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Rheumatology Advance Access originally published online on August 27, 2006
Rheumatology 2007 46(3):490-495; doi:10.1093/rheumatology/kel299
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Time use patterns among women with rheumatoid arthritis: association with functional limitations and psychological status

P. Katz and A. Morris

Department of Medicine, Division of Rheumatology, University of California, San Francisco, CA, USA.

Correspondence to: P. Katz, PhD, Arthritis Research Group, University of California, San Francisco, 3333 California Street, Suite 270, San Francisco, CA 94143-0920, USA. E-mail: Patti.Katz{at}ucsf.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
 References
 
Objectives. This study assessed time use patterns among 375 women with rheumatoid arthritis (RA). We hypothesized that (i) as functional limitations increased, time use imbalances would occur (i.e. time needed for obligatory activities would conflict with time needed for productive and free-time activities) and (ii) time use imbalances would be associated with psychological distress.

Methods. Time use estimates were obtained from written questionnaires; other study data were collected from annual telephone interviews. Activities were categorized as obligatory, committed or discretionary, as defined by Verbrugge. Time use estimates were aggregated to define number of obligatory (e.g. self-care) activities requiring >2 h/day and a number of committed and discretionary activities in which no time was spent each day.

Results. After adjusting for age, education, marital status and pain severity, women with more functional limitations were significantly more likely to spend >2 h/day in obligatory activities. As functional limitations increased, the proportion spending no time in each committed activity and many discretionary activities increased. Spending >2 h/day in obligatory activities was not significantly associated with poor psychological status, but spending no time in a greater number of committed and discretionary activities was associated with lower life satisfaction and higher levels of depressive symptoms.

Conclusions. Having more severe functional limitations appears to shift time use patterns towards more time spent in obligatory activities and less time spent in committed and discretionary activities. These imbalances in time use were associated with psychological distress, highlighting the need for women with RA to maintain important productive, social and discretionary activities.

KEY WORDS: Rheumatoid arthritis (RA), Disability, Functioning, Psychological well-being, Time use


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
 References
 
The disability in a wide range of life activities that rheumatoid arthritis (RA) can produce is well documented [1, 2]. Standard assessments of disability focus on difficulty performing activities. However, there is also the possibility that because of functional difficulties, individuals with RA may need to restructure the way they use time. They may need more time to perform required activities (e.g. self-care) and thus have less time to spend on discretionary activities or may relinquish some activities in order to preserve time or energy for others [3–5].

Studies have shown differences in time use patterns between individuals with and without disabilities, such that individuals with disabilities spend more time in personal care activities, more time sleeping and/or resting and less time in productivity-related activities [6, 7]. In one of the very few studies to examine time use among individuals with RA, Yelin and colleagues [3] used time diaries to estimate the allocation of time to various activities of daily life and found that individuals with RA spent far more time on personal care and hygiene, household chores, shopping and errands than did controls. Kuper and colleagues [8] found that individuals with early RA spent an average of 1.9 h/day or approximately 12% of an effective 16 h day in disease-related activities (for example, extra time needed for activities of daily living, daily care of disease and transportation to medical appointments). Clearly, in order to commit 12% of a day to disease-related activities, other activities must be foregone. If the foregone activities are the ones that are highly valued, there may be a significant impact in terms of health and well-being. Backman et al. [9] found that dissatisfaction with time use patterns was associated with poor health status ratings. Likewise, in RA and other chronic health conditions, inability to perform valued life activities or difficulty in performing those activities has been associated with depression and lower perceived quality of life [10–14].

In this study, our goal was to assess patterns of time use among a sample of 375 women with RA using a conceptual model of disability formulated by Verbrugge and Jette [15]. In this model, the disablement process is described as a pathway progressing from pathology, to impairments, to functional limitations (defined as restrictions in basic physical and mental activities such as walking and basic mobility, gripping and reaching, and cognition), to disability (defined as difficulty in performing activities of daily life). Of particular significance to these analyses, when assessing disability, Verbrugge and colleagues [15–17] proposed that life activities be grouped into three categories: obligatory activities, required for survival and self-sufficiency, including ADL-type activities such as hygiene and self-care, walking inside, walking outside and using transportation or driving; committed activities, associated with one's principal productive social roles, such as paid work, household responsibilities, child and family care; and discretionary activities, such as socializing, exercise, engaging in leisure time activities and pastimes, participating in religious or spiritual activities and pursuing volunteer work or hobbies, or other activities that individuals engage in for relaxation and pleasure. We hypothesized that as functional limitations increased, we would observe time use patterns suggestive of time use imbalance or indications that the time needed to perform obligatory activities would conflict with the time needed for committed and discretionary activities. We also expected that an imbalance in time use would be associated with psychological distress.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusion
 Acknowledgements
 References
 
Subjects
The sample for the present study was drawn from the 2003 wave of the Rheumatoid Arthritis (RA) Panel Study (n = 548). The RA Panel was constructed in 1982 from a random sample of rheumatologists practicing in Northern California. Participants have been recruited from lists maintained by participating rheumatologists of all persons with RA presenting to their offices over a 1-month period who expressed an interest in participating in the study. The original RA Panel consisted of 822 patients who were enrolled between June 1982 and July 1983. There were subsequently four additional enrolment periods in 1989–90, 1995, 1999 and 2003, during which 203, 131, 122 and 169 individuals were enrolled, respectively. Retention from year to year has averaged 93%; the 7% attrition includes deaths. The principal data source for the RA Panel is an annual telephone interview that includes questions on demographics, RA symptoms, comorbidities and functioning. The study was approved by the University's Committee on Human Research, and all the participants provided written consent.

In 2003, panel members were also asked to complete a written questionnaire that was sent and returned by mail following the telephone interview. Of the 548 individuals who completed the telephone interview, 446 (81%), i.e. 375 women and 71 men, returned completed questionnaires. Because men and women have been shown to exhibit different time use patterns [18, 19] and the sample of men was too small for adequate analysis, only the 375 women with both questionnaire and interview data were considered in these analyses.

Variables
Time use
In the written questionnaire, participants were asked to estimate how much time, on average, they spent in a typical day in each of 16 activities, using the following response scale: no time, 1–30 min, 30–60 min, 60–90 min, 90 min–2 h or >2 h. For estimates of the average amount of time spent per day on sleeping and on paid employment, an open-ended response format was used. For analysis, activities were divided into the three categories described above—obligatory, committed and discretionary—according to Verbrugge's definitions.

Functional limitations
Functional limitations were assessed using the Health Assessment Questionnaire (HAQ) [20]. The HAQ is a widely used measure of functional limitations specifically developed to measure functioning among persons with arthritis. Scores range from 0 to 3 in increments of 0.125, with higher scores indicating greater limitations. The study sample's mean HAQ score was 1.04 (S.D. 0.71).

Psychological status
We examined three measures of psychological status: perceived stress, depressive symptoms and life satisfaction. Perceived stress was measured with the 4-item version of the Cohen Perceived Stress Scale, which measures the degree to which situations in one's life are appraised as stressful [21]. Scores range from 1 to 5, with higher scores reflecting greater perceived stress. The mean perceived stress score for the sample was 2.1 (S.D. 0.9).

Depressive symptoms were assessed with the 15-item Geriatric Depression Scale—Short Form [22]. The GDS was constructed to minimize questions measuring somatic aspects of depression, which could actually reflect the results of a physical condition rather than depression. This is of particular importance in RA, since some of the physical dimensions of depression, such as fatigue or difficulty in sleeping, may also be manifestations of RA [23, 24]. Scores range from 0 to 15, with higher scores reflecting more depressive symptoms; the mean score in the sample was 2.3 (S.D. 2.8).

Life satisfaction was measured with the 5-item Satisfaction with Life Scale (SWLS) [25]. The SWLS is narrowly focused to assess global life satisfaction. Scores range from 1 to 5, with higher scores indicative of greater satisfaction. The mean score for the sample was 3.7 (S.D. 0.9).

Statistical analysis
Frequency distributions of time use variables and HAQ score were computed. After examining the frequency distribution for HAQ scores, the sample was divided into three approximately equal groups, divided on the basis of functional limitations as measured by the HAQ. The scores of HAQ group 1 (n = 115) ranged from 0 to 0.50, those of group 2 (n = 126) ranged from 0.625 to 1.25 and those of group 3 (n = 129) were 1.375 and higher. Time use categories describing the amount of time spent in each activity were collapsed into four groups to simplify interpretation: no time, <1 h, 1–2 h and >2 h.

Differences by HAQ group in time use in specific activities were first examined with chi-square analyses and then with multiple logistic regression analyses. HAQ group differences in time spent sleeping and working at paid employment were examined first with analyses of variance and then multiple linear regression analyses. Multiple regression analyses controlled for age, years of education, marital status and pain severity rated on a 0 (no pain) to 100 (very severe pain) scale.

Previous research suggested that individuals with greater disability would spend more time in obligatory activities and less time in committed and discretionary activities. Therefore, for obligatory activities, logistic regression models estimated the likelihood of spending 2 h or more in the activity. For committed and discretionary activities, regression analyses estimated the likelihood of spending no time in an activity. All analyses used HAQ group 1 (fewest functional limitations) as the reference group.

To examine the association of time use with psychological status, totals were first compiled of the number of obligatory activities in which >2 h were spent per day, and the number of committed activities and discretionary activities in which no time was spent per day. Because these counts were not normally distributed, log transformations were applied to normalize the values (after adding 1 to the count because of the large number of zero counts). Analyses of variance were computed to examine these log-transformed activity counts by HAQ group. Pearson's correlations were computed to assess the association between log-transformed activity counts and measures of psychological status. Multiple regression analyses were also computed, with psychological status variables as the dependent variables, log-transformed time use totals as the primary independent variables and controlling for age, education, marital status, pain severity and HAQ. For analyses of psychological status, the depressive symptom score was also log-transformed to normalize the distribution of scores; perceived stress and life satisfaction scores were normally distributed.

All analyses were conducted using the Statistical Package for the Social Sciences (SPSS), version 14.0 (SPSS, 2005, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusion
 Acknowledgements
 References
 
Sample characteristics
The mean age of participants was 60.0 (S.D. 13.2) yrs, and with mean duration of RA of 19.4 (S.D. 11.6) yrs. Most of the women were white (79.4%), and 61.1% reported that they were married or with a partner. Of those under age 65, 62.2% reported that they were currently employed for pay.

Table 1 summarizes the frequency distributions of time allocated to each activity and the mean number of hours spent in sleep and paid work (among those aged ≤65). Spending <1 h/day in each of the obligatory activities was most common, although 13.1 and 18.6% of the women reported spending 2 h or more per day in personal care and resting, respectively. Few women reported spending no time in the obligatory activities. Spending <1 h/day in each of the committed activities was also most common. Few women reported spending no time in each of the committed activities, with the exception of ‘taking care of family’ this may reflect their living situations or family characteristics. In contrast, relatively large proportions of women, ranging from 30.6% (physical recreational activities) to 66.2% (volunteer activities), reported spending no time per day in four of the six discretionary activities. With the exception of ‘leisure activities in your home’, few women spent >2 h/day in any discretionary activity.


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  		TABLE 1. Time use estimates for 375 women with RA

 
Time use by functional limitation group
As can be seen in Table 2, in bivariate analyses, there were significant differences by HAQ group in the proportion spending >2 h/day taking care of RA ({chi}2 = 15.9, P < 0.0001) and resting ({chi}2 = 5.8, P = 0.05) and, marginally, in personal care ({chi}2 = 5.6, P = 0.06). Average nightly sleeping time of the HAQ groups was not significantly different (HAQ group 1: 7.3 h; HAQ group 2: 7.3 h; HAQ group 3: 7.2 h; F = 0.14, P = 0.87). After adjusting for age, education, marital status and pain severity, the odds of individuals in the highest HAQ group spending >2 h/day in personal care and resting, compared with individuals in the lowest group, were still elevated [odds ratios (OR) of 1.62 and 2.35, respectively], but the confidence intervals for personal care and resting did not exclude 1.0. None of the women in HAQ group 1 spent >2 h or more per day taking care of RA. However, those in HAQ group 3 were significantly more likely than women in HAQ group 2 to spend >2 h/day in RA care [OR 8.9, 95% confidence interval (CI) 1.1, 73.1].


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  		TABLE 2. Proportion of women spending >2 h in obligatory activities, by HAQ groupa

 
In contrast, as HAQ increased, the proportion of individuals spending no time at all increased for each committed activity, although differences among HAQ groups were significant only for housework ({chi}2 = 22.5, P < 0.0001) and paid work ({chi}2 = 25.3, P < 0.0001) (Table 3). Adjustment for age, education, marital status and pain severity did not change this pattern.


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  		TABLE 3. Proportion of women spending no time at all in committed and discretionary activities, by HAQ groupa

 
Among the discretionary activities, there were no differences among HAQ groups in the proportion of individuals spending no time in visiting friends or family ({chi}2 = 1.8, P = 0.42) or leisure in the home ({chi}2 = 1.8, P = 0.40); for all the groups, these proportions were quite low. There were also no significant differences in the proportion of women who spent no time in volunteer work ({chi}2 = 2.9, P = 0.24). However, for the other discretionary activities, as HAQ increased, a greater percentage of individuals reported spending no time in the activity (leisure outside the home, {chi}2 = 13.9, P = 0.001; hobbies, {chi}2 = 11.9, P = 0.003; physical recreational activities, {chi}2 = 46.5, P < 0.0001). Again, adjustment for covariates did not alter the results substantially.

Time use summaries
Women in HAQ group 3 reported spending >2 h/day in significantly more obligatory activities than women in the two lower HAQ groups (Table 4). As functional limitations increased, the number of committed and discretionary activities with no time spent per day also increased. Women in HAQ group 3 reported spending no time in significantly more committed and discretionary activities than women in the two better functioning groups.


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  		TABLE 4. Time use summaries by HAQ group

 
Time use and psychological status
Correlation analyses indicated that the more obligatory activities in which women spent >2 h/day, the higher their levels of perceived stress (R = 0.18, P < 0.0001) and depressive symptoms (R = 0.18, P < 0.0001). The more the number of committed and discretionary activities in which no time was spent, the higher their levels of perceived stress (committed: R = 0.17, P < 0.0001; discretionary: R = 0.22, P < 0.0001) and depressive symptoms (committed: R = 0.23, P < 0.0001; discretionary, R = 0.32, P < 0.0001), and the lower their life satisfaction (committed: R = –0.28, P < 0.0001; discretionary, R = –0.29, P < 0.0001).

Regression analyses controlling for age, education, marital status, pain severity and HAQ yielded results similar to the correlations for committed and discretionary activities (Table 5). A greater number of committed activities in which no time was spent was associated with higher levels of depressive symptoms and lower life satisfaction, but was not associated with perceived stress; a greater number of discretionary activities in which no time was spent was associated with greater perceived stress, higher levels of depressive symptoms and lower life satisfaction. After controlling for covariates, however, the number of obligatory activities with >2 h was not significantly associated with psychological status.


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  		TABLE 5. Time use and psychological well-being

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusion
 Acknowledgements
 References
 
In these analyses, we had expected to observe different patterns of time use among individuals with different degrees of functional limitations. Specifically, we expected that individuals with the greatest limitations would spend more time in obligatory activities and less time in committed and discretionary activities. In general, results were consistent with these hypotheses. Individuals with the highest HAQ scores were more likely to spend >2 h/day in personal care, resting and doing things to take care of their RA. These individuals were also more likely to spend no time at all doing housework, paid work, leisure activities outside the home, hobbies, recreational activities and volunteer work. Taken together, the findings present a very different picture of the balance of activities in daily life between women with few functional limitations and women with greater limitations, a picture consistent with previous findings among other groups with disabilities [7, 26, 27]. Having to spend more time on obligatory activities appeared to cut into time available to spend on productive and free-time pursuits, corresponding to Backman's definition of time use imbalance [28].

Individuals’ daily activities are typically composed of a mix of obligatory, committed and discretionary activities. Achieving ‘balance’ in life activities usually entails spending an adequate amount of time in each domain [28]. Previous studies have found that having a satisfactory balance of activities makes a substantial contribution to health and well-being [9, 29–32], whereas dissatisfaction with the balance of life activities appears to be associated with poor health status ratings [9]. Individuals whose life satisfaction was low have been found to spend less time in recreation and work, and more time in rest and daily living tasks compared with those whose life satisfaction was high [31]. Conversely, participation in leisure activities has been shown to be especially important for physical and mental health [32] and for perceived balance of life activities. Our findings are consistent with this previous work. We found that imbalance in time use was associated with disruptions in psychological well-being—higher levels of perceived stress, depressive symptoms and lower life satisfaction.

It is possible that these different patterns of time use are the result of inability to perform certain activities or relinquishment of activities to preserve time and/or energy. Some research would suggest that relinquishment of activities is a fairly common method of coping with functional problems. For example, Gignac and colleagues [4, 5] identified several domains of adapting to disability, one of which was ‘selection’. Selection included performing activities less often, giving up or avoiding activities, or restricting or limiting activities. The use of selection processes increased as activities moved from those that would be classified as obligatory (e.g. personal care; selection processes used by 8.7% of the sample) to committed (e.g. household activities; selection processes used by 24.8%) to discretionary (e.g. ‘valued activities’; selection processes used by 36.5%). Our results confirm these previous findings and expand them by presenting the impact of activity loss and/or relinquishment on the daily balance of time use.

The imbalance of time use noted, particularly little time spent in committed and discretionary activities, appears to affect psychological well-being. Research on multiple social roles among women has shown that having fewer ‘productive’ adult social roles (worker, homemaker and parent) is associated with poorer health outcomes [33, 34]. Among the elderly disabled, patterns of time use have been associated with symptoms of depression [35] and quality of life [27]. In RA specifically, the loss of the ability to perform valued life activities in general, and social and recreational activities in particular, has been linked to the development of depression [10, 11]. Thus, the inability to spend any time at all on activities central to important social roles may put women at risk for poor psychological outcomes. Whether these effects differ according to the mechanism of loss (inability to perform vs relinquishment to preserve time or energy) is not known. It should also be noted that the relationship between time use imbalance and psychological status may be bi-directional. In other words, time use imbalance may lead to psychological distress, or psychological distress may shift actual or perceived time use patterns. Longitudinal study will be required to address the causal direction of this relationship.

The retrospective nature of the time use reports raises the possibility of bias or error in reporting. However, in a comparison of methods to study time spent on housework among a sample of husbands and wives, survey methods tended to yield higher estimates of time spent on activities, as compared with other methods of estimating time use [19]. This suggests that if reports of time spent in committed and discretionary activities were biased, that bias would be towards the null, i.e. fewer reports of no time spent in these activities. It is also possible than the time use patterns of these women are different that those of the general population of women with RA, although these findings are broadly consistent with those reported by Yelin and colleagues [3] two decades ago.


   Conclusion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
Acknowledgements
 References
 
The presence of more severe functional limitations among women with RA appears to shift time use towards obligatory activities and away from committed and discretionary activities. These time use imbalances were associated with greater stress, higher levels of depressive symptoms and lower life satisfaction. Whether the respondents in this study considered their time use patterns satisfactory was not assessed, but the association between measures of psychological distress and high amounts of time in obligatory activities on the one hand and low amounts of time in committed and discretionary activities on the other is suggestive. In addition, other studies have shown a link between loss of valued discretionary activities and the onset of depression [10, 11] suggesting that, at least for some, the loss of these discretionary activities creates an unsatisfactory balance of activities. Our findings highlight the risk that individuals with severe functional problems face of being unable to maintain a satisfactory balance of life activities, especially maintaining valued committed and discretionary activities. The findings also suggest the potential negative psychological outcomes that may accompany imbalances of activities and underscore the importance of assisting individuals to maintain important productive, social and discretionary activities.

Formula


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
References
 
We would like to thank Marissa San Pedro and Naomi Friedling for conducting the telephone interviews for this study. Funding was provided by NIAMS grant AR 50015.

The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 Acknowledgements
 References
 

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Submitted 19 April 2006; revised version accepted 14 July 2006.
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