despite important developments in the medical treatment of rheumatoid arthritis ( ra ) , this disease has a major impact on important life areas of many patients . over the past two decades , a growing emphasis has been put on arthritis self management strategies to help patients with ra cope with the consequences of the disease . in order to manage the disease on a day - to - day basis , patients need a formal body of knowledge and skills . individual , group - wise and internet - based educational programmes have proven to be effective in improving self - efficacy , as well as in diminishing pain and disability [ 35 ] in patients with ra . however , recent studies show limited long - term effects of standardised educational interventions , and the provision of more patient - centred and tailor - made programmes is advocated [ 69 ] . tailor - made patient education requires good insight into the individual 's educational needs . until recently , no instruments were available to systematically assess ra patients ' educational needs . this meant that the provision of educational strategies that were timely and relevant to the individual patient was difficult , and the planning of educational interventions on the group level more so . lately , the arthritis educational needs assessment tool ( enat ) was developed   in the uk . its early face validity was assessed among arthritis patients , and its test  retest reliability demonstrated a good repeatability of the instrument ( rs  =  0.82 ; icc  =  0.87 ) . the enat was later validated in patients with ra by rasch analysis and found to be a robust tool . until now , little has been known about the educational needs of ra patients in the netherlands . the aim of this paper is to describe the educational needs of dutch patients with ra by using a translated dutch version of the enat ( denat ) . the original enat is a patient - completed questionnaire , comprising 39 items , grouped into seven domains : managing pain ( seven items ) , movement ( five items ) , feelings ( four items ) , arthritis process ( seven items ) , treatments ( seven items ) , self - help measures ( six items ) and support systems ( four items ) . within each domain , patients are asked to rate the question  how important is it for you to know more about   for all items in that domain . the patients rate their responses using five - point likert scales with the descriptors :  not at all important =  3 ,  very important   =  4 and  extremely important the scores of the various items are summed and divided by the number of items in that domain , resulting in all domain scores ranging from one to five . if a single patient missed one or more items in a domain , the patient was not included in the analysis of that specific domain . examples of statements in the denat are the following :  ways to deal with moods and depression ( domain  feelings  ) and  exercises i should be doing  ( domain  self - help measures  ) . the enat was translated into dutch using an established translation methodology , which comprised the following stages : an initial forward translation was undertaken by two independent bilingual translators ( cd and ib ) whose mother tongue was the target language ( dutch ) . then , a back - translation was produced by an independent assessor ( pl and fk ) , translating the newly translated enat back into english . finally , an expert committee including a methodologist ( tv ) , a health professional ( jv ) , all the previously mentioned translators and a translation recorder ( jh ) agreed upon the final version for field testing . the same process has been used successfully to translate the enat into finnish , norwegian , spanish   and swedish . in the subsequent field testing , 30 ra patients completed the denat and were interviewed to assess their understanding of the questions . in october 2006 , a random sample of 319 patients with ra [ 283 women ( 89% ) and 36 men ( 11% ) , median age 68  years ] was selected from the total population of 1,054 ra patients visiting the outpatient clinic of the department of rheumatology at the leiden university medical center ( lumc ) in leiden , the netherlands , during a period of 12  months . all patients were given a number using a microsoft excel random digit generator , and the highest 350 numbers were selected . after verification of the diagnosis in the medical record and a check of the national population register , 319 patients remained . the denat and a questionnaire on age , gender , self - reported disease duration ( years ) and educational background were sent to these patients to complete at home and return to the lumc in a pre - stamped envelope via postal mail . educational background was defined as highest formal education achievement and categorised as primary ( up to and including lower technical and vocational training ) , secondary ( up to and including secondary technical and vocational training ) and tertiary ( up to and including higher technical and vocational training and university ) . the study was judged to be non - medical research according to the medical research involving human subjects act by the medical ethics review committee of the lumc . for this reason , it was not necessary to obtain individual informed consent ( the participants were free to either fill in the questionnaire or not ) . the questionnaires were analysed descriptively using the statistical package for the social sciences ( spss 15.0 for windows , chicago , il , usa ) . because all items were measured at an ordinal level , for each domain , a median score with the inter - quartile range ( iqr ) was computed . the educational needs were then compared between patient groups , categorised by age , disease duration , gender and educational background . the kruskal wallis test ( h value ) was used to determine significant differences between patient groups . the questionnaire was returned by 165 patients ( response rate  =  52% ) with ra , including 146 females ( 88.5% ) and 19 males ( 11.5% ) , with a median age of 68  years ( iqr 5577 ) and a median disease duration of 13  years ( iqr 721 ) . based on their educational background , the numbers of patients with primary education were 29 ( 18% ) , with secondary education 99 ( 60% ) and with tertiary education 35 ( 21% ) , and two ( 1% ) had unknown educational backgrounds . the internal consistency of the 39 denat items ( cronbach 's alpha reliability ) was 0.97 . the median scores within the domains  arthritis process  ,  treatments from health professionals  and self - help measures  were the highest ( 3.5 ) , whereas the scores for  managing pain  ,  movement  ,  support systems  and  feelings  were lower ( 3.0 ) . high educational needs ) according to the denat completed in 165 dutch patients with ramanaging painmovementfeelingsarthritis processtreatments from health professionalsself - help measuressupport systemsmedian2.53.02.04.04.03.52.5iqr14141435352413 educational need scores ( range from one to five , equalling low high educational needs ) according to the denat completed in 165 dutch patients with ra table  2 shows comparisons of enat domain scores between subgroups of patients . with the sample divided at the median age ( 68  years ) , it was found that older patients expressed significantly less educational need than younger patients regarding managing pain , feelings and support systems . based on the cut - off point of the median disease duration ( 13  years ) , patients with longer disease durations had significantly more educational needs within the domain support systems than those with shorter disease duration . there were no statistically significant differences in the enat domain scores between men and women or between patients with different educational backgrounds . table  2differences in ra patients ' educational needs by age , disease duration , gender and educational backgroundmanaging painmovementfeelingsarthritis processtreatments health professionalsself - help measuressupport systemsage ( degrees of freedom ( df ) = 1)age group6868686868686868686868686868n7160776576687063726476627366median score2.52.03.03.02.51.04.04.04.04.03.53.52.51.5h value4.962 * 3.3095.644 * 2.3422.7621.04312.195*disease duration ( df = 1)years1313131313131313131313131313n7357766474687359726476597464median score2.03.03.03.02.02.04.04.04.04.03.03.52.02.5h value0.6660.5050.5821.1260.6780.0354.462*gender ( df = 1)gendermalefemalemalefemalemalefemalemalefemalemalefemalemalefemalemalefemalen17119181291813116121171241712517127median score1.82.52.03.01.02.54.04.03.04.03.03.51.02.5h value1.4041.1270.7290.2741.4990.8103.376educational background ( df  =  2)level123123123123123123123n248229248933259032248131248730238830238931median score1.52.52.32.04.03.02.52.02.04.04.03.54.04.03.03.03.53.33.02.02.5h value4.0804.1220.7821.3864.4842.1720.751age ( divided in 68  years and 68 years , cut - off based on median age ) , disease duration ( divided in 13  years and 13 years , cut - off based on median duration ) , educational background ( divided in 1 : primary , 2 : secondary and 3 : tertiary)df degrees of freedom*h value indicating significant associations ( p  <  0.05)managing pain associated with age : group 68 : mean rank  =  72.7 and group 68 : mean rank  =  58.1 ; p  =  0.026feelings associated with age : group 68 : mean rank  =  80.1 and group 68 : mean rank  =  63.9 ; p  =  0.018support systems associated with age : group 68 : mean rank  =  81.1 and group 68 : mean rank  =  57.7 ; p  =  0.000support systems associated with disease duration : group 13 : mean rank  =  63.0 and group 13 : mean rank  =  77.1 ; p  =  0.035 differences in ra patients ' educational needs by age , disease duration , gender and educational background age ( divided in 68  years and 68 years , cut - off based on median age ) , disease duration ( divided in 13  years and 13 years , cut - off based on median duration ) , educational background ( divided in 1 : primary , 2 : secondary and 3 : tertiary ) df degrees of freedom * h value indicating significant associations ( p  <  0.05 ) managing pain associated with age : group 68 : mean rank  =  72.7 and group 68 : mean rank  =  58.1 ; p  =  0.026 feelings associated with age : group 68 : mean rank  =  80.1 and group 68 : mean rank  =  63.9 ; p  =  0.018 support systems associated with age : group 68 : mean rank  =  81.1 and group 68 : mean rank  =  57.7 ; p  =  0.000 support systems associated with disease duration : group 13 : mean rank  =  63.0 and group 13 : mean rank  =  77.1 ; p  =  0.035 the questionnaire was returned by 165 patients ( response rate  =  52% ) with ra , including 146 females ( 88.5% ) and 19 males ( 11.5% ) , with a median age of 68  years ( iqr 5577 ) and a median disease duration of 13  years ( iqr 721 ) . based on their educational background , the numbers of patients with primary education were 29 ( 18% ) , with secondary education 99 ( 60% ) and with tertiary education 35 ( 21% ) , and two ( 1% ) had unknown educational backgrounds . the internal consistency of the 39 denat items ( cronbach 's alpha reliability ) was 0.97 . the median scores within the domains  arthritis process  ,  treatments from health professionals  and self - help measures  were the highest ( 3.5 ) , whereas the scores for  managing pain  ,  movement  ,  support systems  and  feelings  were lower ( 3.0 ) . high educational needs ) according to the denat completed in 165 dutch patients with ramanaging painmovementfeelingsarthritis processtreatments from health professionalsself - help measuressupport systemsmedian2.53.02.04.04.03.52.5iqr14141435352413 educational need scores ( range from one to five , equalling low table  2 shows comparisons of enat domain scores between subgroups of patients . with the sample divided at the median age ( 68  years ) , it was found that older patients expressed significantly less educational need than younger patients regarding managing pain , feelings and support systems . based on the cut - off point of the median disease duration ( 13  years ) , patients with longer disease durations had significantly more educational needs within the domain support systems than those with shorter disease duration . there were no statistically significant differences in the enat domain scores between men and women or between patients with different educational backgrounds . table  2differences in ra patients ' educational needs by age , disease duration , gender and educational backgroundmanaging painmovementfeelingsarthritis processtreatments health professionalsself - help measuressupport systemsage ( degrees of freedom ( df ) = 1)age group6868686868686868686868686868n7160776576687063726476627366median score2.52.03.03.02.51.04.04.04.04.03.53.52.51.5h value4.962 * 3.3095.644 * 2.3422.7621.04312.195*disease duration ( df = 1)years1313131313131313131313131313n7357766474687359726476597464median score2.03.03.03.02.02.04.04.04.04.03.03.52.02.5h value0.6660.5050.5821.1260.6780.0354.462*gender ( df = 1)gendermalefemalemalefemalemalefemalemalefemalemalefemalemalefemalemalefemalen17119181291813116121171241712517127median score1.82.52.03.01.02.54.04.03.04.03.03.51.02.5h value1.4041.1270.7290.2741.4990.8103.376educational background ( df  =  2)level123123123123123123123n248229248933259032248131248730238830238931median score1.52.52.32.04.03.02.52.02.04.04.03.54.04.03.03.03.53.33.02.02.5h value4.0804.1220.7821.3864.4842.1720.751age ( divided in 68  years and 68 years , cut - off based on median age ) , disease duration ( divided in 13  years and 13 years , cut - off based on median duration ) , educational background ( divided in 1 : primary , 2 : secondary and 3 : tertiary)df degrees of freedom*h value indicating significant associations ( p  <  0.05)managing pain associated with age : group 68 : mean rank  =  72.7 and group 68 : mean rank  =  58.1 ; p  =  0.026feelings associated with age : group 68 : mean rank  =  80.1 and group 68 : mean rank  =  63.9 ; p  =  0.018support systems associated with age : group 68 : mean rank  =  81.1 and group 68 : mean rank  =  57.7 ; p  =  0.000support systems associated with disease duration : group 13 : mean rank  =  63.0 and group 13 : mean rank  =  77.1 ; p  =  0.035 differences in ra patients ' educational needs by age , disease duration , gender and educational background age ( divided in 68  years and 68 years , cut - off based on median age ) , disease duration ( divided in 13  years and 13 years , cut - off based on median duration ) , educational background ( divided in 1 : primary , 2 : secondary and 3 : tertiary ) df degrees of freedom * h value indicating significant associations ( p  <  0.05 ) managing pain associated with age : group 68 : mean rank  =  72.7 and group 68 : mean rank  =  58.1 ; p  =  0.026 feelings associated with age : group 68 : mean rank  =  80.1 and group 68 : mean rank  =  63.9 ; p  =  0.018 support systems associated with age : group 68 : mean rank  =  81.1 and group 68 : mean rank  =  57.7 ; p  =  0.000 support systems associated with disease duration : group 13 : mean rank  =  63.0 and group 13 : mean rank  =  77.1 ; p  =  0.035 this cross - sectional study among a random sample of patients with ra in the netherlands shows that there is a considerable educational need , particularly with respect to arthritis process , treatments from health professionals and self - help measures . less importance was attributed to the need for education in the domains managing pain and movement . these findings are in agreement with previous studies among ra patients   and patients with various rheumatic diseases [ 10 , 18 , 19 ] which demonstrate a high need for information on disease and medical care . a little important  , despite the relatively high prevalence of anxiety and depression in patients with ra in general . however , our results are in concordance with a recent study showing that patients with ra are the least interested in information regarding dealing with emotions . in our study , younger patients had a higher need for education within the domains managing pain , feelings and support systems than older patients . the inverse association between age and information need is in line with the findings of other studies in the field of patient information and education [ 17 , 18 , 21 ] . patients with longer disease duration showed higher educational needs on support systems , which is possibly related to more disease - related disability . the division of the sample in two categories ( < or > 13  years ) for disease duration was merely based on the sample distribution . in addition , no significant association between gender and educational needs was observed in the present study , whereas other studies showed significantly higher needs for information   and education   in women than in men . our results , however , point in the same direction , and the lack of significance could probably be explained by the fact that , in our sample , men were relatively underrepresented ( male / female ratio 1:8 ) . our study showed no significant differences in educational needs among patients with different educational backgrounds . in literature , conflicting results regarding the association between educational level and educational needs among patients with arthritis have been reported [ 10 , 17 ] . first , the sample was selected from only one hospital , the response was 52% , men were relatively underrepresented and the median age of the sample was relatively high ( 68  years ) , so the generalizability of the results may be limited . in the present study , we did not measure if the need for information was related to the actual level of knowledge of the patients . previous research by mkelinen   in ra patients has demonstrated that younger and female patients obtained higher scores than older and male counterparts on the patient knowledge questionnaire , which was designed to assess patients ' general knowledge of ra and its treatments . as younger people and women also appear to have the highest educational needs , measuring both the educational needs and the actual level of knowledge is probably to be preferred in the design of an educational programme for ra patients . to conclude , the results of this study have shown that educational needs among dutch - speaking ra patients are high . the findings underline the importance for patient education in ra as an integrated part of standard rheumatologic care . given the emphasis on patient - centred health care   and tailor - made educational programmes [ 8 , 9 ] , the identification of individual educational needs becomes imperative . so far , the denat is the only objective tool to identify educational needs among dutch - speaking patients with ra . further research into the usefulness of the denat in daily clinical practice , and its application in other rheumatic diseases is needed . moreover , a cross - cultural comparison of educational needs across countries [ 1316 ] would be interesting . this collaborative work is currently underway , involving all countries which participated in the translation of the enat .