DOI: https://doi.org/10.21203/rs.3.rs-1968533/v1
To determine the quality of life and the relationship between sociodemographic, psychopathological, and socio-environmental factors and quality of life in patients with chronic low back pain.
The study used a descriptive cross-sectional design. Data was collected using sociodemographic and WHOQOL-BREF Questionnaires. Three hundred and eighteen patients were consecutively sampled and data analyzed using computer software. Categorical demographic data were analyzed using frequency and percentages, significant findings were further analyzed by multivariate linear regression.Statistical significance was set at a p-value of < 0.05.
Seventy percent of participants were females while thirty percent were males. The mean Quality of life score for the 4 domains was 50.56(SD = 9.55). On a scale of 1–5, the mean score of the Overall Quality of life facet was 2.42 (SD = 0.80) while that of the general health facet was 2.31 (SD = 0.69). The psychological domain had the highest number of patients with poor scores at n = 69. Older age (46–65) was significantly associated with lower mean QOL at 49.4(SD = 9.2) p < 0.001 compared to younger age groups. This age bracket also reported low physical and psychological health domain scores (mean 36.97 and 54.62, p < 0.0016 respectively). Patients with a higher income level reported a higher psychological domain score (mean 56.75, p < 0.0076). A higher level of education was significantly associated with a high mean QOL (p < 0.022).
Patients with chronic low back pain have a reduced quality of life. Older age, low level of income, and low level of education were significantly associated with low quality of life in patients with chronic low back pain. There is a subset of patients with psychological impairment. A multidisciplinary,biopsychosocial approach to the treatment of this condition is recommended.
Low back pain is an enormous and important clinical and public health problem throughout the world, with the highest prevalence among female individuals and those aged 40–80 years [1]. From international surveys, 75–85% of all people will experience back pain in some form during their life [2].
This condition is classified as a psychosomatic illness with some reports indicating that up to 95% of low back pain cases are psychological in origin [3].
Previous findings have shown a high degree of comorbid psychopathology in chronic back pain. Prevalence is reported to be between 40%-100% depending on the methods being used, sample, or setting [4]. In this regard, psychopathological and socio-environmental risk factors such as psychological distress, depressive mood, low job satisfaction, emotional trauma or abuse in childhood, and pain level have been known to influence the progression of subacute low back pain to chronic low back pain [5].
Quality of life has been described as "the missing measurement in health" because the biomedical model of medicine is only concerned with the eradication of disease and symptoms with a minimal humanistic element [5]. Therefore, quality of life assessment goes beyond physical health and focuses attention on this aspect of health [6].
While the general topics of chronic back pain and Quality of Life in different circumstances have been widely researched and published in different parts of the world, sub-Saharan Africa has contributed little to this body of knowledge. In this regard, the author has found no information available on the QOL of patients with chronic low back pain in the Kenyan setting.
Early consideration of the relationships between quality of life, psychopathology, and socio-environmental factors will promote a multidisciplinary approach to this condition of multidimensional etiology and hence influence the assessment, prevention, treatment, and rehabilitation of patients with chronic low back pain.
Assessment of psychological function, social relationships, and environmental health domains will paint a clearer picture of patient concerns and expectations and thus promote holistic treatment of chronic back pain.
The study findings in the psychological, social, and environmental health domains of quality of life will help clinicians in identifying and prioritizing patient concerns, will facilitate communication on patient’s main concerns, facilitate screening for hidden problems and facilitate shared decision making by taking into consideration patient expectations.
The study sought to determine the quality of life in patients with chronic back pain at the orthopedic spine clinic at Moi Teaching and Referral Hospital, Eldoret (MTRH). The aspects covered in this study include the quality of life and general health perception of patients with chronic back pain. The study also assesses the physical, psychological, social, and environmental health domains of Quality of Life (QOL) using the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. This information was collected from patients presenting with chronic back pain at the orthopedic spine clinic between January 2018 and December 2019.
This study was carried out at the Orthopedic spine out-patient clinic, at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Uasin Gishu County. The clinic provides specialized consultation for out-patient and in-patient orthopaedic and spinal surgery. Study Design was a descriptive cross-sectional study using questionnaires and standardized structured interviews
The study population was new adult patients presenting with chronic low back pain at the facility.
New adult (age > 18 years) patients presenting with chronic low back pain duration over 3 months limited to somatic referred pain/non-radicular pain above the knee were included
Patients who were cognitively impaired with a Mini-mental State Exam (MMSE) less than 22, and patients with low back pain due to a definite spinal pathology or condition that explains the back pain were excluded [7].
Patients were recruited as they presented at the clinic over the study period between January 2018 and December 2019.
A researcher-designed socio-demographic questionnaire was used in which the patient's demographic characteristics including age, gender, level of education, employment status, income, religion, residence, number of children, and marital status were recorded.
The study participants were then screened for cognitive impairment by assessing their mental status using the MMSE.
The WHOQOL-BREF was then administered to assess the health-related quality of life of patients presenting with chronic back pain.
Approval to administer the questionnaires was sought from the IREC and permission from the Chief Executive Officer MTRH. Upon approval from both, new adult patients with chronic back pain were recruited as they presented at the orthopedic/spine out-patient clinic until 318 patients were recruited based on the inclusion and exclusion criteria
Patients were interviewed after clinical assessment and review by orthopedic surgery registrars and consultants. Patients who met the criteria for the study were briefed on the nature of the study; informed consent was then sought and consent forms signed.
All the study participants were subjected to the same questions in the socio-demographic questionnaire and WHOQOL-BREF questionnaire.
The collected data was stored on Computer Media and analyzed using the SPSS computer program version 22. Categorical demographic data was analyzed using frequency and percentages and presented in tables and figures. Socio-demographic factors that were significant in the bivariate analysis were further analyzed by multivariate linear regression to further elucidate the association between socio-demographic factors and HRQOL in patients with chronic back pain.
Moreover, continuous data from the WHOQOL-BREF facet and domain scores was summarized with descriptive statistics including frequency, mean, and standard deviation. Item responses are coded from 1 to 5; items 3, 4, and 26 are reverse coded. The mean score of items in each domain is used to calculate a domain score. WHOQOL-BREF recommended manual scoring and conversion of raw to transformed scores, achieving domain scores was done. Cases with greater than 20% missing data from a domain are automatically excluded from analyses.
All data was Analyzed at a 95 percent level of confidence.
The computed data has been presented in form of tables,figures and descriptive/prose form.
The study had 380 patients but 62 patients gave incomplete responses or had lower than 22 points on the MMSE leaving 318 patients whose data was analyzed.
By sex, 70 percent of the patients were female while 30 percent were male.
By age, 49.2 percent of the patients were aged 46–65 years,24.9 percent were aged 31–45 years,13 percent were aged 18–30 years while a similar percentage- 12.9 percent were aged over 65 years.
By level of income, 48.2 percent of the patients earned less than kshs.5000 per month while 23.9 percent earned more than Kshs.20, 000 per month.
In terms of educational level, 15.5 percent had no formal education, 37.5 percent had primary school level education, 31.5 percent had secondary school level education, and 12 percent had tertiary level education while 3.2 percent reported having university-level education.
| Variable | Freq | Percentage |
|---|---|---|
| Age in years | ||
| 18–30 | 41 | 12.90% |
| 31–45 | 79 | 24.90% |
| 46–65 | 156 | 49.20% |
| > 65 | 41 | 12.90% |
| Sex | ||
| Female | 222 | 70.00% |
| Male | 95 | 30.00% |
| Residence | ||
| Rural | 220 | 69.40% |
| Urban | 97 | 30.60% |
| Marital status | ||
| Married | 264 | 83.50% |
| Single | 35 | 11.10% |
| Divorced/Separated/Widowed | 17 | 5.30% |
| Missing | 1 | |
| Number of children | ||
| 1–4 Children | 154 | 48.60% |
| 5–9 Children | 106 | 33.40% |
| > 10 | 25 | 7.90% |
| None | 32 | 10.10% |
| Religion | ||
| Catholic | 80 | 25.20% |
| Protestant | 232 | 73.10% |
| Muslim | 4 | 1.30% |
| Other | 1 | 0.30% |
| Education | ||
| No education | 49 | 15.50% |
| Primary | 119 | 37.50% |
| Secondary | 100 | 31.50% |
| Tertiary | 39 | 12.30% |
| University | 10 | 3.20% |
| Employed | ||
| No | 222 | 70.50% |
| Yes | 93 | 29.50% |
| Missing | 2 | |
| Income | ||
| < 5000 | 147 | 48.20% |
| 5001–10000 | 44 | 14.40% |
| 10001–15000 | 25 | 8.20% |
| 15001–20000 | 16 | 5.20% |
| > 20000 | 73 | 23.90% |
| Missing | 12 |
Using 75 ± 2.5 as a cut-off range for normal mean QOL (8), and a cut-off of less than 60 as indicative of poor mean QOL (9), the average Quality of life score for the 4 domains was 50.56 (SD = 9.55) for this study at MTRH. WHOQOL-BREF has facets that assess the overall quality of life and perception of general health. On a scale of 1–5, the mean score of the Overall Quality of life facet was 2.42 (SD = 0.80) while that of the general health facet was 2.31 (SD = 0.69).
Older age (age 46–65) was significantly associated with lower overall mean QOL at 49.4(9.2) p < 0.001 compared to younger age groups.
Overall mean QOL significantly got better with a higher level of education since participants with a university-level education reported the highest overall mean QOL and general health at 59.1(8.0) p < 0.017.
Patients in the older age bracket, (age 46–65 years) reported significantly lower physical and psychological domain scores (mean 37.0, p < 0.0016 and mean 55.3, p < 0.0392) respectively.
Patients with a high level of income (> Kshs 20,000) reported significantly higher psychological function domain scores (mean 57.19 SD 9.7. p < 0.008).
Not being married was significantly associated with better physical domain scores at 42.3(2.3) compared to married participants at 37.8(0.8) p < 0.035.
| Variable | Domain | |||||||
|---|---|---|---|---|---|---|---|---|
| Physical | Psychological | Social | Environment | |||||
| Mean (std) | P-value | Mean (std) | P-value | Mean (std) | P-value | Mean (std) | P-value | |
| Sex | 0.603 | 0.792 | 0.558 | 0.775 | ||||
| Female | 39.0 (13.7) | 55.7 (9.3) | 58.7 (20.0) | 50.2 (10.0) | ||||
| Male | 38.1 (14.7) | 55.4 (10.4) | 57.3 (19.7) | 50.0 (10.6) | ||||
| Age | 0.002 | 0.039 | 0.119 | 0.151 | ||||
| 18–30 | 46.4 (15.9) | 59.4 (9.7) | 64.4 (16.9) | 53.2 (11.1) | ||||
| 31–45 | 38.5 (13.0) | 55.3 (8.3) | 59.5 (19.1) | 50.3 (10.1) | ||||
| 46–65 | 37.0 (13.4) | 54.6 (9.9) | 56.7 (20.0) | 49.2 (9.9) | ||||
| > 65 | 38.0 (13.7) | 56.4 (10.4) | 55.8 (22.8) | 50.9 (10.0) | ||||
| Residence | 0.388 | 0.519 | 0.222 | 0.878 | ||||
| Rural | 38.3 (13.4) | 55.9 (9.3) | 59.2 (19.3) | 50.2 (9.7) | ||||
| Urban | 39.7 (15.3) | 55.1 (10.4) | 56.2 (21.3) | 50.3 (11.2) | ||||
| Employed | 0.572 | 0.687 | 0.490 | 0.349 | ||||
| No | 39.0 (14.1) | 55.5 (9.8) | 58.8 (19.1) | 49.8 (10.0) | ||||
| Yes | 38.0 (12.3) | 56.0 (9.5) | 57.1 (21.9) | 51.0 (10.7) | ||||
| Income | 0.558 | 0.008 | 0.958 | 0.162 | ||||
| < 5000 | 38.6 (15.2) | 56.8 (9.6) | 58.4 (19.1) | 49.6 (9.3) | ||||
| 5001–10000 | 41.1 (11.3) | 52.3 (9.5) | 59.6 (23.0) | 49.3 (9.1) | ||||
| 10001–15000 | 39.9 (11.4) | 52.9 (8.0) | 58.4 (18.4) | 51.1 (9.4) | ||||
| 15001–20000 | 35.8 (11.2) | 51.9 (9.0) | 60.1 (21.2) | 45.8 (10.4) | ||||
| > 20000 | 37.3 (13.2) | 57.2 (9.7) | 57.0 (20.5) | 52.0 (11.6) | ||||
| Marital status | 0.035 | 0.690 | 0.478 | 0.608 | ||||
| Not married | 42.3 (2.3) | 55.0 (1.7) | 59.9 (3.0) | 50.7 (1.8) | ||||
| Married | 37.8 (0.8) | 55.6 (0.6) | 57.8 (1.2) | 49.9 (0.6) | ||||
| Education level | 0.093 | 0.171 | 0.126 | 0.100 | ||||
| None | 38.0 (14.7) | 57.5 (10.2) | 54.9 (20.6) | 49.6 (9.4) | ||||
| Primary | 37.2 (13.0) | 54.9 (9.2) | 57.1 (20.0) | 49.3 (9.5) | ||||
| Secondary | 38.6 (13.9) | 54.7 (9.9) | 59.9 (18.3) | 50.0 (10.7) | ||||
| Tertiary | 42.5 (14.5) | 56.5 (9.7) | 58.6 (22.8) | 52.6 (11.3) | ||||
| University | 47.0 (17.3) | 60.6 (7.9) | 71.8 (14.6) | 57.0 (9.1) | ||||
Socio-demographic variables that were statistically significant in the bivariate analysis were considered in the multivariate analysis. These variables were age, level of education, marital status, and level of income.
Older age (age 31–45 and 46–65) was statistically significantly associated with low overall mean 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.
Older age (age 46–65) was statistically significantly associated with low physical and psychological health domain scores compared to their younger counterparts aged 18–30 (OR coefficient β -4.64, p < 0.015 95% CI -8.36 -0.93)
Patients who earned kshs. 5,001–10,000 had significantly less psychological domain scores compared to those who earned less than kshs. 5000 (OR Coefficient β -3.69 p < 0.028 95% CI -6.99 -0.39).
| Variable | Coefficient | P-value | [95% Confidence Interval] | |
|---|---|---|---|---|
| Age in years | ||||
| 31–45 vs 18–30 | -3.80 | 0.038 | -7.40 | -0.21 |
| 46–65 vs 18–30 | -5.20 | 0.003 | -8.65 | -1.75 |
| > 65 vs 18–30 | -4.35 | 0.059 | -8.87 | 0.17 |
| Education | ||||
| Primary vs None | -0.69 | 0.675 | -3.93 | 2.55 |
| Secondary vs None | -0.18 | 0.918 | -3.62 | 3.26 |
| Tertiary vs None | 0.72 | 0.738 | -3.52 | 4.96 |
| University vs None | 5.54 | 0.106 | -1.19 | 12.27 |
| Variable | Coefficient | P-value | [95% Confidence Interval] | |
|---|---|---|---|---|
| Age in years | ||||
| 31–45 vs 18–30 | -5.79 | 0.054 | -11.68 | 0.10 |
| 46–65 vs 18–30 | -7.38 | 0.010 | -12.99 | -1.76 |
| > 65 vs 18–30 | -6.48 | 0.078 | -13.71 | 0.74 |
| Education | ||||
| Primary vs None | -1.52 | 0.551 | -6.52 | 3.48 |
| Secondary vs None | -1.17 | 0.666 | -6.48 | 4.15 |
| Tertiary vs None | 1.27 | 0.704 | -5.29 | 7.82 |
| University vs None | 2.65 | 0.618 | -7.79 | 13.09 |
| Marital status | ||||
| Married vs Not married | -2.13 | 0.361 | -6.70 | 2.45 |
| Variable | Coefficient | P-value | [95% Confidence Interval] | |
|---|---|---|---|---|
| Age in years | ||||
| 31–45 vs 18–30 | -3.02 | 0.132 | -6.97 | 0.92 |
| 46–65 vs 18–30 | -4.64 | 0.015 | -8.36 | -0.93 |
| > 65 vs 18–30 | -4.24 | 0.084 | -9.05 | 0.58 |
| Education | ||||
| Primary vs None | -2.56 | 0.145 | -6.01 | 0.89 |
| Secondary vs None | -2.83 | 0.140 | -6.60 | 0.93 |
| Tertiary vs None | -2.20 | 0.349 | -6.81 | 2.41 |
| University vs None | -0.93 | 0.800 | -8.16 | 6.30 |
| Income | ||||
| 5001–10000 vs < 5000 | -3.69 | 0.028 | -6.99 | -0.39 |
| 10001–15000 vs < 5000 | -3.23 | 0.131 | -7.43 | 0.97 |
| 15001–20000 vs < 5000 | -4.05 | 0.115 | -9.09 | 1.00 |
| > 20000 vs < 5000 | 0.93 | 0.509 | -1.83 | 3.68 |
Using the proposed WHOQOL-BREF norms of 73.5,70.6,71.5 and 75.1 for the physical health domain, psychological health domain, social relationships domain, and environmental health domain respectively, the scores for the physical, psychological, social relationships, and environmental health domains were 38.60, 55.47, 58.11 and 50.05 respectively.
Using one SD below the mean as the cut-off standard for low HRQOL, the psychological domain had the highest number of patients with poor scores at n = 69 or 21.7 percent (See Table 6 and Fig. 1 below)
| Domain | N | Mean | SD | Number of patients with poor scoresa, n (%) |
|---|---|---|---|---|
| Physical | 318 | 38.60 | 14.12 | 43 (13.52) |
| Psychological | 318 | 55.47 | 10.12 | 69 (21.7) |
| Social | 318 | 58.11 | 20.13 | 58 (18.24) |
| Environment | 318 | 50.05 | 10.54 | 53 (16.86) |
| aUsing one SD below the mean as the cut-off standard for low QOL | ||||
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.
This study looked at the subjective aspect of chronic low back pain.
Patients with chronic low back pain have a reduced quality of life.
Socio-demographically, older age (age over 35 years), low level of income, and low level of education were statistically significantly associated with low quality of life in patients with chronic back pain at the MTRH orthopaedic outpatient clinic.
While the physical health domain had the lowest mean score at 38.6 (SD=14.12), psychopathological factors influence the quality of life in patients with chronic back pain as shown by the fact that the psychological domain had the highest number of patients with poor scores at n=69 or 21.7 percent. This means there is a subset of patients with psychological impairment and future interventions need to put more emphasis on improving functional status and psychological distress for patients with chronic back pain at MTRH orthopaedic clinic.
When socio-environmental factors that affect the quality of life in patients with chronic back pain are considered, patients reported low scores in the social support and the personal relationships facets and were dissatisfied with the facets that assessed participation in and opportunities for recreation, financial resources, freedom, physical safety, security, and physical environment.
A multidisciplinary approach to the treatment of this condition by stratification of patients with sociodemographic, psychopathological, and socio-environmental risk factors due to low domain and facet scores and then applying an integrative biopsychosocial approach by consulting mental health practitioners is thus warranted and recommended.
Psychosocial interventions focusing on psychopathological and socio-environmental consequences of chronic back pain will improve outcomes and increase the quality of life of patients with chronic back pain at the MTRH orthopaedic and spine outpatient clinic.
Analytical/comparative studies in other centres to yield cross-culturally comparable scores are recommended.
Longitudinal studies that include randomized controlled trials (RCTs) using the WHOQOL-BREF can help in monitoring changes and response to treatments since interventions deemed as relevant by patients may improve adherence to treatment of chronic low back pain.
We wish to submit an original research article entitled “Quality of life in patients with chronic low back pain at Moi Teaching and Referral Hospital, Eldoret” for consideration by Quality of Life Research.
This work was part of a thesis submitted to the Moi University School of Medicine, Department of Mental Health in partial fulfillment of the requirement for the award of the degree of Master of Medicine in Psychiatry.
We believe that this manuscript is appropriate for publication by Quality of Life Research because it focuses on assessment of quality of life in patients with chronic low back pain who seek clinical services.
Compliance with ethical standards:This study was performed in line with the principles of the Declaration of Helsinki and was reviewed and approved by the Moi Teaching and Referral Hospital - Research and Ethics Committee (IREC); approval Number :0002061 on 1st March 2018. In addition, the necessary and appropriate IREC policies were followed.
Informed written consent was obtained from all individual participants included in the study.
Competing interests:The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
The authors have no conflicts of interest to disclose.
All authors read and approved the final manuscript.
We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere.
Acknowledgement:We wish to acknowledge in a special way, colleagues and supervisors at School of Medicine, Moi University, for their precious mentorship, sincere support and encouragement.
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