Discussion
The culture and lifestyle in the Middle East are different when compared
to the developed world, which could influence the experience of people
with knee OA. This is the first study to explore the knowledge of knee
OA and its impact on health in patients diagnosed with the condition
living in the Middle East, particularly in Jordan. Limited knowledge of
knee OA was reported, which in part is attributed to the inappropriate
service delivery process with poor communication with healthcare
professionals and lack of education. Knee OA significantly limited
physical activity and participation, however this limitation was not
only caused by their knees but also by the culture in Jordan. Mapping
the results to the ICF framework allowed international comparisons
emphasizing the impact of culture on health.
There was lack of understanding of body changes with knee OA as
demonstrated by the mixed answers of the participants. Most limited the
changes to affect body structures only and none mentioned changes to
body functions as in muscle weakness. Knee OA is known in Arabic as
”roughness of the knee” which might explain why most considered knee OA
as dryness of the liquid inside the joint and increased friction.
However, little was known on how it develops, risk factors, and
prognosis. Limited knowledge of the pathology of knee OA was also
reported in the United Kingdom3. Moreover, knee OA was
perceived as an ”inevitable” condition that would deteriorate with age.
Similar perspectives towards knee OA were reported
worldwide8.
When exploring our participants’ understanding of the change in
symptoms, they mainly linked other emotions and feelings such as
tiredness and fear of pain. Fear would limit activities and
participation and increase the risk of disability35.
For example, people with knee OA decrease their activity fearing
exacerbation of symptoms8. However, physical activity
and exercises are self-management strategies used to decrease
symptoms36,37. Therefore, it is essential to overcome
fear of pain and falling which could be established through education
and self-management programs38.
Our participants were not aware of appropriate self-management options
or behavioral modification techniques to manage their symptoms.
Comparable with other studies, the use of medication was the first
option39,40. One would expect the participants who
were referred to physiotherapy to use exercises more often to decrease
their symptoms and improve function. However, this was not demonstrated
which could be justified by lack of education on the importance of
exercise with knee OA and inappropriate exercise prescription resulting
in lack of effectiveness and direct the participants to use medications
to relief their pain. Hurley et al39 reported similar
results on the limited use of exercise as a self-management option.
Nevertheless, their participants were aware of more self-management
strategies such as ice, knee sleeves, and pacing which might be
explained by the increased contact sessions with the physiotherapists
compared to the physicians.
The lack of knowledge of knee OA and inability to manage it could also
be caused by the inappropriate service delivery process. In Jordan,
exercises were not considered core management options for knee OA as
recommended by international guidelines24,25. This was
demonstrated by the late referrals to physiotherapy and the limited and
inappropriate prescription of exercises. A systematic review showed that
GP’s beliefs varied from advising complete rest to recommending
exercises, still their actual behaviour showed low physiotherapy
referral rate41. These results should be considered
carefully as they are based on small number of studies and some depended
on patient’s reporting of their GP’s behaviour.
Moreover, our participants referred their limited knowledge to the
insufficient information provided by healthcare professionals. It is
worth noting that many of our participants had basic school education so
their ability to read and seek information by themselves was limited.
Several studies reported that patients with knee OA lacked the knowledge
that would enable them to manage their pain2-5. Lack
of education resulted in more pain, depression, and lack of coping
strategies42. Therefore, international guidelines
recommend providing education individualised to the participant
including: knowledge of OA, pacing activities, exercise, weight loss,
and assistive technology25.
Our participants’ experience of symptoms with knee OA were comparable to
those of other populations worldwide including pain, stiffness, fatigue,
swelling, muscle weakness, crepitus, and fear8. Fear
included fear of falling, fear of deterioration of OA, fear of becoming
a burden8. Our participants depended on their families
to overcome these fears. However, there was a sense of frustration
caused by this dependence on others. Many studies reported frustration
of people with knee OA as a result of limited activity and loss of
independence5,43.
Exploring the experiences of people diagnosed with knee OA worldwide,
mainly in developed countries, demonstrated activity limitations were
similar across populations including walking, standing, sitting,
ascending and descending stairs2,3,8,14. Our study
showed similar results in addition to restrictions in religious
activities as people living in Jordan are mainly Muslims. Xie et
al14 reported comparable results from the experiences
of participants from Singapore as they have a large Muslim population.
A Few of our participants reported limitation in walking long distances
(n=6) and none reported limitation in activities such as getting on or
off a bus, travelling, driving, or activities needed for a certain job.
Those activities were restricted by knee OA in
Singapore14. Also, limitation in work performance was
reported by different populations8. However, Jordan
has a different culture; most female participants in our study are
housewives which is common for women in Jordan and the male participant
is retired, the transportation system is not well structured and people
have to walk long distances to reach a bus stop thus limiting physical
activity. In addition, Jordan has many hills and valleys limiting
walking long distances. From the social perspective, families are
accustomed to attending many social events. Our participants reported
restrictions in socializing where they would depend on family members to
help them.
Environmental facilitators reported by our participants included using
cars, elevators, and wheelchairs. On the other hand, uneven grounds,
cold weather, and service accessibility difficulties adversely affected
the participants’ experience. Xie et al14 was the only
study to explore environmental factors affecting participants from
Singapore and reported similar results.
This is the first study to explore the knowledge of knee OA and its
impact on the health in the Middle East and to compare the results with
developed countries. The results increase the awareness of healthcare
professionals in Jordan on the limitations in delivered services and the
importance of education. They also highlight the role of healthcare
professionals worldwide in understanding the impact of culture on health
when managing people with knee OA from different populations. Using a
triangulation method enriched the data. The ICF was used to comprehend
the experiences of participants as it provides a common language for
research and clinical practice. Therefore, mapping our results to this
framework allowed comparability with other studies and both
environmental and personal factors were explored which was limited in
previous studies. Furthermore, the principle investigator conducted the
focus group and interviews which allowed close observation of the
participants’ responses and eliciting more responses based on her
experience with knee OA. Nonetheless, consensus meetings were held by
the research team to interpret the data to avoid imposing previous
knowledge on emerging data44.
We had access to one local hospital therefore a convenient sampling
method was used instead of the ideal purposive method. Although this is
a central hospital in the Capital Amman, the results might not be
generalised to the Jordanian population. Moreover, the majority of the
participants were middle-aged unemployed females. We aimed to recruit
both genders and conducted gender-specific focus groups to respond to
cultural sensitivity, to avoid any embarrassment when expressing ideas,
and to take into consideration that activities and participation might
be gender-specific. However, we were able to recruit one male
participant only; which might have biased our results. This could be
explained by the culture as men are perceived the main providers for
their homes and do not have time to participate in research whereas
older women are mainly housewives and have time to spare. Therefore,
future studies should explore the perspectives of a larger sample of
both genders with a wider educational background and work experiences
and in different settings in Jordan.