A Public Health 

S trate g y

National Art h ritis

Action Plan:
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National Art h ritis

Action Plan

A Public Health 

S trate g y
National Art h ritis

Action Plan:

A Public Health 

S trate g y

P R E PARED UNDER THE LEADERSHIP OF

A rthritis Foundation

Association of State and Te rritorial Health Off i c i a l s

Centers for Disease Control and Pre v e n t i o n

1999

A C K N O W L E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i v

P R E FA C E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

I. BA C K G R O U N D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

A. Definition of Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

B. The Arthritis Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

C. The Public Health Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

D. Development of a National Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3

II. STRATEGIC FRAMEWORK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5

A. Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5

B. Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5

C. Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 6

D. Action Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 6

III. SURVEILLANCE, EPIDEMIOLOGY, AND PREVENTION RESEARCH . . 1 9

A. Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9

B. Surveillance Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9

C. Epidemiology Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1

D. Prevention Research Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3

E. Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 4

I V. COMMUNICATION AND EDUCAT I O N. . . . . . . . . . . . . . . . . . . . . . . . . . 2 9

A. Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 9

B. Communication Strategies for the Public . . . . . . . . . . . . . . . . . . . . . . . . . . 2 9

C. Communication Strategies for People with Arthritis and their Families . . . . . . 3 2

D. Communication Strategies for Health Professionals . . . . . . . . . . . . . . . . . . . 3 4

E. Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 7

V. PROGRAMS, POLICIES, AND SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . 3 9

A. Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9

B. Program Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 0

C. Policy Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1

D. System Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2

E. Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5

VI. IMPLEMENTAT I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7

A. General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7

B. Priority Strategies for Early Implementation . . . . . . . . . . . . . . . . . . . . . . . . 4 8

C. Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 9

Appendix A: Working Group Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 0

Appendix B: State Health Department Reviewers . . . . . . . . . . . . . . . . . . . . . . 5 3

Appendix C: Partnership Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4

Appendix D: Proposed Healthy People 2010 Objectives . . . . . . . . . . . . . . . . . . 5 6

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 7

TABLE OF CONTENTS
i v

A C K N O W L E D G M E N T S

The National Arthritis Action Plan: A Public Health Strategy became a reality because

of the devoted attention of key individuals from the Centers for Disease Control

and Prevention and the Arthritis Foundation. We thank them for their invaluable

contributions and for helping to move the nation forward to prevent arthritis whenever possible and to improve the quality of life for those affected by this important

public health problem. 

A rthritis Foundation

Teresa J. Brady, Ph.D.

Doyt L. Conn, M.D.

Jamila Fonseka, M.P. H .

Robert F. Meenan, M.D., M.P.H., M.B.A. 

Centers for Disease Control and Pre v e n t i o n

Jeanne Alongi, M.P.H. 

Michael T. Gay, M.S.Ed.

Andree Harris 

Charles G. Helmick, M.D.

Gary C. Hogelin, M.P. A .

James Holt, M.P. A .

Suzanne Smith, M.D., M.P. H .

A special thanks also to the Arthritis Foundation’s Public Health Task Force and

Arthritis Foundation staff, Michele Boutaugh, M.P.H. and Mary Long, R.N., for

their detailed review of early drafts of the Plan; to Pat Drehobl, R.N., M.P.H., for

assisting with the initiation of this endeavor; and to James S. Marks, M.D., from the

Centers for Disease Control and Prevention, and Debra Lappin, Esq., from the

Arthritis Foundation, for their inspiration and leadership throughout the Plan’s

development. Lastly, we commend our writer, Susan B. Toal, M.P.H., and editor,

Phyllis L. M o i r, M.A., for helping to make this document understandable for a

broad audience. 
v

P R E FA C E

The National Arthritis Act, signed into law by the President on January 4, 1975,

authorized substantial expansion of arthritis research, training, public education, and treatment. In particular, it recommended establishment of comprehensive arthritis centers, an institute of arthritis in the National Institutes of

Health (NIH), an arthritis data bank, and development of a long-range arthritis

plan to address arthritis across the nation. Since that date, the first three of the

A c t ’s major recommendations have been realized: Multipurpose Arthritis Centers

(MACs) conduct comprehensive research on arthritis and musculoskeletal diseases at academic centers across the country; the National Institute of Arthritis

and Musculoskeletal and Skin Diseases in the NIH focuses on and promotes

arthritis research; and ARAMIS (Arthritis, Rheumatism and Aging Medical

Information System) serves as a clinic-based data source to advance the body of

knowledge in the field of arthritis. 

The sole remaining component i s the development of a public h e a l t h

approach to arthritis. It is with great pride that we share the National Arthritis

Action Plan: A Public Health Strategy. It is our hope that the Plan will guide the

use and organization of our nation’s health resources to combat the greatest single cause of chronic pain and disability among Americans. The Plan’s implementation will help us to achieve a greater recognition nationwide — among the

general public, people with arthritis and their families, medical care providers,

and policy makers — of the impact of arthritis, what can be done to prevent or

delay its onset, and what effective interventions are available to reduce disability and improve the quality of life of people with arthritis. We believe that true

integration of the perspectives, values, and resources of the public health and

arthritis communities will allow us to lessen the burden of arthritis on our citizens and our nation. 
The Facts

Arthritis encompasses more than 100 diseases and conditions that affect joints, the

surrounding tissues, and other connective tissues. It affects nearly one of every six

Americans, making it one of the most common diseases in the United States. By the

year 2020, an estimated 60 million people will be affected. While all Americans are at

risk of arthritis, the prevalence of this disease is higher among women than men. 

In addition, arthritis is the leading cause of disability, limiting daily activities for

more than 7 million citizens. It has a significant effect on quality of life — not only

for the individual who experiences its painful symptoms and resulting disability, but

also for family members and care givers. Compounding this picture are the enormous

costs that our nation bears for treating arthritis and its complications and for the disability that can result from these conditions. These medical and social costs total

almost $65 billion — a figure equivalent to a moderate national recession. 

Prevailing myths inaccurately portray arthritis as an old person’s disease, an inevitable

part of aging that must be endured. On the contrary, some forms of arthritis, such

as osteoarthritis, can be prevented with weight control and precautions to avoid certain occupational and sports injuries. Similarly, the pain and disability accompanying all types of arthritis can be minimized through early diagnosis and appropriate

management, including weight control, physical activity, self-management, physical

and occupational therapy, and joint replacement surgery. 

The Challenge

Arthritis has become one of our most pressing public health problems. Research has

yielded a better understanding of many types of arthritis and an array of effective

interventions to prevent arthritis and its complications, yet those interventions are

not widely applied. The public health challenge before us is to ensure the delivery

of effective interventions to those at greatest risk of arthritis and its complications.

Three national agencies — the Arthritis Foundation, the Association of State and

Territorial Health Officials, and the Centers for Disease Control and Prevention —

recently joined forces to meet this challenge and focus national attention on this

important problem. The result of their collaboration is this National Arthritis Action

Plan: A Public Health Strategy. The Plan represents a combined effort of nearly 90

organizations, including governmental agencies, voluntary organizations, academic

institutions, community interest groups, professional associations, and others with an

interest in arthritis prevention and control. 

1

EXECUTIVE SUMMARY
The ultimate aims of the National Arthritis Action Plan: A Public Health Strategy

are to: 

• Increase public awareness of arthritis as the leading cause of disability and an

important public health problem. 

• Prevent arthritis whenever possible.

• Promote early diagnosis and appropriate management for people with

arthritis to ensure them the maximum number of years of healthy life.

• Minimize preventable pain and disability due to arthritis. 

• Support people with arthritis in developing and accessing the resources they

need to cope with their disease.

•Ensure that people with arthritis receive the family, peer, and community support they need. 

The Plan

Three major focal areas — surveillance, epidemiology, and prevention research; communication and education; and programs, policies, and systems — are proposed to

stimulate and strengthen a national coordinated effort for reducing the occurrence

of arthritis and its accompanying disability. 

S U RVEILLANCE, EPIDEMIOLOGY, AND PREVENTION RESEARCH

Objective: To establish a solid scientific base of knowledge on the prevention o f

arthritis and related disability.

S u rv e i l l a n c e

1 . Improve surveillance of arthritis in general and of specific types of arthritis at

national and state levels.

2 . Ensure standard and consistent use of data terms and coordinate use of arthritis

databases. 

3. Increase understanding of current and future clinical treatments for arthritis.

E p i d e m i o l o g y

1. Develop population-based, longitudinal data systems to track the occurrence,

progression, and impact of arthritis. 

2 . Identify modifiable risk factors to reduce the incidence of and disability from

a r t h r i t i s .

3. Study the personal effects of arthritis.

2 N AT I O N A L A R T H R I T I S A C T I O N P L A N
P revention Researc h

1 . Evaluate the efficacy and cost-effectiveness of current and future interventions

and community strategies.

2 . Estimate the costs of arthritis in general and of specific types of arthritis.

C O M M U N I C ATION AND EDUCATION 

O b j e c t i v e : To increase awareness of arthritis, its impact, the importance of early

diagnosis and appropriate management, and effective prevention strategies. 

For the Public

1 . Promote partnerships to deliver consistent messages that reach entire populations.

2 . Conduct market research to shape the messages.

3 . Increase awareness throughout all communities. 

For People with Arthritis and Their Families

1 . Incorporate arthritis into chronic disease prevention, health promotion and education, and other programs of state and local health departments.

2 . Create national and local communication campaigns to motivate people with

arthritis symptoms to seek early diagnosis and appropriate management.

3 . Improve the ability of people with arthritis to make informed decisions about the

use of unproven remedies. 

For Health Pro f e s s i o n a l s

1 . Improve the knowledge, attitudes, and practices of primary care practitioners and

other physicians through undergraduate and graduate education, continuing

medical education, and in-service education. 

2 . Improve the knowledge, attitudes, and practices of other health professionals

through undergraduate and graduate education, continuing education, and inservice education.

3 . Extend the reach of arthritis-related messages by using communication vehicles

such as state and county medical societies, state and national professional organizations, professional newsletters and conferences, and websites of professional

organizations and advocacy groups.

E X E C U T I V E S U M M A R Y 3
PROGRAMS, POLICIES, AND SYSTEMS 

O b j e c t i v e : To implement effective programs to prevent the onset of arthritis and its

related disability. 

P ro g r a m s

1 . Develop and disseminate primary, secondary, and tertiary prevention intervention

p r o g r a m s .

2 . Develop and disseminate arthritis management education programs for health

professionals. 

P o l i c i e s

1 . Create awareness of arthritis as a public health issue.

2 . Incorporate arthritis objectives into Healthy People 2010.

S y s t e m s

1 . Build arthritis capacity and competency into the public health infrastructure. 

2 . Modify health care systems to better meet the needs of people with arthritis.

3 . Build state and local interagency alliances to address arthritis.

4 . Target state and local efforts to those at greatest risk of arthritis.

Effective arthritis strategies exist, yet few have been implemented fully. Given the

importance of this health problem — its prevalence, its impact on disability and

quality of life, and the resulting cost — the time for action is now. This strategic plan

outlines a comprehensive, systematic public health approach that heretofore did not

exist. It is our intention that the Plan will guide the use of the nation’s resources to

decrease the burden of arthritis for all Americans and increase the quality of life of

those affected by arthritis.

4 N AT I O N A L A R T H R I T I S A C T I O N P L A N
A . Definition of Arthritis 

Arthritis and other rheumatic conditions are among the most common chronic conditions and the leading cause of disability* in the United States.1 These conditions

frequently lead to limitations in work, recreation, and usual activities, including b a s i c

self-care. Some types of arthritis can result in life-threatening complications. The term

“arthritis,” as used here, encompasses more than 100 diseases and conditions affecting

joints, the surrounding tissues, and other connective tissues. These diseases and conditions include osteoarthritis, rheumatoid arthritis, lupus, juvenile rheumatoid arthritis, gout, fibromyalgia, bursitis, rheumatic fever, and Lyme disease. Three of the most

common forms of arthritis are osteoarthritis, rheumatoid arthritis, and fibromyalgia. 

* The scientific community uses diff e rent terms and definitions to describe disability concepts. For the sake of simplicity, the disability concepts used in this Plan are based on the

World Health Org a n i z a t i o n ’s draft classification ICIDH-2, which pro g resses from “impairment” at the level of body function to “activity limitation” at the level of personal function

to “participation restriction” at the level of societal function. In this document, the word

“disability” encompasses this entire spectru m . 1

S E C T I O N

5

A rthritis or rh e u m a t i s m

Back or spine pro b l e m

H e a rt tro u b l e

Lung or re s p i r a t o ry tro u b l e

High blood pre s s u re (hypert e n s i o n )

S t i ffness or deformity of limb

D i a b e t e s

Blindness or other visual impairm e n t

Deafness or serious trouble hearing

S t ro k e

0 5 10 15 2 0

S o u rce: CDC. Prevalence of disability and associated health conditions — United States, 199 1 - 1992. M M W R 199 4 ; 4 3 ( 40) : 7 3 0 -731, 737-7 39.

Pe rc e n t a g e o f a ll d i s a b i l i t y

I. BACKGROUND

Leading Causes of Disability Among Pe r s o n s

Aged 15 Years and Older, United States, 1991–19 9 2
B .

• O s t e o a r t h r i t i s , or “degenerative joint disease,” most often affects the hip, knee,

foot, and hand — but can affect other joints as well. Degeneration of joint cartilage and changes in underlying bone and supporting tissues lead to pain, stiffness,

movement problems, and activity limitations. 

• Rheumatoid arthritis is characterized by chronic inflammation of the joint lining.

Symptoms include pain, stiffness, and swelling of multiple joints. The inflammation may extend to other joint tissues and cause bone and cartilage erosion, joint

deformities, movement problems, and activity limitations. Rheumatoid arthritis

can also affect connective tissue and blood vessels throughout the body, triggering inflammation in a variety of organs, including the lungs and heart, and

increasing a person’s risk of dying of respiratory and infectious diseases.

• F i b r o m y a l g i a is a pain syndrome involving muscle and muscle attachment areas.

Common symptoms include widespread pain throughout the muscles of the body,

sleep disorders, fatigue, headaches, and irritable bowel syndrome. 

The Arthritis Burden 

Arthritis affects an estimated 42.7 million Americans — nearly one of every six people.2

Approximately 21 million people have osteoarthritis, 3.7 million have fibromyalgia,

and another 2.1 million have rheumatoid arthritis.3

Although this prevalence is high, it is expected to increase even more as the U.S.

population ages. By the year 2020, an estimated 60 million people will have arthrit i s .4 This trend is due in large part to the growing number of older Americans over

the next 25 years and to the relatively high frequency of arthritis, primarily

osteoarthritis, among older people. 

In addition, arthritis has a significant effect on quality of life — not only for

those who experience its painful symptoms and resulting disability, but also for their

family members and care givers. Over 7 million Americans are limited in their ability to participate in their main daily activities, such as going to school or work or

maintaining their independence — simply because of their arthritis.4 Like arthritis

prevalence, the prevalence of arthritis-related disability is also expected to rise by

the year 2020, when an estimated 11.6 million people will be affected.4

Compounding this picture are the enormous costs that our nation bears for

treating arthritis, its complications, and the disability that results from uncontrolled

disease. The total cost is almost $65 billion — a figure equivalent to a moderate

national recession.5 This amount includes an estimated medical bill of $15 billion

each year5for such expenses as 39 million physician visits and more than half a million hospitalizations (CDC, unpublished data). The balance is largely due to indirect costs resulting from wage losses.5

Thus, arthritis has become one of our most pressing public health problems —

a problem that is expected to worsen in the next millennium unless prompt and

responsible action is taken. 

6 N AT I O N A L A R T H R I T I S A C T I O N P L A N

“

”

A rthritis and other

rheumatic conditions

have an annual 

economic impact 

on the nation ro u g h l y

equivalent to a

moderate re c e s s i o n ,

with an aggre g a t e

cost of about 1.1% 

of the gross national

p ro d u c t .

– ED WA R D H. YE L I N, PH. D . ,

PR O F E S S O R O F ME D I C I N E A N D

HE A LT H PO L I C Y, UN I V E R S I T Y O F

CA L I F O R N I A, SA N FR A N C I S C O
How does arthritis affect individuals? 

Arthritis is a threat to a person’s physical, psychological, social, and economic wellbeing. It often deprives people of their freedom and independence and can disrupt

the lives of family members and other care givers. 

•P h y s i c a l symptoms of arthritis include pain, loss of joint motion, and fatigue.

Because of these symptoms, people with arthritis are significantly less physically

active than the rest of the adult population — even after taking their disability

into account.6 This level of inactivity puts them at higher risk for a variety of

other diseases, including premature death, heart disease, diabetes, high blood

pressure, colon cancer, overweight, depression, and anxiety. In fact, in its severe

forms arthritis can shorten life expectancy. The 2 million Americans with

rheumatoid arthritis, for example, are at risk for premature death because of systemic complications of the disease and complications of its treatment.7

•P s y c h o l o g i c a l stress, depression, anger, and anxiety often accompany arthritis.

People with arthritis may experience difficulty coping with pain and disability,

which in turn can lead to feelings of helplessness, lack of self-control, and changes

in self-esteem and self-image. 

• Social well-being is affected by arthritis. People with arthritis frequently experience decreased community involvement, difficulties in school, and sexual

problems. These social problems are often aggravated by a lack of understanding

and empathy among co-workers, employers, teachers, school nurses, and others.

•E c o n o m i c implications of arthritis include inadequate access to care, and financial burdens due to health care costs and income loss resulting from work limitations. Arthritis is second only to heart disease as a major cause of missed work.8

What are some common myths about arthritis? 

• Arthritis is an old person’s disease. Although arthritis affects one of every two

people over 65 years of age, most people with arthritis — nearly three out of f i v e

— are younger than age 65.4 People of all ages are affected, including child r e n

and teens. Juvenile rheumatoid arthritis is one of the most common chronic illnesses of childhood.9

• Arthritis is just a normal part of aging. If this were true, most older adults — and

no children — would have arthritis. However, nearly half of the elderly p o p u l ation never experience these conditions, and an estimated 285,000 children are

indeed affected (CDC, unpublished data). Furthermore, some forms of arthritis

(e.g., osteoarthritis of the knee) can be prevented.

I . B A C K G R O U N D 7
•There is no cure for most forms of arthritis. Although no “magic bullet” for a l l

types of arthritis exists, research shows that early diagnosis and appropriate management can help reduce the consequences associated with many types of arthritis. Medication, education, physical activity, and surgery are four effective treatment strategies that can indeed make a difference. One intervention in particular

— the Arthritis Self-Help Course — has been shown to reduce pain by 20% and

physician visits by 40%.1 0

Who is at risk for arthritis? 

Certain factors are known to be associated with a greater risk of arthritis. Three of these

factors are n o n m o d i f i a b l e: female sex, older age, and genetic predisposition. Although

these factors cannot be changed, knowledge of their presence helps identify groups at

higher risk for arthritis so that intervention efforts can be targeted accordingly. 

•Wo m e n aged 15 years and older account for 60% of arthritis cases. At least 26.4

million women have arthritis, the leading chronic condition among women,1 1 , 1 2

and by the year 2020, an estimated 36 million women will be affected.1 1 F u r t h e r m o r e ,

approximately 4.6 million women report arthritis as a major or contributing cause of

activity limitation.1 2

• A g e is also associated with increased risk of arthritis. Half of the elderly population is affected by arthritis, and risk increases with age.

• Genetic predisposition to arthritis is a third nonmodifiable risk factor. C e r t a i n

genes are known to be associated with a higher risk of some types of arthritis.

Because of the growing body of research in the area of genetics, discovery of additional genes associated with specific types of arthritis is anticipated. 

Some demographic factors, such as lower levels of education and lower income,

are associated with arthritis. Although these risk factors are potentially modifiable,

it is not clear if modifying them would indeed reduce the risk of arthritis since the

mechanisms by which they increase that risk are not yet understood.

In addition, a few clearly m o d i f i a b l e risk factors are also associated with i n c r e a s e d

risk of arthritis. These include

• O b e s i t y.

1 3

• Joint injuries.

• I n f e c t i o n s.

•Certain occupations (e.g., shipyard work, farming, heavy industry, and occupations with repetitive knee-bending).1 4 , 1 5

8 N AT I O N A L A R T H R I T I S A C T I O N P L A N

My friends think I’m

crazy for playing tennis

with arthritis, but I 

enjoy the challenge,

camaraderie and

a t m o s p h e re. I’m the

competitive type – 

I’ve had to be to surv i v e

in this business. Don’t

just settle back and say,

‘ Well, I’ve got art h r i t i s

and I can’t just do 

anything about it.’ The

m o re you give in to it,

the worse it gets. 

– TH E L AT E SA R A H CA N N O N

( NA S H V I L L E’S MI N N I E PE A R L)

“

”
C . The Public Health Appro a c h

The role of biomedical research is to increase our understanding of the causes and

mechanisms of diseases, and to help develop efficacious interventions for them.

Responsibility for applying those interventions rests with the medical care and public health communities, who must ensure that patients and their families and the

public at large receive appropriate information about the interventions and have

access to them as early as possible. 

Because arthritis imposes a tremendous individual and societal burden — and

because effective interventions are available — arthritis needs a coordinated public

health approach. The focus of that approach should be broad and encompass

whole population groups — in contrast with the classic medical approach, which

I . B A C K G R O U N D 9

S o u rce: CDC. Factors associated with prevalent self-re p o rted arthritis and other rheumatic conditions – 

United States, 1989-1991. MMWR 1996; 45(23) : 487-4 9 1

Association of Arthritis and Weight 

Among Women Ages 18 Years and Older

1.6

1.4

1.2

1

0.8

0.6

0.4

0.2

0
a d d r e s ses the individual patient. The challenge for public health is to identify and

help implement strategies for improving the health of an entire population. 

Key to the public health model for arthritis is the concept of prevention. This

concept encompasses three levels: 

•Primary prevention is designed to prevent a disease or condition (arthritis, for

example) from occurring in the first place. Vaccination against infectious diseases

and physical activity to reduce the risk of heart disease are classic examples of primary prevention measures.

• Secondary prevention attempts to identify a disease in its earliest stage so that

prompt and appropriate management can be initiated. Successful secondary prevention reduces the impact of the disease. Mammograms to detect breast cancer

early are a secondary prevention measure. 

•Tertiary prevention focuses on reducing or minimizing the consequences of a d i sease once it has developed. The goal of tertiary prevention is to eliminate, or at least

d e l a y, the onset of complications and disability due to the disease. Most medical

interventions fall into this level. A typical example is the tight control of blood glucose levels in a person with diabetes to prevent complications. 

Do primary prevention strategies exist for art h r i t i s ?

Only a few primary prevention strategies are considered effective for arthritis. These

include 

•Weight control. Maintaining an appropriate weight or reducing weight to a recommended level lowers a person’s risk for certain common forms of arthritis. Obesity

i s a risk factor for o s t e o a r t h r i t i so f the knee in women and gout in men.14-16 

• Occupational injury prevention. Taking precautions to avoid repetitive joint

use and resulting joint injury in the occupational setting can help to prevent

arthritis.15

• Sports injury prevention. Using recommended injury prevention strategies (e.g.,

warm-ups, strengthening exercises, and appropriate equipment) helps to avoid

joint injuries and damage to ligaments and cartilage, all of which can increase the

risk of osteoarthritis.1 4

• Infectious disease control. Certain protective strategies can prevent the tick bites

that cause Lyme disease and associated arthritis. Such strategies include using

insect repellents, wearing long-sleeved shirts and pants when walking in the

woods, and being educated on tick recognition and removal. For those at risk,

vaccination can provide additional protection.

1 0 N AT I O N A L A R T H R I T I S A C T I O N P L A N
What secondary prevention strategies exist?

The following secondary prevention strategies are available but under-used: 

•Early diagnosis. Early diagnosis of all types of arthritis is important. Many people with arthritis, particularly men and young people, never even see a physician for their arthritis,17 especially if they are in generally good health, have few

activity or work limitations due to their arthritis, have no health insurance, or

are overweight. Nearly 200,000 people fail to see a doctor even when their

arthritis is causing activity limitation.17

• Medical treatment. Antibiotic treatment for early Lyme disease can prevent later

stage disease.1 8 , 1 9 Reduction of uric acid levels in gout and early use of disease modifying anti-rheumatic drugs (DMARDs) for rheumatoid arthritis can improve

long-term outcomes. Non-steroidal anti-inflammatory drugs help alleviate symptoms of osteoarthritis, and steroids are often prescribed for people with lupus. 

What about tert i a ry prevention strategies? 

Tertiary prevention strategies can reduce pain and disability, increase a person’s

sense of control, and improve quality of life. 

• S e l f - m a n a g e m e n t

•Weight control and physical activity are important components of a disease

management program. Being overweight is associated with increased risk

of osteoarthritis, and weight loss reduces the risk of knee osteoarthritis.2 0

Physical activity maintains joint health and may also reduce the risk of

other adverse outcomes unrelated to arthritis, such as premature death, heart

disease, diabetes, high blood pressure, and colon cancer. Studies indicate that

an exercise program can improve aerobic capacity and alleviate depression

and anxiety among people with arthritis.21-25

PACE (People with Arthritis Can Exercise) is one such community-based

recreational exercise program. Trained instructors select from 72 different

exercises and use a variety of endurance-building activities, games, relaxation techniques, and health education topics. Benefits include improved

functional ability, decreased depression, and a stronger conviction that one

can perform required behaviors.2 6 , 2 7

Arthritis Foundation YMCA Aquatics Program involves gentle physical

activity in warm water. This program has demonstrated beneficial results

and is being further evaluated.

•E d u c a t i o n is another effective self-management intervention for people with

arthritis. A good example is the Arthritis Self-Help Course (ASHC). D e v e l o p e d

in the early 1980s at Stanford University and currently sponsored by the

Arthritis Foundation, ASHC has proven to reduce arthritis-related pain by 20%

while also reducing overall costs — making it a highly cost-effective public

I . B A C K G R O U N D 1 1

In the water, I can

run and do things

that I no longer can

do on land. I feel like

a person again.

Once you’ve learn e d

to live with art h r i t i s

in a way that you can

see some good out

of it, then you’ve

begun to heal. 

- TUOVI COCHRANE,

1960 OLYMPIC GYMNAST

“

”
health intervention.28,29 The course consists of a 6-week session (2 hours per

week) guided by two trained instructors who follow a detailed protocol of

instruction. Currently reaching between 8,000 and 12,000 adults each year,

ASHC typically is delivered in a community setting to groups of about 15 people. It includes 

Information on nutrition, patient-physician communication, types of

arthritis, appropriate use of painful joints, and the effects and uses of

medications. 

Interactive, participatory components on designing individual physical

a c t i v i t y, relaxation, and pain management programs. 

Methods for solving problems that arise from the conditions. 

Other effective arthritis self-management interventions that have not been studied as extensively as ASHC include

•B o n e - U p, a home-study, self-care education program consisting of six lessons

on audio cassettes, supplemented by printed materials at a fifth-graderea d i n g

l e v e l .30- 32 P rog r a mcontent closely resembles t h a t of the ASHC.

• Arthritis Home Help Program, a mail-delivered arthritis home study program that takes an individualized approach to developing self-care skills.

Benefits include improvements in joint pain, mobility, and ability to communicate with physicians.3 3

• Arthritis phone service interventions, consisting of initial telephone contact

and follow-up by trained nonmedical personnel who provide information,

referral, and problem-solving strategies. People with osteoarthritis, rheumatoid arthritis, and lupus have shown improvements in physical and psychological health and pain as a result of this type of intervention.3 4 , 3 5

•Cognitive behavioral interventions, group or individual interventions that

focus on altering cognitive, behavioral, or emotional patterns using a variety

of methods including relaxation, biofeedback, cognitive therapy, and stress

management. These interventions have been effective in reducing arthritis

p a i n .3 6

U n f o r t u n a t e l y, most of these interventions have not been widely applied. Some

effective interventions reach fewer than 1% of those likely to benefit from them

(Arthritis Foundation unpublished data). 

•Rehabilitation services. Physical and occupational therapy can remediate

impairments and diminish activity limitations. Therapeutic interventions include

muscle strengthening, joint protection, activity modification, pain management,

and education to preserve independence, encourage self-management, and

promote wellness.

1 2 N AT I O N A L A R T H R I T I S A C T I O N P L A N

The Arthritis Self-Help

Course helped me

l e a rn how to manage

the pain, find out 

that there really are

lots of things I CAN

do, keep a positive 

attitude, and better

meet the challenges

of the workplace.

– JO Y C E GA L L A G H E R

“

”
D .

•Medical and surgical treatment. Many different drugs are used to treat arthritis.

Medications for some types of arthritis can limit disease progression, control symptoms, and prevent serious complications. Common medications to reduce the

effects of the disease are DMARDs (disease modifying anti-rheumatic drugs) f o r

rheumatoid arthritis, muscle relaxants and low-dose antidepressants for fibromyalgia,

allopurinol for gout, and antibiotics for Lyme disease.

Joint replacement therapy is most appropriate for people with chronic, severe

pain or activity limitations. This expensive intervention, performed most often for

severe destructive arthritis of the hip or knee, often reduces pain to a negligible

level and improves activity by increasing the range of motion of the affected joint. 

Development of a National Plan

In recognition of arthritis as an escalating public health problem, the Arthritis

Foundation, the Association of State and Territorial Health Officials (ASTHO), and

the Centers for Disease Control and Prevention (CDC) initiated the development of

this strategic plan in the summer of 1997. The agencies first convened a working group

of representatives of 22 organizations with expertise in arthritis, public health, and

health services delivery (see Appendix A for a complete roster). During a 2-day meeting, the working group outlined strategies for a public health approach to arthritis and

its resulting disability. The working group then helped to prepare and revise drafts of

the Plan; these drafts were eventually reviewed by selected state chronic disease and

health promotion program managers and a wider partnership network of governmental agencies, voluntary organizations, academic institutions, community interest

groups, and professional associations (listed in Appendices B and C). 

Congress strongly supported the Plan’s development in its fiscal year 1999

House Appropriations Conference Report on CDC: 

The conferees support the recent effort by CDC to develop a national plan for

addressing the large and growing public health problem of arthritis. The conferees encourage CDC to continue to expand the arthritis knowledge base necessary

to better identify an appropriate public health response for the nation’s leading

cause of disability.

The National Arthritis Action Plan: A Public Health Strategy is consistent with

the congressional mandate. The Plan lays out a vision and a framework for addressing the arthritis problem in our nation. It further proposes strategic initiatives that

would constitute a coordinated, responsible approach at all levels of the public

health structure — national, state, and local. Lastly, it identifies gaps in our knowledge of arthritis that need to be filled by appropriate prevention research to strengthe n the success of this concerted and worthwhile effort.

I . B A C K G R O U N D 1 3
B .

A . Vi s i o n

The ultimate aims of the National Arthritis Action Plan: A Public Health Strategy

(NAAP) are to 

• Increase public awareness of arthritis as the leading cause of disability and an

important public health problem. 

• Prevent arthritis whenever possible.

• Promote early diagnosis and appropriate management for people with arthritis

to ensure them the maximum number of years of healthy life.

• Minimize preventable pain and disability due to arthritis. 

• Support people with arthritis in developing and accessing the resources they

need to cope with their disease.

•Ensure that people with arthritis receive the family, peer, and community s u pport they need. 

Va l u e s

Complementing this vision are four key values that must underlie a successful public health approach to arthritis. These values mandate that the NAAP 

•Emphasize prevention. 

P r i m a r y, secondary, and tertiary prevention of arthritis must be the main thrust

of the initiative. 

• Use and expand the science base.

Decision making must be data driven, and research and demonstrations that

enhance our scientific knowledge must be encouraged and supported.

• Seek social equity. 

The unique issues affecting the uninsured, the underinsured, the poor, the disabled, the poorly educated, the unskilled workforce, minority populations and

other vulnerable groups must be understood and addressed.

•Build partnerships. 

No one organization can effectively address arthritis. Strong partnerships must

be built among the medical, voluntary, and public health communities to

ensure a coordinated, united effort. Only through the collective energy of an

interdisciplinary approach can we truly reduce the arthritis burden.

2

S E C T I O N

1 5

I I . S T R ATEGIC FRAMEWORK
D .

G o a l s

The overall goal of this Plan is to stimulate and strengthen a national coordinated effort for reducing the occurrence of arthritis and its accompanying disability.

Specific goals are to

•Establish a solid scientific base of knowledge on the prevention of arthritis and

related disability.

• Increase awareness of arthritis, its impact, the importance of early diagnosis

and appropriate management, and effective prevention strategies.

• Implement effective programs to prevent the onset of arthritis and its related

d i s a b i l i t y. 

• Achieve the arthritis-related objectives included in Healthy People 2010. These

objectives, listed in Appendix D, reflect benchmarks of success for measuring

improvements in health and quality of life.

Action Framework

Accomplishing these goals while adhering to the key values requires a multifaceted

approach — one that is ambitious but practical. The proposed approach consists

of activities in three major areas:

S u rveillance, epidemiology, and prevention re s e a rch — the scientific

tools of public health.

S u r v e i l l a n c e is the ongoing and systematic collection, analysis, and interpretation

of health data essential to the planning, implementation, and evaluation of public

health practice. Surveillance is closely integrated with timely dissemination of

these data and their translation into action. 

E p i d e m i o l o g y is the study of the distribution and determinants of health-related

states or events in specified populations and the application of this study to the

control of health problems.

Prevention research is the development and evaluation of interventions designed

to prevent onset of or disability from a health problem or condition.

Communication and education — the tools to raise awareness of a

public health problem and to stimulate action.

C o m m u n i c a t i o n is the effective transmission of a message from the sender to the

r e c e i v e r. Successful communication depends upon the selection of a message and

a delivery strategy that best suit the intended audience. For most public health

efforts, the audience includes the general public, people with or at risk of arthritis and their family members, and health professionals. 

1 6 N AT I O N A L A R T H R I T I S A C T I O N P L A N

C .
Health education is a combination of organized learning experiences that facilitate knowledge, attitudes, and voluntary behavior changes conducive to health.

Health education also involves strategies to foster employer-, community-, and

societal-level changes conducive to health in individuals and populations.3 7

P rograms, policies, and systems — tools for effecting change.

P r o g r a m s are the actual implementation — at the national, state, and community levels — of specific interventions for the primary, secondary, and tertiary prevention of a public health problem. 

P o l i c i e s include legislation, regulations, ordinances, guidelines, and norms that

establish an environment conducive to prevention. Examples of national policies

are entitlement programs (e.g., Medicare and Medicaid) and the Americans with

Disabilities Act; equally influential are policies at the state and community levels. 

S y s t e m s are the health infrastructure required to operate and manage effective

prevention programs. As our health system continues to evolve, delivery of quali t y

care and preventive services becomes more complex. Relationships among the

public and private sectors, individual practitioners and managed care organizat i o n s ,

and voluntary health organizations directly influence access to care and provision

of clinical and community preventive services.

The next three sections of the NAAP are devoted to these major areas. Each section begins by outlining overall Guiding Principles to frame the approach, then

proposes specific Strategies for action. Remaining Research Questions to further

enhance our knowledge and success are also provided. 

While the three strategic areas are by definition distinct, that distinction

becomes blurred when translated into action. Thus some overlap among the recommended activities in the three areas is natural and necessary. Additionally, the

activities are not listed in order of priority.

I I . S T R A T E G I C F R A M E W O R K 1 7
B .

A .

3 1 9

Guiding Principles 

Surveillance, epidemiology, and prevention research are the scientific tools of public

health. These tools are used to obtain accurate and reliable data, identify knowledge

gaps and ways to address them, and make provisions for disseminating data to appropriate people. The underlying principles are threefold:

•To obtain better scientific information. 

•To disseminate that information to those who need to know. 

•To translate that information into action. 

S u rveillance Strategies

Three primary strategies constitute a national and state surveillance effort for arthritis.

These strategies are explained below, along with specific activities for each strategy.

1 . I m p rove surveillance of arthritis in general and of specific types of

a rthritis at national and state levels.

Current surveillance is limited to self-reports of “any type” of arthritis aggregated

at the national level. Surveillance of specific types of arthritis (e.g., gout) at national, state, and local levels would allow accurate measures of the occurrence of that

condition in the population. It would also facilitate greater understanding of who

is affected; who is at greatest risk; what health beliefs and behaviors increase that

risk; which occupations and occupational activities increase that risk; and how the

disease affects physical health, quality of life, economics, and other areas. Such

data help to set public health priorities and focus the use of limited public health

resources in the most effective way. Monitoring changes over time can also help

assess the effectiveness of public health and other interventions. Thus, surveillance

for arthritis is critical for understanding the epidemiology of these diseases, targeting interventions, developing policy, and setting priorities for prevention

research. Specific activities to improve arthritis surveillance include

•Encourage states to use the Behavioral Risk Factor Surveillance System

(BRFSS) modules on arthritis 2and quality of life.

•Encourage the development and use of modules on arthritis and quality of life

in national data sets (e.g., National Health Interview Survey, National Health

and Nutrition Examination Survey).

• Analyze data on arthritis and quality of life (e.g., from the Behavioral Risk

Factor Surveillance System, National Health Interview Survey, National Health

and Nutrition Examination Survey) to quantify the impact of arthritis on qualS E C T I O N ity of life.

I I I . S U RVEILLANCE, EPIDEMIOLOGY, AND 

PREVENTION RESEARCH
• Identify surveillance gaps, including lack of data on children with arthritis.

•Explore the surveillance value of other data (e.g., from the National Hospital

Discharge Survey, National Ambulatory and Medical Care Survey, National

Hospital Ambulatory Medical Care Survey, Medicare Current Beneficiary

S u r v e y, Medicare claims, and other health plan data sources). 

• Monitor changes in the occurrence of arthritis and its impact (e.g., on disability and quality of life).

• Identify the existence and causes of disparities in arthritis prevalence in different populations. 

• Describe arthritis and factors associated with different types of arthritis.

• Foster collaborative and comparative studies to identify factors responsible

for wide variations in rates of arthritis among people in different industries

and occupations. 

• Develop classification systems that capture better etiologic information ( e . g . ,

related to trauma).

2 . E n s u re standard and consistent use of data terms and coord i n a t e

use of arthritis databases.

Strong surveillance efforts depend on standardized definitions of common terms

and consistent use of those definitions in different settings. Only through such

consistency can communication be expedited. Coordinating use of arthritis data

will efficiently use analytic resources and avoid duplication. 

• Reach consensus on definitions of measures to ensure their consistent use.

•Explore the value of standardized definitions of inflammatory and noninflammatory arthritis. 

• Develop a comprehensive inventory of past and current research studies and

databases that can be used to address knowledge gaps. 

• Validate self-report and other methods of arthritis measurement.

• Piggyback new arthritis studies on existing studies of other conditions. 

•Encourage provision of more data sources on the Internet to encourage use

of arthritis data. 

• Adopt common data elements in population-based surveys (e.g., Behavioral

Risk Factor Surveillance System, National Health Interview Survey, and N a t i o n a l

Health and Nutrition Examination Survey). 

• Support the National Arthritis Data Workgroup as the source for coordinating

prevalence and impact data.

2 0 N AT I O N A L A R T H R I T I S A C T I O N P L A N
C .

3 . I n c rease understanding of current and future clinical treatments for

a rt h r i t i s .

No population-based data exist to help determine how arthritis is currently treated

in the United States. A wide variety of health care providers are involved in arthritis treatment, and the rapidly changing health care system complicates efforts to

track the current practices of these providers. Further research is needed to identify the pivotal process measures and other performance indicators that will help

track progress toward improved health outcomes. In addition, many people use

alternative medicine approaches to alleviate arthritis symptoms, but the prevalence

and success of these approaches are not well understood. A greater understanding

of these issues would help determine the most effective use of health care dollars. 

• Monitor provision and availability of services. 

• Analyze differences by state, sex, and racial/ethnic groups. 

• Gather information to better define the types of professionals who treat people with arthritis.

• Study medical referral systems and access to different types of medical care.

• Survey physicians and other providers on treatment strategies used and their

beliefs about arthritis. 

•Examine complementary and alternative therapy approaches.

•Collect and analyze more detailed state-level information on occupational factors using available Workers’ Compensation databases, hospital discharge

records, and health care data.

•Evaluate costs associated with appropriate and inappropriate delay of expensive treatment (e.g., joint replacement).

Epidemiology Strategies

1 . Develop population-based, longitudinal data systems to track the

o c c u rrence, pro g ression, and impact of arthritis. 

Understanding a chronic disease such as arthritis requires knowledge of how the

disease affects people over their life span. This understanding will help identify

potentially modifiable factors that can reduce the incidence of and disability from

arthritis. The longitudinal studies needed to provide this type of information are

rare because they are more expensive than traditional cross-sectional, or snapshot,

studies of affected people. Unfortunately, cross-sectional studies will never provide the information needed to understand the complexities of the more than 100

forms of arthritis. We can get a better understanding only by studying the same

people with osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis,

lupus, or other forms of arthritis for several years. Cohorts of healthy people, unaffected by arthritis, also need to be studied to determine the precursors of arthritis. 

I I I . S U R V E I L L A N C E , E P I D E M I O L O G Y, A N D P R E V E N T I O N R E S E A R C H 2 1

“

”

S u rveillance, 

e p i d e m i o l o g y, 

and pre v e n t i o n

re s e a rch are the

scientific tools of 

public health
• Support existing longitudinal studies and, where needed, develop and implement longitudinal studies of arthritis disability, concurrent health problems,

and the natural history of arthritis. 

• Design longitudinal follow-up studies of the National Health Interview Survey

and the National Health and Nutrition Examination Survey cohorts that include

a r t h r i t i s .

2 . Identify modifiable risk factors to reduce the incidence of and disability from art h r i t i s .

A key to prevention is the identification of modifiable risk factors and their interaction with the nonmodifiable risk factors that can help identify high risk groups.

A few modifiable risk factors (e.g., obesity, joint injury, repetitive hand use in

hand-intensive jobs) have already been identified, but this list needs to be greatly

expanded to make a significant difference in the incidence and prevalence of

arthritis. Sophisticated scientific inquiry is required to identify modifiable risk

factors; this information can then be used to shape primary prevention efforts and

intervention strategies to reduce disability. 

• Use longitudinal databases to identify risk factors.

•Compare and contrast discrete population subgroups to identify potential

risk factors for arthritis and their interaction with nonmodifiable risk factors. 

• Identify strategies to reduce disability.

• Increase knowledge of the role of traumatic, occupational, and sports injuries

as arthritis risk factors.

•Clarify the mechanisms by which overweight leads to arthritis.

3 . Study the personal effects of art h r i t i s .

Arthritis can challenge a person in many ways. Physical health can be affected by

impairments and activity limitations. Mental health can be affected by depression

and the difficulties of adjusting to new ways of coping. Economic effects can

occur directly through higher health care costs and indirectly through constraints

on ability to work, such as increased absenteeism. All these effects can be compounded by a person’s lack of social, emotional, and economic resources, as well

as by other medical problems. Knowing how these factors interact can help suggest better ways of adapting to the disease.

• Define the impact of coping, depression, and other emotional responses to

arthritis. 

•Examine accommodations to disease (e.g., use of adaptive equipment, use of

self-help strategies, changes in expectations with aging).

22 N AT I O N A L A R T H R I T I S A C T I O N P L A N
D .

• Assess satisfaction regarding personal accommodations to arthritis and health

care services.

• Study how individuals attribute disability to arthritis and their other chronic

c o n d i t i o n s .

P revention Research Strategies

1 . Evaluate the efficacy and cost-effectiveness of current and future

i n t e rventions and community strategies.

The purpose of arthritis interventions is to reduce the impact of arthritis.

Knowing which ones improve or maintain health and their relative benefits and

costs is crucial when making choices about spending limited health care and public health resources. 

•Evaluate the efficacy of physical activity, weight control, and other interventions in modifying the risks of arthritis. 

•Evaluate outcomes of early treatment for common forms of arthritis.

•Compare the costs of different interventions.

• Study the role of structural and environmental modifications (e.g., curb cuts,

access, flexible work schedules) in delaying the onset of disability and in

improving quality of life.

•Evaluate the cost-effectiveness of self-management and other existing prevention interventions. 

• Develop strategies to engage people with arthritis who do not participate in

self-management programs. 

• Develop and evaluate new cost-effective self-management strategies. 

•Conduct studies of employers and managed care organizations to identify

appropriate surveillance and intervention strategies.

• Obtain evidence on the effectiveness of arthritis prevention measures for the

U.S. Preventive Services Task Force.

• Include arthritis services in the Guide to Community Preventive Services.

2 . Estimate the costs of arthritis in general and of specific types of art h r i t i s .

To make rational decisions about priorities for spending society’s resources, decision makers at all levels need information about the true costs of specific diseases.

Such costs encompass both direct and indirect economic expenditures as well as

personal and societal health costs (e.g., death, illness, quality of life, and disability).

Limited research has been done to describe these costs fully and to translate and

share this information with those responsible for allocating resources. 

I I I . S U R V E I L L A N C E , E P I D E M I O L O G Y, A N D P R E V E N T I O N R E S E A R C H 2 3
E .

•Estimate the costs of health outcomes (e.g., illness, death, and health-related

quality of life).

• Determine indirect costs, including work disability, lost productivity, and

general disability.

R e s e a rch Questions

Even if all of the strategies and activities proposed above were implemented successf u l l y, many questions would still remain about the surveillance and epidemiology of

arthritis and its prevention. Ongoing research in a variety of areas is needed to answer

these questions and further strengthen national and state efforts to prevent arthritis.

The following table lists several areas and related questions important in research.

2 4 N AT I O N A L A R T H R I T I S A C T I O N P L A N

A R E A Q U E S T I O N S

Case definition

Epidemiology 

• How do self-re p o rted diagnoses and symptoms re l a t e

to medical diagnoses?

• Is diagnosis of specific forms of arthritis necessary for

public health interv e n t i o n s ?

• Is the inflammatory / n o n i n f l a m m a t o ry arthritis distinction

u s e f u l ?

• Can we develop public health definitions for specific 

conditions?

• A re the 1990 American College of Rheumatology diagnostic criteria for fibromyalgia sensitive and specific?

• Who are the vulnerable high-risk populations?

• What is the incidence of common forms of arthritis? 

• What are the unique limitations in social participation 

experienced by children with arthritis (e.g., in school)? 

• What is the prevalence of less common forms of art h r i t i s ?

• What factors are responsible for racial diff e rences in

rates of total knee re p l a c e m e n t s ?

• What factors affect employment of people with art h r i t i s ?

• How does physical activity affect disability? 

• What are re s e a rch-based warning signs and symptoms

of art h r i t i s ?
I I I . S U R V E I L L A N C E , E P I D E M I O L O G Y, A N D P R E V E N T I O N R E S E A R C H 25

A R E A Q U E S T I O N S

Natural history 

Cost 

I n t e rv e n t i o n

• What is the nature, occurrence, and course of pain

symptoms; what are the responses to symptoms; and

what is the re l a t i o n s h i p of symptoms to objective criteria (e.g., pain threshold, depression, fatigue, sleep,

physical activity pattern s ) ?

• How does the presence of other conditions affect

arthritis outcomes? 

• Which factors contribute most to the development of

a rthritis? Can the onset of arthritis be postponed?

• Which types and sites of arthritis cause which types of disability? 

• How do the physical or occupational activity patterns of

people with arthritis change over time without intervention? 

• What are the outcomes of art h r i t i s ?

• How do medical/disease outcomes affect functional and

work status? 

• To what degree do sex, genetics, and race/ethnicity

a ffect the incidence, impact, and treatment outcomes of

d i ff e rent arthritis conditions?

• What are the intangible costs of art h r i t i s ?

• How can indirect costs be assessed fully and accurately?

• What are the direct and indirect economic costs to 

employers? 

• What are the most cost-effective exercise interv e n t i o n s ?

• How effective are clinical practice tools (e.g., practice

guidelines, care pathways) for early diagnosis and 

a p p ropriate management?

• A re disease-modifying drugs being used appropriately to

manage chronic inflammatory art h r i t i s ?

• What factors facilitate or hinder self-management and 

t reatment-seeking behaviors? 

• What strategies effectively reduce environmental barriers? 

• Which disability prevention strategies are most effective? 

• What factors are effective in promoting initial and continued participation in physical activity interventions? 

• How do community factors affect disability and quality of

l i f e ?
2 6 N AT I O N A L A R T H R I T I S A C T I O N P L A N

A R E A Q U E S T I O N S

I n t e rv e n t i o n

( c o n t i n u e d )

P re v e n t i o n

R e s e a rc h

• What types of interventions are culturally appropriate for

minority at-risk populations?

• What are the barriers to and facilitators of participation in 

physical activity interventions by minority at-risk populations? 

• Do diff e rent types and levels of physical activity aff e c t

the risk of art h r i t i s ?

• Do levels of physical activity recommended in P h y s i c a l

Activity and Health: A Report of the Surgeon General

d e c rease the risk of art h r i t i s ?

• How do outcomes of the early use of selected medications and surgical interventions compare with those of

s t a n d a rd tre a t m e n t ?

• How do self-management approaches differ in diff e re n t

social, cultural, and economic gro u p s ?

• Does participation in managed care change willingness

to seek care or patterns of diagnosis and tre a t m e n t ?

Does it affect access to specialized care ?

• Does engaging in the care-giving role change the likelihood of seeking care ?

• Do health care systems have appropriate numbers of

educated and trained primary care physicians to pro v i d e

a rthritis tre a t m e n t ?

• Is care-giving for a person with arthritis as consequential for the care-giver as for those caring for a person

with other chronic diseases (e.g., Alzheimer’s disease)?

• Does self-care for arthritis produce adequate independ e n c e ?

• Can activity limitation in arthritis be defined more completely than is usually done using Instrumental Activities

of Daily Living measure s ?

• What are the mechanisms by which low education levels

and low income increase the risk of art h r i t i s ?
I I I . S U R V E I L L A N C E , E P I D E M I O L O G Y, A N D P R E V E N T I O N R E S E A R C H 27

S U M M A RY OF SURVEILLANCE, EPIDEMIOLOGY, 

AND PREVENTION RESEARCH STRAT E G I E S

S u rv e i l l a n c e

1 . I m p rove surveillance of arthritis in general and of specific

types of arthritis at national and state levels.

2 . E n s u re standard and consistent use of data terms and

c o o rdinate use of arthritis databases.

3 . I n c rease understanding of current and future clinical tre a tments for art h r i t i s .

E p i d e m i o l o g y

1 . Develop population-based, longitudinal data systems to

track the occurrence, pro g ression, and impact of arthritis. 

2 . Identify modifiable risk factors to reduce the incidence of

and disability from art h r i t i s .

3 . Study the personal effects of art h r i t i s .

P revention Researc h

1 . Evaluate the efficacy and cost-effectiveness of current and

f u t u re interventions and community strategies. 

2 . Estimate the costs of arthritis in general and of specific

types of art h r i t i s .
B .

A . Guiding Principles 

Raising awareness of the impact of arthritis and of effective strategies for arthritis

prevention and treatment is an important objective of the NAAP. Two avenues are

available for achieving this objective: health communications and health education.

The former is designed to increase awareness — the first important step in changing

b e h a v i o r. The latter encompasses the entire spectrum of behavior change. 

Overarching principles for communicating about arthritis include the following: 

• Structure health communication messages and health education about arthritis to reach three broad audiences: the public, people with arthritis and their

families, and health professionals. 

•Tailor the content and delivery mode of messages for subgroups within each

of the three main audiences. 

• For all audiences, 

• Use factual information.

• Use correct and consistent terminology. 

•Convey that something can be done about arthritis.

Communication Strategies for the Public

This target audience, the broadest of the three, includes all Americans. A few subgroups are given a higher priority, however, because they have decision-making

power or authority, or because they are more likely to be affected by arthritis. These

priority audiences include

• People with arthritis symptoms. 

• At-risk populations (e.g., ethnic groups, medically underserved populations,

and groups with low socioeconomic status).

• Family members of people with arthritis.

•Wo m e n .

• Managed care organizations, payers, and members.

• Businesses and employers (including the public sector).

• Nontraditional partners (e.g., co-workers, neighbors, faith communities, Meals

on Wheels programs, and local merchants).

• Federal, state, and community government leaders.

4

S E C T I O N

2 9

I V. COMMUNICATION AND EDUCAT I O N
The predominance of misinformation about arthritis necessitates careful crafting of

public messages to provide accurate information and to challenge myths and erroneous beliefs. Key concepts to be emphasized include 

• Arthritis is a major national health problem and the leading cause of disability.

• Arthritis affects people of all ages, including children.

• Arthritis is a major health problem for women.

•Early diagnosis is a key to better outcomes; know the warning signs and seek

treatment early.

• All forms of arthritis can be treated; some can be prevented. Use weight control to prevent osteoarthritis. Physical activity, rest, and activity modification

can reduce pain and disability.

Three major strategies should be used to deliver these messages to the priority

public audiences:

1 . P romote partnerships to deliver consistent messages that re a c h

e n t i re populations. 

Because of the breadth of the audience needing arthritis-related messages and

the diversity of subpopulations within that audience, organizations and agencies

must pool their resources and efforts to deliver a consistent message. The prevalence of misconceptions regarding arthritis heightens the need for uniform messages among the various organizations delivering arthritis awareness messages.

Many communities have coalitions that address chronic diseases and their risk

factors. These coalitions should be encouraged to add arthritis awareness to

their educational campaigns.

• Identify national and state coalitions that address risk factors for arthritis.

• Strengthen collaborations among government agencies, voluntary health

agencies, and professional organizations.

•Coordinate a communication campaign on behalf of all partnership network

m e m b e r s .

• Seek and build on reliable sources of arthritis information, actions, and services. 

• Involve new and innovative partners (e.g., agricultural extension agents, Area

Agencies on Aging, city housing departments, employers, and religious

organizations) in disseminating key messages.

2 . Conduct market re s e a rch to shape the messages.

Because arthritis potentially affects all community members, arthritis-related

messages and delivery channels need to be tailored to appeal to different segments of the community. This degree of specification requires market research

3 0 N AT I O N A L A R T H R I T I S A C T I O N P L A N

When you have art h r i t i s ,

i t ’s a condition of your

life, and you can do

things to keep it at 

b a y, but it’ll always be

with you. That can be

f rustrating. I want to let

people know that you

can cope with art h r i t i s

and go on with your life.

I go on... I’m busy with

my career and raising

my child, and on bad

days I get my cane out. 

- AC T R E S S AN N I E PO T T S

( MA RY JO E SH I V E LY I N

T V ’S DE S I G N I N G WO M E N)

“

”
to both shape the message and delivery channels and test their effectiveness as awareness campaigns are developed.

• Identify subpopulations within target groups for arthritis messages.

• Design and implement behavioral research to determine the health practices

and media preferences of each target group. 

• Develop and test arthritis and disability messages for physical activity 

campaigns and nutrition and weight control programs.

• Develop messages about the importance of weight maintenance and 

physical activity.

• Produce materials that can be used by agencies and organizations that serve

target groups.

3 . I n c rease awareness throughout all communities. 

Arthritis affects nearly one of every six people and more than one of every three families. It touches people throughout the community: children in schools, employees

in the worksite, participants in senior centers, members of all faiths, and isolated

individuals living alone. Prevailing myths and misinformation (such as “There is

nothing you can do” or “Arthritis is an inevitable consequence of aging”) dominate

current arthritis information. Millions of advertising dollars are spent to promote

pain-relieving products for the “minor aches and pains of arthritis.” Accurate messages about arthritis must be disseminated throughout the community to counteract these erroneous perceptions. 

•Tailor messages and develop campaigns to reach people with undiagnosed arthritis and to prompt them to seek early diagnosis and appropriate management.

•Tailor messages about community norms for weight and physical activity.

• Develop messages about injury prevention.

• Add to existing physical activity campaigns messages about the role of physical activity in minimizing arthritis disability.

• Increase awareness of the link between arthritis and weight control, physical

a c t i v i t y, and nutrition.

• Use broad-based messages about the wide range of benefits of physical 

a c t i v i t y.

•Ensure that messages effectively counteract prevailing misconceptions.

•Create messages that challenge the “just learn to live with it” or the “stiff upper

l i p ” approach to arthritis management.

• Add arthritis prevention to sports education programs. 

• Include arthritis prevention messages in health education/healthy lifestyle

programs in schools and workplaces. 

I V. C O M M U N I C A T I O N A N D E D U C A T I O N 3 1
C . Communication Strategies for People with Arthritis and 

Their Families

This audience includes those referred to in the medical system as the patients —

anyone with any type of arthritis, regardless of age. It also encompasses families

(and significant others) of these patients. 

As for the public, market research is needed to shape effective messages for this

audience. Key concepts to be emphasized are

• Arthritis comes in many different forms; for management to be most effective, it is important to know your type of arthritis. 

•Effective interventions exist; seek treatment early, then continue to see your

doctor and follow your management plan. 

• Self-management can help improve quality of life. 

• Physical activity and maintenance of appropriate weight can reduce pain and

disability and promote general health.2 1

• Healthy living with arthritis is possible. 

The strategies outlined below should be implemented and rigorously tested to determine their relative effectiveness. 

1. Incorporate arthritis into chronic disease prevention, health

p romotion and education, and other programs of state and

local health depart m e n t s .

Several prevention strategies for arthritis are similar to risk-factor reduction

strategies for other chronic conditions. Many state and local health departments

already have programs directed toward increasing physical activity, promoting a

healthy diet, and reducing obesity. All of these programs could be modified to

incorporate an arthritis-specific message. In addition, state and local health

departments have the opportunity to design programs directed at reducing arthrit i s disability through appropriate prevention messages.

• Identify potential partners with similar messages.

• Develop arthritis-specific messages to be incorporated into physical activity,

weight control, and injury prevention campaigns.

• Develop and test communications messages directed at reducing arthritis 

d i s a b i l i t y.

• Provide funding for state health departments to develop programs to address

issues identified by analysis of data from state BRFSS arthritis modules (e.g.,

failure to seek diagnosis, failure to follow treatment plans).

•Encourage state and local health departments to make arthritis patient education materials available at all treatment sites.

3 2 N AT I O N A L A R T H R I T I S A C T I O N P L A N

I am proud of how far

I have come... from

the little girl who was

too embarrassed to

ask for help and who

let ‘Arthur’ rule her

emotions to a person

who has learned to

ask for help when

needed and who

rules ‘Arthur’ more

than he rules her.

- LINDA WILSON

“

”
• Facilitate partnerships between public health agencies and managed care

organizations to provide appropriate arthritis education across the natural disease spectrum, from prediagnosis through disability management, and in all

types of care settings (e.g., community-based care, in-home care).

2 . C reate national and local communication campaigns to motivate

people with arthritis symptoms to seek early diagnosis and appropriate management.

In addition to seeking appropriate medical care, people with arthritis must

become active self-managers if they are to successfully reduce the disability and

threats to quality of life that arthritis can pose. H o w e v e r, many people with arthritis are either unaware of self-management strategies or find the appropriate selfmanagement behaviors difficult to adopt. A comprehensive social marketing c a mpaign could increase awareness of appropriate self-management and also help

people with arthritis overcome their personal barriers to adopting appropriate

self-management behaviors.

•Convene a scientific panel to determine which self-management strategies are

most effective in reducing activity limitations. 

• Develop a social marketing campaign to move people with arthritis through the

stages of change necessary to adopt recommended self-management behaviors.

• Develop and disseminate a media campaign to promote the importance of

seeking early diagnosis for the type of arthritis, obtaining medical treatment,

and following prescribed management plans.

•Expand and update Arthritis Foundation booklets for people with arthritis.

• Adapt or develop educational materials for large minority groups (e.g.,

Hispanic, Chinese, Vi e t n a m e s e ) .

• Sponsor support groups that meet locally or through the Internet.

• Develop arthritis education materials for delivery through emerging technology vehicles such as interactive television, Internet, and CD ROM.

• Develop materials to educate family members on ways to facilitate appropriate

self-management and strategies to cope with their own arthritis-related stressors.

3 . I m p rove the ability of people with arthritis to make informed decisions about the use of unproven re m e d i e s .

Using unproven remedies for arthritis can waste time and money. Some

unproven remedies can be harmful to those who use them; others may not be

directly harmful but may cause people to delay seeking early diagnosis and approp r i a t e management. Because of their ongoing pain and lack of awareness of helpful intervention strategies, people with arthritis are particularly vulnerable to

promoters of unproven remedies.

I V. C O M M U N I C A T I O N A N D E D U C A T I O N 3 3
D .

• Develop and disseminate messages to inform people about unproven remedies and to explain how to evaluate the health claims of various products.

• Support efforts to monitor and restrict the untruthful promotion of unproven

remedies on the World Wide Web and other promotion avenues.

• Identify factors contributing to the use of unproven, harmful remedies and craft

messages to counteract those factors.

Communication Strategies for Health Pro f e s s i o n a l s

This audience includes all clinical, community, and public health professionals who

potentially affect the health and well-being of people with or at risk for arthritis.

Subgroups of the health professional audience include

• Primary health care providers, including pediatricians, who see the majority

of arthritis patients.

• R h e u m a t o l ogists, phys iatrists, orthopedic surgeons, pediatric rheumatologis t s ,

and other physicians.

• N u r s e s .

• Physical therapists and occupational therapists.

• Social workers and mental health workers.

•C h i r o p r a c t o r s .

• P o d i a t r i s t s .

• Orthotists and pedorthists.

•Exercise and fitness professionals, teachers, and coaches.

• Alternative medicine practitioners.

• P h a r m a c i s t s .

• Public health community members (e.g., educators, public health nurses, and

program managers). 

Although the specific message will vary for different types of providers, all of these

professionals must know

•The prevalence of arthritis and its impact on disability and quality of life.

•The most common myths about arthritis and accurate information to dispel

t h e m .

• Prevention strategies. 

•The importance of early diagnosis of the type of arthritis and appropriate

management strategies.

3 4 N AT I O N A L A R T H R I T I S A C T I O N P L A N
• Referral sources (i.e., when and where to refer).

• Sources of support.

•The value of self-management and other nonpharmacological interventions.

To be able to intervene early and appropriately to reduce disability, health professionals

must have accurate, up-to-date information about arthritis. The following approaches

should be tailored, based on behavioral research, to each type of health professional. 

1 . I m p rove the knowledge, attitudes, and practices of primary care

practitioners and other physicians through undergraduate and

graduate education, continuing medical education, and in-serv i c e

education. 

Because most people with arthritis initially see a primary care provider in their

quest for a diagnosis, primary care physicians are the first line of defense for the

early diagnosis and appropriate management of arthritis. Primary care training

programs vary in the amount of attention given to rheumatology training, even

though arthritis is one of the most common conditions seen by primary care physicians. Increased training and continuing medical education on arthritis would

address this discrepancy. Important topics include arthritis as a prototype chronic disease and the complementary roles of clinical care and community supports. 

• Provide professional education for primary care providers through partnerships with managed care organizations.

• Influence physician behavior through the use of “champions” and influential

opinion leaders.

• Partner with organizations that have expertise in medical education.

• Advocate for core rheumatology training in all primary care training programs.

•Test alternative delivery mechanisms such as interactive media or distance

learning to provide continuing medical education credits to busy physicians.

• Develop a training module that emphasizes the importance of early diagnosis

and appropriate management, the value of self-management, and other nonpharmacological strategies.

2 . I m p rove the knowledge, attitudes, and practices of other health

p rofessionals through undergraduate and graduate education,

continuing education, and in-service education. 

Similar to physicians, most health professionals receive a limited amount of education about rheumatology in their professional training programs but then see

many patients with arthritis (often as a concurrent condition) in clinical practice.

Health professionals need current rheumatology knowledge to ensure they are

providing competent care to their patients with arthritis. 

I V. C O M M U N I C A T I O N A N D E D U C A T I O N 3 5
• Partner with organizations that have expertise in providing professional

e d u c a t i o n .

• Develop short-term specialty training programs to increase health professionals’

arthritis expertise.

• Develop a training module that emphasizes the importance of early diagnosis

and appropriate management, the value of self-management, and other nonpharmacological strategies.

• Advocate for core rheumatology training in all health professional training

p r o g r a m s .

•Test alternative delivery mechanisms such as interactive media or distance

learning to provide continuing education credits to health professionals.

3 . Extend the reach of art h r i t i s - related messages by using communication vehicles such as state and county medical societies, state

and national professional organizations, professional newsletters

and conferences, and websites of professional organizations and

advocacy gro u p s .

The fast pace of the current medical practice environment makes it difficult for

physicians and other health professionals to attend all of the continuing education sessions they need. Consequently, they must be able to access arthritis information when they need it — without leaving their offices. Emerging technology

such as websites and listservs, as well as standard newsletters and journals, can

make arthritis information readily available. 

•Create a listserv for all physicians and health professionals who would like to

receive updates on arthritis information.

•Create a consortium of website links to relevant arthritis information and

education sites.

• Develop tailored arthritis education articles and disseminate to professional

and managed care organizations for publication in their newsletters.

3 6 N AT I O N A L A R T H R I T I S A C T I O N P L A N
R e s e a rch Questions

Even if these proposed strategies and activities were implemented effectively, many

questions would still need to be answered to ensure effective communication and

education. A few key research questions are highlighted below.

I V. C O M M U N I C A T I O N A N D E D U C A T I O N 3 7

E .

TARGET AUDIENCE

The public

People with arthritis 

and their families

Health pro f e s s i o n a l s

Q U E S T I O N S

• A re diff e rent messages and communication techniques more or

less useful among specific age, race, and ethnic subgroups and

g roups at diff e rent stages of change?

• Does recognition of early warning signs and symptoms result in

early diagnosis and appropriate management? 

• What messages and interventions result in appropriate behavior

changes for weight control and injury pre v e n t i o n ?

• What does the public know and believe about effective arthritis 

i n t e rvention strategies?

• What are employer and employee knowledge and attitudes about

the impact of arthritis on ability to work? 

• What public health or population-based programs are most eff e ctive in reducing pain and disability from art h r i t i s ?

• What methods are effective for teaching self-management on an

individual rather than a group basis?

• What factors encourage or inhibit seeking early treatment? 

• Which assistive devices are most likely to help people with art h r itis stay independent? 

• What are the comparative benefits of home-based, communitybased, and job site-based physical activity strategies? 

• What do people with arthritis know and believe about eff e c t i v e

a rthritis intervention strategies?

• How can use of self-management techniques be incre a s e d ?

• What factors encourage or inhibit physical activity among people

with arthritis? 

• A re managed care gatekeepers sufficiently aware of the signs

and symptoms of arthritis and types of arthritis? 

• What programs are successful in promoting early diagnosis?

• What communication strategies influence providers to adopt 

appropriate management strategies?
3 8 N AT I O N A L A R T H R I T I S A C T I O N P L A N

S U M M A RY OF COMMUNICATION 

AND EDUCATION STRAT E G I E S

For the Public

1 . P romote partnerships to deliver consistent messages that

reach entire populations. 

2 . Conduct market re s e a rch to shape the messages.

3 . I n c rease awareness throughout all communities. 

For People with Arthritis and Their Families

1 . Incorporate arthritis into chronic disease prevention, health

p romotion and education, and other programs of state and

local health depart m e n t s .

2 . C reate national and local communication campaigns to motivate people with arthritis symptoms to seek early diagnosis

and appropriate management.

3 . I m p rove the ability of people with arthritis to make inform e d

decisions about the use of unproven remedies. 

For Health Pro f e s s i o n a l s

1 . I m p rove the knowledge, attitudes, and practices of primary

c a re practitioners and other physicians through underg r a d uate and graduate education, continuing medical education,

and in-service education. 

2 . I m p rove the knowledge, attitudes, and practices of other

health professionals through undergraduate and graduate

education, continuing education, and in-service education.

3 . Extend the reach of art h r i t i s - related messages by using communication vehicles such as state and county medical societies, state and national professional organizations, pro f e ssional newsletters and conferences, and websites of pro f e ssional organizations and advocacy gro u p s .
A . Guiding Principles

This section describes recommended programs, policies, and systems at the national, state, and local levels to promote increased quality of life for people with arthritis and facilitate prevention measures. Efforts must be expanded beyond data and

communication to modify our social systems to deal appropriately with arthritis. We

must have

• A continuum of health services that includes primary, secondary, and tertiary

p r e v e n t i o n .

• A system of health services that bridges medical, voluntary, and public health

agencies. 

• Supportive policies to establish an environment conducive to preventive

e f f o r t s .

•Community norms that promote prevention and improved quality of life.

• A well-trained public health workforce to implement a national arthritis prevention effort.

Programs, policies, and systems are tools for effecting change.

P r o g r a m s are the actual implementation — at the national, state, and community

levels — of specific effective interventions for primary, secondary, and tertiary

p r evention of a public health problem. 

P o l i c i e s include legislation, regulations, ordinances, guidelines, and norms that

establish an environment conducive to prevention. Examples of national policies

are entitlement programs (e.g., Medicare and Medicaid) and the Americans with

Disabilities Act. Policies at the state and community levels influence public health

efforts as well.

S y s t e m s are the health infrastructure required to operate and manage effective

prevention programs. As our health care system continues to evolve, delivery of

quality care becomes more complex. Relationships among the public and private

sectors, individual practitioners and managed care organizations, and voluntary

health organizations directly influence access to care and provision of clinical and

community preventive services.

Strategies and activities supporting each of these components are presented in the following sections.

5

S E C T I O N

3 9

V. PROGRAMS, POLICIES, AND SYSTEMS
B . P rogram Strategies

Key prevention techniques are identified in the Background section. Program strategies for promulgating these prevention techniques are twofold:

1 . Develop and disseminate primary, secondary, and tert i a ry pre v e ntion intervention programs. 

Self-management education and exercise programs have beneficial effects for

people with arthritis.2 0 , 2 1 , 2 8 Maintaining appropriate weight can reduce the risk of

developing osteoarthritis, and getting regular physical activity can reduce disability from arthritis. However, these interventions are underused. People with

arthritis have low levels of physical activity, even when their disability is taken

into account.6 The following activities should target whole populations as well as

specific at-risk groups.

•Conduct model demonstration programs to assess the effectiveness of

interventions.

• Use pilot tests and demonstration programs to better define effective interventions in various settings.

• Identify and facilitate the dissemination of effective program or intervention

research. 

• Pilot test alternative delivery mechanisms to reach underserved populations. 

• Develop and evaluate model programs for weight control and physical activity. 

•Test weight control strategies among people with arthritis. 

• Develop telephone service for arthritis education and support to decrease

disability.

• Facilitate the widespread dissemination of self-management programs, with possible funding by the pharmaceutical industry or managed care organizations.

•Promote responsible use of medication.

• Promote implementation of self-management programs in work settings.

2 . Develop and disseminate arthritis management education programs for health pro f e s s i o n a l s .

Most people with arthritis are seen by primary care providers; many are told initially that “it’s only arthritis” or “it’s arthritis so there’s nothing we can do.” These

dismissive responses waste the opportunity for early intervention. Similarly, many

providers overlook nonpharmacological interventions that may reduce disability.

Because of the widespread prevalence of arthritis, all health care providers need

up-to-date information on treating and managing arthritis. Primary care p r o v i d e r s

also need to know when to refer patients to rheumatologists, orthopedists, and

other specialists. 

4 0 N AT I O N A L A R T H R I T I S A C T I O N P L A N

The healthcare

system has not 

yet recognized 

the crucial role

patients have in 

their own selfmanagement. 

- HA L S T E D R. HO L M A N, MD 

“

”
C .

•Emphasize nonpharmacological management strategies in primary care training programs. 

• Develop training modules that emphasize the importance of early diagnosis

and appropriate management and the value of self-management and other

nonpharmacological strategies.

• Incorporate training modules on arthritis management into programs that

train nontraditional health care providers.

Policy Strategies 

Certain policies, if widely adopted, would greatly enhance the chances of success in

preventing arthritis and improving the quality of life of those affected by this condition. These policies can best be built around the following strategies. 

1 . C reate awareness of arthritis as a public health issue.

Before effective arthritis-related policies can be developed, policy makers must

be aware that arthritis is an important public health issue. This awareness has

been limited by prevailing misconceptions of arthritis as just minor aches and

pains resolved by simple pain relievers, by lack of recognition of the high prevalence of arthritis, and by a lack of understanding of the significant financial and

human costs of arthritis to American society. Policy makers need to be educated

about arthritis’ effects on society and the success of intervention programs; only

then can they develop relevant arthritis-related policies. 

•Educate policy makers on the health burden and costs of arthritis.

• Promote the recognition of arthritis as both a women’s health and a minority

health issue.

•Collaborate with state public health officials to ensure that they have the

information they need to better address arthritis in their states.

• Include arthritis in federal health and disability policies that are not intended

to be specifically for persons with arthritis (e.g., those related to the Americans

with Disabilities Act).

• Develop grassroots activities to focus attention on arthritis issues in individual

s t a t e s .

• Delineate the continuum of primary, secondary, and tertiary prevention strategies and indicators of success to guide policy and other decision makers.

• Develop a policy requiring managed care organizations to cover any intervention proven to be cost-effective. 

2 . Incorporate arthritis objectives into Healthy People 2010.

The nation will not be able to achieve its goal of increasing years of healthy life

unless we are able to address arthritis, the leading cause of disability. It is essent i a l

V . P R O G R A M S , P O L I C I E S , A N D S Y S T E M S 41
D .

to include arthritis objectives in Healthy People 2010, future versions of this document, and other long-term projections of health policy issues. 

• Submit arthritis objectives to be included in Healthy People 2010.

• Monitor success in achieving Healthy People 2010 arthritis objectives.

System Strategies 

A strong public health infrastructure is essential to carrying out the strategies outlined in this Plan. Specific strategies follow for strengthening the infrastructure to

effectively support arthritis prevention and intervention activities. 

1 . Build arthritis capacity and competency into the public health infras t ru c t u re .

Public health agencies are just beginning to turn their attention to the public health

implications of arthritis. An investment of time and human resources will ensure

that an infrastructure is in place for managing effective public health programs.

• Devise programs to attract a variety of professionals to the arthritis field.

• Support activities to attract professionals to rheumatology-related specialties.

•Expand training in health education, prevention research and translation.

•Establish an arthritis office or program at CDC.

• Build capacity at the state level for professional and public education, linkages

with external partners, data collection and analysis, technical assistance and

training, and strategic planning to address all subpopulations (especially

minorities and women).

• Support comprehensive statewide public programs to implement strategic

plans in collaboration with managed care and other health delivery systems

and with other public health prevention programs.

• Develop a resource manual and slide presentation on how to define the arthritis

problem in a community.

• Provide financial and technical assistance to states for data collection and analysis, training, and strategic planning.

2 . Modify health care systems to better meet the needs of people

with art h r i t i s .

Existing health care systems, which were built around the need for acute care,

are not well structured to meet the needs of people with arthritis and other c h r o nic diseases. These systems must be modified to ensure that people with arthritis

get the care they need at the appropriate time and place. They also must be

staffed with sufficient numbers of qualified health care professionals, including

primary care practitioners and specialty care providers. 

4 2 N AT I O N A L A R T H R I T I S A C T I O N P L A N
• Develop arthritis indicators for performance measurement as used by the

Health Plan Employer Data and Information Set (HEDIS) and the Foundation

for Accountability (FA C C T ) .

• Gather and evaluate data to identify critical performance indicators that can

help track progress toward improved health outcomes from clinical care.

•Establish standard reportable outcome measures.

•Establish guidelines or standards of care for arthritis.

•Ensure that adequate numbers of primary care and specialty providers are

trained to deliver quality care.

•Ensure that providers are reimbursed for effective intervention strategies, including nonpharmacological, educational, and support strategies.

• Link provider compensation with good arthritis outcomes.

•Educate the health care system about the true costs of arthritis, both the direct

medical costs and the indirect personal and societal costs, including lost wages

and productivity.

• Improve standard methodologies to measure the indirect costs of arthritis.

• Build self-management education programs, such as the Arthritis Self-Help

Course, into routine arthritis care.

• Implement population-based arthritis surveillance and intervention strategies

in managed care organizations.

•Encourage the development and implementation of appropriate physical

activity programs for people with arthritis.

• Facilitate access to care for medically underserved people with arthritis.

3 . Build state and local interagency alliances to address art h r i t i s .

Addressing arthritis will require the coordinated work of multiple organizations,

including governmental, public, and private organizations; public health, medical care, and social service agencies; and a variety of nontraditional partners

including Area Agencies on Aging, American Association of Retired Persons,

Arthritis Foundation chapters, faith communities, and other community groups.

To o p t i m i ze the use of r e s o u r c e s, these e f f o r t s should be c o o r d i n a t e d by a

unified vision. 

• Build collaborations between managed care organizations and public health

a g e n c i e s .

• Strengthen alliances among community organizations (e.g., state health

departments, Arthritis Foundation chapters, Medicaid agencies, voluntary

health agencies, American Association of Retired Persons, Area Agencies on

Aging, senior centers, and churches).

V . P R O G R A M S , P O L I C I E S , A N D S Y S T E M S 4 3
•Explore the value of establishing arthritis advisory boards or incorporating

arthritis into existing advisory boards with similar goals.

• Develop a community resource package on how to promote early diagnosis

and appropriate management of arthritis in a community.

• Develop a community resource package on how to delay arthritis-related disability in a community.

• Form alliances with organizations that focus on weight control and physical activity. 

• Develop linkages with Neighborhood Settlement Houses and Community Free

C l i n i c s.

4 . Ta rget state and local eff o rts to those at greatest risk of art h r i t i s .

Focusing energy and resources on those at greatest risk of arthritis and its related disability is likely to produce the greatest return on investment.

•Examine the utility of existing sources of state-level data for assessing the burden and

risks associated with arthritis (e.g., hospitalization, long-term care, and disability).

• Promote the use of the arthritis and quality of life BRFSS modules to identify populations and regions with the greatest burden of arthritis and related disability.

•Encourage strategic planning that focuses on populations in greatest need and at

greatest risk. 

4 4 N AT I O N A L A R T H R I T I S A C T I O N P L A N

S o u rce: CDC. Arthritis prevalence and activity limitations –

United States, 1990. M M W R 1994; 43( 24) : 4 33-4 3 8 .

10 .0% – 13.9%

14.0% – 15.9%

16 .0% – 19.1 %

S t a te-Specific Prevalence of Self-R e p o rted Arthritis United States, 199 0

N H

VT

CT

MA

M D

NJ

RI

DC

D E
E . R e s e a rch Questions

Research on the following priority questions would further strengthen programs, polic i e s , and systems related to arthritis prevention. 

V . P R O G R A M S , P O L I C I E S , A N D S Y S T E M S 4 5

• What motivates people with arthritis to participate in physical activity and

other self-management pro g r a m s ?

• Which self-management programs are most effective in community settings? 

• Which interventions are most effective in moving individuals with art h r i t i s

t h rough the stages of behavior change needed to increase the fre q u e n c y

of physical activity and other self-management behaviors?

• What are appropriate outcome indicators?

• What community, environmental, and worksite modifications can best help

people with arthritis maintain or improve their function, independence, and

quality of life?

• How well does the Americans with Disabilities Act serve people with

a rt h r i t i s ?

• Do determinations of disability by the Social Security Administration, as

well as other federal policies, meet the needs of people with arthritis for

independence, employment, and community involvement?

• To what extent are rheumatic diseases included in the Social Security

A d m i n i s t r a t i o n ’s list of disabilities? 

• What policy modifications will help people with arthritis remain in the

w o r k f o rc e ?

• What medication reimbursement plans facilitate optimal arthritis care? 

• How can collaborations between public health and medical care systems

be fostered? 

• Does the continuity of care in managed care settings differ from that in

other health care delivery settings?

• What is the optimum continuum and organization of care and who are

a p p ropriate pro v i d e r s ?

• What nonpolicy barriers prevent people with arthritis from participating in

the workforce? 

• What re f e rral patterns are commonly used for people at risk of art h r i t i s ?

For people with art h r i t i s ?

• How can we use arthritis as an indicator condition for quality of care in

managed care ?

A R E A Q U E S T I O N S

P rograms 

Policies 

Systems 
4 6 N AT I O N A L A R T H R I T I S A C T I O N P L A N

S U M M A RY OF PROGRAMS, POLICIES, 

AND SYSTEMS STRAT E G I E S

P ro g r a m s

1 . Develop and disseminate primary, secondary, and tert i a ry

p revention intervention pro g r a m s .

2 . Develop and disseminate arthritis management education

p rograms for health professionals. 

P o l i c i e s

1 . C reate awareness of arthritis as a public health issue.

2 . Incorporate arthritis objectives into Healthy People 2010.

S y s t e m s

1 . Build arthritis capacity and competency into the public

health infrastru c t u re. 

2 . Modify health care systems to better meet the needs of

people with art h r i t i s .

3 . Build state and local interagency alliances to address art h r i t i s .

4 . Ta rget state and local eff o rts to those at greatest risk of

a rt h r i t i s .
A . General Considerations

Critical to the ultimate success of any strategic plan are indicators with which to

gauge progress. These should be established, along with a system for measuring them.

Indicators drawn from the activities outlined in this Plan might include the following: 

S u rveillance, Epidemiology, and Prevention Researc h

• Incidence and prevalence rates of specific types of arthritis.

•Early diagnosis rates. 

• Percentage of people with arthritis symptoms who have not received an arthritis diagnosis.

• Percentage of people with diagnosed arthritis who can identify their specific

type of arthritis. 

• O b e s i t y, lack of physical activity, and other risk factor rates in the general population and among people with arthritis.

• Percentage of people with arthritis changing their behavior in ways that will

alleviate arthritis symptoms (e.g., adopting regular physical activity).

• Percentage of population covered by arthritis surveillance.

• Sentinel events such as joint replacement and nursing home admission among

people with arthritis.

• Percentage progressing from risk factors to disease and from disease to disability in key populations.

Communication and Education

• Percentage of the public knowledgeable about arthritis symptoms, prevalence, impact, outcomes, and prevention.

• Percentage of health professionals knowledgeable about the prevention, differential diagnosis, early diagnosis, and appropriate management of arthritis.

• Percentage of people with arthritis who are aware of two or more arthritis

interventions. 

P rograms, Policies, and Systems

• Percentage of federal health funds dedicated to arthritis.

• Number of federal staff dedicated to arthritis at CDC, the National Institutes

of Health, the Agency for Health Care Policy and Research, and the Ve t e r a n s

A d m i n i s t r a t i o n .

6

S E C T I O N

47

VI. IMPLEMENTAT I O N
B .

• Number of state and local public health staff dedicated to arthritis.

• Incorporation of arthritis issues into other areas, such as disability, aging, and

w o m e n ’s health.

• Percentage of people with arthritis who are satisfied with health services.

• P e r c e n t a g e of health research budgets dedicated to arthritis.

• Percentage of health maintenance and managed care organizations offering

arthritis self-management strategies as part of their benefit package.

• Percentage of people with arthritis who maintain their desired level of participation in the workforce.

Priority Strategies for Early Implementation

Of all the recommended strategies, the following can be viewed as high priority —

either because of their potential impact or because they can be implemented quickly

with minimal cost: 

S u rveillance, Epidemiology, and Prevention Researc h

• Determine arthritis prevalence using accepted, standardized definitions and

describe the natural history of these diseases.

• Validate self-report measures.

•Evaluate prevention interventions.

• Define risk factors for arthritis. 

Communication and Education

• Determine the level of knowledge of public health professionals regarding

arthritis prevention, early diagnosis, and appropriate management. 

•Educate providers and the public that arthritis is not a normal part of aging,

that there are different types of arthritis, that arthritis affects people as early as

i n f a n c y, and that treatment interventions are available.

• Promote the value of early diagnosis and appropriate management, including

s e l f - m a n a g e m e n t .

• Facilitate the collection and dissemination of information about existing state

and local arthritis programs.

P rograms, Policies, and Systems

•Establish focal points for arthritis programs in state health departments (e.g.,

in chronic disease and health promotion program areas).

4 8 N AT I O N A L A R T H R I T I S A C T I O N P L A N
C .

•Encourage health systems, such as managed care organizations and Medicaid

and Medicare programs, to adopt arthritis prevention recommendations and

to know when to seek expert consultation. 

• Develop public-private arthritis education programs for people with arthritis

and health professionals.

Next Steps 

The impact of arthritis on Americans, both now and in the decades ahead, is clear

and profound. A variety of effective prevention interventions, if applied appropriately and effectively, could significantly improve the quality of life of people with or

at risk for arthritis and their families. Arthritis prevention has the potential to become

a model for collaboration between public health and clinical care professionals in

addressing a chronic condition of significant magnitude and cost. 

It is no accident that the development of the National Arthritis Action Plan: A

Public Health Strategy coincides with the fiftieth anniversary of the Arthritis

Foundation. To date, the Foundation has been the primary voice and advocate for

people with arthritis and their families. The time has come to strengthen that voice

by applying the collective energy and resources of the public and private sectors.

This strategic plan sets in motion a course of action for establishing partnerships,

making arthritis a prominent public health issue, and preparing society for concerted efforts to prevent arthritis and many other chronic conditions. 

The Plan’s development was a collaborative effort of public health, medical, and

voluntary health organizations and agencies under the leadership of the Arthritis

Foundation, the Association of State and Territorial Health Officials, and the

Centers for Disease Control and Prevention. Similarly, implementing the Plan will

require ongoing collaboration and partnership because no single organization can

effectively address the burden of arthritis alone. To capitalize on the specialized

knowledge and expertise of various collaborating partners, public-private partnerships, some established through requests for proposals, contracts, and cooperative

agreements, will be used to implement discrete elements of the Plan. 

With the Plan as a guide, and with dedication and persistence, we can indeed

lessen the burden of arthritis on the health of our nation.

V I . I M P L E M E N T AT I O N 4 9
5 0 N AT I O N A L A R T H R I T I S A C T I O N P L A N

A P P E N D I X A WORKING GROUP MEMBERS

American Association of Health Plans

Richard Raskin, M.D., F. A . C . P.

Medical Director, Quality Management

Personal Care Insurance Company of Illinois

101 West University Av e n u e

Champaign, Illinois 61820

(217) 366-8766

r r a s k i n @ c h r i s t i e c l i n i c . c o m

American College of Physicians - American

Society of Internal Medicine

Mary E. Moore, M.D., Ph.D.

Emeritus Head, Division of Rheumatology

Albert Einstein Medical Center

12th Street and Tabor Road

Korman Building

Suite 103

Philadelphia, Pennsylvania 19141

(215) 456-7380

m m o o r e m d @ v m . t e m p l e . e d u

American College of Rheumatology

Rosemarie Hirsch, M.D., M.P. H .

National Center for Health Statistics

6525 Belcrest Road

Presidential Building

Room 900

Hyattsville, Maryland 20782

(301) 436-7072

r r h 7 @ c d c . g o v

Marc Hochberg, M.D., M.P. H .

Division of Rheumatology

University of Maryland

10 Pine Street MSTF 8-34

Baltimore, Maryland 21201

(410) 706-6474

m h o c h b e r @ u m a b n e t . a b . u m d . e d u

Arthritis Foundation

Leigh Callahan, Ph.D.

Associate Director

Thurston Arthritis Research Center

University of North Carolina

3330 Thurston Building, CB #7280

Chapel Hill, North Carolina 27599

(919) 966-0564

l e i g h _ c a l l a h a n @ m e d . u n c . e d u

Kathleen Ferrell, P. T., M.L.A.

Associate Director

Washington Univ. Regional Arthritis Center

Division of Rheumatology

Box 8045

60 South Euclid

Saint Louis, Missouri 63110

(314) 454-7263

kferrell@imgate.wustl.edu 

Dawn Hafeli

Vice President for Programs

Arthritis Foundation, Michigan Chapter

17117 West Nine Mile Road 

Suite 950

Southfield, Michigan 49075

(248) 424-9001

d h a f e l i @ a r t h r i t i s . o r g

Susan Nesci, M.S., M.A., C.H.E.S.

Program Director

Arthritis Foundation, Southern New England

C h a p t e r

35 Cold Spring Road 

Suite 411

Rocky Hill, Connecticut 06067

(860) 563-1177

s n e s c i @ a r t h r i t i s . o r g .

Susan Wozenski, M.P.H., J.D.

Assistant Dean for Student Affairs

University of Maryland School of Nursing

1002 Chestnut Ridge Drive

Lutherville, Maryland 21093

(410) 706-0447

w o z e n s k i @ n u r s e - 1 . a b . u m d . e d u

Edward H. Yelin, Ph.D.

Arthritis Research Group 

University of California

1388 Sutter Street 

Suite 700

San Francisco, California 94143

(415) 476-9027

y e l i n 2 @ i t s a . u c s f . e d u
A P P E N D I X A — W O R K I N G G R O U P M E M B E R S 5 1

A P P E N D I X A WORKING GROUP MEMBERS

Association of Rheumatology Health

P r o f e s s i o n a l s

Marian T. Hannan, D.Sc., M.P. H .

1200 Center Street

Boston, Massachusetts 02131-1097

(617) 325-8000 X491

h a n n a n @ m a i l . h r c a . h a r v a r d . e d u

Margaret Lethbridge-Cejku, Ph.D.

Gerontology Research Center

Box 04

N I A / N I H

4940 Eastern Av e n u e

Baltimore, Maryland 21224

(410) 588-8402

p e g g y c @ v a x . g r c . n i a . n i h . g o v

Association of Schools of Public Health

Robert F. Meenan, M.D., M.P.H., M.B.A. 

Dean, School of Public Health

Boston University

715 Albany Street

Suite 130

Boston, Massachusetts 02215

(617) 638-4644

r m e e n a n @ b u . e d u

Association of State and Territorial Chronic

Disease Directors

Frank Bright, M.S.

C h i e f

Bureau of Health Promotion and 

Risk Reduction

Ohio Department of Health

246 North High Street

P.O. Box 11

Columbus, Ohio 43266-0118

(614) 466-2144

f x b 0 @ c d c . g o v

Association of State and Territorial Directors

of Health Promotion and Public Health

E d u c a t i o n

Steve Knobloch, M.P.H., C.H.E.S.

Illinois Department of Health

535 West Jefferson Street

Springfield, Illinois 62761

(217) 785-2060

s k n o b l o c @ i d p h . s t a t e . I L . U S

Association of State and Territorial Health

O f f i c e r s

Charles Danielson, M.D.

P.O. Box 369

Wayne, Maine 04282

(207) 873-KIDS (o)

(207) 685-3669 (h)

Division of Nutrition and Physical Activity,

National Center for Chronic Disease

Prevention and Health Promotion, CDC

David Brown, Ph.D.

Physical Activity and Health Branch

Division of Nutrition and Physical Activity

National Center for Chronic Disease Prevention

and Health Promotion

Centers for Disease Control and Prevention

MS K-46

4770 Buford Highway, N.E.

Atlanta, Georgia 30341

(770) 488-5526

d r b 8 @ c d c . g o v

Office on Disability and Health, National

Center for Environmental Health, CDC

Don Lollar, Ed.D.

Office on Disability and Health

National Center for Environmental Health

Centers for Disease Control and Prevention

MS F-29

4770 Buford Highway, N.E.

Atlanta, Georgia 30341

(770) 488-7094

d c l 5 @ c d c . g o v

Office of Wo m e n ’s Health, Office of the

D i r e c t o r, CDC

Wanda Jones, Dr. P. H .

Current address:

Deputy Assistant Secretary for Health 

( Wo m e n ’s Health)

U.S. Department of Health and 

Human Services

200 Independence Avenue, S.W., Room 712E

Washington, D.C. 20201

(202) 690-7650

w j o n e s @ o s o p h s . d h h s . g o v
5 2 N AT I O N A L A R T H R I T I S A C T I O N P L A N

A P P E N D I X A WORKING GROUP MEMBERS

Council of State and Territorial 

E p i d e m i o l o g i s t s

Norma Kanarek, Ph.D., M.P. H .

Chronic Disease Epidemiologist

Maryland Department of Health and Mental 

H y g i e n e

201 West Preston Street, Room 225

Baltimore, Maryland 21201

(410) 767-5944

k a n a r e k n @ d h m h . s t a t e . m d . u s

k a n a 1 0 0 w @ c d c . g o v

Health Care Financing Administration

Michael Lyman, M.P.H., R.N.

E p i d e m i o l o g i s t

H C FA / O C S Q / Q M H A G

7500 Security Boulevard

Baltimore, Maryland 21244-1850

(410) 767-5944

m l y m a n @ h c f a . g o v

Alliance of Community Health Plans

(Formerly The HMO Group)

Daniel Wo l f s o n

President and Chief Executive Officer

100 Albany Street

Suite 130

New Brunswick, New Jersey 08901-1227

(732) 220-1388

d a n t h m o g e r @ a o l . c o m

National Association of State Units on Aging

Theresa Lambert, M.Ed.

Associate Director

National Association of State Units on Aging

1225 Eye Street, N.W.

Suite 725

Washington, District of Columbia 20005

(202) 898-2578

s t a f f @ n a s u a . o r g

National Institute of Arthritis,

Musculoskeletal, and Skin Diseases, NIH

Reva Lawrence, M.P. H .

Epidemiology/Data Systems Program Officer

N I A M S / N I H

Building 45 

Room 5As13

45 Center Drive MSC 6500

Bethesda, Maryland 20892-6500

(301) 594-5014

r l 2 7 b @ n i h . g o v

National Institute on Aging, NIH

Sidney M. Stahl, Ph.D.

Chief, Health Care Organization and Older 

People in Society

N I A / N I H

Gateway Building #533

7201 Wisconsin Av e n u e

Bethesda, Maryland 20892-9205

(301) 402-4156

S i d n e y _ s t a h l @ n i h . g o v

Older Wo m e n ’s League

Kathryn Ceja

Older Wo m e n ’s League

666 11th Street, N.W.

Suite 700

Washington, District of Columbia 20001

(202) 783-6686 ex. 224

Prevention Research Centers

Donald Patrick, Ph.D., M.S.P.H. 

Box 357660

University of Wa s h i n g t o n

Seattle, Washington 98195-7660

(206) 616-2981

d o n a l d @ u . w a s h i n g t o n . e d u

Washington Business Group on Health

Ellen Abisch, M.S., R.N.

M a n a g e r

Pepsico, Inc.

700 Anderson Hill Road

Mail Drop 113

Purchase, New York 10577-1444

(914) 253-2728

e l l e n . a b i s c h @ p e p s i c o . c o m

Arthritis Foundation Staff

Teresa Brady, Ph.D. 

Doyt Conn, M.D. 

Patricia Drehobl, R.N., M.P. H .

Jamila Fonseka, M.P.H., C.H.E.S.

Centers for Disease Control and Prevention,

National Center for Chronic Disease

Prevention and Health Promotion, Office of 

the Director and Division of Adult and 

Community Health Staff

Jeanne Alongi, M.P. H .

Michael Gay, M.S.Ed.

Andree Harris 

Charles Helmick, M.D.

James Holt, M.P. A .
A P P E N D I X B — S T A T E H E A LT H D E P A R T M E N T R E V I E W E R S 5 3

A P P E N D I X B S TATE HEALTH DEPA RTMENT REVIEWERS

I l l i n o i s

Edie Sternberg, M.P.H., C.H.E.S.

Division of Chronic Disease

Illinois Department of Public Health

535 West Jefferson Street

Springfield, IL 62671

(217) 758-2060

K a n s a s

Paula F. Marmet, M.S., R.D.

D i r e c t o r

Bureau of Disease Prevention and 

Health Promotion

Kansas Department of Health and Environment

109 S.W. 9th Suite 605

Topeka, KS 66612

(785) 296-8126

M a i n e

Randy Schwartz, M.S.P. H .

D i r e c t o r

Director of Community Health and 

Family Health

Maine Department of Human Services

Bureau of Health

State House Station #11

Augusta, ME 04333-0011

(207) 287-5180

M i s s o u r i

Jeannette Jackson-Thompson, Ph.D.

Missouri Department of Health

101 Park de Ville Drive, Suite A

Columbia, Missouri 65203

(573) 876-3283

M o n t a n a

Robert W. Moon, M.P. H .

C h i e f

Health System Bureau

Montana Department of Public Health and 

Human Services

Cogswell Building, Room A206

Helena, MT 59620

(406) 444-4488

New Mexico

Lydia Pendley, M.A.

C h i e f

Office of Health Promotion and Health 

Systems Bureau

New Mexico Department of Health

1190 St. Francis Drive

P.O. Box 26110

Santa Fe, NM 87502

(505) 827-2380

New Yo r k

David C. Momrow, M.P. H .

D i r e c t o r

Division of Chronic Disease Prevention 

and Adult Health

New York State Department of Health

Room 515

Corning To w e r

Empire State Building

A l b a n y, NY 12237

(518) 474-0512
5 4 N AT I O N A L A R T H R I T I S A C T I O N P L A N

A P P E N D I X C PA RTNERSHIP NETWORK

Administration on Aging 

Agency for Health Care Policy and Research

American Academy of Nurse Practitioners

American Academy of Orthopaedic Surgeons

American Academy of Pediatrics

American Academy of Physical Medicine and Rehabilitation 

American Academy of Physician Assistants

American Association of Retired Persons

American College of Osteopathic Family Physicians

American Geriatrics Society

American Medical Association

American Physical Therapy Association

American Public Health Association

Association for Health Services Research

Association of Teachers of Preventive Medicine

Association of Wo m e n ’s Health, Obstetric, and Neonatal Nurses

Centers for Disease Control and Prevention

National Center for Environmental Health

National Center for Health Statistics

National Center for HIV, STD, and TB Prevention

National Center for Infectious Diseases

National Center for Injury Prevention and Control

National Institute for Occupational Safety and Health

Office for Minority Health

Fibromyalgia Association of Greater Washington, Inc.

Gerontological Society of America

Health Resources and Services Administration

Indian Health Service

Multipurpose Arthritis and Musculoskeletal Diseases Centers

Boston University 

Brigham and Wo m e n ’s Hospital

Case Western Reserve University

Indiana University – Purdue University at Indianapolis

Northwestern University 

University of Alabama at Birmingham

University of California, San Francisco

University of Connecticut Health Center

University of North Carolina at Chapel Hill

University of Pittsburgh

National Association of Orthopaedic Nurses

National Council on the Aging

National Council on Disability
A P P E N D I X C — P A RT N E R S H I P N E T W O R K 5 5

A P P E N D I X C PA RTNERSHIP NETWORK

National Gerontological Nursing Association

National Institute for Disability Rehabilitation Research, Department of Education

National Institutes of Health

National Human Genome Research Institute

National Institute on Child Health and Human Development

National Institute of Nursing Research

Office on Disability Social Security Administration, Social Security Administration

Office of Disease Prevention and Health Promotion, U.S. Department of Health 

and Human Services

Office on Wo m e n ’s Health, U.S. Department of Health and Human Services 

Partnership for Prevention

Prevention Research Centers

Columbia University Harlem Center for Health Promotion and Disease Prevention

University of Alabama at Birmingham Center for Health Promotion

University of Illinois at Chicago Prevention Research Center

University of New Mexico Center for Health Promotion and Disease Prevention

University of North Carolina at Chapel Hill Center for Health Promotion and 

Disease Prevention

University of South Carolina at Columbia Center for Health Promotion and 

Disease Prevention

Public Health Foundation

Society for Public Health Education 

Spondylitis Association of America
5 6 N AT I O N A L A R T H R I T I S A C T I O N P L A N

A P P E N D I X D PROPOSED HEALTHY PEOPLE 2010 OBJECTIVES

P roposed Healthy People 2010 A rthritis-Related Objectives

September 15, 1998

Chapter 16. Arthritis, Osteoporosis, and Chronic Back Conditions

1 . Increase mean days without severe pain for U.S. adults with arthritis to more than 20 of the past 30 days. (Baseline: 16.0

days in 1995)

2 . Reduce to no more than 15 percent the proportion of people with arthritis who experience a limitation in activity due

to arthritis. (Baseline: 18.4 percent in 1990)

3 . Reduce the proportion of all people with arthritis who have difficulty in performing two or more personal care activities, thereby preserving independence.

4 . Increase the proportion of people with arthritis aged 18 and older who seek help in coping with personal and emotional problems.

5 . Increase the proportion of the working-age population with arthritis who desire to work (i.e., both those who are employed

and those who are unemployed but looking for work, called the labor force participation rate) to 60 percent. (Baseline: 45

percent in 1994)

6 . Reduce racial differences in the rate of total knee replacement for severe pain and disability.

7 . Decrease to 5 percent the proportion of individuals who report they have arthritis but have not seen a doctor for it.

(Baseline: 16.4 percent in 1990)

8 . Increase the early diagnosis and appropriate treatment of individuals with systemic rheumatic diseases.

9 . Increase the proportion of people with arthritis who have had effective, evidence-based arthritis education (including

information about community and self-help resources) as an integral part of the management of their condition.

1 0 . Increase the proportion of hospitals, managed care organizations, and large group practices that provide effective, evidence-based arthritis education (including information about community and self-help resources) as an integral part of

the management of their condition.

1 1 . Increase the proportion of overweight people with arthritis who have adopted some dietary practices combined with regular physical activity to attain an appropriate body weight. 

Chapter 1. Physical Activity and Fitness

1 2 . Increase to 85 percent the proportion of people aged 18 and older who engage in any leisure time physical activity.

(Baseline: People with arthritis symptoms—65 percent in 1991; People without arthritis symptoms—72 percent in

1 9 9 1 )

1 3 . Increase to at least 30 percent the proportion of people aged 18 and older who engage regularly, preferably daily, in sustained physical activity for at least 30 minutes per day. (Baseline: People with arthritis symptoms—21 percent in 1991;

People without arthritis symptoms—22 percent in 1991)

1 4 . Increase to at least 25 percent the proportion of people aged 18 and older who engage in vigorous physical activity that

promotes the development and maintenance of cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion. (Baseline: People with arthritis symptoms—11 percent in 1991; People without arthritis symptoms—

16 percent in 1991)

Chapter 2. Nutrition

1 5 . Increase to at least 60 percent the prevalence of healthy weight (defined as a BMI equal to or greater than 19.0 and less

than 25.0) among all people aged 20 and older. (Baseline: males and females with and without arthritis)

1 6 . Reduce to less than 15 percent the prevalence of BMI at or above 30.0 among people aged 20 and older. (Baseline: males

and females with and without arthritis)
R E F E R E N C E S 57

R E F E R E N C E S

1 . CDC. Prevalence of disabilities and associated health conditions - United States, 1991-1992. MMWR

1 9 9 4 ; 4 3 ( 4 0 ) : 7 3 0 - 9 .

2 . CDC. Prevalence and impact of chronic joint symptoms - seven states, 1996. MMWR 1998;47(17):345-51.

3 . Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998;41:778-99. 

4 . CDC. Arthritis prevalence and activity limitations - United States, 1990. MMWR 1994;43(24):433-8.

5 . Yelin E. Callahan, LF. The economic cost and social and psychological impact of musculoskeletal conditions. Arthritis Rheum 1995;38(10):1351-62. 

6 . CDC. Prevalence of leisure-time physical activity among persons with arthritis and other rheumatic

conditions - United States, 1990-1991. MMWR 1997;46(18):389-93. 

7 . Wolfe F, Mitchell DM, Sibley JT, et al. The mortality of rheumatoid arthritis. Arthritis Rheum

1994;37(4):481-94. 

8 . La Plante MP. Data on disability from the National Health Interview Survey, 1983-85. An InfoUse

Report. Washington, DC: U.S. National Institute on Disability and Rehabilitation Research, 1988. 

9 . Gortmaker SL, Sappenfield W. Chronic childhood disorders: prevalence and impact. Ped Clin North

Am 1984;31:3.

1 0 . Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management

in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis

Rheum 1993:36(4):439-46. 

1 1 . Callahan LF, Rao J, Boutaugh M. Arthritis and women’s health: prevalence, impact and prevention. Am

J Prev Med 1996;12(5):401-9.

1 2 . CDC. Prevalence and impact of arthritis among women - United States, 1989-1991. MMWR

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