Evaluation of a Community Health Practitioner Self-care Program for Rural Korean Patients with Osteoarthritis

The prevalence of arthritis is one of the highest among self-perceived medical symptoms. According to a national health survey in Korea, 28.9% of those aged 30 years and older had high blood pressure and 14.7% of those aged 50 years and older had arthritis. However, those who had arthritis had lower EQ-5D index, which means the quality of life, 0.811, than those who had high blood pressure, 0.896. (Ministry of Health and Welfare [MOHW], 2011)

According to 2007-2009 National Health Interview Survey of U.S.A, 22.2% of those aged 18 years and older had self-reported doctor-diagnosed arthritis, and 9.4% had activity limitations due to arthritis (Centers for Disease Control and Prevention [CDC], 2010). Arthritis is the most prevalent health condition among seniors and it causes significant pain and disability (Devos-Comby, Cronan, & Roesch, 2006). In addition, arthritis leads activity limitation associated with joint symptoms and reduction of health-related quality of life included physical and mental health (Cook, Pietrobon, & Hegedus, 2007).

Since arthritis should be managed life-long, self-care management is a useful intervention for elderly arthritis patients. The 6-week Arthritis Self-care Management (ASCM) Program developed by Lorig and colleagues at Stanford University in the early 1980s has been used widely in studies and has shown significant changes in pain, health status, and self-care ability (Lorig et al., 1989). Many other studies have used Lorig's ASCM and have reported significant changes in pain and self-care ability (Nuñez, Keller, & Ananian, 2009; Osborne, Wilson, Lorig, & McColl, 2007; Yip et al., 2007). Also, self-care management has been recommended by the CDC for arthritis patients in the United States. The CDC self-care program consisted of the following components: a) techniques to deal with problems such as pain, fatigue, frustration, and isolation; b) appropriate exercise for maintaining and improving strength, flexibility, and endurance; c) appropriate use of medications; d) communicating effectively with family, friends, and health professionals; e) healthy eating; f) making informed treatment decisions; g) disease related problem-solving; and h) getting a good night's sleep (CDC, 2011).

The Korean Rheumatology Health Professionals Society (KRHPS) developed a 6-week Self-help Health Promotion Program (SHP) for arthritis patients (KRHPS, 1999). The SHP consisted of 6 areas: 1) principles of self-care and arthritis; 2) exercise and pain management; 3) endurance exercise and individual evaluation; 4) nutrition and problem-solving methods; 5) folk remedies and communication; and 6) arthritis medication and self-control methods. Lee et al. (2002) reported the effectiveness of SHP intervention during 1997-2001 for 845 arthritis patients in one community. Pain, flexibility, depression, and self-efficiency were significantly improved; however, since this study only used a single pre-post comparison population, there are issues with the validity of the study results.

There have been studies on arthritis implemented in primary health care settings. Lee et al. (2001) implemented a study at a health center and community health post and reported that the experimental group showed significantly better pain status, self-efficiency, and muscle strength than the control group. Choi (2001) also used SHP as an intervention at a community health post and reported no changes to pain and fatigue, but significant improvement to self-efficiency. Kim et al. (2003) also evaluated the effectiveness of SHP and reported significant improvement to self-care ability and flexibility.

Problems with previous studies implemented in Korea have been lack of validity, generalization, and dissemination. The studies were implemented only in certain areas, so the study results cannot be generalized to other areas. Most of the interventions were implemented by researchers, so the SHP was not easily disseminated by other health care providers. To solve these problems, this study covered various areas to increase generalization and was provided by Community Health Practitioners (CHP) who had been trained by researchers.

Because of the World Health Organization (WHO) Alma-Ata Declaration in 1978, the community health post was developed as a major primary health care setting in rural areas in Korea in 1980. Each community health post covers about 500-1000 people (Kim et al., 2010) and is managed by one CHP. The CHP is a registered nurse who receives 6 months of primary health care training. They have been providing primary health care services in rural areas since 1981, including medical treatment and prescribing medications. Since the nurses were not able to provide medical treatment and prescription medications by 'Medical Law', the Korean government made a 'Special Law for Rural Areas' in 1980 to support the activities of the CHPs. There are 1,912 CHPs working at the community level in the health care delivery system in Korea (MOHW, 2010). The CHPs manage all the health problems for people in the community and the activities of the CHPs are covered by national medical insurance. The CHPs have been improving health accessibility and have been shown to be cost-effective primary health care providers in rural areas (Kim, 2004; Lee, & Ko, 2002; Oh, 2003). Health care for elderly populations in rural areas is important, since there are twice as many elderly living in rural areas than in the city. This study was implemented at the community health posts in 4 provinces and the intervention, a self-care program (SCP) that was modified from the SHP and CDC programs, was provided by CHPs after they received training in self-care program for arthritis patients. Rheumatoid arthritis patients were referred to community hospitals and osteoarthritis patients in rural areas were managed by CHPs. Therefore, only osteoarthritis (hereafter referred to as 'arthritis') patients were included in this study.

Since Rosenbaum and Rubin (1983) developed the concept of propensity scores estimated at baseline to control for selection bias in cohort studies, the propensity score matching (PSM) analysis has been used to control for confounding variables in various studies (Ahmed et al., 2006; Lee et al., 2007). PSM can be usually used when baseline demographics and other covariates between experimental and control groups are imbalanced. Propensity scores are generated through a logistic regression model, treating the intervention as the dependent variable and all confounding covariates as predictor variables (Qin, Titler, Shever, & Kim, 2008). Although the subjects were randomly assigned to an experimental or control group, there were several significantly different characteristics between the two groups in this study. PSM was a valuable tool to control for the differences between the two groups in this study.

This study was intended to evaluate a self-care program for elderly arthritis patients in rural areas, and especially those managed by CHPs in rural Korea, and had the following specific objectives: To measure health and arthritis-related characteristics of arthritis patients in rural areas; and to measure the effectiveness of a self-care program for arthritis patients in rural areas.

The SCP was implemented by the CHP for arthritis patients in rural areas in the community health post, which is the health clinic run by the CHP. The CHP was started in 1980 per the recommendation of WHO's 1978 meeting at Alma-Ata (WHO, 1978). WHO set a goal of 'Health for All by the Year 2000 in 1978 and recommended primary health care to achieve that goal. Korea developed the CHP as a national primary health care strategy in rural areas. According to Park (2010), the community had higher satisfaction with CHPs compared to other health care providers in rural areas. People older than 65 years old receive health services and pay only a small fee for medication. The medication fee is free for elderly patients of CHPs compared to 23,914 won per 1 patient per month from community hospitals by medical doctors (Moon, 2007). The National Health Insurance Cooperation (NHIC) reimburses the health care fee to health institutions for patient care. The reimbursement fee to CHPs from NHIC is about one third compared to community hospitals. CHPs contribute in two ways. One is that CHPs contribute to increased health accessibility for rural populations, because the community health post is in a nearby community, within walking distance.

To increase the generalization of the study results, study participants should be recruited from various areas. However, former studies (Kim et al., 2003; Kim, 2004) were performed at the limited areas for their intervention. This study was implemented at three provinces including 47 community health posts. Therefore, the results of this study can be contributed for better generalization compared to the former studies.

Since the SCP was provided by the CHPs at their community health post, this study provided two days of training for the CHPs before the intervention. The content of the CHPs' training program were arthritis assessment, ROM measurement, group education strategies, the contents of the SCP, and data collection methods. In most of the studies, researchers provided the intervention (Lee et al., 2002; Lee et al., 2001). Therefore, there was a lack of continuity of services after the study. However, in this study, CHPs were trained as providers of the intervention, and they can follow-up continuously with arthritis patients in the community. These were the advantages of utilizing health care providers in the study for both community members and health care providers.

Many studies have reported significant outcomes after 6 weeks of an arthritis self-care program. Osborne et al. (2007) reported the results of their 6 weeks Arthritis Self-care Management for 452 arthritis patients. Although the absolute changes in health status were small, pain, fatigue, health distress, and self-efficacy showed significant improvement. Yip et al. (2007) also reported on their 16-week self-management arthritis program for 67 experimental subjects and 53 controls. There were significant improvements in arthritis self-efficacy, most self-management skills, and pain. Goeppinger, Armstrong, Schwartz, Ensley, and Brady (2007) compared the effectiveness of a 6-week arthritis self-help course (ASHC) for 26 arthritis patients and a Chronic Disease Self-Management Program (CDSMP) for 22 arthritis patients. The ASHC participants showed significant improvement in self-efficacy, stretching, and general health, but not in pain.

There are problems with some of the previous studies. First, some of the studies include only an experimental group and compare pre-post changes in that group (Lee et al., 2002; Osborne et al., 2007). As a result, we cannot control for changes due to natural improvements with time. Second, some of the studies included too small a sample size to measure the effect of the intervention (Kim et al., 2003; Lee et al., 2001). Since 64 study subjects were needed for a moderate effect, .05 significance level, and .8 study power, no significant differences in those studies could be due to low study power from a small study population.

Most previous intervention periods were 6 weeks. Since arthritis is the chronic health problem, arthritis patients should maintain the self-care ability even after 6 weeks of intervention. One study followed up with the study participants 1 year after the intervention: Arthritis self-care ability had decreased compared to the outcome right after the intervention (Goeppinger et al., 2007). Future studies are needed to find effective strategies to maintain life-long self-care ability for arthritis patients after the intervention.

The assignment of study participants was generally performed based on the individual. This study, however, was concerned the diffusion of treatment because of frequent contacts among participants if participants managed by one CHP were divided into experimental and control group. Therefore, in order to prevent the diffusion of treatment, four provinces were randomized into 2 experimental and 2 control groups in this study; however, several characteristics of the two groups were significantly different. In this study, PSM was used to control for the confounding variables. In many studies, multivariate regression analysis (MRA) has been used to control for confounding variables, which can affect to the outcome of studies. However, PSM is recognized as better than MRA for controlling confounding variables. Lee et al. (2007) reported that MRA might have less reliability compared to PSM due to its linear relationship assumption between dependent variables and independent variables. Also, frequently making dummy variables for MRA causes problems in measuring the effectiveness of the intervention. Rubin and Thomas (2000) also recommended PSM to reduce the probability of measurement errors by matching. However, there have been not many studies using PSM in the field of nursing in Korea.

Even though this study applied PSM analysis to control for the confounding variables, there may be limitations in interpretation of results because baseline demographics between two groups were not homogeneous. Therefore, future study is required to select and assign study participants carefully.

In conclusion, a 6-week SCP for arthritis managed by primary health care workers (CHP at community health post) was effective at reducing pain and increasing the self-care ability. However, since arthritis is a chronic health problem, future studies to develop strategies to maintain the life-long self-care ability of arthritis patients are needed.

This study was intended to evaluate a self-care program for elderly arthritis patients, and especially those managed by CHPs in rural area of Korea. As CHPs are taking care of the health problems of the community people, this type of program is an efficient way to provide intervention by CHPs. Two days training of CHPs was provided ahead of the intervention. The training for CHPs was useful to increase capacity for CHPs. Total 290 participants from four provinces were randomized into experimental and control groups. Even after controlling the possible confounding variables by PSM, 6-week self-care program for arthritis managed by CHPs showed effectiveness at reducing arthritis-attributable pain and increasing the self-care ability. Based on the findings of this study, evaluation of long-term effects of self-care program is recommended to develop strategies to maintain the life-long self-care ability of arthritis patients in future studies.