Analysis Factors that Affect Low Back Pain in Medical Students during the Study from Home

Low Back Pain (LBP) is a health problem that affects performance in working. Indonesia is a country affected by the COVID-19 pandemic, so a study from the home policy has been issued. This study aimed to determine the association between the factors that affect LBP in Medical Students at the Faculty of Medicine, University of Mataram during the study from home. This study is an observational analytic study design with the cross-sectional approach. The population of this study is Medical Students, Faculty of Medicine, University of Mataram with total sample of 185 people. Collecting data using questionnaires and analyzed using univariate, bivariate, and multivariate analysis. According to univariate analysis, amount of LBP complaints (53 people). Based on bivariate analysis, the p-value of gender factor (0.000); body mass index factor (0.840); social-economy status factor (0.499); sitting position factors (sitting position while studying factor (0.008), sitting location while studying factor (0.046), chair shape while studying factor (0.286), body position while studying factor (0.037), legs position while studying factor (0.339), back support use while studying factor (0.

by this. Ministry of the Education Republic of Indonesia said in Official Statement Number 4 in 2022 that studies should be done by distance learning/study from home 3 . The study by Fitriani, et al. (2021) on UIN Syarif Hidayatullah Jakarta students throughout the study from home, shows an association between study time and body position during lectures with low back pain complaints 4 .
Low Back Pain (LBP) is a health problems that usually happens in people and could affect work performance 5 . The prevalence of LBP globally in 2017 was 577.0 million cases, which increased compared to 1990 with 377.5 million cases. In 2017, LBP prevalence was highest in South Asia with 96.3 million cases, followed by East Asia with 67.7 million cases, meanwhile the lowest prevalence was found in Oceania with 0.7 million cases 6 . Based on PERDOSSI's Pain Study Group, it was found that 18,37% of overall patient pain was LBP 7 . The study done by Fitriani, et al. (2021) on UIN Syarif Hidayatullah Jakarta students, it was found that 278 students felt LBP pain and 116 students did not felt LBP throughout the study from home 4 . 90% of LBP cases was caused by inappropriate body position while working 8 . Factors that affect LBP are work/study factors (sitting position factor and sitting duration factor), demographic factors (gender factor, age factor, education factor, and social-economy status factor), health factor (Body Mass Index [BMI] factor), psychological factor (depression factor), and lower back trauma history factor 9 . History of spinal disorders factor (scoliosis, kyphosis, and lordosis) could affect LBP 10 . Moreover, a history of spine surgery factor could cause back pain 11 .
Based on the description above, researchers are interested in conducting this study to analyze the factors that influence LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram, especially during the learning period from home, because the COVID-19 pandemic has not ended which allows learning from home to continue. Latest studies only analyze the association between one or two factors with LBP such as sitting position factors generally, and there is no study that analyze factors affecting LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram, especially during the period of study from home.

MATERIAL AND METHODS
This study used an observational analytic study design with the cross-sectional study approach. The population of this study is all students of the Medical Education Study Program, Faculty of Medicine, University of Mataram in 2019, 2020, and 2021 academic years. The sample selection in this study used Total Sampling. Independent variables (predictor) are sitting position factors, sitting duration factor, gender factor, socialeconomy status factor, and BMI factor. Dependent variable (criterion) is LBP. Controlled confounding variables are history of lower back trauma factor, history of spine disorder factor, history of spine surgery factor, and depression factor. Inclusion criteria in this study are all students of the Medical Education Study Program, Faculty of Medicine, University of Mataram in 2019, 2020, and 2021 academic years and all students of the Medical Education Study Program, Faculty of Medicine, University of Mataram in 2019, 2020, and 2021 academic years that willingly included as study sample, no LBP before the study from home, no lower back trauma history before the study from home, no spine surgery history before the study from home, no spine disorder history before the study from home, and not depressed. Exclusion criteria in this study are all students of the Medical Education Study Program, Faculty of Medicine, University of Mataram in 2019, 2020, and 2021 academic years that does not want to be included as study sample, has LBP before the study from home, has lower back trauma history before the study from home, has spine surgery history before the study from home, has spine disorder history before the study from home, and depressed. This study used a questionnaire that was done validity and reliability test, primary data collection was done by the researchers. In this study, data analysis was done with SPSS for Windows version 25. The type of hypothesis testing used in this study is the Chi-Square hypothesis test, and the data analysis used is univariate, bivariate, and multivariate analysis.

RESULTS AND DISCUSSION
In this study, 372 participants filled out a questionnaire and 185 participants were included as inclusion criteria. For the sitting position factors, some factor components have the number of participants following the number of respondents in the previous factor component. Based on Table 1 and Table 2, respondents with LBP complaints is 53  Table 3, there is a significant association between gender factor and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 185 participants, it was found based on bivariate analysis, the p-value was 0.000 (<0.05). This result is in parallel with the study done by Rahayu & Dayanti (2021), which showed a significant association between gender and LBP 12 . This result is also in parallel with the study done by Abdu, et al. (2022), which showed a significant association between gender and LBP 13 .

Association Between Body Mass Index Factor and Low Back Pain
According to Table 1, respondents with underweight BMI is 40 people (21.6%), normal BMI is 113 people (61.1%), and overweight BMI   Table 3, there is no significant association between social-economy status factor and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 185 participants, it was found based on bivariate analysis, the p-value was 0.499 (>0.05). This is because most of the student's parents have a very high income. This result is in accordance with the study done by Ikeda, et al. (2019), in which their study showed higher social-economy status tend to have lower LBP complaints, compared to lower social-economy status 16 .

Association Between Sitting Position Factors and Low Back Pain Association Between Sitting Position Factor (Sitting Position While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with sitting position while studying (ergonomic) is 167 people (90.3%) and position other than sitting while studying (not ergonomic) is 18 people (9.7%). Based on Table 3, there is a significant association between sitting position factor (sitting position while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 185 participants, it was found based on bivariate analysis, the p-value was 0.008 (<0.05). This result is in line with the study done by Widjayanti & Pratiwi (2016), which had a significant association between sitting position and LBP 17 . This result is also in line with the study done by Fitriani, et al. (2021), which had a significant association between body position and LBP 4 .

Association Between Sitting Position Factor (Sitting Location While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with sitting location on chair while studying (ergonomic) is 124 people (74.3%). Respondents with sitting location on floor while studying is 27 people (16.2), on bed is 16 people (9.5%), and the total not ergonomic is 43 people (25.7%). Based on Table 3, there is a significant association between sitting position factor (sitting location while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 167 participants, it was found based on bivariate analysis, the p-value was 0.046 (<0.05). This result is in line with the study done by Widjayanti & Pratiwi (2016), which had a significant association between sitting position and LBP 17 . This result is also in line with the study done by Fitriani, et al. (2021), which had a significant association between body position and LBP 4 .

Association Between Sitting Position Factor (Chair Shape While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with fits back shape while studying (ergonomic) is 84 people (67.8%). Respondents with not fit back shape while studying is 36 people (29.0%), has no back shape is 4 people (3.2%), and the total not ergonomic is 40 people (32.3%). Based on Table 3, there is no significant association between sitting position factor (sitting location while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 124 participants, it was found based on bivariate analysis, the p-value was 0.286 (>0.05). This result is in parallel with the study done by Pratami, et al. (2019), which had no significant association between sitting posture and LBP 18 . This result is also in parallel with the study done by Akbar & Nilapsari (2021), which had no significant association between sitting position and LBP 19 .

Association Between Sitting Position Factor (Body Position While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with upright body position while studying (ergonomic) is 85 people (50.9%) and bending body position/slouching (not ergonomic) is 82 people (49.1%). Based on Table 3, there is a significant association between sitting position factor (body position while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 167 participants, it was found based on bivariate analysis, the p-value was 0.037 (<0.05). This result is in parallel with the study done by Widjayanti & Pratiwi (2016), which had significant association between sitting position and LBP 17 . This result is also in parallel with the study done by Fitriani, et al. (2021), which had a significant association between body position and LBP 4 .

Association Between Sitting Position Factor (Legs Position While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with foothold while studying (ergonomic) is 75 people (44.9%) and without foothold (not ergonomic) is 92 people (55.1%). Based on Table 3, there is no significant association between sitting position factor (legs position while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 167 participants, it was found based on bivariate analysis, the p-value was 0.339 (>0.05). This result is in line with the study done by Pratami, et al. (2019), which had no significant association between sitting posture and LBP 18 . This result is also in line with the study done by Akbar & Nilapsari (2021), which had no significant association between sitting position and LBP 19 .

Association Between Sitting Position Factor (Back Support Use While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with back support use while studying (ergonomic) is 47 people (28.1%) and without back support use while studying (not ergonomic) is 120 people (71.9%). Based on Table 3, there is no significant association between sitting position factor (back support use while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 167 participants, it was found based on bivariate analysis, the p-value was 0.455 (>0.05). This result is in line with the study done by Pratami, et al. (2019), which had no significant association between sitting posture and LBP 18 . This result is also in line with the study done by Akbar & Nilapsari (2021), which had no significant association between sitting position and LBP 19 .

Association Between Sitting Position Factor (Table Use While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with table use while studying (ergonomic) is 176 people (95.1%) and without table use while studying (not ergonomic) is 9 people (4.9%). Based on Table 3, there is a significant association between sitting position factor (back support use while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 186 participants, it was found based on bivariate analysis, the p-value was 0,010 (<0,05). This result is in line with the study done by Widjayanti & Pratiwi (2016), which had significant association between sitting position and LBP 17 . This result is also in line with the study done by Fitriani, et al. (2021), which had significant association between body position and LBP 4 .

Association Between Sitting Position Factor (Elbows Position While Studying Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with elbows placed on table while studying (not ergonomic) is 134 people (76.1%) and elbows not placed on the table (ergonomic) is 42 people (23.9%). Based on Table 3, there is no significant association between sitting position factor (elbows position while studying factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 176 participants, it was found based on bivariate analysis, the p-value was 0.627 (>0.05). This result is in line with the study done by Pratami, et al. (2019), which had no significant association between sitting posture and LBP 18 . This result is also in line with the study done by Akbar & Nilapsari (2021), which had no significant association between sitting position and LBP 19 .

Association Between Sitting Position Factor (Stretching Between Study Time Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with stretching between study time (ergonomic) is 142 people (76.8%) and not stretching between study time (not ergonomic) is 43 people (23.2%). Based on Table 3, there is no significant association between sitting position factor (stretching between study time factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 185 participants, it was found based on bivariate analysis, the p-value was 0.372 (>0.05). This result is in line with the study done by Pratami, et al. (2019), which had no significant association between sitting posture and LBP 18 . This result is also in line with the study done by Akbar & Nilapsari (2021), which had no significant association between sitting position and LBP 19 .

Association Between Sitting Position Factor (Duration in Each Stretch Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with duration in each stretch 5-10 minutes (ergonomic) is 33 people (23.2%). Respondents with duration in each stretch <5 minutes is 104 people (73.2%), >10 minutes is 5 people (3.6%), and the total not ergonomic is 109 people (76.8%). Based on Table 3, there is no significant association between sitting position factor (duration in each stretch factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 142 participants, it was found based on bivariate analysis, the p-value was 0.389 (>0.05). This result is in line with the study done by Pratami, et al. (2019), which had no significant association between sitting posture and LBP 18 . This result is also in line with the study done by Akbar & Nilapsari (2021), which had no significant association between sitting position and LBP 19 .

Association Between Sitting Position Factor (Time Range Between Stretch Factor) and Low Back Pain
According to Table 1 and Table 2, respondents with time range between stretch every 2 hours (ergonomic) is 27 people (19.0%). Respondents with time range between stretch <2 hours is 69 people (48.6%), >2 hours is 46 people (32.4%), and the total not ergonomic is 115 people (81.0%). Based on Table 3, there is no significant association between sitting position factor (time range between stretch factor) and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 142 participants, it was found based on bivariate analysis, the p-value was 0.311 (>0.05). This result is in line with the study done by Pratami, et al. (2019), which had no significant association between sitting posture and LBP 18 . This result is also in line with the study done by Akbar & Nilapsari (2021), which had no significant association between sitting position and LBP 19 .

Association Between Sitting Duration Factor and Low Back Pain
According to Table 1, respondents with short sitting duration is 24 people (13.0%), moderate is 96 people (51.9%), and long is 65 people (35.1%). Based on Table 3, there is a significant association between sitting duration factor and LBP in students of the Medical Education Study Program, Faculty of Medicine, University of Mataram throughout the study from home. In 185 participants, it was found based on bivariate analysis, the p-value was 0.011 (<0.05). This result is in line with the study done by Hutasuhut, et al.
(2021), which had significant association between sitting duration and LBP 20 . This result is also in line with the study done by Abdu, et al. (2022), which had significant association between sitting duration and LBP 13 .

Dominant Factor to Low Back Pain
Based on Table 4, multivariate analysis done with logistic regression analysis with backward method LR (Likelihood Ratio), this study showed dominant factors to LBP which are gender factor, sitting position factor (sitting position while studying factor), and sitting duration factor. Based on multivariate analysis, there was a significant association between gender factor with p-value 0.000 (<0.05), sitting position factor (sitting position while studying factor) with p-value 0.001 (<0.05), and sitting duration factor with p-value 0.028 (<0.05) to LBP. Based on multivariate analysis, the factor that had the strongest association to LBP is sitting position factor (sitting position while studying factor) with OR 8.232, compared to OR in sitting duration factor with 1.956 and gender factor with 0.187. These results are in accordance with a study done by Fitriani, et al. (2021), found in multivariate analysis that had the strongest association to LBP is body position while in lecture 4 .

Study Strength
There are 185 participants in this study. This study analyzed many factors to LBP throughout the study from home. Sitting position factors was analyzed in detail, there were sitting position while studying factor, sitting location while studying factor, chair shape while studying factor, body position while studying factor, legs position while studying factor, back support use while studying factor, table use while studying factor, elbows position while studying factor, stretching in between study factor, stretching duration factor, and time range of stretch factor.

Study Limitation
This study was done only in one study program, so it did not represent a wider population. This study used a cross-sectional approach, so if there was a LBP complaint after data collection, researchers would not know. In this study LBP complaints only based on participant's subjective complaint and there was no further examination.

CONCLUSION
Based on the result, it is concluded as follows, there are association between factors that affects LBP, such as gender factor, sitting position factors (sitting position while studying factor, sitting location while studying factor, body position while studying factor, table use while studying factor), and sitting duration factor; dominant factors to LBP are gender factor, sitting position factor (sitting position while studying factor), and sitting duration factor; and the factor that had the strongest association to LBP is sitting position factor (sitting position while studying factor).

ACkNOWLEDGEMENT
Researchers express their greatest gratitude to all parties, both from inside and outside the institution of Faculty of Medicine, University of Mataram.

Conflict of Interest
There is no conflict of interest in this study.

Funding Source
There is no funding source in this study.