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Quality of Life in American Indian and White Women

With and Without Rheumatoid Arthritis

Janet L. Poole, Heather Chiappisi, Jennifer Schukar Cordova,


Wilmer Sibbitt, Jr.

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

Demographic Variables M Range M Range M Range M Range p values


QOL
Global QOL, present 7.8 (510) 6.9 (310) 8.1 (510) 8.1 (510) ns
Global QOL, 5 years past 7.1 (010) 7.6 (010) 6.1 (110) 7.2 (210) ns
Global QOL, 5 years future 8.9 (510) 7.5 (210) 8.9 (410) 9.0 (210) ns
COOP total 16.1a (1023) 14.6a (821) 20.1b (1624) 21.2b (1325) < 0.0001
Body FunctionsBody Structures
Pain 2.8a (15) 2.1a (15) 4.4b (25) 3.8b (25) < 0.0001
UE KFT 12.9a (435) 12.9a (450) 5.1b (49) 4.5b (46) < 0.001
LE KFT 9.4 (038) 4.9a b (015) 1.2b (04) 1.3b (04) < 0.001
Total KFT 22.3a (558) 17.9a (658) 6.3b (411) 5.8b (48) < 0.0001
AHFT: Hand strength (in lbs) 98.9a (55.9190.1) 112.6a (50.2177.3) 186.0b (164.1220.7) 181.9b (122.8213.9) < 0.0001
AHFT: Dexterity (in sec) 49.5a (32.5113.0) 45.8a (33.095.0) 38.9b (33.046.0) 36.0b (31.040.0) < 0.05
AHFT: Applied dexterity (in sec) 133.5a (82.5265) 118.5a b (94.5180.5) 85.5c (66.5109.5) 91.8b c (74.0105.0) < 0.0001
AHFT: Applied strength (in ml) 1879.0 (02012) 1928.0 (12552012) 2012.0 (2012) 2012.0 (2012) ns
Psychosocial status 6.6a b (310) 6.3a (210) 7.7a b (69) 8.3b (510) < 0.05
Activities and Participation
HAQ 1.0a (02.38) 1.4a (0.252.13) 0.2b (01.125) 0.1b (00.63) < 0.0001
CIQ total 18.4a (2.2525) 20.0a (12.75 28) 21.8a (1825) 25.7b (22.2528) < 0.001
Note. Means having the same superscript are not significantly different at p < .05 in the Tukey honestly significant difference comparison; QOL= quality of life;
ns = not significant; UE = upper extremity; KFT = Keital Functional Test; LE = lower extremity; HAQ = Health Assessment Questionnaire; CIQ = Community
Integration Questionnaire; AHTF = Arthritis Hand Function Test; COOP = Dartmouth Primary Care Cooperative Information Project.

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.

The American Journal of Occupational Therapy 285


Second, although the four groups were similar in regard household management occupations such as cooking and
to demographics characteristicsexcept for current health shopping, as well as planning their social occupations. The
status and employment statuspeople with rheumatoid lower scores in community integration seen in both Amer-
arthritis had significantly poorer health, were less likely to ican Indian groups compared to the White groups could be
work full-time, and had more Body FunctionsBody Struc- that the American Indians participated in household and
tures and Activities and Participation limitations than the community activities with family and friends rather than by
healthy control groups. These differences appeared to be themselves. This finding is not surprising because the
due to the presence of rheumatoid arthritis. Pain, limited majority of our American Indian participants lived on their
joint motion, and decreased hand strength were related to pueblos or reservations near extended families (National
the presence of rheumatoid arthritis, which agrees with pre- Indian Council on Aging, 1981). On the CIQ, participat-
vious researchers who found that people with moderate to ing or doing an activity alone results in a higher score (more
severe rheumatoid arthritis tend to have greater pain and integration) than performing an activity with family or
less joint motion compared to healthy controls (Katz & friends, which may reflect the importance of independence
Yelin, 1993; Wolfe et al., 1988). However, in the current to the White culture (Leininger, 1994).
study, the differences in dexterity, applied dexterity, and Third, our findings revealed similarities and differences
emotional and social function were related to both the pres- in the factors related to QOL in people with rheumatoid
ence of rheumatoid arthritis and ethnicity. For example, the arthritis and healthy controls. Factors of current health and
major difference in emotional and social function was emotional and social function were found to relate to QOL
between the Whites with rheumatoid arthritis and the in all four participant groups. Current health has previously
healthy Whites, indicating that the White groups emo- been shown to be a factor related to QOL in both Ameri-
tional and social function was highly related to rheumatoid can Indians and Whites (Burckhardt et al., 1989, 1993;
arthritis. No significant difference, however, was seen in Johnson et al., 1986), and emotional and social function
emotional and social function between the two American previously has been found to be a factor related to QOL in
Indian groups. Thus, in this sample, rheumatoid arthritis in Whites with rheumatoid arthritis (Burckhardt, 1985; Katz
American Indians did not appear to be related to emotional & Yelin, 1993). In the two groups with rheumatoid arthri-
and social function. Perhaps the American Indian popula- tis, however, additional Body FunctionsBody Structures
tions had learned to manage the emotional impact of variables related to QOL. For American Indians with
rheumatoid arthritis. Indeed, Kramer et al. (2002b) found rheumatoid arthritis, joint motion and hand function also
that American Indians with rheumatoid arthritis did not related to QOL, whereas for Whites with rheumatoid
tend to experience negative thoughts and catastrophizing. arthritis, only hand function additionally correlated with
For the Activities and Participation variables, we found QOL. In the healthy control groups, the only additional
that significant differences in the ability to perform every- Body FunctionsBody Structures variable that related to
day occupations were related only to the presence of QOL was pain, but only for the healthy American Indians.
rheumatoid arthritis; however, differences in community The only Activities and Participation variable that
integration were related to both the presence of rheumatoid related to QOL in any of the groups was the ability to per-
arthritis and ethnicity. Healthy Whites had significantly form everyday occupations as reported on the HAQ. Occu-
higher community integration scores compared to the other pational performance related to QOL in both American
three groups. This difference in community integration Indian groups and for Whites with rheumatoid arthritis.
may be due to the greater physical limitations of the groups Indeed, occupational performance has been reported previ-
with rheumatoid arthritis or the amount of social support. ously to be an important factor influencing QOL (Katz &
American Indian women with rheumatoid arthritis had the Yelin, 1995; MacKinnon & Miller, 2003; Stamm et al,
most limitations in joint mobility and hand function. In 2004). In fact, maintaining independence was acknowl-
people with rheumatoid arthritis, limitations in joint edged by numerous researchers to be an important part of
motion and hand function can lead to more dependency on QOL for Whites (Archenholtz et al., 1999; Burckhardt et
others for everyday and social occupations, especially in an al., 1989, 1993; MacKinnon & Miller, 2003) but not for
inaccessible environment (Burckhardt et al., 1993; Soder- American Indians (Leininger, 1994).
lin, Kautiainen, Skogh, & Leirisalo-Repo, 2004; Whalley et Most of the demographic variables were not associated
al., 1997; Yelin et al., 1987). On the other hand, the differ- with QOL in any of the groups. No relationship was found
ence in community integration may be that more of the between QOL and age, number of years with rheumatoid
healthy White women lived alone compared to people in arthritis, or education level, which is similar to findings
the other groups and therefore had to rely on themselves for from other studies (Burckhardt, 1985; Katz & Yelin, 1993).
286 May/June 2007, Volume 61, Number 3
Limitations and Implications for Further Research determine the effectiveness of occupational therapy inter-
The small sample size may not have been representative of ventions for people with arthritis.
the overall population of women with rheumatoid arthritis. Although this was the first study comparing QOL in
The low power from the small sample raises the possibility American Indian and White women with and without
of a Type II error (not finding associations where they actu- rheumatoid arthritis, it appears that in this particular sam-
ally exist). Further research should replicate the current ple QOL was influenced more by having a chronic disease
study with a larger sample size and cover a larger geographic than by ethnicity. Some of the factors found to relate to
location to deal with the small sample of convenience in the QOL across disease and ethnic groupssuch as occupa-
present study, which also would extend the generalizability tional performance, emotional and social function, and
of the results. Due to the exacerbations and remissions seen joint motion in the rheumatoid arthritis groupsare
with rheumatoid arthritis, further research could include amenable to occupational therapy intervention.
two interview periods separated by time to compare pre-
dicted and actual future QOL as well as to investigate the
changes in demographics, Body FunctionsBody Structures Acknowledgments
(especially in disease severity), and Activities and Participa- The authors would like to thank Drs. Bankhurst, Gregg,
tion variables over time. and Maldonado and the UNMH Rheumatology Clinic
staff; the people who participated in this study; and Betty
Malloy, statistician. The second authors work was sup-
Implications for Practice ported in part by a grant from the University of New Mex-
ico Office of Graduate Studies. This study also was sup-
With a better understanding of QOL and the factors
ported in part by a grant to the first author from the
influencing QOL in American Indian and White women
Disability and Health Program of the Public Health Divi-
with rheumatoid arthritis, occupational therapists can be
sion of the New Mexico Department of Health in coopera-
more effective in designing interventions for people with
tion with the Centers for Disease Control and Prevention.
rheumatoid arthritis. Indeed, the ability to perform every-
This article was written in partial fulfillment of a master of
day occupations was a factor related to QOL for people
occupational therapy degree for the second author at the
with rheumatoid arthritis. Although Blalock et al. (1998)
University of New Mexico, Albuquerque. An earlier version
found evidence that dissatisfaction with illness-related abil-
of this paper was presented at the 37th Annual Scientific
ities can exacerbate psychological distress, improving peo-
Meeting of the Association of Rheumatology Health Pro-
ples ability to perform valued occupations such as partici-
fessionals, October 2002, New Orleans, Louisiana.
pating in social and leisure pursuits has been shown to
increase emotional and social function. Furthermore, the
findings from this study, as well as from previous research
(Blalock et al., 1998; Katz & Yelin, 1995), suggested that
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The American Journal of Occupational Therapy 289


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