A faith-based arthritis self-help program for rural African Americans.

Abstract: This case study was designed to review the strategies for implementing an arthritis self-help curriculum into rural African American churches, using two nationally recognized prevention/self-help models. The study used a combination of two science-based prevention/intervention programs cooperatively in the anticipation of providing a culturally appropriate arthritis self-help program for older, rural faith-based African Americans population. The participating population was derived from five participating faith-based organizations within rural Jackson County Florida. A total of seventy-five participants completed one of the five six-week courses offered. Local community member teams trained by the National Arthritis Foundation conducted courses. The teams consisted of qualified church leaders trained to facilitate specific course materials to participating church or community members who have or are providing care for someone with arthritis.

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Throughout history churches have tradition ally been associated with the health and healing process. Numerous church and faith-based groups have recurrently sponsored hospitals and drug rehabilitation centers. More commonly, today churches and their pastors are including health, as well as alcohol and other drug prevention (AOD) programs, as a part of the church setting through their ministries (Sutherland & Harris, 2001). The promotion of these programs in the church setting is a combination of spiritual, educational, environmental, advocacy, social, and community organizational activities directed toward members of a community of faith (Miller, 1998). Within the African American community in particular, churches are a social and cultural gathering site and can serve as a key community-gathering center. Levin (1984) asserts the importance of the African American church stating; "The black church is the most important social institution in the black community and is the conservator of the black ethos." Many current studies of faith-based programs in African-American communities demonstrate the promise of these efforts (Trulear, 2000; White & de Marcellus, 1998; Foundation Center, 2001). Furthermore, church-based health promotion programs are tremendously effective in encouraging changes in behavior within the African-American community. The church provides an authoritative platform for disseminating health information, providing social support, obtaining resources and client referrals, and encouraging and developing cooperative relationships within the community for health promotion activities (Irwin, 1997). Churches have established an organized infrastructure; i.e., governance structure, through which mutual support for behavior change can be facilitated (Murphy, 1992). This important infrastructure has provided African American churches the imperative ability to not just reach the individual but also reach the entire family as a unit. Church-based health education programs are especially effective in reaching African American women who are 65 years of age and older. (Kumanyika & Charleston, 1992) This explanation is derived from the fact that 75% of older African Americans belong to a church. These individuals are more likely to participate in heath promotion programs within the church (Ransdell, 1995).

SELF-HELP PREVENTION PROGRAMS

Self-help intervention programs have developed into significant components in the struggle to reduce common hindrances associated with arthritis and its mobility limitations. These programs have provided unique strategies for the individual living with arthritis, or the individual providing care for those persons with arthritis. Numerous intervention strategies have proven effective in reducing the burden of illness, thus increasing health related quality of life.

ARTHRITIS

The numerous forms of arthritis affect more than 15% of the U.S. population--over 43 million persons--and more than 20% of the adult population. In 2001, 49 million American adults reported doctor-diagnosed arthritis and another 21 million reported chronic joint symptoms, making arthritis one of the nation's most common health problems. As the U.S. population ages, this number is likely to increase dramatically. For example, the number of people aged 65 or older who have arthritis or chronic joint symptoms is projected to nearly double from 2001 (21.4 million) to 2030 (41.4 million) (MMWR 2001).

Arthritis also affects 50% of people aged 65 years and older. (HP 2010). This disease consistently limits 3% of the entire U.S. population (7 million persons), nearly one out of every five persons with arthritis. Major limitations of activities from this disease include limited capacity within the workplace, school, and domestic activities. As a consequence, arthritis limits the independence of affected persons and disrupts the lives of family members and other caregivers (HP 2010). Arthritis has a considerable economic impact as well. Arthritis causes at least 44 million visits to health care providers, 744,000 hospitalizations, and 4 million days of hospital care per year. It is estimated that medical care costs for persons with arthritis were $15 billion, and total costs (medical care plus lost productivity) were $65 billion in 1992. Arthritis and other rheumatic conditions are among the most prevalent chronic conditions in the United States, affecting an estimated 40 million persons in 1995 and a projected 60 million by 2020. Previous reports have documented marked differences in the prevalence rates of arthritis and related activity limitations by race and ethnicity, suggesting the relative importance of arthritis may vary among these groups. In addition, race and ethnicity are associated with important differences in health characteristics and must be addressed in efforts to reduce health disparities as specified by the national health objectives for the year 2000 (MMWR, 1996).

ARTHRITIS AND AFRICAN AMERICANS

Arthritis is unquestionably a prime well-being issue within all demographic groups, yet it is evident that considerable disparities within these groups do exist. Caucasians and African Americans have comparable rates of disease; however, African Americans have greater rates of activity limitation (HP 2010). Within the African American population, arthritis is the third most common chronic condition and it is the leading cause of activity limitation. Many obstacles faced by individuals who are experiencing health problems, disproportionately, fall on older ethnic or racial minority populations.

Approximately 3 million of the 30 million Americans with arthritis are African American, yet the ratio of activity limitations are a lot higher among African American Americans versus Caucasians with arthritis (Newman, 2001). Socio-economic rates also contribute the rate of arthritis, and its associated disabilities are higher among persons with low education and low income. African Americans have lower rates of total joint replacement, a surgical procedure that is highly successful in reducing the impact of arthritis in persons with severe pain or disability, than do Caucasians. These disparities directly affect quality of life of African Americans with this disease. Dramatic differences in the incidence, severity, process of care, and outcome are evident in the number of arthritis and musculoskeletal conditions that exist within diverse racial and ethnic groups (Jordan, 2002).

INTERVENTIONS AND SOLUTIONS

THE FAITH-BASED PREVENTION MODEL

The Faith-Based Prevention Model (FBPM; Sutherland & Harris, 2001), is a Promising CSAP Universal Program, and is described as a "constellation of planning/program strategies." The model suggests that once those strategies are combined they will have a positive impact on rural, African-American church members, and the community. The study primarily uses the four phases of development outlined in the Faith-Based Prevention Model. These phases consist of an initial phase, which focuses on researching the community, its values, leaders and developing community relationships. The second phase includes several intensive prevention committee in-service trainings. These intensive trainings address numerous model strategies such as: life skills development, intergenerational activities, public relations, committee training activities, data collection, and other related activities. These selected activities are all components of the model programs. The third phase is the action/ fiscal plan implementation. The fourth phase is outcome, impact & process evaluation, and design.

THE ARTHRITIS SELF-HELP COURSE

The Arthritis Self-Help Course (ASHC) (Lorig, 1992), which is endorsed by the Arthritis Foundation, is a 6-week intervention program specifically designed to enhance self-efficacy in persons with arthritis, yet it also contains components that address exercise and relaxation, and pain management. The course is a community-based, group education program in which participants learn principles of self-management, important information on medications and nutrition, and principles of the relationship between pain and depression. The program consists of eight primary goals. The first involves educating sufferers about the nature of the condition. The arthritis self-help course is designed to inform participants about basic aspects of arthritis and joint anatomy. Additionally, principles of exercise are taught along with the opportunity to practice stretching and strengthening exercises. The program is proactive, focusing on teaching prevention strategies, including joint protection, energy conservation; and most important it provides a platform that allows participants to share ideas about improving functional ability. Moreover, it teaches participants the appropriate use of arthritis medications and encourages informed decisions about special diets and nontraditional forms of medications.

Participants are encouraged to take an active role in arthritis management and make appropriate use of care providers, and they are also encouraged to share experiences and work cooperatively to solve problems. Ultimately, the program provides an opportunity for learning and practicing stress management and other self-help behaviors designed to decrease stress, pain, and depression.

The proposed Faith-Based Arthritis Self-Help program for older, African American individuals used the ASHC behavioral and self-efficacies education program in conjunction with the four phases of the Faith-Based Prevention Model, which provided spirituality and culturally sensitive aspects to the intervention. Ultimately, the proposed program attempted to facilitate healthy behavior changes in self-awareness and self-care among an underserved population, in addition to maintaining the systematic processes that are included within both models.

PHASE I: ASSESSMENT

The assessment phase consisted of evaluating the population through interviews, surveys and questionnaires. The initial assessment of the population was derived from the directives of the Faith-Based Prevention model. Phase I: FBPM primary goals were to lay the groundwork and secure commitment for project implementation. This was done in the form of a community development meeting involving both faith-based and grass-roots organizations in the targeted area. The community development meeting agenda addressed the identification of key community contacts, which was done using a modified key informant oral survey. This survey acquired data that included answers to several vital questions:

1. Does the program address an identified need?

2. Is the program a duplication of services?

3. Will qualified staff or volunteers be available?

This was followed by the overview and discussion of the community demographic study of related problems and available resources. An examination of resources was also an important aspect of the assessment process. Considerations of the availability of facilities and equipment, as well as possible supplementary community resources were extremely important in assessing the process or priority needs of the target population.

Additionally, a survey of area churches was completed to identify the churches with the largest active target population. Furthermore, a dinner with ministers, key contacts and lay-leaders was organized to determine potential project interest. The interest dinner for potentially interested ministers, key contacts and/ or lay-leaders discussed the program in-depth, specific church responsibilities and expectations, church costs, benefits to the church, and benefit to the church community. An open line of communication with ministers, lay-leaders and key contacts, was provided in order to answer any concept or programmatic questions that may arise within their decision making process. Sufficient time for faith organizations to come to a decision on program participation was allotted, yet a deadline was established. Participation start-up dates and comprehensive program time lines must promptly followed this participation deadline date.

PHASE II: PLANNING AND GOAL SETTING

The second phase of the Faith-Based Prevention Model was used during the initial component of the planning and goal setting phase. In this portion of the planning phase, recruitment of qualified individuals for trainer certification was central in the planning process. Consistent contact was kept with key contacts; and once buy-in from the participating churches was obtained, a program-planning, in-service meeting was scheduled with each of the participating churches, key participants, and ministers. The program-planning in-service meeting covered program planning, implementation, and evaluation processes.

The key participants were informed about the responsibilities involved to be potential trainers; however, they had to be approved and trained by the National Office of the Arthritis Foundation and their certified trainers. Applications and letters of commitment were obtained from potential trainers.

Once qualified individuals were approved to be certified ASHC trainers, a training workshop was scheduled with a Certified ASHC Leader's Trainer endorsed by the Arthritis Foundation. Each key leader was required to complete the 2-day training session with the Certified ASHC Leader Trainer in order to be certified as an ASHC leader/trainer. The ASHC Workshop dates were scheduled 2 months in advance in the hopes of getting optimum key leader turn out and to avoid disinterest. A central workshop site, which was comfortable and convenient to trainees, was established and informational reminder memorandums were sent to the qualified participants informing them of training location, date and time. Once training was completed, each leader also completed a course leader commitment form and received a course completion certificate.

PHASE III: IMPLEMENTATION

In the implementation phase, the program was applied following Arthritis Self-Help Course measures and specifications. The ASHC primarily focuses on the enhancement of self-efficacy and uses certain strategies to ensure that. Course leader teams were formed to act in accordance with the ASHC model, which required that each class be taught by a pair of course leaders. Team construction was structured to be cohesive, balanced and diverse. Within the training process individuals were encouraged to find another individual within the group who would eventually become their training partner. Partnerships were encouraged to be diverse by separating instructors with and instructors with out arthritis, and males and females; yet the majority of the teams consisted of individuals who attended the same church or individuals who lived or worshiped in the same surrounding community. The participating churches provided important meeting space for the 6 week course. The teams recruited eligible individuals within their churches to become participants within the 6 week course. When the teams determined course dates and times, convenience for attendants was considered. Participants were required to complete an application process consisting of a course application form and a participant release form before entry into the program. After approval, each team scheduled and planned an initial course meeting with course participants. During the initial course meeting course leaders instructed course participants to complete the ASHC pre-test questionnaire. The leaders conducted the 6 week course as instructed within the ASHC manual. The program manual consisted of 6 weekly sessions, and each session introduced new concepts of self-help and arthritis.

Session I of the ASHC curriculum focused primarily on program introduction. Major objectives of the session included defining principles of self-help and providing basic information about arthritis and the benefits of physical fitness for arthritis. Session II focused on fitness and pain management. Major objectives of this session included exercise, pain distraction, and muscle relaxation techniques. Session III progressed into strategies of physical endurance and the uses of guided imagery as a pain management technique. Session IV focused on nutrition and introduced the concept of "self-talk". In session V, participants were instructed on the importance of practicing good communication skills when communicating with family, friends and doctors. Principles of problem solving were introduced during this session as well. The final session, session VI, addressed arthritis medications, assessed progress and acknowledges accomplishments. Session VI also addressed strategies of creating a future self-management program.

PHASE IV: EVALUATION

The ASHC, through research, has proven to have certain benefits. The Arthritis Prevention and Education Program's objective was to determine whether the faith-based classes would produce similar benefits within the varied population. Included in the ASHC/ Arthritis Prevention and Education Program was the ASHC pre-/post-class survey that was administered on the first and last nights of class, respectively. Domains measured included overall health, pain, physical activity, doctors' visits, and self-efficacy.

The statistical test used for analyzing the data was the independent samples t-test. All of the courses offered by a particular CHD were analyzed together. Results of the analysis are presented below.

Five classes completed pre- and post-tests, equaling 75 participants (as measured by completed posttests). The study demographics of the participating classes consisted of 63 (84%) females and 12 (16%) males. The primary age groups for the study was 65 and older, yet 13% of the participants were under 45 and 27% of the participants were between the ages of 45 and 64. The classes were conducted exclusively in African American churches, thus the percentage of African American participation was at 93%. Hispanic and non-Hispanic Caucasians participants made up the remaining 7%. Education proved to be very important within this study.

Previous studies using the Arthritis Self-Help Course reported successes based on population which primarily consisted of Caucasian women with a mean of 14 years of education. Little research has been conducted using the ASHC program with African Americans with arthritis (Newman, 2001). The highest percentages of the population reported that they had a high school education (34%), or less (18.7%). Similar to education, few studies were done using the ASHC program that specifically targeted low-income individuals. The majority of the previous ASHC program successes were within program populations, largely consisting of middle class participants. Participants in this study had income levels well below the middle class economic standards, with 55.1% of program participant income under $20,000 per year.

ASSESSING OUTCOMES

The study uses an Arthritis Foundation endorsed evaluation instrument to assess participant change. The pre/post survey is separated into six qualitative and quantitative divisions. Such divisions include overall health, pain, function/disability, well-being, physical activity, and self-efficacy, which are comprehensively described in the following table and overview:

Overall Health Participants were asked the following question in the survey: "Considering all the ways that arthritis affects you at this time, please rate how you are doing." The scale ranged from 0 (very well) to 10 (very poorly). Over the duration of the courses, participants experienced a 64% increase in overall health. Additionally, participants on average rated their overall health as 2.2 at the beginning of the courses and an average of 0.8 at the end of the courses (lower numbers represent better health).

Pain. With regard to pain, participants were asked the following: "How much pain have you had because of your arthritis condition over the past week? Please rate how severe your pain has been." The scale ranged from 0 (no pain) to 10 (pain as bad as it can be). Over the duration of the courses, participants experienced no change in their level of pain. Throughout the study, participants, on average, rated their pain as 2.8 on the 10-point scale

Function/Disability. Participants were asked with what level of difficulty they were capable of completing certain tasks such as walking outdoors on the flat ground or turning regular faucets on and off. The degree of difficulty ranged from without any difficulty (1 on the 3-point scale) to unable to do (3 on the 3-point scale). Over the extent of the courses, there was no significant change in the ability of the participants to function versus being disabled by the disease.

Well-being. Participants were asked with what degree of difficulty they were able to do the following: "Deal with feelings of anxiety or being nervous?" Deal with feelings of depression or feeling blue?" Within the study there was no significant change in participant responses to feeling of anxiety and nervousness.

Physical Activity. Participants were asked the following: "During the past week, even if it was not a typical week, how much total time (for the entire week) did you spend on each of the following activities: walking for exercise, swimming or aquatic exercising, bicycling (including stationary exercise bikes), using other aerobic exercise equipment, or other aerobic exercises?" There was substantial change during the duration of the courses; participants experienced a 185% increase in physical activity.

During inception of the project, participants on average had less than 30 minutes per week of physical activity. By the conclusion of the project participants reported participating in between 30-45 minutes per week and 60-90 minutes per.

Self-Efficacy. Participants were asked a series of questions about their confidence level in doing certain things. There were three broad categories of self-efficacy which rate levels of confidence of participants to perform self-management behaviors, disease management, and outcomes/goals achievement. Participants were asked to respond to the questions using a 10- point scale ranging from 1 (not at all confident) to 10 (totally confident). For self-efficacy to perform self-management behaviors, participants experienced an 18% increase in self-efficacy. Participants, on average, rated their self-efficacy as 7 at the beginning of the courses and as 8.3 at the conclusion of the courses. For self-efficacy to manage the disease, participants experienced a 19% increase in self-efficacy. Participants, on average, rated their self-efficacy as 7.2 at the beginning of the courses and as 8.6 at the conclusion of the courses. For self-efficacy to achieve outcomes, participants experienced a 20% increase in self-efficacy. Participants, on average, rated their self-efficacy as 7.1 at the beginning of the courses and as 8.5 at the conclusion of the courses.

SUMMARY AND CONCLUSIONS

Many obstacles were encountered before and during the actual implementation of the course. First, because of extensive negotiations, and a lengthy contract routing period, the contract was executed 3 months late, leaving approximately 9 months to implement a year long project. Second, there were many discussions whether the course was too high level for the audience. Third, the Department of Health and Human Services was interested in outcomes based on the normal delivery of the course, to see if the course could be effective within this particular population.

Course fidelity specifications require two-day training sessions, as a result trainings had to be done on two consecutive Saturdays, resulting in a shortfall of lay leaders completing the training. Further, due to unexpected death in the community some of the individuals, who attended the first day of training, were not available for the second day. This then created a need for a second training, which was of additional expense to the provider. A total of 11 leaders had been trained. There was some concern that some of the ASHC trainers were not effective in training this population to accurately implement the course. This became evident upon making site visits to the rural communities and observing ASHC class implementation. The stronger leaders tended to have more participants present and more involved class participation. Other leaders struggled through the course and even modified class lessons slightly to accommodate their target population.

The information shared with the rural, African-American, faith-based population provided some insight about the implementation of a Caucasian middle class arthritis self-help course. Additionally, this study shared critical insight on how income, education and faith networks affect the implementation process. Using the Faith-Based Prevention Model within the assessment, planning and goal setting, implementation phases, and evaluation redesign enhanced these processes. In summary, the study presented information and strategies for implementing arthritis activities with rural African Americans.

REFERENCES

Arthritis Foundation (1992). Arthritis self-help course. Atlanta: The Foundation.

Braithwaite, R. L. (1992). Coalition partnerships for health promotion and empowerment. In R.L. Braithwaite & S.E. Taylor (Eds.), Health issues in the black community, (pp. 321-337). San Francisco: Jossey-Bass.

Braithwaite, R. L., & Lythcott, N. (1989). Community empowerment as a strategy for black and other minority populations. Journal of American Medical Association, 261, 282-283.

Foundation Center. (2001). Pew trust to help faith-based organizations deliver social services. The Philanthropy News Digest, 6(13).

Irwin, C. & Braithwaite, R. L. (1997). A church-based diabetes education program for older, African-American women. American Journal Health Studies, 13(1), 1-7.

Jordan, J. M. & Lawrence, R. (2002). Ethnic health disparities in arthritis and musculoskeletal disease. Arthritis &Rheumatism, 48(9), 2280-2286.

Kumanyika, S.K. & Charleston, J.B. (1992). Lose weight and win: A church-based weight loss program for blood pressure control among black women. Patient Education and Counseling, 19, 19-32.

Levin, J. (1984). The role of the black church in community medicine. Journal of the National Medical Association, 75(5), 477-482.

Lorig, K. (1992). Arthritis self-help course: Leader's manual and reference material. Atlanta: The Arthritis Foundation.

Lorig, K. & Fries J. F. (1990). The Arthritis helpbook: A tested self-management program for coping with arthritis. Reading, MA: Addison Wesley.

Miller, L., Davies, M., & Greenwald, S. (2000). Religiosity and substance use and abuse among adolescents in the national co morbidity survey. Journals of the American Academy of Child and Adolescent Psychiatry, 39, 1190- 1197.

Miller, W. R. (1998). Researching the spiritual dimensions of alcohol and other drug problems. Addiction, 93, 979-990.

Morbidity Mortality Wkly Report. 1996 May 10;45(18):373-8.

Murphy, F. G. & Elders, M.J. (1992). Diabetes and the black community. In R.L. Braithwaite & S.E. Taylor (Eds.), Health issues in the black community (pp. 121-131). San Francisco: Jossey-Bass.

Newman, A. M. (2001). Self-help care in older African Americans with arthritis. Geriatric Nursing, 22, 135-8.

Office of Disease Prevention and Health Promotion. (1998). Healthy people 2010 objectives (Draft for public comment). Washington, DC: Author.

Ransdell, L. B. (1995). Church-based health promotion: An untapped resource for women 65 and older. American Journal Health Studies, 9(5), 333-336.

Sutherland, M. S. & Harris, G. J. (2001). Faith based prevention model implementation manual. Tallahassee, FL: Health Promotion Program Initiatives, Inc.

Trulear, H. D. (2000). Faith based institutions and high-risk youth: First report to the field. Public Private Ventures, 1-20.

White, J. & de Marcellus, M. (1998). Faith-based outreach to at-risk youth in Washington, D.C. Public Private Ventures, The Jeremiah Project Report. 98(1).

CHES AREAS

Responsibility III--Implementing Health Education Programs

Terrell M. Irvin is a Graduate Health Education Student in the College of Education, Department of Middle and Secondary Education at Florida State University. Dr. Mary S. Sutherland, Ed.D., is a Professor in the College of Education, Department of Middle and Secondary Education at Florida State University. Gregory J. Harris, MASS, is a Ph.D. Student in the Department of Family and Child Sciences in the College of Human Sciences at Florida State University, Executive Director of the Council of Church-Based Health Programs, Inc. and Associate Director of Health Promotions Program Initiatives, Inc. Address all correspondence to Terrell M. Irvin, 2639 N. Monroe St., Tallahassee, Fl. 32303, PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].

Table 1. Demographics (N=75)

Total
                                      N           %     Class I
Gender
  Male                                12        16.1          2
  Female                              63        83.9         16
Age
  18 - 44                             10        13.2          0
  45 - 64                             20        27.2          3
  65 +                                45        59.2         15
Race
  White, non-Hispanic                  3         4.1          1
  Black, non-Hispanic                 69        93.2         17
  Hispanic                             2         2.7          0
  Other                                0         0.0          0
Education Level
  Less than High School               14        18.7          1
  High School Graduate                34        45.3         15
  Some College (1-3 yrs)              16        21.3          0
  College Graduate                    11        14.7          2
Annual Household Income
  Less than $20,00                    38        55.1         16
  $20,00 to less than $35,000         17        24.6          2
  $35,00 to less than $50,000          8        11.6          0
  $50,00 to less than $75,000          6         8.7          0
  $75,00 or more                       0         0.0          0

Total
                                 Class II   Class III
Gender
  Male                                 5           0
  Female                              14          12
Age
  18 - 44                              4           1
  45 - 64                              7           3
  65 +                                 8           8
Race
  White, non-Hispanic                  2           0
  Black, non-Hispanic                 15          12
  Hispanic                             2           0
  Other                                0           0
Education Level
  Less than High School                3           3
  High School Graduate                 7           4
  Some College (1-3 yrs)               6           3
  College Graduate                     3           2
Annual Household Income
  Less than $20,00                     6           6
  $20,00 to less than $35,000          7           3
  $35,00 to less than $50,000          2           0
  $50,00 to less than $75,000          4           1
  $75,00 or more                       0           0

Total
                                 Class IV   Class V
Gender
  Male                                 2           3
  Female                               9          12
Age
  18 - 44                              0           5
  45 - 64                              5           2
  65 +                                 6           8
Race
  White, non-Hispanic                  0           0
  Black, non-Hispanic                 11          14
  Hispanic                             0           0
  Other                                0           0
Education Level
  Less than High School                6           1
  High School Graduate                 3           5
  Some College (1-3 yrs)               1           6
  College Graduate                     1           3
Annual Household Income
  Less than $20,00                     8           2
  $20,00 to less than $35,000          2           3
  $35,00 to less than $50,000          1           5
  $50,00 to less than $75,000          0           1
  $75,00 or more                       0           0

Table 2. Total Group Outcomes (N=75).

                                       Pre-Test    Post-Test
QUESTION                               Mean        Mean        Trends
Overall Health--Scale range 0 (very
well)--10 (very poorly)

Considering all the ways that
arthritis affects you at this time,
please rate how you are doing.
                                           2.02        .80      POS
Pain--Scale range 0 (no pain)--10
(pain as bad as it can be)

How much pains have you had because
of your arthritis condition
over the past week.                       2.80        2.80      NSC

Function/Disability--Scale range 0
(with out any difficulty)--3
(unable to do)
Walk out doors on flat ground.             .30         .36      NSC
Turn regular faucets on and off.
                                           .38         .40      POS
Well-Being--Scale range 0 (with out
any difficulty)--5 (unable to do)

Deal with feelings of anxiety or           1.39        1.37     NSC
being nervous?

Deal with feelings of depression
or feeling blue?                           1.07        1.09     NSC

Physical Activity--Scale range 0 (none)--4 (more than 90 minutes a week)
Walk for exercise?                         .50        1.90      POS
Swimming or aquatic exercise?              .11         .67      POS
Bicycling? (including stationary           .15         .87      POS
exercise bikes)
Other aerobic exercise equipment?          .30         .67      POS
Other aerobic exercise?
                                           .07         .10      POS
Self-Efficacy--Scale range 1 (not at all confident)--10
(totally confident)

Get information about your disease         5.67        9.11     POS
from community resources?

Get friends and family to help you         6.93        7.84     POS
with things you need?

Get emotional support form                 7.34       9.20      POS
friends and family?

Get help with your daily tasks
from sources other
than friends or family, if needed?        6.70         7.53     POS

Ask your doctor things about your          7.11        8.35     POS
illness that concerns you?

Do the different tasks and
activities needed to manage your
health condition so it doesn't
affect your daily life?                    6.52        8.27     POS

Get your errands done despite              7.32        7.49     NSC
your health problems

Reduce your physical comfort or pain?      5.96        7.39     POS

Keep the physical discomfort or
pain of your disease from inter-
fering with things you want to do?
                                           6.07        7.39     POS
Keep from getting discouraged when
nothing you do seems to
make any difference?                       6.26        7.44     POS

Keep from getting sad or down              6.33        7.47     POS
in the dumps?

Do something to make yourself feel         7.34        7.54     POS
better when you're feeling lonely?

* POS reflects positive trends ** NSC reflects no sufficient change
*** NEG reflects Negative trends