Arthritis is the leading cause of disability in the United States [1,2] though not all racial and ethnic groups are equally affected by the disease. Nationally, non-Latino Blacks, Latinos, and multiracial persons living with arthritis were more likely to report arthritis-attributable activity limitations, work limitations, and joint pain when compared with non-Latino Whites [1, 3-5]. In North Carolina, Latinos were more likely to report poor or fair health than Blacks or Whites, while Blacks were most likely to report eight or more days of poor physical and mental health as well as eight or more days of activity limitations [6].

In a recent report of National Health Interview Survey data, access to health care was identified as a potential cause of racial disparities in arthritis-related health outcomes [3]. Using a sample of individuals with arthritis who have access to a primary care physician in North Carolina, our goal is to describe how Black, White, and Latino participants with arthritis differ from each other demographically and in terms of quality of life. Specifically, we will describe differences in self-reported health status, physical and mental quality of life, and activity limitations.

Cross-sectional data were collected in 2005 and 2008 as part of the North Carolina Health Project, which enrolled participants from the North Carolina Family Medicine Research Network (NC-FM-RN). The NC-FM-RN is a statewide practice-based network comprising multiple family practice sites across North Carolina [7]. For the 2005 and 2008 recruitment periods, 11 primary practice sites were purposefully selected from both urban and rural areas of North Carolina to increase enrollment of non-white participants. Five sites were for-profit private practices, four were nonprofit outpatient clinics, one was part of a hospital system, and one was a community health center. This study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill. All participants provided written consent prior to enrolling in the study.

At each NC-FM-RN practice site, all consecutive patients seeking care were approached by study staff and informed of the North Carolina Health Project. To be eligible to participate, individuals had to be at least 18 years of age and agree to complete the written study questionnaire. The 10 to 15-minute questionnaire was available in English or Spanish. The English version of the survey was translated into Spanish and then reverse-translated into English by two native Spanish-speakers. Discrepancies in translation were resolved and reviewed by two other staff members who were fluent in Spanish, yielding the final version of the Spanish survey.

All questionnaires were self-administered, although trained research assistants were available to assist individuals as needed. No incentive was provided to complete the survey. The response rates for the 2005 and 2008 data collection waves were 74.8% and 63.9%, respectively (Fig. 1). Individuals listed as ‘unable to communicate’ were unable to do so because of dementia or illness-related issues. A total of 3,542 eligible participants completed the survey, though we have restricted our analyses to participants with self-reported arthritis (n=749) who reported White (n = 405), Black (n = 244), or Hispanic/Latino (n = 100) race/ethnicity. Six-hundred fifty-two participants completed the survey in English and 97 (93 Latino, 4 White) participants completed the survey in Spanish. The arthritis prevalence rate was 25.1% for Whites, 24.7% for Blacks, and 15.7% for Latinos.

Fig. (1). Recruitment flow chart.

In our sample of people seeking care at family practice clinics, Whites, Blacks, and Latinos with arthritis all reported compromised quality of life, as evidenced by reporting nine or more days of poor physical and mental health as well as six or more days of activity limitations during the past month. Moreover, over 50% of the sample reported poor or fair health status. Even though all groups reported compromised health, there were two racial/ethnic differences: 1) Latinos were more likely than Whites and Blacks to report a poor or fair health status but less likely to report activity limitations, and 2) Blacks reported fewer days of poor mental health.

Our finding that Latinos were more likely to report fair/poor health and fewer days of activity limitations than Blacks and Whites is consistent with other studies [11] and the 2005 North Carolina BRFSS data [6]. The disparity between general health and activity limitations could be due to cultural differences in the understanding of health. As noted by Wagner and colleagues [12], the “fair” response carries a less negative connotation in Spanish than in English. Alternatively, Latinos may be more likely to associate their health status with other factors, such as socioeconomic status (SES). As demonstrated by Kandula and associates [13], Latinos’ probability of selecting fair/poor health was reduced by almost half when adjusting for SES. However, in our regression model which controlled for education level, Latinos still reported fewer days of activity limitations than Blacks or Whites. Future research should explore the reasons behind this somewhat paradoxical finding. Specifically, qualitative investigations could describe the impact different factors, such as language, culture, and employment situations, make on individuals’ reports of self-rated health and activity limitations.

We also found that, when controlling for various sociodemographic factors, Blacks reported significantly fewer days of poor mental health than Whites. Similarly, our unadjusted analyses revealed that Blacks reported the fewest number of poor mental health days, although the unadjusted difference between racial/ethnic groups was not statistically significant. This finding is not consistent with the 2005 North Carolina BRFSS data, which found that Latinos reported the fewest days of poor mental health. We are unsure of why our results differ with previous research. Blacks in our sample had a relatively high level of education when compared with other samples [6]. Consequently, they may have had more economic resources, which could contribute to positive perceptions of mental health.

Almost half of the sample reported engaging in little or no exercise during a usual day. Although our measure of physical activity was limited and does not explicitly include exercise at work, given that physical activity can reduce arthritis symptoms and increase patient quality of life [14,15], it is important to accurately assess individuals’ exercise behaviors and explore what barriers exist for patients engaging in physical activity. Family practice settings may provide a suitable venue through which to reach these participants and promote physical activity interventions. Because the arthritis prevalence rate for Latinos (15.7%) in our sample was higher than that of non-clinic based samples [3,6], clinics may provide an ideal venue to reach Latinos with arthritis.

Our regression models revealed that younger age, single marital status, and a greater number of comorbid conditions were robust predictors of worse health and more activity limitations. These factors should be taken into account when targeting arthritis interventions to different racial/ethnic groups. Given these preliminary results, providers may want to consider discussing quality of life issues with patients, with a specific focus on whether their arthritis is interfering with their ability to conduct activities of daily living.

Our study results should be interpreted with caution for several reasons. First, our measure of self-reported arthritis status may not be accurate, although it has been shown to be valid and reliable in previous studies [16,17]. Second, even though participants had access to a primary care physician at the time our interview, this does not mean that they had consistent access to quality health care. Also, the generalizability of our results is limited by our sample, which was predominantly female and well-educated. Although our response rates were over 60%, we cannot be sure if people who refused were statistically different from those who responded or whether our results from a clinic-based sample in North Carolina would generalize to other states. Because our data are cross-sectional, we do not know what caused participants to report lower quality of life and greater activity limitations. It is possible other non-rheumatic health conditions may have been responsible for patients’ compromised quality of life and increased activity limitations. Additionally, we did not compare specific types of arthritis because subdividing the sample by arthritic condition would lead to small cell sizes and decrease power to test for differences across our three racial/ethnic groups. Future studies may want to examine whether quality of life and activity limitations vary across race/ethnicity as well as arthritis type. Last, our grouping of racial categories did not allow us to explore how people who reported multiple races/ethnicities, such as Black race and Latino ethnicity, differed.

Despite access to a primary care physician, racial/ethnic differences in quality of life, health status, and activity limitations exist. Latinos and Blacks reported significantly worse health status than Whites and this difference remained significant for Latinos after adjusting for various demographic and clinical factors. There was not a significant difference in activity limitations or physical health between Whites and Blacks. Access to a primary care physician alone may not benefit Latinos because language and cultural issues may impact providers’ ability to deliver the same quality of care to Latinos as Blacks and Whites. Thus, we agree with Abraido-Lanza and colleagues’ [18] assessment that quality of care may be more important for health-related outcomes than access to care.