Quality of Life in American Indian and White Women
With and Without Rheumatoid Arthritis
KEY WORDS
activities of daily living (ADLs)
ethnicity
quality of life
rheumatoid arthritis
women
Janet L. Poole, PhD, OTR/L, FAOTA, is Associate
Professor, Occupational Therapy Graduate Program,
Department of Pediatrics, MSC09 5240, University of
New Mexico, Albuquerque, NM 87131-0001;
jpoole@salud.unm.edu
Heather Chiappisi, MOT, OTR/L, is Staff Occupational
Therapist, Sacred Heart Medical Center, Eugene, OR.
Jennifer Schukar Cordova, OTR/L, is Occupational
Therapist, Albuquerque Public Schools.
Wilmer Sibbitt, Jr., MD, is Professor, Internal
Medicine and Neurology, University of New Mexico,
Albuquerque.
280
Janet L. Poole, Heather Chiappisi, Jennifer Schukar Cordova,
Wilmer Sibbitt, Jr.
OBJECTIVE. The purpose of this study was to examine quality of life (QOL) in American Indian and White
women with and without rheumatoid arthritis.
METHOD. This cross-sectional study included 64 women in four groups: American Indians with rheuma-
toid arthritis, healthy American Indians, Whites with rheumatoid arthritis, and healthy Whites. Participants
received evaluations of pain, joint motion, hand function, daily task performance, community participation,
and QOL.
RESULTS. There was a significant difference in QOL between the participants with rheumatoid arthritis and
the healthy control groups but not between the American Indian and White groups. Current health and emo-
tionalsocial function related to QOL in all groups. Dexterity also correlated with QOL in the two groups with
rheumatoid arthritis. Performance of daily activities correlated with QOL in all groups except the healthy White
groups. Community participation did not correlate with QOL.
CONCLUSIONS. The findings suggest that rheumatoid arthritis in American Indian and White women does
affect QOL and that QOL does not seem to be influenced by ethnicity. Factors that related to QOL also were sim-
ilar for both groups with rheumatoid arthritis.
Poole, J. L., Chiappisi, H., Cordova, J. S., & Sibbitt, W., Jr. (2007). Quality of life in American Indian and White women with
and without rheumatoid arthritis. American Journal of Occupational Therapy, 61, 280289.
uality of life (QOL) refers to ones global feeling of well-being or satisfaction
Q with ones life in the context of the culture and value system in which one lives
(Campos & Johnson, 1990). QOL has been studied over the past 20 years in peo-
ple with chronic disorders, such as rheumatoid arthritis, that interfere with con-
tinued involvement in valued occupations and thus disrupt feelings of well-being.
Research has shown that rheumatoid arthritis causes specific impairments in body
function and structure such as pain, stiffness, swelling, and loss of motion in joints
(American College of Rheumatology, 2000). The progression in these impairments
over time results in a loss of ability to perform occupations of self-care, leisure, and
work (Doeglas et al., 2004; Hewlett, Young, & Kirwan, 1995; Katz & Yelin, 1995;
Pincus et al., 1984; Roberts, Matecjyck, & Anthony, 1996; Stamm, Wright,
Machold, Sadio, & Smolen, 2004; Wright & Owen, 1976; Yelin, Lubeck, Hol-
man, & Epstein, 1987). Indeed, a loss of valued occupations has been reported to
be a strong risk factor for developing depressive symptoms, leading to decreased
QOL (Blalock, Orlando, Mutran, DeVellis, & DeVellis, 1998; Doeglas et al.,
2004; Katz & Yelin, 1995). Decreased occupational performance, therefore, may
be a major factor in influencing QOL (Blalock et al., 1998; Burckhardt, 1985;
Katz & Yelin, 1993, 1995; MacKinnon & Miller, 2003; Pincus et al., 1984;
Reisine, Fifield, & Winkelman, 1998; Stamm et al., 2004; Wikstrom, Isacsson, &
Jacobsson, 2001; Wright & Owen, 1976). However, Burckhardt (1985) found
May/June 2007, Volume 61, Number 3
that QOL for people with arthritis depended more on psy-
chosocial factors than occupational performance or pain. A
later study showed that psychological functioning was the
best predictor of QOL in women with rheumatoid arthritis
(Burckhardt, Archenholtz, & Bjelle, 1993).
Sociodemographic variables also have been shown to be
important factors related to QOL. Studies report that being
married relates to having higher QOL (Katz, 1998; Katz &
Yelin, 1993; Wright & Owen, 1976; Zautra et al., 1998).
Social support may allow people with rheumatoid arthritis
to continue participation in valued activities because social
support minimizes anxiety and depression at times of stress
(Zautra et al., 1998) and keeps people from becoming
dependent on social services (Archenholtz, Burckhardt, &
Segesten, 1999). The ability to be employed is another fac-
tor reported to affect QOL. Loss of employment is associ-
ated with poorer health, greater psychosocial distress, and
monetary losses, which result in decreased QOL (Reisine et
al., 1998).
Most of the research on QOL in people with rheuma-
toid arthritis has been based on a narrow population: mostly
middle-class, White, and well-educated (Burckhardt, 1985;
Burckhardt, Woods, Schultz, & Ziebarth, 1989; Husted,
Gladman, Farewell, & Cook, 2001; Lambert, Lambert,
Klipple, & Mewshaw, 1989; Pincus et al., 1984; Reisine et
al., 1998; Sherrer, Bloch, Mitchell, Young, & Fries, 1986;
Whalley, McKenna, De Jong, & Van Der Heijde, 1997;
Zautra et al., 1998). However, some of the highest preva-
lence rates of rheumatoid arthritis are in American Indian
populations (Ferucci, Templin, & Lanier, 2004; Klippel,
1997; Peschken & Esdaile, 1999). Studies have shown that
American Indians with rheumatoid arthritis have an earlier
disease onset and greater disease severity than the White
population (Ferucci et al., 2004; Peschken & Esdaile, 1999).
In addition, American Indian populations are reported to
have less health insurance, limited access to health care
especially to specialists such as rheumatologistslower edu-
cation levels, and lower median incomes and are reported to
be in poorer health than the general population of the
United States (John, Kerby, & Hennessy, 2003; U.S. Depart-
ment of Health and Human Services, 2001). American Indi-
ans with rheumatoid arthritis may live for a long time with
pain, loss of joint motion, and inability to perform occupa-
tions of daily living, which might lead to decreased QOL.
However, the impact of rheumatoid arthritis on occupational
performance and QOL in American Indians has been stud-
ied minimally (Kramer, Harker, & Wong, 2002a, 2002b),
and no studies have compared QOL and related factors in
American Indians and Whites with rheumatoid arthritis.
This study sought to compare whether disease or eth-
nicity relate to perceived QOL in American Indian and
The American Journal of Occupational Therapy
White women with and without rheumatoid arthritis and
to determine whether pain, joint motion, or the ability to
perform activities of daily living affects perceived QOL.
The research questions were the following: (a) Did per-
ceived QOL differ in American Indian and White women
with and without rheumatoid arthritis? (b) What factors
were related to perceived QOL in American Indian and
White women with and without rheumatoid arthritis? (c)
How did factors relating to perceived QOL differ between
American Indian and White women with and without
rheumatoid arthritis?
Methodology
The current study is a cross-sectional design in which par-
ticipants were tested once and within one geographic area
to keep the variables, such as access to health care and
rheumatology expertise, consistent for all groups. The sam-
ple was one of convenience.
Participants
The participants consisted of 64 women organized into
four groups based on ethnicity and presence of rheumatoid
arthritis: American Indians with rheumatoid arthritis (n =
17), healthy American Indians without rheumatoid arthri-
tis (n = 17), Whites with rheumatoid arthritis (n = 15), and
healthy Whites without rheumatoid arthritis (n = 15). The
participants in the rheumatoid arthritis groups had been
diagnosed by a rheumatologist as having rheumatoid arthri-
tis according to diagnostic criteria of the American College
of Rheumatology (formerly the American Rheumatism
Association; Arnett et al., 1988) for at least 1 year. People
with rheumatoid arthritis were excluded from the study if
they had more than one rheumatic disease or any other dis-
abling co-morbid conditions such as stroke or a cardiac con-
dition. Participants in the healthy control groups did not
self-report any neurological, psychological, medical, or
orthopedic conditions that impaired their occupational per-
formance. Healthy control groups were used because differ-
ences have been found in the factors related to QOL
between two different groups living in the same geographic
area (Archenholtz et al., 1999; Yelin et al., 1987); therefore,
a difference could exist in the domains of QOL when com-
paring women with rheumatoid arthritis to healthy women
without rheumatoid arthritis. Because QOL may be depen-
dent on more than just health, the participants were group
matched for age and education level (see Table 1 for demo-
graphics of participants). All participants could understand,
read, and follow instructions in English. This study was
approved by the Human Research Review Committee at
the authors institution, the Albuquerque Service Unit
281
Table 1. Demographic Statistics of Participants by Disease and Ethnic Group
American Indians With Whites With Healthy
Rheumatoid Arthritis Rheumatoid Arthritis American Indians Healthy Whites
Demographic Variables (n = 17) (n = 15) (n = 17) (n = 15) p values
Years of age (range) 44.1 (1974) 47.7 (1972) 45.7 (2472) 45.8 (1974) ns
Years with rheumatoid arthritis (range) 9.3 (1.331) 10.6 (2.235) ns
Education level
<1 years (%) 11.8 13.3 11.8 6.7 ns
12 years (%) 23.5 33.3 23.5 26.7 ns
>2 years (%) 64.7 53.3 64.7 66.7 ns
Marital status
Married (%) 52.9 53.3 41.2 40.0 ns
Single, never married (%) 29.4 20.0 41.2 33.3 ns
Work status (% full-time) 47.1 26.7 70.6 66.7 < 0.05
Health now (15) 3.0 (15) 2.7 (14) 4.12 (35) 4.17 (15) < 0.0001
Health now
Very good or excellent (%) 29.4 13.3 88.2 86.6 ns
Good (%) 23.5 26.7 11.8 6.7 ns
Fair (%) 47.1 60.0 0 6.7 ns
Poor (%) 0 0 0 0 ns
Note. ns = not significant. 1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor.

Health Board, and the Albuquerque Area Combined
Indian Health Services Institutional Review Board.
Instruments
Perceptions of QOL were assessed using global QOL and
component-specific QOL instruments. The remainder of
the instruments covered the International Classification of
Functioning, Disability, and Health (ICF) categories of (a)
Body FunctionsBody Structures and (b) Activities and
Participation (World Health Organization, 2001). The
Body FunctionsBody Structures instruments assessed
pain, hand function, upper- and lower-extremity joint
motion, and emotional and social function. Activities and
Participation instruments assessed the ability to perform
everyday occupations and community participation. A
focus group of American Indian women found the instru-
ments culturally acceptable.
Measures of QOL
Global QOL. Cantrils (1965) Self-Anchoring Scale was
used to measure perceived global QOL. Campos and John-
son (1990) described this instrument as being the most
capable of assessing QOL using comparable and quantifi-
able data without imposing culture-specific standards (p.
168). Participants were shown a picture of a 10-rung ladder.
The top rung, 10, represented the best possible life, and
rung 0 the worst possible life. Participants indicated where
on the ladder they would place themselves at present, 5
years ago, and 5 years in the future. Interrater reliability was
reported to be .95 (Cantril, 1965).
Component-specific QOL. The Dartmouth Primary Care
Cooperative Information Project (COOP) chart system is a
series of pictorial charts that measure perceived QOL: daily
282
activities, physical fitness, health, social activities, pain, and
feelings (Nelson et al., 1987; Palmer, 1987). Each chart asks
participants to rate the item with reference to the past 2
weeks on a 5-point scale from 1 (great difficulty) to 5 (no
problem). A higher score indicated better QOL. The Dart-
mouth COOP charts were adapted for use with American
Indians and reported to be both reliable and acceptable by
this population (Gilliland et al., 1998).
Measures of Body FunctionsBody Structures
Pain. Pain was measured using the Dartmouth COOP
chart for pain (Gilliland et al., 1998; Nelson et al., 1987).
Participants were asked to rate themselves on a 5-point
single-item scale ranging from 1 (severe pain) to 5 (no pain).
The Dartmouth COOP charts have been used with both
American Indian and White populations.
Hand function. The Arthritis Hand Function Test
(AHFT) comprises 11 items that measure hand strength,
dexterity, applied dexterity, and applied strength (Backman
& Mackie, 1995, 1997). Hand strength (i.e., grip and pinch
strength) was measured with an adapted sphygmomanome-
ter and a pinch meter, respectively. Dexterity was measured
using the nine-hole pegboard. The applied dexterity section
consisted of five timed bilateral activities (lacing and tying a
bow on a shoe, buttoning, fastening and unfastening safety
pins, cutting meat, and manipulating coins). The applied
strength items consisted of pouring a measured volume of
water from a pitcher and lifting a tray of cans. The AHFT
has been reported to be a reliable and valid instrument for
measuring hand function in people with rheumatoid arthri-
tis (Backman, Mackie, & Harris, 1991).
Joint motion. The Keital Functional Test (KFT) was
used to assess joint limitations in the upper and lower
May/June 2007, Volume 61, Number 3
extremities (Eberl, Fasching, Rahlfs, Schleyer, & Wolf,
1976; Kalla, Kotze, Meyers, & Parkyn, 1988). The KFT has
a range of scores for the 24 separate items; a lower score rep-
resents better joint motion. The KFT has been reported to
be reliable and valid with people with rheumatoid arthritis
(Eberl et al., 1976; Kalla et al., 1988).
Emotional and social function. Emotional and social
function was measured using the Dartmouth COOP Emo-
tional charts, which included social activities and feelings
(Gilliland et al., 1998; Nelson et al., 1987). For social activ-
ities, participants were asked to rate themselves from 1 (no
participation in social activities) to 5 (much participation in
social activities). For feelings, they were asked to rate them-
selves from 1 (bothered a lot by feeling nervous, sad, or easily
angry) to 5 (not at all bothered by feeling nervous, sad, or eas-
ily angry). The scores are combined to form an emotional-
and-social-function score. The emotional and social scores
on the COOP correlated with scores on the Emotional
Scale of the RAND (Nelson et al., 1987).
Measures of Activities and Participation
Everyday occupations. The Health Assessment Ques-
tionnaire (HAQ) is a self-administered questionnaire that
measures occupational performance in people with
rheumatic disease (Fries, Spitz, Kraines, & Holman,
1980). It consists of eight categories: dressing and groom-
ing, arising, eating, walking, hygiene, reach, grip, and out-
side activity. Each question was scored on a 4-point scale
from 0 (no difficulty) to 3 (cannot do). The highest score
within each category was the score for that category.
Adding the scores for each category and dividing by the
number of categories answered yielded a disability index
score between 0 and 3. Higher scores reflected greater dis-
ability. Reliability and validity of the HAQ with people
with rheumatoid arthritis has been well documented
(Fries et al., 1980; Hakala, Nieminen, & Manelius, 1994;
Pincus et al., 1984; Wolfe et al., 1988). The HAQ also has
been reported as valid to use with American Indians
(Poole, Schukar, & Sibbitt, 2000).
Community participation. The Community Integration
Questionnaire (CIQ) is a 15-item self-report questionnaire
designed to assess the three domains of integration: home
integration, social interaction, and productive activity
(Willer, Ottenbacher, & Coad, 1994). Twelve of the items
are scored on a 3-point scale; the other three are scored on
a 6-point scale. The total score for the CIQ ranged from 0
to 29, with a higher score indicating a higher level of com-
munity integration. In general, the more items one does by
oneself, the greater the integration. The CIQ has been
shown to be reliable and valid for American Indians and
Whites with rheumatoid arthritis (Poole et al., 2000).
The American Journal of Occupational Therapy
Procedures
Once a participant was identified and informed consent
obtained, an assessment consisting of the described instru-
ments was administered to the participant.
Data collection took about 1 hr per participant, and
each participant was compensated $30 for her time.
Data Analysis
The data were analyzed using MiniTab and SAS statistical
packages. Descriptive statistics computed the means and
ranges for the QOL, Body FunctionsBody Structures, and
Activities and Participation measures (see Table 2). Because
so many items were on the AHFT, items were combined to
make four categories: hand strength (grip, 2-point pinch,
and 3-point pinch), dexterity (nine-hole pegboard), applied
dexterity (lacing and tying a bow on a shoe, buttoning, fas-
tening/unfastening safety pins, cutting meat, and manipu-
lating coins), and applied strength (pouring a measured
amount of water from a pitcher and lifting a tray of cans).
Two-way analyses of variance (ANOVA) with appro-
priate post hoc analyses were performed to determine
whether significant differences existed between the groups
for any of the variables. Bonferroni adjustments were used
to compute the p values. Spearman rho correlations were
then computed to examine which variables related to QOL
and the strengths of those relationships; p < .05 was set for
determining statistical significance.
Results
Participants
The demographic characteristics of people by condition
and ethnic group are shown in Table 1. ANOVAs showed
no significant differences between the groups for mean age,
education, income, marital status, or hand dominance.
There also was no significant difference in disease duration
between the American Indian and White groups with
rheumatoid arthritis.
There was, however, a significant difference between
the groups on employment status (p < .01) and health sta-
tus (p < .0001). Both groups with rheumatoid arthritis
worked significantly fewer hours than the healthy controls
(p < .01), and the total percentage of the participants with
rheumatoid arthritis working full-time was significantly less
than the healthy controls. Participants with rheumatoid
arthritis reported significantly poorer health status than the
healthy controls (p < .01). However, there were no signifi-
cant differences in self-reported health status between the
283
Table 2. Scores for the QOL, Body FunctionsBody Structures, and Activities and Participation Variables by Disease and Ethnic Group
American Indians With Whites With Healthy
Rheumatoid Arthritis Rheumatoid Arthritis American Indians Healthy Whites

Demographic Variables M Range M Range M Range M Range p values

QOL
Global QOL, present 7.8 (510) 6.9 (310) 8.1 (510) 8.1 (510) ns
Global QOL, 5 years past 7.1 (010) 7.6 (010) 6.1 (110) 7.2 (210) ns
Global QOL, 5 years future 8.9 (510) 7.5 (210) 8.9 (410) 9.0 (210) ns
COOP total 16.1a (1023) 14.6a (821) 20.1b (1624) 21.2b (1325) < 0.0001
Body FunctionsBody Structures
Pain 2.8a (15) 2.1a (15) 4.4b (25) 3.8b (25) < 0.0001
UE KFT 12.9a (435) 12.9a (450) 5.1b (49) 4.5b (46) < 0.001
LE KFT 9.4 (038) 4.9a b (015) 1.2b (04) 1.3b (04) < 0.001
Total KFT 22.3a (558) 17.9a (658) 6.3b (411) 5.8b (48) < 0.0001
AHFT: Hand strength (in lbs) 98.9a (55.9190.1) 112.6a (50.2177.3) 186.0b (164.1220.7) 181.9b (122.8213.9) < 0.0001
AHFT: Dexterity (in sec) 49.5a (32.5113.0) 45.8a (33.095.0) 38.9b (33.046.0) 36.0b (31.040.0) < 0.05
AHFT: Applied dexterity (in sec) 133.5a (82.5265) 118.5a b (94.5180.5) 85.5c (66.5109.5) 91.8b c (74.0105.0) < 0.0001
AHFT: Applied strength (in ml) 1879.0 (02012) 1928.0 (12552012) 2012.0 (2012) 2012.0 (2012) ns
Psychosocial status 6.6a b (310) 6.3a (210) 7.7a b (69) 8.3b (510) < 0.05
Activities and Participation
HAQ 1.0a (02.38) 1.4a (0.252.13) 0.2b (01.125) 0.1b (00.63) < 0.0001
CIQ total 18.4a (2.2525) 20.0a (12.75 28) 21.8a (1825) 25.7b (22.2528) < 0.001
Note. Means having the same superscript are not significantly different at p < .05 in the Tukey honestly significant difference comparison; QOL= quality of life;
ns = not significant; UE = upper extremity; KFT = Keital Functional Test; LE = lower extremity; HAQ = Health Assessment Questionnaire; CIQ = Community
Integration Questionnaire; AHTF = Arthritis Hand Function Test; COOP = Dartmouth Primary Care Cooperative Information Project.

groups with rheumatoid arthritis or between the healthy
control groups.
Perceived QOL in American Indian and White women with
and without rheumatoid arthritis. An ANOVA showed no
significant differences between any of the four groups for
past, present, or future perceived QOL on Cantrils Self-
Anchoring Scale (see Table 2). Significant differences in
perceived QOL between the four groups (p < .0001) were
observed for the Dartmouth COOP charts. Both groups
with rheumatoid arthritis had significantly lower COOP
scores than both healthy control groups (p < .0001), indi-
cating poorer perceived QOL in people with rheumatoid
arthritis.
Body FunctionsBody Structures differences in American
Indian and White women with and without rheumatoid arthritis.
ANOVAs calculated to determine differences in disease and
ethnic groups for the Body FunctionsBody Structures
variables revealed significant differences for pain, joint
motion, hand strength, dexterity, applied dexterity, and
emotional and social function (see Table 2). Both groups
with rheumatoid arthritis had significantly more pain than
did both healthy control groups (p < .0001).
The groups with rheumatoid arthritis had significantly
more limitations in joint motion as measured by the total
and upper-extremity KFT scores than the healthy control
groups (p < .001). Although both groups with rheumatoid
arthritis had similar lower-extremity KFT scores, only the
American Indians with rheumatoid arthritis had signifi-
cantly lower lower-extremity KFT scores (i.e., less motion)
than both healthy controls.
284
Both the American Indian and White groups with
rheumatoid arthritis had significantly less hand strength
than the healthy control groups (p < .0001). However, there
were no significant differences in hand strength between the
two groups with rheumatoid arthritis or between the two
groups of healthy controls. The American Indians with
rheumatoid arthritis had significantly slower dexterity
scores than only the healthy White participants (p < .05);
however, their applied dexterity scores were significantly
slower than both healthy groups (p < .0001). On the other
hand, the White participants with rheumatoid arthritis had
significantly slower applied dexterity scores than the healthy
American Indians (p < .0001), but their scores were not sig-
nificantly different from the healthy White group. There
were no significant differences in applied dexterity or
applied strength between the groups with rheumatoid
arthritis or between the healthy control groups.
The Whites with rheumatoid arthritis had the lowest
emotional and social function scores (see Table 2), which
were significantly lower than those for the healthy White
women (p < .05) but not significantly lower than those for
the healthy American Indian women. However, there were
no significant differences in emotional and social function
scores between the two groups with rheumatoid arthritis or
between the two healthy control groups.
Activities and Participation differences in American Indians
and Whites with and without rheumatoid arthritis. ANOVAs
comparing the four groups on the Activities and Participa-
tion variables revealed significant differences between the
groups for the HAQ and CIQ scores. The Whites with
May/June 2007, Volume 61, Number 3
rheumatoid arthritis had the highest HAQ scores, indicat-
ing greater disability in everyday occupations (see Table 2).
Indeed, both groups with rheumatoid arthritis had signifi-
cantly higher HAQ scores than both healthy control groups
(p < .0001). However, the American Indians with rheuma-
toid arthritis had the lowest community integration as indi-
cated by the CIQ, yet the CIQ scores for both groups with
rheumatoid arthritis were similar. The scores from both
groups with rheumatoid arthritis also were not significantly
different from the healthy American Indians but were sig-
nificantly different from the scores of the healthy White
group. Furthermore, the CIQ was the only measure that
revealed significantly different scores between the healthy
American Indians and the healthy Whites.
Factors related to perceived QOL in American Indians and
Whites. Spearman rho correlation analyses were performed
to examine the relationships between perceived QOL and
demographics (age, disease duration, income, marital sta-
tus, education level, employment status, income, perceived
current health), Body FunctionsBody Structures, and
Activities and Participation variables for each disease and
ethnic group (see Table 3). Only the variables are presented
for which there was a significant correlation between the
variable and QOL measure for at least one participant group.
For all four groups, the only demographic variable that
correlated with perceived QOL was health status, which
significantly correlated with present global QOL and,
except for the White participants with rheumatoid arthritis,
the COOP total score. For the Body FunctionsBody
Structures variables, emotional and social function corre-
lated with present global QOL in the two groups with
rheumatoid arthritis. However, in all four groups, emo-
tional and social function correlated with the COOP total.
For the other Body FunctionsBody Structures variables,
there were differences for the groups. In the American Indi-
ans with rheumatoid arthritis, total KFT and dexterity cor-
related with the COOP total. In the healthy American Indi-
ans, pain correlated significantly with present global QOL
and the COOP total. In the Whites with rheumatoid
arthritis, applied dexterity and applied strength correlated
significantly with the COOP total. For the Activities and
Participation variables, only the HAQ correlated with both
present global QOL and the COOP total in both Ameri-
can Indian groups. For the White groups, the HAQ corre-
lated only with the COOP total in the Whites with
rheumatoid arthritis. In the healthy White participants,
none of the other Body FunctionsBody Structures vari-
ables correlated with any of the perceived QOL variables.
Additionally, no significant correlations were found
between any of the variables and past and future global
QOL in any of the four groups.
Discussion
Three major findings emerged from this study. First, con-
trary to our expectations, we found no significant differ-
ences in present, past, or future global perceived QOL
between any of the four groups. In our study, therefore, nei-
ther ethnicity nor disease status affected global QOL. How-
ever, for the second perceived QOL measure, the Dart-
mouth COOP, there were differences based on the presence
of rheumatoid arthritis but not ethnicity. The differences
between the findings could be due to how the two assess-
ments measured perceived QOL. Cantrils Self-Anchoring
Scale measured QOL in general, whereas the COOP mea-
sured QOL based on a summation of specific information
regarding health, feelings, and daily physical and social
activities. The finding that perceived QOL was similar for
American Indian and White participants is in contrast with
a previous study, which indicated that ethnicity did influ-
ence component-specific QOL (Johnson et al., 1988).
However, our findings do agree with others (Berzon, Hays,
& Shumaker, 1993; Leininger, 1994) who reported that
some basic QOL factors transcend ethnic groups.

Table 3. Correlations Between QOL and Impairment, Activities and Participation Variables
American Indians Whites With
With Rheumatoid Arthritis Rheumatoid Arthritis Healthy American Indians Healthy Whites
QOL COOP QOL COOP QOL COOP QOL COOP
Variables at Present Total at Present Total at Present Total at Present Total
Health now 0.89*** 0.85*** 0.58* ns 0.65** 0.65** 0.51* 0.66**
Pain ns ns ns ns 0.71** 0.48* ns ns
KFT total ns 0.53* ns ns ns ns ns ns
AHFT: Dexterity ns 0.57* ns ns ns ns ns ns
AHFT: Applied Dexterity ns ns ns 0.65* ns ns ns ns
AHFT: Applied Strength ns ns ns 0.58* ns ns ns ns
Psychosocial status 0.71** 0.93*** 0.63* 0.94*** ns 0.61* ns 0.88***
HAQ 0.61* 0.83*** ns 0.86*** 0.67** 0.80*** ns ns
Note. QOL = Quality of Life; COOP = Dartmouth Primary Care Cooperative Information Project; ns = not significant; KFT = Keital Functional Test; AHFT = Arthritis
Hand Function Test; HAQ = Health Assessment Questionnaire.
*p < 0.05; **p < 0.01; ***p < 0.0001.

The American Journal of Occupational Therapy 285

 Second, although the four groups were similar in regard
to demographics characteristicsexcept for current health
status and employment statuspeople with rheumatoid
arthritis had significantly poorer health, were less likely to
work full-time, and had more Body FunctionsBody Struc-
tures and Activities and Participation limitations than the
healthy control groups. These differences appeared to be
due to the presence of rheumatoid arthritis. Pain, limited
joint motion, and decreased hand strength were related to
the presence of rheumatoid arthritis, which agrees with pre-
vious researchers who found that people with moderate to
severe rheumatoid arthritis tend to have greater pain and
less joint motion compared to healthy controls (Katz &
Yelin, 1993; Wolfe et al., 1988). However, in the current
study, the differences in dexterity, applied dexterity, and
emotional and social function were related to both the pres-
ence of rheumatoid arthritis and ethnicity. For example, the
major difference in emotional and social function was
between the Whites with rheumatoid arthritis and the
healthy Whites, indicating that the White groups emo-
tional and social function was highly related to rheumatoid
arthritis. No significant difference, however, was seen in
emotional and social function between the two American
Indian groups. Thus, in this sample, rheumatoid arthritis in
American Indians did not appear to be related to emotional
and social function. Perhaps the American Indian popula-
tions had learned to manage the emotional impact of
rheumatoid arthritis. Indeed, Kramer et al. (2002b) found
that American Indians with rheumatoid arthritis did not
tend to experience negative thoughts and catastrophizing.
For the Activities and Participation variables, we found
that significant differences in the ability to perform every-
day occupations were related only to the presence of
rheumatoid arthritis; however, differences in community
integration were related to both the presence of rheumatoid
arthritis and ethnicity. Healthy Whites had significantly
higher community integration scores compared to the other
three groups. This difference in community integration
may be due to the greater physical limitations of the groups
with rheumatoid arthritis or the amount of social support.
American Indian women with rheumatoid arthritis had the
most limitations in joint mobility and hand function. In
people with rheumatoid arthritis, limitations in joint
motion and hand function can lead to more dependency on
others for everyday and social occupations, especially in an
inaccessible environment (Burckhardt et al., 1993; Soder-
lin, Kautiainen, Skogh, & Leirisalo-Repo, 2004; Whalley et
al., 1997; Yelin et al., 1987). On the other hand, the differ-
ence in community integration may be that more of the
healthy White women lived alone compared to people in
the other groups and therefore had to rely on themselves for
286
household management occupations such as cooking and
shopping, as well as planning their social occupations. The
lower scores in community integration seen in both Amer-
ican Indian groups compared to the White groups could be
that the American Indians participated in household and
community activities with family and friends rather than by
themselves. This finding is not surprising because the
majority of our American Indian participants lived on their
pueblos or reservations near extended families (National
Indian Council on Aging, 1981). On the CIQ, participat-
ing or doing an activity alone results in a higher score (more
integration) than performing an activity with family or
friends, which may reflect the importance of independence
to the White culture (Leininger, 1994).
Third, our findings revealed similarities and differences
in the factors related to QOL in people with rheumatoid
arthritis and healthy controls. Factors of current health and
emotional and social function were found to relate to QOL
in all four participant groups. Current health has previously
been shown to be a factor related to QOL in both Ameri-
can Indians and Whites (Burckhardt et al., 1989, 1993;
Johnson et al., 1986), and emotional and social function
previously has been found to be a factor related to QOL in
Whites with rheumatoid arthritis (Burckhardt, 1985; Katz
& Yelin, 1993). In the two groups with rheumatoid arthri-
tis, however, additional Body FunctionsBody Structures
variables related to QOL. For American Indians with
rheumatoid arthritis, joint motion and hand function also
related to QOL, whereas for Whites with rheumatoid
arthritis, only hand function additionally correlated with
QOL. In the healthy control groups, the only additional
Body FunctionsBody Structures variable that related to
QOL was pain, but only for the healthy American Indians.
The only Activities and Participation variable that
related to QOL in any of the groups was the ability to per-
form everyday occupations as reported on the HAQ. Occu-
pational performance related to QOL in both American
Indian groups and for Whites with rheumatoid arthritis.
Indeed, occupational performance has been reported previ-
ously to be an important factor influencing QOL (Katz &
Yelin, 1995; MacKinnon & Miller, 2003; Stamm et al,
2004). In fact, maintaining independence was acknowl-
edged by numerous researchers to be an important part of
QOL for Whites (Archenholtz et al., 1999; Burckhardt et
al., 1989, 1993; MacKinnon & Miller, 2003) but not for
American Indians (Leininger, 1994).
Most of the demographic variables were not associated
with QOL in any of the groups. No relationship was found
between QOL and age, number of years with rheumatoid
arthritis, or education level, which is similar to findings
from other studies (Burckhardt, 1985; Katz & Yelin, 1993).
May/June 2007, Volume 61, Number 3
Limitations and Implications for Further Research
The small sample size may not have been representative of
the overall population of women with rheumatoid arthritis.
The low power from the small sample raises the possibility
of a Type II error (not finding associations where they actu-
ally exist). Further research should replicate the current
study with a larger sample size and cover a larger geographic
location to deal with the small sample of convenience in the
present study, which also would extend the generalizability
of the results. Due to the exacerbations and remissions seen
with rheumatoid arthritis, further research could include
two interview periods separated by time to compare pre-
dicted and actual future QOL as well as to investigate the
changes in demographics, Body FunctionsBody Structures
(especially in disease severity), and Activities and Participa-
tion variables over time.
Implications for Practice
With a better understanding of QOL and the factors
influencing QOL in American Indian and White women
with rheumatoid arthritis, occupational therapists can be
more effective in designing interventions for people with
rheumatoid arthritis. Indeed, the ability to perform every-
day occupations was a factor related to QOL for people
with rheumatoid arthritis. Although Blalock et al. (1998)
found evidence that dissatisfaction with illness-related abil-
ities can exacerbate psychological distress, improving peo-
ples ability to perform valued occupations such as partici-
pating in social and leisure pursuits has been shown to
increase emotional and social function. Furthermore, the
findings from this study, as well as from previous research
(Blalock et al., 1998; Katz & Yelin, 1995), suggested that
improving emotional and social function will, in effect, also
improve QOL. Kramer et al. (2002b) found that American
Indians with rheumatoid arthritis were interested in educa-
tion regarding self-care, pain management, and joint pro-
tection. Therefore, the role of occupational therapists treat-
ing people with rheumatoid arthritis should be to
collaborate with their clients and to examine not only ways
by which clients can continue to perform occupations that
are meaningful and valued to them, but also ways to
increase emotional and social support. Occupational ther-
apy may also be valuable in assisting clients with goal setting
and problem solving to cope with pain, fatigue, stress, and
feelings and communication (MacKinnon & Miller, 2003;
Steultjens et al., 2002).
Furthermore, the measures used in the present study
may interest occupational therapists who work with clients
with arthritis. These measures are appropriate to be used to
The American Journal of Occupational Therapy
determine the effectiveness of occupational therapy inter-
ventions for people with arthritis.
Although this was the first study comparing QOL in
American Indian and White women with and without
rheumatoid arthritis, it appears that in this particular sam-
ple QOL was influenced more by having a chronic disease
than by ethnicity. Some of the factors found to relate to
QOL across disease and ethnic groupssuch as occupa-
tional performance, emotional and social function, and
joint motion in the rheumatoid arthritis groupsare
amenable to occupational therapy intervention.
Acknowledgments
The authors would like to thank Drs. Bankhurst, Gregg,
and Maldonado and the UNMH Rheumatology Clinic
staff; the people who participated in this study; and Betty
Malloy, statistician. The second authors work was sup-
ported in part by a grant from the University of New Mex-
ico Office of Graduate Studies. This study also was sup-
ported in part by a grant to the first author from the
Disability and Health Program of the Public Health Divi-
sion of the New Mexico Department of Health in coopera-
tion with the Centers for Disease Control and Prevention.
This article was written in partial fulfillment of a master of
occupational therapy degree for the second author at the
University of New Mexico, Albuquerque. An earlier version
of this paper was presented at the 37th Annual Scientific
Meeting of the Association of Rheumatology Health Pro-
fessionals, October 2002, New Orleans, Louisiana.
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