Fatigue in Egyptian patients with rheumatic diseases: a qualitative study

Mortada et al. Health and Quality of Life Outcomes (2015) 13:134 DOI 10.1186/s12955-015-0304-7 RESEARCH Open Access Fatigue in Egyptian patients with rheumatic diseases: a qualitative study Mohamed Mortada1*, Amal Abdul-Sattar1 and Laure Gossec2 Abstract Objectives: Fatigue is frequent in rheumatic diseases. Fatigue expression and consequences may be modified by cultural differences. Our objective was to increase the understanding of the fatigue experience and characteristics among Egyptian, Muslim patients with rheumatic diseases. Methods: Prospective monocentric qualitative study based on conventional qualitative content analysis, inductive reasoning, grounded theory. Egyptian patients with rheumatoid arthritis (RA), fibromyalgia or axial spondyloarthritis (AxSpA) were asked about fatigue, its patterns, consequences and self-management. Results: Of the 60 patients interviewed, 20 patients had each disease (RA, fibromyalgia and AxSpA); median ages ranged from 34 to 40 years. Patients were mainly male (N = 40, 66 %), had 3 to 7 years (mean) of disease duration and had moderate disease activity. Some aspects of the patients’ experience of fatigue may be specific to the Egyptian and Muslim culture such as the description of fatigue as a physical more than a mental impact of the disease, the response to the effect of fatigue on sexual function and the gender specific (women more than men) limitation of social activities due to fatigue which was more obvious in our study than other previous studies. Other aspects of patients’ experience of fatigue like overlap between the patients’ perception of fatigue and pain and coping strategies were similar to the findings in previous studies. Conclusion: This study gives insights regarding fatigue in rheumatic diseases in an Arabic and Muslim culture. Similarities and differences with previous studies were noted and should be taken into account when assessing these patients. Keywords: Rheumatoid arthritis, Fibromyalgia, Fatigue, Patient perspective, Quality of life, Qualitative study Introduction Fatigue is common across all rheumatic and musculoskeletal diseases (RMDs), with significant fatigue reported by 41–80 of patients with rheumatoid arthritis (RA) [1, 2]. The prevalence of fatigue has been reported to range from 40 % to 76 % in patients with osteoarthritis and fibromyalgia respectively [1] and from 60 to 74 % for those with axial spondyloarthritis (AxSpA) [3, 4]. Fatigue can have a substantial impact on patients’ selfcare activities and overall quality of life [5–8]. It is often identified as one of the most challenging aspects of chronic rheumatic diseases [9–11]. The causes of fatigue appear multi-factorial in RMDs; disease activity plays a role but additional factors such as psychological distress * Correspondence: 1 Rheumatology & Rehabilitation Department, Zagazig University, Faculty of Medicine, 28 Qawmeia street, Zagazig, Egypt Full list of author information is available at the end of the article and treatments may be additional causes of fatigue [12]. Pharmacological interventions for rheumatic diseases have a limited effect on fatigue [11, 13]; therefore, patients rely on self-management techniques. There is an increasing trend to study the impact of fatigue in RMDs [14]: several quantitative studies have explored the causality of fatigue or its relationship with rheumatic disease activity. While qualitative studies are less frequent [11, 15–20], such studies may help in further exploration of the perceived causes, consequences and management of fatigue from the patients’ point of view by developing and understanding patients’ experiences of living with and managing fatigue [20]. This may allow health professionals to orient patients towards self-management strategies. Cultural aspects may play a role in the expression of fatigue. Fatigue in RMDs has to date, to our knowledge, © 2015 Mortada et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mortada et al. Health and Quality of Life Outcomes (2015) 13:134 only been explored in Western-culture countries [15–24]. However, qualitative studies on fatigue have shown the importance of culture and religion. Indeed, patients’ beliefs and perceptions about diseases and pharmaceutical measures are important to explain coping strategies and these beliefs can be related to cultural background [25]. A qualitative study including patients with knee and hip osteoarthritis in the Dominican Republic, demonstrated that among this population beliefs about etiology included illness being caused by God’s will and exposure to water (e.g. bathing). Among these patients coping strategies reflected their beliefs about disease causation and included prayer, avoidance of water and giving a great importance to drainage of knee effusions [21]. Kumar et al, when performing interviews with RA and lupus patients of South Asian origin in the United Kingdom in 2011, found that patients who think that disease is ‘God’s will’ usually don’t believe that they can play an active role in managing their disease. In some cases, this attitude may hinder their compliance with treatment recommended by their doctor [22]. It also appeared these same patients believed that drugs in general were more overused and more harmful than did their Caucasian counterparts [23]. Thus, culture and religion are important aspects to consider when assessing disease impact. A recent multinational study (the COMORA study) has shown fatigue levels were variable across countries and these differences might be explained by inter-country differences rather than disease activity levels [25]. The current qualitative study aimed to increase the understanding of the fatigue experience and characteristics among non-Western culture, Egyptian and Muslim patients with rheumatic diseases: RA, fibromyalgia and AxSpA. Patients and methods Design A prospective monocentric qualitative study was conducted by individual interviews. Ethical approval was obtained from the Institutional Review Board (IRB) at Zagazig university hospitals and all participants provided their informed consent before participation. Page 2 of 8 AxSpA patients, fulfilling the ASAS criteria for classification of AxSpA [28]. Furthermore all patients had definite and established disease, according to their treating rheumatologist. All patients were Egyptian and of Muslim religion, and were willing and able to come in for a thirt (...truncated)