Prevalence of Low Back Pain and Its Associated Factors Among Medical Students at Nineveh University in Iraq: A Cross-Sectional Study

Background Low back pain (LBP) is a common problem encountered in medical practice, leading to limitations in daily activities and causing social and economic hardships. Objectives This study aimed to assess the prevalence of LBP and its associated factors among medical students at Nineveh University in Iraq. Methods Between December 2022 and January 2023, a cross-sectional study was conducted among medical students at Nineveh University. A modified version of the Standard Nordic Questionnaire was used for data collection. Results Out of 308 students, 229 (74.4%) experienced LBP at some point in their lives. In addition, 209 (67.9%) reported having LBP during the last 12 months, 148 (48.1%) during the previous seven days, and 126 (40.9%) at the time of answering the survey. Factors significantly associated with LBP during the last 12 months were being in the fifth-stage academic year (p=0.047), family history of LBP (p=0.003), and history of trauma (p=0.006). On the multivariable logistic regression analysis, factors significantly associated with LBP during the last 12 months were family history of LBP (p=0.02) and history of trauma (p=0.01). Conclusions The prevalence of LBP among medical students at Nineveh University was comparatively high. A family history of LBP and a history of trauma were factors significantly associated with LBP during the last 12 months. Managing this health concern should be a priority for the administration of medical schools.


Introduction
Low back pain (LBP) is a common health problem that has been reported to affect 50-80% of individuals at least once in their lifetime and about 18% at any given time [1][2][3].LBP is a cause of activity limitation and adversely affects quality of life [4].Additionally, LBP has growing economic burdens due to loss of productivity and the cost of treatment [5].
Several risk factors have been reported to influence the occurrence of LBP, including increased physical stress on the spine, psychological stress, and poor general health [6].Furthermore, stress, body position at work, and lack of physical activity have been identified as risk factors among healthcare providers [7].Regarding medical students, in the final year of study, anxiety, high mental pressure, or psychological distress have been reported to be associated with LBP [8].
Medical students encounter highly demanding curricula throughout their academic years, which may expose them to stress and a sedentary lifestyle due to long hours of lectures, practical training, and studying.The stress and sedentary lifestyle put them at risk of developing LBP [6,9].Because LBP can affect their academic

Instruments
We used an online, self-administered survey conducted via Google Forms (Google LLC, Mountain View, CA, USA) to gather data.The questionnaire was designed in English and was an adapted variant of the standardized Nordic questionnaire [12].This adaptation was performed from previous studies [13,14] and specifically tailored for use among medical students, with a particular focus on assessing LBP.Before being used in the study, the questionnaire was piloted with five students to ensure its suitability.
The questionnaire had three sections: (i) summarize the survey's purpose, aim, and target participants; (ii) include demographic data (sex, age, academic years, height, and weight), lifestyle-related questions (physical exercise, studying hours in a day, smoking or not, type of participant activity), family history of LBP, and history of trauma; and (iii) investigate the prevalence of LBP during the last 12 months and its related questions, which include duration, if LBP reduces his activity, and if LBP makes the participant see a doctor.Additionally, questions about the prevalence of LBP during the time of answering the survey (point prevalence), during the previous seven days, and at some point in life (lifetime prevalence) were included in this section.

Sample size calculation
Study size calculation was handled using OpenEpi version 3.01 (www.openepi.com).Under a 95% confidence level, 0.05 margin of error, 1,651 total population, and 33% prevalence of LBP based on a study conducted among medical students at Taif University in Saudi Arabia [15], a sample of 282 participants was considered a minimum sample.

Statistical analysis
Data analyses were conducted using jamovi version 2.4.11, which is accessible for use at the website (www.jamovi.org).In our descriptive analysis, the continuous variables were summarized using the median and IQR, while the categorical variables were presented as proportions and percentages.The chi-squared test and univariate logistic regression were first used to determine the association and ORs and 95% CIs for factors associated with LBP.Mann-Whitney was conducted to identify the difference for the non-normally distributed variables (studying hours in a day).Significant variables with a p-value less than 0.05 were included in the multivariate logistic regression analysis.All statistical analyses were performed with a significance level set at p<0.05 and a confidence interval of 95%.

Prevalence of LBP
Out of 308 students, 229 (74.4%) experienced LBP at some point in their lives.In addition, 209 (67.9%) reported having LBP during the last 12 months, 148 (48.1%) during the previous seven days, and 126 (40.9%) at the time of answering the survey, as shown in Figure 2. Of a total of 209 students who reported LBP during the last 12 months, 119 (56.94%) mentioned that their pain duration was between one and seven days, 28 (13.4%) between eight and 30 days, and 27 (12.92%)more than 30 days, and 19 (9.09%) reported that their pain was every day, and 16 (7.66%)reported that their pain was less than one day.Moreover, 111 (53.11%) reported a reduction in their activity, and 33 (15.79%) had seen a doctor.

Factors associated with LBP during the last 12 months
Factors associated with LBP during the last 12 months were examined separately using univariate and multivariate logistic regression, as shown in

Factors associated with LBP during the previous seven days
Factors associated with LBP during the previous seven days were examined separately using univariate and multivariate logistic regression, as shown in Table 3  On the multivariable logistic regression analysis, factors significantly associated with LBP during the previous seven days were BMI greater than 25 kg/m² (OR=1.81,95% CI (1.11-2.96),p=0.02) and performing regular exercise (OR=0.37,95% CI (0.17-0.794), p=0.01).
Stoicism and resilience in the face of adversity are often valued traits in Iraqi culture.This cultural norm may lead individuals, including medical students, to underreport symptoms of pain or to endure discomfort without seeking medical help.The perception that enduring pain without complaint is a sign of strength can result in a high threshold for reporting LBP.Additionally, there may be a stigma associated with admitting to health issues, especially in a competitive and demanding field such as medicine, where students might fear being perceived as weak or less capable.However, Iraqi medical students reported a relatively high prevalence of LBP, which reflects the extent of the impact of the problem in the presence of this cultural norm.
The findings of our study revealed that gender was not associated with the prevalence of LBP during the last 12 months and during the previous seven days, which is in agreement with previous studies [23,24].Conversely, other studies indicated that the prevalence of LBP increases with female gender [25,26].Notably, our study found that fifth-year students had a greater prevalence of LBP during the last 12 months than other students.The explanation of this finding may be that fifth-year students at any Iraqi medical school are exposed to significantly longer study hours, hospital training, and demanding routines than students at other academic levels.
Although overweight and obesity have been reported to be risk factors for LBP [27], our study demonstrated no association between BMI and the prevalence of LBP during the last 12 months.On the other hand, our study showed that a BMI of more than 25 kg/m² showed an association with LBP during the previous seven days.Furthermore, although evidence has suggested that smoking is associated with LBP [6], we found no association between smoking status and LBP during the last 12 months and during the previous seven days.
Our study showed no association between participant activity patterns and LBP during the last 12 months and during the previous seven days.However, students performing regular exercise had a lower prevalence of LBP during the previous seven days than other students.The explanation for this finding may be that physical activity is associated with a lower prevalence of LBP because it has several benefits related to physiological health [28,29].
Interestingly, our study showed that participants whose family members have suffered from LBP in the past and those who have suffered from trauma have a higher chance of suffering from LPB in the future.However, the details about the family history, as well as the nature of the trauma and its complications, are not known.Notably, students with LBP during the last 12 months showed shorter daily studying hours compared to those without LBP, which may reflect the negative effect of LBP on the quality of academic life, academic performance, and achievement.Conversely, students with LBP during the previous seven days showed longer daily studying hours compared to those without LBP, which reflects the association between long studying hours and LBP.

Strengths and limitations
To our knowledge, this is the first study undertaken at Ninevah University and in the country on this topic; as such, it contributes to the scientific community with valuable new information.However, cross-sectional studies are limited in demonstrating causation or defining temporal correlations since they only record a single snapshot of data at a particular point in time.Additionally, convenient sampling may not accurately represent the population of interest and may lead to selection bias.Participants who are more willing to participate in the study may have different characteristics from those who are not, which can limit the generalizability of the results.

Recommendations
Overall, LBP is an important problem among medical students that needs more attention.Managing this health concern should be a priority for the administration of medical schools.Students' education, advice to be more physically active, and performing regular exercise may be preventive measures against LBP [30].The administration of medical schools should provide workshops about LBP prevention and management and periodically host sports activities.

Conclusions
The prevalence of LBP among medical students at Nineveh University was comparatively high.Family history of LBP and a history of trauma were factors significantly associated with LBP during the last 12 months.Managing this health concern should be a priority for the administration of medical schools.
Students' education about LBP prevention and management is recommended.

FIGURE 1 :
FIGURE 1: Questionnaire distribution flow chart of the sample population

FIGURE 2 :
FIGURE 2: Prevalence of LBP at different times LBP: low back pain

TABLE 1 : Sociodemographic and lifestyle factors of the study participants
BMI: body mass index, LBP: low back pain, IQR: interquartile range

TABLE 3 : Factors associated with LBP during the previous seven days using univariate and multivariate logistic regression (N=308)
* indicates significant differences (p<0.05)BMI: body mass index, LBP: low back pain, IQR: interquartile range, OR: odds ratio, CI: confidence interval