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2009; 31: 230237

Implementing arthritis clinical practiceguidelines in primary care

SYDNEY C. LINEKER1, MARY J. BELL2, JENNIFER BOYLE3, ELIZABETH M. BADLEY4, LOIS FLAKSTAD5,

JOHN FLEMING5, ANNE LYDDIATT5, JANE MACDONALD5, JACK MCCARTHY5 & MICHEL ZUMMER5

1The Arthritis Society, Toronto Western Research Institute, Toronto, 2Sunnybrook Health Sciences Centre, University of

Toronto, Toronto, 3Toronto Western Research Institute, University Health Network, Toronto, 4Toronto Western Research

Institute, University of Toronto, Toronto, 5Getting a Grip on Arthritis Partners Group

Abstract

Background: Multi-faceted interventions are among the strongest methods for changing provider behavior.

Aims: This paper reports the design, implementation and process evaluation of an educational program to disseminate clinical

practice guidelines (CPGs) on the management of rheumatoid arthritis (RA) and osteoarthritis (OA) in primary care.

Methods: Organizations were invited to participate in inter-professional workshops on OA and RA followed by six months ofactivities to support the delivery of care in the community. Confidence in ability to manage arthritis was assessed at baseline using

a 10 point numerical rating scale. Qualitative assessments were done immediately and 312 months post workshop.

Results: 646 multidisciplinary providers from 216 organizations attended one of 30 workshops. Providers ( n 584) reported

moderate confidence in managing arthritis: family physicians: mean: SD7.46(1.42), n 145; nurse practitioners: 6.10(1.84),

n73; other health care professionals: 5.23(2.83), n 389. Participants identified team learning, the opportunity to network and

the involvement of trained patient educators as strong features of the workshops. At follow-up, participants indicated the greatest

impact of the program was on collaborative care (83%) and patient self-management (79%).

Conclusions: Qualitative results suggest that inter-professional learning may be a successful strategy for improving the delivery of

collaborative arthritis care and supporting patient self-management.

IntroductionArthritis and related conditions affect over 4.4 million

Canadians aged 15 years and older and in 2003 accounted

for close to 9 million physician visits (Perruccio et al. 2006).

Most treatment for people with arthritis occurs at the primary

care level yet many studies have documented the need for

improved arthritis management in this environment (Mazzuca

et al. 1991; Holt Jr & Mazzuca 1992; Davis & Suarez-Almazor

1995; Glazier et al. 1996a, 2003; Glazier 1998; Knott 2000;

Jawad 2005). Challenges for providers include, delay

in referring to specialists, and underutilization of non-

pharmacological interventions (Glazier et al. 1996b, 1998,

2003; Beaulieu et al. 2004; Chevalier et al. 2004; Sarzi-Puttiniet al. 2005).

The dissemination of clinical practice guidelines (CPGs)

has been suggested as one method for improving arthritis

service delivery at the primary care level. In a review of CPG

implementation studies, it was concluded that multi-faceted

interventions were among the strongest methods for chan-

ging provider behaviour (Davis & Taylor-Vaisey 1997).

Getting a Grip on Arthritis, a multi-faceted educational

program based on Social Cognitive Theory (SCT) and

targeting primary health care providers (providers), was

designed, implemented and pilot tested in Ontario

Community Health Centres (CHCs) to disseminate CPGs for

the management of osteoarthritis (OA) and rheumatoid

arthritis (RA) (Glazier et al. 2005). The project demonstrated

that an accredited inter-professional workshop on arthritis

best practices followed by a 10-month reinforcement phase

could improve provider and patient outcomes. Arthritis best

practices included patient education, exercise, joint protec-

tion and energy conservation, social support, non-steroidal

anti-inflammatory medications and referral to surgery, with

the addition of weight management, analgesics, and intra-

articular injections for OA, and disease modifying medica-

tions, and referral to rheumatology for RA.

Practice points. Most primary care providers reported barriers and only

moderate confidence and satisfaction in their ability to

deliver arthritis care.

. Inter-professional learning, the opportunity to network

and the involvement of patients were seen as strengths

of the workshop.

. Inter-professional learning may be a successful strategy

for the dissemination of arthritis clinical practice guide-

lines in primary care, improving collaborative care and

supporting patient self-management.

Correspondence: Sydney Lineker, Director of Research, The Arthritis Society, Ontario Division, 393 University Avenue, Suite 1700, Toronto, ON,

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To disseminate and evaluate the program more broadly, a

submission was made to Health Canada and funding was

received through the Primary Health Care Transition Fund

(PHCTF) for implementation of the program in a variety of

primary health care settings across Canada. This paper will

describe the delivery of the program, provider baseline results,

and process evaluation and discuss the practicalities ofnational implementation.

Materials and methods

The Getting a Grip on Arthritis (Grip) program consisted of

three components: health care provider and patient educa-

tional materials, an accredited inter-professional provider

workshop on the evidence-based management of OA and

RA, and six months of reinforcement activities to support the

delivery of arthritis care in the community. Table 1 provides a

description of the program partners (Partners Group) and

their roles in the national implementation. Coordinators witha health background and support staff were hired in each

of Canadas five regions to facilitate implementation over

a 2.5 year timeframe.

Study population and recruitment of health care

providers

Primary health care organizations across Canada (defined

broadly as not-for-profit organizations serving adults with

arthritis and delivering primary health care services) were

invited to participate in the Grip program. All team members

from the participating organizations were then invited by their

site to register for a Grip workshop in their community orregion. To help establish community networks and provide

support for implementation activities, a number of guests

(local rheumatologists, community providers, representatives

of support groups, provincial and regional government

representatives) were also invited.

Needs assessment

A needs assessment included a baseline assessment of

community or regional resources relevant to each participating

site, a survey of participating providers (see ACREU Primary

Care Survey described below (Glazier et al. 1996b, 1998)) and

focus groups with adults with arthritis receiving care at

selected CHCs. The focus groups explored participants

experiences in relation to getting information on arthritis and

their medications, obtaining social support, exercise and

maintaining a healthy weight, accessing care, care receivedand gaps in service.

Intervention

Educational materials:The Partners Group updated materials

from the pilot project following a systematic review of the

recent literature on the evidence-based management of OA

and RA and established CPGs. Materials included a patient

resource kit emphasizing arthritis self-management strategies

and a poster for the public which included prevention

messages related to OA (Rao & Hootman 2004) and

encouraged people with early signs of arthritis to seek care.Materials were reviewed by patients from arthritis consumer

groups across Canada for clarity, appropriate reading level and

relevance. Provider resources consisted of a laminated pocket

card summarizing arthritis CPGs and a prescription pad to

prompt appropriate community referrals.

Workshop on OA and RA: The objectives of the workshops

were to increase provider understanding of arthritis CPGs, to

improve the delivery of arthritis care, to review and improve

their musculoskeletal (MSK) physical examination skills and to

create a plan for local implementation of arthritis best

practices. A sample workshop agenda is provided in Table 2.

Faculty consisted of local multidisciplinary arthritis specialists(rheumatologists, dietitians, physical and occupational thera-

pists, social workers, pharmacists) who received standardized

training and materials.

Content emphasized self-management interventions, the

early identification and differentiation of arthritis, interdisci-

plinary care and appropriate referral. Hands-on skills were

developed through a review of the MSK examination with

trained patient educators (Bell et al. 1997). A communications

module provided an interactive opportunity to discuss the

challenges of inter-professional communications and referral

Table 1. Partners group membership and roles.

Partner RoleArthritis Community Research and Evaluation Unit Ethics submissions, evaluation of project

Arthritis Health Professions Association Identification of local workshop faculty (arthritis specialists), review of educational materials,

communications, dissemination

Canadian Alliance of Community Health Centre Associations Identification of primary health care sites and providers (primary target group for intervention)

Provider input to project, communications, dissemination

C an ad ian N ur se s Asso ci at ion Pri mar y ta rge t gro up f or i nte rve nt ion, c ommun ica ti on s, di sse mi na ti on

Provider input to project

Canadian Rheumatology Association Identification of local workshop faculty, dissemination, communications

Ontario Ministry of Health and Long-term Care Funder of pilot project, identification of primary health care sites and providers in Ontario

Patient Partners in Arthritis1 Trained patient educators for demonstration of the musculoskeletal examination, review of

educational materials

Consumer input to project

Sun nyb roo k Hea lth Sci enc es C en tr e Admin ist ra ti ve a nd c ommu ni cati on s s upp ort

The Arthritis Society Administrative support, oversight, reporting, communications, IT support, regional

implementation

Implementing arthritis guidelines

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(Keely et al. 2002). At the end of the day, providers from each

site or community met in facilitated small group sessions to

discuss implementation of best practices. Participants then

returned to their sites with plans for applying arthritis CPGs

and personal goals to change their practice.

Reinforcement activities: Primary care organizations that sent

providers to one of the workshops were eligible for reinforce-

ment activities during the six months post workshop (e.g.

newsletters, textbooks, referral letter templates). Providers

could request additional support for training and resources to

support the delivery of arthritis best practices in their

communities. All providers were asked to complete a self-

administered chart audit (reflective practice exercise) and to

meet with their team to discuss audit findings and reinforce

best practices. In addition, participating sites were asked to

identify a local public library for the donation of arthritis books

and videos.

Evaluation

At the end of each workshop, participants (faculty, facilitators,

guests and providers) completed a workshop evaluation.

In addition, workshop faculty, guests and group facilitators

were surveyed at the end of the program (three to 12 months

post workshop) to help determine the impact on arthritis care

delivery in the community.

Provider evaluation took place at baseline (needs assess-

ment), and 6 and 12 months post-workshop using a modified

version of the ACREU Primary Care Survey (Glazier et al.

1996b, 1998) which provided information on their character-

istics, their confidence in and satisfaction with the delivery ofarthritis care, their perceptions of barriers to the delivery of

arthritis care and their responses to three case scenarios (early

and late RA, moderate knee OA) reflecting their use of arthritis

best practices (case scenario results and six and 12 month

results will be submitted separately). Perceptions of barriers

to physiotherapy, occupational therapy, social work, rheuma-

tology or orthopedic surgery were measured on a nominal

scale from 1 to 7 with 1no barriers; 2available but waiting

time unacceptable; 3available but travel time unacceptable;

4available but no confidence in service; 5available but

funding barrier; 6not available; 7not sure if available. The

categories were collapsed for analysis with 0no barriers and1barriers. Confidence in the management of arthritis and

satisfaction with their ability to deliver arthritis care were

measured on a 10 point numerical rating scale with 1not at

all confident/satisfied and 10 extremely confident/satisfied.

Providers were also asked to rate the influence of the project

on various aspects of arthritis care delivery (patient self-

management, collaborative care, arthritis prevention and early

detection and access to specialty care).

Sites were invited to participate in the evaluation of patient

outcomes. Eligible patients with a chart diagnosis of RA or OA

(ICD-9 714/715) were surveyed pre-intervention and at 6 and

12 months after the provider workshops. Questions exploredtheir pain, fatigue, self-rated health, disability, best practices

recommendations received from providers, use of best

practices and health professionals visited.

The project received ethics approval from the University of

Toronto, Health Canada and relevant provincial, regional,

university and hospital ethics boards across Canada.

Results

Figure 1 demonstrates the success of the recruitment strategies.

Four hundred and seventy primary health care organizations in

10 provinces were identified that treated adults with arthritis,and 254 sites (54.0%) accepted the invitation to participate in

the program. Once the final workshop dates were set, 38 sites

(15%) withdrew from the project, leaving 216 (85.0%) sites that

sent one or more providers to a workshop. Participating sites

represented several different models of primary health care

Table 2. Sample Getting a Grip on Arthritis workshop agenda.

Time1 Agenda Item2

8:15 Introduction and welcome

Objectives and plan for the day

Burden of illness from musculoskeletal (MSK) disordersOverview of best practices in arthritis

Resource materials

9:00 Communications module

9:15 Exercises for arthritis management Part 1: Range of motion exercises

9:35 Pharmacological and complementary therapies for arthritis

10:35 Break

10:50 Patient Partners in Arthritis: hands-on musculoskeletal examination skills review

12:50 Lunch

1:20 Non-pharmacological Management of Arthritis [Series of 30minute presentations, in rotation]

. Exercise and physiotherapy

. Occupational therapy, joint protection and assistive devices

. Psychosocial interventions and the Arthritis Self-Management Program (ASMP)

. Nutrition and weight management

3:20 Exercise for arthritis management Part 2: Aerobic and strengthening exercises

3:40 Break

3:55 Implementing arthritis best practices/Resource development in your community (small group then report back large group)

5:456:00 Wrap up and next steps, conference evaluation

1Workshop length reduced from 2 days (16 hours) in the pilot in response to participant feedback.

S. C. Lineker et al.

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delivery and included CHCs (22.0%), Centres de sante et

services sociaux (CSSSs) and Groupes de medecine de famille

(GMFs) in Quebec (15.0%), Family Health Networks and

Primary Care Networks in Ontario (5.5%) and other regionally

and federally funded primary health care sites (42.5%).

Seventy-seven adults with OA or RA who were patients at

one of the CHCs participated in the focus groups; 80% of the

participants were female (Adam 2005). Access to care issues

included lack of public/patient education around when and

how to seek care for arthritis, long waits for specialist opinion

and primary health care professionals who were poorlyinformed about arthritis care and management.

Participating sites sent 646 providers to one of 30 work-

shops delivered over a one year period. In addition, 254

providers from other health care agencies (hospitals, rehabi-

litation centres, home care, fee for service clinics) were invited

to enhance networking opportunities, resulting in a total of 900

providers. Due to funding timelines for the evaluation

component, baseline surveys were sent only to participants

attending the first 27 workshops (n 789). Respondents

(n 765) reflected the interdisciplinary model of arthritis

care (nurses: 24%; physicians: 23%; physiotherapists: 19%;

nurse practitioners: 11%; occupational therapists: 11%; otherhealth care providers: 10%; non-clinical staff/students: 2%).

Most providers were female (81%) and worked full time (69%)

At baseline, most primary care providers (n 553) reported

one or more barriers to access rheumatologists (92%),

orthopedic surgeons (91%), and rehabilitation specialists

(occupational therapy: 76%; physiotherapy: 74%; social

work: 65%). Providers reported moderate confidence in

managing arthritis, with physicians reporting greater confi-

dence than nurse practitioners (NPs) and NPs reporting greater

confidence than other health care providers (one sample t-test,

p< 0.001): family physicians: mean: SD 7.40(1.41), n108;

NPs: 6.29(1.62), n45; other health care professionals:

5.37(2.86), n 271. Satisfaction with their ability to deliverarthritis care was also moderate with family physicians

reporting greater satisfaction than both NPs and other health

care providers (Kruskal Wallis test, p< 0.001): family physi-

cians: 6.25 (SD: 1.52, n106; NPs: 4.86 (SD: 1.90), n50;

other health care providers: 4.38 (SD:2.37), n 360). These

results were shared with workshop participants and incorpo-

rated into the workshop content and discussions.

A limited number of sites [(n25 (12%)] consented to take

part in the evaluation of the intervention on patient outcomes.

These results will be reported separately.

A total of 249 multidisciplinary faculty contributed to

workshop content and delivered standardized evidence-based messages. This included 20 Arthritis Self-Management

Program (ASMP) leaders, 26 dietitians, 1 internist, 25

470 primary health care sites

identified and invited to participate

254 sites agreed to

participate

38 sites

withdrew

216 sites sent providers to a

workshop

30 workshops

249 multidisciplinary

faculty

254 community

providers

128 group

facilitators/guests646 primary health care

providers

942/1277 workshop

evaluations (73.8%)

765/789 baseline surveys

(97%) and 395/765# 6 month

follow-up surveys (52%)

207/377 follow-up surveys

(55%) (3-12 months post

workshops)

Figure 1. Recruitment strategies.


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18 rheumatologists, 17 social workers, 3 psychologists, and

94 people with arthritis (Patient Partners in Arthritis).

Following the workshops, 942/1277 participants completed

evaluations (73.8%). This number included participating healthcare providers as well as workshop guests, group facilitators

and faculty. Workshop sessions evaluated well with scores

varying from a high of 18.3/20 for the Patient Partners hands-

on session (joint examination) to a low of 16.7 for the

pharmacological session. Participants were asked to describe

two particularly strong features of the workshop and two areas

needing improvement. As reflected in the quotes in Table 3,

the most common strengths identified included team learning

and the team model of care presented, the opportunity to link

with their peers, arthritis specialists and local resources and the

involvement of people with arthritis (the opportunity for hands

on skill development). Challenges included limited time for

delivery of the content, the mixed needs of the participants,

inconsistent content delivery, and scope of practice issues

relating to who can diagnose and treat arthritis and who can

refer to specialists.

All providers from the 216 enrolled primary health care sites

received at least one reinforcement activity following the

workshop (mean: 6 activities per site). This included arthritis

books and videos for patients, arthritis texts for providers,

community resource lists, referral letter templates to encourage

appropriate referral to rheumatology and follow-up of

personal goals established at the workshops. A chart audit

was sent to providers in 213 sites (99%); 58/151 physicians

(38%) completed the exercise and received Mainpro-C credits.In addition, 98 non-physicians participated in this process.

In addition, 143 sites (66%) ordered educational materials for

their patients or providers. The most common request was for

the Resource Kit for Patients with Arthritis (26,495 copies).

Forty-six sites (21%) requested additional reinforcement

activities that were funded by the project (education materials:

27 requests; staff training: 19 requests). There were also

87 regional or provincial reinforcement activities provided to

support the delivery of arthritis care in the community

(e.g. providing educational materials and professional devel-

opment activities for community providers). Arthritis books and

videos were donated to 159 community or regional libraries.At follow-up, workshop providers (n 395; response rate:

52%) and faculty, facilitators and workshop guests (n 207;

Grip program was on collaborative care in the community

(84.5% and 82.6% respectively) and patient self-management

(83.3% and 75.4% respectively) (Table 4).

Discussion

The Getting a Grip on Arthritis needs-based educational

intervention, grounded in theory and directed to the health

care team, was successfully implemented in 216 primary care

sites across Canada. This study contributes to the sparse

literature on arthritis inter-professional learning and qualitative

feedback and process evaluation strategies suggest that this

educational model may be successful in disseminating arthritis

CPGs and improving patient self-management and collabora-

tive care.Patient focus groups and a provider needs assessment

conducted prior to the intervention identified barriers to care

and issues relating to access to arthritis information and

services. Most providers reported one or more barriers in

accessing specialist and rehabilitation services for their

patients. These same issues have been identified in other

studies (Glazier et al. 1996b, 1998, 2003, 2005; Lineker et al.

1997; Gamez-Nava et al. 1998; Lacaille et al. 2005; Brand &

Cox 2006; Suter et al. 2006). Providers also reported moderate

confidence in and satisfaction with their ability to deliver

arthritis care. Physicians have been shown previously to lack

confidence in their ability to assess and manage musculoske-letal MSK conditions and to be only moderately satisfied with

their ability to deliver arthritis care (Glazier et al. 1996a),

Table 3. Qualitative workshop feedback: Strengths and weaknesses.

Themes: Workshop strengths Qualitative commentsTeam learning/team model of care It also demonstrated that inter professional learning works, and enriches the experience. . .

. . .and an emphasis on team work are strong features of this workshop.

Opportunity to link with local resources Nice to have local speakers so you can have a resource here.

Involvement of people with arthritis Patient Partners: Excellent, phenomenal amazing, reality, super educational

Improved my assessment skills and the background knowledge of services, etc for my patients.

Themes: Workshop weaknesses

Limited time for content delivery Very organized and times were adhered to, but more time needed to be allotted as time frames left presenters too

rushed.

Mixed needs of participants The pharmacological component was difficult to follow need more common drug names during the talk, to help

with understanding.

Inconsistent content delivery The psychosocial and nutritional sessions, in my opinion, were much weaker both in terms of offering practical

recommendations for families in need and in terms of content.

Scope of practice issues He [the pharmacist] should not be telling us how to treat arthritis with medications. He has no clinical experience.

Table 4. Number (percentage) of providers and workshop faculty/facilitators/guests indicating a positive influence of getting a grip on

arthritis on areas of arthritis care at follow-up.

Aspect of arthritis Workshop providersFaculty/Facilitators/

Guestscare delivery N395n (%) N207n (%)

Collaborative care 334(84.5) 171(82.6)

Patient self-management 329(83.3) 156(75.4)

Early arthritis detection 296(74.9) 147(71.0)

Access to specialty care 268(67.8) 145(70.0)

Arthritis prevention 246(62.3) 90(43.4)


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and satisfaction levels in non-physicians, with NPs and other

health providers being less confident and less satisfied than

physicians.

The Grip program addressed these issues by successfully

recruiting 646 multidisciplinary providers practicing in a

variety of primary health care delivery models to participate

in 30 workshops to disseminate arthritis best practices. Theworkshops were well received with participants identifying

team learning, the opportunity to link with local resources and

the involvement of people with arthritis as the main strengths

of the workshops. Trained patient educators have been shown

in previous studies to improve physicians and medical

students skills, knowledge, confidence and attitudes relating

to the management of arthritis (Gruppen et al. 1996; Branch

et al. 1999; Schrieber et al. 2000; Raj et al. 2006). At follow-up,

workshop participants indicated that arthritis collaborative care

was one of the areas in which the program had the most

impact. This supports the federal and provincial governments

primary health care reform efforts to emphasize morecollaborative practice.

Qualitative feedback suggests that this model of learning

supported team care. The workshops provided participants

with an opportunity to meet and network with their team, local

inter-professional arthritis specialists and community providers

(an external team) to discuss the implementation of arthritis

CPGs. A review of knowledge transfer interventions in general

practice concluded that social influence was an important

component of successful interventions (Wensing et al. 1998).

Physicians themselves have indicated their preference for

discussion of guidelines with colleagues (Stone et al. 1999),

and it has been suggested that opportunities for networking

and the use of local opinion leaders may be successful

strategies for influencing the dissemination of research

findings to physicians (Grol et al. 1998; Kaufman et al. 1999;

OBrien et al. 1999; Bellamy et al. 2000; Ray et al. 2001;

Verstappen et al. 2003; Beaulieu et al. 2004; Curtis et al. 2005;

Glazier et al. 2005).

Challenges in workshop delivery included scope of practice

issues and inconsistent content delivery. While involving local

faculty builds capacity and networks in the community,

delivery of workshop content may be variable. This might be

improved through more comprehensive faculty training and

support. Scope of practice issues could be addressed through

inter-professional undergraduate and post licensure trainingthat focuses on the attitudes of providers and emphasizes the

roles of each profession in the management of chronic

diseases (Oandasan et al. 2003; Cook 2005; Hall 2005). In a

study of CHCs in Quebec, conflicting values and beliefs were

shown to influence providers ability to practice in a

collaborative model, and it was suggested that organizational

processes must be in place to support the inter-professional

roles of providers (Sicotte et al. 2002).

Social cognitive theory (Bandura 1986) suggests that

reinforcement of learning is important and this program

included multiple methods for reinforcing the key messages

delivered at the workshops. All sites received at least one formof reinforcement and some sites (21%) took advantage of

opportunities presented for professional development and

copies of the Patient Resource Kit emphasizing self-manage-

ment strategies. At follow-up, workshop participants reported

that the program had an important impact on patient self-

management. This has potential to improve patient outcomes

and reduce health care utilization and costs (Lorig et al. 1993,

1999, 2001a, 2001b; Lorig and Holman 2003). Only a small

number of the physicians (38%) participated in the reflectivepractice exercise required for accreditation suggesting that

continuing health education credits may not be a strong

incentive for participation. Further studies are required to

understand the strategies that influence provider participation

in ongoing learning activities and behaviour change in primary

care. Analysis of the 6 and 12-month provider surveys will

provide the opportunity to further examine the effectiveness of

this program and the factors that influence the uptake of CPGs

in this environment.

In summary, qualitative results suggest that successful

implementation strategies included opportunities for team

learning and networking, local inter-professional faculty actingas credible role models, the involvement of people with

arthritis, and the provision of reinforcement strategies to

support the delivery of arthritis care in the community. If

follow-up surveys show improved provider use of arthritis best

practices and changes in patient behaviour, this model for the

dissemination of CPGs could be adapted for other audiences

(hospitals, home care settings, clinics, rehabilitation centres,

fee for service environments, aboriginal communities) or to

address other types of arthritis or other chronic diseases.

Acknowledgements

The research team would like to thank the staff and patients of

the participating primary health care organizations across

Canada and the 155 health professionals and 94 Patient

Partners that participated in workshop delivery. We would

also like to acknowledge the significant contributions of

Annette Wilkins and Paula Veinot and all the staff and students

at ACREU who participated in the evaluation phases of the

project and the many Arthritis Society staff, both nationally and

provincially, in particular, the regional staff responsible for

project implementation: Lois Chafe, Iris Bussey, Jane

Bannister, Jocelyne Gadbois, Jennifer Vezina, Sheila Renton,

Nancy Violette, Sylvia Jones, Corey Olson, Wendy McCrea,

Marja Kauppi and Kathryn Hatashita-Lee. Special thanks toJoel Scarf for his efforts coordinating the project and

supporting the team.

Notes on contributors

SYDNEY LINEKER was Director of the project and co-principal investigator

on the Health Canada grant that funded this project. She was responsible

for the overall administration of this national project and was a member of

the evaluation team.

MARY J. BELL, was co-principal investigator on this grant, Scientific Advisor

to the project and member of the evaluation team and presented at several

of the workshops. She was responsible for coordinating the involvement of

the rheumatologists in this project and was the key link with the CanadianRheumatology Association.

JENNIFER BOYLE managed all phases of the project evaluation including


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and training of students and other research staff involved in the project and

dissemination of results through poster presentations and abstracts.

ELIZABETH M. BADLEY was a member of the Partners Group and

responsible for the overall evaluation of this project. She provided scientific

advice on all phases of the research including design of the evaluation of

the pilot and national implementation (workshop evaluation, qualitative

and quantitative evaluations).

LOIS FLAKSTAD, JOHN FLEMING, ANNE LYDDIATT, JANE MACDONALD,JACK MCCARTHY, MICHEL ZUMMER, Members of the Getting a Grip on

Arthritis Partners Group were involved in the design, implementation

and evaluation of the project, engaged members of their organizations in

the project as needed and disseminated results.

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