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Arthritis-Specific Health Beliefs Related to Aging Among Older Male Patients With Knee and/or Hip Osteoarthritis

¹ Mental Illness Research, Education and Clinical Center, Verterans Administration Pittsburgh Healthcare System, Pennsylvania.
² Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, Ohio.
³ Department of Social and Behavioral Health, School of Medicine, Virginia Commonwealth University, Virginia.
⁴ Center for Health Equity Research and Promotion, Veterans Administration Pittsburgh Healthcare System, Pennsylvania.
⁵ Department of Medicine, School of Medicine, University of Pittsburgh, Pennsylvania.

Address correspondence to Cathleen J. Appelt, PhD, Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, 7180 Highland Drive Division (151R-HD), Pittsburgh, PA 15206. E-mail: cathleen.appelt{at}va.gov

	Abstract

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Background. Disease-specific beliefs may impact patients' perceptions of the efficacy of various treatment options, thus, it is important to understand these beliefs. We examined the relationship between patients' demographic characteristics and arthritis-specific beliefs related to aging.

Methods. We performed a cross-sectional survey of 591 elderly primary care patients, who had symptomatic osteoarthritis (OA) of the knee and/or hip, at the Louis Stokes VA Medical Center in Cleveland, Ohio. Data were collected on age, race, educational level, income, and whether patients agreed or disagreed with four statements regarding aging and arthritis. We also assessed OA symptom severity using the Western Ontario McMaster Universities Index (WOMAC) and depressive symptoms using the Geriatric Depression Scale. We used logistic regression analyses to examine relationships between patients' age, race, and educational level and arthritis-specific health beliefs, while adjusting for OA symptom severity, radiographic confirmation of OA, OA joint burden, depressive symptoms, and income.

Results. Patients 70 years old or older, as compared to patients 50–59 years old, were more likely to believe that: arthritis is a natural part of growing old; people should expect that when they get older, they won't be able to walk as well, and people should expect to live with pain as they grow older.

Conclusion. Among older, male veterans, health beliefs regarding the relationship between aging and arthritis vary by age. Clinicians should consider these differences when discussing treatment strategies with their patients with knee and/or hip OA.

Gaining a better understanding of patients' health beliefs regarding OA and aging is clinically important because research suggests that health beliefs may have serious health-related consequences for older adults. Findings from a community-based study of 400 adults aged 20–90 years suggest that the belief that aging is associated with an increased vulnerability to disease and a decreased potential for effective treatment was found to be prevalent among adults of all ages (13). Additional findings from the same study data suggest that elderly adults, those aged 60–89 years, were more likely than younger adults to view themselves as susceptible to disease, to view disease as having more serious consequences for them than it would for younger persons (14), to attribute disease symptoms to aging (15), and they were less likely to view mild symptoms as illness warnings (14). In another population-based study of older adults, holding the belief that nothing can be done to treat arthritis, heart disease, or difficulty sleeping has been found to be associated with a decreased likelihood of having a regular physician (16). In addition, holding the belief that these medical conditions are a natural part of aging was associated with decreased utilization of preventative health services (16). Moreover, findings from an 18-year longitudinal study of over 400 patients aged 50 and older suggest that individuals who hold positive beliefs about their own aging are more likely than those who hold negative beliefs about aging to report better functional health as they age, even when age, race, gender, and socioeconomic status are held constant (17). Findings based on another analysis of these same longitudinal data suggest that older persons who held positive beliefs about aging lived about 7.5 years longer than those who held negative beliefs about their own aging (18). Another study of approximately 1400 participants suggested that older adults who attribute poor health to a natural part of aging may be more likely to dismiss symptoms of illness and less likely to seek medical attention (19). Findings from the same study also suggested an association between mortality and attribution of difficulties with Activities of Daily Living to "old age" (19).

Although the importance of understanding patients' perceptions regarding OA has been illustrated in our prior work, which has shown that patients' culturally based beliefs and attitudes toward OA treatment options may underlie disparities in joint replacement utilization (20–24), little is known about arthritis-specific beliefs related to aging. Three studies that focused on perceptions regarding the causes of arthritis have examined the prevalence of the belief that arthritis is a natural or normal part of aging (16,25,26). Findings from these studies suggest that between 28% (26) and 54% (16) of persons may believe that arthritis is a natural or normal part of aging and that as many as 66% (25) of OA patients may share this belief. In summary, research suggests that beliefs about aging and declining health are common (13); that older persons are more likely to associate disease with aging than are younger persons (14,15); and that beliefs about health and aging may have serious health-related consequences (16–19). Therefore, it is important to investigate health beliefs associated with one of the most common chronic conditions that affect older patients (1). It is with this in mind that we examined the prevalence and distribution of age-related, arthritis-specific beliefs among patients with moderate-to-severe OA of the knee and/or hip; specifically, we hypothesized that with increasing age, arthritis patients are more likely to believe that arthritis and its symptoms are an inevitable part of aging.

	METHODS

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Sample Selection and Study Setting
Older, male patients attending primary care clinics at the Cleveland VA Medical Center were screened for the presence of chronic, frequent hip or knee pain, the severity of pain, and its impact on daily functioning. Trained interviewers administered two screening questions from the Arthritis Supplement of the National Health and Nutrition Examination Survey I (NHANES I): (i) Have you ever had pain in and around your knee/hip on most days for at least a month?; and (ii) Over the past month, have you had pain in your knee/hip when walking or standing on at least half of the days (27)? If a patient responded "yes" to either question, he was categorized as having knee and/or hip pain. We then assessed severity of knee or hip pain using the validated Lequesne Osteoarthritis Severity Index (28). Study inclusion criteria for patients included self-identified ethnicity of African American or white, age of 50 years, no history of joint replacement, and a score indicating at least moderate severity on the Lequesne Index. Of the 1351 patients screened, 776 met the inclusion criteria. Of those who were eligible, 737 agreed to participate. A total of 591 patients were included in this analysis. Study participants who had not received radiographic evaluation of their affected knee or hip during the previous 12 months received radiographs as part of their participation in the study.

All aspects of this study were approved by the Institutional Review Board of the Louis Stokes Cleveland VA Medical Center. Written informed consent was obtained from all patients who participated in the study.

Main Outcome Measure
To assess arthritis-specific beliefs related to aging, patients were asked whether they agree or disagree with the following statements regarding the arthritis and the aging process:

1. Arthritis is a natural part of growing old.
   
2. People should expect that when they get older they won't be able to walk as well.
   
3. Once you get arthritis, it can only get worse, not better.
   
4. People should expect to have to live with pain as they grow older.
   

Study Covariates
Patients' demographic characteristics, OA symptom severity, and depressive symptoms were assessed using an interviewer-administered questionnaire. Demographic characteristics in this analysis included patients' self-reported age, race, educational level, and annual household income. Patients' age, measured in years, was coded into three categories: 50–59, 60–69, or 70. Only those patients who reported African American or white as their primary racial background were included in this sample. Patients' highest level of educational attainment was coded into three categories: less than high school graduation; high school graduation; or greater than high school. Patients' annual household income was coded into two income categories: <$15,000 or $15,000.

Patients were asked whether they had pain in the right and/or left knee(s) and/or hip(s). Patients' responses were coded into two categories: having OA in only one joint site or having OA in more than one joint site. OA symptom severity was assessed using the Western Ontario McMaster Universities Index (WOMAC) (29). The WOMAC is a 24-question index with three subscales that encompass three clinically important dimensions of OA severity: pain (5 questions), stiffness (2 questions), and physical function (17 questions). Patients with scores of 39 or higher are generally considered to be candidates for joint replacement surgery (30). The WOMAC yields a continuous measure of patients' symptom severity, with a range from 0 to 100. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS) (31), which yields a continuous measuring ranging from 0 to 15. Normal scores (reflecting no significant level of depressive symptoms) range from 0 to 3; scores of 5–9 reflect moderate depressive symptoms; and severe depressive symptoms are indicated by scores of 10–15 (32,33).

Each knee or hip was assigned a Kellgren–Lawrence (K-L) Scale score (0–4). The K-L Scale for knee OA uses a grade of 0 (normal), 1 (doubtful joint space narrowing and possible osteophytes), 2 (definite osteophytes with possible joint space narrowing), 3 (moderate multiple osteophytes and definite joint space narrowing, bony sclerosis, and possible deformity of bone ends), or 4 (large osteophytes, marked joint space narrowing, severe sclerosis, and definite deformity of bone ends) (34). The K-L Scale for hip OA uses a grade of 0 (normal), 1 (doubtful joint space narrowing medically and possible osteophytes around the femoral head), 2 (definite joint space narrowing inferiorly, definite osteophytes, slight sclerosis), 3 (marked joint space narrowing, definite osteophytes, some sclerosis and cyst formation, and deformity of the femoral head and acetabulum), and 4 (gross joint space narrowing with sclerosis and cysts, large osteophytes, and deformity of the femoral head and acetabulum) (34). Patients with scores of 2 are considered to have radiographic evidence of OA. Unfortunately, we do not have appropriate data to make radiographic comparisons between patients with and without pain.

Data Analysis
The objective of this analysis is to assess the potential relationships between OA patients' age and their arthritis-specific health beliefs related to aging. Patient age in years was coded into three age groups; 50–59, 60–69, or 70 years, and two dichotomous variables, with the youngest group (age 50–59 years) as the reference group, were constructed. For patient race/ethnicity, a dichotomous variable was constructed, with African Americans as the reference group. Income was treated as a dichotomous variable; patients with an annual household income of less than $15,000 were set as the reference group. Two dichotomous variables, each with less than high school education as the reference group, were constructed for the three educational levels included in the analyses. OA joint burden was also dichotomized, with those reporting only one joint (knee or hip) affected by OA set as the reference group. Individual K-L Scale scores were also collapsed into a dichotomous variable. With patients scoring < 2 as the reference group. WOMAC and GDS scores were included in the analyses as continuous variables.

First, chi-square tests for bivariate associations between health belief variables (paired in all possible 2 x 2 combinations) were run to test for associations between the four arthritis-specific health beliefs related to aging. Then, multivariable analyses were conducted for each of the four dichotomous health beliefs using logistic regression analyses. Each multivariable model included patient age, race, educational level, and annual household income. In each model, we also adjusted for OA symptom severity [WOMAC], OA disease severity [K-L Scale score], OA knee and/or hip joint burden, and depressive symptoms [GDS]. We also tested for significant interactions between all of the independent variables, and included significant interaction terms in the final models.

	RESULTS

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The study sample consisted of 591 participants whose mean age was 66 years (see Table 1). Forty-four percent of patients identified themselves as African American and the remaining 56% as white. Fifty-nine percent reported an annual household income of less than $15,000. Sixteen percent reported an educational level of higher than high school. About 83% of patients reported having OA in only one joint (one hip or one knee). On the WOMAC, the mean score was 46, which indicates a higher than moderate level of overall pain, stiffness, and difficulty in physical function. The mean score on the GDS was approximately 5, which indicates a relatively low mean level of depressive symptoms among participants. On the K-L Scale for rating OA disease severity based on radiographic evidence, about 44% of patients sampled scored 2, the diagnostic threshold for radiographic evidence of OA. Bivariate analyses of the arthritis-specific beliefs showed significant chi-square relationships between agreeing versus not agreeing between all possible pairs of the beliefs (p <.001).

For the belief that once you get arthritis it can only get worse, not better (see Table 3), patients with an educational level equal to high school had higher odds of reporting agreement than did those with less than a high school education. In addition, patients who scored higher on the WOMAC had higher odds of believing that once you get arthritis it can only get worse, not better, as were patients aged 60–69 years and 70 year with K-L scores of 2 (as compared to those aged 50–59 years with K-L scores < 2). Additionally, patients with both an annual household income of $15,000 and K-L scores 2 (as compared to patients with both annual household incomes < $15,000 and K-L scores < 2) and those patients aged 70 years with high WOMAC scores (as compared to patients in both of the younger age groups with lower WOMAC scores) had higher odds of believing that once you get arthritis it can only get worse, not better.

Finally, patients in both older age categories (60–69 years and 70 years) had higher odds than did patients aged 50–59 years of believing that people should expect to have to live with pain as they grow older (see Table 3). Additionally, patients with higher WOMAC scores had higher odds of reporting agreement with this belief, but those aged 60–69 years who scored higher on the WOMAC had lower odds than those aged 50–59 years with lower WOMAC scores of believing that people should expect to have to live with pain as they grow older.

In summary, we found that the odds of believing three of the four statements regarding arthritis as an inevitable part of aging increased with age. For the other belief that once you get arthritis, it can only worse, we found that older age alone was not enough to increase odds of agreement, but that having a K-L score of 2 and being in either of two older age groups or being in the oldest age group and having higher WOMAC score increased the odds of agreement.

	DISCUSSION

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In this sample of nearly 600 African American and white, male veterans aged 50–80 years with moderate to severe knee and/or hip OA, we found that patient age was significantly associated with arthritis-specific health beliefs related to aging. After adjusting for race, educational level, income, total OA joint burden, OA symptom severity [WOMAC], disease severity [K-L], and depressive symptoms [GDS], we found that patients in the oldest age group ( 70 years) had increased odds of believing that arthritis is a natural part of growing old, that people should expect that when they get older they won't be able to walk as well, and that people should expect to have to live with pain as they grow older. We also found increased odds for believing that once you get arthritis, it can only get worse among older patients with either increased disease severity [K-L] or increased symptom severity [WOMAC]. In addition, we found that WOMAC score, a multidimensional measure of OA symptom severity that assesses pain, stiffness, and difficulty in physical functioning, was significantly associated with all of the belief responses, except one (people should expect that when they get older they won't be able to walk as well); this finding suggests that disease severity including pain might modify patient beliefs regarding arthritis and aging. In our sample, about 61% reported believing that arthritis is a natural part of growing old. Three previous studies also examined the prevalence of the belief that arthritis is a natural or normal part of growing old. Two of these studies, one published in 1983 (26) and another in 1999 (16), were population-based and reported that 28% and 54% of participants, respectively, reported believing that arthritis is a natural or normal part of growing old. Two important differences are that Price and colleagues (26) included participants aged 20–69 years and did not adjust for the presence of chronic medical conditions, whereas Goodwin and colleagues (16) sampled persons 75 years old and older and adjusted for presence of chronic medical conditions. A study by Elder (25) sampled patients aged 45–64 years with OA, and found that 66% believed that arthritis is a natural part of growing old. Our findings most closely resemble those of Elder, most likely because our sample composition is similar to hers.

Unfortunately, neither Elder nor Price and colleagues reported having examined the relationship between age and the belief that arthritis is a natural part of aging. Goodwin and colleagues found no significant association between age and the belief that arthritis is a natural part of aging. Interestingly, Goodwin and colleagues did report a significant (p =.001) relationship between race and the belief that arthritis is a natural part of aging; we found no association between race and this health belief. The differences between our findings and Goodwin and colleagues may also be due to differences in sample composition. All three of the aforementioned studies sampled both men and women, and none reported a significant association between gender and the belief that arthritis is a natural part of aging.

We found that patients with an educational level of greater than high school, as compared to those with less than high school, were more likely to believe that arthritis is a natural part of growing old. This finding is counterintuitive. Because our sample is limited to the VA only, where the patient population tends to have lower socioeconomic status and educational levels than the general population, it is possible that replication of this study within the general population, which would include more persons with higher levels of educational attainment, would yield different results. Further research is necessary to determine the nature of the relationship between educational level and the belief that arthritis is a natural part of aging.

Recent research findings have indicated that patients' health beliefs about disease and aging may impact health services utilization (16), functional health (17), longevity (18), and mortality (19). In a population-based study of older patients, holding the belief that nothing can be done to treat arthritis, heart disease, or difficulty sleeping has been found to be associated with a decreased likelihood of having a regular physician (16). Moreover, holding the belief that these medical conditions are a natural part of aging was associated with decreased utilization of preventative health services (16). In addition, findings from a longitudinal study suggest that older persons who held positive beliefs about their own aging are more likely than those who hold negative beliefs about aging to report better functional health as they age, even when age, race, gender, and socioeconomic status are held constant (17). Moreover, findings from another analysis of those same data suggest that older persons who held positive beliefs about their own aging lived about 7.5 years longer those who held negative beliefs about their own aging (18). Generally speaking, if patients believe that illness symptoms are related to aging and thus, are less likely to seek medical attention, it is likely that they may not be aware of treatment options that could potentially lead to increased functional health and even longevity. In the specific case of knee and/or hip OA, research has shown that health beliefs may impact perceptions of the efficacy of various treatment options (35), which may affect treatment decisions (36,37). Our previous research has shown that patients' culturally based beliefs and attitudes about OA treatment options may underlie race-based disparities in joint replacement utilization (20–24). It is possible that patients' beliefs regarding OA and the aging process may play a similar role in treatment utilization.

Our current findings suggest that physicians should consider that patients with OA, especially patients aged 70 years or older, may believe that their arthritis is an inevitable part of the aging process rather than a condition for which they could seek treatment. As OA patients age, clinicians may find it useful to assess patients' expectations regarding OA symptoms and aging. When appropriate, it may be beneficial for clinicians to talk with patients about realistic expectations for pain and/or function with and without specific treatment options given the patient's overall health and disease state.

There are several limitations to consider when interpreting our findings. First, the cross-sectional design precludes isolation of effects due solely to aging from effects potentially due to time and/or generation. Although a confirmation of findings by other cross-sectional studies does not constitute scientific control for generational and period effects, the consistency between our findings and those of Elder (25) published in 1974 does suggest a consistency in the prevalence of this health belief among middle-aged to older-aged OA patients spanning two periods. Second, our sample includes only patients with moderate to severe OA symptom severity and those who do not meet radiographic criteria for OA diagnosis, which precludes estimation of the potential associations between age and arthritis-related beliefs among those patients who have lesser or no symptom severity with and without radiographic confirmation of OA. In addition, data were not available to include adjustment for patient duration of OA symptoms or the effects of any medications that patients could be taking that may affect OA symptom severity. These data were collected at one VA Medical Center; findings may differ for patients at other VA Medical Centers and/or for other non-VA populations. Generalizability of our findings is further limited by our all-male sample. Because the prevalence of OA is higher among women than men (38), it is conceivable that the distribution of responses we observed might be different in a gender-balanced sample. Finally, because previous research has indicated that individuals who attribute disease to aging are less likely to utilize health services, our clinic-based sample is potentially less desirable than a community-based sample for investigating health beliefs related to aging.

Summary
Among older, male veterans with moderate to severe knee and/or hip pain, we found that older patients were more likely to view arthritis and its symptoms as being associated with aging. Further research is needed to determine whether these observed differences in attitudes have a significant impact on treatment decisions and health outcomes for OA patients.

	Acknowledgments

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This project was funded in part by a Merit Review Grant from the Department of Veterans Affairs Health Services Research and Development (HSR&D) Service and by a Veterans Affairs HSR&D Advanced Career Development Award to Said A. Ibrahim, MD, MPH.

We thank Jennifer A. Sartorius for providing us with local statistical support; specifically, with the multivariable models. In addition, we thank Kimberly R. Hansen for providing administrative support throughout the preparation of this manuscript.

These findings were presented in poster format at the 9^th World Congress of the Osteoarthritis Research Society International (OARSI) and in the Plenary Paper Session at the Veterans Affairs Health Services Research and Development (HSR&D) Service's National Meeting in 2005.

	Footnotes

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Decision Editor: Luigi Ferrucci, MD, PhD

Received November 16, 2005

Accepted June 6, 2006

	References

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