Качество жизни и ее детерминанты среди иорданских пациентов с множественным склерозом: перекрестное аналитическое исследование.

INTRODUCTION

Multiple sclerosis (MS) is a major cause of non-traumatic disability worldwide.[ 1 ] It is a progressive autoimmune disorder that leads to demyelination and inflammation in the central nervous system.[ 2 ] The disease shows variable symptoms due to immune attacks and axonal injury.[ 3 ] Patients may suffer from sensory-motor, visual, cognitive, bladder, sexual, and psychological problems such as depression and anxiety.[ 4 ] Globally, more than 1.8 million people have MS,[ 5 ] with young adults and women more commonly affected.[ 3 6 7 8 ] Prognosis can vary with age; one study found that complete recovery ranged from 87.4% in the youngest age group (0–18 years) to 68% in the oldest age group (>44 years).[ 7 ] Although there have been advances, its exact cause is unclear, with the most likely causes being genetics, environment, and possible viral infections.[ 9 ]

Clinically, MS is divided into types based on severity and progression. Benign MS is the mildest, with minimal disability for years (EDSS ≤3 within 10 years).[ 10 ] Clinically Isolated Syndrome (CIS) is a single neurological episode lasting ≥24 hours and may precede MS.[ 11 ] Relapsing–remitting MS (RRMS), the most common type, alternates between relapses and remissions.[ 12 ] Early-onset RRMS (i.e., occurring before the age of 18 years) is associated with more frequent relapses, faster disability, and severe progression.[ 13 ] Secondary progressive MS (SPMS) develops from RRMS, with gradual worsening even during remission.[ 14 ] Primary progressive MS is less common, requires longer observation, and often has poorer outcomes.[ 15 ] RRMS is generally milder than primary progressive MS and progressive-relapsing MS, but needs early, accurate diagnosis for better management.[ 16 ]

The World Health Organization defines health as “a state of complete physical, mental, and social well-being, not merely the absence of disease”.[ 17 ] Quality of life (QoL) is described as an individual’s perception of their life position within cultural and personal contexts.[ 18 ] Patients with MS have significantly reduced QoL,[ 2 3 6 ] and report lower QoL than the general population.[ 19 ] Factors associated with QoL include age, sex, disease duration, MS type, smoking, and comorbidities.[ 20 ]

In Jordan, MS prevalence is about 39 per 100,000 people.[ 21 ] Few studies from Jordan have explored the challenges faced by patient with MS. One qualitative study reported on challenges such as disease progression, healthcare barriers, miscommunication, delayed diagnosis, poor understanding of management, and physical and psychological symptoms.[ 22 ] However, no study has specifically assessed the QoL in Jordanian MS patients. Therefore, this study was conducted to determine the QoL of Jordanian MS patients and to identify sociodemographic and medical factors associated with impaired QoL. Understanding the impact of MS on the QoL of patients is essential for both patients and healthcare providers.

METHODS

Study design, setting, and population

This cross-sectional analytical study included adult Jordanian MS patients (aged ≥18 years) from the MS Unit at Albasheer Governmental Teaching Hospital, Amman, which is the only referral center for MS patients in Jordan, and was conducted between December 2023 and July 2025. Patients with pre-existing psychiatric disorders were excluded.

Written informed consent was obtained from each participant, and verbal consent was obtained from healthcare providers. Prior to participation, all participants were provided with information about the study, including its purpose and procedures. Participants were informed that their participation was entirely voluntary, that they could decline to participate or withdraw from the study at any time without any consequences, and that their responses would be treated confidentially and analysed anonymously. Participants were also assured that no personally identifiable information would be disclosed in any reports or publications. No incentives or compensation were provided for participation.

Ethical approval for this study was obtained from Mutah University Committee (Ref no.: 1122023), Jordanian Ministry of Health (Ref no.: MOH/REC/2023/243; date: August 2, 2023), and from the hospital director (Ref nos.:119922 and 10450; date: August 6, 2023).

The sample size was calculated using OpenEpi version 3.01, assuming the prevalence of poor QoL among MS patients to be 50% (as no prior studies had been conducted in Jordan) and setting a type I error rate (α) at 0.05. The minimum calculated sample size was 292.

Sampling technique and data collection

A systematic random sampling method was employed based on hospital records, with a sampling interval of five; an interval of five was chosen to achieve the required sample size from the about 1400 patients with MS recorded in the hospital. Face-to-face interviews were conducted at the outpatient clinic waiting room during routine follow-up visit before the scheduled medical consultation.

A two-part structured questionnaire was used to elicit data. The first part of the questionnaire collected sociodemographic information (e.g., age gender, etc.) and medical history (e.g., chronic diseases and autoimmune conditions). In the second part, QoL was assessed using the validated Arabic version of the WHOQOL-BREF.[ 18 ] The WHOQOL-BREF has good reliability and contains 26 items across four domains: physical (7 items), psychological (6 items), social (3 items), and environmental (8 items). Each item is rated on a 5-point Likert scale ranging from 1 (very poor) to 5 (very good). Domain and overall scores were converted to a 0–100 scale following the WHOQOL-BREF scoring guidelines. In addition, each participant’s weight and height were measured to calculate the body mass index (BMI), expressed in kg/m 2 .

Data analysis

Data were entered into Excel and analyzed with SPSS version 27. Descriptive statistics included means, standard deviations (SDs), frequencies, and percentages; inferential statistics included t -tests, ANOVA with post hoc tests, Chi-square tests, odds ratios, correlations, reliability analysis (Cronbach’s alpha) and multivariable binary logistic regression. Significance was set at P < 0.05. QoL was categorized as poor (<60) or good (≥60) depending upon Silva et al . (2014).[ 23 ] This threshold was adopted to enhance the clinical interpretability of the results by identifying a distinct subgroup of vulnerable patients. To ensure data robustness, QoL was also analyzed as a continuous variable during the initial descriptive phase.

RESULTS

Demographic and clinical characteristics

A total of 300 Jordanian patients MS were included in the study. The mean age of the participants was 35.3 (±11.1) years (range: 18 to 92 years) and the mean BMI was 25.7 ± 5.0 kg/m 2 (range: 15 to 52 kg/m 2 ). More than two-thirds of the patients were female (68.7%), of whom 72% had a regular menstrual cycle. Most patients lived in the central region (88%), had a university degree (52.7%), were married (58.3%), had access to a caregiver at home (78.7%), were non-smokers (58.0%), and unemployed (67.3%). Among smokers, 65.9% had been smoking for >5 years, while among unemployed patients, 37.2% reported being unemployed due to MS. In addition, most patients had no non-autoimmune comorbidity (76.3%) and no other autoimmune disease (86.3%) [ Table 1 ].

Table 1 Sociodemographic and medical characteristics of multiple sclerosis patients in Jordan ( n =300) Characteristics n (%) Age (years) (mean±SD) 35.3±11.1 BMI (kg/m 2 ) (Mean±SD) 25.7±5.0 Sex  Male 94 (31.3)  Female 206 (68.7) Residency location  North 25 (8.3)  Middle 264 (88.0)  South 11 (3.7) Education level  High school and below 100 (33.3)  Diploma degree 42 (14.0)  University degree 158 (52.7) Marital status  Single 114 (38.0)  Married 175 (58.3)  Previously married 11 (3.7) Income Jordanian dinar/month  <500 143 (47.7)  500–1000 115 (38.3)  >1000 42 (14.0) parental consanguinity  No 163 (72.8)  Yes 61 (27.2) Living with caregiver  No 64 (21.3)  Yes 236 (78.7) Occupational status  Unemployed 202 (67.3)  Employed 98 (32.7) MS is reason for unemployment  No 108 (62.8)  Yes 64 (37.2) Smoking status  Nonsmoker 174 (58.0)  Smoker 126 (42.0) Smoking duration (years)  <3 24 (19.0)  3–5 19 (15.1)  >5 83 (65.9) Menstrual cycle  Irregular 54 (28.0)  Regular 139 (72.0) Number of non-autoimmune comorbidities  None 229 (76.3)  One 58 (19.3)  Two or more 13 (4.3) Non-autoimmune comorbidities  Hypertension 31 (10.3)  Depression 21 (7.0)  Type 2 DM 19 (6.3)  Cardiac diseases 9 (3.0)  Lung diseases 6 (2.0) Number on autoimmune diseases  None 259 (86.3)  One 34 (11.3)  Two or more 7 (2.3) Autoimmune comorbidities  Psoriasis 14 (4.7)  Eczema 12 (4.0)  Type 1 DM 4 (1.3)  Rheumatoid arthritis 5 (1.7)  Grave’s disease 14 (4.7) BMI – Body mass index; MS – Multiple sclerosis; SD – Standard deviation; DM – Diabetes mellitus

Sociodemographic and medical characteristics of multiple sclerosis patients in Jordan ( n =300)

BMI – Body mass index; MS – Multiple sclerosis; SD – Standard deviation; DM – Diabetes mellitus

Quality of life scores

The WHOQOL-BREF in our study showed good overall internal consistency (Cronbach’s alpha: 0.799). For the individual domains, the reliability coefficients ranged from 0.658 to 0.799. The overall mean QoL score was 57.2 ± 15.2, indicating a generally low level of QoL. The social and environmental domains had the highest mean scores (61.3 ± 20.9 and 60.2 ± 19.6, respectively), while physical and psychological domains had lower mean scores (49.7 ± 18 and 57.8 ± 18.4, respectively). From the 26 questionnaire items, the highest mean score (3.7 ± 1.2) was observed for both items “How satisfied are you with your personal relationships” and “How safe do you feel in your daily life.” Conversely, the lowest mean score (2.7 ± 1.2) was recorded for the item “To what extent do you feel that physical pain prevents you from doing what you need to do.” The mean QoL score was non-significantly higher among females (57.8 ± 14.7) than males (56.1 ± 16.3) ( t = −0.905; P = 0.366) [ Table 2 ]. In total, 167 (55.7%) and 133 (44.3%) patients were classified as having poor and good QoL, respectively.

Table 2 Quality of life of Jordanian multiple sclerosis patients according to the WHOQOL-BREF-26 ( n =300) Domains Items Mean±SD Physical domain How do you rate your QoL 3.46±0.97 How Satisfied are you with your health 3.5±1.11 To what extent do you feel that physical pain prevents you from doing what you need to do? 2.7±1.2 How much do you need any medical treatment to function in your daily life? 3.3±1.3 Do you have enough energy for everyday life? 2.9±0.9 How well are you able to get around? 3.4±1.2 How satisfied are you with your sleep? 2.9±1.3 How satisfied are you with your ability to perform your daily living activities? 3.1±1.1 How satisfied are you with your capacity for work? 2.9±1.1 Total mean 49.7±18.0 Psychological domain How much do you enjoy life? 3.2±1.1 To what extent do you feel your life to be meaningful? 3.4±1.2 How well are you able to concentrate? 2.8±1.2 Are you able to accept your bodily appearance? 3.7±1.1 How satisfied are you with yourself? 3.7±1.1 How often do you have negative feelings, such as blue mood, despair, anxiety, depression? 2.9±1.1 Total Mean 57.8±18.4 Environmental domain How safe do you feel in your daily life? 3.7±1.2 How healthy is your physical environment? 3.5±1.2 Have you enough money to meet your needs? 2.9±1.3 How available to you is the information that you need in your day-to-day life? 3.4±1.2 To what extent do you have the opportunity for leisure activities? 3.0±1.2 How satisfied are you with the conditions of your living place? 3.5±1.2 How satisfied are you with your access to health services? 3.6±1.2 How satisfied are you with your mode of transportation? 3.2±1.3 Total Mean 60.2±19.6 Social relationship domain How satisfied are you with your personal relationships? 3.7±1.2 How satisfied are you with your sex life? 3.1±0.9 How satisfied are you with the support you get from your friends? 3.5±1.3 Total Mean 61.3±20.9 Overall mean 57.2±15.2 SD – Standard deviation; QoL – Quality of life

Quality of life of Jordanian multiple sclerosis patients according to the WHOQOL-BREF-26 ( n =300)

SD – Standard deviation; QoL – Quality of life

Quality of life and sociodemographic variables

A statistically significant but weak negative correlation was observed between QoL and both age ( r = −0.172, P = 0.003) and BMI ( r = −0.155, P = 0.007). Additionally, a significant difference in mean QoL scores was found across the three education levels ( F = 5.552, P = 0.004). Participants with a university degree reported the highest mean QoL score (59.5 ± 15.1), whereas those with a high school education or less reported the lowest (53.2 ± 15.3). Post hoc analysis revealed a significant difference between these two groups ( P = 0.003). The mean QoL scores significantly increased with higher household income levels ( F = 8.086, P = 0.001). Patients with a monthly income of <500 JD had significantly lower QoL scores than those with monthly incomes of 500–1000 JD ( P = 0.01) and >1000 JD ( P = 0.001). A significant positive correlation was also found between household income and QoL ( r = 0.219, P < 0.001). No significant differences in mean QoL scores were found based on caregiver status ( t = 1.923, P = 0.055) or employment status ( t = −1.572, P = 0.117) [ Table 3 ].

Table 3 Quality of life OF Jordanian multiple sclerosis patients in relation to the sociodemographic and medical characteristics ( N =300) Variables Mean±SD 95% CI mean difference Test of significance
P
Effect size Age (years) 35.3±11.1 N/A r =−0.172 0.003 N/A BMI (kg/m 2 ) 25.7±5.0 N/A r =−0.155 0.007 N/A Gender  Male 56.1±16.3 −5.44 to 2.01 t (298) =−0.91 1.000 −0.113  Female 57.8±14.7 Educational level  High school and below 53.2±15.3 N/A F (2, 297) =5.55 0.004 0.036  Diploma 58.3±13.8  Bachelor’s and above 59.5±15.1 Living with a caregiver  No 60.5±15.8 −0.10 to 8.30 t (298)=1.92 0.055 0.271  Yes 56.4±150 Occupational status  Employed 59±15.5 −6.61 to 0.74 t (298)=−1.57 0.117 −0.194  Unemployed 56.3±150 Income (JDs/month)  <500 53.8±16.6 N/A F (2, 112)=8.09 r =0.219 0.001 <0.001 0.110  500–1000 59.0±12.0  More than 1000 67.0±15.4 Residency  North 59.4±13.9 N/A F (2, 20)=1.04 1.000 0.003  Middle 57.4±14.9  South 48.7±22.7 Consanguinity of parents  No 57.5±15.2 1.02 to 9.98 t (222)=2.42 0.016 0.363  Yes 52.0±15.0 Disease duration (years)  <5 59.0±15.1 N/A F (2, 297)=2.64 r =−0.106 0.876 0.067 0.017  5–10 54.2±15.1  >10 56.8±15.2 Smoking status  Yes 54.1±16.4 1.83 to 8.93 t (241)=2.98 0.003 0.358  No 59.5±13.9 Smoking duration (years)  <3 58.3±17.9 N/A F (2, 123)=1.04 r =−0.137 0.356 0.127 0.017  3–5 54.5±14.1  ? 5 52.8±16.4 Number of non-autoimmune comorbidities  None 59.9±14.3 N/A F (2, 297)=18.16 <0.001 0.109  One 49.8±13.8  Two or more 42.9±18.6 Number of autoimmune diseases  None 56.9±15.0 N/A F (2, 297)=0.47 0.627 0.003  One 58.7±16.1  Two or more 61.4±18.3 N/A – Not available; CI – Confidence interval; BMI – Body mass index; SD – Standard deviation

Quality of life OF Jordanian multiple sclerosis patients in relation to the sociodemographic and medical characteristics ( N =300)

N/A – Not available; CI – Confidence interval; BMI – Body mass index; SD – Standard deviation

Patients with parental consanguinity reported significantly lower mean QoL scores (52.0 ± 15.0) than those without consanguinity ( t = 2.417, P = 0.016). Similarly, patients with MS who smoked had significantly lower QoL scores (54.1 ± 16.4) than non-smokers (59.5 ± 13.9) ( t = 2.983, P = 0.003). Although mean QoL scores tended to decline with longer smoking duration, the difference was not statistically significant ( F = 1.040, P = 0.356), and no significant correlation was found between smoking duration and QoL ( r = −0.137, P = 0.127) [ Table 3 ]. No significant differences in QoL scores were found based on region of residence ( F = 1.039, P = 0.372. Additionally, MS disease duration was not significantly associated with QoL [ Table 3 ].

When assessed according to the category of QoL (i.e., good: ≥60; poor: <60), previously married individuals (widowed/divorced) had a significantly higher prevalence of poor QoL (84.6%) than unmarried and married participants ( χ 2 = 6.06, P = 0.048). Similarly, patients with parental consanguinity demonstrated a significantly higher rate of poor QoL (69.8%) than those without parental consanguinity (55.2%) ( χ 2 = 4.03, P = 0.044), and were nearly twice as likely to have poor QoL (OR = 1.88, 95% CI: 1.01–3.45). Patients who smoked had a significantly higher proportion of poor QoL (63.5%) compared to non-smokers (50%) ( χ 2 = 5.39, P = 0.02), and they were nearly twice at risk to have poor QoL (OR = 1.74, 95% CI: 1.08–2.77). Poor QoL was non-significantly more prevalent among residents from the southern region (63.3%; χ 2 = 1.893, P = 0.639) and those who were unemployed (58.4%; χ 2 = 1.893, P = 0.169) [ Table 4 ].

Table 4 Quality of life of Jordanian multiple sclerosis patient in relation to sociodemographic and medical characteristics ( N =300) Variable Category Poor QOL ( n =167; 55.7%), n (%) Good QOL ( n =133; 44.3%), n (%)
χ
2

P
OR (95% CI) Marital status Unmarried 57 (50) 57 (50) 6.068 0.048 Married 99 (57.2) 74 (42.8) Previously married 11 (84.6) 2 (15.4) Consanguinity* No 90 (55.2) 73 (44.8) 4.03 0.043 1.88 (1.01–3.45) Yes 44 (69.8) 19 (30.1) Occupation Unemployed 118 (58.4) 84 (41.6) 1.893 0.169 Employed 49 (50.0) 49 (50.0) Residency North 12 (48.0) 13 (52.0) 1.893 0.639 Middle 148 (56.1) 116 (43.9) South 7 (63.6) 4 (36.4) Smoking status Non-smoker 87 (50.0) 87 (50.0) 5.390 0.02 1.74 (1.08–2.77) Smoker 80 (63.5) 46 (36.5) First symptoms to appear Limb paraesthesia 78 (75.15) 57 (59.85) 4.60 0.203 Painful loss of vision 51 (59.01) 55 (46.99) Face Paraesthesia 22 (19.48) 13 (15.52) Speech difficulty/dizziness 16 (13.36) 8 (10.64) MS type Benign 14 (41.2) 20 (58.8) 20.61 <0.001 Primary progressive 24 (42.1) 33 (57.9) Secondary progressive 43 (74.1) 15 (25.9) Relapsing remitting 15 (40.5) 22 (59.5) Unclassified type 71 (62.3) 43 (37.7) Family history No 137 (55.0) 112 (45.0) 0.248 0.618 Yes 30 (58.8) 21 (41.2) OR – Odds ratio; CI – Confidence interval; MS – Multiple sclerosis; QOL – Quality of life *Only 226 participants answered this question

Quality of life of Jordanian multiple sclerosis patient in relation to sociodemographic and medical characteristics ( N =300)

OR – Odds ratio; CI – Confidence interval; MS – Multiple sclerosis; QOL – Quality of life *Only 226 participants answered this question

Quality of life and clinical variables

A significant association was observed between the number of non-autoimmune comorbidities and QoL scores ( F = 18.1, P < 0.001), with post hoc analysis confirming the result ( P < 0.001). In contrast, the number of autoimmune diseases other than MS had no significant effect on QoL ( F = 0.468, P = 0.627). [ Table 3 ]. When assessed according to the category of QoL, a significant association was found between MS type and QoL, with the highest rate of poor QoL among those with the SPMS (74.1%) ( χ 2 = 20.610, P < 0.001). Poor QoL was non-significantly more prevalent among patients with a family history of MS (58.9%; χ 2 = 0.248, P = 0.618, respectively). In addition, no significant association was observed between the nature of the first MS symptom and QoL classification ( χ 2 = 4.604, P = 0.200) [ Table 4 ].

Multivariate binary logistic regression analysis

All variables that were significant in the univariable analysis were included in the multivariate binary logistic regression model. Multivariable logistic regression showed that smoking (odds ratio [OR] = 0.454, 95% CI: 0.236–0.871; P = 0.018), having one comorbidity (OR = 0.278, 95% CI: 0.108–0.714; P = 0.008), and SPMS (OR = 0.260, 95% CI: 0.084–0.798; P = 0.019) were independently associated with lower odds of higher QoL [ Table 5 ].

Table 5 Multivariable binary logistic regression analysis of factors associated with higher quality of life Prognostic variable OR 95% CI Adjusted P Age 1.005 0.971–1.040 0.778 BMI 0.942 0.878–1.011 0.098 Educational level  High school and below Reference  Diploma 1.411 0.507–3.927 0.510  Bachelor’s and above 1.191 0.543–2.612 0.662 Income  <500 Reference  500–1000 1.358 0.652–2.830 0.414  More than 1000 1.460 0.510–4.181 0.481 Smoking  Nonsmoker Reference  Smoker 0.454 0.236–0.871 0.018 Number of comorbidities  None Reference  One 0.278 0.108–0.714 0.008  Two or more 0.647 0.102–4.106 0.644 Marital status  Unmarried Reference  Married 1.552 0.684–3.522 0.293  Previously married 0.168 0.014–2.002 0.158 Consanguinity  No Reference  Yes 0.741 0.355–1.547 0.43 MS type  Benign Reference  Primary progressive 1.170 0.385–3.556 0.782  Secondary progressive 0.260 0.084–0.798 0.019  Relapsing remitting 1.461 0.442–4.831 0.534  Unclassified type 0.497 0.173–1.425 0.193 BMI – Body mass index; OR – Odds ratio; CI – Confidence interval; MS – Multiple sclerosis

Multivariable binary logistic regression analysis of factors associated with higher quality of life

BMI – Body mass index; OR – Odds ratio; CI – Confidence interval; MS – Multiple sclerosis

Factors independently associated with lower odds of higher QoL were smoking, having one comorbidity, and SPMS.

DISCUSSION

This study revealed a generally low QoL among Jordanian patients with MS, with more than half of the cohort (55.7%) classified as having poor QoL. While participants scored highest in the social and environmental domains, they demonstrated the lowest scores in the physical and psychological dimensions. In the multivariable logistic regression, smoking, have one comorbidity, and SPMS were significant independent factors associated with lower QoL. In our study, most participants were female (68.7%), consistent with findings of a previous study on MS.[ 6 ] In general, MS globally is more prevalent in women than men.[ 24 ] The mean age of participants with MS was 35.3 ± 11.1 years, which aligns with those reported previously[ 6 7 ] and reflects the well-documented trend of MS predominantly affecting young adults, a factor that can significantly influence individual productivity and broader economic outcomes.[ 25 ]

Participants demonstrated a low overall QOL score (57.2 ± 15.2), supporting similar findings from studies conducted in Australia,[ 26 ] the United States,[ 19 ] and the West Bank, Palestine.[ 27 ] Reduced QoL among individuals with MS is commonly associated with functional limitations, disruption of social and familial roles, and decreased engagement in daily activities. In addition, the findings that physical and psychological domains yielded the lowest scores in our study is consistent with global patterns. In a systematic review, Gil-González et al .[ 2 ] reported that these dimensions are typically the most affected in MS patients regardless of geographical location, as they directly capture the burden of functional impairment and emotional distress associated with the disease.

The relatively moderate scores observed in the social domain might reflect the robust family-based caregiving networks that characterize Jordanian society.[ 22 ] In our local context, the extended family often acts as a primary support system, potentially buffering patients against the social isolation and psychological distress that frequently accompany MS in more individualistic cultures.

Multiple factors influence QoL in individuals with MS, including disease characteristics and sociodemographic variables. In the present study, participants with higher education levels reported significantly better QoL, consistent with previous finding.[ 28 ] This may be attributed to increased disease awareness, greater adherence to treatment regimens, and more frequent engagement with healthcare services among educated patients.[ 29 ]

The current study found no significant association between employment status and QoL, which contrasts previous finding.[ 30 ] Nonetheless, our study found that employed MS patients had a higher mean QoL score and 50% had “good” QoL, which is consistent with finding from Kuwait, where employed/previously employed MS patients reported higher QoL than those who had never worked.[ 31 ] Similarly, a systematic review found that that maintaining activity, particularly through employment, acts as a protective factor against poor QoL.[ 2 ] However, in our study, about two-thirds of the unemployed patients stated that their unemployment was unrelated to MS. This may be partially explained by the demographic profile of the sample, in which two-thirds of participants were female. In the Jordanian cultural context, women are less likely to participate in the formal workforce.[ 22 ] In addition, in the current study, about one-third and one-fourth of participants had low educational level and were aged <25 years, respectively, and thus potentially had limited opportunity/eligibility for employment.

Among unemployed MS patients, 58.4% had poor QoL, potentially due to lower household income, as a significant association was also noted between lower income and lower QoL, and higher income and better QoL. This is consistent with the literature,[ 31 32 ] suggesting that higher income is associated with better QoL in MS patients, possibly because of better capacity to manage the high financial burden of care associated with MS.[ 33 ] Interestingly, income was not a significant independent predictor of QoL in the multivariable analysis. This could be explained by the universal health insurance coverage available to most MS patients in Jordan, which facilitates equitable access to essential disease management. Such a system likely mitigates the impact of socioeconomic disparities, ensuring that clinical management remains standardized regardless of a patient’s financial status.

Notably, participants who were previously married (widowed/divorced) reported significantly poorer QoL compared to their married or never-married counterparts. This could be related to reduced social and familial support, as well as limited access to caregivers, which are protective factors for QoL among individuals with chronic conditions.[ 34 ] Non-smokers had significantly higher mean QoL scores than smokers, which aligns with previous finding,[ 35 ] wherein MS patients who smoked had lower QoL and more severe symptoms, such as fatigue. The lower QoL observed in smokers could be associated with a higher burden of comorbid conditions, such as cardiovascular disease, type 2 diabetes mellitus and depression.[ 36 37 38 ] Consistent with this, we also found that having one comorbidity was a significant independent risk factor of lower QoL in MS patients.

Patients with a disease duration >10 years (n = 23) demonstrated significantly higher rates of poor QoL. This finding could be related to the cumulative effects of disease progression and the associated increase in disability over time.[ 39 ] Age also appeared to negatively correlate with QoL in our study, further reinforcing the impact of long-term disease burden on patients’ well-being.

Our findings showed that the highest rate of poor QOL was observed among patients diagnosed with SPMS, with 74.1% reporting poor QoL. This is consistent with Gross et al . (2017),[ 40 ] who noted that individuals with SPMS often experience more severe neurological impairment, longer hospital stays, and increased healthcare needs, all of which can negatively impact QoL. Our study found that patients with the SPMS subtype reported the lowest QoL scores. While SPMS is typically associated with older age and longer disease duration, our regression model confirmed that the SPMS subtype was independently associated with significantly lower QoL.

No significant association was found between family history of MS and QoL, in agreement with previous finding.[ 41 ] This may be due to greater disease awareness and preparedness among individuals with a family history of MS, potentially mitigating its impact on their perceived QOL. We also found no significant differences in QoL based on region of residence. This may reflect the relative homogeneity of the population across regions in Jordan, as well as the centralized nature of MS care, with most patients receiving services from a national referral center. Of note, the variability in access to advanced disease-modifying therapies remains a pivotal factor in the Middle Eastern context. Disparities in insurance coverage and the high costs of newer therapies can impact long-term clinical outcomes and overall QoL,[ 39 ] a factor that warrants further detailed investigation in future studies.

Limitations

This study has several limitations. The study was conducted at a single national referral center, and thus patients with milder disease who attend irregularly or seek private care may have been underrepresented, potentially limiting the generalizability of the findings. Additionally, logistical challenges, particularly the geographic distance between our university and the central referral hospital in Amman, resulted in time constraints, which may have affected the recruitment process. Furthermore, this study did not account for physical disability or psychological symptoms such as fatigue, depression, and anxiety, which are known predictors of QoL. Future research should incorporate these multidimensional variables to provide a more comprehensive assessment.

CONCLUSION

This study found that patients living with multiple sclerosis (MS) in Jordan experience generally poor QoL, particularly in the physical and psychological domains. Factors independently associated with lower odds of higher QoL were smoking, having one comorbidity, and secondary progressive MS. Further studies can assess if comprehensive interventions targeting modifiable risk factors and comorbidities in patients with MS, smoking cessation programs and awareness campaigns and psychosocial and mental health services, improve the QoL of MS patients.

Ethical considerations

Ethical approval for this study was obtained from Mutah University Committee (Ref no.: 1122023), Jordanian Ministry of Health (Ref no.: MOH/REC/2023/243; date: August 2, 2023), and from the Director of Albasheer Hospital (Ref nos.:119922 and 10450; date: August 6, 2023). All study participants provided written consent before inclusion in the study. The study adhered to the principles of the Declaration of Helsinki, 2024.

Peer review

This article was peer-reviewed by two independent and anonymous reviewers.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author contributions

Conceptualization: A.S.O.A. and W.A.A.; Methodology: N.E.M., A.S.O.A., M.M.M.H., A.O.K.S., O.H.H., N.A.T., A.A.T., R.O.A., A.S.A., and W.A.A.; Data analysis: W.A.A., N.E.M., M.M.M.H., N.A.T., R.O.A., A.S.A., A.A.T., and N.A.T.; Writing–original draft preparation: N.E.M., A.S.O.A., A.O.K.S., O.H.H., A.A.T., N.A.T., M.M.M.H., R.O.A., A.S.A., and W.A.A.; Writing – review and editing: W.A.A., N.E.M., A.O.K.S., and O.H.H.; Supervision: W.A.A., N.E.M., and R.O.A.

All authors have read and agreed to the published version of the manuscript.

Conflicts of interest

There are no conflicts of interest.