Prevalence of spinal pain in a population of Bosnia and Herzegovina

Objectives To determine the prevalence and risk factors of spinal pain in the population of Bosnia and Herzegovina (BiH). Methods This was a cross-sectional survey conducted online in November/December 2018. Participants were inhabitants of BiH of both sexes, aged ≥ 16 years. The sample was stratified based on region and demographic characteristics. Current pain was analyzed; point prevalence was measured. Results We received 1048 responses, of which data from 1017 could be used. The prevalence of spinal pain in BiH was 70.9%: 75.5% in women (n = 440) and 64.7% in men (n = 281). Low back pain (LBP) was more common compared to neck pain (NP) and thoracic pain (TP) in both sexes and all age groups. Significant associations with spinal pain in the bivariate analysis were found for the following groups: women, aged from 30 to 50 years, with high school education, employed persons and retirees, spinal pain in parents, smoking, irregular physical activity, longer use of TV or computer/mobile phone per day. Conclusion To our knowledge, this is the first study of the prevalence of spinal pain in BiH. Some factors associated with spinal pain are modifiable. Therefore, public health interventions should target those factors to reduce the burden of spinal pain in BiH.


Inviting the participants
Potential participants received a personal message (cover letter) with a written invitation about the study and a link to the study. In both the cover letter and the introductory part of the questionnaire, participants were asked to forward the message and questionnaire to other individuals living in the BIH. We used "snowball sampling" by first contacting known contacts who were asked to forward a study web address with an available questionnaire to their contacts with different demographic characteristics in all regions of BIH. We asked contacts for information about the number of individuals that they have further contacted.

Pilot testing of the questionnaire
Pilot testing of the questionnaire for understanding, clarity, and relevance was conducted before the start of the survey (n = 50 participants with different sociodemographic characteristics). We revised the survey items based on the feedback from pilot testing. The survey took approximately 10 min to complete.

A detailed structure of the questionnaire
The full questionnaire used in this study is presented in the last section of this Appendix. The questionnaire consisted of 29 questions, open and closed-ended nominal, ordinal, and ratio/interval answers. The first 14 questions were about demographic characteristics (geographical region, age, sex, height, weight, education, work, smoking status (Yes/No), physical activity (Yes/No), intensity of physical activity (day/week), time spent (h/day) watching television and using computer and cell phone, history of spinal pain in parents) and 13 questions were about characteristics and consequences of spinal pain (presence, duration, back segment, type of pain, pain intensity, pain frequency, medical help, drug use, absence from work/school, frequency of absenteeism due to spinal pain). To avoid recall bias, we asked participants about their present pain and its duration. The point prevalence was measured. The presence of spinal pain was examined through the question "Do you have spinal pain". Participants who responded "yes" were considered to have spinal pain. Subjects who chose the upper back for localization of their pain were classified as neck pain; middle back as thoracic pain and lower back as LBP. The duration of spinal pain was classified as follows: the presence of pain symptoms for up to 6 weeks indicates acute pain, 6 to 12 weeks of sub-acute pain, and ≥12 weeks of chronic pain.
Pain intensity was measured via a numerical rating scale ranging from 0 to 10, with 0 indicating "no pain", and 10 indicating "worst pain". Pain intensity scores were converted into four categories: 0-1 no pain, 2-4 mild pain, 5-7 moderate pain, and 8-10 intensive pain. The question about "Diagnosed change" refers to identified changes in the spine, an intervertebral disc (IVD) hernia. The frequency of physical activity was studied with three answers that indicated specific frequency, and the fourth answer "I don't know, depends on the week" was considered irregular physical activity.

Data storage and handling
Only the principal investigator (AH) had access to the stored data; she monitored the data collection daily and re-contacted primary contacts from targeted regions with a request for the recruitment of further potential participants with the required demographic characteristics. Collected data were downloaded immediately after the study was completed, then removed and permanently deleted from the Internet.

Spinal pain prevalence questionnaire
Dear Sir/Madam, You are invited to participate in a study conducted to determine epidemiological data on the prevalence of spinal pain in the population of Bosnia and Herzegovina (BiH). Eligible study participants are inhabitants of BiH, of both sexes, aged 16 years and older. The questionnaire consists of 29 questions. The first 15 questions are related to risk factors that can lead to spinal pain. Other questions include information needed to determine the prevalence of the current spinal pain and the factors associated with it. The questionnaire is completely anonymous; you will not be asked to specify Your name date, place of birth, or place of residence (only canton). It takes on average 7 minutes to complete the questionnaire. Please read carefully and answer the questions honestly. Before completing the questionnaire, please read the Informed Consent outlining your rights.
Request: Please forward the accompanying message and the link on which the questionnaire can be accessed to your contacts all over BiH. Thank you! Informed Consent: Participation in the study is voluntary and completely anonymous. Participation as well as refusal to participate does not and will have no consequences on you and your health. The collected personal data will remain known only to the researchers; they will serve to determine the epidemiological data in this study and will not be used for other purposes. Filling in and submitting the questionnaire below will be considered as your acceptance of participating in the study. Thank you in advance! If you have read your rights related to participation in this study and if you agree with the above and would like to participate in this research, please confirm this by entering the study questions.