Effects of patient education on knee joint injections and the impact on patient care and satisfaction in rural Guatemala

INTRODUCTION

Global health interventions and patient care present many challenges for clinicians and public health experts. Many countries across the globe have limited healthcare resources, which can lead to global health inequity.^1,2 Additionally, a staggering number of patients across the globe do not have healthcare access.^3,4 Rural populations particularly raise concern for their lack of healthcare access, sometimes requiring multiple hours of travel. This inevitably results in large healthcare disparities among those living in rural communities.^5,6 Rural populations may not have the necessary transportation resources to reach distant healthcare facilities.^7-9 In addition, rural populations may have decreased health literacy, which could also lead to health disparities.^10,11 A major social challenge is that some rural populations may also have beliefs against medical care and may avoid medical systems.¹² Healthcare and research must continue to expand by involving rural populations for equal representation and providing rural populations across the globe with the necessary healthcare they deserve.

The rates of osteoarthritis (OA) have steadily increased among older populations across the world.^13,14 Osteoarthritis affects millions of people annually across the globe.^13,14 Management of OA costs healthcare systems across the globe billions annually.^15,16 Osteoarthritis is a degenerative disease where bones lose their articular cartilage and begin to develop bone remodeling.^17,18 The American Academy of Orthopaedic Surgeons (AAOS) clinically defines osteoarthritis as stiffness, pain, inflammation, and pain that is worse in the morning and feels better with activity.¹⁹ There are many risk factors for osteoarthritis, such as weight genetics, trauma, and most importantly, age.^20,21 Knees, being weight-bearing joints that see much wear and tear, are among the most commonly affected joints by osteoarthritis.²² Osteoarthritis can be physically disabling, particularly for individuals who have physically demanding jobs to provide for their families²³. Additionally, OA has a major impact on one’s physical and mental capacity and can play a role in inducing other medical conditions such as depression, metabolic syndrome, and stroke.^24,25 This can lead to a domino effect and severely impair the patients and the relationships of those around them.

Osteoarthritis is managed through a variety of modalities. Some common routes include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, hyaluronic acid, platelet-rich plasma, stem cells, and total joint arthroplasty. Glucocorticoids remain one of the top modalities in the conservative management of OA due to their ability to reduce pain, increase mobility, and improve the quality of life in patients.^26,27 Many patients often develop relief of their symptoms for some time; however, the length of time is often variable amongst patients.^27,28 Glucocorticoid injections will remain a top modality in the management of osteoarthritis due to their efficacy.^27,28

The National Institute of Health (NIH) study on patient perspective surrounding intra-articular injections for knee arthritis conducted a qualitative study interviewing participants with knee OA and identified themes that shaped a patient’s decision on receiving an injection: 1) the impact of OA on participants’ lives; 2) participants’ attitudes and concerns, including the desire to avoid surgery, willingness to accept uncertain outcomes, and concerns about side effects and dependence; 3) the way participants gathered and processed information from physicians, peers, and the internet; and 4) the availability of injectable products.²⁹ The study found that participants were concerned about the effectiveness, toxicity, availability, and cost of injectable products.²⁹ The findings of these studies can help healthcare providers and clinicians become aware of the challenges that patients face when making injection decisions and help guide their patients into making informed decisions.

The goal of this study was to compare the ratings of anxiety level, pain level, and education about glucocorticoid injections between the group who received expansive education about joint injections and the group who received minimal education about joint injections. Additionally, the study examined the concerns that participants have regarding the injection. We hypothesize, in this study, that after the intervention and injection, both groups would have decreased anxiety levels, pain levels, and severity of symptoms. Furthermore, we hypothesize that after the intervention and injection, both groups would have increased educational levels. We also hypothesize that group A, the group with more extensive education, would have better ratings on these scores when compared with group B. We further hypothesize that there would be no statistical difference in demographic or survey data.

METHODS

Ethical approval

Participants were provided a consent recruitment statement in both English and Spanish to obtain their verbal consent before being involved in any research activity (A1, A2). This research was approved by the Kansas City University Institutional Review Board.

Study design

This study was cross-sectional that occurred in February 2023. The study was completed over eight days in rural Guatemala in the following order: Tecpán Guatemala, San Pedro Yepocapa, Patzun, Chimaltenango Centro, Santa Cruz Balanya, Chimaltenango Alameda, San Juan Alotenango, and Santa Catarina Barahona. All participants who met the criteria for OA clinically, according to the AAOS (stiffness, pain, inflammation, and pain that is worse in the morning and feels better with activity) and who verbally consented to participate in the research study were recruited into the study.¹⁹

Each participant was given a pre-injection survey (A7, A8) allowing them to rate their anxiety level, pain level, education level about knee injections, and duration and severity of symptoms.

Prior to the visit with their physician, participants in group A received an informational sheet with a full description of the injection procedure (A3, A4) and an accompanying video of the injection (Section 2.2), and participants in group B received a generic description of the procedure (A5, A6). After completing the pre-injection survey (A7, A8) and reading the attachment (A3, A4, or A5, A6), participants received the injection in their affected knee. After the injection, each participant received a post-injection survey (A9, A10) with a list of concerns.

After the injection, participants again rated their anxiety level, pain level, and education level. The primary investigator and translators were onsite to answer additional questions or concerns.

Participants

Participants at the clinic sites in Guatemala were screened for osteoarthritis. Inclusion criteria included anyone over the age of 18 and who met the criteria for OA19 outlined in the study design. Exclusion criteria included anyone below the age of 18 or who did not meet the criteria for OA19. Participants consented to the risks, benefits, and potential harm of the study and to the treatment with glucocorticoids (A1, A2). Selected participants were randomized to the two groups through block randomization (ABAB) to reduce selection bias.³⁰

Sample size included 40 participants, with 20 participants in group A and 20 participants in group B. Participants provided data including age, gender, education level, socioeconomic status, perceptions of glucocorticoid injections, and current symptomatology ratings in a pre-survey. Participants in group A received an informational sheet with a full description of the injection procedure (A3, A4) and an accompanying video of the injection (Section 2.2), and participants in group B received a generic description of the procedure (A5, A6). All patient education was carried out by the lead author of the research to maintain consistency throughout the study. After the injection, participants completed a post-survey about their symptomatology ratings and concerns (A9, A10).

Data analysis

An unpaired t-test was conducted to compare the two research groups before and after the knee injection for each of the following survey ratings: anxiety level, pain level, educational level about glucocorticoids, and severity of pain. A paired t-test was conducted to compare each of the above survey ratings of each research group against themselves before and after the knee injection. A Fisher’s exact test was conducted to compare the demographic data and pre-survey data between the two groups (Table 1). The top post-survey injection concerns were collected and tallied (Table 2).

RESULTS

Forty participants met the inclusion criteria for osteoarthritis. Twenty participants were assigned to each of the groups through block randomization. All 40 participants completed the pre-injection survey and ratings (A7, A8). Thirty-nine participants completed the post-injection survey and ratings (A9, A10). One participant in group B did not complete the post-injection survey and ratings due to medical contraindications. One participant was retained in the study rather than excluded due to the completion of the pre-survey perceptions and ratings.

The study population consisted mostly of people 65 years old and older, with 52.5% of the population aged 65 or older. The study was 80% female and 20% male. Of the 40 participants, 72.5% of the participants did not complete high school-level education, and 97.5% of the participants were low-middle income class. A Fisher’s exact test was run to compare the survey and demographics data between groups A and B (Table 1). There was no statistical significance noted when comparing the age (p=0.924), gender (p=0.464), educational level (p=1.00), socioeconomic status (p=1.00), the reason for joint injection (p=1.00), and duration of symptoms (p=0.330) between the two groups.

An unpaired t-test was conducted between groups A and B in both pre-injection ratings and post-injection ratings. There was no statistical significance noted before the knee injection was administered between groups A and B for anxiety level (p=0.9616), pain level (p=0.2174), educational level about glucocorticoid injections (p=0.1968), and severity of symptoms (p=0.5178). There was no statistical significance noted after the knee injection was administered between groups A and B for anxiety level (p=0.3510), pain level (p=0.2360), and educational level about glucocorticoid injections (p=0.5212).

A paired t-test was conducted to compare the pre-injection ratings and post-injection ratings for both groups A and B. Statistical significance was noted between pain levels before and after the knee injection was administered in group A (p<0.001). There was also statistical significance noted when a paired t-test was run between pain levels before and after the knee injection was administered in group B (p<0.001). Statistical significance was noted when comparing the educational levels of glucocorticoid injections before and after the knee injection was administered in group A (p=0.0351) and was not statistically significant for group B (p=0.0586). There was no statistical significance between anxiety levels before and after the knee injection in group A (p=0.2296) or group B (p=0.4535).

Post-survey injection concerns were collected, with the top concerns tallied in Table 2. The top concern by participants after the injection was “none”, with 67.5% of participants having no concerns after receiving the glucocorticoid injection. The second highest concern was the pain level, with 25.0% of participants concerned about the pain level after the glucocorticoid injection.

DISCUSSION

The results of this study demonstrated that group A had increased educational levels on corticosteroid injections after the procedure which was statistically significant, whereas group B did not have increased educational levels. These results emphasize the importance of proper education prior to a procedure like a corticosteroid joint injection, as the group that received extensive information on injections became more well-informed about the process. Additionally, there was also a reduction in pain levels before and after the knee injection in both groups A and B as predicted, and these results were statistically significant. This possibly showed that pain levels after a joint injection weighed more heavily on the injection itself rather than the educational aspect of injections as both groups experienced a reduction in pain regardless of the type of education they received.

The results of this study showed there was no statistical significance noted before the knee injection was administered in comparison between groups A and B for anxiety level, pain level, educational level about glucocorticoid injections, and severity of symptoms. There was also no statistical significance noted after the knee injection was administered between comparison groups A and B for anxiety level, pain level, and educational level about glucocorticoid injections. This could be due to the possibility that corticosteroid injections are limited in rural Guatemala. Considering the lack of research emphasizing the lack of projects involving injectables, many participants in the rural clinics mentioned that this was possibly their first and only chance of receiving a corticosteroid injection for their long-standing osteoarthritic pain. Thus, this can explain why many participants did not report high anxiety levels before or after the corticosteroid injection. Additionally, Guatemala still ranks the lowest in terms of literacy.³¹ In 2014, 19 percent of the adult population (15 years and older) was illiterate.³¹ This could have contributed to results that were not statistically significant in increasing the educational level about corticosteroid injections when comparing the two groups. Furthermore, the subjectivity of rating pain levels prior to and after the joint injection is heavily based on the joint injection itself and not the process of educating the participants about the injection.

The most common reasons for a joint injection were as expected, including the availability of injectable products and the impact of OA on the participants’ lives. Many of the participants in the study complained about their osteoarthritic pain and its impact on their lives. They opted for a knee injection due to their inability to carry out their activities of daily living, including walking and working. In addition, many participants had not seen a doctor in many years and took this one opportunity to receive a joint injection without cost. According to the demographics data, 72.5% of the participants did not have a high school degree, and 97.5% of the participants made less than 13.9 Guatemalan quetzals per day, which roughly amounted to 1.78 US dollars per day (as of February 2023). Although there is a lack of data on the cost of a corticosteroid joint injection in rural Guatemala, many of the participants most likely could not afford a luxury such as a joint injection.

According to a previous research study by Lenhard et al, patient perspectives surrounding intra-articular injections of the knee concluded that participants were concerned about the effectiveness, toxicity, availability, and cost of injectable products.²⁹ However, in our study, 67.5% of the participants in rural Guatemala had no concerns following the joint injection, while 25.0% of the participants were concerned about the pain after the injection. This may be due to the lack of education and knowledge on joint injection prior to and even after the injection. Although group A received the most information on knee injections, the documentation they received included information on how injections reduce vascular permeability and inhibit the production of inflammatory cytokines and mediators such as prostaglandins and leukotrienes.³² Participants may not have understood these terms, possibly inhibiting their educational level on knee joint injections. Furthermore, group A also received a video on the process of joint injections. While watching the video, most of the participants presented with fear about the pain of the injection. Thus, this could have contributed to concerns about pain following the injection rather than concerns about toxicity and effectiveness. The participants that had no concerns following the joint injections may have been more content with possibly feeling relief from the injection after years of suffering from OA that their top concerns were not focused on the toxicity of the injections.

This study was limited due to several factors. Transportation in rural Guatemala is a factor that contributed to which types of participants were able to come into the clinic for a knee joint injection. This limitation can skew the data when examining for differences in patient perception of knee joint injections amongst varying demographic groups. A second limitation of this study is the lack of literacy among many of the participants in rural Guatemala. If participants were unable to read, medical students would read the information sheet to the participants. However, words can be lost in translation due to differences in the pronunciation of certain words. A third limitation of this study was the misunderstanding of certain keywords for the study. For example, many participants did not understand the word “anxiety,” which made it difficult for rating anxiety levels before and following the joint injection. Therefore, the word “scared” was substituted many times to allow participants to provide a rating for that category. A fourth limitation of this study is the lack of follow-up after the knee joint injection. Due to this factor, participant satisfaction was not recorded a few weeks or months after their knee joint injection. The final limitation of this study is that we excluded participants who did not feel comfortable with filling out a survey on their experience. While we would have liked to include all participants, we wanted to ensure the utmost respect and privacy for all participants at the clinic in rural Guatemala. We also believe that even with the exclusion of participants we believe that we had a sufficient sample size, particularly for a rural population study.

Future research should be conducted to further understand knee injections in rural populations. A future study that can be implemented to further provide patients with more information before joint injections include providing information sheets that can be understood by those who do not have any background in medicine. Providing information in layman’s terms can help patients feel more comfortable before a procedure such as a joint injection. Additionally, studies can also focus on allowing patients to provide feedback on the information they would have liked to be included in the information sheets to further educate them about the process of injections. Future studies regarding patient perceptions of knee injections for OA will help improve the patient-physician relationship. Additionally, future studies can help seek out procedures that can be implemented in healthcare facilities to improve patient satisfaction before and following orthopedic knee injections

CONCLUSION

This research study was able to show that extensive education on corticosteroid knee injections before the procedure can increase educational levels following the injection and decrease pain levels following the injection in participants with clinical osteoarthritis in rural Guatemala. These results could serve as important literature for clinicians managing osteoarthritis in rural populations.

ACKNOWLEDGEMENTS

We would like to acknowledge Kansas City University and DOCare International for their dedication to providing care to under-resourced clinics in rural Guatemala. We would like to give a special acknowledgment to Dr. Gautam Desai, DO, and Dr. Kenneth Stewart, DO for their relentless dedication and leadership in guiding KCU students to serve the rural Guatemala population. Additionally, we would like to thank Dr. Jeffrey Zollinger, DO, and the staff of Sweetwater Pain and Spine Clinic for their assistance in Guatemala and their donation of steroid injections, lidocaine, sterile gloves, syringes and needles, betadine, and other products that allowed the injections process to run smoothly.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee Kansas City University Institutional Review Board

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APPENDIX

A1. Recruitment statement for research participation in English.

A2. Recruitment statement for research participation in Spanish.

A3. Informational sheet for participants in Group A in English.

A4. Informational sheet for participants in Group A in Spanish.

A5. Informational sheet for participants in Group B in English.

A6. Informational sheet for participants in Group B in Spanish.

A7. Pre-injection survey in English

A8. Pre-injection survey in Spanish

A9. Post-injection survey in English.

A10. Post-injection survey in Spanish