Quality of life
This study adopted a cut-off score of 75 ±2.5 as indicative of low overall mean quality of life. [8,9].
The QOL scores at MTRH are in contrast and considerably lower than the proposed norm [8] and concur with findings by [10], who did a descriptive-analytical study comparing patients with CLBP and normal subjects. In patients with CLBP, they found a mean of 3.32 (SD 0.99) for the overall quality of life facet and 3.47 (SD 0.81) for the general health facet. Scores of the four domains of WHOQOL-BREF were also lower in low back pain patients with these differences being statistically significant in physical health and environmental health.
In this study at MTRH, patients reported the lowest scores in the physical health domain and were especially dissatisfied with the facets that assessed work capacity, dependence on medical substances and medical aids, activities of daily living, energy and fatigue, sleep, and rest, and pain and discomfort. These findings concur with [11] whose multivariate analysis revealed: “not needing medical treatment to function in daily life” with an odds ratio (OR) (95% CI) of 6.3 (2.6–15.3) and 4.2 (2.1–8.5) as the strongest predictor for health satisfaction in men and women, respectively. Additionally, “satisfaction with one’s sex life” and “satisfaction with work capacity”, OR: 6.6 (2.9–14.8) and 3.7 (1.5–9.3) were predictors of health satisfaction [11].
Sociodemographic factors and QoL
The higher prevalence of chronic low back pain in females concurs with findings of prevalence studies in similar settings [12,13].
The fact that overall, women have a high prevalence of low back pain across all age groups has been attributed to the role female sex hormones play in the pathophysiology of musculoskeletal disorders and has been shown to increase after menopause [14]. Biologic response to pregnancy and childbearing, the physical stress of childbearing, and peri-menopausal abdominal weight gain are additional causes of CLBP.
As expected, older age groups (age over 45 years) reported lower overall QOL (mean 66.37 SD 7.73, p<0.008), especially in the physical health and psychological domains (mean 36.97, SD 13.4 and mean 54.62 SD 9.91 p<0.0016 respectively). Conversely, patients in the lower age bracket had higher quality of life scores in the physical and psychological domains (mean 46.44, SD 5.94, p<0.0016, and mean 59.39 SD 9.71, p<0.0392 respectively).
In the multivariate analysis, when factors associated with overall QOL were analysed, older age (age 31-45 and 46-65) was statistically significantly associated with low overall QOL scores compared to their younger counterparts in the 18-30 age group (OR Coefficient β -3.25 P<0.041 95% CI -6.38 -0.13 and OR Coefficient β -4.62 P<0.003 95% CI -7.62 -1.62) respectively. Similarly, older age (age 46-65) was statistically significantly associated with low psychological domain scores compared to their younger counterparts aged 18-30 (OR coefficient β -4.64, p<0.015 95% CI -8.36 -0.93).
The finding that age affects the overall QOL, physical and psychological health domains concurs with findings by [15] and can be explained by the fact that QOL generally decreases across the lifespan, especially for the physical domain; and is better for the younger people in their prime of life (in their 20s and 30s) compared to the elderly [15].
The finding of a lower QOL in the older age group in this study concurs with findings by [16] and was influenced by the likelihood of co-occurring co-morbidities, polypharmacy and physical frailty [17]. Moreover, this finding supports the view that older adults have unique treatment goals and expectations about the patient-clinician relationship and/or priorities for quality of life when compared to persons in younger age groups [17]. There is thus a need for clinicians to be aware of and screen for low HRQOL in elderly patients with chronic back pain.
As anticipated, the level of income had an impact on QOL, similar to Aminde, et al.,(2020). This was significant for the psychological domain with patients with a higher income (>kshs.20000) reporting a higher psychological domain score (mean 57.19, SD 9.7P<0.0076). Patients who earned more than kshs.20, 000 per month had a better environmental health domain score (mean 52, p<0.1623) compared to patients who earned less. In addition, the multivariate analysis findings are similar to those of , who found that tertiary education, age, and being a student contributed to better Overall QOL.
These findings suggest that interventions that do not cause financial hardship will have a positive impact on patients’ HRQOL. This can be achieved through interventions at the community level that strengthen financial resources, health, and social care accessibility and quality.
Psychopathological factors
Given the robust nature of the WHOQOL study instrument, the low quality of life scores in this study indicate poor psychological and socio-environmental health.
The psychological domain score (Mean 55.47) is in contrast and is considerably low compared to the proposed norm of 70.6 (8). In addition, the psychological domain had the highest number of patients with poor scores at n=69 or 21.7 percent compared to the physical domain at n= 43 or 13.52 percent. In the psychological domain, patients had particularly low scores in the spirituality/religion/personal beliefs facet and self-esteem facet.
Concurrent findings can be found in a study by [18] on predicting health-related quality of life in patients with low back pain who similarly found that the HRQOL of patients with low back pain depended on psychological factors more than simple physical impairment.
Further support for psychological interventions for patients with chronic back pain is demonstrated in a study by [19] to examine pain and quality of life in a group of preoperative chronic low back pain patients and a group of postoperative chronic low back pain patients treated with instrumented fusion 1-8 years earlier; results showed that the postoperative group reported significantly less pain and better physical and mental health compared with the preoperative group. However, despite surgery, the postoperative group reported suffering from pain and reduced quality of life. These findings were relevant to clinical practice in that, psychosocial interventions focusing on psychosocial consequences of pain are needed to modify the pain experience and increase the quality of life in these patients who have undergone this kind of surgery [19], and thus imply that future interventions need to put more emphasis on improving functional status and psychological stress for these patients.
Interventions that specifically target to improve spirituality/religion/personal beliefs and self-esteem will have a positive impact on the QOL of patients with chronic back pain at MTRH.
Socio-environmental factors
Quality of life is determined by the quality of social relationships and the environment. The social relationships domain score (mean 58.11 SD 20.13) contrasts and is lower than the proposed norm of 71.5 [8].
The finding that patients with chronic low back pain at the orthopedic spine outpatient clinic of MTRH are dissatisfied with social support and personal relationships concurs with findings by [17], who found that restricting back pain affected patients socially whereby they experienced social isolation and inability to pursue hobbies thus forcing them to change social behavior.
This finding has clinical implications in that, interventions that incorporate efforts to improve social support for patients with chronic back pain will improve their QoL.
This study at MTRH found comparatively lower environmental health domain scores (mean 50.05, SD 10.27) than the social relationship (mean 58.11, SD 20.13) and psychological (mean 55.47, SD 10.12) domains. The environmental health domain score is also substantially lower than the proposed norm of 75.1 [8].
While the findings in the social relationships and environmental health domains can be explained by the socio-cultural context and demographic characteristics of the study population at orthopedic spine clinic of MTRH, their relative impact on the overall QoL score for this study was not elucidated by stepwise multiple regression since there was no comparison group. However, a systematic review by [20] found that variables relating to the work environment and demographic variables were less useful for predicting worse outcomes. It can thus be similarly suggested that the most helpful components for predicting chronic low back pain are maladaptive pain-coping behaviours, non-organic signs, functional impairment, general health status, and the presence of psychiatric co-morbidities.
Study limitations
Being a cross-sectional study, causal correlations between chronic back pain and quality of life cannot be established. Possible confounders were however reduced by the strict inclusion and exclusion criteria.
Even though the study instrument has been demonstrated to have good reliability, validity and internal consistency in similar settings [15], non-probabilistic testing and lack of a comparison group might have affected the reliability of these study findings since a normal distribution was assumed.
While the WHOQOL–BREF questionnaire has a Kiswahili translation, most participants needed help to complete the questionnaires hence there is a possibility of reporting bias. To reduce reporting bias, patients were interviewed after review and assessment by orthopaedic registrars and consultants.