Relationship between cognitive factors and healthy spine-related behavior among pupils


 Background Back pain is one of the most important public health problems. It is on rise among adolescent and pupils’ population. The aim of this study was to assess the relationship between cognitive factors (skills, knowledge, self-efficacy, and expectation beliefs) and back care behavior among pupils.Methods A cross sectional study was conducted on a random sample of students attending public elementary schools in Tehran, Iran from October 2018 to March 2019. They completed a questionnaire containing items on cognitive abilities and a checklist to assess their skills on back care behaviors. Stepwise multiple regression analysis was performed to find out the contribution of cognitive factors on outcome.Results In all, 204 students were entered into the study. The results revealed that 95.3% of the variance in the back behavior was explained by self-efficacy (β=0.586, t=12.08, P<0.001), expectation beliefs (β=0.232, t= 5.08, P<0.001), and skills (β=0.181, t=4.46, P<0.001).Conclusion These results showed that the pupils who had more confident, skills, and expectation beliefs were more likely to do proper back behavior. In this regard, school-based back pain prevention interventions should be addressed using key cognitive factors that consider the potential change strategies.

Thus it is argued that in order to prevent or reduce burden of back pain in pupils, theorybased back care educational programs for this population are of prime importance [10].
One such theory that might help to enrich these programs and make them effective is the Social Cognitive Theory (SCT). The Social Cognitive Theory was originated from the Social Learning Theory (SLT) and according to the theory three main psychological determinants that predict any behavior changes are: behavioral capability (knowledge and skills to perform a given behavior); Self-Efficacy (SE); and outcome expectation beliefs (behavioral beliefs) [11,12].
The applications of SCT in many health education/promotion programs are well documented [13][14][15][16][17]. For instance, a review of literature on Physical Activity (PA) and diet behavior among cancer survivors reported that SCT-based interventions demonstrated promising results [17]. Similarly, a review on the explanatory power of SCT to explain PA among adolescents showed that the model explained greater proportion of variance for intention compared to behavior [16]. Hall et al. [14] developed and validated a SCT-based survey instrument that focused on knowledge, behavior, and SE for fifth grade students in order to assess the relationships between knowledge, behavior, and SE for healthy eating.
They have demonstrated that SE and behaviors were positively correlated (r = 0.40, P = 0.0001); but knowledge was not associated with SE or behavior. However, we could not locate any studies that use this theory for back care education. Most existing studies on the topic are usually did not apply any theoretical models and only implemented interventions that thought could work to change or modify pupils' back care behaviors.
Spence et al. [18] and Sheldon et al. [19] for the first time presented a healthy back behavior education. They determined the effects of verbal presentation, demonstration, and guided discovery teaching methods on children's proper lifting techniques and at the end they could not show that any behavior change occurred. Cardon et al. [20] [21], the intensive back posture education through the elementary school curriculum is effective till adolescence. It was shown that school-based back education programme did not change spinal care behaviour or self-efficacy [22].
Santos et al. [23], argued that no statistically significant difference was found between post-test and follow-up in relation to theoretical knowledge and posture during activities of daily living. A key limitation of these investigations is that they do not address cognitive factors causing back behavior and this issue has been scarcely investigated from the theoretical point of view.
However, to the best of our knowledge, as mentioned earlier this theory has not been used in any back pain prevention programs in elementary schools and we are not aware of a quantitative study that explores cognitive factors causing back behavior. Therefore, we were interested to investigate the extent to which the SCT could explain back care behavior among schoolchildren. It was hoped the findings from this study could help to design and implement an appropriate intervention for pupil populations attending elementary schools.

Design
This study used a cross-sectional design among 5th-grade students attending elementary schools in Tehran, Iran from October 2018 to March 2019. The independent variables were the constructs of the SCT (self-efficacy, knowledge, skills, and outcome expectation beliefs). The dependent variable was the back behavior ( Fig.1).

The study sample
The study sample was consisted of female students aged 11 years. They were selected from two (out of 8) randomly selected elementary schools in North-West of Tehran, Iran.
The district has a population of variety socio-economic background. In order to explore the predictive factor, the study of Dullien article [1] was referred to determine the required sample size. According to Dullien to conduct a study with power of 80%, and standard deviation of 14.5 for performance score with a minimum precision of 2 at 5% significance level, a sample of 202 pupils would be required. However, since in school-based studied, selection almost is impossible, thus the whole classes were selected and 204 fifth grade students were recruited. We obtained permission from school principals and all parents completed written informed consent.

1.
Information on pupils' parents job and level of education and a question about the presence of back pain during last week among pupils (Yes, No).

2.
To measure main independent variables the Cardon et al. questionnaire was used [20]. The questionnaire contained 43 items including the following sections: (iii). Self-efficacy contained 4 questions asking that how easy or difficult the following were: participation in daily physical activity and sports, attaining a natural curvature of the spine, minimal loading of the book bag and paying attention to ergonomical postures.
Each item is rated on a five-point scale (from difficult to easy) giving score ranging from 4 to 20 where the higher scores indicated higher self-efficacy.
(iv). Outcome expectation beliefs (behavioral beliefs) contained 6 items asking whether sitting, swimming, running, participating in physical education, cycling and lifting heavy objects are 'dangerous' when having a backache. Each item is rated on a five-point scale (strongly disagree to strongly agree) giving score ranging from 6 to 30 where higher score indicated stronger beliefs.
3. Back care behavior as outcome measure contained six questions regarding daily activities on checking weight of the book bag; carrying the bag with 2 straps; knee position when putting on shoes; doing exercises every day; and postural behavior while lifting and carrying objects. Each question is rated on a five-point scale (never = 1 to ever = 5) giving a score ranging from 6 to 30 where higher scores indicated better preventive behavior.

Data collection
Before data collection, we explained the aim of this study to the principal, class teacher, and pupils of the two schools. After indicating the permission from them, we distributed the questionnaire. There were two independent research assistants to help in this study, and rated students' skills based on checklist. Since the analysis of the relationship between the variables is worthy of attention, in fact, we are looking to identify that the relationships between variables that are extracted from the theory are confirmed by the data collected from the sample.

Data analysis
Descriptive statistics were used to explore the data. In addition, we used stepwise multiple regression analysis in order to assess the relationship between back care behavior (outcome variable) and independent variables including knowledge, skills, SE and expectation beliefs. The level of significance was set at p <.05. The data were analyzed using the SPSS V 24 software to test the correlation between study variables.

Participants
In all, 204 pupils aged 11 years participated in the study. Of these, 22.5% (n = 46) reported back pain during last week. The common characteristics of the students are presented in Table 1.
In general, the students' scores on knowledge were reasonable (mean = 4.71). The means and standard deviations of independent and dependent variables are demonstrated in Table 2.
The results obtained from stepwise multiple regression analysis to predict the back care behavior are showed in Table 3. The analysis revealed that 95.3% of the variance in the back care behavior was explained by skills (β = 0.181, P<0.001), expectation beliefs (β = 0.232, P<0.001) and self-efficacy (β = 0.586, P<0.001). Fig. 2 shows the plot of regression standardized residual.

Discussion
This study was carried out in order to predict healthy spine-related behavior among pupils  [25]. Therefore, in order to enhance proper back behavior, we need to reinforce the proper beliefs and active approach towards dangers of pain and limitations that might exceed. In fact, belief change is much easier at a younger age; so appropriate actions should be considered in educational programs in order to correct any misunderstandings and misbelieves at this stage. As such the findings from the current study indicates promoting expectation beliefs could be an appropriate strategy for back care interventions.
We found a significant and positive relationship between skills and BB (P<0.001) that has been not indicated previously. This however, indicates that with improving students' skills, we might be able to promote their proper back behavior. As suggested in educational initiatives we need to target children's skills toward BB, during key constructive years when maladaptive beliefs, habits, and attitudes about the condition are being shaped [25]. improved from pre-to post-test but increase in the intervention group' knowledge did not significantly affect their behavior [1]. Santos et al. also reported that there was no statistically significant difference between the post-test and follow-up concerning the back care knowledge and posture during activities of daily living although the performance of students was higher in the post-test and follow-up, when compared with the pretest [23].
Perhaps this is because people usually do not act on what they know and the fact that education alone is unlikely to promote positive and persisting behavioral change without coincident strategies [25].

Limitations
There were some limitations with this study. First, we used a cross-sectional design and data were collected through self-reported measures and raters' assessments; thus, the findings designs cannot provide evidence for cause-effect relationships. Longitudinal data and experimental studies are needed to confirm the results observed in this study.   Figure 1 Conceptual framework of the study Figure 2 Normal P-P plot of regression standardized residual (dependent variable: back care behavior)