Assessment of Health-related Quality of Life in Multiple Sclerosis Patients at Azadi Teaching Hospital, Kirkuk City, Iraq

1. INTRODUCTION

Multiple sclerosis is a chronic inflammatory disorder that primarily affects the central nervous system (CNS). It is characterized by autoimmune-mediated degradation of myelin, the protective covering of nerve fibers. The disease commonly involves critical CNS regions such as the brainstem, spinal cord, optic nerve, and periventricular white matter, which are essential for vision, motor control, and sensory perception [1]. Despite extensive research, the exact cause of MS remains unknown. However, genetic factors, particularly specific alleles of the human leukocyte antigen (HLA) complex [2], along with environmental influences such as viral infections, vitamin D deficiency, smoking, and obesity, have been associated with its onset and progression [3–5].

Globally, MS affects approximately 2.8 million people, with an estimated prevalence of 35.9 per 100,000 individuals. Since 2013, prevalence rates have increased worldwide, although estimates vary across regions. In 75 reporting countries, the annual incidence is estimated at 2.1 per 100,000 individuals[6]. In Iraq, MS incidence has risen markedly, reaching 11.73 per 100.00 people, with rates observed among females (16.2 per 100,000) compared with males (7.3 per 100,000). This represents a substantial increase from 0.05 per 100,000 in 2000 to 1.5 per 100,000 in 2017 [7]. Neighboring countries, such as Turkey and Saudi Arabia, report even higher prevalence rates of 105.2 and 40.4 per 100,000, respectively [8, 9]. MS is also estimated to affect approximately 162 per 100,000 individuals in Iran [10].

Multiple sclerosis leads to significant morbidity through acute flare-ups that exacerbate symptoms and contribute to CNS lesion formation. These lesions result in scarring that disrupts brain function, leading to a wide range of physical, cognitive, and emotional impairments. Consequently, MS has a profound impact on patients’ quality of life (QoL) [2, 11]. Beyond physical disability, MS substantially reduces HRQoL, reflecting patients’ perceptions of how the disease and its treatment affect overall well-being and daily functioning [12].

A range of demographic, clinical, and psychological factors influence HRQoL in patients with MS. Fatigue, depression, mobility limitations, and cognitive dysfunction are among the most prominent contributors to reduced HRQoL. Research consistently demonstrates that individuals with MS experience significantly lower HRQoL compared with the general population [13, 14]. In addition, access to healthcare services, adherence to treatment, and supportive social environments play important roles in shaping HRQoL outcomes [15].

Despite growing international research on MS and QoL, studies examining these issues within the Iraqi context remain limited, particularly in Kirkuk City. Some previous research conducted in Iraq has assessed neurological imaging and QoL among patients with chronic diseases more broadly, offering valuable methodological and diagnostic insights [16]. However, the influence of sociodemographic and clinical factors on the HRQoL of MS patients within Iraq's unique cultural and healthcare environment remains underexplored. Given the increasing prevalence of MS in the region and ongoing challenges in accessing comprehensive healthcare, addressing this knowledge gap is essential. Therefore, this study aims to assess the HRQoL of MS patients at Azadi Teaching Hospital in Kirkuk City, with a particular focus on the relationships between sociodemographic characteristics, clinical features, disease duration, relapse frequency, and physical, mental, and overall HRQoL outcomes.

2. MATERIALS AND METHODS

3. RESULTS

A total of 135 patients diagnosed with MS participated in the study. The mean age of participants was 36.96 ± 10.70 years (range: 16-67 years), and the majority were female (77.8%).

Regarding HRQoL categories, most participants reported a fair level of overall MSQOL 85 (63.0%), followed by good 36 (26.7%) and poor 13 (9.6%) levels. Only one participant (0.7%) reported an excellent level of HRQoL (Fig. 1).

Descriptive statistics for MSQOL subdomains are presented in Table 2. The highest mean scores were observed in social functioning (63.26 ± 12.30), health perceptions (59.97 ± 11.94) and cognitive functioning (54.04 ± 11.96). Emotional well-being (52.74 ± 13.66), pain (52.10 ± 13.95), energy/fatigue (50.46 ± 19.52), and health distress (50.96 ± 10.61) showed moderate effects. Physical functioning showed the lowest mean score (40.96 ± 20.76), along with role limitations due to physical (41.85 ± 27.46) and emotional problems (42.72 ± 38.34). The overall MSQOL score was 43.52 ±11.18, ranging from 20 to 68.

No statistically significant differences in overall MSQOL were observed across sociodemographic variables, including age groups (p = 0.782, η² = 0.013), gender (p = 0.399, d = 0.16), place of residence (urban vs. rural; p = 0.102, d = 0.35), employment status (p = 0.068, d = 0.39), marital status (p = 0.993, η² = 0.006), educational level (p = 0.664, η² =0.01), and income (p = 0.849, η² = 0.006), all with small or negligible effect sizes (Table 3).

Regarding clinical variables, MS severity did not significantly affect overall MSQOL (p = 0.300, η² = 0.018). However, disease duration showed a significant negative correlation with overall MSQOL (r = -0.232, p = 0.007, r² = 0.054), while the number of MS relapses did not significantly correlate (r = -0.123, p = 0.154, r² = 0.015) (Table 4).

In addition to the p-value, effect size measures were reported to indicate the magnitude and practical relevance of the observed association. Eta squared (η²) was used to estimate the proportion of variance explained in group comparisons, Cohen’s d to describe the size of differences between two groups, and r² to indicate the proportion of variance explained by correlation analyses. Small effect sizes suggest limited practical impact, whereas larger values reflect stronger and more meaningful relationships.

The Physical Composite Score (r = 0.826, p < 0.001, r² = 0.682) and Mental Composite Score (r = 0.895, p < 0.001, r² = 0.801) showed strong positive correlations with overall MSQOL, both with large effect sizes. A moderate positive correlation was also found between the Physical and Mental Composite Scores (r = 0.488, p < 0.001, r² = 0.238) (Table 5).

4. DISCUSSION

Iraq, particularly Kirkuk city, has a relatively limited history of research on MS. Despite this, the incidence of MS has increased markedly in Iraq, while prevalence remains lower than in several neighboring countries[7]. Therefore, this study aimed to assess the HRQoL among 135 patients diagnosed with MS who were attending the MS Consultation Unit at Azadi Teaching Hospital in Kirkuk City, Iraq.

Although the sample size of the present study was limited to 135 participants, it reflects the realistic recruitment capacity for a single-center study focusing on a relatively low-prevalence condition within the local Iraqi context. The MS Consultation Unit at Azadi Teaching Hospital serves as a major referral center in Kirkuk City; therefore, the study sample represents a substantial proportion of patients receiving specialized MS care during the study period. The sample size was sufficient to detect statistically meaningful associations, including the observed relationship between disease duration and HRQoL. Nevertheless, the single-center design and sample size may limit broader generalizability, and future multicenter studies with larger cohorts are recommended to validate these results across different regions.

The socioeconomic characteristics of the participants showed that approximately two-thirds were females, with a mean age of 36.96 years. This sex distribution is consistent with previous literature, which consistently reports a higher prevalence of MS among women than in men [8, 18, 19]. The predominance of female participants may reflect broader epidemiological patterns, suggesting that sex-specific biological factors contribute to MS etiology. Hormonal influences on immune function, along with genetic susceptibility, have been proposed as possible explanations for the higher incidence of MS in women. In addition, the study findings indicated no significant differences in HRQoL across sociodemographic characteristics, including age, employment status, marital status, educational level, and income. These results indicate that socioeconomic status may not play a dominant role in determining HRQoL within this population. Similar findings have been reported in studies conducted in the Netherlands, France, the United Kingdom, Spain, Germany, and Italy, which found no significant differences in HRQoL based on demographic factors among MS patients [20, 21]. In contrast, a study from Turkey reported that high unemployment rates and financial challenges among MS patients may contribute to a shared experience of reduced QoL, irrespective of specific socio-demographic differences [9]. Furthermore, findings from Iran have indicated significant differences in HRQoL across demographic and clinical subgroups, highlighting potential regional variations [10].

The present study revealed that more than half of the participants (63.0%) reported a fair level of HRQoL, while only a small proportion (0.7%) reported a high level of HRQoL. These findings highlight the considerable burden that MS imposes on affected individuals. The comparatively low overall MSQOL score (M = 43.52) suggests that many patients experience substantial challenges in daily life, likely related to both medical and psychological aspects of the disease. Cultural and social factors may also influence how patients perceive and report their QoL. In Iraq, family support, religious coping mechanisms, and societal perceptions of neurological illness play important roles in the management of chronic disease. These factors should be considered when interpreting HRQoL findings and when comparing results across different cultural settings. Similar observations were reported in a study conducted in Egypt, where most participants demonstrated fair HRQoL levels, emphasizing the growing importance of QoL as an outcome measure in chronic disease management and clinical research[18]. In contrast, a study from Saudi Arabia reported predominantly moderate to high QoL levels among MS patients [15]. Analyses of MSQOL domains indicate that social functioning and health perceptions were relatively well preserved, whereas physical functioning was notably impaired. This finding aligns with evidence from a Canadian study demonstrating physical comorbidities significantly reduce HRQoL in MS patients [22]. These results underscore the complex and multifaceted nature of MS and highlight the need for comprehensive care strategies that address not only medical management but also physical rehabilitation, psychological support, and social and occupational functioning. Recent research conducted in Iraq has explored the role of L-arginine in immune modulation in autoimmune diseases. These findings offer new biochemical perspectives that may contribute to more integrated approaches to MS care in the future [23].

A significant negative correlation was observed between disease duration and overall HRQoL, indicating that longer disease duration is associated with poorer HRQoL. This finding is consistent with previous studies reporting similar patterns, suggesting that the chronic and progressive nature of MS leads to cumulative physical and psychological burdens that adversely affect patients' lives [19, 24]. However, other studies conducted in Egypt and Portugal did not find a significant association between disease duration and overall HRQOL, possibly reflecting differences in disease course, healthcare access, or coping mechanisms [18, 25].

Beyond statistical significance, the interpretation of effect sizes provides additional insight into the practical relevance of the findings. In the present study, the magnitude of the association between disease duration and HRQoL suggests a clinically meaningful relationship, whereas the small effect sizes observed for most sociodemographic variables indicate limited practical impact. This distinction emphasizes the importance of considering both statistical and clinical relevance when interpreting HRQoL outcomes in MS.

In contrast, relapse frequency was not significantly correlated with HRQoL, suggesting that the impact of relapses on QoL may vary among individuals and may be influenced by factors such as coping strategies, social support, and access to healthcare services. This finding differs from the results of some longitudinal studies, which have reported a significant association between clinical MS characteristics and QoL outcomes [25]. A notable strength of this study is the use of the modified MSQOL-54 instrument, which captures both physical and mental health dimensions. The strong correlations observed between the Physical Composite Score, the Mental Composite Score, and overall MSQOL highlight the importance of addressing both aspects in MS management. These findings reinforce the need for a comprehensive, biopsychosocial approach to MS care, incorporating physical rehabilitation, psychological support, and social interventions. This perspective is supported by a systematic review published in 2020, which emphasized the importance of comprehensive assessment and management strategies to improve HRQoL in adults with MS [4].

5. STUDY LIMITATIONS

This study has several limitations that should be considered when interpreting the findings. The cross-sectional design allowed HRQoL to be assessed at a single point in time, which limits the ability to examine temporal changes or establish causal relationships between disease-related factors and HRQoL outcomes. Additionally, although standardized instruments were used, reliance on self-reported MSQOL-54 data collected through face-to-face interviews may have introduced response bias. Participants' responses could have been influenced by social desirability, variations in attention, or interaction with the reviewer. These limitations should be considered when generalizing the results, and future longitudinal studies may provide a more comprehensive understanding of HRQoL dynamics in patients with MS.

CONCLUSION

This study indicates that HRQoL among patients with MS in Kirkuk is influenced more strongly by clinical factors, particularly disease duration, than by sociodemographic characteristics. These findings suggest that long-term MS management should prioritize continuous clinical monitoring and supportive care to address the progressive impact of the disease on patients’ daily functioning. Future multicenter studies are needed to confirm these findings and to further explore contextual and health-related influences on HRQoL.

REFERENCES