Unconventional Practitioners' Causal Beliefs and Treatment Strategies for Chronic Low Back Pain in Rural Nigeria

Addiction stigma and opioid use in chronic non-cancer pain management in Nigeria

This study uses 26 in-depth interviews conducted with people who use drugs (PWUD) who had sought care for chronic non-cancer pain in public health facilities in Nigeria, to explore how drug consumption stigma constitutes patient legitimacy based on neoliberal ideals. It found drug consumption stigma to be salient and pervasive in PWUD health-care encounters, operating through interpersonal interactions and institutionalised policies and practices to shape access to care. Crucially, stigma emerged through disciplinary opioid prescribing and dispensing practices that defined, categorised and marginalised PWUD based on how their drug consumption disrupted normative values of rationality and responsibility. Accounts additionally revealed disengagement from biomedical care and reliance on alternative pain management approaches (e.g. herbal remedies and illegal drugs), which show how structural positions shape the exercise of choice and agency in socially marginalised populations. In conclusion, the study considers the need to improve the health-care experiences of PWUD as a strategy for enhancing health-care engagement and improving health outcomes. It called for interventions to address the structural factors and interactional dynamics that influence stigma in health-care settings as well as for a review of current guidelines and practices to improve access to opioids for chronic non-cancer pain management.

Challenges of Measuring Self-Reported Exposure to Occupational Biomechanical Risk Factors Amongst People with Low Literacy Engaged in Manual Labour: Findings from a Cross-Cultural Adaptation and Psychometric Investigation in an African Population with Chronic Low Back Pain

PURPOSE

Occupational biomechanical factors are implicated in the aetiology and progression of low back pain (LBP). This study cross-culturally adapted and psychometrically investigated the Occupational Risk Factor Questionnaire (ORFQ) in a low literate Nigerian Igbo population with chronic LBP.

METHODS

Forward and back translation of the original ORFQ by clinical and non-clinical translators was followed by an expert committee review. The adapted ORFQ was pre-tested amongst rural Nigerian adults with chronic LBP using cognitive think-aloud interviewing. Internal consistency (Cronbach's alpha) and test-retest reliability (unweighted and linear weighted k statistic for item-by-item agreement, and intra-class correlation coefficient-ICC) were investigated amongst 50 rural and urban Nigerian dwellers with chronic LBP. Spearman's correlation and regression analyses were conducted with the Igbo-ORFQ, and measures of disability [World Health Organisation Disability Assessment Schedule (WHODAS 2.0), Roland Morris Disability Questionnaire (RMDQ), Back performance scale (BPS)], pain intensity [Eleven-point box scale (BS-11)] and social support [Multidimensional Scale of Perceived Social Support (MSPSS)], to test construct validity with 200 rural Nigerian dwellers with chronic LBP.

RESULTS

Cross-cultural adaptation highlighted difficulty conceptualising and concretising exposure to biomechanical risk factors. Item-by-item agreement, internal consistency (α = 0.84) and intraclass correlation coefficient (ICC = 0.83) were good. Some unexpected direction of associations between the biomechanical components of the Igbo-ORFQ, and disability, pain intensity, and social support prohibits establishment of construct validity.

CONCLUSION

Prospective studies comparing the Igbo-ORFQ to other measures of exposure to occupational biomechanical risk factors are required to establish the construct validity of the Igbo-ORFQ.

The influence of cultural and religious factors on cross-national variations in the prevalence of chronic back and neck pain: an analysis of data from the global burden of disease 2019 study

Introduction

Low back pain and neck pain are among the most commonly reported forms of chronic pain worldwide, and are associated with significant distress, disability and impairment in quality of life. Though these categories of pain can be analyzed and treated from a biomedical perspective, there is evidence that they are both related to psychological variables such as depression and anxiety. The experience of pain can be significantly influenced by cultural values. For example, cultural beliefs and attitudes can influence the meaning attached to the experience of pain, the responses of others to a sufferer's pain, and the likelihood of seeking medical care for particular symptoms. Likewise, religious beliefs and practices can influence the both experience of pain and the responses to it. These factors have also been associated with variations in the severity of depression and anxiety.

Methods

In the current study, data on the estimated national prevalence of both low back pain and neck pain, obtained from the 2019 Global Burden of Disease Study (GBD 2019), is analyzed in relation to cross-national variations in cultural values, as measured using Hofstede's model (n =115 countries) and in religious belief and practice, based on the most recent Pew Research Center survey (n = 105 countries). To address possible confounding factors, these analyses were adjusted for variables known to be associated with chronic low back or neck pain, namely smoking, alcohol use, obesity, anxiety, depression and insufficient physical activity.

Results

It was found that the cultural dimensions of Power Distance and Collectivism were inversely correlated with the prevalence of chronic low back pain, and Uncertainty Avoidance was inversely correlated with the prevalence of chronic neck pain, even after adjustment for potential confounders. Measures of religious affiliation and practice were negatively correlated with the prevalence of both conditions, but these associations were not significant after adjusting for cultural values and confounders.

Discussion

These results highlight the existence of meaningful cross-cultural variations in the occurrence of common forms of chronic musculoskeletal pain. Psychological and social factors that could account for these variations are reviewed, along with their implications for the holistic management of patients with these disorders.

Qualitative research in physiotherapy: A systematic mapping review of 20 years literature from sub-Saharan Africa

STUDY AIM

To summarize the current state and quality of qualitative research conducted by physiotherapists in sub-Saharan Africa (SSA).

METHODS

We systematically searched multiple databases from 2000 to December 2020 and included peer-reviewed qualitative studies conducted by physiotherapists in SSA countries. Two reviewers independently screened citations, extracted data, and assessed the quality of the included studies using the 45-items checklist by Lundgren, and colleagues. Conventional content analysis was employed to create physiotherapy subject areas from the included studies.

RESULTS

We included 114 studies, a majority of 84 (74%) conducted in South Africa. Included studies were categorized into five subject areas: sports (n = 2), disability (n = 16), professional practice (n = 24), education and training (n = 36), and care provision (n = 36). We rated 74 (65%), 29 (25%), and 11 (10%) of the included research as low reporting quality, moderate- and high reporting quality, respectively. There was a significant lack of reporting on researchers' team characteristics, reflexivity, and member checking.

CONCLUSION

We conclude that the reporting of published qualitative studies in SSA shows variable quality, albeit mostly low, focused mainly on care provision, education, and training. Physiotherapy-researchers are encouraged to report reflexive practice and member checking when conducting qualitative research.

Only two subscales of the Coping Strategies Questionnaire are culturally relevant for people with chronic low back pain in Nigerian Igbo populations: a cross-cultural adaptation and validation study

BACKGROUND

Pain coping strategies are important in the chronicity of low back pain and the associated disability. However, their exact influence is unknown in many African contexts such as rural Nigeria due to lack of outcome instruments with which to measure them. This study aimed to cross-culturally adapt and psychometrically test the Coping Strategies Questionnaire (CSQ) in Igbo populations in Nigeria.

METHODS

The CSQ was forward and back translated by clinical and non-clinical translators; evaluated by an expert review committee. The translated measure was piloted amongst twelve rural Nigerian dwellers with chronic low back pain (CLBP) using the think-aloud cognitive interviewing style. Internal consistency (Cronbach's alpha), test-retest reliability (intra-class correlation coefficient-ICC and Bland-Altman plot), and minimal detectable change were examined amongst 50 people with CLBP in rural and urban Nigerian populations. Construct validity was determined by assessing the correlations between the adapted CSQ and measures of disability, pain intensity, fear avoidance beliefs, and illness perceptions using Spearman's correlation analyses with 200 adults with CLBP in rural Nigeria. Exploratory factor analyses using Kaiser criterion (eigenvalue) and parallel analysis as methods for determining dimensionality were conducted with the same sample.

RESULTS

Fourteen out of 42 items were routinely adopted in this population including all items of catastrophising subscale, and all but one item of praying and hoping subscale. Catastrophising and praying and hoping subscales had the highest Cronbach's alpha. All subscales had high ICCs with Bland-Altman plots that showed good agreement. All coping strategies were positively correlated with self-reported disability and pain intensity with catastrophising subscale having the highest values. Seven-factor and three-factor structures were produced with the Kaiser criterion and parallel analysis, with different items from the original CSQ, except for catastrophising.

CONCLUSIONS

Catastrophising and praying and hoping may be the relevant coping strategies in this population. More culturally relevant measures of pain coping strategies that include adaptive coping strategies may need to be developed for African contexts such as rural Nigeria.

Detecting anxiety and depression among people with limited literacy living with chronic low back pain in Nigeria: adaptation and validation of the hospital anxiety and depression scale

Background

The Hospital Anxiety and Depression Scale (HADS) is one of the most popular measures of anxiety and depression. The original HADS is mostly used in Nigeria precluding people with limited literacy. This study aimed to cross-culturally adapt and psychometrically test the HADS for rural and urban Nigerian Igbo populations with chronic low back pain (CLBP) who have limited literacy.

Methods

The HADS was forward translated, back translated, and appraised. Face and content validity was ensured by pre-testing the translated measure among a convenience sample of twelve rural Nigerian dwellers with CLBP. Reliability utilising Cronbach’s alpha, intraclass correlation coefficient, Bland–Altman plots and minimal detectable change were investigated amongst a convenience sample of 50 people living with CLBP in rural and urban Nigerian communities. Construct validity testing involving correlations between Igbo-HADS and Roland Morris Disability Questionnaire measuring self-reported back pain-specific disability, World Health Organisation Disability Assessment Schedule assessing generic self-reported disability, Fear Avoidance Beliefs Questionnaire measuring fear avoidance beliefs, and eleven-point box scale assessing pain intensity, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) among a random sample of 200 adults with CLBP in rural Nigerian communities were conducted.

Results

Idioms and colloquialisms were difficult to adapt. Internal consistency was good (α = 0.78) and acceptable (α = 0.67) for anxiety and depression subscales respectively. Intraclass correlation coefficients were very good (ICC ≃ 0.8) for both subscales. Minimal detectable change was 6.23 and 5.06 for anxiety and depression subscales respectively. The Igbo-HADS and the anxiety subscale had strong correlations (≃ 0.7) with generic self-reported disability; moderate correlations (≃ 0.5–0.6) with pain intensity, self-reported back pain-specific disability, and fear avoidance beliefs. The depression subscale had the lowest correlations (≃ 0.3–0.4) with these outcomes. The EFA produced a two-factor structure with cross-loading of items. The CFA showed poor fit indices for the EFA structure, the original two-factor structure, and one-factor structure.

Conclusion

The HADS may not be suitable for assessing anxiety and depression, or emotional distress in this population due to difficulty achieving cross-cultural equivalence with western idioms; and the expression of emotional distress through somatisation in this culture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00586-4.

World Health Organisation Disability Assessment Schedule (WHODAS 2.0): development and validation of the Nigerian Igbo version in patients with chronic low back pain

Background

Globally, the leading cause of years lived with disability is low back pain (LBP). Chronic low back pain (CLBP) is responsible for most of the cost and disability associated with LBP. This is more devastating in low income countries, particularly in rural Nigeria with one of the greatest global burdens of LBP. No Igbo back pain specific measure captures remunerative or non-remunerative work outcomes. Disability measurement using these tools may not fully explain work-related disability and community participation, a limitation not evident in the World Health Organisation Disability Assessment Schedule (WHODAS 2.0). This study aimed to cross-culturally adapt the WHODAS 2.0 and validate it in rural and urban Nigerian populations with CLBP.

Methods

Translation, cultural adaptation, test–retest, and cross-sectional psychometric testing was performed. WHODAS 2.0 was forward and back translated by clinical/non-clinical translators. Expert review committee evaluated the translations. Twelve people with CLBP in a rural Nigerian community piloted/pre-tested the questionnaire. Cronbach’s alpha assessing internal consistency; intraclass correlation coefficient and Bland–Altman plots assessing test–retest reliability; and minimal detectable change were investigated in a convenience sample of 50 adults with CLBP in rural and urban Nigeria. Construct validity was examined using Spearman’s correlation analyses with the back-performance scale, Igbo Roland Morris Disability Questionnaire and eleven-point box scale; and exploratory factor analysis in a random sample of 200 adults with CLBP in rural Nigeria. Ceiling and floor effects were investigated in both samples.

Results

Patient instructions were also translated. ‘Waist pain/lower back pain’ was added to ‘illness(es)’ to make the measure relevant for this study whilst allowing for future studies involving other conditions. The Igbo phrase for ‘family and friends’ was used to better represent ‘people close to you’ in item D4.3. The Igbo-WHODAS had good internal consistency (α = 0.75–0.97); intra class correlation coefficients (ICC = 0.81–0.93); standard error of measurements (5.05–11.10) and minimal detectable change (13.99–30.77). Igbo-WHODAS correlated moderately with performance-based disability, self-reported back pain-specific disability and pain intensity, with a seven-factor structure and no floor and ceiling effects.

Conclusions

Igbo-WHODAS appears psychometrically sound. Its research and clinical utility require further testing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03763-8.

Determinants of healthcare utilisation for low back pain: A population-based study in Ethiopia

Low back pain (LBP) remains one of the major public health problems worldwide. However, in low-income countries, such as those in Africa, the epidemiological data on healthcare utilisation for LBP are lacking due to more pressing problems such as infectious diseases, to which the majority of health resources are channelled. Therefore, this study aimed at investigating the determinants of healthcare utilisation for LBP in the general population of Ethiopia. A population-based cross-sectional study was conducted in South-West Shewa zone of Ethiopia from June to November 2018. The data were collected by interviewing adults with LBP (n = 1812, randomly selected) using a psychometrically tested and validated instrument, analysed using R version 3.5.1. A log-binomial regression model was used to determine the prevalence ratio with a 95% confidence interval (CI) in identifying factors associated with healthcare utilisation for LBP. Estimates of population parameters were also presented with 95% CIs and p values. For all applications of inferential statistics, a p value of ≤.05 was taken as the significance level. The lifetime prevalence of healthcare utilisation for LBP was 36.1%, 95% CI: 33.9-38.1, while the annual prevalence rate was 30%, 95% CI: 27.9-32.2. Of those with a 1-year history of healthcare utilisation, while 7.4%, 95% CI: 4.9-10.3 rural and 36.6%, 95% CI: 29.5-44 urban populations utilised healthcare from general hospitals, 1.4%, 95% CI: 0.3-2.7 rural and 6.8%, 95% CI: 3.1-10.8 urban populations utilised healthcare from specialised hospitals. Several sociodemographic factors, modifiable health behaviours/lifestyle habits, pain interrelated factors, and specific factors such as beliefs about the pain, depressive symptoms and insomnia were associated with healthcare utilisation for LBP. The implications of this research are that it may be prudent for the Ethiopian healthcare policy makers to develop the necessary strategies to meet the health needs of both urban and rural populations with LBP.

Cross-cultural adaptation and psychometric evaluation of the Yoruba version of the Back beliefs questionnaire among patients with chronic low-back pain

Purpose

To translate, culturally adapt and conduct a psychometric evaluation of the Yoruba version of the Back Beliefs Questionnaire (BBQ) among patients with chronic low-back pain.

Methods

The English version of the BBQ was translated into the Yoruba language through a process of forward-backward translation, reconciliation and harmonization of the reconciled items sequentially. Thereafter, Cronbach’s Alpha, Intra-Class Correlation (ICC), Bland-Altman’s analysis were used to determine the internal consistency, test-retest reliability and limits of agreement of the Yoruba version of the BBQ (BBQ-Y). Other psychometric properties of the BBQ-Y explored comprised acceptability, standard error of measurement (SEM), minimal detectable change (MDC), convergent validity and floor and ceiling effects. While 119 respondents participated in the validity testing, only 51 of them were involved in the reliability testing of the BBQ-Y. Data were analysed using descriptive and inferential statistics. Alpha level was set at p < 0.05.

Results

The mean age of the respondents all the respondents was 56.8 ± 8.5 years. The BBQ-Y had excellent acceptability with a global Cronbach Alpha score of 0.71. The SEM and MDC of the BBQ-Y were 2.3 and 6.4. The BBQ-Y ICC score for test-retest was 0.89, while the Bland-Altman analysis showing limits of agreements for the test-retest reliability were − 6.84 and 5.70. The convergent validity of the BBQ-Y showed a weak correlation (r = 0.273, p = 0.001) with pain intensity using the visual analogue scale.

Conclusion

This is the first study to culturally adapt the BBY-Y and determined its psychometric properties. The BBQ-Y has adequate psychometric properties and it is an appropriate outcome measure for use among Yoruba speaking patients with chronic low-back pain.

Evidence, theory and context: using intervention mapping in the development of a community-based self-management program for chronic low back pain in a rural African primary care setting - the good back program

BACKGROUND

Rural Nigeria has one of the greatest burdens of low back pain but there are no effective evidence-based interventions to manage it in this population. This paper presents the application of the intervention mapping (IM) approach in the development of a complex behavior change intervention - The Good Back program, aimed at reducing non-specific chronic low back pain (CLBP) disability in rural Nigeria.

METHODS

The first four steps of IM were applied. A critical review of the literature, 2 qualitative studies and a population-based cross-sectional study in rural Nigeria helped to identify two key program objectives in order to reduce CLBP disability in this population: reduce the impact of illness perceptions, fear avoidance beliefs, catastrophising, anxiety and depression by targeting maladaptive illness perceptions about CLBP; and facilitate the adoption of exercises and good posture to limit disability. A systematic review plus these studies, identified the personal and environmental determinants of the performance objectives including health literacy, self-awareness, self-efficacy, personal preference, health professional skills, health facility structure and family/community support. The theory, techniques and strategies for modifying personal and environmental determinants were also identified from these studies. Intervention components and materials were then produced for practical application. The initial developed intervention was described.

RESULTS

The feasibility and acceptability of the developed program was then tested using a small pragmatic non-randomised controlled study incorporating qualitative exit feedback interviews in a rural Nigerian primary health care centre. The program appeared feasible and acceptable when delivered by a highly trained physiotherapist. There were promising clinical outcomes in disability, pain intensity, illness perceptions, fear avoidance beliefs and pain medication use. Suggestions for program improvement included shorter but ongoing sessions, video demonstration of exercises/good posture, spacious exercise/demonstration rooms, and community legitimisation of exercise as treatment for back pain. Subsequent modifications to program content and delivery were then described. Theoretical modification included the addition of aspects of the social cognitive theory to the Leventhal's self-regulatory model of illness cognitions.

CONCLUSIONS

IM appears to be a suitable framework for designing complex behavior change interventions in rural Nigeria. The need for further testing of the intervention was highlighted.

Effects of motor control exercise and patient education program in the management of chronic low back pain among community-dwelling adults in rural Nigeria: a study protocol for a randomized clinical trial

Background

The impact of chronic low back pain (CLBP) is disproportionally higher in rural Nigeria than in urban areas but lack access to rehabilitation. While exercise and education are commonly advocated interventions for the rehabilitation of CLBP, there is a paucity of community-based randomized clinical trials assessing their benefits among adults with CLBP in rural Nigeria. The purpose of this study is to investigate the effects of motor control exercise (MCE) and patient education (PE) in the management of CLBP among community-dwelling adults in rural Nigeria.

Methods

This is an assessor-blind, three-arm parallel randomized clinical trial and will be conducted at Tsakuwa Primary Health Care Center in Kano, Northwestern Nigeria. One hundred and twenty adults with CLBP will be recruited and randomized to one of three intervention arms; MCE plus PE, MCE, or PE groups. The MCE will be administered twice a week for 8 weeks while the PE will be provided once a week for 8 weeks. Participants will be assessed pre-intervention, immediately post-intervention and at 3-month post-intervention. Primary outcomes will be pain intensity and functional disability. Secondary outcomes will be quality of life, fear-avoidance beliefs, pain catastrophizing, back beliefs, global perceived recovery, and physical performance.

Discussion

This will be the first community-based trial to assess the benefits of exercise and education in the management of CLBP among adults in rural Nigeria. The study may provide a relatively inexpensive, assessable, and effective alternative intervention for reducing CLBP disability in a low-resource rural Nigerian community. Trial registration:This study is registered at ClinicalTrial.gov and the trial registration number is NCT03393104.