Fatigue Strikes Hard: South African Rheumatoid Arthritis Patients Face Heavy Burden

Rheumatoid arthritis has long been recognized as a disease of inflamed, painful joints, but a new study from South Africa shines a spotlight on one of its most disabling yet invisible symptoms: fatigue. In the first investigation of its kind in the country, researchers found that nearly three-quarters of rheumatoid arthritis patients attending a tertiary hospital in the Western Cape experienced fatigue, and more than two in five suffered from severe exhaustion that persisted regardless of rest. The findings, published in Frontiers in Musculoskeletal Disorders, reveal that the burden of fatigue in this socioeconomically disadvantaged population is enormous and closely tied to factors well beyond joint inflammation alone.

The research team, led by Sariu Ali Didi and Bridget Hodkinson from the Division of Rheumatology at Groote Schuur Hospital and the University of Cape Town, drew on an ongoing rheumatoid arthritis registry at a tertiary state-sector academic hospital. Between January 2021 and December 2023, 550 consecutive adults who fulfilled the 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for rheumatoid arthritis were enrolled in the cross-sectional analysis. The cohort was predominantly female, with 467 of the 550 participants (84.9 percent) being women, and the mean age was 55.8 years. Notably, 67.1 percent of participants were classified as socioeconomically disadvantaged using a composite multidimensional deprivation index.

To measure fatigue, the researchers used the 13-item Functional Assessment of Chronic Illness Therapy–Fatigue scale, a validated patient-reported instrument that yields a composite score ranging from 0 to 52, with higher scores indicating less fatigue. Any fatigue was defined as a score below 40, while severe fatigue was defined as a score below 27. The results were striking: 403 participants (73.3 percent) reported some degree of fatigue, with 168 (30.5 percent) reporting some fatigue, 148 (26.9 percent) quite a lot, and 87 (15.8 percent) experiencing extreme fatigue. In total, 235 participants (42.7 percent) met the study’s definition of severe fatigue.

What makes these findings particularly compelling is the pattern of associations that emerged. Using multivariable logistic regression on 516 complete cases, the researchers found that severe fatigue was independently associated with current smoking, multimorbidity, problems with usual activities, pain severity, pain interference, anxiety symptoms, and depressive symptoms. Anxiety carried the strongest association, with patients scoring 11 or above on the Hospital Anxiety and Depression Scale anxiety subscale facing more than three times the odds of severe fatigue compared to those below that threshold. Depression similarly nearly doubled the odds, while having two or more comorbidities increased the odds by more than twofold.

These results align closely with the conceptual model of rheumatoid arthritis fatigue proposed by Hewlett and colleagues, which identifies three interacting domains: rheumatoid arthritis–related factors such as inflammation, pain, and disability; personal factors including socioeconomic circumstances and comorbidities; and cognitive or behavioral factors such as anxiety and depression. The South African findings suggest that all three domains contribute meaningfully to fatigue in this population, and that the relationships are likely mutually reinforcing rather than following a simple one-directional pathway.

Interestingly, while disease activity measures such as the Clinical Disease Activity Index showed significant correlations with fatigue in univariable analysis, none of the individual disease activity components—tender joint count, swollen joint count, patient global assessment, or physician global assessment—remained independently associated with fatigue after adjustment for other factors. This pattern echoes previous international research suggesting that fatigue in rheumatoid arthritis reflects pain and psychological distress more strongly than it reflects inflammatory activity alone. It also helps explain a clinical puzzle that has long frustrated rheumatologists: many patients whose joint disease is well controlled continue to report profound exhaustion.

The socioeconomic dimension of the study deserves particular attention. Rather than relying on education alone, which the researchers note remains strongly influenced by historical inequalities under apartheid-era policies among older South African adults, the team constructed a composite deprivation index comprising four equally weighted binary indicators: receipt of a disability grant or unemployment, low educational attainment, household crowding, and lack of access to domestic technology such as washing machines. Using the Alkire–Foster multidimensional poverty framework, participants were classified as socioeconomically disadvantaged if they experienced deprivation in at least one indicator. Although low socioeconomic status correlated with greater fatigue in univariable analysis, it did not remain independently significant in the multivariable models, suggesting that its influence may operate through the other measured factors such as pain, mental health, and comorbidity.

The study also revealed the functional toll of fatigue on daily life. Among the individual items on the fatigue scale, 36.1 percent and 37.1 percent of patients reported that fatigue made starting or finishing tasks difficult or very difficult, 34.4 percent experienced substantial limitation in social activities, 31.0 percent needed to sleep during the day, and 37.0 percent felt frustrated at being too tired to do the things they wanted to do. These figures underscore that fatigue is not merely an abstract symptom but a concrete barrier to employment, social participation, and overall quality of life—concerns that are especially acute for patients already facing economic hardship.

The authors acknowledge several limitations of their work. The single-center design and reliance on consenting participants may limit generalizability, and the cross-sectional nature of the analysis precludes causal inference; fatigue may influence pain perception and activity levels just as much as those factors influence fatigue. Objective inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate, hemoglobin levels, sleep quality, and physical activity were not assessed and may represent unmeasured confounders. Questionnaires were administered only in English, which may have introduced measurement bias among participants with limited English proficiency, particularly the 20.5 percent of the cohort with primary-level education or less.

Nevertheless, the findings carry important clinical implications. The researchers argue that fatigue should be assessed and managed in conjunction with conventional joint-related symptoms in rheumatoid arthritis care, and that addressing pain, psychological distress, smoking, and comorbid conditions could potentially alleviate the fatigue burden. They call for integrating psychological support, pain management, and comorbidity care into rheumatoid arthritis management, emphasizing a patient-centered approach that recognizes the individualized nature of the disease. Future qualitative research is planned to explore the cultural, social, and healthcare access factors unique to this socioeconomically disadvantaged population, along with interventional and longitudinal studies to evaluate whether targeted interventions can reduce the heavy toll of fatigue in this group.

Subject of Research: Prevalence and associated factors of fatigue among socioeconomically disadvantaged South African patients with rheumatoid arthritis

Article Title: High burden of fatigue amongst socioeconomically disadvantaged South Africans with rheumatoid arthritis

Article References: Didi, S. A., & Hodkinson, B. (2026). High burden of fatigue amongst socioeconomically disadvantaged South Africans with rheumatoid arthritis. Frontiers in Musculoskeletal Disorders, 4, Article 1882572. https://doi.org/10.3389/fmscd.2026.1882572

Image Credits: AI Generated

DOI: 10.3389/fmscd.2026.1882572

Keywords: rheumatoid arthritis, fatigue, South Africa, socioeconomic disadvantage, pain, anxiety, depression, multimorbidity, smoking, patient-reported outcomes, FACIT-F scale, functional disability