Effectiveness of Health Education Given To Prevent Back Pain In Women: Pre- And Post-Test Study

Back pain is a common symptom that affects all age groups across the globe, when left untreated may eventually lead to disability. A convenient sample selection method was used in this study due to the global Covid-19 pandemic lockdown which was effective in Turkey during the investigation period. Thus, virtual data collection and health education including some health risks were employed. A total population of two hundred adult women was involved in the study but one hundred and twenty-one responses were collected. Findings show that, for sociodemographic characteristics, the pain was found highest in women between the ages of 41-50 and obese/overweight individuals. Although, there was no significant difference recorded in the marital status category. Moreover, statistical mean differences were detected between the scales for ODI (4.18) and BPFS (6.09). Also, p<0.05, paired sample t-test was 0.001 ODI and 0.001 BPFS after the training exercise. This suggests that exercise training is inversely correlated with pain severity which implies that training has a significant influence on pain intensity. Thus, it could be concluded that there is a relationship between the training exercise and ODI/BPFS.


Introduction
Functional health is a general conception of an indication of optimal levels of spiritual functions, psychosocial and physiological maintenance of holistic care in an individual, families, and communities (Gordon, 1994). Nothing can be compared to living healthy. There is a lack of sensitization of health education on low back pain for the populace since the public health programs' concentration is on the awareness of infectious diseases.
Low back pain (LBP) is mostly defined as discomfort and pain, located below the rib and above the buttock, with or without added leg pain. It is prevailing in the general population as a social and economic global problem (Bos et. al., 2007). Painful conditions and chronic pain in the musculoskeletal system affect women in larger numbers than men (Leveille et. al., 2005)). Overall, there is a higher prevalence of LBP experienced in women than men due to pain sensitivity reports associated with menstrual cycle fluctuation in young adults (Riley et. al., 1999). Also, psychosocial factors, responses to pregnancy and childbirth, child-nurturing stress, weight gain in the abdomen, poor postures, and smoking are responsible for LBP (Bailey, 2009). Though back pain affects all populations irrespective of different occupations which are estimated to affect about half the population of adults (Myśliwiec et. al., 2011). But female healthcare personnel are at higher risk to experience LBP (Ghoussoub et al., 2016;Yan et. al., 2017) which is attributable to occupational risk factors such as heavy physical workload, prolonged standing, cyclic movements, transfer of patients, and unhealthy bodily postures (Nourollahi et. al., 2018;Pheasant & Stubbs, 1992;Smedley et. al., 1995). According to a 2013 research carried out in Poland, the absence from work for men and women due to pain were 15% and 10% respectively. Among the Turkish community, the risk factors investigated for LBP were age (a significant risk factor), occupational activities, obesity, lifestyle, smoking, gender, and genetic makeup (Ercalık & Tuncer, 2011).
Pain (subjective emotion) is a distasteful feeling of the mind but an identifiable unpleasant emotional state felt in the mind but restricted to a part of the body. Pain is a designed resistance for the protection of the injured part from further deterioration (Malcom, 1987). Low back pain is a symptom, not a disease, though a significant burden to patients and can result from several different known or unknown abnormalities or diseases.
Low back pain cause is broadly divided into three: i) Mechanical (broken vertebra, degenerative discs, and herniated discs) ii) Non-mechanical (infections and tumors) iii) Referred pain from internal organs (kidney infections, gallbladder disease) (Manusov, 2012). A thorough physical examination and medical history check can be used in the identification of conditions causing pain. Imaging tests may be used to eliminate certain causes of pain including tumors even though they are not necessary in most cases. Neurologic tests may be useful in the determination of causes of pain and convenient treatment.
Prevention is categorized into three: primary, secondary, and tertiary. Primary prevention of low back pain is centered on precautions taken to shun the occurrence of pain and secondary prevention is given to individuals with past episodes of pain. Postural correction and educational procedures enhance the spine functions in the treatment of chronic LBP (Donzelli et. al., 2006). One benefit of health education is the circulation of new information, thereby creating awareness and increasing positive behaviors. Hence, exercise emerge as a primary prevention approach of health education utilized in LBP conditions and also help to prevent recurrences in individuals whose pain has exceeded six weeks (Steffens et. al., 2016;Casazza, 2012).
Public health programs should aim for the provision of a forum to decrease the impact of low back pain on daily living. Also, health education regarding mechanisms, prognosis, causes, history, beneficial impacts of exercise, and physical activity should be delivered on regular basis by healthcare professionals (Buchbinder et. al., 2018). Studies have shown that a combination of education and/or exercise is proven to be effective in the prevention of low back pain (Steffens et. al., 2016).
There is an improvement in acute or sub-chronic low back pain over time irrespective of the treatment. Improvement is often evident within the first month. Avoiding pain-triggering activities and remaining active are highly recommended. Low back pain management depends on the cause prompted by any of the three categories: mechanical, non-mechanical, or referred pain. Comprehensive treatment programs may help with the management of sub-chronic or chronic low back pain. Non-medication treatments such as massage, spinal manipulation, or superficial heat are recommended as initial management. There is valid evidence that patient education may positively have an impact on low back pain, with 150 minutes of an educational meeting having more effect than regular care offered to help people return to work.

Methodology
The study was an interventional design with the distribution of brochures and health education lecture to participants. The convenience sampling (also known as availability sampling) technique was used in this study. One hundred and twenty-one internship students in Turkey which consisted of adult women between the ages of 18 and 65 participated in the study. Due to the effective global covid-19 pandemic lockdown in Turkey during this period, health education theoretically and face-to-face techniques were carried out virtually and data were collected via google mails. The questionnaire used in this study comprises of 5 sections, namely: sociodemographic information (age, gender, years of experience, etc), visual analog form, 12-item back pain functional scale questionnaire, 10-item Oswestry disability index questionnaire extracted from (Spine, 2000) and back pain health education intervention. The data garnered was analyzed using frequency counts and descriptive statistics while the relationship between the socio-demographic characteristics, Oswestry Disability Index and Back Pain Functional Scale were analyzed using Paired Sample Test and Kruskal Wallis test to determine the extent of the pain severity before and after the training exercise given to the women with the low back pains participants. This was analyzed at a 95% level of confidence which is p-value 0.05 significant level on Statistical Package for Social Science (SPSS) 26. Majority were between 41-50 years 38% (n = 46) and 20.7% (n = 25) below 30 years.

Results
Overweight had the highest percentage with 43% (n = 52) and 24.8% (n = 30) were obese. Majority were married with 76% (n = 92) and 6.6% (n = 8) divorced. Nuclear family group had the highest frequency of 76% (n = 92) while the large group has the lowest frequency of 29% (n = 24.00). In terms of family economic situation, 76.9% (n = 93) had enough, 19% (n= 23) were insufficient without help and 4.1% (n = 2) were very good. For jobs that bring money in 6 months, more than half 64.5% (n = 78) indicated no while 8.2% (n = 10) of the respondents indicated self-employed. Almost half of the group 42.1% (n = 51) had a medium health status, 33.9% (n =41) good and very good while 24% (n = 29) were bad. Majority were non-smokers 77.7% (n = 94). Most of the respondents sleep more than 6 hours 80.9% (n = 99) and 18.2% (n = 22) sleep less than 6 hours. Majority never exercise 62.8% (n = 76) and very few exercises more than 3 times a week 7.4% (n = 9).   , there was a decrease in all sub-scale scores after health education. The highest mean score difference was seen in lifting heavy box from ground (0.69) sub-scale, lowest mean score difference in sleeping sub-scale (0.30) and (6.09) as total mean score difference. Convincingly, the table depicts a reduction in all the back pain functional scale items. However, it can be deduced from the mean differences that the training has a statistical significant impact on the women suffering from low back pains. In pre-test period, the mean scores were 42.85±13.00 and 27.43±11.71; (t = -12.093, p = 0.001), post-test period, mean scores were 36.76±13.58 and 23.25±11.42; (t = -10.636, p = 0.001).
There was a decrease in the pain levels of both scales after health education. This depicts a statistical difference of p<0.05.

Discussion
Low back pain is most frequent among women than men and increases in effect with age. It affects the 45-55 years age range and most prevalent among female health personnel which can be accredited to prolonged standing at work (Whelan et al., 2005). Also, age and obesity which is a high Body Mass Index (BMI) can be significant factors in low back pain (Ercalik & Tuncer, 2011). This study reveals majority of the participants were between the ages 41-50, overweight, married, and had no job that generates income in 6 months. Hence, having an understanding of back pain is important to its mitigation through exercise, because therapy can prove hard when the cause is unknown (McGill, 2011). More so, exercise and weight loss programs with a healthy lifestyle can control the BMI for the individual to live a healthy life which corroborates Nabiyev & Acaroglu, (2015) study. According to this study, it was revealed that 62.80% of participants never exercised, 29.70% less than 3 times a week, and 7.40% more than 3 times a week. This simply means lack of exercise contributed more to LBP. Previous reports have it that the prevalence of LBP is greater in smokers than in non-smokers and former smokers. Participants' smoking status reveals that 77.70% were non-smokers.
Pain may occur as a result of spinal nerve roots irritation, abdominal muscle weakness, and imbalanced facet joints. The clinical symptoms of LBP comprise lumbar pain, restricting the movements, and identifying stiffness of the lumbar spine (Hoppenfeld, 1987). This study reveals that 41.3% of the participants had no medical diagnosis but used pain killers, muscle relaxants, antidepressants, and non-steroid anti-inflammatory drugs (NSAIDs) that are commonly prescribed for chronic low back pain (Miller, 2012). In this study, 58% of the participants who suffered low back pain didn't undergo any medical treatment. This study reveals that 90.18% of movements as a factor contributes to a surge in low back pain, 89.4% take break while at work, 53.7% mentioned having suitable materials at home/work and 52.1% revealed that bed doesn't cause LBP. This was by Delleman & Dul, (2007) that stated in their study that Occupational LBP is in connection with vulnerability to ergonomic strain at work, psychosocial and environmental factors.
The Oswestry Disability Index (ODI) got its derivation from the Oswestry LBP Questionnaire used by researchers and clinicians for the quantification of low back pain disability (Fairbank & Pynsent, 2000). This study reveals a decline in all sub-scale scores (pain intensity, personal precaution, lifting, walking, sitting, standing, sleeping, social life, travel, degree of pain) after health education with a mean score difference of 4.18 (Table 3). It implies that health education was highly effective as all sub-scale mean scores were statistically significant except lifting (p>0.05).
The Back Pain Functional Scale (BPFS) established by  is subjectively used in the measurement of the physical function of patients after LBP with an overall score of 60. The original scale (BPFS) was compared with this study; the minimum score in this study was 1 and a maximum of 60. Hence, it implies that the instrument used is proven valid and reliable. Paired sample t-test was used in the comparison of scale questions (pre-test and posttest). Convincingly, the result depicts a reduction in all the back pain functional scale items after exercise as indicated in (Table 4).
The BPFS is a suitable and reliable tool in assessing patients with low back pain. It has internal consistency, retest reliability, and susceptible to change (Straford & Binkley, 2000). Although despite ODI limitation of insufficiency in indicating disability level, it is a valid, reliable, and most frequently used scale for LBP (Yakut et. al., 2004). From this study, there is a statistical mean difference of 4.18 and 6.09 for ODI and BPFS respectively before and after the training exercise p = 0.000 which is less than the critical value p<0.05 (Table 5). This suggests a relationship between the ODI and BPFS which is in agreement with the literature of Koç et. al. (2018) and Maras et. al. (2019) that found out in their investigations that BPFS has a significant correlation with ODI functional measures. Convincingly, it could, however, be inferred with the training put in place, there is a likelihood of a large statistical mean difference if the period is wide.

Conclusion
This study has considered the importance of exercise through education to pain lessening in women although it can be deduced from the findings of this study that there are a lot of factors responsible for back pain in women. These factors include prolonged standing, weight gain during pregnancy, stress, poor posture, smoking, occupational risk factors (female healthcare personnel), disc degeneration, spine infection, osteoporosis, ovarian cyst and cancer, and a lot more. But in all, if women can cultivate continuous or regular exercise habits into their lifestyle regardless of having pains or not, the level of pain suffering will be minimized if not eradicated. For the older women, it could be deduced that the significant reduction in pain intensity could be attributable to their judicious implementation of the training exercise while the young women should be actively engaged. In other words, active involvement in regular physical activities keeps the body fit. Therefore, engaging people in exercise could be of great help. It can then be concluded that there is an inverse correlation between the training and the severity of the pain.

Recommendation
This study has been limited in scope to the Near East University Public Health students and their relatives. However, other workers in other schools or organizations could have different observations for the effectiveness of health education given to prevent back pain in women: pre-test and post-test study. Hence, this should cut across different geographical zones. More so, this study has a great limitation of no sufficient recent resources in terms of outcomes. The available kinds of literature did not show major statistical results that can be compared with this study. In other words, there were no previous studies that show much in-depth in terms of statistical analysis. In the same way, widen the time frame between the pre-test and post-test to a period of three months, persuasion on the individual exercise participation should expatiate and this calls for a need for further study to be conducted.

Limitations of the Study
The major limitation of this study is confined to geographical as this research is restricted to women who consented to take part in this research. Likewise, the time frame for the period between the pre-test and the post-test is statistically short. This implies that the results in this study cannot be used as a benchmark to determine the effectiveness of health education given to prevent low back pain in women on the exterior of geographical space.