This study aimed to establish the prevalence of arthritis in Trinidad as well as to compare the Health-Related Quality of Life in patients with and without joint pain. Self-reported data serve as an invaluable resource in epidemiological studies and the Centres for Disease Control (CDC) recommends using self-reported, doctor-diagnosed arthritis as the case definition for estimating the prevalence of arthritis (14). The prevalence of self-reported joint pain was found to be almost 60% with half reporting joint swelling; figures in keeping with South American and other Caribbean countries’ prevalences (15).
In accordance with findings by the Centres for Disease Control (CDC) and Prevention (16), the prevalence was also higher in females than males and the average age of those reporting joint pain was significantly higher compared to those who did not. Our data revealed the prevalence of self-reported joint pain being more in Trinidadian women as opposed to men which can be due to reduced physical activity or muscle weakness. These findings are consistent with previous reports (17, 18). The knee joint was most commonly affected (63.4%). This can be explained by the age-associated increase in the incidence of knee OA as highlighted in The Framingham Osteoarthritis study (19). OA was the second most common self-reported arthritis in our study group.
The majority of persons interviewed attained up to primary or secondary level of education with only 15.2% acquiring tertiary level. Although reports have shown the prevalence of chronic pain to be inversely related to socio-economic status (20) the American Pain Society in 2017 reported that prevalence differences according to education were insignificant (21). It is important to note that in countries with generally easily accessible healthcare systems, educational background does not directly impact disease activity but patients with a higher educational level may have slightly less pain and less functional disability. This was explored in a study conducted in Sweden (22).
The level of education attained may be linked to unemployment (23). Notably, joint pain may have been a contributing factor to the inability to work. The impact of arthritis on unemployment has been highlighted by Mayo Clinic researchers (24). The majority of persons suffering with joint pain were in fact unemployed however this category did include persons who were retired. As it has already been established that the prevalence of joint pain increases with age (25), this too may have been a confounding factor that could explain the aforementioned associations.
Persons of East Indian descent reported experiencing more severe joint pains both “on average” and when the joint pain was “at its worst” as compared to persons of the ethnic group “Other” - which included multiracial, Caucasian, Chinese and other respondents. In a cross sectional study conducted in Malaysia it was found that knee pain was more prevalent in Indians than compared to Malays and Chinese (25). In our study persons of African descent reported less severe joint pain in both domains. In a 2010 study conducted by Bolen et al in the United States (26), it was found that Blacks and Hispanics were 1.8–1.9 times as likely to have severe joint pain as Whites, and MRO (Multi-Racial and Other) were 1.9 times as likely. Some reasons given for the disparities between severities of joint pain in ethnic groups were - access to healthcare and use of healthcare services as well as “cultural differences in understanding of survey questions”, willingness to report pain, “variations in patterns of medication use and self-management approaches to manage pain.” Although the ethnic groups compared were different, in our study, persons of African descent reported less severe joint pain than either ethnic group, contradicting the findings of Bolen et al.
A previous Trinidadian survey sought to investigate inequalities in health using the EQ-5D instrument. Pain and discomfort were found to be the dimension with the highest prevalence of reported problems with one fifth of the adult population surveyed reporting pain at any level (27). In this study older age, female gender and lower educational level were also significant predictors of pain or discomfort (27). This may be explained by the higher burden of arthritis in older women as seen in this study.
Persons who self-reported joint pain experienced significantly greater difficulty with mobility, activities of daily life, social activities, general health perception, jobs around the house and mental function as compared to those who did not. Similarly, patients who were diagnosed with some form of arthritis suffered more in mobility, activities of daily life, jobs around the house and mental function. These findings are similar to those of other studies in which patients diagnosed with various forms of arthritis experienced an overall reduced quality of life compared to those who were not (28–32). In this study Chikungunya related arthritis attained the highest percentage (12%) of self-reported cases followed by OA and lupus. In December 2013, PAHO/WHO received confirmation of the first cases of autochthonous transmission of chikungunya in the Caribbean (33, 34). This may explain why it was the most common self-reported form of arthritis.
Several recommendations are proposed in light of these findings. Continuing education for clinicians on the latest and best practices for the diagnosis and screening of arthritis may help in earlier diagnosis and result in better health related quality of life. Physician education has been linked to improved management of arthritis (35). At the time of this study there were three practicing rheumatologists for a population of 1.3 million. A systematic review of the literature on workforce planning for rheumatologists suggested a conservative estimate of 0.7 per 100,000 or 9 rheumatologists for our population (36). There is clearly a need for training, hiring and retention of rheumatologists in the local setting.
Primary care physicians (PCPs) being on the front line need also to be aware of most recent guidelines. A toolkit specifically designed to update PCPs on latest rheumatology guidelines has been shown to be effective in improving PCP competence in diagnosis and management of common rheumatic conditions (37).
Education of the public about the treatment services available for arthritis such as rheumatology clinics would enable them to have a better standard of care. This can be done through media and social media. Structured patient education programs have been shown to be effective for rheumatic diseases (38).
The treatment services for arthritis should be increased to accommodate the national prevalence rate. Rheumatology clinics as well as other treatment services for arthritis and its co-morbidities should be available in each Regional Health Authority in Trinidad and quality standards for these outpatient clinics need to be adopted (39).
Ancillary services such as physiotherapy and rehabilitation services should also be strengthened as there is strong evidence supporting their role in managing arthritis (40). Provision of essential medications including steroid sparing drugs and biologic agents is also recommended. Lastly, responsive evaluative measures can be implemented to detect important changes in HRQOL during a period of time as a means to improve patient management.
Strengths of this study was it was the first national survey of its kind to measure joint pain, arthritis and related symptoms. It also adds to the QOL research done in the Trinidadian setting. A large representative sample from 16 based primary care institutions was used spanning all geographic areas of the island.
There were some limitations of this work. Recall bias was a limitation with the reporting of previous diagnosis of arthritis as well as with frequency and timing of joint pain. Recall bias may have influenced the prevalence of self-reported diagnoses as many persons may not have accurately reported their diagnosis. The data obtained was not verified with physician diagnosis from patient records and this serves as a limitation of this study. The cross-sectional design of this survey provided no causal evidence of a relationship between risk factors, joint symptoms and quality of life. Self-reporting was used to determine diagnosis of arthritis and specific conditions in this survey. Self-reporting has a primary limitation of inadequacy of other risk factor measures such as chronic diseases that affect HRQOL. Our data collection did not include other possible confounding factors such as body mass index, history of physical trauma or the menopausal status of women. This study did not incorporate lifestyle factors as a contributor to HRQOL. It is imperative to include the assessment of comorbidities and other lifestyle factors in future studies when assessing HRQOL outcomes.