Quality of Life Among Tawau Hospital Staff

Quality of Life Among Tawau Hospital Staff With Osteoarthritis (knees) Been Treated in Physiotherapy Unit

Quality of life among Tawau hospital staff with osteoarthritis (knees) being treated in physiotherapy unit

Pilot study

Demographics

Knowledge about OA before physiotherapy

Severity of disease before and after rehabilitation

Degree of difficulty as a result of knee OA

Effect on work performance

Effect on emotional status and social activities

Opinion on self-management

Impact of physiotherapy on their knowledge and understanding of the disease

Impact of physiotherapy on their ability to cope and QoL

Publication of the study

Time schedule

Budget

Consent form

Appendix 4: Interview schedule

Quality of life among Tawau hospital staff with osteoarthritis (knees) being treated in physiotherapy unit

Introduction

Osteoarthritis (OA) in general is also referred to as degenerative joint disease and is a progressive joints disorder whereby there is gradual cartilage loss that results in formation of spurs (areas of abnormal hardening) and subchondral cysts (fluid-filled pockets in the marrow) of the bones at the margins of the joints. OA of the knee comes about as a result of "wear and tear" or gradual degradation of the hyaline cartilage that covers the articulating surfaces of the knee joint bones Solomon et al., 2010: 6.

It is characterized by atrophic thinning and wear of the cartilage, sclerosis of the underlying bone and osteophytic hypertrophy and roughening of the tibia and femur. Obesity predisposes individuals to greater risk of developing knee OA Coggon et al., 2001: 624(, Felson, 1996: 430S)

. Other risk factors of OA are muscle weakness and high bone density Bosomworth, 2009: 872()

As OA of the knee progresses, it causes deformation of bones and accumulation of fluids in the joints. Rest often relieves the pain. However, it may be made worse by placing weight on the joint. In the early stages of the disease, the pain is usually minor and may manifest as mild stiffness in the morning. As the disease progresses, inflammation develops and the patient may experience pain even when they are not using the joint. The person may also suffer from permanent loss of the normal range of motion in that particular joint.

Until the late 1980s, OA was regarded as an inevitable part of aging, caused by simple "wear and tear" of the joints. This view has been replaced by recent research into cartilage formation. OA is now considered to be the end result of several different factors contributing to cartilage damage, and is classified as either primary or secondary. In the UK alone, OA is the primary cause of disability, joint deformity and loss of joint mobility that have substantial impact on the health of an individual The National Collaborating Centre for Chronic Conditions, 2008: 8.

The increasing number of cases of OA, especially with knee pain, being referred from primary care or orthopedic clinics show that there are many people experiencing problems with OA. This problem now also affects middle age people who are considered to be active and career-oriented. However, due to little knowledge and awareness of the condition, it impacts and limits their physical activities, psychosocial life and working life quality.

Quality of life (QoL) generally refers to the well-being of an individual. This includes their physical, mental and emotional well-being Fallowfield, 2009.

General occurrence of knee pain caused by OA could lead to a decline of quality of life.

The research study is aimed at identifying the impact of OA on patients and the limitations they face as a result of their condition. This will help to evaluate the impact of OA on their quality of life. The study will also find out the coping behaviors that patients have developed to mitigate these limitations and how rehabilitation affects their coping behaviors. The findings or results of study will help to inform practitioners on the impact of OA on patient's QoL in order to develop more client-centered interventions.

Literature review

Joint pain especially in the knees is a most common complaint which impact quality of life. Osteoarthritis (OA) or a degenerative joint disease (DJD) is the most common form of joint disease, cause by wear and tear process of the articular cartilage and the underlying bone become deteriorated Brandt et al., 2009: 3.

There may also be hypertrophy of bone at the joint margins, with the formation of osteophytes

ADDIN EN.CITE

(Arehart-Treichel, 1982: 156, Hutton, 1989: 959)

. The changes may affect predominantly the femoro-tibial joint or the patello-femoral joint, but usually the whole joint is affected. Effusion of fluid into the joint is unusual, except after much activity Sattler and Harland, 1990: 82-85.

The knee works similar as to a modified hinge of the door which allows bending (flexion) and straightens (extension) movement. It is a major weight-bearing joint which is held together or supported by a muscles, ligaments and soft tissues Felson, 2005: 626.

The articular cartilage provides shock absorption especially when we walk, run, climb stairs or play. Clinically, patients with knee OA suffer pain in and around the knee joint which worsens with weight-bearing activities but improves with rest. They also experience morning stiffness and gel phenomenon Felson, 2004: 9

( ADDIN EN.CITE )

. On physical examination, they often have tenderness, bony enlargement, crepitus on motion, and/or limitation of joint motion Hochberg et al., 1995: 11()

"Patient quality of life is an increasingly important outcome measure in medicine and healthcare. It is now widely used in clinical trials and in patient management for assessing morbidity and the impact of treatment," Rees et al., 2005: 563

( ADDIN EN.CITE )

. The clinical outcome of people suffering from knee OA includes limitations of daily living activities, pain and overall decline in the quality of life. More importantly, knee OA leads to the state of unbalance where those suffering from knee OA face the risk of frequent falls as a result of bone deterioration. Age also plays an important role in knee OA progression and cartilage degradation Moskowitz, 2009: S224()

Overall, people suffering from knee OA not only experience a significant deterioration in overall performance-based status but also low quality of life. Chacon et al. (2004: 377-381)

focus on the impact of knee OA on the quality of life of patients. The authors point out that knee OA generally affects people aged 40 years and above and is the most rheumatic disease among general population (p. 379). However, the disease generally affects the joints, and it increases the level of pain, risk of physical disability and mobility restriction. Knee OA may also lead to decreased joint function, early retirement and physical disability. More importantly, knee OA contributes to increased mortality and impairment of the quality of life among people suffering from the condition. Pain is the major clinical component in knee OA leading to the negative sense of well-being among people. OA also leads to increment in anxiety and mortality rate. Though there is evidence that there is a direct correlation between knee OA and patient's well-being, the overall conclusion of the authors is that knee OA leads to a decline in the quality of life of patients because the chronic pain associated with knee of patients (p. 380).

Breedveld, 2004: i6()

provides a similar argument of knee OA by ranking the health impact of OA equally with congestive heart failure, heart disease, and chronic obstructive pulmonary disorder (COPD). People suffering from knee OA generally require human assistance in carrying out functional activities such as walking long distances, climbing stairs, carrying heavy loads and housekeeping chores. However, the risk of knee osteoarthritis worsens with increase in age. Typically, more than 13% of people between 55 and 64 in the United States suffer from knee osteoarthritis. It is a general agreement that influence of age may result from insufficient cartilage repair, hormonal changes as well as cumulative exposure to damaging environmental effects. The author further argues that presence of knee OA may trigger the occurrence of other diseases (p. i5). A large proportion of people suffering from OA also suffer from comorbidities such as cardiovascular disease, congestive heart failure, renal function impairment, peripheral vascular disease, respiratory and diabetes disease.

Murphy and Helmick (2012: S13 - S15)

in their own case reveal the cost burden of OA on patients. "In 2003, the costs attributable to knee osteoarthritis and other rheumatic conditions were $128 billion ($81 billion in medical expenditures and $47 billion in earnings losses), which represented nearly 1% of that year's U.S. Gross domestic product" (p. S13). Furthermore, the total cost burden for knee and hip replacements in the United States was approximately $43.9 billion in 2009. Nevertheless, people with knee OA are likely to bear the burden of medical costs. The authors also found that those with rheumatic conditions caused by OA are likely to spend $3,613 per person (p. S14). These findings show that the costs associated with OA in general are extremely high. Knee OA is also seen to contribute a huge chunk of medical expenditure on patients which may cause them financial stress that deteriorates their quality of life through stress and depression.

In a study that was conducted under the PraxArt project, it was found that OA has a negative effect on the quality of life of patients. The study also reveals that when a patient-centered intervention that allows for longer follow-up is not applied, the quality of life of patients which is measured by their satisfaction, presence of comorbidities and levels of stress and depression deteriorates Rosemann et al., 2005: 77

( ADDIN EN.CITE )

ADDIN EN.CITE

Jinks et al. (2007: 59)

also provide amodel for examining the quality of life of patients suffering from knee pain that may be associated with OA. Their study used a multi-method approach over a 12-month period and found that knee OA results to difficulties in conducting normal activities such as bending, domestic chores, climbing stairs, bathing, and getting in and out of a car. The study thus supported the findings of previous authors on the negative effects of knee OA on quality of life of patients.

OA represents a significant public health problem and contributes a major disease burden globally. It also makes daily activities to become slower, harder and painful to perform and it also can change people's lifestyle Brooks, 2002: 575.

It is also a long-term problem since it has no cure and it can only be managed by educating the public, controlling pain, increasing fitness and strengthening muscles. These can improve joint mobility, limit functional impairment and slow the progression of OA. OA is been considered as one of the chronic illnesses. A research study on the impact of OA on QoL shows that the impact of OA on QoL, especially on pain and disability, does not differ between female or male patients Okanlawon, 2012: 31.

The study also shows that OA of the knee usually begins at the age of 40 and is most common in people over the age of 65 Ji et al., 2010: 672

( ADDIN EN.CITE )

. However, recent studies have shown that people in their 20s or 30s can also get OA Rodriguez-Fontenla et al., 2012: 907

( ADDIN EN.CITE )

. Some predisposing factors include overuse of the knee joint, occupational or sports-related injuries, and obesity. However, a study conducted by David T. Felson, showed that recreational walking, jogging or other self-reported activity has no relation with the development of knee OA which creates ambiquity over the cause of knee OA Felson et al., 2007: 534-540

( ADDIN EN.CITE )

By learning more about OA, the public will be able to understand how it impacts QoL and thus apply appropriate preventive measures. Practitioners will also be able to understand the impact of the disease on QoL of patients and thus develop and adopt appropriate control measures to improve patient outcomes.

Methodology

Research design

The research was designed to be a qualitative study. It was carried out in an outpatient physiotherapy setting where most of the patients is been referred from primary care (outpatient department) and orthopedic clinic. According to Lindlof and Taylor (2002: 19)

, the qualitative method is best when the researcher is looking to answer the why and how question regarding decision-making. Since this study dwells with why and how those suffering from knee OA have coped with their illness, the qualitative study method is chosen. Marshall and Rossman (1999: 52)

also state that qualitative research is best for focused samples which are what this study looks at. This study focuses on Tawau hospital staff suffering from knee OA which is a small cohort that is best focused on with the qualitative research method.

Setting

The study is to be conducted among the staff of Tawau Hospital which is located in Tawau. It is the biggest government hospital in the east coast of Sabah, Malaysia. Tawau Hospital is known as the central zone for main referral cases from other hospital in the East Coast zone of Sabah. Tawau Hospital is a teaching and learning hospital which provides training for new doctors, other allied health professionals from the private or local government healthcare facilities, local universities and international settings. Tawau Hospital also operates in collaboration with the Sabah Health Department.

Subjects

Purposive sampling study was used to identify study subjects. This sampling method was deemed best to help the researcher find a small sample which is accessible for in-depth interviews and whose findings can be generalized to the accessible population rather than the complete target population Denzin and Lincoln, 2005: 23(, Saldana, 2012: 74)

. Purposive sampling is a nonprobability sampling method which is used to include only those subjects who are relevant to the study Groves et al., 2009: 103.

As stated by Patton (1990: 61)

, purposive sampling is best when the study is designed to be qualitative for reasons such as it ensures the study is information-rich, it illustrates what is typical, average or normal, it is opportunistic meaning it follows new leads, it saves time, effort and money, and many others.

To be included in the study, participant had to fulfill the selection criteria which meant they had to be members of staff in the hospital and had to be suffering from knee OA or bilateral knee pain. They also have to have registered with the physiotherapy outpatient department between Jun and Dec 2012 and to be undergoing treatment at the facility. The physiotherapy session had to be for at least a month. To be included, the subject had to be able to communicate in Bahasa Malaysia or English. The researcher left the forms at the department after which willing participants contacted the researcher or left their contact number at the department. The researcher then chose 7 participants for the study.

Procedure

Data collection

After the participants were identified, they were introduced to the study and the purpose of the study was explained to them in detail. The date and time for an interview was then set at the convenience of both the researcher and the participant. The researcher then called the participants to remind them of the interview on the day of the interview. On the interview day, the participants were reminded that the interview will be tape-recorded but no personally identifiable information will be collected or used. The data collected was kept in a locker at the facility's physiotherapy unit and was coded to ensure it was not personally identifiable.

A semi-structured interview with open-ended questions was conducted with all 7 participants. The interviews were guided by the schedule attached in the appendix. The major reason for this was as given by Holloway and Wheeler (2002: 82)

, to ensure the interviewer maintains some control of the interview and to ensure external validity and reliability of the study. All information collected was treated as confidential and the patient's identity was kept anonymous.

Detail of instruments

A hand-held audio tape recorded with capability to record up to 60 minutes of audio was used to record the interviews. These were then transcribed in verbatim by playing, fast-forwarding or rewinding the audio. The transcripts were then analyzed to find themes that arose from the discussions.

Pilot study

A pilot study was conducted for several reasons. First was to test the tools which include the recruitment procedures, sampling and data collection methods. The pilot study thus allowed the researcher to find issues in the methodology and change them appropriately to ensure the success of the study. As suggested by Prescott and Soeken (1989: 60)

, it is important to do a pilot study in order to modify the materials and procedures of the study towards the better.

Data analysis

The interviews were transcribed in verbatim and reread to ensure they were in verbatim. This was done by two people who were not involved in the study. Where any differences arose, they were resolved by discussion. Once transcribed, the transcripts were then read repeatedly before being coded to find emerging themes and issues. A thematic content analysis was then conducted with an open coding system in order to accommodate emerging themes and issues. Member-checking was also used to ensure higher validity. This is where the participant was called in to check the transcript to ensure it was transcribed and coded correctly.

Ethical considerations

Ethical approval from the Teesside University and Tawau Hospital was sought before the study commenced. The researcher first had to register as a member of the National Medical Research Registry. The researcher then registered the study with the Medical Research and Ethics Committee who reviewed the project and provided approval. The study was also approved by the school research governance and ethics committee. To ensure internal and external validity and reliability of the study, the data was collected and held confidentially and stored securely. All participants were required to provide written informed consent after being informed of their right to confidentiality, anonymity and withdrawal at any time.

Results and discussion

The sample population of the study was 7 who were Tawau hospital staff. Table 1 below shows the study profile. 20 participant forms were distributed at the physiotherapy department and 15 were returned. Of the 15, 8 were valid but 7 were purposively sampled for the study.

Table 1 Study profile

Total research participant forms

20

Non-returned research participant forms

5

Returned research participant forms

15

Partly filled or improperly filled forms

2

Unfilled forms

1

Did not meet criteria

4

Total number of valid participants

8

Total participants selected for the study

7

Demographics

Five of the seven participants were female while only two were male. The respondent's age ranged from 44 to 56 years' of age. The respondents also had varying hobbies from dancing to sports such as badminton, hiking and gardening. Their professions or occupation ranged from nurses, assistant medical officers, attendants and social workers. Upon testing the responses against these demographic variables, we found that there was no significant difference between gender or age and the individual responses on the interview questions. The higher number of female respondents is thought to come from the higher number of females attending the physiotherapy clinic and therefore this supports it not being a significant demographic variable.

Knowledge about OA before physiotherapy

All participants in this question stated that they had no or little information regarding knee OA prior to attending physiotherapy. All respondents stated that their knowledge of OA was "limited" or "inadequate" and all they knew was that they had joint pain or discomfort or knee problems. Participants stated that they had heard about other diseases such as gout, osteoporosis, and arthritis. However, they only had little information about knee OA.

Severity of disease before and after rehabilitation

The severity of disease before rehabilitation varied greatly. However, all participants stated that they had some improvement after rehabilitation. Two patients stated that the pain was now "tolerable" as a result of rehabilitation and another said that they "feel much better now." Three patients went ahead to elaborate on the improvement and stated that "morning stiffness and pain have reduced," that the pain has "become less" and that the stiffness they used to feel was now "getting less after some period of physio treatment."

Degree of difficulty as a result of knee OA

The respondents stated they have varying levels of difficulty as a result of knee OA. These ranged from walking difficulties "difficult to walk for long journey" and "I cannot join my friend to go hiking" to the condition affecting their work performance "the pain occasionally affects my work" and "there is a lot of difficulty as my nature of work involves a lot of getting up from sitting." Only one respondent stated there was no difficulty as a result of knee OA "actually nothing much to change and I feel everything is OK."

Effect on work performance

The respondents' work performance was affected in different ways by knee OA. Only one respondent said that knee OA did not have much of an effect on their work performance "I feel no problem." This participant was the same one who stated that they did not feel any difficulty in their life as a result of knee OA. The other respondents stated that knee OA made them have to sit down more often "because of pain I have to sit and limit my movement" and "I'm less confident to walk or stand too long," or to limit their knee movement "I have to be careful with my knee movement and need to be little bit slow." The other respondents reported similar effects of knee OA on their work performance.

Effect on emotional status and social activities

One of the seven respondents stated that there was no negative effect of knee OA on their emotional and social status "not so much as pain is short lived, still able to attend social activities." The respondent who earlier stated that the degree of difficulty with knee OA and its effect on work performance, however, stated it does affect their emotional and social status "On emotional, nothing much to say. On social activities, I have to change my daily activities for example from playing badminton to jogging and walking." Other respondents stated that their emotional status was adversely affected by knee OA as well as their social activities "I always feel emotional." Others stated that knee OA has brought them boredom as a result of not being able to continue with their various hobbies.

Adaptations or how they cope with knee OA in their working life

Respondents have found different ways of coping with knee OA. These range from massaging their knee and using bandages to avoiding frequent knee movement through sitting down more often. "I've to avoid frequent movement like sitting to standing or squatting," "every 20-30 minutes I need to sit down while walking" and "short rest is required in between walking." Only one participant stated that there was no adaptation they formed "actually nothing much to change and I feel everything is OK." One respondent stated that they have been able to cope by accepting their age and their condition this has helped them "to be happy and just enjoy" life.