Knowledge and Awareness Regarding Osteoarthritis and Its Factors in Hail Region, Saudi Arabia

Objectives Osteoarthritis (OA) is a common chronic degenerative joint disease linked to age, joint overuse abnormalities, and previous trauma. This research aims to assess the awareness levels, as well as the knowledge gap and misconceptions, about OA and its risk factors among the general population in Hail, Saudi Arabia. Methods The research adopted an observational cross-sectional method. Participants from Hail, Saudi Arabia, were recruited and then interviewed between 1 April and 15 July 2022. Adult males and females aged 18 or more were recruited via an online questionnaire using a Google Form link, inviting them to take part in a study concerning their knowledge of OA. The questionnaire was split into three sections. The first section covered demographic data, the second section contained general knowledge regarding OA, and the third section was made up of a 20-item quiz. The collected data was reviewed and then analyzed using the Statistical Package for Social Sciences (SPSS) Version 21 (IBM Corp., Armonk, NY, USA). The statistical methods employed were all two-tailed, with an alpha level of 0.05 considered significant if the P value was less than, or equal to, 0.05. Results Nine hundred six (906) eligible respondents completed the questionnaire. Participants ranged from 18 to 65 in age. More than 66% were female, while 77.5% had a university level of education or above. 13.6% had been diagnosed with OA. Overall, 40.9% of the study participants demonstrated a good knowledge level regarding OA, while 59.1% showed a poor knowledge level. Conclusion The study revealed that the awareness and knowledge levels of the general population in Hail about OA are unsatisfactory. Efforts are recommended to increase the awareness and knowledge of the population through public education, which in turn can lead to a reduction in risk factors and improved early detection of the disease.


Introduction
Osteoarthritis (OA) is a joint disease that causes a person's bones to rub against each other due to degeneration of the cartilage lining them [1]. Progressive loss and destruction of articular cartilage, osteophyte formation, subchondral bone thickening, variable degrees of synovium inflammation, knee menisci, and ligament degeneration, along with joint capsule hypertrophy, are pathological changes in OA joints [2]. The hallmark symptom and most common presenting complaint in persons with OA is joint pain [3]. However, there is a poor correlation between the radiographic changes and the degree of joint pain [4]. As OA is presently incurable, the primary goals of therapies are therefore to ease pain and improve joint function [5]. In the advanced stages, the patient may require invasive procedures, like joint replacement therapy [6].
Multiple risk factors are linked to the development of OA, with age being the primary risk factor [7]. The Framingham Study showed there was radiographic evidence of knee OA in 27% of the local population aged 1 1 1 1 The aim of this research was to assess the awareness and knowledge levels, as well as the knowledge gap and misconceptions regarding OA and its risk factors among the general population in Hail, Saudi Arabia. Due to the increase in the prevalence of OA, recent guidelines for OA management should be considered in the GCC countries [14]. Weight loss for overweight or obese people, exercise, and walking aids for lower extremity osteoarthritis are among the most recent guidelines for non-pharmacological management of people with osteoarthritis [14]. The justification for selecting Hail is that there has been no discussion of the state of the field with respect to OA research in the Kingdom of Saudi Arabia (KSA).

Sample and setting
The study was conducted in Hail, Saudi Arabia, between April 1 and July 15, 2022. An observational crosssectional design was employed. This study has been reviewed and approved by the Research Ethics Committee (REC) at the University of Hail, No: H-2022-421, dated December 19, 2022. A total of 384 participants were needed to estimate knowledge and awareness regarding osteoarthritis and its risk factors. The estimated sample size for this cross-sectional study was calculated using the following formula: ss= (Z2pq)/c2. Where ss = sample size, Z = 1.96, p = 0.5, q = (1-p) = 0.5, and c = sampling error of 5%. In total, 906 respondents participated. Incomplete submissions were excluded. Adult males and females aged 18 or more were recruited via an online questionnaire using a Google Form link, inviting them to take part in a study concerning their knowledge of OA. The agreement to fill out the questionnaire was considered consent to participate in the study. The invitation was sent using multiple social media platforms, i.e., WhatsApp, Twitter, Facebook, etc. Snowball sampling was utilized by encouraging participants to extend an invitation to more people using the same link they received.

Questionnaire development
The questionnaire was developed by adopting multiple questions from other studies' validated questionnaires. In the end, the questionnaire was passed on to two orthopedic surgeons to ensure the accuracy of the items. A pilot study followed, and all items were understood by the participants. Thus, no further modifications to the questionnaire were made. The questionnaire was split into three sections. The first section covered demographic data, the second section contained general knowledge regarding OA, and the third section was made up of a 20-item quiz. The questions for the second section were taken verbatim from Alyami et al. (2020).

Statistical analysis
Data were collected, reviewed, and then analyzed via the Statistical Package for Social Sciences (SPSS) Version 21 (IBM Corp., Armonk, NY, USA). The employed statistical methods were all two-tailed, with an alpha level of 0.05 considered significant if the P value was less than, or equal to 0.05. Each correct answer received a score of 1 point. Participant knowledge about chronic OA was determined by tallying the discrete scores for the different questionnaire items. A total score of 60% was taken to signify a good level of awareness, while scores of less than 60% were considered poor. Descriptive analysis was conducted by prescribing frequency distributions and percentages for all study variables, including participants' personal data and OA-related medical history, as well as whether they knew others with OA. Participants' awareness about chronic OA was tabulated, whereas the overall awareness level was graphed. Cross-tabulation helped demonstrate the distribution of participants' overall awareness levels, per their data and other factors. A Pearson chi-square test was used to determine significance, along with an exact probability test if there were small frequency distributions.

Results
Nine hundred six (906) respondents completed the questionnaire. They were aged from 18 to 65 years old. The mean age was 34.2 ± 14.7. Six hundred four (604, 66.7%) participants were female. Seven hundred two (702, 77.5%) had a university education (or higher), while 175 (19.3%) had only a secondary level of education. One hundred twenty-three (123, 13.6%) had been diagnosed with OA. As for the mechanism of OA development, 237 (26.2%) believed that the cartilage at the end of the bones wears away over time, 119 (13.1%) thought that the nerve that passes near the joint is pressed, while 83 (9.2%) thought the amount of blood that reaches the joint decreases with age. Three hundred sixty-five (365, 40.3%) reported that they know someone with OA. The results are presented in Table 1.

Discussion
This study analyzed the awareness levels and knowledge gap about OA and its risk factors present in the population of Hail, Saudi Arabia. Most participants were female (66.7%). The majority (77.5%) had a bachelor's degree or above. The study found that of 906 participants, 371 (40.9%) had a good knowledge level regarding OA aspects such as risk factors, causes, symptoms, and management. A majority of 535 (59.1%) had poor knowledge and awareness levels.
This finding was similar to that of a study conducted in Jeddah, Saudi Arabia, which also found a low level of knowledge regarding OA among the study population [9]. On the other hand, another study was conducted on the general population in Sudair, Saudi Arabia, found that the majority demonstrated good knowledge about OA [10].
OA is a degenerative disease that has many inflammatory markers and cytokines involved in its development [20]. A mixture of genetic susceptibility and poor lifestyle choices can lead to further progression of the disease [20][21]. When asked "Do you think osteoarthritis is caused by cold, damp weather?" and "Do you think it is developed by a microorganism?" only 25.7% and 45.4% of participants answered correctly, respectively, demonstrating a poor understanding of the pathophysiology of OA.
Women are more likely to develop OA [21][22], but only 35.8% of participants showed an awareness of the gender differences in OA, even though most participants were themselves female. Notably, 82.9% and 70.1% were aware that weight gain and aging, respectively, were risk factors. Genetics is another known risk factor [21], but less than half of the respondents (44.9%) were aware of this. Some respondents expressed concern that physical activity would make OA worse. The majority (67.8%) agreed that physiotherapy can result in significant reductions in OA symptoms [23].
In relation to OA management, non-steroidal anti-inflammatory drugs (NSAIDs) play a significant role in improving the symptoms of OA [24], but only 39.4% of the participants were aware of this. The mainstay of treatment for OA remains joint replacement [24], and half of the participants 50.4% knew that this will be the ultimate option.
Regarding sources of information about OA, the least reported source was from healthcare staff (8.9%). This was consistent with other studies [9]. It in turn demonstrated how important it is that healthcare professionals should increase efforts to improve awareness among their patients, families, and friends.
The major limitation of this study was the self-administered questionnaire method, which was suitable only for those who had access to the right technology, can read and were interested in participating. Further research is needed to explore population knowledge levels, as well as to determine what if any common misconceptions exist.
This research's clinical significance is increasing the awareness, knowledge gap, and misconceptions about OA and its risk factors. Moreover, due to the increase in the prevalence of OA, recent guidelines for OA management should be considered in Saudi Arabia. Weight loss for overweight or obese people, exercise, and walking aids for lower extremity osteoarthritis are among the most recent guidelines as nonpharmacological management for people with osteoarthritis [14]. Weight management has shown improvement in symptoms for people with weight-bearing osteoarthritis, such as the knee or hip [14,16].
Exercise, including resistance, aerobic, and mind-body exercise, are essential components of treatment, regardless of age, pain level, symptoms, and functional status [14]. Crutches are recommended for people with knee or hip OA, and orthosis have been suggested for hand OA [14,21]. Because of the high prevalence of OA in the GCC countries, it is important to use these recommendations for managing people with OA.

Conclusions
The research indicated that OA awareness levels among the general population in Hail, Saudi Arabia, were unsatisfactory. Therefore, it is recommended that efforts be made to enhance awareness and knowledge levels through public education campaigns. In turn, this can help reduce risk factors and improve early detection of the disease. Hopefully, this will lead to overall improvements in the population's lifestyle as well as reduce the socioeconomic burden of OA.

Age
Human subjects: Consent was obtained or waived by all participants in this study. The Research Ethics Committee (REC) at the University of Hail issued approval No: H-2022-421. 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.