Arthritis Care & Research

Vol. 63, No. 8, August 2011, pp 1098 1107

DOI 10.1002/acr.20490
2011, American College of Rheumatology
ORIGINAL ARTICLE

Evaluation of Group and Self-Directed Formats of

the Arthritis Foundations Walk With Ease
Program
LEIGH F. CALLAHAN,1 JACK H. SHREFFLER,1 MARY ALTPETER,1 BRITTA SCHOSTER,1
JENNIFER HOOTMAN,2 LAURA O. HOUENOU,1 KATHRYN R. MARTIN,1 AND TODD A. SCHWARTZ1

Objective. To evaluate the effects of a revised 6-week walking program for adults with arthritis, Walk With Ease (WWE),
delivered in 2 formats, instructor-led group or self-directed.
Methods. In an observational pre-post study design, 462 individuals with self-reported arthritis selected either a group
format (n 192) or a self-directed (n 270) format. Performance and self-reported outcomes were assessed at baseline
and at 6 weeks. Self-reported outcomes were assessed at 1 year. Adjusted mean outcome values for group and self-
directed participants were determined using regression models, adjusting for covariates.
Results. At 6 weeks, signicant adjusted mean improvements (P < 0.05) were seen for nearly all self-report and
performance measures in both formats. Modest to moderate effect sizes (ES) were seen for disability (ES 0.16 0.23), pain,
fatigue, and stiffness (ES 0.21 0.40), and helplessness (ES 0.24 0.28). The Arthritis Self-Efcacy (ASE) pain and symp-
tom scales had modest improvements (ES 0.09 0.21). The performance measures of strength (ES 0.29 0.35), balance
(ES 0.12 0.36), and walking pace (ES 0.12 0.32) all showed modest to moderate improvements. No adverse events were
reported for either format. At 1 year, both formats showed modest improvement in ASE pain, but there were 5 outcomes
where self-directed participants showed signicant improvement, while the group participants did not.
Conclusion. The revised WWE program decreases disability and improves arthritis symptoms, self-efcacy, and per-
ceived control, balance, strength, and walking pace in individuals with arthritis, regardless of whether they are taking
a group class or doing the program as self-directed walkers. At 1 year, some benets are maintained, particularly among
the self-directed. This is a safe, easy, and inexpensive program to promote community-based physical activity.

INTRODUCTION with arthritis (25). Regular moderate-intensity physical

Arthritis is the most common cause of disability among
adults in the US and is a highly prevalent chronic condi-
tion (1). A growing body of work has demonstrated that
moderate aerobic exercise is safe and benecial for people
The ndings and conclusions in this report are those of
the author(s) and do not necessarily represent the ofcial
position of the Centers for Disease Control and Prevention.
Supported by a cooperative agreement between the Cen-
ters for Disease Control and Prevention and the Association
of American Medical Colleges (MM-0975-07/07).
1
Leigh F. Callahan, PhD, Jack H. Shrefer, PhD, Mary
Altpeter, PhD, MSW, MPA, Britta Schoster, MPH, Laura O.
Houenou, Kathryn R. Martin, PhD, MPH, Todd A. Schwartz,
DrPH: University of North Carolina, Chapel Hill; 2Jennifer
Hootman, PhD: Centers for Disease Control and Prevention,
Atlanta, Georgia.
Address correspondence to Leigh F. Callahan, PhD, Uni-
versity of North Carolina at Chapel Hill, Thurston Arthritis
Research Center, 3300 Thurston Building, CB#7280, Chapel
Hill, NC 27599. E-mail: leigh_callahan@med.unc.edu.
Submitted for publication January 17, 2011; accepted in
revised form April 19, 2011.
activity can decrease the severity of arthritis and its symp-
toms of pain, fatigue, and stiffness. As a result, various
physical activity programs have been developed and
tested specically for people with arthritis.
Walking is a low-impact activity that is inexpensive,
safe, and acceptable to people with arthritis. It can be done
almost anywhere and anytime. Walking has been shown to
improve functional status in individuals with arthritis,
without exacerbating pain (2). In fact, a meta-analysis of
32 land-based exercise trials, including walking studies,
in people with arthritis revealed benecial treatment ef-
fects for pain (standardized mean difference [SMD] 0.40;
95% condence interval [95% CI] 0.30, 0.50) and function
(SMD 0.37; 95% CI 0.25, 0.49) (5). Adults with arthritis are
less active than adults without arthritis (6) and struggle
with disease-specic barriers to being physically active,
such as episodic pain and fear of making their condition
worse (7,8). Despite this, people with arthritis know being
physically active is important and that physical activity
can help improve arthritis-related symptoms (7,9). How-
ever, many adults with arthritis do not know how much

1098
Evaluating the Revised Walk With Ease Program
Signicance & Innovations
The revised Walk With Ease program is a safe,
easy, and inexpensive program that can promote
community-based physical activity, decrease dis-
ability, and improve arthritis symptoms.
Physical activity opportunities traditionally do not
include both a group and a self-directed option.
Offering both options may allow more people to
benet from the program and incorporate walking
into their lifestyle.
walking they should do or how to start an exercise pro-
gram safely (8). Therefore, there is a need to develop and
evaluate a standardized walking program that can be easily
accessed and distributed widely.
Walk With Ease (WWE), a 6-week community-based
walking group program for adults with arthritis, was de-
veloped 10 years ago by the Arthritis Foundation (AF)
(10). The program included a book and instructor-led
group walks and was based on the stages of change behav-
ioral theory, which encourages participants to tailor chap-
ter readings and the overall program to their unique needs.
Previously, the WWE program was evaluated in a non-
randomized pilot study of 102 adults with arthritis. The
control group participated in an educational seminar on
the pain cycle. The WWE group participants were less
depressed, had less pain and health distress, and had
increased arthritis self-efcacy at the end of the 6-week
program; however, signicant gains in walking endurance
were not maintained at 4 months (11). Despite these initial
positive ndings, WWE was not widely used. In addition,
not all persons with arthritis have access to, or a desire to
participate in, group programs. This suggests a need to
expand the delivery options (e.g., self-directed) for physi-
cal activity intervention programs for adults with arthritis.
In 2006, our research team evaluated and revised the
existing WWE program to be suitable for both group and
self-directed formats (12). We conducted a formative eval-
uation of the program by querying former WWE leaders
and participants in order to identify participant prefer-
ences and determine needed modications to the program
structure and materials.
Guided by the formative evaluation feedback, we drafted
a standardized WWE group and self-directed program
structure and materials. The revised WWE workbook stan-
dardized the program, and the new leader training and
manual allowed the leaders to maintain better delity to
the program protocol. We replaced the Stages of Change
(Transtheoretical Model) (13) approach in the original WWE
workbook with Social Cognitive Theory (SCT) as the con-
ceptual framework (14). We felt the SCT approach was a
better choice for an intervention with both group and self-
directed options. Specically, we focused the WWE program
content on having all participants engage in motivational
strategies, including goal setting, setting up action plans,
monitoring progress, identifying rewards, and using social
supports. After these changes were made, we conducted a
1099
small pilot of the revised WWE program and further re-
ned the materials based on feedback. The purpose of the
current study was to conduct a large community-based
evaluation of the revised WWE program in both group and
self-directed formats.
PARTICIPANTS AND METHODS
Participants. To be eligible for the community trial,
participants had to self-report joint pain, stiffness, or any
type of doctor-diagnosed arthritis, be age 18 years
without a serious medical condition, be able to speak
English, and have no cognitive impairments. The WWE pro-
gram was publicized in newspaper advertisements, mass
e-mails, and yers sent to senior centers, aging councils,
public health departments, medical centers, rheumatology
clinics, tness/wellness centers, retirement communities,
colleges and universities, churches, recreation centers,
and various employers across rural and urban counties
throughout North Carolina.
Upon enrollment into the study, participants selected
either the instructor-led group or self-directed format of
the 6-week program. Group participants were led by an
instructor and met 3 times a week for 1 hour. Self-directed
participants followed the program on their own, using the
WWE workbook as their guide.
Participants who enrolled in the group format of WWE
were taught by trained WWE leaders who were recruited
from senior centers and tness/wellness centers across
North Carolina. The leaders attended a 1-day certication
course led by a senior behavioral scientist (MA) using the
newly created AF WWE Leader Training Guide. Leaders
were also required to obtain cardiopulmonary resuscita-
tion certication. At the time of the training, leaders re-
ceived a WWE workbook and a leaders guide, which
included a script, a syllabus, and instructional tools for
each of the group sessions.
All participants completed self-report and performance-
based assessments at baseline and at the end of the 6-week
program. Participants also completed self-report assessments
1 year after completion of the program; no performance-
based assessments were conducted at that time. All study
methods were approved by the University of North Caro-
lina at Chapel Hill Biomedical Institutional Review Board.
Baseline and followup assessments. Baseline assess-
ments took place from June to September 2008 and were
performed at community sites 1 week before the group
classes began. Group and self-directed participants at-
tended the assessments and provided informed consent,
completed a self-report questionnaire (paper or computer-
based), and underwent a series of performance-based tests
administered by a trained research team member. The
computer-based questionnaires were completed at the
the facilities of the Assessment Center (www.assessment
center.net), part of the National Institutes of Health Patient-
Reported Outcomes Measurement Information System
(PROMIS) initiative, and allowed participants to directly
enter their data. The paper forms were entered into the
same system and stored on the Assessment Center servers
1100
for later retrieval. All participants received a WWE work-
book at the time of the baseline assessment. Group classes
began within a week of the baseline assessments, and
self-directed participants were able to begin the program
immediately following the baseline assessments. The
6-week followup assessments were conducted at each site
from August to November 2008. At the time of the follow-
up assessment, participants completed the performance-
based physical function tests, the self-report survey, and a
written satisfaction survey composed of closed and open-
ended questions about their experience in the program.
One year after completing the WWE program, group and
self-directed participants were mailed followup surveys
(self-reported outcomes only) to assess the long-term effect
of the program.
Primary outcome measures. Primary outcomes included
physical function (performance based and self-report) and
arthritis symptoms (pain, fatigue, stiffness). These out-
comes were obtained through physical performance tests
and self-reported measures. Physical performance tests
were completed on the same day as the self-report instru-
ments. Participants completed 5 performance-based phys-
ical function measures: timed chair stands, timed 360
turn test, single-leg stance, walking speed test, and the
2-minute step test (1518). All measures have established
reliability.
Timed chair stands. The timed chair stands assess
lower extremity strength (17,18). Participants sit in a stan-
dardized armless chair with their backs against the chair
and arms folded across the chest. The participant stands
up and sits back down as quickly as possible 1 time, and
then 3 times in a row without stopping. There was 1 trial
for each of the chair stands with the measurement in
seconds.
Turn tests. The 360 turn test measures turning ability
and balance (17,18). Participants stand with arms at their
side and feet comfortably apart and turn in a full circle to
the right, and then in a full circle to the left. There were
2 trials for each direction and the times (in seconds) were
averaged.
Single-leg stance. This test measures balance (16). Par-
ticipants stand next to a chair, wall, or raised surface and
stand on one leg, and then the other, while placing their
arms across their chest. There was 1 trial on each leg, and
the measurement is the number of seconds of balance up to
a maximum of 30 seconds.
Walking speed. The walking speed test measures func-
tional mobility (17,18). Participants walk a premeasured
20-foot distance on at ground, with 6-foot acceleration
and deceleration zones at each end, at both a normal and a
fast walking pace. There were 2 trials for each pace, and
the times (in seconds) to complete the distance were aver-
aged. The average speed was calculated in units of meters/
second for use in the analysis.
2-minute step test. The 2-minute step test measures
aerobic endurance (15). Participants march in place for
2 minutes, taking as many steps as possible in that time
and raising both knees to a predetermined height (based on
Callahan et al
the height of the participant) as marked on the wall next to
them. There was 1 trial for this test.
Self-reported physical function: PROMIS Health As-
sessment Questionnaire (HAQ). The disability scale of
the PROMIS HAQ (19) assesses self-report function. The
PROMIS HAQ differs from the standard HAQ disability
index in that it has 5 responses (0 4), instead of 4 (0 3),
for 20 questions that remain virtually the same. The item
scores are adjusted for assistance by people or devices,
averaged, and then multiplied by 25 to give the total score
on a scale of 0 100. A higher score on the PROMIS HAQ
indicates more disability. For brevity, going forward the
PROMIS HAQ will be referred to as the HAQ.
Arthritis symptoms: pain, stiffness, and fatigue. A vi-
sual analog scale (VAS) was used to measure arthritis
symptoms of pain, stiffness, and fatigue (20,21). The par-
ticipants marked a spot on a 100-mm line corresponding
to their pain experience over the last 7 days. For pain, the
VAS is anchored with the descriptors no pain and pain
as bad as it could be. Stiffness and fatigue were measured
similarly. The VAS is measured in millimeters from the
left anchor to the point marked by the respondent. Higher
VAS scores indicate more pain, fatigue, or stiffness.
Secondary outcome measures. Three psychosocial in-
struments were administered as part of the self-report
survey.
Arthritis Self-Efcacy (ASE) pain and symptom scales.
The ASE measure characterizes an individuals con-
dence in managing their arthritis pain and symptoms (22).
This 11-item instrument has 2 subscales; one for pain (5
items) and one for other symptoms (6 items). Each item is
scored as an integer (110) and averaged over the subscale.
Higher scores express greater condence for managing
arthritis.
Rheumatology Attitudes Index (RAI). The 5-item help-
lessness subscale of the RAI measures perceived helpless-
ness (23). The items are scored from 15 (least to greatest
amount of helplessness), and the average of the 5 items is
used for analysis.
Self-Efcacy for Physical Activity (SEPA). The 5-item
SEPA scale assesses the respondents condence in their
ability to be physically active despite barriers (24). A sum-
mary score (range 15) is calculated by averaging the 5
items. Higher scores reect higher levels of self-efcacy.
Covariates. Demographic data included age, sex, race,
education, and body mass index (BMI; kg/m2) calculated
from self-reported height and weight. In the modeling
analyses, age was trichotomized as 60 years, 60 74
years, and 75 years. Race was classied as white, African
American, or other. Education was dichotomized as either
greater than high school or less than or equal to high
school. Finally, BMI was dichotomized as 30 kg/m2 or
30 kg/m2, and sex was female or male.
Satisfaction surveys. Individuals in both group and self-
directed study arms were queried regarding their overall
satisfaction with the WWE program, the extent to which
they were satised with the length of the program and
Evaluating the Revised Walk With Ease Program
program topics, whether the program increased their
knowledge about walking in a safe and comfortable man-
ner, and whether they would recommend the program to a
friend.
Statistical analysis. The baseline mean values of all
variables were calculated separately for self-directed and
group format, and the differences were examined with
either t-tests or chi-square tests, as appropriate. Approxi-
mately 42% of the participants enrolled in the group for-
mat and 58% enrolled in the self-directed format.
Repeated-measure linear regression models for each out-
come, using data from all the participants in both formats,
were formulated to assess changes in an outcome measure
through multiple time points, either baseline to 6 weeks or
baseline to 6 weeks and 1 year. Model outputs include
adjusted mean outcomes for each format at all time points,
and adjusted mean outcomes at baseline vary by format.
Results are displayed as differences from the values at
baseline, e.g., 6 weeks minus baseline or 1 year minus
baseline. Modeling each outcome measure controlled for
the baseline outcome value, age, sex, BMI, race, and edu-
cation. A positive difference indicates that the measure of
outcome has increased from baseline to the followup. De-
pending on the scale of the particular outcome, the in-
crease may be viewed as either benecial or detrimental in
terms of the participants well-being. For example, an in-
Figure 1. Walk With Ease (WWE) Program participant ow chart.
1101
crease in the HAQ score would be detrimental (more dis-
ability), while an increase in the leg stance measure would
be benecial (increased time maintaining balance).
For each format and each outcome, the differences from
baseline were tested using the null hypothesis that the
difference is zero, i.e., no change over time. This testing
procedure addresses the primary question, Does the
WWE program improve physical function and arthritis
symptoms? In addition, for each outcome, the differences
from baseline between the 2 formats were tested under the
null hypothesis that they are the same. This procedure
addresses the secondary question, Were the effects of the
WWE program the same for the self-directed and the group
format? For the results from baseline to 6 weeks, the effect
size (ES) was calculated as the within-format difference in
outcomes divided by the SD of the outcome at baseline.
Positive ES indicates improvement in an outcome, and
negative ES indicates deterioration in an outcome mea-
sure. Qualitatively, ES 0.1 0.3 will be termed modest,
and ES 0.3 0.5 will be termed moderate.
RESULTS
A total of 462 participants enrolled into the study and
entered self-report data at baseline (Figure 1). Data were
collected at 33 sites located in communities throughout
1102 Callahan et al

Table 1. Baseline characteristics of both self-directed and group participants who completed the 6-week followup*

Participants, no.

Self- Self-
Characteristic directed Group P Total directed Group

Demographics
Age, mean SD years 64.9 11.4 70.7 9.8 0.001 403 225 178
Education, less than/equal to high school, % 25.1 34.3 0.039 403 225 178
Race
White, % 72.9 70.8
African American, % 23.1 25.8 0.790 403 225 178
Other, % 4.0 3.4
Female, % 88.9 85.4 0.295 403 225 178
Body mass index 30 kg/m2, % 39.1 36.5 0.594 403 225 178
Performance-based physical function, mean SD seconds
Lower-extremity strength
1 chair stand 3.34 1.85 3.70 1.5 0.063 305 159 146
3 chair stands 9.59 3.76 10.4 3.5 0.069 301 156 145
Standing balance/turning ability
360 turn right 3.16 1.4 3.73 1.2 0.001 306 163 143
360 turn left 3.14 1.46 3.68 1.2 0.001 306 163 143
Balance
Right leg stance 12.16 10.92 8.6 9.1 0.004 276 150 126
Left leg stance 12.2 11.25 8.3 9.2 0.002 286 155 131
Functional mobility, mean SD meters/second
Normal walking speed 1.12 0.22 1.06 0.20 0.008 308 163 145
Fast walking speed 1.54 0.31 1.44 0.32 0.005 307 162 145
Aerobic endurance, mean SD step count
2-minute step test 75.0 23.7 75.6 23.2 0.821 286 148 138
Self-reported function, mean SD
HAQ (range 0100) 13.7 12.8 15.8 14.5 0.128 394 221 173
Arthritis symptoms, mean SD mm
Pain, VAS (range 0100) 38.6 23.6 37.6 27.1 0.536 387 216 171
Fatigue, VAS (range 0100) 36.0 27.5 38.2 28.8 0.418 388 216 172
Stiffness, VAS (range 0100) 43.4 25.7 40.8 27.7 0.664 388 216 172
Psychosocial, mean SD
Pain ASE (range 110) 6.8 2.05 6.6 2.3 0.318 390 216 174
Symptom ASE (range 110) 7.08 1.93 6.9 2.1 0.464 389 216 173
Rheumatology Attitudes Index (range 04) 1.16 0.87 1.22 0.85 0.528 368 206 162
SEPA (range 15) 2.82 0.71 2.95 0.75 0.061 374 210 164

* HAQ Patient-Reported Outcomes Measurement Information System Health Assessment Questionnaire; VAS visual analog scale; ASE Arthritis
Self-Efcacy scale for pain and symptoms; SEPA Self-Efcacy for Physical Activity.
Analysis includes only participants who completed followup measures at 6 weeks (n 403).
Result of t-test (continuous variables) or chi-square test (categorical variables) for determining if the group and self-directed participants means are
signicantly different.

the state. Study sites included 9 senior centers (27.7% of
participants), 4 churches (8.2% of participants), 4 employ-
ers (11.1% of participants), 4 community health/tness/
wellness centers (11.3% of participants), and 4 depart-
ments or councils on aging (11.6% of participants). Other
venues included assisted-living and retirement commu-
nities, medical centers, and a service sorority. Ten sites
offered the self-directed format only, 6 sites offered the
group format only, and the remainder (17 sites) offered
both formats. Groups ranged in size from 2 or 3 to 19
participants, with most groups in the range of 512 partic-
ipants.
A majority (n 270, 58.4%) of the participants opted for
the self-directed format and the remainder (n 192,
41.6%) opted for the group format. Followup rates at 6
weeks were 83.3% and 92.7% for self-directed and group
participants, respectively. Rates for performance-based
assessments were lower than self-reported assessments for
participants in both formats at the 6-week followup. Due to
scheduling conicts, a total of 38% self-directed partici-
pants and 22.6% group participants did not complete
performance-based assessments. Followup rates at 1 year
from baseline were 75.5% for self-directed and 82.3% for
group participants. In both formats, 90% of those fol-
lowed up at 6 weeks were also followed up at 1 year
(Figure 1). No differences were found for 6-week followup
rates by baseline demographic characteristics (data not
shown).
The baseline demographics and scores by format of
participation, either group or self-directed, are summa-
rized in Table 1. Data are restricted to only those 403
participants (87%) who completed followup at 6 weeks.
Of the 403 participants with 6-week data, 362 returned
followup data at the 1-year point. The sample was
Evaluating the Revised Walk With Ease Program 1103

Table 2. Differences in performance-based physical function test results from baseline to

6-week followup as determined from an adjusted repeated-measures regression model*

Difference from baseline

Physical function measure (95% condence interval) Effect size No.

Lower extremity strength, seconds

1 chair stand
Self-directed format 0.57 (0.77, 0.37) 0.31 159
Group format 0.52 (0.73, 0.31) 0.35 146
3 chair stands
Self-directed format 1.27 (1.66, 0.88) 0.34 156
Group format 1.02 (1.42, 0.62) 0.29 145
Standing balance/turning ability, seconds
360 turn right
Self-directed format 0.30 (0.43, 0.16) 0.21 163
Group format 0.43 (0.58, 0.29) 0.36 143
360 turn left
Self-directed format 0.34 (0.46, 0.21) 0.23 163
Group format 0.43 (0.57, 0.3) 0.37 143
Balance, seconds
Right leg stance
Self-directed format 1.87 (0.39, 3.35) 0.17 150
Group format 2.78 (1.17, 4.4) 0.31 126
Left leg stance
Self-directed format 1.39 (0.04, 2.83) 0.12 155
Group format 2.49 (0.93, 4.05) 0.27 131
Functional mobility, meters/second
Normal walking speed
Self-directed format 0.048 (0.022, 0.074) 0.22 163
Group format 0.064 (0.037, 0.091) 0.32 145
Fast walking speed
Self-directed format 0.038 (0.005, 0.071) 0.12 162
Group format 0.078 (0.043, 0.113) 0.24 145
Endurance, count
2-minute step test
Self-directed format 1.56 (5, 1.88) 0.07 148
Group format 1.54 (5.1, 2.02) 0.07 138

* Adjusted for baseline outcome value, age, sex, body mass index, race, and education.
P 0.01 for test that difference from baseline is 0 (within format).
P 0.05 for test that difference from baseline is 0 (within format).
P 0.05 for test that difference from baseline is 0 (within format) and for test that group and
self-directed differences are the same (between formats).
P 0.01 for test that difference from baseline is 0 (within format) and P 0.05 for test that group and
self-directed differences are the same (between formats).

mostly female (87.3%), most had continued education
beyond high school (71%), and most were white (72%).
On average, self-directed participants were younger
than the group participants by 5.8 years, better edu-
cated, and had better baseline scores on all the perfor-
mance tests except the step test. Although not statisti-
cally different, the self-directed participants at baseline
reported less disability on the HAQ and were more
condent in being able to exercise (SEPA). Group and
self-directed participants had similar symptoms and
psychosocial measures (except SEPA noted above) at
baseline. The participants who completed the 6-week
and 1-year followups were not signicantly different in
demographic makeup for the baseline characteristics of
the samples. Also, there were no signicant differences
in the demographics between individuals who com-
pleted the performance-based assessments and those
who did not.
Pre-post test results after 6-week intervention. The
modeling results for performance-based physical function
at 6-week followup are presented in Table 2. The model
produces adjusted mean differences from baseline to 6
weeks separately for those in each format. Participation in
the WWE program, both the self-directed and group for-
mats, resulted in signicant improvements in almost all
performance-based physical measures. ES for lower ex-
tremity strength measures indicated moderate improve-
ment (0.29 0.35), balance measures indicated modest to
moderate signicant improvement (0.12 0.37), and func-
tional mobility measures indicated modest improvement
(0.12 0.32). No signicant improvement was seen in the
2-minute step test, which is a measure of endurance
(Table 2). Although fast walking speed is improved from
baseline in both formats (within format test), the improve-
ment is signicantly greater for group format (between-
formats test).
1104 Callahan et al

Table 3. Differences in self-reported physical function, arthritis symptoms, and

psychosocial from baseline to 6-week followup as determined from adjusted
repeated-measures regression models for each outcome*

Difference from baseline

Self-reported measure (95% condence interval) Effect size No.

Function
HAQ (range 0100)
Self-directed format 2.98 (4.08, 1.87) 0.23 221
Group format 2.26 (3.51, 1.01) 0.16 173
Symptoms
VAS (range 0100)
Pain
Self-directed format 8.4 (11.65, 5.15) 0.36 216
Group format 7.82 (11.48, 4.17) 0.29 171
Fatigue
Self-directed format 5.68 (9.07, 2.3) 0.21 216
Group format 6.33 (10.12, 2.54) 0.22 172
Stiffness
Self-directed format 10.27 (13.67, 6.87) 0.40 216
Group format 8.75 (12.55, 4.94) 0.32 172
Psychosocial
Pain Arthritis Self-Efcacy (range 110)
Self-directed format 0.19 (0.11, 0.5) 0.09 216
Group format 0.49 (0.15, 0.83) 0.21 174
Symptom Arthritis Self-Efcacy (range 110)
Self-directed format 0.26 (0.02, 0.54) 0.13 216
Group format 0.4 (0.09, 0.72) 0.19 173
Rheumatology Attitudes Index (range 04)
Self-directed format 0.21 (0.3, 0.11) 0.24 206
Group format 0.23 (0.34, 0.13) 0.28 162
Self-efcacy for physical activity (range 15)
Self-directed format 0.06 (0.03, 0.15) 0.09 210
Group format 0.07 (0.03, 0.18) 0.10 164

* Adjusted for baseline outcome value, age, sex, body mass index, race, and education. HAQ Patient-
Reported Outcomes Measurement Information System Health Assessment Questionnaire; VAS visual
analog scale.
P 0.01 for test that difference from baseline is 0 (within format).
P 0.05 for test that difference from baseline is 0 (within format).

Results from regression models for the self-reported out-
comes are presented in Table 3. Similar to the perfor-
mance-based measures, numerically, all differences repre-
sent improvements from baseline, and most are signicant.
Self-reported disability (HAQ) improved modestly (ES
0.16 0.23), arthritis symptoms of pain, fatigue, and stiff-
ness improved moderately (ES 0.21 0.40), and the psycho-
social measures improved modestly (ES 0.09 0.28). There
were no signicant differences in the amount of improve-
ment for any variable between formats of intervention.
One-year followup data. The model results out to the
1-year followup are presented in Table 4. All outcomes are
self-reported since no site visits were made to include
performance-based tests. The model requires data from all
3 time points. The results at 6 weeks are comparable, but
not identical, to those found in Table 3, since the sample
has decreased in size and the model includes the 1-year
data. At 1 year, there are several measures where the
difference from baseline is signicant for the self-directed
participants, the difference from baseline is nonsignicant
for group participants, and the between-format results are
signicant (HAQ, pain VAS, stiffness VAS, and RAI). The
self-directed participants held onto their gains or even
improved, while the group participants lost ground (e.g.,
pain VAS, ASE pain and symptoms). The signicant SEPA
difference from baseline in group format is actually a loss
of self-efcacy for physical activity.
Six-week satisfaction survey data. Among the 232 self-
directed participants who completed the satisfaction sur-
vey at the end of the 6-week program, 92% reported that
they agreed or strongly agreed that they would recommend
the WWE program to a friend or family member. The
majority agreed or strongly agreed that the program moti-
vated them to become more active (80%), were satised
with the program (78%), beneted from the program
(80%), and thought 6 weeks was an appropriate program
length (82%). Approximately 84% reported that, as a re-
sult of the WWE program, they learned how to exercise
safely and comfortably. At the end of the program, 47% of
self-directed participants were extremely condent that
they would continue walking or being physically active
after WWE, and 35% were fairly condent. Of the 109 (of
Evaluating the Revised Walk With Ease Program 1105

Table 4. Differences in self-reported physical function, arthritis symptoms, and psychosocial outcomes from
baseline to 6-week followup and baseline to 1-year followup as determined from a repeated-measures
regression model for each outcome, for participants with 1-year data*

Differences from baseline

(95% condence interval)

Self-reported measure 6-week followup 1-year followup No.

Format
HAQ
Self-directed format 2.97 (4.31, 1.62) 2.63 (3.97, 1.28) 193
Group format 2.5 (4.04, 0.96) 0.78 (0.76, 2.32) 148
Arthritis symptoms, VAS (range 0100)
Pain
Self-directed format 7.56 (11.51, 3.6) 9.68 (13.63, 5.73) 186
Group format 8.34 (12.82, 3.87) 0.37 (4.84, 4.11) 145
Fatigue
Self-directed format 5.29 (9.43, 1.16) 2.85 (6.98, 1.29) 185
Group format 5.74 (10.38, 1.1) 0.90 (3.74, 5.55) 147
Stiffness
Self-directed format 9.1 (13.0, 5.21) 9.73 (13.62, 5.84) 186
Group format 8.98 (13.38, 4.57) 1.54 (5.95, 2.87) 145
Psychosocial
Pain Arthritis Self-Efcacy (range 110)
Self-directed format 0.09 (0.25, 0.43) 0.34 (0, 0.68) 185
Group format 0.66 (0.28, 1.04) 0.39 (0.01, 0.78) 142
Symptom Arthritis Self-Efcacy (range 110)
Self-directed format 0.21 (0.11, 0.52) 0.42 (0.1, 0.73) 186
Group format 0.53 (0.17, 0.89) 0.36 (0.01, 0.72) 140
RAI (range 04)
Self-directed format 0.19 (0.3, 0.08) 0.24 (0.35, 0.13)# 176
Group format 0.23 (0.36, 0.1) 0.08 (0.21, 0.05)** 125
Self-efcacy for physical activity (range 15)
Self-directed format 0.07 (0.05, 0.18) 0.04 (0.16, 0.07) 177
Group format 0.02 (0.11, 0.16) 0.22 (0.36, 0.09) 130

* HAQ Patient-Reported Outcomes Measurement Information System Health Assessment Questionnaire; VAS visual analog
scale; RAI Rheumatology Attitudes Index.
P 0.01 for test that the difference from baseline is 0 (within format).
P 0.01 for test that the difference from baseline is 0 (within format) and for test that the group and self-directed differences
are the same (between formats).
P 0.01 for test that the group and self-directed differences are the same (between formats).
P 0.05 for test that the difference from baseline is 0 (within format).
# P 0.01 for test that the difference from baseline is 0 (within format) and P 0.05 for test that the group and self-directed
differences are the same (between formats).
** P 0.05 for test that the group and self-directed differences are the same (between formats).

178) group format participants who completed the satis-
faction survey, 100% reported that they would recom-
mend the WWE program to a friend. Nearly all participants
(99%) stated that their WWE leader maintained their in-
terest fairly or very well; 100% were satised with the way
the leader presented the topics, with the length of the
program (94%), with the extent to which the program
fullled their expectations (99%), and with the program
overall (100%). More than 99% reported that they in-
creased their knowledge about walking in a safe and com-
fortable manner.
DISCUSSION
The revised AF WWE program appears to decrease dis-
ability and improve arthritis symptoms, self-efcacy and
perceived control, balance, strength, and walking pace
in individuals with self-reported arthritis, regardless of
whether they are taking an instructor-led group class or
doing the program on their own as self-directed walkers.
At 1 year after completing WWE, both self-directed and
group participants maintained some benets. However,
self-directed participants were more likely to continue
walking and retained improvement in more self-reported
physical function, symptoms, and psychosocial outcomes.
Future study is needed to determine if there are successful
motivational strategies to transition group format partici-
pants and/or those who are less healthy and older to con-
tinue in an independent walking lifestyle that produces
ongoing benets comparable to those experienced by our
self-directed participants. WWE is a safe, easy, and inex-
pensive program for community-based physical activity
delivery.
The WWE program is unique in that it offers both a
group and a self-directed option, expanding traditionally
offered opportunities for physical activity. This may allow
1106
more people to benet from the program and incorporate
walking into their lifestyle, since some individuals may
not enroll in group-based physical activity programs for
reasons such as dislike of groups or scheduling conicts.
In our study, the individuals who chose to do the self-
directed format were younger and more likely to have a
high school education or beyond. They also reported better
status on most of the outcome measures at baseline, which
may be attributable to the age difference. These ndings
suggest that the self-directed version of the program may
be more desirable or marketable to younger working-age
adults with arthritis, since it may help them t walking
into their daily routine.
In terms of meaningful change, several of the arthritis
symptoms and physical function measures demonstrated
statistically signicant differences that are in line with
meaningful change scores previously reported in the liter-
ature. In our study, change for the 100-mm pain VAS was
found to be 8.4 (self-directed) and 7.8 (group), both above
and within the previously established range (6.8 8.2) for
meaningful changes (25). These meaningful changes in
pain were obtained and maintained for those in the self-
directed mode at 6 weeks and 1 year, i.e., 7.6 and 9.7,
respectively; a meaningful change of 8.3 was obtained for
those in the group format at the 6-week followup. In ad-
dition, changes for the 100-mm fatigue VAS were found to
be 5.68 (self-directed) and 6.3 (group), which are slightly
lower than the meaningful change range of 6.717.0 that
has been established in patients with rheumatoid arthritis
(26). Small meaningful change for gait speed has previ-
ously been estimated at 0.05 meter/second (27). We ob-
served meaningful change for normal walking speed in
both intervention formats, with a 0.05 meter/second (self-
directed) and a 0.06 meter/second (group) observed differ-
ence from baseline.
Our study recruited participants from multiple sources,
including worksites, and it also includes individuals from
rural and urban settings, therefore enhancing our general-
izability. Benets of the program were seen regardless of
whether participants had been exercising before they be-
gan WWE, demonstrating that the program is appropriate
for individuals of various physical activity backgrounds.
Our study was limited in that we did not have a control
group. However, previous randomized trials of physical
activity among adults with arthritis have used walking as
the main mode of exercise and have shown signicant
improvements in physical function and quality of life and
reduced disability compared with controls, which is likely
to apply to this walking intervention as well (28 31).
Therefore, our primary interest was to examine the com-
parative effectiveness of the 2 modes of program adminis-
tration; group and self-directed.
Our study was also limited by having a smaller percent-
age of participants complete the performance-based phys-
ical function measures. A total of 62% of self-directed
participants and 77.4% of group participants completed
performance-based assessments at the 6-week followup.
Participants could not attend the followup assessment for
various reasons. Those that did not attend were invited to
complete a paper self-report survey by mail or over the
phone soon after the followup assessment. There were no
Callahan et al
differences in the demographics between the participants
who completed the performance-based physical function
measures and those who did not. The self-directed partic-
ipants were 1.8 times more likely not to have performance-
based assessment data than the group participants, which
we believe was largely due to scheduling conicts. We
held the group format assessments the day of the last WWE
class, which helped to minimize attrition. Despite our
lower followup rate among the self-directed participants,
our sample size was still quite large and clinical, and sig-
nicant effects were found. Another limitation of our
study was the absence of a measure of physical activity
levels. Finally, our study was limited in that we enrolled
more female than male participants, but this demographic
divide is reective of differences in the prevalence of arthritis
(more common in women) in the general population.
In summary, our study of more than 450 community-
dwelling adults from urban and rural areas of North Car-
olina provides evidence that the revised AF WWE program
modestly improves symptoms and function after a 6-week
intervention, regardless of whether delivery format is in-
structional group or self-directed. Benets were more
likely to be maintained over time in self-directed walkers.
ACKNOWLEDGMENTS
The WWE program would not have been possible without
the coordinated efforts of the AF, the Centers for Disease
Control and Prevention, the University of North Carolina
Institute on Aging, and the Thurston Arthritis Research
Center. We wish to thank Dr. Peter Blanpied of the Uni-
versity of Rhode Island and Rebecca Martinique from the
Rhode Island region of the Northern and Southern New
England chapter of the AF for sharing their experiences,
research ndings, and program materials from their imple-
mentation of the WWE program. We thank AF advisor
Michele Boutaugh, Area Agency on Aging leaders Carolyn
Tracy and Gayla Woody, as well as Thurston Arthritis
Research Center team members Drs. Margaret Morse,
Thelma Mielenz, Jean Goeppinger, and Ms. Katherine
Buysse for their contributions to the revision of the WWE
workbook. We thank Dr. Tiffany Shubert for assistance in
training the assessment team. We also thank Dr. Kate
Queen for supporting the leader trainings and assess-
ments, Drs. Darren DeWalt and Robert DeVellis for loaning
us assessment equipment, Janice Woodard, Sue Savage-
Guin, and Lynn Joyner for their help with participant
recruitment and assessments, and My-Linh Luong for as-
sistance in manuscript preparation. We thank the Assess-
ment Center (www.assessmentcenter.net) for the use of
their data entry facilities. We thank the WWE group lead-
ers Nancy Alton, Myra Austin, Sue Brooks, Gloria Brown,
Judy Burnett, Adrienne Calhoun, Rebecca Chaplin, Lillian
Corprew, Pam Doty, Peggy Evans, Madeline Fillman,
Kacky Hammon, Ethel Hennessee, Jan Horton, Katelyn
Irwin, Jamie Ives, Joy Jones, Jennifer Lanier, Marilyn Mad-
den, Lauren Mangili, Sigrun Mapes, Laura Martelle, Jean
Moncrief, Meaghan Morgan, Susan Musselman, Dana Oar,
Lauren Scharf, Cherie Shaffer, Michele Skeele, Olivia
Sweet, Alice Taylor, Theresa Thomas, Susan Whitley, and
Anita Wilkins. We also thank the WWE assessment team of
Evaluating the Revised Walk With Ease Program
Jennifer Abramson, Kirsten Nyrop, Katherine Buysse,
Brian Charnock, Amanda Cornett, Karl Eklund, Betsy
Hackney, Brennan Martin, Diana McAllister, Michael
Narveson, James Norris, John Shadle, Bonnie Shaw, Joan
Phillips Trimmer, Robert Whitehill, Lauren Wood, and
John Wright. Finally, we thank all of the WWE partici-
pants, whose generous donations of time and effort made
this project a success.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising
it critically for important intellectual content, and all authors
approved the nal version to be submitted for publication.
Dr. Callahan had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study conception and design. Callahan, Altpeter, Hootman.
Acquisition of data. Callahan, Shrefer, Schoster, Houenou,
Martin.
Analysis and interpretation of data. Callahan, Shrefer, Hootman,
Schwartz.
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