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1.  Independent Influences of Current and Childhood Socioeconomic Status on Health Outcomes in a North-Carolina Family-Practice Sample of Arthritis Patients 
Arthritis care & research  2013;65(8):1334-1342.
Compelling evidence suggests that socioeconomic status (SES) is a determinant of health outcomes among persons with arthritis. SES in early-life has likewise been associated with various aspects of health, but the connection between childhood SES and health among people with arthritis remains to be investigated. The purpose of this study is to determine the influences of current and childhood SES on self-reported disability, depression, and physical and mental health among people with self-reported doctor-diagnosed arthritis.
Data originated from a North Carolinian network of primary care centers. Participants with self-reported arthritis with complete sociodemographic and relevant health information were retained in our sample (n = 782). We created summary measures for current and childhood SES from indicators of education, occupation and homeownership, using parental SES as a proxy for participants’ childhood SES. Linear regression models were used to assess the associations between health outcomes and SES variables separately and together, adjusting for key covariates.
Lower childhood and current SES scores were associated with worse disability and physical health. Current SES was furthermore associated with mental health and depressive symptoms. Associations of low current and childhood SES with health outcomes remained significant when concurrently included in a linear model.
Childhood and current SES are both determinants of health among persons with arthritis. This underscores the importance of childhood SES as a determinant of adult health among individuals with arthritis. Further studies should focus on these associations in different populations and across different types of arthritis.
PMCID: PMC3701039  PMID: 23401367
2.  Associations of Educational Attainment, Occupation and Community Poverty with Hip Osteoarthritis 
Arthritis care & research  2013;65(6):954-961.
To examine cross-sectional baseline data from the Johnston County Osteoarthritis Project for the association between individual and community socioeconomic status (SES) measures with hip osteoarthritis (OA) outcomes.
We analyzed data on 3,087 individuals (68% Caucasian and 32% African American). Educational attainment and occupation were used as individual measures of SES. Census block group household poverty rate was used as a measure of community SES. Hip OA outcomes included radiographic OA (rOA) and symptomatic OA (sxOA) in one or both hip joints. Multivariable logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association of each hip OA outcome with each SES variable separately, then with all SES measures simultaneously. Associations between hip OA outcomes and SES variables were evaluated for effect modification by race and gender.
Living in a community of high household poverty rate showed independent associations with hip rOA in one or both hips (OR=1.50; 95% CI=1.18–1.92) and bilateral (both hips) rOA (OR=1.87; 95% CI=1.32–2.66). Similar independent associations were found between low educational attainment among those with sxOA in one or both hips (OR=1.44; 95% CI=1.09, 1.91) or bilateral sxOA (OR=1.91; 95% CI=1.08–3.39), after adjusting for all SES measures simultaneously. No significant associations were observed between occupation and hip OA outcomes, nor did race or gender modify the associations.
Our data provide evidence that hip OA outcomes are associated with both education and community SES measures, associations which remained after adjustment for covariates and all SES measures.
PMCID: PMC3612553  PMID: 23225374
3.  Limited educational attainment and radiographic and symptomatic knee osteoarthritis: a cross-sectional analysis using data from the Johnston County (North Carolina) Osteoarthritis Project 
Applying a cross-sectional analysis to a sample of 2,627 African-American and Caucasian adults aged ≥ 45 years from the Johnston County Osteoarthritis Project, we studied the association between educational attainment and prevalence of radiographic knee osteoarthritis and symptomatic knee osteoarthritis.
Age- and race-adjusted associations between education and osteoarthritis outcomes were assessed by gender-stratified logistic regression models, with additional models adjusting for body mass index, knee injury, smoking, alcohol use, and occupational factors.
In an analysis of all participants, low educational attainment (<12 years) was associated with higher prevalence of four knee osteoarthritis outcomes (unilateral and bilateral radiographic and symptomatic osteoarthritis). Women with low educational attainment had 50% higher odds of having radiographic knee osteoarthritis and 65% higher odds of symptomatic knee osteoarthritis compared with those with higher educational attainment (≥ 12 years), by using fully adjusted models. In the subset of postmenopausal women, these associations tended to be weaker but little affected by adjustment for hormone replacement therapy. Men with low educational attainment had 85% higher odds of having symptomatic knee osteoarthritis by using fully adjusted models, but the association with radiographic knee osteoarthritis was explained by age.
After adjustment for known risk factors, educational attainment, as an indicator of socioeconomic status, is associated with symptomatic knee osteoarthritis in both men and women and with radiographic knee osteoarthritis in women.
PMCID: PMC2888194  PMID: 20298606
4.  Impact of the Arthritis Foundation’s Walk With Ease Program on Arthritis Symptoms in African Americans 
Inadequate program design and lack of access to evidence-based programs are major barriers to the management of chronic diseases such as arthritis, particularly for African Americans. This study evaluates the effectiveness of the Arthritis Foundation’s Walk With Ease Program (WWE) in a subsample of African Americans who were part of a larger study that established evidence of the program’s efficacy.
Participants were African Americans (N = 117) with self-reported arthritis who chose to participate in either a self-directed (n = 68) or group (n = 49) 6-week WWE program. Arthritis-related symptoms (ie, pain, fatigue, stiffness; measured using visual analog scales) were assessed at baseline, 6 weeks, and 1 year. Independent samples t tests were conducted to examine group differences (ie, self-directed vs group) in arthritis-related symptoms at baseline, and paired sample t tests were conducted to examine differences over time (ie, baseline to 6 weeks and baseline to 1 year) in symptoms. Satisfaction was examined by descriptive statistics.
Younger, more educated individuals chose the self-directed format (P < .001, P = .008; respectively). After the 6-week intervention, participants reported a decrease in pain (P < .001), fatigue (P = .002), and stiffness (P < .001). At 1 year, the decrease in pain (P = .04) and stiffness (P = .002) remained constant. Overall, participants were satisfied with both program formats.
The individualized and group formats of the WWE program improved arthritis-related pain, fatigue, and stiffness in African Americans. Culturally appealing arthritis interventions ultimately may increase the use of existing arthritis interventions.
PMCID: PMC4232333  PMID: 25393747
5.  Comparisons of Body Image Perceptions of a Sample of Black and White Women with Rheumatoid Arthritis and Fibromyalgia in the US 
Objective :
To explore the disease-related, body image (BI) perceptions of women diagnosed with, rheumatoid arthritis (RA) and fibromyalgia (FM).
Methods :
A purposive sample of twenty-seven females participated in individual semi-structured phone interviews to elicit BI perceptions relative to pain, activity limitations and coping measures. Sessions were digitally recorded, transcribed verbatim, and content analyzed.
Results :
Body image perceptions relative to 5 major themes emerged in the analysis. They focused on Pain, Disease Impact on Physical and Mental Function, Weight, Diseased-Induced Fears and, Coping measures. Pain was a common experience of all participants. Other troubling factors verbalized by participants included dislike and shame of visibly affected body parts, and disease-induced social, psychological and physical limitations. RA participants thought that manifested joint changes, such as swelling and redness, undergirded their prompt diagnosis and receipt of health care. Contrarily, women with fibromyalgia perceived that the lack of visible, disease-related, physical signs led to a discounting of their disease, which led to delayed health care and subsequent frustrations and anger. All but one participant used prayer and meditation as a coping measure.
Conclusion :
The body image perceptions evidenced by the majority of participants were generally negative and included specific focus on their disease-affected body parts (e.g. joints), mental function, self-identity, health care experiences, activity limitations and overall quality of life. Given the global effect of RA and FM, assessment and integration of findings about the BI perceptions of individuals with FM and RA may help define suitable interdisciplinary strategies for managing these conditions and improving participants’ quality of life.
PMCID: PMC4319189
Black women; body image; fibromyalgia; perceptions; rheumatoid arthritis; white women.
6.  The HLA–DRB1 Shared Epitope Is Associated With Susceptibility to Rheumatoid Arthritis in African Americans Through European Genetic Admixture 
Arthritis and rheumatism  2008;58(2):349-358.
To determine whether shared epitope (SE)–containing HLA–DRB1 alleles are associated with rheumatoid arthritis (RA) in African Americans and whether their presence is associated with higher degrees of global (genome-wide) genetic admixture from the European population.
In this multicenter cohort study, African Americans with early RA and matched control subjects were analyzed. In addition to measurement of serum anti–cyclic citrullinated peptide (anti-CCP) antibodies and HLA–DRB1 genotyping, a panel of >1,200 ancestry-informative markers was analyzed in patients with RA and control subjects, to estimate the proportion of European ancestry.
The frequency of SE-containing HLA–DRB1 alleles was 25.2% in African American patients with RA versus 13.6% in control subjects (P = 0.00005). Of 321 patients with RA, 42.1% had at least 1 SE-containing allele, compared with 25.3% of 166 control subjects (P = 0.0004). The mean estimated percent European ancestry was associated with SE-containing HLA–DRB1 alleles in African Americans, regardless of disease status (RA or control). As reported in RA patients of European ancestry, there was a significant association of the SE with the presence of the anti-CCP antibody: 86 (48.9%) of 176 patients with anti-CCP antibody–positive RA had at least 1 SE allele, compared with 36 (32.7%) of 110 patients with anti-CCP antibody–negative RA (P = 0.01, by chi-square test).
HLA–DRB1 alleles containing the SE are strongly associated with susceptibility to RA in African Americans. The absolute contribution is less than that reported in RA among populations of European ancestry, in which ~50–70% of patients have at least 1 SE allele. As in Europeans with RA, the SE association was strongest in the subset of African American patients with anti-CCP antibodies. The finding of a higher degree of European ancestry among African Americans with SE alleles suggests that a genetic risk factor for RA was introduced into the African American population through admixture, thus making these individuals more susceptible to subsequent environmental or unknown factors that trigger the disease.
PMCID: PMC3726059  PMID: 18240241
Pain  2013;154(12):10.1016/j.pain.2013.08.024.
Pain behaviors that are maintained beyond the acute stage post-injury can contribute to subsequent psychosocial and physical disability. Critical to the study of pain behaviors is the availability of psychometrically sound pain behavior measures. In this study we developed a self-report measure of pain behaviors, the Pain Behaviors Self Report (PaB-SR). PaB-SR scores were developed using item response theory and evaluated using a rigorous, multiple-witness approach to validity testing. Participants included: a) 661 survey participants with chronic pain and with multiple sclerosis (MS), back pain, or arthritis; b) 618 survey participants who were significant others of a chronic pain participant; and c) 86 participants in a videotaped pain behavior observation protocol. Scores on the PaB-SR were found to be measurement invariant with respect to clinical condition. PaB-SR scores, observer-reports, and the video-taped protocol yielded distinct, but convergent views of pain behavior, supporting the validity of the new measure. The PaB-SR is expected to be of substantial utility to researchers wishing to explore the relationship between pain behaviors and constructs such as pain intensity, pain interference, and disability.
PMCID: PMC3875313  PMID: 23994451
Chronic pain; assessment; psychometrics
8.  Occurrence of Radiographic Osteoarthritis of the Knee and Hip Among African Americans and Whites: A Population-Based Prospective Cohort Study 
Arthritis care & research  2013;65(6):928-935.
To compare the incidence and progression of radiographic osteoarthritis (OA) in the knee and hip among African Americans and whites.
Using the joint as the unit of analysis, we analyzed data from the Johnston County Osteoarthritis Project, a population-based prospective cohort study in rural North Carolina. Baseline and followup assessments were 3–13 years apart. Assessments included standard knee and hip radiographs read for Kellgren/Lawrence (K/L) radiographic grade. Weighted analyses controlled for age, sex, body mass index, level of education, and baseline K/L grade; bootstrap methods adjusted for lack of independence between left and right joints. Time-to-event analysis was used to analyze the data.
For radiographic knee OA, being African American had no association with incidence (adjusted hazard ratio [HRadj] 0.80, 95% confidence interval [95% CI] 0.53–1.22), but had a positive association with progression (HRadj 1.67, 95% CI 1.05–2.67). For radiographic hip OA, African Americans had a significantly lower incidence (HRadj 0.44, 95% CI 0.27–0.71), whereas the association with progression was positive but nonsignificant (HRadj 1.46, 95% CI 0.53–4.01). In sensitivity analyses, the association with hip OA incidence was robust to a wide range of assumptions.
African Americans are protected against incident hip OA, but may be more susceptible to progressive knee OA.
PMCID: PMC4206562  PMID: 23281251
9.  Independent and Combined Influence of Homeownership, Occupation, Education, Income and Community Poverty on Physical Health in Persons with Arthritis 
Arthritis care & research  2011;63(5):643-653.
To examine the independent and combined influence of individual and community-level socioeconomic (SES) measures with physical health status outcomes in people with self-reported arthritis.
From 2004-2005, 968 participants completed a telephone survey assessing health status, chronic conditions, community characteristics, and socio-demographic variables. Individual-level SES measures: homeownership, occupation [professional, or not], educational attainment (< high school (HS), HS degree, and > HS), income (<15, 15-45, >$45K) and community poverty: 2000 U.S. Census block-group “% of individuals living below the poverty line” (low, medium, high) were used. Outcomes were physical functioning (MOS SF-12v2 PCS), functional disability (HAQ) and the CDC HRQOL Healthy Days physical and limited activity days and were analyzed via multivariable regressions.
When entered separately, all individual-level SES variables were significantly (p<0.01) associated with poorer PCS, HAQ, and CDC HRQOL scores. A higher magnitude of effect was seen for household income, specifically <$15,000 in final models with all 4 individual SES measures and community poverty. The magnitude of effect for education is reduced and marginally significant for PCS and number of physically unhealthy days. No effects were seen for occupation, homeownership, and community poverty.
Findings confirm that after adjusting for important covariates, lower individual and community-level SES are associated with poorer physical health outcomes, while household income is the strongest predictor (as measured by both significance and effect) of poorer health status in final models. Studies not having participant-reported income available should make use of other SES measures as they do independently predict physical health.
PMCID: PMC3091982  PMID: 21225675
Socioeconomic Status; Health Status
10.  Associations of Perceived Neighborhood Environment on Health Status Outcomes in Persons with Arthritis 
Arthritis care & research  2010;62(11):1602-1611.
To examine the association between four aspects of the perceived neighborhood environment (aesthetics, walkability, safety, and social cohesion) and health status outcomes in a cohort of North Carolinians with self-report arthritis, after adjustment for individual and neighborhood SES covariates.
696 participants self-reported one or more types of arthritis or rheumatic condition in a telephone survey. Outcomes measured were physical and mental functioning (MOS SF-12v2 PCS and MCS); functional disability (HAQ); depressive symptomatology (CES-D scored <16; ≥16). Multivariate regression and multivariate logistic regression analyses were conducted using STATA v11.
Results from separate adjusted models indicate that measures of associations for perceived neighborhood characteristics are statistically significant (p≤0.001 to p=0.017) for each health status outcome (except walkability and MCS) after adjusting for covariates. Final adjusted models included all four perceived neighborhood characteristics simultaneously. A one point increase in perceiving worse neighborhood aesthetics predicted lower mental health (B= −1.81, p=0.034). Individuals had increased odds of depressive symptoms if they perceived lower neighborhood safety (OR: 1.36; CI: 1.04, 1.78, p=0.023) and if they perceived lower neighborhood social cohesion (OR 1.42; CI: 1.03, 1.96, p=0.030).
Study findings indicate that an individual’s perception of neighborhood environment characteristics, especially aesthetics, safety and social cohesion, is predictive of health outcomes among adults with self-report arthritis, even after adjusting for key variables. Future studies interested in examining the role that community characteristics play on disability and mental health in individuals with arthritis might consider further examination of perceived neighborhood.
PMCID: PMC2962729  PMID: 20521309
11.  Individual and Community Socioeconomic Status: Impact on Mental Health in Individuals with Arthritis 
Arthritis  2014;2014:256498.
To examine the impact of individual and community socioeconomic status (SES) measures on mental health outcomes in individuals with arthritis, participants with self-reported arthritis completed a telephone survey assessing health status, health attitudes and beliefs, and sociodemographic variables. Regression analyses adjusting for race, gender, BMI, comorbidities, and age were performed to determine the impact of individual and community level SES on mental health outcomes (i.e., Medical Outcomes Study SF-12v2 mental health component, the Centers for Disease Control and Prevention Health-Related Quality of Life Healthy Days Measure, Center for Epidemiological Studies Depression [CES-D] scale). When entered singly, lower education and income, nonmanagerial occupation, non-homeownership, and medium and high community poverty were all significantly associated with poorer mental health outcomes. Income, however, was more strongly associated with the outcomes in comparison to the other SES variables. In a model including all SES measures simultaneously, income was significantly associated with each outcome variable. Lower levels of individual and community SES showed most consistent statistical significance in association with CES-D scores. Results suggest that both individual and community level SES are associated with mental health status in people with arthritis. It is imperative to consider how interventions focused on multilevel SES factors may influence existing disparities.
PMCID: PMC4137496  PMID: 25152816
12.  Associations of Occupational Tasks with Knee and Hip Osteoarthritis: The Johnston County Osteoarthritis Project 
The Journal of rheumatology  2010;37(4):842-850.
This cross-sectional study examined associations of occupational tasks with radiographic and symptomatic osteoarthritis (OA) in a community-based sample.
Participants from the Johnston County Osteoarthritis Project (n = 2729) self-reported the frequency of performing 10 specific occupational tasks at the longest job ever held (never/seldom/sometimes vs often/always) and lifetime exposure to jobs that required spending > 50% of their time doing 5 specific tasks or lifting 22, 44, or 110 pounds 10 times weekly. Multivariable logistic regression models examined associations of each occupational task separately with radiographic and symptomatic knee and hip OA, controlling for age, race, gender, body mass index, prior knee or hip injury, and smoking.
Radiographic hip and knee OA were not significantly associated with any occupational tasks, but several occupational tasks were associated with increased odds of both symptomatic knee and hip OA: lifting > 10 pounds, crawling, and doing heavy work while standing (OR 1.4–2.1). More occupational walking and standing and less sitting were also associated with symptomatic knee OA, and more bending/twisting/reaching was associated with symptomatic hip OA. Exposure to a greater number of physically demanding occupational tasks at the longest job was associated with greater odds of both symptomatic knee and hip OA.
Our results confirm an association of physically demanding occupational tasks with both symptomatic knee and hip OA, including several specific activities that increased the odds of OA in both joint groups. These tasks represent possibilities for identifying and targeting at-risk individuals with preventive interventions.
PMCID: PMC4051278  PMID: 20156951
13.  Racial Differences in Knee Osteoarthritis Pain: Potential Contribution of Occupational and Household Tasks 
The Journal of rheumatology  2011;39(2):337-344.
We examined whether occupational and household tasks contributed to differences in pain between African Americans and whites with radiographic knee osteoarthritis (OA).
Participants from the Johnston County Osteoarthritis Project self-reported the frequency (often/always vs never/seldom/sometimes) of performing 9 occupational tasks involving lower extremity joint loading at their longest job (N = 868) and current job (N = 273), as well as 8 household tasks ever performed (N = 811) and currently being performed (N = 767). The associations of the numbers of occupational or household tasks with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale were first examined in simple linear regression models. If significantly associated with greater pain, each of these was included in adjusted linear regression models to examine whether the association of race with pain remained statistically significant.
African Americans reported significantly greater WOMAC pain scores than whites. Exposures to more occupational tasks at the longest job and the current job were associated with greater WOMAC pain scores (p < 0.01). The association of race with greater pain scores remained statistically significant when controlling for occupational tasks at the longest job, but was reduced by 26% and no longer significant when controlling for the number of current occupational tasks. Exposures to an increasing number of household tasks were associated with lower pain scores and were not further analyzed.
Current performance of physically demanding occupational tasks contributed to racial differences in pain severity among individuals with knee OA. Better workplace policies to accommodate OA-related limitations may help to reduce racial differences in pain.
PMCID: PMC4031236  PMID: 22133621
14.  Comparison of the Disease Activity Score using Erythrocyte Sedimentation Rate and C-reactive Protein in African-Americans with Rheumatoid Arthritis 
The Journal of rheumatology  2013;40(11):1812-1822.
The Disease Activity Score based on 28 joints (DAS28) has been increasingly used in clinical practice and research studies of rheumatoid arthritis (RA). Studies have reported discordance between DAS28 based on erythrocyte sedimentation rate (ESR) versus C-reactive protein (CRP) in RA patients. However such comparison is lacking in African-Americans with RA.
This analysis included participants from the Consortium for the Longitudinal Evaluation of African Americans with Early Rheumatoid Arthritis (CLEAR) Registry which enrolls self-declared African-Americans with RA. Using tender and swollen joint counts separate ESR-based and CRP-based DAS28 scores (DAS28-ESR3 and DAS28-CRP3) were calculated, as were DAS28-ESR4 and DAS28-CRP4, which included the patient’s assessment of disease activity. The scores were compared using paired t-test, simple agreement and kappa, correlation coefficient and Bland-Altman plots.
Of the 233 included participants, 85% were women, mean age at enrollment was 52.6 years, and median disease duration at enrollment was 21 months. Mean DAS28-ESR3 was significantly higher than DAS28-CRP3 (4.8 vs. 3.9; p<0.001). Similarly, mean DAS28-ESR4 was significantly higher than DAS28-CRP4 (4.7 vs. 3.9; p<0.001). ESR-based DAS28 remained higher than CRP-based DAS28 even when stratified by age, sex, and disease duration. Overall agreement was not high between DAS28-ESR3 and DAS28-CRP3 (50%) or between DAS28-ESR4 and DAS28-CRP4 (59%). DAS28-CRP3 underestimated disease activity in 47% of the participants relative to DAS28-ESR3 and DAS28-CRP4 in 40% of the participants relative to DAS28-ESR4.
There was significant discordance between the ESR-based and CRP-based DAS28 which could impact clinical treatment decisions in African-Americans with RA.
PMCID: PMC3987124  PMID: 23950187
DAS28; Rheumatoid Arthritis; African-Americans
15.  Complementary and Alternative Medicine Use in African Americans With Rheumatoid Arthritis 
Arthritis care & research  2014;66(2):180-189.
Racial/ethnic differences with regard to complementary and alternative medicine (CAM) use have been reported in the US. However, specific details of CAM use by African Americans with rheumatoid arthritis (RA) are lacking.
Data were collected from African Americans with RA enrolled in a multicenter registry regarding the use of CAM, including food supplements, topical applications, activities, and alternative care providers. Factors associated with CAM use by sex and disease duration were assessed using t-test, Wilcoxon’s rank sum test, chi-square test, and logistic regression analyses.
Of the 855 participants, 85% were women and mean age at enrollment was 54 years. Overall, ever using any of the CAM treatments, activities, and providers was 95%, 98%, and 51%, respectively (median of 3 for number of treatments, median of 5 for activities, and median of 1 for providers). Those with longer disease duration (>2 years) were significantly more likely (odds ratio >2.0, P < 0.05) to use raisins soaked in vodka/gin, to take fish oils, or to drink alcoholic beverages for RA treatment than those with early disease. As compared to men, women were significantly (P < 0.05) more likely to pray/attend church, write in a journal, and use biofeedback, but were less likely to smoke tobacco or topically apply household oils for treatment of RA.
CAM use was highly prevalent in this cohort, even in individuals with early disease. Health care providers need to be aware of CAM use as some treatments may potentially have interactions with conventional medicines. This could be important within this cohort of African Americans, where racial disparities are known to affect access to conventional care.
PMCID: PMC3977347  PMID: 23983105
16.  Independent associations of childhood and current socioeconomic status with risk of self-reported doctor-diagnosed arthritis in a family-medicine cohort of North-Carolinians 
Associations of socioeconomic status (SES) with the prevalence of various forms of arthritis are well documented. Increasing evidence suggests that SES during childhood is a lasting determinant of health, but its association with the onset of arthritis remains unclear.
Cross-sectional data on 1276 participants originated from 22 family practices in North-Carolina, USA. We created 4-level (high, medium, low, lowest) current SES and childhood SES summary scores based on parental and participant education, occupation and homeownership. We investigated associations of individual SES characteristics, summary scores and SES trajectories (e.g. high/low) with self-reported arthritis in logistic regression models progressively adjusted for race and gender, age, then BMI, and clustered by family practice.
We found evidence for independent associations of both childhood and current SES with the reporting of arthritis across our models. In covariate-adjusted models simultaneously including current and childhood SES, compared with high SES participants in the lowest childhood SES category (OR = 1.39 [95% CI = 1.04, 1.85]) and those in the low (OR = 1.66 [95% CI = 1.14, 2.42]) and lowest (OR = 2.08 [95% CI = 1.16, 3.74]) categories of current SES had significantly greater odds of having self-reported arthritis.
Current SES and childhood SES are both associated with the odds of reporting arthritis within this primary-care population, although the possibly superseding influence of existing circumstances must be noted. BMI was a likely mechanism in the association of childhood SES with arthritis onset, and research is needed to elucidate further pathways linking the socioeconomic environment across life-stages and the development of rheumatic diseases.
PMCID: PMC3907039  PMID: 24256740
Arthritis; Lifecourse; SES; Health disparities
17.  Association of Self-Efficacy and Outcome Expectations with Physical Activity in Adults with Arthritis 
Arthritis  2013;2013:621396.
Background and Purpose. The purpose of this study is to determine whether higher baseline levels of (a) self-efficacy for physical activity, (b) self-efficacy for arthritis self-management, and (c) outcome expectations for exercise are associated with higher physical activity levels following an exercise intervention for adults with arthritis. Methods. A secondary analysis of the intervention cohort (n = 130) within a randomized controlled trial of the People with Arthritis Can Exercise program was performed. Multiple linear regression evaluated the relationship between physical activity at a time point three months after the completion of an exercise intervention and three main explanatory variables. Results. After controlling for baseline physical activity, neither self-efficacy for arthritis self-management nor outcome expectations for exercise related to three-month physical activity levels. There was a relationship between three-month physical activity and self-efficacy for physical activity. Conclusions. Future research is needed to evaluate the ability of self-efficacy-enhancing programs to increase physical activity in adults with arthritis.
PMCID: PMC3821889  PMID: 24260714
18.  Independent associations of socioeconomic factors with disability and pain in adults with knee osteoarthritis 
The purpose of this study is to explore the relationship between function, pain and stiffness outcomes with individual and community socioeconomic status (SES) measures among individuals with radiographic knee osteoarthritis (rOA).
Cross-sectional data from the Johnston County Osteoarthritis Project were analyzed for adults age 45 and older with knee rOA (n = 782) and a subset with both radiographic and symptomatic knee OA (n = 471). Function, pain and stiffness were measured using the Western Ontario and McMasters Universities Index of Osteoarthritis (WOMAC). Individual SES measures included educational attainment (<12 years, ≥12 years) and occupation type (managerial, non-managerial), while community SES was measured using Census block group poverty rate (<12%, 12-25%, ≥25%). SES measures were individually and simultaneously examined in linear regression models adjusting for age, gender, race, body mass index (BMI), occupational physical activity score (PAS), comorbidity count, and presence of hip symptoms.
In analyses among all individuals with rOA, models which included individual SES measures were observed to show that occupation was significantly associated with WOMAC Function (β =2.91, 95% Confidence Interval (CI) = 0.68-5.14), WOMAC Pain (β =0.93, 95% CI = 0.26-1.59) and WOMAC Total scores (β =4.05, 95% CI = 1.04-7.05), and education was significantly associated with WOMAC Function (β =3.57, 95% CI = 1.25-5.90) and WOMAC Total (β =4.56, 95% CI = 1.41-7.70) scores. In multivariable models including all SES measures simultaneously, most associations were attenuated. However, statistically significant results for education remained between WOMAC Function (β =2.83, 95% CI = 0.38-5.28) and WOMAC Total (β =3.48, 95% CI = 0.18-6.78), as well as for the association between occupation and WOMAC Pain (β =0.78, 95% CI = 0.08-1.48). In rOA subgroup analyses restricted to those with symptoms, we observed a significant increase in WOMAC Pain (β =1.36, 95% CI = 0.07-2.66) among individuals living in a block group with poverty rates greater than 25%, an association that remained when all SES measures were considered simultaneously (β =1.35, 95% CI = 0.06-2.64).
Lower individual and community SES are both associated with worse function and pain among adults with knee rOA.
PMCID: PMC3906978  PMID: 24134116
Osteoarthritis; Knee; Pain evaluation; Education; Occupation; Poverty; Social class; Socioeconomic
19.  Coping with Prescription Medication Costs: a Cross-sectional Look at Strategies Used and Associations with the Physical and Psychosocial Health of Individuals with Arthritis 
Prescription medication costs increase financial burden, often leading individuals to engage in intentional nonadherence. Little is known about what specific medication cost-coping strategies individuals with arthritis employ.
The purposes of this study are (1) to identify characteristics of individuals with arthritis who self-report prescription medication cost-coping strategies and (2) to examine the association between medication cost-coping strategies and health status.
Seven hundred twenty-nine people self-reporting arthritis and prescription medication use completed a telephone survey. Adjusted regression models examined medication cost-coping strategies and five health status outcomes.
Participants reported engaging in cost-coping strategies due to medication costs. Those borrowing money had worse psychosocial health and greater disability; those with increasing credit card debt reported worse physical functioning, self-rated health, and greater helplessness. Medication underuse was associated with worse psychosocial health, greater disability, and depressive symptoms.
Individuals with arthritis use multiple strategies to cope with medication costs, and these strategies are associated with adverse physical and psychosocial health status.
PMCID: PMC3443256  PMID: 22740363
Medication cost; Medication underuse; Coping strategies; Health status outcomes; Arthritis
20.  Social determinants and osteoarthritis outcomes 
Aging health  2012;8(4):413-437.
Osteoarthritis (OA) is one of the most frequently occurring musculoskeletal diseases, posing a significant public health problem due to its impact on pain and disability. Traditional risk factors fail to account for all of the risk observed for OA outcomes. In recent years, our view of disease causation has broadened to include health risks that are created by an individual’s socioeconomic circumstances. Early research into social determinants has focused on social position and explored factors related to the individual such as education, income and occupation. Results from these investigations suggest that low education attainment and nonprofessional occupation are associated with poorer arthritis outcomes. More recently, research has expanded to examine how one’s neighborhood socioeconomic environment may be relevant to OA outcomes. This narrative review proposes a framework to help guide our understanding of how social context may interact with pathophysiological processes and individual-level variables to influence health outcomes in those living with OA.
PMCID: PMC3519433  PMID: 23243459
osteoarthritis; sociall determinant; socioeconomic status
21.  Interactions of Cigarette Smoking with NAT2 Polymorphisms Impact Rheumatoid Arthritis Risk in African Americans 
Arthritis and Rheumatism  2012;64(3):655-664.
To examine whether polymorphisms in genes coding for drug metabolizing enzymes (DMEs) impact rheumatoid arthritis (RA) risk due to cigarette smoking in African Americans.
Smoking status was evaluated in African American RA cases and non-RA controls categorized as heavy (≥ 10 pack-years) vs. other. Individuals were genotyped for a homozygous deletion polymorphism in glutathione S-transferase Mu-1 (GSTM1-null) in addition to tagging single nucleotide polymorphisms (SNPs) in N-acetyltransferase (NAT)1, NAT2, and epoxide hydrolase (EPXH1). Associations of genotypes with RA were examined using logistic regression and gene-smoking interactions were assessed.
There were no significant associations of any DME genotype with RA. After adjustment for multiple comparisons, there were significant additive interactions between heavy smoking and NAT2 SNPs rs9987109 (Padd = 0.000003) and rs1208 (Padd = 0.00001); attributable proportions (APs) due to interaction ranged from 0.61 to 0.67. None of the multiplicative gene-smoking interactions examined remained significant after adjustment for multiple testing in overall disease risk. There was no evidence of significant gene-smoking interactions in analyses of GSTM1-null, NAT1, or EPXH1. DME gene-smoking interactions were similar when cases were limited to anti-citrullinated protein antibody (ACPA) positive individuals.
Among African Americans, RA risk imposed by heavy smoking appears to be mediated in part by genetic variation in NAT2. While further studies are needed to elucidate mechanisms underpinning these interactions, these SNPs appear to identify African American smokers at a much higher risk for RA with relative risks that are at least two-fold higher compared to non-smokers lacking these risk alleles.
PMCID: PMC3272109  PMID: 21989592
rheumatoid arthritis; African Americans; cigarette smoking; anti-CCP antibody; drug metabolizing enzyme; N-acetyltransferase; epoxide hydrolase; glutathione S-transferase
22.  What community resources do older community-dwelling adults use to manage their osteoarthritis? A formative examination 
Community resources can influence health outcomes, yet little research has examined how older individuals use community resources for osteoarthritis (OA) management. Six focus groups were conducted with 37 community-dwelling older adult African Americans and Caucasians who self-reported OA and resided in Johnston County, North Carolina. Descriptive analyses and qualitative constant comparison methodology revealed individuals use local recreational facilities, senior centers, shopping centers, religious organizations, medical providers, pharmacies and their social network for OA management. Participants also identified environmental characteristics (e.g., sidewalk conditions, curb-cuts, handicapped parking, automatic doors) that both facilitated and hindered use of community resources for OA management. Identified resources and environmental characteristics were organized around Corbin & Strauss framework tasks: medical/behavioral, role, and emotional management. As older Americans live with multiple chronic diseases, better understanding of what community resources are used for disease management may help improve the health of community-dwelling adults, both with and without OA.
PMCID: PMC3462463  PMID: 23049159
osteoarthritis; self-management; community resources; built environment; focus groups
23.  Most Common SNPs Associated with Rheumatoid Arthritis in Subjects of European Ancestry Confer Risk of Rheumatoid Arthritis in African-Americans 
Arthritis and Rheumatism  2010;62(12):3547-3553.
Large-scale genetic association studies have identified over 20 rheumatoid arthritis (RA) risk alleles among individuals of European ancestry. The influence of these risk alleles has not been comprehensively studied in African-Americans. We therefore sought to examine whether these validated RA risk alleles are associated with RA in an African-American population.
27 candidate SNPs were genotyped in 556 autoantibody-positive African-Americans with RA and 791 healthy African-American controls. Odds ratios (OR) and 95% confidence intervals (CI) for each SNP were compared to previously published ORs of RA patients of European ancestry. We then calculated a composite Genetic Risk Score (GRS) for each individual based on the sum of all risk alleles.
There was overlap in the OR and 95% CI between the European and African-American populations in 24 of the 27 candidate SNPs. Conversely, 3 of the 27 SNPs (CCR6 rs3093023, TAGAP rs394581, TNFAIP3 rs6920220) demonstrated an OR in the opposite direction from those reported in RA patients of European ancestry. The GRS analysis indicated a small but highly significant probability that African-American cases were enriched for the European RA risk alleles relative to controls (p=0.00005).
The majority of RA risk alleles previously validated among European ancestry RA patients showed similar ORs in our population of African-Americans with RA. Furthermore, the aggregate GRS supports the hypothesis that these SNPs are risk alleles for RA in the African-American population. Future large-scale genetic studies are needed to validate these risk alleles and identify novel risk alleles for RA in African-Americans.
PMCID: PMC3030622  PMID: 21120996
24.  Associations of cigarette smoking with rheumatoid arthritis in African Americans 
Arthritis and rheumatism  2010;62(12):3560-3568.
To examine the associations of cigarette smoking with rheumatoid arthritis (RA) in African Americans and to determine to whether this association is impacted by HLA-DRB1 shared epitope (SE).
Smoking status, cumulative smoking exposure, and SE status were measured in African American patients with RA and in healthy controls. Associations of smoking with RA were examined using age- and gender-adjusted logistic regression. Additive and multiplicative SE-smoking interactions were examined.
After adjusting for age and gender, ever (OR = 1.45; 95% CI 1.07 to 1.97) and current smoking (OR = 1.56; 95% CI 1.07 to 2.26) were more common in African American RA cases (n = 605) than in controls (n = 255). The association of smoking with RA was limited to those with a cumulative exposure exceeding 10 pack-years, associations that were evident in both autoantibody positive and negative disease. There was evidence of a significant additive interaction between SE status and heavy smoking (≥ 10 pack-years) in RA risk (attributable proportion due to interaction [AP] of 0.58, p = 0.007) with an AP of 0.47 (p = 0.006) between SE status and ever smoking. There was no evidence of multiplicative interactions.
Among African Americans, cigarette smoking is associated not only with the risk of autoantibody positive RA but also with the risk of autoantibody negative disease. RA risk attributable to smoking is limited to African Americans with more than 10 pack-years of exposure and is more pronounced among individuals positive for HLA-DRB1 SE.
PMCID: PMC2995845  PMID: 20722010
rheumatoid arthritis; African Americans; cigarette smoking; rheumatoid factor; anti-CCP antibody; HLA-DRB1 shared epitope
25.  Associations of educational attainment, occupation and community poverty with knee osteoarthritis in the Johnston County (North Carolina) osteoarthritis project 
Arthritis Research & Therapy  2011;13(5):R169.
The purpose of this study was to examine data from the Johnston County Osteoarthritis (OA) Project for independent associations of educational attainment, occupation and community poverty with tibiofemoral knee OA.
A cross-sectional analysis was conducted on 3,591 individuals (66% Caucasian and 34% African American). Educational attainment (< 12 years or ≥12 years), occupation (non-managerial or not), and Census block group household poverty rate (< 12%, 12 to 25%, > 25%) were examined separately and together in logistic models adjusting for covariates of age, gender, race, body mass index (BMI), smoking, knee injury and occupational activity score. Outcomes were presence of radiographic knee OA (rOA), symptomatic knee OA (sxOA), bilateral rOA and bilateral sxOA.
When all three socioeconomic status (SES) variables were analyzed simultaneously, low educational attainment was significantly associated with rOA (odds ratio (OR) = 1.44, 95% confidence interval (CI) 1.20, 1.73), bilateral rOA (OR = 1.43, 95% CI 1.13, 1.81), and sxOA (OR = 1.66, 95% CI 1.34, 2.06), after adjusting for covariates. Independently, living in a community of high household poverty rate was associated with rOA (OR = 1.83, 95% CI 1.43, 2.36), bilateral rOA (OR = 1.56, 95% CI 1.12, 2.16), and sxOA (OR = 1.36, 95% CI 1.00, 1.83). Occupation had no significant independent association beyond educational attainment and community poverty.
Both educational attainment and community SES were independently associated with knee OA after adjusting for primary risk factors for knee OA.
PMCID: PMC3308104  PMID: 22011570
knee osteoarthritis; educational attainment; occupation; community poverty; socioeconomic status

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