The Effect of Online Intervention on the Malang Rheumatic Exercise

Community during the Covid-19 Pandemic

Edwin Kinesya, S.Ked 1 , Elen Putri Cintya, S.Ked 1, Maria Juliana Dorothy, S.Ked1 , Rizqi
Rius Wibowo, S.Ked 1, dr Asri Maharani MMRS, Ph.D 2 , Dr. dr. C. Singgih Wahono SpPD-
KR 3
1.
Medical Faculty of Brawijaya University, Malang, Indonesia
2.
Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
3
Division of Rheumatology, Departement of Internal Medicine, Saiful Anwar General
Hospital, Malang, Indonesia.

Abstract

Introduction : Rheumatoid arthritis (RA) is one of the most common autoimmune arthritis and can cause
disability, where rheumatic exercises can be done to relieve the condition. With the Covid-19 pandemic,
rheumatic exercises routinely carried out at RSSA were eliminated. This study aims to understand the effect of
online intervention with self determination and frequency of doing home exercise and the association between
age and ability to access online intervention

Methods: This study used experimental research with pre and post test controls.

Results: The effect of online intervention on the frequency of doing rheumatic exercise was tested with
Wilcoxon test having a significant p-value of 0.000. The effect of online intervention with self determination to
do rheumatic home exercise tested using chi-square showed a significant p-value of 0.026. The association
between age and ability to access online interventions we tested using the Mann Whitney test showed a
significant p-value of 0.025.

Conclusion: Based on the description above, it can be concluded that the age characteristics of the respondents
are mostly 54-77 years, and the gender characteristics are 100% female. In this study, it can also be concluded
that the influence of online intervention can significantly increase the self determination and frequency of doing
rheumatic home exercise during the Covid-19 pandemic, and there is a relationship between old age and the
ability to access online interventions.

Introduction

Rheumatoid arthritis (RA) is one of the most common autoimmune inflammatory arthritis
among adults. It limits ability to perform daily activities, including work and household tasks 1. Based
on study from Debora, Colin and Bruce in the global burden of RA in the year 2000, the prevalence of
RA is up to 1% worldwide,and mostly affected adults aged 30 until 50 years old 2. The major
consequence of this disease is work disability. A cohort study in the US found that 35% individuals
with RA experienced work disability after 10 year 3. RA caused permanent work disability. This work
in 20-30% in 2-3 years. Intervention to prevent work disability thus has become crucial among patient
with RA4. The prevalence and incidence of this disease varies between countries. In the US and some
countries in Europe, the prevalence of RA reached 1% in adult caucasians; 0.3% for France; 0.8% for
UK and Finland; 1.1% for US; 0.28% for China; 1.7% for Japan and 0.75% for India. The incidence
in America and Northern Europe reaches 20-50/100000 and Southern Europe only 9-24/100000.

In Indonesia, an epidemiological survey in Bandungan, Central Java, revealed that the

prevalence of RA was 0.3% in 1988 . RA prevalence among population over 40 years is 0.5% in City
of Malang and 0.6% in Malang Regency. At the Rheumatology Polyclinic of Cipto Hospital
Mangunkusumo Jakarta, in 2000, 4.1% of all new cases were RA. At the rheumatology polyclinic, in
Hasan Sadikin Hospital, 9% of all new cases were rheumatism in 2000-2002 5.

In 11 March 2020, based on WHO International news, WHO director General dr Tedros
Adhanom made assessment that characterized COVID 19 as a pandemic 6. This virus very contagious
and spread quickly throught the global. This pandemic has become the more challanging as, in it
affects not only health, but also economic. For example, in the field of health like for the patient to
seeker delivery health care. Based on WHO 2019 nCOV essential health services 2020 interm
guidance 2020, this pandemic makes some of patient restrictive to come to public health and
gradually eased 6. As the health resources are limited, some services have been prioritised, such as
pregnancy and childbirth, core service for vulnerable population, management of emergency health,
critical facility for therapies. As the result, less people seek healthcare services 7. This study discuss
and make some alternative program especially for rheumatic association in Saiful Anwar Malang that
their have limitation to get any healthcare facility. This study aims to understand the effect of online
intervention with self determination and frequency of doing home exercise and the association
between age and ability to access online intervention.

Material and Methods:

Participants

The sample for this study are all of the member of Rheumatic exercise association in Saiful
Anwar General Hospital Malang called Perhimpunan Masyarakat Peduli Reumatik Indonesia
(Permari) branch of Malang City. The number of participants in this study are 17 persons.

Location and time

We conducted the research in September - October 2020. The location is Malang city and
Malang district.

Research Design

This study is an experimental study. The instrument of this study, we used online pre
intervention questionnaire and post intervention questionnaire. Pre questionnaire used to identify the
problems that appeared on the community. After sorting the priorities of the problem, then we give
online intervention for the problem. The post questionnaire is used to evaluate the effect of the
intervention.

Intervention Method

The intervention method of this study is online video rheumatic exercise via youtube channel.
We evaluated the intervention with questionnaire after video rheumatic exercise intervention.
Data Analysis

The data we got is tested with normality test. To compare the frequency of exercise before
and after intervention we used Wilcoxon test. The association between age and ability to open online
intervention we used Mann Whitney test. We then compared the self determination to do exercise
before and after intervention with Chi Square. The data is significant if p-value < 0,05.

Result

We got a total of 17 respondents from rheumatic exercise association in Saiful Anwar General
Hospital Malang. The characteristic of our respondent age varies from 54 -77 years old with 14
persons is below 70 years old (82%) and 3 persons more than 70 years old (18%). The gender of our
respondents are 100% woman.

Table 1. Characteristic of the respondents

Age Gender
8 18
7 16
6 14
5 12
10
4
8
3
6
2 4
1 2
0 0
51-55 56-60 61-65 66-70 71-75 76-80 Woman Men

Age Gender
Table 1.1 Age of the respondents Table 1.2 Gender of the respondents

Frequency of doing rheumatic Self determination to do

exercise before pandemic rheumatic exercise
12 16
10 14
12
8
10
6 8
4 6
4
2
2
0 0
0 1x 2x Yes No
Frequency of doing rheumatic exercise before
pandemic Self determination to do rheumatic exercise
Table 1.3 Frequency of exercise before the pandemic Table 1.4 Self determination to do rheumatic exercise
 We conduct 3 data analysis. The first one is the effect of online intervention to the frequency
doing rheumatic exercise. We used Wilcoxon to analyze between the frequency before and after
intervention with p-value 0.000 which is significant. The second one is the effect of online
intervention with the self determination to do rheumatic exercise. We use chi-square and the p-value
is 0.026 which is significant. The third one is the association between age and the ability to access our
online intervention. We use Mann Whitney test resulting p-value 0.025 which is significant.

Table 2 Data Analysis

Tests of Normality

Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
The value of the
,227 34 ,000 ,805 34 ,000
questionnaire

Test Statistics (Wilcoxon)

Timing the distribution – Value of
questionnaire
Z -4,041b
Asymp. Sig. (2-tailed) ,000

Table 2.1 The effect of online intervention with the frequency of doing
rheumatic exercise before and after intervention

Chi-Square Tests
Asymp. Sig. Exact Sig. (2- Exact Sig. (1-
Value df (2-sided) sided) sided)
Pearson Chi-Square 4,958a 1 ,026
Continuity Correctionb ,765 1 ,382
Likelihood Ratio 3,787 1 ,052
Fisher's Exact Test ,176 ,176
Linear-by-Linear
4,667 1 ,031
Association
N of Valid Cases 17
Table 2.2 The effect of online intervention with the self determination to do
rheumatic exercise before and after the online intervention
 Tests of Normality
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
Age ,096 17 ,200* ,981 17 ,967
Need help for access the
,521 17 ,000 ,385 17 ,000
online intervention

Test Statisticsa
Usia
Mann-Whitney U ,000
Wilcoxon W 120,000
Z -2,242
Asymp. Sig. (2-tailed) ,025
Exact Sig. [2*(1-tailed Sig.)] ,015b

Table 2.3 Association between age and the ability to access online intervention

Discussion

Characteristic of the respondents

The result of this research was doing in 17 person respondent of rheumatic exercise in Saiful
Anwar General Hospital Malang. The result of this research shows the average of respondent 54-77
years old. This corresponds to Houchi (2017) that says rheumatoid arthritis began at the age ≥ 60
years old 8. Based on a research by Houchi (2017), the incidence of Rheumatoid Arthritis in men
gradually increase with their age. As in woman, the Rheumatioid Arthritis incidence increase since 45
years old and flatten at 75 years old8.

While the distribution of gender in this study is all woman (100%). This corresponds to the
research of the distribution of gender in Rheumatic Arthritis with ratio 1,5-2 women to 1 in man in
elderly people8.

During the pandemic there were only 4 respondents who still do rheumatic home exercise,
and the other 13 did physical activities like taking care of their grandchildren, cleaning the house,
have a walk and sunbath in the morning.

Data analysis of online intervention of doing rheumatic exercise

The Wilcoxon test we conduct for the effect of online intervention with the frequency of
doing rheumatic exercise before and after intervention is significant (p-value 0.000). This means that
online intervention is significant to increase the frequency of doing rheumatic exercise. In our
research, the respondent doesn't have access to the same exercise video that they used before the
pandemic. Even they can access the other exercise video online but there were no identical video.
They find it hard to browse the internet. The effect of online intervention provide meaningful
improvement for the exercise needed by patients. A research by Bennell et al. (2017) who give online
intervention as online video conference for physiotherapy sessions home exercise, resulting with
improvement of patients clinical condition9.

The effect of online intervention with the self determination to do rheumatic exercise before
and after the online intervention is tested with Chi Square and the result is significant (p-value 0.026).
This means that online intervention can increase the self determination to do rheumatic exercise. A
research by Teixeira et al. (2012) found that there is positive relation between motivation and exercise
with short term adoption is strongly encouraged by the regulation and the long term exercise
adherence is encouraged by the self determination10.

For the association between age and the ability to access online intervention was tested with
Mann Whitney. The p-value is 0.025 which means there is association between age and the ability to
access our online intervention. The respondents who find difficulties to access the intervention was
the oldest respondent with 77 and 74 years old. They can access the intervention by the help of their
family member. A research by Waterworth and Honey (2018) found that older adults with aged > 65
years is finding difficulties to access the internet for online health information. The factors influencing
this problem are demographics, health status, trust in the information, attitudes of health
professionals, and especially lack of skills using the internet 11.

These results were gained during the COVID-19 pandemic. There were some country or
regional restrictions to lower the transmission. Our respondents also find it hard and scary to meet up
offline as their age is more than 50 which increase the morbidity and mortality of COVID-19.

Limitation of research

The limitation of this research is the sample is too little, and we found difficulties to contact and
collect data online from the respondents because this study is conducted on the COVID-19 pandemic
and there are physical distantion regulation to lower the transmission of COVID-19.

Conclusion and suggestions

Based on the discussion above we can conclude that the characteristic age of our respondent mostly
54- 77 years old, charasteristic of gender is 100% woman. In this research, the effect of online
intervention can significantlly increase the self determination and frequency doing rheumatic exercise
during the Covid-19 pandemic, and there are association between older age with the ability to access
the online intervention. During the data collection, we also found that elderly is having difficulties to
access online video because their lack of gadgets, internet connection, ability to do online conference,
is not used to the other exercise video on internet, and the lack of motivation to do exercise alone. Our
suggestion for future research are to increase the scale of research to increase the population and
sample, do the online intervensions in sessions, and intervene with the other difficulties found from
data collection.

Reference

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Supporting Data

No Frequency of doing rheumatic N Self determination Self determination

exercise o pre intervention post interventiom
PreIntervention PostIntervention 1 Yes Yes
2 No Yes
1 1x 2x 3 Yes Yes
2 2x 2x
No Age Need / not need help for access
the online intervention
1 64 years No
2 70 years No
3 69 years No
4 77 years Yes
5 63 years No
6 66 years No
7 66 years No
8 67 years No
9 61 years No
10 70 years No
11 69 years No
12 60 years No
13 54 years No
14 56 years No
15 59 years No
16 74 years Yes
17 59 years No