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Original Research (Original Article)
IJMDC. 2020; 4(3): 668-675

Ahmad Ali Hazzazi et al, 2020;4(3):668–675.

International Journal of Medicine in Developing Countries

## Population awareness about rheumatoid arthritis in Jazan region, Saudi Arabia

### Ahmad Ali Hazzazi1*, Mohssen Hassen Ageeli1, Ahmed Ali Muyidi1, Abdulaziz Mohammad Abulgasim1, Abdullah Ahmad Yateemi1, Nabil Alhakami2

Correspondence to: Ahmad Ali Hazzazi

*Faculty of Medicine, Jazan University, Jazan, Saudi Arabia.

Full list of author information is available at the end of the article.

Received: 13 December 2019 | Accepted: 09 January 2020

## ABSTRACT

### Background:

Low awareness about rheumatoid arthritis (RA) in the general population was associated with poor outcomes and delayed diagnosis. Raising public awareness about RA is the first step to improve early diagnosis and treatment. We aimed in this study to explore Jazan population awareness about RA.

### Methodology:

A cross-sectional study conducted in Jazan region, Saudi Arabia using a multistage cluster random sampling technique used. Eight primary health care centers (PHCCs) were selected. People visited these PHCCs during the period from 25 August to 25 September were included. Descriptive statistics were performed. Chi-square test was used to compare knowledge among categorical variables. Independent sample t-test and analysis of variance was calculated to find an association between mean knowledge score and demographic variables with two categories and more. p-value < 0.05 indicated statistical significance.

### Results:

A total of 678 participants answered the survey. The mean age of the participants was 34.05 ± 12.22 years. Of the participants, 59.7% were females. The average correct responses of the knowledge about the symptoms of RA was 38.54%, epidemiology and diagnosis 38.74%, risk factors and disease impact 42.47%, features that differentiate Osteoarthritis and osteoporosis from RA was 30.43% and 34.40%, respectively. Connection to RA, Increasing age, higher education, and income more than 10000 SR were associated with better knowledge.

### Conclusion:

The study population had poor knowledge about RA which may be associated with the delayed seeking of medical advice for non-diagnosed patients and non-desirable consequences to the patients. Better knowledge among those connected to RA gives good chances for educational interventions to succeed.

### Keywords:

Jazan, population, knowledge, awareness, rheumatoid arthritis, rheumatic disorders.

## Introduction

Rheumatoid arthritis (RA) is a major immunological inflammatory disease. Globally, the frequency of RA is growing up with significant disability and death rates [1]. Features of RA are demonstrated in the swelling, tenderness, and damage of synovial joints, which might lead to intractable incapacity and early mortality [2]. Low awareness about RA in the general population is associated with poor outcomes and delay in the diagnosis and raising public awareness of this disease is the first step to improve early diagnosis and treatment of RA [3]. In this setting, we conducted this study to explore Jazan population awareness about RA.

## Subjects and Materials

This is a cross-sectional study conducted during the period from 25 August to 25 September 2019. Multistage cluster random sampling technique was used. We classified Jazan region into three geographically distinct zones, the mountain, plain, and coastal zones. Two primary health care centers (PHCCs) from the mountain, two PHCCs from the coast, and four PHCCs from plain zones were selected randomly with proportional distribution according to the population size of each zone. Based on the 2010 census, Jazan population was 1,374,845. Populations of the mountain, Coast and plain zones were 214,423 (15.6%), 259,124 (18.8%), and 901,298 (65.6%), respectively. Based on the formula our sample was 666 participants. We collected data represented the population of each zone as the following: from mountain zone 104 (15.6%), coast zone 125 (18.8%), and plain zone 437 (65.6%) participants included. The participants were the visitors to these PHCCs. Sample size determined by:

$\text{n}=\frac{{\left(1.96\right)}^{2}×\left(0.5\right)×\left(1-0.5\right)}{{\left(0.038\right)}^{2}}=666$

Data collected through interviews with a questionnaire developed based on relevant literature. The questionnaire divided into six parts including demographics, participants' characteristics, knowledge source, knowledge about the cause, the epidemiology and diagnosis, the risk factors and RA effect on the patients, and the features differentiate osteoarthritis (OA) and osteoporosis (OP) from RA. Informed consent was a prerequisite to participate in the study. This study was approved by Jazan hospital institute review board with approval no. 1925. All variables were coded and verified. Descriptive statistics were performed. Then, presented in tables and graphs as frequencies and percentages for categorical variables. Correct answers were given one point and incorrect answers were given zero. The average of correct responses then calculated and compared among groups. A chi-square test was used to compare knowledge among categorical variables. Independent sample t-test and analysis of variance were calculated to find an association between mean knowledge score and demographic variables with two categories and with more than two categories, respectively. p-value < 0.05 indicates statistical significance.

## Results

### Demographic characteristics

A total of 678 participants included in our study. The mean age of the participants was 34.05 ± 12.22 years. Of the respondents, 59.7% were females. The majority were married (61.6%) and 31.9% were single. About half of the participants (51.8%) were university students or with higher education, 41.7% with formal education and only 6.5% were illiterate. Of all participants, 51.6% were living in urban areas. The unemployed participants were 45.7%. Demographic characteristics are presented in table 1. Near half of the participants (44.69%) indicated that they have no awareness about RA while others indicated that they are aware because they have RA (7.82%), have a friend with RA (9.88%), have a relative with RA (20.21%) or saw information about RA on the media/internet (17.40%) as shown in Figure 1.

Table 1. Demographic characteristics of study participants.

Variable N %
Age 34.05 ± 12.22 years
Gender
Male 273 40.3
Female 405 59.7
Marital status
Single 216 31.9
Married 414 61.1
Divorced 28 4.1
Widow 20 2.9
Education
Illiterate 44 6.5
Formal education 283 41.7
University and beyond 351 51.8
Monthly income
<2,000 140 20.6
2,000–4,999 140 20.6
5,000–10,000 203 29.9
>10,000 195 28.8
Residence
Rural 328 48.4
Urban 350 51.6
Occupation
Employed 290 42.8
Unemployed 310 45.7
Student 78 11.5

Figure 1. Source of knowledge about RA.

### Knowledge about the symptoms of the disease

The average of correct responses of the knowledge about RA symptoms for all participants was 38.54%. People who have a connection with RA (those who have RA themselves, have relative/friend with RA or had read about RA) have better knowledge about RA symptoms compared to those without connection. Around half of those with connection to RA (56.4%) recognized joint swelling as a symptom of RA compared to others (44.2%) (p = 0.002). When looking at those who recognized movement limitation as a symptom, only 51% of those with connection to RA acknowledge this compared to 41.1% of the others (p = 0.012). Also, more than half of those with the connection of RA recognized morning stiffness as a symptom compared to only 37.5% of the others (p = 0.000). A low percentage of people with a connection to RA (14.8%) recognize joint deformity as a symptom and similarly among the others (15%) (p = 0.950). Unexpectedly, around one-fifth of those with connection to RA (20.6%) thought migraine is a symptom of RA compared to a lower proportion of those without connection to RA (6.9%) (p = 0.000) (See Table 2).

### Knowledge about the epidemiology and diagnosis of RA

Overall, the average of correct responses was 38.74%. As expected, those with a connection to RA were more aware than others about the epidemiology of RA (average correct responses 41.5% vs. 37.07%). However, only 15.6% of those with connection to the disease and 22.8% of others were able to indicate that RA is an autoimmune disease (p = 0.000). About two-thirds of those with connection to the disease (63.8%) were aware that women are more susceptible to develop RA than men compared to 45.6% of the others (p = 0.000). Near equal correct responses to the statement that RA can affect young people was found between the two groups (p = 0.544). In contrast, 63.8% of those with connection to RA and 74.3% of others believe that RA could be cured completely with surgery (p = 0.004). Agreement with the point that RA patients should restrict exercise was found in 75.5% and 83.4% of those with connection to RA and others, respectively. To be diagnosed with RA, 66.9% of those with connection to RA and 79.3% of others falsely believe that general practitioners (GPs) can diagnose RA easily (p = 0.000). More than 90% of participants believe that RA is can be diagnosed by orthopedics easily (See Table 3).

Table 2. Knowledge about the symptoms of RA.

Knowledge questions RA patient or has Family/friend with RA (N = 257) No relation with RA (N=421) p-value
Responses with “True” N (%)
Joint swelling(T) 145 (56.4) 186 (44.2) 0.002
Vomiting(F) 10 (3.89) 10 (2.4) 0.258
Morning stiffness(T) 151 (58.8) 158 (37.5) 0.000
Movement limitation(T) 131 (51) 173 (41.1) 0.012
Migraine(F) 53 (20.6) 29 (6.9) 0.000
Joint deformity(T) 38 (14.8) 63 (15) 0.950
Average correct responses (%) 45.25% 34.45%
Average correct responses for all (%) 38.54%

p-values expressed in BOLD indicates statistical significance (p < 0.05).

T (true) indicates the correct symptoms of the disease.

F (False) indicates incorrect symptoms of the disease.

Table 3. Knowledge about the epidemiology and diagnosis of RA.

Knowledge questions RA patient or has Family/friend with RA (N = 257) No relation with RA (N = 421) p-value
Responses with “True” N(%)
Cause of RA (T) 40(15.6) 96(22.8) 0.000
Women are more likely to have RA than men (T) 164(63.8) 192(45.6) 0.000
RA occurs in young people (T) 116 (45.1) 180 (42.8) 0.544
RA can be cured with surgery (F) 164 (63.8) 313 (74.3) 0.004
RA patients are better to restrict exercise(F) 194 (75.5) 351 (83.4) 0.012
GPs can diagnose RA easily (F) 172 (66.9) 334 (79.3) 0.000
Orthopedic surgeon can diagnose RA easily(F) 239(93) 402 (95.5) 0.166
Average correct responses (%) 41.5% 37.07%
Average correct responses for all (%) 38.74%

p-values expressed in BOLD indicates statistical significance (p < 0.05).

T (true) indicates the correct statement about the disease.

F (False) indicates an incorrect statement about the disease.

### Knowledge about the effect of RA on individuals and the risk factors

The overall average of correct responses about the impact of the disease was 42.47%. People with a connection to the disease (42.4%) were more aware than others (33%) that RA can negatively affect a person's life expectancy (p = 0.014) and (63.4% vs. 53.4%) agreed that RA can negatively affect a person’s ability to walk short distances (p = 0.011). They were more aware that RA affects the internal organs of the body. However, this did not reach statistical significance (p = 0.057) (See Table 4). The risk factors identified by the participants are shown in Figure 2. Being obese or overweight incorrectly was the most identified risk factor for RA at nearly equal proportions of those with relation to RA (62.26%) in comparison with other participants (61.52%). However, 45.14% and 22.18% of those with a relation to RA correctly identified genetics and smoking as contributing factors in the development of RA, respectively. However, exercise was incorrectly identified as a risk factor for RA development by 8.56% of those with connection to RA and 10.69% of those without connection.

Table 4. Knowledge about the effect of RA on individuals.

Knowledge questions RA patient or has Family/friend with RA (N = 257) No relation with RA (N = 421) p-value
Responses with “True” N (%)
RA can negatively affect a person’s life expectancy(T) 109 (42.4) 139 (33) 0.014
RA can negatively affect a person’s ability to walk short distances(T) 163 (63.4) 225 (53.4) 0.011
RA affects the internal organs of the body(T) 97 (37.7) 129 (30.6) 0.057
Average correct responses (%) 32.19% 39%
Average correct responses for all (%) 42.47%

p-values expressed in BOLD indicates statistical significance (p < 0.05).

T(true) indicates the correct statement about the disease.

Figure 2. Knowledge about the risk factors of RA.

### Knowledge about features that differentiate other similar diseases from RA

The average correct responses about the features that differentiate OA and OP from RA was 30.43% and 34.40%, respectively (see Table 5). People with a connection to RA have better knowledge than others (average correct responses 31.90% vs. 29.53% for OA and 37.50% vs. 32.90 for OP). Statistically, a significant difference was found between those with connection to the disease (57.2%) and others (46.8%) in recognizing correctly that OA is different from RA by which OA has a relation to body weight (p = 0.009). Agreement about that OA could be cured with surgery was found only in 10.9% and 15.7% of those with connection to RA and others, respectively. A similar proportion among the two groups (27.6% vs. 26.1%) believes that OA is associated with joints pain during movement. Compared to people without connection to RA, 43.6%, 27.6%, 22.6%, 19.1%, and 13.6% of the participants with connection to RA incorrectly indicated that OA is related to vitamin D deficiency, OA is associated with joint deformity, OA is associated with morning stiffness, OA is an autoimmune disease and is associated with increased risk of fractures, respectively. On the other hand, about two thirds (64.6%) of those with connection to RA and 52.3% of others correctly identified that OP is related to vitamin D deficiency (p = 0.002). Low but similar proportions among the two groups (14.8% vs. 13.1%) recognized that OP may be associated with short stature (p = 0.527). Similarly, about one third among each of the two groups (33.1% vs. 33.3%) correctly acknowledged that OP is associated with a high risk of fractures (p = 961).

Table 5. Knowledge about the difference between RA and other similar diseases.

Knowledge questions RA patient or has Family/friend with RA (N = 257) No relation with RA (N = 421) p-value RA patient or has Family/friend with RA (N=257) No relation with RA (N=421) P-value
Responses with “True” N (%) Responses with “True” N(%)
Osteoarthritis is … Osteoporosis is …
An autoimmune disease(F) 49(19.1) 57(13.5) 0.055 33(12.8) 50(11.9) 0.710
Related to weight(T)# 147(57.2) 197(46.8) 0.009 91(35.4) 134(31.8) 0.337
Related to Vit. D deficiency(T)** 112(43.6) 170(40.4) 0.412 166(64.6) 220(52.3) 0.002
Associated with joint deformity(F) 71(27.6) 88(20.9) 0.045 59(23) 67(15.9) 0.022
Can be treated by surgery(T)# 28(10.9) 66(15.7) 0.080 29(11.3) 58(13.8) 0.346
Associated with morning stiffness(F) 58(22.6) 97(23) 0.887 51(19.8) 53(12.6) 0.011
Associated with short stature(T)** 21(8.2) 28(6.7) 0.458 38(14.8) 55(13.1) 0.527
Associated with a high risk of fractures(T)** 35(13.6) 78(18.5) 0.096 85(33.1) 140(33.3) 0.961
Associated with joint pain with movement(T)# 71(27.6) 110(26.1) 0.669 62(24.1) 114(27.1) 0.395
Average correct responses (%) 31.90% 29.53% 37.50% 32.90%
Average correct responses for all (%) 30.43% 34.40%

p-values expressed in BOLD indicates statistical significance (p < 0.05).

T; true, F; False.

**Correct features of osteoporosis but incorrect for osteoarthritis.

#Correct features of osteoarthritis but incorrect for osteoporosis.

### Total knowledge score and demographics

Knowledge differences between age groups were significant (p = 0.005) (see Table 6). Further analysis found participants aged more than 40 years or aged 26–40 years have higher knowledge compared to those less than 26 years old (p = 0.003 and 0.006, respectively). Education level can affect the knowledge about RA, too (p = 0.001). Those with a university education or beyond have higher knowledge than those with formal education (p = 0.000). Participants with a monthly income of more than 10,000 Saudi riyals were more knowledgeable than those with lower income (p = 0.002). However, Gender, marital status, living area, and occupation did not significantly affect the knowledge about RA.

## Discussion

Poor patients' awareness and ignorance of early symptoms of RA and limited access to the rheumatologists were important obstacles to seeking early medical care. Consequently, patients seeking medical care once the disease impacts their performance [6]. Therefore, population awareness of RA symptoms is greatly important. In this study, the average awareness about RA symptoms was 38.54%. likewise, one study conducted in the UK found 40% only aware of RA symptoms[3]. Additionally, Simon et al found a limited understanding of RA symptoms among the general population [7]. In our study, the elderly have better knowledge than the young population. Many other studies had reported similar findings as in the UK [3] and Netherlands [4]. This indicates that younger people have less desire to seek early medical advice at the onset of the symptoms [3]. In the same way, the Netherlands study found young population has less use of the media to get information about RA than the elderly [4]. Education level was associated positively with the knowledge in our study. Similarly found among Turkish RA patients [5] and Netherlands population [4]. Among our people, 20% only identified RA as an autoimmune disease. Similarly, found in Taif City, Saudi Arabia [8]. Lack of knowledge about the cause of RA found among RA patients in which 71% consider joints injury as a cause of RA [9]. Among the Portuguese population 72% beliefs that RA may be caused by poor diet, and cold and damp weather [10]. The same beliefs found among 70% Netherlands of the population [4].

In our study, 52.5% of people were aware that women are more susceptible to RA. In the UK they found few people 28 % were aware of this fact [3]. One study among RA patients found 58% believed that women are more affected by RA [9]. The Majority in our study (80.33%) falsely believed that RA patients are better to restrict exercise. One study in Turkey reported 30% of RA patients believed that RA patients should avoid exercises during disease activity [5]. In the UK, 34% of the population falsely believed that exercise promotes disease progression [3]. In contrast, 82% of Portuguese and 74.6% of Netherlands populations were aware that rheumatic patients should not restrict exercises [10]. Our study, 43.6% know that RA can occur in young people and 29.6% identified RA cannot be cured by surgery. Better knowledge reported in the UK as 78% of the population was aware of the occurrence of RA in young people and 68% identified the RA cannot be cured by surgery [3]. Among RA patients 80% thought RA could occur at any age and 92% indicated that RA is incurable disease [9]. Among the Portuguese population, 86% indicated falseness of the statement that RA occurs only in elderly women [10] and 88.5% among the Netherlands population [4]. One of the most important and difficult challenges that worsen RA patient's conditions is the delayed diagnosis and management. The patients postpone medical checking and the physicians face difficulty in the diagnosis of RA early due to non-specific features [11]. Three months of delaying the diagnosis and management were associated with more progression of the disease, worsening functional status and radiographic features. For this reason, it has been recommended that disease-modifying anti-rheumatic drugs (DMARD) treatment be initiated within the first three months after the onset[12-17]. One cohort study concluded that RA patients who were treated by a rheumatologist continuously were significantly lower in the functional disability than those treated intermittently or by other providers [18]. Another study was found the earliest rheumatologist consultation related to less need for surgical interventions [19]. These findings justify a recommendation for the early referral of individuals suspected to have RA to the rheumatologists as recommended by The National Institute for Health and Care Excellence (NICE) and Emery et al [11,20]. Raciborski et al found 95% of the patients sought care from General Practitioner (GP) and 43% from orthopedics. Nearly 21% of RA patients visited four or more physicians before they met the rheumatologist. Two-thirds were wrongly referred to non-rheumatologists. Another problem is the delayed appointments from the rheumatologists as they found 25% of the patients had their appointments after 4 months from referral [6]. In Saudi Arabia one study found 96.8% of the patients met non-rheumatologist at the onset, most of them visited the orthopedics firstly (67.2%). However, 75.6% of them were diagnosed finally by rheumatologists. Absence of hand and fatigue manifestations, living in a rural area, and the patients' postponement of medical checking were the most important causes for the diagnosis delay. On average these patients visited 4 physicians before reaching accurate diagnosis [21]. In our study about three-fourth of participants incorrectly believe that the GP can diagnose RA easily. The striking point is that the overwhelming majority of our people (90%) mistakenly believe that orthopedics can diagnose RA easily. This poor awareness about the proper way of diagnosis prone the patients to significant delays for diagnosis and management which can cause catastrophic consequences.

Table 6. Knowledge mean scores among different demographic characteristics.

Variable Variable level N Mean (SD) p-value
Age ≤ 25 years 192 6.69 (3.21) 0.005*
26–40 years 324 7.48 (3.18)
> 40 years 162 7.69 (2.97)
Gender Male 273 7.04 (3.13) 0.071#
Female 405 7.48 (3.18)
Marital Status Unmarried 264 7.10 (3.23) 0.202#
Married 414 7.42 (3.12)
Education Illiterate 44 7.36 (3.11) 0.001*
Formal education 283 6.80 (3.18)
University and beyond 351 7.71 (3.10)
Monthly Income ≤ 10,000 483 7.07 (3.21) 0.002#
> 10,000 195 7.89 (2.95)
Residence Rural 238 7.31 (3.24) 0.935#
Urban 350 7.29 (3.09)
Occupation Employed 290 7.59 (3.06) 0.120*
Unemployed 310 7.12 (3.22)
Student 78 6.99 (3.25)

p-values expressed in BOLD indicates statistical significance (p < 0.05).

*Results of independent- sample t-test.

#Results of analysis of variance test.

Our population awareness about the impact of RA is generally poor. Their awareness is poorer than the UK population as only 36.57% know that RA can negatively affect a person’s life expectancy versus 52% in the UK and 57.22 % only agreed that RA can negatively affect a person’s ability to walk short distances versus 80% in the UK. However, our people awareness of the impact of RA on the internal organs is much better than the UK population (33.3% versus 16%) [3].

Features of OA and OP can be wrongly thought it is related to RA. Many studies have revealed limited knowledge regarding OA among the general population [10,22,23]. In Saudi Arabia, one study revealed poor awareness regarding OA among the Saudi population[24].In Saudi Arabia, two studies reported poor knowledge regarding OP [25,26]. These reports support ours as we found poor awareness about the features differentiating these diseases from RA. Nearly in all aspects of our study, those connected to RA are superior in the knowledge to those have no connections. Similar findings reported in studies among UK, Netherlands, and Portuguese populations [35]. The desire for getting information about RA found among two-thirds of the UK population [3]. Netherlands population had a moderate desire to get information about RA [4]. These findings indicate once people connected to any source of information about RA their knowledge will improve which in joint with the desire to get information give hope for the success of different educational interventions.

## Conclusion

Generally, our population has poor knowledge of RA. This can be associated with the delayed seeking of medical advice for non-diagnosed patients and non-desirable consequences to the diagnosed patients. Better knowledge among those connected to RA gives good chances for educational interventions to succeed. Our study justifies the need for various educational and regulatory interventions for the improvement of population knowledge which consequently will improve RA patients' status.

### List of Abbreviations

 RA Rheumatoid Arthritis OA Osteoarthritis OP Osteoporosis SR Saudi Riyal UK United Kingdom

### Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

None.

### Consent for publication

Informed consent was obtained from all the participants.

### Ethical Approval

This study was approved by Jazan hospital institute review board with approval no. 1925.

### Author details

Ahmad Ali Hazzazi1, Mohssen Hassen Ageeli1, Ahmed Ali Muyidi1, Abdulaziz Mohammad Abulgasim1, Abdullah Ahmad Yateemi1, Nabil Alhakami2

1. Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
2. Consultant Rheumatology, King Fahad Central Hospital, Ministry of Health, Saudi Arabia

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