Florence A. M. O Koitsiwe
University of Zambia

Loveness A Nkhata
University of Zambia

DOI: https://doi.org/10.55320/mjz.52.1.624

Keywords:Low back pain, caregivers, spinal degeneration, musculoskeletal strain, caregiving burden, healthcare support.

Introduction

Low back pain (LBP) is a widespread public health concern associated with spinal degeneration, including changes in intervertebral discs, facet joints, and multifidus muscles. In Zambia, primary caregivers of children with disabilities report lower health status and are disproportionately affected by back pain.

Objective

To determine the prevalence of LBP and spinal degenerative conditions among primary caregivers of children with disabilities and identify associated risk factors.

Methodology

A quantitative cross-sectional study was conducted among caregivers of children with disabilities attending the outpatient physiotherapy clinic at the University Teaching Hospitals. Data were gathered using a structured two-part questionnaire and analysed using SPSS. Associations between LBP and risk factors were evaluated with ANOVA at a 5% significance level.

Results

Ninety percent (90%) of caregivers reported experiencing LBP in the past year, highlighting significant musculoskeletal strain from caregiving. Degenerative spinal conditions, such as lumbar spondylitis, were less prevalent, observed in only 5% of participants. This indicates that while LBP is highly common, it does not necessarily signal degenerative spinal conditions.

Clinical Implications

Routine screening and early intervention are essential to prevent chronic pain and disability among caregivers. Strategies such as ergonomic support and education on proper caregiving techniques should be prioritised by healthcare providers to reduce musculoskeletal strain.

Conclusion

Caregiving places substantial physical demands on individuals, often leading to LBP and potential long-term musculoskeletal issues. Addressing the physical and emotional burdens of caregiving through supportive measures is crucial for improving caregivers’ well-being.

In Zambia, low back pain (LBP) is a common health condition among caregivers, who often face poorer health outcomes compared to non-caregivers. Studies report that adult informal caregivers in Zambia are more likely to be in fair to poor health and exhibit higher levels of depressive symptoms than non-caregivers.^[1] Additionally, caregivers frequently report difficulty sleeping, with 46% of African caregivers experiencing this issue, and 31% describing their health as fair or poor.^[2] Caregivers of children with cognitive developmental disabilities experience elevated psychological symptoms and heightened parenting stress, which intensifies with the severity of the child’s condition.^[3] Activity limitations due to chronic conditions are also reported by parents of non-institutionalised children with disabilities in Africa.^[4] In Southern Africa, ageing parents, often the primary caregivers for disabled children, face significant functional limitations and health challenges, highlighting the critical importance of caregiver well-being.^[5]

The quality of care provided to disabled children is closely linked to the health of their primary caregivers, predominantly mothers, whose physical and emotional well-being directly affects caregiving capacity.^[6] In Zambia, limited access to healthcare and ergonomic support exacerbates the physical and emotional strain on caregivers. LBP is a major concern, with lifetime prevalence estimates ranging from 70% to 94%, and nerve entrapment contributing to up to 28% of cases, leading to clinical interventions or time off work.^[7]

Lumbar spondylosis, a degenerative condition involving intervertebral disc degeneration, is characterised by cyst formation, subchondral sclerosis, osteophyte growth, and joint space narrowing.^[8] Spondylitis, an inflammatory condition of the vertebrae, often presents with localised pain that worsens at night and significantly impacts quality of life.^[9] Globally, LBP has an annual prevalence rate of up to 45%, with an increasing incidence over the past 13 years.^[10] While LBP is more common in women and peaks among individuals aged 60–65 years, its association with caregiving, particularly in low-resource settings, remains underexplored.

In Zambia, caregivers, particularly those supporting children with disabilities, often undertake physically demanding tasks without adequate ergonomic support or knowledge of proper techniques to protect their musculoskeletal health. These challenges are compounded by limited healthcare resources and a lack of preventative strategies. As informal caregiving remains the primary mode of care provision in Africa, addressing LBP among caregivers is critical to improving their health and the quality of care for children with disabilities.

Research shows that caregiving adversely impacts the physical and psychological well-being of caregivers.^[11] LBP, predominantly mechanical in nature, can progress to chronic conditions associated with disc degeneration or spondylosis.^[12] This study aimed to assess the prevalence of LBP among primary caregivers of children with disabilities, examine the link between caregiving activities and LBP, and identify risk factors for degenerative spinal conditions. Findings from this study are expected to inform targeted interventions to improve caregiver health, enhance care quality, and reduce stress and depressive symptoms among caregivers. These measures will ultimately benefit both caregivers and children, strengthening families and communities.

Study Design and Population

This study employed a quantitative, cross-sectional design, chosen for its cost-effectiveness and suitability for capturing population-based data^[13]. The design facilitated a focused examination of caregivers' experiences with low back pain (LBP) and its associated risk factors. While appropriate for identifying prevalence and correlations, this design has inherent limitations, including the inability to establish causation between caregiving activities and LBP. These limitations were acknowledged in interpreting the findings. The study population consisted of primary caregivers, including biological parents and others providing care to children with disabilities for at least one year. Participants were recruited from the outpatient physiotherapy clinic at the University Teaching Hospitals, Zambia, between January and August 2024. On average, 13 children attended the clinic daily, with 12 accompanied by caregivers. The inclusion criteria encompassed caregivers from diverse age groups, genders, and socioeconomic backgrounds to ensure varied representation.

Sample Size

A total of 40 participants were recruited for this study. This was fewer than the anticipated 65 due to declining clinic attendance and participant refusals. While the sample size provided valuable insights, its small size limits the generalisability of the findings to broader populations. Future studies with larger, more representative samples are needed to strengthen external validity.

Data Collection

Data collection was facilitated using a structured, researcher-administered questionnaire. The questionnaire comprised two main sections: Section A included demographic information and employed the Standardised Nordic Questionnaire, a validated tool widely used for assessing musculoskeletal complaints^[14],^[15]. Section B focused on caregiver burden using a modified four-part caregiver burden assessment questionnaire^[16]. Modifications were made to suit the study context, tailoring questions to reflect the unique caregiving challenges in Zambia, such as physically demanding tasks and limited access to ergonomic support. While these adaptations enhanced relevance, further detailed documentation is necessary to ensure transparency and facilitate replication in similar settings.

Bias Minimisation

Efforts were made to minimise potential biases. Participants were recruited through departmental registers to reduce selection bias and capture a wide range of experiences. Recall bias was addressed by structuring questions to focus on recent caregiving experiences, including LBP occurrences within the past 7 days, year, or lifetime. Despite these measures, potential biases may not have been fully eliminated, and this limitation was explicitly acknowledged in interpreting the findings.

Data Analysis

Data were analysed using SPSS version 30.0. Descriptive statistics were employed to calculate means and standard deviations for key variables. Associations between LBP and potential risk factors—such as caregiving duration, physical workload, and ergonomic practices—were analysed using ANOVA. Statistical significance was set at the 5% level, ensuring robust analytical rigour.

Ethical Considerations

Ethical approval was obtained from the University of Zambia School of Health Sciences Undergraduate Research Ethics Committee (UNZASHUREC), Protocol ID 20231270285, and the University Teaching Hospitals management. Informed consent was obtained from all participants before data collection. Data confidentiality was ensured by securely storing all data in password-protected and biometric-secure databases, with cloud backups protected by two-factor authentication.

Demographic Details of the Participants

Table 1 provides a summary of the demographic details of the study participants. The majority (85%) were female, with the most common age group being 31 to 34 years (40%). A notable 55% of participants were single, and the vast majority (87.5%) were unemployed. Regarding education, 42.5% had completed secondary school. The children of the caregivers were predominantly under the age of 5, representing 45% of the total sample.

Prevalence of Low Back Pain and Degenerative Conditions

The prevalence of low back pain (LBP) was high among participants. As shown in Table 2, 90% of participants reported experiencing LBP in the past year, while 65% had experienced it at some point in their lives. However, degenerative spinal conditions were less common, with only 5% reporting lumbar spondylitis and 2.5% reporting lumbar spondylosis. Additionally, 45% of participants reported experiencing LBP in the last 7 days.

Risk Factors Influencing Low Back Pain and Degenerative Conditions

Table 3 presents significant risk factors for LBP and degenerative conditions. The most strenuous caregiving activity was strongly associated with LBP (p < 0.001), highlighting that physically demanding caregiving tasks contribute to back pain. Additionally, the availability of orthotic devices (p = 0.016) and emotional stress (p = 0.003) were significant factors, indicating that inadequate support for the spine and psychological burden increase the risk of LBP among caregivers.

Severity of Low Back Pain and Degenerative Conditions

As detailed in Table 4, most participants (47.5%) reported severe LBP, as measured on the visual analogue scale (VAS). Additionally, 45% of participants indicated that the pain lasted less than five days. Despite the severity of pain, only 17.5% sought medical help, suggesting a potential underutilisation of healthcare services. Stress levels were also high, with 40% reporting severe stress related to their caregiving responsibilities.

Participants’ Coping Strategies for Back Pain and Degenerative Conditions

Table 5 highlights the coping strategies employed by participants. The most used strategy was pharmacological treatment, with 55% of participants relying on over-the-counter medication. Rest (32.5%) and herbal concoctions (10%) were also commonly used. Remarkably, only 2.5% of participants used exercise as a coping strategy, indicating a significant underuse of potentially effective non-pharmacological interventions for LBP management.

Caregivers of children with disabilities face significant physical and emotional challenges, particularly in resource-limited settings like Zambia. This discussion highlights the substantial burdens these caregivers endure, with caregiving demands affecting various aspects of their lives, including family dynamics, financial stability, and emotional well-being. The unique challenges faced by caregivers in Zambia, such as limited access to healthcare, ergonomic support, and financial resources, exacerbate these burdens. This study provides valuable insights into the health issues faced by caregivers in Zambia, focusing on the prevalence of low back pain (LBP) and its connection to caregiving activities. The findings are consistent with global trends but also reveal specific contextual factors that influence caregiving in Zambia. These include the absence of structured caregiver support programmes and the cultural expectation for women to assume caregiving roles.

Consistent with global trends, most caregivers in this study were women, reflecting the disproportionate burden they bear in providing informal care^[17]. The high prevalence of LBP among caregivers is a significant finding, indicating that caregiving duties, particularly those involving physically demanding tasks, contribute significantly to musculoskeletal strain. The diverse range of disabilities among the children further complicates caregiving, as each condition requires unique physical and emotional support^[18]. The discrepancy between the high prevalence of LBP (90%) and the low prevalence of degenerative conditions (5%) suggests that most LBP cases are mechanical in nature and reversible with timely intervention. This finding underlines the importance of early identification and management of LBP to prevent progression to chronic conditions. While LBP was common, it was notable that many caregivers did not seek medical attention, possibly due to prioritising the child's needs over their own health, financial constraints, or limited access to healthcare. This reluctance aligns with other research, which suggests that the heavy responsibilities of caregiving often lead to both physical and psychological strain, exacerbating the condition^[19],^[20]. Improving caregivers' access to affordable healthcare and creating awareness about the importance of self-care are critical to addressing this gap.

The relationship between stress and the severity of LBP is a significant concern. The study found that high levels of emotional stress are closely linked to the intensity of physical pain, supporting existing literature that highlights the role of psychological factors such as stress, anxiety, and depression in the onset and exacerbation of LBP^[22]. This highlights the need for integrated health interventions that address both physical and psychological aspects of caregiver well-being. The study explored the risk factors for LBP among caregivers, revealing that the most physically demanding caregiving tasks, such as lifting or transferring the child, significantly increase the risk of developing LBP. Emotional stress was also identified as a key risk factor, highlighting the negative impact of psychological strain on physical health. The availability of supportive equipment, including orthotic devices, was found to reduce some of the physical strain associated with these tasks, in line with previous research that emphasises the importance of providing caregivers with appropriate support to reduce the risk of musculoskeletal injuries such as LBP^[23]. Healthcare systems in Zambia must prioritise the provision of ergonomic support tools, such as orthotic devices, and train caregivers on their proper use.

When examining coping strategies for managing LBP, the study found that caregivers primarily relied on pharmacological treatments and rest. However, exercise, a known effective strategy for managing LBP, was rarely utilised. This may be due to time constraints, lack of awareness about its benefits, or barriers such as physical limitations. Notably, the study also revealed a significant association between the use of orthotic devices and more effective coping strategies, emphasising the importance of access to appropriate resources in alleviating both physical and emotional strain^[24]. Integrating physiotherapy-based education and exercise programmes into caregiving support services could enhance LBP management.

Conclusion

The study highlights the significant physical and emotional challenges faced by caregivers, particularly in relation to LBP. The findings emphasise the importance of addressing both the physical and psychological health needs of caregivers, with a focus on providing practical resources, support, and education. Although degenerative spinal conditions were not prevalent, the high rates of LBP emphasise the need for targeted interventions such as caregiver training, ergonomic support, and stress management programmes. While the study provides valuable insights, its findings are limited by the small sample size and cross-sectional design. Future research with larger, longitudinal studies is necessary to explore causation, identify long-term impacts, and develop sustainable policies for supporting caregivers.

Study Limitations

With only 40 respondents, the findings may not be generalised to a broader caregiver population, because the outcomes are based on individual responses, which limits the study’s external validity. The reliance on a single study site due to budget constraints further limits representativeness, and expanding study locations in future research is recommended. Although quantitative cross-sectional studies are useful for finding correlations and comprehending prevalence, they are less appropriate for studies that require more in-depth understanding of cause-and-effect relationships or changes over time due to their limitations, particularly with regard to causality, temporal changes, and confounding variables. The small sample size also precluded the use of advanced statistical analyses, such as factor analysis. Future studies should aim for larger sample sizes to allow for more robust analytical methods.

Acknowledgement

This study, conducted by F.A.M.O. Koitsiwe as part of the Bachelor of Science (BSc) in Physiotherapy programme at the University of Zambia (UNZA), investigated the prevalence and risk factors of low back pain (LBP) among caregivers of children with disabilities at the Paediatric Department of Physiotherapy, University Teaching Hospital (UTH), Lusaka. We extend our heartfelt gratitude to the participants and the staff of UTH and UNZA for their invaluable support in making this project a success.

Competing Interest

The authors affirm that neither financial interests nor personal relationships influenced the development of this article.

Author's Contribution

All participants contributed significantly to the successful completion of this project. The initial manuscript was drafted by F.A.M.O. Koitsiwe, while the conceptualisation and planning of the research were led by L.A. Nkhata. The final version of the manuscript underwent thorough review and received approval from all contributors.

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