Pain and quality of life in older osteoarthritic women living in different environments
by Phyllis Charlene Christiaens
A thesis submitted in partial fulfillment of the requirements for the degree of Master of Nursing
Montana State University
© Copyright by Phyllis Charlene Christiaens (1991)
Abstract:
This descriptive study was conducted to determine the relationship that exists between the perception
of pain and the quality of life among older women with osteoarthritis. A secondary purpose was to
determine the influence of living in urban, rural, and frontier environments on these perceptions. Data
reported in this study were obtained from a larger data set of a longitudinal study conducted by Dr.
Helen J. Lee, Assistant Professor, Montana State University.
Forty-five older women between the ages of 65-75 who have osteoarthritis and presently live in their
own home composed the purposive sample. Fifteen of the women resided in each of the three
environmental settings as defined by Lee (1989). The sample was obtained through community health
nurses. Using a multiple case study design, data were collected through a combination of mailed
questionnaires and face-to-face interview/assessment. The variable of pain was measured using the
pain subscale of the Geriatric Arthritis Functional Status Index (FSI) (Deniston & Jette, 1980) and
quality of life was measured using the Index of Well-Being (IWB) (Campbell, Converse, & Rodgers,
1976).
Results, using a Spearman rho correlation coefficient, indicated that a significant inverse relationship
exists between pain and quality of life (p=.031) in older women with osteoarthritis. The frontier group
reported the lowest level of perceived pain and the highest quality of life. Inversely, the urban group
reported the highest level of perceived pain and the lowest quality of life. The rural group reported the
medium score for both perceived pain and quality of life. Further research is needed to examine the
magnitude and nature of differences that exist between persons living in urban, rural, and frontier
environments. PAIN AND QUALITY OF LIFE
IN OLDER OSTEOARTHRITIC WOMEN
LIVING IN DIFFERENT ENVIRONMENTS
by
Phyllis C harlene Christiaens
A th e sis subm itted in partial fulfillment
of th e requirem ents for th e d eg ree
of
M aster of Nursing
MONTANA STATE UNIVERSITY
Bozem an, M ontana
May 1991
APPROVAL
of a thesis subm itted by
Phyllis C harlene Christiaens
This th esis h as been read by each m em ber of the thesis com m ittee and h as
been found to b e satisfactory regarding content, English usag e, format, citations,
bibliographic style, a n d consistency, and is ready for subm ission to th e College of
G raduate Studies.
Chairperson, Gra6udfe Committee
Approved for th e Major Department
____________ Z 3 ,
I f cO
-ZkVijfjuuuL
id, Major Departm ent
Date
Approved for th e College of G raduate Studies
/Y ,
Date
/ f f /
/ 2 . 4 , fz /C f
Ni
STATEMENT OF PERMISSION TO USE
In presenting this th esis in partial fulfillment of the requirem ents for a m aster’s
d eg ree at M ontana State University, I ag ree that the Library shall m ake it available to
borrow ers under rules of th e Library. Brief quotations from this th esis are allowable
without special perm ission, provided that accurate acknow ledgem ent of so u rce is
m ade.
Perm ission for extensive quotation from or reproduction of this thesis may be
granted by my major professor, or in her a b sen ce , by the Dean of Libraries when, in
the opinion of either, the p ro p o sed u se of the material is for scholarly p urposes. Any
copying or u se of the material in this thesis for financial gain shall not be allowed
without my written perm ission.
Signature
Date
ACKNOWLEDGEMENTS
I would like to thank Dr. Helen Lee, A ssistant Professor, M ontana State
University for th e opportunity to a ssist in th e Northcentral M ontana R esearch Project. I
would also like to ex p ress my sincere appreciation to my com m ittee, Dr. Helen Lee,
Eleanor Yurkovich, an d Sharon Hovey, for their guidance, su p p o rt an d understanding.
I would like to thank my h u sb an d Allyn, and children N athan an d S h een a for
standing by my side to offer their love and su p p o rt through this long an d enduring
p ro cess. I would also like to thank my m other Maxine Ashworth, classm ates Jo an n
Robbins an d Ja n M esaros, family, and friends. Their concern, understanding and
en co u rag em en t have carried m e through this project.
I am grateful to Ruth Quimby, Lee Faulkner and Dr. Paul Renz for their
expertise, guidance, and encouragem ent. Their contribution to my learning experience
w as not only their level of expertise, but their exam ple a s individuals and
professionals.
I would like to ex p ress my gratitude to th e G reat Falls cam p u s nursing faculty
for their su p p o rt and contribution to my learning experience. I ap p reciate the
a ssista n c e of Mavis Olson and Pat Mueller, G reat Falls cam p u s staff m em bers.
I would like to thank God for his abiding love. He h as en ab led me to achieve
m ore than I ever d ream ed possible.
vi
TABLE OF CONTENTS
P ag e
1.
INTRODUCTION ....................................................................................................................
Statem ent of P u r p o s e ...................................................................................................
Significance to th e Nursing Profession ...................................................................
Definition of T e r m s ........................................................................................................
A ss u m p tio n s .............................................................................>......................................
C onceptual F ram ew o rk .................................................................................................
1
2
3
3
4
4
2., REVIEW OF RELATED LITERATURE..............................................................................
Older W o m e n ..................................................................................................................
Chronic D is e a s e ..........................................................................................................
Chronic P a in ..................................................................................................................
Quality of L if e ...........................................................
Environmental Influence ............................................................................................
9
9
11
13
15
18
3. METHODS ....................................................................................................................... .. .
Design ............................................................................................................................
S a m p l e ............................................................................................................................
In stru m en ts.................................................................................................
P ro c e d u re .......................................................................................................................
Protection of Human Rights ....................................................................................
Data Analysis ................................................................................................................
21
21
22
23
24
25
26
4. PRESENTATION AND ANALYSIS OF D ATA ..................................................................
S a m p le ................................................... ........................................................................
Mental S tatus Q u e s tio n n a ire ....................................................................................
Descriptive Analysis of Pain and Quality of L ife ...................................................
FSI Pain S u b s c a l e .........................................................................................
Index of Well-Being .......................................................................................
Correlational Analysis of Pain and Quality of L ife...............................................
Environmental Influence ............................................................................................
28
28
31
31
31
32
32
33
5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS.............................................
D iscussion ....................................................................................................................
Pain and Quality of L ife..............................................................................................
FSI Pain S u b s c a l e .........................................................................................
Index of W ell-B ein g .......................................................................................
Relationship Between Pain and Quality of Life................................................
Environmental Influence ................................
Limitations .....................................................................................................................
Implications for Nursing ............................................................................................
R ecom m endations ......................................................................................................
37
37
38
38
38
39
39
42
43
44
6. REFERENCES C IT E D ........................................................................................................
46
vii
TABLE OF CONTENTS-cont.
P ag e
7. A P P E N D IC E S ......................................................................................................................
A ppendix A
C o n sen t Form
50
...............................................................................................................
51
A ppendix B
Mental S tatus Q u e s tio n n a ire .......................................................................................
55
A ppendix C
Geriatric Arthritis Functional S tatus Pain S u b s c a le ...............................................
57
A ppendix D
Index of W ell-B eing........................................................................................................
61
Appendix E
D em ographic Q u e s tio n s ..............................................................................................
63
viii
LIST OF TABLES
Table
P age
1.
Income Levels for Older W om en by Environmental Setting ...............................
2.
Area W here Participants Lived from Birth to Age Seventeen (N=45) ............. 30
3.
Mean S co res for Pain (FSI Pain S ubscale) and Quality of Life
(IWB) (N = 45) ..................................................................................................................
32
Relationship of Pain (FSI Pain S ubscale) and Quality of Life
(IWB) (N=45) ..................................................................................................................
33
5.
FSI Pain S u b scale Mean S co res by Environmental Setting (N = 4 5 )...............
34
6.
Index of Well-Being Mean S co res and S tandard Deviation (N=45)
...............
35
7.
Profile of Mean S co res for (FSI Pain S ubscale) and Quality of Life
(IWB) by Environmental Setting (N = 45) .................................................................
36
4.
29
ix
LIST OF FIGURES
Figure
1.
P age
C hristiaen’s Adaptation of th e Neum an System s Model (1991) ......................
6
ABSTRACT
This descriptive study w as co n d u cted to determ ine th e relationship th at exists
betw een th e perception of pain and th e quality of life am ong older w om en with
osteoarthritis. A seco n d ary p u rp o se w as to determ ine the influence of living in urban,
rural, and frontier environm ents on th e se perceptions. Data reported in this study
w ere obtained from a larger d a ta s e t of a longitudinal study co n d u cted by Dr. Helen J.
Lee, A ssistant Professor, M ontana State University.
Forty-five older w om en betw een th e a g e s of 65-75 who have osteoarthritis an d
presently live in their own hom e co m p o sed th e purposive sam ple. Fifteen of the
w om en resided in eac h of th e three environmental settings a s defined by Lee (1989).
The sam ple w as obtained through community health nurses. Using a multiple c a se
study design, d a ta w ere collected through a com bination of mailed questionnaires an d
face-to-face interview /assessm ent. The variable of pain w as m easu red using th e pain
su b sc a le of th e GeriatricArthritis Functional Status Index (FSI) (D eniston & JeHe, 1980)
and quality of life w as m easu red using th e Index o f Well-Being (IWB) (Campbell,
Converse, & R odgers, 1976).
Results, using a S pearm an rho correlation coefficient, indicated th a t a
significant inverse relationship exists betw een pain and quality of life (e= .031) in older
w om en with osteoarthritis. The frontier group reported the low est level of perceived
pain and th e h ig h est quality of life. Inversely, th e urban group reported th e h ig h est
level of perceived pain an d th e low est quality of life. The rural gro u p reported th e
medium sc o re for both perceived pain an d quality of life. Further research is n eed e d
to exam ine th e m agnitude an d nature of differences that exist betw een p erso n s living
in urban, rural, an d frontier environm ents.
1
CHAPTER 1
INTRODUCTION
Older w om en in th e United S tates rep resen t the fastest growing seg m en t of the
population. In 1985, of th e 26.3 million people over 65 years of ag e, 15.8 million or 60
p ercent w ere w om en. In addition, c e n s u s figures indicate th at by 2035 th e num ber of
w om en over 65 will increase to 33.4 million (Lewis, 1985). This in crease h a s definite
c o n s e q u e n c e s in term s of th e num ber of older w om en th e United S ta te s can ex p ect to
have in th e future. As a result of th e prolonged length of life for older w om en in th e
United S tates, chronic d is e a s e h a s b eco m e a major problem for th e s e older w om en
and th e health care profession. O ne su ch chronic d isease is osteoarthritis which
affects four of every nine individuals over 65 (Laborde & Powers, 1985). Thus, how
older w om en feel on a daily b asis, how prevalent chronic d ise a se is am ong them , an d
how m uch their social an d physical activities are ham pered by health problem s are
now key co n ce rn s of health research ers and health planners (Haug, Ford, & Sheafor,
1983).
Pain is a major sym ptom of osteoarthritis in older w om en. Although the
functional sta tu s of this population with osteoarthritis h as been a d d re s s e d , th e variable
of pain a s it relates to quality of life h a s not b een ad d ressed in health research . Older
w om en with chronic osteoarthritic pain find th at their lives are constricted by their pain.
They find difficulty with personal relationships, an d problem s with concentrating,
sleeping, working an d eating (Meinhart & McCafferty, 1983).
2
A ccep tan ce of pain usually reflects cultural beliefs (Fogel & W oods, 1981). The
ability of older w om en to a c c e p t pain is th e result of th e different social characteristics
within their environm ent. T h ese environm ental characteristics create different attitudes,
beliefs, coping m echanism s, an d su p p o rt system s. A rural environm ent se e m s to
p resen t different problem s from th o se in an urban setting, an d th e solutions that
em erge are also different (R osenblatt & Moscovice, 1982). Differences th a t exist
betw een rural environm ents have led to th e em erg en ce of a new categ o ry called
"frontier" (Elison, 1986). Identified by Popper, a dem o g rap h er at R utger's University,
this new category h a s distinguishing characteristics different from urban an d rural.
Thus, th ree b asic environm ental settings m ust b e ad d ressed .
Statem ent of P urpose
The p u rp o se of this descriptive study w as to determ ine th e relationship that
exists betw een th e perception of pain and th e quality of life am ong older w om en with
osteoarthritis. A seco n d ary p u rp o se w as to determ ine th e influence of living in urban,
rural, an d frontier environm ents on th e se perceptions. R esearch q u estio n s ad d re sse d
include th e following:
1. W hat relationship existed betw een th e perception of pain an d th e quality of
life in older w om en with osteoarthritis?
2. W hat differences existed in th e am ount of perceived pain an d th e quality of
life of older osteoarthritic w om en living in different environm ents?
3
Significance to th e Nursing Profession
B ecau se th e num ber of older w om en in America is rapidly increasing, o n e of
th e g reatest problem s for health care professionals will b e th e prevention an d
m anagem en t of chronic d ise a se conditions. Before specific guidelines pertaining to
health interventions an d health m aintenance can be developed, a s s e s s m e n t and
system atic m easurem ent of differences betw een older w om en living with varying
d is e a s e conditions in different com munity environm ents n eed to b e established. Such
information will assist th e nursing profession in developing interventions th at
specifically a d d re s s th e health m aintenance an d health care n e e d s of older w om en in
urban, rural, an d frontier environm ents.
Definition of Term s
1. Chronic Pain is pain th at lasts six m onths or longer (Meinhart & McCafferty,
1983). T he variable of chronic pain w as operationalized using th e pain su b sc ale of
th e Geriatric Functional Status Index (FSI) (Deniston & JeHe, 1980).
2. Frontier Environment is a rural a re a or town under 2,500 population with
ho m es located m ore th an 60 m inutes from a hospital of m ore th an 100 b e d s (Lee,
1989).
3. Older W om en are defined in this study a s p erso n s b etw een 65 an d 75 years
of age.
4. O steoarthritis (OA) is a noninflammatory degenerative joint d is e a s e which is
a normal re sp o n se to aging. It is characterized by m arked deg en eratio n of th e
articular cartilage, hypertrophy of b o n e at th e margins, an d c h a n g e s in th e synovial
4
m em brane. This d ise a se p ro cess is accom panied by varying d e g re e s of chronic pain
and stiffness (M atteson & McConnell, 1988).
5. Pain is "whatever th e experiencing person say s it is, existing w henever he or
s h e sa y s it d o es, including both verbal and nonverbal behaviors" (Meinhart &
McCafferty, 1983, p. 11).
6. Quality of Life includes both conditions of life and th e ex perience of life
(Campbell, C onverse, & R odgers, 1976). Quality of life w as operationalized using
Cam pbell, C onverse, an d R odgers (1976) IndexofWell-Being (IWB).
7. Rural Environment is a city or town under 49,999 population with hom es
located m ore than 31 m inutes, but less than 59 m inutes from a hospital of m ore than
100 b e d s (Lee, 1989).
8. Urban Environment is a city of 50,000 or m ore population with hom es
located less than 30 m inutes from a hospital of m ore than 100 b e d s (Lee, 1989).
A ssum ptions
1. The assum ption w as m ade th at th e older w om en honestly an d accurately
com pleted th e pain su b sc a le of th e FSI (Deniston & J e tte 1 1980) during th e interview.
2. The assum ption w as m ade th at th e w om en honestly an d accurately
com pleted th e JWB (Campbell, C onverse, & R odgers, 1976) in th e mailed
questionnaire.
C onceptual Framework
This study w as b a se d on th e conceptual model for nursing d esig n ed by Betty
N eum an (1970). The Neuman Systems Model, "the total system approach," is a holistic,
5
sy stem s-b ased conceptual framework for nursing. The aim of th e Neuman model is to
provide a unifying focus for approaching varied nursing problem s and for
understanding th e basic phenom enon of th e co n stan t interaction betw een man and
his environm ent (Marriner, 1986). The N eum an model considers th e relationship of
stre ss to an individual’s reactions to stre sso rs occurring in o n e ’s internal and external
environm ent (Neuman, 1982). Thus, th e N eum an model explains how stability is
achieved in relation to th e stresso rs im posed upon it.
The "total person" or holistic ap p ro ach ad o p ted by N eum an w as consistent
with the goal of this study. However, N eum an’s conceptualization of environm ent
refers to th e internal and external factors surrounding man. For this study,
environm ent w as limited to th e external factors of the different sociocultural settings of
urban, rural, and frontier. Older w om en w ere viewed a s the b asic structure or system
which is diagrammatically represented by th e basic core a s show n in Figure I . The
basic core structure is surrounded by th e flexible lines of resistan ce representing th e
internal factors which help to defend older w om en against th e stre sso rs that attem pt
to invade th e core. T h ese flexible lines of resistance are exemplified by the activation
of white blood cells or th e immune re sp o n se m echanism . The normal line of d efen se
is the next ring which is developed over time through learned coping m echanism s,
cultural influences, an d p a st experiences. The outer broken ring represents th e
flexible line of defense. This flexible line of d efen se provides a protective buffer for
internal n e e d s which attem pt to prevent stre sso rs from breaking through the normal
line of d efen se. Thus, the flexible line of defense, the normal Iine-Qf defense, an d th e
flexible lines of resistance assist older w om en in coping with th e existing stresso rs.
6
VARIABLES
STRESSO RS
P H Y S IO L O G IC A L
P H Y S IO L O G IC A L
O ste o a rth ritis
O s te o a rth ritis
------------------- >
P S Y C H O L O G IC A L
P S Y C H O L O G IC A L
C h ro n ic P a in
C h ro n ic P a in
DEVELOPM ENTAL
DEVELOPM ENTAL
O Id e rA g e
O ld e r A ge
S O C IO C U L T U R A L
S O C IO C U L T U R A L
U rb an , R ural, F ro n tie r
E n v iro n m e n ts
U rb an , R ural, F ro n tie r
E n v iro n m e n ts
/
BASIC X
CORE
STRUCTURE
RECONSTITUTION
V '
Quality of Life
^WELLNESS
ILLNESS
F ig u re 1. C h ris tia e n s ' a d a p ta tio n of th e N e u m a n S y s te m s M odel (1 9 9 1 )
7
For this study th e internal an d external variables affecting older w om en
included th e physiological variable of osteoarthritis, th e psychological variable of
chronic pain, th e developm ental variable of older age, and th e sociocultural variable of
environm ent. The variable of osteoarthritis is a chronic degenerative d ise a se which is
a continuing p ro cess. The usual sym ptom s of stiffness, pain, an d limitation of mobility
in crease or d e c re a se depen d in g on d isease activity, physical activity, an d individual
coping m echanism s. The developm ental variable of a g e is a continuing p ro cess
which affects th e ability of older w om en to co p e with pain. The variable of
sociocultural environm ent indicates th e dem an d s, th e cultural beliefs, an d th e su p p o rt
sy stem s of th e com m unities in which th e se older w om en live.
C h an g es in th e s e variables may c a u s e them to b eco m e internal an d external
stresso rs. The progression of osteoarthritis c a u s e s stiffness an d limited mobility which
may affect th e ability of older w om en to participate in activities they w ant to do. As
pain increases, so m e older w om en may experience significant c h a n g e s in their ability
to think, co ncentrate, sleep, work, and eat. T h ese ch an g e s can also affect their
personal relationships, an d their ability to achieve an accep tab le level or quality of life.
The p ro c e ss of aging affects eac h body system differently an d e a c h sy stem ’s ability to
resp o n d to stre sso rs is altered. Different environm ents also provide different ty p e s of
stre sso rs su c h a s distan ce to m edical care, different su p p o rt sy stem s, coping
m echanism s, an d reso u rces. Thus, th e se stre sso rs interact with lines of d efen se an d
lines of resistan ce. This interaction affects th e ability of older w om en to maintain a
b alan ce or stead y sta te of w ellness-illness which in turn will affect their quality of life.
S om e older w om en may experience stre ss or tension c a u s e d by this interaction
with th e internal an d external variables while others d o not. T he internal variables
8
ta k e place within th e internal b asic structure of older women. The external variable
ta k e s place outside th e basic structure and within th e different sociocultural
environm ents. In interacting with th e se variables a s they b eco m e stresso rs, older
w om en receive information which influences their coping m echanism s an d their
functioning. Therefore, older w om en ten d tow ard a stead y sta te of equilibrium or
b alan ce betw een forces within th e internal basic structure an d th e external
environm ent. Older w om en resist disturbances, and they attem pt to restore balance
which results in a new equilibrium b a se d on statu s quo or on ch an g e. The flexible
lines of defen se, th e normal line of defense, and th e flexible lines of resistan ce a ssist
older w om en in coping with th e stre sso rs of d isease, pain, ag e, an d environm ent in
order to reconstitute at a level of w ellness. The outcom e of th e achieved level of
w ellness is th e quality of life of older w om en a s m easured by th e Index o f Well Being
(Campbell, C onverse, & R odgers, 1976),
9
CHAPTER 2
REVIEW OF RELATED LITERATURE
Five specific a re a s of literature w ere identified for review for this study. The first
a re a selec ted w as older w om en. Review of chronic d isease, specifically osteoarthritis,
rep resen ted th e se c o n d area. The third area reviewed w as chronic pain. The fourth
a re a reviewed w as quality of life. The fifth a re a reviewed w as th e influence of different
environm ents upon th e older population. T h ese a re a s w ere selec ted to provide
background information ab o u t osteoarthritic w om en and their satisfaction with their
quality of life.
Older W omen
The fastest growing population seg m en t of th e United S tates is w om en ag ed
65 and over. In 1 9 7 8 ,1 1 2 million people or 51% of th e population in th e United S tates
w ere w om en; of th e se, 13,5 million w ere w om en ag ed 65 an d over. W om en
;
rep resen ted 58% of th e over a g e 65 population (Kjervick & Martinson, 1986).
In 1981, th e av erag e life expectancy w as 77.9 years for w om en an d 70.3 years
for m en (Kjervick an d Martinson, 1986). The U.S. C en su s Bureau projects th at th e
difference in life expectancy betw een m en an d w om en may in crease until th e year
2050 w hen rates will level off. At this point, life expectancy is projected to b e 81 y ears
for w om en an d 71.8 y ears for men, a 9.2 year difference (Lewis, 1985). This increase
in life expectancy indicates th e potential num ber of older w om en th e United S tates can
have in th e future.
10
While w om en a g e d 65 an d over are th e fastest growing seg m en t of th e
American population, this fem ale longevity is all to o often a handicap. The C en su s
Bureau reports th a t w om en a g e d 65 an d over continue to b e th e p o o rest group in th e
country, econom ically d ep e n d e n t on incom e or p ensions from th e p a s t work of their
h u sb an d s. One-third of th e se w om en are currently below th e poverty level; m ore than
half are widowed, an d two-thirds live alone (Kahn, 1984; Lewis, 1985) .
Although th e majority of elderly people experience better physical health th an is
generally believed, their n eed for g o o d health care services is still o n e of th e m ost
pressing health care problem s (Kahn, 1984). Older people are ill m ore often than th e
young and tak e twice a s long to recover. Over 70% of th e older population
experience o n e or m ore chronic conditions. Older w om en specifically report more
acute and chronic conditions th an d o older m en an d m ake m ore outpatient doctor
visits. Older w om en characterize their health care experiences with reports of neglect,
undertreatm ent, an d disresp ect; they report th at they can n o t co u n t on th e m edical
profession an d their caregivers. The high c o sts of health care an d th e lack of
information an d research ab o u t th e chronic conditions faced by w om en in th e se c o n d
half of life create two m ore problem s for older w om en (Kahn, 1984).
Even th ough older w om en have long outnum bered older m en an d u se health
care services m ore frequently, th ere are few resources, basic research , or health care
services th a t co n sid er or provide for th e special n e e d s of older w om en (Fogel &
W oods, 1981; Kahn, 1984). A significant lack of research exists ab o u t chronic
illnesses an d preventive health care in fem ales. The lack of services, com bined with
th e negative values a sso ciated with aging, crea tes a double challenge for older
w om en an d health care providers.
11
Chronic D isease
The illness an d disability patterns of w om en in th e U.S. follow logically from
their greater longevity. Using d a ta from ongoing national health surveys and vital
statistics, V erbrugge (1984) com pared w om en a g e d 65 and older to m en ag ed 65 and
older. V ariables reported included mortality, physical health, prevalence of acu te and
chronic conditions, an d disability. Data com paring th e mortality an d physical health of
older m en an d w om en indicated th at older w om en often report a lower health statu s
th an older m en, yet older w om en live longer. In this report, older w om en identified
four general health problem s: general discom forts not a sso ciated with any specific
d isease, circulatory d ise a se sym ptom s, digestive sym ptom s, an d m usculoskeletal
sym ptom s. T h ese older w om en also indicated th a t arthritis w as th e m ost com m on
chronic d isease. Fifty-three percent said th at they had d iag n o sed arthritis; thirteen
p ercen t of th a t g ro u p indicated arthritis-related limitation on their activities. Overall,
com paring w om en an d m en betw een th e a g e s of 65-74, w om en w ere m ore likely to
have sev ere arthritis, high blood p ressure, an d elevated cholesterol.
O steoarthritis (OA) is th e m ost prevalent chronic d ise a se affecting adults in th e
United S tates an d is a major c a u s e of functional impairment, morbidity, an d utilization
of health care reso u rces. The sym ptom s of OA increase with advancing years.
O steoarthritis is characterized a s a d ise a se of th e joints that involves breakdow n of th e
articular cartilage an d other tissu e s which m ake m ovable joints o p e ra te properly. The
d am ag e from OA is confined to th e joints an d surrounding tissu es. T here is little or no
inflammation, but pain an d limitation on normal motion can occur.
12
D egeneration of th e articular cartilage begins at the a g e of 20 to 30 and is
thought to b e a normal resp o n se to aging. Although more than 90% of the population
is affected by ag e 40, few people experience sym ptom s of chronic pain and limited
mobility until after a g e 60 (M atteson & McConnell, 1988). The prevalence of CA
increases with advancing age; by a g e 65 there is involvement of at least one joint
group in at least 50% of th e population (Kerwan & Silman, 1987).
An estim ate obtained from th e National Health and Nutritional Survey
(NHANES I) 1971 -75 (N=20,749) and b a se d on medical histories an d medical
exam inations co n d u cted without radiographs revealed that an approxim ately 15.8
million adults (12.1%) of th e U.S. population have signs and sym ptom s of CA. Of
th e se affected individuals, 11.7 million are reported to be w om en (Lawrence et al.,
1989). F em ales are generally affected m ore than m ales in the older ag e group. The
above estim ate ap p ea rs relatively small w hen com pared with th e estim ate from d ata
using radiographs which show ch an g e s in specific joints regardless of sym ptom s
obtained from a su b sam p le of individuals (N=6,913) from NHANES 1 1971-75 and
National Health Interview Survey (NHIS) 1960-62. T hese results dem onstrated that th e
potential overall prevalence of CA in adults ag ed 25-74 w as 76.4 million. According to
this estim ate, 42.4 million individuals have OA of th e hands, 29.0 million individuals
have OA of th e feet, and 5.0 million individuals have OA of th e kn ees. The differences
in th e se estim ates indicate that many individuals with radiologic evidence of OA have
no sym ptom s of disability.
National d ata regarding th e increasing num ber of th e older population, th e
im pact of OA on th e health care system , th e num ber of Social Security Insurance
benefits a s a result of OA, and th e increasing prevalence of OA with advancing y ears
13
led W einberger, Tierney, an d Booher (1989) to exam ine th e prevalence of so m e of th e
m ore com m on problem s experienced by older w om en (N =315) a g e d 51 -75 with OA.
Their self report instrum ent a s s e s s e d dem ographic characteristics, functional status,
and com pliance with m edications. Seventy-one percent of th e sam p le reported
limitation in their activities c a u se d by joint pain. Thirty-four p ercen t reported
noncom pliance in taking their m edications for at least o n e day during th e preceding
w eek, an d 24% reported noncom pliance for two or m ore days. G astrointestinal
com plaints w ere reported by 36% of th e sam ple with 5% requiring im m ediate
intervention. Seventy-seven p ercen t reported co-existing chronic d is e a s e s . Problem s
in ac c e ssin g care w ere reported by 33% of th e w om en. Additional problem s identified
by th e sam p le included noncom pliance c a u se d by patients taking m ore than o n e
nonsteroidal antiinflammatory a g en ts (NSAID) a t th e sam e time or taking to o m uch of
a m edication. A nother problem w as a know ledge deficit related to taking two
m edications th a t could potentially interact. Thus, m any of th e problem s identified w ere
considered treatab le or correctable. Health care professionals have th e potential to
consider specific patient oriented interventions th at may eliminate so m e of th e se
problem s.
Chronic Pain
O lder w om en with chronic pain experience a com plex p h en o m en o n which
sim ultaneously involves m any a s p e c ts of life: sleep, concentration, eating, em otions
(such a s anxiety an d depression), relationships with others, and physical activities at
hom e an d work (Meinhart & McCafferty, 1983). R esearch to d a te concerning chronic
pain an d OA h a s fo cu sed on th e functional disability cau sed by OA an d th e overall
14
im pact th at osteoarthritis h a s on th e individual (Riley, Ahern & Rollick, 1988).
Functional ability is likely to vary with subjective pain only to th e extent th a t th e se two
constructs are perceived a s linked by an individual with chronic pain. Therefore,
disability may b e red u ced m ost am ong th o se individuals who are able to view their
functional ability a s related to factors other than their level of pain.
T hom as & Roy (1988) co n d u cted a study of individuals (N =205) com paring
pain and d em ographic characteristics of younger elderly, ag ed 60-69, with older
elderly, a g e d 80-89. Instrum ents included th e Beck Depression scale an d th e Illness
Behavior Questionnaire. Data w ere also collected on th e report of pain, duration of
pain, an d th e u se of m edications. Results indicated that a s a group, older elderly did
not show significantly m ore pain or illness th an th e younger elderly. Actually, only
64% of th e 80’s group reported pain a s com pared to 81% of th e 60’s group. The
m ean duration of chronic pain in th e fem ale 60’s group w as 12.5 years. T he w om en in
th e 80’s group reported chronic pain with a m ean duration of 16.3 years. Forty-nine
percent of both g ro u p s reported being on m edication for pain. Of th e m en reporting
chronic pain, th o se in th e 60’s group indicated a m ean duration of 15.8 years; 40%
reported being on m edication. The m en in th e 80’s group reported chronic pain with
a m ean duration of 15.2 years, and 50% of this group reported currently taking
m edication. The overall incidence of chronic pain in subjects over 65 y ears of ag e
w as 73%. The view th a t th e p ro cess of ongoing aging is a sso ciated with increasing
pain w as not su pported.
T hom as an d Roy (1986) co n d u cted an earlier study th at investigated th e
prevalence of chronic pain in two g ro u p s of elderly people (N = 97) b etw een th e a g e s
65 and 80. M em bers of th e first group w ere residents of a nursing hom e an d th e
15
s e c o n d group w ere individuals attending a day treatm ent program for six hours a
w eek at th e sa m e nursing hom e. Data w ere collected using a self-report questionnaire
and H uskisson’s VisualAnalogue scale to m easure pain. Results sh o w ed th at 83% of
th e participants reported having current pain-related problem s. Eighty-eight p ercen t of
th e participants with pain reported various kinds of back, joint a n d m uscle pain.
Eighty-four p ercen t w ere being treated with an alg esics and 80% of th o s e treated
reported th a t th e m edication w as effective. Seventy-four p ercen t reported th at pain
interfered with daily living an d varied in d e g re e s from very little to m aking life
im possible. The authors recom m ended th at pain problem s in th e elderly n eed to be
m ore closely monitored.
Pain, disability, an d other physical sym ptom s from OA m ay fluctuate over time
in re sp o n se to d ise a se activity an d m edical an d personal interventions (V erbrugge &
Balaban, 1989). Although th e treatm ent of OA h a s improved, m any elderly still suffer
from chronic pain th at often acco m pan ies this d isease. As a result of living with
chronic pain, quality of life may d ecrease,
Quality of Life
Quality of life h a s m any dim ensions including physical activity, work, social and
leisure activity, econom ic statu s, cognition, em otional adaptation, self esteem ,
interpersonal relationships, an d overall satisfaction with life (Bergner, 1989). Quality of
life a s it is u se d in clinical research is a v ag u e term lacking concep tu al clarity. From a
literature survey of approxim ately 100 scientific publications in which th e co n ce p t of
quality of life w as u sed , Bergner (1989) found th at rarely w as a definition of th e term
16
given. Quality of life, health status, functional status, and life satisfaction were term s
u sed interchangeably.
Literature indicates that, over time, OA is believed to have a negative effect on
the stability, satisfaction an d h ap p in ess of th e lives of elderly w om en, particularly on
th e se m ore subjective a sp e c ts of life which are not easily quantified (Burckhardt,
1988). Burckhardt u sed th e Flanagan Quality o f Life scale (1978) to com pare the
re s p o n s e s of a convenience sam ple of w om en ag ed 18-98 with arthritis (N=225) with
the results of a randomly selected national population of w om en without arthritis in the
original Flanagan Study (N=SOOO). Results indicated women with arthritis tend to be
m ore satisfied with their material com forts and m ore satisfied with relationships with
relatives an d close friends than w om en without osteoarthritis. W om en with arthritis
also indicated m ore satisfaction with helping and encouraging others, and passive
recreation than w om en in th e Flanagan Study. However, w om en with arthritis w ere
significantly le ss satisfied with their health, work, and active recreation than the
participants of th e original Flanagan Study. Burckhardt concluded th at overall, w om en
with arthritis w ere more similar than different from women of their com parable ag e
group within th e general population.
.
Palm ore and Luikart (1972) con d u cted a study of p erso n s a g e d 45-69
(N=502) using d a ta collected in 1968 from th e Duke Adaptation Study. Variables
affecting life satisfaction w ere exam ined; they included self-rated health, activity, socialpsychological status, and socioeconom ic status. The Cantril Ladder w as u sed to
m easure life satisfaction an d a similar ladder w as used to rate health. The num ber of
religious an d organizational m eetings atten d ed an d the num ber of hours sp en t in
social activities w ere sum m ed for th e variable of activity. The social-psychological
17
variable w as m easu red using J e s s o r ’s Internal-External Control o f Reinforcement scale.
Palm ore an d Luikart found th at self-rated health w as by far th e stro n g e st variable
related to quality of life. The se c o n d stro n g est variable related to quality of life w as
organizational activity, followed by th e variable of internal control orientation.
Laborde and Pow ers (1985) investigated th e im pact of d e g re e of pain, extent of
d ise a se involvement, duration of illness, perception of health, an d health locus of
control on life satisfaction in 160 individuals with OA a g e d 40-93. The convenience
sam ple w as obtained from four different settings (urban senior center, urban outpatient
clinic, and tw o rural community cen ters in two tow ns with populations le ss than 3,500).
The participants w ere ask ed to com plete th e Cantril Self-anchoring Striving scale, an d
the Wallston, Wallston, Kaplan, & M aides' Multidimensional Health Locus o f Control
scale. Perceived level of life satisfaction w as m easured by using th e Cantril ten step
ladder technique. Duration of illness, extent of d ise a se involvement, an d pain
a sso ciated with arthritis w ere extracted from health histories. T he participants’
perception of their p resen t quality of life w as found to b e significantly a sso ciated with
better health perception, internal health locus of control, and less joint pain. Despite
th e fact th a t osteoarthritics rated their pain a s distressing, their d e g re e of pain did not
seem to im pinge upon their overall satisfaction with life. However, so m e participants
viewed their p a s t life a s m ore satisfying than their p resen t life.
In an earlier study using th e Cantril Self-anchoring Life Satisfaction scale,
Laborde an d Pow ers (1980) com pared d a ta from 20 patients receiving treatm ent for
osteoarthritis, a g e d 40-60, with 20 patients receiving dialysis, a g e d 40-60. While they
found no differences in p a st and future life satisfaction for both gro u p s, p resen t life
satisfaction for th e osteoarthritics w as lower th an for th e hem odialysis patients. Even
18
though th e dialysis treatm ent is life threatening, th e social interaction surrounding the
treatm ent m ay increase th e life satisfaction for dialysis patients. O steoarthritis patients,
for th e m ost part, d o not have th e sam e opportunity for group interaction or the
ap p are n t su p p o rt sy stem s of dialysis patients. Essentially, osteoarthritics are alone in
their illness. Therefore, th e chronic pain an d d e c re a se d mobility th a t acco m p an ies
osteoarthritis can have an even greater negative im pact on th e s e n s e of well-being
than d o e s a life-threatening d ise a se th at is not m arked by pain.
Environmental Influence
Several stu d ies examining national or regional health statistics have reported
higher incidence of health problem s am ong th e rural elderly population th an for th e
urban elderly population (Krout, 1989). Using national d ata collected in th e early
1960’s, Ellenbogen (1967) concluded th at th e health statu s of rural elderly people
com pared unfavorably to th a t of elderly urban people. The indicators u se d in this
study included incidence of acu te conditions, selected chronic conditions and
im pairm ents, an d incidence of injuries or disabilities. Palmore (1983) u se d more
recent d a ta from th e National C enter o n Health Statistics, and co n clu d ed th at rural
elders have b een affected m ore by d ise a se than their urban counterparts.
Burckhardt (1977) exam ined vital an d health statistics d a ta pertaining to
transportation an d nutritional services for th e elderly collected in 1975. Her analysis
revealed th a t th e rural elderly population experienced m ore restricted mobility th an th e
urban population in all regions of th e country.
Allen an d Miller (1986) surveyed individuals (N=94) a g e d 55 an d older to
determ ine th e actual conditions, opportunities, activities, an d attitudes of older citizens
19
living in rural area s and to a s s e s s their specific psychological, social, and medical
n eed s. The survey results indicated that th e rural elderly have lower incom es, p oorer
health, inferior housing, and less ad eq u a te transportation sy stem s com pared to th e
general population.
Krout (1989) indicated that th e level of determ inants of health status am ong
elderly people h a s received considerable attention in gerontological literature.
R esearch ,h as focused on variations of health statu s for the elderly population b a se d
on factors su ch a s sex, income, race, and marital status. However, factors that have
b een given substantially less attention in health research have b e e n th o se related to
com munity ty pe-rural v ersus urban differences.
S cheldt an d Windley (1982) studied 989 individuals a g e d 65 and older to
determ ine differences in well-being am ong elderly in small rural tow ns that vary in size
and in rural context. C ategories w ere developed using a com munity b ased index of
rurality which contained three com ponents: th e population of th e county; the num ber
of p erso n s not em ployed in agriculture, forestry, or fisheries; an d th e population
proximity ratio. A three by three matrix com prized of three county index categories
(more rural, m oderately rural, and m ore urban) cro ss classified with three town size
categ o ries (100-500, 501 -1,500,1,501 -2,000) w as developed. Eighteen tow ns from 39
counties in K ansas (two from each matrix) w ere selected for study. Data were
collected on variables of well being; they included mental health, housing,
neighborhood satisfaction, contact with friends an d relatives, mobility, functional
health, availability of confidants, feelings of security, and activity participation.
Mental health, activity participation, an d contact with friends and relatives w ere
indices for which a c a s e for similarity am ong g ro u p s w as m ade. With th e exception of
20
o n e group show ing significantly higher levels of activity from all others, th e remaining
gro u p s did not differ significantly in this dim ension (Scheldt & Windley1 1982). The
older residents of th e sm allest tow ns in th e counties reported higher co n tact with
relatives than all other town groups, but inversely low sco res on activity an d security.
Activity s c o re s w ere higher for older residents of th e largest tow ns in m oderately rural
counties, relating positively with security. C ontact with friends w as generally high
a c ro ss groups. R esidents of th e large tow ns in low an d m oderately rural counties
reported a higher s e n s e of security than residents in medium sized tow ns in highly
rural counties an d th e sm allest tow ns in th e m ost urban counties. Generally, th o se
residents of m ost rural counties, reg ard less of town size consistently reported lower
security sco res. Older residents of th e sm allest tow ns in th e m ost urban counties
reported th e highest sc o re s for co n tact with relatives; th e se sc o re s differed
significantly from all other categories. The low est reported frequency for co n tact with
relatives w as reported by older residents of th e largest tow ns in m oderately rural
counties. Overall, individuals living in largest tow ns, regardless of d e g re e of rurality,
reported lower co n tact with relatives than th o se residing in m edium -sized and sm allest
tow ns. T he results of th e study illustrated th e im portance of differentiating within and
betw een rural an d small town contexts w hen a sse ssin g profiles of well-being of older
residents.
Bigbee (1984) indicated th at while rural-oriented health research h a s been fairly
active, it h a s also b een limited in sco p e. M ost prior research h a s fo cu sed on th e
maldistribution of health care providers. Very little research h a s actually fo cu sed on
th e characteristics, determ inants, an d c o n se q u e n c e s on the health an d illness of rural
w om en.
21
CHAPTER 3
METHODS
Data reported in this descriptive study w ere obtained from a larger d ata s e t of
a longitudinal study con d u cted by Helen J, Lee, A ssistant Professor, M ontana S tate
University, College of Nursing. The design, m ethods, and sam ple for this study w ere
consistent with Dr. Lee’s research project. This researcher served a s an assistan t for
the first round of d ata collection ih th e larger study. The initial project w as funded in
part on a grant from Montanans on a New Tracfor Science (MONTS).
Design
A multiple c a se study research design w as u sed for this descriptive study (Yin,
1984). The pu rp o se of a multiple c a s e study design is to describ e an d to explore th e
relationships betw een two or more p h en o m en a (W oods & C atanzaro, 1988). The term
c a s e study d o e s not d en o te a single or specific technique but rather a general
strategy for research which allows for multiple d ata gathering m ethods. Face-to-face
interview /assessm ent and mailed questionnaires w ere the two m ethods used to g ather
d ata from th e purposive sam ple recruited for th e study. The flexibility of th e design
provided th e b est m ethod of gathering in-depth, real-life su b ject matter.
22
Sam ple
The gradual increase in proportion of elderly population is already a reality in
th e sta te of M ontana. The national average of 11 % of th e population which is ag e d 60
an d above is true for only five of 55 M ontana counties; th e other 50 counties have an
even greater p ercen tag e of ag ed . Thirty-three of th e counties report th a t 12% to 19%
of their population are a g e d 60 and ab o v e while 17 counties indicate th a t 20% or m ore
of their population are a g e d 60 an d ab o v e (Lee, 1989).
The th ree environm ents included in th e study w ere urban, rural, an d frontier
are a s of northcentral M ontana.
Low population density an d diversity have b een
identified a s characteristics of th e rural environm ent (Lee, 1989). The wide diversity of
th e rural environm ent h a s b eco m e m uch m ore evident a s specific definitions of th e
com p o n en ts an d d eg ree of rurality have occurred. Rural is a relative term;
dichotom ous divisions th a t se p a ra te populations into urban an d rural categories for
com parison s ignore th e fact th a t th ere is a continuum from m ost rural to m ost urban
(R osenblatt & M oscovice, 1982). The 1987 U. S. C en su s defines p e rso n s living in
incorporated or c e n su s d esig n ated p laces of 2,500 or m ore inhabitants a s urban.
Populations not classified a s urban are considered rural (Lee, 1989). Using this
definition, 75.6% of M ontana’s population is rural. Although th e sta te is recognized a s
a rural state, th e em erg en ce of a "frontier" category holds prom ise for identifying
unique conditions found in m ore sparsely populated areas. In M ontana, this frontier
category, with param eters of six or few er p erso n s per sq u are mile, e n c o m p a s se s 41%
or 23 of th e 56 counties (Elison, 1986).
23
The purposive sam ple w as obtained through community health nurses in th e
three environm ents targeted for study. W om en born betw een Jan u ary 1, 1913, and
D ecem ber 31, 1923, w ho had osteoarthritis and lived in their own hom es at the time of
the first round of d ata collections w ere participants in the study. The purposive
sam ple u sed w as cohort an d d ise a se specific. Forty-five w om en, 15 in each of th e
three environm ental settings, co m p o sed th e sam ple. Participants’ ability to read and
write in order to com plete th e mailed questionnaire w as determ ined by the returned
questionnaire. B ecau se th e majority of th e d ata collection w as b a s e d on individual
perceptions, th e Mental Status Questionnaire (Kahn, Goldfarb, Pollack, & Peck, 1960)
w as adm inistered to th e participants at th e beginning of th e interview /assessm ent.
Participants who m ade three or m ore errors, th e level asso ciated with organic m ental
d isease, w ere eliminated from the study.
Instrum ents
Mental Status Questionnaire (MSP) (Kahn et al., 1960): Kane and Kane (1981)
reported extensive u se of th e MSQ in geriatric research and practice. The instrum ent
contains ten items which quantitatively determ ine mental statu s (Appendix B). Kahn et
al. reported test-retest reliability better than .80 and alpha reliabilities of .84.
Geriatiric Arthritis Functional Status IndexlFSI Pain Subscale) (Deniston & Jette,
1980): Pain w as operationalized using th e pain su b scale of th e FSI (Appendix C).
The FSI is a self report instrum ent which includes an a s s e ssm e n t of degree of help
used, pain experienced, and difficulty involved in performing 15 different activities of
daily living (ADL). Higher sco res on th e pain su b scale indicated a g reater am ount of
chronic pain being experienced. Reliability, using repeated m easurem ent of sam e
24
p e rso n s by different interviewers, yielded th e sam e sco re 85% of th e time (Kane &
Kane, 1981).
Index o f Well-Beim (IWB) (Campbell, C onverse & R odgers, 1976): Ih eIW B
w as u se d to m easu re quality of life (Appendix D). It contains sev en items m easuring
satisfaction with self, stan d ard of living, family life, marriage, friends, work, an d n o n ­
work activities. Higher sc o re s indicated a higher perceived well-being. Engel (1984)
indicated th a t test-retest reliability for th e IWB w as greater than .70.
Demographic Questions: Background d a ta collected for th e total sam ple
included a re a of resid en ce th e majority of time from birth until a g e 17, marital statu s,
num ber of y ears of sch o o l, num ber of p erso n s living in th e sam e residence, and
financial situation (Appendix E).
P rocedure
D ata w ere collected using a com bination of mailed questionnaires an d face-toface interview s/assessm ents. Potential participants identified by com m unity health
n u rses a s m eeting th e study criteria w ere co n tacted by telephone. If p erso n s ag reed
to participate following a verbal explanation of th e study, a co n sen t form and
questionnaire which included th e Index o f Well Being (IWB) w ere mailed.
Approximately ten d ay s after th e co n sen t form and questionnaire w ere mailed,
eac h participant w as reco n tacted by telep h o n e to determ ine w hether th e mailing had
b een received an d to s e t up an appointm ent for an interview. Interviews w ere
co n d u cted in eac h participant’s hom e by th e primary investigator or o n e of th e two
research assistan ts.
25
At th e beginning of th e interview th e co n sen t form w as reviewed, signed, and
collected. The Mental Status Questionnate w as then adm inistered; if th e participants
obtained s c o re s of eight or better th e assessm ent/interview w as co n d u cted . The FSI
containing th e pain su b sc a le w as part of th e interview schedule.
Protection of Human Rights
Following th e initial co n tact with th e potential participants, a c o n se n t form w as
mailed to ea c h (see A ppendix A). This co n sen t form explained th e nature of th e study,
th e potential risks an d benefits, th e m ethod for participant selection, th e se q u e n c e and
duration of questionnaires, an d interviews for th e study. In addition, th e co n se n t form
explained th a t eac h participant would have th e opportunity to a s k q u estio n s an d that
s h e could refuse to participate or withdraw a t any time. A greem ent to com plete th e
questionnaire an d to s e t up a sch ed u led interview w ere co n sid ered to b e continued
consent. T he co n se n t form w as reviewed, signed, and collected a t th e time of th e
interview.
The participants in th e study w ere informed th at while th e stu d y did not directly
benefit them , th e information provided could a ssist n u rses an d o th er health
professionals in developing m ethods of providing services for older p eo p le living in
different environm ents. They w ere informed th at participation w ould n o t rep resen t a
risk. However, it w as explained that participation in th e study could b e an
inconvenience b e c a u se of th e time n eed ed to answ er questions. T he participants
w ere told th a t approxim ately 30 to 60 m inutes would b e n ece ssary to com plete th e
interview. Additionally, it w as conveyed to th e participants th a t if th ey b eca m e tired
during th e interview, a se c o n d interview could b e scheduled.
26
Each study participant w as informed that sh e had th e right to refuse to answ er
any question th a t s h e felt w as an invasion of her privacy. Each participant w as also
informed th a t in order for her re sp o n se s to be kept confidential, s h e would be
assig n ed a co d e num ber. In addition, each participant w as ask e d not to write her
nam e anyw here on th e questionnaire. The questionnaire, sig n ed c o n se n t forms, and
th e information obtained from eac h interview w ere kept in an a re a acc essib le only to
th e primary research er an d her assistan ts. Consequently, n am es w ere known to only
th e research e r an d /o r th e interviewers who assisted with th e study. Each participant
w as told th e information from th e study would be sh ared with health professionals
through publication in m edical an d nursing journals, at health professional m eetings
and, if appropriate, with lay public through organizations serving p eo p le with arthritis.
Thus, ea c h participant w as informed th at sh e would not be specifically identified in any
reports stem m ing from th e study b e c a u se d ata obtained from th e g ro u p a s a whole
would b e published.
Data Analysis
Descriptive statistics w ere u sed to d escribe th e sam ple (range & m ean) an d th e
sc o re s obtained on th e Index o f Well-Being (Campbell, Converse, & R odgers, 1976)
and th e GeriatricArthritis Functional Status Index Pain Subscale (D eniston & JeHe, .1980)
(range, m ean, & stan d ard deviation). S pearm an rho correlational coefficient w as u sed
to determ ine th e relationships betw een pain and quality of life for th e total sam ple.
This nonparam etric statistical te s t w as selected b e c a u se of th e sam p le size (N=45). A
probability (g = < 0 .0 5 ) w as selected for level of significance. Descriptive statistics,
(range m ean an d stan d ard deviation) w ere then com puted on th e instrum ent sc o re s
27
for com parison of g ro u p s by environm ental setting. All statistical te sts w ere com puted
using the Statistical Package for the Social Sciences (SPSS) at M ontana S tate University,
Bozem an, M ontana.
28
CHAPTER 4
PRESENTATION AND ANALYSIS OF DATA
■
The d a ta analysis is p resen ted in four areas. The first presentation d escrib es
th e sam ple by environmental setting. The s e c o n d presentation is th e descriptive
analysis of d a ta obtained from th e FSI Pain Subscale and th e IWB. The third
presentation is th e correlational analysis of th e m ean pain sc o re to th e m ean IWB and
the individual questions on the IWB. The final presentation is th e descriptive analysis
of pain an d quality of life by environmental setting.
Sam ple
The sam ple included forty-five w om en, betw een the a g e s of 65 to 75 (M =70
years), w ho have osteoarthritis and live in their own hom es. The sam ple w as divided
into three g ro u p s by environmental setting according to place of residence at th e time
of th e study.
Urban S am ple: The ag e of th e fifteen w om en residing in th e urban
environm ent ranged from 65 to 75 years with a m ean of 70 years. Seven of the
participants w ere married, one w as divorced/separated, and sev en w ere widowed.
Educational level of th e fifteen urban participants ranged from eight to 17 years. Two
of the participants com pleted g rad e school, four com pleted high school, nine
participants reported p o st seco nd ary education, and one reported graduate education.
Seven of th e older urban w om en lived alone, seven reported o n e other person living in
th e sa m e residence, and o n e reported two other perso n s living in th e sam e residence.
29
Incom e levels for th e urban participants ranged from less than $4000 to m ore than
$25,000 (Table 1).
Table 1. Income Levels for Older W omen by Environmental Setting______________
Environmental group
Incom e ran o e
Rural
Urban
Frontier
(n=14)
(n=15)
(n=14)
$ < 4,000
I
$4,001-7,999
2
2
I
$8,000-11,999
1
5
1
$12,000-14,999
2
3
4
$15,000-24,999
5
3
6
> $25,000
3
2
2
Rural S am p le: The a g e of th e participants in th e rural g roup ran g ed from 65 to
75 y ears with th e m ean being 70 years. Seven of th e participants in th e rural group
w ere married, two w ere divorced/separated, five w ere widowed, an d o n e never
married. Educational level of th e fifteen rural participants ranged from 8 to 17 years.
Two of th e participants com pleted g rad e school, four com pleted high school, three
reported p o st seco n d ary education, an d two reported g rad u ate education.
Seven of
th e older rural w om en lived alone and eight reported o n e other p erso n living in th e
sa m e resid en ce. Income levels for th e rural participants ranged from $4,001 to m ore
th an $25,000 (Table 1).
Frontier S am p le: The a g e of th e participants in th e frontier g ro u p ran g ed from
65 to 75 y ears with a m ean of 71 years. Ten of th e participants in th e frontier group
w ere m arried an d five w ere widowed. Educational level of th e fifteen frontier
participants ran g ed from 8 to 17 years. Three of th e participants com pleted g rad e
30
school, six com pleted high school, five reported p o st seco n d ary education, an d o n e
reported g rad u ate education. Four of th e older frontier w om en lived alone, eight
reported o n e other p erso n living in th e sam e residence and th ree reported two
p erso n s living in th e sam e residence. Income levels for th e frontier participants
ranged from $4,001 to m ore than $25,000 (Table 1).
C ross-tabulations w ere calculated to show w here participants in each of th e
three environm ental settin g s lived from birth to a g e seventeen (Table 2). Of th e fifteen
participants currently in th e frontier setting; twelve originally lived on a farm /ranch; o n e
w as from a rural a re a not a farm /ranch; an d two w ere from a small tow n (< 500
population). Ten of th e fifteen rural participants originally lived on a farm /ranch; two
w ere from a small tow n (501-2,500 population); and two w ere from a large town
(2,501 -5,000 population). The urban participants originally lived in varied locations
representing sev en of th e eight environm ental settings. Four of th e urban participants
originally lived on a rural farm /ranch, o n e w as from a rural area, not a farm /ranch; two
w ere from a small tow n (< 5 0 0 population); two w ere from a small city (15,001 -49,999);
an d three w ere from a big city of (50,000 or m ore population).
Table 2. Area W here Participants Lived from Birth to Age S ev en teen (N = 45)
Area lived
Urban
Environmental gro u p
Rural
Frontier
Rural farm /ranch
4
Rural-not a farm /ranch
1
1
Small town < 5 0 0 population
2
2
Small tow n 501 to 2,500
2
3
Big town 2,501 to 5,000
1
2
Small city 5,001 to 15,000
Small city 15,001 to 50,000
2
Big city over 50,000
3
10
12 ‘‘
31
a
Mental S tatus Q uestionnaire
The MSQ w as adm inistered to participants to establish self-perceptual ability at
th e start of th e interview (Appendix B). Participants’ sco res on th e ten-item Mental
Status Questionnaire ranged from 9 to 10 in a possible range of 0 to 10. None of th e
participants w ere eliminated from th e study.
Descriptive Analysis of Pain an d Quality of Life
FSI Pain Subscale
The FSI Pain Subscale included 15 different items ad d ressin g th e level of pain
experienced by older w om en w hen doing activities of daily living (Appendix C). The
range of th e FSI w as 0 to 76; th e m ean w as 20.44; and th e stan d ard deviation w as
19.96. Individual item s of th e FSI Pain Subscale ad d re ss pain involved in doing a
variety of functional task s. Participants in this study w ere affected by OA in a variety
of joints, including th e h an d s, shoulders, back, an d knees. Therefore, a m ean pain
sc o re w as calculated (m ean divided by num ber of items) in o rder to provide a
meaningful num ber for com parison with th e IWB an d its individual items. For th e total
sam ple th e m ean pain sc o re w as 1.36 on a sc a le of 0 to 7 an d th e stan d ard deviation
w as 1.33. This finding indicated th at th e older w om en in th e sam p le reported a low
level of pain at this point in their d ise a se progression.
Index o f Well-Beine
T he IWB includes sev en items ad d ressin g quality of life (Appendix D). The
range of th e IWB w as 19 to 35;, th e m ean for th e total sam ple w as 28.20; an d th e
32
stan d ard deviation w as 4.28. A m ean quality of life satisfaction sc o re w as calculated
by dividing th e IWB m ean by th e num ber of items; th e sco re w as 4.03 on a scale of 1
to 5. T he m ean s c o re s for th e individual items of th e IWB w ere th en calculated; they
ran g ed from 3.73 to 4.36. Satisfaction with work w as th e low est of th e individual items
(3.73). The a re a s of highest satisfaction w ere friendships (4.36) an d place w here you
live (4.22).
Table 3. Mean S co res for Pain (FSI Pain Subscale) and Quality of Life (IWB) (N = 45)
Instrum ents
Mean
FSI Pain su b sc a le
1.34
1.33
IWB
4.03
.61
Marital relationship
3.84
1.24
Work th a t you do
3.73
.96
Financial situation
3.82
.94
Place w here you live
4.22
.93
Non-work activity
4.11
1.00
Family life
4.11
.98
Friendships
4.36
.65
S tan d ard deviation
Correlational Analysis of Pain and Quality of Life
The S pearm an rho correlation coefficient w as utilized to determ ine th e
relationship betw een th e variables of pain (FSI Pain Subscale) an d quality of life (IWB).
33
The results indicated a strong significant inverse relationship (£=.03) betw een pain
an d quality of life (Table 4). This finding su g g e ste d that th e greater am o u n t of
perceived pain in th e older w om en in th e sam ple, th e lower their quality of life. The
m ean sc o re of th e FSI Pain Subscale w as correlated With th e individual items of th e
IWB. The only individual item of th e IWB indicating a significant relationship to pain
w as financial situation (£=.01). Two other IWB items ap p ro ac h ed significance: marital
statu s (£=.09) an d work th at you d o (£=.08).
Table 4. Relationship of Pain {FSI Pain Subscale) and Quality of Life (IWB) (N=45)*
-.21
Work th a t you d o
-.21
£ = .09
P resen t financial situation
-.38
£ = .01
Place w here you live
-.14
to
Il
Non-work activities
-.13
Il
Family life
-.03
H
O l
S
to
Marital relationship
£
N
q
9
Friendships
-.28
* S pearm an rho correlation coefficient, one-tailed te st
Il
-.13
Il
O l
Index of Well Being
£ = < .0 5
to
r
£ = .31
Environmental Influence
FSI Pain Subscale: Descriptive statistics for th e FSI Pain Subscale w ere
calculated by environm ental setting (Table 5). The lowest m ean sc o re for pain w as
reported by th e frontier group at .60. The rural group’s m ean sc o re for pain w as 1.51
and th e m ean sco re, of th e urban group w as 1.98.
34
Table 5. FSI Pain Subscale Mean S co res by Environmental Setting (N = 45)
'
Environmental group
Rural
Urban
Frontier
Mean
S tandard deviation
1.9822
1.5739
1.5067
1.1981
.6000
.7721
Index o f Well Being: While quality of life w as reported to b e high for th e total
sam ple (M =4.03), calculating m eans by environmental setting revealed interesting
results (Table 6). The frontier group obtained th e highest m ean sc o re of 4.12. The
rural group reported a medium sco re of 4.10 an d th e urban group reported th e low est
sco re of 3.87. The m ean sc o re s for th e individual items of th e IWB w ere then
calculated. The frontier group reported th e highest level of satisfaction with marital
status, work th at you do, p resen t financial situation, and non-work activities. The rural
group reported th e highest level of satisfaction with place w here you live, family life
and friendships. The urban group reported medium to low m ean sc o re s for all of th e
IWB items. Table 7 provides a profile for pain {FSI Pain Subscale) an d quality of life
(IWB) by environm ental setting.
35
Table 6. Index o f Well-Being Mean S co res an d Standard Deviation (N =45)
Mean
Index of Well-Being
Urban
Rural
Frontier
S tandard deviation
3.87
4.10
4.12
.59
.54
.70
Marital relationship
Urban
Rural
Frontier
3.47
4.00
4.07
1.51
1.13
1.03
Work th a t you do
Urban
Rural
Frontier
3.53
3.73
3.93
.74
1.10
1.03
P resen t financial situation
Urban
Rural
Frontier
3.80
3.73
3.93
.94
1.03
.88
Place w here you live
Urban
Rural
Frontier
4.07
4.33
4.27
.80
.82
1.16
Non-work activities
Urban
Rural
Frontier
4.07
4.01
4.20
.88
1.16
1.01
Family life
Urban
Rural
Frontier
3.80
4.33
4.20
1.21
.72
.94
Friendships
Urban
Rural
Frontier
4.33
4.47
4.27
.49
.64
.80
36
Table 7. Profile of Mean S co res for Pain (FSI Pain Subscale) an d Quality of Life (IWB)
by Environmental Setting (N=45)
__________________________________ Urban________Rural________ Frontier___________
Pain
high
medium
low
Quality of life
low
medium
high
Marital relationship
low
medium
high
Work th a t you do
low
medium
high
P resen t financial
situation
medium
low
high
P lace w here you live
medium
high
medium
Non-work activities
medium
medium
high
Family life
low
high
medium
Friendships
medium
high
low
37
CHAPTER 5
DISCUSSION, IMPLICATIONS, RECOMMENDATIONS
This investigation w as co n d u cted to a s s e s s th e relationship betw een pain an d
quality of life of older w om en with osteoarthritis an d to determ ine different
environm ental influences on th e perception of pain and quality of life of older w om en
with osteoarthritis. The theoretical framework for this study w as b a s e d on th e major
co n c e p ts of th e N eum an S ystem s Model. The multiple c a s e study d esig n w as u sed in
an attem pt to g ath er real-life su b ject matter. Face-to-face interview /assessm ent an d
mailed questio n n aires provided d ata for th e analysis of th e relationship betw een
chronic pain an d quality of life. The purposive sam ple included 45 older w om en
betw een th e a g e s of 65 an d 75 w ho w ere d iag n o sed with osteoarthritis, a chronic
d ise a se th a t p ro g re sse s with aging which is m arked by sym ptom s of pain an d
disability. Study participants w ere g rouped categorically a s urban, rural, or frontier.
The grouping by environm ental settings allowed for th e analysis an d com parison of
perceived pain an d quality of life of older w om en living in different environm ents.
Discussion
The d iscu ssio n provides an interpretation of findings for th e sam p le studied
and a com parison of th e findings by environmental setting. Findings from this
investigation are related to previous relevant studies.
38
Pain and Quality of Life
The degenerative p ro c e ss of osteoarthritis begins at a g e 20-30; however,
chronic pain an d disability are not usually experienced until after a g e 60 (M atteson &
McConnell, 1988). Although few stu d ies of pain an d quality of life have b een
conducted, chronic pain is known to b e a com plex phenom enon which involves m any
a sp e c ts of an individual’s life, an d a s a result, may d ecre ase th e quality of life
(Meinhart & McCafferty, 1983; V erbrugge & B alaban1 1989).
FSI Pain Subscale
The older w om en in this study reported a low m ean sc o re for overall pain
a c ro ss th e th ree environm ents. The low perception of pain could b e related to th e
d eg ree of d is e a s e progression at th e time of th e investigation. T hom as & Roy (1988)
reported th a t w om en in their sixties had an av erag e duration of 12.5 y ears of pain.
As th e chronic d is e a s e p ro g re sse s with ag e, older w om en may possibly learn to live
with th e pain an d a c c e p t it a s a normal part of th e aging p ro cess. In addition, chronic
pain is often a sso ciated with functional disability. If older w om en are able to carry out
their normal activities of daily living, th e pain may n o t sto p them from doing th e things
they w ant to do. As a result of being able to d o th e things they w ant to do, the
perception of pain is altered (Riley, Ahern & Rollick, 1988).
Index o f Well-Being
At th e time of th e interview th e se older w om en (N=45) with osteoarthritis rated
their quality of life a s satisfying. Laborde & Pow ers (1985) also found th a t
osteoarthritics rated their overall satisfaction with life a s good. In addition, p resen t life
39
satisfaction w as related to better health perception, internal health locus of control,
and less arthritic pain. Burckhardt (1988) indicated that w om en with arthritis
re sp o n d ed similarly to w om en in th e general population w hen a sk e d to rate the
im portance of American life. In com parison, Laborde & Pow ers (1980) found that
p resen t life satisfaction w as lower for arthritics than for hem odialysis patients. The
variable of health w as th e stro n g est of all variables th at related to life satisfaction and
th e variable of pain fostered lower life satisfaction.
Relationship Between Pain and Quality of Life
Results of this study indicated a strong inverse relationship betw een pain and
quality of life. A significant inverse relationship w as found betw een pain an d financial
situation for th e w om en in this study. Burckhardt (1988) w as also able to show an
inverse relationship betw een pain and quality of life. Although th e findings by
Burckhardt w ere not conclusive, th e results sh o w ed so m e significant differences which
may have b een arthritis related. Laborde & Pow ers (1985) found th a t perception of
p resen t quality of life w as significantly asso ciated with less joint pain. Laborde &
Pow ers noted th a t although osteoarthritics rated their pain a s distressing, their d eg ree
of pain did not seem to impinge on their overall quality of life.
Environmental Influence
Although th e m ean sco re for pain w as low an d th e m ean sc o re for quality of
life w as high, differences in th e perception of pain an d quality of life existed am ong the
different environm ental groups. The frontier group had th e low est s c o re for perceived
pain and th e highest sco re for quality of life. The rural group reported medium sc o re s
40
for both perceived pain an d quality of life. The urban group reported th e highest
sc o re for pain an d th e low est sco re for quality of life. There are several possible
explanations in th e literature for th e se differences. Bigbee (1984) identified th e
stren g th s of rural w om en a s pride in rural heritage an d culture, tradition of self-care,
strong family attachm ent, community involvement, an d support. Findings by Krout
(1989) w ere con g ru en t with th o se described by Bigbee. In contrast, S cheldt an d
Windley (1983) found th at a higher rural context, by im posing greater d istan ces an d
few er proxim ate social supports; negatively influenced th e reports of well-being offered
by older residents. Palm ore (1983) reported th at rural non-farm an d farm elders have
m ore acu te chronic d isease, chronic activity limitation, m ore d ay s of restricted activity,
and m ore work-loss d ay s an d bed d ays d u e to injury. However, rural elders sp e n d
few er d ay s in b e d desp ite their greater incidence of acu te an d chronic illness.
Palm ore surm ised th at this ten d en cy may result from a stronger belief am ong rural
elders th a t o n e should g e t out of b ed and carry out normal activities a s m uch a s
possible.
The h ig h est sc o re for satisfaction with marital relationship w as reported by th e
frontier group, th e rural group reported a m oderate score, an d th e u rban group
reported th e low est sco re. O ther research ers (Palmore & Luikart, 1972; Krout, 1989)
found th a t marital relationship show ed little or no relationship to quality of life.
The m ore rural th e group, the m ore satisfied they w ere with th e work th at they
did. The frontier group reported th e highest level of satisfaction with th e work th at
they did, th e rural group reported th e m oderate level, and th e urb an g ro u p indicated
low est level of satisfaction. Although Burckhardt (1988) d o e s not relate work
41
satisfaction to environm ent, sh e noted th at w om en in th e 70 y ear old a g e group w ere
not satisfied with their work.
A cross th e th ree environm ental groups, both th e m ean an d stan d ard deviation
show ed minimal variation for satisfaction with financial situation. The frontier group
reported th e h ighest level of satisfaction with financial situation; th e urban group
reported a m oderate sco re; and th e rural group reported th e low est sco re. The results
of this stud y imply th at older w om en with m ore m oney reported a lower perceived
level of pain an d a higher quality of life. Krout (1989) reported similar findings in
relationship to financial situation.
Participants in th e rural environm ent reported th e highest level of satisfaction
with th e place w here o n e lives. The frontier group reported a m o d erate level of
satisfaction an d th e urban group reported the low est level of satisfaction. Rural an d
frontier g ro u p s resided in th e environm ent in which they lived th e majority of time from
birth until a g e 17. Findings from this study imply th at older w om en living in th e less
populated environm ents are m ore satisfied with their place of resid en ce.
No
professional literature could be found that exam ined satisfaction with place of
resid en ce a s a variable of quality of life.
Satisfaction with non-work activities, su ch a s hobbies, w as h ighest for th e
participants living in th e frontier. Participants in th e rural and urban environm ents
reported th e sa m e level of satisfaction with non-work activities. In contrast, Scheldt
an d Windley (1982) found th at non-work activity sc o re s w ere significantly higher for
residents of th e largest tow ns in m oderately rural counties than for resid en ts in all
other g ro u p s by town size an d d eg ree of rurality.
42
Older w om en living in th e rural environm ent reported th e h ig h est level of
satisfaction with family life, The older w om en in th e frontier environm ent indicated a
m oderate level of satisfaction with family life an d th e older w om en in th e urban
environm ent reported th e low est level of satisfaction with family life. Findings for
satisfaction with family life w ere con g ru en t with th o se of Scheldt an d Windley (1982).
S cheldt and Windley surm ised th at older w om en living in th e m ore rural a re a s may
e n g a g e in m ore frequent co n tact with family to co m p en sate for lower likelihood of
socializing with friends.
A cross th e th ree environm ental groups, friendships w ere reported to provide a
so u rce of satisfaction with life. Rural w om en reported th e highest level of satisfaction;
urban w om en reported a m oderate level of satisfaction; and frontier w om en reported
th e low est level of satisfaction with friendships. Findings for satisfaction with
friendships from this study w ere congruent with th o se in th e professional literature.
S cheldt an d Windley (1982) found that significant differences for satisfaction with
friendships existed am ong individuals living in differing rural contexts. Larger tow ns
may p o s s e s s facilities which can h o st m ore formal an d informal activities an d in
addition, provide a larger population of possible confidants. Thus, S cheldt & Windley
su g g e s te d th at th e greater d eg ree of social self-sufficiency in large counties may relate
to higher satisfaction levels with friendships.
Limitations
A purposive sam ple w as u sed in this study; therefore, m em bers of th e sam ple
m ay not b e an accu rate representation of older w om en with OA. However, findings
43
from this stu d y can b e generalized to a volunteer sam ple in similar urban, rural, an d
frontier environm ents.
implications for Nursing
O steoarthritis is a chronic d ise a se th at p ro g resses with th e aging p rocess.
Little can b e d o n e to sto p th e d isease, but m uch can b e d o n e to slow th e progression
of th e d is e a s e an d to improve th e quality of life of individuals affected by th e chronic
pain and disability which acco m p an ies OA. Professional n u rses are able to recognize
chronic pain a s an extremely com plex p h enom enon which e n c o m p a sse s sensory,
affective, an d cognitive co m p o n en ts of an individual’s life.
In th e p ro c e ss of helping older w om en co p e with th e chronic pain from
osteoarthritis, n u rses m ust b e sensitive to th e individual's reports of pain an d th e
im pact of th e pain on th e individual’s quality of life. In order to maintain th e OA
victim’s quality of life, preventive an d promotional educational program s should
a d d re ss th e psychological a s well a s th e physiological an d sociocultural need s.
T h ese educational program s can b e u sed to improve know ledge, e n h an c e pain
m anagem en t skills, improve functional statu s, an d prom ote health habits which may
possibly slow th e d is e a s e p ro cess.
N urses m ust b e very cautious ab o u t making broad generalizations ab o u t all
older w om en with OA. Results of this study indicate that there are differences in th e
perception s of w om en living in urban, rural, and frontier environm ents. Frontier
w om en in th e sa m e a g e group with th e sam e chronic d ise a se reported le ss pain and
higher quality of life th an did w om en living in urban and rural environm ents.
Nursing
intervention should b e d esig n ed to maintain th e cultural values an d p erspectives of the
44
population served. Instead of trying to a d a p t th e frontier w om en to th e nursing
intervention, n u rse s m ust a d a p t th e intervention to th e older population within their
specific environm ent.
Health care n e e d s of rural an d frontier dwellers can n o t b e adequately
a d d re s s e d by applying m odels developed in urban areas. However, th e u se of
C hristiaens' adaptation of th e N eum an S ystem s Model would allow for th e care of rural
a s well a s urban dwellers. This model indicates th e care for th e "total person" through
a com posite of four variables: physiological, psychological, sociocultural, and
environm ental. T h ese variables include th e different elem ents th a t are vital to caring
for n e e d s of th e "total person," en co m p assin g their physical, psychological, cultural,
and environm ental b ackgrounds.
R ecom m endations
O ne recom m endation is to replicate this study using a larger sam ple. The
p u rp o se of th e replicated stu d ies in similar settings would establish reliability.
A longitudinal stu d y com paring osteoarthritic perception of pain an d quality of
life at several time intervals would establish facts indicating th e effects of th e d ise a se
progression. This d a ta m ay then provide a com prehensive picture of th e chronic
nature of th e d isease.
Testing th e directional hypothesis indicated by th e results of this descriptive
study is also recom m ended. The hypothesis indicates that pain should have a
negative effect on quality of life. Increased understanding of factors a sso ciated with
c h a n g e s in th e extent of pain an d th e effect of pain on th e quality of life could expand
45
th e scientific understanding of chronic pain. The clinical appreciation of th e
com plexities of th e chronic pain experience, could also b e e n h an c ed by further study.
The results of this study indicated th at w om en with osteoarthritis can maintain
a high quality of life by adapting to th e chronic pain and th e disability th at
acco m p an ies this d isease. Further research is n eed e d to exam ine th e elem ents which
prom ote adaptation to th e chronic pain an d th e disability th at acco m p an ies OA in
order to preserve quality of life.
Future stu d ies are recom m ended to exam ine differences in p e rso n s residing in
different environm ents. The m agnitude and nature of th e differences betw een urban,
rural and frontier environm ents also n eed additional study.
46
REFERENCES CITED
47
REFERENCES CITED
Allen, V., & Miller, M. (1986). A model for a sse ssin g health n e e d s of th e rural elderly:
M ethodology an d results. Journal of Allied Health. 8, 213-224.
Bigbee, J. L. (1984). The changing role of rural women: Nursing an d health
implications. Health C are for W om en International, 5, 307-322.
Bergner, M. (1989). Quality of life, health statu s an d clinical research . Medical Care,
27(3), 148-156.
Burckhardt, C. (1988). Quality of life for w om en with arthritis. Health C are for W omen
International. 9, 229-238.
Burckhardt, J.E. (1977). T echniques for translating units of n eed to units of service:
The c a s e of transportation an d nutrition services for th e elderly. Administration
on Aging W ashington, D.C.. Unpublished manuscript.
Cam pbell, A., C onverse, P. E., & R odgers, W. L (1976). The quality of American life.
New York: Sage.
Deniston, 0 . L, & Jette, A. M. (1980). A functional statu s a s s e s sm e n t instrument:
Validation in an elderly population. Health Service R esearch, 15(1), 21-34.
Ellenbogen, B. L (1967). Health statu s of th e rural ag ed . In E. G. Y oum ans (Ed.),
Older rural A m ericans. Lexington: University of Kentucky P ress.
Elison, G. (1986). Frontier areas: Problem s for delivery of health care services. Rural
Health C are. 8(5), 1-3.
Engel, (1984). On th e vicissitudes of health appraisal. A dvances in Nursing
S cience. 7 (1), 12-23.
Fogel, C. I., & W oods, N. F. (1981). Health care of women: A nursing perspective. St.
Louis: Mosby.
Haug, M. R., Ford, A. B., & Sheafor, M. (1983). The physical an d m ental health of
a g e d w om en. New York: Springer.
Kahn, E. D. (1984). The w om en’s m ovem ent and older w om en’s health: issu es and
policy implications. W om en an d Health. 9(4), 87-100.
Kahn, R. L, Goldfarb, A. I., Pollack, M., & Peck, A. (I960). Brief objective
m e asu re s for th e determ ination on mental statu s in adults. American Journal of
Psychiatry. 117. 326-328.
48
Kane, R A., & Kane, R L (1981). A ssessing th e elderly. Lexington, MA:
Lexington Books.
Kerwan, J. R , & Silman, A. J. (1987). Epidemiological, sociological an d environm ental
a s p e c ts of rheum atoid arthritis and osteoarthritis. Bailliere’s Clinical
Rheum atology. 1(3), 467-488.
Kjervik, D. K., & Martinson, I. M. (1986). W omen in health an d illness: Life
experien ces and crisis. Philadelphia: S aunders.
Krout, J. A. (1989). Rural v erses urban differences in health d e p e n d e n c e am ong th e
elderly populations. International Journal on Aging an d Human Development.
28(2), 141-156.
Laborde, J. M., & Powers, M. J. (1985). Life satisfaction, health control orientation and
illness-related factors in p erso n s with osteoarthritis. R esearch in Nursing and
Health. 8,183-190.
Laborde, J. M., & Powers, M. J. (1980). Satisfaction with life for patients undergoing
hem odialysis an d patients suffering from osteoarthritis. R esearch in Nursing
and Health. 3, 19-24.
Lawrence, R C., H ochberg, M. C., Kelsey, S. L , McDuffie, F. C., M edsger, I . A., Felts,
W. R., & Shulm an, L E. (1989). Estim ates of th e prevalence of selected arthritic
an d m usculoskeletal d ise a se s in th e United S tates. Journal of Rheum atology.
8(4), 427-439.
Lee, H. (1989, July). C om parison of elderly w om en living in differing environm ents.
P ap er p resen ted at a sym posium , "Meeting Health Promotion an d Health
M aintenance N eeds of Rural Populations." Bozeman, Mt.
Lewis, M. L (1985). Older w om en and health: An overview in Health an d Older
W om en in New York S tate. New York Statew ide C onference on Older W omen.
Fordham University, New York, City.
Marriner, A. (1986). Nursing theorists and their w ork. St. Louis: Mosby.
M atteson, M. A., & McConnell, E. S. (1988). Gerontological nursing: C o n cep ts to
practice. Philadelphia: S aunders.
Meinhart, N. T., & McCafferty, M. (1983), Pain: A nursing ap p ro ach to a ss e s sm e n t and
analysis. Norwalk: Appleton-Century-Crofts.
N eum an, B. (1982). The N eum an sy stem s model: Application to nursing
education a n d practice. Norwalk: Appleton-Century-Crofts.
Palm ore, E. (1983). Health care n e e d s of th e rural elderly. International Journal of
Aging an d Human Development. 18. 39-45.
49
Palm ore, E., & Luikart, C. (1972). Health and social factors related to life satisfaction.
Journal of Health an d Social Behavior. 13(3), 68-72.
Riley, J. F., Ahern, D. K., & Rollick, M. J. (1988). Chronic pain an d functional
impairment: A ssessing beliefs ab o u t their relationship. Archives of Physical
M edicine an d Rehabilitation. 69(8), 579-582.
Rosenblatt, R. A., & M oscovice, I. S. (1982). Rural health c a re . New York: Wiley.
Scheldt, R. J., & Windley, P. G. (1982). Well-being profiles of small-town elderly in
differing rural contexts. Community Mental Health Journal. 18(4), 257-267.
Siegal, S. (1956). N onparam etric statistics for th e behavioral s c ie n c e s . New York:
McGraw-Hill.
Thom as, M. R., & Roy, R. (1986). A survey of chronic pain in th e elderly population.
C anadian Family Physician. 32. 513-516.
Thom as, M. R., & Roy, R. (1988). Age an d pain: A com parison study of th e younger
an d older elderly. Pain M anagem ent. July/August, 174-180.
V erbrugge, L M. (1984). A health profile of older w om en with com parison to older
m en. R esearch on Aging. 6(3). 291-322.
V erbrugge, L M., & Balaban, D. J. (1989). P atterns of ch an g e in disability and
well-being. Medical C are. 27(3). 128-147.
W einberger, M., Tieney, W. M., & Booher, P. (1989). Com m on problem s experienced
by adults with osteoarthritis. Arthritis C are and R esearch. 2(3), 94-100.
W oods, N. F., & C atanzaro, M. (1988). Nursing research: Theory an d practice.
St. Louis: Mosby.
Yin, R. K (1984). C a se study research . Newbury Park, CA.: S ag e.
50
APPENDICES
51
APPENDIX A
CONSENT FORM
.52
SUBJECT CONSENT FORM
FOR
PARTICIPATION IN HUMAN RESEARCH
MONTANA STATE UNIVERSITY
Project title: C om parison of Perceived Health, H ardiness, Social Support, Functional
Independence, an d Use of Health C are Facilities Between Older W om en with Arthritis
Living in Urban, Rural, and Frontier Environments.
Investigator:
Helen Lee, Ph.D., R.N., A ssistant Professor,
College of Nursing
455-5610 (Great Falls) 243-6515 (Missoula)
You are being ask ed to participate in a long term study to learn ab o u t factors which
m ay m ake a difference in how you m eet your health needs. Knowing m ore ab o u t
w hether differences exist betw een th o se w ho live in a city a s co m p ared to th o se living
in rural a re a s or very rural (frontier) a re a s will help u s obtain a b etter understanding of
your health care n eed s. This study is of no direct benefit to you; how ever, th e
information you provide will b e u sed to d esig n w ays that n u rses an d other health
professionals can help elderly people living in different environm ents.
You w ere selec ted a s a possible su b ject in this study b eca u se you a re female; w ere
born betw een Jan u ary 1 ,1 9 1 3 , an d D ecem ber 3 1 ,1 9 2 3 ; have arthritis; an d live in your
own hom e in either a city, a rural area, or a very rural (frontier) area.
If you a g re e to participate in this study, you will receive a questionnaire an d participate
in an interview every two years for a s long a s th e study continues (ten years
anticipated). The questionnaire a sk s q u estio n s ab o u t your life, your opinions, and
your health; it will tak e approxim ately 30 to 60 m inutes to com plete. Within 7 to 14
d ay s after you have received th e questionnaire, I or my research a ssista n t will co n tact
you to s e t up a time for an interview. The interview will be co n d u cted by myself or an
assistan t an d will ta k e ab o u t an hour. The interview can take place in your hom e or
any other setting you ch o o se. During th e interview, I or my assista n t will ask
questions ab o u t how you m an ag e your activities of daily living (bathing, dressing
eating) an d how m uch you u se th e various health care facilities (visits to physicians,
num ber of tim es hospitalized).
Participating in this study should not rep resen t a risk to you, but it m ay b e an
inconvenience b e c a u se of th e time n eed e d to answ er questions. If you should
b eco m e tired during th e interview, a se c o n d interview can be sch ed u led .
53
P lease do not write your nam e anyw here on th e questionnaire. The
questionnaire an d th e information obtained from your interview will b e k ep t in an area
accessib le only to myself. Information taken from your questionnaire an d interview will
b e available only to th e health professionals directly involved in this study. Your nam e
will be known only to myself and/or an interviewer w ho is assisting with this study
b e c a u se th e co n se n t form you sign will b e sto red in a locked office file.
You will not b e specifically identified in any reports stem m ing from this study
b e c a u se only d a ta obtained from th e group a s a whole will be published. Information
from th e stu d y may b e sh ared with health professionals through publications in
medical an d nursing journals, a t health professionals m eetings and, if appropriate, with
th e lay public through organizations serving people with arthritis.
You are free to not answ er any questions that you feel are an invasion of your
privacy. You m ay withdraw from th e study at any time without penalty an d without
c h an g e in any relationship you may have with M ontana State University College of
Nursing. The study is planned to continue for approximately ten years. If you ag ree
to participate during this first y ear of th e study, you will be given th e opportunity to
participate in ea c h su b se q u e n t y ear of th e study.
This study is funded in part by a grant from M ontanans On a New Trac for
S cience (MONTS), M ontana S tate University.
AUTHORIZATION: Having read the above, I , _____________________________ agree
to participate in the research. I have had an opportunity to ask questions, and understand
that future questions I may have about the research or about participant’s rights will be
answered by the investigator. I understand that I tnay later refuse to or that I may withdraw .
from the study a t any time. I have received a copy o f this consent form for my own records.
Signed
W itn e ss_______________________________
Investigator_______ _____________________
Date
54
July 15, 1988
Dear
T hank you for agreeing to be a participant in my study!
E nclosed are two items. The first is a co n sen t form. P lease read it carefully. You
may feel som ew hat overw helm ed by its length; I certainly w as w hen I con stru cted it for
th e MSU Human Rights Committee. However, it is a n ecessary requirem ent for any
study co n d u cted by th e University in order to en su re th at your rights are protected.
You will note in reading th e c o n sen t form th at th ere are two activities to study
-filling out a questionnaire (the se c o n d item enclosed) an d participating in an
interview. P lease fill o u t th e questionnaire a s so o n a s you can after receiving it. Very
shortly, I or o n e of my research assistan ts, Eleanor Yurkovich or C har Christiaens, will
contact you to m ake an appointm ent for an interview. The questionnaire will be
picked up at th e time of th e interview.
You will also n o te in th e co n sen t form th at I wish to continue th e study for a period of
time. While you are under no obligation to continue beyond this initial time, I h o p e
you will d o so.
If you have any questions, p lease co n tact m e at 727-8956 (Great Falls) or
721-3983 (Missoula).
Sincerely,
Helen J. Lee, Ph.D., R.N.
A ssistant P rofessor
55
APPENDIX B
MENTAL STATUS QUESTIONNAIRE
56
MEMORY QUESTIONS
First, I have a few q u estio n s co n cern ed with memory. T h ese q u estio n s a s k ab o u t
particular bits of information th a t many p eople seem to forget from time to time.
T h ese are routine q u estio n s w e a sk everyone.
1.
W hat day in th e m onth is it tod ay ? ___________
2.
W hat day of th e w eek is it? __________
3.
W hat y ear is it? __________
4.
How old are you? __________
5.
W hen is your birthday? __________
6.
In w hat year w ere you born? ___________
7.
W hat is th e nam e of th e president? __________
8.
Who w as president before this o n e? __________
9.
W hat is this place (or: Tb w hat town are you nearest)? __________
10.
W here is this place located (in relation to th e above tow n)?
Mental S tatus Q uestionnaire
Kahn, Gdldforb, Pollack & P eck (1960)
57
APPENDIX C
GERIATRIC ARTHRITIS FUNCTIONAL STATUS PAIN SUBSCALE
I
58
SECTION III
PAIN
In this section of th e interview, we are trying to m easure th e am ount of pain you
experienced w hen you perform ed your daily activities during th e p a st w eek. For eac h
activity, I would like you to ju d g e th e am ount of pain you experienced w hen doing it.
By pain, I m ean th e discom fort or sen satio n of hurting you experienced w hen doing
th e activity. Do you have any q u estio n s before we start?
**************
I’d like you to co n sid er th e am ount of pain you experienced, on th e av erag e during
th e p a st w eek, for e a c h of th e activities listed. C onsider th e ladder ab o v e each activity
w here th e bottom rung eq u als NO PAIN w hen performing an activity, th e middle rung
rep resen ts a MODERATE AMOUNT OF PAIN, an d th e to p rung eq u als EXTREME PAIN
w hen performing th a t activity during th e p ast 7 days.
The m ore pain you experienced, th e higher
u
p
on th e ladder you should g o .
Make a ch eck on th e rung of th e ladder which b e s t represents th e am o u n t of pain you
experienced w hen doing ea c h activity, on th e average, last w eek. Feel free to ch an g e
your mind a s you g o along.
(Give th e questionnaire to th e respondent)
59
PAIN
For ea c h activity you perform, on th e scale from 0 to 7, w here 0 = NO PAIN and
7 = SEVERE PAIN, circle th e num ber that b e st rep resen ts th e av erag e am ount of
PAIN you experienced w hen performing the activity during th e p a s t 3 d a y s.
NO
PAIN
1. Getting in/out of bed
0
l
2. Rising from a sitting
position
3. Walking inside th e
h o u se
SEVERE
PAIN
1
l
0
l
l
l
0
l
l
1
1
6
1
l
4
5
0
1
2
3
4
5
6
1
I
I
I
I
I
l
0
1
2
3
4
5
6
1
7. Putting on
stockin g s/p an ts
0
1
2
3
4
5
6
1
8. Buttoning clothes
0
1
2
3
4
5
6
1
I
l
l
l
l
l
6
1
6
I
9. O pening jars
10. Lifting p o ts an d p an s
l
0
1
l
l
0
1
l
6
5. Doing yardw ork
l
l
'
l
l
l
6
4. Climbing stairs
6. Putting on a shirt
or blouse
l
5
l
3
'
l
4
l
2
5
l
3
6
l
4
l
2
5
l
3
l
1
4
l
2
l
l
3
l
1
0
l
2
l
2
l
l
3
l
2
l
l
4
l
3
l
l
5
l
4
1
l
5
60
NO
PAIN
SEVERE
PAIN
11. Putting d ish es into
high c u p b o ard s
0
12. Doing laundry
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
0
1
2
3
4
5
6
7
0
I
1
13. Cutting food
1
I
2
I
3
I
4
I
5
I
6
I
7
I
I
14. W ashing all a re a s
of body
15. Turning on faucets
I
Functional S tatu s Index Pain S u b scale
0 . L Deniston & A. M. Je tte (1980)
I
I
2
I
I
3
I
I
4
I
I
5
I
I
6
I
I
7
I
I
61
APPENDIX D
INDEX OF WELL-BEING
62
Directions: Here is a list of so m e of th e things th a t are u sed to m easu re quality of life.
M ost of th e se things are im portant to all of us, but eac h p erso n feels th a t so m e of
th e s e things are m ore im portant than others, an d w hat o n e p erso n co n sid ers m ost
important, so m e o n e else may think is less important.
To th e right of th e list is a scale with num bers from 1 through 5, w here 1 m ean s "Not
at all satisfied" an d 5 m ean s "Extremely satisfied." Think ab o u t eac h thing on th e list
and circle th e num ber from th e scale to show how satisfied you presently are with th at
a re a of your life.
Not at all Satisfied--------- Extremely Satisfied
I.
Your marital rela tio n sh ip ..................
1
2
3
4
5
2.
T he work th a t you d o ......................
I
2
3
4
5
3.
Your p resen t financial situation . . .
1
2
3
4
5
4.
T he place w here you l i v e ...............
I
2
3
4
5
5.
Your non-work activities,
su c h a s h o b b ie s .........................
1
2
3
4
5
6.
Your family l i f e .........................
I
2
3
4
5
7.
Your f r ie n d s h ip s .........................
I
2
3
4
5
Index Well Being
A. Cam pbell, P. E. C onverse, & W. L R odgers (1976)
63
APPENDIX E
DEMOGRAPHIC QUESTIONS
64
DEMOGRAPHIC QUESTIONS
Next, I would like to ask m ore specific questions ab o u t w here you lived an d your
p resen t location within North Central M ontana.
1.
How would you describ e th e area w here you lived th e majority of th e time until
you reach ed th e a g e of 17?
1.
2.
3.
4.
5.
6.
7.
8.
2.
Rural farm /ranch
Rural - not a farm /ranch
Small town less than 500 population
Small town 501 to 2,500
Big town 2,501 to 5,000
Small city 5,001 to 15,000
Small city 15,001 to 50,000
Big city over 50,000
How would you describ e th e a re a you live in now?
1.
2.
3.
4.
5.
6.
7.
8.
Rural farm /ranch
Rural - not a farm /ranch
Small tow n le ss than 500 population
Small tow n 501 to 2,500
Big tow n 2,501 to 5,000
Small city 5,001 to 15,000
Small city 15,001 to 50,000
Big city over 50,000
BACKGROUND QUESTIONS
1.
Are you currently
I. Married?
2.
3. W idowed?
4. Never Married?
How m any y ears of school did you finish?
<8
3.
2. D ivorced/Separated?
8
9
10
11
12
13
14
15
16 > 1 6
How m any p erso n s live in th e sam e residence with you?
0 1
2 3 >3
65
4.
Would you tell m e within which of th e categ o ries on th e s h e e t your total family
incom e last y ear before tax es fall into?
1.
Less than $4,000
2.
Between $4,000 an d 7,999
3.
Between $8,000 and 11,999
4.
Between $12,000 and 14,999
5.
Between $15,000 and 24,999
6.
$25,000 or greater
D em ographic Q uestions Lee (1985)
MONTANA STATE UNIVERSITY LIBRARIES
3
7 6 2 1011 8 9 9 5 7
bSSSFSb
UTlCfVOMMW
NE.
.