Professional Documents
Culture Documents
KEY WORDS OBJECTIVE. The purpose of this study was to examine quality of life (QOL) in American Indian and White
activities of daily living (ADLs) women with and without rheumatoid arthritis.
ethnicity METHOD. This cross-sectional study included 64 women in four groups: American Indians with rheuma-
quality of life toid arthritis, healthy American Indians, Whites with rheumatoid arthritis, and healthy Whites. Participants
received evaluations of pain, joint motion, hand function, daily task performance, community participation,
rheumatoid arthritis
and QOL.
women
RESULTS. There was a significant difference in QOL between the participants with rheumatoid arthritis and
the healthy control groups but not between the American Indian and White groups. Current health and emo-
tionalsocial function related to QOL in all groups. Dexterity also correlated with QOL in the two groups with
rheumatoid arthritis. Performance of daily activities correlated with QOL in all groups except the healthy White
groups. Community participation did not correlate with QOL.
CONCLUSIONS. The findings suggest that rheumatoid arthritis in American Indian and White women does
affect QOL and that QOL does not seem to be influenced by ethnicity. Factors that related to QOL also were sim-
ilar for both groups with rheumatoid arthritis.
Poole, J. L., Chiappisi, H., Cordova, J. S., & Sibbitt, W., Jr. (2007). Quality of life in American Indian and White women with
and without rheumatoid arthritis. American Journal of Occupational Therapy, 61, 280289.
Janet L. Poole, PhD, OTR/L, FAOTA, is Associate uality of life (QOL) refers to ones global feeling of well-being or satisfaction
Professor, Occupational Therapy Graduate Program,
Department of Pediatrics, MSC09 5240, University of
Q with ones life in the context of the culture and value system in which one lives
(Campos & Johnson, 1990). QOL has been studied over the past 20 years in peo-
New Mexico, Albuquerque, NM 87131-0001;
jpoole@salud.unm.edu ple with chronic disorders, such as rheumatoid arthritis, that interfere with con-
tinued involvement in valued occupations and thus disrupt feelings of well-being.
Heather Chiappisi, MOT, OTR/L, is Staff Occupational
Therapist, Sacred Heart Medical Center, Eugene, OR.
Research has shown that rheumatoid arthritis causes specific impairments in body
function and structure such as pain, stiffness, swelling, and loss of motion in joints
Jennifer Schukar Cordova, OTR/L, is Occupational (American College of Rheumatology, 2000). The progression in these impairments
Therapist, Albuquerque Public Schools.
over time results in a loss of ability to perform occupations of self-care, leisure, and
Wilmer Sibbitt, Jr., MD, is Professor, Internal work (Doeglas et al., 2004; Hewlett, Young, & Kirwan, 1995; Katz & Yelin, 1995;
Medicine and Neurology, University of New Mexico, Pincus et al., 1984; Roberts, Matecjyck, & Anthony, 1996; Stamm, Wright,
Albuquerque. Machold, Sadio, & Smolen, 2004; Wright & Owen, 1976; Yelin, Lubeck, Hol-
man, & Epstein, 1987). Indeed, a loss of valued occupations has been reported to
be a strong risk factor for developing depressive symptoms, leading to decreased
QOL (Blalock, Orlando, Mutran, DeVellis, & DeVellis, 1998; Doeglas et al.,
2004; Katz & Yelin, 1995). Decreased occupational performance, therefore, may
be a major factor in influencing QOL (Blalock et al., 1998; Burckhardt, 1985;
Katz & Yelin, 1993, 1995; MacKinnon & Miller, 2003; Pincus et al., 1984;
Reisine, Fifield, & Winkelman, 1998; Stamm et al., 2004; Wikstrom, Isacsson, &
Jacobsson, 2001; Wright & Owen, 1976). However, Burckhardt (1985) found
280 May/June 2007, Volume 61, Number 3
that QOL for people with arthritis depended more on psy- White women with and without rheumatoid arthritis and
chosocial factors than occupational performance or pain. A to determine whether pain, joint motion, or the ability to
later study showed that psychological functioning was the perform activities of daily living affects perceived QOL.
best predictor of QOL in women with rheumatoid arthritis The research questions were the following: (a) Did per-
(Burckhardt, Archenholtz, & Bjelle, 1993). ceived QOL differ in American Indian and White women
Sociodemographic variables also have been shown to be with and without rheumatoid arthritis? (b) What factors
important factors related to QOL. Studies report that being were related to perceived QOL in American Indian and
married relates to having higher QOL (Katz, 1998; Katz & White women with and without rheumatoid arthritis? (c)
Yelin, 1993; Wright & Owen, 1976; Zautra et al., 1998). How did factors relating to perceived QOL differ between
Social support may allow people with rheumatoid arthritis American Indian and White women with and without
to continue participation in valued activities because social rheumatoid arthritis?
support minimizes anxiety and depression at times of stress
(Zautra et al., 1998) and keeps people from becoming
dependent on social services (Archenholtz, Burckhardt, & Methodology
Segesten, 1999). The ability to be employed is another fac- The current study is a cross-sectional design in which par-
tor reported to affect QOL. Loss of employment is associ- ticipants were tested once and within one geographic area
ated with poorer health, greater psychosocial distress, and to keep the variables, such as access to health care and
monetary losses, which result in decreased QOL (Reisine et rheumatology expertise, consistent for all groups. The sam-
al., 1998). ple was one of convenience.
Most of the research on QOL in people with rheuma-
toid arthritis has been based on a narrow population: mostly Participants
middle-class, White, and well-educated (Burckhardt, 1985; The participants consisted of 64 women organized into
Burckhardt, Woods, Schultz, & Ziebarth, 1989; Husted, four groups based on ethnicity and presence of rheumatoid
Gladman, Farewell, & Cook, 2001; Lambert, Lambert, arthritis: American Indians with rheumatoid arthritis (n =
Klipple, & Mewshaw, 1989; Pincus et al., 1984; Reisine et 17), healthy American Indians without rheumatoid arthri-
al., 1998; Sherrer, Bloch, Mitchell, Young, & Fries, 1986; tis (n = 17), Whites with rheumatoid arthritis (n = 15), and
Whalley, McKenna, De Jong, & Van Der Heijde, 1997; healthy Whites without rheumatoid arthritis (n = 15). The
Zautra et al., 1998). However, some of the highest preva- participants in the rheumatoid arthritis groups had been
lence rates of rheumatoid arthritis are in American Indian diagnosed by a rheumatologist as having rheumatoid arthri-
populations (Ferucci, Templin, & Lanier, 2004; Klippel, tis according to diagnostic criteria of the American College
1997; Peschken & Esdaile, 1999). Studies have shown that of Rheumatology (formerly the American Rheumatism
American Indians with rheumatoid arthritis have an earlier Association; Arnett et al., 1988) for at least 1 year. People
disease onset and greater disease severity than the White with rheumatoid arthritis were excluded from the study if
population (Ferucci et al., 2004; Peschken & Esdaile, 1999). they had more than one rheumatic disease or any other dis-
In addition, American Indian populations are reported to abling co-morbid conditions such as stroke or a cardiac con-
have less health insurance, limited access to health care dition. Participants in the healthy control groups did not
especially to specialists such as rheumatologistslower edu- self-report any neurological, psychological, medical, or
cation levels, and lower median incomes and are reported to orthopedic conditions that impaired their occupational per-
be in poorer health than the general population of the formance. Healthy control groups were used because differ-
United States (John, Kerby, & Hennessy, 2003; U.S. Depart- ences have been found in the factors related to QOL
ment of Health and Human Services, 2001). American Indi- between two different groups living in the same geographic
ans with rheumatoid arthritis may live for a long time with area (Archenholtz et al., 1999; Yelin et al., 1987); therefore,
pain, loss of joint motion, and inability to perform occupa- a difference could exist in the domains of QOL when com-
tions of daily living, which might lead to decreased QOL. paring women with rheumatoid arthritis to healthy women
However, the impact of rheumatoid arthritis on occupational without rheumatoid arthritis. Because QOL may be depen-
performance and QOL in American Indians has been stud- dent on more than just health, the participants were group
ied minimally (Kramer, Harker, & Wong, 2002a, 2002b), matched for age and education level (see Table 1 for demo-
and no studies have compared QOL and related factors in graphics of participants). All participants could understand,
American Indians and Whites with rheumatoid arthritis. read, and follow instructions in English. This study was
This study sought to compare whether disease or eth- approved by the Human Research Review Committee at
nicity relate to perceived QOL in American Indian and the authors institution, the Albuquerque Service Unit
The American Journal of Occupational Therapy 281
Table 1. Demographic Statistics of Participants by Disease and Ethnic Group
American Indians With Whites With Healthy
Rheumatoid Arthritis Rheumatoid Arthritis American Indians Healthy Whites
Demographic Variables (n = 17) (n = 15) (n = 17) (n = 15) p values
Years of age (range) 44.1 (1974) 47.7 (1972) 45.7 (2472) 45.8 (1974) ns
Years with rheumatoid arthritis (range) 9.3 (1.331) 10.6 (2.235) ns
Education level
<1 years (%) 11.8 13.3 11.8 6.7 ns
12 years (%) 23.5 33.3 23.5 26.7 ns
>2 years (%) 64.7 53.3 64.7 66.7 ns
Marital status
Married (%) 52.9 53.3 41.2 40.0 ns
Single, never married (%) 29.4 20.0 41.2 33.3 ns
Work status (% full-time) 47.1 26.7 70.6 66.7 < 0.05
Health now (15) 3.0 (15) 2.7 (14) 4.12 (35) 4.17 (15) < 0.0001
Health now
Very good or excellent (%) 29.4 13.3 88.2 86.6 ns
Good (%) 23.5 26.7 11.8 6.7 ns
Fair (%) 47.1 60.0 0 6.7 ns
Poor (%) 0 0 0 0 ns
Note. ns = not significant. 1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor.
Health Board, and the Albuquerque Area Combined activities, physical fitness, health, social activities, pain, and
Indian Health Services Institutional Review Board. feelings (Nelson et al., 1987; Palmer, 1987). Each chart asks
participants to rate the item with reference to the past 2
Instruments weeks on a 5-point scale from 1 (great difficulty) to 5 (no
Perceptions of QOL were assessed using global QOL and problem). A higher score indicated better QOL. The Dart-
component-specific QOL instruments. The remainder of mouth COOP charts were adapted for use with American
the instruments covered the International Classification of Indians and reported to be both reliable and acceptable by
Functioning, Disability, and Health (ICF) categories of (a) this population (Gilliland et al., 1998).
Body FunctionsBody Structures and (b) Activities and
Participation (World Health Organization, 2001). The Measures of Body FunctionsBody Structures
Body FunctionsBody Structures instruments assessed Pain. Pain was measured using the Dartmouth COOP
pain, hand function, upper- and lower-extremity joint chart for pain (Gilliland et al., 1998; Nelson et al., 1987).
motion, and emotional and social function. Activities and Participants were asked to rate themselves on a 5-point
Participation instruments assessed the ability to perform single-item scale ranging from 1 (severe pain) to 5 (no pain).
everyday occupations and community participation. A The Dartmouth COOP charts have been used with both
focus group of American Indian women found the instru- American Indian and White populations.
ments culturally acceptable. Hand function. The Arthritis Hand Function Test
(AHFT) comprises 11 items that measure hand strength,
Measures of QOL dexterity, applied dexterity, and applied strength (Backman
Global QOL. Cantrils (1965) Self-Anchoring Scale was & Mackie, 1995, 1997). Hand strength (i.e., grip and pinch
used to measure perceived global QOL. Campos and John- strength) was measured with an adapted sphygmomanome-
son (1990) described this instrument as being the most ter and a pinch meter, respectively. Dexterity was measured
capable of assessing QOL using comparable and quantifi- using the nine-hole pegboard. The applied dexterity section
able data without imposing culture-specific standards (p. consisted of five timed bilateral activities (lacing and tying a
168). Participants were shown a picture of a 10-rung ladder. bow on a shoe, buttoning, fastening and unfastening safety
The top rung, 10, represented the best possible life, and pins, cutting meat, and manipulating coins). The applied
rung 0 the worst possible life. Participants indicated where strength items consisted of pouring a measured volume of
on the ladder they would place themselves at present, 5 water from a pitcher and lifting a tray of cans. The AHFT
years ago, and 5 years in the future. Interrater reliability was has been reported to be a reliable and valid instrument for
reported to be .95 (Cantril, 1965). measuring hand function in people with rheumatoid arthri-
Component-specific QOL. The Dartmouth Primary Care tis (Backman, Mackie, & Harris, 1991).
Cooperative Information Project (COOP) chart system is a Joint motion. The Keital Functional Test (KFT) was
series of pictorial charts that measure perceived QOL: daily used to assess joint limitations in the upper and lower
282 May/June 2007, Volume 61, Number 3
extremities (Eberl, Fasching, Rahlfs, Schleyer, & Wolf, Procedures
1976; Kalla, Kotze, Meyers, & Parkyn, 1988). The KFT has
Once a participant was identified and informed consent
a range of scores for the 24 separate items; a lower score rep-
obtained, an assessment consisting of the described instru-
resents better joint motion. The KFT has been reported to
ments was administered to the participant.
be reliable and valid with people with rheumatoid arthritis
Data collection took about 1 hr per participant, and
(Eberl et al., 1976; Kalla et al., 1988).
each participant was compensated $30 for her time.
Emotional and social function. Emotional and social
function was measured using the Dartmouth COOP Emo-
tional charts, which included social activities and feelings
(Gilliland et al., 1998; Nelson et al., 1987). For social activ-
Data Analysis
ities, participants were asked to rate themselves from 1 (no The data were analyzed using MiniTab and SAS statistical
participation in social activities) to 5 (much participation in packages. Descriptive statistics computed the means and
social activities). For feelings, they were asked to rate them- ranges for the QOL, Body FunctionsBody Structures, and
selves from 1 (bothered a lot by feeling nervous, sad, or easily Activities and Participation measures (see Table 2). Because
angry) to 5 (not at all bothered by feeling nervous, sad, or eas- so many items were on the AHFT, items were combined to
ily angry). The scores are combined to form an emotional- make four categories: hand strength (grip, 2-point pinch,
and-social-function score. The emotional and social scores and 3-point pinch), dexterity (nine-hole pegboard), applied
on the COOP correlated with scores on the Emotional dexterity (lacing and tying a bow on a shoe, buttoning, fas-
Scale of the RAND (Nelson et al., 1987). tening/unfastening safety pins, cutting meat, and manipu-
lating coins), and applied strength (pouring a measured
Measures of Activities and Participation amount of water from a pitcher and lifting a tray of cans).
Everyday occupations. The Health Assessment Ques- Two-way analyses of variance (ANOVA) with appro-
tionnaire (HAQ) is a self-administered questionnaire that priate post hoc analyses were performed to determine
measures occupational performance in people with whether significant differences existed between the groups
rheumatic disease (Fries, Spitz, Kraines, & Holman, for any of the variables. Bonferroni adjustments were used
1980). It consists of eight categories: dressing and groom- to compute the p values. Spearman rho correlations were
ing, arising, eating, walking, hygiene, reach, grip, and out- then computed to examine which variables related to QOL
side activity. Each question was scored on a 4-point scale and the strengths of those relationships; p < .05 was set for
from 0 (no difficulty) to 3 (cannot do). The highest score determining statistical significance.
within each category was the score for that category.
Adding the scores for each category and dividing by the
number of categories answered yielded a disability index Results
score between 0 and 3. Higher scores reflected greater dis-
Participants
ability. Reliability and validity of the HAQ with people
with rheumatoid arthritis has been well documented The demographic characteristics of people by condition
(Fries et al., 1980; Hakala, Nieminen, & Manelius, 1994; and ethnic group are shown in Table 1. ANOVAs showed
Pincus et al., 1984; Wolfe et al., 1988). The HAQ also has no significant differences between the groups for mean age,
been reported as valid to use with American Indians education, income, marital status, or hand dominance.
(Poole, Schukar, & Sibbitt, 2000). There also was no significant difference in disease duration
Community participation. The Community Integration between the American Indian and White groups with
Questionnaire (CIQ) is a 15-item self-report questionnaire rheumatoid arthritis.
designed to assess the three domains of integration: home There was, however, a significant difference between
integration, social interaction, and productive activity the groups on employment status (p < .01) and health sta-
(Willer, Ottenbacher, & Coad, 1994). Twelve of the items tus (p < .0001). Both groups with rheumatoid arthritis
are scored on a 3-point scale; the other three are scored on worked significantly fewer hours than the healthy controls
a 6-point scale. The total score for the CIQ ranged from 0 (p < .01), and the total percentage of the participants with
to 29, with a higher score indicating a higher level of com- rheumatoid arthritis working full-time was significantly less
munity integration. In general, the more items one does by than the healthy controls. Participants with rheumatoid
oneself, the greater the integration. The CIQ has been arthritis reported significantly poorer health status than the
shown to be reliable and valid for American Indians and healthy controls (p < .01). However, there were no signifi-
Whites with rheumatoid arthritis (Poole et al., 2000). cant differences in self-reported health status between the
The American Journal of Occupational Therapy 283
Table 2. Scores for the QOL, Body FunctionsBody Structures, and Activities and Participation Variables by Disease and Ethnic Group
American Indians With Whites With Healthy
Rheumatoid Arthritis Rheumatoid Arthritis American Indians Healthy Whites
groups with rheumatoid arthritis or between the healthy Both the American Indian and White groups with
control groups. rheumatoid arthritis had significantly less hand strength
Perceived QOL in American Indian and White women with than the healthy control groups (p < .0001). However, there
and without rheumatoid arthritis. An ANOVA showed no were no significant differences in hand strength between the
significant differences between any of the four groups for two groups with rheumatoid arthritis or between the two
past, present, or future perceived QOL on Cantrils Self- groups of healthy controls. The American Indians with
Anchoring Scale (see Table 2). Significant differences in rheumatoid arthritis had significantly slower dexterity
perceived QOL between the four groups (p < .0001) were scores than only the healthy White participants (p < .05);
observed for the Dartmouth COOP charts. Both groups however, their applied dexterity scores were significantly
with rheumatoid arthritis had significantly lower COOP slower than both healthy groups (p < .0001). On the other
scores than both healthy control groups (p < .0001), indi- hand, the White participants with rheumatoid arthritis had
cating poorer perceived QOL in people with rheumatoid significantly slower applied dexterity scores than the healthy
arthritis. American Indians (p < .0001), but their scores were not sig-
Body FunctionsBody Structures differences in American nificantly different from the healthy White group. There
Indian and White women with and without rheumatoid arthritis. were no significant differences in applied dexterity or
ANOVAs calculated to determine differences in disease and applied strength between the groups with rheumatoid
ethnic groups for the Body FunctionsBody Structures arthritis or between the healthy control groups.
variables revealed significant differences for pain, joint The Whites with rheumatoid arthritis had the lowest
motion, hand strength, dexterity, applied dexterity, and emotional and social function scores (see Table 2), which
emotional and social function (see Table 2). Both groups were significantly lower than those for the healthy White
with rheumatoid arthritis had significantly more pain than women (p < .05) but not significantly lower than those for
did both healthy control groups (p < .0001). the healthy American Indian women. However, there were
The groups with rheumatoid arthritis had significantly no significant differences in emotional and social function
more limitations in joint motion as measured by the total scores between the two groups with rheumatoid arthritis or
and upper-extremity KFT scores than the healthy control between the two healthy control groups.
groups (p < .001). Although both groups with rheumatoid Activities and Participation differences in American Indians
arthritis had similar lower-extremity KFT scores, only the and Whites with and without rheumatoid arthritis. ANOVAs
American Indians with rheumatoid arthritis had signifi- comparing the four groups on the Activities and Participa-
cantly lower lower-extremity KFT scores (i.e., less motion) tion variables revealed significant differences between the
than both healthy controls. groups for the HAQ and CIQ scores. The Whites with
284 May/June 2007, Volume 61, Number 3
rheumatoid arthritis had the highest HAQ scores, indicat- ans, pain correlated significantly with present global QOL
ing greater disability in everyday occupations (see Table 2). and the COOP total. In the Whites with rheumatoid
Indeed, both groups with rheumatoid arthritis had signifi- arthritis, applied dexterity and applied strength correlated
cantly higher HAQ scores than both healthy control groups significantly with the COOP total. For the Activities and
(p < .0001). However, the American Indians with rheuma- Participation variables, only the HAQ correlated with both
toid arthritis had the lowest community integration as indi- present global QOL and the COOP total in both Ameri-
cated by the CIQ, yet the CIQ scores for both groups with can Indian groups. For the White groups, the HAQ corre-
rheumatoid arthritis were similar. The scores from both lated only with the COOP total in the Whites with
groups with rheumatoid arthritis also were not significantly rheumatoid arthritis. In the healthy White participants,
different from the healthy American Indians but were sig- none of the other Body FunctionsBody Structures vari-
nificantly different from the scores of the healthy White ables correlated with any of the perceived QOL variables.
group. Furthermore, the CIQ was the only measure that Additionally, no significant correlations were found
revealed significantly different scores between the healthy between any of the variables and past and future global
American Indians and the healthy Whites. QOL in any of the four groups.
Factors related to perceived QOL in American Indians and
Whites. Spearman rho correlation analyses were performed
to examine the relationships between perceived QOL and Discussion
demographics (age, disease duration, income, marital sta- Three major findings emerged from this study. First, con-
tus, education level, employment status, income, perceived trary to our expectations, we found no significant differ-
current health), Body FunctionsBody Structures, and ences in present, past, or future global perceived QOL
Activities and Participation variables for each disease and between any of the four groups. In our study, therefore, nei-
ethnic group (see Table 3). Only the variables are presented ther ethnicity nor disease status affected global QOL. How-
for which there was a significant correlation between the ever, for the second perceived QOL measure, the Dart-
variable and QOL measure for at least one participant group. mouth COOP, there were differences based on the presence
For all four groups, the only demographic variable that of rheumatoid arthritis but not ethnicity. The differences
correlated with perceived QOL was health status, which between the findings could be due to how the two assess-
significantly correlated with present global QOL and, ments measured perceived QOL. Cantrils Self-Anchoring
except for the White participants with rheumatoid arthritis, Scale measured QOL in general, whereas the COOP mea-
the COOP total score. For the Body FunctionsBody sured QOL based on a summation of specific information
Structures variables, emotional and social function corre- regarding health, feelings, and daily physical and social
lated with present global QOL in the two groups with activities. The finding that perceived QOL was similar for
rheumatoid arthritis. However, in all four groups, emo- American Indian and White participants is in contrast with
tional and social function correlated with the COOP total. a previous study, which indicated that ethnicity did influ-
For the other Body FunctionsBody Structures variables, ence component-specific QOL (Johnson et al., 1988).
there were differences for the groups. In the American Indi- However, our findings do agree with others (Berzon, Hays,
ans with rheumatoid arthritis, total KFT and dexterity cor- & Shumaker, 1993; Leininger, 1994) who reported that
related with the COOP total. In the healthy American Indi- some basic QOL factors transcend ethnic groups.
Table 3. Correlations Between QOL and Impairment, Activities and Participation Variables
American Indians Whites With
With Rheumatoid Arthritis Rheumatoid Arthritis Healthy American Indians Healthy Whites
QOL COOP QOL COOP QOL COOP QOL COOP
Variables at Present Total at Present Total at Present Total at Present Total
Health now 0.89*** 0.85*** 0.58* ns 0.65** 0.65** 0.51* 0.66**
Pain ns ns ns ns 0.71** 0.48* ns ns
KFT total ns 0.53* ns ns ns ns ns ns
AHFT: Dexterity ns 0.57* ns ns ns ns ns ns
AHFT: Applied Dexterity ns ns ns 0.65* ns ns ns ns
AHFT: Applied Strength ns ns ns 0.58* ns ns ns ns
Psychosocial status 0.71** 0.93*** 0.63* 0.94*** ns 0.61* ns 0.88***
HAQ 0.61* 0.83*** ns 0.86*** 0.67** 0.80*** ns ns
Note. QOL = Quality of Life; COOP = Dartmouth Primary Care Cooperative Information Project; ns = not significant; KFT = Keital Functional Test; AHFT = Arthritis
Hand Function Test; HAQ = Health Assessment Questionnaire.
*p < 0.05; **p < 0.01; ***p < 0.0001.