Factors associated with low back pain among construction workers in Nepal: A cross-sectional study

Background Low back pain (LBP) is the commonest cause of disability throughout the world. This study aimed to determine the prevalence and factors associated with LBP among the construction workers in Nepal. Methods A community-based cross-sectional study was conducted among the construction workers working in Banepa and Panauti municipalities of Kavre district, from September 2019 to February 2020. Data was collected purposively by face-to-face interview from 402 eligible participants from the both municipalities using semi-structured questionnaire. Mobile-based data collection was done using KoboCollect. Data were exported to and analysed using R-programming software (R-3.6.2). Univariate and multivariate logistic regressions were performed. All tests were two tailed and performed at 95% confidence interval (CI). Result One-year prevalence of LBP among construction workers were 52.0% (95%CI: 47.0–57.0). The higher odds of LBP was reported among females [adjusted odds ratio (aOR) = 2.42; 95%CI: 1.12–5.23], those living below poverty-line (aOR = 2.35; 95%CI: 1.32–4.19), participants with more than five years of work experience (aOR = 1.66; 95%CI: 1.01–2.73) and those with intermediate sleep quality (aOR = 2.06; CI: 1.03–4.11). About 80.0% of construction workers with LBP never seek healthcare services due to: a) time constraints (90.9%), b) financial constraints (18.1%) and c) fear of losing wages on seeking healthcare services (40.9%). The majority of the participants (94.8% among those without LBP and 72.3% among those with LBP) did nothing to prevent or manage LBP. Conclusion The prevalence of LBP in the past one year was high among construction workers where majority of workers never did anything to prevent or manage LBP. Therefore, the public health professionals should set up the health promotion, education, and interventions aimed at increasing awareness on preventive techniques and predisposing factors of LBP.

engaged in this sector [22]. 50 Construction work is renowned as unhealthy because of the high mechanical nature and hard 51 physical labor involved [18,19]. A construction manual worker is a general/blue-collar worker 52 employed in the construction industry and works predominantly on construction sites and is 53 typically engaged in hands-on aspects of the industry other than design or finance. This 54 includes members of specialist trades such as builders, electricians, carpenters, bricklayer, 55 manual labor, armature fixing workers, internal finish workers and plumbers [20]  were purposively selected. Principal investigator visited every ward of each municipalities and 84 located building construction sites with the assistance of local people. All people working in 85 construction sites which researcher located within study duration and who meet eligibility 86 criteria were enrolled in the study. The inclusion criteria to enrol participants were: a) building 87 construction workers aged 18 years or above and b) work experience of one year or more. The 88 exclusion criteria were: a) building construction workers who were not able to communicate 89 clearly and b) those who did not give consent. Anthropometric measurement: Height and weight were measured using the digital weighing 106 machines and the portable measuring tape, respectively, from which body mass index (BMI) 107 was calculated. The BMI was calculated using the formula: weight (kg) / height (cm) ². 108 Job satisfaction: It was measured by the questions-"Please tell me whether you: strongly 150 agree, agree, disagree, or strongly disagree with this statement: I am satisfied with my job". 151 Responses of "strongly disagree" and "disagree" were defined as low job satisfaction [29]. 152 Work-family imbalance: It was measured by the following question: "Please tell me 153 whether you: strongly agree, agree, neutral, disagree, or strongly disagree with this statement: 154 It is easy for me to combine work with family responsibilities." Responses of "strongly 155 disagree" and "disagree" were defined as high work-family imbalance [29]. 156 Exposure to the hostile work environment: It was measured by the question "During the past 157 12 months were you threatened, bullied, or harassed by anyone while you were on the job?" 158 The response of "Yes" was defined as exposure to a hostile work environment [29]. 159 Job insecurity: Job insecurity was measured by the question: "Please tell me whether you: 160 strongly agree, agree, disagree, or strongly disagree with this statement: I am worried about 161 becoming unemployed." Responses of "strongly agree" and "agree" were defined as high job 162 insecurity [29].

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The majority of the participants without LBP (95.0%) in the last one year did not use any 243 protective measures to prevent low back pain. Only 5.0% of participants used some protective 244 measures of which 4.0% used patuka (special piece of cloth worn around the waist) and 245 remaining 1.0% did exercise. 246 The majority of the participants with low back pain (61.2%) did nothing against low back pain 247 in past one year. 28.7% used patuka, 8.6% took medication prescribed by doctors, 7.2% took 248 medication from the pharmacy, 2.4% had physiotherapy and 1.4% did the exercise to manage 249 low back pain. 250 251

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This study aimed to find out prevalence of LBP, factors associated with LBP among 253 construction workers of Nepal and find out measures taken to prevent and manage LBP. 254

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The overall one-year prevalence of LBP among construction workers was 52.0%. Our findings 256 are consistent with the previous cross-sectional questionnaire based study that reported a 257 similar one year prevalence of LBP among construction workers(13,28 In the current study, LBP was found to be significantly higher among construction workers 299 living below poverty line. This association can be explained in two possible ways. One is the 300 inability to perform productive work due to the presence of low back pain may be driving 301 workers into poverty. Another is poor nutrition due to poverty might be leading to LBP. 302 303

Lifestyle risk factors 304
Alcohol: Several studies have not listed alcohol intake as a risk factor of LBP but a study have 305 shown that continued alcohol intake was related to the deterioration of muscle strength and 306 appearance of histological injury to muscle [41]. So alcohol consumption was taken as one of 307 the associated factors for LBP but current study did not find any significant association of LBP 308 with alcohol consumption like in the study by Ueno et al [11]. 309 Smoking: Researchers don't take smoking as a cause of musculoskeletal pain but as a 310 confounding factor[11] as smoking is associated with job dissatisfaction, job insecurity, 311 anxiety, stress, and depression [42]. A population-based study showed that smokers were 1.23 312 times likely to develop low back pain than non-smokers [38]. In contrast, the present study did 313 not find any association between smoking and LBP among construction workers. . It is believed that mental strain linked with job insecurity 352 may indirectly lead to "physiological vulnerability" which, in turn, may contribute to low back 353 pain [26]. Hence job insecurity was taken as independent variable in the present study. We 354 found significant association between job insecurity and LBP among construction workers in 355 univariate analysis but there existed no significant association after adjusting other variables. force confirmed that on wearing patuka or lumbar supporter might be accountable for the low 372 incidence of LBP [59]. But very few construction workers, 28.7% among those with LBP and 373 4.0% among those without LBP were using patuka to prevent or manage low back pain. Similar 374 to the present study, construction workers of Japan also poorly use lumbar supporter as 375 protective equipment for LBP [32]. According to a study by Shrestha et al, safety practices of 376 Nepalese construction projects, mainly the use of personal protective equipment, is gradually 377 growing [60]. Though the use of PPE is growing in the context of Nepal, construction workers 378 in the present study were poorly using PPE like patuka or belt to prevent LBP. 379 Most of the construction workers in our study felt LBP as a consequence of hard work and 380 subsides immediately after taking rest which results in the reduction of healthcare utilization 381 among construction workers for LBP. From this findings, we can support the statement that 382 low back pain is a neglected problem among construction workers in the context of Nepal. 383 384

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Though this study did best to find the prevalence of low back pain and factors associated with 386 low back pain among construction workers, it is not free from limitations. Because of the cross-387 sectional nature of the study, the directionality of the risk associations cannot be established.