood safety (odds ratio [OR] 1.36, 95% confidence interval [95% CI] 1.04-1.78; P = 0.023) and lower neighborhood social cohesion (OR 1.42, 95% CI 1.03-1.96; P = 0.030). CONCLUSION: Study findings indicate that an individual's perception of neighborhood environment characteristics, especially aesthetics, safety, and social cohesion, is predictive of health outcomes among adults with self-reported arthritis, even after adjusting for key variables. Future studies interested in examining the role that community characteristics play on disability and mental health in individuals with arthritis might consider further examination of perceived neighborhood environment.

Limited educational attainment and radiographic and symptomatic knee osteoarthritis: a cross-sectional analysis using data from the Johnston County (North Carolina) Osteoarthritis Project.

INTRODUCTION: Applying a cross-sectional analysis to a sample of 2,627 African-American and Caucasian adults aged > or = 45 years from the Johnston County Osteoarthritis Project, we studied the association between educational attainment and prevalence of radiographic knee osteoarthritis and symptomatic knee osteoarthritis. METHODS: Age- and race-adjusted associations between education and osteoarthritis outcomes were assessed by gender-stratified logistic regression models, with additional models adjusting for body mass index, knee injury, smoking, alcohol use, and occupational factors. RESULTS: In an analysis of all participants, low educational attainment (<12 years) was associated with higher prevalence of four knee osteoarthritis outcomes (unilateral and bilateral radiographic and symptomatic osteoarthritis). Women with low educational attainment had 50% higher odds of having radiographic knee osteoarthritis and 65% higher odds of symptomatic knee osteoarthritis compared with those with higher educational attainment (> or = 12 years), by using fully adjusted models. In the subset of postmenopausal women, these associations tended to be weaker but little affected by adjustment for hormone replacement therapy. Men with low educational attainment had 85% higher odds of having symptomatic knee osteoarthritis by using fully adjusted models, but the association with radiographic knee osteoarthritis was explained by age. CONCLUSIONS: After adjustment for known risk factors, educational attainment, as an indicator of socioeconomic status, is associated with symptomatic knee osteoarthritis in both men and women and with radiographic knee osteoarthritis in women.

Perceptions of individual and community environmental influences on fruit and vegetable intake, North Carolina, 2004.

INTRODUCTION: Increases in obesity and other chronic conditions continue to fuel efforts for lifestyle behavior changes. However, many strategies do not address the impact of environment on lifestyle behaviors, particularly healthy dietary intake. This study explored the perceptions of environment on intake of fruits and vegetables in a cohort of 2,479 people recruited from 22 family practices in North Carolina. METHODS: Participants were administered a health and social demographic survey. Formative assessment was conducted on a subsample of 32 people by using focus groups, semistructured individual interviews, community mapping, and photographs. Interviews and discussions were transcribed and content was analyzed using ATLAS.ti version 5. Survey data were evaluated for means, frequencies, and group differences. RESULTS: The 2,479 participants had a mean age of 52.8 years, mean body mass index (BMI) of 29.4, and were predominantly female, white, married, and high school graduates. The 32 subsample participants were older, heavier, and less educated. Some prevalent perceptions about contextual factors related to dietary intake included taste-bud fatigue (boredom with commonly eaten foods), life stresses, lack of forethought in meal planning, current health status, economic status, the ability to garden, lifetime dietary exposure, concerns about food safety, contradictory nutrition messages from the media, and variable work schedules. CONCLUSION: Perceptions about intake of fruits and vegetables intake are influenced by individual (intrinsic) and community (extrinsic) environmental factors. We suggest approaches for influencing behavior and changing perceptions using available resources.

Health-related quality of life in adults from 17 family practice clinics in North Carolina.

INTRODUCTION: We examined health-related quality of life (HRQOL) in white and African American patients based on their own and their community's socioeconomic status. METHODS: Participants were 4,565 adults recruited from 17 family physician practices in urban and rural areas of North Carolina. Education was used as a proxy for individual socioeconomic status, and the census block-group poverty level was used as a proxy for community socioeconomic status. HRQOL measures were the 12-Item Short Form Survey Instrument, physical component summary (PCS) and mental component summary (MCS), and 3 Centers for Disease Control and Prevention HRQOL healthy days measures. Multilevel analyses examined independent associations of individual and community poverty level with HRQOL, adjusting for demographics and clustering by family practice. Analyses were stratified by race and were conducted on subgroups of arthritis and cardiovascular disease patients. RESULTS: Among whites, all 5 HRQOL measures were significantly associated with the lowest individual socioeconomic status, and 4 HRQOL measures were associated with the lowest community socioeconomic status (MCS being the exception). Among African Americans, 4 HRQOL measures were significantly associated with the lowest individual socioeconomic status and the lowest community socioeconomic status (PCS being the exception). Arthritis and cardiovascular disease subgroup analyses showed generally analogous findings. CONCLUSION: Better HRQOL measures generally were associated with low levels of community poverty and high levels of education, emphasizing the need for further exploration of factors that influence health.

Arthritis in the family practice setting: associations with education and community poverty.

OBJECTIVE: To examine associations of self-reported arthritis in 25 urban and rural family practice clinics with education (individual socioeconomic status) and community poverty (community socioeconomic status). METHODS: A total of 7,770 patients at 25 family practice sites across North Carolina self-reported whether they had arthritis. Education was measured as less than a high school (HS) degree, a HS degree, and more than a HS degree. The US Census 2000 block group poverty rate (percentage of households in poverty in that block group) was grouped into low, middle, and high tertiles. We assumed heterogeneity by race (non-Hispanic white and African American) for the effects of these sociodemographic variables, and therefore stratified by race. Multilevel analyses were performed using a 2-level mixed logistic model to examine the independent associations and joint effects of education and poverty with self-reported arthritis as the outcome, adjusting for age, sex, and body mass index. RESULTS: White participants with less than a HS degree living in block groups with high poverty had 1.55 times the odds (95% confidence interval [95% CI] 1.10-2.17) of reporting arthritis compared with white participants with more than a HS degree and low poverty rates. African American participants with less than a HS degree and high poverty rates had 2.06 times the odds (95% CI 1.16-3.66) of reporting arthritis compared with African American participants with more than a HS degree and low poverty rates. CONCLUSION: In the family practice setting, both disadvantaged white and African American participants showed increased odds of self-reported arthritis, with stronger associations in African Americans.

Modifications to the Active Living Every Day (ALED) course for adults with arthritis.

INTRODUCTION: Active Living Every Day (ALED) is a 20-week behavioral theory-based physical activity program originally developed for the general population; the purpose of our qualitative evaluation was to investigate whether the existing program is also appropriate (regarding safety, content, and instructor training) for sedentary adults with arthritis. METHODS: We conducted telephone interviews with 30 of 355 participants in a randomized control trial of the ALED program for sedentary adults with arthritis within 6 months after they completed the program. Interviewees, who attended at least 50% of program classes, were asked about the safety of program activities, the knowledge they gained from the program, how they felt about their program instructors, and any recommendations they had for how the program could be modified to better serve people with arthritis. We used NUD*IST (N6) (QSR International, Melbourne, Australia) software for the qualitative data analysis. We also conducted a conference call with program instructors to elicit their opinion of the course and how it might be improved to better meet the needs of people with arthritis. RESULTS: Twenty seven (90%) of the program participants we interviewed were female, and their average age was 69 years. Components of the course that they reported finding particularly helpful were being encouraged to exercise "bit by bit" and receiving social support from other adults with arthritis. Program instructors and program participants both generally felt that the program was appropriate for people with arthritis but could be enhanced with the following modifications: 1) incorporating arthritis-specific information in the textbook, 2) providing information on pain management, 3) and providing dietary and nutritional information for arthritis management. Instructors also reported a need for more information on pain management and arthritis during their training. CONCLUSION: Although instructors and participants felt the ALED program as designed for the general population was useful for people with arthritis, they suggested minor modifications that would make the program even more beneficial. Some of these modifications may be applicable to other community-based activity programs not designed specifically for people with arthritis.