Education and self-care activities among persons with rheumatoid arthritis

Abstract

Associations between low formal education and increased morbidity and mortality have been well established among persons with rheumatoid arthritis (RA) and other conditions. This study attempted to identify a partial explanation for the association between low education and poor outcomes among persons with RA by examining self-care activities performed by persons with different levels of education. Persons with 13⁺ yr of education were significantly more likely to perform specific self-care activities (e.g., using a heated pool, tub, shower, OR=2.59; using relaxation methods, OR=3.00; using stress control methods, OR=2.41; avoiding certain foods, OR=1.74). The association between education and performance of self-care activities was not linear. When significant differences were noted, 13 yr of education was usually the point at which performance was significantly different than among lower education groups; individuals with 12 yr of education often exhibited lower frequencies of particular behaviors than did individuals with 9–11 yr of education. The association between higher education and performance of more self-care activities may shed light on previously described associations between education and morbidity. However, low education should not be viewed as the cause of increased morbidity and mortality, but as a proxy for a constellation of factors responsible for poor health outcomes.

Introduction

Rheumatoid arthritis (RA) is a chronic, systemic disease, characterized by joint inflammation (Schumacher, 1993). The physical effects of RA include joint inflammation and stiffness that result in pain, fatigue, and joint deformities. RA is more common in women. The peak incidence of RA in women is between ages 30 and 50, in contrast to osteoarthritis, which typically occurs later in life.

The association between low levels of formal education and increased morbidity and mortality among persons with RA is well established. Pincus and Callahan (1985)noted that low education was a significant risk factor for mortality over a nine year period among a group of RA patients. Later, they noted poorer clinical status (e.g., higher erythrocyte sedimentation rate (ESR), poorer grip strength and walking time, higher ratings of pain, greater number of painful joints) among patients who did not complete high school, as compared with those who had completed high school (Callahan and Pincus, 1988). Hannan et al. (1992)found that knee osteoarthritis was more prevalent among persons with low levels of formal education, even after controlling for known risk factors such as age, knee injury, race, obesity and occupation.

The associations between education and morbidity have not been limited to rheumatic diseases. Individuals with low education have been found to have higher rates of many chronic diseases, such as hypertension, nervous/emotional conditions, vision problems, and chronic lung conditions (Pincus et al., 1987). Adler et al. (1993)traced the documentation of differences in mortality by social class and occupation back to the 19th century. More recently, based on a study of over 12 000 people, Valkonen et al. (1997)reported that in Finland the higher the level of education, the longer one's life expectancy and one's disability-free life expectancy. Macintyre (1997)points out the clear gradient that exists between socioeconomic status (SES), whether defined as income, education, or in other ways, and mortality and health. As socioeconomic status decreases, mortality rates increase and health status decreases.

The reasons for these associations are less clear than their existence. Several authors have speculated about the reasons for the association between education and health, citing hypotheses such as the impact of poverty, including poor housing and nutrition, or lack of access to health care or health insurance. However, that the association of health and education has been found in countries with universal health insurance (Townsend and Davidson, 1982), exists even when similar treatments are provided (Tofler et al., 1993), and is even seen in the upper range of SES (Marmot et al., 1984), would seem to discount these as the primary source of the associations. Behavioral risk factors, such as smoking, dietary factors, obesity, and sedentary lifestyle, appear to be more frequent among persons with low education or SES (Matthews et al., 1989; Winkelby et al., 1990; Otten et al., 1990; Paffenbarger et al., 1993). Individuals with low education are more likely to be unemployed or to work in occupations that are more physically demanding or have greater risks of injury (Leigh, 1983; Leigh and Fries, 1991a, Leigh and Fries, 1991b; Lynch et al., 1997). Individuals with low education may also be more likely to be exposed to damaging environmental conditions (e.g., crime or toxins) (Stokols, 1992). Low education is associated with greater degrees of stress and social isolation, both of which have been linked to mortality (Ruberman et al., 1984). Finally, lower education may hinder the development of traits and coping mechanisms that may affect the risk of disease, or the personal resources that individuals have to deal with stress.

Thus, as noted by Hannan (1996), education is unlikely to be the underlying cause of chronic disease or poor outcomes; rather, it seems more reasonable to view education as a confounder, or a marker for other risk factors. Pincus and Callahan (1994); Pincus, 1988and others (Matthews, 1989; Adler et al., 1993) have suggested that education may be a surrogate marker for many variables that produce the association between low education and poor outcomes, including diet, compliance with medical care, health habits, and overall lifestyle. Matthews (1989)suggested that low education may be a marker for negative affect (e.g., anxiety, depression and anger) and poor coping strategies, including health-damaging behaviors.

Some combination of all of these, or other, factors may indeed explain the association between education and outcomes. Another factor, a behavioral one, that may contribute to the association between low education and poor outcomes is the type of self-care activities in which people engage. Dean (1989)defined three forms of self-care: routine daily habits that affect health, conscious health maintenance behavior, and self-treatment, or responses to the symptoms of illness. She described self-treatment as the basic level of health care in all societies, and further defined the self-treatment component of self-care as the “... decision by lay persons to diagnose and treat perceived symptoms themselves rather than seek professional treatment services” (Dean, 1981, p. 673). The focus of this study is on the third type of self-care, responses to illness, which in this case is rheumatoid arthritis.

People do not bring all, or even most, of the symptoms they experience to the attention of a physician. Rather, they deal with the symptoms themselves in a variety of ways, from choosing to do nothing about them, to using home remedies, to seeing alternative health practitioners. Historically, self-care has been viewed as noncompliance at best and potentially dangerous at worst (Dean, 1981). For a chronic disease such as RA, however, standard medical treatment may not prevent or alleviate the effects of the disease and may not address some aspects of the disease. The result is that individuals with RA and other chronic conditions are left to provide much of the day-to-day care and management of their condition themselves.

Self-care of a chronic condition requires that one be knowledgeable about one's condition; i.e., it requires both the acquisition and use of knowledge (Clark et al., 1991; Ailinger and Dear, 1993). Performance of self-care behaviors also requires motivation; that is, the individual must perceive some benefit of the behavior. Bandura's social cognitive theory and principles of self-regulation (Bandura, 1986; Clark and Zimmerman, 1990) are helpful in considering these two requirements. Bandura proposed that behavior is determined by personal, behavioral, and environmental influences. Self-regulation is the process by which the individual tries to control these factors to achieve some goal, for example, to lessen the pain from RA. Self-regulatory behaviors will not be continued unless the individual believes some benefit to result; e.g., perceives the behavior to decrease their pain or the distress caused by their pain. Persons with greater educational experience are likely to be both more adept at the acquisition of knowledge and more comfortable with its application. Higher socioeconomic status is also associated with greater ability to control one's environment (Adler et al., 1993). Hence, an individual with higher education may be more likely to seek out self-care methods and have a greater expectation of success and thus be more likely to attempt the self-care behaviors.

Studies examining self-care activities of persons with arthritis or other musculoskeletal conditions have found that most do, in fact, engage in self-care activities. Engagement in self-care behaviors is influenced by a number of factors, both disease- and nondisease-related. Cronan et al. (1993)found that, among individuals with musculoskeletal complaints, those with more severe disease, with more activities affected, or who reported greater effects of their condition on their energy level used more self-care activities. Hampson et al. (1993)found that not only did the number of self-care activities performed by persons with osteoarthritis differ according to disease severity, but that the types of self-care activities also differed on days when arthritis was “worse” than usual. Sociodemographic and cultural factors may also affect self-care activities. For example, age and ethnicity have been shown to influence the number and type of self-care activities for arthritis in which people engage (Coulton et al., 1990; Davis et al., 1990), and for chronic conditions in general, women have been found to use more and/or different types of self-care (Kart and Engler, 1994; Rakowski et al., 1988).

This study examined the number and type of self-care activities performed by persons with RA to determine whether differences in these activities existed among persons with different levels of formal education. It is hypothesized that such differences will exist.