Citation
Arthritis in rural communities

Material Information

Title:
Arthritis in rural communities correlates of physical activity
Creator:
Christenson, Mary Elizabeth
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
xvii, 253 leaves : ; 28 cm.

Subjects

Subjects / Keywords:
Rural health -- Colorado ( lcsh )
Arthritis -- Colorado ( lcsh )
Arthritis -- Exercise therapy -- Colorado ( lcsh )
Arthritis ( fast )
Arthritis -- Exercise therapy ( fast )
Rural conditions ( fast )
Rural health ( fast )
Rural conditions -- Colorado ( lcsh )
Colorado ( fast )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Colorado Denver, 2008. Health and behavioral sciences
Bibliography:
Includes bibliographical references (leaves 238-253).
General Note:
Department of Health and Behavioral Sciences
Statement of Responsibility:
by Mary Elizabeth Christenson.

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Source Institution:
|University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
320082666 ( OCLC )
ocn320082666

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I ARTHRITIS IN RURAL COMMUNITIES: CORRELATES OF PHYSICAL ACTIVITY by Mary Elizabeth Christenson B.A. University of Colorado at Boulder 1974 B.S. University of Colorado Health Sciences Center 1983 M.S., Colorado State University, 1996 A thesis submitted to the University of Colorado Denver in partial fulfillment of the requirements for the degree of Doctor of Philosophy Health and Behavioral Sciences 2008

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This thesis for the Doctor of Philosophy degree by Mary Elizabeth Christenson has been approved by Maura Iversen

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This thesis for the Doctor of Philosophy degree by Mary Elizabeth Christenson has been approved by the r e presentati ve for the Rural Arthritis Committee

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Christenson, Mary E. (Ph.D., Health and Behavioral Sciences) Arthritis in Rural Communities : Correlates of Physical Activity Thesis directed by Professor Kitty Corbett ABSTRACT Background and Rationale: Arthritis affects over 46 million individuals in the United States and is the leading cause of disability Despite the lack of clear standards for levels and types of PA appropriate for individuals with arthritis, evidence suggests that P A can have significant health benefits. Rural communities may offer unique challenges for people with arthritis to participate in P A. This study investigated factors that influence physical activity (PA) in people with arthritis living in rural communities and set the stage for studies with larger representative samples Among arthritis studies this project was unusual in its focus on individuals from rural areas with community research participation throughout the project. Specific aims: 1) identify correlates of P A in individuals with arthritis in rural communities of east and northeast Colorado 2) quantify current types and intensity of physical activity 3) enhance findings through the participation of community partners. Methods : This stud y employed a cross-sectional survey completed by 119 participant s and was guided by a Rural Arthritis Committee (RAC) comprised of residents from the involved counties. Survey instruments included the previously validated AIMS2

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Lorig's Arthritis Self-Efficacy Scale, PA questions from the Behavioral Risk Factor Surveillance System and the Occupational Physical Activity Questionnaire, the Environmental Supports for Physical Activity Questionnaire, and in addition, a P A and Arthritis Questionnaire based on the Theory of Reasoned Action and Theory of Planned Behavior that was piloted and analyzed prior to inclusion. Findings: Rural community members from diverse geographical locations effectively engaged in health-related research. Sixty-seven percent of respondents reported time increments ofweekly PA and 73% ofthis subgroup met weekly PA recommendations through non-work P A. A higher prevalence of diabetes and obesity than State averages was reported. Independent variables were not significantly associated with time spent in PA except minutes ofvigorous non-work PA with attitude about PA Implications : A process for engaging community members in chronic disease research has been established. P A self-report measurement tools may not be optimal in this population. P A levels appear to be higher in this sub-population than previous literature suggests. Additional mixed methods research may elucidate correlates of P A. This abstract accurately represents the content of the candidate s thesis. I recommend its publication. Signed

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DEDICATION This thesis is dedicated with love to my Mother sister and Grandma Gladys who have supported me with their unconditional love, sacrifice, inspiration and strength. It is also dedicated to my Father for his love and guidance to value education and Jack for his patience, love, and support of my goals.

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ACKNOWLEDGEMENT I would like to thank my committee members for the guidance and expertise they willingly shared during this process. Dr. Kitty Corbett tailored her feedback to enrich my project. Her creative wisdom inspired this research process and helped me stretch in new directions Her level of expertise in many diverse areas demands great respect. She offered encouragement and support and will continue to serve as a role model. Dr. Cindy Bryant's depth of review and research proficiency guided and enhanced my research reflections. Her expertise in aging research and working with community partners was instrumental as a mentor. Her encouragement and timely feedback kept me moving forward. Dr. Maura Iversen gave me confidence as a researcher in physical therapy and supported my professional development in this field. Her mentorship and expertise in arthritis has been invaluable. It was a privilege working with Dr. Iversen as a leader in our field Dr. Nancy Leech provided guidance with patience and insight as I learned the process of research and analysis. She answered the tough stats" questions and gave me confidence to rely on my decision-making in research Her book went with me everywhere.

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Dr. Jack Westfall shared his pa ssio n for reaching out to the rural communities. As a leader in community-based research he served as an inspirational role model and m e ntor. Hi s humor kept the process fun and his willingness to open community doors for me greatl y facilitated the research. The Rural Arthritis Committee (RAC) was the spirit of this project. They opened their communities to me welcomed my efforts and demonstrated passion for their communities. They offered areas of expertise and levels of participation that made the project what it is. I am indebted to their generosity There were many other individuals who shared their research expertise to help me through this process thank you for your interest in my professional development.

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TABL E OF CONT E N T S List of Figur e s .... .. ........ .. ........................... ..... .. .............. .... .. .. ..... ....... ..... x iv Lis t of Tabl es ..... .. ...... .......... ......... ..................... ..... .. ... ... ..... .. ....... ..... ...... .. xv CHAPT E R 1. INTROD U CTION . ...... .. ...... ...... ......... .. .... ...... ... ........ ............. ...... .. ....... 1 Research Question .. .. ...... .. .... ........ ........ .. .. ...... ............ ............... ...... 1 Rationale .......... ...... .. ...... .... ...... ..... .. ..... .. .. ...... .... .. ........ .......... ..... .... . 1 Specific Aims .... ...... .. ...... .. .... .. ....... .. .. .... .... .. ..... .. .... .... .... ..... .... .... . 5 2. BACKGROUND ................. .............. ........ .. .... ... ..... ....... .. .. .......... .. .. .... . 7 Introduction .. ... .. .. ...... ...... .......... ..... ...... .. ...... ........... ... ........... ..... ..... . 7 Osteoarthritis . .............. .. ..... .. .. ..... .... ....... .............. ..... ... ...... .... .. ........ 8 Importance ......... ........ .. ..... ...... .. ...... .. .................... ...... ........ . 8 Patho g enesi s and Diagno sis .. .......... ..... ....... .................. ....... 9 Ri s k Factors ... .... .. ...... ............................... ....... .. .. .... .. .... 11 Guidelines for the Management of O s teoarthritis ........ .. .. .... 13 Arthritis in Colorado ......... .... .. .............. .... . ........... ...... ....... 16 Issues of Rurality .. .. .... .... ..... ........... ...... ..... .... .... .... .. ................... . 19 Defining Rur a l .... .. .......... .. .... .. ...... .. .. ...... . .. .. .............. .. .. .... 20 Health Dis p a rities in Rural Comrnuniti e s .................. ....... .... 21 lX

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Colorado Rur a l Communities-Healthcare Disparities .... ... 23 Colorado Rural Counties Sociodemographics .... ....... .... ... 25 Physical Activity .... . .................................................................. ...... 30 Ph ysica l Act ivit y and Health ....... .......... .. ....... ............... ..... 31 B e n efits of Ph ysi cal Activity ......... .................. ................... 34 Environment and Physical Activity ...................................... 38 Self-Efficacy and Ph ys ical Activity ..................................... .40 Rural Health Individuals with Arthritis and Physical Activity ...... .42 Community-Based Participatory Research ....................................... 46 Theoretical Model .............................. ..... ................................... ....... 51 3 METHODS .................... ......................................... .. ...... ........... ............ 5? Research Design .................. .... .. ....... .... ...... ...... ....... ...... ... ............ .. 57 S e tting ...... .......................... ...... .... ........ ...................... .... ............... .. 58 Participants ... ................. .. ........ .. .. .... .. .... ....... .. .. ...... ..... ................ ... 60 Rural Arthritis Committee (RAC) Recruitment.. .................. 61 Survey Group Recruitment ... ......... ....... ................................ 66 Procedures ..... .. .... .. ... .. .. .. ..... .. ...... ........ .... ........ ....... ..... .. .. ............... 69 Pilot Survey . .................... ...... ..... .. .. ........... .. ....... ................. 70 Rural Arthritis Committee (RAC) Meetings ......................... 74 Quantitative Procedures ....... .. ....... .............................. .......... 80 Measures ........................................ .... .......... ........ .. .. ....... ..... .. ...... .. 83 X

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Ph ys ical Acti v i ty ..... . .... ... ...... .................. ......... . .... . . .... 83 Ph ys ical Acti v it y and Arthriti s ... ... . ... ... ...... ......... . ... ........ 86 A rthritis Impact . . ..... .... . . ... ...... ... ... . .... . . ..... . ... ... ..... 89 S e lf -Efficac y . .... . ..... . .... . . ... . . .... . . ... ...... . ... ... . ..... ...... . 9 2 E n v i r onmental Support s for Phy sical Acti v it y Que s tionnaire .... . .... .... ...... .... ........ . . . ... . ... ...... . . ....... ...... 93 Final Que s tionnaire ... ....... . . . . ...... . ..... . . .... . ...... ...... .... . 95 Variable s ... . . .... .... . . .... . ...... .......... . . .... ........ ..... ...... . ... . . .... . 95 Surve y Return ... .... . . .... .... .... ........ . . . . .... . . . . . .... . ... ..... ... .... . 99 Anal ys i s ... . ........ .... . .... . .... ..... ... ..... . ...... . ... . . ... .... ... . ..... . .... 1 05 4 RESULTS ... .... . . . ... .... . .... .... . .... .... ..... .... . ... . ..... . .... . . ... ....... ...... 1 07 Introduction ....... ...... .... ....... .... . . ... . ........ ....... .... ..... . ..... . .... I 07 Geographic and Sociodemographic D es criptions .... ... ... . . . . . .... 1 07 Geographic Distribution ......... ... .. ... ... ... . .... ... ... . ............ 1 07 S o ciodemo gr aphics .... ... .... ... . . ... ... ... . .... ... ..... . . . ........ 1 09 Ph y sical and Health Characteristics of Sample Population . ... .... ... 111 Specific Aims and Hypotheses Anal ys es . . ............ . . ... . . ... ....... 114 Specific Aim # 1 ....... ..... . ........ ..... ... ... . .... . . . ... . . . . .... . 114 Specific Aim #2 . ... ..... ........ . . ... .... ... ..... ... ....... ....... ... .... 118 Specific Aim # 3 .... .... .... .............. . ..... . ........ ... . . ... ........ 140 Model of Re g re ss ion ...... ......... .... ... . . ... .... ...... .... ......... ....... ...... . 142 Xl

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5. DISCUSSION .......... .. .... .... ..... .... ..... ...... .... .... ... ..... ..... .. ... .. .. .. ..... ...... 145 Introduction .... .......... ........ ..... .. .... .. .... .. ..... .................... ...... .. ...... 145 Community-Based Support and Investigative Influence ..... .... ..... . 146 Compari s on of Results to Colorado Data ........ .. ..... ........ ..... ...... .. 152 Sociodemographics ....... ..... .... ....... .. ..... ... .. .. ... .... ...... .. ...... 152 Health Characteristics ...... .. .. .. .. ...... .. .......... .. ........... .. ...... . 154 Physical Activity-Discovery and Highlights .... .. ......... ...... .. .. ...... 157 Time Spent in Physical Activit y ........ .. .. .... ..... .. .. .. ..... .. .. .... 157 Does It Add Up ? ... .......... ............ ...... .. ...... ....... ......... ....... 164 Hypotheses Discussion .......................................... ........ .......... ...... 165 Correlates of Physical Activity in a Sample Population ..... 165 Effect of Gender Distance from Town and HCP Influence on Physical Activity ... ......... . ... .... ....... .......... ... ..... ..... ...... 165 Arthritis and Physical Activity .... .. ..... .... .... ....................... 167 Environmental Resources ....... .... .... .... ...... .. ...... .... .. ..... .. 167 Theoretical Perspective Quantitative and Qualitative Insight .. .. 171 Contributions Starting the Dialogue ........... .. ...... ...... .................. 173 Limitations . .. ...... ...... ......... ............ ..... ...... ..... ...... ..... ... . ..... ... .... .... 174 Dissemination Future Directions and Interventions ... .. .. ....... ........ 176 Summary Statement ....... ..... ....... ... .... .. ....... ........ ........................ .... 1 78 Xll

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APPENDIX A. CONSENTS AND HUMAN SUBJECTS APPROVAL ................ 181 B. RURAL ARTHRITIS COMMITTEE COMMUNICATION ........ 191 C. SURVEY QUESTIONNAIRES ..................................................... 200 D. RAW FREQUENCIES FOR VARIABLES IN THE INSTRUMENTS USED IN THIS STUDY .................................... 227 BIBLIOGRAPHY ............................................................................................. 238 Xlll

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LIST OF FIGURES Figure 2.1 Theory of Reasoned Action and Theory of Planned Behavior ..................... 52 3.1 Colorado Counties ........................................................................................ 60 3.2 Consort Model Sample Size ..................................................................... 100 XIV

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LIST OF TABLES Table 2.1 U.S. Census Bureau: Population totals age gender 2000 ... ......... ......... . 26 2.2 U.S. Census Bureau: Occupation (percent distribution)2000 ....... ... . ..... 27 2.3 U S Census Bureau : Race (percent distribution) 2000 ...... ... . .... .............. 28 2.4 U.S Census Bureau: Income and poverty-1999 ......... ....... ..... ....... ... ...... 29 2.5 Behavioral risk factor surveillance system (BRFSS) dataset information: 2004-2005 . . ... ................... ...... ..... ........ .............. ....... ....... ... ...... .............. 30 3.1 Demographics of rural members ofthe Rural Arthritis Committee by county ..... ................ .... . . ............................................ . . . ... . . . .................... 65 3.2 Summary of community organizations contacted by principal investigator ....... . . ... . .... ....... . .... . ....... .... . ....... .... . ......... .......................... 68 3.3 Scale reliability for Physical Activity and Arthritis Questionnaire Items n=30 ...... ............................................................................. .... . . . ....... ... . ..... 73 3.4 Scale reliability for Physical Activity and Arthritis Questionnaire Items, n = 119 .......... . ........ . . ............. ...... ......... .... ......... ... . . ......... ... .... ..... ........ 88 3.5 Independent variables not related to the physical environrnent.. . . . . . . ..... 97 3.6 Independent variables related to the physical environrnent.. ....... ....... ....... 98 3. 7 Independent samples test: Responders and non-responders group statistics . ....... . .......... ..... ... .... ....... .... ....... . ...... ..... ... ....... . .... . ............. ....... I 03 3.8 Independent samples test: Difference between responders and nonresponders on key variables . .... ....... .... .... ..... .... ........ ........... ....... ..... ....... 04 XV

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3.9 Chi-square test: Gender and responder or non-re s ponder. . .. .... ....... .. ........ I 05 4.1 Survey municipalities and population representation .................. ..... .. ..... ... 1 08 4.2 Descriptive statistics of general demographic s of sample .. ....... .. ..... ..... .... 11 0 4.3 Work status for individuals with arthritis .... ......... ..... ........ .. .... ..... ..... ..... 111 4.4 Physical and health characteristics of the sample population ......... .. .. ....... 113 4.5 Minutes of work and non-work physical activity (PA) per week ...... . .... . 114 4.6 Total minutes work and non-work-related moderate physical activity per week ... ........... ...... . ................. .. ......... ...... .... ......... ............... ........ .. ..... 116 4.7 Total minutes work and non-work-related vigorous physical activity per week ........ ............. .. ...... ..... ....... ..................... .... .. ...... ....... ...... .. .. .. .. .. ...... 116 4.8 Descriptive statistics of transformed variable minutes moderate non-work physical activity (P A) ...... .... ......... ....... .. .. ...... ..... ............... .. .. .... 117 4.9 Descriptive statistics: Arthritis physical function impact and minutes physical activity ................................ ............ ........................ . ..... ............. 119 4.10 Correlation: Arthritis physical function impact and minutes physical activity .. ... ... ... ........ ....... ............. ....... .... ................................ ....... .. .. .. .. .. ...... 119 4.11 Independent samples test: Gender with PA group statistics ... ..... . ..... ...... . 122 4.12 Independent samples test: Differences in physical activity by gender ..... 123 4.13 Spearman rho correlation : Distance from town and minutes physical activity .... ...... .. ........ .... ............. ..... .. ..... .. .. ..... .. ............. ....... ....................... 125 4.14 MannWhitney test: Private recreation facilities and physical activity .... 127 4.15 MannWhitney test: Trails parks playgrounds fields and physical activity ........ . ........... .... ........ .. ............................ ...... ....... .......... 128 4.16 MannWhitney test: Shopping malls and physical activity ........... ..... ....... 129 XVI

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4.17 MannWhitn ey test: Public recreation centers and physical activity ..... . . 130 4.18 MannWhitney test: Schools and physical activity .... . .... . .... .......... . . ... 131 4.19 Spearman Rho correlation: Arthritis self-efficacy function and minutes physical activity ........................ . . ......... ..... ....... ............. ........................... 133 4.20 Spearman Rho correlation: Attitude about physical activity and minutes physical activity .... . ..... ........... . .... ............ . . .......... ...... ......... ..... ........... 134 4.21 Spearman Rho correlation: Subjective nom1 and minutes physical activity . .................. ... ..... .... .... ... ................................... . .... ........ ....... ..... 136 4.22 Speam1an Rho correlation: Perceived behavioral control and minutes physical activity .... ................... ........ .... ... ....... ..... . ........ ...... ....... . ... ..... 13 7 4.23 Independent samples test: Recommend versus not recommend with PA ..... ... ........... .... ..... .... ... ........ ............. .................. ... .. ... ...... ............ ...... 139 4 24 Independent samples test : Differences in PA by recommend or not recommend . ........ .................... . ... .... ....... ..................................... 140 5.1 Health characteristics: Survey participants and county or Colorado 2004-05 BRFSS data .............. .... .... ....... ............ . .... ........ . ...... .... . . . . . . 155 5.2 Colorado and PMR 1 BRFSS data: Participation in physical activity ........ 160 XVll

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CHAPTER 1 INTRODUCTION Research Question The study addressed the question, What are the correlates of physical activity in individuals with arthritis living in rural communities? In order to understand promotion of healthy living in rural settings through physical activity (PA) for people with arthritis it is important to understand facilitators and barriers of P A. Rationale Less than four decades ago, it was commonly believed that individuals with arthritis should limit their activity levels and rest affected joints. Current research indicates that appropriate physical activity can reduce pain and increase strength and endurance, which ultimately can enhance functional ability cardiovascular health and quality of life. Whether or not individuals with arthritis are physically active may depend on multiple factors. The correlates of physical activity in people with osteoarthritis or factors that influence their activity level have only been addressed by one known study that includes participants recruited from an outpatient setting at a university medical center (Neuberger Kasal, Smith, Hassanein & DeViney, 1994). No known research has looked at correlates of PA in individuals with arthritis in rural communities Understanding the facilitators and barriers to PA in this sub-population 1

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and including the active voice of community members through community-based participatory research can empower these individuals and those interested in their well-being to make well-informed health decisions related to their needs Identifying the factors that encoura ge or discourage ph ys ical activity in individuals with arthritis in rural communities adds clarity to developing tailored interventions to improve their functional abilities and overall health. Arthritis is a broad descriptive term literally meaning inflammation of a joint," and it is the leading cause of disability in the United States The National Center for Chronic Disease Prevention and Health Promotion (2008) refers to disability as a condition which causes activity limitations. It affects approximately 46 million Americans (National Center for Chronic Disease Prevention and Health Promotion, 2008). According to Y elin, Herrndorf, Trupin and Sonneborn (as cited in D D. Dunlop Manheim Yelin, Song & Chang 2003) direct costs of arthritis care in the United States (US) in 1996, defined as the actual cost of medical care provided to individuals for their arthritis signs and symptoms were $42.6 billion as expressed in the year 2000 US dollars Similarly, indirect costs including lost productivity and resources unrelated to the direct medical care costs of arthritis were estimated at $82.2 billion in 1996 as expressed in 2000 US dollars (Yelin et al. as cited in D. D Dunlop et al. 2003). Pain and loss of function often associated with arthritis can negatively affect the individual s ability to stay active in family work, community and societal roles leading to psychosocial costs (Hurley Mitchell & Walsh 2003) 2

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The Centers for Disease Control and Pre v ention ( 1998) have identified physical inactivity a potentially modifiable behavior as a major cause of premature mortality. An estimated 200 000 to 300 000 premature deaths occur annuall y in the United States due to physical inactivity (Powell & Blair as cited in Brownson Baker et al. 2004). The effects of physical inactivity on the general population include an increased "risk of heart disease stroke, hypertension type 2 diabetes colon cancer breast cancer osteoporosis depression anxiety and injuries from falls among the elderly" (Garrett, Brasure, Schmitz Schultz, & Huber 2004 p 304). PA can reduce joint pain and swelling associated with arthritis (Macera Hootman, & Sniezek, 2003) Data from the 2000 Behavioral Risk Factor Surveillance System (BRFSS) indicate that the level of P A among people with arthritis is lower than the general population (Hootman Macera Ham Helmick & Sniezek, 2003; Shih Hootman Kruger & Helmick 2006). The increased prevalence of physical inactivity among people with arthritis suggests that a larger relative percentage of this sub-population may be at risk for the comorbidities associated with physical inactivity than in the general population Rural residency can lend itself to higher risks of non-health promoting lifestyles which can affect individuals with arthritis living in these communities. The Health United States 2001 With Urban and Rural Health Chartbook (Department of Health and Human Services 200 I) lists sedentary behavior during leisure time and body mass index (BMI), a measure commonly used to classify someone as 3

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overweight or obese as higher in most rural settings. In rural counties of east and northeast Colorado a lower percentage of individuals participate in physical activities other than work whil e a higher percent report being o v erwei g ht or obese than the average for the State (Colorado Health Information Dataset 2002-2003). Their total level of physical activity including work acti v ity is unknown. It is also unknown what proportion of individuals with arthritis is represented in this data. It has been demonstrated that obesity is a risk factor for knee osteoarthritis the most common type of arthritis (Coggon et al. 2001 ; Cooper et al. 2000; Felson & Zhang 1998; Felson et al., 1997 ; Wei Gibbons Kampert Nichaman & Blair 2000). Multiple factors including living with a chronic disease relatively lower levels of P A and residing in a rural community can have serious consequences to the health of individuals with arthritis. In order to determine if interventions for people living with arthritis in rural communities are needed it was important to understand the current levels and types of P A in this sub-group and to identify barriers and facilitators to P A. Including community participation in this process gave a voice to people with arthritis living in rural communities and helped to ensure that potential future actions meet the needs of the individuals living with arthritis. 4

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Specific Aims The specific aims and hypotheses of this investigation were to: Aim #1: Determine current levels of physical activity (P A) in participating individuals with arthritis Jiving in rural communities of east and northeast Colorado. Aim #2: Determine the factors that influence physical activity for individuals with arthritis Jiving in rural communities. Hypotheses: a. There will be a relationship between arthritis impact on physical function and minutes of moderate or vigorous physical activity. b. Men with arthritis living in a rural community will have significantly more minutes of physical activity than women with arthritis living in a rural community. c. Distance from town will be associated with minutes of physical activity in individuals with arthritis in rural communities. d. There will be a difference between perceived environmental availability of resources for physical activity and minutes of physical activity. e. There will be a relationship between self-efficacy and minutes of physical activity in individuals with arthritis who live in rural communities. 5

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f. Individual attitude towards physical activity will be associated with minutes of PA in individuals with arthritis who live in rural communities. g. There will be a relationship between individuals with arthritis perception of how others' perceive physical activity and arthritis and the individual's minutes of physical activity. h. There will be a relationship between individuals with arthritis who perceive they have control over their level of P A and minutes of P A. 1. There will be a difference between individuals with arthritis who report that a healthcare pro vider recommended physical activity versus those who report no recommendation and minutes of physical activity. Aim #3: Enhance the quality of the content of the study and the usefulness of the study's findings by fostering the participation of community members in the research process through a regional community-based Rural Arthritis Committee. 6

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CHAPTER2 BACKGROUND Introduction Incorporating appropriate physical activity (PA) into an individual s routine plays a key role in promoting health, enhancing functional activities and improving the quality of life in individuals with arthritis (Altman Hochberg Moskowitz, & Schnitzer 2000; D. D Dunlop, Lyons Manheim, Song & Chang 2004 ; Fontaine Heo, & Bathon, 2004). Adequate levels of physical activity can have a positive effect on arthritis (de Jong et al. 2004 ; Minor 1999; Shih et al. 2006; Stenstrom & Minor 2003; U.S. Department ofHealth and Human Services 1996) a term that encompasses over 100 rheumatic and musculoskeletal conditions. Access to information resources appropriate social and physical environments and behavioral strategies can support safe and effective levels of P A. In order to maintain appropriate P A levels people with arthritis in rural Colorado communities may require healthful living interventions based on their current perceptions and resource availability. Living in a rural community can add to the complexity of living with a chronic disease Issues including, but not limited to access to care, resource 7

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availability socioeconomic and educational status cultw:e, attitudes and behavior and the environment may influence health choices in these communities. Physical activity can contribute to healthful living and is a predictor of decreased pre-mature mortality (Brown Yore Ham & Macera 2005; M. E. Nelson et al., 2007a). Physical activity has been shown to reduce the risk of chronic disease pathology (Bauman 2004 ; Macera et al. 2003; Paffenbarger et al. 1993 ; U.S. Department of Health and Human Services, 1996) and the associated functional losses that limit daily activiites. For individuals with arthritis who already face disability and functional losses the reduction in morbidity by participation in appropriate P A can significantly enhance the quality and longevity of life Osteoarthritis The term "arthritis" literally means inflammation of a joint. This section introduces the most common type of arthritis, osteoarthritis and describes management guidelines that include information on physical activity. Importance Osteoarthritis (OA) is the most common type of arthritis and affects over 20 million individuals in the United States (Robbins Burckhardt, Hannan & Dehoratius 2001). It is estimated that 37% of adults in the United States (US) have some evidence of radiographic OA and one-quarter of these individuals have moderate or severe disease (Robbins et a!., 2001 ) US economic costs are estimated to be more than $60 billion per year (Elders, 2000) and this estimate does not include costs 8

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related to pain and suffering reduced ability to be active in work or leisure time psychosocial adverse effects or factors related to care provision by family or friends (Carr 1999). World-wide 10% of the population over the age of 60 years is estimated to have "significant clinical problems that can be attributed to osteoarthritis" (World Health Organization and The Bone and Joint Decade, 2001 p. 4). Pathogenesis and Diagnosis Joints commonly affected by OA include the weight-bearing hip knee, spine and first metatarsophalangeal (MTP) joints as well as the first metacarpophalangeal (MCP) joint of the thumb and the proximal and distal interphalangeal joints of the hand. Joint changes generally occur slowly over many years and are characterized by variab le changes in the cartilage, subchondral bone and marginal joint regions. Cartilage degeneration subchondral bone sclerosis and osteophyte formation can occur progressively over time and lead to varying degrees of pain, functional loss and disability. Inflammation of the synovial membrane and capsular thickening has also been noted (Bartlett Bingham Maricic Iversen & Ruffing, 2006 ; Rogers Shepstone & Dieppe 2004) Laboratory tests alone such as blood work are not used to definitively diagnose OA (Bartlett et al. 2006; Rogers et al., 2004) Typically a diagnosis requires a physical exam and history. Evidence of joint changes on radiographs can verify the diagnosis of those with advanced disease. 9

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Common signs and symptoms associated with OA are palpable bone changes muscle weakness pain stiffness or gelling of joints after inactivity and fatigue (Bartlett et al. 2006 ; Hurley et al. 2003 ; Klippel Stone Crofford & White 2008) Bony enlargements are often palp a ble at the affected joint surfaces of the hand knee and great (first) toe Muscle weakness can be evaluated by the healthcare provider and or reported by the individual affected by arthritis. Slemenda et al. ( 1997) reported that quadriceps weakness was commonly noted in individuals with s y mptomatic knee OA. Pain often drives the initial contact with a healthcare provider. Although the intensity frequency and subjective description vary greatly between individuals, pain is primarily experienced with use of the joint. Stiffness or gelling of the joint occurs after periods of inactivity and is reported as difficulty in getting started again by individuals. This often subsides within 30 minutes of resumed activity Individuals also report generalized fatigue which could result from increased energy expenditure required to perfom1 acti v ities with painful stiff joints or it could be related to disrupted sleep patterns (Klippel et al. 2008). Osteoarthritis signs and symptoms can compromise an individual s hand and weight-bearing functional ability Activities of daily liv ing work and leisure-time activities can be limited resulting in reduction in the indi v idual s health-related quality of life. Reduction in overall activity level can negatively impact the individual s cardiovascular s tatus (Elmer et al. 2006 ; Folta et al. 2008; King et al. 1995 ; Sundquist Qvist Sundquist & Johansson 2004) Cardiorespiratory fitness as 10

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defined by Sui et al. (2008), can reflect cardiovascular status and has been shown to be a significant mortality predictor in older adults (Sui et al., 2008). Degree of severity of OA is classified by the American College of Rheumatology based on the individual's symptoms, clinical signs, laboratory tests, and or radiographic findings. Specific classification criteria exist for the hand, hip and knee (Klippel et al., 2008). There is poor correlation between radiographic findings and pain and disability noted by individuals with OA (Bartlett et al. 2006; Hurley et al. 2003; Rogers et al., 2004) Individuals with severe radiographic findings often report less pain than those with mild joint damage noted on x-ray (Hurley, 2003; Rogers et al., 2004). Pain perception may limit an individual's ability to fully participate in work and or leisure activities. Risk Factors There are many risk factors associated with OA. Increasing age and a genetic predisposition are non-modifiable risk factors at all joint sites (Klippel et al., 2008). Female gender and ethnicity are additional non-modifiable risk factors at selected joints. For example, hip OA is rare in people of Chinese descent (Klippel et al., 2008). Modifiable, or potentially modifiable risk factors for osteoarthritis include obesity previous joint injury, repeated overuse, knee bending lifting and biomechanical factors including abnormal stresses to the joint (Cooper et al., 1998; Cooper et al., 2000; Felson et al., 1997 ; Hurley, 2003) Dunlop et al. (2005) also 11

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report lack of regular vigorous physical activity as a potentially modifiable risk factor in older adults with artluitis that can substantially reduce their functional ability Obesity a potentially modifiable risk factor, has been linked to the development of knee OA (Cooper et al., 2000 ; Felson et al., 1997; Grabiner 2004; Klippel et al., 2008) Obesity is often defined by the body mass index (BMI) calculated from the [(individual s weight in kilograms) / (individual s height in metersiJ. BMI categories include underweight ( < 20.0 kg / m2), normal weight (20.024.9 kg/m2), overweight (25 .0-29.9 kg/m2), and obese (2:30.0 kg/m2 ) (Coggon et al., 2001 ). Sharma Lou, Cahue and Dunlop (2000) looked at the correlation between knee alignment (varus= "bowlegged valgus= "knock-kn eed") and the presence of OA in individuals with a mean BMI of32.3 or 29.8.5 kg / m2 (varus group and valgus group respectively). They noted, "BMI and malalignment were correlated in patients with varus knees but not those with valgus knees" (Sharma et al. 2000 p. 574). The BMI effect appeared to intensify with increased severity of varus malalignment suggesting that the effect of obesity on knee OA may be selective depending on the alignment of the knee joint. In addition Grabiner (2004) reports that cartilage cell destruction and / or changes in the density of bone underlying the cartilage may contribute to the development of knee OA. Both of these effects may be magnified as a result of increased body weight. Abnormal stress applied to a joint over time affects the biomechanical forces across that joint. Muscle weakness may allow abnormal stress production across the 12

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joint. Hurley (2003) suggests "that quadriceps dysfunction may play a role in the pathogenesis of knee OA (p. 450). In addition quadriceps weakness has been identified as a more important cause of pain and disability in knee OA than destruction of bone and cartilage noted on radiographs (Slemenda et al., 1997). Muscle weakness may decrease the stability ofthe knee joint and also limit the shock absorbing capacity of the knee complex thereby increasing the risk of abnormal biomechanical stress and OA. Occupations such as farming that apply repeated stress to joints may facilitate the destructive arthritic process often described as "wear and tear" arthritis (Cooper et al., 1998; Croft, Coggon, Cruddas, & Cooper, 1992). Croft et al. (1992) reported an association between farming and high rates of surgery for hip OA following data analysis of a cross-sectional survey. The authors suggested "one possible cause is cumulative mechanical stress on the joint from physical activities such as heavy lifting ... (p. 1269) They stated the increase in surgery rate in farmers compared to controls might be related to the need to correct the disability related to hip OA in order to continue the work associated with farming The risk for hip OA increased with years working in farming. Prevention of destructive mechanical forces could reduce the risk of developing hip OA. Guidelines for the Management of Osteoarthritis Optimal medical management of osteoarthritis involves a team of health related professionals partnering with the individual with arthritis to maximize health 13

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outcomes. Reduction of pain symptoms, normalization of movement patterns and maximizing functional abilities through appropriate body systems training including the musculoskeletal cardiovascular and neuromuscular systems can improve health related quality of life and reduce functional limitations. The American College of Rheumatology Subcommittee on Osteoarthritis has developed guidelines for the medical management of hip and knee osteoarthritis (Altman et al. 2000). Their findings suggest treatments that consist of client education including self-management strategies, physical and occupational therapy pharmacological or surgical intervention, and weight management. Non pharmacological management emphasizes strength and aerobic exercise based on evidence from multiple recent reports (Ettinger et al. 1997; Hurley 1999 ; Slemenda et al. 1997). Appropriate exercise and/or physical activity are major components of the guidelines. The European League Against Rheumatism (EULAR) developed similar recommendations for managing knee OA. A task force within EULAR developed evidence-based guidelines for the treatment of knee OA (Pendleton et al : 2000) Non-pharmalogical and phannalogical options were analyzed using an evidence based and expert opinion approach. The e v idence-based non-pharmalogical and non surgical approach included patient education exercise, insoles nutrients weight reduction patellar taping spa, and telephone contact with a HCP. Expert opinion ratings of these options were highest for exercise, patient education, and diet which 14

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were ranked first, fifth and seventh respectively when comparing all pharmacological and non-pharmacolo gica l management options Current liter at ure supports the role of exercise in the management of OA. According to Diepp e, Minor and Blair who participated as experts in the National Institutes of Health (NIH) conference Stepping Away from OA: Prevention of Onset Progression and Disability of Osteoarthritis in 1999 (Felson et al. 2000), muscle conditioning is necessary to provide joint stability and to assist with shock absorption during weight-bearing activities which can result in reduced signs and symptoms of osteoarthritis. They included range of motion and flexibility exercise cardiovascular training and muscle conditioning as components of exercise activities for individuals with OA. Dekker et al. and Hurley et al. (as cited in Steultjens Dekker van Baar, Oostendorp & Bijlsma 2001) reported that "improving muscle strength is regarded as one of the most important mechanisms towards reducing pain and disability (p. 332). In addition, Dunlop et al. (2003) state that the strong association of lack of vigorous exercise with subsequent functional deterioration is particularly important from a public health point of view because this risk factor is amenable to intervention (p 11 0). Additional data support the use of exercise and or physical activity in the management of signs and symptoms associated with osteoarthritis The Fitness Arthritis and Seniors Trial (FAST) research study reported modest but consistent impro v ements (Ettinger et al. 1997 p 29) in pain and disability level as well as 15

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functional tests in individuals with knee OA participating in aerobic or strength training programs The control group for this study had received health education without a structured exercise program. Philbin Groff, Ries and Miller (1995) report the effectiveness ofPA in older adults with OA who are sedentary. Improvements are noted in cardiovascular fitness and muscle strength in people with significant OA without making their symptoms worse. The recent Ottawa Panel results (Brosseau, 2005) suggest there is strong evidence for the use of P A, including exercise in the management of OA particularly in pain reduction and improvement in function. Minor (1999) states "Exercise may be the most effective malleable, and inexpensive modality available to achieve optimal outcomes for people with osteoarthritis" (p. 397). Guidelines for management of osteoarthritis include pharmacological and non-pharmacological strategies. Multiple options can be considered to achieve optimal functional ability and reduce the impact of this disabling condition. Arthritis in Colorado Data from the 2005 Colorado Behavioral Risk Factor Surveillance System (BRFSS) (Gannon, n.d.) provide estimates that almost one-quarter of the adults in Colorado have been told by a physician or other health care provider that they have arthritis. Analysis by age group reveals of individuals over 65 years of age of individuals between 55 and 64 years of age, of individuals between 45 and 54 years of age and II% of individuals between 18 and 44 years of age have I6

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some type of arthritis (Gannon n d ) Fifty-seven percent of these individuals across all age groups report being overweight or obese (Gannon n.d .). The pre v alence of arthritis is lower in individuals of Hispanic descent than white / non-Hispanic Black/non-Hispanic or individuals reporting race / ethnicity in the Other category (Gannon n.d.). An additional 700 000 individuals suffer from undiagnosed joint pain and or stiffness (Gannon n d.) No information is available to detem1ine percent of the affected individuals in rural versus urban areas The Colorado 2005 BRFSS also reports other health characteristics of persons with arthritis compared to individuals without arthritis. Persons with arthritis are nearly three times as likely to have diabetes as individuals without arthritis. Also, nearly 39% of persons with arthritis report high blood pressure (Gannon, n.d.). In contrast only 14% of individuals without arthritis report hypertension (Gannon n.d.). Individuals with arthritis identify their overall general health as fair or poor (Gannon n.d.). They also report less or limited time spent in leisure-time physical activity (Gannon, n.d .). State-by -st ate information related to arthritis-attributable work limitations (AA WL) was captured in the 2003 BRFSS. Participants in this random-digit state based telephone survey answered the following: "In this next question we are referring to work for pay Do arthritis or joint symptoms now affect whether you work the type of work y ou do or the amount of work you do? (Centers for Disease Control and Prevention 2007b ) Colorado data indicates 28% of working age adults 17

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between the ages of 18 and 64 years of age responded affirmatively to this question (Centers for Disease Control and Prevention 2007b). Data was not reported for individuals who work but are not between the ages of 18 and 64. Data from the 2005 BRFSS estimate an increasing effect of arthritis in Colorado over the next 25 years. The number of individuals reporting doctor diagnosed arthritis is expected to rise 25% (Centers for Disease Control and Prevention 2007a) An additional 68 000 persons with arthritis are estimated to experience arthritis-attributable activity limitations (Centers for Disease Control and Prevention 2007a), which will have an impact on personal and economic resources. Colorado organizations interested in arthritis joined forces between 1999 and 2003 to examine resources and plan strategies to address arthritis -related concerns Guided by a model presented in the National Arthritis Action Plan : A Public Health Strategy" (Arthr iti s Foundation Association of State and Territorial Health Officials & Centers for Disease Control and Prevention 1999) the Rocky Mountain Chapter of the Arthritis Foundation headquartered in Denver, and the Colorado Department of Public Health and Environment joined together to form the Colorado Arthritis Advisory Committee in 1999. This committee comprised individuals from the public private professional volunteer, and non-profit sectors and was organized to address the concerns associated with arthritis as a leading cause of disability. They developed a strategic plan and although it was not fully funded the plan identified several goals to address the topic of arthritis in Colorado : to id entify and describe the population of 18

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people with arthritis in Colorado develop a research agenda focused on improving prevention and management of arthritis in Colorado provide resources to increase knowledge for health care providers and educators increase public awareness about arthritis from prevention to management implement programs for the prevention early diagnosis, and management of arthritis, improve the quality of life for people with arthritis and educate policy-makers on the health burden and cost of arthritis to the State of Colorado (Arthritis Foundation & Colorado Department of Public Health and Environment, n.d.). Due to a lack of sufficient funding, the goals were not fully met and require continued investigation. The Rocky Mountain Chapter ofthe Arthritis Foundation continues to focus on meeting the needs of people with arthritis in Colorado and has developed a public health strategy. Supporting a population prevention and partnership approach, they specifically recognize the need to focus attention on rural areas. A forum held in August 2004, asked participants with a stake in rural health concerns to brainstorm on effective management strategies for people with arthritis in rural Colorado communities The need for advancing current strategies to assist those with arthritis in more remote locations in Colorado was discussed and current resource limitations described. Issues of Rurality This section presents a definition of "rural used for the purpose of this study and provides an overview of health disparities that exist in rural communities. 19

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Specific information related to health disparities in rural Colorado is reported as well as sociodemographic characteristics of the counties considered for this investigation. D efining Rural The term rural has been defined in a number of ways, and there is no general consensus on the definition (Hart Larson, & Lishner 2005). For the purpose of this inv estigation this study used the Office of Management and Budget (OMB) classification scheme reported in Health United States 2001 With Urban and Rural Health Chart book (Department of Health and Human Ser v ices 2001 ), a metropolitan and non-metropolitan classification using counties as the geographical unit. Metropolitan statistical areas contain at least one urbanized area with 50 000 or more people and strong social and economic ties with adjacent territory A separate OMB Bulletin No 03-04 (2003) further divided non-metropolitan into micropolitan statistical areas or non-core based on their population A micropolitan statistical area is considered to be a county that has at least one urban cluster defined as less than 50 000 but greater than 10, 000 population and adjacent territory that has significant social and economic integration with core which is determined by commuting ties (Office of Management and Budget 2003). Non-core" counties are those counties that are not defined as a metropolitan or micropolitan statistical area. The OMB does not intend for micropolitan statistical areas or non-core areas to be equivalent to rural. They base their rationale on the fact that man y counties contain both urban and rural areas which may be based on Census Bureau 20

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definitions. However, Census Bureau rural and urban designations are based on census tracts, which are difficult to apply to health data that are often reported by county Part of the data used as a reference for this study is health data reported only by county. Therefore, the micropolitan and non-core designations used by the OMB equated to rurality for the purposes of this investigation. Health Disparities in Rural Communities Multiple health disparities exist in rural communities when compared to their urban or in particular their suburban counterparts. Health disparities within a particular population have been defined as "a population where there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status ofthe general population" (National Institute of Health as cited in Hartley, 2004, p. 1676). Although traditional explanations of health disparities in rural communities have been attributed to access to care issues shortages of health care providers, and economic factors there also appears to be rationale related to environmental, cultural, and behavioral characteristics that contribute to the health concerns of rural communities. These factors are reflected differently in the uniqueness of each rural region. Examples of environment, culture, and behavior impacting rural regions are noted in the "Health, United States 2001 With Urban and Rural Health Chartbook" (Department of Health and Human Services, 2001 ). Being sedentary during leisure time, smoking, and a BMI 30 kg /m2 (obese) were all listed as higher in the most 21

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rural settings. Conceptually, all of these characteristics could be related to the environment, culture or behaviors of the rural community. An unsafe environment such as cracked sidewalks, absence of non-roadway walking spaces, or poor lighting could prevent outdoor leisure activities such as walking The prevailing rural culture might not value or recognize the health risk associated with smoking. And the pattern of a rural diet and reduced physical activity could lead to obesity. These examples demonstrate compositional and contextual perspectives of rural communities that affect health Phillips & McLeroy (2004) delineate these two perspectives by stating that "health problems in rural areas are compositional when they derive from the characteristics of people residing in rural settings" and "contextual when they derive from the special characteristics of rural areas" (p. 1662). Both perspectives should be considered when investigating the specific regional needs in rural communities. Approximately 20% of the US population lives in rural areas (Hart et al. 2005) and disparities exist in health characteristics and resource availability between rural and urban settings There is a higher incidence of chronic health problems, including arthritis, in rural communities (Garkovich & Harris, 1994; Hart et al., 2005). There are fewer employer-offered health insurance plans and a higher rate of unemployment (Garkovich & Harris, 1994; Hart et al. 2005). In addition higher poverty rates affect rural communities and fewer health care providers (HCPs) are available per capita than in urban areas (Garkovich & Harris, 1994). The 22

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combination of lower income (Saag et al., 1998), reduced insurance benefits, and fewer HCPs can lead to disparities in health care. Age and access to services also influence health disparities. Saag et al. (1998) note that elderly people with arthritis in rural communities self-report greater disability than those in urban areas. Individuals who have not been able to access an appropriate referral for accurate diagnosing due to Jack of transportation, absence of HCPs or financial restrictions are of particular concern in rural areas. Colorado Rural Communities Healthcare Disparities The State of Colorado comprises 64 counties, 4 7 of which are designated as rural or frontier (Colorado Rural Health Center, 2007) and were considered equivalent to micropolitan or non-core respectively for the purpose of this study. Frontier counties are defined as counties with six or fewer people per square mile (Denton, n.d.), and the term "rural" included frontier counties for the purpose of this investigation. Nearly 80,000 square miles in Colorado are considered rural (Colorado Rural Health Center, 2007). Within these rural counties, data indicate that health care challenges surpass those in urban counties. Over 90% of Colorado counties are designated partially or wholly as a "Health Care Professional Shortage Area" and six counties are designated as "Medically Underserved" (Colorado Rural Health Center, 2007) per Federal guidelines (U.S. Department of Health and Human Services, 1976, 1993). There has also been significant population growth in rural counties of more than 32% from 1990-2000 (Colorado Health Information Dataset, 2002-2003). 23

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Demographics and statistics related to Colorado offer a rationale for potential disparities in health care when compared to urban areas. The average median income is $36 892 in rural counties as compared to $53 799 for urban counties (Co lorado Rural Health Center, 2007). A reported 12.7% of families in rural areas live below the Federal Poverty Level compared to 8.6% in urban areas Health insurance rates for working adults are relatively higher in rural areas due to lower wages limited choices and few group plans (Denton, n.d. ; Larson & Hill 2005). The combination of lower income and higher health insurance costs potentially leaves many Colorado rural inhabitants without health insurance. Elderly individuals in Colorado may also face greater hardships in rural communities than in urban areas A higher percentage of rural residents are over 65 years of age compared to urban areas (Colorado Rural Health Center 2007) Fewer health care facilities are available in rural Colorado and 14 counties do not have a hospital (Colorado Rural Health Center 2007). It is also reported as often difficult to locate a rural provider who accepts Medicaid Medicare or Child Health Plan Plus in rural Colorado" (Colorado Rural Health Center, 2007 p. 2). A larger proportion of elderly individuals in rural Colorado with fewer health facilities and insurance challenges may limit quality and timeliness of care. Healthcare provider (HCP) shortages in rural Colorado limit access to medical care particularly in specialty areas. There are currently 46 rheumatologists in urban areas listed by the Arthritis Foundation and 8 listed as serving rural communities 24

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(Arthritis Foundation, 2005). However, the rheumatologists listed as serving rural areas a re often based in a city outside of the counties they serve, requiring the individual from a rural community to come to their office in a distant city often a hardship or impossibility for the individual affected by arthritis Data for the number ofHCPs in rural settings including discipline location and specialty area, may not exist or be known by the rural community For example it is unknown how many physical therapists currently serve clients in rural communities and how many specialize in arthritis making it difficult to provide this as a resource for rural Coloradoans There are significant obstacles to optimal health of individuals living in rural Colorado Demographics resource availability, access to care and economic factors influence healthful living in this rural sub-population. Colorado Rural Counties-Sociodemographics This study originally included the counties of Cheyenne, Elbert Kit Carson Lincoln, Logan Morgan Phillips Sedgwick, Washington, and Yuma. Sociodemographic data are available for these counties from the US Census Bureau data (2000) in Tables 2.1, 2.2 2.3 2.4 and 2.5. Column headings are those established by the US Census Bureau (2000). In addition to providing total population age percentages, gender occupation and race within each county, these data also confirm the lower income levels in these rural counties compared to the State of Colorado averages with one exception Elbert County. Although the eastern 25

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section of this county remains sparsely populated western Elbert County has seen explosive growth as a commuter neighborhood to Denver and Colorado Springs. Property values and income averages are significantly higher than the State average. Elbert County is included in the demographics because it has been grouped with Cheyenne, Kit Carson, and Lincoln counties in reports of the Behavioral Risk Factor Surveillance System (BRFSS) data and because the surveyed areas included rural portions of this county. Table 2.1 US Census Bureau: Pop_ulation Totals, Age, Gender 2000 State of Colorado Total Population Age: Age: Gender: or Colorado Estimates-45 to 64 years 65 year and over Males per 100 County Census 2000 (%of total fema l es (%of total population) population) (all ages) State of Colorado 4,301 261 22.2 9.7 101.4 Cheyenne 2,231 21.3 16.6 100.6 Elbert 19,872 25.5 6.0 100.6 Kit Carson 8,011 22.2 14.6 112.2 Lincoln 6,087 21.8 14.3 130.9 Logan 20,504 21.7 14.5 112.0 Morgan 27 ,171 19.8 13.0 100.4 Phillip s 4,480 22.2 19.4 93.4 Sedgwick 2,747 25.0 22.1 100.1 Washington 4,926 24 2 18. 2 103.4 Yuma 9,841 22.3 16.3 96.8 26

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Table 2.2 U.S. Census Bureau: Occupation (percent distribution) 2000 State of ManageService Sales F a rming, Co nProdu c ti on, Colorado or m en!, proocc upaand fis hin g s tru c ti o n Colorado fessional, trans-County and r e lat e d li o n s office and ext ra c ti o n port at ion, occ upation s occupa forestry and mainm ate rial li ons t e nan ce m oving State of 37.4 13. 9 2 7 .2 0.6 10. 5 10. 5 Colorado Cheyenne 35.3 16.7 17.8 4.6 15. 1 I 0.4 Elbert 36.2 11.2 26.7 1.8 13.8 10.3 Kit Carson 33.7 15.4 24.4 7.4 8 7 10.3 Lincoln 32 .2 24.0 20.5 3.3 10.1 10. 0 Logan 28.4 19.7 23.5 2.9 11.0 14. 5 Morgan 24.4 15.0 20.9 4 0 13.8 21.9 Phillips 35.3 13. 8 21.5 10.8 10.9 7 7 Sedgwick 31.7 15. 1 22. 0 8 0 10.1 13.1 Washington 37.9 11.3 20.2 5.3 I I. I 14. 3 Yuma 34 0 13.4 22.2 8.7 11.2 10. 6 27

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Table 2.3 U.S Census Bureau: Race (p_ercent distribution) 2000 State of White Black A merAsian Native Some Two Hi spa nic Colorado or Or i can Hawaiothe r or o r Latino Colorado African Indian ian and race more (of any County and races race/ American Other Alaska Pacific Native Island er State of 82.8 3 8 1.0 2.2 0.1 7.2 2 8 17.1 Colorado Cheyenne 92. 9 0 5 0.8 0 1 0.0 5 1 0 6 8.1 Elbert 95.2 0 6 0.6 0.4 0.1 1.3 1.8 3.9 Kit Carson 87.3 1.7 0.5 0.3 0.0 9 2 0.9 13.7 Lincoln 86.3 5.0 0.9 0 6 0.0 5.7 1.6 8. 5 Logan 91.7 2.0 0 6 0.4 0.1 3.8 1.4 11.9 Morgan 79.7 0.3 0 8 0.2 0.2 16.4 2.5 31.2 Phillips 93.0 0.2 0.3 0.4 0 0 4 7 1.3 11.8 Sedgwick 90.5 0.5 0 1 0.8 0 1 6.0 2.0 11.4 Washing-96.4 0 0 0 6 0.1 0 0 2.0 0 9 6.3 ton Yuma 94.2 0.1 0.3 0.1 0.0 4.1 1.2 12.9 a Percent of total population 28

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Table 2.4 US Censu s Bur eau: Income and Poverty 1999 State of Median M e dian P e r c apit a In co m e be l ow Incom e Colorado or inco m e in co m e p ove r ty all b e l ow Colorado incom e ages(% o f p ove r ty -65 Coun ty h o u se h o lds f a milies (do llar s) p o pulati o n ) and o v e r(% ( d o ll ars) ( d o llar s) of p o pulati on) State of 47,20 3 55 883 24 049 9 3 7.4 Colorado Cheyenne 37 054 44 394 17, 850 11.1 10.9 Elbert 62 480 66 740 24 960 4.0 4.5 Kit Car s on 33 ,152 41, 867 16, 964 12. 1 11.1 Lincoln 31, 914 39,738 15, 510 11.7 11.5 Logan 32 724 42 ,241 16,721 12. 2 10.9 Morgan 34 568 39 ,102 15, 492 12.4 9 5 Phillip s 32 177 38 ,144 16, 394 11.6 7 2 Sedgwick 28 278 33, 953 16,125 10.0 4 2 Washington 32 ,431 37 287 17, 788 11.4 9.4 Yuma 33 169 29 814 16, 005 12. 9 10.7 Table 2.5 includes responses to BRFSS questions by the Colorado counties of interest grouped into two Planning and Management Regions (PMR) Data on healthrelated questions in the grouped counties are compared to the State averages 29

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Table 2.5 Behavioral Ri s k Factor Surveillance System (BRFSS) Dataset Information : 2004-2005 BRFS S Topic Colorado Data How is yo ur general hea lth ? %Good/excellent For how many days durin g the pa s t 30 da ys was your phys ical health not goo d ? % Bad physical health = 0 da ys For how man y days during the p as t 30 days was your physica l health not good? % Bad physical health = 1-7 days For how many days during the past 30 da ys was your phys ical health not goo d ? % Bad phys ical health = 8 or more da ys Ba se d on bod y mass index are you overweight? %yes Based on body mass ind ex, are yo u obese? %yes Durin g the past 30 day s, other than your regular job, did yo u participate in any physical activities? %yes Do yo u have any kind of health care coverage? % yes State of PMR f a Co l o rado 87.9 79.3 67.0 63.4 21.7 19.7 11.3 16.8 53.7 61.4 16.4 28.2 82 1 66 0 84.4 85.4 a PMR I Counties: Logan Morgan Phillips Sedgwick, Washin gto n Yuma b PMR 5 Counties: Cheyenne Elbert, Kit Carso n Lincoln cN ot available fewer than 50 re s pondents d 2002-2003 BRFSS data set information Physical Activity PMR 56 86.0 66 .2d 26.1d 67.6 73.5 In this section, ph ys ical activity is defined and information related to current levels of physical activity (PA) in the US is presented Literature supporting the benefits of P A in the general population is exan1ined and an overview of information related to P A in people with arthritis is discussed 30

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Physical Activity and Health Physical activity is recognized as a major component of healthful living and can reduce the risk of developing s ome c hronic diseases (Bauman 2004 ; Macera et a!., 2003 ; Paffenbarger eta!. 1993 ; U .S. Department of Health and Human Services 1996). It is broadly defined as any activity involving mu s cular contraction and can vary in intensity from minimal to maximal effort. It is considered distinct from exercise which implies a structured activity with the goal of increasing physical fitness (Caspersen Powell & Christenson 1985). Activity that increases physical fitness consists of components that promote endurance strength flexibility and / or balance (Caspersen eta!. 1985). Both exercise and physical activity can improve physical fitness. Physical inactivity has associated high direct costs to the medical system Garrett eta!. (2004) report total medical expenses attributable to physical inactivity to be $83 6 million in a study that reviewed data from a health plan population and their paid claim costs and pharmacy data in the state of Minnesota. This represented approximately 1.5 million residents about one-third the population of Minnesota and worked out to $56 per member in 2000 which could have been avoided if the entire population was active (Garrett eta!. 2004 p. 306). According to the authors this per capita state estimate of charges related to physical inactivity was on par with several other states that ranged from $19 per capita to $79 per capita. Physical inactivity attributed to increased costs associated with ischemic heart disease high blood 31

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pressure stroke, depression and anxiety, type 2 diabetes breast cancer osteoporosis, and colon cancer (Garrett et al., 2004). Increasing physical activity has become a national initiative. The Surgeon General's comprehensive r e port Physical Activity and Health," (U.S. Department of Health and Human Services, 1996) states that individuals can improve their health and quality oflife through increasing their activity levels. Healthy People 2010 (Office of Disease Prevention and Health Promotion n.d.) recognizes physical activity (P A) as one of the ten leading health indicators to be addressed during this decade and one of its objectives is "to increase the proportion of adults who engage in regular preferably daily in moderate PA for at least 30 minutes per day (p. 26). The National Blueprint: Increasing Physical Activity Among Adults Age 50 and Older (Robert Wood Johnson Foundation 2001) identifies strategies to enhance the physical activity levels in older adults in order to extend years of active, independent living (Cress et al., 2005). Updated recommendations from the combined efforts of the American College of Sports Medicine and the American Heart Association clarify previous guidelines related to physical activity and public health (Haskell et al. 2007). A companion paper specifically addresses recommendations for physical activity in older adults (M. E. Nelson et al. 2007b ). Both papers use a system to classify recommendations based on classification of recommendations (COR) and level of evidence (LOE). (Haskell et al., 2007). 32

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Current levels of PA in adults in the United States are inadequate. More than 60% of individuals in the United States do not participate in regular physical activity and over 25% of this population is sedentary (Franklin Whaley, & Howley 2000). In individuals with arthritis 30.8% were reported as inactive according to the 2000 BRFSS (Hootman et al. 2003). Demographics indicate that 33% of the individuals with arthritis who were inactive were 45 years of age, obese black Hispanic other" race / ethnicity or had :S 12 years of education. The term "lifestyle physical activity" (LPA) identifies the physical activity performed by an individual on a daily basis. Part of the challenge in determining needs for changes in P A levels is understanding current levels of LP A as well as the individual s level of fitness. Current recommendations for LP A includes at least 30 minutes of work activity, leisure-time activities, and any other daily activity in which the individual is actively moving, for example buying groceries or cleaning the house at a moderate to vigorous intensity level (Dunn, Andersen & Jakicic, 1998). The definition of moderate and vigorous intensity levels may vary based on the fitness level ofthe participant. For example the cardiopulmonary response to climbing six stairs may be elevated in an individual with low cardiovascular fitness and yet barely noted in an individual with high cardiovascular fitness An assessment of the types and intensity ofPA can clarify the need for change in activity levels to promote a positive cardiovascular conditioning response. 33

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Individual levels of P A are influenced by many factors. These might include age, gender, general health, ethnicity, socioeconomic status, social and physical environments and personal behaviors. Parks Housemann and Brownson (2003) investigated correlates of physical activity in adults from rural and urban setting with diverse backgrounds. A sample of 1818 adults 18 years of age and older participated in a telephone survey that used a combination of questions from the BRFSS the National Health Interview Survey, and other un-named surveys. Their results indicate that income level and urban rural status were predictors of this population's likelihood to meet P A daily recommendations. Participants with lower income levels or rural residents were Jess likely to be active. They also noted that environmental factors influenced levels of P A across socioeconomic and rural-urban settings Benefits of Physical Activity Multiple studies have looked at the relationship of PA to health. Reduction in mortality and morbidity associated with conditions such as coronary heart disease, colon cancer, diabetes and obesity is noted with improved physical fitness (Franklin et al., 2000; King et al. 1995). In 1992 Fletcher Blair and Blumenthal (1992) noted that the American Heart Association listed physical inactivity as an independent risk factor for cardiovascular disease. Furthermore reduced morbidity with increased P A in individuals with chronic diseases such as arthritis is reported (Whaley Brubaker, & Otto 2006). The American College of Sports Medicine (Whaley et al., 2006) reports that as little as 1 0-minute sessions of aerobic activity three times per day can help 34

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achieve and maintain fitness. Nelson et al (2007b) state Regular physical activity, including aerobic activity and muscle-strengthening activity is essential for healthy aging. This preventive recommendation specifies how older adults by engaging in each recommended type of physical activity can reduce the risk of chronic disease, premature mortality functional limitations and disability (p 1 098). Coronary heart disease (CHD) for example is the leading cause of mortality in the United States, accounting for 28 .5% of all deaths in the year 2002 (National Vital Statistics Reports 2004). Although many risk factors including smoking high cholesterol (hypercholesterolemia), high blood pressure (hypertension), and obesity have been linked to cardiac disease physical inactivity is a risk factor that when addressed can help reduce several other risk factors including hypercholesterolemia hypertension and obesity. In people with arthritis, physical inactivity is more prevalent than in the general population, which potentially predisposes them to a higher relative risk (RR) of CHD (Philbin et al. 1995) It is therefore critical to develop effective prevention strategies, either high-risk or population based that will increase physical activity in people with arthritis in order to reduce the risk of developing CHD. CHD involves degenerative changes in the inner lining of the larger arteries that supply blood to the myocardium and as noted above is linked to the risk factor of physical inactivity (Fletcher et al. 1992). The American Heart Association (AHA) reports the relative risk of CHD associated with physical inactivity ranges from 1.5 35

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to 2.4 (American Heart A s sociation, 2005 p. 38) in the g e neral population which compares to the RR observed with smoking, hypertension and hyperlipidemia Macera Hootman and Sniezek (2003) report that population attributable risk estimates for physical inactivity and CHD have ranged from 23% to 46%" and that "if all sedentary individuals could achieve at least a moderate level of P A CHD events in the entire population would (theoretically) decrea s e by 35%" (p 123). Thompson et al (2003) note a graded relationship of decreasing CAD [coronary artery disease] with increasing levels of activity (p 311 0) Dunn et al. (1999) performed a randomized clinical trial to compare a lifestyle physical activity program and a structured exercise intervention in healthy sedentary adults. Adu lt s randomized to the lifestyle group were asked to perform 30 minutes of "moderate-intensity P A most days of the week in a way that matched their lifestyle. They were also instructed in behavioral interventions designed to help them maintain this level of P A for the remainder of the study ( 18 months). The structured exercise group initially participated in individualized exercise training 5 days per week and then became more autonomous with their activities. Motivational strategies were used with the exercise group to encourage continued participation over the next 18 months. Significant positive changes were noted in cardiorespiratory fitness blood pressure and percent body fat in both groups. The authors concluded that P A, as well as a structured exercise program can improve risk factors for coronary heart disease including hypertension obesity and a sedentary lifestyle. 36

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Wei et al. (1999) reported the need for clinicians to evaluate their clients regular P A levels. Their research was based on the Aerobics Center Longitudinal Study (ACLS). The y looked at the results of individual maximal graded exercise te s ts as an objecti v e marker for PA levels in normal-weight overweight and obese male subjects. Their findings demonstrated that excluding participant baseline cardiovascular disease health concerns such as diabetes elevated cholesterol levels hypertension current smoking and low cardiorespiratory fitness were comparable predictors of mortality in the over-weight and obese subjects Low cardiorespiratory fitness had a relative risk for cardiovascular disease and all-cause mortality comparable to or higher than the other predictors in this cohort. These significant findings suggest that P A can be used as a strategy to reduce the risk of the other predictors: i.e., cardiovascular disease diabetes hypertension high cholesterol levels and obesity. Sahyoun Hochberg Helmick Harris and Pamuk ( 1999) looked more specifically at the benefits ofPA in females who are obese in reducing the risk of developing osteoarthritis. Data were taken from the first National Health and Nutrition Examination Survey (NHANES 1971-1975) and the NHAN E S I Epidemiologic Follow-Up Study (1982-1984). The data analysis indicates that women who are overweight or obese ( > 25kg / m2 ) have a significantly higher risk of developing arthritis than women with a BMI between 19kg / m2 and 21.9kg / m2 As noted previously there is a higher prevalence of obesity in rural communities. This 37

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study also stated that obese women who lost weight were not a t higher risk of developing OA than women who had maintained normal-weight throughout the study The authors also reported that lower educational attainment was a predictor for arthritis even after controlling for weight, which might suggest the influence of other factors on the development of OA. According to the Tufts University Health and Nutrition Letter (2003), the reduced risk for OA with weight reduction may in part be due to the decreased pressure across weight-bearing joints. Each additional pound of body weight puts an additional three pounds of pressure across the knees and hips during level ambulation. Climbing stairs can increase this load to six pounds for each step indicating an additional 10 pounds of body weight can increase pressure on the hips and knees by sixty pounds Therefore, the health benefits of P A are strongly supported and can be applied to various populations Cardiorespiratory fitness, weight management, and the reduced risk of the effects of chronic disease are a few of the benefits of participating in regular P A. Environment and Physical Activity Research supports that the physical environment can influence the amount and type of activity. Brownson et al. (2000) report that previous cross-sectional studies demonstrate a relationship between environmental variables and P A behaviors Giles-Corti and Donovan (2002) found that "accessi ble recreational facilities 38

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determined use of those facilities and thus good access is necessary to create a supportive environment (p. 1809). Living with a chronic disease in a rural environment without access to recreational facilities may have a significant effect on the ability for an individual to be physically active. Humpel Owen, and Leslie (2002) reviewed 19 studies relating physical activity to perceived or actual environmental attributes. Outdoor environmental features positively associated with physical activity included access to cycle paths, a local park, and a park, beach, or shops in walking distance. Negative associations were noted with busy street crossings, steep hills residential neighborhoods and distance to a bikeway. Other associations related to facilities catering to exercise or physical activity interventions. Distance to and adequacy of facilities impacted the level of physical activity. Opportunities for activity in an individual's geographic area including local clubs were positively associated with physical activity. Weather was not found to significantly impact P A in the reviewed studies, but safe environments and pleasant aesthetics positively influenced PA It was not noted if rural communities were represented in these results. Addy et al. (2004) investigated perceived social and environmental facilitators for physical activity. Individuals living primarily in rural communities in a southeastern county in the United States indicated that good street lighting trust in their neighbors and the use of parks, sports fields playgrounds, and private recreational facilities promoted regular activity Wilson, Ainsworth and Bowles 39

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(2007) expanded these results through in v estigating the relationship between change in BMI and en v ironmental support for ph y sical activity. They conclude that "improving environmental supports for access and use of trails and recreational facilities may be important for future e n v ironmental interventions aimed at reducing obesity among inacti v e indi v iduals ( Wilson et al. 2007 p. 71 0). Brownson Chang et al. (2004) compared the reliability of three questionnaires that assess the social and physical enviromnental impact on P A. Using a survey test-retest methodology that was conducted by telephone interviews they determined that questions related to the physical environment demonstrated higher reliability than questions targeting the social environment. Participants from rural and urban environments were included. They supported the critical importance of physical activity in health outcomes and of note, suggested that some survey variables "may be largely irrelevant for rural environments One research priority is to identify environmental variables in rural settings that might be related to physical activity (Brownson Chang et al. 2004 p. 479). The environment can positively or negatively affect levels of physical activit y Discovery of environmental facilitators or barriers to physical activity within a community can direct interventions that will encourage appropriate le v els of P A Self-Efficacy and Physical A ctivity Self-efficacy is a concept that describes an individual s belief that he or she can perform or have control over a particular behavior. Bandura (1977) is credited 40

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with "the first theoretical treatment of his cognitive concept of self-efficacy (p 167). This concept is used as a construct in many theories of health behavior and can provide insight into an individual's health actions Self-efficacy can influence an individual s level of function Harrison (2004) used the Arthritis Self-Efficacy Scale (ASES) to assess multiple influences on function in women with knee osteoarthritis The ASES is divided into three subscales including a self-efficacy function scale (Lorig Chastain Ung, Shoor & Holman 1989). Her findings suggest that "functional self-efficacy is an important factor affecting the functional performance outcome for people with OA ofthe knee" (Harrison 2004, p. 822). Assessing an individual's self-efficacy in functional abilities such as their ability to walk 100 feet in 20 seconds on flat ground (Lorig et al. 1989) may be associated with their level of physical activity Sharma et al. (2003) used several outcome measures to investigate physical function over a three year period. Two of these tools included the ASES physical function subscale that measured self-efficacy and the Physical Activity Scale for the elderly (PASE) which determined levels of physical activity in 236 individuals with diagnosed knee OA. The relationship of self-efficacy and physical activity scores to a function score from the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was investigated. Two categories of WOMAC scores included participants with a good baseline to 3-year function outcome and participants with a poor baseline to 3-year function outcome. Results indicated that individuals who 41

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sustained high function over the 3-year time period had high levels of self-efficacy and a greater level of aerobic physical activity. The average age of the participants was 68.6 years, and the study took place in the Chicago area. Rural Health Individuals with Arthritis, and Physical Activity This section describes literature related to tying together the three components (rural, individuals of arthritis, PA) of the research question: What are the correlates of P A in individuals with arthritis in rural communities? Literature concerning P A levels of individuals with arthritis in rural communities is sparse There are no known studies specifically addressing the correlates of P A in people with arthritis living in rural communities More information is needed in order to effectively promote healthy living in this population Rosemann, KueWein, Laux and Szecsenyi (2007) examined factors associated with physical activity in individuals with hip or knee osteoarthritis. This multi-site research study included 1 ,021 men and women grouped by primary diagnosis of hip or knee OA based on which joint had the most severe symptoms Participants were recruited from 75 general practitioner sites in two states in Germany, and it was not stated if the sites were designated as rural or urban. Participants completed the Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF), the International Physical Activity Questionnaire (IP AQ), and the depression module of a patient health questionnaire. Results focused on relative levels of P A in people with knee OA 42

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versus persons with hip OA. Individuals with knee OA were significantly less physically active than those individuals with hip OA. The AIMS2-SF low e r extremity function social, and sym ptom (pain) subscales were the s tron ges t predictors of the dependent variable, PA in individu a ls with knee OA. Similarly lower extre mity function and symptom subscales were the strongest predictors of the dependent variable, PAin individuals with hip OA The authors suggested tailored interventions might be strengthened as a result of their findings. Wilcox Castro, King, Housemann and Brownson (2000) investigated determinants of leisure time P A in 40 years of age of diverse ethnic backgrounds living in rural or urban areas. Leisure time physical activity (L TPA) reflects activity not related to work physical activity and was measured using questions adapted from the BRFSS and National Health Information Survey (NHIS). Morbidity data was not reported including the diagnosis of arthritis. However 14. 8 % of urban and 17.5 % of rural women stated they were not in good health (p. 670) In addition nearly 25% of both groups reported physical limitations that were not further defined. Results suggested rural women were more likely to be categorized as more sedentary than their urban counterparts Careg iving duties were the most frequently cited barrier to increased leisure time phys ical activity by women in rural areas In contrast women in urban areas cited lack of time as the top barrier. In urban settings, participants noted a higher prevalence of sidewalks, str eet lights crime access to facilities and ability to observe others exercising than in rural areas. Rural 43

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participants reported a higher presence of unattended dogs. A higher BMI was also noted in women living in rural areas. Although not specified in this study, it could be assumed that a portion of the participants have arthritis since an estimated 21.6% of the population in the United States report doctor-diagnosed arthritis. Identifying co morbidities in tllis population would clarify additional impact on L TP A. Exercise behaviors in individuals with RA were identified by Iversen et al. (2004). The predictors of exercise patterns six months following a visit to the rheumatologist were determined by: a) whether the patient had participated in exercise previously, or b) the rheumatologist's exercise behavior. There were 132 individuals with RA who completed baseline questionnaire s to determine demographics pain level, physical function, mental health, self-efficacy and disease activity. Questionnaires included subsca les ofthe Medical Outcomes Study (MOS) SF-36 and Arthritis Impact Measurement Scale (AIMS) as well as Lorig s Self Efficacy Other Scale. The majority of participants with RA were female (79%), Caucasian (93%), college educated and earned $30,000 or more (55%) annually. The rheumatologists also completed questionnaires that related to their beliefs and attitudes on exercise management of individuals with RA. The authors noted that a physician's knowledge of current exercise guidelines for individuals with RA is lacking or inaccurate and influences their client's exercise participation. The authors acknowledged uncertainty as to applicability to other populations. Also, exercise as opposed to daily P A was the dependent variab le. Other influences of environment on 44

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exercise (social and / or physical) were not addressed The study did not specify if the clients were from a rural or urban setting. A qualitati v e study by Roberto and Reynolds (2001) investigated the effects of osteoporosis on women in a rural setting. The study was supported b y the concept that older adults in rural communities have age adjusted higher levels of most chronic conditions (National Center for Health Statistics and the US Senate Special Committee on Aging as cited in Roberto & Reynolds 2001) and that this may be due to fewer resources environmental concerns and lower socioeconomic status. Thirty percent of the women also reported arthritis. Through focus group discussions the authors identified five major themes through data analysis. One of these themes dealt with the changes the women needed to make in their daily activities. Women living on farms faced the challenges of continuing to do daily chores without risking a fall. Some reported reduced social interaction including babysitting grandchildren or avoiding sustained travel by car. It was suggested that isolation due to reduced ability to travel the distances required in rural communities for social interaction could increase stress greater than seen in women with osteoporosis in urban settings A major concern of the participants was loss of independence and ability to live within their current environment. Living in a rural environment increased the complexity of living with a chronic disease. These studies address components of the current research question What are the correlates ofPA in individuals with arthritis in rural communities? None of the 45

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studies specifically addressed all components ofthe research question: ph y sical activity arthritis and rural residence. Roseman et al. (2007) do not address rural or urban influences on P A and Wilcox et al. (2000) do not differentiate the effects of a disease state on P A in an older population. The stud y addressing indi v iduals with RA in v estigates specific factors related to P A as opposed to exercise or rural communities. Research by Roberto and Reynolds (2001) looks at the o v erall meaning of a chronic disease in women's lives specifically in rural communities. However osteoporosis has different precautions related to P A and influences functional abilities in a different manner. Therefore it is important to closely examine the determinants of PA in individuals with arthritis in rural communities to identify how to impro v e the functional ability and quality of life that can be adversely affected by these disabling disease processes. Community-Based Participatory Research The section describes the underlying principles and applications of community-based participatory research (CBPR) CBPR was used in this investigation to inform the research process. Community-based participatory research (CBPR) describes a process that strives to form a partnership between the community and the investigator in performing research relevant to the participating community. It is an ori e ntation to research (Minkler & Wallerstein 2003) typically based in traditions of critical interpretive or feminist theory (Frisby Crawford & Dorer 1997) and seeks to 46

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produce practical knowledge that is useful to people in e v eryday conduct of their lives (Bradbury & Reason 2003). CBPR has gained respectability and attention in the health field (Wallerstein & Duran 2003 p 28) and includes a public health goal "of eliminating disparitie s" (Wallerstein & Duran 2003 p. 29). Inherent in CBPR is the concept of" community. According to the Webster s New World College Dictionary (Agnes 2006) community is defined as : a) "all the people living in a particular district city etc ," and orb) a group of people forming a smaller social unit within a larger one and sharing common interests work identity location etc (p. 296). Israel Schulz Parker and Becker (1998) state Community is characterized by a sense of identification and emotional connection to other members common symbol systems shared values and norms mutual -although not necessarily equal-influence common interests, and commitment to meeting shared needs (p 178). An example of shared identification might include living in a rural community or living with arthritis. CBPR has evolved from a history of action research and participatory research processes Kurt Lewin developed the concept of "action research" (AR) in the 1940s (Minkler & Wallerstein 2003) and helped provide the foundation of what has been called the northern tradition of community-involved research (Wall e r s tein & Duran 2003 p. 28). This tradition works to bring stakeholders together to collaboratively solve problems as opposed to more traditional top down" approaches In the United States the northern approach allows inv ol v ement ofthe 47

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affected individual but is not necessarily focused on broader social change objectives (Minkler & Wallerstein 2003). On the other hand the Southern tradition ( Wallerstein & Duran, 2003 p. 28) of participatory action research (PAR) developed in the 1970s as emancipatory research to understand societal transformation and to work with communities subject to domination by an elite group such as that seen in underdeveloped communities in Latin America Asia, and Africa (Wallerstein & Duran 2003). Therefore AR and PAR lie on either end of a continuum from "problem solving to societal transformation (Wallerstein & Duran 2003 p. 29). Wallerstein & Duran (2003) state that CBPR contains elements of both traditions although the authors believe an "emancipatory perspective" (Southern tradition) more precisely incorporates the concept of eliminating health disparities. Ultimately CBPR can be envisioned as a practice of research that allows for collaboration between the community and researcher and that fosters shared goals. Israel et al. (1998) has defined key principles that describe the concept of CBPR. They are : a) recognizes community as a unit of identit y," (p. 178) b) "builds on strengths and resources within the community, (p. 178) c) facilitates collaborative partnerships in all phases of the research ," (p 178) 48

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d) integrates knowledge and action for mutual benefit of all partners ," (p 179) e) promotes a co-learning and empowering process that attends to social inequalitie s," (p. 179) f) involves a c y clical and iterative process ," (p 180) g) addresses health from both positive and ecological perspectives, (p 180) and h) disseminates findings and knowledge gained to all partners (p. 180). Although listed individually the authors acknowledge that these principles often overlap and may or may not all be integrated in any particular study depending on the type of study and participants involved Minkler and Wallerstein (2003) add to these principles of participatory research defined by Israel et al. (1998). They state we would underscore that CBPR principles should also include prominent attention to the centrality of issues of gender, race, class and culture as these interlock and influence every aspect ofthe research enterprise (Minkler & Wallerstein, 2003 p 6) This strengthens the aspect of empowering all individuals of a defined community and reduces the power imbalance critical to emancipatory research Cameron Hayes and Wren (2000) describe their approach to power in community-based participatory action research (CBPAR) as a power with approach (p. 215). These investigators used a CBPAR process itself based in principles of 49

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egalitarian power relationships (p 2 16) to reflect on the interactive practices between healthcare professionals community agencies clients and the management team of the Community Care Program in British Columbia Canada (Cameron et al. 2000) They concluded that the characteristics and principles of PAR were beneficial in guiding their research to promote health. Frisby et al. (1997) used PAR as an orientation to researching access to physical activity (PA) resources by women in Canada who have low income. Stating "participation in physical activity is heavily dependent upon financial resources and cultural capital (p. 9) the authors chose the advocacy participatory approach of PAR to view the effects of socioeconomic status on P A. They followed Green et al. s (1995) definition of participatory research: Participatory research is the systematic inquiry with the collaboration ofthose affected by the issue being studied for purposes of education and taking action or effecting social change" (p 4). The authors wanted diverse community members representing all aspects of the issues of physical activity in the community to be collectively involved in addressing this issue. Again the concept of equalizing power between the researched and the researcher" was paramount to this study. CBPR as an orientation to research can bring together the shared knowledge of community members and the researcher. Multiple perspectives skills and insights enrich the potential for a successful understanding of an issue Recognition of 50

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approaches to health promotion and collective decision-making in community-based areas of interest strengthens the potential for positive interventions. Theoretical Model The underlying theory for this research study is the Theory of Reasoned Action and Theory of Planned Behavior. The Theory of Reasoned Action (TRA) was developed by Martin Fishbein and introduced in 1967 (Glanz, Rimer & Lewis, 2002). The Theory ofPla1med Behavior was proposed as an extension ofthe original TRA by leek Ajzen in 1991. This model of health behavior frames the likelihood of making a change in behaviors at the individual level. The following section describes how this theory informed the research process. The Theory of Reasoned Action and the Theory of Planned Behavior provided the theoretical perspective for this investigation as illustrated in Figure 2 .1. The Theory of Reasoned Action (TRA) suggests that performance of a behavior, in this case physical activity is directly influenced by behavioral intention or the intent to perform physical activity (Glanz et al., 2002). In turn behavioral intention according to the TRA, can be determined by the attitude of the individual towards performing PA and the individual s subjective norm beliefs on whether most people approve of PA or not. Attitude towards performing PA is further influenced by their beliefs about outcomes and / or attributes when performing P A as well as an evaluation of the outcomes / attributes. Subjective norm is influenced by the referents opinions on performing PA and by their willingness or motivation to comply with the referents' 51

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opmwns. The Theory of Planned Behavior (TPB) is an extension of the TRA and adds a critical component to this investigation: the concept of percei ved control over the implementation of a behavior that can affect the beha v ioral intentions of the individual (Glanz eta!., 2002). There may be environmental factors perceived to be outside the control of the individual that challenge the ability of the person to perform the behavior. The influence of these environmental factors can be measured. Ajzen's concept of perceived control has been compared to the construct of self-efficacy as developed by Bandura (Glanz et al., 2002) Behavioral b eliefs Evaluation of behavioral outcomes Normative beliefs Motivation to comply Gonhol beliefs Perceived power Theory o f Reasoned Action and Theory of Planned Behavior Behavioral intention Behavior Figure 2.1 Theory of Reasoned Action and Theory of Planned Behavior 52

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These theories are useful in supporting methodological strategies that elicit individual and environmental considerations associated with an individual s P A behavior. Measurement scales are designed to link attitudes subjective norms and perceived behavioral control to behavioral intention and ultimately to behavior. Information obtained from analysis of the Physical Activity and Arthritis Questionnaire (PAAQ) used in this investigation addressed the three main constructs of the TRA and TPB to inform the research question What are the correlates of physical activity in individuals with arthritis in rural communities?" Additional constructs from two other instruments used in this survey relate to self-efficacy and the environment respectively and add insight into the impact of perceived behavioral control on performing P A Collette Godin Bradet and Gionet et al (1994) used the TRA to inform their research related to understanding intention to perform daily P A by individuals in a community. Three hundred fifty three participants were surveyed to determine intent to exercise. The survey was developed from responses to open ended questions that related to advantages and disadvantages of being physically active referents considered important to the participants with regards to being active and perceived barriers to physical activity. Respondents were grouped into high intenders and low intenders." A regression anal y sis identified four variables that explained over 52% ofthe variability in intention to perform physical activity. These variables in order of importance were current physical activity, age attitude toward P A and the 53

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individual s normative belief. Current physical activity level was measured using a seven day recall questionnaire. An intervention P A marketing program was developed incorporating the findings of this study The Theory of Planned Behavior informed a study by Vicki Conn (200 I). Dr. Conn interviewed 30 community-dwelling older women to determine behavioral beliefs perceived behavioral control and normative beliefs influencing their physical activity decisions. The participants were from small communities and rural areas in the Midwest. Qualitative analysis revealed three main themes: social influences on physical activity psychosocial benefits of activity and joint problems and fatigue as factors that interfere with activity" (p 3 70). Results indicated "a health promotion program instituted in naturally occurring social groups .. could be more effective than programs that attempt to attract individual women and emphasize the health benefits of physical activity (p 376). These results were compared to previously published data retrieved from interviews with women with similar demographics involved in episodic exercise. The women performing episodic exercise viewed exercise as something separate from their daily lives and not a part of their social activities Dr. Conn suggested a social model might be more influential in the incorporated P A model than with episodic exercise. She also concluded that joint pain and fatigue often associated with arthritis would need to be incorporated into any intervention to be effective in promoting P A in populations comprised of older women. 54

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The TRA and the TPB have recently been used to examine adherence to exercise by individuals with RA following a clinical visit to a rheumatologist (Iversen et al. 2004). Use of"an expectancy-value questionnaire (p 710) elicited response from patients regarding their beliefs in outcomes for exercise interventions Expectancy-value conceptualized the attitudes forming expectations related to attributes of the action (exercise) and the value associated with that action. A model was developed to identify potential relationships between patients or rheumatologists and exercise interventions based on the TRA and TPB. The PRECEDE model provides a framework that incorporates concepts of the TRA and TPB. Glanz et al. (2002) illustrate incorporation of the TRA/TPB during Steps 3 and 4 of the PRECEDE Planning Phases Step 3 the behavioral and environmental assessment phase emphasizes determining the factors contributing to the health issue under investigation (Green & Kreuter as cited in Glanz et al. 2002) in this case physical activity in individuals with arthritis Behavioral aspects according to the TRA/TPB relate to factors over which the individual has control. Environmental factors that influence behavior are considered external to the individual. An example relevant to P A that demonstrates external factors would be safety concerns with walking on uneven surfaces or lack of sufficient lighting. The emphasis is on the relationship between individuals and their environment. Step 4 focuses on an educational and ecological assessment (Glanz et al., 2002). It determines if there are support structures available to handle behavioral and 55

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environmental factors identified in Step 3. The components to address during this step include predisposing reinforcing and enabling factors (Green & Kreuter as cited in Glanz et al. 2002). An asses s ment is carried out to see if s trategies or resources exist to address or support predisposing factors such as an individual's knowledge or beliefs about PA reinforcing factors such as social support or networks, and enabling factors such as services required to enhance P A in the environment. Self-efficacy would also be considered a predisposing factor that could influence P A behaviors. The PRECEDE Model also supports the concept of Community-Based Participatory Research that is a key component of the methodology. The first step in the model, social assessment allows for expanding knowledge of a defined community through focus groups interviews questionnaires and direct observation (Glanz et al. 2002). It allows the community to have a voice into perceived needs and goals Step two can involve the community in defining which health issue to address and allows an epidemiologic assessment. The final step of the PRECEDE pathway assesses the policy and administration within the population to help determine facilitators or barriers to change at this level. The concept of Community Based Participatory Research is supported at these three assessment steps. 56

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CHAPTER3 METHODS Research Design A cross-sectional survey informed by a rural advisory committee generated data for the investigation of correlates of physical activity (PA) in people with arthritis in rural communities. Individuals with a diagnosis of osteoarthritis in rural east or northeast Colorado were invited to participate in the survey which consisted of six self-administered questionnaires. The overarching goal was to identify barriers to and facilitators of P A in order to determine what strategies if any are needed to improve PA functional ability, and quality of life in people with arthritis in these rural communities. A community advisory committee informed the design methods, analysis and dissemination. The study included focused meetings with the Rural Arthritis Committee (RAC) members and pictorial documentation of their respective communities as well as a broader quantitative survey including multiple instruments that served to identify the factors associated with P A in individuals living with arthritis in these communities. Use of a community advisory board representing the rural areas of study pictorial evidence documenting correlates to PA in people with arthritis and quantitative instruments addressing aspects of living with arthritis, the 57

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environment, and physical activity approached the research question from multiple perspectives in order to strengthen the findings. Setting Ten counties in east and northeast Colorado were chosen as potential sites for this study These counties are historically grouped into two Planning and Management Regions (PMR) PMR 1 and PMR 5 for reporting BRFSS data and therefore allowed comparisons between the current survey data and previously recorded BRFSS data. PMR 1 included Logan, Morgan, Phillips Sedgwick Washington, and Yuma counties. Cheyenne, Elbert Kit Carson and Lincoln counties comprised PMR 5. Planning and Management Regions were developed in 1977 to combine data from several counties with small populations in rural Colorado, which would increase reliable estimates of data from these rural areas (Colorado Health Information Dataset n d .). The ten counties were also considered for this study because they are geographically bound are identified as micropolitan statistical areas or non-core areas according to the classification scheme of the Office of Management and Budget (Office of Management and Budget 2003) and because nine out often of these counties are part of the High Plains Research Network (HPRN). The HPRN is a rural research network organized in northeast Colorado in 1997 that is part of the Department of Family Medicine at the Anschutz Medical Campus of the University of Colorado Denver and includes members living in these rural communities. The 58

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HPRN's mission is to provide excellent rural health care by translating the best scientific evidence into every-da y clinical practice (Colorado Con v ocation 2003). The counti es tar g eted for this s tudy included Logan Sedgwick Phillips, Morgan Yuma Kit Carson Lincoln E lbert Washington and Che y enne counties and are dis played in Figure 3.1. According to the Colorado Rural Health Council (2007) eight of the targeted counties are designated as Health Professional Shortage Areas, one is listed as a Medically Underserved County and one is listed as No Underservice Designation meaning the county has not applied for a designation These federal designations help identify areas with a severe need for health care professionals and / or health care delivery (U.S Department of Health and Human Services 1976 1993). 59

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MOFFAT LARIMER MONTEZUMA ARCHULETA Figure 3 1 Colorado Counties Participants SEDGWICK LOGAN PHI L UPS MORGAN YUMA WASHINGTON KIT CARSON CHEl'ENNE KIOWA BENT PROWERS LAS ANIMAS This research study involved two identified groups of individuals : 1) Rural Arthritis Committee (RAC) -El even individua l s who volunteered to serve as part of a rural community advisory board for this project 2) Survey Group -The survey group initially consisted of 177 individuals with arthritis who returned the packet of six questionnaires Adjustments to this group size following initial review of the returned survey are discussed in the Survey Return section. 60

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Rural A rthriti s C ommittee (RAC ) r e cruitm e nt Recruitment of a rural advisory committee was a critical component of the goal to understand the barriers and facilitators to physical activity by persons with arthritis in rural communities. This committee ser v ed to guide and direct the progression ofthe project and increase relevance to and acceptance by the communities. Initial inclusion criteria for individuals serving as part of the RAC were a) individuals living in a micropolitan or non-core county (as defined by the OMB) in east and northeast Colorado who are affected by OA are associated with someone with OA or who provide health care to individuals with OA; b) individuals who speak and understand English; c) individuals who are 45 years of age or older ; d) individuals who can attend meetings at locations designated by the RAC members. The exclusion criterion for the RAC participants was inability to comprehend and discuss the proposed research topic. Voluntary participation in this project was verbally assured by the investigator as well as listed on the Informed Consent Form as a criterion for their participation (see Appendix A) A committee of eleven individuals representing four counties in east and northeast Colorado was recruited to support the multiple phases ofthis research project by members ofthe High Plains Research Network (HPRN) Community Advisory Council (CAC) and the principal investigator (PI) Recruitment for the RAC began in May of2005. The PI attended a meeting ofthe HPRN Community Advisory Council (CAC) to describe the focus of the project and ask for interested individuals 61

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to contact the Pl. The CAC was formed in 1997 to address health care issues specific to the concerns identified by the council members in east and northeast Colorado and consists of individuals who live in the rural counties of east and northeast Colorado. Three members of the CAC contacted the PI approximately one month after the meeting to volunteer to participate in the project which included recruiting additional Rural Arthritis Committee (RAC) members from their counties Two additional CAC members unable to personally serve on the committee agreed to assist with recruiting members from the designated rural communities. Volunteer members were told the project would begin following the presentation and acceptance of the proposal by the PI's graduate school committee and that she would keep them informed. Members of the CAC recruited additional potential committee members, and meetings or telephone calls occurred between the PI and these individuals in February and March of 2006. Interest and availability to serve with the Rural Arthritis Committee was determined. Over the next two months eight additional community members were recruited as members of the RAC. Four members were recruited in person by the PI and a confirmed RAC member in the individual s home town. Three additional members were recruited through telephone conversations with the researcher and one member was recruited by the confim1ed RAC member alone. 62

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Descriptions of the project research question as well as four key points were discussed with each of the potential RAC members. These key" points were: a) Arthritis is the leading cause of disability in the United States, b) The right kind of physical activity can reduce the risk of chronic disease and improve function in persons with arthritis, c) We don't currently know how much or the types of physical activity people get in rural communities in Northeast Colorado, and d) Rural communities may lack resources that help persons with arthritis be active. Time and travel commitments were also discussed with potential RAC members and they were informed there would be three committee meetings over the next 12 to 15 months Mileage reimbursement would be available following each committee meeting and a $50 community gift card would be presented to each RAC member following completion of the RAC meetings Potential committee members were asked to provide feedback on the proposed project. One individual commented that there was nothing in their community for people with arthritis. They felt that bringing attention to the problem of arthritis would be good, even if it was a way to start support groups. They also felt that many other things go with arthritis, including depression, and that specialists in arthritis came to their region infrequently Another individual wanted to be involved in the project to help people in the community They recognized some barriers to access for 63

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people with arthritis in their community, such as stairs instead of ramps and stated people would often take the stairs even if a ramp were available, so they didn t look disabled. Individuals willing to serve as RAC members gave verbal consent to participate and recruitment ended when the target number of eight to twelve persons was attained. Written informed consent was mailed to willing members and collected at the first RAC meeting. Six individuals rejected the invitation to take part in the community meetings and research project prior to completion of subject recruitment. These individuals cited transportation barriers (reported by non-health care providers in the community) time restrictions (reported by physical therapists in the community), or lack of familiarity with the community (reported by non-health care providers in the community) as rationale for not participating in the community group meetings. Eleven rural community members comprised the original RAC and lived in one of five communities in a total of 4 of the target counties. Table 3.1 displays general demographics of the RAC. 64

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Table 3.1 Demograf!.hics of. Rural Members of. the Rural Arthritis Committee by County County n Gender Age Years in Occupation Arthritis? (N = 11) communityb (yes/no) Logan 2 M 62 45 Retired Yes F 66 51 Retired No Yuma 4 F 80 45 Retired Yes F 76 76 Retired No F 70 70 Retired Yes F 76 75 Retired Yes Phillips .., M 34 2 5 HCP No .) F 59 22.5 Retired Yes F 75 44 Retired Yes Lincoln 2 F 65 35 Retired Yes F a 30 Education No Note. HCP=health care provider a Age was not reported b Average years in community= 45.1 years; average years in community excluding HCP = 49.4 As noted in the demographjcs an exception was made to the inclusion criteria for one participant. This individual did not meet the age or length of residency inclusion criteria. However this individual represented a health care provider's (HCP's) perspective to the project which is considered to be critical in understanding implications for physical activity in the large patient population presenting with osteoarthritis. This individual's willingness to participate amongst the often severe 65

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time restrictions experienced by HCPs serv ing rural communities justified the exception made to the inclusion criteria for this study. The average age including this participant was 66.3 years and excluding this participant was 69.9 years Survey group recruitment Survey group recruitment occurred over a period of 15 months and involved the RAC members including the principal investigator (PI). Several modes were used to "anno unce the project to the community and deli ver surveys to interested parties. The research project was introduced to several communities represented by the committee members through short newspaper articles. A draft of the article was written by the PI and circulated to the RAC members via email or mail for suggestions and edits. The RAC members identified the local newspapers to approach for publication and these were contacted by the PI. A total of four articles were published without cost as editorials or short articles by local newspapers These articles served to alert the community regarding the arthritis project and the involvement of local community members. The PI contact information was provided to answer questions related to the project. Subject recruitment for the six-questionnaire survey used multiple points of contact that involved all members of the RAC, including the PI. Adult male and female rural community members with self-reported physician diagnosed osteoarthritis who met the inclusion criteria were invited to participate in completion of the survey. RAC members implicitly asked Who knows a lot about [living with 66

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arthritis in rural communities]? Whom should I talk to" to identify participantscritical questions asked according to Patton (2002) during snowball sampling. According to Babbie (200 1 ), snowball sampling collects data on the few members of the target population he or she can locate, then asks those individuals to provide the infonnation needed to locate other members of that population whom they happen to know" (p. 180). Answers to these questions led to recruitment of participants as well as other key informants who could assist with survey distribution. Recruiting techniques involved networking noted in snowball sampling. Individual RAC members identified the number of surveys they could distribute to individuals in the community. RAC and CAC members forwarded potential key informant names to the PI and follow up calls and meetings were scheduled by the Pl. These key informants were creative in and critical to survey distribution. For example, one community informant and family member used the $10 gift card incentive as a fundraiser for a local club. RAC members used this model to recruit additional participants who met the inclusion criteria from community groups. This stimulated widespread interest in survey completion. RAC members also identified community organizations they believed would be interested in the project topic. Table 3.2 summarizes the organizations recommended for contact with the initial date of contact. 67

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Table 3.2 Summary of Communi ty Organizations Contac ted by Prin cipa l Inve s tigat o r Organization Initial Contact Date PT clinic 11/ 06 Seniors' Workshop 2 / 07 PT clinic 2 / 07 Senior Expo 3 / 07 Young Farmers Group 4 / 07 Senior Residence Apartments 4 / 07 Meet and Eat northeast 4 / 07 Meet and Eat east 4 / 07 Lions Club Logan County 4 / 07 Lions Club-Sedgwick County 5 107 Woman's Club 11/ 07 The PI visited organizations to distribute survey packets to interested individuals and answer questions regarding the project. In addition the PI offered informational sessions on arthritis if requested by the organization. Sessions were generally scheduled after the return of survey packets to avoid knowledge bias in completing the questionnaires. Survey packets were distributed in person at the time of contact or delivered by mail if requested by the participant. Flyers with investigation information and 68

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contact numbers (phone, mail, or email) were available for community postings in healthcare and other facilities in the designated counties. Individuals with osteoarthritis (OA) could obtain a flyer during their clinical visit and contact the PI if interested in participating Inclusion and exclusion criteria were defined and placed on the outside of each survey packet to assist in accurate self-selection to participate in this study. Inclusion criteria for the survey group included: a) individuals living in a micropolitan or non-core county (OMB, 2003) in Northeast Colorado who are affected by OA b) individuals who speak and understand English, c) individuals who are 45 years of age or older, d) individuals who are ambulatory with or without an assistive device. Exclusion criteria for the survey participants were a) individuals who are unable to comprehend the measurement instruments b) individuals with acute medical conditions restricting their P A level, c) individuals who require another person to assist with arnbulation. Procedures There were three primary components to this research study: 1) A Physical Activity and Arthritis Questionnaire (P AAQ) drafted and piloted by the PI followed by enrichment and finalization by the RAC, 2) Three Rural Arthritis Committee meetings to inform the processes associated with the investigation 3) One hundred and seventy-seven individuals voluntarily completing a survey composed of six questionnaires to inform the quantitative portion of this study. The University of 69

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Colorado at Denver Human Subjects Research Committee reviewed and approved all materials and contact with human subjects prior to the start of this study (see Appendix A). Annual human subjects renewal criteria were provided and approved throughout the data collection process. Voluntary informed consent was obtained for all individuals participating in any component of this investigation. Pilot Survey A pilot questionnaire titled the Physical Activity and Arthritis Questionnaire (P AAQ) was developed and piloted by the PI to assess four constructs defined by the Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB) (Glanz et al. 2002). These constructs include Behavioral Intention ," Attitude," Subjective Norm ," and Perceived Behavioral Control" (Glanz et al. 2002) The PI developed each statement based on the construct definitions identified in the book by Glanz et al. (2002). The first draft of the pilot questionnaire included 28 statements designed to identify the individual's beliefs about factors influencing arthritis and their ability to be physically active. A Likert scale ranging from "Strongly Agree" to Strongly Disagree" was used and most statements were positively or negatively slanted. The questionnaire was piloted by the PI in rural Colorado communities in four counties adjacent to those identified for the primary research project as well as given to members ofthe Rural Arthritis Committee (RAC). Key community members living or working in one of these four counties were contacted by the coordinating researcher to discuss forums for distribution of the pilot questionnaire. These key 70

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members identifi e d health care facilities s e nior living re s idencies Lion s Clubs or other organi z ed meetings and pri v ate community residents they felt would participate in the pilot survey. The PI followed up w ith contact information from the key community members as well as with members of the RAC. Surveys were distributed following consent (see Appendix A) to individuals receiving physical therapy at a clinic, members of a Lions Club residents in a skilled nursing facility attendees at senior meetings and individuals in private residencies. Survey distribution took place between February 21, 2006 and June 23, 2006. A total of 27 surveys were distributed to and completed by individuals living in Arapahoe Adams Douglas or Weld County In addition three RAC members completed and returned the survey Feedback on format wording general survey themes and survey meaning were verbally solicited from pilot survey participants The PAAQ was piloted in adjacent rural communities to achieve three primary goals. First it was important that the survey was readable and understandable by community members Feedback on grammar and terminology was solicited. Also it was essential to determine if the P AAQ appeared to seek meaningful information to the community. Finally, piloting the questionnaire gave a time range for completion of the questionnaire which was estimated at five minutes. Analysis of the PAAQ started in July 2006. Items initially identified by the PI that related to each of the four TRA / TPB constructs were analyzed to determine if the 71

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identified it e ms formed a reliable scale. To evaluate the items comprising each construct scale, Cronbach's coefficient alpha was computed. Principal components analysis (PCA) was not performed due to challenges with multicollinearit y According to Tabachnick and Fiddell's text (2001) it is acceptable to have this problem when doing PCA for descriptive reasons. Based on reliability analysis for each construct items were deleted in order to represent constructs with the fewest number of variables (Leech, Barrett & Morgan, 2005) and to improve consistency of items in a scale. Analysis resulted in reducing the number of questionnaire items from 28 to 18. Individual items were categorized into three of the four original constructs as noted in Table 3.3 One construct Behavioral Intention, was eliminated as a result of lack of reliability amongst items believed to be related to the construct. However according to the TRA/TPB model, this construct is determined by the remaining three constructs: Attitude ," Subjective Norm ," and Perceived Behavioral Control" (Glanz et al., 2002, p. 69) and would be represented by values associated with these three concepts 72

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Tabl e 3 3 Sc al e R e liabili ty for Physi ca l Act iv i ty and Arthriti s Q ues ti o nnair e It e ms, n = 30 Con s truct Item Number Cronbach s Alpha Attitude Subjective Norm Percei v ed Behavioral Control N ot e rv = reversed Item06 Item11r v Item16r v Item18r v Item03 Item OS ItemlO Item19 Item20 Item02rv Item04rv ltem08 Item12 Item14rv ltem17rv 722 638 .700 The RAC was presented with the revised pilot questionnaire for recommendations and final approval during the second RAC meeting on August 11, 2006 ( see Procedures-Rural Arthritis Committee Meetin g s ) The mean score on each of the remaining 18 items was presented and the RAC discussed these finding s One indi v idual wa s surprised that the majority of the pilot survey participants agreed or strongly agreed with the statement I believe being more active is up to 73

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me. As a result of this discussion two statements were added that the RAC felt were important and not represented in the current form. One statement, "Arthritis is a normal part of aging and can t be helped by being more active" was suggested by a member who consistently heard this reported by individuals seeking health care. I have friends or family available to do activities with me such as going for a walk" was suggested to determine if this resource was available as implied by other P AAQ questions The RAC also recommended and approved addition of a "not applicable" (N / A) column. Other changes involved reordering of items to assist with the "flow," personalizing all items by including terms such as "my physical environment" rather than "the physical environment, and clarification of the instructions for survey completion Final approval was unanimously given to include this final version of the PAAQ into the research survey. Rural Arthritis Committee (RAC) Meetings RA C Meeting # 1 Development of the RA C project a group process The Rural Arthritis Committee first met on March 31, 2006, to begin to examine understand and shape the group project which would look at facilitators and barriers to physical activity in people with arthritis in rural communities of east and northeast Colorado. This was the first time many of these individuals had met; they only knew they shared a common interest. Five communities with populations from 982 to 11,360 (U .S. Census Bureau, 2000) and situated in four counties were 74

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represented by the RAC. Members drove from 27 miles to 120 miles one way to attend the meeting at a "central location. One week prior to the first meeting an introductory letter with several enclosures was mailed to each member of the committee (see Appendix B). Enclosures included an agenda (see Appendix B) a copy of the pilot survey draft (see Appendix C) with a consent form (see Appendix A), a RAC consent form (see Appendix A), and a sample flyer (see Appendix B). Instructions to help prepare for this initial meeting and directions to the site were included. The first meeting was organized to allow participants a chance to meet, turn in their written informed consent, develop an understanding of the project be introduced to the concept and process of community-based participatory research and offer insight into the direction and start of activities for this project. The group consented to tape-recorded sessions for accurate content recall. Each individual introduced himself or herself and how long they had lived in their community. The PI identified basic principles of CBPR and offered a short Power Point presentation that overviewed the key tenets of the project including arthritis physical activity and rural communities. The group then discussed the pilot survey which had been sent to them in advance. Results of this discussion are presented in the section titled Pilot Survey." Important modifications were made to the final version of this survey (see Appendix C). 75

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RAC members were also given the option of using a disposable digital camera to document barriers and facilitators to physical activity for people living with arthritis in their communities. All committee members were interested in taking community pictures. The procedure for obtaining informed consent from individuals in pictures was explained. Copies of this informed consent were given to the RAC members with instructions to call the PI with any questions. The PI was responsible for collecting the cameras as members completed the task and for developing the pictures. Several additional topic areas were introduced by the PI and discussed by the RAC. Questions opened up for discussion included a) How can we proceed with survey distribution? b) What additional questions can we ask to help inform our research question? c) Would newspaper articles be valuable in promoting the project and survey distribution? d) Are there community contacts that would be important resources for this project? Members brainstormed responses during lunch and volunteered to continue looking at options to move forward with recruitment following the meeting. Recruitment resources, key community contacts, other modes of distribution, and marketing 76

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strategies were to be funneled to the PI via email and phone conversations for PI follow up. The first meeting ended on schedule after three hours and plans were discussed for the next meeting. Although the location was a two hour drive for two of the participants the group agreed this was the most central location for all members Topics for the next meeting to be held at the end of the summer were discussed. RAC Meeting # 2 Photovoice &finali z ation of the survey for distribution The second RAC meeting was held on August 11,2006. Ten ofthe eleven original RAC members were in attendance and one member was unable to attend due to work commitments. However a community member from the same area agreed to attend the meeting in her place. Following introductions the meeting started with an activity. Members were given copies of the pictures they had taken of their communities This activity allowed a photographer to voice their opinions on the research topic and is referred to as Photovoice. They were provided with poster boards adhesive putty and markers with instructions to display the photos for a presentation to the rest of the committee Members chose to work individually or in pairs (if they were from the same community) The activity took approximately 45 minutes to complete prior to the pr e sentations. 77

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According to Wang and Burris (1997) Photovoice can be used to 1) enable people to record and reflect their community s strengths and concerns ," 2) promote critical dialogue and knowledge about important issues through large and small group discussion of photographs ," and 3) to re a ch policymakers (p. 3 70) In this investigation it enhanced the strategies of CBPR by allowing individuals to provide "proof' of daily encounters that enhance or prevent ph y sical activity Photo documentation facilitated community discussion around identified correlates of P A in their community for individuals with arthritis as well as provided a resource for community change. All members participated in the verbal presentation of their posters. Pictures were representative of both facilitators and barriers to physical activity in their communities and all members appeared attentive during the presentations. Examples of pictures representing facilitation of physical activity by people with arthritis included door handles that were easy to use wheelchair ramps, electric doors for entering buildings a therapeutic pool and a local physical therapy gym. Examples of pictures representing challenges to physical activity by people with arthritis included uneven or missing sidewalks tractors difficult to mount flights of stairs to enter buildings and gates to open and enter for ranchers. Members discussed what each picture represented and the group had time to ask questions This activity culminated in a diagrammatic summary produced at the meeting by the PI of the areas that would be addressed by the survey including the relationships of environment self-efficacy, 78

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arthritis impact and beliefs about phy s ical activity to the amount of time spent performing physical activity This diagram helped clarify the overall project for the committee members. The second half of the meeting in v olved finalization of the sur v e y and discussion of survey implementation. The new draft of the pilot survey based on all previous feedback was presented and results of each item reviewed RAC members reviewed mean value scores on items of interest and discussed what the values indicated. Final changes to the pilot survey were suggested and approved by the committee. Also, a questionnaire to capture information recommended by the RAC was finalized and approved by the committee (see Appendix C). This questionnaire would ask open-ended questions that could allow survey participants a chance to voice any other comments related to the research question Cover sheets were added to all questionnaires as recommended by the RAC to clarify instructions and identify completion times Survey implementation strategies were discussed by all members. The PI would gather survey distribution recornn1endations from the community members and arrange for follow up Communication would occur through email phone or mail to develop new points of contact for this phase and the next and final meeting for this project would be scheduled to discuss findings of the survey and identify dissemination pathwa y s 79

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RAC Meeting # 3 Results and Discussion The final RAC meeting was held on September 7 2007 and took place in the same location as previous meetings. Six members, including the PI, attended the meeting. One individual discontinued involvement in the RAC following relocation to a different geographical area outside of the research study boundaries. A RAC member from the same community was unable to continue after this point since they no longer had transportation to the meeting. School-year commitments prevented three additional members from attending the meeting, and the health care provider developed scheduling conflicts. However, the attending members contributed excellent insight into the ensuing discussions on data collection, preliminary results, community outcomes, and future directions. Outcomes from this meeting are discu sse d in the Results section. Quantitative Procedures Survey data collection occurred over a period of 15 months. Questionnaires were used to collect sociodemographic, arthritis impact, physical activity, self efficacy, general health, and environmental data. The six instruments used to collect this data were the Arthritis Impact Measure Scales 2 (AIMS2), physical activity questions from the Behavioral Risk Factor Surveillance System (BRFSS) combined with work -r elated PA questions from the Occupational Physical Activity Questionnaire (OPAQ), 80

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the Arthritis Self-Efficacy Scale (ASES) the Environmental Supports for Physical Activity Long Questionnaire (ESPALQ) the Physical Activity and Arthritis Questionnaire (P AAQ) and a final questionnaire that included open-ended questions. Individuals identified through the recruitment process and who voluntarily consented to participate completed the survey information. Likert -t ype scales dichotomous or multiple-choice answer single response items, and written reported time increments (for the physical activity component) were used to obtain data. Four open-ended questions were included in the final questionnaire to allow comments on focused areas of the study. Surveys were distributed in person or by mail. Each survey packet contained an informational letter with the PI contact information six questionnaires a pre addressed stamped envelope for survey return, and a postcard to return for a $10 gift certificate. All included items were approved by the Human Subjects in Research Committee at the University of Colorado Denver. Returned surveys indicated the participant's consent to participate Several logistics were considered in survey packaging. Individual participants did not need to provide any identifying information on the survey instrument. All questionnaires were numerically coded. Questionnaires were placed in a random order into the survey packets to reduce the risk of order bias with the exception of the 81

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final questionnaire which was placed last in each packet. The final questionnaire allowed individuals a chance to include any other comments related to the research topic that they felt had not been previously addressed. Total completion time for the survey was estimated at 45 to 60 minutes. In order to maintain confidentiality of the surveys and yet compensate with the $10 gift certificate a pre-addressed stamped postcard was included in each packet with instructions. The participant was instructed to return the postcard separately with a mailing address for the gift card. The postcards were coded with the survey packet number so that they could be matched by the PI upon return of each item. However the survey packet could remain de-identified and only the PI would be able to link the postcard information with the survey packet. Gift certificates were purchased from the community associated with the participant's residence. Sources for the gift certificates or cards were identified by RAC members individuals who completed the survey, other key informants involved in recruiting participants or the organization hosting the survey distribution. The goal was to support the participating communities by purchasing local gift incentives that would be spent in the same communities. Gift certificates were purchased from local diners, drugstores, and grocery stores. In addition gift cards from Walmart were purchased at the local store division as requested by many community members within a 50 mile radius of this store. 82

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Measures The following instruments were used to collect data on individuals with arthritis in rural east and northeast Colorado. Physical Activity Two measurement tools were used to determine current levels of physical activity in participating individuals with arthritis in rural communities in east and northeast Colorado (see Appendix C). Non-work-related physical activity was measured using the physical activity questions from the 2003 BRFSS (Centers for Disease Control and Prevention, 2003). Work-related physical activity was measured using the Occupational Physical Activity Questionnaire (OP AQ) for individuals who were employed. The OP AQ follows a similar question format as the BRFSS. The BRFSS was originally developed to collect data at the state level but has also been used to estimate prevalence for regions within a state. There are seven questions that relate to physical activity. One question differentiates the type of physical activity performed at work and the remaining questions identify the amount of non-work-related PA performed by an individual each week This "leisure time" PAis categorized into moderate and vigorous physical activity. Nominal variables and recorded time intervals are used to collect data. Use of this survey allowed comparison of collected county data to Colorado state data. The BRFSS has been used as a telephone survey that randomly incorporates all ages, including the age range for this investigation (2: 45 years old with no upper 83

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limit). Kirtland et al. (2003) used the 2001 physical activity modules to assess physical activity levels when investigating social and environmental effects on P A. Fontaine, Heo and Bathon (2004) analyzed data from the 2001 BRFSS to classify individuals with arthritis by level of activity. It is currently being used in a project funded by the Centers for Disease Control and Prevention in San Diego (J. Hootman, personal communication August 11, 2005). Reliability and validity of the BRFSS P A data have been studied. Validity of the adult BRFSS physical activity data is reported as acceptable, or relative advantage" by Glasgow et al. (2005). According to the same report, reliability is "unreported or not studied." Nelson Holtzman Bolen, Stanwyck, and Mack (200 1) provided a comprehensive review and summary of more than 200 studies analyzing measures on the BRFSS Data related to intense leisure-time physical activity had moderate reliability and validity A comparison of data from the National Health Interview Survey and the BRFSS by Nelson, Powell-Griner Town, and Kovar (2003) concluded that BRFSS data results were comparable to NHIS data and could be used to guide national policy development. The current study required self-completion of the BRFSS survey as opposed to the traditional telephone completion employed with historical BRFSS distribution. Link Battaglia, Frankel Osborn and Mokdad (2005) at the Centers for Disease Control and Prevention have done preliminary work to examine the data quality obtained from random digit dialing (RDD) survey distribution and completion versus 84

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the United States Postal Service (USPS) Delivery Sequence File (DSF). The DSF contains all addresses used by the USPS and is updated every two months (Delivery sequence file (DSF), n.d.). This pilot survey randomly sampled 1 680 addresses per state. Eight items were compared including frequencies of asthma, diabetes high blood pressure obesity current smoker, binge drinking tested for HIV and HIV risk behaviors. The mailed survey results from March-May 2005 were compared to monthly RDD survey results from the same time period. The authors concluded that weighted estimates for five of the eight items included in the survey were similar and that higher reports were received in the mail on sensitive behaviors The authors suggested that reduced response rates noted in RDD surveys might be improved with DSF sampling. Individuals with cell phones can be reached with DSF sampling Further pilot research to compare modes of BRFSS distribution is planned Directions for completion of the BRFSS physical activity questions were slightly modified to help clarify examples of moderate and vigorous non-work-related P A in the rural settings. "Fishing" and home repair" were added as examples of moderate activity based on comparable MET levels of activities that might be more meaningful in a rural environment (B. E. Ainsworth, 2002). Similarly shoveling heavy snow" was added to the examples of vigorous physical activity based on MET levels ofPA (B. E. Ainsworth, 2002) comparable to BRFSS examples. 85

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The Occupational Physical Activity Questionnaire (OPAQ) was used to assess weekly levels and amount of work-related physical activity This measure was developed to identify the average time per week spent in occupational sitting or standing, walking, and heavy labor activities" (Reis, Dubose Ainsworth, Macera & Yore 2005, p. 2076) Seven questions identify time spent at work per week and how many hours if any the individual spends in sit or stand activity walking, and or heavy labor each week. The OPAQ test-retest reliability coefficients for hours ranged from an ICC of0.55 to 0.91. Fa ir to substantia l criterion validity was noted when comparing OP AQ constructs to detailed P A records of like activities. Convergent validity displaying the ability of the OPAQ to correctly identify participants who performed mostly sitting or standing, mostly walking, or mostly heavy labor at work was substantia l [kappa= 0.71 (95% CI = 0.49 0.94)]" (Reis eta!. 2005, p. 2075). These va lues are comparable to other surveys that measure P A. The questionnaire format is similar to the BRFSS physical activity questions and the BRFSS and OP AQ questions were asked consecutively in one questionnaire packet. It took approximately 5-l 0 minutes to complete this questionnaire. Physical Activity and Arthritis An individual's intent to perform PA was assessed using the Physical Activity and Arthritis Questionnaire (P AAQ). The development and piloting of this survey was previously described The Theory of Reasoned Action/Theory of Planned Behavior is the theoretical foundation for this questionnaire. This tool was used to 86

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ascertain the individual's attitudes subjective norms and perceived behavioral control pertaining to P A and its relationship to their arthritis A total of 20 statements were rated on a Likert type scale from "strongly agree to "strongly disagree A not applicable response was also available as recommended by the Rural Advisory Committee The P AAQ required approximately 3-5 minutes to complete A principal axis factor analysis was perfom1ed using 119 surveys to identify items associated with the three main constructs : attitude subjective norm, and perceived behavioral control. Factor ana lysis is appropriate to use when it is believed that latent variab l es or constructs underlie the measured items (Leech eta!., 2005). Principal axis factor analysis with varimax rotation was conducted to assess the underlying structure for the 20 items of the P AAQ. Three factors were requested based on the Theory of Reasoned Action/Theory of Planned Behavior constructs of attitude perceived behaviora l contro l and subjective nom1 as previously described After rotation the first factor accounted for 13.6% of the variance the second factor accounted for 12.6% ofthe variance, and the third factor accounted for 8 9%. Cronbach s coefficient alpha was calculated to determine internal consistency reliability for each subscale of the P AAQ. Reliability of the scaled items was maximized by deleting items to improve Cronbach's alpha Following the principal axis factor analysis and Cro n bach's alpha computation, PAAQ subscales were identified and displayed in Table 3.4 The alpha for the four items creating the attitude scale was 700 which indicates reasonable interna l consistency between the 87

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scale items. Similarly the alpha for the five items forming the perceived behavioral control scale was .787 indicating good internal consistency. The alpha for the three items in the percei v ed behavioral control scale w a s .677 suggesting minimally adequate reliability. Table 3.4 Scale Reliability for Physical Activity and Arthritis Qu es tionnaire Items n = 119 Construct Item Number Cronbach's Alpha Attitude Subjective Norm Perceived Behavioral Control ltemOl Item03 Item06 lteml6rv Item OS Item19 Item20 Item02rv Itemll rv ltem14rv Item15rv Item18rv .700 .677 .787 Note rv = reversed; item responses were recoded to indicate a high score favors physical activity Final scale items varied from the subscales identified in the pilot survey. Potential reasons for this variation included use of a larger sample group in the main survey sampling of different counties for the pilot versus the primary survey, and 88

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bias introduced through purposeful sampling. Subscales identified from the main survey sample, n=ll9, were used during consequent analyses since they were determined from a larger sample and were established through survey response by individuals from east/northeast Colorado counties In contrast, the pilot survey's scale results n =30, were identified through survey completion by individuals living in adjacent counties to the main survey populace Arthritis Impact The Arthritis Impact Measurement Scale 2 (AIMS2) assessed health status indicators in individuals with arthritis including physical function, pain affect, comorbidities, social support, medication use and work impact (see Appendix C). Demographic data was collected using the AIMS2 The AIMS2 represents a revision of the original Arthritis Impact Measurement Scale that was designed to evaluate the health status in individuals with arthritis. The AIMS2 consists of 12 scales that have internal consistency coefficients between 0.74 and 0.96 for individuals with osteoarthritis (Meenan, Mason Anderson Guccione, & Kazis, 1992). This indicates high consistency for individuals responding to the items within an instrument. Validity was tested using internal standards based on a subject's consistency of response to related items throughout the AIMS2. The AIMS2 required approximately 23 minutes to complete and used a Likert-type scale (normal measurement) or yes /no responses (dichotomous measurement) to determine health status and arthritis impact. Low scores indicated a high health status. This tool collected demographic and health 89

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status data using nominal ordinal and normal types of measurement (Leech et al. 2005) as well as one continuous single response item (age). For the purpose of this study, sociodemographic data type of arthritis, health demographics and information related to physical function were gleaned from the AIMS2. Sociodemographic data included age gender racial background current marital status, highest level of education and family income. Type of arthritis was identified from a list of 11 rheumatological-related diagnoses and or an other category. Twenty-five participants out of 119 indicated low back pain as their main kind of arthritis (Meenan 1990b ). These participants were included in the research study as individuals with osteoarthritis since they also listed peripheral joints affected by arthritis and were not taking arthritis medications on a daily basis The participants by completing six questionnaires related to arthritis, perceived that they have arthritis. Listing additional joints commonly affected by osteoarthritis such as the hip or knee strengthened the argument that they were likely to have osteoarthritis. The additional criterion related to lack of regular arthritis medication and would suggest the individual did not have rheumatoid arthritis (RA) a less common form of arthritis that can affect peripheral joints Individuals with a diagnosis of RA are generally on an aggressive medication regimen and have been told they have rheumatoid arthritis. If the participant identified low back pain as the type of arthritis from the list of 11 diagnoses completed all questionnaires on arthritis, and followed 90

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the above criteria of listing arthritis-affected joints and reporting non-routine arthritis medication management they were included as an OA participant. Six AIMS2 scales were grouped to measure physical function as defined by Meenan (1990a). The six scales were mobility, walking and bending, hand and finger arm function self-care and household tasks. Principal axis factor analysis was performed on the 119 collected AIMS2 questionnaires to compare with AIMS2 scales reported in the literature. Six factors were requested based on the fact that items were designed to index the six constructs identified above. The six rotations accounted for the variance as follows: 16.0% 14. 0%, 13.9% 10.5% 8 8%, 3 1 % The current research subscales that matched the scale items identified in the AIMS2 literature (Meenan et al., 1992) included the mobility, hand and finger, self-care and arm function scales. Minor deviations in grouping were noted in the walking and bending scale (four out of five items grouped together) and the household task scale (three out of five items grouped together). Deviations in scale configurations could be due to smaller sample size in the current research population difference in interpretation of the items between the sample population and the original population, and or sampling bias associated with purposeful sampling in the current study. Raw scores from each of the six AIMS2 scales were added and normalized per Meenan (1990a) to obtain values between zero and ten which would allow expression of all scales in similar units. The mean of the six normalized scales produced a physical function component of health status. 91

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SelfEfficac y Self-efficacy was measured using the Arthritis Self-Efficacy Scale (ASES) de v eloped b y Lorig Chastain Ung Shoor and Holman (1989) ( s ee Appendi x C) Self-efficacy has been defined as an individual s belief that he or she can perform a specific task or behavior. A cover sheet provided to the AS E S in the survey packets defined self-efficacy as how much control you feel y ou ha v e o v er y our arthritis to help participants understand the term as it relates to arthritis. The ASES was developed and evaluated to look at s elf-efficacy in mediating health outcomes in individuals with arthritis (Lorig et al. 1989). It measures three areas of self-efficacy as it relates to pain functional and other behaviors. There are five nine and six Likert-type items in each area respectively. The three area reliabilities were 0 .85, 0 90 and 0 87 respect i vely which indicate high reliability and that the different items in each scale are consistent with one another in measuring that variable. Pearson correlations determined the item reliabilities to be between 0.71 and 0.85 which indicates a high correlation between items in the scale. The self efficacy pain and self efficacy other scale scores can be combined. The self-efficacy function scale score is measured separately. It w a s estimated to take two to five minutes to complete this questionnaire Principal a x is factor anal y sis with varimax rotation w as performed on the 119 returned self-efficacy questionnai re s Anal y sis was performed to determine if three scales including pain function and other would be apparent i n the sample 92

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population. Three factors were requested to assess the underlying structure for the 20 items of the ASES. After rotation, the first factor accounted for 27.0% of the variance, the second factor accounted for 20 6% of the variance, and the third factor accounted for 18.1 %. All function scale items grouped together as the first factor Items from the pain and other scales were split between the final two factors. This would support the potential two scale interpretation (Stanford Patient Education Center n.d.). The self-efficacy function scale was selected to represent the construct of self -efficac y during analysis with the dependent variable, physical activity. The relationship between belief in ability to perform functional tasks and amount of physical activity performed was explored. Environmental Supports for Physical Activity Questionnaire The Environmental Supports for Physical Activity Long Questionnaire evaluated the participants perceptions of support for physical activity in their physical and social environments (see Appendix C). This tool consists of 11 Likert type (ordinal measurement) or dichotomous (nominal measurement) items that were taken from an original instrument because they were found to be an accurate and reliable measure of an individual's perception of the social and physical environment (SIP 44-99 Research Group, 2002 October). This questimmaire takes approximately 5-l 0 minutes to complete. It was developed by the University of South Carolina Pre vention Research Center to inform a future BRFSS module to assess support for PA in the environment (SIP 44-99 Research Group, 2002 October). 93

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This survey asks questions related to the neighborhood and the community which are defined as separate concepts. Neighborhood is defined as "a Yz mile radius or a 10-minute walk from the respondent's home and community which is defined as a 10mile radius or a 20 minute drive from the respondent's home (Brownson Chang et al. 2004). Internal consistency coefficients have been reported between 0.42 and 0 87 by Brownson and Chang et al. (2004). The items have been used in univariate and multivariate logistic regression analyses to predict P A levels (University of South Carolina Prevention Research Center personal communication September 13, 2005) The first six questions of the Environmental Supports for Physical Activity Long Questionnaire required completion by individuals living in a neighborhood" as defined above and all participants completed the final five questions Since all participants were requested to complete items seven through eleven and these statements included environmental correlates to P A items seven through eleven were chosen to represent the environmental component to this research study. These items assessed presence of recreation facilities trails parks playground sports fields shopping malls and schools in the community. All five items contained both behavioral and environmental information and were coded to create two separate variables that reflect either the behavioral or environmental component (University of South Carolina Prevention Research Center personal communication September 13, 2005). In order to address environmental correlates only the environmental 94

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components of items seven through elev e n were used as supported b y the University of South Carolina Prevention Research Center (D. Pluto personal communication April 21, 2008). I f the participant ans we red yes or "no" to any of the fiv e items that asked Do you use ... the variable was coded as having the environmental amenity. If the participant answered my community does not have ... the variable was coded to indicate lack of presence of the amenit y Responses to these items indicated potential environmental barriers or facilitators to P A. Final Qu es tionnair e Thirteen questions were compiled to add insight into the research question and specific aims of this investigation (see Appendix C). The questions addressed additional physical characteristics of the individual with arthritis the distance the respondent lives from the nearest town health care provider recommendations for physical activity opinions on work-related PA assistance with survey completion voluntary contact information and an opportunity to answer open ended questions related to the research aims. Variables Data collection took place over a period of 15 months Sample data from all surveys were incorporated into the analysis ; however, not all data collected were used in this research project and will be available for future analyses. The dependent variable data was obtained from the 2003 BRFSS (see Appendix C) that measures amount of non-work-related physical activity and from the Occupational Physical 95

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Activity Questionnaire (OPAQ) (see Appendix C), which measures work-related activity Non work-related physical activity was measured in minutes per day over the time period of one week. The OP AQ identified hours per week spent in v arious levels of physical activity in order to estimate work-related physical activity. Minutes of physical activity were considered approximately normal" measurement types as defined by Leech (Leech et al., 2005 p. 14). Independent variable data was captured from the remaining questionnaires. Tables 3.5 and 3.6 present the independent variables and their operational definitions. 96

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Table 3.5 Ind ependent Variables Not R e lated to the Physical Environmen t Variabl e Qu estionnaire Source Age AIMS2 Arthritis Impact physical model of health status AIMS2 Self-efficacy function ASES Attitude PAAQ Perceived Behavioral Control PAAQ Subjective Nonn PAAQ Operational Definition Answered in years: What i s yo ur age at thi s time? Sum of fir s t 6 normalized scales ofthe AIMS2 divided b y 6 ; Low score indicate s high health status Mean of9 items in the function sca l e of the ASES ; Low score indicates less perceived control over functional abi I ity Mean of 4 items from the PAAQ ; Low score indicate s more negative attit ud e about physical activity and arthriti s Mean of 5 items from the PAAQ; Low s core indicates less perceived behavioral control over effects of physical activity and arthritis Mean of 3 items from the P AAQ ; Low score indicates less effect of others opinion on level of phy s ical activity Defin e d P ote ntial Range 45 +year s 1.0-10.00 1.010.00 1.0 5.0 1.0 -5.0 1.0-5.0 Note. AIMS2 = Arthritis Impact Measurement Scale 2; ASES = Arthritis Self Efficacy Scale ; P AAQ = Physical Activity and Arthritis Questionnaire 97

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Table 3.6 Independent Variables Rel ated to the Physical Environment Variable Questionnaire Source Di stance from town Final Survey Private recreation facilities ESPALQ Outdoor pleasure ESPALQ Shopping malls ESPALQ Public recreation centers ESPALQ Schools ESPALQ Operational D efi nition Distance (in miles) from the nearest town where participant can buy groceries or gasoline Identifies use of private or membership only recreation facilities ldentifies use of walking trails parks playgrounds sports fields Identifies use of shopping malls ldentifies use of pub I ic recreation centers Identifies use of schools open in the community Defined Potential Range 0 +miles Yes No Community doesn't have facilities Yes No Community doesn't have facilities Yes No Community doesn t have shopping malls Yes No Community doesn t have facilities Yes No Schools not open for public u se Note. ESPALQ =Environmental Supports for Physical Activity Long Questionnaire 98

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Survey Return In total, 278 surveys were distributed over a 15 month period. One hundred and seventy-seven surveys, or 63.7%, of the surveys were returned An initial review of the returned surveys indicated that 37 participants provided insufficient data to warrant their inclusion, and these surveys were therefore excluded from the study. An additional 17 participants with a self-reported diagnosis of rheumatoid arthritis (RA) and without self-report of OA were excluded from the current study. Therefore, 123 surveys or 44.2%, were initially accepted for analysis. Figure 3.2 identifies the survey distribution return, and inclusion history. 99

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I S wveys Distributed ( n = 278) I I Swveys Retumed(n= 177) I I Excluded Swve)&: Considerable I I Mssing Dare ( n = 37) I Excluded Swve)&: Diagnosis I I RA, Exclusive o fOA ( n= 17) I Eligible S wveys ( n = 123) I r Excluded Swveys Exceeded l Qu.estionnaire-Srecific Allowable Mssing Data (n = 4) I Eligible S wveys ( n = 119) I I Excluded Swveys : terendent I I Variable N o t Quantifle d ( n = 39) I Swveys for Final Anal)&is I (n=80) Figure 3 2 Consort Model Sample Size Data for analysis were further reviewed and prompted additional changes. Four ofthe 123 surveys were excluded due to an unacceptable level of missing data in analyses scales. Meenan (1990a) suggests using the mean of an individual s scale score if one item is missing in the AIMS2. A closer review of the scale data is indicated if more than one item is missing. This prompted exclusion of two surveys with incomplete AIMS2 scale data Two additional surveys were excluded upon closer examination. The first survey lacked >25% of the data in the self-efficacy function scale of the ASES which are the guidelines for exclusion (Stanford Patient 100

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Education Center n d.) The final excluded survey lacked > 25% ofthe PAAQ data and was eliminated to prevent a potentially inaccurate estimate of the large percent of the missing data in this questionnaire. The remaining 119 surveys demonstrated less than 0.4% missing independent variable data from non-demographic variables. This percentage is far less than the 5% noted by Tabaclmick and Fidell (200 1) as a potential boundary of imputation for missing data. Missing values appeared to be scattered randomly through the database. Imputation by substitution of the overall mean values replaced the small percent of missing independent variable values Tabachnick and Fidell (2001) state "In the absence of all other information the mean is the best guess about the value of a variable. Part of the attraction of this procedure is that it is conservative; the mean for the distribution as a whole does not change and the researcher is not required to guess at missing values (p. 62) Imputation was chosen rather than the use of"prior knowledge" or regression. This study provides new knowledge ; missing data could not be estimated with prior knowledge since the hypotheses had not been previously tested in this population. Regression uses variables without missing data as independent variables to predict missing data, labeled as the dependent variable, in a regression equation Disadvantages to regression in predicting missing values include an artificial reduction in variance from the mean and lack of evidence that the independent variables would be a good predictor of the variable with missing data; this technique to replace missing data was not used. 101

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Review of data obtained for the dependent variable led to additional analyses decisions The data revealed that 80 out of the 119 participants responded that they participate in moderate non-work related physical activity and listed actual number of days per week and minutes per day of activity. The remaining 39 participants either left day and or minute items blank (n = 14) responded don t know / not sure" when asked ifthey participate in moderate non-work PA (n=2) don t know / not sure to number of days per week they participate in moderate PA (n=4) and or "don't know / not sure" to total time per day (in hours and minutes) they participate in moderate P A (n=22) Missing dependent variable values or selection of the "don't know / not sure" response excluded 39 respondents from analyses. An independent samples t-test was used to compare individuals who listed days and minutes of physical activity (responders) and participants who answered "don't know / not sure" (non responders) to determine if there was a significant difference between groups on a sample of independent variables. The null hypothesis for this analysis was that there would be no difference between the responders and non responders on the chosen independent variables If the null hypothesis is true any difference between the two means would be due to chance Table 3.7 identifies the independent variables and sample means for the re s ponders and non-responders. Table 3.8 presents results of the independent samples test. 102

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Table 3.7 Indep e ndent Samples Test: Re spo nder s and Non-Responders Group Statistics N Mean Std Dev Age Responder 80 68.24 10. 20 Non-responder 36 70.89 11.77 Arthritis Pain a Responder 75 2.57 99 Non-responder 39 2.41 .94 ASES Responder 78 6.98 2.30 Function Scale Non-responder 38 6.13 2.12 BMib Responder 76 28. 56 5.75 Non responder 36 30.18 7.29 Walk Bend c Responder 80 3.56 2 .65 Non-responder 37 5.01 2 .93 Note ASES =Arthritis and Self-Efficacy Scale; BMI =Body Mass Index a Arthritis Pain measured by Arthritis Impact Measurement Scale 2 Item 38 1 =None, 2 = Very Mild 3=Mild 4 = Moderate 5=Severe b BMI = body weight in kilograms divided by height in meters squared c Walk Bend measured by Arthritis Impact Measurement Scale 2 Normalized Scale Items 6-10 1-10 with lower score indicating higher ability to perform walk and bend tasks 103

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Table 3.8 Independent Samples Test : Differe n ce B etwee n Re sponde r s and No n-R esponde rs on K ey Variables 95% Cl of Mean Difference t df p-value Lower Upper Age (AIMS2, 73) -1. 23 114 .22 -6.90 1.61 Arthritis Pain 85 112 .40 .22 .54 (AIMS2, 38) Self-Efficacy 1.89 114 .06 .04 1.72 Function (ASES) BMJ (Final Survey) -1.27 110 .21 -4 14 .90 Walking/Bending -2.67 115 .01 -2 .54 -.38 (AJMS2, 6-1 0) Note. AIMS2 73=1tem number 73 from Arthritis Impact Measurement Scale 2 (AJMS2) ; AlMS2 38 = Item number 38 from AIMS2 ; ASES = Arthritis Self-Efficacy Scale; BMI = Body Mass Index ; AIMS 6-IO = Normalized scale items 6-10 from AIMS2 BMI = body weight in kilograms divided by height in meters squared No significant difference was found between responders and non-responders on four of the five independent variables: age arthritis pain self-efficac y function and body massindex (BMI) This suggests the mean value for age pain le v el due to arthritis over the past month how much control the indi v idual with arthritis had over their function and the height to weight ratio was similar in both groups. There was a significant difference between responders and non-responders in average ability to perform walking and bending activities, t(115) = -2.672 p = 009. The p value of .009 was less than the alpha le ve l of .05 Responders walking and bending scale score (M = 3.56 SD = 2.65) was significantly lower than the non104

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responders (M = 5 0I SD = 2.93) on a normalized scale with a range between one and ten Low scores on the AIMS2 instrument indicate a higher health status which would suggest responders were able to perform walking and bending activities on more days over the past month than non-responders. A chi-square test was performed to detect if there was a significant association between gender and responders or non-responders. Table 3.9 displays results from this test. Table 3.9 Chi-Square Test: Gender and Responder or Non-Responder Pearson Chi Square N ofValid Cases Value .024 I18 df p-value I .877 Results of the chi-square statistic indicate there was not a significant association between gender and responders or non-responders. In this sample population gender was not associated with whether or not they responded with discrete values to days and minutes of physical activity per week. Analysis Eighty participants were chosen for final data analysis with the dependent variable physical activity. These 80 individuals provided days and minutes of moderate physical activity, which could be used to inform the research hypotheses and specific aim #1. The 80 responders did not significantly differ from the 39 nonI 05

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responders in several independent variables including gender, age, arthritis pain level, self-efficacy with function and BMI. A significant difference was noted between the two groups in ability to perform walking and bending tasks. Caution must be used with generalizing the results of responders to non-re s ponders. SPSS Version 16. 0 was used for statistical analyses. Raw frequencies of variables from the instruments used in this study are reported in Appendix D for the 80 participants. There were several major components to the analysis Sociodemographic and health demographic variables were used to describe the sample population. Time spent in physical activity was summated from data provided on the BRFSS and OPAQ questionnaires. The hypotheses were analyzed using basic associational or difference statistics. A multiple regression model was developed to analyze predictors of physical activity in individuals with arthritis residing in rural counties of east and northeast Colorado. Finally evidence was provided to support the positive effect of involving a community-based research committee on the research project. Univariate analysis was performed on variables to determine the presence or absence of skewness. Variables indicating skewness were transformed when possible to provide a normally distributed variable for analyses indicated by a skewness value within the recommended guidel in es of -1 to + 1. Transformed variables are clearly identified in the Results section. 106

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CHAPT E R FOUR RESULTS Introduction The following four sections present results of the research investigation. Section one describes the geographic and sociodemographic data; section two defines the physical and health characteristics of the survey population; section three identifies findings from specific aims and hypotheses testing; and section four offers a regression model to identify predictors of physical activity. Geographic and Sociodemographic Descriptions Geographic Distribution Individuals participating in the arthritis and physical activity survey represented five counties in east and northeast Colorado: Lincoln Yuma Logan Phillips and Sedgwick. Lincoln County was considered "east" Colorado as it is bisected by a line dividing the state in half and is located on the eastern half of the state. Yuma, Logan Phillips and Sedgwick counties were identified at northeast Colorado as they form the borders of the northeast comer of the state. Thirteen municipalities and their associated zip code regions were represented by survey participants Table 4 1 lists the towns and their respective populations as well as the number of participants from each town region. 107

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Table 4 1 SurveJ:_ Muni cip_alities and Pop_ulation Rep_rese ntation Municipality Census 2000 Es timated #Survey %of Survey Census 2006 Participants Popul a tion Sedgwick 191 171 5 6.25 Atwood 195 a 1 1.25 Genoa 211 187 1 1.25 Aniba 244 217 2 2.50 Ovid 330 306 14 17.50 Fleming 426 442 1.25 Hugo 885 771 1.25 Haxtun 982 997 3 3 .75 Limon 2 ,071 I 817 15 18.75 Wray 2,187 2,160 4 5 00 Holyoke 2 ,261 2 ,291 1.25 Yuma 3,285 3,249 13 16.25 Sterling 11, 360 12,581 17 21.25 Missing b 2 2.50 TOTAL 24 628 25,384 80 100 Note. Census data reference retrieved on 052408 a Not available from U.S. Census Bureau ; Census 2000 used to estimate total b Not listed in survey information 108

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Approximately 46% of the participants indicated they lived in town and 52% lived between 0.25 and 30 miles from town. Town was defined as a place where you can buy groceries and gasoline on the final questionnaire. Zip code data to identify the associated municipality was missing for two individuals (2. 5%). Since survey distribution occurred only in the identified counties it was assumed the individuals lived in one of the five counties and their survey data was included in the analyses. The farthest driving distances between any two of the listed towns was 171 miles or just under a three hour drive. Sociodemographics As described in the Methods chapter, a total of 80 participants completed the required data fields for this investigation. Table 4.2 presents general demographics of the sample population. The majority ofthe participants was female, white, married and had a high school education Fan1ily income ranged from Jess than $10,000 to greater than $70 000 per year. The two income ranges reported most commonly were $10,000-$19,999 and $20 000-$29,999. 109

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Table 4 2 D e scriptiv e Statisti cs ofGene ral D e mographics ofSample Characteristic n = 80 Age y ears (range 46-96) 68 24 1.02 Male 70 60 1 .93 Female 67.46 1.37 Gender no.(%) Male Female Ethnicity White Asian or Pacific Islander American Indian or Alaskan Native Marital Status Married Divorced Widowed Highest level of education Grades 7-9 Grades 1 0-11 High school graduate 1-4 years college College graduate Professional or graduate school Approximate family incomea < $10 000 $10 000-$19 999 $20 000$29 999 $30 000$39 999 $40 000$49 999 $50,000$59 999 $60 000$69 999 More than $70 000 an= 71 (88.75% ofn) 20 (25 0) 60 (75.0) 75 (93.8) 2 (2.5) 3 (3.8) 51 (63.8) 7 (8. 8) 22 (27.5) 3 (3.8) 2 (2.5) 38 (47.5) 24 (30 0) 10 (12 5) 3 (3.8) 5 (7. 0) 16 (22.5) 16 (22.5) 12 (16.9) 7 (9 9) 8(11.3) 2 (2. 8) 5 (7.0) More than 41% of the respondents indicated they were employed and nearly 50% reported they were retired Gender distribution indicated that 63.2% of males 110

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and 56.9% of females were not working which included retirees The AIMS2 asked what has been your main form of work over the past month? Options included paid work house work school work unemplo y ed disabled or retired. Individuals were considered working if they chose one of the first three answers respectively and not working if they chose one of the last three categories. Table 4.3 indicates the frequency of response to each category Table 4.3 Work Status for Individuals with Arthritis Paid work House work School work Unemployed Disabled Retired Total Missing Total Frequency Percent 22 27.5 9 11. 2 1 1.2 2 2.5 5 6 2 38 47.5 77 96.2 3 3.8 80 100.0 Valid Percent 28.6 11.7 1.3 2.6 6.5 49.4 100 Physical and Health Characteristics of Sample Population Participants reported physical and health information that added insight into the overall health of the study population. The mean body mass index (BMI) which describes a relationship between weight and height, was 27.7 and 28.9 kgm2 for males and females respectively, or overweight (Panel 1998). The average BMI for females was higher than the average BMI for males. Twenty-three respondents (28.8%) had a BMI > 30 kgm-2 which is considered to be obese and ranged from 111

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30.2 kgm-2 to 51.7 kgm-2 The 80 participants with self-reported arthritis noted several co-morbidities. Over 42% of the individuals reported high blood pressure and 22.5% stated they had "heart disease Participants also noted "diabetes" and "ulcer or other stomach disease," with approximately 16% and 15% reporting these comorbidities, respectively. Respondents reported additional types of perceived arthritic conditions Low back pain was noted by over 50% ofthe participants. More than 20% indicated they had osteoporos i s Table 4.4lists the health characteristics of the sample population. 112

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Table 4.4 Physical and Health Characteristics of the Sample Population Characteristic Mean SD Height, inches (n=80) Male 68.8 3.2 Female 63 9 2.9 Weight pounds (n=76) Male 184.5 24 6 Female 167.2 37.4 BMe (n=76) Male 27 7 3.4 Female 28 9 6.4 Years with arthritis 13.0 8 7 Arthritis painb (n=75) 2.6 1.0 Type of arthritis comorbidity Rheumatoid arthritis Fibromyalgia Scleroderma Gout Low back pain Tendonitis Bursitis Osteoporosis Other c Type of medical comorbidity Hypertension Heart disease Mental illness Diabetes Cancer Lung diseased Liver disease Ulcer or other stomach disease Anaemia or other blood disease BMI = body mass index b Pain scale: 1 =none, S=severe e n = 79 (98. 7% of n=80) d n = 78 (98. 7% of n=79) 113 n=80 % 3 4 1 2 44 8 17 8 3.8 5 0 1.2 2.5 55. 0 10 0 21.2 10.0 n = 79 % 34 18 2 13 2 5 1 12 3 42.5 22.5 2 5 16.2 2.5 6 2 1.2 15.0 3.8

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Specific Aims and Hypotheses Analyses Specific Aim # I Specific Aim #1: Determine current minutes of physical activity (PA) in participating individuals living with arthritis in rural communities in Northeast Colorado. Time increments of non-work and work-related physical activity (PA) were requested from all participants, using the BRFSS physical activity module (Centers for Disease Control and Prevention, 2003) and the OPAQ (Reis et al., 2005) as described in the Methods chapter. Table 4.5 presents the range and average minutes of activity. Table 4.5 Minutes o[_Work and Non-Work Physical Activity (PA) p_er Week n Mean Mean so Min Max (minutes) (hours) (minutes) (minutes) (minutes) Minutes non-work 80 503.2 8.4 775 3 15.0 4200 0 moderate PA Minutes non-work 33 492.0 8.2 962.3 26.2 5040 0 vigorous PA Minutes work in sit or 34 1402 0 23.4 991.9 120.0 4800.0 stand Minutes work walking 24 980 0 16.3 872.4 60.0 2850.0 Minutes work heavy labor 12 865.0 14.4 756.0 90.0 2100.0 Minutes of moderate, non-work-related PAper week were calculated for all 80 participants. Moderate non-work P A was defined as activities that "cause small 114

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increases in breathing or heart rate and included examples such as brisk walking, bic y cling vacuuming, gardening fishing and home repair that was performed for at lea s t ten minutes at a time (Centers for Disease Control and Prevention 2003) Individuals were asked to report time increments for days they spent more than I 0 minutes at a time doing moderate P A. Answers v aried from 15 minutes to 70 hours per week of non-work moderate P A and the data was markedly positively skewed (skewness = 3.0). Forty-one percent of the sample population reported participating in vigorous non-work PA for at least ten minutes at a time. Vigorous PA was defined as "large increases in breathing or heart rate (Centers for Disease Control and Prevention 2003). Examples of vigorous PA included running aerobics shoveling heavy snow and heavy yard work. Reported vigorous non-work P A ranged from 26.25 minutes to 84 hours per week and was distinctly positively skewed (skewness= 3 8). Work-related PA measured time spent in sitting or standing walking or heavy labor using the OPAQ. The OPAQ identified the three categories as light, moderate or vigorous intensity activities respectively based on the compendium list by Ainsworth et al. (2000). Thirty-four participants listed sitting or standing as work related P A 24 stated they walked at work and 12 reported work involving heavy labor. Participants could report all three forms of P A at work if applicable. As noted above walking was considered moderate physical activity by Reis et al. (2005) and supported by a position statement issued by an expert panel for the Centers for 115

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Disease Control and Prevention and the American College of Sports Medicine (Pate 1995) that classified activities by MET levels. The sum of work and non-work related moderate PA is reported in Table 4.6. Table 4.6 Total Minutes Work and Non-Work-Related Moderate Physical Activity Per Week n Mean (minutes) Moderate PA 24 1576.5 Mean (hours) 26.3 so (minutes) 1375.5 Min (minutes) 240.0 Max (minutes) 6000.0 Work activity identified as heavy labor and non-work related vigorous activity were summed to describe total minutes spent in vigorous physical activity per week. The OPAQ examples of heavy labor which equated to vigorous activity ( > 6 METs) included "moving furniture carpentry jackhammers or using a shovel or pick." Total vigorous activity per week is listed in Table 4. 7. Table 4.7 Total Minutes Work and Non-Work-Related Vigorous Physical Activity Per Week n Mean (minutes) Vigorous PA 9 1500.1 Mean (hours) 25 0 Physical Activity as the Dependent Variable so (minutes) 2141.9 Min (minutes) 116.2 Max (minutes) 6840.0 Physical activity was used as the dependent variable for analysis of the research hypotheses Moderate non-work PA was markedly positively skewed (skewness= 3.0) and violated the assumption of normality. Therefore, the decision 116

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was made to transform the dependent variable, moderate non-work-related physical activity, to improve normality for any parametric analyses Since minut es of moderate PA were positively skewe d the logarithm of this var iable was computed to see ifnom1ality improved (Leech e t al. 2005; Tabachnick & Fidell 2001). Table 4.8 displays the descriptive results for the transformed variable The skewness value became 0.48 which is still slightly skewed but falls well within the recommended guidelines of less than absolute one. Log( 1 0) minutes of moderate P A was used during paran1etric analyses and is noted in the reporting of data. Table 4.8 D esc ripti ve Statistics o[Transfor m e d Variable Minutes Moderate Non -Work Physi ca l Activity (PA) N Minimum Maximum Mean Std. Skewness Stati s tic Statistic Statistic Stati st ic Statistic Statistic Std. Error Lo g iOPA 80 1.18 3.62 2.41 .48 .48 .27 ValidN 80 (listwise) Log(1 0) transformations were performed for vigorous non-work related PA total work and non-work moderate P A, and total work and non-work v igorous P A to normalize data during parametric analyses and are identified in the results when transformed. 117

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Specific A im # 2 Specific Aim #2: Determine the factors that influence phy s ical activity for individual s with arthritis liv ing in rural communities. There are severa l h y pothese s th at addressed potential factors of influence on phy s ical activity in indi v iduals with arthritis living in east or northeast Colorado. Each analysis is described in the following section. H ypo th eses Testing Hypothesis 1 : There will be a relationship between arthritis impact on phy s ical function and minutes of moderate or vigorous ph ys ical activity. The association of arthritis impact on physical function as measured by the AIMS2, and minutes of physical activity, calculated using data from the BRFSS and or OP AQ, was analyzed using the Pearson product moment correlation. Cases were excluded pairwise during this SPSS analysis to include all available data. Descriptive and bi va riate analyses results for moderate and v igorous work and or non-work related minutes of physical activity are presented in Tables 4.9 and 4.10. 118

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Table 4.9 Descriptive Statistics: Arthritis Physical Function Imp act and Minut es Physical Activity N Mean so AIMS2 physical function log I 0 78 .05 .45 Minutes moderate non-work PA log I 0 80 2.41 .48 Minutes moderate work PA 24 980.00 872 39 Total moderate PA lo g I 0 24 3.04 .39 Minutes vigorous non-work PA logiO 33 2.31 .53 Minutes vigorous work PA 12 865 00 756.01 Total vigorous PA log I 0 9 2 86 .55 Note. log I 0 noted on variables transformed to reduce skew AIMS2 = Arthritis Impact Measurement Scales 2 P A = physical activity Table 4.10 Correlat i o n : Arthritis Physical Function Impa c t and Minutes ofPhysica / Activity Physical Activity (minutes) AIMS2 physical function scale logiO N Correlation Minutes moderate non-work PA log I 0 78 Minutes moderate work PA 23 Total moderate PA logiO 23 Minutes vigorous non-work PAiogiO 32 Minutes vigorous work PA II Total vigorous PA log I 0 8 Note log I 0 noted on variables transformed to reduce skew AIMS2 = Arthritis Impact Measurement Scales 2 P A = physical activity 119 .101 .403 .353 013 -.144 -.070 p-value .380 .057 .099 946 .672 869

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Arthritis impact on physical function was measured by averaging six normalized scales (range between 0 and 10) from the AIMS2: mobility level wa lking and bending hand and finger function arm function self care and household ta s ks as indicated by Meenan (1990a). Initial descriptive results indicated substantial positive skewness (skewness= 1.969) with the mean= 1 336 SD = 1.229 Low scores on the AIMS2 indicate higher health status. A log 10 transformation of the arthritis impact data resulted in a reduction of skewness (skewness = -.646) which was in the acceptable range to be considered normally distributed. The logl 0 AIMS2 data was used in the bivariate analyses. Minutes of moderate or vigorous work or non work related physical activity were transformed if skewness was greater than one or less than negative one. All transformations were performed using log 10 and each transformed variable is labeled with "loglO" in Tables 4.9 and 4.10. Analyses indicate that there was no significant association between arthritis impact on physical function and minutes of moderate or vigorous, work or non-work related physical activity Fewer ind i viduals reported part i cipation in vigorous non work physical activity than moderate non-work PA. Of the 32 individuals who reported working 75% indicated they performed moderate PA and 37 5% stated they do vigorous P A at work The log 10 transformation of the arthritis impact data excluded two participants whose normalized arthritis impact score was zero. 120

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Hypothesis 2: Men with arthritis living in a rural community will have significantly more minutes of physical activity than women with arthritis living in a rural community. An independent samples t-test was used to compare males and females (a between group design) on their average (mean) minutes of physical activity per week to determine if there was a significant difference. According to Spatz (200 1 ), "parametric tests such as t tests and ANOV A produce accurate probabilities when the populations are normally distributed and have equal variances." Although the group sizes were different (male= 20, female= 60), Levene's test for all comparisons of means was higher than .05, indicating the variances of the two groups were equal. The assumption of independence of observations" was met; knowing the gender of the participant did not allow prediction of their minutes of PA. The t-test is robust against the assumption of normality Table 4 .11 presents the group statistics for mean comparisons of males and females on minutes of moderate or vigorous work and or non-work related physical activity The independent samples t-test results are indicated in Table 4.12 121

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Table 4.11 Indep e ndent Samples Test : Gender with PA Group Stati s ti c s Gender N Mean Std. Dev. moderate non-work Male 20 2.46 .52 PA logiO Female 60 2.39 .47 moderate work PA (hr) Male 6 18.67 739.40 Female 18 15. 56 927 .17 total moderate P A Male 6 3.09 .47 loglO Female 18 3.02 .38 vigorous non-work PA Male 9 2.32 .60 l oglO Female 24 2.30 .52 vigorous work PA (hr) Male 5 17.80 605.08 Female 7 12.00 863.08 total vigorous nonMale 4 3.10 .53 work PA log I 0 Female 5 2.67 54 Note. loglO noted on variab l es transformed to reduce skew PA =physical activity in minutes per week 122

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Table 4.12 Indqz ende nt Samf!_les T es t : Diffe r e nc es in PA by_ G ende r 95% Cl of Mean Difference df p-value Lower log I 0 moderate .51 78 .62 -.18 non-work PA moderate work P A .47 22 .66 -681.46 loglO total .38 22 .71 -.32 moderate PA log I 0 vigorous .12 31 .90 -.41 non-work PA vigorous work P A .77 10 .46 -657.00 log! 0 total 1.19 7 .27 -.42 vigorous PA Not e log I 0 indicated where data transformed to improve normality PA =physical activity in minutes per week Upper .31 I 054.80 .46 .46 1353.00 1.28 There was no significant difference between males and females in minutes of physical activity as demonstrated by the p-value in Table 4.12. Equal variances were assumed for all of the independent samples t-tests as Levene s test was significant in all cases. Therefore the hypothesis "Men with arthritis living in a rural community will have different minutes of physical activity than women with arthritis living in a rural community was rejected. Hypothesis 3: Distance from town will be associated with minutes of physical activity in individuals with arthritis in rural communities. 123

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Participants in this investigation identified if they lived in a town defined as a place where they could buy groceries or gas, or a measured distance from town. Distance from town varied from 0.25 mile s to 30 miles per individual report. Thirty seven individuals, or 46.2%, reported that they lived in town. In order to determine if there was a correlation between distance from town and minutes of moderate or vigorous activity, Spearman Rho correlation was selected for analysis. The var iable "distance from town" was positively skewed (skewness= 1.516). A log10 transformation did not improve skewness and elimated zero values, which reduced the included participants for analysis to 43. The square root transformation reduced skewness to -. 768 but reduced the "valid n to 42 due to exclusion of zero values Therefore, Spearman Rho was selected for this analysis since the normality assumption required for Pearson product moment correlation was markedly violated. A two-tailed test of significance and the option to exclude cases pairwise was chosen for the analysis Table 4.13 presents correlation values for distance from town with minutes of moderate or vigorous, work or non-work related PA. Physical activity data was not transformed since a normal distribution is not an assumption of Spearman Rho. 124

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Table 4.13 Spearman Rho Correlation: Distance from Town and Minutes of Physical Activity Distance from Town Physical Activity (minutes) N Correlation p-value Moderate non-work PA 80 .190 .092 Moderate work P A 24 .106 .623 Total moderate PA 24 .086 .691 Vigorous non-work PA 33 .206 .249 Vigorous work PA 1 2 .258 .418 Total vigorous PA 9 -.068 .862 Note. PA =physical activity Analyses indicate there was no significant association between distance from town and minutes of moderate or vigorous, work or non-work related physical activity. A positive, significant correlation would indicate that as the distance from town increased, the minutes ofweekly PA would increase. The null hypothesis, "distance from town will not be associated with minutes of physical activity in individuals with arthritis in rural communities," cannot be rejected. Hypothesis 4: There will be a difference between perceived environmental availability of resources for physical activity and minutes of physical activity. The Environmental Supports for Physical Activity Long Questionnaire (ESPALQ) asked participants if they used a variety of community resources, if available for physical activity The participant could indicate if their community did 125

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not have the listed resource. If environmental resources were available, indicated by the respondent answering yes" or "no" to "Do you use ... [resource], the potential environmental facilitator of PA was believed to exist for the purpose of this study If the respondent answered "my community does not have . [resource], the potential environmental barrier to P A was noted. The MannWhitney U test was used to assess the relationship between physical activity and availability of environmental resources. Cases were excluded test by test. The sample sizes in groups one (has the resource) and two (does not have the resource) were patently different and suggested the use of the nonparametric statistic (N.L. Leech, personal communication June 8 2008). When the number of individuals in one of the two independent groups is greater than 20 a z score with critical values of .96 (alpha= .05) is used to determine significance (Spatz, 2001) Tables 4.14 through 4 .18 present the information on the five targeted questions related to availability of resources. Each table is preceded by the corresponding questionnaire item for clarity. ESPALQ Item # 7 : Do you use any private or membership only recreation facilities in your community for physical activity? 126

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Table4.14 Mann-Whitney T est: Pri vate R ecreatio n Facilities and Physical Activity Res2on se N z Mean Rank p_-value Moderate non-work P A Yes has 72 3 8.50 No doesn t have 7 55.43 Analysis -1.8 6 06 Moderate w ork P A Yes has 21 12.86 No doe s n t have 3 10.00 Analysis -.66 .51 Total moderate PA Yes has 21 12.19 No doesn't h ave 3 14.67 Analysis 57 .57 Vigorous non-work P A Yes has 30 17.03 No doesn t ha ve 3 16.67 Analysis -.06 .95 Vigorous work P A Yes has 10 6 .15 No doesn t have 2 8.25 Analysis 76 .45 Total v igorous PA Yes has 8 4.63 No doesn t have 1 8 00 Analysis .24 .44 Note. PA =physical activity in minutes The observed z values did not exceed the critical z value of .96 (p :S .05 critical value for a two-tailed test) in any of the P A categories. Significance would indicate that the amount of physical activity performed per week is related to the presence of private recreation facilities in the community. The null hypothesis was not rejected based on the data results. These results mean that indi viduals who percei ve d that their environment had private recreation facilities did not report significantly different levels of P A than those individuals who did not. 127

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ESPALQ Item #8: Do you use walking trails parks playgrounds sports fields in your community for physical activity ? Table 4.15 Mann-Whitney Test: Trails, Parks, Pla y grounds, Fields and Phy s ical A ctivity Response N z Mean Rank p-value Moderate non-work P A Yes has 71 39.38 No doesn t have 8 45. 50 Analysis 79 .72 .47 Moderate work P A Yes has 20 11.98 No doesn t have 4 15.13 Analysis 24 -.82 .41 Total moderate PA Yes has 20 11.75 No doesn't have 4 16 .25 Analysis 24 -1.16 .24 Vigorous non-work P A Yes has 27 16.13 No doesn't have 5 18.50 Analysis 32 52 .60 Vigorous work P A Yes has 10 6.15 No doesn t have 2 8.25 Analysis 12 76 .45 Total vigorous PA Yes has 8 4.63 No doesn t have 1 8.00 Analysis 9 -1.16 .24 Note. PA =physical activity in minutes The observed z values did not exceed the critical z value of .96 (p .:S .05 critical value for a two-tailed test) in any of the PA categories. The null hypothesis was not rejected based on the data results The mean rank of individuals who perceived their environment had walking trails, parks playgrounds and or sports fields was not significantly different than those indi v iduals who did not perceive these resources existed in their environment. The data suggests that there is no difference between whether an individual perceives environmental availability of the four 128

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resources for physical activity or not and minutes of physical activity performed per week. ESPALQ Item #9: Do you have shopping malls in your community for physical activity and/or walking programs? Table 4.16 Mann-Whitney Test: Shopping Malls and Physical Activity Respon se N z Mean Rank p-value Moderate non-work P A Yes has 50 40.24 No doesn't have 30 40.93 Analysis 80 -.13 .90 Moderate work P A Yes has 14 12.21 No doesn't ha ve 10 12.90 Analysis 24 -.24 .81 Total moderate PA Yes has 14 12.57 No doesn t have 10 12.40 Analysis 24 -.06 .95 Vigorous non-work P A Yes has 23 16.20 No doesn't have 10 18.85 Analysis 33 -.72 .47 Vigorous work P A Yes has 8 6.38 No doesn t have 4 6.75 Analysis 12 -.17 .86 Total vigorous PA Yes has 6 4.67 No doesn t have 3 5.67 Analysis 9 .52 .61 Note. PA = physical activity in minutes The observed z values did not exceed the critical z value of .96 (p S .05 critical value for a two-tailed test) in any of the PA categories. The null hypothesis was not rejected based on the data results Over 37% of the participants indicated their community did not have shopping malls. The mean rank of individuals who perceived their environment had shopping malls for P A or walking programs was not 129

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significantly different than those individuals who did not perceive these resources existed in their environment. This data suggests that there is no difference between whether an individual perceives environmental availability of shopping malls for physical activity or not and minutes of phy s ical activity performed per week. ESP ALQ Item # 10: Do you use any public recreation centers in your community for physical activity? Table 4.17 Mann-Whitney Test: Public Recreation Centers and Physical Activity Response N z Mean Rank p-value Moderate non-work P A Yes has 66 39.57 No doesn t have 14 44.39 Analysis 80 -.69 .49 Moderate work P A Yes has 19 11.97 No doesn t have 5 14.50 Analysis 24 -.71 .48 Total moderate PA Yes has 19 11.74 No doesn t have 5 15.40 Analysis 24 -1.03 .30 Vigorous non-work PA Yes has 19 16.02 No doesn't have 5 22.50 Analysis 24 -1.38 .17 Vigorous work P A Yes has 9 6.00 No doesn t have 3 8.00 Analysis 12 -.84 .40 Total vigorous PA Yes has 7 4.29 No doesn't have 2 7.50 Analysis 9 -1.46 .14 Note PA =physical activity in minutes The observed z values did not exceed the critical z value of .96 (p S .05 critical value for a two-tailed test) in any of the PA categories The null hypothesis was not rejected based on the data results. The mean rank of individuals who 130

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perceived their environment had public recreation centers for PA was not significantly different than those individuals who did not perceive these resources existed in their en v ironment. The null hypothesis "There is no difference between w hether an individual perceives environmental availability of public recreation centers for physical activity or not and minutes of physical activity performed per week ," cannot be rejected. ESP ALQ Item # 11: Do you use any schools that are open in your community for public recreation activities? Table 4 .18 Mann-Whitney Test : Schools and Physical Activity Response N z Mean Rank p-value Moderate non-work P A Yes has 67 39 54 No doesn t have 11 39.23 Analysis 78 -.04 .97 Moderate work P A Yes has 22 12.34 No doesn t have 2 14.25 Analysis 24 -.37 .71 Total moderate P A Yes has 22 11.95 No doesn t have 2 18.50 Analysis 24 -1.25 .21 Vigorous non-work P A Yes has 28 16.16 No doesn t have 4 18.88 Analysis 32 -.54 59 Vigorous work P A Yes has 10 6.15 No doesn t have 2 8.25 Anal ys is 12 -.76 .45 Total vigorous PA Yes has 8 4.63 No doesn t have 1 8.00 Analysis 9 -1.16 .24 Note. P A = physical activity in minutes 131

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The observed z values did not exceed the critical z value of .96 (p :S .05 critical value for a two-tailed test) in any of the PA categories. The null hypothesis was not rejected based on the data results. The mean rank of individuals who perceived their environment had schools that were open in their community for public recreation was not significantly different than those individuals who did not perceive these resources existed in their environment. The null hypothesis There is no difference between whether an individual perceives environmental availability of schools for physical activity or not and minutes of physical activity performed per week," cannot be rejected. Hypothesis 5: There will be a relationship between self-efficacy and minutes of physical activity in individuals with arthritis who live in rural communities Self-efficacy was measured using the Arthritis Self-Efficacy Scale (Lorig et al., 1989). Self-efficacy was defined for the survey participants as "how much control you have over your arthritis" by the principal investigator with RAC agreement. Scatterplot analysis between self-efficacy function scale and minutes of moderate P A log I 0 indicated a low r2 linear line of fit (/linear = 0.007 r=.084 ), which violated the assumption of a linear relationship when using Pearson product moment correlation (Morgan Leech, Gloeckner, & Barrett, 2004). Therefore, Spearman Rho was computed to assess the relationship between the self-efficacy function scale discussed in the Methods section, and minutes of physical activity. Cases were excluded pairwise. Normality is not an assumption of Spearman Rho and the minutes 132

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ofPA were not transformed for this analysis. Table 4.19 displays the results of the analysis. Table 4.19 Spearman Rh o Corre l ation: Arthr iti s Self Efficacy Function and Minutes Physical Acti vity Arthritis Self-Efficacy Phys ical Activity (minutes) N Correlation p-value Moderate non-work PA 80 .031 .786 Moderate work P A 24 I I I 605 Total moderate PA 24 -.0 36 .868 Vigorous non-work PA 33 236 186 Vigorous work P A 12 -.138 670 Total vigorous PA 9 -.025 .949 No te. PA = physical activity Correlation values were low for all categories of minutes of P A, ranging from 138 to .236. These results indicate that with the represented populations for each categor y of PA the null hypothesis there will be no relationship between selfefficacy and minutes of physical activity in individuals with arthritis who live in rural communities ," cannot be rejected H y pothesis 6 : There will be a relationship between attitude towards physical activity and minutes of physical activity in individual s with arthritis who live in rural communities. 133

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The Physical Activity and Arthritis Questionnaire (P AAQ), developed by the rural arthritis committee was used to assess attitude regarding arthritis and physical activity in individuals with arthritis residing in rural east or northea st Colorado. The relationship between the individual's attitude about PA and their minutes ofPA was analyzed using Spearman Rho Spearman Rho was chosen for the analysis based on the violation of a linear relationship (r2 linear=0.038 r=0 195), an assumption with Pearson product moment correlation (Morgan, 2004). Normality is not an assumption of Spearman Rho and the minutes of P A were not transformed for this analysis. Table 4.20 displays the results Table 4.20 Spearman Rho Correlation: Attitude about Phy sica l Activity and Minutes Physical Activity Attitude about Physical Activity Physical Activity (minutes) N Correlation p-value Moderate non-work P A 74 -.213 .068 Moderate work P A 24 -.113 .598 Total moderate PA 24 .047 .826 Vigorous non-work P A 30 -.426 .019* Vigorous work PA 12 .275 .387 Total vigorous PA 9 .101 .795 Note. PA = physical activity *Correlation is significant at the 0.05 level (2-tailed) 134

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The res ults presented in Table 4 20 indicate the null hypothesis there wi ll be no relationship bet ween attitude towards physical activity and minutes of physical activity in individual s with arthritis w ho live in rural communities," cannot be rejected for all activity categories except minutes vigorous non-work PA. The Spearman Rho s tatistic for minutes vigorous non-work PA was calcul a t e d r5(28) = -.426 p = 0 19. The direction of the correlation was negati ve, which means that participants who had higher scores in the P AAQ, indicating a positive attitude about being more physically active, reported fewer minutes of PAper week. For all other categories there was no significant association between attitude about P A and minutes of physical activity, based on the sample population data The null hypothesis could not be rejected for the remaining categories of P A. Hypothesis 7: There will be a relationship between individuals with arthritis perception ofhow others perceive physical activity and arthritis and the individual's minutes ofphysical activity. According to Ajzen and Fishbein (1980) the concept of subjective norm suggests an individual's behavior will be influenced by other peoples opinion about the behavior. The P AAQ captured the participant's response to items in the subjective norm scale. Higher s cores on the subjective norm scale indicated the participant would be more active if others indicated they should be and if their sphere of influence was active as well. Spearman Rho was calculated to determine if there was a relationship between subjective norm and minutes of work or non-work moderate 135

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or vigorous P A. Spearman Rho was chosen for the analysis based on the violation of a linear relationship( / linear=0.019 r = 0.138), which is an assumption with Pearson product moment correlation. Findings ofthis analysis are presented in Table 4.21. Table 4.21 Sp e arman Rho Corr e lation : Subj e cti ve Norm and Minut e s Ph y sical Activity Subjective Norm Physical Activity (minutes) N Correlation p-v alue Moderate non-work P A 72 -.068 .569 Moderate work PA 22 .249 264 Total moderate PA 22 .271 .222 Vigorous non-work PA 28 -.266 .171 Vigorous work PA 10 -.305 .391 Total vigorous PA 7 .337 .460 Note. PA = physical activity The Spearman Rho analysis indicates no correlation between how individuals perceive other s view physical activity and arthritis and minutes of P A With alpha= 0.05 the null hypothesis "there will be no relationship between individuals with arthritis perception of how others perceive physical activity and arthritis and the individual s minutes of physical activity ," could not be rejected Hypothesis 8 : There will be a relationship between individuals with arthritis who perceive they have control over their level of physical activity and minutes of physical activity 136

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The construct of perceived behavioral control, described in the Theory of Planned Behavior by Ajzen (1991), parallels the concept of self-efficacy and incorporates the idea that an individual s perceived control over a behavior, in this case, physical activity, will influence the behavior. Individuals with a high score on this scale indicated a higher belief in the ability to be active and fewer concerns P A would negatively impact their arthritis. Spearman Rho was used for this analysis for the same reasons identified in analyzing Hypothesis 7 and the results are presented in Table 4.22. Table 4.22 Spearman Rho Correlation: Perceived Behavioral Control and Minutes Physical Activity Perceived Behavioral Control Phy sica l Activity (minutes) N Correlation p-value Moderate non-work PA 78 .059 .606 Moderate work PA 24 -.071 .740 Total moderate PA 24 -.005 .981 Vigorous non-work PA 32 -.015 .934 Vigorous work P A 12 .016 .960 Total vigorous PA 9 .230 .552 Note. PA = physical activity The null hypothesis "there will be no relationship between individuals with arthritis who perceive they have control over their level of physical activity and minutes of physical activity,' could not be rejected at the alpha level 0.05. No 137

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correlation was noted between an individual's perceived behavioral control and minutes of P A based on the level of significance determined during this analysis Hypothesis 9: There will be a difference between individuals with arthritis who report that a healthcare provider recommended physical activity versus those who report no recommendation and minutes of physical activity. Survey participants were asked "Has anyone that you see for your health told you to be more physically active?" on the final survey. Over 57% of the respondents reported that they had not been told to be more physically active. An Independent Samples t-test was performed to determine if there was a difference between respondents who were told to be active versus those individuals who were not told to be active and the minutes of reported P A per week. Minutes of P A were transformed for moderate non-work P A, total moderate P A, vigorous non-work P A, and total vigorous PA in order to meet the assumption of normality for the t-test. Table 4.23 describes the group statistics and Table 4.24 presents the independent samples t-test results. 138

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Table 4 .23 Ind ependen t Samp l es Test: R ecommend versus No t R ecommend w ith PA Recomm e nd N Mean Std. D ev. (yes / no) moderate nonwork No 44 2.46 .51 PA logiO Yes 32 2.33 .45 moderate work P A No 14 1146.43 1003.11 Y es 9 630.00 531.60 total moderate PA No 14 3.08 .44 logiO Yes 9 2.94 .33 vigorous non-work No 19 2.38 .53 PA lo giO Yes 12 2.20 57 vigorous work P A No 8 896.25 716.86 Yes 4 802.50 942.78 total v igorous nonNo 6 2023.33 2499.65 work PA loglO Yes 3 453.75 517 87 Note log I 0 noted on variable s transformed to reduce s kew PA =physical activity in minutes Table reflect s gro up s tati s tics 139

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Table 4.24 Indep_ende nt Samp_les T es t : Diffe r e nc es in PA by_ Recomm end or Not Recommend 95% CI of Mean Difference df p-value Lower log I 0 moderate 1.12 74 27 -.I 0 non-work PA moderate work P A 1.41 21 .17 -243.00 log I 0 total .87 21 .40 .21 moderate PA log I 0 vigorous .91 29 .37 -.23 non-work PA vigorous work P A .19 10 .85 -986.12 logiO total 1.04 7 .33 -1992.95 vigorous PA Note. log I 0 indicated where data transformed to improve normality PA =physical activity in minutes per week Upper 35 1275.86 .50 .59 1173.62 5132 .12 There was no significant difference in minutes of P A performed per week between individuals who were told to be more physically active by the health care provider(s) and those who reported not being told to be active The null hypothesis cannot be rejected at the alpha=0 .05 level. Specific Aim # 3 Specific Aim #3: Enhance the quality of the content of the survey, and the usefulness of the study's findings by fostering the participation of community members in the research process through a regional cornnmnity-based rural arthritis advisory committee. 140

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A rural advisory committee comprised of the principal investigator and up to eleven rural residents representing four counties in east and northeast Colorado significantly impacted the proceedings ofthis research study. Although this will be part of the Discussion section, results of community interactions will be highlighted in this section. The Methods section described the contributions of the community conunittee members during the organization and survey distribution phases. A pilot survey was completed, flyers and other marketing tools were developed, a distributions plan was identified, networking with other community members interested in arthritis was initiated, and thoughtful reflection on the impact of arthritis on individuals and the community was incorporated The approach to the community and meaningful "language" was critical in inspiring participation and providing value to survey respondents. Advocacy for the project was meaningful to the community because it was presented by community members Qualitative data enriched the findings through the addition of questions to the final survey by the RAC. Although the qualitative results will not be formally analyzed in detail for the purpose of this investigation, a few anecdotal reports will be discussed to add support to the value of the RAC's involvement in this project. The RAC added the open-ended question "What things in the physical environment keep you from being as active as you would like to be?" Responses included references to individual physical impairments to environmental conditions. 141

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For example respondents listed obesity pain, allergies macular degeneration comorbidities and fatigue as physical impairments to being active. Environmental barriers to incr e asing acti v ity levels included heat cold ice snow rain, wind uneven sidewalk s, lack of indoor facilities lack of pretty scenery and no warm water therapy facilities. Time old age ," and "a stagnant life were also mentioned as barriers to increasing activity. A second open-ended question "If you want to be more active, what would motivate you to be more physically active was included in the survey. Several respondents mentioned the availability of water therapy and or swimming. Other answers included having someone to be physically active with living in town weight loss money to access PA resources such as a gym accessibility of recreation facilities and convenient bathroom facilities, pain reduction with increased P A, more time and successful surgery. "Getting younger" was also provided as a theme for increasing P A The community s vision into a project directly addressing a community health concern provided information and perspective throughout the research process. The Discussion section identifies additional community-based contributions that provided value and insight into the research project. Model of Regression Simple linear regression was performed to determine if independent variables appropriate for this analysis predicted the dependent variable, minutes of moderate 142

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P A. Approximately normal variables, including those that were normalized through transformation, were examined through bivariate regression. Independent variables included the log 10 transformed AIMS2 physical function scale, the Arthritis Self Efficacy function scale, and the three scales from the P AAQ (attitude, subjective norm, and perceived behavioral control). Minutes of moderate non-work P A, transformed using log 10 was the dependent variable. Results of the bivariate regre ssion indicated no significant predictors of the dependent variable, minutes of moderate non-work P A. The R value for all regression equations was s .212, indicating small effect sizes (Leech et al., 2005). Analysis of several independent variables combined to predict the dependent variable, minutes of moderate non-work PA, was conducted using multiple regression. The independent variables included AIMS2 physical function scale transformed with log I 0, perceived behavioral control, subjective norm, attitude, gender, and use of private facilities for P A. These variables were generally linearly related to the dependent variable as demonstrated on the scatterplot matrix Variables excluded from this analysis included four additional environmental measures and the self-efficacy function scale due to high correlations with like-variables. Backward stepwise regression was used and "exclu de cases listwise selected. The adjusted R square from the multiple regression suggests that at most 9.8% of the variance in minutes of moderate non-work P A can be explained b y the model. The variables significantly predicting minutes of moderate non-work P A, F( 4,62) = 143

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2.79,p < .05, are the AIMS2 physical function sca le transfonned with loglO, perceived behavioral control, attitude, and use of private facilities for P A as predictor variables. Beta weights suggest that attitude contributes most to minutes of non-work moderate P A. Interpretation from the PAAQ would indicate that individuals who want to be more active have the fewest minutes of P A. The regression equation using standardized beta coefficients is: Minutes of moderate non-work PA loglO transformed= 2.48 + ( .35)attitude + ( 23)use of private facilities+ (.25)perceived beha viora l control+ (.17)AIMS2 physical function scale transformed with log 10. 144

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CHAPTER FIVE DISCUSSION Introduction This investigation used an inclusive community approach to examine correlates of physical activity in persons with arthritis living in rural communities in east and northeast Colorado. It was an opportunity to quantitatively identify perceptions of multiple factors affecting the lives of individuals who self reported doctor-diagnosed OA: time allotted to physical activity during work and or non-work activities the rural physical environment how much control they have over their arthritis their beliefs about the interaction between arthritis and PA and ultimately the impact of the arthritis itself on their lives. The study also for the first time gathered important demographic and health characteristics data on individuals with arthritis living in these communities It is believed that this is the first study to include community research partners in addressing physical activity outcomes in a population with a common disease process osteoarthritis which can affect function and the quality of life for individuals living in these rural locations. The literature supports many tenets of this study: P A can improve function and the qualit y of life in people with arthritis (Altman et al. 2000 ; D D. Dunlop et al. 2004 ; Fontaine et al., 2004 ; Macera et al. 2003) 145

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individuals with arthritis are les s active (Hootman et al. 2003; Shih et al. 2006) inactivity can increase morbidity (Garrett et al. 2004) and the risk of mortality (Powell & Blair as cited in Brownson Baker et al., 2004 ; Centers for Disease Control and Prevention 1998) P A can reduce the risk of serious disease processes (Bauman, 2004 ; Macera et al. 2003 ; Paffenbarger et al. 1993; U.S. Department of Health and Human Services 1996) health disparities exist in rural communities (Garkovich & Harris 1994; Hart et al. 2005) and correlates of P A in arthritis affected rural sub populations in Colorado are unknown. However, literature investigating a combination of these tenets does not exist. Pulling together multiple tenets to address a public health concern inactivity more accurately reflects "real life" communities i.e. individuals living within the context ofthe community with various states of health and reporting perceived levels of P A. A Rural Advisory Committee informed the research methods, results and discussion and increased relevance of the findings to the communities. The following discussion is divided into nine sections: community-based approach to the investigation demographic and health characteristics of the survey participants physical activity highlights hypotheses discussion theoretical perspectives contribution limitations, future directions and a summary statement. Community-Based Support and Investigative Influence Community-based participatory research (CBPR) shifts the focus from an investigator's curiosity about a problem or discovery within a community to the 146

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identified interests of the community itself. It empowers a community to voice concerns, challenges, opportunities, and questions related to their topic of interest and enables community members to specify outcomes. Decisions affecting the community's well-being involve those individuals intimately engaged in day to day interactions with the research area. The Rural Arthritis Committee (RAC) represented five distinct rural communities with a common interest in arthritis. The eleven individuals on this committee had not previously met to work on a health concern relevant to their municipalities. The literature supports nine basic principles of CBPR (Minkler & Wallerstein, 2003), which were described in Chapter II. Due to the nature of a graduate school dissertation project, the research question was identified prior to the formation of this group and members were recruited who had a particular interest in community involvement in general and arthritis specifically. However, guidelines for CBPR note that no one set of community based participatory research principles is applicable for all partnerships (Minkler & Wallerstein 2003, p. 55) and voluntary participation by the RAC members indicated that they were supportive ofthe overarching goal to determine correlates of P A by persons with arthritis. As described previously the RAC had three community meetings over a period of 18 months. The final meeting was highlighted as an opportunity to discuss the findings, review the process and determine future directions which informs this section. During the RAC's third and final meeting initial descriptive survey results 147

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were prese nted by the PI and several topic areas were addressed. The group discussed the process of data collection Members felt barriers to survey participation included the len gt h ofthe survey as well as th e inclusion criterion of"doctor-diagnosed self reported osteoarthritis They indicated participants were more willing to answer the lengthy survey because th ey knew the RAC memb er. The $10 gift incentive also prompted participation Potential participants often knew they had arthritis from personal experience but had not been told by a HCP that they have arthritis and were therefore unable to participate due to the inclusion criteria. Interestingly Rao Callahan and Helmick ( 1997) found that more than 16% of individuals who reported that they have arthritis did not seek care for arthritis from a doctor. In contrast the PI noted that often individuals with apparent observable osteoarthritis did not feel they had arthritis. These individuals would describe community members with rheumatoid arthritis as examples of" people with arthritis ." Finally RAC members had hoped for a mechanism to determine if individuals they had personally given a survey to had actually completed the survey. Due to confidentiality this was not po ssi ble The RAC discussion also centered around HCP themes ." The committee felt HCPs needed to be more aware of community resources for people with arthritis. The y also commented that individuals with arthritis needed to have faith in their physicians and that ph ys icians needed to realize that the treatment needs for arthritis might change over time ; a prescribed treatment may not work after a period of time. Comments also included observations that there is often a level of tension or 148

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frustration experienced by the person with arthritis when the treatment isn t working and that patient input was not as valued as scientific literature. The committee acknowledged that often physicians are ver y busy and do not have time to educate about arthritis. The RAC considered how the rural component of this project influenced the process Concepts arising from this discussion included the mindset of farmers : it is inevitable that they will hobble" after the age of 45 years. The HCP member of the RAC had previously stated this was a common belief and this prompted addition of a statement onto the P AAQ. This was again validated by a previous discussion with a young farmers' organization that wanted advice on how to prevent this inevitable perceived disability. It was suggested that older males would not admit having arthritis; they had grown up in an environment of not asking for help. "Owning" arthritis might be perceived as disabled and requiring assistance. Other rural factors related to this project were brought up by various members. Twenty years ago one town represented by a RAC member instigated its first community "walk." Currently they have an annual relay for people with Alzheimer's, and it is a recognized activity of the community "Walks" aren t laughed at any more in this rural community and it was suggested that they should occur more often. It was perceived that urban life results in higher levels of stress. Activities such as going to the grocery store are perceived as more stressful in urban areas. And 149

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although their urban counterparts may have more resources for P A they don't take advantage of them. A final discu ssion involved brainstom1ing about current and future resource availability for persons with arthritis. A historical perspective indicated that one community had offered an arthritis support group approximately 14 years ago. Attendance dropped from an initial count of 45 people to 4-5 people within three weeks. Expectations were not met, and it was perceived the group participants wanted to do more than talk about arthritis Education on aspects of arthritis was suggested by a RAC member. In contrast, an individual from a different community reported the need for a support group in their area. One RAC member who was also a former HCP stated that if a friend were diagnosed with arthritis, they would not be able to suggest one available community resource to help their friend. It was mentioned that the "pat answer" was to lose weight," and this was often unhelpful and hurtful. Disclosure of a recent course offering on how to live with a chronic condition was of interest to the RAC It was agreed that HCPs should be aware of resources to recommend to their patients. Several considerations arose from this final meeting. Communities including the HCPs that serve these areas, must be aware of current resources for people with arthritis Open evolving discussions with the individual's primary physician about treatment options is important. Support systems perceived relevant to the community for people with arthritis might be useful. P A such as walking can be incorporated into 150

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fund raising events, and people with arthritis need to know what type and intensity of P A is safe and effective Understanding the "vantage of the rural residents may effectively direct educational interventions A follow up post meeting optional questionnaire was sent to the RAC members to allow additional input on the research project. Seven members responded. In addition to the previous discussions members suggested additional resource needs: indoor walking exercise and heated pool facilities at a reasonable cost; additional structured educational opportunities and exercise programs for people with arthritis, including written materials. The representatives from five communities joined together to engage in a project that addressed the l eading cause of disability in the United States : arthritis. The benefits to this process have been identified in the methods and discussion sections. It is valuable to describe challenges to the process of CBPR for future consideration. Individuals participating on the RAC commuted up to 2 hours one-way to attend the committee meetings Although the meetings were scheduled three to four months in advance unanticipated events precluded some participants from attending all three meetings. Sufficient time needs to be allowed to reach a comfort level between individuals from very different rural communities rural does not necessarily mean similar cultures The nine hours allowed for the RAC meetings gave wonderful insight for this relatively short period of time ; the wealth of information being shared increased dramatically at the final meeting and indicated the need for 151

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much more discussion on this topic. Rising transportation costs, time constraints and time to develop group relationships must be considered in future projects. Comparison of Results to Colorado Data Sociodemographics The AIMS2 and Final Questionnaire captured relevant descriptive information that can be compared to Colorado state data. The sample population included 80 participants. The average age of this sample population was 68.2 years; age ranged from 46 to 96 years of age. Males were underrepresented and comprised 25% of the survey participants as compared to slightly over 50% of Coloradoans. Over 93% of the samp le group self-characterized their race as "white;" this compares to 82.8% noted for the State of Colorado (U.S. Census Bureau 2000). Two median salary ranges were each reported by 22 5% of the sample population for a total of 45% respondent representation: $10 000-$19,999 and $20 000-$29,999. This compares to the median household income of$47,203 for the State (U .S. Census Bureau 2000), or potentially 36% to 78% less than the median State income. In fact the high end of the range, $29,999, was less than the median household income for four out of the five counties represented in this study Sedgwick was the only county reporting a lower median income of $28 278 The average median income for urban counties in Colorado is $53,799 (Colorado Rural Health Center 2007) which indicates an even larger disparity in income between the sample rural population and Colorado urban counties. The lower reported income might reflect that 58.5% of this population is 152

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retired unemployed or disabled per s elf-report and could be on a fix ed income The surve y population data was primaril y collected in 2007 which could also affect comparison with the U.S. Census dat a reported in 2000. As n o ted in the results there was no represent a tion of indi v iduals of Hispanic ethnicit y in the surve y s ample. U S Census Bureau d a ta indicates that a total of 8 5 % to 12.9 % of the population in the five represented counties were of Hispanic or Latino ethnicity in 2000 (U.S. Cen s us Bureau population, 2000). Further examination of this data indicates that of households comprised of individuals who are Hispanic or Latino only 14.4% were greater than 45 years of age (U.S. Census Bureau 2000). This represents only 0 01% of the entire population in these five counties which could account for the lack of representation in this sample of individuals of Hispanic ethnicit y who are 45 y ears of age or older. Snowball sampling may have further reduced the chance of including individuals of this ethnicity in the survey sample. Parks et al. (2003) found that income level predicts an adult s likelihood to meet PA recommendations. Using a modified telephone sampling plan and a survey instrument based on the BRFSS, National Health Interview Survey and other unnamed questionnaires they asked rural urban and suburban residents about demographics the phy sical environment social support for exercise and personal barriers to increasing P A. Their results confim1 that income level is as important if not more important than area of residence in analyzing individual s phy s ical activit y levels (Parks et al. 2003 p 34). In addition rural residents were least likely to be 153

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physically active when compared to urban and suburban resident s Consideration of income and rurality is important when discussing l ev els of PA. Although not analyzed for this project future analyses could ob se rve the association between income and PA in the s e communities. Educational att a inment varied between the survey population and State data For individuals 25 years of age and older in the state of Colorado 23.2% are high school graduates (U .S. Census Bureau 2000) compared to 47.5% ofthe sample group who reported achievement of a high school diploma. In contrast 21.6% of the State population has obtained a bachelor s degree (U.S Census Bureau 2000) whereas 12. 5% of the survey respondents stated that they had this degree. Educational attainment has repeatedly been positively associated with physical activity in adults and is noted by Trost Owen Bauman Sallis and Brown (2002). Higher levels of education may indicate higher l evels of P A. The correlation of P A with education in the sample population which currently does not exist could be analyzed in subsequent projects. Health Characteristics The health profile of the eighty participants can also be compared to Colorado 2004-2005 BRFSS data (Colorado Health Information Dataset, 2004-2005). As noted previously health limitations are often amenab l e to change through regular PA Table 5.1 compares key health characteristics of the survey respondents to the PMR 1 and Colorado state data. BRFSS data for individuals 65 years of age or older was used for 154

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comparison values since the average age of the survey participants was 68.2 years. In addition PMR 1 was included for comparison because four of the five counties represented in this stud y are a part of this classified grouping: Logan Phillips, Sedgwick and Yuma. The PMR 5 data, which includes Lincoln County, were unavailable for 2004-2005 and are not displayed The BRFSS protocol notes that a sample size of less than 50 is not statistically reliable (Colorado Health Information Dataset 2004-2005). All Colorado state data exceeded the minimal sample size for reliability. Although the sample size for PMR 1 was not statistically reliable for hypertension general tendencies can be observed. Table 5.1 Health Characteristics: Survey Participants and County or Colorado 2004-05 BRFSS Data Characteristic %Survey % PMR I Overweight (25.0-29 9 kg/m2 ) 44.7 (n = 76) 59.3 (n=54) Obese kg/m2 ) 31.6 (n=76) 28 2 (n=l82) Hypertension 42.5 (n=79) 71.1 (n=29) a Diabetes 16.2 (n=78) 24 0 (n=58) Note. PMR I and Colorado data reported for 65 years old a Not statistically reliable per BRFSS protocol %Colorado 55.7 14. 9 49.1 12.7 The sample population reported a lower percentage of people who were overweight and a higher percentage of obesity than PMR 1 or Colorado state values. The positive association between obesity and osteoarthritis has been previously 155

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described (Cooper et al., 2000; Felson et al., 1997 ; Grabiner, 2004; Klippel et al. 2008; Sharma et al., 2000). The fre quenc y of hypertension (HTN) and diabetes differed from PMR 1 and State data. Even though 42 5 percent of the respondents reported HTN, which was the highest reported co-morbidity, this fell short of the State average of 49% This may reflect that there were younger participants contributing to the health characteristics data of the survey group; the prevalence ofHTN increases with age (Lloyd-Jones, Evans & Levy, 2005). Only individuals > 65 years of age comprised the PMR 1 and State data, favoring a higher rate ofHTN. In addition the PMR 1 percentage of people with hypertension represented a sample size of29, which was noted as statistically unreliable per the BRFSS protocol (Colorado Health Information Dataset, 2004-2005). The prevalence of diabetes was higher in the survey group than the State data. Obesity is a risk factor for Type II diabetes. Type I and Type II diabetes were not separated in the survey questionnaire, and it is unknown if or how many self reporting adults had Type I or Type II diabetes. The study population, however, demonstrated a higher prevalence of diabetes and obesity than Colorado data reported for individuals::_ 65 years of age. Obesity can be affected by lifestyle intervention including physical activity (Knowler et al., 2002). As noted previously osteoarthritis can also be positively affected by physical activity. An investigation of the relative 156

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impact of physical activity on individuals with a combination of obesity Type II diabetes and arthritis is warranted. Physical Activity Discovery and Highlights Time Spent in Physical Activity The literature supports the integration of physical activity into an individual s lifestyle to promote health and reduce the risk or effects of chronic diseases (Dipietro 2001; Macera et al. 2003; U.S. Department ofHealth and Human Services 1996). Current recommendations from the American Heart Association and the American College of Sports Medicine advise a minimum of 30 minutes of moderate PA on five days per week or 20 minutes of vigorous P A on three days per week for adults including older adults (Haskell et al. 2007; M. E. Nelson eta!., 2007b). The current study investigated perceived weekly minutes of PA in individuals with OA between the ages of 45 and 96 years old. The data indicate perceived PA performance tendencies in this population. Survey selection predicated that one hundred percent of the 80 study participants reported time spent in non-work related moderate P A per week, and these 80 individuals reported variable amounts of other PA. Forty-one percent of this group stated they participate in vigorous leisure-time P A. As expected fewer respondents reported moderate or vigorous work activity with 56 2% of this group not working. Of the 32 individuals who reported working 75% included moderate activity as part of their work day and 37 5% stated that they inc orporated vigorous work activity. 157

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Examination ofthe results determined how many of the individuals were meeting the weekly P A recommendations. Based on current recommendations, a total of 150 minutes of moderate activity or 60 minutes of vigorous P A per week is recommended for adu lts and older adults (Haskell et al., 2007; M. E. Nelson et al., 2007b ). Sixty-nine percent of individuals reporting nonwork related moderate PA met the recommendations based on non-work moderate activity alone. Eighty-eight percent of the 33 individuals listing minutes of vigorous PA met the weekly PA requirements per self-report based on vigorous P A alone An additional eight respondents met the weekly recommendations through non-work P A by summating their reported moderate and vigorous P A per week. This increased the total number of respondents meeting adult PA guidelines through non-work PA to 73.8%. Of those individuals who worked, all but three met the moderate P A weekly recommendation through work activity alone, and the 12 participants who reported minutes of vigorous PA at work per week all achieved PA goals. Adding moderate non work PA to the three participants who did not meet guidelines through work activities alone increased their weekly moderate PA accumulated minutes to meet recommendations. The percentage of individuals meeting moderate and vigorous P A recommendations is markedly higher than reflected in previous literature For example, Schoenborn and Barnes (2002) state that nearly 40% of adults do not participate in leisure (non-work) activities. However, the Colorado Health Information Dataset (COHID) indicates that 82.1% of the Colorado population 158

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reported participation in "any physical activities" over the timeframe of one month (Colorado Health Information Dataset, 2004-2005). Colorado is listed as one offive states with 80.8% or higher adult participation in "any physical activities" (Centers for Disease Control and Prevention, 2006). This percentage is the highest attainable category of reported PA. Eyler (2003) also noted higher PA levels than reported in national survey reports in white women between 20 and 50 years of age living in rural communities. Over 50% met moderate activity recommendations compared to 26.1% reported in the 1997-1998 National Health Interview Survey. Although this study included a younger, all female survey population it reflects the variance that can occur from national data The CO HID data reports the response to the P A item as "yes" or "no" and labels it as leisure time exercise" (Colorado Health Information Dataset 2004-2005). Data do not differentiate between levels of intensity for the P A. Results of the COHID data by age group relevant to the current study for Colorado and PMR 1 are listed in Table 5.2 Data for PMR 5 is not reported for 2004-2005. 159

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Table 5.2 Colorado and PMR 1 BRFSS Data: Participation in Ph ysical Activity Colorado: n (%) PMR 1: n (%) Age Group 45-54 Leisure time exercise= no 398 (16.4) 45-54 Leisure time exercise = yes 2,267 (83.6) 55-64 Leisure time exercise= no 370 (19.1) 55-64 Leisure time exercise= yes 1 633 (80.9) 65+ Leisure time exercise = no 604 (27.0) 65+ Leisure time exercise = yes 1,636 (73.0) Note. Data reflects leisure time activity over the last month. (Colorado Health Information Dataset, 2004-2005) 9 (22.6) 30 (77.4) 8 (27.3) 23 (72.7) 21 (34.9) 37 (65.1) These data reflect a relatively high percent of individuals who perceive that they participate in P A during a one month time period. Between 65% and 77% of the respondents in PMR I indicated they participated in leisure time exercise." This is comparable to the 73.8% reporting participation in moderate or vigorous PAin the current study. A direct comparison cannot be made due to lack of reported level (moderate or vigorous) or minutes ofPA in the COHID data but it suggests a high percentage of people in Co l orado perceive they participate in non-work P A. A challenge with interpretation may arise between the stated question, During the past 30 days other than your regular job, did you participate in any 160

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physical activities?" and the reporting of data as "le isure time exercise." As noted previously exercise and P A are defined differently. There are several potential explanations for the large range and relatively high levels of reported PA in the survey population. These details will be discussed in the following paragraphs. The RAC members were instrumental in the development and progression of this investigation. Committee members volunteered to participate for a number of reasons, which affected subject recruitment. They were active community members who were diagnosed with arthritis and or were committed to helping the people in their community. One individual, when asked for his or her reason for volunteering on the committee stated "I have arthritis and thought it might be able to impact the availability of exercise opportunities (personal communication, October, 2007) Another individual wrote, We need more info, support groups, and community awareness of arthritis needs in area" (personal communication, October, 2007). Their involvement in the community often led to distribution of surveys to individuals attending similar group functions such as women's or men s club meetings social activity groups and or community enrichment groups. It was the impression of the principal investigator that the RAC members were knowledgeable and committed to the health and well-being of people with arthritis. They may have directed survey distribution to like-minded individuals who were active and high functioning members of the community. 161

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The RAC community connections also connected the PI with active community groups who used the $10 gift card incenti v e to raise money for service goals. Again the mindset of community involvement and helping community members selected participants who were willingly engaged in the community and through snowball sampling "chose individuals involved in similar active lifestyles. One particular group collecting the gift card contributions for service to others indicated they would reach every adult in their county with OA. Self-reported minutes of moderate and vigorous non-work related P A spanned a large range : 15 minutes to 70 hours of moderate non-work P A per week and 26 minutes to 84 hours of non-work vigorous P A per week Self-report measurement tools inherently have benefits and limitations to their use. Sallis and Saelens (2000) addressed the concept of assessing an individual's amount of P A through selfreport and reviewed multiple P A measurement tools including four tools developed for self report by older adults. The benefits of such tools included the ability to collect large quantities of data at low cost, lack of investigative effect on the behavior being studied and the ability to assess patterns of behavior by addressing multiple dimensions of physical activity (Sallis & Saelens 2000). Limitations included the inability of a tool to capture relevant acti v ities for the target population (Sallis & Saelens 2000) difficult nature of recalling P A over time (Baranowski 1988) ambiguity ofterms such as moderate intensity" and physical activit y," (Sallis & Saelens 2000) and potential for social desirability bias that can lead to inflated values 162

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of reported P A (Warnecke et al. 1997) Sallis and Saelens (2000) noted that children and very old adults are likely to have particular memory and recall skill limitations (p. 1 ). Their literature review indicated that although reliable and valid self-report instruments exist that measure PA most self-report studies conclude that self-reports do not reflect accurate estimates of true P A levels. They recommended use of additional objective measures to enhance findings of self-report P A tools such as accelerometers. DiPietro (200 1) adds that P A is a complex behavior that is difficult to assess particularly in older adults The literature supports measuring P A in order to find associations with health outcomes and other variables. In older adults active lifestyles as opposed to structured exercise programs may result in moderate intensity PA which contributes to reduced morbidity. Activities might include housework, gardening, and vacuuming. Accurate measurement of time increments can be intrusive such as through observation or accelerometer use and may alter habitual P A patterns. Therefore investigators often rely on self-report instruments. DiPietro (200 1) notes that issues of recall ... in older people lead to less than precise estimates" (p. 13). Further research on the accurate measurement of PA through self report tools in diverse populations is needed Other factors likel y influenced reported P A. As noted in the Methods section nearly one-third of the respondents answered "don t know / not sure to questions related to time increments of P A per week Calculating time spent in P A per week 163

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requires time and recall effort. Individuals may have chosen not to spend this time, given they were already completing a lengthy survey. Differentiating work and leisure time P A may have been difficult for self-employed participants. Boundaries may overlap, for example, with individuals who farm or ranch for a living. Examples of moderate and vigorous PA provided on the questionnaire may not have had meaning to respondents and allowed for error in estimation of P A. More activities representative of the survey population may have clarified the P A questionnaires. The fact that there was a wide range of reported P A time increments may reflect the wide age range and or variability in lifest yles Outliers were not excluded in order to preserve all participants' perceptions of their weekly PA. Does It Add Up? The sum of work and non-work related moderate or vigorous P A can indicate whether or not a survey participant achieved the recommended PA va lues. Few studies have examined the total amount of work and non-work related P A in achieving P A guidelines (Trost et al., 2002), particularly in a sub-population with a chronic disease. Two questionnaires using s imilar formats, the BRFSS and the OPAQ, allowed respondents to estimate their time in work and non-work P A. In this study, 100% ofthe participants who worked achieved PA guidelines when including their reported non-work related activities. Over 73% of the research cohort met the recommendations through non-work P A alone. Including work and non-work P A in 164

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future investigation in diverse populations may demonstrate a higher percent of individuals meet the national P A recommendations. Hypotheses Discussion Correlates of Physical Activity in a Sample Population The literature suggests adults with arthritis are not meeting the current recommendations for PA (Fontaine et al., 2004; Hootman et al., 2003). Multiple influences can affect levels of PA. This survey was designed to identify potential correlates of P A in individuals with arthritis residing in rural east and northeast Colorado. Arthritis impact arthritis self-efficacy, environmental influences, gender, distance from town HCP interactions and factors influencing the intent to perform PA were examined. Open-ended questions allowed participants an opportunity to expand beyond the survey's quantitative boundaries. Survey results related to correlates of P A are discussed in this section. Effect ofGender, Distance from Town, and HCP Influence on PA Gender, distance from town and a HCP's recommendation to be physically active did not produce results that had statistical significance in this sample population. There was no difference between the average number of minutes in intensity or amount of P A between males and females. The literature suggests that females in rural communities are the least active subgroup when compared with males in rural and urban areas (Centers for Disease Control and Prevention 1998; Wilcox et al., 2000). In this sample, females were, on average, more than three years 165

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younger than males and 63% of women were still in the w ork force compared to 56 % of the surveyed males. Younger average age and accumulation of work P A may ha v e contributed to the lack of difference between males and females Males were underrepresented in this study which affected the sample size and over all result reporting in this sub g roup of the sample population. Distance from town did not significantly affect the perception of how much time was spent in P A per week. Additional information regarding the type of work and or non-work activities performed by individuals living in town versus out of town would inform these results and clarify perceptions. Only 42% of individuals who reported moderate non-work PA were told to be physically active by a HCP. Exclusion criteria disallowed individuals who were unable to be physically active and therefore respondents were eligible for P A education It is unknown if the HCP perceived the individual was already active enough which could be investigated in the future Given the health characteristics profile of this population including high rates of obesity and significant HTN and diabetes discussion of the individual s current level and types of P A is warranted. For example the HCP can identify risk factors amenable to change through P A. HCPs with specialty in exercise prescription for individuals with comorbidities such as ph y sical therapists can educate in safe and effective forms of PA that can be performed through work and or non-work related activities favored by the individual. 166

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Education by HCPs as noted previously, w as a recommendation b y the community members and can be incorporated into c ommunity and individual health education A rthriti s and Physical A c ti v i ty The independent v ariable arthriti s impact ," was most clos e l y associated with minutes of moderate work PA as opp o sed to vigorou s or non-work PA (r(23) = .403 p = 0.057) Six ofthe 12 AIMS2 s cales provided a combined score for each respondent that reflected the impact of arthritis on their physical function. This value was used to determine if a relationship exist e d between the independent variable and minutes ofPA per week. Arthritis impact frequency data was markedly positively skewed (skewness = 1.97) indicating that the lower scores which reflect a higher health status were more common in this population. The positive correlation indicates that individuals who reported less arthritis impact on physical function were associated with fewer minutes of P A. A negative correlation would indicate individuals with a lower health status reported fewer minutes of P A which might be expected. The sample size may have prevented finding a significant relationship between the two variables. Data representing other areas of arthritis impact such as on affect social interaction symptoms and work roles were not anal y zed for this study Environmental R e sources Questions related to P A resources in the physical environment did not provide significant results. Whether or not the respondents perceived their communit y had resources for P A did not correlate with minutes of P A. Ninety-one percent of 167

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respondents who reported participation in moderate non-work P A indicated their communities had private recreation facilities availabl e for PA which was surpri s ing in the rural areas. The strongest association occurred between moderate non-work P A and the availability of private recreational facilities (n = 79 p = 0.062) A significant result would have indicated that there was an association between the presence of private recreational facilities and minutes of non-work moderate P A. Although this correlation had the largest sample size relative to P A response more participants might be needed to detect a significant association between P A and availability of P A resources. The ESPAQL survey provided questions to determine whether or not certain P A resources existed in the community and served to identify potential facilitators or barriers to PA by their presence or absence in the community The environmental resource presence or absence was not significantly associated with time spent in P A in this study The wording ofthe questions could have led to confusion for respondents. For example the question "Do you use any public recreation centers in your community for physical activity? was followed by four potential responses: yes ," no ," my community does not have these facilities ," and "don t know / not sure It is possible a participant would stop after the second answer, no ," because they did not believe the facilities exist and therefore did not use them. For analyses the "yes" and "no" responses were combined to indicate the community has the 168

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resources as previously described. If answered incorrectly this would inflate the perception that the community had the resource. Additional factors likely influenced the results. Trost et al. (2002) notes the challenges associated with drawing conclusions from perceived environmental influences on PA from cross-sectional study designs. At any point in time, individuals who are active outdoors may have greater awareness of resource availability, or, on the flip side perceived barriers that prevent access Eyler (2003) reported that only one of seven investigated environmental barriers, fair compared to good street lighting, was significantly correlated with P A. The question of validity of measurement tools the ability to detect only outdoor activities, or sample size to discover a significant relationship were cited as possible explanations. Bauman, Smith, Stoker, Bellew and Booth ( 1999) reiterate the need to produce valid measurement tools that include environmental perceptions. They consider the option that certain environments entice individuals who prefer a more active lifestyle. The high levels of P A in the current sample population may have been due to lifestyle activities available through work and non-work related activities in a rural environment where they chose to live. Responses to a qualitative question in the Final Survey added insight into environmental barriers. Participants were asked "What things in the physical environment keep you from being as active as you would like to be?" As reported in the results section, common themes developed. A major concern was the lack of 169

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accessible indoor facilities available for P A to provide a level surface for walking and climate control. A community-based intervention might look at current resource availability such as schools in the area and provide scheduled time for use. Community discussions revolving around intergenerational PA programs might promote increased accessibility Motivation to be active was addressed by asking "If you want to be more active what would motivate you to be more physically active? RAC members phrased the question to include only those with a desire to be active. As reported previously several environmental components surfaced. Warm water pools low or no cost facilities and access to parks were suggested. The perception of needing "a place" to be active at an attainable cost could direct communities including their governance to consider options One community represented in this project recently (during the time period of this research) directed fundraising at providing money for a warm water therapy pool in their new hospital. It was designated as a therapy pool with the added benefit of availability for independent exercises This was a specific and very successful example of a community-recognized need being met by the direct efforts of community members. It is difficult to be sure the right questions related to a particular culture are being asked about P A and the physical environment. Although rural environments may predispose to certain physical environmental barriers such as uneven or lack of sidewalks this may not affect an individual's decision to participate in outdoor 170

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activities. How much can be generalize d from one rural enviro nment to another? Additional communit y -ba se d qualitative research could inform this process and strengthen the ability to de ve lop a va lid m eas ur ement t ool. Theoretical Perspective-Qu a ntitative and Qualitative Insi ght The constructs based on the Theory of Reason e d Action/Theory of Planned Beha v ior were examined for an association with actual minute s of P A performed. The three constructs, "attitude ," "s ubjective norm ," and percei ve d behavioral control," were embedded in statements in the P AAQ and were based on concepts that would measure the intent to perform P A. "Attitude had a significant negative correlation with minutes of non-work vigorous PA (n = 30 p = .019). Four statements from the PAAQ were found to form an Attitude subscale following principal axis factor analysis. The negati v e correlation suggests that those who reported more minutes of P A had a lower score on "Attitude ." Lower scores on the P AAQ indicated the participant disagreed with the construct statements. The wording of the statements clarifies this negati ve correlation For example, the statement I would like to be more physically active was part of this construct reflecting attitude about P A. The negative correlation indicates th a t individuals with fewer minutes of P A agreed with the P AAQ statement that they would like to be more ph ys ically active. Conversely, respondents with high minutes ofPA did not agree that they would like to be more ph ys ically active. Potentially individuals who are less active recognize the need to be more active and their attitude 171

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could be considered favorable towards being more active Further qualitative investigation of the relationship between attitude and PAin this population is warranted. Although the relationship between the construct of subjective norm and minutes of PA did not reach significance, qualitative indicators of the need for social support a related concept were evident. The concept of subjective norm carries a social component that indicates whether or not others' approval of a behavior is important to the individual. Approval could be represented by co-participation in a behavior in this case PA. The construct of subjective norm was represented by three statements following principal axis factor analysis including, "I am likely to be physically active if my friends are active as well." Responses to the Final Survey question, "If you want to be more active what would motivate you to be more physically active? supported social support as a motivator to be active as noted in the results section. Respondents wanted someone to "be physically active with" as well as "encouragement from my husband and myself." Access to social PA groups and encouragement from "significant others" could be points of discussion for community members interested in directing interventions to increase P A. Further information is needed on the barriers to social support. The final construct perceived behavioral control did not significantly relate to the amount of time spent in P A per week. Statements such as "Arthritis keeps me from being physically active ," which were reverse coded for analysis, reflected the 172

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subscale of percei ve d beh aviora l control. This construct is considered similar to Bandura's self-efficacy construct (Glanz et al., 2002). A sig nificant po sitive correlation would suggest that an individu a l who dis agrees with this statement would have high le ve ls of P A. In this population there was no association between control over arthritis and P A with minutes of P A per week. The ASES tested another perception of control over daily functions Self efficacy or perceived control over daily physical functions in individuals with arthritis was examined to determine if control over functional activities such as the ability to walk a certain distance over a defined period oftime related to the amount of P A performed per week Similar to the concept of perceived behavioral control belief in one's ability to perform functions was not related to the amount of time spent in PAper week. It is interesting that the correlation between perceived behavioral control and moderate non-work P A log(l 0) (p = .445) and the correlation between self-efficacy function from the ASES and moderate non-work PA log(IO) (p = .446) were virtually identical. Contributions Starting the Dialogue This is the first known study that invited communities in rural Colorado to participate in the research process regarding the most common cause of disability arthritis. Individuals most affected by arthritis have offered insight into how their communities are affected; they have shared their voice, expertise, organizational skills, passion insight and concerns to inform the research process. Meetings with 173

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the RAC have provided a model to begin discussions with other rural communities that share an interest in arthr itis This investigation has initiated a process of discovery into factors that influence the activity levels of people with arthritis living in rural communities in east and northeast Colorado Questions can be posed to continue this discovery process: Are the measurement tools appropriate for this population are there other correlates that predict the P A level in this population how can health risk factors be reduced and are perceived levels of P A equal to actual levels of P A? Limitations Self-report bias. Verification of doctor-diagnosed self-reported osteoarthritis was not confirmed by the PI's direct examination. Self-reported diagnoses can be inaccurate and therefore distort research findings It is possible the diagnosis of OA was over-reported. Dunlop et al. (2003) and Sacks et al. (2005) note that self-reported diagnoses are useful to capture responses from individuals who may or may not see their physician for arthritis. Distinguishing the type of arthritis by the individual may also interfere with the accuracy of diagnosis if their HCP has told the individual that they have arthritis. Bursitis and tendonitis are categorized in the broad spect rum of "art hritis and an individual's interpretation of their diagnosis might be inaccurate. It is difficult to determine how the self-report bias would impact the overall survey results. Individual characteristics of those with a diagnosis other than OA might have 174

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varying degree s of pain activity limitation s, comorbiditi es beha v ioral b e liefs or other factors that could affect their response to the s ur v ey que s tions Generalizabilit y The 80 survey participants w ere not significantl y differ e nt in ke y variabl e s from the original sample of 119 p e ople. The results could be generalized to this larger g roup. Effort s w ere made to represent a v ariet y of geographical communities by the RAC from east and northeast Colorado. An increased sample size with random sampling methods could increase the generalizability of this study. Additional research with similar parameters is needed to better understand the generalizability to other rural populations. Measurement instruments for P A. Multiple choice options for the PA survey questionnaires allowed participants to choose "don' t know / not sure for minutes and da y s spent in work or non-work PA each week. Nearly 33% of the completed surve y s demonstrated this response and were excluded from further analysis. This significantly reduced the sample size for results and discussion A comparison between the respondents and non-respondents on several key variables did not find a significant difference However a larger sample size may have resulted in significance in additional analysis for chosen independent v ariables. Recall bias. Recall bias may hav e resulted in errors in reporting time spent in P A. There is consid e rable personal time and effort required to recall levels and amount of P A over a timeframe and respondents may have overestimated or underestimated their minutes of P A. Social desirability bias would also explain 175

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overestimation Individuals may want to be perceived as more physically active than accurate times would reflect. The data indicate a few extreme outliers for minutes of P A. Tllis significantly affects scatterplot tests for linearity prior to performing correlations and positively skews the data. Snowball sampling The method of survey distribution, snowball sampling can limit the breadth of contacts made in the community. Individuals distributing surveys most likely sought participants they knew through social or work context. RAC members directed the survey distribution which may have limited it to their known networks This could limit generalizability to populations with different cultural backgrounds, educational levels socioeconomic backgrounds, etc. Time commitments. The members of the RAC often overcame barriers of travel and time to attend the three scheduled meetings. It is difficult to schedule a date that meets a total of 12 individuals schedules within a 200 mile radius. The logistics need to be carefully monitored to allow maximal involvement with minimal intrusion into daily lives Dissemination Future Directions and Interventions Community-based participatory research (CBPR) supports the dissemination of results "to all partners and involves them in the wider dissemination of results" (B. A. Israel Eng E., Schulz A. J., & Parker E. A., 2005 p 9). The next step is to inform the RAC and other interested community members ofthe comprehensive results of this project. Dissemination suggestions from the RAC had included 176

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developing strategies to shape the community's hospital and clinic strategi es for working with individuals with OA de ve loping and publishing a resource g uide that would include education on the benefits of P A and writing an executi v e summary to be sent to the local new s paper local development coordinators ," and m e dic a l facilities. Multiple unanswered questions often lead to dynamic and thought-pro v oking discu s sions and research pathways. The community-based approach allows for informed and relevant future direction decisions and development of community identified intervention strategies to facilitate health within the communities Additional information may be needed to determine correlates pertinent to these areas For example measurement tools may need to be changed or modified to provide useful and scientifically sound infom1ation. Survey data were also collected on 16 individuals with doctor-diagnosed self reported rheumatoid arthritis (RA). These data can be analyzed to describe correlates of P A in a sample of individuals with RA Further investigation of RA and other types of arthritis could provide information and applications to a broader population Primary prevention strategies to reduce the prevalence of arthritis need to be explored. The National Arthritis Action Plan: A Public Health Strategy identifies four points of entry for effective interventions including weight management occupational injury prevention sports injury prevention, and infectious disease control (for example with Lyme disease) (Arthritis Foundation et al. 1999). Joint protection and 177

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education are key principles of these interventions and could be directed through rural community channels in partnership with healthcare providers. Reducing the prevalence of arthritis, the leading cause of disability in the United States would have significant benefits to individuals and their associated communities. Summary Statement I have learned so much more than the communities ... Physical activity is a complex behavior that can be influenced by many factors. Involving community members in discovery of what shapes their physical activity experience is necessary to achieve clarity and accuracy Communities must be directly involved in the discovery process to determine interventions that will affect their health, function, and quality of life. Individuals share common chronic diseases processes that affect their functional ability and quality of life. Osteoarthritis, a chronjc disease affecting the joints is the leading cause of disability in the United States and promises to adversely affect more lives as the population ages. Effective management of the disease process, including physical activity, can reduce the individual and economic burdens as well as the comorbidities often noted with inactivity such as diabetes and hypertension. This investigation was unique in its focus on PA in individuals with arthritis in rural communities. Instruments to measure P A, the dependent variable, required self-report recall oftime spent in work and non-work (where indicated) PA per week. 178

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A high percentage of respondents did not estimate actual minutes of P A and answered, "don't know / not sure" to this portion of the survey. Ofthose who provided minutes of work and or non-work PA data were highly skewed and overall indicated higher than previously reported levels of moderate and or vigorous P A. Few investigations have attempted to estimate total work and non-work P A. Understanding the levels of total PA in varied communities may require a more tailored approach to measurement. It is unclear if individuals living in these rural communities differentiated between work and non-work P A if their work was intimately intertwined with their daily activities, such as might occur in farming communities. Operationalization and measurement of P A in similar subgroups needs to be clarified through methodological studies that seek to accurately define P A. Qualitative research, including insight from the Rural Arthritis Committee, would also be useful to inform the assessment ofPA; it can help in the construction of instruments that take into account the definitions of P A of rural residents, in light of the complex "real life" scenarios noted in this study. More precise estimates oftotal PA may help identify relationships between PA and factors affecting PA in individuals with osteoarthritis in these rural communities that have not been detected. Communities that acknowledge the associated disability of arthritis can work together to lessen the burden. Facilitating discussions and investigating common perceptions of the effects of arthritis with the community s involvement can help elucidate an understanding ofthe needs of the communities in combating the 179

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disabilities related to arthritis. 180

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APPENDIX A CONSENT AND HUMAN SUBJECTS APPROVAL Informed ConsentPilot Survey Informed Consent-Rural Arthritis Committee Informed ConsentPhotograph Informed Consent-Survey Human Subjects Research Committee Approval : 2006 Human Subjects Research Committee Approval : 2007 181

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Informed ConsentPilot Survey Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson PT MS Doctoral Student Health and Behavioral Sciences University of Colorado at Denver This is a pilot survey for a research study and includes only those people who want to participate. Why is this study being done? This is a research project about physical activity for people living in rural areas who have arthritis. People with arthritis who live in rural communities may have unique challenges in getting the right types of physical activity that could improve their overall well being. The community and individuals within the community are in the best position to look at what affects their ability to be physically active This study is being done to look at issues that help or make it harder for people with arthritis to be active in rural communities. It will involve a community advisory board and individual responses to look at these issues. What will I have to do if I agree to be in the study? You are being asked to complete a list of questions that will help make a final list of questions for the study being performed in Northeast Colorado. These questions look at your opinions on physical activity and arthritis Answering these questions should take about 15 minutes. You will meet with the researcher or assistant one time in person to answer these questions and give feedback about the questions. You can decide the best place to meet with the researcher or assistant. What are the benefits and risks of being in the study? Potential benefits: There will be no direct benefits to your participation in answering these questions. This study may provide information to local, state and national organizations interested in the health of people with arthritis and/or health of individuals in rural communities in order to look at resources that might benefit the communities. Potential risks: The research may make you think about what you can t do because of your arthritis rather than what you can do This might cause mild concern. Can I quit before finishing? Your decision to answer the survey questions is voluntary and you can quit at any time You can also choose to not talk about anything that makes you uncomfortable. How will you keep others from knowing what I said? I will make every effort to keep the information you share with me confidential. I will be the only person storing the answers to the questions. Any information shared with the community advisory meetings written about in published reports, or given at national meetings will be reported as group information and not have information that would identify an individual. What if I have questions about the research? Please feel free to ask me any questions about your rights in this study before starting to answer the questions. If you have other questions before during or after the study is complete you can contact me at 303-909-5978. If you have any concerns about your rights as a person in this study please contact the Human Subjects in Research Committee 1380 Lawrence Street Suite 1400 at 303-5564060. 182

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Participant Authorization I have read this consent form or the researcher has read the consent form to me. My questions have been answered and I understand what will happen if I am a part of this study. I consent voluntarily to be in this study and I will receive a signed and dated copy of this consent form to keep Participant Signature Date 183

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Informed Consent-Joint Arthritis Committee Focus Group Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson, PT, MS, Doctoral Student, Health and Behavioral Sciences University of Colorado at Denver This is a research study and includes only those people who want to be in the study. Why is this study being done? This is a research project about physical activity for people living in rural areas who have arthritis. People with arthritis who live in rural communities may have unique challenges in getting the right types of physical activity that could improve their overall well being The community and individuals within the community are in the best position to look at what affects their ability to be physically active. This study is being done to look at issues that help or make it harder for people with arthritis to be active in rural communities. What will I have to do if I agree to be in the study? You are being asked to be a part of the Joint Arthritis Committee (JAC), which is a group of people representing counties in Northeast Co lor ado who are interested in arthritis This committee will meet about three times over the next year (focus groups) in a community setting chosen by the committee for 2-3 hours to help the researcher make the study important for rural communities in Northeast Colorado. You will be asked to look over and make changes to a list of questions in a survey so they apply to you r communities take photographs of things in the community that make activity hard for people with arthritis look at flyers and newspapers ads asking people to be in the study to make them apply to people in your community and ask people with arthritis to be a part of the study that involves answering questionnaires. You will a lso be asked to look at the results of the study and discuss the findings. These meetings will be tape-recorded, if the entire group approves taping to make sure the records of the meetings are accurate. What are the benefits and risks of being in the study? Potential Benefits: JAC members will receive a disposable digital camera for use while documenting the environment. If funded each JAC member will receive a $50 gift certificate after the three focus groups have been completed. A resource guide will be made avai l able that lists community offerings for people with arthritis JAC members will help develop a model that may be used by other rural communities to look at what may help or make it harder for people with arthritis to be active. This study m ay also provide information to local, state, and national organizations interested in the health of individuals with arthritis and/or health of individuals in rural communities in order to look at resources that might be useful. Potential Risks: This study may point out problems in the community for people with arthritis doing physical activity that cannot be fixed This could cause frustration Also the JAC members may not agree during focus groups discussions which could cause frustration There could be mild discomfort if information discussed in the meetings i s discussed outside of the meetings depending on the nature ofthe information. Can I quit before finishing? Your attendance at the meetings is voluntary and you can quit at an y time. You can also choose to not talk about anything that makes you uncomfortable 184

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How will you keep others from knowing what l said? I will make every effort to keep the information discussed in the focus groups confidential. I will be the only person storing the notes and tape r e cordings of our meetings The researchers will not release any information that would identify your part in the meetin g s We ask that all of the committee members respect each other's privacy. What if I have questions about the research? Please feel free to ask me any questions about your rights in this study before starting the focus groups. If you have other questions before during or after the study is complete you can contact me at 303909-5978. If you have any concerns about your rights as a person in this study please contact the Human Subjects in Research Committee, 1380 Lawrence Street, Suite 1400 at 303 -556-4060 Participant Authorization I have read this consent form or the researcher has read the consent form to me. My questions have been answered, and I understand what will happen if I am a part of this study. I consent voluntarily to be in this study and I will receive a signed and dated copy of this consent form to keep Participant Signature Date Authorization of Tape-Recording I agree to tape-recording of the JAC meetings and understand that they Yes No will only be tape-recorded if the entire group agrees to the taping. ( please check one) D D 185

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Informed ConsentPhotograph Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson, PT, MS, Doctoral Student Health and Beh av ioral Sciences University of Colorado at Denver This is a research study and includes only those people who want to be in the study. Why is this study being done? This is a research project abo ut physical activity for people livin g in rural areas who ha ve arthritis. People with arthritis who live in rural communities may have unique challenges in getting the rig ht types of physical activity that could improve their overall well being The community and individuals within the community are in the best position to look at what affects their ability to be physically active. This study is being done to look at issues that help or make it harder for people with arthritis to be active in rural communities. It will involve a community advisory board and individual responses to look at these issues. Pictures of different parts of the community will help show what affects activity levels in people with arthritis in rural communities. What will I have to do if I agree to be in the study? Your picture will be taken to show how arthritis affects physical activity in a rural community. This photograph may be u se d to show others how activity is affected in people with arthritis in a rural community This could include showing the picture at local, state, or national meetings that are related to the study topic or including this picture in an article for a scientific magazine What are the benefits and risks of being in the study? Potential benefits: There will be no direct benefits for having your picture taken for this s tudy However a resource guide will be made available that lists community offerings for people with arthritis at the end of this study. Also this study may provide information to local state, and national organizations interested in the health of people with arthritis and/or health of individuals in rural communities in order to look at resources that might benefit the communities. Potential risks: You might experience mild embarrassment by seeing your picture at meetings or in scientific magazines. Can I decide not to have my picture used? You can decide not to have yo ur picture used at any time prior to its publication if accepted for publication Consent to use pictures already included in a publication cannot be withdrawn. You will need to contact Mary Christenson at 303-909-5978 if you decide to not have your picture used What if I have questions about the research? Please feel free to ask me any questions about your rights in this study before having your picture taken. I can be reached at 303-909-5978. If you have other questions before during or after the study is complete, you can contact me at the same number. If you have any concerns about your rig hts as a person in this study, please contact the Human Subjects in Re searc h Committee 1380 Lawrence Street Suite 1400 at 303-556-4060. Participant Authorization I have read this consent form or the researcher has read to me this consent form. My questions have been answered, and I understand what will happen if I am a part of this study. I consent voluntarily to be in this study and I will receive a signed and dated copy of this consent form to keep Participant Signature Date 186

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Informed Consent-Survey Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson, PT, MS Doctoral Student Health and Behavioral Sciences University of Co lorado at Denv er This is a research study and includes only those people who want to be in the study. Why is this study being done? This is a research project about physical activity for people livin g in rural areas who have arthritis. People with arthritis who live in rural communities may have unique challenges in getting the right types of physical activity that could improve their overall well being The community and individuals within the community are in the best position to look at what affects their ability to be physically active. This study is being done to look at issue s that help or make it harder for people with arthritis to be active in rural communities. It will involve a community advisory board and individual responses to look at these issues. What will I have to do if I agree to be in the study? You are being asked to complete six separate groups of que s tions. These questions look at how arthritis affects your life your opinions on physical activity and arthritis how much control you have over your arthritis, how ph ys ically active you are and aspects of living in a rural environment. Answering these questions should take about I to I \12 hours. You will meet with the researcher or assistant (if funded) one to two times in person to answer these questions. You can decide the best place to meet the researcher What are the benefits and risks of being in the study? Potential benefits: If the researcher receives funding each individual completing the survey will receive a $20 gift certificate following completion of the questions A resource guide will be made available that lists community offerings for people with arthritis. Also this study may provide information to local state, and national organizations interested in the health of people with arthritis and/or health of individuals in rural communities in order to look at resources that might b e nefit the communities. Potential risks: The research may make you think about what you can't do because of your arthritis rather than what you can do This might cause mild concern. There may be minimal embarrassment in disclosing health and physical activity history information. This study may point out problems in the community for people with arthritis doing physical activity that cannot be fixed. This could cause frustration. If confidentiality is broken there could be discomfort experienced with the release of information. Can I quit before finishing? Your deci s ion to answer the survey questions is voluntary, and you can quit at any time You can also choose to not talk about anything that makes yo u uncomfortable. How will you keep others from knowing what I said? I will make every effort to keep the information you share with me confidential. I will be the only person storing the answers to the questions Any information shared with the community advisory meetings written about in published reports or given at national meetings will be reported as group information and not have information that would identify an individual. 187

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What if I have questions about the research? Please feel free to ask me any questions about your rig hts in this study before starting to answer the sets of questions. If you have other questions before, during or after the study is complete you can contact me at 303-909-5978. If you have any concerns about your rights as a person in this study, please contact the Human Subjects in Research Committee 1380 Lawrence Street Suite 1400 at 303556-4060 Participant Authorization I have read this consent form or the researcher has read the consent form to me. My questions have been answered and I understand what will happen if I am a part of this st udy. I consent voluntarily to be in this study, and I will receive a signed and dated copy of this consent form to keep Participant Signature Date 188

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University of Colorado at Denver and Health Sciences Center Human Subjects Research Committee -Institutional Review Board Downtown Denver Campus Box 120, P .O. Box 173364 Denver Colorado 80217-336 4 Phone : 303-556-4060 Fax : 303 556 5855 DATE: February 6, 2006 TO: FROM: Dorothy Yates, HSRC Chair SUBJECT: Mary Christenson Human Subjects Research Protocol 2006-035 -Arthritis in Rural Communities: Correlates of Physical Activity Your protocol has been approved as non-exempt. This approval is good for up to one year from this date. Your responsibilities as a researcher include: If you make changes to your research protocol or design you should contact tt HSRC. You are responsible for maintaining all documentation of consent. Unless specified differently in your protocol all data and consents should be maintained for three years. If you should encounter adverse human subjects issues please contact us immediately. If yo ur research continues beyond one year from the above date contact the HSRC for an extension. The HSRC may audit your documents at any time. Good Luck with your research. 189

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University of Colorado at Denver and Health Sciences Center Human Subjects Research CommitteeInst i tut i onal Review Board Downto w n Den ver Campus Box 120 P .O. Box 173364 Denver, Colorado 80217 3364 Phone : 303 556-4060 Fax: 303-556-3377 DATE: December 6 2006 TO: Mary Christenson FROM: Deborah Kellogg HSRC Chair SUBJECT : Hwnan Subjects Research Protocol #2006-035Arthritis in Rural Communities: Correlates of Physical Activity Your human s ubject research protocol's modification r equest has been approved. This approval is good through 12/6/2007 (note new date} Your responsibilities as a researcher include: If you make changes to your research protocol or design you should contact the HSRC. You are responsible for maintaining all documentation of consent. Unless s pecified differently in your protocol all data and consents should be maintained for three years. If you should encounter adverse human subjects issues, please contac t us immediately. If your research continues beyond one year from the above date, contact the HSRC for an extension. The HSRC may audit your documents at any time Good Luck with your research. 190

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APPENDIX B RURAL ARTHRITIS COMMITTEE COMMUNICATION Cover Letter-RAC Meeting # 1 Agenda RAC Meeting # 1 Advertising Flyer Pre RAC input Advertising Flyer Post RAC input Agenda RAC Meeting # 2 Agenda RAC Meeting # 3 191

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March 24, 2006 Dear I want to thank you again for agreeing to be on the Arthritis Committee. I am enclosing some information for our first meeting on March 315 1 from 1 Oam to I pm. This includes the: Agenda Pilot survey with consent form A sample flyer We will be reviewing the pilot survey and flyer to see what changes need to be made to make them more meaningful to your community, so I thought it would be helpful for you to review them before the meeting. The survey will be used to determine how people with arthritis living in Northeast Colorado feel about physical activity. If you have arthritis and can complete the survey as a participant," please first read and sign the consent form if you agree to participate. Whether or not you complete the survey as a participant, I am hoping to receive your feedback on how to make the survey and flyer better. We can discuss your feedback at the meeting on March 315 1 I will also be bringing cameras for you to use to take pictures of issues in your community over the next few weeks that make it harder or easier for people with arthritis to be active. The meeting will be held at the Church at Ill 15 1 Avenue in Town. Directions when you arrive in Town are as follows: [Directions posted] Please let me know if you have any questions. I am l ooking forward to working with you! Sincerely, Mary Christenson 000-000-0000 192

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Agenda Rural Arthritis Committee (RAC) meeting March 31, 2006 10 a.m.-1p.m. I. Welcome and introductions II. Communit y -based research Structuring our committee III JAC consent forms Church 111 1st A v e Town CO 80000 IV. Brief overview of arthritis physical activity and rural communities V. Pilot survey review and discussion VI. Flyer review and discussion VII Camera procedures VIII. Lunch (provided from Subway)Open discussion/feedback 193

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Do you have arthritis? Volunteers are needed to participate in a research study about arthritis. You may be able to participate in this study if: You are 45 years of age or older Your doctor has said you have osteoarthritis You live in a rural community in Northeast Colorado Participation in this study involves: Answering a series of questions related to: o How arthritis affects your life o Your opinions on physical activity and arthritis o How much control you have over your arthritis o How physically active you are o Living in a rural environment Approximately 1-1.5 hours to answer the questions If interested, please contact: Mary Christenson, PT, MS (000) 000-0000 University of Colorado at Denver and Health Sciences Center 194

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Doctoral Program in Health & Behavioral Sciences Campus Box 188, P O. Box 173364 Denver, CO 80217-3364 or Email: mchristenson.email 195

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Arthritis Gotch a? ..... Volunteers are needed to participate in a research study about arthritis. You may be able to take part if: You are 45 years of age or older Your doctor has said you have osteoarthritis You have lived in East/Northeast Colorado for 5+ years You speak and understand English Your involvement in this project would include: Answering a series of questions related to: o How arthritis affects your life o Your opinions on physical activity and arthritis o How much control you have over your arthritis o How physically active you are o Living in a rural environment Approximately 30-45 minutes to answer this survey If you are interested, please contact me by: Phone: 000-000-0000 (I will reimburse this call) Mail: Mary Christenson, PT, MS 196

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Email: University of Colorado at Denver and Health Sciences Doctoral Program in Health & Behavioral Sciences Campus Box 188, P.O. Box 173364 Denver, CO 80217-3364 or mchristenson.email Receive a $10 community gift card for completing the survey 197

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Agenda Rural A rthritis Committee (RAC) meeting August 11, 2006 10 a.m.-1p.m. I. Welcome Church 111 1st Ave Town CO 80000 II. Review photographs identify findings and common themes III. Identify changes to the pilot survey based on feedback IV. Pilot survey results and discussion V Group discussion on impact of arthritis on communities VI. Identify the next steps in the research process VII. Discuss community outcomes for this project VIII. Travel reimbursement forms IX Lunch (provided from Subway) Open discussion/feedback 198

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Agenda Rural Arthritis Committee (RAC) meeting September 7, 2007 11 a.m.-2p.m. I. Welcome II. Review survey and research goals Church 111 1st Ave Town CO 80000 III. Discuss process of data collection: community response to survey IV. Review characteristics of those who took the survey V. Initial results How they are put into a database VI. Lunch VII Group discussion on impact of arthritis on communities VIII. List resources currently available for people with arthritis in their communities IX Discuss community outcomes for this project X. Discuss future directions / goals with the information XI. Follow-up information survey XII. Travel reimbursement forms 199

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APPENDIX C SURVEY INSTRUMENTS Arthritis Impact Measurement Scale 2 Arthritis Self-Efficacy Scale BRFSS and OPAQ Physical Activity Questions Environmental Supports for Physical Activity LONG Final Questionnaire Physical Activity and Arthritis Questionnaire 200

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ID ___ 1-4/ Adm # 5-6/ Card ARTHRITIS IMPACT MEASUREMENT SCALES 2 (AIMS2) # l 7 / Instructions : Please answer the following questions about your health. Most questions ask about your health during the past month. There are no right or wrong answers to the questions and most can be answered with a simple check (X). Please answer every question. Please begin by providing the following information about yourself. NAME: ADDRESS: Number Street Apt# City State Zip PHONE: TODA Y'S DATE: Area Code Number Month Day Year AIMS2 Copyright 1990 Boston University 201

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Pl ease chec k (X) the most appropriate answer for each question. These questions r efe r to MOBILITY LEVEL. DURING THE PAST MONTH ... l. 2. 3. How often we r e you physically able to drive a ca r or use public t ransportation? How often were you out of the house for at least par t o f the day? How often were yo u able lo do errand s in the neighborhood? 4 How o ft en did someone have to assist you to get a r o und outsi d e yo ur h ome? 5. How often were yo u in a be d o r chair for most o r all o f the d ay? All Days (l) These que stions r e f e r to WALKING AND BENDING. DURING THE PAST MONTH ... 6. Did yo u h ave trouble doing vigo r o u s activities such as running l ifting h eavy objects o r participating in strenu o us spor ts? 7. Did yo u have trouble eithe r wal kin g seve r al blocks or climbing a f ew flights of stai rs? 8. Did yo u have t r o ubl e bending lif ting o r stooping? 9. Did yo u have trouble eithe r walking one block o r climbing one flight of stairs? I 0. Were yo u unable to walk nnl ess assisted by anoth e r person o r by a cane crutches, o r wal k e r? All D ays (1) 202 Most Days (2) Most D ays (2) Some Days (3) Some D ays (3) Few Days (4) F ew Days (4) No Days (5) N o Days (5) AIMS 8 / 9 / 1 0 / ll/ 12/ AIMS 13/ 14/ 1 5 / 1 6 / 17/

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Please chec k (X) th e most appr op riate answe r f o r each que s t ion. These questions r e f e r to lL-\N D AND FINGER FUNCTION DURIJ\'G THE PAST MONTH ... All Days ( 1 ) II Cou ld you easily write with a pen o r pencil? 12. Cou ld you easily button a sh irt o r blouse? 13. Coul d you easily turn a ke y in a lock? 14. Could you easily tie a knot o r a bow ? 15. Could you easily open a new jar o f food ? These qu estions r e f e r to ARM FUNC TION D U RlNG THE PAST MONTH ... 16. Coul d yo u easily wipe you r mouth with a napkin? 17. Coul d yo u easily put on a pullover sweate r ? 18. Coul d yo u easily comb o r brush yo ur hair ? 19. Could yo u easily s cratch your low back with your band ? 20. Coul d yo u easily r eac h shelves that wer e above yo ur head? All D ays ( 1 ) 203 Most Days (2) Most Days (2) Some Days (3) Some D ays (3) Few D ays ( 4 ) Few D ays ( 4 ) No D ays (5) N o D ays (5) AIMS 18/ 19/ 20 / 21/ 22/ AIMS 23/ 2 4 / 25 / 26 / 27/

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Please check (X) the most appropriate answer for each question. These questions refer to SELF-CARE TASKS. DURING THE PAST MOr--.T'fi-1... Always ( l) 21. Did you need help to take a bath o r showe r ? __ 22. Did you need help to get dressed? 23. Did you need help to use the toilet? 24. Did you need help to get in or out of bed? These questions r e f e r to HOUSEHOLD TASKS. DURING THE PAST lONTH ... 25. If you had the necessary transportation, could you go shopping for g rocer ies without help? 26 If you had kitchen facilities could you prepare your own meals without help? 27 If you had household tools and appliances could you do your own housework without help? 28. If you had laundry facilities, could you do your own laundry without help? Always (l) 204 Very Almost Often Sometimes Never (2) (3) (4) Very Almost Often Sometimes Never (2) (3) (4) AIMS Never (5) 28/ 29/ 30/ 31/ AIMS Never (5) --32 / --33/ --34 / --35/

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Please check (X) the most appropriate answer for each question. The se que stions ref e r to SOCIAL ACTIVITY. DURING THE PAST MONTH ... 29. H ow often d i d you get together with friends or r elatives? 30 How often did you have friends or r elatives over to your home? 31. How often did yo u visit friends or r elatives at thei r homes? 32 How often were you on the telephone with close friends or r elatives? 33. How often did you go to a meeting of a church club team or other group? All Days (l) Most Days (2) Some Days (3) F ew Days (4) The se ques tions refer to SUPPORT FROM FAMILY AND FRIENDS. Very Almost Alway s Often Sometimes Never DURING THE PAST MONTH.. (l) (2) (3) (4) 34. Did yo u feel that your family or friends would be around if you needed assista nce ? 35. Did yo u feel that yo ur f amily or friends wer e sensitive to your personal needs ? 36. Did you feel that your f amily or friend s were interested in helping you solve problems? 37. Did you feel that your famil y or friend s understood the effects of your arthritis? 205 No Days (5) Never (5) AIMS 36/ 37/ 38/ 39/ 40/ AIMS 41/ 42 / 43/ 44/

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AIMS Please check (X) the most appropriate answe r for each question. These questions refer to ARTHRITIS PAIN. Dt;Ril'iG THE PAST MONTH ... 38. How would you descr i be the arthritis pain you usually had? 39. How often did you have severe pain from your arthritis? 40. How often did you have pai n in two or more joints at the same time? 41. How often did your morning stiff ness last more than one hour from the time you woke up? 42 How often did your pain make it difficult for you to s l eep? These questions refer to WORK. Severe (l) All Days (l) Moderate Mild Very Mild None (2) (3) (4) (5) Mos t Days en Some Days (3) Few Days (4) __ 45/ No Days (5) __ 46 / __ 4 7 / __ 48 / __ 49 / AIMS P aid House School DURING THE PAST MONTH ... 43. What has been your main form of work? wo rk (l) work work Unemployed Disabled Ret i r ed (2) (3) (4) (5) (6) __ 50 / If you answere d unemployed, disabled or r etired please skip the next four questions and go to the next page. All Most Some Few No Days Days Days Days Days DURING THE PAST MONTH... ( 1 ) (2) (3) (4) (5) 44 How often were you unable to do any paid work, housework o r school wo rk ? 4 5 On the days that you d i d wor k how often did you have to work a sho r te r day? 46 On the days that you did work, how often we r e you unable to do your work as ca r efully and accu ratel y as you would like? 47 On the days that you did work how often did you have to change the way your paid work, housework o r school wo rk is usually done? __ 51/ __ 52/ __ 53/ __ 54/ 206

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Please check (X) the most appropriate answer for each question. These questions refer to LEVEL OF TENSION. DURING THE PAST MONTH ... 48. How often have you felt tense or high strung? 49. How often have you been bothered by nervousness o r your nerves? 50. How often were you able to relax without difficulty? 5L How often have you felt relaxed and free of tension? 52. How often have you felt calm and peaceful? These questions refer to MOOD. DURING THE PAST MONTH ... 53. How often have you enjoyed the things you do? 54. How often have you been in low o r ve r y low spirits? 55. How often did you feel that nothing turned out the way you wanted it to? 56. How often did you feel that othe r s would be better off if you we re dead? 57. How often did you feel so down in Always (l) Always (l) the dumps that nothing would cheer you up? __ 207 Very Almost Often Sometimes Never (2) (3) (4) Very Almost Never (5) Often Sometimes Never Never (2) (3) (4) (5) AIMS 55/ 56/ 57/ 58/ 59/ AIMS 60 / 61/ 62/ 63 / 6 4 /

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Please check (X) the most appropriate answe r for each que stion. These que stio ns refer to SATISFACI'ION WITH EACH HEALTH AREA. Very Satisfied DURING THE PAST MONTH... (l) 58. How satisfied have you be e n with each of these areas of your heal t h ? MOBILITY LEVEL (example: do errand s) WALKING AND BENDING (example: climb stairs) HAND AND FINGER FUNCTION (example: tie a. bow) ARM FUNCTION (example: comb hair) SELF-CARE (example: take bath) HOUSEHOLD TASKS (exa mple: housework) SOCIAL ACTIVITY (example: visit friends ) SUPPORT FROM FAMILY (example: help with problems) ARTHRITIS PAIN (example: joint pain) WORK (example: reduce hours) LEVEL OF TENSION (example: felt tense) MOOD (example: down in dumps) Neither Satisfied Somewhat Nor Di s Somewhat Sati sfie d satis fied D issat isfied (2) (3) (4) 208 AIMS Very Dissatis fied (5) 65/ 66 / 67 / 68/ 69 / 70 / 71/ 72/ 73/ 74 / 75/ 76 /

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Please check (X) the most appropriate answer for each question. ID l-4 / ADM# 5-6 / CARD #2 7 / AIMS These questions refer to A R THR I TIS I MPACT ON EACH AREA OF HEALTH. DU R ING T H E PAST MONTH ... 59. How much of your pro blem in each area of health was due to your arthritis? MOBILITY LEVEL (example: do errands) W ALKJNG AND BENDING (example: climb stairs) HAND AND FINGER FUNCTION (example: tie a bow) ARM FUNCfiON (example: comb hair) SELF-CARE (example: take ba tl1) HOUSEHOLD TASKS (example: housework) SOCIAL ACTIVITY (example: visit friends) SUPPO R T FROM FAMILY (example: help with problems) ARTHRITIS PAIN (example: joint pain) WORK (example: reduce hours) LEVEL OF TENSION (example: felt tense) MOOD (example: do w n in dumps) NotA Probl em For Me (0) Due Due Entirely Largely To Other To Other Causes Causes ( I ) (2) 209 Due Partly To 1\rthriti s Due Due And Partly Largely Entirely To Other To My To My Causes Arthritis Arthtitis (3) (4) (5) 8 / 9 / 10/ 11/ 12/ 13/ ----14/ 15/ 16/ 17/ 18/ 19/

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AIMS You have now answe r ed questions about different AREAS OF YOUR HEALTH. These areas are 1isted below. Please check (X) UP to THREE AREAS in which you would M OST LIXE T O SEE IMPROVElVIENT. Please read all 12 a r eas of health choices be fore making your decision: 60. AREAS OF HEALTH MOBILITY LEVEL (example: do errands) WALKIN G AND BENDING (example: climb stairs) HAND AND FINGER FUNCTION (example: tie a bow) AR.Jvt FUNCTION (example: comb hair) SELF-CA R E (example: take bath) HOUSEHOLD TASKS (example: housework) SOCIAL ACTIVITY (example: visit friends) SU PPORT F ROM FAMILY (example: help with problems) A RTHRI TIS PAIN (example: joint pain) WORK (example: reduce hours) LEVEL OF TENSION (example: felt tense) MOOD (example: down in dumps) THREE AREAS FOR IMPROVEMENT P le ase mak e s ur e that you have checked no m o r e than 1HREE A R EAS for improvem e nt. 210 check = 1 blank = 0 20 / 21/ 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30/ 31/

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Please check (X) the mos t appropriate answer for each question. These questions r e fer to your CURRENT and FUTURE HEALTH. 6!. In general would you say that your HEALTH NOW is excellent, good, fair or poor? 62. How satisfied are you with your I -lEAL TH NOW? Very Satisfied (I) Due Not A Entirely Problem To Other For Me 63. How much of your problem with your HEALTH NOW is due to your arthritis? 64. In general do you expect that your HEALTH 10 YEARS FROM NOW will be excellent good, fair or poor? (0) 65. How big a problem do you expect your arthritis to be lO YEARS FROM NOW? Causes (I) 211 Excellent ( l) Good (2) Neither Satisfied Fair (3) Poor (4) Somewhat Nor Dis-Somewhat Very Dis Satisfied satisfied Dissatisfied satis fied (2) (3) (4) (5) Due Partly Due To Arthritis Due Largely And Partly Largely To Other To Other To My Causes Causes Arthritis (2) (3) ( 4) Excellent Good Fair (I) (2) (3) No Problem Minor Moderate At All Problem Problem (l) (2) (3) Due Entirely To My Arthritis (5) Poor (4) Major Problem (4) AIMS 64 / 32/ 34/ 35 / 36 /

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Please check (X) the most appropriate answer for each question This question refers to OVERALL ARTHRITIS IMPACT. 66. CONSIDERING ALL THE WAYS THAT YOUR ARTHRITIS AFFECTS YOU, how well are you doing compared to othe r people you r age? Very Well Well ( l) (2) 67. What is the main kind of arthritis that you have? Rh eumatoid Arthritis O steoa r th riti s / De gene rative Artbri bs Systemic Lupus Erythematosis Fibrom yalgia Scleroderma Psoriat ic Arthritis Reiter's Syndrome Gout Low B ack Pain Tendon itis / Bur sitis Osteoporosis Other 68. How many years have you had arthritis? DURING THE PAST MONTH ... 69. How often have you had to take MEDICATION for you r arthritis? 2 1 2 All Days (1) Most Days (2) AIMS Fair (3) Poor Very Poorly (4) (5) --------------------------------------------Some Days (3) F ew Days (4) 37/ check = l blank = 0 No Days (5) 38/ 39 / 40/ 41/ 4 2 / 43/ 44/ 45/ 4 6 / 47/ 48/ 49/ 50-51/ 52/

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Please check (X) yes or no for each question. 70. Is your health currently affected by any of the following medical problems? High blood pressure -------------Heart djsease ________________ Mental illness Diabetes ________________ Cancer Alcohol or drug use --------------Lung disease Kidney disease Liver disease ---------------Ulcer or other stomach disease Anaemia or other blood disease ________ 71. Do you take medicine every day for any problem other than your arthritis? 72. Did you see a doctor more than three times last year for any problem other than arthritis? 213 AIMS Yes No ( l) (2) 53/ 54 / 55/ 56 / 57/ 58/ 59/ 60/ 61/ 62 / 63/ Yes No (1) (2) 64/ 65/

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Please provide the followin g info rm ation about yourself: 73. What is your age at this time? 74. What is your sex? M ale ( l ) F emale (2) 75. What i s you r r acial backg round ? White (1) Black (2) Hispanic (3) Asian o r P acific I s l an d e r (4) Ame r ican Indian o r Alask an N ative (5) Other (6) 76. What is your current mar ital status? M a rried ( 1 ) Separate (2) Di vorce d (3) Wid owe d ( 4 ) Never married (5) 77. What is t h e highe st l evel of e duc ation you r eceive d ? Le ss than seven yea r s o f schoo l (l) Grades seven through nine (2) Grades ten through eleven (3) High schoo l graduate (4) On e to f ou r years of college (5) College gradu ate (6) Professional or graduate school (7) 78. What is your appr oximate f amily income including wages d isability payment r etiremen t income an d welfa re? Less than $10, 000 (l) $ 1 0,000 $ 1 9 ,999 (2) $20,000 $29 999 (3) $30,000--$39 999 ( 4 ) $ 40 ,000 $ 4 9 ,999 (5) $50 000 $59 999 (6) $60,000--$69 999 (7) M o re than $70,000 (8) Thank you for c ompleting this questionnaire. 214 AIMS 66 -67/ 68/ 69 / 70 / 71/ 72/

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Arthritis Self-Eff i c acy STANFORD PATIENT EDUCATION 1' For each of the foil o\11/i ng questions, please circle the number that corresponds to how certain you are that you can do the foil o\11/i ng t asks regularl y at the pre sent time Self-Effie acy Pain Scale (ma y be comb i ned w i th Other Symptoms Sca le) 1 How certain are you that you can -------------decrease your pai n quite a bit ? very I I I I I I I I I very uncertain 2 3 4 5 6 7 8 9 10 c ertain 2 Ho w certain are you that you can --------------continue most of you r d aily very I I I I I I I I I very activities? uncertain 2 3 4 5 6 7 8 9 10 certain 3. Ho w certain a r e you that yo u can -------------keep arthritis pain from interfering very I I I I I I I I I very with y our s leep ? uncertain 2 3 4 5 6 7 8 9 10 certain 4 Ho w certain are you that yo u can that you can make a small-to-------------moderate reduction in you r arthritis very I I I I I I I I I very pain b y using method s ot her than uncertain 2 3 4 5 6 7 8 9 10 certain taking e xtra medica tion ? 5 How certain a r e yo u that yo u can make a large red uction in yo ur -------------arthritis pain by using methods other very I I I I I I I I I very uncertain 2 3 4 5 6 7 8 9 10 certain than taking extra medication? Self-Efficacy Function Scale 1 How certain are yo u th at yo u can wa l k 1 00 feet on flat ground in 20 very T-1 I very seconds? uncertain 2 3 4 5 6 7 8 9 10 certain 2 How certa i n are you that yo u can -------------that you can walk 1 0 steps very I I I I I I I I I very downstairs in 7 seconds? uncertain 2 3 4 5 6 7 8 9 10 certain 3 H ow certain are you tha t you can get out of an armless chair quick l y, -------------very I I I I I I I I I very withou t using yo ur hand s for uncer tain 2 3 4 5 6 7 8 9 10 c ertain support? 4 How certain are you that you can ------------very very 215

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button and unbutton 3 medium-s i ze uncertain 1 2 3 4 5 6 7 8 9 10 certain buttons in a row in 12 seconds? 5 How certain are you that you can cut 2 b i te-size pieces of meat with a very I I I I I I I I I very knife and fork in 8 seconds? uncertain 2 3 4 5 6 7 8 9 10 certain 6 How certain are you that you can turn an outdoor faucet all the way on very I I I I I I I I I very and all the way off? uncertain 2 3 4 5 6 7 8 9 10 certain 7 How certain are you that you can scratch your upper back with both very I I I I I I I I I very your right and left hands? uncertain 2 3 4 5 6 7 8 9 10 certain 8 How certain are you that you can get in and out of the passenger side of a very I I I I I I I I I very car without assistance from another uncertain 2 3 4 5 6 7 8 9 10 certa i n person and without physical aids? 9. How certain are you that you can put on a long-sleeve front-opening shirt very I I I I I I I I I very or blouse (without buttoning) in 8 uncertain 2 3 4 5 6 7 8 9 10 certain seconds? Self-Efficacy Other Symptoms Scale (may be combined with Pain Scale) 1. How certain are you that you can I I I I I I I I I I very control your fatigue? very uncertain 1 2 3 4 5 6 7 8 9 10 certain 2 How certain are you that you can regulate your activity so as to be very I I I I I I I I I very active without aggravating your uncertain 2 3 4 5 6 7 8 9 10 certain arthritis? 3 How certain are you that you can do something to help yourself feel better very I I I I I I I I I very if you are feeling blue? uncertain 2 3 4 5 6 7 8 9 10 certain 4. As compared with other people with arthritis like yours how certain are very I I I I I I I I I very you that you can manage arthritis uncertain 2 3 4 5 6 7 8 9 10 certa i n pai n during your daily activities? 5 How certain are you that you can manage your arthritis symptoms so very I I I I I I I I I very that you can do the things you enjoy uncertain 2 3 4 5 6 7 8 9 10 certain doing? 6. How certain are you that you can very I I I I I I I I I very deal with the frustration of arthritis? uncertain 2 3 4 5 6 7 8 9 10 certain 216

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BRFSS and OP AQ Physical Activity Questions Part I: Physical Activity Questions: Not Related to Work You Do to Earn a Living These questions will ask you about two types of physical activity-moderate and vigorous -that are not part of work you may do to earn a living Moderate activities cause small increases in breathing or heart rate while vigorous activities cause large increases in breathing or heart rate. I. When you think about moderate activities you do in a usual week (that are not part of work you may do to earn a living) do you do moderat e activities for at least 10 minutes at a time s uch as brisk walking bicycling, vacuuming, gardening, fis hing home repair or anything else that causes so me increase in breathing or heart rate? Circle one answer: Yes No Don't know/Not sure 2. If you do moderate activities how many days per week do yo u do these moderate activities for at lea s t I 0 minute s? Number of days per week: Don't know/Not sure: 3. On days when you do moderate activities for at least I 0 minutes at a time how much total time per day do you spend doing these activities? Hours and minutes per day: Don't know/Not sure: 4. Now think about the vigorous activities you do (that are not part of work you do to earn a living if you work or are self-employed) in a usual week. Do you do vigorous activities for at least 10 minutes at a time, such as running aerobics h eavy yard work, shoveling heav y snow, or anything else that causes large increases in breathing or heart rate ? Circle one answer: Yes No Don't know/Not sure 5. How many days per week do you do these vigorous activities for at least I 0 minutes at a time? Number of days per week : Don't know/Not sure 6. On days when yo u do vigorous activities for at least I 0 minutes at a time, how much total time per day do you spend doing these activities? Hours and minutes per day: 217

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Don't know/Not sure: Part 2: Physical Activity Questions: Work or Self-Employed Physical Activity These questions will ask you about the physical activity that is part of the work you do to earn a living. Please answer these questions if you work or are self-employed. I. When you are at work which of the following best describes what you do? Note: If you have multiple jobs, include all jobs. Circle one answer: Mostly sitting or standing Mostly walking Mostly heavy labor or physically demanding work Don't know/Not sure 2. How many hours per week do you usually work in your primary job? Hours per week: Don't know/Not sure: 3. In a usual week do you perform any sitting or standing doing work such as using a computer desk work using hand tools light assembly lab tech or driving a car or truck while at work? Circle one answer: Yes No Don't know/Not sure 4. In a usual week how many hours do you do these sitting or standing activities at work ? Hours per week: Don't know/Not sure: 5. In a usual week, do you perform any walking at work as in the halls between buildings or in jobs like a postal carrier, waiter, or roving salesperson? Circle one answer: Yes No Don't know/Not sure 6. In a usual week how many hours do you walk at work ? Hours per week: Don't know/Not sure: 7 In a usual week do you perform any heavy labor or use power tools during work such as moving furniture, carpentry, jackhammers or using a shovel or pick? Circle one answer: Yes No Don't know/Not sure 218

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8. In a usual week how many hours do you perform these heavy labor activities at work? Hours per week: Don't know/Not sure: References Centers for Disease Control and Prevention (CDC). (2003) Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Reis J.P., Dubose, K. D., Ainsworth B. E., Macera C. A. & Yore M. (2005). R eliab ility and Validity ofthe Occupational Physical Activity Questionnaire. Med & Sci in Sports & Ex, 37(12) 2075-2083. 219

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BRFSS Module Environmental Supports for Physical Activity LONG (N = 11) SIP 4-99 Research Group (2002 October). Environmental Supports for Physical Activity Long Questionnaire. Prevention Research Center Arnold School of Public Health University of South Carolina. These questions will ask y ou about the neighborhood in which you live followed by some questions about the community in which you live. For the purposes of these questions, neighborhood is defined as the area within one-half mile or a ten-minute walk from your house and community is defined as a I 0-mile or 20-minute drive from your house Please circle the best answer. I. In general would you say that the people in your neighborhood are ... a. very physically active b. somewhat physically active c. not very physically active d. not at all physically active e. don t know / not sure 2. Overall, how would you rate your neighborhood as a place to walk? Would you say .. a. very pleasant b. somewhat pleasant c. not very pleasant d. not at all pleasant e. don't know / not sure 3. For walking at night would you describe the street lighting in your neighborhood as ... a. very good b good c fair d. poor e very poor f. don t know / not sure 4 How safe from crime do you consider your neighborhood to be? Would you say ... a extremely safe b. quite safe c. slightly safe d. not at all safe e don t know / not sure 220

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5. Generally speaking would you say most people in your neighborhood can be trusted? a. yes b. no c don t know / not sure 6 Does your neighborhood have any sidewalks? a. yes b. no c. don t know / not sure 7. Do you use any private or members hip only recreation facilities in your community for physical activity? a. yes b. no c. my community does not have these facilities d. don't know/ not sure 8. Do you use walking trails parks, playgrounds sports fields in your community for physical activity? a. yes b. no c. my community does not have these facilities d don t know/ not sure 9. Do you use shopping malls in your community for physical activity and/or walking programs? a. yes b. no c. my community does not have shopping malls d don t know/ not sure I 0. Do you use any public recreation centers in your community for physical activity? a. yes b. no c. my community does not have any public recreation facilities d. don t know / not sure 11. Do you use schools that are open in your community for public recreations activities? a. yes b. no c. schools in my community are not open for the public to use d. don't know / not sure 221

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Today's Date: ___ Final Questions-Thank you for you r time! I. Where i s your arthritis located? __________________________ 2. How far (in mile s ) do you live from the neare s t town where you can buy g roceries and gasoline ? ____ miles (Please put '"0' if y ou live in town) 3. How t all are you? ________ How much do you weigh? ____ _ 4 What things in the physical environment keep you from being as active a s you would like to be? 5. If you want to be more active what would motivate you to be more physically active ? ______ 6. Has anyone that you see for your health told you to be more physically active ? Yes D No D Don' t Know D 7.1fso,who? ________________________________ 8 If you work do you think your work-rela ted activity is enough daily physical activity to keep you healthy? Yes D No D Don'tKnow D 9 Do you have suggestions of things that would help you be more active if you wanted to be (for example changes in your environment or the resources available in your area)? ______ _ ____ I 0 Did anyone help you fill out this survey? Yes D No D II I s there anything else you would like to bring up about you r arthritis and physical activity ? 12. Would you be willing to be contacted about this study ? This might include an examination of y our hand and or knee joints by the lead researcher, who is a licen sed physical therapist in the state of Colorado. This might also include talking about your arthritis and physical activity. Yes D 0 D 13. If y es, please provide your contact infonnation (address phone, and or email) : _________________________________ _ 222

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PHYSICAL ACTIVITY OPINION SURVEY !ORIGINAL! Physical activity, for this survey, is defined as any activity you do for I 0 minutes or more at a time and that makes you breath at least somewhat harder than normal. For this group of questions, physical activity is not part of what you do for "work." Work" means what you do to earn a living. If you are retired or do not currently work it will include any activities you do for I 0 minutes or more at a time that makes you breath at lea st somewhat harder than normal. Examples might be vacuuming gardening walking for exercise bicycling running or anything else that causes you to breath at least somewhat harder than normal. How much do you agree or disagree with each opinion statement below? (Please circle your answer) Opinion Statement Please circle how much you agree or disagree: I. I would like to be more Strongly Agree Undecided Disagree Strongly physically active. agree disagree 2. Physical activity is good for Strongly Agree Undecided Disagree Strongly my arthritis. agree disagree 3. There are physical activities I Strongly Agree Undecided Disagree Strongly can t do because of my arthritis. agree disagree 4. My family or friends think I Strongly Agree Undecided Disagree Strongly should be physically active. agree disagree 5. Physical activity can prevent Strongly Agree Undecided Disagree Strongly other diseases. agree disagree 6. The weather determines ifl Strongly Agree Undecided Disagree Strongly can participate in physical agree disagree activity. 7. I am likely to be physically Strongly Agree Undecided Disagree Strongly active during the day (if working, agree disagree when not at work). 8. In general, I'm )jkely to do Strongly Agree Undecided Disagree Strongly what my friends and family think agree disagree I should do. 9 Physical activity keeps people Strongly Agree Undecided Disagree Strongly healthy. a !!fee disagree 10. People my age don't Strongly Agree Undecided Disagree Strongly normally do a lot of physical agree disagree activity. II. People living in rural Strongly Agree Undecided Disagree Strongly communities are generally more agree disagree active than those who live in cities. 12. I will take the time to do Strongly Agree Undecided Disagree Strongly physical activity even when I agree disagree have a lot to do 223

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13. My doctor or other he alth Strongly Ag r ee Undeci ded Disagree Stro n g l y care advisor thinks I s hould be agree disagree ph ysically active. 14. Something usually gets in Strongly Agree Undecided Disagree Strongly the way of" fun" physical agree disagree activities. 15. Physical activity i s b a d for Strongly Agree Undec ided Disagree Strongly my arthritis. agree dis agree 16. Living in a rural community Strongly Agree Undecided Disagree Strongly affects how much physical agree disagree activity I get. 17. I would be more active if a Strongly A g ree Undecided D isag ree Strongly doctor told me I s hould be for my agree disagree health 18. r would rather relax than be Strongly Agree Undecided Disagree Strongly physically active. agree disagree 19. Arthritis keeps me from Strongly Agree Undecided Disagree Strongly bein g ph ys ically active. agree disa g ree 20. There is a difference Strongly Agree Undecided Disagree Strongly between physical activity and agree disagree exercise. 21. My family or friends think I Strongly Agree Undecided Disag ree Strongly will hurt myself if I m mor e agree disa gree physically active 22. I wony that physical activity Strongly Agree Undecided Disagree Strongly will increase other health agree disagree problems, besides arthritis that 1 may have 23. In ge neral I'm likel y to do Strongl y A gree Undecided Dis a g ree Strongly what my doctor or other health agree disagree care advisor thinks I s hould do. 24. I m already active enough Strongly Agree Undecided Disagree Strongly during the day I don't need agree disagree more physical activity. 25. The physic a l environment Strongl y Agree Undecided Disagree Strongly kee p s me from bein g active. agree disagree 26 I believe being more active Strongly Agree Undecided Disagree Strongly is up to me. agree disagree 27. I am concerned I will make Strongly Agree Undecided Disag ree Strongly m y arthritis worse if I am mor e agree disagree active. 28 I am likely to be physically Strongly Agree Undecided Disagree Strongly active if my friends are active as agree disagree well. 224

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PHYSICAL ACTIVITY and ARTHRITIS SURVEY [revised) Physical activity, for this survey, is defined as any activity you do for 10 minutes or more at a time and that makes you breathe at least somewhat harder than normal. For this group of questions physical activity is not part of what you do for "work." Work means what you do to earn a living. If you are retired or do not currently work it will include any activities you do for 10 minutes or more at a time that makes you breathe at least somewhat harder than normal. Examples might be vacuuming, gardening, walking for exercise bicycling, running, or anything else that causes you to breathe at least somewhat harder than normal. How much do you agree or disagree with each statement below? (Please circle your answer) N/A =not applicable Statement Please circle how much you agree or disagree: 1. I would like to be more Strongly Agree Undecided Disagree Strongly physically active. agree disagree 2. There are physical Strongly Agree Undecided Disagree Strongly activities I can t do because agree disagree of my arthritis. 3. My family or friends Strongly Agree Undecided Disagree Strongly think I should be physically agree disagree active. 4. Bad outdoor weather Strongly Agree Undecided Disagree Strongly (wind, s now etc.) keeps me agree disagree from participating in physical activity. 5. I would be more active if Strongly Agree Undecided Disagree Strongly a doctor told me I should be agree disagree for my health. 6. Physical activity keeps Strongly Agree Undecided Disagree Strongly people healthy. agree 7. People who live in rural Strongly Agree Undecided Disagree Strongly communities get a lot of agree disagree physical activity. 8 Arthritis is a normal part Strongly Agree Undecided Disagree Strongly of aging that can t be helped agree disagree by being more active. 9. I have friends or family Strongly Agree Undecided Disagree Strongly available to do activities agree disagree with me such a going for a walk. 10. My doctor or other Strongly Agree Undecided Disagree Strong l y health care advisor thinks I agree disagree should be physically active. 11. Physical activity is bad Strongly Agree Undecided Disagree Strongly for my arthritis. 225 N / A N / A N / A N / A N / A N / A N I A N / A N / A N / A N / A

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12. I believe being more Strongly Agree Undecided Disagree Strongly N / A active is up to me. agree disagree 13. I would rather relax Strongly Agree Undecided Disagree Strongly N / A than be physically active. disagree 14. Arthritis keeps me from Strongly Agree Undecided Disagree Strongly N / A being physically active agree disagree 15. [worry that physical Strongly Agree Undecided Disagree Strongly N / A activity will increase other agree disagree health problems, besides arthritis, that 1 may have. 16. I'm already active Strongly Agree Undecided Disagree Strongly N / A enough during the day I agree disagree don't need more physical activity. 17. My physical Strongly Agree Undecided Disagree Strongly N / A environment keeps me from agree disagree being_ active. 18. I am concerned I will Strongly Agree Undecided Disagree Strongly N / A make my arthritis worse if I agree disagree am more active. 19. I would be more active Strongly Agree Undecided Disagree Strongly N / A if my friends and family agree disagree think I should be. 20. I am likely to be Strongly Agree Undecided Disagree Strongly N / A physically active if my agree disagree friends are active as well. 226

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APPENDIXD RAW FREQUENCIES OF VARIABLES IN THE INSTRUMENTS USED IN THE STUDY Arthritis Impact Measurement Scales 2 (AIMS2) Arthritis Self-Efficacy Scales (ASES) Physical Activity and Arthritis Questionnaire (P AAQ) Environmental Supports for Physical Activity Long Questionnaire Final Questionnaire Behavioral Risk Factor Surveillance System (BRFSS) and Occupational Physical Activity Questionnaire (OP AQ) 227

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ARTHRITIS IMPACT MEASUREMENT SCALES 2 (AIMS2) These questions refer to mobility level. Item DURJNG THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) How often were you physically able to 71 3 I 2 3 1.29 drive a car or use public transportation? 2 How often were you out of the house for 52 21 4 ., 0 1.48 .) at least part of the day? 3 How often were you able to do errands in 59 14 2 0 5 1.48 the neighborhood? 4 How often did someone have to assist 2 3 73 4.80 you to get around outside your home? 5 How often were you in a bed or chair for 0 7 16 73 4 .58 most or all of the day? These questions refer to walking and bending. Item DURJNG THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) 6 Did you have trouble doing vigorous 25 19 12 II 13 2.6 activities such as running, lifting heavy objects, or participating in strenuous sports? 7 Did you have trouble either wa lkin g 8 12 16 12 32 3.6 several blocks or climbing a few flights of stairs? 8 Did you have trouble bending, lifting or 1 2 II 19 18 20 3.28 stooping? 9 Did you have trouble either walking one 6 9 14 13 38 3.85 block or climbing one flight of stairs? 10 Were you unable to walk unl ess assisted 5 3 5 66 4.55 by another person or by a cane, crutches or walker? 228

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These questions refer to hand and finger function. Item DURING THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) Could you easily write with a pen or 62 15 2 I 0 1.28 pencil? 2 Could you easily button a shirt or 51 17 8 3 1.57 blouse? .., Could you easily turn a key in a lock ? 54 19 7 0 0 1.41 .) 4 Could you easily tie a knot or a bow? 50 20 6 3 I 1.56 5 Could you easily open a new jar of food? 18 29 23 9 2.32 These questions refer to arm function. Item DURING THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) Could you easily wipe your mouth with a 79 I 0 0 0 1.0 I napkin? 2 Could you easily put on a pullover 64 12 .., 0 1.26 .) sweater? 3 Could you easily comb or brush your 65 12 3 0 0 1.22 hair ? 4 Could you easily scratch your low back 46 13 13 4 4 1.84 with your hand ? 5 Could you easily reach shelves that were 44 16 12 3 5 1.86 above your head ? These questions refer to self-care tasks Item DURING THE PAST MONTH Very SomeAlmost Mean Always Often times Never Never (I) (2) (3) (4) (5) Did you need help to take a bath or I I 2 4 72 4.81 shower? 2 Did you need help to get dressed ? 0 0 3 4 73 4.88 3 Did you need help to use the toilet? I 0 0 2 77 4.92 4 Did you need help to get in or out of 0 2 0 2 76 4.90 bed? 229

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These questions refer to household tasks. Item DURJNG THE PAST MONTH Very SomeAlmost Mean Always Often times Never Never (I) (2) (3) (4) (5) If you had the necessary 72 4 I I 2 1.21 transportation could you go shopping for groceries without help ? 2 lfyou had kitchen facilities could you 73 5 2 0 0 I. II prepare your own meals without help? 3 If you had household tools and 63 12 2 2 1.32 appliances could you do your own housework without help? 4 lfyou had laundry facilities could 71 5 2 1.22 you do your own laundry without help? 230

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ARTHRITIS SELF-EFFICACY SCALES Arthritis Self Efficacy Function Scale Item Very Uncertain Very Certain Mean I 2 3 4 5 6 7 8 9 10 I How certain are you that 5 4 4 3 12 5 6 10 9 22 6.88 you can walk I 00 feet on flat ground in 20 seconds? 2 How certain are you that 8 3 4 3 9 6 6 10 8 23 6.78 you can walk I 0 steps downstairs in 7 seconds? 3 How certain are you that 15 6 7 6 10 5 5 5 8 13 5.36 you can get out of an armless chair quickly without using your hands for support? 4 How certain are you that 5 4 3 4 13 6 4 15 II 15 6 70 you can button and unbutton 3 medium-size buttons in a row in 12 seconds? 5 How certain are you that 2 2 0 4 10 6 3 12 15 26 7.75 you can cut 2 bite size pieces of meat with a knife and fork in 8 seconds? 6 How certain are you that 2 4 3 3 8 4 7 13 9 27 7.48 you can turn an outdoor faucet all the way on and all the way off? 7 How certain are you that 12 5 6 8 6 5 9 II 3 15 5.75 you can scratch your upper back with both your right and left hands? 8 How certain are you that 4 2 3 2 5 2 6 9 II 36 7.94 you can get in and out of the passenger side of a car without assistance from another person and without physical aids? 9 How certain are you that 2 2 .., 0 10 8 6 5 13 31 7.78 .) you can put on a longsleeve front-opening shirt or blouse (without buttoning) in 8 seconds? 231

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PHYSICAL ACTIVITY AND ARTHRITIS QUESTIONNAIRE Statement Strongly Strongly Not Mean Agree Agree Undecided Disagree Disagree Applicable (5) (4) (3) (2) (I) I. I would like to be 21 49 7 3 0 0 4 .10 more physically active. 2. There are physical 8 40 16 10 4 I 3 .51 activities I can't do because of my arthritis. 3 My family or 8 52 7 5 2 6 3.80 friends think I should be physically active. 4. Bad outdoor 12 43 7 15 2 0 3.61 weather (wind snow, etc.) keeps me from participating in physical activity. 5. I would be more 8 36 II 21 I 3 3.38 active if a doctor told me I should be for my health. 6. Physical activity 39 40 I 0 0 0 4.48 keeps people healthy. 7. People who live in 5 41 20 13 0 I 3.48 rural communities get a lot of physical activity. 8. Arthritis is a normal I 12 15 45 7 0 2.44 part of aging that can't be helped by being more active. 9. I have friends or 10 39 7 22 I I 3.44 family available to do activities with me such as going for a walk. 10. My doctor or other 13 47 10 8 0 2 3.83 health care advisor thinks I should be physically active. I I. Physical activity is 0 4 9 54 13 0 2.05 bad for my arthritis. 12. I believe being 23 52 5 0 0 0 4.22 more active is up to me 13. I would rather 0 20 22 36 2 0 2.75 relax than be physically active. 232

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14. Arthritis keeps me 0 23 15 39 .., 0 2.72 .) from being physically active 15. I worry that 2 II 9 46 12 0 2.31 physical activity will increa s e other health problems besides arthriti s, that I may have 16. I m already active 2 16 12 44 6 0 2.55 enough during the day I don t need more physical activity. 17. My physical 0 8 10 56 5 0 2.26 environment keeps me from being active 18. I am concerned l I 4 8 58 7 I 2 .16 will make my arthritis worse if I am more active. I 9. I would be more I 18 14 35 5 7 2 66 active if m y friends and family think I should be 20. I am likely to be 6 42 II 16 2 3 3.44 physically active if my friends are active as well. 233

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ENVIRONMENTAL SUPPORTS FOR PHYSICAL ACTIVITY LONG QUESTIONNAIRE Yes No Does not Don't have / are not know / not open sure 1. Do you use any private or membership 23 49 7 1 only recreation facilities in your community for physical activity? 2 Do you use walking trails, parks, 27 43 9 1 playgrounds, sports fields in your community for physical activity? 3. Do you use shopping malls in your 7 43 30 0 community for physical activity and/or walking programs? 4. Do you use any public recreation 15 51 14 0 centers in your community for physical activity? 5 Do you use schools that are open in 9 58 11 2 your community for public recreation activities? 234

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FINAL QUESTIONNAIRE Where is your arthritis located? Location of Arthritis Fingers Thumbs Hands Elbows Shoulders Hips Knees Ankles Feet/toes Neck Back (or spine) Everywhere Other ( arms, " legs, " wrists") Frequency of Response 18 I 36 3 19 23 36 4 9 7 39 2 10 How far (in miles) do you live from the nearest town where you can buy groceries and gasoline? Distance from Town (miles) 0 0.25 2 2.5 3 3 5 4 5 6.5 7 8 8.5 9 10 12 13 15 17 20 30 235 Frequency of Response 37 I 4 I I 2 I 2 2 8 2 I 2 5 I I 3 I 4 I

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Has anyone that you see for your health told you to be more physically active? Yes No Don t Know 32 44 3 If so, who has told you to be more physically active? Source of advice to be more active Medical doctor (MD) MD and chiropractor Chiropractor Physician's Assistant Missing Frequency of Response 24 I I I 5 If you work, do you think your work-related activity is enough daily physical activity to keep you healthy? Yes No Don t Know Missing 13 27 8 32 Did anyone help you fill out this survey? Yes No 6 74 Would you be willing to be contacted about this study? Yes No 40 35 236

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DATA CATEGORIZED from the BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM and OCCUPATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE Freq_uencJ:_ of Non-Work or Work PhJ:_sical Activity p_er Week Non-work n (%) Work n (%) Time Moderate a v b 1gorou s Moderatec Vigorousd < 60 minutes 4 (5.00) 4 (12.12) 0 (0.00) 0 (0.00) 60 120 minutes 16 (20.00) 10 (30 30) 3 (12.50) 3 (25.00) 121180 minutes 15 (18.75) 4 (12.12) 2 (8.33) 0 (0.00) 181-239 minutes 6 (7.50) 1 (3. 03) 0 (0.00) 0 (0.00) 4-6 hours 15 (18.75) 7 (21.22) 4 (16.67) 2 (16.67) 7 10 hours 7 (7.50) 1 (3. 03) 3 (12.50) 1 (8. 33) 10.512 hours 4 (5.00) 1 (3. 03) 1 (4.16) 0 (0.00) 12.5-19. 5 hours 3 (3.75) 2 (6.06) 0 (0.00) 2 (16.67) 20-21 hours 4 (5.00) 0 (0.00) 4 (16.67) 0 (0.00) 21.5-28 hours 1 (1.25) 1 (3.03) 1 (4.17) 1 (8.33) 29-42 hours 2 (2.50) 1 (3.03) 4 (16 .6 7) 3 (25.00) 43-49 hours 1 (1.25) 0 (0.00) 2 (8.33) 0 (0. 00) 50-59 hours 1 (1.25) 0 (0.00) 0 (0.00) 0 (0.00) > 60 hours 1 (1.25) 1 (3.03) 0 (0.00) 0 (0.00) a Range: 15 minutes70 hours, N = 80 bRange: 26.25 minutes-84 hours N = 33 c Range : 60 minutes-47.5 hours N = 24 dRange: 90 minutes-35 hours, N = 1 2 237

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' / ARTHRITIS IN RURAL COMMUNITIES: CORRELATES OF PHYSICAL ACTIVITY by Mary Elizabeth Christenson B.A., University of Colorado at Boulder, 1974 B.S., University of Colorado Health Sciences Center, 1983 M.S., Colorado State University, 1996 A thesis submitted to the University of Colorado Denver in partial fulfillment of the requirements for the degree of Doctor of Philosophy Health and Behavioral Sciences 2008

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This thesis for the Doctor of Philosophy degree by Mary Elizabeth Christenson has been approved by Cindy BT)fanY Maura Iversen Nancy Leech J ck Westfall

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This thesis for the Doctor of Philosophy degree by Mary Elizabeth Christenson has been approved by the representative for the Rural Arthritis Committee Shil1tf Cowart

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Christenson, Mary E. (Ph.D., Health and Behavioral Sciences) Arthritis in Rural Communities: Correlates of Physical Activity Thesis directed by Professor Kitty Corbett ABSTRACT Background and Rationale: Arthritis affects over 46 million individuals in the United States and is the leading cause of disability. Despite the lack of clear standards for levels and types of P A appropriate for individuals with arthritis, evidence suggests that P A can have significant health benefits. Rural communities may offer unique challenges for people with arthritis to participate in P A. This study investigated factors that influence physical activity (PA) in people with arthritis living in rural communities and set the stage for studies with larger representative samples. Among arthritis studies, this project was unusual in its focus on individuals from rural areas. with community research participation throughout the project. Specific aims: 1) identify correlates of P A in individuals with arthritis in rural communities of east and northeast Colorado, 2) quantify current types and intensity of physical activity, 3) enhance findings through the participation of community partners. Methods: This study employed a cross-sectional survey completed by 119 participants and was guided by a Rural Arthritis Committee (RAC) comprised of residents from the involved counties. Survey instruments included the previously validated AIMS2,

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Lorig's Arthritis Self-Efficacy Scale, PA questions from the Behavioral Risk Factor Surveillance System and the Occupational Physical Activity Questionnaire, the Environmental Supports for Physical Activity Questionnaire, and in addition, a P A and Arthritis Questionnaire based on the Theory of Reasoned Action and Theory of Planned Behavior that was piloted and analyzed prior to inclusion. Findings: Rural community members from diverse geographical locations effectively engaged in health-related research. Sixty-seven percent of respondents reported time increments ofweekly PA and 73% ofthis subgroup met weekly PA recommendations through non-work P A. A higher prevalence of diabetes and obesity than State averages was reported. Independent variables were not significantly associated with time spent in P A except minutes of vigorous non-work P A with attitude about P A. Implications: A process for engaging community members in chronic disease research has been established. P A self-report measurement tools may not be optimal in this population. P A levels appear to be higher in this sub-population than previous literature suggests. Additional mixed methods research may elucidate correlates of P A. This abstract accurately represents the content of the candidate's thesis. I recommend its publication. ______ Kitty Corbett

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DEDICATION This thesis is dedicated with love to my Mother, sister, and Grandma Gladys who have supported me with their unconditional love, sacrifice, inspiration, and strength. It is also dedicated to my Father for his love and guidance to value education and Jack for his patience, love, and support of my goals.

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ACKNOWLEDGEMENT I would like to thank my committee members for the guidance and expertise they willingly shared during this process. Dr. Kitty Corbett tailored her feedback to enrich my project. Her creative wisdom inspired this research process and helped me stretch in new directions. Her level of expertise in many diverse areas demands great respect. She offered encouragement and support and will continue to serve as a role model. Dr. Cindy Bryant's depth of review and research proficiency guided and enhanced my research reflections. Her expertise in aging research and working with community partners was instrumental as a mentor. Her encouragement and timely feedback kept me moving forward. Dr. Maura Iversen gave me confidence as a researcher in physical therapy and supported my professional development in this field. Her mentorship and expertise in arthritis has been invaluable. It was a privilege working with Dr. Iversen as a leader in our field. Dr. Nancy Leech provided guidance with patience and insight as I learned the process of research and analysis. She answered the tough "stats" questions and gave me confidence to rely on my decision-making in research. Her book went with me everywhere.

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Dr. Jack Westfall shared his passion for reaching out to the rural communities. As a leader in community-based research, he served as an inspirational role model and mentor. His humor kept the process "fun," and his willingness to "open community doors" for me greatly facilitated the research. The Rural Arthritis Committee (RAC) was the spirit of this project. They opened their communities to me, welcomed my efforts, and demonstrated passion for their communities. They offered areas of expertise and levels of participation that made the project what it is. I am indebted to their generosity. There were many other individuals who shared their research expertise to help me through this process thank you for your interest in my professional development.

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TABLE OF CONTENTS List of Figures ............................................................................................. xiv List of Tables ................................................................................................ xv CHAPTER 1. INTRODUCTION .................................................................................... 1 Research Question .............................................................................. 1 Rationale ............................................................................................. 1 Specific Aims ...................................................................................... 5 2. BACKGROUND ...................................................................................... 7 Introduction ......................................................................................... 7 Osteoarthritis ....................................................................................... 8 Importance .............................................................................. 8 Pathogenesis and Diagnosis .................................................... 9 Risk Factors .......................................................................... 11 Guidelines for the Management of Osteoarthritis ................. 13 Arthritis in Colorado ............................................................. 16 Issues of Rurality .............................................................................. 19 Defining Rural ...................................................................... 20 Health Disparities in Rural Communities ............................. 21 IX

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Colorado Rural Communities-Healthcare Disparities ........ 23 Colorado Rural Counties-Sociodemographics ................... 25 Physical Activity ............................................................................... 30 Physical Activity and Health ................................................ 31 Benefits of Physical Activity ................................................ 34 Environment and Physical Activity ...................................... 38 Self-Efficacy and Physical Activity ..................................... .40 Rural Health, Individuals with Arthritis, and Physical Activity ...... .42 Community-Based Participatory Research ...................................... .46 Theoretical Model ............................................................................. 51 3. METHODS ............................................................................................. 51 Research Design ................................................................................ 57 Setting ............................................................................................... 58 Participants ........................................................................................ 60 Rural Arthritis Committee (RAC) Recruitment.. .................. 61 Survey Group Recruitment ................................................... 66 Procedures ......................................................................................... 69 Pilot Survey ........................................................................... 70 Rural Arthritis Committee (RAC) Meetings ......................... 74 Quantitative Procedures ........................................................ 80 Measures ........................................................................................... 83 X

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Physical Activity ................................................................... 83 Physical Activity and Arthritis .............................................. 86 Arthritis Impact ..................................................................... 89 Self-Efficacy ......................................................................... 92 Environmental Supports for Physical Activity Questionnaire ........................................................................ 93 Final Questionnaire ............................................................... 95 Variables ........................................................................................... 95 Survey Return ................................................................................... 99 Analysis ........................................................................................... I 05 4. RESULTS ............................................................................................. } 07 Introduction ..................................................................................... I 07 Geographic and Sociodemographic Descriptions ........................... } 07 Geographic Distribution ...................................................... I 07 Sociodemographics ............................................................. I 09 Physical and Health Characteristics of Sample Population ............ 111 Specific Aims and Hypotheses Analyses ........................................ ll4 Specific Aim #I .................................................................. 114 Specific Aim #2 .................................................................. 118 Specific Aim #3 .................................................................. 140 Model of Regression ....................................................................... 142 XI

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5. DISCUSSION ....................................................................................... 145 Introduction ..................................................................................... l45 Community-Based Support and Investigative Influence ................ 146 Comparison of Results to Colorado Data ....................................... 152 Sociodemographics ............................................................. 152 Health Characteristics ......................................................... 154 Physical Activity-Discovery and Highlights ................................ l57 Time Spent in Physical Activity ......................................... 157 Does It Add Up? ................................................................ 164 Hypotheses Discussion ................................................................... 165 Correlates of Physical Activity in a Sample Population ..... 165 Effect of Gender, Distance from Town, and HCP Influence on Physical Activity ............................................................ 165 Arthritis and Physical Activity ............................................ l67 Environmental Resources ................................................... 167 Theoretical Perspective-Quantitative and Qualitative Insight ..... 171 Contributions Starting the Dialogue ............................................ I 73 Limitations ...................................................................................... 174 Dissemination, Future Directions and Interventions ...................... 176 Summary Statement ........................................................................ 178 Xll

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APPENDIX A. CONSENTS AND HUMAN SUBJECTS APPROVAL ................ 181 B. RURAL ARTHRITIS COMMITTEE COMMUNICATION ........ 191 C. SURVEY QUESTIONNAIRES ..................................................... 200 D. RAW FREQUENCIES FOR VARIABLES IN THE INSTRUMENTS USED IN THIS STUDY .................................... 227 BIBLIOGRAPHY ............................................................................................. 238 X Ill

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LIST OF FIGURES Figure 2.1 Theory of Reasoned Action and Theory of Planned Behavior ..................... 52 3.1 Colorado Counties ........................................................................................ 60 3.2 Consort Model Sample Size ..................................................................... 1 00 XIV

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LIST OFT ABLES Table 2.1 U.S. Census Bureau: Population totals, age, gender2000 ......................... 26 2.2 U.S. Census Bureau: Occupation (percent distribution) 2000 ................... 27 2.3 U.S. Census Bureau: Race (percent distribution) 2000 ............................. 28 2.4 U.S. Census Bureau: Income and poverty-1999 ........................................ 29 2.5 Behavioral risk factor surveillance system (BRFSS) dataset information: 2004-2005 ..................................................................................................... 30 3.1 Demographics of rural members ofthe Rural Arthritis Committee by county ............................................................................................................ 65 3.2 Summary of community organizations contacted by principal investigator .................................................................................................... 68 3.3 Scale reliability for Physical Activity and Arthritis Questionnaire Items, n=30 .............................................................................................................. 73 3.4 Scale reliability for Physical Activity and Arthritis Questionnaire Items, n=119 ............................................................................................................ 88 3.5 Independent variables not related to the physical environment.. .................. 97 3.6 Independent variables related to the physical environment.. ........................ 98 3. 7 Independent samples test: Responders and non-responders group statistics ....................................................................................................... I 03 3.8 Independent samples test: Difference between responders and nonresponders on key variables ........................................................................ 1 04 XV

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3. 9 Chi-square test: Gender and responder or non-responder. .......................... 1 05 4.1 Survey municipalities and population representation ................................. 1 08 4.2 Descriptive statistics of general demographics of sample .......................... 11 0 4.3 Work status for individuals with arthritis ................................................... 111 4.4 Physical and health characteristics of the sample population ..................... 113 4.5 Minutes of work and non-work physical activity (P A) per week ............... 114 4.6 Total minutes work and non-work-related moderate physical activity per week ...................................................................................................... 116 4.7 Total minutes work and non-work-related vigorous physical activity per week ............................................................................................................ 116 4.8 Descriptive statistics oftransformed variable minutes moderate non-work physical activity (PA) ................................................................. 117 4.9 Descriptive statistics: Arthritis physical function impact and minutes physical activity .......................................................................................... 119 4.10 Correlation: Arthritis physical function impact and minutes physical activity ......................................................................................................... 119 4.11 Independent samples test: Gender with P A group statistics ....................... 122 4.12 Independent samples test: Differences in physical activity by gender ....... 123 4.13 Spearman rho correlation: Distance from town and minutes physical activity ......................................................................................................... 125 4.14 MannWhitney test: Private recreation facilities and physical activity ...... 127 4.15 MannWhitney test: Trails, parks, playgrounds, fields and physical activity .......................................................................................... 128 4.16 MannWhitney test: Shopping malls and physical activity ........................ 129 XVI

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4.17 MannWhitney test: Public recreation centers and physical activity .......... 130 4.18 MannWhitney test: Schools and physical activity ..................................... 131 4.19 Spearman Rho correlation: Arthritis self-efficacy function and minutes physical activity .......................................................................................... 133 4.20 Spearman Rho correlation: Attitude about physical activity and minutes physical activity .......................................................................................... 134 4.21 Spearman Rho correlation: Subjective norm and minutes physical activity ......................................................................................................... 136 4.22 Spearman Rho correlation: Perceived behavioral control and minutes physical activity .......................................................................................... 137 4.23 Independent samples test: Recommend versus not recommend with PA ............................................................................................................... 139 4.24 Independent samples test: Differences in P A by recommend or not recommend ....................................................................................... 140 5.1 Health characteristics: Survey participants and county or Colorado 2004-05 BRFSS data ................................................................................... 155 5.2 Colorado and PMR 1 BRFSS data: Participation in physical activity ........ 160 XVll

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CHAPTER 1 INTRODUCTION Research Question The study addressed the question, "What are the correlates of physical activity in individuals with arthritis living in rural communities?" In order to understand promotion of healthy living in rural settings through physical activity (PA) for people with arthritis, it is important to understand facilitators and barriers of P A. Rationale Less than four decades ago, it was commonly believed that individuals with arthritis should limit their activity levels and rest affected joints. Current research indicates that appropriate physical activity can reduce pain and increase strength and endurance, which ultimately can enhance functional ability, cardiovascular health, and quality of life. Whether or not individuals with arthritis are physically active may depend on multiple factors. The correlates of physical activity in people with osteoarthritis, or factors that influence their activity level, have only been addressed by one known study that includes participants recruited from an outpatient setting at a university medical center (Neuberger, Kasal, Smith, Hassanein, & DeViney, 1994). No known research has looked at correlates of P A in individuals with arthritis in rural communities. Understanding the facilitators and barriers to P A in this sub-population 1

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and including the active voice of community members through community-based participatory research can empower these individuals and those interested in their well-being to make well-informed health decisions related to their needs. Identifying the factors that encourage or discourage physical activity in individuals with arthritis in rural communities adds clarity to developing tailored interventions to improve their functional abilities and overall health. Arthritis is a broad descriptive term literally meaning "inflammation of a joint," and it is the leading cause of disability in the United States. The National Center for Chronic Disease Prevention and Health Promotion (2008) refers to disability as a condition which causes activity limitations. It affects approximately 46 million Americans (National Center for Chronic Disease Prevention and Health Promotion, 2008). According to Y elin, Herrndorf, Trupin, and Sonneborn (as cited in D. D. Dunlop, Manheim, Yelin, Song, & Chang, 2003), direct costs of arthritis care in the United States (US) in 1996, defined as the actual cost of medical care provided to individuals for their arthritis signs and symptoms, were $42.6 billion as expressed in the year 2000 US dollars. Similarly, indirect costs, including lost productivity and resources unrelated to the direct medical care costs of arthritis, were estimated at $82.2 billion in 1996 as expressed in 2000 US dollars (Yelin et al. as cited in D. D. Dunlop et al., 2003). Pain and loss of function often associated with arthritis can negatively affect the individual's ability to stay active in family, work, community, and societal roles leading to psychosocial costs (Hurley, Mitchell, & Walsh, 2003). 2

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The Centers for Disease Control and Prevention ( 1998) have identified physical inactivity, a potentially modifiable behavior, as a major cause of premature mortality. An estimated 200,000 to 300,000 premature deaths occur annually in the United States due to physical inactivity (Powell & Blair as cited in Brownson, Baker et al., 2004). The effects of physical inactivity on the general population include an increased "risk of heart disease, stroke, hypertension, type 2 diabetes, colon cancer, breast cancer, osteoporosis, depression, anxiety, and injuries from falls among the elderly" (Garrett, Brasure, Schmitz, Schultz, & Huber, 2004, p. 304). PA can reduce joint pain and swelling associated with arthritis (Macera, Hootman, & Sniezek, 2003). Data from the 2000 Behavioral Risk Factor Surveillance System (BRFSS) indicate that the level of P A among people with arthritis is lower than the general population (Hootman, Macera, Ham, Helmick, & Sniezek, 2003; Shih, Hootman, Kruger, & Helmick, 2006). The increased prevalence of physical inactivity among people with arthritis suggests that a larger relative percentage of this sub-population may be at risk for the comorbidities associated with physical inactivity than in the general population. Rural residency can lend itself to higher risks of non-health promoting lifestyles, which can affect individuals with arthritis living in these communities. The Health, United States, 2001 With Urban and Rural Health Chartbook (Department of Health and Human Services, 2001) lists sedentary behavior during leisure time and body mass index (BMI), a measure commonly used to classify someone as 3

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overweight or obese, as higher in most rural settings. In rural counties of east and northeast Colorado, a lower percentage of individuals participate in physical activities other than work, while a higher percent report being overweight or obese than the average for the State (Colorado Health Information Dataset, 2002-2003). Their total level of physical activity, including work activity, is unknown. It is also unknown what proportion of individuals with arthritis is represented in this data. It has been demonstrated that obesity is a risk factor for knee osteoarthritis, the most common type of arthritis (Coggon et al., 2001; Cooper et al., 2000; Felson & Zhang, 1998; Felson et al., 1997; Wei, Gibbons, Kampert, Nichaman, & Blair, 2000). Multiple factors including living with a chronic disease, relatively lower levels of P A, and residing in a rural community can have serious consequences to the health of individuals with arthritis. In order to determine if interventions for people living with arthritis in rural communities are needed, it was important to understand the current levels and types of P A in this sub-group, and to identify barriers and facilitators to P A. Including community participation in this process gave a voice to people with arthritis living in rural communities and helped to ensure that potential future actions meet the needs of the individuals living with arthritis. 4

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Specific Aims The specific aims and hypotheses of this investigation were to: Aim #1: Determine current levels of physical activity (PA) in participating individuals with arthritis living in rural communities of east and northeast Colorado. Aim #2: Determine the factors that influence physical activity for individuals with arthritis living in rural communities. Hypotheses: a. There will be a relationship between arthritis impact on physical function and minutes of moderate or vigorous physical activity. b. Men with arthritis living in a rural community will have significantly more minutes of physical activity than women with arthritis living in a rural community. c. Distance from town will be associated with minutes of physical activity in individuals with arthritis in rural communities. d. There will be a difference between perceived environmental availability of resources for physical activity and minutes of physical activity. e. There will be a relationship between self-efficacy and minutes of physical activity in individuals with arthritis who live in rural communities. 5

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f. Individual attitude towards physical activity will be associated with minutes of PA in individuals with arthritis who live in rural communities. g. There will be a relationship between individuals with arthritis perception of how others' perceive physical activity and arthritis and the individual's minutes of physical activity. h. There will be a relationship between individuals with arthritis who perceive they have control over their level of P A and minutes of P A. 1. There will be a difference between individuals with arthritis who report that a healthcare provider recommended physical activity versus those who report no recommendation and minutes of physical activity. Aim #3: Enhance the quality of the content of the study and the usefulness of the study's findings by fostering the participation of community members in the research process through a regional community-based Rural Arthritis Committee. 6

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CHAPTER 2 BACKGROUND Introduction Incorporating appropriate physical activity (PA) into an individual's routine plays a key role in promoting health, enhancing functional activities, and improving the quality of life in individuals with arthritis (Altman, Hochberg, Moskowitz, & Schnitzer, 2000; D. D. Dunlop, Lyons, Manheim, Song, & Chang, 2004; Fontaine, Heo, & Bathon, 2004). Adequate levels of physical activity can have a positive effect on arthritis (de Jong et al., 2004; Minor, 1999; Shih et al., 2006; Stenstrom & Minor, 2003; U.S. Department of Health and Human Services, 1996), a term that encompasses over 1 00 rheumatic and musculoskeletal conditions. Access to information, resources, appropriate social and physical environments, and behavioral strategies can support safe and effective levels of P A. In order to maintain appropriate P A levels, people with arthritis in rural Colorado communities may require healthful living interventions based on their current perceptions and resource availability. Living in a rural community can add to the complexity of living with a chronic disease. Issues including, but not limited to, access to care, resource 7

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availability, socioeconomic and educational status, culture, attitudes and behavior, and the environment may influence health choices in these communities. Physical activity can contribute to healthful living and is a predictor of decreased pre-mature mortality (Brown, Yore, Ham, & Macera, 2005; M. E. Nelson et al., 2007a). Physical activity has been shown to reduce the risk of chronic disease pathology (Bauman, 2004; Macera et al., 2003; Paffenbarger et al., 1993; U.S. Department of Health and Human Services, 1996) and the associated functional losses that limit daily activiites. For individuals with arthritis who already face disability and functional losses, the reduction in morbidity by participation in appropriate P A can significantly enhance the quality and longevity of life. Osteoarthritis The term "arthritis" literally means inflammation of a joint. This section introduces the most common type of arthritis, osteoarthritis, and describes management guidelines that include information on physical activity. Importance Osteoarthritis (OA) is the most common type of arthritis and affects over 20 million individuals in the United States (Robbins, Burckhardt, Hannan, & Dehoratius, 2001). It is estimated that 37% of adults in the United States (US) have some evidence of radiographic OA, and one-quarter of these individuals have moderate or severe disease (Robbins et al., 2001 ). US economic costs are estimated to be more than $60 billion per year (Elders, 2000), and this estimate does not include costs 8

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related to pain and suffering, reduced ability to be active in work or leisure time, psychosocial adverse effects or factors related to care provision by family or friends (Carr, 1999). World-wide, 10% of the population over the age of 60 years is estimated to have "significant clinical problems that can be attributed to osteoarthritis" (World Health Organization and The Bone and Joint Decade, 2001, p. 4). Pathogenesis and Diagnosis Joints commonly affected by OA include the weight-bearing hip, knee, spine, and first metatarsophalangeal (MTP) joints as well as the first metacarpophalangeal (MCP) joint of the thumb and the proximal and distal interphalangeal joints of the hand. Joint changes generally occur slowly over many years and are characterized by variable changes in the cartilage, subchondral bone, and marginal joint regions. Cartilage degeneration, subchondral bone sclerosis and osteophyte formation can occur progressively over time and lead to varying degrees of pain, functional loss, and disability. Inflammation of the synovial membrane and capsular thickening has also been noted (Bartlett, Bingham, Maricic, Iversen, & Ruffing, 2006; Rogers, Shepstone, & Dieppe, 2004 ). Laboratory tests alone such as blood work are not used to definitively diagnose OA (Bartlett et al., 2006; Rogers et al., 2004). Typically, a diagnosis requires a physical exam and history. Evidence of joint changes on radiographs can verify the diagnosis ofthose with advanced disease. 9

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Common signs and symptoms associated with OA are palpable bone changes, muscle weakness, pain, stiffness or gelling of joints after inactivity, and fatigue (Bartlett et al., 2006; Hurley et al., 2003; Klippel, Stone, Crofford, & White, 2008). Bony enlargements are often palpable at the affected joint surfaces of the hand, knee, and great (first) toe. Muscle weakness can be evaluated by the healthcare provider and or reported by the individual affected by arthritis. Slemenda et al. (1997) reported that quadriceps weakness was commonly noted in individuals with symptomatic knee OA. Pain often drives the initial contact with a healthcare provider. Although the intensity, frequency, and subjective description vary greatly between individuals, pain is primarily experienced with use of the joint. Stiffness or gelling of the joint occurs after periods of inactivity and is reported as "difficulty in getting started again" by individuals. This often subsides within 30 minutes of resumed activity. Individuals also report generalized fatigue which could result from increased energy expenditure required to perform activities with painful, stiff joints or it could be related to disrupted sleep patterns (Klippel et al., 2008). Osteoarthritis signs and symptoms can compromise an individual's hand and weight-bearing functional ability. Activities of daily living, work, and leisure-time activities can be limited resulting in reduction in the individual's health-related quality of life. Reduction in overall activity level can negatively impact the individual's cardiovascular status. (Elmer et al., 2006; Folta et al., 2008; King et al., 1995; Sundquist, Qvist, Sundquist, & Johansson, 2004) Cardiorespiratory fitness, as 10

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defined by Sui et al. (2008), can reflect cardiovascular status and has been shown to be a significant mortality predictor in older adults (Sui et al., 2008). Degree of severity of OA is classified by the American College of Rheumatology based on the individual's symptoms, clinical signs, laboratory tests, and or radiographic findings. Specific classification criteria exist for the hand, hip, and knee (Klippel et al., 2008). There is poor correlation between radiographic findings and pain and disability noted by individuals with OA (Bartlett et al., 2006; Hurley et al., 2003; Rogers et al., 2004). Individuals with severe radiographic findings often report less pain than those with mild joint damage noted on x-ray (Hurley, 2003; Rogers et al., 2004). Pain perception may limit an individual's ability to fully participate in work and or leisure activities. Risk Factors There are many risk factors associated with OA. Increasing age and a genetic predisposition are non-modifiable risk factors at all joint sites (Klippel et al., 2008). Female gender and ethnicity are additional non-modifiable risk factors at selected joints. For example, hip OA is rare in people of Chinese descent (Klippel et al., 2008). Modifiable, or potentially modifiable risk factors for osteoarthritis include obesity, previous joint injury, repeated overuse, knee bending, lifting, and biomechanical factors including abnormal stresses to the joint (Cooper et al., 1998; Cooper et al., 2000; Felson et al., 1997; Hurley, 2003). Dunlop et al. (2005) also 11

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report lack of regular vigorous physical activity as a potentially modifiable risk factor in older adults with arthritis that can substantially reduce their functional ability. Obesity, a potentially modifiable risk factor, has been linked to the development of knee OA (Cooper et al., 2000; Felson et al., 1997; Grabiner, 2004; Klippel et al., 2008). Obesity is often defined by the body mass index (BMI) calculated from the [(individual's weight in kilograms)/(individual's height in meters)2]. BMI categories include underweight ( < 20.0 kg/m2), normal weight (20.024.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (2:30.0 kg/m2 ) (Coggon et al., 200 I). Sharma, Lou, Cahue and Dunlop (2000) looked at the correlation between knee alignment (varus= "bowlegged," valgus= "knock-kneed") and the presence of OA in individuals with a mean BMI of32.3 or 29.8.5 kg/m2 (varus group and valgus group respectively). They noted, "BMI and malalignment were correlated in patients with varus knees but not those with valgus knees" (Sharma et al., 2000, p. 574). The BMI effect appeared to intensify with increased severity of varus malalignment suggesting that the effect of obesity on knee OA may be selective depending on the alignment of the knee joint. In addition, Grabiner (2004) reports that cartilage cell destruction and/or changes in the density of bone underlying the cartilage may contribute to the development of knee OA. Both of these effects may be magnified as a result of increased body weight. Abnormal stress applied to a joint over time affects the biomechanical forces across that joint. Muscle weakness may allow abnormal stress production across the 12

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joint. Hurley (2003) suggests "that quadriceps dysfunction may play a role in the pathogenesis of knee OA" (p. 450). In addition, quadriceps weakness has been identified as a more important cause of pain and disability in knee OA than destruction of bone and cartilage noted on radiographs (Slemenda et al., 1997). Muscle weakness may decrease the stability of the knee joint and also limit the shock absorbing capacity of the knee complex, thereby increasing the risk of abnormal biomechanical stress and OA. Occupations such as farming that apply repeated stress to joints may facilitate the destructive arthritic process often described as "wear and tear" arthritis (Cooper et al., 1998; Croft, Coggon, Cruddas, & Cooper, 1992). Croft et al. ( 1992) reported an association between farming and high rates of surgery for hip OA following data analysis of a cross-sectional survey. The authors suggested "one possible cause is cumulative mechanical stress on the joint from physical activities such as heavy lifting ... (p. 1269). They stated the increase in surgery rate in farmers compared to controls might be related to the need to correct the disability related to hip OA in order to continue the work associated with farming. The risk for hip OA increased with years working in farming. Prevention of destructive mechanical forces could reduce the risk of developing hip OA. Guidelines for the Management of Osteoarthritis Optimal medical management of osteoarthritis involves a team of health related professionals partnering with the individual with arthritis to maximize health 13

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outcomes. Reduction of pain symptoms, normalization of movement patterns, and maximizing functional abilities through appropriate body systems training including the musculoskeletal, cardiovascular and neuromuscular systems can improve health related quality of life and reduce functional limitations. The American College of Rheumatology Subcommittee on Osteoarthritis has developed guidelines for the medical management of hip and knee osteoarthritis (Altman et al., 2000). Their findings suggest treatments that consist of client education including self-management strategies, physical and occupational therapy, pharmacological or surgical intervention, and weight management. Non pharmacological management emphasizes strength and aerobic exercise based on evidence from multiple recent reports (Ettinger et al., 1997; Hurley, 1999; Slemenda et al., 1997). Appropriate exercise and/or physical activity are major components of the guidelines. The European League Against Rheumatism (EULAR) developed similar recommendations for managing knee OA. A task force within EULAR developed evidence-based guidelines for the treatment of knee OA (Pendleton et al., 2000). Non-pharmalogical and pharmalogical options were analyzed using an evidence based and expert opinion approach. The evidence-based non-pharmalogical and non surgical approach included patient education, exercise, insoles, nutrients, weight reduction, patellar taping, spa, and telephone contact with a HCP. Expert opinion ratings of these options were highest for exercise, patient education, and diet, which 14

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were ranked first, fifth, and seventh respectively when comparing all pharmacological and non-pharmacological management options. Current literature supports the role of exercise in the management of OA. According to Dieppe, Minor, and Blair who participated as experts in the National Institutes of Health (NIH) conference, "Stepping Away from OA: Prevention of Onset, Progression, and Disability of Osteoarthritis" in I999 (Felson et al., 2000), muscle conditioning is necessary to provide joint stability and to assist with shock absorption during weight-bearing activities, which can result in reduced signs and symptoms of osteoarthritis. They included range of motion and flexibility exercise, cardiovascular training, and muscle conditioning as components of exercise activities for individuals with OA. Dekker et al. and Hurley et al. (as cited in Steultjens, Dekker, van Baar, Oostendorp, & Bijlsma, 200I) reported that "improving muscle strength is regarded as one of the most important mechanisms towards reducing pain and disability" (p. 332). In addition, Dunlop et al. (2003) state that "the strong association of lack of vigorous exercise with subsequent functional deterioration is particularly important from a public health point of view because this risk factor is amenable to intervention" (p. II 0). Additional data support the use of exercise and or physical activity in the management of signs and symptoms associated with osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST) research study reported "modest but consistent improvements" (Ettinger et al., I997, p. 29) in pain and disability level as well as IS

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functional tests in individuals with knee OA participating in aerobic or strength training programs. The control group for this study had received health education without a structured exercise program. Philbin, Groff, Ries and Miller (1995) report the effectiveness of P A in older adults with OA who are sedentary. Improvements are noted in cardiovascular fitness and muscle strength in people with significant OA without making their symptoms worse. The recent Ottawa Panel results (Brosseau, 2005) suggest there is strong evidence for the use of P A, including exercise, in the management of OA, particularly in pain reduction and improvement in function. Minor (1999) states "Exercise may be the most effective, malleable, and inexpensive modality available to achieve optimal outcomes for people with osteoarthritis" (p. 397). Guidelines for management of osteoarthritis include pharmacological and non-pharmacological strategies. Multiple options can be considered to achieve optimal functional ability and reduce the impact of this disabling condition. Arthritis in Colorado Data from the 2005 Colorado Behavioral Risk Factor Surveillance System (BRFSS) (Gannon, n.d.) provide estimates that almost one-quarter of the adults in Colorado have been told by a physician or other health care provider that they have arthritis. Analysis by age group reveals of individuals over 65 years of age, of individuals between 55 and 64 years of age, of individuals between 45 and 54 years of age, and 11% of individuals between 18 and 44 years of age have 16

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some type of arthritis (Gannon, n.d.). Fifty-seven percent ofthese individuals across all age groups report being overweight or obese (Gannon, n.d.). The prevalence of arthritis is lower in individuals of Hispanic descent than white/non-Hispanic, Black/non-Hispanic, or individuals reporting race/ethnicity in the "Other" category (Gannon, n.d.). An additional 700,000 individuals suffer from undiagnosed joint pain and or stiffness (Gannon, n.d.). No information is available to determine percent of the affected individuals in rural versus urban areas. The Colorado 2005 BRFSS also reports other health characteristics of persons with arthritis compared to individuals without arthritis. Persons with arthritis are nearly three times as likely to have diabetes as individuals without arthritis. Also, nearly 39% of persons with arthritis report high blood pressure (Gannon, n.d.). In contrast, only 14% of individuals without arthritis report hypertension (Gannon, n.d.). Individuals with arthritis identify their overall general health as fair or poor (Gannon, n.d.). They also report less or limited time spent in leisure-time physical activity (Gannon, n.d.). State-by-state information related to arthritis-attributable work limitations (AA WL) was captured in the 2003 BRFSS. Participants in this random-digit state based telephone survey answered the following: "In this next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do?" (Centers for Disease Control and Prevention, 2007b ). Colorado data indicates 28% of working-age adults 17

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between the ages of 18 and 64 years of age responded affirmatively to this question (Centers for Disease Control and Prevention, 2007b ). Data was not reported for individuals who work but are not between the ages of 18 and 64. Data from the 2005 BRFSS estimate an increasing effect of arthritis in Colorado over the next 25 years. The number of individuals reporting doctor diagnosed arthritis is expected to rise 25% (Centers for Disease Control and Prevention, 2007a). An additional 68,000 persons with arthritis are estimated to experience arthritis-attributable activity limitations (Centers for Disease Control and Prevention, 2007a), which will have an impact on personal and economic resources. Colorado organizations interested in arthritis joined forces between 1999 and 2003 to examine resources and plan strategies to address arthritis-related concerns. Guided by a model presented in the "National Arthritis Action Plan: A Public Health Strategy" (Arthritis Foundation, Association of State and Territorial Health Officials, & Centers for Disease Control and Prevention, 1999), the Rocky Mountain Chapter of the Arthritis Foundation, headquartered in Denver, and the Colorado Department of Public Health and Environment joined together to form the Colorado Arthritis Advisory Committee in 1999. This committee comprised individuals from the public, private, professional, volunteer, and non-profit sectors and was organized to address the concerns associated with arthritis as a leading cause of disability. They developed a strategic plan, and although it was not fully funded, the plan identified several goals to address the topic of arthritis in Colorado: to identify and describe the population of 18

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people with arthritis in Colorado, develop a research agenda focused on improving prevention and management of arthritis in Colorado, provide resources to increase knowledge for health care providers and educators, increase public awareness about arthritis from prevention to management, implement programs for the prevention, early diagnosis, and management of arthritis, improve the quality of life for people with arthritis, and educate policy-makers on the health burden and cost of arthritis to the State of Colorado (Arthritis Foundation & Colorado Department of Public Health and Environment, n.d.). Due to a lack of sufficient funding, the goals were not fully met and require continued investigation. The Rocky Mountain Chapter of the Arthritis Foundation continues to focus on meeting the needs of people with arthritis in Colorado and has developed a public health strategy. Supporting a population, prevention, and partnership approach, they specifically recognize the need to focus attention on rural areas. A forum held in August, 2004, asked participants with a stake in rural health concerns to brainstorm on effective management strategies for people with arthritis in rural Colorado communities. The need for advancing current strategies to assist those with arthritis in more remote locations in Colorado was discussed and current resource limitations described. Issues of Rurality This section presents a definition of "rural" used for the purpose of this study and provides an overview of health disparities that exist in rural communities. 19

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Specific information related to health disparities in rural Colorado is reported as well as sociodemographic characteristics of the counties considered for this investigation. Defining Rural The term "rural" has been defined in a number of ways, and there is no general consensus on the definition (Hart, Larson, & Lishner, 2005). For the purpose of this investigation, this study used the Office of Management and Budget (OMB) classification scheme reported in "Health, United States, 2001 With Urban and Rural Health Chartbook" (Department of Health and Human Services, 2001), a metropolitan and non-metropolitan classification using counties as the geographical unit. Metropolitan statistical areas contain at least one urbanized area with 50,000 or more people and strong social and economic ties with adjacent territory. A separate OMB Bulletin No. 03-04 (2003) further divided non-metropolitan into micropolitan statistical areas or non-core based on their population. A micropolitan statistical area is considered to be a county that has at least one urban cluster, defined as less than 50,000 but greater than 10,000 population, and adjacent territory that has significant social and economic integration with core which is determined by commuting ties (Office of Management and Budget, 2003). "Non-core" counties are those counties that are not defined as a metropolitan or micropolitan statistical area. The OMB does not intend for micropolitan statistical areas or non-core areas to be equivalent to "rural." They base their rationale on the fact that many counties contain both urban and rural areas, which may be based on Census Bureau 20

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definitions. However, Census Bureau rural and urban designations are based on census tracts, which are difficult to apply to health data that are often reported by county. Part of the data used as a reference for this study is health data reported only by county. Therefore, the micropolitan and non-core designations used by the OMB equated to rurality for the purposes of this investigation. Health Disparities in Rural Communities Multiple health disparities exist in rural communities when compared to their urban or, in particular, their suburban counterparts. Health disparities within a particular population have been defined as "a population where there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population" (National Institute of Health as cited in Hartley, 2004, p. 1676). Although traditional explanations of health disparities in rural communities have been attributed to access to care issues, shortages of health care providers, and economic factors, there also appears to be rationale related to environmental, cultural, and behavioral characteristics that contribute to the health concerns of rural communities. These factors are reflected differently in the uniqueness of each rural region. Examples of environment, culture, and behavior impacting rural regions are noted in the "Health, United States, 2001 With Urban and Rural Health Chartbook" (Department of Health and Human Services, 2001 ). Being sedentary during leisure time, smoking, and a BMI 2:. 30 kg/m2 (obese) were all listed as higher in the most 21

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rural settings. Conceptually, all ofthese characteristics could be related to the environment, culture, or behaviors of the rural community. An unsafe environment such as cracked sidewalks, absence of non-roadway walking spaces, or poor lighting could prevent outdoor leisure activities such as walking. The prevailing rural culture might not value or recognize the health risk associated with smoking. And, the pattern of a rural diet and reduced physical activity could lead to obesity. These examples demonstrate compositional and contextual perspectives of rural communities that affect health. Phillips & McLeroy (2004) delineate these two perspectives by stating that "health problems in rural areas are compositional when they derive from the characteristics of people residing in rural settings" and "contextual when they derive from the special characteristics of rural areas" (p. 1662). Both perspectives should be considered when investigating the specific regional needs in rural communities. Approximately 20% ofthe US population lives in rural areas (Hart et al., 2005), and disparities exist in health characteristics and resource availability between rural and urban settings. There is a higher incidence of chronic health problems, including arthritis, in rural communities (Garkovich & Harris, 1994; Hart et al., 2005). There are fewer employer-offered health insurance plans and a higher rate of unemployment (Garkovich & Harris, 1994; Hart et al., 2005). In addition, higher poverty rates affect rural communities and fewer health care providers (HCPs) are available per capita than in urban areas (Garkovich & Harris, 1994). The 22

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combination of lower income (Saag et al., 1998), reduced insurance benefits, and fewer HCPs can lead to disparities in health care. Age and access to services also influence health disparities. Saag et al. (1998) note that elderly people with arthritis in rural communities self-report greater disability than those in urban areas. Individuals who have not been able to access an appropriate referral for accurate diagnosing due to lack of transportation, absence of HCPs, or financial restrictions are of particular concern in rural areas. Colorado Rural Communities Healthcare Disparities The State of Colorado comprises 64 counties, 4 7 of which are designated as rural or frontier (Colorado Rural Health Center, 2007) and were considered equivalent to micropolitan or non-core respectively for the purpose of this study. Frontier counties are defined as counties with six or fewer people per square mile (Denton, n.d.), and the term "rural" included frontier counties for the purpose of this investigation. Nearly 80,000 square miles in Colorado are considered rural (Colorado Rural Health Center, 2007). Within these rural counties, data indicate that health care challenges surpass those in urban counties. Over 90% of Colorado counties are designated partially or wholly as a "Health Care Professional Shortage Area" and six counties are designated as "Medically Underserved" (Colorado Rural Health Center, 2007) per Federal guidelines (U.S. Department of Health and Human Services, 1976, 1993 ). There has also been significant population growth in rural counties of more than 32% from 1990-2000 (Colorado Health Information Dataset, 2002-2003). 23

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Demographics and statistics related to Colorado offer a rationale for potential disparities in health care when compared to urban areas. The average median income is $36,892 in rural counties as compared to $53,799 for urban counties (Colorado Rural Health Center, 2007). A reported 12.7% of families in rural areas live below the Federal Poverty Level compared to 8.6% in urban areas. Health insurance rates for working adults are relatively higher in rural areas due to lower wages, limited choices, and few group plans (Denton, n.d.; Larson & Hill, 2005). The combination of lower income and higher health insurance costs potentially leaves many Colorado rural inhabitants without health insurance. Elderly individuals in Colorado may also face greater hardships in rural communities than in urban areas. A higher percentage of rural residents are over 65 years of age compared to urban areas (Colorado Rural Health Center, 2007). Fewer health care facilities are available in rural Colorado and 14 counties do not have a hospital (Colorado Rural Health Center, 2007). It is also reported as "often difficult to locate a rural provider who accepts Medicaid, Medicare, or Child Health Plan Plus in rural Colorado" (Colorado Rural Health Center, 2007, p. 2). A larger proportion of elderly individuals in rural Colorado with fewer health facilities and insurance challenges may limit quality and timeliness of care. Healthcare provider (HCP) shortages in rural Colorado limit access to medical care, particularly in specialty areas. There are currently 46 rheumatologists in urban areas listed by the Arthritis Foundation and 8 listed as serving rural communities 24

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(Arthritis Foundation, 2005). However, the rheumatologists listed as serving rural areas are often based in a city outside of the counties they serve, requiring the individual from a rural community to come to their office in a distant city often a hardship or impossibility for the individual affected by arthritis. Data for the number of HCPs in rural settings, including discipline, location, and specialty area, may not exist or be known by the rural community. For example, it is unknown how many physical therapists currently serve clients in rural communities and how many specialize in arthritis, making it difficult to provide this as a resource for rural Coloradoans. There are significant obstacles to optimal health of individuals living in rural Colorado. Demographics, resource availability, access to care, and economic factors influence healthful living in this rural sub-population. Colorado Rural Counties Sociodemographics This study originally included the counties of Cheyenne, Elbert, Kit Carson, Lincoln, Logan, Morgan, Phillips, Sedgwick, Washington, and Yuma. Sociodemographic data are available for these counties from the US Census Bureau data (2000) in Tables 2.1, 2.2, 2.3, 2.4, and 2.5. Column headings are those established by the US Census Bureau (2000). In addition to providing total population, age percentages, gender, occupation, and race within each county, these data also confirm the lower income levels in these rural counties compared to the State of Colorado averages, with one exception, Elbert County. Although the eastern 25

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section of this county remains sparsely populated, western Elbert County has seen explosive growth as a commuter neighborhood to Denver and Colorado Springs. Property values and income averages are significantly higher than the State average. Elbert County is included in the demographics because it has been grouped with Cheyenne, Kit Carson, and Lincoln counties in reports of the Behavioral Risk Factor Surveillance System (BRFSS) data and because the surveyed areas included rural portions ofthis county. Table 2.1 U.S. Census Bureau: Pop_ulation Totals, Age, Gender2000 State of Colorado Total Population Age: Age: Gender: or Colorado Estimates-45 to 64 years 65 year and over Males per /00 County Census 2000 (%of total females (%of total population) population) (all ages) State of Colorado 4,301, 261 22.2 9.7 101.4 Cheyenne 2,231 21.3 16.6 100.6 Elbert 19,872 25.5 6.0 100.6 Kit Carson 8,011 22.2 14.6 112.2 Lincoln 6,087 21.8 14.3 130.9 Logan 20,504 21.7 14.5 112.0 Morgan 27,171 19.8 13.0 100.4 Phillips 4,480 22.2 19.4 93.4 Sedgwick 2,747 25.0 22.1 100.1 Washington 4,926 24.2 18.2 103.4 Yuma 9,841 22.3 16.3 96.8 26

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Table 2.2 US. Census Bureau: Occul!_ation (f!_ercent distribution) 2000 State of ManageService Sales Farming, ConProduction, Colorado or ment, prooccupa-and fishing struction, Colorado fessional, trans-County and related lions office and extraction, port at ion, occupations occupaforestry and mainmaterial lions tenance moving State of 37.4 13.9 27.2 0.6 10.5 10.5 Colorado Cheyenne 35.3 16.7 17.8 4.6 15.1 10.4 Elbert 36.2 11.2 26.7 1.8 13.8 10.3 Kit Carson 33.7 15.4 24.4 7.4 8.7 10.3 Lincoln 32.2 24.0 20.5 3.3 10.1 10.0 Logan 28.4 19.7 23.5 2.9 11.0 14.5 Morgan 24.4 15.0 20.9 4.0 13.8 21.9 Phillips 35.3 13.8 21.5 10.8 10.9 7.7 Sedgwick 31.7 15.1 22.0 8.0 10.1 13.1 Washington 37.9 11.3 20.2 5.3 II. I 14.3 Yuma 34.0 13.4 22.2 8.7 11.2 10.6 27

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Table 2.3 U.S. Census Bureau: Race (p_ercent distribution) 2000 State of White Black A merAsian Native Some Two Hispanic Colorado or Or ican Hawaiother or or Latino Colorado African Indian ian and race more (of any County and races race/ American Other Alaska Pacific Native Islander State of 82.8 3.8 1.0 2.2 0.1 7.2 2.8 17.1 Colorado Cheyenne 92.9 0.5 0.8 0.1 0.0 5.1 0.6 8.1 Elbert 95.2 0.6 0.6 0.4 0.1 1.3 1.8 3.9 Kit Carson 87.3 1.7 0.5 0.3 0.0 9.2 0.9 13.7 Lincoln 86.3 5.0 0.9 0.6 0.0 5.7 1.6 8.5 Logan 91.7 2.0 0.6 0.4 0.1 3.8 1.4 11.9 Morgan 79.7 0.3 0.8 0.2 0.2 16.4 2.5 31.2 Phillips 93.0 0.2 0.3 0.4 0.0 4.7 1.3 11.8 Sedgwick 90.5 0.5 0.1 0.8 0.1 6.0 2.0 11.4 Washing-96.4 0.0 0.6 0.1 0.0 2.0 0.9 6.3 ton Yuma 94.2 0.1 0.3 0.1 0.0 4.1 1.2 12.9 a Percent of total population 28

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Table 2.4 US. Census Bureau: Income and Poverty 1999 State of Median Median Per capita Income below Income Colorado or income income poverty all below Colorado income ages(% of poverty-65 County households families (dollars) population) and over(% (dollars) (dollars) of population) State of 47,203 55,883 24,049 9.3 7.4 Colorado Cheyenne 37,054 44,394 17,850 11.1 10.9 Elbert 62,480 66,740 24,960 4.0 4.5 Kit Carson 33,152 41,867 16,964 12.1 II. I Lincoln 31,914 39,738 15,510 11.7 11.5 Logan 32,724 42,241 16,721 12.2 10.9 Morgan 34,568 39,102 15,492 12.4 9.5 Phillips 32,177 38,144 16,394 11.6 7.2 Sedgwick 28,278 33,953 16,125 10.0 4.2 Washington 32,431 37,287 17,788 11.4 9.4 Yuma 33,169 29,814 16,005 12.9 10.7 Table 2.5 includes responses to BRFSS questions by the Colorado counties of interest grouped into two Planning and Management Regions (PMR). Data on healthrelated questions in the grouped counties are compared to the State averages. 29

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Table 2.5 Behavioral Risk Factor Surveillance System (BRFSS) Dataset Information: 2004-2005 BRFSS Topic-Colorado Data How is your general health? % Good/excellent For how many days during the past 30 days was your physical health not good? % Bad physical health = 0 days For how many days during the past 30 days was your physical health not good? % Bad physical health = 1-7 days For how many days during the past 30 days was your physical health not good? % Bad physical health = 8 or more days Based on body mass index, are you overweight? %yes Based on body mass index, are you obese? %yes During the past 30 days, other than your regular job, did you participate in any physical activities? %yes Do you have any kind of health care coverage? % yes State of PMR Ia Colorado 87.9 79.3 67.0 63.4 21.7 19.7 11.3 16.8 53.7 61.4 16.4 28.2 82.1 66.0 84.4 85.4 PMR I Counties: Logan, Morgan, Phillips, Sedgwick, Washington, Yuma b PMR 5 Counties: Cheyenne, Elbert, Kit Carson, Lincoln c Not available fewer than 50 respondents d 2002-2003 BRFSS dataset infonnation Physical Activity PMR5h 86.0 66.2d 26.1d 67.6 73.5 In this section, physical activity is defined and information related to current levels of physical activity (PA) in the US is presented. Literature supporting the benefits of P A in the general population is examined and an overview of information related to P A in people with arthritis is discussed. 30

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Physical Activity and Health Physical activity is recognized as a major component of healthful living and can reduce the risk of developing some chronic diseases (Bauman, 2004; Macera et al., 2003; Paffenbarger et al., 1993; U.S. Department of Health and Human Services, 1996). It is broadly defined as any activity involving muscular contraction and can vary in intensity from minimal to maximal effort. It is considered distinct from exercise, which implies a structured activity with the goal of increasing physical fitness (Caspersen, Powell, & Christenson, 1985). Activity that increases physical fitness consists of components that promote endurance, strength, flexibility and/or balance (Caspersen et al., 1985). Both exercise and physical activity can improve physical fitness. Physical inactivity has associated high direct costs to the medical system. Garrett et al. (2004) report total medical expenses attributable to physical inactivity to be $83.6 million in a study that reviewed data from a health plan population and their paid claim costs and pharmacy data in the state of Minnesota. This represented approximately 1.5 million residents, about one-third the population of Minnesota, and "worked out to $56 per member in 2000, which could have been avoided if the entire population was active" (Garrett et al., 2004, p. 306). According to the authors, this per capita state estimate of charges related to physical inactivity was on par with several other states that ranged from $19 per capita to $79 per capita. Physical inactivity attributed to increased costs associated with ischemic heart disease, high blood 31

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pressure, stroke, depression and anxiety, type 2 diabetes, breast cancer, osteoporosis, and colon cancer (Garrett eta!., 2004). Increasing physical activity has become a national initiative. The Surgeon General's comprehensive report, "Physical Activity and Health," (U.S. Department of Health and Human Services, 1996) states that individuals can improve their health and quality of life through increasing their activity levels. Healthy People 2010 (Office of Disease Prevention and Health Promotion, n.d.) recognizes physical activity (PA) as one of the ten leading health indicators to be addressed during this decade and one of its objectives is "to increase the proportion of adults who engage in regular, preferably daily, in moderate PA for at least 30 minutes per day" (p. 26). The National Blueprint: Increasing Physical Activity Among Adults Age 50 and Older (Robert Wood Johnson Foundation, 2001) identifies strategies to enhance the physical activity levels in older adults in order to extend years of active, independent living (Cress eta!., 2005). Updated recommendations from the combined efforts of the American College of Sports Medicine and the American Heart Association clarify previous guidelines related to physical activity and public health (Haskell eta!., 2007). A companion paper specifically addresses recommendations for physical activity in older adults. (M. E. Nelson eta!., 2007b). Both papers use a system to classify recommendations based on classification of recommendations (COR) and level of evidence (LOE). (Haskell eta!., 2007). 32

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Current levels of PA in adults in the United States are inadequate. More than 60% of individuals in the United States do not participate in regular physical activity, and over 25% of this population is sedentary (Franklin, Whaley, & Howley, 2000). In individuals with arthritis, 30.8% were reported as inactive according to the 2000 BRFSS (Hootman eta!., 2003). Demographics indicate that 33% ofthe individuals with arthritis who were inactive were female, 45 years of age, obese, black, Hispanic, "other" race/ethnicity, or had :S 12 years of education. The term "lifestyle physical activity" (LPA) identifies the physical activity performed by an individual on a daily basis. Part of the challenge in determining needs for changes in P A levels is understanding current levels of LP A as well as the individual's level of fitness. Current recommendations for LP A includes at least 30 minutes of work activity, leisure-time activities, and any other daily activity in which the individual is actively moving, for example, buying groceries or cleaning the house, at a moderate to vigorous intensity level (Dunn, Andersen, & Jakicic, 1998). The definition of moderate and vigorous intensity levels may vary based on the fitness level of the participant. For example, the cardiopulmonary response to climbing six stairs may be elevated in an individual with low cardiovascular fitness and yet barely noted in an individual with high cardiovascular fitness. An assessment ofthe types and intensity ofPA can clarify the need for change in activity levels to promote a positive cardiovascular conditioning response. 33

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Individual levels of P A are influenced by many factors. These might include age, gender, general health, ethnicity, socioeconomic status, social and physical environments and personal behaviors. Parks, Housemann, and Brownson (2003) investigated correlates of physical activity in adults from rural and urban setting with diverse backgrounds. A sample of 1818 adults 18 years of age and older participated in a telephone survey that used a combination of questions from the BRFSS, the National Health Interview Survey, and other un-named surveys. Their results indicate that income level and urban rural status were predictors of this population's likelihood to meet PA daily recommendations. Participants with lower income levels or rural residents were less likely to be active. They also noted that environmental factors influenced levels of P A across socioeconomic and rural-urban settings. Benefits of Physical Activity Multiple studies have looked at the relationship of P A to health. Reduction in mortality and morbidity associated with conditions such as coronary heart disease, colon cancer, diabetes, and obesity is noted with improved physical fitness (Franklin et al., 2000; King et al., 1995). In 1992, Fletcher, Blair, and Blumenthal (1992) noted that the American Heart Association listed physical inactivity as an independent risk factor for cardiovascular disease. Furthermore, reduced morbidity with increased P A in individuals with chronic diseases such as arthritis is reported (Whaley, Brubaker, & Otto, 2006). The American College of Sports Medicine (Whaley et al., 2006) reports that as little as 1 0-minute sessions of aerobic activity three times per day can help 34

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achieve and maintain fitness. Nelson et al (2007b) state "Regular physical activity, including aerobic activity and muscle-strengthening activity, is essential for healthy aging. This preventive recommendation specifies how older adults, by engaging in each recommended type of physical activity, can reduce the risk of chronic disease, premature mortality, functional limitations, and disability" (p. I 098). Coronary heart disease (CHD), for example, is the leading cause of mortality in the United States, accounting for 28.5% of all deaths in the year 2002 (National Vital Statistics Reports, 2004). Although many risk factors, including smoking, high cholesterol (hypercholesterolemia), high blood pressure (hypertension), and obesity have been linked to cardiac disease, physical inactivity is a risk factor that, when addressed, can help reduce several other risk factors including hypercholesterolemia, hypertension, and obesity. In people with arthritis, physical inactivity is more prevalent than in the general population, which potentially predisposes them to a higher relative risk (RR) of CHD (Philbin et al., 1995). It is therefore critical to develop effective prevention strategies, either high-risk or population based, that will increase physical activity in people with arthritis in order to reduce the risk of developing CHD. CHD involves degenerative changes in the inner lining of the larger arteries that supply blood to the myocardium and, as noted above, is linked to the risk factor of physical inactivity (Fletcher et al., 1992). The American Heart Association (AHA) reports "the relative risk of CHD associated with physical inactivity ranges from 1.5 35

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to 2.4" (American Heart Association, 2005, p. 38) in the general population, which compares to the RR observed with smoking, hypertension and hyperlipidemia. Macera, Hootman and Sniezek (2003) report that "population attributable risk estimates for physical inactivity and CHD have ranged from 23% to 46%" and that "if all sedentary individuals could achieve at least a moderate level of P A, CHD events in the entire population would (theoretically) decrease by 35%" (p. 123). Thompson et al (2003) note "a graded relationship of decreasing CAD [coronary artery disease] with increasing levels of activity" (p. 311 0). Dunn et al. ( 1999) performed a randomized clinical trial to compare a lifestyle physical activity program and a structured exercise intervention in healthy, sedentary adults. Adults randomized to the lifestyle group were asked to perform 30 minutes of "moderate-intensity" P A most days of the week in a way that matched their lifestyle. They were also instructed in behavioral interventions designed to help them maintain this level of P A for the remainder of the study ( 18 months). The structured exercise group initially participated in individualized exercise training 5 days per week and then became more autonomous with their activities. Motivational strategies were used with the exercise group to encourage continued participation over the next 18 months. Significant positive changes were noted in cardiorespiratory fitness, blood pressure, and percent body fat in both groups. The authors concluded that P A, as well as a structured exercise program, can improve risk factors for coronary heart disease including hypertension, obesity, and a sedentary lifestyle. 36

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Wei et al. (1999) reported the need for clinicians to evaluate their clients' regular P A levels. Their research was based on the Aerobics Center Longitudinal Study (ACLS). They looked at the results of individual maximal graded exercise tests as an objective marker for PA levels in normal-weight, overweight, and obese male subjects. Their findings demonstrated that excluding participant baseline cardiovascular disease, health concerns such as diabetes, elevated cholesterol levels, hypertension, current smoking and low cardiorespiratory fitness were "comparable predictors of mortality" in the over-weight and obese subjects. Low cardiorespiratory fitness had a relative risk for cardiovascular disease and all-cause mortality comparable to or higher than the other predictors in this cohort. These significant findings suggest that P A can be used as a strategy to reduce the risk of the other predictors: i.e., cardiovascular disease, diabetes, hypertension, high cholesterol levels, and obesity. Sahyoun, Hochberg, Helmick, Harris, and Pamuk ( 1999) looked more specifically at the benefits of P A in females who are obese in reducing the risk of developing osteoarthritis. Data were taken from the first National Health and Nutrition Examination Survey (NHANES, 1971-1975) and the NHANES I Epidemiologic Follow-Up Study (1982-1984). The data analysis indicates that women who are overweight or obese (>25kg/m2 ) have a significantly higher risk of developing arthritis than women with a BMI between 19kg/m2 and 21. 9kg/m2 As noted previously, there is a higher prevalence of obesity in rural communities. This 37

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study also stated that obese women who lost weight were not at higher risk of developing OA than women who had maintained normal-weight throughout the study. The authors also reported that lower educational attainment was a predictor for arthritis even after controlling for weight, which might suggest the influence of other factors on the development of OA. According to the Tufts University Health and Nutrition Letter (2003), the reduced risk for OA with weight reduction may in part be due to the decreased pressure across weight-bearing joints. Each additional pound of body weight puts an additional three pounds of pressure across the knees and hips during level ambulation. Climbing stairs can increase this load to six pounds for each step indicating an additional 10 pounds of body weight can increase pressure on the hips and knees by sixty pounds. Therefore, the health benefits of P A are strongly supported and can be applied to various populations. Cardiorespiratory fitness, weight management, and the reduced risk of the effects of chronic disease are a few of the benefits of participating in regular P A. Environment and Physical Activity Research supports that the physical environment can influence the amount and type of activity. Brownson et al. (2000) report that previous cross-sectional studies demonstrate a relationship between environmental variables and P A behaviors. Giles-Corti and Donovan (2002) found that "accessible recreational facilities 38

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determined use of those facilities and thus, good access is necessary to create a supportive environment" (p. 1809). Living with a chronic disease in a rural environment without access to recreational facilities may have a significant effect on the ability for an individual to be physically active. Humpel, Owen, and Leslie (2002) reviewed 19 studies relating physical activity to perceived or actual environmental attributes. Outdoor environmental features positively associated with physical activity included access to cycle paths, a local park, and a park, beach, or shops in walking distance. Negative associations were noted with busy street crossings, steep hills, residential neighborhoods, and distance to a bikeway. Other associations related to facilities catering to exercise or physical activity interventions. Distance to and adequacy of facilities impacted the level of physical activity. Opportunities for activity in an individual's geographic area including local clubs were positively associated with physical activity. Weather was not found to significantly impact P A in the reviewed studies, but safe environments and pleasant aesthetics positively influenced PA. It was not noted if rural communities were represented in these results. Addy et al. (2004) investigated perceived social and environmental facilitators for physical activity. Individuals living primarily in rural communities in a southeastern county in the United States indicated that good street lighting, trust in their neighbors, and the use of parks, sports fields, playgrounds, and private recreational facilities promoted regular activity. Wilson, Ainsworth and Bowles 39

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(2007) expanded these results through investigating the relationship between change in BMI and environmental support for physical activity. They conclude that "improving environmental supports for access and use of trails and recreational facilities may be important for future environmental interventions aimed at reducing obesity among inactive individuals" (Wilson et al., 2007, p. 710). Brownson, Chang, et al. (2004) compared the reliability ofthree questionnaires that assess the social and physical environmental impact on PA. Using a survey test-retest methodology that was conducted by telephone interviews, they determined that questions related to the physical environment demonstrated higher reliability than questions targeting the social environment. Participants from rural and urban environments were included. They supported the critical importance of physical activity in health outcomes and of note, suggested that some survey variables "may be largely irrelevant for rural environments. One research priority is to identify environmental variables in rural settings that might be related to physical activity" (Brownson, Chang et al., 2004, p. 479). The environment can positively or negatively affect levels of physical activity. Discovery of environmental facilitators or barriers to physical activity within a community can direct interventions that will encourage appropriate levels of P A. Self-Efficacy and Physical Activity Self-efficacy is a concept that describes an individual's belief that he or she can perform or have control over a particular behavior. Bandura (1977) is credited 40

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with "the first theoretical treatment of his cognitive concept of self-efficacy" (p. 167). This concept is used as a construct in many theories of health behavior and can provide insight into an individual's health actions. Self-efficacy can influence an individual's level of function. Harrison (2004) used the Arthritis Self-Efficacy Scale (ASES) to assess multiple influences on function in women with knee osteoarthritis. The ASES is divided into three subscales including a self-efficacy function scale (Lorig, Chastain, Ung, Shoor, & Holman, 1989). Her findings suggest that "functional self-efficacy is an important factor affecting the functional performance outcome for people with OA of the knee" (Harrison, 2004, p. 822). Assessing an individual's self-efficacy in functional abilities such as their ability to walk I 00 feet in 20 seconds on flat ground (Lorig et al., 1989) may be associated with their level of physical activity. Sharma et al. (2003) used several outcome measures to investigate physical function over a three year period. Two of these tools included the ASES physical function subscale that measured self-efficacy and the Physical Activity Scale for the elderly (P ASE), which determined levels of physical activity in 236 individuals with diagnosed knee OA. The relationship of self-efficacy and physical activity scores to a function score from the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was investigated. Two categories of WOMAC scores included participants with a good baseline to 3-year function outcome and participants with a poor baseline to 3-year function outcome. Results indicated that individuals who 41

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sustained high function over the 3-year time period had high levels of self-efficacy and a greater level of aerobic physical activity. The average age ofthe participants was 68.6 years, and the study took place in the Chicago area. Rural Health, Individuals with Arthritis, and Physical Activity This section describes literature related to tying together the three components (rural, individuals of arthritis, PA) of the research question: What are the correlates of P A in individuals with arthritis in rural communities? Literature concerning P A levels of individuals with arthritis in rural communities is sparse. There are no known studies specifically addressing the correlates of P A in people with arthritis living in rural communities. More information is needed in order to effectively promote healthy living in this population. Rosemann, Kuehlein, Laux and Szecsenyi (2007) examined factors associated with physical activity in individuals with hip or knee osteoarthritis. This multi-site research study included 1,021 men and women grouped by primary diagnosis ofhip or knee OA based on which joint had the most severe symptoms. Participants were recruited from 75 general practitioner sites in two states in Germany, and it was not stated ifthe sites were designated as rural or urban. Participants completed the Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF), the International Physical Activity Questionnaire (IP AQ), and the depression module of a patient health questionnaire. Results focused on relative levels of PA in people with knee OA 42

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versus persons with hip OA. Individuals with knee OA were significantly less physically active than those individuals with hip OA. The AIMS2-SF lower extremity function, social, and symptom (pain) subscales were the strongest predictors of the dependent variable, PA, in individuals with knee OA. Similarly, lower extremity function and symptom subscales were the strongest predictors of the dependent variable, P A in individuals with hip OA. The authors suggested tailored interventions might be strengthened as a result of their findings. Wilcox, Castro, King, Housemann, and Brownson (2000) investigated determinants of leisure time P A in women 2:. 40 years of age of diverse ethnic backgrounds living in rural or urban areas. Leisure time physical activity (L TPA) reflects activity not related to work physical activity and was measured using questions adapted from the BRFSS and National Health Information Survey (NHIS). Morbidity data was not reported, including the diagnosis of arthritis. However, 14.8% of urban and 17.5% of rural women stated they were "not in good health" (p. 670). In addition, nearly 25% of both groups reported physical limitations that were not further defined. Results suggested rural women were more likely to be categorized as more sedentary than their urban counterparts. Care-giving duties were the most frequently cited barrier to increased leisure time physical activity by women in rural areas. In contrast, women in urban areas cited lack of time as the top barrier. In urban settings, participants noted a higher prevalence of sidewalks, street lights, crime, access to facilities, and ability to observe others exercising than in rural areas. Rural 43

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participants reported a higher presence of unattended dogs. A higher BMI was also noted in women living in rural areas. Although not specified in this study, it could be assumed that a portion of the participants have arthritis since an estimated 21.6% of the population in the United States report doctor-diagnosed arthritis. Identifying co morbidities in this population would clarify additional impact on L TP A. Exercise behaviors in individuals with RA were identified by Iversen et al. (2004). The predictors of exercise patterns six months following a visit to the rheumatologist were determined by: a) whether the patient had participated in exercise previously, or b) the rheumatologist's exercise behavior. There were 132 individuals with RA who completed baseline questionnaires to determine demographics, pain level, physical function, mental health, self-efficacy and disease activity. Questionnaires included subscales of the Medical Outcomes Study (MOS) SF-36 and Arthritis Impact Measurement Scale (AIMS) as well as Lorig's Self Efficacy Other Scale. The majority of participants with RA were female (79%), Caucasian (93%), college educated, and earned $30,000 or more (55%) annually. The rheumatologists also completed questionnaires that related to their beliefs and attitudes on exercise management of individuals with RA. The authors noted that a physician's knowledge of current exercise guidelines for individuals with RA is lacking or inaccurate and influences their client's exercise participation. The authors acknowledged uncertainty as to applicability to other populations. Also, exercise as opposed to daily P A was the dependent variable. Other influences of environment on 44

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exercise (social and/or physical) were not addressed. The study did not specify if the clients were from a rural or urban setting. A qualitative study by Roberto and Reynolds (200 I) investigated the effects of osteoporosis on women in a rural setting. The study was supported by the concept that older adults in rural communities have age-adjusted higher levels of most chronic conditions (National Center for Health Statistics and the US Senate Special Committee on Aging as cited in Roberto & Reynolds, 2001) and that this may be due to fewer resources, environmental concerns, and lower socioeconomic status. Thirty percent of the women also reported arthritis. Through focus group discussions, the authors identified five major themes through data analysis. One of these themes dealt with the changes the women needed to make in their daily activities. Women living on farms faced the challenges of continuing to do daily chores without risking a fall. Some reported reduced social interaction including babysitting grandchildren or avoiding sustained travel by car. It was suggested that isolation due to reduced ability to travel the distances required in rural communities for social interaction could increase stress greater than seen in women with osteoporosis in urban settings. A major concern of the participants was loss of independence and ability to live within their current environment. Living in a rural environment increased the complexity of living with a chronic disease. These studies address components of the current research question, "What are the correlates ofPA in individuals with arthritis in rural communities?" None ofthe 45

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studies specifically addressed all components of the research question: physical activity, arthritis, and rural residence. Roseman et al. (2007) do not address rural or urban influences on P A, and Wilcox et al. (2000) do not differentiate the effects of a disease state on P A in an older population. The study addressing individuals with RA investigates specific factors related to P A as opposed to exercise or rural communities. Research by Roberto and Reynolds (200 I) looks at the overall meaning of a chronic disease in women's lives specifically in rural communities. However, osteoporosis has different precautions related to PA and influences functional abilities in a different manner. Therefore, it is important to closely examine the determinants of P A in individuals with arthritis in rural communities to identify how to improve the functional ability and quality of life that can be adversely affected by these disabling disease processes. Community-Based Participatory Research The section describes the underlying principles and applications of community-based participatory research (CBPR). CBPR was used in this investigation to inform the research process. Community-based participatory research (CBPR) describes a process that strives to form a partnership between the community and the investigator in performing research relevant to the participating community. It is an orientation to research (Minkler & Wallerstein, 2003) typically based in traditions of critical, interpretive, or feminist theory (Frisby, Crawford, & Dorer, 1997) and seeks "to 46

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produce practical knowledge that is useful to people in everyday conduct of their lives" (Bradbury & Reason, 2003). CBPR "has gained respectability and attention in the health field" (Wallerstein & Duran, 2003, p. 28) and includes a public health goal "of eliminating disparities" (Wallerstein & Duran, 2003, p. 29). Inherent in CBPR is the concept of"community." According to the Webster's New World College Dictionary (Agnes, 2006), community is defined as: a) "all the people living in a particular district, city, etc .," and orb) "a group of people forming a smaller social unit within a larger one, and sharing common interests, work, identity, location, etc" (p. 296). Israel, Schulz, Parker, and Becker (1998) state, "Community is characterized by a sense of identification and emotional connection to other members, common symbol systems, shared values and norms, mutual-although not necessarily equal-influence, common interests, and commitment to meeting shared needs" (p. 178). An example of shared identification might include living in a rural community or living with arthritis. CBPR has evolved from a history of action research and participatory research processes. Kurt Lewin developed the concept of "action research" (AR) in the 1940s (Minkler & Wallerstein, 2003) and helped provide the foundation of what has been called the "northern tradition" of community-involved research (Wallerstein & Duran, 2003, p. 28). This tradition works to bring stakeholders together to collaboratively solve problems as opposed to more traditional "top down" approaches. In the United States, the "northern" approach allows involvement of the 47

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affected individual but is not necessarily focused on broader social change objectives (Minkler & Wallerstein, 2003). On the other hand, the "Southern tradition" (Wallerstein & Duran, 2003, p. 28) of participatory action research (PAR) developed in the 1970s as emancipatory research to understand societal transformation and to work with communities subject to domination by an elite group such as that seen in underdeveloped communities in Latin America, Asia, and Africa (Wallerstein & Duran, 2003). Therefore, AR and PAR lie on either end of a continuum from "problem solving to societal transformation" (Wallerstein & Duran, 2003, p. 29). Wallerstein & Duran (2003) state that CBPR contains elements of both traditions although the authors believe an "emancipatory perspective" (Southern tradition) more precisely incorporates the concept of eliminating health disparities. Ultimately, CBPR can be envisioned as a practice of research that allows for collaboration between the community and researcher and that fosters shared goals. Israel et al. ( 1998) has defined key principles that describe the concept of CBPR. They are: a) "recognizes community as a unit of identity," (p. 178) b) "builds on strengths and resources within the community," (p. 178) c) "facilitates collaborative partnerships in all phases of the research," (p. 178) 48

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d) "integrates knowledge and action for mutual benefit of all partners," (p. 179) e) "promotes a co-learning and empowering process that attends to social inequalities," (p. 179) f) "involves a cyclical and iterative process," (p. 180) g) "addresses health from both positive and ecological perspectives," (p. 180) and h) "disseminates findings and knowledge gained to all partners" (p. 180). Although listed individually, the authors acknowledge that these principles often overlap and may or may not all be integrated in any particular study depending on the type of study and participants involved. Minkler and Wallerstein (2003) add to these principles of participatory research defined by Israel et al. (1998). They state "we would underscore that CBPR principles should also include prominent attention to the centrality of issues of gender, race, class, and culture, as these interlock and influence every aspect ofthe research enterprise" (Minkler & Wallerstein, 2003, p. 6). This strengthens the aspect of empowering all individuals of a defined community and reduces the power imbalance critical to emancipatory research. Cameron, Hayes, and Wren (2000) describe their approach to power in community-based participatory action research (CBPAR) as a "power with approach" (p. 215). These investigators used a CBP AR process, "itself based in principles of 49

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egalitarian power relationships" (p. 216) to reflect on the interactive practices between healthcare professionals, community agencies, clients, and the management team of the Community Care Program in British Columbia, Canada (Cameron eta!., 2000). They concluded that the characteristics and principles of PAR were beneficial in guiding their research to promote health. Frisby et a!. ( 1997) used PAR as an orientation to researching access to physical activity (PA) resources by women in Canada who have low income. Stating "participation in physical activity is heavily dependent upon financial resources and cultural capital," (p. 9) the authors chose the advocacy, participatory approach of PAR to view the effects of socioeconomic status on P A. They followed Green et a!.' s (1995) definition of participatory research: "Participatory research is the systematic inquiry, with the collaboration of those affected by the issue being studied, for purposes of education and taking action or effecting social change" (p. 4). The authors wanted diverse community members representing all aspects ofthe issues of physical activity in the community to be collectively involved in addressing this issue. Again, the concept of equalizing power between the "researched" and the "researcher" was paramount to this study. CBPR, as an orientation to research, can bring together the shared knowledge of community members and the researcher. Multiple perspectives, skills, and insights enrich the potential for a successful understanding of an issue. Recognition of 50

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approaches to health promotion and collective decision-making in community-based areas of interest strengthens the potential for positive interventions. Theoretical Model The underlying theory for this research study is the Theory of Reasoned Action and Theory of Planned Behavior. The Theory of Reasoned Action (TRA) was developed by Martin Fishbein and introduced in 1967 (Glanz, Rimer, & Lewis, 2002). The Theory of Planned Behavior was proposed as an extension of the original TRA by leek Ajzen in 1991. This model of health behavior frames the likelihood of making a change in behaviors at the individual level. The following section describes how this theory informed the research process. The Theory of Reasoned Action and the Theory of Planned Behavior provided the theoretical perspective for this investigation as illustrated in Figure 2.1. The Theory of Reasoned Action (TRA) suggests that performance of a behavior, in this case physical activity, is directly influenced by behavioral intention, or the intent to perform physical activity (Glanz et al., 2002). In turn, behavioral intention, according to the TRA, can be determined by the attitude of the individual towards performing P A and the individual's subjective norm beliefs on whether most people approve of PA or not. Attitude towards performing PA is further influenced by their beliefs about outcomes and/or attributes when performing PA as well as an evaluation of the outcomes/attributes. Subjective norm is influenced by the referents' opinions on performing PA and by their willingness or motivation to comply with the referents' 51

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opm1ons. The Theory of Planned Behavior (TPB) is an extension ofthe TRA and adds a critical component to this investigation: the concept of perceived control over the implementation of a behavior that can affect the behavioral intentions of the individual (Glanz et al., 2002). There may be environmental factors perceived to be outside the control ofthe individual that challenge the ability of the person to perform the behavior. The influence ofthese environmental factors can be measured. Ajzen's concept of perceived control has been compared to the construct of self-efficacy as developed by Bandura (Glanz et al., 2002). Behavioral belief s Evaluation of behavioral ou tcomes Normative beliefs Motivation to comply Control beliefs Perceived power Theory' of Reasoned Action and Theory of Planned Behavior Behavioral inte ntion Behavior Figure 2.1 Theory of Reasoned Action and Theory of Planned Behavior 52

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These theories are useful in supporting methodological strategies that elicit individual and environmental considerations associated with an individual's P A behavior. Measurement scales are designed to link attitudes, subjective norms, and perceived behavioral control to behavioral intention and ultimately, to behavior. Information obtained from analysis ofthe Physical Activity and Arthritis Questionnaire (P AAQ) used in this investigation addressed the three main constructs ofthe TRA and TPB to inform the research question "What are the correlates of physical activity in individuals with arthritis in rural communities?" Additional constructs from two other instruments used in this survey relate to self-efficacy and the environment respectively and add insight into the impact of perceived behavioral control on performing P A. Collette, Godin, Bradet, and Gionet et al ( 1994) used the TRA to inform their research related to understanding intention to perform daily P A by individuals in a community. Three hundred fifty-three participants were surveyed to determine intent to exercise. The survey was developed from responses to open-ended questions that related to advantages and disadvantages of being physically active, referents considered important to the participants with regards to being active, and perceived barriers to physical activity. Respondents were grouped into "high intenders" and "low intenders." A regression analysis identified four variables that explained over 52% of the variability in intention to perform physical activity. These variables, in order of importance, were current physical activity, age, attitude toward P A, and the 53

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individual's normative belief. Current physical activity level was measured using a seven day recall questionnaire. An intervention P A marketing program was developed incorporating the findings ofthis study. The Theory of Planned Behavior informed a study by Vicki Conn (200 1 ). Dr. Conn interviewed 30 community-dwelling older women to determine behavioral beliefs, perceived behavioral control, and normative beliefs influencing their physical activity decisions. The participants were from small communities and rural areas in the Midwest. Qualitative analysis revealed three main themes: "social influences on physical activity, psychosocial benefits of activity, and joint problems and fatigue as factors that interfere with activity" (p. 370). Results indicated "a health promotion program instituted in naturally occurring social groups ... could be more effective than programs that attempt to attract individual women and emphasize the health benefits of physical activity" (p. 376). These results were compared to previously published data retrieved from interviews with women with similar demographics involved in episodic exercise. The women performing episodic exercise viewed exercise as something separate from their daily lives and not a part of their social activities. Dr. Conn suggested a social model might be more influential in the incorporated P A model than with episodic exercise. She also concluded that joint pain and fatigue, often associated with arthritis, would need to be incorporated into any intervention to be effective in promoting P A in populations comprised of older women. 54

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The TRA and the TPB have recently been used to examine adherence to exercise by individuals with RA following a clinical visit to a rheumatologist (Iversen et al., 2004). Use of"an expectancy-value questionnaire" (p. 710) elicited response from patients regarding their beliefs in outcomes for exercise interventions. Expectancy-value conceptualized the attitudes forming expectations related to attributes of the action (exercise) and the value associated with that action. A model was developed to identify potential relationships between patients or rheumatologists and exercise interventions based on the TRA and TPB. The PRECEDE model provides a framework that incorporates concepts of the TRA and TPB. Glanz et al. (2002) illustrate incorporation of the TRA/TPB during Steps 3 and 4 of the PRECEDE Planning Phases. Step 3, the behavioral and environmental assessment phase, emphasizes determining the factors contributing to the health issue under investigation (Green & Kreuter as cited in Glanz et al., 2002), in this case, physical activity in individuals with arthritis. Behavioral aspects, according to the TRA/TPB, relate to factors over which the individual has control. Environmental factors that influence behavior are considered external to the individual. An example relevant to P A that demonstrates external factors would be safety concerns with walking on uneven surfaces or lack of sufficient lighting. The emphasis is on the relationship between individuals and their environment. Step 4 focuses on an educational and ecological assessment (Glanz et al., 2002). It determines if there are support structures available to handle behavioral and 55

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environmental factors identified in Step 3. The components to address during this step include predisposing, reinforcing and enabling factors (Green & Kreuter as cited in Glanz et al., 2002). An assessment is carried out to see if strategies or resources exist to address or support predisposing factors, such as an individual's knowledge or beliefs about P A, reinforcing factors, such as social support or networks, and enabling factors, such as services required to enhance P A in the environment. Self-efficacy would also be considered a predisposing factor that could influence P A behaviors. The PRECEDE Model also supports the concept of Community-Based Participatory Research that is a key component of the methodology. The first step in the model, social assessment, allows for expanding knowledge of a defined community through focus groups, interviews, questionnaires and direct observation (Glanz et al., 2002). It allows the community to have a voice into perceived needs and goals. Step two can involve the community in defining which health issue to address and allows an epidemiologic assessment. The final step of the PRECEDE pathway assesses the policy and administration within the population to help determine facilitators or barriers to change at this level. The concept of Community Based Participatory Research is supported at these three assessment steps. 56

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CHAPTER 3 METHODS Research Design A cross-sectional survey, informed by a rural advisory committee, generated data for the investigation of correlates of physical activity (PA) in people with arthritis in rural communities. Individuals with a diagnosis of osteoarthritis in rural east or northeast Colorado were invited to participate in the survey, which consisted of six self-administered questionnaires. The overarching goal was to identify barriers to and facilitators of P A in order to determine what strategies, if any, are needed to improve PA, functional ability, and quality of life in people with arthritis in these rural communities. A community advisory committee informed the design, methods, analysis, and dissemination. The study included focused meetings with the Rural Arthritis Committee (RAC) members and pictorial documentation of their respective communities as well as a broader quantitative survey including multiple instruments that served to identify the factors associated with PA in individuals living with arthritis in these communities. Use of a community advisory board representing the rural areas of study, pictorial evidence documenting correlates to PA in people with arthritis, and quantitative instruments addressing aspects of living with arthritis, the 57

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environment, and physical activity approached the research question from multiple perspectives in order to strengthen the findings. Setting Ten counties in east and northeast Colorado were chosen as potential sites for this study. These counties are historically grouped into two Planning and Management Regions (PMR), PMR 1 and PMR 5, for reporting BRFSS data and therefore allowed comparisons between the current survey data and previously recorded BRFSS data. PMR 1 included Logan, Morgan, Phillips, Sedgwick, Washington, and Yuma counties. Cheyenne, Elbert, Kit Carson, and Lincoln counties comprised PMR 5. Planning and Management Regions were developed in 1977 to combine data from several counties with small populations in rural Colorado, which would increase reliable estimates of data from these rural areas (Colorado Health Information Dataset, n.d. ). The ten counties were also considered for this study because they are geographically bound, are identified as micropolitan statistical areas or non-core areas according to the classification scheme of the Office of Management and Budget (Office of Management and Budget, 2003) and because nine out often ofthese counties are part of the High Plains Research Network (HPRN). The HPRN is a rural research network organized in northeast Colorado in 1997 that is part of the Department of Family Medicine at the Anschutz Medical Campus of the University of Colorado Denver and includes members living in these rural communities. The 58

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HPRN's mission is "to provide excellent rural health care by translating the best scientific evidence into every-day clinical practice" (Colorado Convocation, 2003). The counties targeted for this study included Logan, Sedgwick, Phillips, Morgan, Yuma, Kit Carson, Lincoln, Elbert, Washington, and Cheyenne counties and are displayed in Figure 3.1. According to the Colorado Rural Health Council (2007), eight of the targeted counties are designated as "Health Professional Shortage Areas," one is listed as a "Medically Underserved County," and one is listed as "No Underservice Designation" meaning the county has not applied for a designation. These federal designations help identify areas with a severe need for health care professionals and/or health care delivery (U.S. Department of Health and Human Services, 1976, 1993). 59

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MOFFAT LARIMER MONTEZUMA LAS ANIMAS LA PlATA ARCHUlETA Figure 3.1 Colorado Counties Participants LOGAN WASHINGTON SEDGWICK PHILUPS YUMA KIT CARSON CHEYENNE KIOWA BENT PROWERS This research study involved two identified groups of individuals: I) Rural Arthritis Committee (RAC) Eleven individuals who volunteered to serve as part of a rural community advisory board for this project, 2) Survey Group-The survey group initially consisted of 177 individuals with arthritis who returned the packet of six questionnaires. Adjustments to this group size following initial review of the returned survey are discussed in the "Survey Return" section. 60

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Rural Arthritis Committee (RAC) recruitment Recruitment of a rural advisory committee was a critical component ofthe goal to understand the barriers and facilitators to physical activity by persons with arthritis in rural communities. This committee served to guide and direct the progression of the project and increase relevance to and acceptance by the communities. Initial inclusion criteria for individuals serving as part of the RAC were a) individuals living in a micropolitan or non-core county (as defined by the OMB) in east and northeast Colorado who are affected by OA, are associated with someone with OA, or who provide health care to individuals with OA; b) individuals who speak and understand English; c) individuals who are 45 years of age or older; d) individuals who can attend meetings at locations designated by the RAC members. The exclusion criterion for the RAC participants was inability to comprehend and discuss the proposed research topic. Voluntary participation in this project was verbally assured by the investigator as well as listed on the Informed Consent Form as a criterion for their participation (see Appendix A). A committee of eleven individuals representing four counties in east and northeast Colorado was recruited to support the multiple phases of this research project by members ofthe High Plains Research Network (HPRN) Community Advisory Council (CAC) and the principal investigator (PI). Recruitment for the RAC began in May of2005. The PI attended a meeting of the HPRN Community Advisory Council (CAC) to describe the focus of the project and ask for interested individuals 61

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to contact the PI. The CAC was formed in 1997 to address health care issues specific to the concerns identified by the council members in east and northeast Colorado and consists of individuals who live in the rural counties of east and northeast Colorado. Three members of the CAC contacted the PI approximately one month after the meeting to volunteer to participate in the project, which included recruiting additional Rural Arthritis Committee (RAC) members from their counties. Two additional CAC members, unable to personally serve on the committee, agreed to assist with recruiting members from the designated rural communities. Volunteer members were told the project would begin following the presentation and acceptance of the proposal by the PI's graduate school committee and that she would keep them informed. Members ofthe CAC recruited additional potential committee members, and meetings or telephone calls occurred between the PI and these individuals in February and March of2006. Interest and availability to serve with the Rural Arthritis Committee was determined. Over the next two months, eight additional community members were recruited as members of the RAC. Four members were recruited in person by the PI and a confirmed RAC member in the individual's home town. Three additional members were recruited through telephone conversations with the researcher and one member was recruited by the confirmed RAC member alone. 62

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Descriptions of the project research question as well as four "key points" were discussed with each of the potential RAC members. These "key" points were: a) Arthritis is the leading cause of disability in the United States, b) The right kind of physical activity can reduce the risk of chronic disease and improve function in persons with arthritis, c) We don't currently know how much or the types of physical activity people get in rural communities in Northeast Colorado, and d) Rural communities may lack resources that help persons with arthritis be active. Time and travel commitments were also discussed with potential RAC members, and they were informed there would be three committee meetings over the next 12 to 15 months. Mileage reimbursement would be available following each committee meeting and a $50 community gift card would be presented to each RAC member following completion of the RAC meetings. Potential committee members were asked to provide feedback on the proposed project. One individual commented that there was nothing in their community for people with arthritis. They felt that bringing attention to the problem of arthritis would be good, even if it was a way to start support groups. They also felt that many other things go with arthritis, including depression, and that specialists in arthritis came to their region infrequently. Another individual wanted to be involved in the project to help people in the community. They recognized some barriers to access for 63

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people with arthritis in their community, such as stairs instead of ramps, and stated people would often take the stairs, even if a ramp were available, so they didn't look "disabled." Individuals willing to serve as RAC members gave verbal consent to participate and recruitment ended when the target number of eight to twelve persons was attained. Written informed consent was mailed to willing members and collected at the first RAC meeting. Six individuals rejected the invitation to take part in the community meetings and research project prior to completion of subject recruitment. These individuals cited transportation barriers (reported by non-health care providers in the community), time restrictions (reported by physical therapists in the community), or lack of familiarity with the community (reported by non-health care providers in the community) as rationale for not participating in the community group meetings. Eleven rural community members comprised the original RAC and lived in one of five communities in a total of 4 of the target counties. Table 3.1 displays general demographics ofthe RAC. 64

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Table 3.1 Demog_rap_hics of_ Rural Members of the Rural Arthritis Committee by County County n Gender Age Years in Occupation Arthritis? b (yes/no) (N = 11) commumty Logan 2 M 62 45 Retired Yes F 66 51 Retired No Yuma 4 F 80 45 Retired Yes F 76 76 Retired No F 70 70 Retired Yes F 76 75 Retired Yes Phillips 3 M 34 2.5 HCP No F 59 22.5 Retired Yes F 75 44 Retired Yes Lincoln 2 F 65 35 Retired Yes F a 30 Education No Note. HCP=health care provider a Age was not reported b Average years in community= 45.1 years; average years in community excluding HCP = 49.4 As noted in the demographics, an exception was made to the inclusion criteria for one participant. This individual did not meet the age or length of residency inclusion criteria. However, this individual represented a health care provider's (HCP's) perspective to the project, which is considered to be critical in understanding implications for physical activity in the large patient population presenting with osteoarthritis. This individual's willingness to participate amongst the often severe 65

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time restrictions experienced by HCPs serving rural communities justified the exception made to the inclusion criteria for this study. The average age including this participant was 66.3 years and excluding this participant was 69.9 years. Survey group recruitment Survey group recruitment occurred over a period of 15 months and involved the RAC members, including the principal investigator (PI). Several modes were used to "announce" the project to the community and deliver surveys to interested parties. The research project was introduced to several communities represented by the committee members through short newspaper articles. A draft of the article was written by the PI and circulated to the RAC members via email or mail for suggestions and edits. The RAC members identified the local newspapers to approach for publication, and these were contacted by the PI. A total of four articles were published without cost as editorials or short articles by local newspapers. These articles served to alert the community regarding the arthritis project and the involvement of local community members. The PI contact information was provided to answer questions related to the project. Subject recruitment for the six-questionnaire survey used multiple points of contact that involved all members ofthe RAC, including the Pl. Adult male and female rural community members with self-reported physician diagnosed osteoarthritis who met the inclusion criteria were invited to participate in completion of the survey. RAC members implicitly asked "Who knows a lot about [living with 66

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arthritis in rural communities]? Whom should I talk to" to identify participants critical questions asked, according to Patton (2002), during snowball sampling. According to Babbie (200 I), snowball sampling "collects data on the few members of the target population he or she can locate, then asks those individuals to provide the information needed to locate other members of that population whom they happen to know" (p. 180). Answers to these questions led to recruitment of participants as well as other key informants who could assist with survey distribution. Recruiting techniques involved networking noted in snowball sampling. Individual RAC members identified the number of surveys they could distribute to individuals in the community. RAC and CAC members forwarded potential key informant names to the PI, and follow up calls and meetings were scheduled by the PI. These key informants were creative in and critical to survey distribution. For example, one community informant and family member used the $10 gift card incentive as a fundraiser for a local club. RAC members used this model to recruit additional participants who met the inclusion criteria from community groups. This stimulated widespread interest in survey completion. RAC members also identified community organizations they believed would be interested in the project topic. Table 3.2 summarizes the organizations recommended for contact with the initial date of contact. 67

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Table 3.2 Summary of Community Organizations Contacted by Principal Investigator Organization Initial Contact Date PT clinic 11/06 Seniors' Workshop 2/07 PT clinic 2/07 Senior Expo 3/07 Young Fanners Group 4/07 Senior Residence Apartments 4/07 Meet and Eat northeast 4/07 Meet and Eat east 4/07 Lions Club-Logan County 4/07 Lions Club-Sedgwick County 5/07 Woman's Club 11/07 The PI visited organizations to distribute survey packets to interested individuals and answer questions regarding the project. In addition, the PI offered informational sessions on arthritis if requested by the organization. Sessions were generally scheduled after the return of survey packets to avoid knowledge bias in completing the questionnaires. Survey packets were distributed in person at the time of contact or delivered by mail if requested by the participant. Flyers with investigation information and 68

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contact numbers (phone, mail, or email) were available for community postings in healthcare and other facilities in the designated counties. Individuals with osteoarthritis (OA) could obtain a flyer during their clinical visit and contact the PI if interested in participating. Inclusion and exclusion criteria were defined and placed on the outside of each survey packet to assist in accurate self-selection to participate in this study. Inclusion criteria for the survey group included: a) individuals living in a micropolitan or non-core county (OMB, 2003) in Northeast Colorado who are affected by OA, b) individuals who speak and understand English, c) individuals who are 45 years of age or older, d) individuals who are ambulatory with or without an assistive device. Exclusion criteria for the survey participants were a) individuals who are unable to comprehend the measurement instruments, b) individuals with acute medical conditions restricting their P A level, c) individuals who require another person to assist with ambulation. Procedures There were three primary components to this research study: I) A Physical Activity and Arthritis Questionnaire (P AAQ) drafted and piloted by the PI followed by enrichment and finalization by the RAC, 2) Three Rural Arthritis Committee meetings to inform the processes associated with the investigation, 3) One hundred and seventy-seven individuals voluntarily completing a survey composed of six questionnaires to inform the quantitative portion ofthis study. The University of 69

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Colorado at Denver Human Subjects Research Committee reviewed and approved all materials and contact with human subjects prior to the start of this study (see Appendix A). Annual human subjects renewal criteria were provided and approved throughout the data collection process. Voluntary informed consent was obtained for all individuals participating in any component of this investigation. Pilot Survey A pilot questionnaire titled the "Physical Activity and Arthritis Questionnaire" (P AAQ) was developed and piloted by the PI to assess four constructs defined by the Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB) (Glanz et al., 2002). These constructs include "Behavioral Intention," "Attitude," "Subjective Norm," and "Perceived Behavioral Control" (Glanz et al., 2002). The PI developed each statement based on the construct definitions identified in the book by Glanz et al. (2002). The first draft ofthe pilot questionnaire included 28 statements designed to identify the individual's beliefs about factors influencing arthritis and their ability to be physically active. A Likert scale ranging from "Strongly Agree" to "Strongly Disagree" was used and most statements were positively or negatively slanted. The questionnaire was piloted by the PI in rural Colorado communities in four counties adjacent to those identified for the primary research project as well as given to members ofthe Rural Arthritis Committee (RAC). Key community members living or working in one of these four counties were contacted by the coordinating researcher to discuss forums for distribution of the pilot questionnaire. These key 70

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members identified health care facilities, senior living residencies, Lion's Clubs or other organized meetings, and private community residents they felt would participate in the pilot survey. The PI followed up with contact information from the key community members as well as with members of the RAC. Surveys were distributed, following consent (see Appendix A), to individuals receiving physical therapy at a clinic, members of a Lions Club, residents in a skilled nursing facility, attendees at senior meetings, and individuals in private residencies. Survey distribution took place between February 21, 2006 and June 23, 2006. A total of 2 7 surveys were distributed to and completed by individuals living in Arapahoe, Adams, Douglas, or Weld County. In addition, three RAC members completed and returned the survey. Feedback on format, wording, general survey themes, and survey meaning were verbally solicited from pilot survey participants. The P AAQ was piloted in adjacent rural communities to achieve three primary goals. First, it was important that the survey was readable and understandable by community members. Feedback on grammar and terminology was solicited. Also, it was essential to determine ifthe PAAQ appeared to seek meaningful information to the community. Finally, piloting the questionnaire gave a time range for completion ofthe questionnaire, which was estimated at five minutes. Analysis of the P AAQ started in July, 2006. Items initially identified by the PI that related to each of the four TRA/TPB constructs were analyzed to determine if the 71

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identified items formed a reliable scale. To evaluate the items comprising each construct scale, Cronbach's coefficient alpha was computed. Principal components analysis (PCA) was not performed due to challenges with multicollinearity. According to Tabachnick and Fiddell's text (2001), it is acceptable to have this problem when doing PCA for descriptive reasons. Based on reliability analysis for each construct, items were deleted in order to represent constructs with the fewest number of variables (Leech, Barrett, & Morgan, 2005) and to improve consistency of items in a scale. Analysis resulted in reducing the number of questionnaire items from 28 to 18. Individual items were categorized into three of the four original constructs as noted in Table 3.3. One construct, "Behavioral Intention," was eliminated as a result oflack of reliability amongst items believed to be related to the construct. However, according to the TRA/TPB model, this construct is determined by the remaining three constructs: "Attitude," "Subjective Norm," and "Perceived Behavioral Control" (Glanz et al., 2002, p. 69) and would be represented by values associated with these three concepts. 72

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Table 3.3 Scale Reliabilityfor Physical Activity and Arthritis Questionnaire Items, n=30 Construct Item Number Cronbach's Alpha Attitude Subjective Norm Perceived Behavioral Control Note. rv = reversed Item06 Item11 rv ltem16rv Item18rv Item03 Item05 Item10 Item19 Item20 Item02rv Item04rv ltem08 Item12 ltem14rv ltem17rv .722 .638 .700 The RAC was presented with the revised pilot questionnaire for recommendations and final approval during the second RAC meeting on August 11, 2006 (see ProceduresRural Arthritis Committee Meetings). The mean score on each ofthe remaining 18 items was presented, and the RAC discussed these findings. One individual was surprised that the majority of the pilot survey participants "agreed" or "strongly agreed" with the statement "I believe being more active is up to 73

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me." As a result of this discussion, two statements were added that the RAC felt were important and not represented in the current form. One statement, "Arthritis is a normal part of aging and can't be helped by being more active" was suggested by a member who consistently heard this reported by individuals seeking health care. "I have friends or family available to do activities with me such as going for a walk" was suggested to determine ifthis resource was available as implied by other P AAQ questions. The RAC also recommended and approved addition of a "not applicable" (N/ A) column. Other changes involved reordering of items to assist with the "flow," personalizing all items by including terms such as "my physical environment" rather than "the physical environment," and clarification ofthe instructions for survey completion. Final approval was unanimously given to include this final version of the PAAQ into the research survey. Rural Arthritis Committee (RAC) Meetings RA C Meeting# 1 -Development of the RA C project-a group process The Rural Arthritis Committee first met on March 31, 2006, to begin to examine, understand, and shape the group project which would look at facilitators and barriers to physical activity in people with arthritis in rural communities of east and northeast Colorado. This was the first time many of these individuals had met; they only knew they shared a common interest. Five communities with populations from 982 to 11,360 (U.S. Census Bureau, 2000) and situated in four counties were 74

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represented by the RAC. Members drove from 27 miles to 120 miles one way to attend the meeting at a "central" location. One week prior to the first meeting, an introductory letter with several enclosures was mailed to each member of the committee (see Appendix B). Enclosures included an agenda (see Appendix B), a copy of the pilot survey draft (see Appendix C) with a consent form (see Appendix A), a RAC consent form (see Appendix A), and a sample flyer (see Appendix B). Instructions to help prepare for this initial meeting and directions to the site were included. The first meeting was organized to allow participants a chance to meet, turn in their written informed consent, develop an understanding of the project, be introduced to the concept and process of community-based participatory research, and offer insight into the direction and start of activities for this project. The group consented to tape-recorded sessions for accurate content recall. Each individual introduced himself or herself and how long they had lived in their community. The PI identified basic principles of CBPR and offered a short Power Point presentation that overviewed the key tenets of the project including arthritis, physical activity, and rural communities. The group then discussed the pilot survey which had been sent to them in advance. Results of this discussion are presented in the section titled "Pilot Survey." Important modifications were made to the final version of this survey (see Appendix C). 75

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RAC members were also given the option of using a disposable digital camera to document barriers and facilitators to physical activity for people living with arthritis in their communities. All committee members were interested in taking community pictures. The procedure for obtaining informed consent from individuals in pictures was explained. Copies of this informed consent were given to the RAC members with instructions to call the PI with any questions. The PI was responsible for collecting the cameras as members completed the task and for developing the pictures. Several additional topic areas were introduced by the PI and discussed by the RAC. Questions opened up for discussion included a) How can we proceed with survey distribution? b) What additional questions can we ask to help inform our research question? c) Would newspaper articles be valuable in promoting the project and survey distribution? d) Are there community contacts that would be important resources for this project? Members brainstormed responses during lunch and volunteered to continue looking at options to move forward with recruitment following the meeting. Recruitment resources, key community contacts, other modes of distribution, and marketing 76

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strategies were to be funneled to the PI via email and phone conversations for PI follow up. The first meeting ended on schedule after three hours and plans were discussed for the next meeting. Although the location was a two hour drive for two of the participants, the group agreed this was the most "central" location for all members. Topics for the next meeting, to be held at the end of the summer, were discussed. RAC Meeting #2-Photovoice &finalization of the survey for distribution The second RAC meeting was held on August 11,2006. Ten ofthe eleven original RAC members were in attendance and one member was unable to attend due to work commitments. However, a community member from the same area agreed to attend the meeting in her place. Following introductions, the meeting started with an activity. Members were given copies of the pictures they had taken of their communities. This activity allowed a photographer to "voice" their opinions on the research topic and is referred to as "Photovoice." They were provided with poster boards, adhesive putty, and markers with instructions to display the photos for a presentation to the rest of the committee. Members chose to work individually or in pairs (ifthey were from the same community). The activity took approximately 45 minutes to complete prior to the presentations. 77

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According to Wang and Burris (1997), Photovoice can be used to 1) "enable people to record and reflect their community's strengths and concerns," 2) "promote critical dialogue and knowledge about important issues through large and small group discussion of photographs," and 3) "to reach policymakers" (p. 3 70). In this investigation, it enhanced the strategies of CBPR by allowing individuals to provide "proof' of daily encounters that enhance or prevent physical activity. Photo documentation facilitated community discussion around identified correlates of P A in their community for individuals with arthritis as well as provided a resource for community change. All members participated in the verbal presentation of their posters. Pictures were representative of both facilitators and barriers to physical activity in their communities and all members appeared attentive during the presentations. Examples of pictures representing facilitation of physical activity by people with arthritis included door handles that were easy to use, wheelchair ramps, electric doors for entering buildings, a therapeutic pool, and a local physical therapy gym. Examples of pictures representing challenges to physical activity by people with arthritis included uneven or missing sidewalks, tractors difficult to mount, flights of stairs to enter buildings, and gates to open and enter for ranchers. Members discussed what each picture represented and the group had time to ask questions. This activity culminated in a diagrammatic summary produced at the meeting by the PI of the areas that would be addressed by the survey including the relationships of environment, self-efficacy, 78

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arthritis impact, and beliefs about physical activity to the amount of time spent performing physical activity. This diagram helped clarify the overall project for the committee members. The second half of the meeting involved finalization of the survey and discussion of survey implementation. The new draft of the pilot survey, based on all previous feedback, was presented and results of each item reviewed. RAC members reviewed mean value scores on items of interest and discussed what the values indicated. Final changes to the pilot survey were suggested and approved by the committee. Also, a questionnaire to capture information recommended by the RAC was finalized and approved by the committee (see Appendix C). This questionnaire would ask open-ended questions that could allow survey participants a chance to voice any other comments related to the research question. Cover sheets were added to all questionnaires as recommended by the RAC to clarify instructions and identify completion times. Survey implementation strategies were discussed by all members. The PI would gather survey distribution recommendations from the community members and arrange for follow up. Communication would occur through email, phone, or mail to develop new points of contact for this phase, and the next and final meeting for this project would be scheduled to discuss findings of the survey and identify dissemination pathways. 79

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RAC Meeting #3-Results and Discussion The final RAC meeting was held on September 7, 2007 and took place in the same location as previous meetings. Six members, including the PI, attended the meeting. One individual discontinued involvement in the RAC following relocation to a different geographical area outside of the research study boundaries. A RAC member from the same community was unable to continue after this point since they no longer had transportation to the meeting. School-year commitments prevented three additional members from attending the meeting, and the health care provider developed scheduling conflicts. However, the attending members contributed excellent insight into the ensuing discussions on data collection, preliminary results, community outcomes, and future directions. Outcomes from this meeting are discussed in the Results section. Quantitative Procedures Survey data collection occurred over a period of 15 months. Questionnaires were used to collect sociodemographic, arthritis impact, physical activity, self efficacy, general health, and environmental data. The six instruments used to collect this data were the Arthritis Impact Measure Scales 2 (AIMS2), physical activity questions from the Behavioral Risk Factor Surveillance System (BRFSS) combined with work-related PA questions from the Occupational Physical Activity Questionnaire (OPAQ), 80

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the Arthritis Self-Efficacy Scale (ASES), the Environmental Supports for Physical Activity Long Questionnaire (ESPALQ), the Physical Activity and Arthritis Questionnaire (P AAQ), and a final questionnaire that included open-ended questions. Individuals identified through the recruitment process and who voluntarily consented to participate completed the survey information. Likert-type scales, dichotomous or multiple-choice answer, single response items, and written reported time increments (for the physical activity component) were used to obtain data. Four open-ended questions were included in the final questionnaire to allow comments on focused areas ofthe study. Surveys were distributed in person or by mail. Each survey packet contained an informational letter with the PI contact information six questionnaires, a pre addressed, stamped envelope for survey return, and a postcard to return for a $10 gift certificate. All included items were approved by the Human Subjects in Research Committee at the University of Colorado Denver. Returned surveys indicated the participant's consent to participate. Several logistics were considered in survey packaging. Individual participants did not need to provide any identifying information on the survey instrument. All questionnaires were numerically coded. Questionnaires were placed in a random order into the survey packets to reduce the risk of order bias with the exception of the 81

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final questionnaire which was placed last in each packet. The final questionnaire allowed individuals a chance to include any other comments related to the research topic that they felt had not been previously addressed. Total completion time for the survey was estimated at 45 to 60 minutes. In order to maintain confidentiality of the surveys and yet compensate with the $10 gift certificate, a pre-addressed, stamped postcard was included in each packet with instructions. The participant was instructed to return the postcard separately with a mailing address for the gift card. The postcards were coded with the survey packet number so that they could be matched by the PI upon return of each item. However, the survey packet could remain de-identified and only the PI would be able to link the postcard information with the survey packet. Gift certificates were purchased from the community associated with the participant's residence. Sources for the gift certificates or cards were identified by RAC members, individuals who completed the survey, other key informants involved in recruiting participants, or the organization hosting the survey distribution. The goal was to support the participating communities by purchasing local gift incentives that would be spent in the same communities. Gift certificates were purchased from local diners, drugstores, and grocery stores. In addition, gift cards from Walmart were purchased at the local store division as requested by many community members within a 50 mile radius of this store. 82

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Measures The following instruments were used to collect data on individuals with arthritis in rural east and northeast Colorado. Physical Activity Two measurement tools were used to determine current levels of physical activity in participating individuals with arthritis in rural communities in east and northeast Colorado (see Appendix C). Non-work-related physical activity was measured using the physical activity questions from the 2003 BRFSS (Centers for Disease Control and Prevention, 2003). Work-related physical activity was measured using the Occupational Physical Activity Questionnaire (OPAQ) for individuals who were employed. The OP AQ follows a similar question format as the BRFSS. The BRFSS was originally developed to collect data at the state level but has also been used to estimate prevalence for regions within a state. There are seven questions that relate to physical activity. One question differentiates the type of physical activity performed at work and the remaining questions identify the amount of non-work-related PA performed by an individual each week. This "leisure time" P A is categorized into moderate and vigorous physical activity. Nominal variables and recorded time intervals are used to collect data. Use ofthis survey allowed comparison of collected county data to Colorado state data. The BRFSS has been used as a telephone survey that randomly incorporates all ages, including the age range for this investigation 45 years old with no upper 83

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limit). Kirtland et al. (2003) used the 2001 physical activity modules to assess physical activity levels when investigating social and environmental effects on P A. Fontaine, Heo, and Bathon (2004) analyzed data from the 2001 BRFSS to classify individuals with arthritis by level of activity. It is currently being used in a project funded by the Centers for Disease Control and Prevention in San Diego (J. Hootman, personal communication, August 11, 2005). Reliability and validity of the BRFSS P A data have been studied. Validity of the adult BRFSS physical activity data is reported as "acceptable, or relative advantage" by Glasgow et al. (2005). According to the same report, reliability is "unreported or not studied." Nelson, Holtzman, Bolen, Stanwyck, and Mack (2001) provided a comprehensive review and summary of more than 200 studies analyzing measures on the BRFSS. Data related to intense leisure-time physical activity had moderate reliability and validity. A comparison of data from the National Health Interview Survey and the BRFSS by Nelson, Powell-Griner, Town, and Kovar (2003) concluded that BRFSS data results were comparable to NHIS data and could be used to guide national policy development. The current study required self-completion of the BRFSS survey as opposed to the traditional telephone completion employed with historical BRFSS distribution. Link, Battaglia, Frankel, Osborn, and Mokdad (2005) at the Centers for Disease Control and Prevention have done preliminary work to examine the data quality obtained from random digit dialing (ROD) survey distribution and completion versus 84

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the United States Postal Service (USPS) Delivery Sequence File (DSF). The DSF contains all addresses used by the USPS and is updated every two months (Delivery sequence file (DSF), n.d. ). This pilot survey randomly sampled 1,680 addresses per state. Eight items were compared including frequencies of asthma, diabetes, high blood pressure, obesity, current smoker, binge drinking, tested for HIV, and HIV risk behaviors. The mailed survey results from March-May, 2005 were compared to monthly ROD survey results from the same time period. The authors concluded that weighted estimates for five of the eight items included in the survey were similar and that higher reports were received in the mail on sensitive behaviors. The authors suggested that reduced response rates noted in ROD surveys might be improved with DSF sampling. Individuals with cell phones can be reached with DSF sampling. Further pilot research to compare modes of BRFSS distribution is planned. Directions for completion of the BRFSS physical activity questions were slightly modified to help clarify examples of moderate and vigorous non-work-related P A in the rural settings. "Fishing" and "home repair" were added as examples of moderate activity based on comparable MET levels of activities that might be more meaningful in a rural environment (B. E. Ainsworth, 2002). Similarly, "shoveling heavy snow" was added to the examples of vigorous physical activity based on MET levels of P A (8. E. Ainsworth, 2002) comparable to BRFSS examples. 85

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The Occupational Physical Activity Questionnaire (OPAQ) was used to assess weekly levels and amount of work-related physical activity. This measure was developed to identify "the average time per week spent in occupational sitting or standing, walking, and heavy labor activities" (Reis, Dubose, Ainsworth, Macera, & Yore, 2005, p. 2076) Seven questions identify time spent at work per week and how many hours, if any, the individual spends in sit or stand activity, walking, and or heavy labor each week. The OPAQ test-retest reliability coefficients for hours ranged from an ICC of0.55 to 0.91. Fair to substantial criterion validity was noted when comparing OPAQ constructs to detailed PA records of like activities. "Convergent validity displaying the ability of the OP AQ to correctly identify participants who performed mostly sitting or standing, mostly walking, or mostly heavy labor at work was substantial [kappa= 0.71 (95% CI = 0.49, 0.94)]" (Reis et al., 2005, p. 2075). These values are comparable to other surveys that measure P A. The questionnaire format is similar to the BRFSS physical activity questions, and the BRFSS and OPAQ questions were asked consecutively in one questionnaire packet. It took approximately 5-l 0 minutes to complete this questionnaire. Physical Activity and Arthritis An individual's intent to perform P A was assessed using the Physical Activity and Arthritis Questionnaire (PAAQ). The development and piloting ofthis survey was previously described. The Theory of Reasoned Action/Theory of Planned Behavior is the theoretical foundation for this questionnaire. This tool was used to 86

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ascertain the individual's attitudes, subjective norms, and perceived behavioral control pertaining to P A and its relationship to their arthritis. A total of 20 statements were rated on a Likert-type scale from "strongly agree" to "strongly disagree." A "not applicable" response was also available, as recommended by the Rural Advisory Committee. The PAAQ required approximately 3-5 minutes to complete. A principal axis factor analysis was performed using 119 surveys to identify items associated with the three main constructs: attitude, subjective norm, and perceived behavioral control. Factor analysis is appropriate to use when it is believed that latent variables or constructs underlie the measured items (Leech et al., 2005). Principal axis factor analysis with varimax rotation was conducted to assess the underlying structure for the 20 items of the PAAQ. Three factors were requested based on the Theory of Reasoned Action/Theory of Planned Behavior constructs of attitude, perceived behavioral control, and subjective norm as previously described. After rotation, the first factor accounted for 13.6% of the variance, the second factor accounted for 12.6% ofthe variance, and the third factor accounted for 8.9%. Cronbach's coefficient alpha was calculated to determine internal consistency reliability for each subscale of the PAAQ. Reliability of the scaled items was maximized by deleting items to improve Cronbach's alpha. Following the principal axis factor analysis and Cronbach's alpha computation, PAAQ subscales were identified and displayed in Table 3.4. The alpha for the four items creating the attitude scale was 700, which indicates reasonable internal consistency between the 87

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scale items. Similarly, the alpha for the five items forming the perceived behavioral control scale was .787, indicating good internal consistency. The alpha for the three items in the perceived behavioral control scale was .677, suggesting minimally adequate reliability. Table 3.4 Scale Reliabilityfor Physical Activity and Arthritis Questionnaire Items, n= 119 Construct Attitude Subjective Norm Perceived Behavioral Control Item Number ltemOl ltem03 ltem06 ltem16rv ltem05 Item19 ltem20 ltem02rv ltemllrv Item14rv Item 15rv Iteml8rv Cronbach's Alpha .700 .677 .787 Note. rv = reversed; item responses were recoded to indicate a high score favors physical activity Final scale items varied from the subscales identified in the pilot survey. Potential reasons for this variation included use of a larger sample group in the main survey, sampling of different counties for the pilot versus the primary survey, and 88

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bias introduced through purposeful sampling. Subscales identified from the main survey sample, n=119, were used during consequent analyses since they were determined from a larger sample and were established through survey response by individuals from east/northeast Colorado counties. In contrast, the pilot survey's scale results, n=30, were identified through survey completion by individuals living in adjacent counties to the main survey populace. Arthritis Impact The Arthritis Impact Measurement Scale 2 (AIMS2) assessed health status indicators in individuals with arthritis including physical function, pain, affect, comorbidities, social support, medication use, and work impact (see Appendix C). Demographic data was collected using the AIMS2 The AIMS2 represents a revision of the original Arthritis Impact Measurement Scale that was designed to evaluate the health status in individuals with arthritis. The AIMS2 consists of 12 scales that have internal consistency coefficients between 0.74 and 0.96 for individuals with osteoarthritis (Meenan, Mason, Anderson, Guccione, & Kazis, 1992). This indicates high consistency for individuals responding to the items within an instrument. Validity was tested using internal standards based on a subject's consistency of response to related items throughout the AIMS2. The AIMS2 required approximately 23 minutes to complete and used a Likert-type scale (normal measurement) or yes/no responses (dichotomous measurement) to determine health status and arthritis impact. Low scores indicated a high health status. This tool collected demographic and health 89

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status data using nominal, ordinal, and normal types of measurement (Leech et al., 2005) as well as one continuous single response item (age). For the purpose of this study, sociodemographic data, type of arthritis, health demographics, and information related to physical function were gleaned from the AIMS2. Sociodemographic data included age, gender, racial background, current marital status, highest level of education, and family income. Type of arthritis was identified from a list of 11 rheumatological-related diagnoses and or an "other" category. Twenty-five participants out of 119 indicated "low back pain" as their "main kind of arthritis" (Meenan, 1990b ). These participants were included in the research study as individuals with osteoarthritis since they also listed peripheral joints affected by arthritis and were not taking arthritis medications on a daily basis. The participants, by completing six questionnaires related to arthritis, perceived that they have arthritis. Listing additional joints commonly affected by osteoarthritis, such as the hip or knee, strengthened the argument that they were likely to have osteoarthritis. The additional criterion related to lack of regular arthritis medication and would suggest the individual did not have rheumatoid arthritis (RA), a less common form of arthritis that can affect peripheral joints. Individuals with a diagnosis of RA are generally on an aggressive medication regimen and have been told they have rheumatoid arthritis. If the participant identified low back pain as the type of arthritis from the list of 11 diagnoses, completed all questionnaires on arthritis, and followed 90

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the above criteria of listing arthritis-affected joints and reporting non-routine arthritis medication management, they were included as an OA participant. Six AIMS2 scales were grouped to measure physical function as defined by Meenan (1990a). The six scales were mobility, walking and bending, hand and finger, arm function, self-care, and household tasks. Principal axis factor analysis was performed on the 119 collected AIMS2 questionnaires to compare with AIMS2 scales reported in the literature. Six factors were requested, based on the fact that items were designed to index the six constructs identified above. The six rotations accounted for the variance as follows: 16.0%, 14.0%, 13.9%, 10.5%, 8.8%, 3.1%. The current research subscales that matched the scale items identified in the AIMS2 literature (Meenan et al., 1992) included the mobility, hand and finger, self-care, and arm function scales. Minor deviations in grouping were noted in the walking and bending scale (four out of five items grouped together) and the household task scale (three out of five items grouped together). Deviations in scale configurations could be due to smaller sample size in the current research population, difference in interpretation of the items between the sample population and the original population, and or sampling bias associated with purposeful sampling in the current study. Raw scores from each of the six AIMS2 scales were added and normalized per Meenan (1990a) to obtain values between zero and ten, which would allow expression of all scales in similar units. The mean of the six normalized scales produced a physical function component ofhealth status. 91

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Self-Efficacy Self-efficacy was measured using the Arthritis Self-Efficacy Scale (ASES) developed by Lorig, Chastain, Ung, Shoor, and Holman (1989) (see Appendix C). Self-efficacy has been defined as an individual's belief that he or she can perform a specific task or behavior. A cover sheet provided to the ASES in the survey packets defined self-efficacy as "how much control you feel you have over your arthritis" to help participants understand the term as it relates to arthritis. The ASES was developed and evaluated to look at self-efficacy in mediating health outcomes in individuals with arthritis (Lorig et a!., 1989). It measures three areas of self-efficacy as it relates to pain, functional, and "other" behaviors. There are five, nine, and six Likert-type items in each area respectively. The three area reliabilities were 0.85, 0.90, and 0.87 respectively, which indicate high reliability and that the different items in each scale are consistent with one another in measuring that variable. Pearson correlations determined the item reliabilities to be between 0.71 and 0.85, which indicates a high correlation between items in the scale. The self efficacy pain and self-efficacy other scale scores can be combined. The self-efficacy function scale score is measured separately. It was estimated to take two to five minutes to complete this questionnaire. Principal axis factor analysis with varimax rotation was performed on the 119 returned self-efficacy questionnaires. Analysis was performed to determine ifthree scales including pain, function, and other, would be apparent in the sample 92

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population. Three factors were requested to assess the underlying structure for the 20 items of the ASES. After rotation, the first factor accounted for 27.0% ofthe variance, the second factor accounted for 20.6% of the variance, and the third factor accounted for 18.1 %. All function scale items grouped together as the first factor. Items from the pain and other scales were split between the final two factors. This would support the potential two scale interpretation (Stanford Patient Education Center, n.d.). The self-efficacy function scale was selected to represent the construct of self-efficacy during analysis with the dependent variable, physical activity. The relationship between belief in ability to perform functional tasks and amount of physical activity performed was explored. Environmental Supports for Physical Activity Questionnaire The Environmental Supports for Physical Activity Long Questionnaire evaluated the participants' perceptions of support for physical activity in their physical and social environments (see Appendix C). This tool consists of 11 Likert type (ordinal measurement) or dichotomous (nominal measurement) items that were taken from an original instrument because they were found to be an accurate and reliable measure of an individual's perception of the social and physical environment (SIP 44-99 Research Group, 2002, October). This questionnaire takes approximately 5-10 minutes to complete. It was developed by the University of South Carolina Prevention Research Center to inform a future BRFSS module to assess support for PA in the environment (SIP 44-99 Research Group, 2002, October). 93

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This survey asks questions related to the neighborhood and the community, which are defined as separate concepts. Neighborhood is defined as "a Yz mile radius or a 1 0-minute walk from the respondent's home" and community, which is defined as "a 1 0-mile radius or a 20-minute drive from the respondent's home" (Brownson, Chang et al., 2004). Internal consistency coefficients have been reported between 0.42 and 0.87 by Brownson and Chang et al. (2004). The items have been used in univariate and multivariate logistic regression analyses to predict P A levels (University of South Carolina Prevention Research Center, personal communication, September 13, 2005). The first six questions of the Environmental Supports for Physical Activity Long Questionnaire required completion by individuals living in a "neighborhood" as defined above, and all participants completed the final five questions. Since all participants were requested to complete items seven through eleven and these statements included environmental correlates to P A, items seven through eleven were chosen to represent the environmental component to this research study. These items assessed presence of recreation facilities, trails, parks, playground, sports fields, shopping malls, and schools in the community. All five items contained both behavioral and environmental information and were coded to create two separate variables that reflect either the behavioral or environmental component (University of South Carolina Prevention Research Center, personal communication, September 13, 2005). In order to address environmental correlates, only the environmental 94

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components of items seven through eleven were used as supported by the University of South Carolina Prevention Research Center (D. Pluto, personal communication, April 21, 2008). If the participant answered "yes" or "no" to any of the five items that asked "Do you use ... the variable was coded as having the environmental amenity. If the participant answered, "my community does not have ... the variable was coded to indicate lack of presence of the amenity. Responses to these items indicated potential environmental barriers or facilitators to P A. Final Questionnaire Thirteen questions were compiled to add insight into the research question and specific aims of this investigation (see Appendix C). The questions addressed additional physical characteristics of the individual with arthritis, the distance the respondent lives from the nearest town, health care provider recommendations for physical activity, opinions on work-related PA, assistance with survey completion, voluntary contact information, and an opportunity to answer open-ended questions related to the research aims. Variables Data collection took place over a period of 15 months. Sample data from all surveys were incorporated into the analysis; however, not all data collected were used in this research project and will be available for future analyses. The dependent variable data was obtained from the 2003 BRFSS (see Appendix C) that measures amount of non-work-related physical activity and from the Occupational Physical 95

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Activity Questionnaire (OPAQ) (see Appendix C), which measures work-related activity. Non-work-related physical activity was measured in minutes per day over the time period of one week. The OPAQ identified hours per week spent in various levels of physical activity in order to estimate work-related physical activity. Minutes of physical activity were considered "approximately normal" measurement types as defined by Leech (Leech et al., 2005, p. 14). Independent variable data was captured from the remaining questionnaires. Tables 3.5 and 3.6 present the independent variables and their operational definitions. 96

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Table 3.5 Independent Variables Not Related to the Physical Environment Variable Questionnaire Source Age AIMS2 Arthritis Impact physical model of health status AIMS2 Self-efficacy function ASES Attitude PAAQ Operational Definition Answered in years: What is your age at this time? Sum of first 6 nonnalized scales ofthe AIMS2 divided by 6; Low score indicates high health status Mean of 9 items in the function scale of the ASES; Low score indicates less perceived control over functional ability Mean of 4 items from the PAAQ; Low score indicates more negative attitude about physical activity and arthritis Perceived Behavioral Control Mean of 5 items from the PAAQ Subjective Nonn PAAQ PAAQ; Low score indicates less perceived behavioral control over effects of physical activity and arthritis Mean of 3 items from the PAAQ; Low score indicates less effect of others' opinion on level of physical activity Defined Potential Range 45 +years 1.0-10.00 1.0-10.00 1.0-5.0 1.0-5.0 1.0-5.0 Note. AIMS2 = Arthritis Impact Measurement Scale 2; ASES = Arthritis Self Efficacy Scale; P AAQ = Physical Activity and Arthritis Questionnaire 97

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Table 3.6 Independent Variables Related to the Physical Environment Variable Questionnaire Source Distance from town Final Survey Private recreation facilities ESPALQ Outdoor pleasure ESPALQ Shopping malls ESPALQ Public recreation centers ESPALQ Schools ESPALQ Operational Definition Distance (in miles) from the nearest town where participant can buy groceries or gasoline Identifies use of private or membership only recreation facilities Identifies use of walking trails, parks, playgrounds, sports fields Identifies use of shopping malls Identifies use of pub I ic recreation centers Defined Potential Range 0 +miles Yes No Community doesn't have facilities Yes No Community doesn't have facilities Yes No Community doesn't have shopping malls Yes No Community doesn't have facilities Identifies use of schools open Yes in the community No Schools not open for public use Note. ESPALQ =Environmental Supports for Physical Activity Long Questionnaire 98

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Survey Return In total, 278 surveys were distributed over a 15 month period. One hundred and seventy-seven surveys, or 63.7%, of the surveys were returned. An initial review ofthe returned surveys indicated that 37 participants provided insufficient data to warrant their inclusion, and these surveys were therefore excluded from the study. An additional 17 participants with a self-reported diagnosis of rheumatoid arthritis (RA) and without self-report of OA were excluded from the current study. Therefore, 123 surveys, or 44.2%, were initially accepted for analysis. Figure 3.2 identifies the survey distribution, return, and inclusion history. 99

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I Survey.; (n = 278) l I Survey.; Returned (n = 177) l I Excluded Surve}S: Considerable I I Data (n = 37) I Excluded Surve}S: Diagnosis I I RA, Exclusive ofOA (n = 17) I Eligible Surveys (n 123) I I Excluded Survey.;: Exceeded I I Questionnaire-Sp>cific Allowable Data (n 4) I Eligible Survey.; (n = 119) I r Excluded Survey.;: i:),p>ndent I I v mabie Not Quantifle d (n = 39) I Surveys for F ina! Anal }Sis l (n=80) Figure 3.2 Consort Model Sample Size Data for analysis were further reviewed and prompted additional changes. Four ofthe 123 surveys were excluded due to an unacceptable level of missing data in analyses scales. Meenan (1990a) suggests using the mean of an individual's scale score if one item is missing in the AIMS2. A closer review of the scale data is indicated if more than one item is missing. This prompted exclusion oftwo surveys with incomplete AIMS2 scale data. Two additional surveys were excluded upon closer examination. The first survey lacked >25% of the data in the self-efficacy function scale of the ASES, which are the guidelines for exclusion (Stanford Patient 100

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Education Center, n.d.). The final excluded survey lacked >25% ofthe PAAQ data and was eliminated to prevent a potentially inaccurate estimate of the large percent of the missing data in this questionnaire. The remaining 119 surveys demonstrated less than 0.4% missing independent variable data from non-demographic variables. This percentage is far less than the 5% noted by Tabachnick and Fidell (200 1) as a potential boundary of imputation for missing data. Missing values appeared to be scattered randomly through the database. Imputation by substitution of the overall mean values replaced the small percent of missing independent variable values. Tabachnick and Fidell (2001) state "In the absence of all other information, the mean is the best guess about the value of a variable. Part of the attraction of this procedure is that it is conservative; the mean for the distribution as a whole does not change and the researcher is not required to guess at missing values" (p. 62). Imputation was chosen rather than the use of "prior knowledge" or regression. This study provides new knowledge; missing data could not be estimated with prior knowledge since the hypotheses had not been previously tested in this population. Regression uses variables without missing data as independent variables to predict missing data, labeled as the dependent variable, in a regression equation. Disadvantages to regression in predicting missing values include an artificial reduction in variance from the mean and lack of evidence that the independent variables would be a good predictor of the variable with missing data; this technique to replace missing data was not used. 101

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Review of data obtained for the dependent variable led to additional analyses decisions. The data revealed that 80 out of the 119 participants responded that they participate in moderate non-work related physical activity and listed actual number of days per week and minutes per day of activity. The remaining 39 participants either left "day" and or "minute" items blank (n= 14 ), responded "don't know/not sure" when asked if they participate in moderate non-work PA (n=2), "don't know/not sure" to number of days per week they participate in moderate PA (n=4), and or "don't know/not sure" to total time per day (in hours and minutes) they participate in moderate P A (n=22). Missing dependent variable values or selection of the "don't know/not sure" response excluded 39 respondents from analyses. An independent samples t-test was used to compare individuals who listed days and minutes of physical activity (responders) and participants who answered "don't know/not sure" (non-responders) to determine if there was a significant difference between groups on a sample of independent variables. The null hypothesis for this analysis was that there would be no difference between the responders and non-responders on the chosen independent variables. If the null hypothesis is true, any difference between the two means would be due to chance. Table 3.7 identifies the independent variables and sample means for the responders and non-responders. Table 3.8 presents results ofthe independent samples test. 102

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Table 3.7 Independent Samples Test: Re5ponders and Non-Responders Group Statistics N Mean Std. Dev. Age Responder 80 68.24 10.20 Non-responder 36 70.89 11.77 Arthritis Pain a Responder 75 2.57 .99 Non-responder 39 2.41 .94 ASES Responder 78 6.98 2.30 Function Scale Non-responder 38 6.13 2.12 BMib Responder 76 28.56 5.75 Non-responder 36 30.18 7.29 Walk Bend c Responder 80 3.56 2.65 Non-responder 37 5.01 2.93 Note. ASES =Arthritis and Self-Efficacy Scale; BMI =Body Mass Index a Arthritis Pain measured by Arthritis Impact Measurement Scale 2 Item 38, I =None, 2=Very Mild,3=Mild, 4=Moderate, 5=Severe b BMI = body weight in kilograms divided by height in meters squared c Walk Bend measured by Arthritis Impact Measurement Scale 2, Normalized Scale Items 6-1 0, 1-1 0 with lower score indicating higher ability to perform walk and bend tasks 103

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Table 3.8 Independent Samples Test: Difference Between Responders and Non-Responders on Key Variables 95% Cl of Mean Difference t df p-value Lower Upper Age (AIMS2, 73) -1.23 114 .22 -6.90 1.61 Arthritis Pain .85 112 .40 -.22 .54 (AIMS2, 38) Self-Efficacy 1.89 114 .06 -.04 1.72 Function (ASES) BMia (Final Survey) -1.27 110 .21 -4.14 .90 Walking/Bending -2.67 115 .01 -2.54 -.38 (AIMS2, 6-1 0) Note. AIMS2, 73=1tem number 73 from Arthritis Impact Measurement Scale 2 (AIMS2); AIMS2, 38=Item number 38 from AIMS2; ASES=Arthritis Self-Efficacy Scale; BMI=Body Mass Index; AIMS 6IO=Normalized scale items 6-10 from AIMS2 "BMI =body weight in kilograms divided by height in meters squared No significant difference was found between responders and non-responders on four of the five independent variables: age, arthritis pain, self-efficacy function, and body mass index (BMI). This suggests the mean value for age, pain level due to arthritis over the past month, how much control the individual with arthritis had over their function, and the height to weight ratio was similar in both groups. There was a significant difference between responders and non-responders in average ability to perform walking and bending activities, t(115) = -2.672, p = .009. The p value of .009 was less than the alpha level of .05. Responders walking and bending scale score (M = 3.56, SD = 2.65) was significantly lower than the non104

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responders (M = 5.01, SO= 2.93) on a normalized scale with a range between one and ten. Low scores on the AIMS2 instrument indicate a higher health status which would suggest responders were able to perform walking and bending activities on more days over the past month than non-responders. A chi-square test was performed to detect if there was a significant association between gender and responders or non-responders. Table 3.9 displays results from this test. Table 3.9 Chi-Square Test: Gender and Responder or Non-Responder Pearson Chi-Square N of Valid Cases Value df p-value .024 118 I .877 Results of the chi-square statistic indicate there was not a significant association between gender and responders or non-responders. In this sample population, gender was not associated with whether or not they responded with discrete values to days and minutes of physical activity per week. Analysis Eighty participants were chosen for final data analysis with the dependent variable, physical activity. These 80 individuals provided days and minutes of moderate physical activity, which could be used to inform the research hypotheses and specific aim #1. The 80 responders did not significantly differ from the 39 non105

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responders in several independent variables including gender, age, arthritis pain level, self-efficacy with function, and BMI. A significant difference was noted between the two groups in ability to perform walking and bending tasks. Caution must be used with generalizing the results of responders to non-responders. SPSS Version 16.0 was used for statistical analyses. Raw frequencies of variables from the instruments used in this study are reported in Appendix D for the 80 participants. There were several major components to the analysis. Sociodemographic and health demographic variables were used to describe the sample population. Time spent in physical activity was summated from data provided on the BRFSS and OP AQ questionnaires. The hypotheses were analyzed using basic associational or difference statistics. A multiple regression model was developed to analyze predictors of physical activity in individuals with arthritis residing in rural counties of east and northeast Colorado. Finally, evidence was provided to support the positive effect of involving a community-based research committee on the research project. Univariate analysis was performed on variables to determine the presence or absence of skewness. Variables indicating skewness were transformed, when possible, to provide a normally distributed variable for analyses indicated by a skewness value within the recommended guidelines of -1 to + 1. Transformed variables are clearly identified in the Results section. 106

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CHAPTER FOUR RESULTS Introduction The following four sections present results ofthe research investigation. Section one describes the geographic and sociodemographic data; section two defines the physical and health characteristics of the survey population; section three identifies findings from specific aims and hypotheses testing; and section four offers a regression model to identify predictors of physical activity. Geographic and Sociodemographic Descriptions Geographic Distribution Individuals participating in the arthritis and physical activity survey represented five counties in east and northeast Colorado: Lincoln, Yuma, Logan, Phillips, and Sedgwick. Lincoln County was considered "east" Colorado as it is bisected by a line dividing the state in half and is located on the eastern half of the state. Yuma, Logan, Phillips, and Sedgwick counties were identified at "northeast" Colorado as they form the borders of the northeast comer of the state. Thirteen municipalities and their associated zip code regions were represented by survey participants. Table 4.1 lists the towns and their respective populations as well as the number of participants from each town region. 107

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Table 4.1 Surve)!_ MuniciJ!.alities and Pof!.ulation Ref!.resentation Municipality Census 2000 Estimated #Survey %of Survey Census 2006 Participants Population Sedgwick 191 171 5 6.25 Atwood 195 a 1.25 Genoa 211 187 1.25 Arriba 244 217 2 2.50 Ovid 330 306 14 17.50 Fleming 426 442 1.25 Hugo 885 771 1.25 Haxtun 982 997 3 3.75 Limon 2,071 1,817 15 18.75 Wray 2,187 2,160 4 5.00 Holyoke 2,261 2,291 1 1.25 Yuma 3,285 3,249 13 16.25 Sterling 11,360 12,581 17 21.25 Missing b 2 2.50 TOTAL 24,628 25,384 80 100 Note. Census data reference retrieved on 052408 a Not available from U.S. Census Bureau; Census 2000 used to estimate total b Not listed in survey information 108

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Approximately 46% ofthe participants indicated they lived in town and 52% lived between 0.25 and 30 miles from town. "Town" was defined as a place "where you can buy groceries and gasoline" on the final questionnaire. Zip code data to identify the associated municipality was missing for two individuals (2.5%). Since survey distribution occurred only in the identified counties, it was assumed the individuals lived in one ofthe five counties and their survey data was included in the analyses. The farthest driving distances between any two of the listed towns was 171 miles or just under a three hour drive. Sociodemographics As described in the Methods chapter, a total of 80 participants completed the required data fields for this investigation. Table 4.2 presents general demographics of the sample population. The majority ofthe participants was female, white, married and had a high school education. Family income ranged from less than $10,000 to greater than $70,000 per year. The two income ranges reported most commonly were $10,000-$19,999 and $20,000-$29,999. 109

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Table 4.2 Descriptive Statistics o[General Demographics ofSample Characteristic n = 80 Age, years (range 46-96) 68.24 1.02 Male 70.60 1.93 Female 67.46 1.37 Gender, no.(%) Male Female Ethnicity White Asian or Pacific Islander American Indian or Alaskan Native Marital Status Married Divorced Widowed Highest level of education Grades 7-9 Grades 1 0-11 High school graduate 1-4 years college College graduate Professional or graduate school Approximate family income3 <$10,000 $10,000-$19,999 $20,000$29,999 $30,000$39,999 $40,000$49,999 $50,000$59,999 $60,000$69,999 More than $70,000 3n = 71 (88.75% ofn) 20 (25.0) 60 (75.0) 75 (93.8) 2 (2.5) 3 (3.8) 51 (63.8) 7 (8.8) 22 (27.5) 3 (3.8) 2 (2.5) 38 (47.5) 24 (30.0) 10(12.5) 3 (3.8) 5 (7.0) 16 (22.5) 16 (22.5) 12 (16.9) 7 (9.9) 8(11.3) 2 (2.8) 5 (7.0) More than 41% of the respondents indicated they were employed and nearly 50% reported they were retired. Gender distribution indicated that 63.2% of males 110

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and 56.9% of females were not working, which included retirees. The AIMS2 asked "what has been your main form of work" over the past month? Options included paid work, house work, school work, unemployed, disabled, or retired. Individuals were considered "working" ifthey chose one ofthe first three answers respectively and not working if they chose one ofthe last three categories. Table 4.3 indicates the frequency of response to each category. Table 4.3 Work Status for Individuals with Arthritis Paid work House work School work Unemployed Disabled Retired Total Missing Total Frequency Percent 22 27.5 9 11.2 1 1.2 2 2.5 5 6.2 38 47.5 77 96.2 3 3.8 80 100.0 Valid Percent 28.6 11.7 1.3 2.6 6.5 49.4 100 Physical and Health Characteristics of Sample Population Participants reported physical and health information that added insight into the overall health of the study population. The mean body mass index (BMI), which describes a relationship between weight and height, was 27.7 and 28.9 kgm-2 for males and females, respectively, or overweight (Panel, 1998). The average BMI for females was higher than the average BMI for males. Twenty-three respondents (28.8%) had a BMI > 30 kgm-2 which is considered to be obese, and ranged from Ill

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30.2 kgm-2 to 51.7 kgm-2 The 80 participants with self-reported arthritis noted several co-morbidities. Over 42% of the individuals reported high blood pressure and 22.5% stated they had "heart disease." Participants also noted "diabetes" and "ulcer or other stomach disease," with approximately 16% and 15% reporting these comorbidities, respectively. Respondents reported additional types of perceived arthritic conditions. Low back pain was noted by over 50% of the participants. More than 20% indicated they had osteoporosis. Table 4.4 lists the health characteristics ofthe sample population. 112

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Table 4.4 Physical and Health Characteristics of the Sample Population Characteristic Mean SO Height, inches (n=80) Male 68.8 3.2 Female 63.9 2.9 Weight, pounds (n=76) Male 184.5 24.6 Female 167.2 37.4 BMia (n=76) Male 27.7 3.4 Female 28.9 6.4 Years with arthritis 13.0 8.7 Arthritis painb (n=75) 2.6 1.0 Type of arthritis comorbidity Rheumatoid arthritis Fibromyalgia Scleroderma Gout Low back pain Tendonitis Bursitis Osteoporosis Otherc Type of medical comorbidity Hypertension Heart disease Mental illness Diabetes Cancer Lung diseased Liver disease Ulcer or other stomach disease Anaemia or other blood disease "BMI = body mass index bPain scale: I =none, S=severe en= 79 (98.7% ofn=80) dn = 78 (98. 7% of n=79) 113 n=80 % 3 4 I 2 44 8 17 8 3.8 5.0 1.2 2.5 55.0 10.0 21.2 10.0 n=79 % 34 18 2 13 2 5 I 12 3 42.5 22.5 2.5 16.2 2.5 6.2 1.2 15.0 3.8

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Specific Aims and Hypotheses Analyses Specific Aim# 1 Specific Aim #I: Determine current minutes of physical activity (PA) in participating individuals living with arthritis in rural communities in Northeast Colorado. Time increments of non-work and work-related physical activity (PA) were requested from all participants, using the BRFSS physical activity module (Centers for Disease Control and Prevention, 2003) and the OPAQ (Reis et al., 2005) as described in the Methods chapter. Table 4.5 presents the range and average minutes of activity. Table 4.5 Minutes of Work and Non-Work PhJ!_sical ActiviiJ!.. (PA) p_er Week n Mean Mean so Min Max (minutes) (hours) (minutes) (minutes) (minutes) Minutes non-work 80 503.2 8.4 775.3 15.0 4200.0 moderate PA Minutes non-work 33 492.0 8.2 962.3 26.2 5040.0 vigorous PA Minutes work in sit or 34 1402.0 23.4 991.9 120.0 4800.0 stand Minutes work walking 24 980.0 16.3 872.4 60.0 2850.0 Minutes work heavy labor 12 865.0 14.4 756.0 90.0 2100.0 Minutes of moderate, non-work-related PAper week were calculated for all 80 participants. Moderate non-work P A was defined as activities that "cause small 114

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increases in breathing or heart rate'' and included examples such as brisk walking, bicycling, vacuuming, gardening, fishing, and home repair that was performed for at least ten minutes at a time (Centers for Disease Control and Prevention, 2003). Individuals were asked to report time increments for days they spent more than 1 0 minutes at a time doing moderate P A. Answers varied from 15 minutes to 70 hours per week of non-work moderate P A, and the data was markedly positively skewed (skewness= 3.0). Forty-one percent ofthe sample population reported participating in vigorous non-work P A for at least ten minutes at a time. Vigorous PA was defined as "large increases in breathing or heart rate" (Centers for Disease Control and Prevention, 2003). Examples of vigorous PA included running, aerobics, shoveling heavy snow, and heavy yard work. Reported vigorous non-work P A ranged from 26.25 minutes to 84 hours per week and was distinctly positively skewed (skewness= 3.8). Work-related PA measured time spent in sitting or standing, walking, or heavy labor using the OPAQ. The OPAQ identified the three categories as light, moderate, or vigorous intensity activities, respectively, based on the compendium list by Ainsworth et al. (2000). Thirty-four participants listed sitting or standing as work related P A, 24 stated they walked at work, and 12 reported work involving heavy labor. Participants could report all three forms of P A at work, if applicable. As noted above, walking was considered moderate physical activity by Reis et al. (2005) and supported by a position statement issued by an expert panel for the Centers for 115

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Disease Control and Prevention and the American College of Sports Medicine (Pate, 1995) that classified activities by MET levels. The sum of work and non-work related moderate PA is reported in Table 4.6. Table 4.6 Total Minutes Work and Non-Work-Related Moderate Physical Activity Per Week n Mean (minutes) Moderate PA 24 1576.5 Mean (hours) 26.3 so (minutes) 1375.5 Min (minutes) 240.0 Max (minutes) 6000.0 Work activity identified as heavy labor and non-work related vigorous activity were summed to describe total minutes spent in vigorous physical activity per week. The OPAQ examples of heavy labor which equated to vigorous activity (>6 METs) included "moving furniture, carpentry, jackhammers, or using a shovel or pick." Total vigorous activity per week is listed in Table 4.7. Table 4.7 Total Minutes Work and Non-Work-Related Vigorous Physical Activity Per Week n Mean (minutes) Vigorous PA 9 1500.1 Mean (hours) 25.0 Physical Activity as the Dependent Variable so (minutes) 2141.9 Min (minutes) 116.2 Max (minutes) 6840.0 Physical activity was used as the dependent variable for analysis of the research hypotheses. Moderate non-work P A was markedly positively skewed (skewness= 3.0) and violated the assumption of normality. Therefore, the decision 116

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was made to transform the dependent variable, moderate non-work-related physical activity, to improve normality for any parametric analyses. Since minutes of moderate P A were positively skewed, the logarithm ofthis variable was computed to see if normality improved (Leech et al., 2005; Tabachnick & Fidell, 2001 ). Table 4.8 displays the descriptive results for the transformed variable. The skewness value became 0.48 which is still slightly skewed but falls well within the recommended guidelines of less than absolute one. Log( 1 0) minutes of moderate P A was used during parametric analyses and is noted in the reporting of data. Table 4.8 Descriptive Statistics o[Trans[ormed Variable Minutes Moderate Non-Work Physical Activity (PA) N Minimum Maximum Mean Std. Skewness Statistic Statistic Statistic Statistic Statistic Statistic Std. Error Log10PA 80 1.18 3.62 2.41 .48 .48 .27 ValidN 80 (listwise) Log(10) transformations were performed for vigorous non-work related PA, total work and non-work moderate PA, and total work and non-work vigorous P A to normalize data during parametric analyses and are identified in the results when transformed. 117

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Specific Aim #2 Specific Aim #2: Determine the factors that influence physical activity for individuals with arthritis living in rural communities. There are several hypotheses that addressed potential factors of influence on physical activity in individuals with arthritis living in east or northeast Colorado. Each analysis is described in the following section. Hypotheses Testing Hypothesis 1: There will be a relationship between arthritis impact on physical function and minutes of moderate or vigorous physical activity. The association of arthritis impact on physical function, as measured by the AIMS2, and minutes of physical activity, calculated using data from the BRFSS and or OP AQ, was analyzed using the Pearson product moment correlation. Cases were excluded pairwise during this SPSS analysis to include all available data. Descriptive and bivariate analyses results for moderate and vigorous, work and or non-work related minutes of physical activity are presented in Tables 4. 9 and 4.1 0. 118

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Table 4.9 Descriptive Statistics: Arthritis Physical Function Impact and Minutes Physical Activity N Mean SD AIMS2 physical function log I 0 78 -.05 .45 Minutes moderate non-work PA logiO 80 2.41 .48 Minutes moderate work PA 24 980.00 872.39 Total moderate PA log!O 24 3.04 .39 Minutes vigorous non-work P A log I 0 33 2.31 .53 Minutes vigorous work PA 12 865.00 756.01 Total vigorous PA logiO 9 2.86 .55 Note. log10 noted on variables transformed to reduce skew AIMS2 =Arthritis Impact Measurement Scales 2 PA =physical activity Table 4.10 Correlation: Arthritis Physical Function Impact and Minutes o[Physical Activity Physical Activity (minutes) AIMS2 physical function scale log 10 N Correlation Minutes moderate non-work PA log I 0 78 Minutes moderate work PA 23 Total moderate PA loglO 23 Minutes vigorous non-work PAiog I 0 32 Minutes vigorous work PA II Total vigorous PA log!O 8 Note. log I 0 noted on variables transformed to reduce skew AIMS2 =Arthritis Impact Measurement Scales 2 PA =physical activity 119 -.101 .403 .353 .013 -.144 -.070 p-value .380 .057 .099 .946 .672 .869

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Arthritis impact on physical function was measured by averaging six normalized scales (range between 0 and I 0) from the AIMS2: mobility level, walking and bending, hand and finger function, arm function, self care, and household tasks, as indicated by Meenan ( I990a). Initial descriptive results indicated substantial positive skewness (skewness= I.969) with the mean= I.336, SD = I.229. Low scores on the AIMS2 indicate higher health status. A log I 0 transformation of the arthritis impact data resulted in a reduction of skewness (skewness= -.646), which was in the acceptable range to be considered normally distributed. The log I 0 AIMS2 data was used in the bivariate analyses. Minutes of moderate or vigorous, work or non-work related physical activity were transformed if skewness was greater than one or less than negative one. All transformations were performed using log I 0 and each transformed variable is labeled with "log I 0" in Tables 4. 9 and 4.10. Analyses indicate that there was no significant association between arthritis impact on physical function and minutes of moderate or vigorous, work or non-work related physical activity. Fewer individuals reported participation in vigorous non work physical activity than moderate non-work P A. Of the 32 individuals who reported working, 75% indicated they performed moderate PA and 37.5% stated they do vigorous P A at work. The log I 0 transformation of the arthritis impact data excluded two participants whose normalized arthritis impact score was zero. I20

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Hypothesis 2: Men with arthritis living in a rural community will have significantly more minutes of physical activity than women with arthritis living in a rural community. An independent samples t-test was used to compare males and females (a between group design) on their average (mean) minutes of physical activity per week to determine if there was a significant difference. According to Spatz (200 I), "parametric tests such as t tests and ANOV A produce accurate probabilities when the populations are normally distributed and have equal variances." Although the group sizes were different (male= 20, female= 60), Levene's test for all comparisons of means was higher than .05, indicating the variances of the two groups were equal. The assumption of "independence of observations" was met; knowing the gender of the participant did not allow prediction of their minutes of P A. The t-test is robust against the assumption of normality. Table 4.11 presents the group statistics for mean comparisons of males and females on minutes of moderate or vigorous work and or non-work related physical activity. The independent samples t-test results are indicated in Table 4.12. 121

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Table 4.11 Independent Samples Test: Gender with P A Group Statistics Gender N Mean Std. Dev. moderate non-work Male 20 2.46 .52 PA log!O Female 60 2.39 .47 moderate work PA (hr) Male 6 18.67 739.40 Female 18 15.56 927.17 total moderate P A Male 6 3.09 .47 log!O Female 18 3.02 .38 vigorous non-work PA Male 9 2.32 .60 log!O Female 24 2.30 .52 vigorous work PA (hr) Male 5 17.80 605.08 Female 7 12.00 863.08 total vigorous non-Male 4 3.10 .53 work PA log!O Female 5 2.67 .54 Note. logiO noted on variables transformed to reduce skew PA =physical activity in minutes per week 122

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Table 4.12 Independent Samples Test: Differences in P A by Gender 95% Cl of Mean Difference I df p-value Lower Upper log I 0 moderate .51 78 .62 -.18 .31 non-work PA moderate work P A .47 22 .66 -681.46 1054.80 logiO total .38 22 .71 -.32 .46 moderate PA loglO vigorous .12 31 .90 -.41 .46 non-work PA vigorous work PA .77 10 .46 -657.00 1353.00 logiO total 1.19 7 .27 -.42 1.28 vigorous PA Note. log I 0 indicated where data transformed to improve normality PA =physical activity in minutes per week There was no significant difference between males and females in minutes of physical activity, as demonstrated by the p-value in Table 4.12. Equal variances were assumed for all ofthe independent samples t-tests as Levene's test was significant in all cases. Therefore, the hypothesis "Men with arthritis living in a rural community will have different minutes of physical activity than women with arthritis living in a rural community" was rejected. Hypothesis 3: Distance from town will be associated with minutes of physical activity in individuals with arthritis in rural communities. 123

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Participants in this investigation identified if they lived in a town, defined as a place where they could buy groceries or gas, or a measured distance from town. Distance from town varied from 0.25 miles to 30 miles per individual report. Thirty seven individuals, or 46.2%, reported that they lived in town. In order to determine if there was a correlation between distance from town and minutes of moderate or vigorous activity, Spearman Rho correlation was selected for analysis. The variable "distance from town" was positively skewed (skewness = 1.516). A log I 0 transformation did not improve skewness and elimated zero values, which reduced the included participants for analysis to 43. The square root transformation reduced skewness to -. 768 but reduced the "valid n" to 42 due to exclusion of zero values. Therefore, Spearman Rho was selected for this analysis since the normality assumption required for Pearson product moment correlation was markedly violated. A two-tailed test of significance and the option to exclude cases pairwise was chosen for the analysis. Table 4.13 presents correlation values for distance from town with minutes of moderate or vigorous, work or non-work related P A. Physical activity data was not transformed since a normal distribution is not an assumption of Spearman Rho. 124

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Table 4.13 Spearman Rho Correlation: Distance from Town and Minutes of Physical Activity Distance from Town Physical Activity (minutes) N Correlation p-value Moderate non-work P A 80 .190 .092 Moderate work P A 24 .106 .623 Total moderate PA 24 .086 .691 Vigorous non-work PA 33 .206 .249 Vigorous work P A 12 .258 .418 Total vigorous PA 9 -.068 .862 Note.PA =physical activity Analyses indicate there was no significant association between distance from town and minutes of moderate or vigorous, work or non-work related physical activity. A positive, significant correlation would indicate that as the distance from town increased, the minutes of weekly P A would increase. The null hypothesis, "distance from town will not be associated with minutes of physical activity in individuals with arthritis in rural communities," cannot be rejected. Hypothesis 4: There will be a difference between perceived environmental availability of resources for physical activity and minutes of physical activity. The Environmental Supports for Physical Activity Long Questionnaire (ESP ALQ) asked participants if they used a variety of community resources, if available, for physical activity. The participant could indicate if their community did 125

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not have the listed resource. If environmental resources were available, indicated by the respondent answering "yes" or "no" to "Do you use ... [resource]," the potential environmental facilitator ofPA was believed to exist for the purpose of this study. If the respondent answered "my community does not have ... [resource]," the potential environmental barrier to P A was noted. The MannWhitney U test was used to assess the relationship between physical activity and availability of environmental resources. Cases were excluded test by test. The sample sizes in groups one (has the resource) and two (does not have the resource) were patently different and suggested the use ofthe nonparametric statistic (N.L. Leech, personal communication, June 8, 2008). When the number of individuals in one of the two independent groups is greater than 20, a z score with critical values of .96 (alpha= .05) is used to determine significance (Spatz, 2001 ). Tables 4.14 through 4.18 present the information on the five targeted questions related to availability of resources. Each table is preceded by the corresponding questionnaire item for clarity. ESPALQ Item #7: Do you use any private or membership only recreation facilities in your community for physical activity? 126

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Table 4.14 Mann-Whitney Test: Private Recreation Facilities and Physical Activity Response N Z Mean Rank p-value Moderate non-work PA Yes has 72 38.50 No doesn't have 7 55.43 Analysis -1.86 .06 Moderate work P A Yes has 21 12.86 No doesn't have 3 10.00 Analysis -.66 .51 Total moderate PA Yes has 21 12.19 No doesn't have 3 14.67 Analysis -.57 .57 Vigorous non-work P A Yes has 30 17.03 No doesn't have 3 16.67 Analysis -.06 .95 Vigorous work P A Yes has 10 6.15 No doesn't have 2 8.25 Analysis -.76 .45 Total vigorous PA Yes has 8 4.63 No doesn't have 1 8.00 Analysis .24 .44 Note. P A = physical activity in minutes The observed z values did not exceed the critical z value of .96 (p .05 critical value for a two-tailed test) in any ofthe PA categories. Significance would indicate that the amount of physical activity performed per week is related to the presence of private recreation facilities in the community. The null hypothesis was not rejected based on the data results. These results mean that individuals who perceived that their environment had private recreation facilities did not report significantly different levels of P A than those individuals who did not. 127

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ESPALQ Item #8: Do you use walking trails, parks, playgrounds, sports fields in your community for physical activity? Table 4.15 Mann-Whitney Test: Trails, Parks, Playgrounds, Fields and Physical Activity Response N z Mean Rank p-value Moderate non-work P A Yes has 71 39.38 No doesn't have 8 45.50 Analysis 79 -.72 .47 Moderate work P A Yes has 20 11.98 No doesn't have 4 15.13 Analysis 24 -.82 .41 Total moderate P A Yes has 20 11.75 No doesn't have 4 16.25 Analysis 24 -1.16 .24 Vigorous non-work PA Yes has 27 16.13 No doesn't have 5 18.50 Analysis 32 -.52 .60 Vigorous work P A Yes has 10 6.15 No doesn't have 2 8.25 Analysis 12 -.76 .45 Total vigorous PA Yes has 8 4.63 No doesn't have I 8.00 Analysis 9 -1.16 .24 Note. P A = physical activity in minutes The observed z values did not exceed the critical z value of .96 (p S .05 critical value for a two-tailed test) in any ofthe PA categories. The null hypothesis was not rejected based on the data results. The mean rank of individuals who perceived their environment had walking trails, parks, playgrounds, and or sports fields was not significantly different than those individuals who did not perceive these resources existed in their environment. The data suggests that there is no difference between whether an individual perceives environmental availability of the four 128

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resources for physical activity or not and minutes of physical activity performed per week ESPALQ Item #9: Do you have shopping malls in your community for physical activity and/or walking programs? Table 4 .16 MannWhitne y Test : Shopping Malls and Physical Activit y Response N Z Moderate non-work P A Yes has 50 No doesn't have 30 Analysis Moderate work P A Analysis Total moderate P A Analysis Vigorous non-work P A Analysis Vigorous work P A Analysis Total vigorous PA Analysis 80 -.13 Yes has 14 No doesn't have 10 24 -.24 Yes has 14 No doesn t have 10 24 -.06 Yes has 23 No doesn't have 10 33 -.72 Yes has 8 No doesn't have 4 12 -.17 Yes has 6 No doesn't have 3 9 -.52 Note P A = physical activity in minutes Mean Rank 40.24 40.93 12.21 12.90 12.57 12.40 16.20 18.85 6.38 6.75 4.67 5.67 p-value .90 .81 95 .47 .86 .61 The observed z values did not exceed the critical z value of .96 (p S .05 critical value for a two-tailed test) in any ofthe PA categories. The null hypothesis was not rejected based on the data results. Over 37% of the participants indicated their community did not have shopping malls. The mean rank of individuals who perceived their environment had shopping malls for P A or walking programs was not 129

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significantly different than those individuals who did not perceive these resources existed in their environment. This data suggests that there is no difference between whether an individual perceives environmental availability of shopping malls for physical activity or not and minutes of physical activity performed per week. ESPALQ Item #10: Do you use any public recreation centers in your community for physical activity? Table 4.17 Mann-Whitney Test: Public Recreation Centers and Physical Activity Response N z Mean Rank p-value Moderate non-work P A Yes has 66 39.57 No doesn't have 14 44.39 Analysis 80 -.69 .49 Moderate work P A Yes has 19 11.97 No doesn't have 5 14.50 Analysis 24 -.71 .48 Total moderate P A Yes has 19 11.74 No doesn't have 5 15.40 Analysis 24 -1.03 .30 Vigorous non-work P A Yes has 19 16.02 No doesn't have 5 22.50 Analysis 24 -1.38 .17 Vigorous work P A Yes has 9 6.00 No doesn't have 3 8.00 Analysis 12 -.84 .40 Total vigorous PA Yes has 7 4.29 No doesn't have 2 7.50 Analysis 9 -1.46 .14 Note. P A = physical activity in minutes The observed z values did not exceed the critical z value of .96 (p _:::: .05 critical value for a two-tailed test) in any of the PA categories. The null hypothesis was not rejected based on the data results. The mean rank of individuals who 130

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perceived their environment had public recreation centers for P A was not significantly different than those individuals who did not perceive these resources existed in their environment. The null hypothesis, "There is no difference between whether an individual perceives environmental availability of public recreation centers for physical activity or not and minutes of physical activity performed per week," cannot be rejected. ESP ALQ Item # 11: Do you use any schools that are open in your community for public recreation activities? Table 4.18 MannWhitney Test: Schools and Physical Activity Response N z Mean Rank p-value Moderate non-work P A Yes has 67 39.54 No doesn't have 11 39.23 Analysis 78 -.04 .97 Moderate work P A Yes has 22 12.34 No doesn't have 2 14.25 Analysis 24 -.37 .71 Total moderate P A Yes has 22 11.95 No doesn't have 2 18.50 Analysis 24 -1.25 .21 Vigorous non-work P A Yes has 28 16.16 No doesn't have 4 18.88 Analysis 32 -.54 .59 Vigorous work P A Yes has 10 6.15 No doesn't have 2 8.25 Analysis 12 -.76 .45 Total vigorous PA Yes has 8 4.63 No doesn't have 1 8.00 Analysis 9 -1.16 .24 Note. P A = physical activity in minutes 131

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The observed z values did not exceed the critical z value of .96 (p :S .05 critical value for a two-tailed test) in any of the PA categories. The null hypothesis was not rejected based on the data results. The mean rank of individuals who perceived their environment had schools that were open in their community for public recreation was not significantly different than those individuals who did not perceive these resources existed in their environment. The null hypothesis, "There is no difference between whether an individual perceives environmental availability of schools for physical activity or not and minutes of physical activity performed per week," cannot be rejected. Hypothesis 5: There will be a relationship between self-efficacy and minutes of physical activity in individuals with arthritis who live in rural communities. Self-efficacy was measured using the Arthritis Self-Efficacy Scale (Lorig et al., 1989). Self-efficacy was defined for the survey participants as "how much control you have over your arthritis" by the principal investigator with RAC agreement. Scatterplot analysis between self-efficacy function scale and minutes of moderate P A loglO indicated a low r2linear line of fit (r2linear = 0.007, r=.084), which violated the assumption of a linear relationship when using Pearson product moment correlation (Morgan, Leech, Gloeckner, & Barrett, 2004). Therefore, Spearman Rho was computed to assess the relationship between the self-efficacy function scale, discussed in the Methods section, and minutes of physical activity. Cases were excluded pairwise. Normality is not an assumption of Spearman Rho and the minutes 132

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of P A were not transformed for this analysis. Table 4.19 displays the results of the analysis. Table 4.19 Spearman Rho Correlation: Arthritis Self Efficacy Function and Minutes Physical Activity Arthritis Self-Efficacy Physical Activity (minutes) N Correlation p-value Moderate non-work PA 80 -.031 .786 Moderate work P A 24 -.Ill .605 Total moderate PA 24 -.036 .868 Vigorous non-work PA 33 .236 .186 Vigorous work PA 12 -.138 .670 Total vigorous PA 9 -.025 .949 Note.PA =physical activity Correlation values were low for all categories of minutes of P A, ranging from -.138 to .236. These results indicate that with the represented populations for each category of P A, the null hypothesis, "there will be no relationship between selfefficacy and minutes of physical activity in individuals with arthritis who live in rural communities," cannot be rejected. Hypothesis 6: There will be a relationship between attitude towards physical activity and minutes of physical activity in individuals with arthritis who live in rural communities. 133

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The Physical Activity and Arthritis Questionnaire (P AAQ), developed by the rural arthritis committee, was used to assess attitude regarding arthritis and physical activity in individuals with arthritis residing in rural east or northeast Colorado. The relationship between the individual's attitude about P A and their minutes of P A was analyzed using Spearman Rho. Spearman Rho was chosen for the analysis based on the violation of a linear relationship (r2 linear=0.038, r=0.195), an assumption with Pearson product moment correlation (Morgan, 2004). Normality is not an assumption of Spearman Rho and the minutes of P A were not transformed for this analysis. Table 4.20 displays the results. Table 4.20 Spearman Rho Correlation: Attitude about Physical Activity and Minutes Physical Activity Attitude about Physical Activity Physical Activity (minutes) N Correlation p-value Moderate non-work P A 74 -.213 .068 Moderate work P A 24 -.113 .598 Total moderate P A 24 .047 .826 Vigorous non-work PA 30 -.426 .019* Vigorous work PA 12 .275 .387 Total vigorous PA 9 .101 .795 Note. PA = physical activity *Correlation is significant at the 0.05 level (2-tailed) 134

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The results presented in Table 4.20 indicate the null hypothesis, "there will be no relationship between attitude towards physical activity and minutes of physical activity in individuals with arthritis who live in rural communities," cannot be rejected for all activity categories except "minutes vigorous non-work PA." The Spearman Rho statistic for "minutes vigorous non-work PA" was calculated, r5(28) = -.426, p = .019. The direction of the correlation was negative, which means that participants who had higher scores in the P AAQ, indicating a positive attitude about being more physically active, reported fewer minutes ofPA per week. For all other categories, there was no significant association between attitude about P A and minutes of physical activity, based on the sample population data. The null hypothesis could not be rejected for the remaining categories of P A. Hypothesis 7: There will be a relationship between individuals with arthritis perception of how others perceive physical activity and arthritis and the individual's minutes of physical activity. According to Ajzen and Fishbein ( 1980), the concept of subjective norm suggests an individual's behavior will be influenced by other peoples' opinion about the behavior. The P AAQ captured the participant's response to items in the subjective norm scale. Higher scores on the subjective norm scale indicated the participant would be more active if others indicated they should be and if their sphere of influence was active as well. Spearman Rho was calculated to determine ifthere was a relationship between subjective norm and minutes of work or non-work, moderate 135

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or vigorous P A. Spearman Rho was chosen for the analysis based on the violation of a linear relationship (/ linear=O.O 19, r=0.138), which is an assumption with Pearson product moment correlation. Findings of this analysis are presented in Table 4.21. Table 4.21 Spearman Rho Correlation: Subjective Norm and Minutes Physical Activity Subjective Norm Physical Activity (minutes) N Correlation p-value Moderate non-work P A 72 -.068 .569 Moderate work PA 22 .249 .264 Total moderate PA 22 .271 .222 Vigorous non-work PA 28 -.266 .171 Vigorous work PA 10 -.305 .391 Total vigorous PA 7 .337 .460 Note. PA = physical activity The Spearman Rho analysis indicates no correlation between how individuals perceive other's view physical activity and arthritis and minutes of P A. With alpha= 0.05, the null hypothesis, "there will be no relationship between individuals with arthritis perception of how others perceive physical activity and arthritis and the individual's minutes of physical activity," could not be rejected. Hypothesis 8: There will be a relationship between individuals with arthritis who perceive they have control over their level of physical activity and minutes of physical activity. 136

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The construct of perceived behavioral control, described in the Theory of Planned Behavior by Ajzen (1991 ), parallels the concept of self-efficacy and incorporates the idea that an individual's perceived control over a behavior, in this case, physical activity, will influence the behavior. Individuals with a high score on this scale indicated a higher belief in the ability to be active and fewer concerns P A would negatively impact their arthritis. Spearman Rho was used for this analysis for the same reasons identified in analyzing Hypothesis 7 and the results are presented in Table 4.22. Table 4.22 Spearman Rho Correlation: Perceived Behavioral Control and Minutes Physical Activity Perceived Behavioral Control Physical Activity (minutes) N Correlation p-value Moderate non-work PA 78 .059 .606 Moderate work P A 24 -.071 .740 Total moderate PA 24 -.005 .981 Vigorous non-work PA 32 -.015 .934 Vigorous work P A 12 .016 .960 Total vigorous PA 9 .230 .552 Note. PA = physical activity The null hypothesis, "there will be no relationship between individuals with arthritis who perceive they have control over their level of physical activity and minutes of physical activity,' could not be rejected at the alpha level 0.05. No 137

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correlation was noted between an individual's perceived behavioral control and minutes of P A based on the level of significance determined during this analysis. Hypothesis 9: There will be a difference between individuals with arthritis who report that a healthcare provider recommended physical activity versus those who report no recommendation and minutes of physical activity. Survey participants were asked "Has anyone that you see for your health told you to be more physically active?" on the final survey. Over 57% ofthe respondents reported that they had not been told to be more physically active. An Independent Samples t-test was performed to determine if there was a difference between respondents who were told to be active versus those individuals who were not told to be active and the minutes of reported P A per week. Minutes of PA were transformed for moderate non-work P A, total moderate P A, vigorous non-work P A, and total vigorous PA in order to meet the assumption of normality for the t-test. Table 4.23 describes the group statistics and Table 4.24 presents the independent samples t-test results. 138

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Table 4.23 Independent Samples Test: Recommend versus Not Recommend with PA Recommend N Mean Std. Dev. (yes/no) moderate non-work No 44 2.46 .51 PA loglO Yes 32 2.33 .45 moderate work P A No 14 1146.43 1003.11 Yes 9 630.00 531.60 total moderate P A No 14 3.08 .44 loglO Yes 9 2.94 .33 vigorous non-work No 19 2.38 .53 PA loglO Yes 12 2.20 .57 vigorous work PA No 8 896.25 716.86 Yes 4 802.50 942.78 total vigorous nonNo 6 2023.33 2499.65 work PA loglO Yes 3 453.75 517.87 Note. log I 0 noted on variables transformed to reduce skew PA =physical activity in minutes Table reflects group statistics 139

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Table 4.24 Indep_endent Samp_les Test: Differences in PA by_ Recommend or Not Recommend 95% CI of Mean Difference df p-value Lower log 1 0 moderate 1.12 74 .27 -.10 non-work PA moderate work P A 1.41 21 .17 -243.00 log10 total .87 21 .40 -.21 moderate PA log 1 0 vigorous .91 29 .37 -.23 non-work PA vigorous work PA .19 10 .85 -986.12 log10 total 1.04 7 .33 -1992.95 vigorous PA Note. log1 0 indicated where data transformed to improve normality PA =physical activity in minutes per week Upper .35 1275.86 .50 .59 1173.62 5132.12 There was no significant difference in minutes of P A performed per week between individuals who were told to be more physically active by the health care provider(s) and those who reported not being told to be active. The null hypothesis cannot be rejected at the alpha=0.05 level. Specific Aim #3 Specific Aim #3: Enhance the quality ofthe content ofthe survey, and the usefulness of the study's findings, by fostering the participation of community members in the research process through a regional community-based rural arthritis advisory committee. 140

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A rural advisory committee comprised of the principal investigator and up to eleven rural residents representing four counties in east and northeast Colorado significantly impacted the proceedings ofthis research study. Although this will be part of the Discussion section, results of community interactions will be highlighted in this section. The Methods section described the contributions ofthe community committee members during the organization and survey distribution phases. A pilot survey was completed, flyers and other marketing tools were developed, a distributions plan was identified, networking with other community members interested in arthritis was initiated, and thoughtful reflection on the impact of arthritis on individuals and the community was incorporated. The approach to the community and meaningful "language" was critical in inspiring participation and providing value to survey respondents. Advocacy for the project was meaningful to the community because it was presented by community members. Qualitative data enriched the findings through the addition of questions to the final survey by the RAC. Although the qualitative results will not be formally analyzed in detail for the purpose ofthis investigation, a few anecdotal reports will be discussed to add support to the value ofthe RAC's involvement in this project. The RAC added the open-ended question "What things in the physical environment keep you from being as active as you would like to be?" Responses included references to individual physical impairments to environmental conditions. 141

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For example, respondents listed obesity, pain, allergies, macular degeneration, comorbidities, and fatigue as physical impairments to being active. Environmental barriers to increasing activity levels included heat, cold, ice, snow, rain, wind, uneven sidewalks, lack of indoor facilities, lack of pretty scenery, and no warm water therapy facilities. Time, "old age," and "a stagnant life" were also mentioned as barriers to increasing activity. A second open-ended question "If you want to be more active, what would motivate you to be more physically active" was included in the survey. Several respondents mentioned the availability of water therapy and or swimming. Other answers included having someone to be physically active with, living in town, weight loss, money to access P A resources such as a gym, accessibility of recreation facilities and convenient bathroom facilities, pain reduction with increased PA, more time, and successful surgery. "Getting younger" was also provided as a theme for increasing P A. The community's vision into a project directly addressing a community health concern provided information and perspective throughout the research process. The Discussion section identifies additional community-based contributions that provided value and insight into the research project. Model of Regression Simple linear regression was performed to determine if independent variables appropriate for this analysis predicted the dependent variable, minutes of moderate 142

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P A. Approximately normal variables, including those that were normalized through transformation, were examined through bivariate regression. Independent variables included the log 10 transformed AIMS2 physical function scale, the Arthritis Self Efficacy function scale, and the three scales from the P AAQ (attitude, subjective norm, and perceived behavioral control). Minutes of moderate non-work PA, transformed using log 1 0, was the dependent variable. Results of the bivariate regression indicated no significant predictors ofthe dependent variable, minutes of moderate non-work P A. The R value for all regression equations was S .212, indicating small effect sizes (Leech et al., 2005). Analysis of several independent variables combined to predict the dependent variable, minutes of moderate non-work P A, was conducted using multiple regression. The independent variables included AIMS2 physical function scale transformed with log 10, perceived behavioral control, subjective norm, attitude, gender, and use of private facilities for P A. These variables were generally linearly related to the dependent variable as demonstrated on the scatterplot matrix. Variables excluded from this analysis included four additional environmental measures and the self-efficacy function scale due to high correlations with like-variables. Backward stepwise regression was used and "exclude cases listwise" selected. The adjusted R square from the multiple regression suggests that at most 9.8% ofthe variance in minutes ofmoderate non-work PA can be explained by the model. The variables significantly predicting minutes of moderate non-work P A, F( 4,62) = 143

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2.79,p < .05, are the AIMS2 physical function scale transformed with log10, perceived behavioral control, attitude, and use of private facilities for P A as predictor variables. Beta weights suggest that attitude contributes most to minutes of non-work moderate P A. Interpretation from the P AAQ would indicate that individuals who want to be more active have the fewest minutes of P A. The regression equation using standardized beta coefficients is: Minutes of moderate non-work P A log 10 transformed = 2.48 + ( -.35)attitude + ( .23 )use of private facilities + ( .25)perceived behavioral control + ( .17)AIMS2 physical function scale transformed with log 10. 144

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CHAPTER FIVE DISCUSSION Introduction This investigation used an inclusive community approach to examine correlates of physical activity in persons with arthritis living in rural communities in east and northeast Colorado. It was an opportunity to quantitatively identify perceptions of multiple factors affecting the lives of individuals who self-reported doctor-diagnosed OA: time allotted to physical activity during work and or non-work activities, the rural physical environment, how much control they have over their arthritis, their beliefs about the interaction between arthritis and P A, and ultimately, the impact of the arthritis itself on their lives. The study also for the first time gathered important demographic and health characteristics data on individuals with arthritis living in these communities. It is believed that this is the first study to include community research partners in addressing physical activity outcomes in a population with a common disease process, osteoarthritis, which can affect function and the quality of life for individuals living in these rural locations. The literature supports many tenets of this study: P A can improve function and the quality of life in people with arthritis (Altman et al., 2000; D. D. Dunlop et al., 2004; Fontaine et al., 2004; Macera et al., 2003), 145

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individuals with arthritis are less active (Hootman et al., 2003; Shih et al., 2006), inactivity can increase morbidity (Garrett et al., 2004) and the risk of mortality (Powell & Blair as cited in Brownson, Baker et al., 2004; Centers for Disease Control and Prevention, 1998), P A can reduce the risk of serious disease processes (Bauman, 2004; Macera et al., 2003; Paffenbarger et al., 1993; U.S. Department of Health and Human Services, 1996), health disparities exist in rural communities (Garkovich & Harris, 1994; Hart et al., 2005), and correlates of P A in arthritis-affected rural sub populations in Colorado are unknown. However, literature investigating a combination of these tenets does not exist. Pulling together multiple tenets to address a public health concern, inactivity, more accurately reflects "real life" communities, i.e., individuals living within the context ofthe community, with various states of health and reporting perceived levels of P A. A Rural Advisory Committee informed the research methods, results, and discussion and increased relevance of the findings to the communities. The following discussion is divided into nine sections: community-based approach to the investigation, demographic and health characteristics of the survey participants, physical activity highlights, hypotheses discussion, theoretical perspectives, contribution, limitations, future directions, and a summary statement. Community-Based Support and Investigative Influence Community-based participatory research (CBPR) shifts the focus from an investigator's curiosity about a problem or discovery within a community to the 146

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identified interests of the community itself. It empowers a community to voice concerns, challenges, opportunities, and questions related to their topic of interest and enables community members to specify outcomes. Decisions affecting the community's well-being involve those individuals intimately engaged in day to day interactions with the research area. The Rural Arthritis Committee (RAC) represented five distinct rural communities with a common interest in arthritis. The eleven individuals on this committee had not previously met to work on a health concern relevant to their municipalities. The literature supports nine basic principles of CBPR (Minkler & Wallerstein, 2003), which were described in Chapter II. Due to the nature of a graduate school dissertation project, the research question was identified prior to the formation of this group and members were recruited who had a particular interest in community involvement in general and arthritis specifically. However, guidelines for CBPR note that "no one set of community based participatory research principles is applicable for all partnerships" (Minkler & Wallerstein, 2003, p. 55) and voluntary participation by the RAC members indicated that they were supportive ofthe overarching goal to determine correlates of P A by persons with arthritis. As described previously, the RAC had three community meetings over a period of 18 months. The final meeting was highlighted as an opportunity to discuss the findings, review the process, and determine future directions, which informs this section. During the RAC's third and final meeting, initial descriptive survey results 147

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were presented by the PI and several topic areas were addressed. The group discussed the process of data collection. Members felt barriers to survey participation included the length of the survey as well as the inclusion criterion of "doctor-diagnosed self reported osteoarthritis." They indicated participants were more willing to answer the lengthy survey because they knew the RAC member. The $10 gift incentive also prompted participation. Potential participants often knew they had arthritis from personal experience but had not been told by a HCP that they have arthritis and were therefore unable to participate due to the inclusion criteria. Interestingly, Rao, Callahan, and Helmick ( 1997) found that more than 16% of individuals who reported that they have arthritis did not seek care for arthritis from a doctor. In contrast, the PI noted that often individuals with apparent, observable osteoarthritis did not feel they had arthritis. These individuals would describe community members with rheumatoid arthritis as examples of"people with arthritis." Finally, RAC members had hoped for a mechanism to determine if individuals they had personally given a survey to had actually completed the survey. Due to confidentiality, this was not possible. The RAC discussion also centered around HCP "themes." The committee felt HCPs needed to be more aware of community resources for people with arthritis. They also commented that individuals with arthritis needed to have faith in their physicians and that physicians needed to realize that the treatment needs for arthritis might change over time; a prescribed treatment may not work after a period of time. Comments also included observations that there is often a level of tension or 148

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frustration experienced by the person with arthritis when the treatment isn't working and that patient input was not as valued as scientific literature. The committee acknowledged that often physicians are very busy and do not have time to educate about arthritis. The RAC considered how the "rural" component of this project influenced the process. Concepts arising from this discussion included the mindset of farmers: it is inevitable that they will "hobble" after the age of 45 years. The HCP member of the RAC had previously stated this was a common belief, and this prompted addition of a statement onto the PAAQ. This was again validated by a previous discussion with a young farmers' organization that wanted advice on how to prevent this inevitable perceived disability. It was suggested that older males would not admit having arthritis; they had grown up in an environment of not asking for help. "Owning" arthritis might be perceived as disabled and requiring assistance. Other rural factors related to this project were brought up by various members. Twenty years ago, one town represented by a RAC member instigated its first community "walk." Currently, they have an annual relay for people with Alzheimer's, and it is a recognized activity ofthe community. "Walks" aren't laughed at any more in this rural community, and it was suggested that they should occur more often. It was perceived that urban life results in higher levels of stress. Activities such as going to the grocery store are perceived as more stressful in urban areas. And 149

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although their urban counterparts may have more resources for P A, they don't take advantage of them. A final discussion involved brainstorming about current and future resource availability for persons with arthritis. A historical perspective indicated that one community had offered an arthritis support group approximately 14 years ago. Attendance dropped from an initial count of 45 people to 4-5 people within three weeks. Expectations were not met, and it was perceived the group participants wanted to do more than "talk" about arthritis. Education on aspects of arthritis was suggested by a RAC member. In contrast, an individual from a different community reported the need for a support group in their area. One RAC member who was also a former HCP stated that if a friend were diagnosed with arthritis, they would not be able to suggest one available community resource to help their friend. It was mentioned that the "pat answer" was to "lose weight," and this was often unhelpful and hurtful. Disclosure of a recent course offering on how to live with a chronic condition was of interest to the RAC. It was agreed that HCPs should be aware of resources to recommend to their patients. Several considerations arose from this final meeting. Communities, including the HCPs that serve these areas, must be aware of current resources for people with arthritis. Open, evolving discussions with the individual's primary physician about treatment options is important. Support systems perceived relevant to the community for people with arthritis might be useful. P A such as walking can be incorporated into 150

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fund raising events, and people with arthritis need to know what type and intensity of PAis safe and effective. Understanding the "vantage" ofthe rural residents may effectively direct educational interventions. A follow up post-meeting optional questionnaire was sent to the RAC members to allow additional input on the research project. Seven members responded. In addition to the previous discussions, members suggested additional resource needs: indoor walking, exercise, and heated pool facilities at a reasonable cost; additional structured educational opportunities and exercise programs for people with arthritis, including written materials. The representatives from five communities joined together to engage in a project that addressed the leading cause of disability in the United States: arthritis. The benefits to this process have been identified in the methods and discussion sections. It is valuable to describe challenges to the process of CBPR for future consideration. Individuals participating on the RAC commuted up to 2 hours one-way to attend the committee meetings. Although the meetings were scheduled three to four months in advance, unanticipated events precluded some participants from attending all three meetings. Sufficient time needs to be allowed to reach a comfort level between individuals from very different rural communities "rural" does not necessarily mean similar cultures. The nine hours allowed for the RAC meetings gave wonderful insight for this relatively short period of time; the wealth of information being shared increased dramatically at the final meeting and indicated the need for 151

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much more discussion on this topic. Rising transportation costs, time constraints, and time to develop group relationships must be considered in future projects. Comparison of Results to Colorado Data Sociodemographics The AIMS2 and Final Questionnaire captured relevant descriptive information that can be compared to Colorado state data. The sample population included 80 participants. The average age of this sample population was 68.2 years; age ranged from 46 to 96 years of age. Males were underrepresented and comprised 25% of the survey participants as compared to slightly over 50% of Coloradoans. Over 93% of the sample group self-characterized their race as "white;" this compares to 82.8% noted for the State of Colorado (U.S. Census Bureau, 2000). Two median salary ranges were each reported by 22.5% of the sample population for a total of 45% respondent representation: $10,000-$19,999 and $20,000-$29,999. This compares to the median household income of$47,203 for the State (U.S. Census Bureau, 2000), or potentially 36% to 78% less than the median State income. In fact, the high end ofthe range, $29,999, was less than the median household income for four out of the five counties represented in this study. Sedgwick was the only county reporting a lower median income of $28,278. The average median income for urban counties in Colorado is $53,799 (Colorado Rural Health Center, 2007), which indicates an even larger disparity in income between the sample rural population and Colorado urban counties. The lower reported income might reflect that 58.5% of this population is 152

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retired, unemployed, or disabled, per self-report, and could be on a fixed income. The survey population data was primarily collected in 2007, which could also affect comparison with the U.S. Census data reported in 2000. As noted in the results, there was no representation of individuals of Hispanic ethnicity in the survey sample. U.S. Census Bureau data indicates that a total of 8.5% to 12.9% of the population in the five represented counties were of Hispanic or Latino ethnicity in 2000 (U.S. Census Bureau population, 2000). Further examination of this data indicates that of households comprised of individuals who are Hispanic or Latino, only 14.4% were greater than 45 years of age (U.S. Census Bureau, 2000). This represents only 0.01% of the entire population in these five counties, which could account for the lack of representation in this sample of individuals of Hispanic ethnicity who are 45 years of age or older. Snowball sampling may have further reduced the chance of including individuals of this ethnicity in the survey sample. Parks et al. (2003) found that income level predicts an adult's likelihood to meet PA recommendations. Using a modified telephone sampling plan and a survey instrument based on the BRFSS, National Health Interview Survey, and other unnamed questionnaires, they asked rural, urban, and suburban residents about demographics, the physical environment, social support for exercise, and personal barriers to increasing P A. Their results "confirm that income level is as important if not more important than area of residence in analyzing individual's physical activity levels" (Parks et al., 2003, p. 34). In addition, rural residents were least likely to be 153

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physically active when compared to urban and suburban residents. Consideration of income and rurality is important when discussing levels of P A. Although not analyzed for this project, future analyses could observe the association between income and P A in these communities. Educational attainment varied between the survey population and State data. For individuals 25 years of age and older in the state of Colorado, 23.2% are high school graduates (U.S. Census Bureau, 2000) compared to 47.5% ofthe sample group who reported achievement of a high school diploma. In contrast, 21.6% of the State population has obtained a bachelor's degree (U.S. Census Bureau, 2000) whereas 12.5% ofthe survey respondents stated that they had this degree. Educational attainment has repeatedly been positively associated with physical activity in adults and is noted by Trost, Owen, Bauman, Sallis, and Brown (2002). Higher levels of education may indicate higher levels of P A. The correlation of P A with education in the sample population, which currently does not exist, could be analyzed in subsequent projects. Health Characteristics The health profile ofthe eighty participants can also be compared to Colorado 2004-2005 BRFSS data (Colorado Health Information Dataset, 2004-2005). As noted previously, health limitations are often amenable to change through regular P A. Table 5.1 compares key health characteristics ofthe survey respondents to the PMR 1 and Colorado state data. BRFSS data for individuals 65 years of age or older was used for 154

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comparison values since the average age ofthe survey participants was 68.2 years. In addition, PMR 1 was included for comparison because four of the five counties represented in this study are a part of this classified grouping: Logan, Phillips, Sedgwick, and Yuma. The PMR 5 data, which includes Lincoln County, were unavailable for 2004-2005 and are not displayed. The BRFSS protocol notes that a sample size of less than 50 is not statistically reliable (Colorado Health Information Dataset, 2004-2005). All Colorado state data exceeded the minimal sample size for reliability. Although the sample size for PMR 1 was not statistically reliable for hypertension, general tendencies can be observed. Table 5.1 Health Characteristics: Survey Participants and County or Colorado 2004-05 BRFSS Data Characteristic %Survey % PMR I Overweight (25.029.9 kg/m2 ) 44.7 (n=76) 59.3 (n=54) Obese kg!m2 ) 31.6 (n=76) 28.2 (n=l82) Hypertension 42.5 (n=79) 71.1 (n=29)" Diabetes 16.2 (n=78) 24.0 (n=58) Note. PMR I and Colorado data reported for 65 years old statistically reliable per BRFSS protocol %Colorado 55.7 14.9 49.1 12.7 The sample population reported a lower percentage of people who were overweight and a higher percentage of obesity than PMR 1 or Colorado state values. The positive association between obesity and osteoarthritis has been previously 155

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described (Cooper et al., 2000; Felson et al., 1997; Grabiner, 2004; Klippel et al., 2008; Sharma et al., 2000). The frequency of hypertension (HTN) and diabetes differed from PMR 1 and State data. Even though 42.5 percent of the respondents reported HTN, which was the highest reported co-morbidity, this fell short of the State average of 49%. This may reflect that there were younger participants contributing to the health characteristics data of the survey group; the prevalence of HTN increases with age (Lloyd-Jones, Evans & Levy, 2005). Only individuals> 65 years of age comprised the PMR I and State data, favoring a higher rate of HTN. In addition, the PMR I percentage of people with hypertension represented a sample size of29, which was noted as statistically unreliable per the BRFSS protocol (Colorado Health Information Dataset, 2004-2005). The prevalence of diabetes was higher in the survey group than the State data. Obesity is a risk factor for Type II diabetes. Type I and Type II diabetes were not separated in the survey questionnaire, and it is unknown if or how many self reporting adults had Type I or Type II diabetes. The study population, however, demonstrated a higher prevalence of diabetes and obesity than Colorado data reported for individuals 2:, 65 years of age. Obesity can be affected by lifestyle intervention including physical activity (Knowler et al., 2002). As noted previously, osteoarthritis can also be positively affected by physical activity. An investigation ofthe relative 156

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impact of physical activity on individuals with a combination of obesity, Type II diabetes, and arthritis is warranted. Physical Activity Discovery and Highlights Time Spent in Physical Activity The literature supports the integration of physical activity into an individual's lifestyle to promote health and reduce the risk or effects of chronic diseases (Dipietro, 2001; Macera et al., 2003; U.S. Department of Health and Human Services, 1996). Current recommendations from the American Heart Association and the American College of Sports Medicine advise a minimum of 30 minutes of moderate P A on five days per week or 20 minutes of vigorous P A on three days per week for adults, including older adults (Haskell et al., 2007; M. E. Nelson et al., 2007b). The current study investigated perceived weekly minutes of P A in individuals with OA between the ages of 45 and 96 years old. The data indicate perceived P A performance tendencies in this population. Survey selection predicated that one hundred percent of the 80 study participants reported time spent in non-work related moderate P A per week, and these 80 individuals reported variable amounts of other PA. Forty-one percent of this group stated they participate in vigorous leisure-time P A. As expected, fewer respondents reported moderate or vigorous work activity, with 56.2% of this group not working. Ofthe 32 individuals who reported working, 75% included moderate activity as part of their work day and 37.5% stated that they incorporated vigorous work activity. 157

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Examination of the results determined how many of the individuals were meeting the weekly P A recommendations. Based on current recommendations, a total of 150 minutes of moderate activity or 60 minutes of vigorous P A per week is recommended for adults and older adults (Haskell eta!., 2007; M. E. Nelson eta!., 2007b ). Sixty-nine percent of individuals reporting non-work related moderate P A met the recommendations based on non-work moderate activity alone. Eighty-eight percent ofthe 33 individuals listing minutes ofvigorous PA met the weekly PA requirements per self-report based on vigorous P A alone. An additional eight respondents met the weekly recommendations through non-work P A by summating their reported moderate and vigorous P A per week. This increased the total number of respondents meeting adult PA guidelines through non-work PA to 73.8%. Ofthose individuals who worked, all but three met the moderate P A weekly recommendation through work activity alone, and the 12 participants who reported minutes of vigorous P A at work per week all achieved P A goals. Adding moderate non-work P A to the three participants who did not meet guidelines through work activities alone increased their weekly moderate P A accumulated minutes to meet recommendations. The percentage of individuals meeting moderate and vigorous P A recommendations is markedly higher than reflected in previous literature. For example, Schoenborn and Barnes (2002) state that nearly 40% of adults do not participate in leisure (non-work) activities. However, the Colorado Health Information Dataset (CO HID) indicates that 82.1% of the Colorado population 158

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reported participation in "any physical activities" over the timeframe of one month (Colorado Health Information Dataset, 2004-2005). Colorado is listed as one of five states with 80.8% or higher adult participation in "any physical activities" (Centers for Disease Control and Prevention, 2006). This percentage is the highest attainable category of reported P A. Eyler (2003) also noted higher P A levels than reported in national survey reports in white women between 20 and 50 years of age living in rural communities. Over 50% met moderate activity recommendations compared to 26.1% reported in the 1997-1998 National Health Interview Survey. Although this study included a younger, all female survey population, it reflects the variance that can occur from national data. The CO HID data reports the response to the P A item as "yes" or "no" and labels it as "leisure time exercise" (Colorado Health Information Dataset, 2004-2005). Data do not differentiate between levels of intensity for the P A. Results of the COHID data by age group relevant to the current study for Colorado and PMR 1 are listed in Table 5.2. Data for PMR 5 is not reported for 2004-2005. 159

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Table 5.2 Colorado and PMR 1 BRFSS Data: Participation in Physical Activity Colorado: n (%) PMR 1: n (%) Age Group 45-54 Leisure time exercise = no 398 (16.4) 45-54 Leisure time exercise = yes 2,267 (83.6) 55-64 Leisure time exercise= no 370(19.1) 55-64 Leisure time exercise = yes 1,633 (80. 9) 65+ Leisure time exercise = no 604 (27.0) 65+ Leisure time exercise = yes I ,636 (73.0) Note. Data reflects leisure time activity over the last month. (Colorado Health Information Dataset, 2004-2005) 9 (22.6) 30 (77.4) 8 (27.3) 23 (72.7) 21 (34.9) 37 (65.1) These data reflect a relatively high percent of individuals who perceive that they participate in PA during a one month time period. Between 65% and 77% ofthe respondents in PMR 1 indicated they participated in "leisure time exercise." This is comparable to the 73.8% reporting participation in moderate or vigorous P A in the current study. A direct comparison cannot be made due to lack of reported level (moderate or vigorous) or minutes ofPA in the COHID data, but it suggests a high percentage of people in Colorado perceive they participate in non-work P A. A challenge with interpretation may arise between the stated question, "During the past 30 days, other than your regular job, did you participate in any 160

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physical activities?" and the reporting of data as "leisure time exercise." As noted previously, exercise and PA are defined differently. There are several potential explanations for the large range and relatively high levels of reported P A in the survey population. These details will be discussed in the following paragraphs. The RAC members were instrumental in the development and progression of this investigation. Committee members volunteered to participate for a number of reasons, which affected subject recruitment. They were active community members who were diagnosed with arthritis and or were committed to helping the people in their community. One individual, when asked for his or her reason for volunteering on the committee stated, "I have arthritis and thought it might be able to impact the availability of exercise opportunities" (personal communication, October, 2007). Another individual wrote, "We need more info, support groups, and community awareness of arthritis needs in area" (personal communication, October, 2007). Their involvement in the community often led to distribution of surveys to individuals attending similar group functions such as women's or men's club meetings, social activity groups, and or community enrichment groups. It was the impression of the principal investigator that the RAC members were knowledgeable and committed to the health and well-being of people with arthritis. They may have directed survey distribution to like-minded individuals who were active and high functioning members of the community. 161

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The RAC community connections also connected the PI with active community groups who used the $1 0 gift card incentive to raise money for service goals. Again, the mindset of community involvement and helping community members "selected" participants who were willingly engaged in the community and, through snowball sampling, "chose" individuals involved in similar, active lifestyles. One particular group collecting the gift card contributions for service to others indicated they would reach every adult in their county with OA. Self-reported minutes of moderate and vigorous non-work related P A spanned a large range: 15 minutes to 70 hours of moderate non-work P A per week and 26 minutes to 84 hours of non-work vigorous P A per week. Self-report measurement tools inherently have benefits and limitations to their use. Sallis and Saelens (2000) addressed the concept of assessing an individual's amount of P A through self-report and reviewed multiple P A measurement tools, including four tools developed for self report by older adults. The benefits of such tools included the ability to collect large quantities of data at low cost, lack of investigative effect on the behavior being studied, and the ability to assess patterns of behavior by addressing multiple dimensions of physical activity (Sallis & Saelens, 2000). Limitations included the inability of a tool to capture relevant activities for the target population (Sallis & Saelens, 2000), difficult nature of recalling P A over time (Baranowski, 1988), ambiguity of terms such as "moderate intensity" and "physical activity," (Sallis & Saelens, 2000) and potential for social desirability bias that can lead to inflated values 162

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ofreported PA (Warnecke et al., 1997). Sallis and Saelens (2000) noted that "children and very old adults are likely to have particular memory and recall skill limitations" (p. 1 ). Their literature review indicated that, although reliable and valid self-report instruments exist that measure P A, most self-report studies conclude that self-reports do not reflect accurate estimates of true P A levels. They recommended use of additional objective measures to enhance findings of self-report PA tools such as accelerometers. DiPietro (200 1) adds that P A is a complex behavior that is difficult to assess, particularly in older adults. The literature supports measuring PA in order to find associations with health outcomes and other variables. In older adults, active lifestyles as opposed to structured exercise programs may result in moderate intensity PA which contributes to reduced morbidity. Activities might include housework, gardening, and vacuuming. Accurate measurement of time increments can be intrusive, such as through observation or accelerometer use, and may alter habitual P A patterns. Therefore, investigators often rely on self-report instruments. DiPietro (200 1) notes that "issues of recall ... in older people lead to less than precise estimates" (p. 13 ). Further research on the accurate measurement of P A through self report tools in diverse populations is needed. Other factors likely influenced reported P A. As noted in the Methods section, nearly one-third ofthe respondents answered "don't know/not sure" to questions related to time increments of P A per week. Calculating time spent in P A per week 163

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requires time and recall effort. Individuals may have chosen not to spend this time, given they were already completing a lengthy survey. Differentiating work and leisure time P A may have been difficult for self-employed participants. Boundaries may overlap, for example, with individuals who farm or ranch for a living. Examples of moderate and vigorous P A provided on the questionnaire may not have had meaning to respondents and allowed for error in estimation of P A. More activities representative of the survey population may have clarified the P A questionnaires. The fact that there was a wide range of reported P A time increments may reflect the wide age range and or variability in lifestyles. Outliers were not excluded in order to preserve all participants' perceptions of their weekly P A. Does It Add Up? The sum of work and non-work related moderate or vigorous P A can indicate whether or not a survey participant achieved the recommended PA values. Few studies have examined the total amount ofwork and non-work related PAin achieving P A guidelines (Trost et al., 2002), particularly in a sub-population with a chronic disease. Two questionnaires using similar formats, the BRFSS and the OP AQ, allowed respondents to estimate their time in work and non-work P A. In this study, 100% of the participants who worked achieved P A guidelines when including their reported non-work related activities. Over 73% of the research cohort met the recommendations through non-work P A alone. Including work and non-work P A in 164

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future investigation in diverse populations may demonstrate a higher percent of individuals meet the national P A recommendations. Hypotheses Discussion Correlates of Physical Activity in a Sample Population The literature suggests adults with arthritis are not meeting the current recommendations for PA (Fontaine et al., 2004; Hootman et al., 2003). Multiple influences can affect levels of P A. This survey was designed to identify potential correlates of P A in individuals with arthritis residing in rural east and northeast Colorado. Arthritis impact, arthritis self-efficacy, environmental influences, gender, distance from town, HCP interactions, and factors influencing the intent to perform P A were examined. Open-ended questions allowed participants an opportunity to expand beyond the survey's quantitative boundaries. Survey results related to correlates of P A are discussed in this section. Effect ofGender, Distance from Town, and HCP Influence on PA Gender, distance from town, and a HCP's recommendation to be physically active did not produce results that had statistical significance in this sample population. There was no difference between the average number of minutes in intensity or amount of P A between males and females. The literature suggests that females in rural communities are the least active subgroup when compared with males in rural and urban areas (Centers for Disease Control and Prevention, 1998; Wilcox et al., 2000). In this sample, females were, on average, more than three years 165

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younger than males, and 63% of women were still in the work force compared to 56% of the surveyed males. Younger average age and accumulation of work P A may have contributed to the lack of difference between males and females. Males were underrepresented in this study, which affected the sample size and overall result reporting in this subgroup of the sample population. Distance from town did not significantly affect the perception of how much time was spent in P A per week. Additional information regarding the type of work and or non-work activities performed by individuals living in town versus out of town would inform these results and clarify perceptions. Only 42% of individuals who reported moderate non-work P A were told to be physically active by a HCP. Exclusion criteria disallowed individuals who were unable to be physically active, and therefore respondents were eligible for P A education. It is unknown ifthe HCP perceived the individual was already active enough, which could be investigated in the future. Given the health characteristics profile of this population, including high rates of obesity and significant HTN and diabetes, discussion of the individual's current level and types of PA is warranted. For example, the HCP can identify risk factors amenable to change through P A. HCPs with specialty in exercise prescription for individuals with comorbidities, such as physical therapists, can educate in safe and effective forms of P A that can be performed through work and or non-work related activities favored by the individual. 166

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Education by HCPs, as noted previously, was a recommendation by the community members and can be incorporated into community and individual health education. Arthritis and Physical Activity The independent variable, "arthritis impact," was most closely associated with minutes ofmoderate work PA as opposed to vigorous or non-work PA (r(23) = .403,p = 0.057). Six ofthe 12 AIMS2 scales provided a combined score for each respondent that reflected the impact of arthritis on their physical function. This value was used to determine if a relationship existed between the independent variable and minutes of P A per week. Arthritis impact frequency data was markedly positively skewed (skewness= 1.97), indicating that the lower scores which reflect a higher health status were more common in this population. The positive correlation indicates that individuals who reported less arthritis impact on physical function were associated with fewer minutes of P A. A negative correlation would indicate individuals with a lower health status reported fewer minutes of P A, which might be expected. The sample size may have prevented finding a significant relationship between the two variables. Data representing other areas of arthritis impact such as on affect, social interaction, symptoms, and work roles were not analyzed for this study. Environmental Resources Questions related to P A resources in the physical environment did not provide significant results. Whether or not the respondents perceived their community had resources for P A did not correlate with minutes of PA. Ninety-one percent of 167

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respondents who reported participation in moderate non-work P A indicated their communities had private recreation facilities available for P A, which was surprising in the rural areas. The strongest association occurred between moderate non-work P A and the availability of private recreational facilities (n = 79, p = 0.062). A significant result would have indicated that there was an association between the presence of private recreational facilities and minutes of non-work moderate P A. Although this correlation had the largest sample size relative to P A response, more participants might be needed to detect a significant association between P A and availability of P A resources. The ESPAQL survey provided questions to determine whether or not certain PA resources existed in the community and served to identify potential facilitators or barriers to PA by their presence or absence in the community. The environmental resource presence or absence was not significantly associated with time spent in P A in this study. The wording of the questions could have led to confusion for respondents. For example, the question "Do you use any public recreation centers in your community for physical activity?" was followed by four potential responses: "yes," "no," "my community does not have these facilities," and "don't know/not sure." It is possible a participant would stop after the second answer, "no," because they did not believe the facilities exist and therefore did not use them. For analyses, the "yes" and "no" responses were combined to indicate the community has the 168

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resources as previously described. If answered incorrectly, this would inflate the perception that the community had the resource. Additional factors likely influenced the results. Trost et al. (2002) notes the challenges associated with drawing conclusions from perceived environmental influences on P A from cross-sectional study designs. At any point in time, individuals who are active outdoors may have greater awareness of resource availability, or, on the flip side, perceived barriers that prevent access. Eyler (2003) reported that only one of seven investigated environmental barriers, fair compared to good street lighting, was significantly correlated with P A. The question of validity of measurement tools, the ability to detect only outdoor activities, or sample size to discover a significant relationship were cited as possible explanations. Bauman, Smith, Stoker, Bellew and Booth (1999) reiterate the need to produce valid measurement tools that include environmental perceptions. They consider the option that certain environments entice individuals who prefer a more active lifestyle. The high levels of P A in the current sample population may have been due to lifestyle activities available through work and non-work related activities in a rural environment-where they chose to live. Responses to a qualitative question in the Final Survey added insight into environmental barriers. Participants were asked, "What things in the physical environment keep you from being as active as you would like to be?" As reported in the results section, common themes developed. A major concern was the lack of 169

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accessible indoor facilities available for P A to provide a level surface for walking and "climate control." A community-based intervention might look at current resource availability such as schools in the area and provide scheduled time for use. Community discussions revolving around intergenerational P A programs might promote increased accessibility. Motivation to be active was addressed by asking, "If you want to be more active, what would motivate you to be more physically active?" RAC members phrased the question to include only those with a desire to be active. As reported previously, several environmental components surfaced. Warm water pools, low or no cost facilities, and access to parks were suggested. The perception of needing "a place" to be active at an attainable cost could direct communities, including their governance, to consider options. One community represented in this project recently (during the time period of this research) directed fundraising at providing money for a warm water therapy pool in their new hospital. It was designated as a therapy pool with the added benefit of availability for independent exercises. This was a specific and very successful example of a community-recognized need being met by the direct efforts of community members. It is difficult to be sure the right questions related to a particular culture are being asked about P A and the physical environment. Although rural environments may predispose to certain physical environmental barriers such as uneven or lack of sidewalks, this may not affect an individual's decision to participate in outdoor 170

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activities. How much can be generalized from one rural environment to another? Additional community-based qualitative research could inform this process and strengthen the ability to develop a valid measurement tool. Theoretical Perspective-Quantitative and Qualitative Insight The constructs based on the Theory of Reasoned Action/Theory of Planned Behavior were examined for an association with actual minutes of PA performed. The three constructs, "attitude," "subjective norm," and "perceived behavioral control," were embedded in statements in the PAAQ and were based on concepts that would measure the intent to perform P A. "Attitude" had a significant negative correlation with minutes of non-work vigorous PA (n = 30, p = .019). Four statements from the PAAQ were found to form an "Attitude" subscale following principal axis factor analysis. The negative correlation suggests that those who reported more minutes of P A had a lower score on "Attitude." Lower scores on the P AAQ indicated the participant disagreed with the construct statements. The wording of the statements clarifies this negative correlation. For example, the statement "I would like to be more physically active" was part of this construct reflecting attitude about P A. The negative correlation indicates that individuals with fewer minutes of P A agreed with the P AAQ statement that they would like to be more physically active. Conversely, respondents with high minutes of P A did not agree that they would like to be more physically active. Potentially, individuals who are less active recognize the need to be more active and their attitude 171

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could be considered favorable towards being more active. Further qualitative investigation of the relationship between attitude and P A in this population is warranted. Although the relationship between the construct of subjective norm and minutes of P A did not reach significance, qualitative indicators of the need for social support, a related concept, were evident. The concept of subjective norm carries a social component that indicates whether or not others' approval of a behavior is important to the individual. Approval could be represented by co-participation in a behavior, in this case, P A. The construct of subjective norm was represented by three statements following principal axis factor analysis including, "I am likely to be physically active if my friends are active as well." Responses to the Final Survey question, "If you want to be more active, what would motivate you to be more physically active?" supported social support as a motivator to be active as noted in the results section. Respondents wanted someone to "be physically active with" as well as "encouragement from my husband and myself." Access to social PA groups and encouragement from "significant others" could be points of discussion for community members interested in directing interventions to increase P A. Further information is needed on the barriers to social support. The final construct, perceived behavioral control, did not significantly relate to the amount of time spent in PAper week. Statements such as "Arthritis keeps me from being physically active," which were reverse coded for analysis, reflected the 172

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subscale of perceived behavioral control. This construct is considered similar to Bandura's self-efficacy construct (Glanz et al., 2002). A significant positive correlation would suggest that an individual who disagrees with this statement would have high levels of P A. In this population, there was no association between control over arthritis and P A with minutes of P A per week. The ASES tested another perception of control over daily functions. Self efficacy, or perceived control over daily physical functions in individuals with arthritis, was examined to determine if control over functional activities such as the ability to walk a certain distance over a defined period of time related to the amount of PA performed per week. Similar to the concept of perceived behavioral control, belief in one's ability to perform functions was not related to the amount oftime spent in PAper week. It is interesting that the correlation between perceived behavioral control and moderate non-work P A log(l 0) (p = .445) and the correlation between self-efficacy function from the ASES and moderate non-work P A log(l 0) (p = .446) were virtually identical. Contributions Starting the Dialogue This is the first known study that invited communities in rural Colorado to participate in the research process regarding the most common cause of disability, arthritis. Individuals most affected by arthritis have offered insight into how their communities are affected; they have shared their voice, expertise, organizational skills, passion, insight, and concerns to inform the research process. Meetings with 173

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the RAC have provided a model to begin discussions with other rural communities that share an interest in arthritis. This investigation has initiated a process of discovery into factors that influence the activity levels of people with arthritis living in rural communities in east and northeast Colorado. Questions can be posed to continue this discovery process: Are the measurement tools appropriate for this population, are there other correlates that predict the P A level in this population, how can health risk factors be reduced, and are perceived levels of P A equal to actual levels of P A? Limitations Self-report bias. Verification of doctor-diagnosed self-reported osteoarthritis was not confirmed by the PI's direct examination. Self-reported diagnoses can be inaccurate and therefore distort research findings. It is possible the diagnosis ofOA was over-reported. Dunlop et al. (2003) and Sacks et al. (2005) note that self-reported diagnoses are useful to capture responses from individuals who may or may not see their physician for arthritis. Distinguishing the type of arthritis by the individual may also interfere with the accuracy of diagnosis iftheir HCP has told the individual that they have "arthritis." Bursitis and tendonitis are categorized in the broad spectrum of "arthritis" and an individual's interpretation of their diagnosis might be inaccurate. It is difficult to determine how the self-report bias would impact the overall survey results. Individual characteristics of those with a diagnosis other than OA might have 174

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varying degrees of pain, activity limitations, comorbidities, behavioral beliefs, or other factors that could affect their response to the survey questions. Generalizability. The 80 survey participants were not significantly different in key variables from the original sample of 119 people. The results could be generalized to this larger group. Efforts were made to represent a variety of geographical communities by the RAC from east and northeast Colorado. An increased sample size with random sampling methods could increase the generalizability of this study. Additional research with similar parameters is needed to better understand the generalizability to other rural populations. Measurement instruments for P A. Multiple choice options for the P A survey questionnaires allowed participants to choose "don't know/not sure" for minutes and days spent in work or non-work PA each week. Nearly 33% ofthe completed surveys demonstrated this response and were excluded from further analysis. This significantly reduced the sample size for results and discussion. A comparison between the respondents and non-respondents on several key variables did not find a significant difference. However, a larger sample size may have resulted in significance in additional analysis for chosen independent variables. Recall bias. Recall bias may have resulted in errors in reporting time spent in P A. There is considerable personal time and effort required to recall levels and amount of P A over a timeframe, and respondents may have overestimated or underestimated their minutes of P A. Social desirability bias would also explain 175

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overestimation. Individuals may want to be perceived as more physically active than accurate times would reflect. The data indicate a few extreme outliers for minutes of P A. This significantly affects scatterplot tests for linearity prior to performing correlations and positively skews the data. Snowball sampling. The method of survey distribution, snowball sampling, can limit the breadth of contacts made in the community. Individuals distributing surveys most likely sought participants they knew through social or work context. RAC members directed the survey distribution which may have limited it to their known networks. This could limit generalizability to populations with different cultural backgrounds, educational levels, socioeconomic backgrounds, etc. Time commitments. The members ofthe RAC often overcame barriers of travel and time to attend the three scheduled meetings. It is difficult to schedule a date that meets a total of 12 individuals schedules within a 200 mile radius. The logistics need to be carefully monitored to allow maximal involvement with minimal intrusion into daily lives. Dissemination, Future Directions, and Interventions Community-based participatory research (CBPR) supports the dissemination of results "to all partners and involves them in the wider dissemination of results" (B. A. Israel, Eng, E., Schulz, A. J., & Parker, E. A., 2005, p. 9). The next step is to inform the RAC and other interested community members ofthe comprehensive results of this project. Dissemination suggestions from the RAC had included 176

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developing strategies to "shape" the community's hospital and clinic strategies for working with individuals with OA, developing and publishing a resource guide that would include education on the benefits of P A, and writing an executive summary to be sent to the local newspaper, "local development coordinators," and medical facilities. Multiple unanswered questions often lead to dynamic and thought-provoking discussions and research pathways. The community-based approach allows for informed and relevant future direction decisions and development of community identified intervention strategies to facilitate health within the communities. Additional information may be needed to determine correlates pertinent to these areas. For example, measurement tools may need to be changed or modified to provide useful and scientifically sound information. Survey data were also collected on 16 individuals with doctor-diagnosed self reported rheumatoid arthritis (RA). These data can be analyzed to describe correlates of P A in a sample of individuals with RA. Further investigation of RA and other types of arthritis could provide information and applications to a broader population. Primary prevention strategies to reduce the prevalence of arthritis need to be explored. The National Arthritis Action Plan: A Public Health Strategy identifies four points of entry for effective interventions including weight management, occupational injury prevention, sports injury prevention, and infectious disease control (for example, with Lyme disease) (Arthritis Foundation et al., 1999). Joint protection and 177

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education are key principles of these interventions and could be directed through rural community channels in partnership with healthcare providers. Reducing the prevalence of arthritis, the leading cause of disability in the United States, would have significant benefits to individuals and their associated communities. Summary Statement I have learned so much more than the communities ... Physical activity is a complex behavior that can be influenced by many factors. Involving community members in discovery of what shapes their physical activity experience is necessary to achieve clarity and accuracy. Communities must be directly involved in the discovery process to determine interventions that will affect their health, function, and quality of life. Individuals share common chronic diseases processes that affect their functional ability and quality of life. Osteoarthritis, a chronic disease affecting the joints, is the leading cause of disability in the United States and promises to adversely affect more lives as the population ages. Effective management of the disease process, including physical activity, can reduce the individual and economic burdens as well as the comorbidities often noted with inactivity such as diabetes and hypertension. This investigation was unique in its focus on P A in individuals with arthritis in rural communities. Instruments to measure P A, the dependent variable, required self-report recall oftime spent in work and non-work (where indicated) PAper week. 178

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A high percentage of respondents did not estimate actual minutes of P A and answered, "don't know/not sure" to this portion of the survey. Of those who provided minutes of work and or non-work P A, data were highly skewed and overall indicated higher than previously reported levels of moderate and or vigorous PA. Few investigations have attempted to estimate total work and non-work P A. Understanding the levels oftotal PA in varied communities may require a more tailored approach to measurement. It is unclear if individuals living in these rural communities differentiated between work and non-work PA iftheir work was intimately intertwined with their daily activities, such as might occur in farming communities. Operationalization and measurement of P A in similar subgroups needs to be clarified through methodological studies that seek to accurately define P A. Qualitative research, including insight from the Rural Arthritis Committee, would also be useful to inform the assessment of P A; it can help in the construction of instruments that take into account the definitions of P A of rural residents, in light of the complex, "real life" scenarios noted in this study. More precise estimates oftotal P A may help identify relationships between P A and factors affecting P A in individuals with osteoarthritis in these rural communities that have not been detected. Communities that acknowledge the associated disability of arthritis can work together to lessen the burden. Facilitating discussions and investigating common perceptions ofthe effects of arthritis with the community's involvement can help elucidate an understanding ofthe needs of the communities in combating the 179

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disabilities related to arthritis. 180

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APPENDIX A CONSENT AND HUMAN SUBJECTS APPROVAL Informed ConsentPilot Survey Informed Consent-Rural Arthritis Committee Informed Consent Photograph Informed Consent-Survey Human Subjects Research Committee Approval: 2006 Human Subjects Research Committee Approval: 2007 181

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Informed ConsentPilot Survey Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson, PT, MS, Doctoral Student, Health and Behavioral Sciences University of Colorado at Denver This is a pilot survey for a research study and includes only those people who want to participate. Why is this study being done? This is a research project about physical activity for people living in rural areas who have arthritis. People with arthritis who live in rural communities may have unique challenges in getting the right types of physical activity that could improve their overall well being. The community and individuals within the community are in the best position to look at what affects their ability to be physically active. This study is being done to look at issues that help or make it harder for people with arthritis to be active in rural communities. It will involve a community advisory board and individual responses to look at these issues. What will I have to do if I agree to be in the study? You are being asked to complete a list of questions that will help make a final list of questions for the study being performed in Northeast Colorado. These questions look at your opinions on physical activity and arthritis. Answering these questions should take about 15 minutes. You will meet with the researcher or assistant one time in person to answer these questions and give feedback about the questions. You can decide the best place to meet with the researcher or assistant. What are the benefits and risks of being in the study? Potential benefits: There will be no direct benefits to your participation in answering these questions. This study may provide information to local, state, and national organizations interested in the health of people with arthritis and/or health of individuals in rural communities in order to look at resources that might benefit the communities. Potential risks: The research may make you think about what you can't do because of your arthritis rather than what you can do. This might cause mild concern. Can I quit before finishing? Your decision to answer the survey questions is voluntary, and you can quit at any time. You can also choose to not talk about anything that makes you uncomfortable. How will you keep others from knowing what I said? I will make every effort to keep the information you share with me confidential. I will be the only person storing the answers to the questions. Any information shared with the community advisory meetings, written about in published reports, or given at national meetings will be reported as group information and not have information that would identify an individual. What if I have questions about the research? Please feel free to ask me any questions about your rights in this study before starting to answer the questions. If you have other questions before, during, or after the study is complete, you can contact me at 303-909-5978. If you have any concerns about your rights as a person in this study, please contact the Human Subjects in Research Committee, 1380 Lawrence Street, Suite 1400 at 303-5564060. 182

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Participant Authorization I have read this consent form or the researcher has read the consent form to me. My questions have been answered, and I understand what will happen if I am a part of this study. I consent voluntarily to be in this study, and I will receive a signed and dated copy of this consent form to keep. Participant Signature Date 183

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Informed Consent-Joint Arthritis Committee Focus Group Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson, PT, MS, Doctoral Student, Health and Behavioral Sciences University of Colorado at Denver This is a research study and includes only those people who want to be in the study. Why is this study being done? This is a research project about physical activity for people living in rural areas who have arthritis. People with arthritis who live in rural communities may have unique challenges in getting the right types of physical activity that could improve their overall well being. The community and individuals within the community are in the best position to look at what affects their ability to be physically active. This study is being done to look at issues that help or make it harder for people with arthritis to be active in rural communities. What will I have to do if I agree to be in the study? You are being asked to be a part of the Joint Arthritis Committee (JAC), which is a group of people representing counties in Northeast Colorado who are interested in arthritis. This committee will meet about three times over the next year (focus groups) in a community setting chosen by the committee for 2-3 hours to help the researcher make the study important for rural communities in Northeast Colorado. You will be asked to look over and make changes to a list of questions in a survey so they apply to your communities, take photographs of things in the community that make activity hard for people with arthritis, look at flyers and newspapers ads asking people to be in the study to make them apply to people in your community, and ask people with arthritis to be a part ofthe study that involves answering questionnaires. You will also be asked to look at the results of the study and discuss the findings. These meetings will be tape-recorded, if the entire group approves taping, to make sure the records of the meetings are accurate. What are the benefits and risks of being in the study? Potential Benefits: JAC members will receive a "disposable" digital camera for use while documenting the environment. If funded, each JAC member will receive a $50 gift certificate after the three focus groups have been completed. A resource guide will be made available that lists community offerings for people with arthritis. JAC members will help develop a model that may be used by other rural communities to look at what may help or make it harder for people with arthritis to be active. This study may also provide information to local, state, and national organizations interested in the health of individuals with arthritis and/or health of individuals in rural communities in order to look at resources that might be useful. Potential Risks: This study may point out problems in the community for people with arthritis doing physical activity that cannot be fixed. This could cause frustration. Also, the JAC members may not agree during focus groups discussions, which could cause frustration. There could be mild discomfort if information discussed in the meetings is discussed outside of the meetings, depending on the nature ofthe information. Can I quit before finishing? Your attendance at the meetings is voluntary and you can quit at any time. You can also choose to not talk about anything that makes you uncomfortable. 184

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How will you keep others from knowing what I said? I will make every effort to keep the information discussed in the focus groups confidential. I will be the only person storing the notes and tape recordings of our meetings. The researchers will not release any information that would identify your part in the meetings. We ask that all of the committee members respect each other's privacy. What if I have questions about the research? Please feel free to ask me any questions about your rights in this study before starting the focus groups. If you have other questions before, during, or after the study is complete, you can contact me at 303909-5978. If you have any concerns about your rights as a person in this study, please contact the Human Subjects in Research Committee, 1380 Lawrence Street, Suite 1400 at 303-556-4060. Participant Authorization I have read this consent form or the researcher has read the consent form to me. My questions have been answered, and I understand what will happen if I am a part of this study. I consent voluntarily to be in this study, and I will receive a signed and dated copy ofthis consent form to keep. Participant Signature Date Authorization of Tape-Recording I agree to tape-recording of the JAC meetings and understand that they Yes No will only be tape-recorded if the entire group agrees to the taping. (please check one) D D 185

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Informed Consent-Photograph Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson, PT, MS, Doctoral Student, Health and Behavioral Sciences University of Colorado at Denver This is a research study and includes only those people who want to be in the study. Why is this study being done? This is a research project about physical activity for people living in rural areas who have arthritis. People with arthritis who live in rural communities may have unique challenges in getting the right types of physical activity that could improve their overall well being. The community and individuals within the community are in the best position to look at what affects their ability to be physically active. This study is being done to look at issues that help or make it harder for people with arthritis to be active in rural communities. It will involve a community advisory board and individual responses to look at these issues. Pictures of different parts of the community will help show what affects activity levels in people with arthritis in rural communities. What will I have to do if I agree to be in the study? Your picture will be taken to show how arthritis affects physical activity in a rural community. This photograph may be used to show others how activity is affected in people with arthritis in a rural community. This could include showing the picture at local, state, or national meetings that are related to the study topic or including this picture in an article for a scientific magazine. What are the benefits and risks of being in the study? Potential benefits: There will be no direct benefits for having your picture taken for this study. However, a resource guide will be made available that lists community offerings for people with arthritis at the end of this study. Also, this study may provide information to local, state, and national organizations interested in the health of people with arthritis and/or health of individuals in rural communities in order to look at resources that might benefit the communities. Potential risks: You might experience mild embarrassment by seeing your picture at meetings or in scientific magazines. Can I decide not to have my picture used? You can decide not to have your picture used at any time prior to its publication, if accepted for publication. Consent to use pictures already included in a publication cannot be withdrawn. You will need to contact Mary Christenson at 303-909-5978 if you decide to not have your picture used. What if I have questions about the research? Please feel free to ask me any questions about your rights in this study before having your picture taken. I can be reached at 303-909-5978. If you have other questions before, during, or after the study is complete, you can contact me at the same number. If you have any concerns about your rights as a person in this study, please contact the Human Subjects in Research Committee, 1380 Lawrence Street, Suite 1400 at 303-556-4060. Participant Authorization I have read this consent form or the researcher has read to me this consent form. My questions have been answered, and I understand what will happen if I am a part of this study. I consent voluntarily to be in this study, and I will receive a signed and dated copy of this consent form to keep. Participant Signature Date 186

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Informed ConsentSurvey Arthritis in Rural Communities: Correlates of Physical Activity Mary Christenson, PT, MS, Doctoral Student, Health and Behavioral Sciences University of Colorado at Denver This is a research study and includes only those people who want to be in the study. Why is this study being done? This is a research project about physical activity for people living in rural areas who have arthritis. People with arthritis who live in rural communities may have unique challenges in getting the right types of physical activity that could improve their overall well being. The community and individuals within the community are in the best position to look at what affects their ability to be physically active. This study is being done to look at issues that help or make it harder for people with arthritis to be active in rural communities. It will involve a community advisory board and individual responses to look at these issues. What will I have to do if I agree to be in the study? You are being asked to complete six separate groups of questions. These questions look at how arthritis affects your life, your opinions on physical activity and arthritis, how much control you have over your arthritis, how physically active you are, and aspects of living in a rural environment. Answering these questions should take about I to I hours. You will meet with the researcher or assistant (if funded) one to two times in person to answer these questions. You can decide the best place to meet the researcher. What are the benefits and risks of being in the study? Potential benefits: If the researcher receives funding, each individual completing the survey will receive a $20 gift certificate following completion of the questions. A resource guide will be made available that lists community offerings for people with arthritis. Also, this study may provide information to local, state, and national organizations interested in the health of people with arthritis and/or health of individuals in rural communities in order to look at resources that might benefit the communities. Potential risks: The research may make you think about what you can't do because of your arthritis rather than what you can do. This might cause mild concern. There may be minimal embarrassment in disclosing health and physical activity history information. This study may point out problems in the community for people with arthritis doing physical activity that cannot be fixed. This could cause frustration. If confidentiality is broken, there could be discomfort experienced with the release of information. Can I quit before finishing? Your decision to answer the survey questions is voluntary, and you can quit at any time. You can also choose to not talk about anything that makes you uncomfortable. How will you keep others from knowing what I said? I will make every effort to keep the information you share with me confidential. I will be the only person storing the answers to the questions. Any information shared with the community advisory meetings, written about in published reports, or given at national meetings will be reported as group information and not have information that would identify an individual. 187

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What if I have questions about the research? Please feel free to ask me any questions about your rights in this study before starting to answer the sets of questions. If you have other questions before, during, or after the study is complete, you can contact me at 303-909-5978. If you have any concerns about your rights as a person in this study, please contact the Human Subjects in Research Committee, 1380 Lawrence Street, Suite 1400 at 303556-4060. Participant Authorization I have read this consent form or the researcher has read the consent form to me. My questions have been answered, and I understand what will happen if I am a part of this study. I consent voluntarily to be in this study, and I will receive a signed and dated copy of this consent form to keep. Participant Signature Date 188

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University of Colorado at Denver and Health Sciences Center Human Subjects Research CommitteeInstitutional Review Board Downtown Denver Campus Box 120, P 0. Box 173364 Denver, Colorado 80217-3364 Phone: 303-556-4060, Fax: 303-556-5855 DATE: February 6, 2006 TO: Mary Christenson 1 Dorothy Yates, HSRC Chair FROM: SUBJECT: Human Subjects Research -Arthritis in Rural Communities: Correlates of Physical Activity Your protocol has been approved as non-exempt. This approval is good for up to one year from this date. Your responsibilities as a researcher include: If you make changes to your research protocol or design you should contact tt HSRC. You are responsible for maintaining all documentation of consent. Unless specified differently in your protocol, all data and consents should be maintained for three years. If you should encounter adverse human subjects issues, please contact us irrunediately. If your research continues beyond one year from the above date, contact the HSRC for an extension. The HSRC may audit your documents at any time. Good Luck with your research. 189

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University of Colorado at Denver and Health Sciences Center Human Subjects Research CommitteeInstitutional Review Board Downtown Denver Campus Box 120, P.O. Box 173364 Denver. Colorado 80217-3364 Phone: 303-556-4060, Fax: 303-556-3377 DATE: December 6, 2006 TO: Mary Christenson FROM: Deborah Kellogg, HSRC Chair SUBJECT: Hwnan Subjects Research Protocol #2006-035 -Arthritis in Rural Communities: Correlates of Physical Activity Your human subject research protocol's modifiCation request has been approved. This approval is good through 12/612007 (note new date). Your responsibilities as a researcher include: If you make changes to your research protocol or design you should contact the HSRC. You are responsible for maintaining all documentation of consent. Unless specified differently in your protocol, all data and consents should be maintained for three years. If you should encounter adverse human subjects issues, please contact us immediately. If your research continues beyond one year from the above date, contact the HSRC for an extension. The HSRC may audit your docwnents at any time. Good Luck with your research. 190

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APPENDIX B RURAL ARTHRITIS COMMITTEE COMMUNICATION Cover Letter-RAC Meeting #1 Agenda-RAC Meeting #1 Advertising Flyer Pre RAC input Advertising Flyer Post RAC input Agenda-RAC Meeting #2 Agenda-RAC Meeting #3 191

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March 24, 2006 Dear, I want to thank you again for agreeing to be on the Arthritis Committee. I am enclosing some information for our first meeting on March 3151 from I Oam to I pm. This includes the: Agenda Pilot survey with consent form A sample flyer We will be reviewing the pilot survey and flyer to see what changes need to be made to make them more meaningful to your community, so I thought it would be helpful for you to review them before the meeting. The survey will be used to determine how people with arthritis living in Northeast Colorado feel about physical activity. Ifyou have arthritis and can complete the survey as a "participant," please first read and sign the consent form if you agree to participate. Whether or not you complete the survey as a participant, I am hoping to receive your feedback on how to make the survey and flyer better. We can discuss your feedback at the meeting on March 3151 I will also be bringing cameras for you to use to take pictures of issues in your community over the next few weeks that make it harder or easier for people with arthritis to be active. The meeting will be held at the Church at 111 151 Avenue in Town. Directions when you arrive in Town are as follows: [Directions posted] Please let me know if you have any questions. I am looking forward to working with you! Sincerely, Mary Christenson 000-000-0000 192

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Agenda Rural Arthritis Committee (RAC) meeting March 31,2006 10 a.m.-1p.m. I. Welcome and introductions II. Community-based research Structuring our committee III. JAC consent forms Church Ill I stAve Town, CO 80000 IV. Brief overview of arthritis, physical activity and rural communities V. Pilot survey review and discussion VI. Flyer review and discussion VII. Camera procedures VIII. Lunch (provided from Subway)Open discussion/feedback 193

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Do you have arthritis? Volunteers are needed to participate in a research study about arthritis. You may be able to participate in this study if: You are 45 years of age or older Your doctor has said you have osteoarthritis You live in a rural community in Northeast Colorado Participation in this study involves: Answering a series of questions related to: o How arthritis affects your life o Your opinions on physical activity and arthritis o How much control you have over your arthritis o How physically active you are o Living in a rural environment Approximately 1-1.5 hours to answer the questions If interested, please contact: Mary Christenson, PT, MS (000) 000-0000 University of Colorado at Denver and Health Sciences Center 194

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Doctoral Program in Health & Behavioral Sciences Campus Box 188, P.O. Box 173364 Denver, CO 80217-3364 or Email: mchristenson.email 195

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Arthritis Gotch a? .... Volunteers are needed to participate in a research study about arthritis. You may be able to take part if: You are 45 years of age or older Your doctor has said you have osteoarthritis You have lived in East/Northeast Colorado for 5+ years You speak and understand English Your involvement in this project would include: Answering a series of questions related to: o How arthritis affects your life o Your opinions on physical activity and arthritis o How much control you have over your arthritis o How physically active you are o Living in a rural environment Approximately 30-45 minutes to answer this survey Ifyou are interested, please contact me by: Phone: 000-000-0000 (I will reimburse this call) Mail: Mary Christenson, PT, MS 196

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Email: University of Colorado at Denver and Health Sciences Doctoral Program in Health & Behavioral Sciences Campus Box 188, P.O. Box 173364 Denver, CO 80217-3364 or mchristenson.email Receive a $10 community gift card for completing the survey 197

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Agenda Rural Arthritis Committee (RAC) meeting August 11, 2006 10 a.m.-1 p.m. I. Welcome Church 111 1st Ave Town, CO 80000 II. Review photographs-identify findings and common themes III. Identify changes to the pilot survey based on feedback IV. Pilot survey results and discussion V. Group discussion on impact of arthritis on communities VI. Identify the next steps in the research process VII. Discuss community outcomes for this project VIII. Travel reimbursement forms IX. Lunch (provided from Subway)Open discussion/feedback 198

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Agenda Rural Arthritis Committee (RAC) meeting September 7, 2007 11 a.m.-2p.m. I. Welcome II. Review survey and research goals Church 111 1st Ave Town, CO 80000 III. Discuss process of data collection: community response to survey IV. Review characteristics of those who took the survey V. Initial results-How they are put into a database VI. Lunch VII. Group discussion on impact of arthritis on communities VIII. List resources currently available for people with arthritis in their communities IX. Discuss community outcomes for this project X. Discuss future directions/goals with the information XI. Follow-up information survey XII. Travel reimbursement forms 199

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APPENDIX C SURVEY INSTRUMENTS Arthritis Impact Measurement Scale 2 Arthritis Self-Efficacy Scale BRFSS and OP AQ Physical Activity Questions Environmental Supports for Physical Activity LONG Final Questionnaire Physical Activity and Arthritis Questionnaire 200

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ID l-4/ Adm# 5-6/ Card ARTHRITIS IMPACT MEASUREMENT SCALES 2 (AIMS2) #l 7/* Instructions: Please answer the following questions about your health. Most questions ask about your health during the past month. There are no right or wrong answers to the questions and most can be answered with a simple check (X). Please answer every question. Please begin by providing the following information about yourself. NAME: ADDRESS: Number Street Apt# City State Zip PHONE: TODAY'S DATE: Area Code Number Month Day Year AIMS2 Copyright 1990 Boston University 201

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Please check (X) the most appropriate answer for each question. These questions refer to :\'IOBILITY LEVEL. DURL'lG THE PAST MONTH ... L 2. 3. 4. 5. How often were you physically able to drive a car or use public transportation? How often were you out of the house for at least part of the day? How often were you able to do errands in the neighborhood? How often did someone have to assist you to get around outside your home? How often were you in a bed or chair for most or all of the day? All Days (l) These questions refer to WALKING AND BE!\"TIING. DURING 1HE PAST MONlH ... 6. Did you have trouble doing vigorous activities such as running, lifting heavy objects, or participating in strenuous sports? 7. Did you have trouble either walking several blocks or climbing a few flights of stairs? 8. Did you have trouble bending, lifting or stooping? 9. Did you have trouble either walking one block or climbing one flight of stairs? 10. Were you unable to walk unless assisted by another person or by a cane, crutches, or walker? All Days (I) 202 Most Days (2) Most Days (2) Some Days (3) Some Days (3) Few Days (4) Few Days (4) No Days (5) No Days (5) AIMS 8/ 9/ 10/ II/ 12/ AIMS 13( 14/ 15/ 16/ 17/

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Please check (X) the most appropriate answer for each question. These questions refer to HAND AND FINGER FUNCTION. DURII\'G THE PAST MOI""TH ... All Days (I) II. Could you easily write with a pen or pencil? 12. Could you easily button a shirt or blouse? 13. Could you easily turn a key in a lock? 14. Could you easily tie a knot or a bow? 15. Could you easily open a new jar of food? These questions refer to ARM FUNCTION. DURING THE PAST MONTH ... 16. Could you easily wipe your mouth with a napkin? 17. Could you easily put on a pullover sweater? 18. Could you easily comb or brush your hair? 19. Could you easily scratch your low back with your hand? 20. Could you easily reach shelves that were above your head? All Days (1) 203 Most Days (2) Most Days (2) Some Days (3) Some Days (3) Few Days (4) Few Days (4) No Days (5) No Days (5) AIMS 18/ 19/ 20/ 21/ 22/ AIMS 23/ 24/ 25/ 26/ 27/

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Please check (X) the most appropriate answer for each question These questions refer to SELF-CARE TASKS. DURING THE PAST Always (1) 21. Did you need help to take a bath or shower ? __ 22. Did you need help to get dressed? 23. Did you need help to use the toilet? 24. Did you need help to get in or out of bed? These questions refer to HOUSEHOLD TASKS. DURING THE PAST MONTH ... 25. If you h a d the necessary transport a tion could you go shopping for groceries without help? 26. If you had kitchen facilities could you prepare your own meals without help? 27. If you had household tools and appliances, could you do your own housework without help? 28. [f you had laundry f a c i liti e s could you do your own laundry without help? Always (1) 204 Very Almost Often Sometimes Never (2) (3) (4) Very Almost Often Sometimes Never (2) (3) (4) AIMS Never (5) 2 8 / 29/ 30/ 31/ AIMS Never (5) --32/ 33! 34/ --35/

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Please check (X) the most appropriate answer for each question. These questions refer to SOCIAL ACTIVITY DURING THE PAST MONTH ... 29. How often did you get together with friends or relatives? 30. How often did you have friends or relatives over to your home? 31. How often did you visit friends or relatives at their homes? 32. How often were you on the telephone with close friends or relatives? 33. How often did you go to a meeting of a church, club, team or other group? All Days (l) Most Days (2) These questions refer to SL'"PPORT FROM FAMILY AND FRIENDS. Some Days (3) Few Days (4) Very Almost No Days (5) Always Often Sometimes Never Never DURING THE PAST MONTH... (l) (2) (3) (4) (5) 34. Did you feel that your family or friends would be around if you needed assistance? 35. Did you feel that your family or friends were sensitive to your personal needs? 36. Did you feel that your family or friends were interested in helping you solve problems? 37. Did you feel that your family or friends understood the effects of your arthritis? 205 AIMS 36/ 37/ 38/ 39/ 40/ AIMS 41/ 42 / 43/ 44 /

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AIMS Pleas.: check (X) the most appropriate answer for each question. These questions refer to ARTHRITIS PAIN. Dl.'RING THE PAST MONTH ... 38. How would you describe the arthritis pain you usually had? 39. How often did you have severe pain from your arthritis? 40. How often did you have pain in two or more joints at the same time? 41. How often did your morning stiffness last more than one hour from the time you woke up? 42. How often did your pain make it difficult for you to sleep? These questions refer to WORK. Severe (l) All Days (l) Moderate Mild Very Mild None (2) (3) (4) (5) Most Days (2) Some Days (3) Few Days (4) __ 45/ No Days (5) __ 46/ __ 47/ __ 48/ __ 49/ AIMS Paid House School DURING THE PAST MONTH ... 43. What has been your main form of work? work (l) work work Unemployed Disabled Retired (2) (3) (4) (5) (6) __ 50/ If you answered unemployed, disabled or retired, please skip the next four questions and go to the next page. All Most Some Few No Days Days Days Days Days DURING THE PAST MONTH... (I) (2) (3) (4) (5) 44. How often were you unable to do any paid work, housework or school work? 45. On the days that you did work, how often did you have to work a shorter day? 46. On the days that you did work, how often were you unable to do your work as carefully and accurately as you would like? 47. On the days that you did work, how often did you have lo change the way your paid work, housework or school work is usually done? __ 51/ __ 52/ __ 53/ __ 54/ 206

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Please check (X) rhe most appropriate answer for each question. These questions refer to LEVEL OF TENSION. DURING THE PAST MONTH ... 48. How often have you felt tense or high strung? 49. How often have you been bothered by nervousness or your nerves? 50. How often were you able to relax without difficulty? 5L How often have you felt relaxed and free of tension? 52. How often have you felt calm and peaceful? These questions refer to MOOD. DURING THE PAST MONTH ... 53. How often have you enjoyed the things you do? 54. How often have you been in low or very low spirits? 55. How often did you feel that nothing turned out the way you wanted it to? 56. How often did you feel that others would be better otT if you were dead? 57. How often did you feel so down in Always (l) Always (I) the dumps that nothing would cheer you up? __ 207 Very Almost Often Sometimes Never (2) (3) (4) Very Almost Never (5) Often Sometimes Never Never (2) (3) (4) (5) AIMS 55! 56/ 57/ 58/ 59! AIMS 60/ 61/ 62/ 63/ 64/

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Please check (X) the most appropriate answer for each question. These questions refer to SATISFACTION WITH EACH HEALTH ARE...-\ .. Very Satisfied Dt:RING THE PAST MONTH... (I) 58. How satisfied have you been with each of these areas of your health? MOBILITY LEVEL (example: do errands) WALKING AND BENDING (example: climb stairs) HAND AND FINGER FUNCTION (example: tie a bow) ARM FUNCTION (example: comb hair) SELF-CARE (example: take bath) HOUSEHOLD TASKS (example: housework) SOCIAL ACTIVITY (example: visit friends) SUPPORT FROM FAMILY (example: help with problems) ARTHRITIS PAIN (example: joint pain) WORK (example: reduce hours) LEVEL OF TENSION (example: felt tense) MOOD (example: down in dumps) Neither Satisfied Somewhat Nor DisSomewhat Very DisSatisfied satisfied Dissatisfied satisfied (2) (3) (4) (5) 208 AIMS 65/ 66/ 67/ 68/ 69/ 70/ 71/ 72/ 73/ 74/ 75/ 76/

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Please check (X) the most appropriate answer for each question. ID l-4/ ADM# 5-6/ CARD #2 1/ AIMS T11ese questions refer to ARTHRITIS IMPACT ON EACH AREA OF HEALTH. DURING THE PAST MONTH ... 59. How much of your problem in each area of health was due to your arthritis? MOBILITY LEVEL (example: do errands) WALKING AND BENDING (example: climb stairs) HAND AND FINGER FUNCTION (example: tie a bow) ARM FUNCriON (example: comb hair) SELF-CARE (example: take bath) HOCSEHOLD TASKS (example: housework) SOCIAL ACTIVITY (example: visit friends) SUPPORT FROM FAMILY (example: help with problems) ARTHRITIS PAIN (example: joint pain) WORK (example: reduce hours) LEVEL OF TENSION (example: felt tense) MOOD (example: down in dumps) NotA Problem For Me (0) Due Due Entirely Largely To Other To Other Causes Causes (I) (2) 209 Due Partly To Arthritis Due Due And Partly Largely Entirely To Other To My To My Causes Arthritis Arthritis (3) (4) (5) 8/ 9/ 10/ 11/ 12/ 13/ ----14/ 15/ 16/ 17/ 18/ 19/

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AIMS You have now answered questions about different AREAS OF YOUR HEALTH. These areas are listed below. Please check (X) UP to THREE AREAS in which you would MOST LIKE TO SEE IMPROVEMEL'I"T. Please read all 12 areas of health choices before making your decision: 60. AREAS OF HEALTH MOBILITY LEVEL (example: do errands) WALKING AND BENDING (example: climb stairs) HAND AND FINGER FL'NCTION (example: tie a bow) ARM FUNCfiON (example: comb hair) SELF-CARE (example: take bath) HOUSEHOLD TASKS (example: housework) SOCIAL ACTIVITY (example: visit friends) SUPPORT FROM FAMILY (example: help with problems) ARTHRITIS PAIN (example: joint pain) WORK (example: reduce hours) LEVEL OF TENSION (example: felt tense) MOOD (example: down in dumps) THREE AREAS FOR IMPROVEMENT Please make Slll'e that you have checked no more than THREE AREAS for improvement. 210 check = 1 blank = 0 20/ 21/ 22/ 23/ 24/ 25( 26/ 27/ 28/ 29/ 30/ 31/

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AIMS Please check (X) the most appropriate answer for each question. These questions refer to your CURREJ."lT and FUTURE HEALTH. Excellent Good Fair Poor (1) (2) (3) (4) 61. In general would you say that your HEALTH NOW is excellent, good, fair or poor? 64/ Neither Satisfied Very Somewhat Nor DisSomewhat Very DisSatisfied Satisfied satisfied Dissatisfied satisfied (I) (2) (3) (4) (5) 62. How satisfied are you with your HEALTH NOW? 32/ Due Partly Due Due To Arthritis Due Due Not A Entirely Largely And Partly Largely Entirely Problem To Other To Other To Other To My To My For Me Causes Causes Causes Arthritis Arthritis (0) (I) (2) (3) (4) (5) 63. How much of your problem with your HEALTH NOW is due to your arthritis? 34/ Excellent Good Fair Poor (I) (2) (3) (4) 64. In general do you expect that your HEALTH 10 YEARS FROM NOW will be excellent, good, fair or poor? 35/ No Problem Minor Moderate Major At All Problem Problem Problem (I) (2) (3) {4) 65. How big a problem do you expect your arthritis to be 10 YEARS FROM NOW? 36/ 211

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Please check (X) the most appropriate answer for each question. This question refers to OVERALL ARTHRITIS I:VIPACT. 66. CONSIDERING ALL THE WAYS THAT YOUR ARTHRITIS AFFECTS YOU, how well are you doing compared to other people your age? Very Well (l) 67. What is the main kind of arthritis that you have? Rheumatoid Arthritis Osteoarthritis/Degenerative Arthritis Systemic Lupus Erythematosis Fibromyalgia Scleroderma Psoriatic Arthritis Reiter's Syndrome Gout Low Back Pain Tendonitis/Bursitis Osteoporosis Other 68. How many years have you bad arthritis? DURING THE PAST \10NTII ... 69. How often have you bad to take MEDICATION for your arthritis? 212 All Days (1) Well (2) Most Days (2) Fair (3) Some Days (3) AIMS Poor Very Poorly (4) (5) Few Days (4) 37/ check = I blank = 0 No Days (5) 38/ 39/ 40/ 41/ 42/ 43/ 44/ 45/ 46/ 47/ 48/ 49/ 50-51/ 52/

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Please clleck (X) yes or no for each question. 70. Is your health currently affected by any of tile following medical problems? High blood pressure -------------Heart disease -----------------------------Mental illness Diabetes ------------------Cancer ------------------Alcohol or drug use _____________ Lung disease _______________ Kidney disease ----------------Liver disease -----------------Ulcer or other stomach disease Anaemia or other blood disease ----------------71. Do you take medicine every day for any problem other than your arthritis? 72. Did you see a doctor more than three times last year for any problem other than arthritis? 213 AIMS Yes No (I) (2) 53/ 54/ 55/ 56/ 57/ 58/ 59/ 60/ 61/ 62/ 63/ Yes No (l) (2) 64/ 65/

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Please provide the following information about yourself: 73. What is your age at this time? 74. What is your sex? Male (l) Female (2) 75. What is your racial background? White (I) Black (2) Hispanic (3) Asian or Pacilic Islander (4) American Indian or Alaskan Native (5) Other (6) 76. What is your current marital status? Married (I) Separate (2) Divorced (3) Widowed (4) Never married (5) 77. What is the highest level of education you received? Less than seven years of school ( l) Grades seven through nine (2) Grades ten through eleven (3) High school graduate ( 4) One to four years of college (5) College graduate (6) Professional or graduate school (7) 78. What is your approximate family income including wages, disability payment, retirement income and welfare? Less than $10,000 ( l) $10,000-$19,999 (2) $20,000--$29,999 (3) $30,000--$39,999 (4) $40,000-$49,999 (5) $50,000--$59,999 (6) $60,000--$69,999 (7) More than $70,000 (8) Thank you for completing this questionnaire. 214 AIMS 66-67/ 68/ 69/ 70/ 71/ 72/

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Arthritis Self-Efficacy STANFORD I PATIENT EDUCATION 1 For each of the foil owing questions, please circle the number that corresponds to how certain you are that you can do the following tasks regularly at the present time. Self-Effie acy Pain Scale (may be combined with Other Symptoms Scale) 1. How certain are you that you can -------------decrease your pain quite a bit? very I I I I I I I I I very uncertain 2 3 4 5 6 7 8 9 10 certain 2. How certain are you that you can continue most of your daily very l-1 I very activities? uncertain 1 2 3 4 5 6 7 8 9 10 certain 3. How certain are you that you can -------------keep arthritis pain from interfering very I I I I I I I I I very with your sleep? uncertain 2 3 4 5 6 7 8 9 10 certain 4. How certain are you that you can that you can make a small-to-------------moderate reduction in your arthritis very I I I I I I I I I very pain by using methods other than uncertain 2 3 4 5 6 7 8 9 10 certain taking extra medication? 5. How certain are you that you can make a large reduction in your -------------arthritis pain by using methods other very I I I I I I I I I very uncertain 2 3 4 5 6 7 8 9 10 certain than taking extra medication? Self-Efficacy Function Scale 1 How certain are you that you can walk 1 00 feet on flat ground in 20 very 1-1 I very seconds? uncertain 1 2 3 4 5 6 7 8 9 10 certain 2 How certain are you that you can -------------that you can walk 1 0 steps very I I I I I I I I I very downstairs in 7 seconds? uncertain 2 3 4 5 6 7 8 9 10 certain 3. How certain are you that you can get out of an armless chair quickly, -------------very I I I I I I I I I very without using your hands for uncertain 2 3 4 5 6 7 8 9 10 certain support? 4. How certain are you that you can -------------very very 215

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button and unbutton 3 medium-size uncertain 1 2 3 4 5 6 7 8 9 10 certain buttons in a row in 12 seconds? 5. How certain are you that you can cut 2 bite-size pieces of meat with a very I I I I I I I I I very knife and fork in 8 seconds? uncertain 2 3 4 5 6 7 8 9 10 certain 6. How certain are you that you can turn an outdoor faucet all the way on very I I I I I I I I I very and all the way off? uncertain 2 3 4 5 6 7 8 9 10 certain 7. How certain are you that you can scratch your upper back with both very I I I I I I I I I very your right and left hands? uncertain 2 3 4 5 6 7 8 9 10 certain 8. How certain are you that you can get in and out of the passenger side of a very I I I I I I I I I very car without assistance from another uncertain 2 3 4 5 6 7 8 9 10 certain person and without physical aids? 9. How certain are you that you can put on a long-sleeve front-opening shirt very I I I I I I I I I very or blouse (without buttoning) in 8 uncertain 2 3 4 5 6 7 8 9 10 certain seconds? Self-Efficacy Other Symptoms Scale (may be combined with Pain Scale) 1. How certain are you that you can control your fatigue? very I I I I I I I I I I very uncertain 1 2 3 4 5 6 7 8 9 10 certain 2. How certain are you that you can regulate your activity so as to be very I I I I I I I I I very active without aggravating your uncertain 2 3 4 5 6 7 8 9 10 certain arthritis? 3. How certain are you that you can do something to help yourself feel better very I I I I I I I I I very if you are feeling blue? uncertain 2 3 4 5 6 7 8 9 10 certain 4. As compared with other people with arthritis like yours, how certain are very I I I I I I I I I very you that you can manage arthritis uncertain 2 3 4 5 6 7 8 9 10 certain pain during your daily activities? 5. How certain are you that you can manage your arthritis symptoms so very I I I I I I I I I very that you can do the things you enjoy uncertain 2 3 4 5 6 7 8 9 10 certain doing? 6. How certain are you that you can deal with the frustration of arthritis? very I I I I I I I I I very uncertain 2 3 4 5 6 7 8 9 10 certain 216

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BRFSS and OPAQ Physical Activity Questions Part I: Physical Activity Questions: Not Related to Work You Do to Earn a Living These questions will ask you about two types of physical activity-moderate and vigorous -that are not part of work you may do to earn a living. Moderate activities cause small increases in breathing or heart rate while vigorous activities cause large increases in breathing or heart rate. I. When you think about moderate activities you do in a usual week (that are not part of work you may do to earn a living), do you do moderate activities for at least I 0 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, fishing, home repair or anything else that causes some increase in breathing or heart rate? Circle one answer: Yes No Don't know/Not sure 2. If you do moderate activities, how many days per week do you do these moderate activities for at least I 0 minutes? Number or days per week: Don't know/Not sure: 3. On days when you do moderate activities for at least I 0 minutes at a time, how much total time per day do you spend doing these activities? Hours and minutes per day: Don't know/Not sure: 4. Now, think about the vigorous activities you do (that are not part of work you do to earn a living if you work or are self-employed) in a usual week. Do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, shoveling heavy snow, or anything else that causes large increases in breathing or heart rate? Circle one answer: Yes No Don't know/Not sure 5. How many days per week do you do these vigorous activities for at least I 0 minutes at a time? Number of days per week: Don't know/Not sure 6. On days when you do vigorous activities for at least I 0 minutes at a time, how much total time per day do you spend doing these activities? Hours and minutes per day: 217

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Don't know/Not sure: Part 2: Physical Activity Questions: Work or Self-Employed Physical Activity These questions will ask you about the physical activity that is part of the work you do to earn a living. Please answer these questions if you work or are self-employed. I. When you are at work, which of the following best describes what you do? Note: If you have multiple jobs, include all jobs. Circle one answer: Mostly sitting or standing Mostly walking Mostly heavy labor or physically demanding work Don't know/Not sure 2. How many hours per week do you usually work in your primary job? Hours per week: Don't know/Not sure: 3. In a usual week, do you perform any sitting or standing doing work such as using a computer, desk work, using hand tools, light assembly, lab tech or driving a car or truck while at work? Circle one answer: Yes No Don't know/Not sure 4. In a usual week, how many hours do you do these sitting or standing activities at work? Hours per week: Don't know/Not sure: 5. In a usual week, do you perform any walking at work as in the halls, between buildings, or in jobs like a postal carrier, waiter, or roving salesperson? Circle one answer: Yes No Don't know/Not sure 6. In a usual week, how many hours do you walk at work? Hours per week: Don't know/Not sure: 7. In a usual week, do you perform any heavy labor or use power tools during work such as moving furniture, carpentry, jackhammers, or using a shovel or pick? Circle one answer: Yes No Don't know/Not sure 218

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8. In a usual week, how many hours do you perform these heavy labor activities at work? Hours per week: Don't know/Not sure: References Centers for Disease Control and Prevention (CDC). (2003). Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Reis, J.P., Dubose, K. D., Ainsworth, B. E., Macera, C. A. & Yore, M. (2005). Reliability and Validity of the Occupational Physical Activity Questionnaire. Med & Sci in Sports & Ex, 37(12), 2075-2083. 219

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BRFSS Mod ole Environmental Supports for Physical Activity LONG (N = 11) SIP 4-99 Research Group (2002, October). Environmental Supports for Physical Activity Long Questionnaire. Prevention Research Center, Arnold School of Public Health, University of South Carolina. These questions will ask you about the neighborhood in which you live, followed by some questions about the community in which you live. For the purposes of these questions, neighborhood is defined as the area within one-half mile or a ten-minute walk from your house and community is defined as a 1 0-mile or 20-minute drive from your house. Please circle the best answer. I. In general, would you say that the people in your neighborhood are ... a. very physically active b. somewhat physically active c. not very physically active d. not at all physically active e. don't know/not sure 2. Overall, how would you rate your neighborhood as a place to walk? Would you say ... a. very pleasant b. somewhat pleasant c. not very pleasant d. not at all pleasant e. don't know/not sure 3. For walking at night, would you describe the street lighting in your neighborhood as ... a. very good b. good c. fair d. poor e. very poor f. don't know/not sure 4. How safe from crime do you consider your neighborhood to be? Would you say ... a. extremely safe b. quite safe c. slightly safe d. not at all safe e. don't know/not sure 220

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5. Generally speaking, would you say most people in your neighborhood can be trusted? a. yes b. no c. don't know/not sure 6. Does your neighborhood have any sidewalks? a. yes b. no c. don't know/not sure 7. Do you use any private or membership only recreation facilities in your community for physical activity? a. yes b. no c. my community does not have these facilities d. don't know/not sure 8. Do you use walking trails, parks, playgrounds, sports fields in your community for physical activity? a. yes b. no c. my community does not have these facilities d. don't know/not sure 9. Do you use shopping malls in your community for physical activity and/or walking programs? a. yes b. no c. my community does not have shopping malls d. don't know/not sure I 0. Do you use any public recreation centers in your community for physical activity? a. yes b. no c. my community does not have any public recreation facilities d. don't know/not sure II. Do you use schools that are open in your community for public recreations activities? a. yes b. no c. schools in my community are not open for the public to use d. don't know/not sure 221

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Today's Date: ___ Final Questions-Thank you for your time! I. Where is your arthritis located? __________________________ 2. How far (in miles) do you live from the nearest town where you can buy groceries and gasoline? ____ miles (Please put o if you live in town) 3. How tall are you? ________ How much do you weigh? _______ 4. What things in the physical environment keep you from being as active as you would like to be? 5. If you want to be more active, what would motivate you to be more physically active? ______ 6. Has anyone that you see for your health told you to be more physically active? Yes D No D Don't Know D 7.1fso.who? ________________________________ 8. If you work, do you think your work-related activity is enough daily physical activity to keep you healthy? Yes D No D Don't Know D 9. Do you have suggestions of things that would help you be more active if you wanted to be (for example, changes in your environment or the resources available in your area)? _____________ 10. Did anyone help you fill out this survey? Yes D No D II. Is there anything else you would like to bring up about your arthritis and physical activity? 12. Would you be willing to be contacted about this study? This might include an examination of your hand and or knee joints by the lead researcher, who is a licensed physical therapist in the state of Colorado. This might also include talking about your arthritis and physical activity. Yes D No D 13. If yes. please provide your contact information (address, phone, and or email): __________________________________ 222

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PHYSICAL ACTIVITY OPINION SURVEY [ORIGINAL[ Physical activity, for this survey, is defined as any activity you do for I 0 minutes or more at a time and that makes you breath at least somewhat harder than normal. For this group of questions, physical activity is not part of what you do for "work." "Work" means what you do to earn a living. lfyou are retired or do not currently work, it will include any activities you do for I 0 minutes or more at a time that makes you breath at least somewhat harder than normal. Examples might be vacuuming, gardening, walking for exercise, bicycling, running, or anything else that causes you to breath at least somewhat harder than normal. How much do you agree or disagree with each opinion statement below? (Please circle your answer) Opinion Statement Please circle how much you agree or disagree: I. I would like to be more Strongly Agree Undecided Disagree Strongly physically active. agree disagree 2. Physical activity is good for Strongly Agree Undecided Disagree Strongly my arthritis. agree disagree 3 There are physical activities I Strongly Agree Undecided Disagree Strongly can t do because of my arthritis. agree disagree 4. My family or friends think I Strongly Agree Undecided Disagree Strongly should be physically active. agree disagree 5. Physical activity can prevent Strongly Agree Undecided Disagree Strongly other diseases. agree disagree 6. The weather determines ifl Strongly Agree Undecided Disagree Strongly can participate in physical agree disagree activity. 7 I am likely to be physically Strongly Agree Undecided Disagree Strongly active during the day (if working agree disagree when not at work). 8. In general I'm Likely to do Strongly Agree Undecided Disagree Strongly what my friends and family think agree disagree I should do. 9 Physical activity keeps people Strongly Agree Undecided Disagree Strongly health y. agree disagree 10. People my age don t Strongly Agree Undecided Disagree Strongly normally do a lot of physical agree disagree activity. II. People living in rural Strongly Agree Undecided Disagree Strongly communities are generally more agree disagree active than those who live in cities. 12. I will take the time to do Strongly Agree Undecided Disagree Strongly physical activity even when I agree disagree have a lot to do. 223

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13. My doctor or other health Strongly Agree Undecided Disa g ree Strongly care advisor thinks I should be agree disagree physically active 14. Something usually gets in Strongly Agree Undecided Disagree Strongly the way of"fun" physical agree disagree activities. 15. Physical activity is bad for Strongly Agree Undecided Disagree Strongly my arthritis. agree disagree 16. Living in a rural community Strongly Agree Undecided Disagree Strongly affects how much physical agree disagree activity I get. 17. I would be more active if a Strongly Agree Undecided Disagree Strongly doctor told me I should be for my agree disagree health. 18. I would rather relax than be Strongly Agree Undecided Disagree Strongly physically active. agree disagree 19. Arthritis keeps me from Strongly Agree Undecided Disagree Strongly being physically active. agree disagree 20. There is a difference Strongly Agree Undecided Disagree Strongly between physical activity and agree disagree exercise. 21. My family or friends think I Strongly Agree Undecided Disagree Strongly will hurt myself if I'm more agree disagree physically active. 22. I worry that physical activity Strongly Agree Undecided Disagree Strongly will increase other health agree disagree problems, besides arthritis, that I may have. 23. In general, I'm likely to do Strongly Agree Undecided Disagree Strongly what my doctor or other health agree disagree care advisor thinks I should do. 24. I'm already active enough Strongly Agree Undecided Disagree Strongly during the day I don't need agree disagree more physical activity. 25. The physical environment Strongly Agree Undecided Disagree Strongly keeps me from being active. agree disagree 26. I believe being more active Strongly Agree Undecided Disagree Strongly is up to me. agree disagree 27. I am concerned I will make Strongly Agree Undecided Disagree Strongly my arthritis worse if I am more agree disagree active. 28. I am likely to be physically Strongly Agree Undecided Disagree Strongly active if my friends are active as agree disagree well. 224

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PHYSICAL ACTIVITY and ARTHRITIS SURVEY [revised) Physical activity, for this survey, is defined as any activity you do for I 0 minutes or more at a time and that makes you breathe at least somewhat harder than normal. For this group of questions, physical activity is not part of what you do for "work." "Work" means what you do to earn a living. If you are retired or do not currently work, it will include any activities you do for 10 minutes or more at a time that makes you breathe at least somewhat harder than normal. Examples might be vacuuming, gardening, walking for exercise, bicycling, running, or anything else that causes you to breathe at least somewhat harder than normal. How much do you agree or disagree with each statement below? (Please circle your answer) N/A =not applicable Statement Please circle how much you agree or disagree: 1. I would like to be more Strongly Agree Undecided Disagree Strongly physically active. agree disagree 2. There are physical Strongly Agree Undecided Disagree Strongly activities I can t do because agree disagree of my arthritis. 3. My family or friends Strongly Agree Undecided Disagree Strongly think I should be physically agree disagree active. 4. Bad outdoor weather Strongly Agree Undecided Disagree Strongly (wind snow etc.) keeps me agree disagree from participating in physical activity 5. I would be more active if Strongly Agree Undecided Disagree Strongly a doctor told me I should be agree disagree for my health. 6. Physical activity keeps Strongly Agree Undecided Disagree Strongly people healthy. agree disagree 7. People who live in rural Strongly Agree Undecided Disagree Strongly communities get a lot of agree disagree physical activity. 8. Arthritis is a normal part Strongly Agree Undecided Disagree Strongly of aging that can't be helped agree disagree by being more active. 9. I have friends or family Strongly Agree Undecided Disagree Strongly available to do activities agree disagree with me such a going for a walk. I 0 My doctor or other Strongly Agree Undecided Disagree Strongly health care advisor thinks I agree disagree should be physically active. 11. Physical activity is bad Strongly Agree Undecided Disagree Strongly for my arthritis. agree disagree 225 N / A N / A N / A N / A N/A N / A N / A N / A N I A N / A N I A

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12. I believe being more Strongly Agree Undecided Disagree Strongly N / A active is up to me. agree disagree 13. I would rather relax Strongly Agree Undecided Disagree Strongly N / A than be physically active agree disagree 14. Arthritis keeps me from Strongly Agree Undecided Disagree Strongly N / A being physically active. agree disagree 15. [worry that physical Strongly Agree Undecided Disagree Strongly N / A activity will increase other agree disagree health problems, besides arthritis that I may have. 16. I'm already active Strongly Agree Undecided Disagree Strongly N / A enough during the day I agree disagree don't need more physical activity. 17. My physical Strongly Agree Undecided Disagree Strongly N/A environment keeps me from agree disagree being active. 18. I am concerned I will Strongly Agree Undecided Disagree Strongly N / A make my arthritis worse if I agree disagree am more active. I 9. I would be more active Strongly Agree Undecided Disagree Strongly N / A if my friends and family agree disagree think I should be. 20. I am likely to be Strongly Agree Undecided Disagree Strongly N / A physically active if my agree disagree friends are active as well. 226

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APPENDIX D RAW FREQUENCIES OF VARIABLES IN THE INSTRUMENTS USED IN THE STUDY Arthritis Impact Measurement Scales 2 (AIMS2) Arthritis Self-Efficacy Scales (ASES) Physical Activity and Arthritis Questionnaire (P AAQ) Environmental Supports for Physical Activity Long Questionnaire Final Questionnaire Behavioral Risk Factor Surveillance System (BRFSS) and Occupational Physical Activity Questionnaire (OPAQ) 227

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ARTHRITIS IMPACT MEASUREMENT SCALES 2 (AIMS2) These questions refer to mobility level. Item DURING THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) How often were you physically able to 71 3 I 2 3 1.29 drive a car or use public transportation? 2 How often were you out of the house for 52 21 4 3 0 1.48 at least part ofthe day? 3 How often were you able to do errands in 59 14 2 0 5 1.48 the neighborhood? 4 How often did someone have to assist 2 3 73 4.80 you to get around outside your home? 5 How often were you in a bed or chair for 0 7 16 73 4.58 most or all of the day? These questions refer to walking and bending. Item DURING THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) 6 Did you have trouble doing vigorous 25 19 12 II 13 2.6 activities such as running, lifting heavy objects, or participating in strenuous sports? 7 Did you have trouble either walking 8 12 16 12 32 3.6 several blocks or climbing a few flights of stairs? 8 Did you have trouble bending, lifting or 12 II 19 18 20 3.28 stooping? 9 Did you have trouble either walking one 6 9 14 13 38 3.85 block or climbing one flight of stairs? 10 Were you unable to walk unless assisted 5 3 5 66 4.55 by another person or by a cane, crutches, or walker? 228

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These questions refer to hand and finger function. Item DURING THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) Could you easily write with a pen or 62 15 2 I 0 1.28 pencil? 2 Could you easily button a shirt or 51 17 8 3 1.57 blouse? 3 Could you easily tum a key in a lock? 54 19 7 0 0 1.41 4 Could you easily tie a knot or a bow? 50 20 6 3 I 1.56 5 Could you easily open a new jar of food? 18 29 23 9 I 2.32 These questions refer to arm function. Item DURING THE PAST MONTH All Most Some Few No Mean Days Days Days Days Days (I) (2) (3) (4) (5) Could you easily wipe your mouth with a 79 I 0 0 0 1.01 napkin? 2 Could you easily put on a pullover 64 12 3 0 1.26 sweater? 3 Could you easily comb or brush your 65 12 3 0 0 1.22 hair? 4 Could you easily scratch your low back 46 13 13 4 4 1.84 with your hand? 5 Could you easily reach shelves that were 44 16 12 3 5 1.86 above your head? These questions refer to self-care tasks. Item DURING THE PAST MONTH Very SomeAlmost Mean Always Often times Never Never (I) (2) (3) (4) (5) Did you need help to take a bath or I I 2 4 72 4.81 shower? 2 Did you need help to get dressed? 0 0 3 4 73 4.88 3 Did you need help to use the toilet? I 0 0 2 77 4.92 4 Did you need help to get in or out of 0 2 0 2 76 4.90 bed? 229

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These questions refer to household tasks. Item DURING THE PAST MONTH Very SomeAlmost Mean Always Often times Never Never (I) (2) (3) (4) (5) If you had the necessary 72 4 I I 2 1.21 transportation, could you go shopping for groceries without help? 2 If you had kitchen facilities, could you 73 5 2 0 0 1.11 prepare your own meals without help? 3 If you had household tools and 63 12 2 2 1.32 appliances, could you do your own housework without help? 4 lfyou had laundry facilities, could 71 5 2 1.22 you do your own laundry without help? 230

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ARTHRITIS SELF-EFFICACY SCALES Arthritis Self-Efficacy Function Scale Item Very Uncertain Very Certain Mean I 2 3 4 5 6 7 8 9 10 I How certain are you that 5 4 4 3 12 5 6 10 9 22 6.88 you can walk 1 00 feet on flat ground in 20 seconds? 2 How certain are you that 8 3 4 3 9 6 6 10 8 23 6.78 you can walk 1 0 steps downstairs in 7 seconds? 3 How certain are you that 15 6 7 6 10 5 5 5 8 13 5.36 you can get out of an armless chair quickly, without using your hands for support? 4 How certain are you that 5 4 3 4 13 6 4 15 11 15 6.70 you can button and unbutton 3 medium-size buttons in a row in 12 seconds? 5 How certain are you that 2 2 0 4 10 6 3 12 15 26 7.75 you can cut 2 bite-size pieces of meat with a knife and fork in 8 seconds? 6 How certain are you that 2 4 3 3 8 4 7 13 9 27 7.48 you can tum an outdoor faucet all the way on and all the way off? 7 How certain are you that 12 5 6 8 6 5 9 II 3 15 5.75 you can scratch your upper back with both your right and left hands? 8 How certain are you that 4 2 3 2 5 2 6 9 II 36 7.94 you can get in and out of the passenger side of a car without assistance from another person and without physical aids? 9 How certain are you that 2 2 3 0 10 8 6 5 13 31 7.78 you can put on a longsleeve front-opening shirt or blouse (without buttoning) in 8 seconds? 231

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PHYSICAL ACTIVITY AND ARTHRITIS QUESTIONNAIRE Statement Strongly Strongly Not Mean Agree Agree Undecided Disagree Disagree Applicable (5) (4) (3) (2) (I) I. I would like to be 21 49 7 3 0 0 4.10 more physically active. 2. There are physical 8 40 16 10 4 I 3.51 activities I can't do because of my arthritis. 3. My family or 8 52 7 5 2 6 3.80 friends think I should be physically active. 4. Bad outdoor 12 43 7 15 2 0 3.61 weather (wind, snow, etc.) keeps me from participating in physical activity. 5. I would be more 8 36 II 21 I 3 3.38 active if a doctor told me I should be for my health. 6. Physical activity 39 40 I 0 0 0 4.48 keeps people healthy. 7. People who live in 5 41 20 13 0 I 3.48 rural communities get a lot of physical activity. 8. Arthritis is a normal I 12 15 45 7 0 2.44 part of aging that can't be helped by being more active. 9. I have friends or 10 39 7 22 I I 3.44 family available to do activities with me such as going for a walk. I 0. My doctor or other 13 47 10 8 0 2 3.83 health care advisor thinks I should be physically active. II. Physical activity is 0 4 9 54 13 0 2.05 bad for my arthritis. 12. I believe being 23 52 5 0 0 0 4.22 more active is up to me. 13. I would rather 0 20 22 36 2 0 2.75 relax than be physically active. 232

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14. Arthritis keeps me 0 23 15 39 3 0 2.72 from being physically active. 15. I worry that 2 II 9 46 12 0 2.31 physical activity will increase other health problems, besides arthritis, that I may have. 16. I'm already active 2 16 12 44 6 0 2.55 enough during the day -I don't need more physical activity. 17. My physical 0 8 10 56 5 0 2.26 environment keeps me from being active. 18. I am concerned I I 4 8 58 7 I 2.16 will make my arthritis worse if I am more active. 19. I would be more I 18 14 35 5 7 2.66 active if my friends and family think I should be. 20. I am likely to be 6 42 II 16 2 3 3.44 physically active if my friends are active as well. 233

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ENVIRONMENTAL SUPPORTS FOR PHYSICAL ACTIVITY LONG QUESTIONNAIRE Yes No Does not Don't have/are not know/not open sure I. Do you use any private or membership 23 49 7 I only recreation facilities in your community for physical activity? 2. Do you use walking trails, parks, 27 43 9 I playgrounds, sports fields in your community for physical activity? 3. Do you use shopping malls in your 7 43 30 0 community for physical activity and/or walking programs? 4. Do you use any public recreation 15 51 14 0 centers in your community for physical activity? 5. Do you use schools that are open in 9 58 II 2 your community for public recreation activities? 234

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FINAL QUESTIONNAIRE Where is your arthritis located? Location of Arthritis Fingers Thumbs Hands Elbows Shoulders Hips Knees Ankles Feet/toes Neck Back (or spine) Everywhere Other ("arms," "legs," "wrists") Frequency of Response 18 I 36 3 19 23 36 4 9 7 39 2 10 How far (in miles) do you live from the nearest town where you can buy groceries and gasoline? Distance from Town (miles) 0 0.25 2 2.5 3 3.5 4 5 6.5 7 8 8.5 9 10 12 13 15 17 20 30 235 Frequency of Response 37 I 4 I I 2 I 2 2 8 2 I 2 5 I I 3 I 4 I

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Has anyone that you see for your health told you to be more physically active? Yes No Don't Know 32 44 3 If so, who has told you to be more physically active? Source of advice to be more active Medical doctor (MD) MD and chiropractor Chiropractor Physician's Assistant Missing Frequency of Response 24 I I I 5 If you work, do you think your work-related activity is enough daily physical activity to keep you healthy? Yes No Don't Know Missing 13 27 8 32 Did anyone help you fill out this survey? Yes No 6 74 Would you be willing to be contacted about this study? Yes No 40 35 236

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DATA CATEGORIZED from the BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM and OCCUPATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE Freq_uencJ:_ of Non-Work or Work PhJ:_sical ActiviiJ:_f!.er Week Non-work n (%) Work n (%) Time Moderate a Vigorousb Moderatec Vigorousd < 60 minutes 4 (5.00) 4(12.I2) 0 (0.00) 0 (0.00) 60 I20 minutes I6 (20.00) IO (30.30) 3 (12.50) 3 (25.00) I2II80 minutes I5(I8.75) 4(I2.I2) 2 (8.33) 0 (0.00) 181 239 minutes 6 (7.50) I (3.03) 0 (0.00) 0 (0.00) 4-6 hours 15 (18.75) 7 (2I.22) 4 (I6.67) 2 (16.67) 7IO hours 7 (7.50) 1 (3.03) 3 (12.50) 1 (8.33) I0.512 hours 4 (5.00) 1 (3.03) 1(4.I6) 0 (0.00) 12.5-I9.5 hours 3 (3.75) 2 (6.06) 0 (0.00) 2 (I6.67) 202I hours 4 (5.00) 0 (0.00) 4 (I6.67) 0 (0.00) 21.5-28 hours 1 (1.25) I (3.03) I (4.I7) 1 (8.33) 29-42 hours 2 (2.50) I (3.03) 4 (16.67) 3 (25.00) 43-49 hours I (1.25) 0 (0.00) 2 (8.33) 0 (0.00) 50-59 hours I ( 1.25) 0 (0.00) 0 (0.00) 0 (0.00) > 60 hours 1 (1.25) 1 (3.03) 0 (0.00) 0 (0.00) aRange: I5 minutes70 hours, N = 80 bRange: 26.25 minutes-84 hours, N = 33 cRange: 60 minutes-47.5 hours, N = 24 dRange: 90 minutes-35 hours, N = I2 237

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