Abstract
Objective
The objective of this study was to estimate the prevalence of arthritis among adults in the United States by nonmedical factors that influence health—adverse measures of social determinants of health (SDOH) and health‐related social needs (HRSN).
Methods
Using 2022 Behavioral Risk Factor Surveillance System data, age‐specific arthritis prevalences were estimated for 11 adverse SDOH/HRSN measures and a cumulative adverse SDOH/HRSN index, controlling for relevant covariates.
Results
Arthritis prevalence was higher among adults with adverse SDOH/HRSN compared to adults without adverse SDOH/HRSN. Arthritis prevalence increased as the number of adverse SDOH/HRSN increased.
Conclusion
Modifying or supplementing arthritis‐appropriate, evidence‐based self‐management education programs to address SDOH/HRSN might improve arthritis management and outcomes.
INTRODUCTION
Arthritis is a common chronic condition affecting one in five US adults (21.2%) and is a leading driver of disability. 1 , 2 Many adults with arthritis report severe joint pain as well as physical and social activity limitations. 3 , 4 Social determinants of health (SDOH) are the conditions in which people are born, live, learn, work, play, worship, and age that impact health and quality of life. 5 SDOH refer to nonmedical community or population‐level factors that influence health, such as food insecurity or cost of medical care. Health‐related social needs (HRSN) are individual level factors that influence health and well‐being, such as access to healthy and affordable foods or social services. 5 Although some studies have explored aspects of SDOH/HRSN and arthritis, there is still limited research available on this topic and further investigation is warranted. 6 The objective of this study was to estimate the prevalence of arthritis by adverse measures of SDOH/HRSN among US adults.
SIGNIFICANCE & INNOVATIONS.
Social determinants of health (SDOH) and health‐related social needs (HRSN) are associated with arthritis—a chronic condition affecting one in five US adults.
Using 11 measures and a cumulative index of adverse SDOH/HRSN, this study of 42 US jurisdictions found that arthritis prevalence was significantly higher among adults reporting adverse SDOH/HRSN compared with adults without adverse SDOH/HRSN. Arthritis prevalence varied by age and adverse SDOH/HRSN measure.
By tailoring services to address SDOH/HRSN and enhancing arthritis‐appropriate, evidence‐based self‐management programs to increase access to social safety net programs, public health practitioners can work toward reducing the burden of adverse SDOH/HRSN and arthritis.
METHODS
The Behavioral Risk Factor Surveillance System (BRFSS) is a state‐based, random‐digit‐dialed mobile and landline telephone survey of noninstitutionalized adults aged ≥18 years in all US states and territories. 7 In 2022, 39 states, the District of Columbia, Puerto Rico, and the US Virgin Islands included the optional Social Determinants and Health Equity module. Eleven SDOH/HRSN measures were used from the 2022 BRFSS core and Social Determinants and Health Equity module (Table 1). Respondents were classified as having arthritis if they responded “yes” to the question, “Have you ever been told by a doctor or other health care professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?” Respondents were excluded from analysis if they were missing data for any of the 11 SDOH/HRSN questions, age, or arthritis status, resulting in a sample size of 259,655 (among 338,778 survey respondents). The 11 measures were assessed individually and combined into a cumulative index with a count of adverse responses (range: 0 to ≥5).
Table 1.
Measures of adverse social determinants of health and health‐related social needs — Behavioral Risk Factor Surveillance System, 2022*
| Measure | Definition |
|---|---|
| Social determinants of health | |
| Cost barrier for needed medical care | Responded “yes” to the question, “Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?” |
| Experiencing threat to shut off utility services | Responded “yes” to the question, “During the last 12 months, was there a time when an electric, gas, oil, or water company threatened to shut off services?” |
| Food insecurity | Responded “always/usually/sometimes” to the question, “During the past 12 months, how often did the food that you bought not last, and you didn't have money to get more? Was that…” |
| Housing insecurity | Responded “yes” to the question, “During the last 12 months, was there a time when you were not able to pay your mortgage, rent, or utility bills?” |
| Lack of reliable transportation | Responded “yes” to the question, “During the past 12 months, has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?” |
| Loss or reduced hours of employment | Responded “yes” to the question, “In the past 12 months, have you lost employment or had hours reduced?” |
| Health‐related social needs | |
| Lack of social and emotional support | Responded “sometimes/rarely/never” to the question, “How often do you get the social and emotional support that you need? Is that…” |
| Life dissatisfaction | Responded “dissatisfied/very dissatisfied” to the question. “In general, how satisfied are you with your life? Are you…” |
| Mental stress | Responded “always/usually” to the question, “Stress means a situation in which a person feels tense, restless, nervous or anxious, or is unable to sleep at night because their mind is troubled all the time. Within the last 30 days, how often have you felt this kind of stress? Was it…” |
| Receiving food stamps or SNAP | Responded “yes” to the question, “During the past 12 months, have you received food stamps, also called SNAP, the Supplemental Nutrition Assistance Program on an EBT card?” |
| Social isolation or loneliness | Responded “always/usually/sometimes” to the question, “How often do you feel socially isolated from others? Is it…” |
EBT, electronic benefits transfer; SNAP, Supplemental Nutrition Assistance Program.
Age‐stratified (18–44 years, 45–64 years, ≥65 years) arthritis prevalences were generated for the 11 measures and the index. Analyses were age‐stratified because age is one of the strongest risk factors for arthritis, and the prevalence of some adverse SDOH/HRSN measures differ by age group. 1 , 8 Adjusted prevalence ratios (APRs) comparing adults with adverse SDOH/HRSN with adults without adverse SDOH/HRSN were generated from logistic regression models controlling for sex, race and ethnicity, educational attainment, and marital status. An orthogonal linear contrast tested for a significant trend in arthritis prevalence for the SDOH/HRSN index. Statistical significance was determined at α = 0.05. Data from the 42 US jurisdictions were weighted and analyses accounted for complex survey design, selection probability, and nonresponse. Analyses were conducted using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0; RTI International). BRFSS data are publicly available and do not contain personal identifiers; therefore, this secondary data analysis was not considered human subjects research, and the study was exempt from institutional review board review.
RESULTS
Arthritis prevalence was significantly higher among adults with individual adverse SDOH/HRSN compared with adults without adverse SDOH/HRSN for 10 of the 11 measures for all age groups (Table 2). Although younger adults (18–44 years) had the lowest prevalences of arthritis, they had the largest relative differences in arthritis prevalence between adults with and without adverse SDOH/HRSN. For example, unadjusted arthritis prevalence among younger adults aged 18 to 44 years with mental stress (16.4%) was about double that of younger adults without mental stress (7.4%; APR = 2.08, 95% confidence interval [CI]: 1.91–2.26). Arthritis prevalence among adults ≥65 years with mental stress (68.5%) was 26% higher than older adults without mental stress (53.4%; APR = 1.26, 95% CI: 1.19–1.32).
Table 2.
Unadjusted arthritis prevalence and adjusted prevalence ratios stratified by social determinant of health and health‐related social need among adults in 39 states, the District of Columbia, Puerto Rico, and the US Virgin Islands—Behavioral Risk Factor Surveillance System, 2022*
| SDOH or HRSN | Age group, y | Unadjusted arthritis prevalence, % (95% CI) a , b | APR c (95% CI) | |
|---|---|---|---|---|
| Adverse SDOH or HRSN | No adverse SDOH or HRSN (ref) | |||
| Cost barrier for needed medical care | ||||
| 18–44 | 13.7 (12.6–14.9) | 8.3 (7.9 –8.7) | 1.58 (1.42–1.76) | |
| 45–64 | 46.7 (44.5–49.0) | 32.4 (31.7–33.1) | 1.37 (1.29–1.45) | |
| ≥65 | 63.2 (59.1–67.1) | 53.9 (53.1–54.6) | 1.15 (1.08–1.23) | |
| Experiencing threat to shut off utility services | ||||
| 18–44 | 18.1 (16.4–19.9) | 8.2 (7.8–8.5) | 1.91 (1.70–2.15) | |
| 45–64 | 47.3 (44.5–50.0) | 32.7 (32.1–33.4) | 1.34 (1.26–1.43) | |
| ≥65 | 67.8 (63.7–71.6) | 53.7 (53.0–54.5) | 1.24 (1.16–1.32) | |
| Food insecurity | ||||
| 18–44 | 14.0 (12.8–15.3) | 8.2 (7.8–8.6) | 1.68 (1.51–1.87) | |
| 45–64 | 47.1 (45.0–49.1) | 31.8 (31.1–32.5) | 1.38 (1.30–1.45) | |
| ≥65 | 61.9 (59.2–64.6) | 53.4 (52.6–54.2) | 1.14 (1.08–1.20) | |
| Housing insecurity | ||||
| 18–44 | 15.4 (14.2–16.6) | 8.0 (7.6–8.4) | 1.77 (1.60–1.96) | |
| 45–64 | 46.0 (43.8–48.2) | 32.3 (31.6–33.0) | 1.35 (1.28–1.43) | |
| ≥65 | 65.6 (62.0–69.0) | 53.6 (52.9–54.4) | 1.20 (1.13–1.27) | |
| Lack of reliable transportation | ||||
| 18–44 | 14.9 (13.4–16.5) | 8.4 (8.1–8.8) | 1.77 (1.57–1.99) | |
| 45–64 | 53.1 (50.4–55.8) | 32.4 (31.7–33.1) | 1.49 (1.40–1.59) | |
| ≥65 | 68.7 (64.6–72.5) | 53.5 (52.8–54.3) | 1.26 (1.18–1.34) | |
| Lack of social and emotional support | ||||
| 18–44 | 11.1 (10.4–11.8) | 8.3 (7.9–8.8) | 1.42 (1.29–1.54) | |
| 45–64 | 40.5 (39.0–42.1) | 31.9 (31.2–32.6) | 1.23 (1.18–1.29) | |
| ≥65 | 57.4 (55.6–59.2) | 53.4 (52.6–54.2) | 1.08 (1.04–1.12) | |
| Life dissatisfaction | ||||
| 18–44 | 16.0 (14.3–17.9) | 8.6 (8.2–8.9) | 1.95 (1.72–2.21) | |
| 45–64 | 56.4 (53.4–59.2) | 32.5 (31.8–33.2) | 1.57 (1.48–1.68) | |
| ≥65 | 68.6 (65.0–71.9) | 53.6 (52.8–54.3) | 1.26 (1.19–1.33) | |
| Loss or reduced hours of employment | ||||
| 18–44 | 10.8 (9.8–11.8) | 8.7 (8.4–9.1) | 1.26 (1.13–1.41) | |
| 45–64 | 35.7 (33.5–37.9) | 33.6 (32.9–34.3) | 1.06 (1.00–1.14) | |
| ≥65 | 51.7 (46.9–56.5) | 54.3 (53.5–55.0) | 0.97 (0.89–1.06) | |
| Mental stress | ||||
| 18–44 | 16.4 (15.3–17.4) | 7.4 (7.0–7.7) | 2.08 (1.91–2.26) | |
| 45–64 | 53.7 (51.8–55.5) | 31.0 (30.3–31.7) | 1.60 (1.53–1.67) | |
| ≥65 | 68.5 (65.3–71.6) | 53.4 (52.6–54.1) | 1.26 (1.19–1.32) | |
| Receiving food stamps or SNAP | ||||
| 18–44 | 16.0 (14.7–17.4) | 7.9 (7.6–8.3) | 1.82 (1.63–2.04) | |
| 45–64 | 50.3 (48.1–52.5) | 31.7 (31.0–32.4) | 1.48 (1.40–1.56) | |
| ≥65 | 62.7 (59.8–65.5) | 53.4 (52.7–54.2) | 1.14 (1.08–1.20) | |
| Social isolation or loneliness | ||||
| 18–44 | 11.2 (10.6–11.8) | 7.8 (7.4–8.3) | 1.48 (1.36–1.61) | |
| 45–64 | 44.0 (42.7–45.3) | 30.0 (29.3–30.8) | 1.39 (1.34–1.45) | |
| ≥65 | 61.4 (59.9–63.0) | 51.9 (51.1–52.7) | 1.16 (1.13–1.20) | |
APR, adjusted prevalence ratio; CI, confidence interval; HRSN, health‐related social needs; ref, referent; SDOH, social determinants of health; SNAP, Supplemental Nutrition Assistance Program.
Responded “yes” to the question, “Have you ever been told by a doctor or other health professional that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”
Estimates are weighted and account for the complex sampling design.
Adjusted prevalence ratios controlled for sex, race and ethnicity, educational attainment, and marital status.
Arthritis prevalence was significantly higher among adults with one or more adverse SDOH/HRSN compared with adults with zero adverse SDOH/HRSN for all age groups (Table 3). Additionally, for all age groups, arthritis prevalence increased linearly as the cumulative number of adverse SDOH/HRSN increased (P‐trends < 0.001). Similar to findings from the individual measures, arthritis prevalence was higher among older adults (≥65 years), but larger prevalence ratios were observed for younger adults (18–44 years). For example, arthritis prevalence among adults 18 to 44 years reporting five or more adverse SDOH/HRSN (17.2%) was triple that of adults 18 to 44 years reporting zero adverse SDOH/HRSN (6.0%; APR = 3.15, 95% CI:2.76–3.59). Arthritis prevalence among older adults (≥65 years) reporting five or more adverse SDOH/HRSN (70.7%) was 39% higher compared with older adults reporting zero adverse SDOH/HRSN (50.6%; APR = 1.39, 95% CI:1.30–1.49).
Table 3.
Unadjusted arthritis prevalence and adjusted prevalence ratios for adverse social determinants of health and health‐related social needs index score, stratified by age, among adults in 39 states, the District of Columbia, Puerto Rico, and the US Virgin Islands—Behavioral Risk Factor Surveillance System, 2022*
| Age group, y | Adverse SDOH/HRSN index score | Sample size | Unadjusted arthritis prevalence, % (95% CI) a , b | APR c , d (95% CI) |
|---|---|---|---|---|
| 18–44 | ||||
| 0 | 26,953 | 6.0 (5.5–6.5) | ref | |
| 1 | 16,969 | 7.3 (6.6–8.1) | 1.35 (1.18–1.55) | |
| 2 | 10,784 | 8.5 (7.6–9.5) | 1.63 (1.42–1.88) | |
| 3 | 6,906 | 10.7 (9.6–12.0) | 2.04 (1.77–2.36) | |
| 4 | 4,639 | 13.5 (12.1–15.0) | 2.50 (2.16–2.89) | |
| ≥5 | 8,631 | 17.2 (15.8–18.7) | 3.15 (2.76–3.59) | |
| 45–64 | ||||
| 0 | 41,265 | 27.0 (26.1–27.9) | ref | |
| 1 | 18,463 | 31.9 (30.5–33.4) | 1.21 (1.14–1.28) | |
| 2 | 10,070 | 37.5 (35.7–39.4) | 1.40 (1.31–1.49) | |
| 3 | 5,799 | 41.0 (38.2–43.8) | 1.51 (1.40–1.63) | |
| 4 | 3,781 | 51.9 (48.7–55.2) | 1.95 (1.80–2.10) | |
| ≥5 | 7,069 | 53.9 (51.4–56.4) | 1.96 (1.83–2.09) | |
| ≥65 | ||||
| 0 | 57,515 | 50.6 (49.6–51.5) | ref | |
| 1 | 22,354 | 55.4 (53.7–57.0) | 1.10 (1.06–1.14) | |
| 2 | 9,680 | 58.6 (56.3–60.9) | 1.16 (1.11–1.22) | |
| 3 | 4,273 | 62.2 (58.4–65.9) | 1.23 (1.16–1.31) | |
| 4 | 2,214 | 68.0 (63.9–71.8) | 1.35 (1.27–1.44) | |
| ≥5 | 2,290 | 70.7 (66.2–74.9) | 1.39 (1.30–1.49) |
APR, adjusted prevalence ratio; CI, confidence interval; HRSN, health‐related social needs; ref, referent; SDOH, social determinants of health.
Responded “yes” to the question, “Have you ever been told by a doctor or other health professional that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”
Estimates are weighted and account for the complex sampling design.
Adjusted prevalence ratios controlled for sex, race and ethnicity, educational attainment, and marital status.
Separate orthogonal linear model trend tests were conducted for arthritis prevalence within the three age groups with significance set at α = 0.05. The P for trend for arthritis prevalence for all three age groups was <0.001.
DISCUSSION
Findings from 42 US jurisdictions showed that arthritis prevalence was higher among adults with adverse SDOH/HRSN compared to adults without adverse SDOH/HRSN and that arthritis prevalence increased as the number of adverse SDOH/HRSN increased. These results are consistent with a study using 2017 BRFSS data from 17 US states, which found that the likelihood of adults reporting arthritis increased as the number social risk factors increased. 6 In addition to using more measures of SDOH/HRSN than previous work, a novel contribution of this study was stratification of analyses by age group, which revealed a stronger relative association between adverse SDOH/HRSN and arthritis among adults aged 18 to 44 years. Younger adults experience employment insecurity more often, and arthritis may affect the types of work activities a person is able to do, the workplace accommodations they need, or their ability to remain in the workforce. 8 , 9 , 10 Younger adults also report higher prevalences of financial insecurity and difficulty accessing health care, which could impact the ability to manage arthritis. 5 , 8 Although the relative association between adverse SDOH/HRSN and arthritis prevalence was stronger among younger adults, arthritis was highly prevalent among adults ≥65 years in this study; 7 in 10 older adults with five or more adverse SDOH/HRSN reported having arthritis. Adverse SDOH/HRSN can also be common among older adults. 8 For example, although older adults have access to Medicare, challenges accompanying changing health insurance plans and out‐of‐pocket costs are significant barriers to accessing health care. 11 Social connectedness among older adults is also important for health, 11 but approximately one in four community‐dwelling older adults report social isolation or loneliness. 8 Ultimately, resources needed to address adverse SDOH/HRSN and arthritis may vary by age group, and managing arthritis across the lifespan is crucial for improving quality of life for adults of all ages.
This study has several limitations. First, the BRFSS is cross‐sectional, and causality cannot be inferred. Second, self‐reported survey data is subject to social desirability and recall bias. Third, the BRFSS Social Determinants and Health Equity module was not completed by all US states and territories and is not representative of the US population. Fourth, complete data for the 11 SDOH/HRSN measures, age, and arthritis were missing for 23.4% of the survey population. Missing data for the 11 SDOH/HRSN measures ranged from 0.3% for cost barrier for needed medical care to 17.7% for mental stress. Finally, the Social Determinants and Health Equity module included limited measures for SDOH/HRSN.
Understanding of adverse SDOH/HRSN associated with arthritis can inform public health practice, particularly development of interventions and tailored social and public health services to address SDOH/HRSN. Results from this study may be used to enhance arthritis‐appropriate, evidence‐based self‐management programs. 12 Integrating information into these programs to increase access to social safety net programs for transportation, food insecurity, housing insecurity, health care, and public assistance services that address mental health and social isolation may improve arthritis management and outcomes.
AUTHOR CONTRIBUTIONS
All authors contributed to at least one of the following manuscript preparation roles: conceptualization AND/OR methodology, software, investigation, formal analysis, data curation, visualization, and validation AND drafting or reviewing/editing the final draft. As corresponding author, Dr Stowe confirms that all authors have provided the final approval of the version to be published and takes responsibility for the affirmations regarding article submission (eg, not under consideration by another journal), the integrity of the data presented, and the statements regarding compliance with institutional review board/Declaration of Helsinki requirements.
Supporting information
Disclosure Form:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Author disclosures are available at https://onlinelibrary.wiley.com/doi/10.1002/acr.70020.
References
- 1. Fallon EA, Boring MA, Foster AL, et al. Prevalence of diagnosed arthritis—United States, 2019–2021. MMWR Morb Mortal Wkly Rep 2023;72(41):1101–1107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Theis KA, Steinweg A, Helmick CG, et al. Which one? What kind? How many? Types, causes, and prevalence of disability among U.S. adults. Disabil Health J 2019;12(3):411–421. [DOI] [PubMed] [Google Scholar]
- 3. Duca LM, Helmick CG, Barbour KE, et al. State‐specific prevalence of inactivity, self‐rated health status, and severe joint pain among adults with arthritis — United States, 2019. Prev Chronic Dis 2022;19:E23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Theis KA, Murphy LB, Guglielmo D, et al. Prevalence of arthritis and arthritis‐attributable activity limitation—United States, 2016–2018. MMWR Morb Mortal Wkly Rep 2021;70(40):1401–1407. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Hacker K, Houry D. Social needs and social determinants: The role of the Centers for Disease Control and Prevention and public health. Public Health Rep 2022;137(6):1049–1052. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Rethorn ZD, Rethorn TJ, Cook CE, et al. Association of burden and prevalence of arthritis with disparities in social risk factors, findings from 17 US states. Prev Chronic Dis 2022;19:E08. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Centers for Disease Control and Prevention . Behavioral Risk Factor Surveillance System: Survey data and documentation. Accessed September 15, 2024. https://www.cdc.gov/brfss/data_documentation/index.htm
- 8. Town M, Eke P, Zhao G, et al. Racial and ethnic differences in social determinants of health and health‐related social needs among adults—Behavioral Risk Factor Surveillance System, United States, 2022 [supplementary table]. MMWR Morb Mortal Wkly Rep 2024;73(9):204–208. https://stacks.cdc.gov/view/cdc/148477 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Theis KA, Roblin DW, Helmick CG, et al. Prevalence and causes of work disability among working‐age U.S. adults, 2011‐2013, NHIS. Disabil Health J 2018;11(1):108–115. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Brown T, Hammond A, Ching A, et al. Work limitations and associated factors in rheumatoid arthritis, axial spondyloarthritis, osteoarthritis and fibromyalgia. Musculoskeletal Care 2023;21(3):827–844 [DOI] [PubMed] [Google Scholar]
- 11. Office of Disease Prevention and Health Promotion . US Department of Health and Human Services. Social determinants of health and older adults. Accessed November 11, 2024. https://odphp.health.gov/our‐work/national‐health‐initiatives/healthy‐aging/social‐determinants‐health‐and‐older‐adults
- 12. Centers for Disease Control and Prevention . Physical activity and self‐management education programs for arthritis. Accessed September 30, 2024. https://www.cdc.gov/arthritis/programs/index.html
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Disclosure Form: