Public Health Interventions for Arthritis: Expanding the Toolbox of Evidence-Based Interventions

Abstract

Background:

Since 1999, the Centers for Disease Control and Prevention's (CDC) Arthritis Program has worked to improve the quality of life for people with arthritis, in part by funding state health departments to disseminate physical activity (PA) and self-management education (SME) interventions. Initially, only one SME and two PA interventions were considered evidence-based and appropriate for people with arthritis. The purposes of this article are to describe the processes and criteria used to screen new or existing intervention programs and report the results of that screening, including an updated list of recommended intervention programs.

Methods:

A series of three sets of screening criteria was created in consultation with subject matter experts: arthritis appropriateness, adequacy of the evidence base, and implementability as a public health intervention. Screening interventions were categorized as Recommended, Promising Practices, Watch List, Future Possibility, or Unlikely to Meet criteria based on how well the intervention met the screening criteria.

Results:

A total of 15 packaged PA interventions and six SME interventions were screened. Three PA and three SME interventions met all three sets of criteria and were added to the list of recommended public health interventions for use by CDC-funded state arthritis programs. An additional two SME interventions are developing the infrastructure for public health dissemination and were categorized as Promising Practices, and six PA interventions have evaluations underway and are on the Watch List.

Conclusions:

The CDC Arthritis Program identified arthritis-appropriate interventions that can be used effectively and efficiently in public health settings to improve the quality of life of people with arthritis. The screening criteria used offer a guide to intervention developers on necessary characteristics of interventions for use in public health settings. The expanded menu of interventions is beneficial to clinical care and public health professionals and, ultimately, to people with arthritis.

Introduction

Arthritis is a significant public health issue based on prevalence and impact, and both are projected to increase substantially in the coming decades. Based on 2003–2005 data, 46.4 million (21.4%) noninstitutionalized adults over age 18 reported a doctor's diagnosis of arthritis,¹ and prevalence is projected to increase to 67 million (25%) by 2030.² Arthritis is the most common cause of disability³; 41% of adults with arthritis report arthritis-associated activity limitations,¹ and 31% of working-age adults report arthritis-associated work limitations.⁴ The number of people with activity limitation due to arthritis is projected to increase to 25 million by 2030.²

Arthritis also disproportionally affects women, in both prevalence and impact. Sixty-one percent (28 million) of the 46 million Americans with arthritis are women.⁵ Women with arthritis also report greater prevalence of arthritis-attributable activity limitation (42%), work limitation (30%), and severe joint pain (27%) than do men with arthritis.⁵

Since 1999, the Centers for Disease Control and Prevention (CDC) has spearheaded the public health response to reduce the burden of arthritis. CDC's activities have been guided by two key public health documents: Healthy People 2010 and the National Arthritis Action Plan: A Public Health Approach. Healthy People 2010, the nation's 10-year blueprint for health, was published in 1999 and included, for the first time, arthritis-specific health objectives for the United States.⁶ Concurrently, the Association of State and Territorial Health Officers, the CDC, and the Arthritis Foundation (AF) published the National Arthritis Action Plan: A Public Health Approach, which outlined priority public health strategies for reducing the burden of arthritis.⁷ Simultaneously, CDC received its first congressional appropriation to address arthritis.

Central to CDC's public health response has been funding state health departments to address arthritis, primarily through the dissemination and implementation of evidence-based self-management interventions, specifically packaged (i.e., ready to use, with standardized implementation procedures) self-management education and physical activity intervention programs.⁸ These community-based public health interventions are complementary to the traditional care provided in clinical settings. The American College of Rheumatology's guidelines for the management of rheumatoid arthritis and osteoarthritis of the hip and knee all highlight the importance of self-management education and appropriate physical activity.^9,10 Recommendations to participate in these community-based self-management interventions can be an important component of self-management support provided by healthcare practitioners.¹¹

When CDC first began funding state arthritis activities in 1999, only three community-based self-management education or physical activity interventions, with varying degrees of evidence to document their benefits for people with arthritis, were available. All three are disseminated by the AF. These included the Arthritis Self-Help Course (also known as the Arthritis Self-Management Program),¹² the Arthritis Foundation Aquatics Program, and the People with Arthritis Can Exercise (PACE) program.¹³

A key focus of the CDC Arthritis Program has been to expand the number of community-based interventions available both by funding the development and evaluation of arthritis-appropriate physical activity and self-management education interventions and by screening existing or newly developed community-based interventions to assess their suitability for a public health approach to reducing the impact of arthritis. The purposes of this report are to describe the process and criteria used by the CDC Arthritis Program to screen potential intervention programs and to report the results of that screening, including an updated list of intervention programs recommended for dissemination by state arthritis programs, their partners, and other public health agencies interested in improving the quality of life of people with arthritis.

Materials and Methods

The initial screening focused on PA interventions, because a quick scan of the literature suggested there were more packaged PA interventions available than packaged SME interventions. In consultation with subject matter experts, CDC developed a series of three sets of screening criteria to guide the assessment of these interventions. Experts in PA and arthritis were consulted to help develop the criteria to determine whether the PA intervention program was arthritis appropriate. The CDC Arthritis Program scientific staff developed criteria to assess the adequacy of the evidence base, and state health department arthritis coordinators were consulted in the development of criteria to judge the implementability of the intervention program in settings typically used by state arthritis programs. Table 1 lists the three sets of screening criteria for interventions. These criteria were used to guide the judgments of the research team screening the interventions and formulating recommendations.

Table 1.

Intervention Screening Criteria

Arthritis appropriateness
Physical-activity interventions	Self-management education interventions
A. Characteristics of intervention design	A. Characteristics of intervention design
Participant control over activity intensity, frequency, duration	Addresses content and outcomes of the importance in managing arthritis (as specified in the CDC Arthritis Program framework: pain, disability, and physical, psychological, or work function)
Instructor training reinforces participant control	Based on a theoretical foundation that enhances behavior change
Instruction is hands off (no touch)
Provides background information on fitness
Flexibility in measures of success (so participant feels competent and successful)
B. Characteristics of physical activity	B. Characteristics of self-management education
No contact/collision sports	Fosters skills important in managing arthritis, such as goal setting, decision making, problem solving, and self-monitoring.
No competitive sports	Consists of more than information dissemination (as provided through print materials, oral instruction)
No jumping or high joint impact activity
C. Characteristics of Research	C. Characteristic of research
Data available on a general adult community population	Data available on adult population
Dropout rates and reasons reported	Dropout rates reported
No safety/injury concerns raised	No safety/injury concerns raised

Adequacy of evidence base (physical activity and self-management education interventions)
A. Intervention evaluated in present form
B. Measured arthritis-relevant outcomes (such as physical activity level, health status)
C. Documentation of evidence
Published journal article or written report
Minimum sample size: 75 subjects in treatment group, and pretest/posttest measurement or more rigorous study design
D. Consistency of evidence: Consistent trends in study results
E. Studies documenting evidence are judged to have reasonable rigor

Implementability as public health intervention (physical activity and self-management education interventions)
A. Leader/implementer requirements
Academic degree not required
Leader training available, if necessary
B. Site requirements: No special facilities beyond a community room (except warm pool for aquatic program)
C. Equipment requirements: No special equipment more expensive than a pedometer or videotape required
D. Cost to participants less than $50
F. Implementation guide available
G. Supporting structures (i.e., training, technical assistance) judged to be adequate to support widespread implementation

Five intervention categories were created based on the intervention screening criteria, ranging from Recommended to Unlikely to Meet Criteria. Those interventions that met all three sets of criteria (arthritis appropriateness, adequacy of evidence base, and implementability in public health settings) were designated Recommended interventions. Interventions that met the arthritis-appropriate and adequate evidence base sets of criteria and were building the infrastructure necessary to be implementable on a wide scale were designated Promising Practices. Interventions that met arthritis-appropriate criteria and were in the process of building their evidence base (i.e., had evaluation underway) were placed on the Watch List, and interventions that seemed arthritis appropriate but needed additional evidence and the structures to support widescale implementation were identified as Future Possibilities. Interventions that required an extensive amount of implementation resources not often found in public health settings were categorized as Unlikely to Meet Criteria. Any intervention with insufficient information available to allow categorization was listed as Unable to Screen. Figure 1 outlines the decision tree used in categorizing interventions.

FIG. 1.

Flow diagram of decision process for assigning intervention categories using standard criteria.

A broad-based environmental scan was used to identify physical activity interventions for screening. The intervention screening team sought nominations for interventions that were appropriate for people with arthritis and deliverable through a state health department from state arthritis coordinators, arthritis subject matter experts, and staff from other CDC chronic disease programs (cancer, cardiovascular health, diabetes, and nutrition and physical activity). A brief literature search was also conducted. Medline, Embase, and Cinhal databases were searched with the search terms arthritis, exercise, and physical activity. Search results were informally reviewed by two members of the intervention screening team (S.L.J., T.J.B.) to identify interventions that appeared to have some possibility for being arthritis appropriate and deliverable through a state health department. The formal screening process was used to screen the interventions identified through this broad environmental scan.

Information was gathered on each identified intervention, including program components; participant, leader, and trainer manuals; implementation guides; implementation costs and procedures; and evaluation reports. Intervention developers and evaluators were contacted to provide the additional information not available in published reports as well as information about evaluations underway. Using a standardized abstraction form, one member of the research team (S.L.J.) abstracted information for all criteria for each intervention from the published articles, developer/evaluator information, and supplemental materials and placed that information onto an intervention summary sheet.

All intervention summary sheets were reviewed by all members of the intervention screening team (T.J.B., J.M.H., S.L.J., J.E.S.); each member independently judged how well each intervention met the screening criteria and whether or not it could be recommended. Discrepancies were resolved by consensus after discussion by the screening team and review of the published articles, developer information, and supplemental materials. Screening team discussion also was used to assign interventions that did not appear to meet all three sets of screening criteria to the appropriate intervention category.

A modified process was followed for screening and rating SME interventions. The criteria developed for screening PA programs were adapted slightly by the CDC Arthritis Program staff to fit the content and processes of educational interventions. Nominations for interventions to be screened were sought from arthritis state coordinators and subject matter experts. A brief literature search of Medline, Embase, Cinhal, and PsychInfo databases was conducted using search terms including arthritis, self-care, self-management, and patient education. The identified SME programs were screened and assigned to categories (Recommended, Promising Practice, Watch List, and Future Possibilities) based on discussion by the full CDC Arthritis Program staff.

The initial screening of interventions took place in 2005, and it was updated in 2007 and in 2009.

Results

A total of 15 packaged PA programs and 6 packaged SME programs were identified for screening. The current status of all interventions screened through these processes is shown in Table 2. Among PA programs, three intervention programs (EnhanceFitness,¹⁴ Active Living Every Day,¹⁵ and Fit & Strong!¹⁶) were added to the menu of Recommended interventions six have evaluations underway and were placed on the Watch List, and an additional four were categorized as Future Possibilities. Two packaged PA interventions were rated as Unlikely to Meet Criteria, and one intervention (Silver Sneakers¹⁷) did not include enough information in the public domain to complete the screening process.

Table 2.

Current Status of Screened Interventions

Physical activity interventions	Self-management education interventions
Recommended	Recommended
Enhanced Fitness (EF)¹⁴	Spanish Arthritis Self- Management Program¹⁹
Active Living Every Day (ALED)¹⁵	Chronic Disease Self-Management Program (CDSMP)¹⁸
Fit & Strong!¹⁶	Spanish Chronic Disease Self-Management Program²⁰
Promising Practices	Promising Practices
	The Arthritis Toolkit²¹
	Healthier Living with Arthritis (internet-based ASMP)²²
Watch List	Watch List
Fitness Exercise for People with Arthritis (FEPA)²³
People Exercising Program²⁴
Tai Chi from the Arthritis Foundation (Unpublished report, Arthritis Foundation)
Walk with Ease (Unpublished report, CDC)
First Step to Active Health²⁵
A Matter of Balance²⁶
Future Possibilities	Future Possibilities
Strong for Life/Faith in Action²⁷	Internet-based Chronic Disease Self-Management Program³¹
Strong Women²⁸	Translated versions of Chronic Disease Self-Management Program
Growing Stronger²⁹
Community Health Activities Model for Seniors II (CHAMPS II)³⁰
Unlikely to Meet Criteria	Unlikely to Meet Criteria
Community Health Activities Model for Seniors I (CHAMPS I)³²
Diabetes Prevention Program³³

Of the SME programs, three interventions were added to the Recommended interventions listing (the Chronic Disease Self-Management Program,¹⁸ the Spanish Arthritis Self-Management Program,¹⁹ and the Spanish Chronic Disease Self-Management Program,²⁰), two were listed as Promising Practices, and two were listed as a Future Possibilities.

Descriptions of the recommended interventions and promising practices are included in Table 3. All the recommended interventions meet the criteria for arthritis appropriateness of the PA or SME intervention itself and have been evaluated in their current form. All the recommended interventions measure arthritis-relevant outcomes and have documented that evidence through either a published journal article or written report and have a sample size of at least 75 people. Most importantly, the recommended interventions are feasible for implementation in a public health setting commonly used by state arthritis programs (i.e., have limited leader, site, and equipment requirements) and have structures such as leader training, implementation guides, and technical assistance available to support their implementation. The interventions listed as promising practices meet the arthritis-appropriateness criteria, have evidence supporting their efficacy or effectiveness in the present form of the intervention and are in the process of developing the implementation supporting structures.

Table 3.

Summary of Recommended Interventions and Promising Practices

Intervention	Program description	Evidence base	Implementation information
Physical activity interventions
Active Living Every Day (ALED) (Recommended) 12–20-week small group psychoeducational intervention designed to help participants incoporate physical activity into lifestyle. Information: Active Living Partners www.activeliving.info	Format: Small group (n = 20) intervention; classroom instruction helps participants learn to initiate and maintain a physically active lifestyle. One-hour classes, led by trained facilitator following a lesson plan, held weekly. No exercise is done in class; participants are encouraged to be active outside of class. Content: Lessons address setting goals/making plans, increasing activity levels, and strategies to overcome barriers to physical activity. Guides decisions about form, frequency, intensity, and dose of physical activity. Appropriate for sedentary people with/without chronic conditions. Theory base: Social cognitive and decisional balance theories; transtheoretical and relapse prevention models.^15,34 Developer: The Cooper Institute www.cooperinstitute.org/education.	RCT (n = 235) of 20-week program with 24 months follow-up (FU)¹⁵ improvements in: Health outcomes Aerobic fitness, blood pressure, lipids, and body fat. Health behavior Physical activity;Arthritis-specific RCT (n = 354) of 20-week version with 12 months FU improvements in: Health outcomes Stiffness, self-efficacy for exercise and for arthritis symptom management. Health behavior Total physical activity.³⁵ Longitudinal FU in older adults (n = 1478 in 20-week and 1501 in 12-week programs) improvements in: Health outcomes Perceived stress, satisfaction with body appearance and body function. Health behavior Physical activity.³⁴	Requirements Leaders: One per class. No educational or fitness certification required; must be comfortable working with groups, have strong teaching skills. Must complete on-line prerequisite and two day on-line or in-person training and pass competency examination. Site: Classroom with adequate seating. Equipment: Pedometer. Costs License fee: None. Training costs: $349 per facilitator; includes materials, training, and competency test. Participant materials: Active Living Every Day,³⁶ $16–25.00. Implementation supports Available from Active Living Partners
Arthritis Foundation Aquatic Program (AFAP) (Recommended) Water exercise class designed specifically for people with arthritis; classes held for 8–12 weeks or ongoing basis. Information: Arthritis Foundation www.arthritis.org/aquatic-program.php.	Format: Small group (n = 20) class held 2–3 times per week for 1 hour. Classes offered ongoing or time-limited (8–12 weeks). Content: Multicomponent exercises. Each class consists of approximately 25 exercises selected from menu of 100 appropriate exercises and activities.¹³ Developer: Arthritis Foundation	Health outcomes In RCT of 20-week program (n = 250), improvements reported in function and perceived physical quality of life.³⁷ Those attending at least 2 classes per week had more positive outcomes.³⁸ RCT of 12-week program found significant improvements in flexibility, strength, and aerobic fitness.³⁹	Requirements Leaders: One leader/instructor per class. Must have CPR certification and be able to swim; instructors also have lifeguard or water safety certification. All must complete 1 day training. Site: Warm (83–90°F) pool, water depth at least shoulder height; must meet state pool safety requirements. Equipment: Floatation devices and gloves/paddles optional Costs License fee: No license is required. Training fee: $50–150 per leader. Implementation supports Available from Arthritis Foundation
Arthritis Foundation Exercise Program (AFEP) Formerly known as PACE (Recommended) Multicomponent exercise program designed specifically for people with arthritis. Classes held for 8–12 weeks or on ongoing basis. Information: Arthritis Foundation www.arthritis.org/af-exercise-program.php	Format: Small group (n = 20) moderate physical activity class held 2–3 times per week for 1 hour Content: Multicomponent exercise; each class consists of approximately 25 exercises selected from a menu of 90 appropriate exercises; instructors have flexibility in the mix of exercises included. Exercises can be done in sitting, standing, or lying positions. Class also includes brief education lessons on exercise-related topics and relaxation.¹³ Developer: Arthritis Foundation	Health outcomes In 2 8-week RCTs (n = 346⁴⁰ and 174⁴¹), improvements reported in pain and fatigue,^40,41 function, and arthritis self-efficacy.⁴¹ Participants attending more than half the classes showed improvements in stiffness, and strength⁴⁰; symptom improvements remained at 6 months FU but declined for function and self-efficacy.⁴⁰ Minimal differences found between 8 and 16 weeks of participation.⁴¹	Requirements Leaders: One per class; must have education or related experience in exercise, fitness, or health-related field; 1 day training required. Site: Community room with chairs and adequate space for exercise. Equipment: Weights, elastic exercise bands and floor mats optional. Costs License fee: None. Training fee: $50–100 per instructor. Participant materials: Participant manual, $2.30. Implementation supports Available from Arthritis Foundation
EnhanceFitness (EF) Formerly known as Lifetime Fitness. (Recommended) Multicomponent small group exercise program originally designed for older adults; exercise revised slightly to be arthritis appropriate. Classes offered 3 times per week on ongoing basis. Information: Project Enhance www.projectenhance.org	Format: Ongoing small group (n = 12–20) exercise program held 3 times per week for 1 hour; participants can join at any time. Content: Class sessions structured to include prescribed amount of flexibility, conditioning, and strength training; instructors have flexibility in type of conditioning exercise used. Exercises can be done sitting or standing. Protocol includes baseline and periodic fitness checks to assess progress.¹⁴ Developer: University of Washington	RCT with 6 months FU (n = 100): improvements: Health outcomes Depression, self-rated health, energy, social function.¹⁴ Preposttest evaluation (n = 2889) found improvements in performance tests and self-rated health.⁴² Health care utilization Retrospective cohort study of Medicare expenses found no cost difference in year 1 but $1186 lower cost in year 2 for participants. Participants who attended at least 1 class per week showed lower costs both years.⁴³	Requirements Leaders: Must be certified fitness instructors, have experience working with older adults, and CPR certification. 2 day training. Site: Noncarpeted community room with adequate room for sitting and standing exercise. Equipment: Armless chairs, adjustable wrist and ankle weights, stopwatch, CD player. Costs License fee: Year 1: $3000 for 1 site; $1000 for each additional site. Renewals: $300 for 1 site, $100 for each additional site. Training fee: Incorporated in license. Equipment costs: One time equipment expenses estimated at $650. Infrastructure supports Available from Project Enhance
Fit & Strong! (F & S) (Recommended) 8-week combination exercise and education program designed for adults with lower extremity osteoarthritis. Classes held 3 times per week for 90 minutes. Information: www.fitandstrong.org	Format: Small group (n = 20–25) program; includes exercise (60 minutes) and exercise-related education/discussion (30 minutes). Originally delivered by physical therapists,¹⁶ recently evaluated with delivery by certified exercise instructors.⁴⁴ Content: Multicomponent program with emphasis on strengthening and aerobic walking. Education/ discussion addresses self-efficacy, exercise adherence, and developing individualized exercise plans.⁴⁴ Theory base: Social cognitive theory. Developer: University of Illinois-Chicago	In immediate posttest and 6 month FU (n = 151) of certified exercise, instructor delivered program, improvements. Health outcomes Symptom management self-efficacy (8 weeks only), barriers efficacy, adherence efficacy (6 months only), stiffness, physical function and muscle strength. Health behavior Exercise frequency and caloric expenditure.⁴⁴	Requirements Leaders: 1 certified fitness instructor or licensed physical therapist per class. 1 day training. Site: Community room with space for participants to stretch out arms laterally; unobstructed area for walking. Equipment: Ankle weights, elastic exercise bands, chairs, floor mats, CD or tape player, access to mirrors, and aerobic exercise equipment ideal. Costs License and training fees: Under development. Participant materials: Manual, 30.00 each. Equipment costs: One-time expenses for equipment estimated at $1500. Implementation supports Under development or available from University of Illinois-Chicago
Self-management education interventions
Arthritis Self-Management Program (ASMP), also known as Arthritis Foundation Self-Help Program (AFSHP), formerly known as Arthritis Self-Help Course (ASHC). (Recommended) Interactive workshop designed specifically for people with arthritis. Information: Stanford University Patient Education Research Center www.patienteducation.stanford.edu or Arthritis Foundation www.arthritis.org	Format: Small-group (n = 16) program; led by two trained leaders following structured protocol. Meets 2 hours per week for 6 weeks. Content: Discussions are arthritis specific and focus on health behaviors, including exercise, medication use, and cognitive symptom management, and skills such as goal setting, decision making, problem solving, and communicating with healthcare providers.¹² Behavior Change Theory: Designed to increase self-efficacy. Developer: Stanford University Patient Education Research Center	Early studies showed improvements in self-efficacy, pain, and physician visits in 4 months and 4-year FU.⁴⁵ 3 recent RCTs (n = 350–800)^46 –48 and a longitudinal FU⁴⁹ (n = 450) show reasonably consistent results with 4–12 month FU; improvements in: Health outcomes Self-efficacy, fatigue, psychological factors (anxiety, depression, health distress), and pain (not all significant). Health behavior Exercise.8-year FU (n = 125) found similar results.⁵⁰	Requirements Leaders: Laypersons and health professionals, prefer at least one with arthritis; two per class required. 3 day training. Site: Community room. Equipment/materials: Flip charts and markers, CD player optional. Costs License fee: License fee not required when delivered under auspices of Arthritis Foundation. Delivered independently: $500–1000 for 3 year license.^a Training registration fee: $100–150. Participant materials: The Arthritis Helpbook,⁵¹ $19.00. Implementation supports Available from the Arthritis Foundation or Stanford University Patient Education Research Center.
The Arthritis Toolkit (Promising Practice) Self-study set of educational tools designed to be self-tailored through initial self-assessment. Toolkit available in English or Spanish from Bull Publishing www.bullpub.com/arthritis_toolkit	Format: Toolkit includes The Arthritis Helpbook,⁵¹ self-assessment, tip sheets, 2 exercise CDs and a relaxation CD. Content: Similar to ASMP, including health behaviors and disease management skills.²¹ Behavior Change Theory: Social learning theory. Developer: The University of North Carolina, Chapel Hill, and Stanford University Patient EducationResearch Center.	RCT (n = 922) with 4-month FU reported improvements in: Health outcomes Self-efficacy, pain, fatigue, disability, depression, health distress, and role function.²¹	Requirements Leaders: No leader required. Site: Done independently at home or office. Equipment: Purchase The Arthritis Toolkit from Bull Publishing www.bullpub.com/arthritis_toolkit Costs Toolkit costs $50.00 Implementation supports Yet to be developed.
Chronic Disease Self-Management Program (CDSMP) (Recommended) Interactive workshop designed for people with a variety of chronic conditions. Classes meet in person for 2–2.5 hours per week for 6 weeks. Information: Stanford University Patient Education Research Center www.patienteducation.stanford.edu	Format: Similar to ASMP, small in-person classes led by 2 trained leaders following structured protocol. People with a variety of chronic conditions attend together. Content: Discussions are not arthritis specific but focus on health behaviors and generic disease management skills similar to ASMP.^18,52 Behavior Change Theory: Designed to increase self-efficacy like ASMP. Developer: Stanford University Patient Education Research Center	Original validation studies showed improvements at 6 and 12 months in: Health outcomes Self-rated health, health distress, disability, fatigue, social role. Health behavior Exercise, cognitive symptom management, communication with provider.^18,52 3 recent RCTs (n = 350–630)^47,48,53 and 2 longitudinal analyses (n = 170–500),^54,55 with 4–12 month FU demonstrated improvements in: Health outcomes Self-efficacy, fatigue, and psychological factors. Health behavior Exercise, cognitive symptom management.	Requirements Leaders: Laypeople and health professionals, prefer at least one with a chronic disease. Site: Community room. Equipment/materials: flip charts and markers, CD player. Costs License fee: $500–1000, for 3 year-license. Multiple intervention license possible.^a Training costs: Depends on where training received. Training at Stanford University, $1600 (health professionals); $900 (layperson). Participant materials: Living a Healthy Life with a Chronic Condition,⁵⁶ $16.00 Time for Healing Audiotape, $10.00. Implementation supports Available from the Stanford Patient Education Research Center
Healthier Living with Arthritis (Internet) (Promising Practice) Six week on-line interactive program featuring structured lessons, activities, and discussion boards, designed for people with arthritis. Information: Stanford University Patient Education Research Center www.patienteducation.stanford.edu	Format: On-line workshop for up to 24 people with arthritis, moderated by 2 trained moderators, 1 or both of whom have arthritis. New lessons are posted on-line weekly; participants are expected to log on 2–3 time weekly. Content: Content is similar to ASMP, covering both health behaviors and disease-management skills.²² Behavior Change Theory: Self-efficacy. Developer: Stanford University Patient Education Research Center	RCT (n = 855) with 6 and 12 month FU showed significant improvements in: Health outcomes Pain, disability, health distress, role function, self reported health, self efficacy. Healthcare utilization Decrease in hospitalizations (12 months only).²²	Requirements Leaders: Two moderators are required, preferably at least 1 layperson with arthritis. Site: Anywhere internet access is available. Equipment: Computer with internet access; Participant materials: The Arthritis Helpbook. ⁵¹ Costs To be determined Implementation supports Program has been licensed to the National Council on Aging, which is exploring feasibility of hosting and supporting these on-line workshops.
Spanish Arthritis Self-Management Program (Programa de Manejo Personal de la Artritis) (Recommended) Interactive workshop designed specifically for Spanish-speaking people with arthritis. Similar in content and format to ASMP, classes meet in person for 2 hours per week for 6 weeks. Information: Stanford University Patient Education Research Center www.patienteducation.stanford.edu	Format: Similar to ASMP, led by 2 trained Spanish-speaking facilitators following structured protocol. Course was developed to be culturally appropriate and is delivered in Spanish without translators. Content: Content is similar to ASMP, addressing both health behaviors and generic disease-management skills.¹⁹ Behavior Change Theory: Self-efficacy. Developer: Stanford University Patient Education Research Center	RCT (n = 300),¹⁹ and longitudinal study,⁵⁷ with 4 and 12 months FU, reported improvements in: Health outcomes Improvements in self-rated health, pain, disability, depression. Health behaviors: Exercise.	Requirements Leaders: Spanish-speaking laypeople and health professionals. Site: Community room. Equipment/materials: Flip charts and markers, CD player. Costs License fee: $500–1000, for 3-year license; multiple intervention license available.^a Training costs: Depends on where training received. Stanford-led local training approximately $20,000. Participant materials: Como Convivir con su Artritis,⁵⁸ $14.00. Relaxation and Exercise CDs or audiotapes, each $10.00. Implementation supports Available from Stanford Patient Education Research Center
Spanish Chronic Disease Self-Management Program (Tomando Control de su Salud) (Recommended) Interactive workshop designed specifically for Spanish-speaking people with chronic conditions. Similar in content and format to CDSMP; classes meet in person for 2–2.5 hours per week for 6 weeks. Information: Stanford University Patient Education Research Center www.patienteducation.stanford.edu	Format: Similar to CDSMP, led by 2 trained Spanish-speaking facilitators following structured protocol. Course was developed to be culturally appropriate and is delivered in Spanish without translators. Participants have a variety of chronic conditions. Content: Content is similar toCDSMP, addressing both health behaviors and generic disease-management skills.²⁰ Behavior Change Theory: Self-efficacy. Developer: Stanford University Patient Education Research Center	RCT (n = 525)²⁰ and a longitudinal study⁵⁹ (n = 450), with 4 and 12 month FU, found significant changes in: Health outcomes Self-rated health, health distress, self-efficacy. Health behaviors: Exercise, mental stress management. A post hoc analysis among participants with arthritis found similar results (K. Lorig, unpublished data).	Requirements Leaders: Spanish-speaking laypeople and health professionals, prefer at least one with a chronic condition. Site: Community room. Equipment/materials: flip charts and markers, CD player. Costs License fee: $500–1000, for 3-year license; multiple intervention license available. Training costs: Depends on where training received. Training at Stanford University, $1600 (health professionals), $900 (layperson). Stanford-led local training approximately $20,000. Participant materials: Tomando Control de su Salud,⁶⁰ $16.00.Relaxation and exercise CDs or audiotapes, each $10.00. Implementation supports Available from Stanford Patient Education Research Center

All Stanford University Patient Education Research Center interventions can be covered under the same license and fee. License fees depend on number of courses offered per year, but a single license can cover multiple interventions.

Discussion

A total of six packaged PA and SME interventions were added to the list of Recommended interventions; these six were judged to be appropriate for people with arthritis, to have documented health benefits, and to have the infrastructure and program characteristics needed to facilitate widescale dissemination and implementation by public health agencies and their community partners. This brings the total number of Recommended interventions to nine, including the original Arthritis Foundation-disseminated interventions in use when the CDC Arthritis Program began in 1999. An additional two interventions are considered Promising Practices.

Two salient issues need to be addressed by several of the interventions that have not yet qualified as Recommended: lack of evidence and lack of infrastructure and materials to support implementation. In some cases, intervention developers continue to build their evidence base; in others, developers have yet to develop trainer/instructor manuals and implementation guides, to plan training events, or to have a mechanism to answer questions from the field. The lack of adequate supporting structures to support widescale dissemination and implementation makes the intervention impractical for wide use. These elements are essential to the successful translation of a research project into a public health intervention.⁶¹

A small number of interventions was rated as Unlikely to Meet Criteria as a community-delivered public health intervention because of the high resource requirements for program delivery. Extensive site, equipment, or program implementer requirements make it unlikely that an intervention will be deliverable on a population basis through the public health system.

The majority of intervention programs added to the list of Recommended interventions are arthritis appropriate but not designed exclusively for people with arthritis. This can be advantageous both for the individual participant/patient and for the organizations offering the programs. More than half the people with arthritis have another chronic condition,⁶² and over half the people with diabetes or heart disease also have arthritis,^63,64 so offering programs that promote generic self-management skills can allow patients with multiple chronic conditions the opportunity to meet their multiple needs. Similarly, organizations offering these interventions may not have the resources to offer a wide variety of disease-specific services, but may find sustaining programs easier when they meet the needs of multiple patient/population groups. The CDC Arthritis Program is currently supporting efforts to expand the implementation of these programs among groups with a range of chronic conditions.

Two of the interventions added to the list of Recommended SME interventions are offered in Spanish and are designed specifically to meet the needs of Spanish-speaking people with chronic disease.^19,20 These two interventions are not mere translations of English interventions but are developed based on needs assessments of Spanish-speaking people with arthritis or chronic disease and are designed to be culturally appropriate for that population. These Spanish language interventions are important because between 1970 and 2000, the Hispanic population in the United States grew by 26 million; nearly half of that growth was due to immigration.⁶⁵ Although the prevalence of doctor-diagnosed arthritis is reported to be lower among Hispanics than Caucasians, Hispanic people with arthritis report a higher proportion of work limitations and severe joint pain than do non-Hispanic Caucasians.⁶⁶

Several of the interventions on the Promising Practices list, such as The Arthritis Toolkit²¹ and the internet-delivered ASMP,²² offer new ways of delivering programs, beyond the small group model typical for community-delivered public health interventions. These new delivery modes can help meet the needs of people who do not have the time, resources (like transportation), or inclination to attend a small group PA or SME program. Because at present, 44% of people with arthritis are inactive⁶⁷ and only 11% of people with arthritis report attending a course or class to help solve problems related to arthritis,⁶⁸ it is clear that these new modes of program delivery are essential to meeting the needs of people with arthritis. Several more of these self-directed or self-study interventions are on the Watch List, and their availability will be eagerly awaited.

Conclusions

Using a systematic process allowed the CDC Arthritis Program to review a wide array of potential intervention programs to identify those arthritis-appropriate evidence-based interventions that can be effectively and efficiently offered through a state health department or in a public health setting. Many promising interventions, whether developed in the field or as research projects, have not built the necessary evidence base or infrastructure. Public health resources are too scarce to recommend programs that have not demonstrated and reported effectiveness. Adequate infrastructure also is necessary for an intervention to be used as a widespread public health intervention. The categorization of interventions by the adequacy of their science base and implementability as a public health intervention can inform intervention developers and evaluators on gaps that need to be filled to prepare an intervention for widespread public health implementation and can inform funding agencies on promising interventions for further intervention research.

Expanding the list of recommended interventions with three SME interventions and three PA interventions is good news for people with arthritis and for both public health and clinical care practitioners. For public health practitioners, it expands the menu of program offerings that can help meet the needs of their constituents with arthritis (and other chronic conditions), and it facilitates partnering with a wider variety of delivery system partner organizations. This expanded list of Recommended interventions provides clinical care providers with a wider array of evidence-based interventions to recommend to their patients with arthritis, and the screening process can give them confidence that these Recommended intervention programs have documented health benefits. Finally, this expanded list of Recommended interventions, both arthritis specific and generic to chronic disease, are beneficial for people with arthritis. This review process can increase their confidence in the merits of these interventions, and the wider array of interventions and potential program delivery organizations can increase their opportunities to participate in these community-based SME and PA interventions that are designed to help them improve their quality of life.

Footnotes

Acknowledgments

The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Disclosure Statement

No competing financial interests exist.

References

Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2003–2005. MMWR, 2006; 55:1089–1092.

Hootman

, Helmick

. Projections of U.S. prevalence of arthritis and associated activity limitations. Arthritis Rheum, 2006; 54:226–229.

Hootmen

, Brault

, Helmick

, Theis

, Armour

. Prevalence and most common causes of disability among adults—United States 2005. MMWR, 2009; 58:421–426.

Theis

, Murphy

, Hootman

, Helmick

, Yelin

. Prevalence and correlates of arthritis-attributable work limitation in the U.S. population among persons age 18–64, 2002 NHIS data. Arthritis Rheum, 2007; 57:355–363.

Theis

, Helmick

, Hootman

. Arthritis burden and impact are greater among U.S. women than men: Intervention opportunities. J Womens Health, 2007; 16:441–453.

U.S. Department of Health and Human Services. Healthy people 2010: Objectives for improving health, 2nd. Washington, DC: U.S. Government Printing Office, 2000.

Arthritis Foundation, Association of State and Territorial Health Officers, Centers for Disease Control and Prevention. National arthritis action plan: A public health strategy. Atlanta, GA: Arthritis Foundation, 1999.

Hootman

, Sniezek

, Helmick

. Women and arthritis: Burden, impact, and prevention programs. J Womens Health Gend Based Med, 2002; 11:407–416.

American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum, 2002; 46:328–346.

10.

American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum, 2000; 43:1905–1915.

11.

Bodenheimer

, Wagner

, Grumbach

. Improving primary care of patients with chronic illness. JAMA, 2002; 288:1775–17791909–1914.

12.

Lorig

, Lubeck

, Kraines

, Seleznick

, Holman

. Outcomes of self-help education for patients with arthritis. Arthritis Rheum, 1985; 28:680–685.

13.

Boutaugh

. Arthritis Foundation community-based physical activity programs: Effectiveness and implementation issues. Arthritis Rheum, 2003; 49:463–470.

14.

Wallace

, Buchner

, Grothaus

et al. Implementation and effectiveness of a community-based health promotion program for older adults. J Gerontol, 1998; 53a:M301–M306.

15.

Dunn

, Marcus

, Kampert

, Garcia

, Kohl

III , Blair

. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: A randomized trial. JAMA, 1999; 281:327–334.

16.

Hughes

, Seymour

, Campbell

, Pollak

, Huber

, Sharma

. Impact of the Fit and Strong intervention on older adults with osteoarthritis. Gerontologist, 2004; 2:217–228.

17.

Silver Sneakers website. www.silversneakers.com/. 2009 April 8.

18.

Lorig

, Sobel

, Stewart

et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Med Care, 1999; 37:5–14.

19.

Lorig

, González

, Ritter

. Community-based Spanish language arthritis education program: A randomized trial. Med Care, 1999; 37:957–963.

20.

Lorig

, Ritter

, González

. Hispanic chronic disease self-management: A randomized community-based outcome trial. Nurs Res, 2003; 52:361–369.

21.

Goeppinger

, Lorig

, Ritter

, Mutatkar

, Villa

, Gizlice

. Mail delivered arthritis self-management tool kit: A randomized trial and longitudinal follow-up. Arthritis Rheum, 2009; 61:867–875.

22.

Lorig

, Ritter

, Laurent

, Plant

. The Internet-based Arthritis Self-Management Program: A one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Rheum, 2008; 59:1009–17.

23.

Levy

, Macera

, Lopez

et al. Effects of an exercise program on functional fitness and arthritis-specific outcomes: Fitness and Exercise for People with Arthritis (FEPA) Rapid communication poster, Society of Behavioral Medicine's 29th Annual Meeting and Scientific Sessions, March 26–29, 2008 San Diego, CA.

24.

Layne

, Arabelovic

, Wilson

et al. Community-based strength training improves physical function in older women with arthritis. Am J Lifestyle MedOnline: July 212009.

25.

First Step to Active Health website. www.firststeptoactivehealth.com/. 2009 April 8.

26.

Healy

, Peng

, Haynes

, McMahon

, Botler

, Gross

. The feasibility and effectiveness of translating A Matter of Balance into a volunteer lay leader model. J Appl Gerontol, 2008; 27:34–51.

27.

Jette

, Lachman

, Giorgetti

et al. Exercise—It's never too late: The Strong-for-Life Program. Am J Public Health, 1999; 89:66–72.

28.

Seguin

, Economos

, Hyatt

, Palombo

, Reed

PNT

, Nelson

. Design and national dissemination of the StrongWomen Community Strength Training Program. Prev Chron Dis, 2008; 5. www.cdc.gov/pcd/issues/2008/jan/06_0165.htm. 2009 April 8 www.strongwomen.com/

29.

Seguin

, Epping

, Bloch

, Buchner

, Nelson

. Growing Stronger: Strength training for older adults. Boston, MA: Tufts University, 2002. www.cdc.gov/physicalactivity/growingstronger/ www.cdc.gov/nccdphp/dnpa/physical/growing_stronger/growing_stronger.pdf

30.

Stewart

, Verboncoeur

, McLellan

et al. Physical activity outcomes of CHAMPS II: A physical activity promotion program for older adults. J Gerontol A Biol Sci Med Sci, 2001; 56:465–470.

31.

Lorig

, Ritter

, Laurent

, Plant

. Internet-based chronic disease self-management. Med Care, 2006; 44:964–971.

32.

Stewart

, Mills

, Sepsis

et al. Evaluation of CHAMPS, a physical activity promotion program for older adults. Ann Behav Med, 1997; 1:353–361.

33.

Knowler

, Barrett-Connor

, Fowler

et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med, 2002; 346:393–403.

34.

Wilcox

, Dowda

, Leviton

et al. Active for life: Final results from the translation of two physical activity programs. Am J Prev Med, 2008; 35:340–351.

35.

Callahan

, Shreffler

, Mielenz

, Hootman

, Schwartz

, Brady

. The impact of a behavioral lifestyle program on physical activity in older adults with arthritis. Abstract presented at the 2nd International Congress on Physical Activity and Public Health, April 13–16, 2008

Amsterdam, The Netherlands

www.icpaph08.org/uploads/files/final%20programme%20update.pdf

36.

Blair

, Dunn

, Marcus

, Carpenter

, Janet

. Active living every day. Human Kinetics: Champaign, IL, 2001.

37.

Patrick

, Ramsey

, Spencer

, Kinne

, Belza

, Topolski

. Economic evaluation of aquatic exercise for persons with osteoarthritis. Med Care, 2001; 39:413–424.

38.

Belza

, Topolski

, Kinne

, Patrick

, Ramsey

. Does adherence make a difference? Results from a community-based aquatic exercise program. Nurs Res, 2002; 51:285–291.

39.

Wang

, Belza

, Thompson

, Whitnes

, Bennett

. Effects of aquatic exercise on flexibility, strength, and aerobic fitness in adults with osteoarthritis of the hip or knee. J Adv Nurs, 2007; 57:141–152.

40.

Callahan

, Mielenz

, Freburger

et al. A randomized controlled trial of the People with Arthritis Can Exercise Program: Symptoms, function, physical activity, and psychosocial outcomes. Arthritis Rheum, 2008; 59:92–101.

41.

Minor

, Prost

, Nigh

, Ge

, Hewett

. Outcomes from the Arthritis Foundation exercise program: A randomized controlled trial. Arthritis Rheum, 2007; 56:S309.

42.

Belza

, Shumway-Cook

, Phelan

, Williams

, Snyder

, LoGerfo

. The effects of a community-based exercise program on function and health in older adults: The EnhanceFitness Program. J Appl Gerontol, 2006; 25:291–306.

43.

Ackermann

, Williams

, Nguyen

, Berke

, Maciejewski

, LoGerfo

. Healthcare cost differences with participation in a community-based group physical activity benefit for medicare managed care health plan members. J Am Geriatr Soc, 2008; 56:1459–1465.

44.

Seymour

, Hughes

, Campbell

, Huber

, Desai

. Comparison of two methods of conducting Fit and Strong! Arthritis Rheum, 2009; 61:876–884.

45.

Lorig

, Mazonson

, Holman

. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis Rheum, 1993; 36:439–446.

46.

Buszewicz

, Rait

, Griffin

et al. Self-management of arthritis in primary care: Randomised controlled trial. BMJ, 2006; 333:879–882.

47.

Lorig

, Ritter

, Plant

. A disease specific self-help program compared with a generalized chronic disease self-help program for arthritis patients. Arthritis Rheum, 2005; 53:950–957.

48.

Goeppinger

, Armstrong

, Schwartz

, Ensley

, Brady

. Self-management education for persons with arthritis: Managing co-morbidities and eliminating health disparities. Arthritis Rheum, 2007; 57:1081–1088.

49.

Osborne

, Wilson

, Lorig

, McColl

. Does self-management lead to sustainable health benefits in people with arthritis? A 2 year transition study of 452 Australians. J Rheumatol, 2007; 34:1112–1117.

50.

Dennis

, Barlow

, Turner

et al. An 8 year follow-up of arthritis self-management program participants. Rheumatology, 2009; 48:128–133.

51.

Lorig

, Fries

. The Arthritis Helpbook. De Capo Press: Cambridge, MA, 2006.

52.

Lorig

, Ritter

, Stewart

et al. Chronic disease self-management program: 2-Year health status and health care utilization outcomes. Med Care, 2001; 39:1217–1223.

53.

Kennedy

, Reeves

, Bower

et al. The effectiveness and cost effectiveness of a national lay-led self-care support programme for patients with long-term conditions: A pragmatic randomised controlled trial. J Epidemiol Community Health, 2007; 61:254–261.

54.

Barlow

, Wright

, Turner

, Bancroft

. A 12 month follow-up study of self-management training for people with chronic disease: Are changes maintained over time? Br J Health Psychol, 2005; 10:589–599.

55.

Gitlan

, Chernett

, Harris

, Palmer

, Hopkins

. Harvest health: Translation of CDSMP for older African Americans in a senior setting. Gerontologist, 2008; 48:698–705.

56.

Lorig

, Holman

, Sobel

, Laurent

, Gonzales

, Minor

. Living a healthy life with a chronic condition. Bull Publishing: Boulder, CO, 2006.

57.

Wong

, Harker

, Lau

, Shatzel

, Port

. Spanish Arthritis Empowerment Program: A dissemination and effectiveness study. Arthritis Rheum, 2004; 51:332–336.

58.

Gonzales

, Niacif de

Brey V

, Lorig

, Fries

. Como convivi con su arthritis. Bull Publishing: Boulder, CO, 2006.

59.

Lorig

, Ritter

, Jacquez

. Outcomes of border health Spanish/English chronic disease self-management programs. Diabetes Educ, 2005; 31:401–409.

60.

Gonzales

, Laurent

, Lorig

, Holman

, Sobel

, Minor

. Tomando control de su Salud. Bull Publishing: Boulder, CO, 2003.

61.

Wilson

, Fridinger

. Focusing on public health: A different look at translating research to practice. J Womens Health, 2008; 17:173–179.

62.

Shih

, Hootman

, Strine

, Chapman

, Brady

. Serious psychological distress in U.S. adults with arthritis. J Gen Intern Med, 2006; 21:1160–1166.

63.

Centers for Disease Control and Prevention. Arthritis as a potential barrier to physical activity among adults with diabetes, U.S., 2005 and 2007. MMWR, 2008; 57:486–489.

64.

Centers for Disease Control and Prevention. Arthritis as a potential barrier to physical activity among adults with heart disease—United States, 2005 and 2007. MMWR, 2009; 58:165–169.

65.

Suro

, Passel

. The rise of the second generation: Changing patterns in Hispanic population growth. Washington, DC: Pew Hispanic Center, 2003.

66.

Centers for Disease Control and Prevention. Racial/ethnic differences in the prevalence and impact of doctor-diagnosed arthritis—United States, 2002. MMWR, 2005; 54:119–123.

67.

Shih

, Hootman

, Kruger

, Helmick

. Physical activity in men and women with arthritis, National Health Interview Survey, 2002. Am J Prev Med, 2006; 30:385–393.

68.

Centers for Disease Control and Prevention. Monitoring progress in arthritis management—United States and 25 states, 2003. MMWR, 2005; 54:484–488.