Predictors of Quality of Life in Patients With Rheumatoid Arthritis in Pakistan: A Cross- Sectional Study

Introduction Rheumatoid arthritis (RA) is a chronic, progressive inflammatory illness that primarily affects peripheral joints and belongs to systemic connective tissue diseases. Rheumatoid arthritis can cause varied and significant impacts on patients' health, including mental and physical wellbeing. The aim of this study is to analyze the factors affecting the quality of life of rheumatoid arthritis patients. Methodology A cross-sectional study was conducted in the outpatient orthopedics department of Indus Hospital and Health Network. The survey questionnaire was used to collect data from participants. The study's 36-item short-form survey (SF-36) questionnaire was used to assess the quality of life (QoL) among RA patients. Linear regression was used to assess the factors associated with the mental and physical components of QoL. Results A total of 154 patients were interviewed in this study. The mean age of participants was 48.96 (±51.35). Factors that contributed to the physical component of QoL included severity of disease, income, age, comorbidity, and anxiety while factors affecting the mental component of QoL included quality of sleep, anxiety, education, comorbidity, and disease severity. Conclusion Healthcare professionals need to work closely with patients to increase their capabilities of being more independent and controlling all the factors that can affect their QoL. Categories: Internal Medicine, Orthopedics, Public Health


Introduction
Rheumatoid arthritis (RA) is a chronic, progressive inflammatory illness that affects the peripheral joints primarily and belongs to systemic connective tissue diseases [1][2]. Even though it is progressive, the illness has its phases of low and high disease activity, and worsening of disease can cause irreversible impacts on the joint [3]. The global prevalence of RA is 1%, and prevalence is higher among women and the elderly [4]. Along with the negative impacts on life expectancy and quality of life of patients, RA can cause significant financial impacts on patients, families, and the health care system. Rheumatoid arthritis can cause varied and significant impacts on the health of life of patients, including both mental and physical wellbeing [5]. Measuring quality of life as it relates to one's health is based on a patient's subjective assessment of their physical, social, and mental wellbeing. It can help determine the severity of any symptoms or side effects that are affecting the quality of life of patients [6]. People who suffer from RA often report a reduction in their quality of life that can be characterized as the effect of the illness on their social, emotional, and physical health. The quality of life of RA patients can be influenced by impaired physical functioning, stiffness, pain, and fatigue [7]. Besides this, socio-economic factors like lifestyle habits, economic status, employment, and age also impact their quality of life [8].
Furthermore, individuals with RA are frequently unable to accomplish daily chores in their personal or professional lives, and they are frequently forced to change careers or retire early [9]. Emotional and mental problems can be triggered by changes in self-perception in response to painful stimuli, decreased functional ability, and labor and social inadequacies. The overall detrimental effects of RA have an impact on the patient's quality of life [10].
The quality of life (QoL) scale has been employed in the evaluation of QoL and the selection of treatment choices for normal and sick populations in recent years, resulting in a significant improvement in our understanding of health and disease [11]. The selection of relevant scales is required for the measurement of QoL scores. Different scales have been used in various studies such as CASP-19 (control, autonomy, selfrealization, and pleasure), and the 36-item short-form survey (SF-36) scales for evaluating the quality of life of rheumatoid arthritis [12]. No studies have been done in the Pakistani population to assess the quality of life of patients with RA and the factors associated with it.
The current study has investigated the demographic and clinical data of patients with RA and evaluated the QoL of these patients using the SF-36 questionnaire. The aim of this study is to analyze the factors affecting the QoL of RA patients in order to provide a platform for improving the QoL of patients with RA.

Methodology
This was a cross-sectional study conducted in the outpatient orthopedics department of Indus Hospital & Health Network. The study was conducted from November 2020 to April 2021 after getting ethical approval from the Institutional Review Board (IRB) of The Indus Hospital with IRB number IRD_IRB_2021_2_014.
All patients who visited the orthopedics clinic during this time period and fulfilled the eligibility criteria were included in the study. Overall, 154 study subjects with RA were included in the study. Verbal consent was taken from all participants enrolled in the study.

Eligibility criteria
All participants included in the study had an age of 18 years or more, no disturbance of consciousness, and RA for a minimum of one year, confirmed by a physician or consultant. Exclusion criteria included pregnant women or lactating mothers, patients with a psychological illness that affects their memory and ability to respond, patients with serious illnesses like cancer, stroke, etc. that affect the quality of life, patients with any physical disability (amputation of any of the limb), and patients unwilling to cooperate.

Data collection
Data were collected using a survey questionnaire. The survey questionnaire was divided into two sections. The first section assessed demographic characteristics and clinical features of patients while the second section of the survey was composed of questions that assessed the quality of life of patients with RA. Clinical features include the severity of disease that was assessed using the Chron Disease Activity Index (CDAI) score that was divided into four categories based on the total score, including remission (less than 150), mild (150-219), moderate (220 to 450), and severe (more than 450). The anxiety of participants was assessed using Hamilton Anxiety Rating Scale (HAM-A) [13]. Each item was scored on a scale of 0-4, with an overall score range of 0 to 56. A score of less than or equal to 7 shows no anxiety, 8-14 shows mild anxiety, 15-23 shows moderate anxiety, and a score of 24 or more shows severe anxiety. For assessing the quality of sleep, the Pittsburgh Sleep Quality Index (PSQI) was used. The PSQI has a scoring key that can be used to calculate a patient's seven subscores, which range from 0 to 3. The subscores are added together to get a "global" value that ranges from 0 to 21. A global score of 5 or more denotes a poor quality of sleep; the greater the score, the poorer the sleep quality [14].
The SF-36 questionnaire was used to assess the quality of life of study participants. The entire questionnaire was translated into the Urdu language. The medical outcomes SF-36 survey questionnaire is one of the common generic measures that is used for quantifying the health-related quality of life of individuals with musculoskeletal disorders. It is composed of 36 items that are utilized for calculating scores on eight dimensions [15]. Every item is scored from 0 to 100, as 100 is defined as a better situation in the dimensions. The eight sections include vitality, physical functioning, bodily pain, general perceptions about health, physical role functioning, emotional role functioning, social role functioning, and mental health [16]. Overall, eight dimensions are grouped into two distinct concepts, including mental dimension, represented by the mental component summary (MCS), and physical health, represented by the physical component summary (PCS) [15].

Data analysis
Data were analyzed using STATA windows version 16.0 (StataCorp, College Station, Texas). Continuous variables were presented as mean and standard deviation while for categorical variables, frequency and percentages were calculated. T-test or analysis of variance (ANOVA) was used to assess the difference of mean PCS and MCS between different group variables. To determine the association between different independent variables and physical and mental components of quality of life, multivariable linear regression was used and coefficients were computed. The cut-off of the p-value was kept at 0.05.

Results
To determine the factors associated with quality of life in patients with rheumatoid arthritis, 154 were surveyed for the study, where 87.01% were females. The mean age of respondents was 48.96 (±51.35), 106 (68.83%) received some form of formal education, and 84 (54.55%) had a household income of more than 16,000 Pakistani Rupees (PKR) per month. More than half of respondents (53.25%) suffered from at least one comorbidity, and it was observed that high blood pressure (hypertension) was the most common comorbidity (22.73%) observed amongst respondents. Both physical and mental components of quality of life were significantly higher in respondents who did not suffer from any comorbidity.
When asked about their smoking habits, only 8.50% of respondents said they smoked. Table 1 shows that the CDAI score for all respondents, where the majority of respondents suffered from moderate disease activity (46.75%) and only a small percentage were in remission (5.19%). It was observed that the mean MCS score was lower than the mean PCS scores when looking at CDAI scores.

Factors associated with MCS and PCS
A multiple linear regression model was used to identify predictors of the mental and physical components of QoL. The regression coefficients were used for interpreting the findings of linear regression. Factors significantly associated with PCS included severity of disease, income, age, comorbidity, and anxiety, as shown in Table 4  Moreover, quality of sleep, anxiety, education, comorbidity, and disease severity are the factors significantly associated with MCS, as shown in Table 5. MCS is lower in patients with poor quality of sleep than their counterparts (B=105.76 p-value=0.001). MCS is significantly lower in patients with no anxiety or mild anxiety than patients with moderate or severe anxiety (B=-116.76, p-value=0.001). Besides this, level of education also has an impact on MCS scores as patients with no formal education have significantly lower MCS scores than their counterparts (B=-95.32, p-value=0.017). Presence of any comorbidity is also significantly associated with the outcome as patients with comorbidity has lower MCS score than patients without comorbidity (B=-108.64, p-value=0.003). Lastly, severity of disease also affects MCS score as patients with high disease activity has lower MCS score than moderate (B=85.21, p-value=0.029), low disease severity (B=156.11, p-value=0.016), and remission (B=196.00, p-value=0.022).

Discussion
To our knowledge, this is the first study to assess the quality of life of patients with RA and factors affecting it in Karachi, Pakistan. In the study, we used SF-36 to assess the quality of life of RA patients. Among the eight dimensions assessed in the study, vitality (energy and fatigue) and limitation in usual goal activities because of physical health problems had the lowest mean score. We assessed the factors affecting the physical and mental health domains of health-related quality of life. Our study findings show that disease severity, presence of any comorbidity, sleeping quality, anxiety, affecting PCS and MCS, in addition to certain demographic characteristics. Furthermore, the mental QoL of RA patients was disrupted more seriously than their physical QOL, as shown by the overall mean of MCS.
Sleeping can affect physical and mental QoL. To some extent, sleep quality can reflect the QoL of patients with RA. In this study, the physical and mental QoL increased with an increase in quality of sleep. Some of the reasons that affect sleep among RA patients include disease severity and pain. Studies have shown that disease activity, joint swelling, fatigue, and long-term pain in RA patients are some of the factors affecting sleep quality and duration [17][18].
The findings of the multivariable analysis suggest that the PCS score reflects both limitations because of the coexisting conditions and radiographic damage and functional limitations because of the current disease activity because of the processes that do not respond to treatment with anti-rheumatic drugs. Our study findings have shown that the disease severity of patients is also a significant factor impacting the physical and mental health-related QoL. It means the more severe the illness is, the more severe the impact it can create on physical and mental health. Similar findings were also reported in the study conducted by Karimi et al. [19]. No correlation has been found between gender and mental and physical components of QoL of patients with rheumatoid arthritis. Results of the current study have also been supported by studies conducted by Tander et al. [20] and Bedi et al. [21].
Age is also another predictor that has an effect on the physical component of QoL of patients with RA. People of young age have a better quality of life as compared to old age people as they are more physically and socially engaged than their counterparts. Similar results were obtained from the study conducted by Karimi et al. [17]. Similarly, some studies have also found a significant association between the monthly income of participants and PCS. In the study conducted by Monjamed et al., educational status and higher family income had a significant correlation with some enhancing aspects in RA patient QOL [2,22] that are consistent with the findings of our study.
Coexisting chronic diseases may have an impact on the outcome of a chronic ailment. It is necessary to integrate an assessment of comorbidity into the studies involving QoL outcomes for patients with comorbidities as coexisting illnesses that may affect outcomes of interest like overall health status, depression, and physical functions. In our study, 53.25% of patients reported at least one comorbidity that is according to the studies conducted by Gabriel [24]. In our study, it was also identified that the presence of comorbidity affects both components of QoL, including physical and mental components that reflect a need for the promotion of self-management and self-care among patients, including proper teaching about a condition to decrease its impacts on the overall quality of life of RA patients.
The current study has certain limitations. First, the study has a small sample size, and participants were enrolled only from The Indus Hospital and Health Network, thus reducing the generalizability of the results obtained. The quality of life is a personal domain, and its improvement needs to reflect the individual's particular experiences. Psychosocial support exercises to increase functional capacities, professional counseling, and the use of medicinal and alternative therapies to alleviate symptoms of RA should all be part of the integrative therapy model. As a result, the findings of this study showed the necessity for more research using a greater number of respondents who were homogenized by gender, comorbidities, age, sociodemographic characteristics, disease duration, and so on. Analyzing the impact of various therapies on QOL should also be a key goal that can aid in the development of a comprehensive and integrated therapy and rehabilitation paradigm for rheumatoid arthritis patients.

Conclusions
The study assessed the factors associated with quality of life among RA patients using the SF-36 tool. The study showed that important factors associated with the physical component and mental component of QoL among RA patients include the severity of disease, presence of any comorbidity, sleeping quality and duration, anxiety, in addition to certain demographic characteristics. Healthcare professionals need to work closely with patients to increase their capabilities to be more independent and control all the factors that can affect their quality of life. Additionally, enhancing the quality of life should also be an ultimate objective of treatment of patients with RA to increase their ability to be more self-dependent and manage their disease well.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. IRB of The Indus Hospital issued approval IRD_IRB_2021_2_014. The IRB of The Indus Hospital has reviewed the abovereferenced study and determined that, as currently described, it was eligible for expedited review and has been approved. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.