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Symptoms, aging-stereotyped beliefs, and health-promoting behaviors of older women with and without osteoarthritis
Geriatric Nursing 34 (2013) 307e313
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Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Symptoms, aging-stereotyped beliefs, and health-promoting behaviors of older women with and without osteoarthritis Hyun-E Yeom, PhD, RN * Department of Nursing, Dongguk University, 707 Sukjang-dong, Gyeongju, Gyeongbuk 780-714, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 November 2012 Received in revised form 1 May 2013 Accepted 6 May 2013 Available online 30 May 2013
The purposes of this study were to examine differences in symptoms, aging-stereotyped beliefs about management of symptoms, and health-promoting behaviors depending on a diagnosis of osteoarthritis and to investigate the associations between symptoms, aging-stereotyped beliefs, and health-promoting behaviors in 171 older Korean women. Compared to older women without osteoarthritis, those with osteoarthritis reported significantly more symptoms, a higher level of aging-stereotyped beliefs, and a lower level of health-promoting behaviors. Regardless of osteoarthritis, older women suffered from multiple symptoms, and musculoskeletal symptoms were the most frequently reported symptoms. Aging-stereotyped beliefs had a negative influence on health-promoting behaviors, whether or not older women were diagnosed with osteoarthritis. Findings of this study suggest that a broader assessment of multiple symptoms, specifically including musculoskeletal symptoms, is needed in order to enhance their management of symptoms. Health care providers should consider age stereotypes with regard to experience and management of symptoms in order to improve self-care behaviors of older people, and development of nursing intervention strategies in order to modify stereotypes and misconceptions about aging and to facilitate positive attitudes about old age is warranted. Ó 2013 Mosby, Inc. All rights reserved.
Keywords: Stereotyping Aging Signs and symptoms Health behavior Osteoarthritis
1. Introduction With the global change toward more aging societies around the world, improving health-promoting behaviors has been emphasized as a critical issue for the maintenance of functional health and independent living of older people.1e4 Health-promoting behaviors are actions that promote health status and/or delay pathophysiological declines including physical exercise, maintaining a healthy body weight and diet, and limiting smoking and alcohol.5e7 Empirical studies have demonstrated that health-promoting behaviors are particularly important for older people who live with chronic and degenerative illnesses, such as diabetes and osteoarthritis, which need consistent self-care to prevent functional limitations and loss of independence.2,3,8,9 Osteoarthritis is a representative degenerative illness that threatens functional capabilities, daily activities, and independent living for older people.10e12 A number of empirical studies have found that various types of behaviors including physical exercise and healthy diet are beneficial to reduce the threat of osteoarthritis as well as to prevent further aggravation of osteoarthritis.1e4,8,9 In This work was supported by the Dongguk University Research Fund. * Corresponding author. Tel.: þ82 54 770 2621; fax: þ82 54 770 2616. E-mail addresses: [email protected], [email protected]. 0197-4572/$ e see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.05.002
spite of the benefits, older people need to overcome physical and perceptual barriers that make it difficult to engage in healthpromoting behaviors. Previous studies have demonstrated that experiencing physical discomfort is a major obstacle to physical activities for the elderly.4,13 More specifically, research has reported a variety of symptoms including aches and pains, stiffness and swelling in joints, general muscle weakness, and limited range of movement or motor disability in patients with osteoarthritis.4,11,12 In addition, aging studies have shown that older people experience numerous symptoms that accompany the natural aging process.14,15 For example, in a study that compared symptoms of older women with and without breast cancer history, both groups of older women had an average of 10 and more aging symptoms, and the most frequently reported symptoms were general pain, joint pain, fatigue, dry mouth, weight gain, inability to concentrate, and constipation, which are all symptoms commonly experienced by the older population.14 Another study about older Korean people has also shown that the majority of older people (68.5%) had symptoms related to aging declines and the most frequently reported symptoms were pain (e.g., joint, back, stomach), fatigue, tingling in hands and feet, dry mouth, dizziness, shortness of breath, constipation, loss of appetite, and difficulty falling asleep.16 These symptoms indicate that older people with osteoarthritis are more
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likely to experience multiple and overlapping symptoms related to either normal aging-related declines or the pathophysiological process of osteoarthritis. However, little research has examined the types of symptoms that older people with osteoarthritis may experience as a part of the aging process or their diagnosis of osteoarthritis, as well as how their symptoms are different from older people without osteoarthritis. An increasing number of aging studies have found that older people’s negative perceptions or attitudes about aging have been barriers to health-promoting behaviors.6,17e20 According to empirical findings, older people who had stronger negative perceptions or lower expectations regarding aging were less likely to practice health-promoting behaviors, such as exercise and a healthy diet, to adhere to a medical regimen, and to seek medical care.21e23 Aging literature has addressed these negative perceptions about aging and found that they are linked to agingstereotyped beliefs, defined as negative stereotypes or misconceptions about aging and health of older people.19,20 For example, the aging process is regarded as synonymous with becoming ill, or the health of older people is undervalued and they are categorically seen as being weak without adequate assessment of the older individual’s functional status.18e20 Empirical studies have provided evidence that older people also have aging-stereotyped beliefs such as attributing their health problems to inevitable consequences of the aging process without appropriate assessment.14,17,21 This tendency has also been seen in older women who had a history of a breast cancer diagnosis.14,17 According to a comparative study about symptom beliefs between older women with and without a breast cancer history, the older women tended to attribute their symptoms to aging rather than other illnesses or cancer, regardless of their personal breast cancer history.14 In addition, empirical studies have reported other aging-stereotyped beliefs that reflect low expectations or pessimistic attitudes about pharmacological or nonpharmacological effects on illnesses in old age.7,24,25 In these studies, older people regarded their illnesses as incurable11 and undervalued the necessity and effectiveness of treating health problems that they particularly viewed as aging-related declines.24,25 Despite the evidence, little research has focused on aging-stereotyped beliefs in managing symptoms as a barrier to health-promoting behaviors of older people. With regard to high prevalence in old age, there is a misconception that osteoarthritis is a normal consequence of the aging process.2,26 However, research has shown that although age is a powerful risk factor for osteoarthritis, osteoarthritis is not an inevitable consequence of aging and not all older people have osteoarthritis.26 In addition, there are other misconceptions such as “exercise can make osteoarthritis worse,”27 even though there is strong evidence supporting the benefits of physical activity for flexibility and muscle strength to reduce osteoarthritis.1,2,28,29 However, there is limited information about aging-stereotyped beliefs about managing symptoms of older people with osteoarthritis. In addition, no research has compared aging-stereotyped beliefs between older people with and without osteoarthritis. Understanding the symptoms and aging-stereotyped beliefs about managing symptoms is essential for enhancing healthpromoting behaviors of older people. In particular, investigating any differences in symptoms and aging-stereotyped beliefs between older people with and without osteoarthritis is an important task for developing concrete and specialized strategies to facilitate active health-promoting behaviors of older people. The purposes of this study were 1) to compare the differences in symptoms, aging-stereotyped beliefs, and health-promoting behaviors between older women with and without arthritis and 2) to investigate how the actual symptoms and the extent to which
older people have aging-stereotyped beliefs affect healthpromoting behaviors in older women with and without arthritis. Specific hypotheses were established as follows: 1) older women with osteoarthritis will experience more symptoms compared to those without osteoarthritis, 2) older women with osteoarthritis will have stronger aging-stereotypical perceptions about symptom management, 3) older women with osteoarthritis will have fewer health-promoting behaviors than those without osteoarthritis, and 4) aging-stereotyped beliefs about symptom management will predict the performance of health-promoting behaviors in older women with and without osteoarthritis. 2. Methods 2.1. Design This study was a cross-sectional and descriptive comparative study. 2.2. Sample and procedure A convenience sample of older women was recruited from public health centers, senior citizens centers, an out-patient clinic at a university hospital, and local clinics in South Korea. Inclusion criteria for this study were 1) 65 years of age or older, 2) community dwelling, 3) no history of surgery or hospitalization due to illnesses within the past 6 months, and 4) able to report whether or not they had been medically diagnosed with osteoarthritis. Older women who were self-diagnosed with osteoarthritis from symptoms but not by health care providers were excluded. Older women were also excluded if they had been diagnosed by health care professionals with cognitive impairments, such as dementia and mild cognitive impairment, or if they had difficulties understanding and/ or responding to questions. To recruit participants, information about the study was advertised in out-patient clinics at a university hospital, senior citizens centers, and public health centers in two cities in South Korea. The typical older Korean person has relatively low education levels and high illiteracy rates.30 Thus, the data were collected through face-to-face interviews with the primary investigator and two research assistants who were trained by the primary investigator. The primary investigator and two research assistants visited the places on advertised dates and contacted potential participants who were interested in participation. During the first contact, eligibility for participation was screened. A total of 182 older women were interested in participation. Three women who were uncertain about their diagnosis of osteoarthritis were excluded. Another eight women were excluded because they had not been medically diagnosed by health care providers but had selfdiagnosed their osteoarthritis. Finally, 171 older women (n ¼ 81 in the osteoarthritis group, n ¼ 90 in the non-osteoarthritis group) completed a face-to-face interview. The purpose, procedural details, and potential benefits and risks of the study were explained before the interview, and then written consent forms were obtained. Each interview took approximately 20e25 min. All procedures were approved by the Institutional Review Board of the university hospital. Data collection was conducted from April to June. 2.3. Instruments 2.3.1. Aging-stereotyped beliefs about symptom management The Korean version of the Symptom Management Beliefs Questionnaire (K-SMBQ) was used for measurement of agingstereotyped beliefs about symptom management. The K-SMBQ
H.-E. Yeom / Geriatric Nursing 34 (2013) 307e313
included 12 items representing negatively stereotyped beliefs and misconceptions about old age with regard to experience and management of symptoms. Each item asked how much a respondent agreed or disagreed, using a 5-point Likert scale ranging from 1 (do not agree at all) to 5 (totally agree). The mean of the 12 items was calculated with a higher score indicating more negatively stereotyped beliefs about symptom management. The K-SMBQ used in this study was a translated version of the Symptom Management Beliefs Questionnaire (SMBQ). Validity and reliability of the original SMBQ have been demonstrated in previous studies across older populations with different health issues, including cancer survivors and community-dwelling healthy older people.14,17 In this study, the reliability was a ¼ 0.79. 2.3.2. Health-promoting behaviors Health-promoting behavior was measured using 10 items of the Health-Promoting Lifestyle Profile II (HPLP II).5 The measurement includes items asking about physical activities, healthy diet, seeking medical information, stress management, and social activities. Each item asks how frequently a respondent performs each of the health-promoting behaviors in daily life on a 4-point Likert scale ranging from 1 (never) to 4 (very much). The mean score for the 10 items was calculated with a higher score indicating greater involvement in health-promoting behaviors. In this study, the reliability was a ¼ 0.84. 2.3.3. Symptom experience and demographic information Symptom experience was assessed for 30 symptoms. Thirty symptoms were chosen from the scales to measure symptoms or pain of older people from the geriatric literature. Thirteen symptoms were from the original Symptom Bother Scale, which is a 13item scale to measure distress related to symptoms common to aging and age-related chronic health problems.14 The validity and reliability of the Symptom Bother Scale have been demonstrated in prior empirical studies of older adults.31,32 Seventeen symptoms were extracted from the scales to assess typical pain and physical discomfort of older Korean women16 and empirical studies about aging-related declines and physical health problems that are common for older Korean women.33,34 Participants were asked whether or not they had experienced each of the symptoms and the sum of symptoms that they reported was calculated. Internal consistency (KudereRichardson Formula 20 [KR-20]) for the 30item dichotomous scale in this sample was KR-20 ¼ 0.81. The number of prescribed medications and the number of chronic health problems regarding ten illnesses that are prevalent among older Korean women were assessed. Participants were asked about general demographic information, including age, education, income, and marital and living arrangements.
the desired power level was at 0.90, the number of predictors was 6, and anticipated effect size was 0.15, the required sample size was 116, so the sample size of the present study was satisfactory. 3. Results 3.1. Description of demographic and health-related characteristics The average age of all participants was 75.9 (SD ¼ 6.23) years: 76.7 (SD ¼ 5.97) for older women with osteoarthritis and 75.1 (SD ¼ 6.96) for older women without osteoarthritis. Almost half of the participants (46.2%) had either no formal education or incomplete elementary education and 39.2% of the participants had graduated from elementary school. More than half of the participants were widowed (58.5%) while the others lived with a spouse or the adult children (56.2%). A comparison of the demographic characteristics between the two groups was performed using a chisquare test (for ordinal-level variables) and t-test for continuous variables (Table 1). No significant differences in age, education, and income were observed between the two groups. The majority of participants (91.8%) had one or more chronic illness. The average number of chronic illnesses was 1.47 (SD ¼ 1.12) for the older women with osteoarthritis and 1.29 (SD ¼ 0.87) for those without osteoarthritis. Across both groups, hypertension (46.8%) and diabetes (23.4%) were the most prevalent chronic illnesses. The average number of medications for all participants was 1.76 (SD ¼ 1.71); 2.04 (SD ¼ 1.77) for the older women with osteoarthritis and 1.51 (SD ¼ 1.67) for those without osteoarthritis. The older women with osteoarthritis were likely to have more chronic illnesses (t ¼ 1.14, p ¼ 0.25) and medications (t ¼ 1.69, p ¼ 0.09), compared to those without osteoarthritis; however, the differences were not statistically significant. 3.2. Symptoms of the older women with and without osteoarthritis The average number of symptoms for all participants was 7.99 (SD ¼ 4.89, range 0e28) and more than 70% of the participants reported six or more symptoms. The average number of symptoms
Table 1 Demographic characteristics (N ¼ 171). Variables
Age Educational status
2.4. Data analysis SPSS 19.0 was used for statistical analyses. Preliminary analysis and descriptive statistics were computed for all variables. Differences in symptom experience and aging-stereotyped beliefs about symptom management between older women with osteoarthritis and those without osteoarthritis were tested using a chi-square test and t-test. Differences in health-promoting behaviors according to the demographic and health-related characteristics were examined using Pearson’s correlations, t-test, and ANOVA. The results of the correlations, t-test, and ANOVA were considered to determine the independent variables of hierarchical linear regression analysis for testing the impact of aging-stereotyped beliefs about symptom management on health-promoting behaviors. The power analysis was conducted using an a-priori sample size tool for multiple regression analyses. When the alpha was at 0.05,
309
Marital status
Living with
Monthly allowance (10,000 won/ month)
Categories
No formal education or incomplete elementary school Elementary school Middle school High school College Married Widowed Divorced or separated Alone Spouse Adult-child Spouse and adult-child <50 50 w 99 100 w 149 150 w 199 200 Missing
With osteoarthritis (n ¼ 81)
Without osteoarthritis (n ¼ 90)
M SD or n (%)
M SD or n (%)
76.7 5.9 38 (46.9)
75.1 6.9 41 (45.6)
31 10 1 1 33 46 2 35 28 13 5 14 25 15 12 8 7
36 11 2 0 35 54 1 40 33 15 2 13 33 19 10 11 4
(38.3) (12.4) (1.2) (1.2) (40.8) (56.8) (2.4) (43.2) (34.6) (16.0) (6.2) (17.2) (30.9) (18.5) (14.9) (9.9) (8.6)
(40.0) (12.2) (2.2) (0) (38.9) (60.0) (1.1) (44.4) (36.7) (16.7) (2.2) (14.4) (36.7) (21.1) (11.2) (12.2) (4.4)
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of the older women with osteoarthritis (M ¼ 9.32, SD ¼ 5.35) was significantly higher (t ¼ 4.01, p < 0.001) than that of the older women without osteoarthritis (M ¼ 6.80, SD ¼ 4.41). The findings indicate that the older women with osteoarthritis had more symptoms than those without osteoarthritis and that the overall high proportions of the older women, regardless of osteoarthritis, suffered from multiple symptoms, rather than a single condition. Table 2 shows, in descending order, the frequency of all symptoms experienced by all participants, the frequency of each symptom by group, and the differences in frequency between the two groups. The majority of the older women with osteoarthritis had joint pain (79%), back pain (75.3%), vision problems (58%), and general pain (58%). They also often reported symptoms such as frequent awakening from sleep (45.7%), fatigue (44.4%), and memory problems (43.2%). The older women without osteoarthritis most frequently reported back pain (54.4%), vision problems (45.6%), joint pain (38.9%), difficulty falling asleep (36.7%), fatigue (31.1%) and memory problems (27.8). The results indicate that musculoskeletal symptoms and vision problems were the most common problems for the older women whether or not they had osteoarthritis. According to the results of the chi-square test for the frequency of symptoms between the two groups, musculoskeletal symptoms (i.e., back pain, joint pain, and joint stiffness), frequent awakening from sleep, and hot flashes were more prevalent in the older women with osteoarthritis compared to those without osteoarthritis.
with osteoarthritis and those without osteoarthritis (t ¼ 1.80, p < 0.05). The older women with osteoarthritis (M ¼ 3.56) had significantly higher scores for aging-stereotyped beliefs about symptom management than those without osteoarthritis (M ¼ 3.11). The mean score for each item on the 12-item K-SMBQ scale was compared between the two groups (see Table 3). Overall, the older women with osteoarthritis tended to show strong agreement with the items and the mean scores of the two items between the two groups were significantly different. The older women with osteoarthritis reported stronger agreement with the items “It is hard to cure symptoms in old age” and “Health care providers need to concentrate on curing the disease rather than on dealing with symptoms” than those without osteoarthritis. Table 4 displays the information about health-promoting behaviors of the older women with and without osteoarthritis. The older women with osteoarthritis (M ¼ 2.88, SD ¼ 0.46) were significantly less likely to practice health-promoting behaviors (t ¼ 1.21, p < 0.05) compared to those without osteoarthritis (M ¼ 2.99, SD ¼ 0.62). In particular, the older women with osteoarthritis reported significantly less engagement in physical activities (t ¼ 1.99, p < 0.05) and less seeking out medical information (t ¼ 2.35, p < 0.05) compared to those without osteoarthritis.
3.3. Comparison of aging-stereotyped beliefs about symptom management and health-promoting behaviors
The result of hierarchical multiple regression analysis indicated that, in the first step, after taking into account for the number of symptoms, chronic illnesses, and medications, age was the only factor significantly affecting health-promoting behaviors (b ¼ 0.329, p < 0.01) and having osteoarthritis or not was not
A significant difference in aging-stereotyped beliefs about symptom management was observed between the older women Table 2 Comparison of symptom frequency between older women with osteoarthritis (n ¼ 81) and without osteoarthritis (n ¼ 90). Symptoms
Back pain Joint pain Vision problem Pain Aching Fatigue Frequent awakening from sleep Memory problem Joint stiffness Dry mouth Hair loss Difficulty falling asleep Headache Irritated eyes Shortness of breath Constipation Hot flashes Feeling anxious Dizziness Urinary incontinence Indigestion Dry skin Weakness Waking too early Depression Balance problem Thirst Weight loss or gain Itching Swelling in hands and feet *p < 0.05, **p < 0.01.
c2
Total
With osteoarthritis
Without osteoarthritis
n (%)
n (%)
n (%)
110 99 88 76 66 64 61
(64.3) (57.9) (51.5) (44.4) (38.6) (37.4) (35.7)
61 64 47 47 37 36 37
(75.3) (79.0) (58.0) (58.0) (45.7) (44.4) (45.7)
49 35 41 29 29 28 24
(54.4) (38.9) (45.6) (32.2) (32.2) (31.1) (26.7)
5.54* 19.7** 1.73 7.33* 2.14 1.75 6.09*
60 56 54 54 52 48 46 45 35 35 34 31 31 30 28 27 23 23 22 21 18 15 15
(35.1) (32.7) (31.6) (31.6) (30.4) (28.1) (26.9) (26.3) (20.5) (20.5) (19.9) (18.1) (18.1) (17.5) (16.4) (15.8) (13.5) (13.5) (12.9) (12.3) (10.5) (8.8) (8.8)
35 36 29 29 19 24 22 23 17 23 16 17 17 16 14 15 11 13 13 11 10 9 7
(43.2) (44.4) (35.8) (35.8) (23.4) (29.6) (27.1) (28.3) (20.9) (28.3) (19.7) (20.9) (20.9) (19.7) (17.2) (18.5) (13.6) (16.0) (16.0) (13.6) (12.3) (11.1) (8.6)
25 20 25 25 33 24 24 22 18 12 18 14 14 14 14 12 12 10 9 10 8 6 8
(27.8) (22.2) (27.8) (27.8) (36.7) (26.7) (26.7) (24.4) (20.0) (13.3) (20.0) (15.6) (15.6) (15.6) (15.6) (13.3) (13.3) (11.1) (10.0) (11.1) (8.9) (6.7) (8.9)
2.80 6.57* 0.69 0.69 2.47 0.12 0.01 0.21 2.51 4.69* 0.00 0.64 1.63 0.39 0.08 0.61 0.05 0.58 0.58 0.14 0.56 0.52 0.01
3.4. Associations between symptoms, aging-stereotyped beliefs, and health-promoting behaviors
Table 3 The comparison of the 12 items of the K-SMBQ between older women with (n ¼ 81) and without osteoarthritis (n ¼ 90). Items
Many symptoms are a natural part of aging process. It is hard to cure symptoms in old age. Health care providers need to concentrate on curing the disease rather than on dealing with symptoms. Old people need to lower their expectations about treating their symptoms. At my age, it is better to learn to live with symptoms rather than to treat symptoms. I will be a complainer if I ask about my symptoms to health care providers. It is unnecessary to worry about many symptoms in old age. It is unnecessary to treat symptoms in old age. Health care providers might find it annoying to be told about symptoms. The ‘cure’ for symptoms is often worse than the disease. It is easier to put up with fatigue or weakness than with the time and hassle of an exercise program. It is unnecessary to find new ways for managing symptoms related to aging.
With Without t osteoarthritis osteoarthritis M (SD)
M (SD)
4.50 (0.83)
4.32 (0.96)
1.14
4.20 (1.14) 4.07 (1.07)
3.73 (1.41) 3.57 (1.28)
2.13* 2.40*
3.61 (1.44)
3.26 (1.49)
1.33
3.33 (1.52)
3.00 (1.58)
1.23
3.32 (1.49)
3.01 (1.50)
1.15
3.15 (1.61)
3.25 (1.66)
0.31
3.03 (1.55)
2.53 (1.55)
1.80
3.01 (1.58)
2.84 (1.57)
0.59
2.91 (1.53)
2.69 (1.65)
0.80
2.54 (1.52)
2.53 (1.47)
0.01
2.56 (1.44)
2.48 (1.52)
0.32
Note. K-SMBQ ¼ aging-stereotyped beliefs about symptom management. *p < 0.05.
H.-E. Yeom / Geriatric Nursing 34 (2013) 307e313 Table 4 Differences in symptoms, K-SMBQ, and health-promoting behaviors between older women with (n ¼ 81) and without osteoarthritis (n ¼ 90). Variables
With osteoarthritis
Without osteoarthritis
t
M (SD)
M (SD)
Number of symptoms Number of chronic illnesses Number of medications Aging-stereotyped beliefs about symptom management Health-promoting behaviors Physical activities Healthy diet Seeking medical information Stress management Social activities
9.32 1.47 2.04 3.56
(5.45) (1.12) (1.77) (0.70)
6.80 1.29 1.51 3.11
(4.41) (0.87) (1.67) (0.91)
4.01** 1.14 1.69 1.80*
2.88 2.31 3.54 2.36 3.11 2.84
(0.46) (1.08) (0.73) (0.97) (0.90) (0.90)
2.99 2.72 3.63 2.82 3.15 3.97
(0.62) (1.21) (0.77) (1.14) (0.98) (1.02)
1.21* 1.99* 0.92 2.35* 0.19 0.76
Note. K-SMBQ ¼ aging-stereotyped beliefs about symptom management. *p < 0.05, **p < 0.01.
a significant predictor of health-promoting behaviors (Table 5). In the second step, after adjusting for the covariates, agingstereotyped beliefs about symptom management was a significant predictor of health-promoting behaviors (b ¼ 0.280, p < 0.01). These findings indicate that regardless of a diagnosis of osteoarthritis, the older women who had stronger agingstereotyped beliefs about symptom management were less likely to practice health-promoting behaviors. 4. Discussion Engaging in health-promoting behaviors is a key issue to prevent health declines and to promote physical functioning and quality of life of older people. A number of previous studies have found that symptoms and aging-related beliefs are powerful factors affecting health-promoting behaviors in older people.7,21,24,25 Older people are quite likely to experience a variety of symptoms related to normal aging declines and degenerative processes of comorbid chronic illnesses.14 In particular, osteoarthritis is a representative illness which causes functional declines and thereby threatens the quality of life of the older population.10e12 However, despite the high prevalence of osteoarthritis among older people, little has been studied about symptoms of older people with osteoarthritis compared to those without osteoarthritis. In addition, as a perceptual factor affecting health-promoting behaviors, little has been found about aging-stereotyped beliefs in terms of the differences depending on a diagnosis of osteoarthritis, as well as its impact on health-promoting behaviors. The current study compared
Table 5 The influence of aging-stereotyped beliefs on health-promoting behaviors. Health-promoting behaviors First step B
SE
Second step
b
Covariates Age 0.025 0.006 0.329** Number of medications 0.035 0.029 0.114 Number of chronic 0.011 0.050 0.024 illnesses Number of symptoms 0.004 0.009 0.042 Osteoarthritis 0.105 0.108 0.097 K-SMBQ F 3.88* 0.134 R2
b
B
SE
0.021 0.032 0.007
0.006 0.274** 0.028 0.138 0.048 0.015
0.002 0.009 0.024 0.109 0.104 0.101 0.281* 0.082 0.280** 5.47** 0.209
Note. K-SMBQ ¼ aging-stereotyped beliefs about symptom management. *p < 0.05, **p < 0.01.
311
symptoms, aging-stereotyped beliefs about symptom management, and health-promoting behaviors of older women with and without osteoarthritis. It also investigated factors affecting healthpromoting behaviors in older women with and without osteoarthritis, focusing on aging-stereotyped beliefs. The current study found that the older women, regardless of a diagnosis of osteoarthritis, had experienced multiple symptoms rather than a single symptom. In particular, the group of older women with osteoarthritis showed higher frequencies of the most common overall symptoms when compared to their counterparts, supporting the hypothesis that older people with osteoarthritis will have more symptoms than those without osteoarthritis. In particular, compared to the older women without osteoarthritis, those with osteoarthritis had musculoskeletal symptoms (i.e., joint and back pain, stiffness) more frequently as well as other symptoms that are common in the older population including general aches and pains and frequent episodes of awakening from sleep. These findings indicate that managing symptoms in older people with osteoarthritis is more challenging with regard to the difficulties in interpreting the causes of symptoms whether or not they are from normal aging declines or the pathological process of osteoarthritis. Apart from the higher frequencies of symptoms in older people with osteoarthritis, musculoskeletal symptoms of back pain and joint pain were the most frequently reported symptoms in both groups of older women with and without osteoarthritis. The findings, therefore, emphasize that special attention is needed to care for the musculoskeletal symptoms of older people regardless of if they have osteoarthritis or not. In addition, it is noteworthy that both groups of older women with and without osteoarthritis frequently reported vision problems, aches and pains, fatigue, and sleep problems (i.e., frequent awakening from sleep, difficulty falling asleep). These findings indicate the importance of nursing interventions on the basis of a broader assessment about symptoms to enhance management of symptoms and quality of life of older people. In support of the hypothesis, this study found that the older women with osteoarthritis had significantly stronger agingstereotyped beliefs about symptom management when compared to the older women without osteoarthritis. In a comparison of each item on the K-SMBQ measurement, the older women with osteoarthritis showed strong agreement with the items “It is hard to cure symptoms in old age” and “Health care providers need to concentrate on curing the disease rather than on dealing with symptoms.” This agreement indicates that older women with osteoarthritis may have more pessimistic views about the controllability of symptoms and more erroneous beliefs about the roles of health care providers, which subsequently may affect their relatively complacent attitudes when interacting with their health care providers in medical encounters. These findings imply that living with chronic illnesses that are particularly regarded as aging-related might trigger or reinforce negative and stereotyped beliefs about old age. With regard to health-promoting behaviors, the older women with osteoarthritis were significantly less active compared to those without osteoarthritis. This finding is particularly worrisome because numerous studies have demonstrated the benefits of various health-promoting behaviors in delaying the progression of osteoarthritis.26e29 Along with the findings of symptoms and aging-stereotyped beliefs, these findings indicate that older women with osteoarthritis are relatively vulnerable to health declines compared to those without osteoarthritis. As hypothesized on the basis of empirical evidence,21e23 the older women’s aging-stereotyped beliefs about symptom management were a significant predictor of their healthpromoting behaviors, meaning that the older women with stronger aging-stereotyped beliefs were significantly less active in
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health-promoting behaviors whether or not they had osteoarthritis. This finding emphasizes the powerful impact of agingstereotyped beliefs on health-promoting behaviors beyond that of osteoarthritis. In particular, it is notable that this study focused on aging-stereotyped and erroneous beliefs about experiencing and managing symptoms as a perceptual barrier to healthpromoting behaviors. Thus, the findings should encourage the development of nursing interventions focusing on rectifying aging-related misconceptions as well as facilitating positive attitudes toward aging of older people. Despite the strong evidence of aging-related beliefs related to behaviors, researchers must be cautious about the interpretation of the findings with regard to the following issue. There is strong evidence supporting the influence of functional health on healthpromoting behaviors in older people,2,3,7 but this study examined health status with regard to the number of chronic illnesses, medications, and symptoms, rather than measuring the actual functional capabilities of older individuals. Thus, further examination including functional health and actual capabilities is suggested. Another issue concerns the assessment of symptoms. Symptoms in the current study were examined based on a list of symptoms, which was developed from empirical evidence about common symptoms for older Korean people and literature reviews about aches and pains of older people, and information about construct validity for this list of symptoms is still limited. Therefore, further effort to cluster symptoms is essential for better understanding about the types of symptoms older people experience. In addition, repeated testing for validity and reliability is necessary. Some other issues should be noted as limitations. Participants in this study were limited to community-dwelling older females. Although osteoarthritis is more prevalent in older women, older males are not free from the risk of osteoarthritis and misconceptions regarding old age. In addition, empirical studies have shown the importance of family interactions in managing the health issues of older Korean people,35 implying that institutionalized older people are relatively vulnerable to barriers to health-promoting behaviors due to limited support from family members. Therefore, further comparative examination about aging-stereotyped beliefs according to the living arrangement (e.g., institutionalized versus community dwelling) as well as gender is suggested. Finally, this study was a cross-sectional study of older Korean people so the causal relationship could not be confirmed. A longitudinal study is needed to ascertain causal relationships between symptom experience, aging-stereotyped beliefs, and healthpromoting behaviors. In addition, given the unique characteristics of aging-related perceptions in different social-cultural contexts, further cross-cultural research is warranted to attain a better understanding of cultural diversity and similarities regarding aging-stereotyped beliefs. 4.1. Implications for nursing researchers and health care providers This study found that older women with osteoarthritis had stronger aging-stereotyped beliefs, compared to those without osteoarthritis. There are other illnesses which are common to older people and regarded as normal consequences of the aging process, such as urinary incontinence and memory problems. Further comparative studies among older people with such health issues are suggested for better understanding about aging-stereotyped beliefs and relevant issues to the beliefs about aging among older people. The current study provides important messages for health care providers. They need to bear in mind that older people have multiple symptoms, which makes it difficult to interpret the meaning of the symptoms and to decide how to cope with these
symptoms. Based on the unique characteristics of older people, health care providers need to develop clinical strategies that could help these older people recognize their health problems as well as set up effective self-care strategies. It is also important that health care providers understand the harmful effects of aging-related stereotypes or misconceptions about engaging in healthpromoting behaviors, and thereby recognize their pivotal role in facilitating appropriate attitudes toward the aging process and difficulties of older people. This study suggests the need to develop psycho-cognitive interventions focusing on enhancing knowledge about effective self-care and positive perceptions about aging. Providing accurate information is a fundamental task to help older people recognize erroneous beliefs about coping with health problems. In addition, empirical findings have emphasized the importance of psychological support that can lead to better outcomes when providing nursing interventions.36 It is particularly essential that older people have the opportunity to explore their own perceptions about aging and to express emotions including concerns and anxiety.37 Furthermore, based on these cognitive and psychological characteristics, setting individualized goals and providing repeated and tailored messages are important.38 Previous studies have demonstrated the importance of health care providers’ attitudes in medical encounters with older patients.17 Older people are particularly dependent on the comments and attitudes of their health care providers, so agingrelated negative attitudes from health care providers could aggravate aging-related negative perceptions of older people.17 Therefore, health care providers need to be quite prudent when expressing comments and attitudes in their interactions with older patients. There is a paucity of studies about aging-related stereotypes and misconceptions in regard to the experience and management of health problems in the older population. However, further studies about older people with diverse social-cultural and health-related characteristics are warranted to enrich our understanding of stereotypes and misconceptions about aging and to enhance the active practice of self-care behaviors leading to better quality of life for older people. References 1. Marks R, Allegrante JP. Chronic osteoarthritis and adherence to exercise: a review of the literature. J Aging Phys Act. 2005;13:434e460. 2. Hurley MV. Muscle, exercise and arthritis. Ann Rheum Dis. 2002;61:673e675. 3. Petursdottir U, Arnadottir SA, Halldorsdottir S. Facilitators and barriers to exercising among people with osteoarthritis: a phenomenological study. Phys Ther. 2010;90:1014e1025. 4. Hendry M, Williams NH, Markland D, Wilkinson C, Maddison P. Why should we exercise when our knees hurt: a qualitative study of primary care patients with osteoarthritis of the knee. Fam Pract. 2006;23:558e567. 5. Walker SN, Sechrist KR, Pender NJ. Psychometric Evaluation of the HealthPromoting Lifestyle Profile II. Unpublished manuscript. University of Nebraska Medical Center; 1996. 6. Kim SH. Older people’s expectations regarding ageing, health-promoting behaviour and health status. J Adv Nurs. 2009;65:84e91. 7. Sarkisian CA, Prohaska TR, Wong MD, Hirsch S, Mangione CM. The relationship between expectations for aging and physical activity among older adults. J Gen Intern Med. 2005;20:911e915. 8. Jamtvedt G, Dahm KT, Christie A, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther. 2008;88:123e136. 9. Lin SY, Davey RC, Cochrane T. Community rehabilitation for older adults with osteoarthritis of the lower limb: a controlled clinical trial. Clin Rehabil. 2004;18:92e101. 10. Hunter DJ, Felson DT. Osteoarthritis. BMJ. 2006;332:639e642. 11. Dong XS, Wang X, Daw C, Ringen K. Chronic diseases and functional limitations among older construction workers in the United States: a 10-year follow-up study. J Occup Environ Med. 2010;5:372e380. 12. Segal NA, Yack HJ, Brubaker M, Torner JC, Wallace R. Association of dynamic joint power with functional limitations in older adults with symptomatic knee osteoarthritis. Arch Phys Med Rehabil. 2009;90:1821e1828.
H.-E. Yeom / Geriatric Nursing 34 (2013) 307e313 13. Carson MG, Mitchell GJ. The experience of living with persistent pain. J Adv Nurs. 1998;28:1242e1248. 14. Heidrich SM, Egan JJ, Hengudomsub P, Randolph SM. Symptoms, symptom beliefs, and quality of life of older breast cancer survivors: a comparative study. Oncol Nurs Forum. 2006;33:315e322. 15. Morgan R, Pendleton N, Clague JE, Horan MA. Older people’s perceptions about symptoms. Br J Gen Pract. 1997;47:427e430. 16. Chang S, Khim S. Perception of somatic symptoms and related variables among old women. J Korean Gerontol Nurs. 2005;7:185e194. 17. Yeom HE, Heidrich SM. Effect of perceived barriers to symptom management on quality of life in older breast cancer survivors. Cancer Nurs. 2009;32:309e 316. 18. Ory M, Kinney Hoffman M, Hawkins M, et al. Challenging aging stereotypes: Strategies for creating a more active society. Am J Prev Med. 2003;25:164e171. 19. Nelson TD. Ageism: Stereotyping and Prejudice Against Older Persons. Cambridge, MA: MIT Press; 2002. 20. Palmore EB. Ageism in Canada and the United States. J Cross Cult Gerontol. 2004;19:41e46. 21. Locher JL, Burgio KL, Goode PS, Roth DL, Rodriguez E. Effects of age and causal attribution to aging on health-related behaviors associated with urinary incontinence in older women. Gerontologist. 2002;42:515e521. 22. Levy BR, Myers LM. Preventive health behaviors influenced by self-perceptions of aging. Prev Med. 2004;39:625e629. 23. Ryan CJ, Zerwic JJ. Perceptions of symptoms of myocardial infarction related to health care seeking behaviors in the elderly. J Cardiovasc Nurs. 2003;18:184e 196. 24. Stoller EP, Kart CS. Symptom reporting during physician consultation. Results of a health diary study. J Aging Health. 1995;7:200e232. 25. Brody EM, Kleban MH. Physical and mental health symptoms of older people: who do they tell? J Am Geriatr Soc. 1981;29:442e449. 26. Shane Anderson A, Loeser RF. Why is osteoarthritis an age-related disease? Best Pract Res Clin Rheumatol. 2010;24:15e26.
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27. Hill J, Bird H. Patient knowledge and misconceptions of osteoarthritis assessed by a validated self-completed knowledge questionnaire (PKQ-OA). Rheumatology (Oxford). 2007;46:796e800. 28. Roper JA, Bressel E, Tillman MD. Acute aquatic treadmill exercise improves gait and pain in people with knee osteoarthritis. Arch Phys Med Rehabil. 2013;94:419e425. 29. Jigami H, Sato D, Tsubaki A, et al. Effects of weekly and fortnightly therapeutic exercise on physical function and health-related quality of life in individuals with hip osteoarthritis. J Orthop Sci.. 2012;17:737e744. 30. Kim SH, Lee E. The influence of functional literacy on perceived health status in Korean older adults. J Korean Acad Nurs. 2008;38:1e9. 31. Heidrich SM. Older women’s lives through time. Adv Nurs Sci. 1998;20: 65e75. 32. Heidrich SM. The relationship between physical health and psychological wellbeing in elderly women: a developmental perspective. Res Nurs Health. 1993;16:123e130. 33. Shin MK, Kang JS. Factors affecting physical symptoms of elders. J Korean Acad Adult Nurs. 2010;22:211e220. 34. Shin KR, Kan Y, Jung D, Choi KA. Study on the depression, somatic symptom, activities of daily living for the elderly women in an Urban area. J Korean Acad Nurs. 2007;37:1131e1138. 35. Choi E, Kim J, Kim H. The correlational study on health-promoting behavior, life satisfaction and family support of elderly people. J Korean Gerontol Nurs. 2003;5:7e16. 36. Gitlin LN, Winter L, Dennis MP, Corcoran M, Schinfeld S, Hauck WW. A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. J Am Geriatr Soc. 2006;54:809e816. 37. Yang S, Kwon M, Choi Y, Lee S. The effects of a case management program of customized home visiting health service for clients with arthritis. J Korean Acad Community Health Nurs. 2011;22:151e161. 38. Nied RJ, Franklin B. Promoting and prescribing exercise for the elderly. Am Fam Physician. 2002;65:419e426.
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Feature Article
Symptoms, aging-stereotyped beliefs, and health-promoting behaviors of older women with and without osteoarthritis Hyun-E Yeom, PhD, RN * Department of Nursing, Dongguk University, 707 Sukjang-dong, Gyeongju, Gyeongbuk 780-714, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 November 2012 Received in revised form 1 May 2013 Accepted 6 May 2013 Available online 30 May 2013
The purposes of this study were to examine differences in symptoms, aging-stereotyped beliefs about management of symptoms, and health-promoting behaviors depending on a diagnosis of osteoarthritis and to investigate the associations between symptoms, aging-stereotyped beliefs, and health-promoting behaviors in 171 older Korean women. Compared to older women without osteoarthritis, those with osteoarthritis reported significantly more symptoms, a higher level of aging-stereotyped beliefs, and a lower level of health-promoting behaviors. Regardless of osteoarthritis, older women suffered from multiple symptoms, and musculoskeletal symptoms were the most frequently reported symptoms. Aging-stereotyped beliefs had a negative influence on health-promoting behaviors, whether or not older women were diagnosed with osteoarthritis. Findings of this study suggest that a broader assessment of multiple symptoms, specifically including musculoskeletal symptoms, is needed in order to enhance their management of symptoms. Health care providers should consider age stereotypes with regard to experience and management of symptoms in order to improve self-care behaviors of older people, and development of nursing intervention strategies in order to modify stereotypes and misconceptions about aging and to facilitate positive attitudes about old age is warranted. Ó 2013 Mosby, Inc. All rights reserved.
Keywords: Stereotyping Aging Signs and symptoms Health behavior Osteoarthritis
1. Introduction With the global change toward more aging societies around the world, improving health-promoting behaviors has been emphasized as a critical issue for the maintenance of functional health and independent living of older people.1e4 Health-promoting behaviors are actions that promote health status and/or delay pathophysiological declines including physical exercise, maintaining a healthy body weight and diet, and limiting smoking and alcohol.5e7 Empirical studies have demonstrated that health-promoting behaviors are particularly important for older people who live with chronic and degenerative illnesses, such as diabetes and osteoarthritis, which need consistent self-care to prevent functional limitations and loss of independence.2,3,8,9 Osteoarthritis is a representative degenerative illness that threatens functional capabilities, daily activities, and independent living for older people.10e12 A number of empirical studies have found that various types of behaviors including physical exercise and healthy diet are beneficial to reduce the threat of osteoarthritis as well as to prevent further aggravation of osteoarthritis.1e4,8,9 In This work was supported by the Dongguk University Research Fund. * Corresponding author. Tel.: þ82 54 770 2621; fax: þ82 54 770 2616. E-mail addresses: [email protected], [email protected]. 0197-4572/$ e see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.05.002
spite of the benefits, older people need to overcome physical and perceptual barriers that make it difficult to engage in healthpromoting behaviors. Previous studies have demonstrated that experiencing physical discomfort is a major obstacle to physical activities for the elderly.4,13 More specifically, research has reported a variety of symptoms including aches and pains, stiffness and swelling in joints, general muscle weakness, and limited range of movement or motor disability in patients with osteoarthritis.4,11,12 In addition, aging studies have shown that older people experience numerous symptoms that accompany the natural aging process.14,15 For example, in a study that compared symptoms of older women with and without breast cancer history, both groups of older women had an average of 10 and more aging symptoms, and the most frequently reported symptoms were general pain, joint pain, fatigue, dry mouth, weight gain, inability to concentrate, and constipation, which are all symptoms commonly experienced by the older population.14 Another study about older Korean people has also shown that the majority of older people (68.5%) had symptoms related to aging declines and the most frequently reported symptoms were pain (e.g., joint, back, stomach), fatigue, tingling in hands and feet, dry mouth, dizziness, shortness of breath, constipation, loss of appetite, and difficulty falling asleep.16 These symptoms indicate that older people with osteoarthritis are more
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likely to experience multiple and overlapping symptoms related to either normal aging-related declines or the pathophysiological process of osteoarthritis. However, little research has examined the types of symptoms that older people with osteoarthritis may experience as a part of the aging process or their diagnosis of osteoarthritis, as well as how their symptoms are different from older people without osteoarthritis. An increasing number of aging studies have found that older people’s negative perceptions or attitudes about aging have been barriers to health-promoting behaviors.6,17e20 According to empirical findings, older people who had stronger negative perceptions or lower expectations regarding aging were less likely to practice health-promoting behaviors, such as exercise and a healthy diet, to adhere to a medical regimen, and to seek medical care.21e23 Aging literature has addressed these negative perceptions about aging and found that they are linked to agingstereotyped beliefs, defined as negative stereotypes or misconceptions about aging and health of older people.19,20 For example, the aging process is regarded as synonymous with becoming ill, or the health of older people is undervalued and they are categorically seen as being weak without adequate assessment of the older individual’s functional status.18e20 Empirical studies have provided evidence that older people also have aging-stereotyped beliefs such as attributing their health problems to inevitable consequences of the aging process without appropriate assessment.14,17,21 This tendency has also been seen in older women who had a history of a breast cancer diagnosis.14,17 According to a comparative study about symptom beliefs between older women with and without a breast cancer history, the older women tended to attribute their symptoms to aging rather than other illnesses or cancer, regardless of their personal breast cancer history.14 In addition, empirical studies have reported other aging-stereotyped beliefs that reflect low expectations or pessimistic attitudes about pharmacological or nonpharmacological effects on illnesses in old age.7,24,25 In these studies, older people regarded their illnesses as incurable11 and undervalued the necessity and effectiveness of treating health problems that they particularly viewed as aging-related declines.24,25 Despite the evidence, little research has focused on aging-stereotyped beliefs in managing symptoms as a barrier to health-promoting behaviors of older people. With regard to high prevalence in old age, there is a misconception that osteoarthritis is a normal consequence of the aging process.2,26 However, research has shown that although age is a powerful risk factor for osteoarthritis, osteoarthritis is not an inevitable consequence of aging and not all older people have osteoarthritis.26 In addition, there are other misconceptions such as “exercise can make osteoarthritis worse,”27 even though there is strong evidence supporting the benefits of physical activity for flexibility and muscle strength to reduce osteoarthritis.1,2,28,29 However, there is limited information about aging-stereotyped beliefs about managing symptoms of older people with osteoarthritis. In addition, no research has compared aging-stereotyped beliefs between older people with and without osteoarthritis. Understanding the symptoms and aging-stereotyped beliefs about managing symptoms is essential for enhancing healthpromoting behaviors of older people. In particular, investigating any differences in symptoms and aging-stereotyped beliefs between older people with and without osteoarthritis is an important task for developing concrete and specialized strategies to facilitate active health-promoting behaviors of older people. The purposes of this study were 1) to compare the differences in symptoms, aging-stereotyped beliefs, and health-promoting behaviors between older women with and without arthritis and 2) to investigate how the actual symptoms and the extent to which
older people have aging-stereotyped beliefs affect healthpromoting behaviors in older women with and without arthritis. Specific hypotheses were established as follows: 1) older women with osteoarthritis will experience more symptoms compared to those without osteoarthritis, 2) older women with osteoarthritis will have stronger aging-stereotypical perceptions about symptom management, 3) older women with osteoarthritis will have fewer health-promoting behaviors than those without osteoarthritis, and 4) aging-stereotyped beliefs about symptom management will predict the performance of health-promoting behaviors in older women with and without osteoarthritis. 2. Methods 2.1. Design This study was a cross-sectional and descriptive comparative study. 2.2. Sample and procedure A convenience sample of older women was recruited from public health centers, senior citizens centers, an out-patient clinic at a university hospital, and local clinics in South Korea. Inclusion criteria for this study were 1) 65 years of age or older, 2) community dwelling, 3) no history of surgery or hospitalization due to illnesses within the past 6 months, and 4) able to report whether or not they had been medically diagnosed with osteoarthritis. Older women who were self-diagnosed with osteoarthritis from symptoms but not by health care providers were excluded. Older women were also excluded if they had been diagnosed by health care professionals with cognitive impairments, such as dementia and mild cognitive impairment, or if they had difficulties understanding and/ or responding to questions. To recruit participants, information about the study was advertised in out-patient clinics at a university hospital, senior citizens centers, and public health centers in two cities in South Korea. The typical older Korean person has relatively low education levels and high illiteracy rates.30 Thus, the data were collected through face-to-face interviews with the primary investigator and two research assistants who were trained by the primary investigator. The primary investigator and two research assistants visited the places on advertised dates and contacted potential participants who were interested in participation. During the first contact, eligibility for participation was screened. A total of 182 older women were interested in participation. Three women who were uncertain about their diagnosis of osteoarthritis were excluded. Another eight women were excluded because they had not been medically diagnosed by health care providers but had selfdiagnosed their osteoarthritis. Finally, 171 older women (n ¼ 81 in the osteoarthritis group, n ¼ 90 in the non-osteoarthritis group) completed a face-to-face interview. The purpose, procedural details, and potential benefits and risks of the study were explained before the interview, and then written consent forms were obtained. Each interview took approximately 20e25 min. All procedures were approved by the Institutional Review Board of the university hospital. Data collection was conducted from April to June. 2.3. Instruments 2.3.1. Aging-stereotyped beliefs about symptom management The Korean version of the Symptom Management Beliefs Questionnaire (K-SMBQ) was used for measurement of agingstereotyped beliefs about symptom management. The K-SMBQ
H.-E. Yeom / Geriatric Nursing 34 (2013) 307e313
included 12 items representing negatively stereotyped beliefs and misconceptions about old age with regard to experience and management of symptoms. Each item asked how much a respondent agreed or disagreed, using a 5-point Likert scale ranging from 1 (do not agree at all) to 5 (totally agree). The mean of the 12 items was calculated with a higher score indicating more negatively stereotyped beliefs about symptom management. The K-SMBQ used in this study was a translated version of the Symptom Management Beliefs Questionnaire (SMBQ). Validity and reliability of the original SMBQ have been demonstrated in previous studies across older populations with different health issues, including cancer survivors and community-dwelling healthy older people.14,17 In this study, the reliability was a ¼ 0.79. 2.3.2. Health-promoting behaviors Health-promoting behavior was measured using 10 items of the Health-Promoting Lifestyle Profile II (HPLP II).5 The measurement includes items asking about physical activities, healthy diet, seeking medical information, stress management, and social activities. Each item asks how frequently a respondent performs each of the health-promoting behaviors in daily life on a 4-point Likert scale ranging from 1 (never) to 4 (very much). The mean score for the 10 items was calculated with a higher score indicating greater involvement in health-promoting behaviors. In this study, the reliability was a ¼ 0.84. 2.3.3. Symptom experience and demographic information Symptom experience was assessed for 30 symptoms. Thirty symptoms were chosen from the scales to measure symptoms or pain of older people from the geriatric literature. Thirteen symptoms were from the original Symptom Bother Scale, which is a 13item scale to measure distress related to symptoms common to aging and age-related chronic health problems.14 The validity and reliability of the Symptom Bother Scale have been demonstrated in prior empirical studies of older adults.31,32 Seventeen symptoms were extracted from the scales to assess typical pain and physical discomfort of older Korean women16 and empirical studies about aging-related declines and physical health problems that are common for older Korean women.33,34 Participants were asked whether or not they had experienced each of the symptoms and the sum of symptoms that they reported was calculated. Internal consistency (KudereRichardson Formula 20 [KR-20]) for the 30item dichotomous scale in this sample was KR-20 ¼ 0.81. The number of prescribed medications and the number of chronic health problems regarding ten illnesses that are prevalent among older Korean women were assessed. Participants were asked about general demographic information, including age, education, income, and marital and living arrangements.
the desired power level was at 0.90, the number of predictors was 6, and anticipated effect size was 0.15, the required sample size was 116, so the sample size of the present study was satisfactory. 3. Results 3.1. Description of demographic and health-related characteristics The average age of all participants was 75.9 (SD ¼ 6.23) years: 76.7 (SD ¼ 5.97) for older women with osteoarthritis and 75.1 (SD ¼ 6.96) for older women without osteoarthritis. Almost half of the participants (46.2%) had either no formal education or incomplete elementary education and 39.2% of the participants had graduated from elementary school. More than half of the participants were widowed (58.5%) while the others lived with a spouse or the adult children (56.2%). A comparison of the demographic characteristics between the two groups was performed using a chisquare test (for ordinal-level variables) and t-test for continuous variables (Table 1). No significant differences in age, education, and income were observed between the two groups. The majority of participants (91.8%) had one or more chronic illness. The average number of chronic illnesses was 1.47 (SD ¼ 1.12) for the older women with osteoarthritis and 1.29 (SD ¼ 0.87) for those without osteoarthritis. Across both groups, hypertension (46.8%) and diabetes (23.4%) were the most prevalent chronic illnesses. The average number of medications for all participants was 1.76 (SD ¼ 1.71); 2.04 (SD ¼ 1.77) for the older women with osteoarthritis and 1.51 (SD ¼ 1.67) for those without osteoarthritis. The older women with osteoarthritis were likely to have more chronic illnesses (t ¼ 1.14, p ¼ 0.25) and medications (t ¼ 1.69, p ¼ 0.09), compared to those without osteoarthritis; however, the differences were not statistically significant. 3.2. Symptoms of the older women with and without osteoarthritis The average number of symptoms for all participants was 7.99 (SD ¼ 4.89, range 0e28) and more than 70% of the participants reported six or more symptoms. The average number of symptoms
Table 1 Demographic characteristics (N ¼ 171). Variables
Age Educational status
2.4. Data analysis SPSS 19.0 was used for statistical analyses. Preliminary analysis and descriptive statistics were computed for all variables. Differences in symptom experience and aging-stereotyped beliefs about symptom management between older women with osteoarthritis and those without osteoarthritis were tested using a chi-square test and t-test. Differences in health-promoting behaviors according to the demographic and health-related characteristics were examined using Pearson’s correlations, t-test, and ANOVA. The results of the correlations, t-test, and ANOVA were considered to determine the independent variables of hierarchical linear regression analysis for testing the impact of aging-stereotyped beliefs about symptom management on health-promoting behaviors. The power analysis was conducted using an a-priori sample size tool for multiple regression analyses. When the alpha was at 0.05,
309
Marital status
Living with
Monthly allowance (10,000 won/ month)
Categories
No formal education or incomplete elementary school Elementary school Middle school High school College Married Widowed Divorced or separated Alone Spouse Adult-child Spouse and adult-child <50 50 w 99 100 w 149 150 w 199 200 Missing
With osteoarthritis (n ¼ 81)
Without osteoarthritis (n ¼ 90)
M SD or n (%)
M SD or n (%)
76.7 5.9 38 (46.9)
75.1 6.9 41 (45.6)
31 10 1 1 33 46 2 35 28 13 5 14 25 15 12 8 7
36 11 2 0 35 54 1 40 33 15 2 13 33 19 10 11 4
(38.3) (12.4) (1.2) (1.2) (40.8) (56.8) (2.4) (43.2) (34.6) (16.0) (6.2) (17.2) (30.9) (18.5) (14.9) (9.9) (8.6)
(40.0) (12.2) (2.2) (0) (38.9) (60.0) (1.1) (44.4) (36.7) (16.7) (2.2) (14.4) (36.7) (21.1) (11.2) (12.2) (4.4)
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of the older women with osteoarthritis (M ¼ 9.32, SD ¼ 5.35) was significantly higher (t ¼ 4.01, p < 0.001) than that of the older women without osteoarthritis (M ¼ 6.80, SD ¼ 4.41). The findings indicate that the older women with osteoarthritis had more symptoms than those without osteoarthritis and that the overall high proportions of the older women, regardless of osteoarthritis, suffered from multiple symptoms, rather than a single condition. Table 2 shows, in descending order, the frequency of all symptoms experienced by all participants, the frequency of each symptom by group, and the differences in frequency between the two groups. The majority of the older women with osteoarthritis had joint pain (79%), back pain (75.3%), vision problems (58%), and general pain (58%). They also often reported symptoms such as frequent awakening from sleep (45.7%), fatigue (44.4%), and memory problems (43.2%). The older women without osteoarthritis most frequently reported back pain (54.4%), vision problems (45.6%), joint pain (38.9%), difficulty falling asleep (36.7%), fatigue (31.1%) and memory problems (27.8). The results indicate that musculoskeletal symptoms and vision problems were the most common problems for the older women whether or not they had osteoarthritis. According to the results of the chi-square test for the frequency of symptoms between the two groups, musculoskeletal symptoms (i.e., back pain, joint pain, and joint stiffness), frequent awakening from sleep, and hot flashes were more prevalent in the older women with osteoarthritis compared to those without osteoarthritis.
with osteoarthritis and those without osteoarthritis (t ¼ 1.80, p < 0.05). The older women with osteoarthritis (M ¼ 3.56) had significantly higher scores for aging-stereotyped beliefs about symptom management than those without osteoarthritis (M ¼ 3.11). The mean score for each item on the 12-item K-SMBQ scale was compared between the two groups (see Table 3). Overall, the older women with osteoarthritis tended to show strong agreement with the items and the mean scores of the two items between the two groups were significantly different. The older women with osteoarthritis reported stronger agreement with the items “It is hard to cure symptoms in old age” and “Health care providers need to concentrate on curing the disease rather than on dealing with symptoms” than those without osteoarthritis. Table 4 displays the information about health-promoting behaviors of the older women with and without osteoarthritis. The older women with osteoarthritis (M ¼ 2.88, SD ¼ 0.46) were significantly less likely to practice health-promoting behaviors (t ¼ 1.21, p < 0.05) compared to those without osteoarthritis (M ¼ 2.99, SD ¼ 0.62). In particular, the older women with osteoarthritis reported significantly less engagement in physical activities (t ¼ 1.99, p < 0.05) and less seeking out medical information (t ¼ 2.35, p < 0.05) compared to those without osteoarthritis.
3.3. Comparison of aging-stereotyped beliefs about symptom management and health-promoting behaviors
The result of hierarchical multiple regression analysis indicated that, in the first step, after taking into account for the number of symptoms, chronic illnesses, and medications, age was the only factor significantly affecting health-promoting behaviors (b ¼ 0.329, p < 0.01) and having osteoarthritis or not was not
A significant difference in aging-stereotyped beliefs about symptom management was observed between the older women Table 2 Comparison of symptom frequency between older women with osteoarthritis (n ¼ 81) and without osteoarthritis (n ¼ 90). Symptoms
Back pain Joint pain Vision problem Pain Aching Fatigue Frequent awakening from sleep Memory problem Joint stiffness Dry mouth Hair loss Difficulty falling asleep Headache Irritated eyes Shortness of breath Constipation Hot flashes Feeling anxious Dizziness Urinary incontinence Indigestion Dry skin Weakness Waking too early Depression Balance problem Thirst Weight loss or gain Itching Swelling in hands and feet *p < 0.05, **p < 0.01.
c2
Total
With osteoarthritis
Without osteoarthritis
n (%)
n (%)
n (%)
110 99 88 76 66 64 61
(64.3) (57.9) (51.5) (44.4) (38.6) (37.4) (35.7)
61 64 47 47 37 36 37
(75.3) (79.0) (58.0) (58.0) (45.7) (44.4) (45.7)
49 35 41 29 29 28 24
(54.4) (38.9) (45.6) (32.2) (32.2) (31.1) (26.7)
5.54* 19.7** 1.73 7.33* 2.14 1.75 6.09*
60 56 54 54 52 48 46 45 35 35 34 31 31 30 28 27 23 23 22 21 18 15 15
(35.1) (32.7) (31.6) (31.6) (30.4) (28.1) (26.9) (26.3) (20.5) (20.5) (19.9) (18.1) (18.1) (17.5) (16.4) (15.8) (13.5) (13.5) (12.9) (12.3) (10.5) (8.8) (8.8)
35 36 29 29 19 24 22 23 17 23 16 17 17 16 14 15 11 13 13 11 10 9 7
(43.2) (44.4) (35.8) (35.8) (23.4) (29.6) (27.1) (28.3) (20.9) (28.3) (19.7) (20.9) (20.9) (19.7) (17.2) (18.5) (13.6) (16.0) (16.0) (13.6) (12.3) (11.1) (8.6)
25 20 25 25 33 24 24 22 18 12 18 14 14 14 14 12 12 10 9 10 8 6 8
(27.8) (22.2) (27.8) (27.8) (36.7) (26.7) (26.7) (24.4) (20.0) (13.3) (20.0) (15.6) (15.6) (15.6) (15.6) (13.3) (13.3) (11.1) (10.0) (11.1) (8.9) (6.7) (8.9)
2.80 6.57* 0.69 0.69 2.47 0.12 0.01 0.21 2.51 4.69* 0.00 0.64 1.63 0.39 0.08 0.61 0.05 0.58 0.58 0.14 0.56 0.52 0.01
3.4. Associations between symptoms, aging-stereotyped beliefs, and health-promoting behaviors
Table 3 The comparison of the 12 items of the K-SMBQ between older women with (n ¼ 81) and without osteoarthritis (n ¼ 90). Items
Many symptoms are a natural part of aging process. It is hard to cure symptoms in old age. Health care providers need to concentrate on curing the disease rather than on dealing with symptoms. Old people need to lower their expectations about treating their symptoms. At my age, it is better to learn to live with symptoms rather than to treat symptoms. I will be a complainer if I ask about my symptoms to health care providers. It is unnecessary to worry about many symptoms in old age. It is unnecessary to treat symptoms in old age. Health care providers might find it annoying to be told about symptoms. The ‘cure’ for symptoms is often worse than the disease. It is easier to put up with fatigue or weakness than with the time and hassle of an exercise program. It is unnecessary to find new ways for managing symptoms related to aging.
With Without t osteoarthritis osteoarthritis M (SD)
M (SD)
4.50 (0.83)
4.32 (0.96)
1.14
4.20 (1.14) 4.07 (1.07)
3.73 (1.41) 3.57 (1.28)
2.13* 2.40*
3.61 (1.44)
3.26 (1.49)
1.33
3.33 (1.52)
3.00 (1.58)
1.23
3.32 (1.49)
3.01 (1.50)
1.15
3.15 (1.61)
3.25 (1.66)
0.31
3.03 (1.55)
2.53 (1.55)
1.80
3.01 (1.58)
2.84 (1.57)
0.59
2.91 (1.53)
2.69 (1.65)
0.80
2.54 (1.52)
2.53 (1.47)
0.01
2.56 (1.44)
2.48 (1.52)
0.32
Note. K-SMBQ ¼ aging-stereotyped beliefs about symptom management. *p < 0.05.
H.-E. Yeom / Geriatric Nursing 34 (2013) 307e313 Table 4 Differences in symptoms, K-SMBQ, and health-promoting behaviors between older women with (n ¼ 81) and without osteoarthritis (n ¼ 90). Variables
With osteoarthritis
Without osteoarthritis
t
M (SD)
M (SD)
Number of symptoms Number of chronic illnesses Number of medications Aging-stereotyped beliefs about symptom management Health-promoting behaviors Physical activities Healthy diet Seeking medical information Stress management Social activities
9.32 1.47 2.04 3.56
(5.45) (1.12) (1.77) (0.70)
6.80 1.29 1.51 3.11
(4.41) (0.87) (1.67) (0.91)
4.01** 1.14 1.69 1.80*
2.88 2.31 3.54 2.36 3.11 2.84
(0.46) (1.08) (0.73) (0.97) (0.90) (0.90)
2.99 2.72 3.63 2.82 3.15 3.97
(0.62) (1.21) (0.77) (1.14) (0.98) (1.02)
1.21* 1.99* 0.92 2.35* 0.19 0.76
Note. K-SMBQ ¼ aging-stereotyped beliefs about symptom management. *p < 0.05, **p < 0.01.
a significant predictor of health-promoting behaviors (Table 5). In the second step, after adjusting for the covariates, agingstereotyped beliefs about symptom management was a significant predictor of health-promoting behaviors (b ¼ 0.280, p < 0.01). These findings indicate that regardless of a diagnosis of osteoarthritis, the older women who had stronger agingstereotyped beliefs about symptom management were less likely to practice health-promoting behaviors. 4. Discussion Engaging in health-promoting behaviors is a key issue to prevent health declines and to promote physical functioning and quality of life of older people. A number of previous studies have found that symptoms and aging-related beliefs are powerful factors affecting health-promoting behaviors in older people.7,21,24,25 Older people are quite likely to experience a variety of symptoms related to normal aging declines and degenerative processes of comorbid chronic illnesses.14 In particular, osteoarthritis is a representative illness which causes functional declines and thereby threatens the quality of life of the older population.10e12 However, despite the high prevalence of osteoarthritis among older people, little has been studied about symptoms of older people with osteoarthritis compared to those without osteoarthritis. In addition, as a perceptual factor affecting health-promoting behaviors, little has been found about aging-stereotyped beliefs in terms of the differences depending on a diagnosis of osteoarthritis, as well as its impact on health-promoting behaviors. The current study compared
Table 5 The influence of aging-stereotyped beliefs on health-promoting behaviors. Health-promoting behaviors First step B
SE
Second step
b
Covariates Age 0.025 0.006 0.329** Number of medications 0.035 0.029 0.114 Number of chronic 0.011 0.050 0.024 illnesses Number of symptoms 0.004 0.009 0.042 Osteoarthritis 0.105 0.108 0.097 K-SMBQ F 3.88* 0.134 R2
b
B
SE
0.021 0.032 0.007
0.006 0.274** 0.028 0.138 0.048 0.015
0.002 0.009 0.024 0.109 0.104 0.101 0.281* 0.082 0.280** 5.47** 0.209
Note. K-SMBQ ¼ aging-stereotyped beliefs about symptom management. *p < 0.05, **p < 0.01.
311
symptoms, aging-stereotyped beliefs about symptom management, and health-promoting behaviors of older women with and without osteoarthritis. It also investigated factors affecting healthpromoting behaviors in older women with and without osteoarthritis, focusing on aging-stereotyped beliefs. The current study found that the older women, regardless of a diagnosis of osteoarthritis, had experienced multiple symptoms rather than a single symptom. In particular, the group of older women with osteoarthritis showed higher frequencies of the most common overall symptoms when compared to their counterparts, supporting the hypothesis that older people with osteoarthritis will have more symptoms than those without osteoarthritis. In particular, compared to the older women without osteoarthritis, those with osteoarthritis had musculoskeletal symptoms (i.e., joint and back pain, stiffness) more frequently as well as other symptoms that are common in the older population including general aches and pains and frequent episodes of awakening from sleep. These findings indicate that managing symptoms in older people with osteoarthritis is more challenging with regard to the difficulties in interpreting the causes of symptoms whether or not they are from normal aging declines or the pathological process of osteoarthritis. Apart from the higher frequencies of symptoms in older people with osteoarthritis, musculoskeletal symptoms of back pain and joint pain were the most frequently reported symptoms in both groups of older women with and without osteoarthritis. The findings, therefore, emphasize that special attention is needed to care for the musculoskeletal symptoms of older people regardless of if they have osteoarthritis or not. In addition, it is noteworthy that both groups of older women with and without osteoarthritis frequently reported vision problems, aches and pains, fatigue, and sleep problems (i.e., frequent awakening from sleep, difficulty falling asleep). These findings indicate the importance of nursing interventions on the basis of a broader assessment about symptoms to enhance management of symptoms and quality of life of older people. In support of the hypothesis, this study found that the older women with osteoarthritis had significantly stronger agingstereotyped beliefs about symptom management when compared to the older women without osteoarthritis. In a comparison of each item on the K-SMBQ measurement, the older women with osteoarthritis showed strong agreement with the items “It is hard to cure symptoms in old age” and “Health care providers need to concentrate on curing the disease rather than on dealing with symptoms.” This agreement indicates that older women with osteoarthritis may have more pessimistic views about the controllability of symptoms and more erroneous beliefs about the roles of health care providers, which subsequently may affect their relatively complacent attitudes when interacting with their health care providers in medical encounters. These findings imply that living with chronic illnesses that are particularly regarded as aging-related might trigger or reinforce negative and stereotyped beliefs about old age. With regard to health-promoting behaviors, the older women with osteoarthritis were significantly less active compared to those without osteoarthritis. This finding is particularly worrisome because numerous studies have demonstrated the benefits of various health-promoting behaviors in delaying the progression of osteoarthritis.26e29 Along with the findings of symptoms and aging-stereotyped beliefs, these findings indicate that older women with osteoarthritis are relatively vulnerable to health declines compared to those without osteoarthritis. As hypothesized on the basis of empirical evidence,21e23 the older women’s aging-stereotyped beliefs about symptom management were a significant predictor of their healthpromoting behaviors, meaning that the older women with stronger aging-stereotyped beliefs were significantly less active in
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health-promoting behaviors whether or not they had osteoarthritis. This finding emphasizes the powerful impact of agingstereotyped beliefs on health-promoting behaviors beyond that of osteoarthritis. In particular, it is notable that this study focused on aging-stereotyped and erroneous beliefs about experiencing and managing symptoms as a perceptual barrier to healthpromoting behaviors. Thus, the findings should encourage the development of nursing interventions focusing on rectifying aging-related misconceptions as well as facilitating positive attitudes toward aging of older people. Despite the strong evidence of aging-related beliefs related to behaviors, researchers must be cautious about the interpretation of the findings with regard to the following issue. There is strong evidence supporting the influence of functional health on healthpromoting behaviors in older people,2,3,7 but this study examined health status with regard to the number of chronic illnesses, medications, and symptoms, rather than measuring the actual functional capabilities of older individuals. Thus, further examination including functional health and actual capabilities is suggested. Another issue concerns the assessment of symptoms. Symptoms in the current study were examined based on a list of symptoms, which was developed from empirical evidence about common symptoms for older Korean people and literature reviews about aches and pains of older people, and information about construct validity for this list of symptoms is still limited. Therefore, further effort to cluster symptoms is essential for better understanding about the types of symptoms older people experience. In addition, repeated testing for validity and reliability is necessary. Some other issues should be noted as limitations. Participants in this study were limited to community-dwelling older females. Although osteoarthritis is more prevalent in older women, older males are not free from the risk of osteoarthritis and misconceptions regarding old age. In addition, empirical studies have shown the importance of family interactions in managing the health issues of older Korean people,35 implying that institutionalized older people are relatively vulnerable to barriers to health-promoting behaviors due to limited support from family members. Therefore, further comparative examination about aging-stereotyped beliefs according to the living arrangement (e.g., institutionalized versus community dwelling) as well as gender is suggested. Finally, this study was a cross-sectional study of older Korean people so the causal relationship could not be confirmed. A longitudinal study is needed to ascertain causal relationships between symptom experience, aging-stereotyped beliefs, and healthpromoting behaviors. In addition, given the unique characteristics of aging-related perceptions in different social-cultural contexts, further cross-cultural research is warranted to attain a better understanding of cultural diversity and similarities regarding aging-stereotyped beliefs. 4.1. Implications for nursing researchers and health care providers This study found that older women with osteoarthritis had stronger aging-stereotyped beliefs, compared to those without osteoarthritis. There are other illnesses which are common to older people and regarded as normal consequences of the aging process, such as urinary incontinence and memory problems. Further comparative studies among older people with such health issues are suggested for better understanding about aging-stereotyped beliefs and relevant issues to the beliefs about aging among older people. The current study provides important messages for health care providers. They need to bear in mind that older people have multiple symptoms, which makes it difficult to interpret the meaning of the symptoms and to decide how to cope with these
symptoms. Based on the unique characteristics of older people, health care providers need to develop clinical strategies that could help these older people recognize their health problems as well as set up effective self-care strategies. It is also important that health care providers understand the harmful effects of aging-related stereotypes or misconceptions about engaging in healthpromoting behaviors, and thereby recognize their pivotal role in facilitating appropriate attitudes toward the aging process and difficulties of older people. This study suggests the need to develop psycho-cognitive interventions focusing on enhancing knowledge about effective self-care and positive perceptions about aging. Providing accurate information is a fundamental task to help older people recognize erroneous beliefs about coping with health problems. In addition, empirical findings have emphasized the importance of psychological support that can lead to better outcomes when providing nursing interventions.36 It is particularly essential that older people have the opportunity to explore their own perceptions about aging and to express emotions including concerns and anxiety.37 Furthermore, based on these cognitive and psychological characteristics, setting individualized goals and providing repeated and tailored messages are important.38 Previous studies have demonstrated the importance of health care providers’ attitudes in medical encounters with older patients.17 Older people are particularly dependent on the comments and attitudes of their health care providers, so agingrelated negative attitudes from health care providers could aggravate aging-related negative perceptions of older people.17 Therefore, health care providers need to be quite prudent when expressing comments and attitudes in their interactions with older patients. There is a paucity of studies about aging-related stereotypes and misconceptions in regard to the experience and management of health problems in the older population. However, further studies about older people with diverse social-cultural and health-related characteristics are warranted to enrich our understanding of stereotypes and misconceptions about aging and to enhance the active practice of self-care behaviors leading to better quality of life for older people. References 1. Marks R, Allegrante JP. Chronic osteoarthritis and adherence to exercise: a review of the literature. J Aging Phys Act. 2005;13:434e460. 2. Hurley MV. Muscle, exercise and arthritis. Ann Rheum Dis. 2002;61:673e675. 3. Petursdottir U, Arnadottir SA, Halldorsdottir S. Facilitators and barriers to exercising among people with osteoarthritis: a phenomenological study. Phys Ther. 2010;90:1014e1025. 4. Hendry M, Williams NH, Markland D, Wilkinson C, Maddison P. Why should we exercise when our knees hurt: a qualitative study of primary care patients with osteoarthritis of the knee. Fam Pract. 2006;23:558e567. 5. Walker SN, Sechrist KR, Pender NJ. Psychometric Evaluation of the HealthPromoting Lifestyle Profile II. Unpublished manuscript. University of Nebraska Medical Center; 1996. 6. Kim SH. Older people’s expectations regarding ageing, health-promoting behaviour and health status. J Adv Nurs. 2009;65:84e91. 7. Sarkisian CA, Prohaska TR, Wong MD, Hirsch S, Mangione CM. The relationship between expectations for aging and physical activity among older adults. J Gen Intern Med. 2005;20:911e915. 8. Jamtvedt G, Dahm KT, Christie A, et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Phys Ther. 2008;88:123e136. 9. Lin SY, Davey RC, Cochrane T. Community rehabilitation for older adults with osteoarthritis of the lower limb: a controlled clinical trial. Clin Rehabil. 2004;18:92e101. 10. Hunter DJ, Felson DT. Osteoarthritis. BMJ. 2006;332:639e642. 11. Dong XS, Wang X, Daw C, Ringen K. Chronic diseases and functional limitations among older construction workers in the United States: a 10-year follow-up study. J Occup Environ Med. 2010;5:372e380. 12. Segal NA, Yack HJ, Brubaker M, Torner JC, Wallace R. Association of dynamic joint power with functional limitations in older adults with symptomatic knee osteoarthritis. Arch Phys Med Rehabil. 2009;90:1821e1828.
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