Patients’ Knowledge on Rheumatoid Arthritis presenting with Arthralgia in a Tertiary Care Teaching Hospital, Pakistan

: Objectives: The main aim of this study was to determine the level of knowledge about rheumatoid arthritis disease among patients presenting with arthralgia in a tertiary care teaching hospital, Pakistan. Materials and Methods: A cross-sectional study during the period of September 2015 - March 2016 in the Medical Out-Patient Department, Shaheed Mohtarma Benzir Bhutto Medical University Hospital, a tertiary care teaching hospital in Larkana, Pakistan. Patients above 40 years of age of either gender were included in the study. A non-probability purposive sampling technique was employed to include the participants in the study. A pre-designed questionnaire with open and close ended questions was used. The questionnaire in English language was also translated in local language to facilitate the participants. All the statistical analysis was conducted using Stata statistical software 14. Results: A total number of 251 participants completed the questionnaires. 42 (56.6%) were from rural settings, while 233 (92.8%) were females. The overall mean age was 59 ± 8.69 years. There were 139 (55.4%) of the participants were ≥ 60 years of age. The average BMI was 23.1 ± 4.3. Moreover, 144 (57.4%) participants were found non-educated. The duration of the disease was less than 10 years in 154 (61.4%) of the participants. While, 157 (62.5%) participants were not knowing about factors which contribute to the onset of rheumatoid arthritis. We observed that, on the basis of responses to the relevant questions, only 4 (1.6%) participants were considered fully aware. Conclusion: We observed lack of knowledge in majority of the participants presenting with arthralgia. The public awareness and education through different vertical programs as well as through social media in the country which can play very important role.

It is hypothesized that genetic and environmental factors play their role in the manifestation of rheumatoid arthritis, and the mechanisms of pathogenesis are established. 2 Heritability is the proportion of phenotypic variance that can be attributed to genetic, rather than environmental, causes. Hence the rheumatoid arthritis has a considerable genetic component. However many environmental factors remain largely unknown other than cigarrete smoke, and their contribution to rheumatoid arthritis aetiology is likely substantial. 3 On the other hand the mechanism that underlie the observed sex-bias in the incidence is still unknown. However, sex hormones which may be play a role have been suggested by the Investigators. 4,5 Globally the prevalence of rheumatoid arthritis ranging from 0.1 -1.0% and varies according to geographical location even within the same country. [6][7][8][9] The prevalence of rheumatoid arthritis reported in studies from south of Pakistan was 0.14%, whereas it was reported 0.55% in the northern part of the country. 10,11 According to European League Against Rheumatism (EULAR) recommendations, the treatment of rheumatoid arthritis must be based on a shared decision between rheumatologist. 12 Which means that the patient should be informed and to participate in the decision as to which treatment should be applied. 13 The sources of knowledge and information described in previous studies are different. 13,14 The most preferred sources of information are health professionals, the physician and rheumatology nurse but people have also used other sources, such as newspaper, television, radio, and Internet. However, in the Netherlands it is reported that media play a little attention to provide information on rheumatic disease. 14 We hypothesized that knowledge in patients with arthralgia about rheumatoid arthritis is much less than the studies conducted in other part of the world, as literacy level in Pakistan is very low. 15 Therefore, to test this hypothesis we carried out this study to determine the level of knowledge about rheumatoid arthritis disease among patients presenting with arthralgia in a tertiary care teaching hospital in Pakistan.

Materials and methods:
A cross-sectional study was conducted during the period of September 2015 -March 2016 in the Medical Out-Patient Department (OPD), Shaheed Mohtarma Benzir Bhutto Medical University (SMBBMU) Hospital, a tertiary care teaching hospital in Larkana, Pakistan. Patients were diagnosed by the consultants. Patients above 40 years of age of either gender were included in the study. Patients with history of chronic disease (cardiac diseases, diabetes mellitus, hypertension, and chronic renal failure), addiction, psychiatric illness and on a drug regimen were excluded. Additionally pregnant women were also excluded from the study. A non-probability purposive sampling technique was employed to include the participants in the study. A pre-designed questionnaire with open and close ended questions was used. The questionnaire had three parts. First part was related to basic information on gender age, level of education, living in rural or urban setting, duration of disease, socio-economic status or household income. Second part was mainly related to signs and symptoms as well as previous investigations results. Signs and symptoms includes; joint pain site of pain, intensity of pain, duration of pain, relation to mobility, morning stiffness length and tenderness of joint, presence of skin nodules and treatment if already taking. Third part focused on the etiology, gender predominance and source of information related to rheumatoid arthritis. The questionnaire in English language was also translated in Sindhi as well as in Urdu language for the facilitation of the participants. The informed oral and written consent were taken. The ethical approval was taken from SMBBMU Ethical review committee before conducting the study. The questionnaires were filled by either patients themselves or by the interviewers in case if patient was illiterate. The mean ± SD of numeric response variables as age was calculated. Categorical response variables like gender (M/F), level of education, duration of disease, body mass index, household income were presented in frequency and proportion. All the statistical analysis was conducted using Stata statistical software 14 (Stata Corp LP, 4905 Lakeway Drive, College Station, Texas 77845, USA) where p-value < 0.05 was considered statistically significant.

Results:
Three hundred participants were invited to participate in this study, and two hundred and fifty one (251) participants completed the questionnaires. Forty nine (49) either refused to participate or withdrew from the study. Table 1 shows the descriptive analysis of the study. Of the 251 participants, 142 (56.6%) were from rural settings while 233 (92.8%) were females and 18 (7.2%) were males. The overall mean age was 59 ± 8.69 years. There were 139 (55.4%) of the participants were ≥ 60 years of age.
Regarding the knowledge about rheumatoid arthritis ( Table 2), 153 (60.9%) knew the name of their disease, however majority were knowing the name of rheumatoid arthritis in their local language. Moreover, 204 (81.3%) participants were aware of the symptoms of the disease, while 186 (74.1%) were aware that rheumatoid arthritis can cause deformities and 179 (71.3%) were aware that the disease is predominantly more common in females. More than ninety one percent (91.2%) knew that the treatment for rheumatoid arthritis is available; however 211 (84.1%) participants selected "the lifelong treatment" as an option for duration of treatment. Figure 1 shows knowledge of the participants regarding risk factors which can lead to the onset of rheumatoid arthritis disease. We observed that 23(9.2%) participants realized that, genetics play a role, while only 7 (2.8%) participants were aware that smoking can increase the risk. While 27 (10.7%) participants asked that multiple environmental factors can also contribute in the development of rheumatoid arthritis as a risk factor. However, 157 (62.5%) participants did not know about factors which contribute to the onset of rheumatoid arthritis. We observed that, on the basis of responses to the relevant questions, only 4 (1.6%) participants were considered fully aware.

Discussion:
The main finding of our study is lack of knowledge about the rheumatoid arthritis in majority of the participants presenting with arthralgia. A recent study from Rawalpindi -Pakistan, showed the similar results. 16 Whereas, the studies from other part of the world also showed low level of knowledge in the patients on the self-reported knowledge about different aspects of rheumatoid arthritis. 12,17 However they found significant association with longer duration of the disease. 12 Another important factor of good knowledge was higher number of visits to the rheumatologist and staying at the hospital due to rheumatoid arthritis has been reported. 18 Some other studies reported that rheumatoid arthritis patients know more about the nature and prognosis of disease and treatment principles. 19,20 It was also observed that older people and women knew less about their disease and treatment, while those with higher education had more knowledge. 17,19,21 The lower level of awareness in the patients can also be a potential to become a barrier to treatment of the disease, which can be reduced by providing patient centered disease knowledge. 16,22 As the progression of the disease is quite slow, patients usually do not have enough knowledge and awareness, so they do not visit clinics until the pain becomes unbearable. Rheumatoid arthritis is one of the chronic inflammatory diseases which predominately occur in females. Its treatment has undergone though dramatic changes over the last few decades, according to a recent systematic review 23 which can be summarized as: 1-availability of reliable assessment tools for clinical trials and practice; 2appreciation of the importance of early diagnosis and concomitant start of conventional synthetic diseasemodifying antirheumatic drug therapy, including their combination with low-dose glucocorticoids; 3recognition of the potential to halt or at least minimize damage progression upon attainment of good clinical states; 4-appreciation that methotrexate, if applied in accordance with relevant insights on dose and folate use, is a powerful agent and the anchor drug in RA; 5development and approval of new biologic diseasemodifying antirheumatic drugs. However this is only possible if patients have enough knowledge to report at clinics to become early diagnosed. Lack of public knowledge and awareness can be a major cause of delays in the diagnosis of rheumatoid arthritis. 16,24 The average time from onset of symptoms to the diagnosis of disease is about nine months. 25 While another study showed that the median time from onset of symptom to the treatment was 6.1 months. 24 A British study evaluated the impact of a rheumatoid arthritis disease education leaflet on patient knowledge, reported that the customized education material increased the knowledge among rheumatoid arthritis patients in the first followup. 26 A quasi-experimental study from two states in Australia evaluated public awareness of lower back pain, revealed that higher level of awareness was observed even after three years of completion of campaigns. 27

Strengths and limitations:
Our study has strengths as well as some limitations.
Cross-sectional studies are useful for description, and we chose this design for our study. The interviews were conducted by one of the primary investigator on a pre-designed questionnaire. Sindhi/Urdu language was used for interviews, which allowed communication between researcher and information provider. Which reduces the misunderstanding between interviewers and interviewees, So, if the interviewee did not understand the question, the researcher could explain the question and obtain relevant data. The study was conducted in one tertiary care hospital of the country and did not cover other hospitals of the same level. However, it covers large number of patients from many districts among three provinces (Sindh, Baluchistan and Punjab) of Pakistan. Other limitations of this study include the absence of a comparative group, the small sample size and the limited time. Although our results may not be generalized to the entire Pakistani population, further studies are necessary among other geographical areas of Pakistan.

Conclusion:
We observed a lack of knowledge about the rheumatoid arthritis in majority of the participants presenting with arthralgia. The public awareness and education, particularly in patients with arthralgia should be provided. It can be provided through different vertical programs as well as through social media in the country which can play very important role.

Acknowledgments:
Our deepest appreciations to all the participants of the study.

Protection of humans and animals:
The authors declare that the procedures were followed according to the regulations established by the Clinical Research and Ethics Committee and to the Helsinki Declaration of the World Medical Association.

Data confidentiality:
The authors declare having followed the protocols in use at their working center regarding patients' data publication.

Conflicts of interest:
The authors reported no conflict of interest.

Funding sources:
This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Authors' contributions: MM participated in study design, data collection, data entry, data interpretation, draft writing and editing. MAS, MA participated in study design, data interpretation and editing. OL participated in data interpretation and editing. MHS participated in study design, data analysis and interpretation, draft writing, editing and submission of manuscript. All authors read and approved the final manuscript.