Evaluation of general public awareness, knowledge and attitude about common rheumatic diseases in Egypt: a multicenter study

Rheumatic diseases are the diseases of the connective tissue and medical disorders of the musculoskeletal system, with pain and/or stiffness as main manifestations, and which may or may not be accompanied by other organ system involvement. Public and patient’s awareness is needed as the number of patients of various forms of arthritis and other musculoskeletal diseases is constantly on rise. The aim of our multicenter study is to evaluate awareness, knowledge, and attitude of general populations regarding common rheumatic diseases in Egypt. This was a multicenter study included 3000 subjects from 4 Egyptian governorates (750 subjects from each): Lower Egypt: Dakahlia and Damietta and Upper Egypt: Sohag and Qena. Entire cases completed the Awareness, Knowledge, and Attitude of Egyptian people towards four of the common rheumatic diseases (Rheumatoid arthritis, Systemic lupus erythematosus, Crystal-induced arthritis, and Osteoarthritis): AKARSCO questionnaire that included basic information, general knowledge, and attitude about rheumatic diseases. The knowledge and awareness of rheumatic diseases are significantly higher among females. Regarding education level, there is a steady increase in the awareness with the rise of education level, with a highly significant correlation. Non-working and married participants had significantly higher knowledge compared to working and non-married ones. The attitude towards rheumatic diseases is significantly satisfactory among females. Regarding education level, there is a steady increase in the attitude with the rise of education level, with a highly significant correlation. Non-working and married participants had significant satisfactory attitude compared to working and non-married ones. The main sources of information about rheumatic diseases are media and Internet. The overall awareness, knowledge, and attitude of population towards rheumatic diseases are limited in Egypt. The participants’ total score regarding the general knowledge level of rheumatic diseases, rheumatoid arthritis, SLE, gout, and osteoarthritis is bad. The participants’ overall level regarding the attitude towards rheumatic diseases is unsatisfactory. The level of knowledge and attitude is affected by many factors like sex, work, education, residence, marital status, and family history of rheumatic diseases. The main sources of information about rheumatic diseases are media and Internet.


Background
Rheumatic diseases are the diseases of the connective tissue and medical disorders of the musculoskeletal system, with pain and/or stiffness as main manifestations, and which may or may not be accompanied by other organ system involvement [1].
Rheumatoid arthritis (RA) is an autoimmune disorder of unknown etiology characterized by symmetric, erosive synovitis, and, in some cases, extra-articular involvement [2].Systemic lupus erythematosus (SLE) is a complex autoimmune disease with chronic relapsing-remitting course and variable manifestations leading to a spectrum from mild mucocutaneous to devastating, life-threatening illness [3].Osteoarthritis (OA) is the most common degenerative joint disease; it affects more than 25% of the population over 18 years old.Crystal-induced arthritis (CIA) is characterized by an intense inflammatory reaction triggered by the deposition of monosodium urate, calcium pyrophosphate, and basic calcium phosphate crystals in articular and periarticular tissues [4].They are characterized by a broad range of clinical manifestations from asymptomatic to severely inflammatory.The most common presentations at the inflammatory end of the disease spectrum are gout and pseudo gout [5].
Providing the general population and patients with good quality information is an important strategy in the management of chronic diseases.Knowledge leads to changes in attitudes and behaviors and directly influences health status [6], and adequate information can promote self-management skills necessary for coping with the disease increasing adherence to therapy [7].Several studies showed that requirements for information are associated with patients age and education, but the level of information about rheumatic diseases is low among patients living with these conditions [8].A survey of the Dutch population showed similar results [7] to raise the need for the identification of dimensions involved in knowledge about rheumatic diseases and the quantification of common knowledge in each specific demographic, social, or pathology group; such quantification would benefit an education program targeted to musculoskeletal health [9].
The awareness, knowledge, and attitude of Egyptian population regarding rheumatic diseases are limited and deficient; thus, widespread mass educational and learning programs are needed [10].So, we will provide in our study data about the present situation of common rheumatic diseases in multicenter, which can be used for the future planning of awareness raising and education programs.
The aim of this multicenter study is to evaluate awareness, knowledge, and attitude of general populations regarding common rheumatic diseases in Egypt.

Study design
This is a multicenter (Lower Egypt includes Dakahlia and Damietta governorates and Upper Egypt includes Sohag and Qena governorates) cross-sectional study conducted on a total of 3000 participants of general population over a period of 12 months (from June 2021 to May 2022).
Inclusion criteria include both sexes whose age is from 18 to 70 years.

Methods
Participants answered the Awareness, Knowledge and Attitude of Egyptian people towards four of the common rheumatic diseases (Rheumatoid arthritis, Systemic lupus erythematosus, Crystal induced arthritis and Osteoarthritis): AKARSCO questionnaire [10].The items of the questionnaire were taken from some papers that used validated questionnaire [8,10].Data was collected via 4 rheumatologic physicians (one for each governorate).Answers were obtained from different centers via selfanswering of the participants of the Arabic version of the questionnaire or through face-to-face interview for participants who were illiterate or via online version of the questionnaire.
The questionnaire applied composed of 7 parts and has 2 versions: Arabic version (the translation of English version): answered by the participants and English version: used in the study analysis.
The 7 parts of the questionnaire were as follows: Basic information about the participants include the following: gender, educational level, occupation, residence, and marital status.The score for each participant was measured by giving each "right answer" a score of 1, each "wrong answer" a score of 0, and each "I do not know" a score of 0, and then we summated answers, giving a total score ranging from 0 to 134.

Results
Table 1 shows that the present study was conducted on 3000 Egyptian populations.Their mean age was 38.1 ± 11.6 years.They were 50.2% females and 49.8% males.Fifty-two percent of them was urban, and 29.7% was rural.Regarding education, 11.4% of participants were illiterate, and most of them (34.6%) were university educated.Most of participants (39.5%) were not working.Most of them (66.2%) were married, and 14.1% was single.
Figure 1 shows that most of our participants (43.8%) got their information from media and Internet.The second source was from a patient (21.3%), from a doctor (17.5%), and lastly from a friend (17.4%).
Table 2 shows the general concept of our populations about rheumatology; only 1356 (45.2%) agreed that it is a separate branch of medicine.Regarding the cause of rheumatic diseases (RDs), 59.3% related RDs to inflammatory cause.About 40% of participants ignored the role of investigations in monitoring disease activity and/ or complications, as 61.6% reported that investigations monitor disease activity and 61.2% reported that investigations monitor disease complications.Only 54% agreed that RDs cannot be contagious, and 23.9% believed that RDs can be contagious.About half of our participants agreed that RDs cannot be healed and reported that it can be heritable.Only 38.6% saw that RDs cannot be prevented by vaccination.
Regarding clinical features of RDs, only 26.9% of participants reported that in RDs, the immune system commonly attacks other body organs and tissues.
Regarding diagnosis of RDs, only 23.9% agreed that it is based on a set of clinical, serological, and radiological measures.
Regarding treatment of RDs, 24.4% of our participants reported that DMARDs are a group of medications commonly used in people with RDs, 31.8% reported that the aim of treatment protocol of RDs is to improve symptoms and stop disease progression in most cases, and only 20.8% agreed that medications used for the treatment of RDs are potentially toxic; only 33.6% agreed that the cost of antirheumatic drugs is a burden, but biologic agents are more expensive than chemical drugs like DMARDs.

Clinical features
In rheumatic diseases, the immune system commonly attacks other body organs and tissues 26.9 Diagnosis of rheumatic diseases is based on a set of clinical, serological, and radiological measures 23.9

Treatment of rheumatic diseases
DMARDs are a group of medications commonly used in people with rheumatic diseases 24.4

31.8
Medications used for the treatment of rheumatic diseases are potentially toxic 20.8 The cost of antirheumatic drugs is a burden, but biologic agents are more expensive than chemical drugs like DMARDs 33.6 Figure 2 shows that participants' total score regarding the general knowledge level of rheumatology is bad (47.5%),only 12.4% is good, 21.5% is average, and 18.6% is very bad.
Table 3 shows the participants' knowledge about RA, 26.1% reported that it is an autoimmune disease, and 30.5% reported that it is an inflammatory disease.Regarding epidemiology of RA, 25.7% reported that it is more common in females, and 43% reported that it can start at any age.
Regarding clinical and laboratory features, 38.1% reported that RA affect joints only, 58.3% reported that it affects musculoskeletal system only, and only 33% of our participants reported that all body systems may be affected by RA.Only 19.4% reported that RF test is not diagnostic for RA.
Regarding treatment of RA, 33.5% reported that RA is a treatable disease, but complete cure is impossible, 28.6% of participants agreed that analgesics are the treatment lines available for RA, 45.4% of participants agreed that steroids are the treatment lines available for RA, and only 26% agreed that the treatment lines available are drugs used to modify the course of RA itself.Regarding biologic drugs, only 25.7% knew that they are drugs specific for certain biologic processes, and 18.4% reported that they are drugs extracted from living tissues only.
Regarding general knowledge about SLE, among our study participants, 50.6% are believed an inherited gene to be the cause of SLE, and 37.8% of our participants reported that SLE is more common in females.Only 16.2% stated that any body system can be affected by SLE.Regarding types of lupus, 24.8% knew discoid lupus, 36.1% knew drug-induced lupus, and 29.2% knew neonatal lupus; 51.5% reported that skin rash is a common symptom of systemic lupus, and 29.6% reported that SLE diagnosis is based on clinical features and laboratory findings.Regarding treatment of SLE, 52.4% of participants reported that SLE is treated by drugs specific for lupus.
Figure 3 shows that participants' total score regarding the general knowledge level of rheumatoid arthritis is bad (48.7%),only 12.6% is good, 26.4% is average, and 12.3% is very bad.
Figure 4 shows that participants' total score regarding the general knowledge of SLE is bad (51.2%),only 9.1% is good, 17% is average, and 22.7% is very bad.
Table 4 explores our participant's knowledge about gout, only 25.3% of our participants knew what is meant by crystal induced arthritis, and only 25.2% knew what is meant by pseudogout; 50.8% of participants stated that gout is a disease which affects the feet of patients when the uric acid is high, 27.7% of participants reported that males are affected much more than females, and 22% stated that uric acid is the cause of gout.
Regarding management of gout, 41.9% saw that gout is a completely curable disease; patient may be cured on appropriate treatment, and 63.1% agreed that it is treated by medical drugs specific for gout.
Regarding general knowledge about OA among our study participants, the cause of OA was multifactorial as decided by most of our subjects, with a complication of obesity (agreed by 55.6%).Regarding epidemiology of OA, our subjects (31.7%) agreed that OA is much more in old-aged persons, over 50 years; regarding sex, 29.9% agreed that OA is more in females.
Subjects agreed that the most affected joints were knees (75.4%) and then spines (48.1%), and the least affected joints were hands (31.2%).Regarding treatment of OA, most of participants (67.2%) agreed that OA can be treated with medication and/or physiotherapy, and     52.7% of them agreed that it can be treated with reduction of weight.Only 18.3% agreed that it is non-treatable at all as it is a normal aging process.
Figure 5 shows that participants' total score regarding the general knowledge of gout is bad (53.3%),only 10.3% is good, 53.3% is average, and 21.8% is very bad.
Figure 6 shows that participants' total score regarding the general knowledge of osteoarthritis is bad (37.1%),only 17.4% is good, 28% is average, and 17.5% is very bad.
Figure 7 shows that participants' total score regarding the general knowledge of rheumatology and all aforementioned diseases is average (38.2%),27.9% is good, 26.8% is bad, and 7.1% is very bad.
Table 5 shows the attitude towards individuals with rheumatic diseases.A substantial proportion of participants had negative attitudes towards individuals with rheumatic diseases.To the extent that 28% of participants reported not to marry a person with a rheumatic disease, 19.1% of participants reported not to live in the same place with a person with a rheumatic disease, and 15.4% reported not to play or work with a patient with a rheumatic disease.This was reflected by their decision not to inform their contacts if they had a rheumatic disease, as 13.6% of participants decided not to inform their wife/husband, 21.9% decided not to inform their friends, and 35.5% decided not to inform their colleagues.The majority of participants (74.8%) agreed to seek medical advice if they had a rheumatic disease.Other nonmedical routs were also agreed by many of them such as buying some over-the-counter medications (36.9%), ask for a person for removing evil spirits (21.5%), ask for physiotherapy (51%), and try herbal and alternative medicine (40.3%).
Figure 8 shows that participants' overall level regarding the attitude towards rheumatic diseases is unsatisfactory (55%), while 45% is satisfactory.
Table 6 shows factors affecting knowledge and awareness of the study population about rheumatic diseases.We found that awareness and knowledge about rheumatic diseases are significantly higher among females.Regarding education level, there is a steady increase in the awareness with the rise of education level, with a  Fig. 8 Participants' overall level regarding the attitude towards rheumatic diseases highly significant correlation.Non-working and married participants had significantly higher knowledge compared to working and non-married ones.Regarding residence, urban people had the highest knowledge scores, followed by rural, and lastly those who came from slum areas.Lastly, participants with positive family history of rheumatic diseases had higher knowledge than those with negative family history.
Regarding association between sources of information and knowledge, we found that our participants with good knowledge about rheumatic diseases got their information from media and Internet (49.9%) and then from a patient (20.8%), a friend (15.1%), and finally from a doctor (14.3%).Participants with a very bad knowledge got their information from media and Internet (44.9%) and then from a patient (22.6%), a doctor (16.7%), and finally from a friend (15.8%).
Table 7 shows factors affecting attitude of the study population towards rheumatic diseases.We found that attitude towards rheumatic diseases is significantly satisfactory among females.Regarding education level, there is a steady increase in the attitude with the rise of education level, with a highly significant relation.Nonworking and married participants had significant satisfactory attitude compared to working and non-married ones.Regarding residence, urban people had more significant satisfactory attitude than rural and subrural.Participants with positive family history of rheumatic diseases had more significant satisfactory attitude than participants with negative family history.

Discussion
Awareness of population about rheumatic diseases is greatly important as lack of awareness may lead to delay in seeking medical care [11].In Egypt, we lack the studies about awareness of Egyptian populations regarding rheumatic diseases.So, we provided in our study data about the present situation of common rheumatic diseases in multicenter in Egypt considering Upper and Lower Egypt.
In terms of general knowledge about rheumatology, we found that 47.5% of our participants had a bad level of knowledge, 21.5% had an average level of knowledge, and only 12.4% had a good level of knowledge.This is in consistent with El Saman et al. study [10], which was conducted in Sohag in Egypt.They reported that the majority of the participants fell in the "bad" level, and "average" levels, with no one had "excellent" level of knowledge regarding RDs.Outside Egypt, Alkhdairi et al. [12] conducted a study to investigate the knowledge and perception of the general population living in the Qassim region in Saudi Arabia regarding RDs.The knowledge of the general public was inadequate.
A community-based survey conducted in Syria revealed that the majority of the participants fell in the "bad" level [13].An analogous study was performed in the Netherlands, showing that in general, the public did not know much about RDs [7].Severo et al. [9] conducted a study in Portugal.The respondents gave the right answer to a mean of 10.5 statements out of 17 statements.This study showed that there are several knowledge flaws about RDs in the general population.One out of four considered the false general beliefs as true, and approximately, 30% did not have detailed knowledge on RDs.
This poor knowledge may be due to that many individuals with musculoskeletal diseases seemingly neglect their disease, not looking for help at all or seeking treatment only above a very high pain threshold [14].Also, the prevalence of RDs in Egypt is not high as other diseases [15].These diseases may take the full attention by our society.Also, RDs are not well included in the mass media in our region, and rheumatic and musculoskeletal diseases are learned by the internists and not the rheumatologists in most of our universities [16].
On the contrary to our study, a community-based survey was conducted in Riyadh City, Saudi Arabia, which showed that 77% of the patients were aware of rheumatic diseases; this high awareness level may be due to that most of this study population were educated [17].
Regarding general knowledge about rheumatoid arthritis, our study revealed that 48.7% of our participants had a bad knowledge, 26.4% of participants had an average knowledge, and only 12.6% had a good knowledge.This is consistent with El Saman et al. study [10] that reported the general knowledge about RA among the study population.About 55% reported having heard of RA.About 14% of participants related RA to an autoimmune cause, while over 33% thought that it is an inflammatory disease.Hazzazi et al. study [18] in Jazan, Saudi Arabia, showed that population had poor knowledge of RA.The average awareness about RA symptoms was 38.54%.
Regarding general knowledge about SLE, our study revealed that 51.2% of our participants had a bad knowledge, 17% of participants had an average knowledge, and only 9.1% had a good knowledge.This is consistent with El Saman et al. study [10] which reported that near half of the participants agreed that SLE is an autoimmune disease.Swollen joints and skin rash were the commonest manifestations approved by the participants as common symptoms of SLE.Less than 1/3 of participants supposed that SLE diagnosis requires a combination of clinical, laboratory, and imaging studies.More than half agreed that SLE is treated by drugs specific for lupus.
In Alharbi et al. study [19] conducted in Dammam, Saudi Arabia, about 54% of respondents had no idea about SLE, the majority of them had no clear idea regarding treatment and complications of the disease, about one-third of respondents had idea that SLE is more prevalent among females, a significant majority of participants did not know about SLE, however, most of them did not know if it is fetal or not.Furthermore, SLE awareness is poor even between medical students in Saudi Arabia; a study was carried out in medical school about major symptoms and reported that they did not have clear idea about complications and treatment of SLE disease [20,21].
Regarding general knowledge about gout, our study revealed that 53.3% of our participants had a bad knowledge, 14.6% of participants had an average knowledge, and only 10.3% had a good knowledge.This is consistent with Osama et al. study [22] in Sohag, Egypt, which revealed that the overall level of awareness about gout was insufficient among the general population in Egypt.Alshammari and Mujtaba's study [23] found low awareness and knowledge regarding gout among Qatari people as knowledge regarding etiology, predisposing factors, complications, and diagnosis of gout was insufficient knowledge.In contrast to our study, Atalla et al. study [24] in Taif city, Saudi Arabia, reported that the majority of the participants were somewhat aware about gout disease.Most of the participants believed that gout disease was preventable.Also, majority of the participants seemed to have an idea about symptoms and causes of gout disease.
Regarding general knowledge about OA, our study revealed that 37.1% of our participants had a bad knowledge, 28% of participants had an average knowledge, and only 17.4% had a good knowledge.This is consistent with Alahmed et al. [25] study that is carried out in Hail, Saudi Arabia, which revealed that 59.1% of participants had a bad knowledge and 40.9% of participants had a good knowledge.Alyami et al. study [26] in Jeddah, Saudi Arabia, demonstrated lack of knowledge about OA and associated risk factors in the general public.
In contrast to our study, a study conducted at Saudi Arabia revealed that the majority of participants were of satisfactory level of awareness regarding all aspects of knee OA such as risk factors, preventive measures, relieving measures, and symptoms, and this is explained by that middle-aged population with high level of education was the main core respondents, and this may be because of the method of data collection, which is according to the electronic survey [27].
In our study, regarding factors affecting knowledge about RDs, we found that female gender and non-working participants are more aware about RDs.This is consistent with El Saman et al. study [10] and based on their reports that awareness and knowledge about RDs were significantly higher in females and non-working.Also, it is in consistent with Alkhdairi et al. study [12] in Qassim and Ali and Kudsi study [13] in Syria that reported a higher knowledge in females than in males.This is in contrast with Alenzi et al. [17] study in Riyadh city, Saudi Arabia, which reported that men had significantly higher awareness scores regarding RDs than women.High knowledge about RDs in females may be due to that men perceived RDs as less serious than did women, were less frightened, had lower intentions, and were less interested in information about RDs [7].
In our study, we found that education level is positively correlated with knowledge about RDs; higher educated respondents knew more about RDs than less educated respondents.This is consistent with other studies as Alkhdairi et al. [12], Ali and Kudsi [13], and Alenzi et al. [17] that reported that people who had received appropriate education were more aware of RDs than those with a lower level of education.
Regarding residence, we found that urban people had the highest knowledge scores, followed by rural, and lastly those who came from slum areas.This is consistent with El Saman et al. [10] study.Our study revealed that married people had the highest level of knowledge; this is in contrast with El Saman et al. [10] and Ali and Kudsi [13] studies which reported that single people had the highest knowledge, while Alkhdairi et al. [12] study found that place of residence, marital status, and occupational status were not the relevant factors for knowledge.This may be due to differences in sample size and score used.
Our study revealed that people who had family history of rheumatic diseases had a higher knowledge about RDs than those without family history.This is consistent with Van Der Wardt et al. [7] study that stated that people who had few contacts with rheumatic patients knew less about RDs.Van Der Wardt et al. [7] attributed this to that respondents with many personal contacts with rheumatic patients felt more susceptible to these diseases and were more interested in information about rheumatic disorders than respondents with fewer personal contacts with rheumatic patients.
In our study, we found the main sources of participants' knowledge about RDs were media and Internet (43.8%).This is consistent with Ali and Kudsi [13] study in Syria that reported social media was the approach that was utilized by the most as a source of information (58.03%).In contrast to our study, Van Der Wardt et al. [7] found that the respondents had rarely consulted the mass media for information on rheumatic diseases.
Regarding attitude towards patients with rheumatic diseases, there is a paucity of researches conducted.Our study revealed 55% unsatisfactory result and 45% satisfactory.This is consistent with El Saman et al. [10] study in which 47.6% showed bad attitude, 24.8% showed average attitude, and 14.4% showed very bad attitude.This may be attributed to cultural beliefs as some were advised to take other courses of action (e.g., alternative medicines, religious consultation) or were advised that symptoms were unimportant [28].
Regarding factors affecting attitude towards rheumatic diseases, we found that it is affected by the same factors affecting knowledge in our study.We found that attitude towards rheumatic diseases are significantly satisfactory among females.Regarding education level, there is a steady increase in the attitude with the rise of education level, with a highly significant relation.Non-working and married participants had significant satisfactory attitude compared to working and non-married ones.Regarding residence, urban people had more significant satisfactory attitude than rural and subrural.Participants with positive family history of rheumatic diseases had more significant satisfactory attitude than participants with negative family history.To our knowledge, we did not find similar data in published articles.

Limitations
Despite this is the first multicenter Egyptian study about evaluation of general public awareness, knowledge, and attitude about common rheumatic diseases, there are several study limitations; first, we cover only 4 governorates representing Upper and Lower Egypt, and further studies to cover other parts of Egypt are recommended.Second, we need to ask about more rheumatic diseases as osteoporosis, ankylosing spondylitis, fibromyalgia, and others.

Recommendations
Further studies including more governorates representing all of the Egyptian population is required.Further studies including more rheumatic diseases are required.Effort must be paid to elevate population knowledge and improve attitude towards rheumatic diseases by different means aiming at improving awareness and giving a positive attitude towards patients with rheumatic diseases.

Conclusion
The overall awareness, knowledge, and attitude of population towards rheumatic diseases are limited in Egypt.The participants' total score regarding the general knowledge level of rheumatic diseases is bad.The participants' total score regarding the general knowledge level of rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, and gout is bad.
The participants' overall level regarding the attitude towards rheumatic diseases is unsatisfactory.The level of knowledge and attitude is affected by many factors like sex, work, education, residence, marital status, and family history of rheumatic diseases.The main sources

Fig. 2
Fig. 2 Participants' total score regarding the general knowledge level of rheumatology

Fig. 3 Fig. 4
Fig. 3 Participants' total score regarding the general knowledge level of rheumatoid arthritis

Fig. 5 Fig. 6 Fig. 7
Fig. 5 Participants' total score regarding the general knowledge of gout

Table 1
The sociodemographic data of the study population The source of participant' knowledge regarding rheumatic diseases

Table 2 General knowledge about rheumatology Frequency of correct answer n % What do you know about rheumatology? Rheumatology is the same as orthopedics 43.8 Rheumatology is a branch of orthopedics 38.6 Rheumatology is a branch of internal medicine 24.4 Rheumatology is the same as immunology 35.9 Rheumatology is directly related to rehabilitation 43.9 Rheumatology is a separate branch of medicine
The role of investigations in the follow up of rheumatic diseases aim to as follows:

Table 3
Participants' general knowledge about rheumatoid arthritis and systemic lupus

Table 4
Participants' knowledge about gout, its related diseases, and osteoarthritis

What is the age of onset of OA is? 31.7 Which gender has a higher risk of OA?
It is nontreatable at all as it is a normal aging process18.3

Table 5
Attitude of participants towards rheumatic diseases

Table 6
Association between the sociodemographic state and the participants' total knowledge of the diseases * t-value, Student's t-test

Table 7
Association between the sociodemographic state and the participants' total attitude level of the diseases