# When poverty gets into your joints: exploring socioeconomic, environmental, and gendered determinants of rheumatoid arthritis in district Dir lower, Pakistan

## TL;DR

This study explores how poverty, climate, and gender affect rheumatoid arthritis in rural Pakistani women, revealing key factors that worsen their condition and access to care.

## Contribution

The study is one of the first to quantify seasonal and gender-based disparities in rheumatoid arthritis in South Asia.

## Key findings

- Colder winter temperatures significantly increase self-reported pain among RA patients.
- Spousal unemployment doubles the risk of treatment dropout for women with RA.
- Living more than 50 km from a specialist care center triples the odds of severe mobility limitations.

## Abstract

Rheumatoid Arthritis (RA) imposes a significant disease burden in low-and middle-income countries (LMICs), yet evidence on its socio-structural factors in underserved populations remains scarce. This study investigates the key environmental, gendered, and structural factors influencing patient-reported experiences of RA among women in rural Pakistan, where access to consistent rheumatology care is extremely limited (<5%).

An epidemiological cross-sectional study was conducted with 300 women with RA in rural Pakistan. Data were collected via structured interviews assessing self-reported pain, perceived mobility limitation, psychological stress, and treatment adherence. Statistical analyses employed ordinal logistic regression and Structural Equation Modeling (SEM) to identify and model the determinants and pathways influencing patient-reported outcomes.

Analysis revealed three primary determinants: (1) Climate-linked disease burden: Colder winter temperatures were significantly associated with exacerbated self-reported pain (Z = 12.24, p < 0.001, r = 0.52). (2) Gendered care barriers: Spousal unemployment doubled the risk of treatment dropout (U = 5690.5, p < 0.001). (3) Structural marginalization: Residing >50 km from a specialist care center was associated with 3.2 times higher odds of reporting severe perceived mobility limitations (χ2 = 28.49, p < 0.001). SEM confirmed significant interconnected pathways, demonstrating how income loss and psychological stress mediate adverse patient-reported outcomes (CFI = 0.94, RMSEA = 0.042).

As one of the first studies to quantify seasonal and gender-based disparities in RA in South Asia, our findings underscore the critical role of socio-structural factors in shaping disease experience in resource-poor settings. The results directly inform the WHO Global RA Action Plan for LMICs. We propose three evidence-based interventions for underserved regions: mobile rheumatology units to bridge geographical gaps, climate-adaptive pain management protocols, and community-led psychosocial support programs to address gendered and economic vulnerabilities.