7 million Americans (usually over age 45). Furthermore, if one takes into account that many of these disorders have been attributed to the way that the female body has been adversely manipulated in patriarchic society, then this can also be seen as a determining social factor that impacts women with osteoarthritis.

Psychological factors also play a role in this condition and can reduce the quality of life for the patient. As a study by Fujita et al. (2006) states, "…our study revealed several problems that have not been mentioned to date, such as an inferiority complex related to abnormal posture prior to THA and distress over body image after undergoing THA" (Fujita et al. 2006. p. 81). THA refers to total hip arthroplasty and OA to osteoarthritis.

In conjunction with this aspect is the real problem of coping with pain and disability that this condition brings. As the above-mentioned study states, "Coping with pain and physical disability seem to be predominant features of patients with advanced-stage OA…Baird (2000) characterized the experience of elderly female patients with OA as "living with pain" and "living with difficulty…" (Fujita et al. 2006. p. 81). This aspect is underlined by an important study from the University of Ontario entitled Personal experience of living with knee osteoarthritis among older Adults ( 2006). The authors of this study found that, among others, "…experiencing mobility limitations devalues self-worth" (Maly and Krupa, 2006, p. 1423). The study also emphasizes that there has been relatively little research on this aspect and on the related and concomitant factors that impact the patient. This is an important aspect as it refers to the actual experience of this condition among older women. The following quotation provides some insight into these experiences.

For & #8230; females, the pain associated with knee OA was the most intense pain of their lives. One woman spoke at length about the experience of pain. Nobody likes pain, believe me . . . With this, how long does it go? When is it going to stop? I can't handle this no more . . . Pain is dominant, it, it took over everything. Your brain becomes so taken and your mind, you think pain, you see pain, you feel pain, you LIVE pain. You're just lost. Its constantly your focus in life. (Maly and Krupa, 2006, p. 1426)

Implications for Professionals, Community and Nursing Practice

One implication that can be clearly derived from the varied determinants is that a receptive and involved mode of nursing is required. This refers to a "…therapeutic relationship between patients and health professionals" which should focus on a "…positive approach to rehabilitation" (Walker, 2009. P.35). A related implication for nursing practice is that the nurse should encourage and motivate the individual's ability to manage her condition. This is aimed at increasing the patient's sense of self- empowerment as well as reducing"… reliance on health services and pharmacological therapies" (Walker, 2009. P.35). Nurses also have the responsibility of providing knowledge and information to the patient that can increase her quality of life.

However what should always be borne in mind is the complexity of this condition and the variety of aspects that need to be catered to. Community nursing is an important area in this regard as it is through this more intimate form of contact that the various social and environmental factors affecting this condition can be addressed. For example, there is a paucity of common knowledge about this condition among sufferers that the community nurse can remedy. Many people believe that forms of arthritis are not able to be treated and they are often not aware of remedies and available treatments. The community nurse may also be able to deal with challenges and issues that are not formally received.

In essence, health professionals at all levels have to be aware of the areas of concern in this condition, especially among older female patients. A more comprehensive and inclusive approach and strategy is essential in dealing with these problematics. This will be explored in the following sections.

Political Action Strategy

Osteoarthritis is a political issue for a number of reasons. First, it can be related to aspect of female marginalization and advancement in society. In other words, the fact that the older women is sometimes prejudiced against is exacerbated by the issues and effects of osteoarthritis. However, osteoarthritis is a political issue in many other senses as well and one of these is the area of medical treatment and the use of alternative medicines and medical treatments.

It is well-known that conventional medicines are not particularly effective when it comes to this condition. This has led to the adoption,...

White and Kawakita ( 2006) state that;
…. acupuncture for osteoarthritis of the knee has a biological effect, has a large clinical effect in practice, has negligible risk, and has a cost effectiveness which is well within the usual acceptable limit. On the present evidence, acupuncture is likely to offer an alternative to treatment with non-steroidal anti-inflammatory drugs (NSAIDs). (White and Kawakita, 2006, p. 71)

However, these treatments are often not subscribed to by the scientific and medical fraternity as well as by the culture, and this imposes a barrier to effective treatment. Coupled with this is the fact that these alternative treatments are often less expensive than conventional medicine. White and Kawakita ( 2006) conclude that, "On present evidence, acupuncture is likely to provide a replacement for NSAIDs, being at least equally effective, probably more cost effective, and much safer" ( p.72).

The above is one example of the political context of the treatment of osteoarthritis that the nursing and healthcare professional has to take into account in the creation of an action plan or strategy. Any action plan should therefore be cognizant of the many political, environmental and cultural factors that may impact the patient. What is also clear is that any action plan or strategy must take place on a number of different but interrelated levels which will include all the stakeholders. One could also include aspects such as differences in race as a factor in osteoarthritis. For example, it has been found that this illness is more severe among African-Americans than whites. Therefore, differences in the experience of this condition can be related to "…personal experience, cultural definitions, and the social interactions that develop around illness" (Silverman, Myrna et al. 2008)

The first of these levels applies specifically to the professional nurse. In order to counteract the possible negative impact of social and environmental determinants that the patient may experience, the nurse should adopt a patient -- centric and interactive approach to care. As noted previously, patients with osteoarthritis often require "… variable health care, and many report challenges in gaining access to appropriate care ('falling between the gaps in provision of care'). In some circumstances, specialist and community services send out mixed or confused messages about what to do and where to seek help & #8230;" (Oliver, 2009) in this light policy directives from medical authorities need to emphasize as more extensive, inclusive and wide-ranging care strategy. Health authorities have realized this and have recently have advocated "…a patient-centered approach using an individualized care plan and support from a key worker" (Oliver, 2009, p.30). This is an important aspect and one that is still in need of work and research.

The strategy that would best help the patients would therefore involve all levels of healthcare, from the nursing staff to those who implement policy. This strategy also applies to the aforementioned social and other determinants, where interaction between the nursing staff sand medical authorities is essential.

What is continually mentioned in the literature is a greater awareness of the comorbid and concomitant factors related to this condition and the way that these affect quality of life. For example, the use of certain problematic drugs such as co-proxamol in the treatment of osteoarthritis has raised questions treatment and the viability of alternative medication.

This awareness also extends to other areas. As Oliver ( 2009) states with regard to the assessment of pain in the osteoarthritis patient:"…nurses frequently fail to provide adequate objective assessment, treatment or support to manage pain" (Oliver, 2009, p.30). An action plan would therefore involve at a fundamental level a more comprehensive analysis of the situation of the patient. In terms of management many studies reiterate the importance of the community nurse. However, at the same time they also note areas of concern in this regard. "The personal challenges for the individual patient are often poorly supported by community teams, with many vulnerable patients struggling to negotiate between different healthcare teams" Oliver, 2009, p.31). This is as concern that applies to other levels and dimensions of the treatment of this condition. In the final analysis there is therefore a need rto more clearly identify the needs and problems that these patients experience.

Conclusion

The issue of osteoarthritis is one that has been conclusively shown to affect many middle-aged women. While there are genetic and hormonal causative factors for to this condition,…