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Arabia, yet patients’ perception of disease can be influenced by cultural differences. For example, in a cross-cultural study of pain intensity in patients with RA, Egyptian women reported worse pain, disease activity and physical function than Dutch women, despite having similar disease severity according to clinical measurements.22 The COMORA study, which evaluated patients with RA from 17 different countries, found that levels of fatigue varied between countries, and the proportion of patients with severe fatigue ranged from 14% in Venezuela to 65% in Egypt. This variation was partly explained by subjective outcomes but not by objective disease outcomes.23 Furthermore, work outcomes varied between countries, with patients in Morocco having the lowest odds of being employed (vs German patients) and the highest odds of absenteeism (vs Japanese patients).24 These studies highlight that patients from different cultures may assess the importance of specific health domains and their impact on the quality of life in different ways. This study is limited by the small number of participants, particularly HCPs. Survey participants had to be literate (both with computers and in general) and available to participate in the survey; therefore, the survey may not be fully representative of patients with RA in Saudi Arabia. A previous study of patients with RA in Saudi Arabia found that 30% (53/185) of patients were illiterate.25 The current study was descriptive and did not include any formal statistical comparisons. Additionally, no information was collected on disease severity or patient comorbidities, which could have affected the results. In general, surveys are limited by the subjective nature of participants’ answers and by the possibility that participants may not necessarily have provided honest answers. In conclusion, this survey of patients with RA and HCPs in Saudi Arabia found that patients and HCPs perceived that people without RA understand the emotional and physical impacts of RA. Most patients either did not work or had experienced a slowing of career progression due to the disease. Ability to perform everyday activities was also affected, which caused patients anxiety. Patients had modest aspirations for the future, their greatest hope being that the emotional impact of RA would be better understood. This study is the first of its kind in Saudi Arabia and should help to increase awareness of the difficulties and concerns of those living with RA in the Arabic world. There is a clear discrepancy in how HCPs in Saudi Arabia perceive patients’ feelings and how patients actually feel, indicating that HCP–patient communication could be improved. The findings of the survey require confirmation in a larger patient population and need to be evaluated in relation to disease activity and disability. Abbreviations HCP, healthcare provider; PRO, patient-reported outcome; RA, rheumatoid arthritis; STROBE, Strengthening the Reporting of Observational studies in Epidemiology. Acknowledgments\ The authors thank the patients and HCPs who participated in this survey, the Charitable Association for Rheumatic Diseases for its role in recruiting patients, and the personnel from KRC Research for conducting the survey. The authors also acknowledge Dr Lizeth Lacharme and Dr Sue Chambers (Rx Communications, Mold, UK) for medical writing assistance with the preparation of this manuscript, funded by Eli Lilly and Company. This study was funded by Eli Lilly and Company (Indianapolis, IN, USA).\ Author Contributions\ All authors made substantial contributions to the conception and design of the study, acquisition of data, or analysis and interpretation of data; participated in drafting the article or critically revising it for important intellectual content; agreed on
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