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The Community Asthma Program was designed to increase awareness of asthma among urban residents and to bring more people into available care. Educational sessions with patients indicated that many adults struggle with the complicated demands of managing a chronic disease. At the same time, however, a good deal of the written materials meant to provide information and assistance instead make inappropriate demands on the average adult reader. The project team members developed a glossary of asthma terms to improve communication between patients and providers and to help patients understand the materials commonly used in neighborhood health centers. We report on the development of the glossary and describe formative research activities, initial dissemination efforts, and an interim evaluation. Health literacy, included in the goals and objectives for Healthy People 2010, can be improved when health materials are written in plain language and designed for the existing skills of the average U.S. adult reader. [ABSTRACT FROM AUTHOR]

GOAL: To explore the influence of social, psychological, and health factors on self-report of function. SUBJECTS: A convenience sample of 289 community-dwelling elderly aged 65-97 years. METHODS: We compared a measure of function based on observed performance, the Physical Capacity Evaluation (PCE) with a self-reported measure of functional limitations (HAQ), in a cross-sectional study. Stepwise multiple regression identified variables predicting self-reported disability, controlling for observed function. RESULTS: Controlling for PCE, self-reports of greater disability (HAQ) were predicted by current joint pain or stiffness, use of prescription medications, urban dwelling, depression, female gender, lack of memory problems, arthritis and lack of exercise. A final model included recent decline in function, dissatisfaction with function, gender, joint pain or stiffness, and observed function, explaining 85% of the variance in self-reported disability. The hypothesis that aging is associated with declining expectations of functional ability was not supported. However, recent health problems affected participants' reporting of limitations, consistent with a recalibration-type response shift. Perceived decline in function over the past six months, a fall within the last month, illness in the last week and pain or stiffness on the day of the exam all raised self-reports of disability. As suggested by adaptation level theory, subjects with recent problems might have an inflated perception of limitations due to shifts in their internal standards. When administered first, the observed performance test improved correlations between observed and self-reported function, primarily among those who did not report a recent decline in function. This suggests that this group may have benefited more from salient information about their abilities provided by performing the PCE before self-report. CONCLUSION: Our data confirm the importance of social, psychological, and health influences in self-report of disability, and are consistent with the hypothesis that people may recalibrate their self assessments based on recent health problems. [ABSTRACT FROM AUTHOR]

The role of response stability in the measurement of coping is examined with a focus on the unique information that can be gleaned from low test retest reliability ('inconsistency'). Data from two studies are presented in which a card sort measure of coping flexibility was used on people with three different chronic diseases and the elderly (n = 219). We begin by testing the hypothesis that the low stability reflects unreliability due to measurement artifacts, such as random error, low ecological validity, long test retest interval, surrogate assistance, or error due to completing the questionnaire in multiple sittings. Our findings suggest that surrogate assistance in completing questionnaires was the only measurement artifact associated with low stability. We then tested the proposition that low stability reflects a genuine behavior pattern (i.e. inconsistency). Hierarchical modeling revealed that measurement artifact accounted for less than one percent of the variance in inconsistency in reported coping behavior and that an additional 21% of the variance could be explained by the behavioral factors, including neuropsychological problems (9%), psychological morbidity (4%), locus of control (3%) and eudaimonistic well-being (5%). Thus inconsistency in reported coping behavior was better explained by behavioral and psychosocial factors than by the tested measurement artifacts. We conclude that inconsistency in reported coping behavior does indeed reflect a meaningful behavior pattern, rather than simply measurement artifact. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of the study were to analyze literacy in 194 consecutive patients at an academic rheumatology setting with the Rapid Estimate of Adult Literacy in Medicine (REALM) and an "Arthritis-Adapted" REALM (A-REALM), and to compare responses to one another and to demographic and clinical measures., Methods: The REALM and A-REALM are two 66-item word recognition tests. Both were administered to 194 consecutive patients in usual rheumatology care. Multidimensional Health Assessment Questionnaire (MDHAQ) scores for physical function, pain, fatigue, and global estimate, and laboratory assessments also were available. Descriptive statistics and analyses of agreement were computed., Results: REALM and A-REALM administration involved 2 to 3 minutes each. Scores below 61, indicating a reading level at eighth grade or less, were seen in 35 (18%) of 194 patients on the REALM and 46 patients (24%) on the A-REALM. No patient was classified as having severely low literacy at or below a third-grade level. However, words not read correctly by 10% or more of the patients on the REALM included diagnosis (14%), osteoporosis (17%), and inflammatory (10%), and on the A-REALM, rheumatologist (11%), cartilage (14%), and symptom (14%). REALM and A-REALM scores were correlated significantly (Pearson r = 0.94, P < 0.001). Almost all patients (33/35) with REALM scores of less than 61 also had A-REALM scores of less than 61, less formal education, and poorer clinical status on all measures, most not statistically significant., Conclusion: Low literacy is an important underrecognized problem in medical care, which may be assessed easily in standard care using the REALM or A-REALM. Further attention to literacy-associated barriers may reduce socioeconomic disparities in health.

To evaluate a theory-based educational program to prevent Lyme disease and other tick-borne illnesses (TBI), a randomized controlled trial of an educational program was delivered to ferry passengers traveling to an endemic area in southeastern Massachusetts. Rates of TBI and precautionary and tick check behaviors were measured over three summers in 30,164 passengers. There were lower rates of TBI among participants receiving TBI education compared with control participants receiving bicycle safety education (relative risk [RR] = 0.79) and a 60% reduction in risk among those receiving TBI education who visited Nantucket Island for more than 2 weeks compared to control participants (RR = 0.41, 95% confidence intervals = 0.18 to 0.95, p < .038). TBI-educated participants were also significantly more likely to take precautions (use repellent, protective clothing, limit time in tick areas) and check themselves for ticks. The study demonstrates that a theory-based Lyme disease prevention program can increase precautionary behavior and result in a significant reduction in TBI.

Lyme disease (borreliosis) incidence continues to increase despite a growing knowledge of primary and secondary prevention strategies. Primary prevention aims to reduce the risk of tick exposure and thereby decrease the incidence of new Lyme disease cases. Secondary prevention targets the development of disease or reduces disease severity among people who have been bitten by infected ticks. Numerous prevention strategies are available, and although they vary in cost, acceptability and effectiveness, uptake has been universally poor. Research in areas where Lyme disease is endemic has demonstrated that despite adequate knowledge about its symptoms and transmission, many people do not perform behaviors to reduce their risk of infection. New prevention strategies should aim to increase people's confidence in their ability to carry out preventive behaviors, raise awareness of desirable outcomes, and aid in the realization that the necessary skills and resources are available for preventive measures to be taken. In this article we evaluate the prevention and treatment strategies for Lyme disease, and discuss how these strategies can be implemented effectively. As many patients with Lyme disease develop arthritis and are referred to rheumatologists it is important that these health-care providers can educate patients about disease-prevention strategies.

Direct-to-consumer (DTC) television advertisements present a number of facts about prescription drug risks and benefits in a brief time. This study assessed comprehension of information in three advertisements among 50 adults with limited literacy. Participants correctly answered an average of 59% of comprehension questions. The percentage of respondents correctly answering individual comprehension questions ranged from 26% to 92%. A multivariate analysis suggested that type of information (risk vs. other) and channel (text vs. audio) predicted comprehension. There was a significant interaction effect for literacy and place of birth. Our results suggest key areas for future research on comprehension of DTC advertising.

The US Food and Drug Administration (FDA) allows television direct-to-consumer (DTC) prescription drug advertisements that do not fully disclose drug risks if the ads include "adequate provision" for dissemination of the drug's approved labeling. This requirement can be met in part by referring consumers to multiple text sources of product labeling. This study was designed to assess the materials to which consumers were referred in 23 DTC television advertisements. SMOG assessments showed that the average reading grade levels were in the high school range for the main body sections of the materials and college-level range for the brief summary sections. The Suitability Assessment of Materials (SAM) instrument identified specific difficulties with the materials, including content, graphics, layout, and typography features. Stronger plain language requirements are recommended. Health care providers should be aware that patients who ask about an advertised drug might not have the full information required to make an informed decision.

This article reports the results of a content analysis of 23 direct-to-consumer (DTC) product-specific television prescription drug advertisements broadcast during 2001. A majority of ads used both medical and lay terms to convey medical ideas. Most gave consumers somewhat more time to absorb facts about benefits than those about risks, which could have implications for the "fair balance" requirement. Complete references to additional product information were given only in text, casting doubt on whether these ads are making"adequate provision"for dissemination of detailed product information. Overall, our results call into question the potential of these ads to educate consumers.

Background and Purpose: When factors that influence exercise behavior are known, health care professionals can more likely design and modify patient education materials targeted to promote exercise behavior. This study aimed to identify predictors of exercise behavior in patients with rheumatoid arthritis 6 months after a visit with their rheumatologist., Subjects and Methods: Twenty-five rheumatologists and 132 patients with rheumatoid arthritis participated. One hundred thirteen patients (85.6%) completed the 6-month follow-up. Rheumatologists and patients completed baseline questionnaires and were audiotaped during a subsequent visit. Physical function and exercise behavior were ascertained via questionnaire 6 months following the visit. Multivariate logistic regression identified predictors of exercise behavior at 6 months. Eighty-nine patients (79%) were female. The average age was 54.8 years (SD=14.4, range=20-94). The mean duration of illness was 9.8 years (SD=8.7, range= <1-35). Patients were moderately impaired (mean Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36] function score=49.3, SD=27.5). Thirty-four patients (27%) were exercising 6 months after visiting their rheumatologist. More than 50% of the rheumatologists had 5 or more years of clinical experience, 18 (72%) were male, and 10 (42%) reported they exercised regularly., Results: Predictors of exercise behavior at 6 months were patients' past history of exercise (odds ratio=6.8, 95% confidence interval=3.1-15) and rheumatologists' current exercise behavior (odds ratio=0.26, 95% confidence interval=0.09-0.77)., Discussion and Conclusion: Patients were nearly 7 times more likely to exercise 6 months after visiting their rheumatologist if they participated in exercise in the past. If a patient's rheumatologist was currently performing aerobic exercise, the patient was 26% more likely to be engaged in exercise at follow-up. These data may be useful in understanding patient motivation to participate in exercise.

Objective: In a cross-sectional study, we previously identified 2 potentially modifiable risk factors for adverse outcomes in systemic lupus erythematosus (SLE): self-efficacy and social support. The goal of this study was to evaluate in a randomized controlled trial a theory-based intervention to improve patient self-efficacy and partner support to manage SLE., Methods: Patients with SLE ages 18 years and older who met the American College of Rheumatology criteria and were able to identify a partner (spouse or family member) were recruited from 2 academic medical centers and randomized into an experimental group or a control group. Patients in the experimental group and their partners received an intervention designed to enhance self-efficacy, couples communication about lupus, social support, and problem solving, in the form of a 1-hour session with a nurse educator followed by monthly telephone counseling for 6 months. Patients in the control group and their partners received an attention placebo, including a 45-minute video presentation about lupus, and monthly telephone calls. Measures of physical and mental health status, disease activity, and psychosocial factors were collected at baseline, 6 months, and 12 months. The effect of the intervention on physical and mental health and disease activity at 6 and at 12 months was modeled with linear regression and adjusted for baseline health status, disease activity, sociodemographic factors, treatment change, and psychosocial factors., Results: One hundred twenty-two patients (plus their partners) were enrolled and randomized as follows: 64 to the experimental intervention and 58 to the attention control group. The participants were predominantly white, approximately half were college educated, and the groups were balanced for sociodemographic factors. At 6 months, significantly higher scores for couples communication (P = 0.01) and problem-focused coping (P = 0.03) were seen in the experimental group compared with the control group. At 12 months (6 months after the intervention ended), social support was higher (4.4 versus 4.1; P = 0.03), self-efficacy was higher (7.2 versus 6.2; P = 0.02), couples communication was higher (3.5 versus 3.1; P = 0.03), and fatigue was lower (5.1 versus 6.3; P = 0.02) in the experimental group compared with the control group. Global mental health status at 12 months, as measured by the Short Form 36 survey, was 69 points in the experimental group compared with 58 points in the control group (P = 0.04). In multivariate models, adjusting for baseline covariates, scores for couple communication (P = 0.01) were significantly higher at 6 months, and scores for self-efficacy (P = 0.004) and global mental health status (P = 0.03) were significantly higher at 12 months in the experimental group compared with the control group, and the mean score for global physical function was higher by 7 points, which was a clinically meaningful change (P = 0.2). The mean score for fatigue was also significantly lower in the experimental group than in the control group (P = 0.05). SLE disease activity was unchanged by this intervention., Conclusion: This randomized, controlled trial of a theory-based educational intervention in SLE demonstrated significantly higher scores for couple communication, self-efficacy, and mental health status, and lower fatigue scores in the experimental group compared with the control group. Because couple communication and self-efficacy appear to be modifiable risk factors, they may also be potential targets in more disadvantaged populations.

The goal of this work was to develop an economical way of tracking disease activity for large groups of systemic lupus erythematosus (SLE) patients in clinical studies. A Systemic Lupus Activity Questionnaire (SLAQ) was developed to screen for possible disease activity using items from the Systemic Lupus Activity Measure (SLAM) and tested for its measurement properties. The SLAQ was completed by 93 SLE patients just prior to a scheduled visit. At the visit, a rheumatologist, blinded to SLAQ results, examined the subject and completed a SLAM. Associations among SLAQ, and SLAM (omitting laboratory items) and between individual items from each instrument were assessed with Pearson correlations. Correlations between pairs of instruments were compared using Student's t-tests. The mean score across all 24 SLAQ items was 11.5 (range 0-33); mean SLAM without labs was 3.0 (range 0-13). The SLAQ had a moderately high correlation with SLAM-nolab (r = 0.62, P < 0.0001). Correlations between patient-clinician matched pairs of items ranged from r = 0.06 to 0.71. Positive predictive values for the SLAQ ranged from 56 to 89% for detecting clinically significant disease activity. In studies of SLE, symptoms suggesting disease can be screened by self-report using the SLAQ and then verified by further evaluation.

Objective: To evaluate the relationship between patient expectations of total joint arthroplasty (TJA) and health related quality of life plus satisfaction 6 months after surgery. Methods. This prospective cohort study included patients undergoing primary total hip (THA) and knee arthroplasty (TKA). Patients were evaluated with self-report questionnaires prior to surgery and 6 months post-surgery. Medical Outcomes Study Short Form 36 (SF-36), the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), and a satisfaction scale were used to evaluate outcomes at final followup. Multivariate regression models were used to evaluate the impact of expectations on outcomes., Results: There were 102 patients with THA and 89 with TKA. Mean age was 66 years. All patients achieved significant improvements in their WOMAC and SF-36 scores following surgery. Patient expectations regarding surgery were not associated with their age, gender, index joint of surgery, marital status, or race. Expectations were not correlated with pre-operative functional health status. Expectation of complete pain relief after surgery was an independent predictor of better physical function and improvement in level of pain at 6 months post-surgery. Expectation of low risk of complications from TJA was an independent predictor of greater satisfaction., Conclusions: Patient expectations were important independent predictors of improved functional outcomes and satisfaction following TJA. Greater understanding of the relationship between expectations and outcomes may improve the process of care and outcomes of TJA.

Assessment of pain, depression, and anxiety by visual analogue scale in Japanese women with rheumatoid arthritis Visual analogue scales (VAS) of depression and anxiety were compared with standard full-length measures of these variables and with VAS of pain (VAS Pain). This was a good way to develop a practical methodology for the routine assessment of pain and affect in rheumatoid arthritis (RA) patients. The reliability of VAS Pain was studied by test-retest. The validity of VAS Pain in our sample was proved by correlations with the results of other tests. We also investigated the relationship between VAS Pain and C-reactive protein (CRP). In 145 female RA patients, VAS of depression and anxiety were significantly correlated with full-length measures of these variables, and accounted for the majority of the explained variance in VAS Pain, while the full-length standard measures contributed little more. In conclusion, VAS measurements of pain and affect were comprehensible, easily filled-out, and reliable in a sample of Japanese women with RA, and could capture some aspect of affective distress unique to RA patients.

Objective: Health status and disease activity in patients with systemic lupus erythematosus (SLE) and other chronic diseases are strongly associated with social support, which suggests that enhanced social support in medical care might improve SLE outcome. There has been little or no study on identifying patients for whom social support would be most beneficial. It would allow practitioners to enable social support more effectively as a complement to disease management., Methods: A retrospective cohort (200 patients with SLE from 5 centers), balanced by race and insurance status, was studied in a cross sectional design. Demographic, clinical, socioeconomic, and psychosocial factors and disease outcomes [Systemic Lupus Activity Measure (SLAM), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR), SF-36] were measured. Using multivariate linear regression and ANOVA (outcome = SF-36 physical function, mental health), we examined the interaction between social support and patients' characteristics, including race, age, income, occupation, insurance, employment, education, and social network, and characteristics of the disease itself such as disease activity (SLAM) at diagnosis, damage (SLICC/ACR) at diagnosis, and comorbidity., Results: In multivariate models, higher social support was significantly associated (p < 0.05) with better physical function when respondents were white, had income above poverty level, had Medicare or private insurance (vs Medicaid or no insurance), and had low disease activity at diagnosis. Social support was associated with better mental health, although there was no significant interaction between social support and other predictors of mental health., Conclusion: The data suggest that social support is beneficial for mental health for all groups, but has the greatest opportunity for influence among those already possessing social, economic, and health advantages.

Objective: Little is known about the features and role of exercise discussions between rheumatologists and patients. The goals of this study were to: 1) describe rheumatologists' and patients' attitudes and beliefs regarding exercise and physical therapy for rheumatoid arthritis (RA); 2) describe frequency and length of exercise discussions; 3) determine the accuracy of recall for exercise discussions; and 4) assess the influence of attitudes regarding exercise on communication about exercise., Methods: Goals 1-3 were addressed with analysis of baseline questionnaires and audiotaped encounters. The influence of attitudes and beliefs regarding exercise on the frequency and length of exercise discussions was assessed prospectively. Patients and rheumatologists were enrolled from a large tertiary care institution. Clinical encounters were audiotaped, transcribed, coded, and analyzed to identify specific characteristics of the exercise discussions., Results: One hundred thirty-two patients and 25 rheumatologists participated in the study. Rheumatologists and patients discussed exercise in 53% of the encounters. Rheumatologists' beliefs regarding the usefulness of exercise for RA varied, with the least positive beliefs being reported for aerobic exercise. Exercise discussions were more likely to occur if the patient was currently exercising, odds ratio (OR) = 2.4; 95% confidence interval (CI) (1.2-4.9), and when the rheumatologist believed aerobic exercises were useful in managing RA, OR = 1.4; 95% CI (1.1-1.9). Current exercise behavior was associated with patients' positive attitude toward exercise (chi 2 1 = 8.4; P = 0.004) and perceived social support for exercise (chi 2 1 = 4.5; P = 0.04). When rheumatologists initiated exercise discussions, there was nearly twice as much discussion (beta = -8.4; P = 0.001)., Conclusions: Exercise talk was influenced by patients' and rheumatologists' beliefs and attitudes regarding the effectiveness of exercise and physical therapy in managing RA, patient experience with exercise, and by characteristics of the rheumatologist.

Objective: Psychoeducational preparation is known to improve postoperative outcome. We tested two common psychoeducational procedures in elderly orthopedic patients, examining how best to match interventions to patients by psychological type., Methods: Two hundred twenty-two elderly patients undergoing total hip or knee replacement were randomly assigned to 1) a slide-tape with information on the postoperative, in-hospital rehabilitation experience, or 2) training in Benson's Relaxation Response with a bedside audiotape, in a 2 x 2 factorial design., Results: The relaxation response did not influence postoperative outcomes. The educational intervention reduced length of stay and pain medication use for patients who exhibited most denial (tendency to avoid thinking about unpleasant events), and reduced postoperative anxiety and cognitive errors on the Mini-Mental State Exam for patients with most baseline anxiety. There was no effect on postoperative pain., Conclusions: The importance of attending to the patient's psychological state and level of preparation before orthopedic surgery is reinforced. Patients who exhibit most denial and highest anxiety may benefit from educational interventions, but patients' directly expressing desire for information may be a poor guide in deciding which patients would benefit, compared with more formal psychological testing for denial and anxiety.

The goal of orthopaedic interventions is to improve the functional health of patients, particularly physical function. The American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America (POSNA) commissioned a work group to construct functional health outcomes scales for children and adolescents, focusing on musculoskeletal health. The work group developed scales assessing upper extremity function, transfers and mobility, physical function and sports, comfort (pain free), happiness and satisfaction, and expectations for treatment. Parent and adolescent self-report forms were developed and tested on 470 subjects aged 2-18 years. The POSNA scales demonstrated good reliability, construct validity, sensitivity to change over a 9-month period, and ability to outperform a standard instrument, the Child Health Questionnaire physical functioning scale. They were useful for a wide variety of ages and diagnoses. They appear to be ideally suited for orthopaedic surgeons to assess the functional health and efficacy of treatment of their patients at baseline and follow-up.

Unlabelled: The influence of psychosocial variables in the outcome of surgery for lumbar stenosis (LSS) has not been evaluated. We studied 257 patients with LSS pre-operatively and at 6 months to: (a) relate patient expectations of surgery to baseline function and pain; and (b) determine how patient expectations and pre-operative function interact to predict post-operative outcomes., Results: On average, patients experienced substantial pain relief, improved function and satisfaction. Patients with many pre-operative expectations, particularly patients with low baseline function, reported more improvement in post-operative function than patients with few expectations. More ambitious expectations for physical function were also associated with improved function and satisfaction at 6 months. Conversely, having more numerous pain relief expectations was associated with more pain and less satisfaction with pain relief., Conclusion: Patient expectations influence recovery from surgery at 6 months. To improve outcomes and satisfaction, clinicians should discuss expectations with patients pre-operatively.

Patients with systemic lupus erythematosus (SLE) may have a variety of neuropsychiatric syndromes. Assessment of cognitive functioning for these patients is complicated by increased prevalence and disease severity among groups obtained lower scores on measures of cognitive functioning in normative national samples. Cognitive ability was quantified in a diverse cohort of patients with SLE and a demographically matched group of control participants. Hierarchical regression demonstrated a small increase (6%) in explained variation in cognitive functioning when presence of SLE was added to the equation derived from demographic variables. No significant interaction was found between race and disease. These results suggest that increased frequency of cognitive impairment in African Americans with SLE is due to the additive effects of psychosocial variables.

The authors tested the hypothesis that individuals with a variety of severe chronic illnesses and the healthy elderly exhibit a loss of flexibility in their response to a variety of stressors, compared with healthy adults. A card sort game designed to assess self-reported coping behavior under different stressful life situations was used to compare healthy adults with individuals with multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and the elderly. The healthy adults were found to exhibit more variability than any of the illness groups or the elderly. Healthy function is marked by a complex type of variability.

Two explanations were tested for why patients who are less healthy tend to be less satisfied with their medical care than healthier patients. The explanations were (a) that poor health produces dissatisfaction directly and (b) that poor health produces dissatisfaction through the mediating effect of physicians' behavior. Two studies are presented that measured patients' health status, patients' satisfaction with care, and their physicians' communication as recorded on audiotape. In Study 1, 114 patients had first visits with rheumatologists; in Study 2, 649 patients had continuing-care visits with physicians in internal and family medicine. Causal modeling revealed that the first study supported the direct explanation. The second study also supported the direct explanation, as well as the mediation explanation with respect to the physician's use of social conversation.

Objective: To study the risk factors for early work disability in systemic lupus erythematosus (SLE)., Methods: A sample of 159 SLE patients who had been employed at some time since diagnosis was drawn from a multicenter study of outcome in SLE. Disease activity, organ damage, education, income, source of health insurance, and work-related factors were measured in a standardized interview. Work disability was defined by patient self-report of not working because of SLE. The outcome measure was current work status. Seven patients were excluded from the analysis because their choice not to work was unrelated to SLE., Results: An average of 3.4 years after diagnosis, 40% had quit work completely, and job modification was substantial. Univariate analysis (chi-square and t-test) showed that significant predictors of early work disability included having a high school education or less, receiving Medicaid or having no health insurance, having a job which required more physical strength, having an income below poverty level, and having greater disease activity at diagnosis. In multivariate models, significant predictors were education level (P = 0.0004), higher physical demands of the job (P = 0.0028), and higher disease activity at diagnosis (P = 0.0078). Race, sex, cumulative organ damage at diagnosis, and disease duration were not significant., Conclusion: Early work disability in SLE is strongly associated with some sociodemographic factors that might be amenable to intervention.

Users of classic summated scales can clear up some common quandaries by considering the underlying assumptions that a scale's items represent a random sample drawn from an infinite pool of items representing a unidimensional domain. Scale reliability is higher with more items and a higher average correlation among items. Standards of reliability need to be higher when decisions about treatment are to be based on scores, because confidence intervals around individual scores expand quickly below alpha = 0.95. Scales that are longer than needed may sometimes be shortened, using a formula to determine the approximate number of questions that will yield the desired reliability. Reliability may be improved by addition of new items or expansion of response sets for existing items. Such alterations of scales should always be corroborated with new data. The use of coefficient alpha for scales with severely limited domains, such as self-care knowledge, is rarely useful or appropriate psychometrically, and can be misleading. Standard item selection procedures in classic scales maximize reliability at the scale center and overestimate change at the center and underestimate it at the ends; there are both classic and modern techniques to improve scale construction in this regard. The omission of specific items (such as symptoms) on many scales is often immaterial to the reliability of the scale and to the usefulness of the summary score; this is because each item is well correlated with other scale items, so that information about the underlying domain from any single item is redundant. Finally, despite the attractiveness of disease-specific scales, generic scales often do as well, even in arthritis populations, and have the added benefit of allowing comparisons with a wider range of disease and cultural groups. The development, modification, and use of classic summated scales can be complex in practice, calling on both statistical skills and content area judgment, but at heart the principles are fairly simple. Keeping the principles in mind is half the battle when solving many common problems. The interested reader is referred to the texts referenced in this article and the one by DeVellis (1) for further discourse on this topic.

Occupational injuries continue to exact a great toll on American workers and their employers--the physical and financial costs are enormous. However, in the current political climate, few employers or regulatory agencies will implement injury prevention interventions without specific evidence of their effectiveness. This paper reviews the literature on the design, conduct, and evaluation of occupational injury interventions. Our review suggests that randomized controlled trials are rare and also notes that the quasi-experimental studies in the literature often use the weakest designs. We recommend a hierarchical approach to evaluating occupational injury interventions--beginning with qualitative studies, following up with simple quasi-experimental designs using historical controls, continuing with more elaborate quasi-experimental designs comparing different firms' experience, and, when necessary, implementing randomized controlled trials.

Background: Tick bite control is an important initiative to prevent Lyme disease and other tickborne infections. While several studies have demonstrated that knowledge and awareness of Lyme disease in endemic areas are good, none has evaluated the relative importance of knowledge with other attitudinal and health belief variables to determine motivators of preventive behavior., Methods: We conducted a cross-sectional analysis of 304 commuter ferry passengers departing Martha's Vineyard Island, Massachusetts, in August 1992, to ascertain the prevalence of tick-avoidance behaviors among individuals from an endemic area of Lyme disease and to identify the knowledge, behavioral, and demographic variables that best determine precautionary behavior., Results: Overall, survey respondents (n = 304) had very good knowledge of Lyme disease (73% items correct on a knowledge test), but only 59% of respondents reported limiting time in tick areas, 58% usually wore protective clothing, 40% wore tick repellent, and 66% usually performed tick checks. By stepwise linear regression analysis, determinants of tick-avoidance behaviors included perceiving the behavior's benefits as outweighing its inconvenience (P < .0001), having confidence in recognizing Lyme disease symptoms (P < .0004), believing that Lyme disease is a serious illness (P < .0009), and believing that the avoidance behavior is effective in reducing the risk of Lyme disease (P < .01). Younger respondents (P < .05) performed fewer avoidance behaviors. Visitors (P < .0001) performed fewer tick checks than residents. Having confidence that one could find a tick on oneself with a tick check also predicted performance (P < .008). Increased general knowledge about Lyme disease did not predict any protective behaviors., Conclusions: Precautionary behaviors were underperformed in an at-risk population despite good knowledge of Lyme disease symptoms and transmission. Instead, performance was related to confidence in finding a tick on oneself and a perception that a precaution's benefit outweighed its inconvenience and would adequately reduce risk for Lyme disease. These data have implications for Lyme disease prevention programs, which typically focus on enhancing general knowledge as a means toward disease reduction.

Purpose: To study gender-specific preferences regarding timing of elective total joint replacement (TJR) surgery in patients with moderately severe osteoarthritis (OA) of the hip or knee., Patients and Methods: Focus group discussions regarding TJR surgery were conducted among 18 women and among 12 men with moderately severe OA of the hip or knee. Discussions were tape recorded, transcribed, coded for themes, and evaluated semiquantitatively and qualitatively for gender differences., Results: In general, men were more likely to choose surgery earlier in the disease than women and had higher expectations for surgical success. Women were more fearful of surgery. Women preferred to suffer arthritis pain rather than risk surgery, and indicated they would delay surgery to await better technology and to avoid disrupting caregiving roles for dependent spouses and others., Conclusion: Men and women differ in their willingness to accept continued functional decline, risks of surgery, and disruption of usual role. Gender differences may influence decisions regarding utilization of TJR.

Objective: To study the relationship of race, socioeconomic status (SES), clinical factors, and psychosocial factors to outcomes in patients with systemic lupus erythematosus (SLE)., Methods: A retrospective cohort was assembled, comprising 200 patients with SLE from 5 centers. This cohort was balanced in terms of race and SES. Patients provided information on socioeconomic factors, access to health care, nutrition, self-efficacy for disease management, health locus of control, social support, compliance, knowledge about SLE, and satisfaction with medical care. Outcome measures included disease activity (measured by the Systemic Lupus Activity Measure), damage (measured by the SLICC/ACR damage index), and health status (measured by the SF-36)., Results: In multivariate models that were controlled for race, SES, center, psychosocial factors, and clinical factors, lower self-efficacy for disease management (P < or = 0.0001), less social support (P < 0.005), and younger age at diagnosis (P < 0.007) were associated with greater disease activity. Older age at diagnosis (P < or = 0.0001), longer duration of SLE (P < or = 0.0001), poor nutrition (P < 0.002), and higher disease activity at diagnosis (P < 0.007) were associated with more damage. Lower self-efficacy for disease management was associated with worse physical function (P < or = 0.0001) and worse mental health status (P < or = 0.0001)., Conclusion: Disease activity and health status were most strongly associated with potentially modifiable psychosocial factors such as self-efficacy for disease management. Cumulative organ damage was most highly associated with clinical factors such as age and duration of disease. None of the outcomes measured were associated with race. These results suggest that education and counseling, coordinated with medical care, might improve outcomes in patients with SLE.

Objectives: Although some patient characteristics are known to be related to physician and patient communication in medical encounters, very little is known about the impact of patients' health status on communication processes. The authors assess relations of patients' physical and emotional health status to verbal and nonverbal communication between physicians and patients in four original studies, and combine results across the four studies using meta-analytic procedures., Methods: In four original studies of routine outpatient visits (consisting of more than 250 physicians and more than 1,300 patients), health status was measured and audiotape or videotape records were coded for verbal content and nonverbal cues indicating task-related behavior and affective reactions on the part of both the physician and the patient. Both physical and mental health data were obtained, using physicians and/or patients as sources; in two studies, physicians' satisfaction with the visit also was measured. All available background characteristics for both physicians and patients were controlled via partial correlations. The meta-analytic procedures used were the unweighted and weighted (by sample size) average partial correlations, the combined P across studies (Stouffer method), and the test of effect size heterogeneity., Results: Physicians showed signs of negative response to sicker or more emotionally distressed patients, both in their behavior and in their ratings of satisfaction with the visit. Sicker patients also behaved more negatively than healthier patients. However, physicians also engaged in a variety of positive and professionally appropriate behaviors with the sicker or more distressed patients. This mixed pattern of responses is discussed in terms of alternative frameworks: the physician's goals, reciprocation of affect, and ambivalence on the part of the physician., Conclusions: The patient's health status appears to influence physician-patient communication. In clinical practice, increased attention by physicians to their own and their patients' behavior may enhance diagnosis and prevent misunderstandings.

Study Design: A cross-sectional study of a convenience sample of lumbar spine patients, with a subsample followed for retest reliability., Objectives: To assess the instrument's reliability, validity, and acceptability to patients., Summary of Background Data: Patients with eight diagnoses, four before surgery and four after surgery, were recruited from six orthopedic practices to test the questionnaire., Methods: One hundred sixty-seven patients were approached through the physician's office, yielding 136 usable questionnaires (84%) and 24-hour retests on 64 patients., Results: The questionnaire took about 20 minutes to administer and was acceptable to patients. The lumbar spine pain and disability and neurogenic symptoms subscales discriminated among patient groups as hypothesized and showed significantly better scores for patients independently judged successful by their physicians after surgery. Test-retest reliability and internal reliability were high (range, 0.85-0.97). Sample sizes of 20-37 would be needed to detect a 20% difference between two groups (alpha, 0.05; beta, 0.20)., Conclusions: The questionnaire should be considered for monitoring of individual patient's progress in treatment and for clinical trials.

The effectiveness of an exercise prescription and unsupervised home exercise programme was tested on 37 subjects with rheumatoid arthritis and 34 with systemic lupus erythematosus. Subjects were randomly assigned to control or stationary bicycling at home, using loaned bicycles. Exercise subjects (with bicycles) did better than controls, but not significantly, on all outcomed measures (exercise tolerance test, fatigue, depression and helplessness) at 3 months. Bicycles were reclaimed at 3 months and all subjects in both groups given instructions for home exercise. Exercise in the second 3 months was predicted primarily by baseline exercise habits and fatigue. It is concluded that although safe, unsupervised home exercise programmes may benefit few patients. Future research should address methods of stimulating and maintaining unsupervised exercise programmes in patients with systemic rheumatic disease.

To develop a technique to screen populations for potential connective tissue disease (CTD), we mailed a 30-item questionnaire to 253 randomly selected patients with systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymyositis, dermatomyositis, mixed connective tissue disease (MCTD), or Sjögren's syndrome and to 340 randomly selected control subjects. The response rate after four mailings was 71% for case subjects and 54% for control subjects. Test-retest reliability for detection of any CTD was 0.82. Sensitivity for specific CTDs was 83 to 96% and specificity was 83 to 93%. The positive predictive value for any CTD (assuming an overall prevalence of 1.3%) was 5.5%; negative predictive value was 99.7%. The CTD Screening Questionnaire has high sensitivity and specificity for screening large populations.

The Physical Capacity Evaluation, a performance measure of functional capabilities comprised of 13 tasks simulating those used in activities of daily living, was tested on 289 community-dwelling elderly people and compared against a widely used self-report measure of function, the Health Assessment Questionnaire. Factor analysis identified one dominant component in each instrument. Internal consistency reliability (Cronbach's alpha) was .90 for both instruments. Global disability (Health Assessment Questionnaire) and function (Physical Capacity Evaluation) scores were correlated -.74. One-week retest reliabilities on 58 subjects were .94 for the Physical Capacity Evaluation and .95 for the Health Assessment Questionnaire. The Physical Capacity Evaluation is a valid and reliable measure of physical performance for use with elderly people.

Objective: We studied the relationship between systemic lupus erythematosus (SLE) morbidity and socioeconomic status (SES) at 5 centers., Methods: Ninety-nine patients who met American College of Rheumatology criteria for SLE were randomly sampled at each center, balancing by race and insurance status. Subjects were interviewed for current and past SES factors, such as insurance, occupation, employment, education, and income. SLE disease activity was measured by the SLE Activity Measure (SLAM)., Result: Higher education, private insurance/Medicare, and higher income were associated with less disease activity at diagnosis. Controlling for SES, race, and center, the best predictors of less active disease at diagnosis were private insurance/Medicare (P = 0.002) and higher education (P = 0.007). From the time of diagnosis to the study visit (mean 3.5 years), insurance, income, and employment status changed for a significant number of subjects (37%, 16%, and 21%, respectively)., Conclusion: Private insurance or Medicare and higher education are associated with less active disease at diagnosis of SLE. Health insurance, income, and employment status are unstable measures of socioeconomic status and may explain the variability in conclusions of previous studies on the role of SES in SLE.

We developed a self-administered questionnaire for the assessment of severity of symptoms and functional status in patients who have carpal tunnel syndrome. The reproducibility, internal consistency, validity, and responsiveness to clinical change of scales for the measurement of severity of symptoms and functional status were evaluated in a clinical study. The scales were highly reproducible (Pearson correlation coefficient, r = 0.91 and 0.93 for severity of symptoms and functional status, respectively) and internally consistent (Cronbach alpha, 0.89 and 0.91 for severity of symptoms and functional status, respectively). Both scales had positive, but modest or weak, correlations with two-point discrimination and Semmes-Weinstein monofilament testing (Spearman coefficient, r = 0.12 to 0.42). In thirty-eight patients who were operated on in 1990 and were evaluated a median of fourteen months postoperatively, the mean symptom-severity score improved from 3.4 points preoperatively to 1.9 points at the latest follow-up examination, while the mean functional-status score improved from 3 to 2 points (5 points is the worst score and 1 point is the best score for each scale). Similar improvement was noted in twenty-six patients who were evaluated before and three months after the operation. We concluded that the scales for the measurement of severity of symptoms and functional status are reproducible, internally consistent, and responsive to clinical change, and that they measure dimensions of outcomes not captured by traditional measurements of impairment of the median nerve. These scales should enhance standardization of measurement of outcomes in studies of treatment for carpal tunnel syndrome.

Organized educational programmes and individual educational counselling are primary means by which health care providers equip rheumatic disease patients with the skills and knowledge necessary to monitor and manage variable symptoms. Many outpatients educational programmes were evaluated in the 1980s. In brief, well designed programmes are generally effective in improving knowledge and compliance with a regimen, and in reducing pain, depression, and disability. However, most persons with arthritis never use such programmes. Greater emphasis is needed on education of patients at the time of the clinical encounter, where the greatest opportunity lies for reaching the greatest number. Researchers have examined the dynamics of the doctor-patient interaction during the clinical encounter. Results show that: better information sharing leads to improved patient satisfaction, compliance, and health outcomes; information sharing could be greatly improved; and doctors and patients can be trained to improve information sharing, resulting in improved outcomes. A review of attribution and decision-making theory and the empirical literature on doctor-patient communication suggests a number of techniques that could be usefully incorporated into the management of each patient. These include: (1) encouraging patients to write down their concerns before each visit; (2) addressing each concern specifically, however briefly; (3) asking patients what they think has caused their problems; (4) tailoring treatments to patients' goals and preferences as possible; (5) explaining the purpose, dosage, common side-effects and inconveniences, and how to judge the efficacy of each treatment, including length of trial; (6) checking patients' understanding; (7) anticipating problems in compliance with treatment plans, and discussing methods to cope with common problems; (8) writing down the diagnosis and treatment plan to help patients remember; (9) giving out written materials that are now widely available; (10) reinforcing patients' confidence in their ability to manage their regimen; (11) using ancillary personnel in patient education; and (12) referring patients to organized programmes in the community.

An educational program designed to reduce low back injuries was modeled after several well-known back schools and taught to postal workers in a randomized trial of about 4,000 workers. Physical therapists taught 3 hours of class sessions, including knowledge, skills, and individual work station assessment, to small groups of workers and supervisors, with reinforcement every 6 months afterward. At 2 1/2 years, a random sample of 209 workers was surveyed for program impact on intermediate outcomes. We observed increased knowledge among experimental unit workers, but no significant improvements in behaviors associated with back health or in proportion of workers with tired backs. Experimental unit workers who had received training by the time of the survey were less likely to report helping/reinforcement for healthy behaviors than controls or untrained experimental unit workers. The program might have led trained workers to perceive a lack of support and reinforcement for back safety among coworkers and supervisors by sensitizing them to what is possible and raising expectations. There appeared to be group social effects in the dissemination of knowledge and perhaps of helpful behaviors; however, it is apparent that worker social support for change in health behaviors is a complex phenomenon that cannot always be relied upon to enhance program goals.

Objective: To examine disclosure of side effects of nonsteroidal antiinflammatory drugs (NSAIDs) and to identify patient- and physician-specific factors associated with greater disclosure., Methods: Forty-six encounters between rheumatologists and new adult outpatients who were prescribed an NSAID they had not been taking prior to the visit were audiotaped. Reviewers coded the NSAID prescribed, specific side effects mentioned, demographic features of patients and physicians, and patient clinical characteristics. Neither patients nor physicians were aware that side effect disclosure was being studied., Results: A mean of 1.7 side effects was mentioned per encounter. Epigastric discomfort was mentioned in 72% of encounters, while other side effects, including hepatic, renal, hematologic, or central nervous system effects, were mentioned in < or = 15% of encounters. Three factors were identified as independent predictors of less disclosure of side effects: senior clinician (versus less experienced), patient not taking another NSAID immediately prior to the visit, and patient age < 40. Increased disclosure by less experienced clinicians occurred exclusively with patients who were taking another NSAID prior to the visit., Conclusion: Disclosure of side effects other than epigastric discomfort to patients who are prescribed a new NSAID is limited. Patients not taking NSAIDs previously, who presumably have the most to gain from such discussions, are told the least. These results have implications with regard to doctor-patient decision-making and malpractice litigation in the outpatient setting.

Objective: To evaluate the efficacy of continuous passive motion (CPM) in the postoperative management of patients undergoing total knee arthroplasty., Design: A randomized controlled single-blind trial of CPM plus standardized rehabilitation vs standard rehabilitation alone., Setting: A referral hospital for arthritis and musculoskeletal care., Patients: Consecutive patients with end-stage osteoarthritis or rheumatoid arthritis undergoing primary total knee arthroplasty who had at least 90 degrees of passive knee flexion. One hundred fifty-four patients were eligible and 102 patients agreed to participate and were randomized. Ninety-three patients completed the study protocol., Intervention: Continuous passive motion machines programmed for rate and specified arc of motion within 24 hours of surgery with range increased daily as tolerated with standardized rehabilitation program compared with standardized rehabilitation program alone., Main Outcome Measures: Primary outcomes were pain, active and passive knee range of motion, swelling (or circumference), quadriceps strength at postoperative day 7, as well as complications, length of stay, and active and passive range of motion and function at 6 weeks., Results: Use of CPM increased active flexion and decreased swelling and the need for manipulations but did not significantly affect pain, active and passive extension, quadriceps strength, or length of hospital stay. At 6 weeks there were no differences between the two groups in either range of motion or function. In this series, use of CPM resulted in a net savings of $6764 over conventional rehabilitation in achieving these results., Conclusion: For the average patient undergoing total knee arthroplasty, CPM is more effective in improving range of motion, decreasing swelling, and reducing the need for manipulation than is conventional therapy and lowers cost.

A variety of functions decline with aging, but whether losses occur in a predictable sequence is unknown. Improved understanding might facilitate the early detection and possible prevention of functional deterioration. We assessed self-reported difficulty with functional tasks in 288 community-dwelling elderly aged 65 to 97. We hypothesized that the ability to perform tasks involving strength, skill, and endurance (run errands, shop, yardwork or housework) would be lost first, followed by activities requiring less strength or mobility (rise from a chair with no hands, walk), followed by easier, but essential tasks (pick up clothes, rise from bed, lift a cup to the mouth). The patterns of decline were evaluated with Guttman scalograms. Picking up clothes and walking were reversed from the predicted order. Scale reliability was 0.92, indicating that functional decline is ordered; 75% of subjects fell into one of the modal sequence types. Analysis by self-reported presence of arthritis showed that 83% of nonarthritic subjects fit the predicted patterns (reliability = 0.95) versus 65% of arthritic subjects (reliability = 0.86), who tended to lose hand ability out of sequence. Sequential functional loss scales may tell more than the typical simple summation of functional loss, and may have predictive value to the clinician monitoring an elderly patient. If the sequence is accelerated or out of order, such as was seen in patients with arthritis, it may indicate the need for intervention. Examination of sequences of loss may help characterize adaptations to impairment and differences among subgroups.

Psychosocial adjustment in 102 children with arthritis, ages 4-16, and their families was assessed by parents, who completed the Child Behavior Checklist (CBCL) and Profile of Mood States (POMS). On average, parental distress (POMS) was lower than reference norms. POMS distress was correlated with children's behavioral problems (r = .41) but not with children's social competence (r = .15). General linear models explained 25% of the variance in CBCL behavioral problem scores. Older age was associated with more behavior problems in males, but not females. Disease severity and disease activity were also associated with behavioral problems. Although 27% of the variance in CBCL social competence could be explained, no single predictor variable was especially strong. Poorer social competence was associated with older age and shorter disease duration. Teenagers, especially those with recent onset and those with mild disease activity, may be at increased risk for psychosocial maladjustment.

This paper describes a psychometric replication study of a British coping scale, the Mental Adjustment to Cancer scale, on 239 USA cancer patients. The internal consistency and construct validity were similar to the original validation study. However, the factor structure was different. Cultural differences between the British and USA patient populations are discussed.

The epidemiology of systemic lupus erythematosus suggests that the excess morbidity and mortality in blacks with the disease is related to lower socioeconomic status. Poverty and factors associated with poverty are powerful predictors of poor outcome in a variety of chronic diseases, and lupus appears to be no exception. A body of studies in other illnesses suggests ways to neutralize, at least partially, the disadvantages of lower socioeconomic status, even though the root causes of poverty may be insurmountable. These include improving access to quality health care; targeting educational programs to promote recognition and understanding of the disease and the comorbid conditions that affect outcome; implementing programs to improve self-monitoring and adherence to medical regimens; developing opportunities to facilitate homemaking, childrearing, and working outside the home; and applying psychosocial interventions to enhance self-confidence and social support. Improved access to quality health care may actually lead to a decrease in health care costs.

We compared the Social Security Administration's (SSA) judgment of disability with uninvolved rheumatologists' evaluations of ability to work. With the cooperation of the SSA, 52 new disability claimants who alleged rheumatoid arthritis, osteoarthritis, or systemic lupus erythematosus were identified at the beginning of their claim. At the same time that their claim was being formally reviewed, they had a standardized examination by an independent rheumatologist who was not involved with their care, and they had a standardized test of observed performance. Rheumatologists' judgments of ability to work were compared with the SSA judgments. Rheumatologist and SSA judgments were in agreement for 35 of the 52 claimants (67%). All 11 claimants who met or equaled the SSA medical evaluation criteria were judged work-disabled by the rheumatologist. Of 27 judged able to work by the SSA, the rheumatologist judged 11 to be unable. Agreement between the SSA judgment of residual functional capacity and observed performance was no more than would be expected by chance. Most SSA judgments agree with a clinician's evaluation but a standardized physical evaluation by a rheumatologist and performance-based tests appear to add important information.

Education of patients with arthritis began with an emphasis on conveying knowledge, grew to include behaviour change, compliance, and more general coping and management of disease and then progressed to consider physical and psychosocial health outcomes. Research continues in all these areas. Control, in many forms (locus of control, self perceived efficacy, learned helplessness), is now suggested to be a central mediating variable. Evaluation of programmes is moving away from programme v usual care towards comparison of alternative methods of delivery and matching of method to learner. The first generation of researchers in arthritis education tended to be care givers with little formal education in behavioural sciences and evaluation methodology; the programmes they designed were often empirically based. The current generation, nurtured in large part by funds from the Arthritis Foundation and the National Institutes of Health, is better trained in designing programmes grounded in behavioural sciences and educational theory. In the long run, collaborations with care givers and patients will considerably strengthen the effectiveness of education programmes for patients. A variety of educational strategies have been shown to change the knowledge, behaviour, and health of patients with arthritis for the better. Many methods seem to work, so long as the programme is planned, has a goal, and is accountable. There is much work still to be done to teach care givers to be better teachers, and patients to be better managers of their diseases, in concert with their doctors, and to focus on high risk groups. Although most work has been done with patients with rheumatoid arthritis and osteoarthritis, many of these findings can and should be safely generalised to less studied rheumatic diseases. Finally, we need to consider the patient first as a person, and to provide education through all avenues, not just the medical care system.