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INTRODUCTION
Osteoarthritis (OA) once considered a consequence of aging; OA could
be found in moving joints, especialy affect the large weight-bearing joints
such as the knee, hip and spine. When OA with clinical symptoms, such as
pain, physical disability and limiting daily activities, which makes the
patients have to see a doctor regularly and be treated. Therefore, this affects
the quality of their life and causes economically costly.
According to a survey conducted in USA, more than 80% of over 55
year-old people show signs of OA on X-ray, in which 10 - 20% of
people have limited mobility. Especially, a few hundred thousands of the
people are not self-serviced due to hip OA and the cost of treating one
patient with drugs was amounted to USD 141.98 in 30 days. In France,
OA accounts for about 28.6% of the musculoskeletal disorder, each year
about 50,000 people are replacemented artificial hip joints.
Along with the increase in average life expectancy of Vietnamese,
musculoskeletal disorder, especially knee OA is common, the more
elderly people are the more severe disease are. This disease does not
directly threaten to the patients’ life so patients and the community has
not paid adequate attention to it, especially manual labors in rural areas.
If this disease is detected and treated late, the result of treatment is not
effective as expected, associated with leaving jobs, reducing labor
productivity and limit daily activities, even leading to lifelong disability.
Therefore, the role of community health workers is very important in the
early detection, proper treatment and counseling for the people.
In Vietnam, there have been research works on the clinical
characteristics and treatments on knee OA in a number of hospitals, but
epidemiological assessment of knee osteoarthritis and diagnose as well as
treatments and counseling for knee OA patients in the community still
received little attention. To make this issue be understood better, we

carried out the thesis: "Study of knee osteoarthritis and improving
capabilities of diagnosis and managements of community health
workers in Hai Duong province"
OBJECTIVES OF THE STUDY
1. Describe the real situation of knee osteoarthritis in people aged 40 and
older from 02 communes in Gia Loc district, Hai Duong province in 2008.
2. Assess on the effectiveness of intervention model to improve
diagnosis and management capabilities of knee OA of community
health workers in Hai Duong province
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NEW CONTRIBUTIONS OTHE THESIS
1. Describe the real situation of knee OA in people aged 40 above from
02 communes in Gia Loc district, Hai Duong province.
2. Assess on the effectiveness of intervention models to improve
diagnostic and management capabilities of knee OA by community
health workers in Hai Duong province.
THESIS STRUCTURE
This thesis is 137 pages thick excluding appendices, including 4
chapters, 35 tables, 10 charts, 191 references in domestic and abroad.
The outline of the thesis consists of Introduction (2 pages), overview
(48 pages), materials and research methodology (16 pages), results
(34 pages), discussion (page 34), conclusions (2 pages) and
recommendations (1 page) and 3 articles related to the thesis published.
CHAPTER 1. OVERVIEW
1.1. Knee joint anatomy
1.1.1. Scope of the knee:

The knee joint is the connection between the upper and lower legs,
which was limited by the upper patellar about 4cm and the lower by the
bottom loop under the tibia tuberosity. Knee is divided into two areas by
the knee joint: anterior and posterior of the knee.
1.1.2. Knee - joint anatomy:
Knee joint is a hinge joint between the bulging of the tibia, femur, and
patella with the face of patella of femur. This is a complex joint with
very wide synovial fluid, easily swollen and distended. Knee joints in
prone areas are easy to be impacted and injurred.
Knee joint is a complex joint consisting of two joints:
- Between the femur and tibia (the hinge joints)
- Between the femur and the patella (the flat joints)
1.1.3. The structure and composition of articular cartilage.
Articular cartilage is white, smooth, elastic wrapped around the
epicoldyle of femur, tibia, and the back patella. Articular cartilage with
physiological functions is to protect the epiphyseal of the bones and
spread out the weight bearing on the entire joint surface. Normally,
articular cartilage is glossy, wet, very hard and strong elastic. The
articular cartilage ensures sliding motion among the articular surfaces
occurring with a very low coefficient of friction, as a buffer layer helps
to reduce compression. Articular cartilage has no blood vessels and
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nerves. The basic composition comprises the cartilage cells, collagen
fibers and basic chemicals, and arranged and form different layers.
1.2. Osteoarthritis
1.2.1. Definition

Osteoarthritis is the dysfunction of articular cartilage, the main
manifestation of this disease is the phenomenon of wear and tear of
articular cartilage in relation to minimizing the mechanical operation of
the joint. OA is the result of the mechanical and biological proccess,
which causes the imbalance between synthesis and destruction of
cartilage and subchondral bone (the spine and intervertebral discs).
1.2.2. Epidemiology of osteoarthritis
Osteoarthritis is a common musculoskeletal disease. Among the
elderly, knee OA is a leading cause of chronic disability in the developed
countries. Several hundred thousand people in the U.S. are unable to
walk independently from bed to the bathroom because of knee or hip
OA.
Under the age of 55, the distribution of this disease in men and
women is alike. For older people, hip OA is often found in men more,
while OA in the knee, finger and thumb are more common in women.
Similarly, X-ray of knee OA is also discovered more in women.
1.2.3. The etiology and pathogenesis of osteoarthritis
 Changes of articular cartilage in OA:
When cartilage is degenerated, the most symptoms are the yellow
discoloration, dull, dry, soft, loss of smoothness, elastic reduction,
thinness and cracks. Initial cartilage damage is small cracked areas; the
cracks can be column form, gray and grainy. The damage will spread and
deepen over time. This situation progresses down deeply and spreads
vertically and in some cases, some cracks will spread to the subchondral
bones. There may be ulcers; loss of cartilage exposes the subchondral
bone. Besides the cracks of the surface cartilage, articular cartilages in
older adults become thinner than articular cartilage in children and
adolescents.
 Pathogenesis: developing process of OA is divided into three main stages:
- Stage I: The PGs were lost gradually and collagen fiber net is degraded,

which hurts the structure and function of the articular cartilage.
- Stage II: The surface of cartilage is corroded and fibrous, the
fragments fall into the synovial fluid and is made thinner by
macrophages cells, so it promotes inflammation proccess.
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- Stage III: widespread inflammatory process, because the synovial
membrane cells afected to release protease and cytokines, that promote
catabolism of cartilage degeneration and basic chemicals.
1.2.4. Symptoms of knee osteoarthritis.
 The main symptom:
- Pain that increases when you are active, relieving when having a
rest, limitation of mobility, stiffness of the knee, etc.
- The majority of joints are not swollen, no heated, may deform due
to the enlargement of spines and fat around the joints, limited the range
of the knee joint, especially, knee folding actions, with the pain in the
patella slots - pulley, - ball pulley; signs of wood shavings; bony
enlargement etc.
 Diagnostic criteria of knee osteoarthritis basing on clinical
symptoms of the American College of Rheumatology (ACR-1991)
1) Pain in the knee.
2) Crepitus on action motion.
3) Stiffness of the knee less than 30 minutes
4) Age ≥ 38
5) Touching the bony enlargment
Diagnosis identified when having factor 1,2,3,4 or 1,2,5 or 1,4,5.
1.2.5. Treatments to OA:

 Principle: Slowing the process of joint destruction, especially to
prevent the degradation of articular cartilage, pain relief, mobility
maintaining, minimizing the disability.
 Medical treatments:
- Using of non-pharmacological methods, avoiding the overloading
for the knee joint due to movement and weight.
- Pain relievers and anti-inflammatory drugs, such as acetaminophen,
non-steroid anti-inflammatory drugs and corticosteroids (intra joint
injections).
- Supplement, including Glucosamine Sulfate, Chondroitin Sulfate, etc.
- IL 1 inhibitor, such as artrodar;
- Stem cell therapies.
 Surgical treatments:
- Treatment under arthroscopy.
- Wedge approach to joint, bone chisels.
- Joint replacement surgery or arthroplasty
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1.3. Factors related to osteoarthritis
Degradation of articular cartilage and intervertebral discs is due to
many causes, which are mostly aging and mechanical factors to promote
the accelerated degradation, mechanical factors that increase downforce
on a surface area of joints and intervertebral discs are also called
overloading phenomenon. The mechanical factors including congenital
malformations, deformations, trauma, increasing body weight, increasing
payload by occupation, habits, menopause, etc.
1.4. The health care for rural residents

1.4.1. Role of Community health centers (CHCs)
In Vietnam, about 80% of the population lives in rural areas. The
nearest and most accessible health care services are CHCs. The
strengthening activities as well as improving the quality of medical
facilities, especially CHCs are necessary to improve people's access to
health facilities and ensure equity in health care for all citizens.
However, primary medical activities have not currently been
comprehensive, the quality of health care at community health centers
have not improved remarkably. The attractiveness of the CHCs in health
care is low; people do not really trust the expertise of clinic staff.
1.4.2. Knowledge of the diagnosis and treatments to common diseases
in the community of the medical workers at CHCs.
CHCs are the first health care facility for people in the community.
However, the proportion of people using medical services at CHCS
when they are ill, is very low despite a large team of health workers. The
situations about the capacity of the health workers is still a matter needed
to be concerned. Most medical workers in CHCs are still lack of
knowledge and skills, especially the ability to examine and detect
common diseases early.
1.4.3. The abilities of diagnosis and management of knee OA at the
CHCs.
Currently, together with the increase in average life expectancy of
people in Vietnam, musculoskeletal diseases, especially knee OA is
common, the more elderly people are the more severe the diseases are.
After the age of 40-50, manifestation of the disease may appear, and
women easily get down this disease twice as often as men. If being
detected and treated late, the treating effect is not as expected. It is
associated with leaving jobs, reducing labor productivity and limit daily
activities, even to lifelong disability. Therefore, the role of health
workers at the grassroots levels is vital in the early detection, proper

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treatment and counseling for people. Whether medical workers have
sufficient knowledge, detection skills, diagnosis and early treatment for
knee OA in the community or not is an issue that needs to be addressed.
According to a survey in Malaysia, most primary doctors order
unnecessary tests for the diagnosis of OA. X-ray images can help in the
diagnosis and severity of illness, but not always parallel with the clinical
manifestations, in some cases people with X-ray evident of OA but no
clinical symptoms. In the diagnosis proccess to identify OA, blood tests
are not worthy much, however, more than 50% of physicians at CHCs
ordered to specify blood tests, such as rheumatoid factor, uric acid,
ANA, etc. to diagnose the OA. This can easily lead to misdiagnosis as
rheumatoid arthritis or lupus if the RF tests or antinuclear antibodies
(ANA) are positive.
Therefore, the authors strongly recommends that training for primary
care physicians focus on the diagnosis and management of OA, and
paying more attention to the musculoskeletal disorder in the training
program at university and guiding OA management for primary care
physicians.
CHAPTER 2. MATERIAL AND METHODS
2.1. Subjects of study
2.1.1. Study sites:
- For rural residents from 40 years above including female and male
in 02 communes in Gia Loc district, Hai Duong province
- For communal health workers of Hai Duong province
2.1.2. Subjects:

- For objective 1: People aged 40 and older including male and female
in Lien Hong and Gia Xuyen communes, Gia Loc district, Hai Duong
province
- For objective 2: Medical doctors and assistant physicians are
working in 263 CHCs in Hai Duong province.
2.2. Methods:
2.2.1. Design of study:
- Cross-sectional study: to determine the incidence, clinical
symptoms, X-ray of the knee osteoarthritis and some related factors in 02
communes of Gia Loc district, Hai Duong province. Besides, we initial
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commented on the diagnosis and management of knee osteoarthritis in
the community.
- Intervention study: basing on cross-sectional study results,
implementing interventions and evaluating its effectiveness for
community health workers is to improve knowledge on diagnosis,
treatment and counseling for the knee OA patients, which also
contributes to good health care for rural residents.
2.2.2. Sample size estimation
* The sample size of the cross-sectional study
- Content 1: Determining the incident, clinical characteristic description, Xray and a number of related factors to the knee OA in people aged 40 years or
older in 02 communes of Gia Loc district, Hai Duong province, applying the
formula of the sample size for cross-sectional descriptive study:
Z12−α / 2 pq
n=
x2

( εp ) 2

n: number of individuals in the study sample
p: estimated propotion of OA (p = 0.3 estimated by the study of
Nguyen Thi Nga).
q: the offset to 1 of p (q = 1 - p)
Z1- α/2: Critical values of the standard distribution, apply to the
significance level. In this study α = 0.05 → Z1- α/2 = 1.96
εp: relative accuracy (ε: relative accuracy coefficient = 0.1)
Applying the formula above, the sample size for the random
sample, it is calculated: 2n = 1794.
In the 23 communes of Gia Loc district, choosing 02 communes:
Gia Xuyen and Lien Hong.
Enumerating people aged 40 above in 2 communes is 2153. We
investigate all 2153 people aged 40 and older in these 02 communes.
- Content 2: The capabilities of diagnosis, treatment and counseling for
the knee OA patients at CHCs (the subjects are medical doctors and
assistant physicians): selecting all the medical doctors and assistant
physicians are working at 263 CHCs in Hai Duong province.
- Content 3: Interventing to improve diagnostic, treating and counseling
capabilities of the knee OA at CHCs:
* The sample size of the intervention study: All medical doctors and
assistant physicians in 263 CHCs of Hai Duong province had
participated in cross-sectional study.
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2.2.3. Intervention

Providing the training programme for health workers about knee OA,
focusing on the diagnosis, treatment and counseling for the knee OA
patients by musculoskeletal specialist doctor of Bach Mai Hospital.
2.2.4. Data collecting techniques
- Questionnaire designing.
- Training collaborators to data collecting information by
rheumatology specialtist doctor of Bach Mai Hospital
- Conducting a pilot survey and completing questionnaires.
- Data Collecting.
2.2.5. Data analysis:
Data was processed and analysed by SPSS program 7.5. The research
results are calculated and presented in numbers and percentage (for qualitative
variables), the average value (for quantitative variables). Comparison was done
before and after the intervention by statistical hypothesis testing (p value) and
considers the magnitude of the efective indicators.
2.3. Research Ethics:
The proposal must be approved and decided by the commitee of Hanoi
Medical University and Ministry of Education and Training
CHAPTER 3. RESULTS
3.1. Describing the characterisstics of knee OA in people aged 40 and
older from 02 communes in Gia Loc district, Hai Duong province in 2008.
27,1%

72,9%

Knee OA
Non Knee OA

Figuge 3.1:
Percentage

of knee OA
(ACR
criteria in
1991 basing

on history and physical examination)
Comments: According to the investigated 2153 people aged 40 and
over, we found 584 of those with knee OA (27.1%).

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Figure 3.2: Site of knee OA
Comments: Of the 584 participants with knee OA, there were 78.9%
painful in both knee joints, while the number of patients suffering pain in
one knee joint accounted for 21.1% 1.
Table 3.1: Relationship between knee OA and age groups
Knee OA based
Not enough
on physical
symptoms of knee
Total
Age group
examination
OA on physical
findings
examination
n

%

n

%

n

%

40 - 49

103

16,7

513

83,3

616

100

50 - 59

161

26,9

438

73,1

599

100

60 - 69

133

33,2

268

66,8

401

100

≥ 70

187

34,8

350

65,2

537

100

p
<0,001
Comments: The prevalence of knee OA in groups of 50 upper is higher
than the group of 40-49 and gradually increases according to age groups.
Table 3.2: Relationship between knee OA and gender
Knee OA based on
Not enough
physical
symptoms of knee
Total
Gender
examination
OA on physical
findings
examination
n
%
n
%
n
%
Male
93

18,4
413
81,6
506
100
Female
491
29,8
1156
70,2
1647 100
p
OR = 1,60 (1,33 – 1,97), p<0,05
Comments: The prevalence of knee OA in female is higher than
male (29.8% compared with 18.4%).
Table 3.3: Relation between knee osteoarthritis and BMI
knee OA Knee OA based
Not enough
on physical
symptoms of knee
Total
BMI
examination
OA on physical
(kg/m2)
findings
examination
n
%
n

%
n
%
176
BMI < 23
456
25,8
1310
74,2
100
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BMI ≥ 23
128
33,1
259
66,9
387 100
p
OR = 1,40 (1,12 – 1,80), p <0,05
Comments: Knee OA prevalence of people with BMI ≥ 23 were
considerably higher than the group with BMI <23 (33.1% compared with 25.8%).
Table 3.4: Knee osteoarthritis with a history of knee joint trauma
Knee OA Knee OA based on
Not enough
physical

symptoms of knee
Total
examination
OA on physical
history of
findings
examination
knee joint trauma
n
%
n
%
n
%
Yes
81
45,5
97
54,5
178 100
No
503
25,5 1472
74,5 1975 100
p
OR = 2,44 (1,79 - 3,34), p<0,001
Comments: Patients with a trauma history having incidence of knee
OA is 2.44 times higher than those without history of trauma.
Table 3.5: Knee OA with menstrual status of women
Knee OA

Knee OA
Not enough
based on
symptoms of
physical
knee OA on
Total
menstrual status
examination
physical
of women by age groups
findings
examination
n
%
n
%
n
%
Menstrual
81
17,6 380
82,4
461 100
40 - 49
Menopause
12
20,7 46
79,3
58 100

p
> 0,05
Menstrual
33
36,7 57
63,3
90 100
50 - 59
Menopause
103
27,5 272
72,5
375 100
p
< 0,05
Comments: The results showed that the prevalence of knee OA in
menopause women increases comparing with menstrual women at all age groups.
Table 3.6: Knee osteoarthritis with a history of childbearing
Knee OA
Knee OA
Not enough
based on
symptoms of
physical
knee OA on
Total
History of childbearing
examination
physical
By age groups

findings
examination
n
%
n
%
n
%
40 - 49
≤2
77 19,6 316
80,4
393 100
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children
≥ 3 children 17 13,9 105
96,1
122 100
p
< 0,001
≤2
10
5,6
167
94,4
177 100

children
50 - 59
≥ 3 children 127 44,7 157
55,3
284 100
p
< 0,001
≤2
9
11,8
67
88,2
76 100
children
60 - 69
≥ 3 children 100 51,8
93
48,2
193 100
p
< 0,001
≤2
10 14,5
59
85,5
69 100
children
≥ 70
≥ 3 children 144 45,4 173
54,6

317 100
p
< 0,001
Comments: The results indicated that in the group aged 50 above,
women with 3 or more children manifesting clinical knee osteoarthritis
are higher than women with 2 children or less.
Table 3.7: Knee osteoarthritis with the nature of work
Knee OA based
Not enough
on physical
symptoms of knee
Total
Index
examination
OA on physical
findings
examination
n
%
n
%
n
%
Heavy carrying
- Yes
539
31,6
1168
68,4
1707 100

- No
45
10,1
401
89,9
446 100
p
OR = 4,11 (2,97 - 5,68), p<0,001
Regular walking
- Yes
482
32,6
995
67,4
1477 100
- No
102
15,1
574
84,9
676 100
p
OR = 2,75 (2,17 – 3,49), p<0,001
Comments: The prevalence of knee OA in the people carrying heavy
weight is remarkably higher than those carrying lightweight (31.6%
compared with 10.1%). Similarly, for the people walking to work
primarily, this rate is also higher than those with less walking to work
(32.6% compared with 15, 1%) p <0.001.
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Table 3.8: Knee osteoarthritis with carrying normal weight per once
Knee OA
Not enough
Knee OA based
symptoms of
on physical
knee OA on
Total
examination
carrying
physical
findings
weight per once time
examination
n
%
n
%
n
%
306
714
102 10
< 50 Kg/ 1 time
30
70
0

0
226
440
10
≥ 50 Kg/ 1 time
33,9
66,1
666
0
p
OR= 1,19 (0,973 - 1,48), p <0,05
Comments: Knee OA percemtage in the people carrying weight ≥
50 kg / 1time is higher than in those carrying under 50 kg per 1 time
(33.9% compared with 30%).
3.2. Commenting on the knowledge of diagnosis and treatment to knee
OA of health workers in the CHCs in Hai Duong province.
Table 3.9: Description of knowledge on knee OA diagnosis of health
workers at CHCs.
Result
Percentage
Quantity
Diagnosis
(%)
Initial
Rheumatoid Arthritis
94
32,4
Diagnosis
Osteoarthritis
214

73,8
Septic arthritis
15
5,2
Rheumatic fever
20
6,9
Lupus
10
3,4
Total
290
100
X-ray
248
85,5
Tests
CBC
194
66,9
Liver function tests
26
9,0
Immunological tests
37
12,8
Synovial fluid tests
84
29,0
Total

290
100
Note: a health worker can select more than one diagnosis and testing
Comments: the proportion of health workers in selecting the reasonable
initial diagnosis such as knee OA and rheumatoid arthritis is quite high

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(73.8% and 32.4%). However, still 5.2% selected septic arthritis, 6.9%
selected rheumatic fever and 3.4% selected lupus.
Tests aim to diagnose: 85.5% of health workers chose to take x-ray,
66.9% selected CBC tests.
Table 3.10: Description of the treating knowledge of health workers to knee OA
Results
quantity
Percentage
Treatments
n=290
(%)
Antibiotics
43
14,8
Oral Corticosteroids
52
17,9
Paracetamol
155

55,5
Non Steroidal anti-inflammatory- drug
161
53,4
Acupuncture
103
35,5
Massage
194
66,9
Acupressure
103
35,5
Traditional medicine
112
38,6
Others (glucosamin, acid hyaluronic …)
35
12,1
Note: A health worker can select more than one treatment
Comments: The rate of health workers selecting the suitable
treatment to OA is high such as using paracetamol (55.5%), NSAIDs
(53.4%), massage (66.9%). However, there is still a significant
proportion of health workers opting for antibiotics (14.8%) and oral
corticoit (17.9%) for the treatment of OA.
Table 3.11: Description of knowledge of health workers in counseling osteoarthritis
Results
Percentage
Quantity
Counseling contents

(%)
Weight reduction (if obesity)
185
63,8
Reduce exercise if feeling painful
162
55,9
Do not squat
149
51,4
Avoid carrying heavy weight
239
82,4
Reduce standing, walking, climbing stairs
129
44,5
Increase exercise if feeling painful
34
11,7
Increase walking, climbing stairs
66
22,8
Total
290
100
Note: A health worker can select more than one advisory content
Comments: The health workers with the sufficient knowledge can
give right advice for the knee osteoarthritis patients such as avoiding
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carrying heavy loads, weight reduction if overweight, reducing exercise if
painful, reducing standing and walking (respectively 82.4 %, 63.8%,
55.9%, 51.2% and 44.5%). There are 11.7% of health workers advising
knee OA patients to increase exercise and 22.8% of health workers advise
patients to enhance standing, walking when feeling painful in knee joint.
3.3. Evaluating the effectiveness of interventions
Table 3:12: Effectiveness of interventions of diagnotic knowledge to knee OA
Results
After
Pre
Effective
Level
interventio
intervention
p
Indicator
n
(%)
(%)
(%)
Good
27,2
49,0
80
p<0.001
Poor
72,8

51,0
-30
Comments: The percentage of health workers in communes
equipped the sufficient knowledge on diagnosing knee OA increased
significantly from 27.2% to 49.0%; Effective indicator = 80% and the
proportion of health workers in communes having the poor knowledge
on diagnosing knee OA significantly reduced from 72.8% to 51.0%;
Effective indicator = -30%.
Table 3:12: Evaluating the effectiveness of interventions of treating
knowledge to knee osteoarthritis
Results
Pre
After
Effective
Level
intervention intervention
p
indicator
(%)
(%)
(%)
Good
44,1
47,2
7
p < 0,05
Poor
55,9
52,8
-6

Comments: The percentage of health workers in communes
equipped the good knowledge on treating knee OA increased
significantly from 44.1% to 47.2% Effective indicator = 7% and the
proportion of health workers in communes having the poor knowledge
on diagnosing knee osteoarthritis significantly reduced from 55.9% to
52.8%; Effective indicator = - 6%.
Table 3.14. Assesss on consulting knowledge of knee osteoarthritis
Results
Pre
After
Effective
Level
interventio intervention
p
indicator
n (%)
(%)
(%)
Good
42,1
67,6
p<
60
0,001
Poor
57,9
32,4
-44
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Comments: The percentage of health workers in communes having
good knowledge on advising patients about knee OA increased
significantly from 42.1% to 67.6%; Effective indicator = 60% and the
proportion of health workers in communes having the poor knowledge
on diagnosing knee osteoarthritis significantly reduced from 57.9% to
32.4%; Effective indicator = -44%.
CHAPTER 4. DISCUSSION
4.1. Describe the knee OA of the people aged 40 and above at 02
communities of Gia Loc district, Hai Duong province in 2008
4.1.1. Prevalence of knee OA of the people aged 40 years and above at 02
communities of Gia Loc district, Hai Duong province
As the investigated results from 2153 people aged 40 and older in
Gia Xuyen and Lien Hong communities, Gia Loc district Hai Duong
province in 2008 and applies ACR criteria for knee OA (1991), showed
that 584 people with knee OA, accounting for 27.1%. Thus, an average of
03 people aged 40 or more, with 01 person with knee OA. This result
shows that the prevalence of the knee OA from aged 40 and older in rural
areas is very high in Hai Duong province. This may be due to the
characteristics of the farmers (98.8%) mainly manual workers, especially
those who often have to carry heavy loads and walking for many hours a
day to make weight bearing on the knee and lead to rapid degradation.
The findings are similar to the 1030 study of 50 years of age in rural
China by Xiazheng Kang et al (2009). The study showed that the
prevalence of knee OA in China's rural areas is higher than in urban areas
as well as the study of the Framingham cohort. Similarly, research by
Behzad in 3018 showed that African Americans are 45% of patients with
symptoms of knee OA, including a higher incidence in the elderly and

women and African Americans have incidence knee OA severe higher
than white ones.
Prevalence of knee OA in weight-bearing ones usually much higher
than those who do not regularly carry heavy loads (31.6% compared with
10.1%). Similarly, the prevalence of knee OA in the people walking for
many hours a day was mostly higher than these were not walking much
(32.6% compared with 15.1%). However, we cannot confirm that this is
the cause of knee OA or due to knee OA, patients’ limited physical
activities or limited heavy lifting. This may be a limitation of the crosssectional study.
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This result is consistent with the conclusions of M.Rosignol (2005),
the most significant occupations, which related to the high prevalence of
knee OA were cleaning women workers (OR 6.2, 95% CI 4.6 - 8.0),
industrial tailoring, male construction workers and farmers (OR: 2.8,
95% CI 2.5 to 3.2). The study also showed that the features of OA occur
in 40% of those who have to do the hard work and often appear the first
symptoms of OA before the age of 50. Andreas Seidler et al (2008)
carried out a case-control study in 295 OA cases with X-ray images and
327 controls in men about the relationship between kneeling, squatting,
and lifting or carrying of heavy loads and knee OA symptoms.
According to the authors, there is an association between the kneeling or
squatting position with symptomatic knee OA, the total time kneeling
and squatting over 10,800 hours, which the OR of X-ray was 2.4 times
(95% CI : 1.5 - 5.0).
Thus, in order to reduce OA related to the occupational, we should to
pay attention to reduce the kneeling, lifting or carrying heavy loads

activities as well as other risk factors of OA.
4.1.2. Factors related to knee osteoarthritis:
- Aging:
In our study, the distribution of prevalence by age groups showed that
the prevalence of knee OA increased gradually in people aged 50 or
more, especially 60 years or older.
Cho et.al. study’s about the prevalence of hand and knee OA in the
community in Koea showed that the average age of OA is 59.2; Rosignol
M et. al. research on the relationship between occupational and primary
OA in France in 2842 people showed that the average age of initial OA
symptoms is 55 years old, and about 75% of patients said OA evidence
begins before age 61.
The results of our study were similar to many comments on the effect
of patient age with OA. According to our research, the effect of age with
disease distribution starts age >50 and markedly >60. In this age,
articular cartilage has become apparent, under the influence of
mechanical factors that causes knee OA development. We can say that
age is not the direct cause of OA, but aging causes cell and tissue
degeneration, loss of cartilage cells. In addition, OA affected by others
risk factors such as abnormal mechanical joint injury, obesity and
genetics.
- Gender:
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The results in table 3.2. showed the prevalence of knee OA in women
higher than men (29.8% compared with 18.4%). This is consistent with the
comments of many other authors. I Haq et. al. study’s showed that the ratio

of knee OA between male and female is one third; M Rosignol surveyed
11,144 people from 25 to 64 years showed that the ratio of OA in women
compared to men is 2:1 at all ages. Hyung Joon Cho et al (2010) showed
that X-ray evident moving from stage 2 to stage 3 and stage 3 to stage 4 (by
Kellgren and Lawrence criteria) in women quicker than in men. Beside of
that, the average level of pain (by WOMAC criteria) in women were severe
than men with the same stage of the X-ray.
In contrast to these results, the study of Rosie J Lacey on 745 OA
patients showed that men with OA represents the X-ray evident more
than they represents in women (77% compared with 61%), especially in
middle age and in femur and kneecap joint.
In general, each author found a distribution rate of different gender,
but almost same as OA is more common in women than in men. This has
not yet satisfactorily explained, some authors suggest that the hormonal
changes in women make them more susceptible to knee OA.
- Body mass index (BMI):
Results showed the prevalence of knee osteoarthritis increases
proportional with BMI. The OR of knee OA was 1.4 times higher in the
group with BMI ≥ 23 compared with group with BMI <23. High BMI
bear much load on the knee when walking, that make the knee OA
rapidly.
Ray Marsk’s study (2007) showed that high BMI increases the risk of
knee OA in both side as well as the hip OA. Similarly, an longitudinal
epidemiological study in 20 years of Margreth Grotle et. al. in 1854 people
from 25 to 76 years old showed that when BMI> 30 is a predictor of knee
OA (OR 2.81, 95% CI: 1.32 - 5.96) and hand OA (OR 2.59, 95% CI: 1.08 6.19). In addition, studies of Andrew K Wills and colleagues showed that
the relationship between BMI and OA after 20 years in men and n is 15
years in wome. Beside of that, the change BMI from childhood in women
and from adolescence in men is also closely related to knee OA.
Felson et, al. found that the reduction of excess weight in middle-aged

people have the effect of substantially reducing the risk of knee OA
symptoms. Hart and Spector detemined the relationship between obesity
and body fat distribution in knee OA women in a residential area has
remarked: Obesity is a major risk factor in the progression of knee OA.
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According to the authors if any increase in body weight by 5 kg, the risk
increases to 35%, they suggest that inflammation is a key factor
promoting the progression of obesity-related diseases. OA, inactivities
lifestyle and hyperlipidemia increased the sensitivity of cartilage cells
and combined with mechanical factors, which caused cells pinched like
joint injury.
Most studies have concluded that excessive weight gain is a risk of
knee OA. Thus, the avoidance of obesity with diet, proper exercise is one
of the effective ways to prevent knee OA.
- Joint injury:
In our study, there were 13.9% of cases with a history of knee injury.
A study of von Porat et. al. showed significant changes in the X-ray
image of people with a history of knee injuries was 78%, which is
mainly in stage 2 (classified by Kellgren and Lawence criteria). This
result is consistent with the opinion of many authors on the relationship
between histories of joint trauma with OA.
Charles R Ratzlaff et. al. study found that joint injury was risk factor
for knee OA, an estimated 50% of people injured anterior cruciate
ligament or meniscus had knee OA. The study showed that about 80%
football athletes, who were anterior cruciate ligament injury have X-ray
evident of knee OA after 12 - 14 years, of which, approximately 70%

limited range of knee movement. The sport requires endurance excessive
joints, causing prolonged micro trauma. The accumulation of this injury
lead to cracks of the cartilage surface and subchondral bone, gradual loss
of cartilage cell, fibrosis of subchondral bones and OA. Knee OA was
more common in football, weightlifting athletes, or hand OA in the
boxing game.
The increase in the incidence of OA after joint injury requires attempt
solutions to prevent knee injuries in order to improve people's health;
joint injury prevention can reduce from 14-25% incidence of OA.
- Menstrual status:
Results of the study showed that in menopause women, the incidence
of knee OA increases with age (≥ 40 years: 20.7% ≥ 50 years: 27.5% ≥
60 years: 39.9 %, ≥ 70 years: 39.2%). According to some authors found
that under the age of 55, the incidence between men and women is
almost equal. However, after 55 years, the incidence is much higher in
women than in men. This suggests that there may be correlation between
menopausal status and knee OA.
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Asokan GV et. al. (2011) reviewed 420 women aged 40 or older with OA,
of which, 68% were menopause. Are oetrogen against OA or not? Currently
there is no answer yet to this problem, but the authors have found correlations
among hypertension, hypercholesterolemia, hyperglycemia (the common
diseases in menopause women) with knee OA.
Spector et.al. suggested that middle-aged women, especially after
menopause were high risk of knee OA. In addition, the authors also
found an association between high blood sugar and cholesterol levels

with knee OA. This led to the hypothesis that physical factors and
hormone metabolism are associated with disease. In the Framingham’s
study found among women with a history of ovarian cut up had high
prevalence of knee OA.
Dang Hong Hoa studied in Vietnam showed that, the prevalence of
knee OA in menopause women accounted for 80.6%, higher than the
group of women who are menstruating (19.4%). So far the role of
menopause for knee OA has not been confirmed, so these are
suggestions for further research on this issue.
- Childbearing history and knee OA:
Stydied 1,647 women aged 40 and older in the 02 communes of Gia
Loc district, Hai Duong province showed that the prevalence of knee OA
in women with 3 or more children in all age groups (table 3.14) is much
higher than the women who had 2 or less than 2 children.
When the women have pregnant, their body weight increased from an
average of 10-15kg, and the fetal growing, that affect the mother when they
walking. Moreover, during pregnancy the mothers change in hormone and
metabolism. All these factors together may increase the risk of knee OA.
Thus, the risk of knee OA may increase in the mothers with many children.
This result is similar to the study of Dang Hong Hoa, the prevalence of knee
OA in women with 3 and more children is 86.1%;
4.2. Commenting on the diagnosis, treatment and counseling for
knee OA patients of health care workers in the CHCs
The result of interviewing 290 medical doctors and assistant
physicians working at CHCs about knowledge of diagnosis, treatment
and counseling for patients with knee OA showed that,
- Knowledge of knee OA diagnosis, the rate of health worker choosing
OA as initial diagnosis is quite high (73.8%). However, there is some
health staffs selecting initial diagnosis inappopriately, such as septic
arthritis, lupus, and rheumatoid arthritis. This led the physicians order

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unnecessary tests or misdiagnose. However, the number of physicians
choosing appropriate tests for knee OA diagnosis was high, such as x-ray
(85%), CBC test (66.9%). Besides, there were a significant proportion of
health workers choosing inappropriate tests for knee OA diagnosis as
liver function tests (9%).
According to the results of the pilot study (Arshad A et. al.) on the
200 general physicians in three states in Malaysia about primary care for
patients with knee OA showed that 75% of general physicians surveyed
would arrange an X-ray, 65% of general practitioners (GPs) surveyed
would arrange a blood test, mostly serum uric acid, rheumatoid factor
and ESR.
- Knowledge of OA treatment, it is showed that a number of health
workers selected appropriate treatment such as paracetamol, nonsteroidal anti-inflammatory, massage (50%). However, there was still a
significant proportion of the health workers choosing antibiotics or oral
corticosteroids for the treatment of OA (14.8% and 17.9%). This is
probably a result of not understanding the pathophysiological of OA as
well as the abuse of antibiotics and corticosteroids, which could negative
consequences for the patients.
According to research results in Malaysia, it is indicated that
pharmacological management consists of first line treatment with
analgesics (32%), NSAIDs (59%) or a combination of the two (4%).
89% of GPs surveyed prescribed some form of complementary
medications. 68% prescribed glucosamine sulphate, 29% chondroitin
sulphate, 18% cod liver oil, 12% evening primrose oil. Only 5% of GPs
surveyed perform intra- articular injection. In addition, the study also

showed that up to 95% of GPs do not know about the national guidelines
for the treatment of OA.
- Counseling knowledge for knee OA patients, health workers also
have basic knowledge of counselling for knee OA patients, such as
weight reduction if overweight, reduce physical activities if have knee
pain, and especially avoid squating or heavy lifting. Since these are
factors increase compression, which made up cartilage damage faster and
more severe. Nevertheless, there were a number of health staffs advising
patients that walking more when they had knee pain (22.8%). This is the
misconception of treatment, because one of the causes of knee OA is
walking too much.
With regard to non-pharmacological management, Arshad A et. al.
also showed that 37% of physicians recommend patients exercise, 18%
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advised patients weight reduction and referral to physiotherapy (6%).
Research by Pham Thi Cam Hung (2004) showed that the combined
pharmacological management with heat and exercise therapies for
patients with OA could relieve knee pain, decrease joint stiffness and
improve functioning knee joint. Therefore, physicians should guideline
for the patients about non-pharmacological management for the
treatment of knee OA at home.
4.3. Assess on the effectiveness of interventions for knowledge of
diagnosis, treatments and counseling of knee OA for community
helath staffs:
According the result of cross-sectional study, we found knee OA is
now common disease for people over 40 years old in rural areas (27.1%).

Moreover, there is a lack of knowledge of diagnosis, management,
counselling and early detection of knee OA of health care workers at
CHCs, even misconception. Whereas, symptoms of knee OA are easy to
detect and ACR criteria for knee OA diagnosis (1991) based on clinical
features can be applied widely in the community.
OA is a common disease, increasingly demanding grassroots doctors
to diagnose. Therefore, the provision of basic knowledge about
symptoms, diagnostic criteria, treatment methods, risk factors and health
education for patients with OA at CHCs is needed, help to improve the
quality of health care services at CHCs, contribute to improving the
quality of life, equality in health care for people, especially people in
rural areas, we conducted training course on examination, diagnosis and
treatment of OA, focusing on knee OA for CHCs health workers.
According to studies evaluating the effectiveness of training programs
on OA management for primary care physicians in the United States
shows that GPs were not trained about the basics of musculoskeletal
diseases and very rare to be re-trained after graduation. After
implementing a mentoring program for GPs by specialty OA physicians,
results at 1 year showed average knowledge and skills of GPs before
training was 58.2%, which increased to 84.1% after training.
According to research by Le Van Them (2003), up to 93.5% of the
physicians worked in CHCs were trained in in-service training system
and their professional was general practitioner. Of whom, 50% reported
that, the in-service medical doctor’s curriculum was not enough
knowledge and skill to help them carry out the health care and disease
prevention, especially specialties. Besides, only 43.5% doctors were
trained at least one time after graduation, mainly about reproductive
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health, health care management, traditional medicine, pediatric primary
health care, etc. Thus the numbers of CHCs’ doctors trained after
graduation is very low and the training content is not appropriate for
their functions that they undertake at CHCs. So maybe this is also a
factor affecting the selection of diagnosis and management of knee OA
in the community should considering for further research. The author
also recommends regular updates and training knowledge and skills in a
number of common diseases for doctors of CHCs is very important to
improve the quality of health care services at CHCs.
Result of intervention study showed that health care workers
significantly increased in knowledge of knee OA diagnosis at good and
very good levels; and the numbers of health care workers lack of knee
OA diagnosis knowledge significantly decreased from 72.8% to 51.0%.
Similarly, the percentage of health workers, who had good knowledge
of knee OA treatment increased from 44.1% to 47.2%; and the
percentage of whom less knowledge in knee OA treatment decreased
from 55.9% to 52.8%. The percentage of commune health workers with
good knowledge of knee OA consulting significantly increased from
42.1% to 67.6%. Moreover, the proportion of health workers with less
knowledge of knee OA counseling significant decreased from 57.9% to
32.4% (p <0.001).
CONCLUSION
5.1. Description of knee OA characteristics in people aged 40 and older
from 02 communes in Gia Loc district, Hai Duong province in 2008.
- The prevalence of knee OA was 27.1% (according to the 1991 ACR
criteria based on history and physical examination findings)
- Factors related to knee OA patients:
+ The prevalence of knee OA was high among people aged 50 and

older, especially among those 60 years and older (p <0.001).
+ The prevalence of knee OA was high among people with BMI ≥ 23
(OR = 1.4, 95% CI: 1.12 - 1.8); menopause women in all age groups of
50 or more (p <0.05)
5.2. Effectiveness of intervention model to improve knee OA
diagnosis and management capabilities of CHC staffs in Hai Duong
province.
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5.2.1. Knee OA diagnosis and management knowledge for CHC
staffs before the intervention
- Health care workers’ education: assistant physicians (70.7%),
medical doctors (29.3%).
- Knowledge of knee OA diagnosis: only 27.2% of health workers with
good knowledge and 72.8% of health workers with poor knowledge;
- Knowledge of knee OA treatment: 44.1% of health workers with
good knowledge and 55.9% poor knowledge.
- Knowledge of knee OA consullting: 42.1% of health workers were
good knowledge, 57.9% were poor.
5.2.2. Effectiveness of interventions of knowledge on knee OA
management for CHCs staffs after 1 year:
- Knowledge of knee OA diagnosis: percentage of health workers with
good knowledge quite increased (effectiveness indicator = 80%) and the
proportion of health workers with poor knowledge remarkably reduced
(effectiveness indicator = -30%), p <0.001.
- Knowledge of knee OA treatment: percentage of health workers with
good knowledge increased slightly (effective indicator = 7%) and the

proportion of health workers with poor knowledge reduced (effective
indicator = -6%), p <0.001.
- Knowledge of knee OA consulting: the percentage of health workers
with good knowledge increased (effective indicator = 60%) and the
proportion of health workers with poor knowledge reduced remarkably
(effective indicator = -44%), p <0.001.
RECOMMENDATIONS
Based on result of the study, we would suggest some
recommendations as follows:
1) Providing information about knee OA and the factors associated
with knee OA for the rural population in order to improve the quality of
life.
2) Applying ACR diagnostic criteria in 1991 based on the history and
physical examination findings for epidemiological investigation and
initial diagnosis at grassroot level. However, in order to confirm
diagnosis of knee OA, we should apply ACR criteria (1991) based on
history, physical examination and laboratory findings.
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3) Strengthening training and re-training for health professionals
working in CHCs about knee OA in early detection, appropriate
treatment and counseling to avoid the severe manifestations of the
disease leading to disability, reducing quality of life and increasing the
burden for patient families and society.

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