811159

research-article2018
APHXXX10.1177/1010539518811159Asia Pacific Journal of Public HealthUdom et al

Original Article
Asia Pacific Journal of Public Health
1­–11
Predictors for Nonspecific Low © 2018 APJPH
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DOI: 10.1177/1010539518811159
https://doi.org/10.1177/1010539518811159
1-Year Prospective Cohort Study journals.sagepub.com/home/aph

Chadayu Udom, MSc1, Rotsalai Kanlayanaphotporn, PhD1,

and Prawit Janwantanakul, PhD1

Abstract
High prevalence of low back pain (LBP) has been reported among farmers. A number of
contributing factors have been associated with LBP. However, predictors for LBP in this
population are unknown. This longitudinally designed study aimed to identify the predictors of
LBP in a sample of rubber farmers whose work involves heavy manual labor. Three hundred
and twenty-seven rubber farmers, aged 18 to 70 years who reported no LBP in the previous
year, were face-to-face interviewed and examined physically. The incidence of LBP was assessed
monthly. The 12-month incidence of LBP in the cohort was 35%. Having a history of LBP (hazard
ratio = 1.55, 95% confidence interval = 1.05-2.30) and an active job (hazard ratio = 1.98, 95%
confidence interval = 1.16-3.40) were the predictors for the new onset of LBP in this sample.
These 2 factors could therefore potentially be targeted to prevent or reduce the incidence of
LBP in rubber farmers.

Keywords
farmers, incidence, job strain, low back pain, predictors

Introduction
Low back pain (LBP) is a common musculoskeletal problem in general population and as high
as 80% of the general population experience LBP at some time during their lives.1 The 12-month
incidence of LBP ranges from 21% to 31%.2,3 Consequently, this results in significant costs to
individuals in society due to low quality of life4 and lost work days5 in association with LBP.
A number of factors have been found to be associated with LBP. These include history of
LBP,6 low level of education,7 low income,8 perceived fatigue,8 working posture,9 high frequency
of heavy lifting,6,10 and low levels of perceived social support.11 However, all of these factors are
not generalized risk factors for all populations as it was suggested that the predictors for LBP was
occupation specific.12 The predictors for LBP were history of LBP and high initial pain intensity
in office workers12 while it was an active duty status in a military inception cohort.13
Rubber farming, which is an occupation widely found in Southeast Asia that involves hard
physical work was also found to contain some of the aforementioned factors.7,8 It comprises 3

1Chulalongkorn University, Bangkok, Thailand

Corresponding Author:
Rotsalai Kanlayanaphotporn, Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn
University, 154, Rama 1 Road, Soi Chula 12, Pathumwan, Bangkok 10330, Thailand.
Email: rotsalai.k@chula.ac.th
2 Asia Pacific Journal of Public Health 00(0)

main tasks, that is, rubber tapping, rubber collecting, and rubber sheeting. During rubber tapping,
rubber farmers use a knife to cut a line on the rubber trees that causes the rubber latex to drip into
a cup located below the bark line. Rubber collecting occurs when rubber farmers continuously
walk to collect rubber latex or rubber piece from a cup and put it into a big bucket. Rubber sheet-
ing involves processing rubber latex or rubber piece into rubber sheets. High 12-month preva-
lence of LBP between 56% and 77% was reported in this population.7,14,15
Nevertheless, most of the previous studies on risk factors of LBP in manual laborers employed
cross-sectional research design. There is a lack of research that has described the incidence of
LBP or predictors of LBP in rubber farmers. This therefore limits our ability to draw causal con-
clusions regarding the causes or prospective predictive risk factors of LBP in this population. By
assessing for baseline variables that are associated with the new onset of LBP, better planning for
potential intervention could be administered.
This study aimed to identify the predictors of LBP over a 12-month period in a cohort of rub-
ber farmers. We hypothesized that several predictors of LBP would be identified.

Methods
Study Design
This study used a prospective longitudinal research design with a 1-year follow-up. Data were
collected from July 2016 to August 2017 in rubber farmers of Nakhonsrithammarat province,
Thailand, using convenience sampling. The Research Ethics Review Committee for Research
Involving Human Research Participants, Health Sciences Group, Chulalongkorn University,
approved the study protocol (Approval Number 106/2016 and 092/2017).

Study Sample
Rubber farmers aged between 18 and 70 years, who had at least 1 year experience in rubber farm-
ing, were considered for participation in this study. They were required to have no LBP with a
pain intensity greater than 30 mm on a 100-mm visual analog scale (VAS) in the previous year.
They were excluded if they met any of the following criteria: (1) endorsed a history of physician-
diagnosed neurological or musculoskeletal disorders of spinal condition that might be aggravated
by physical examinations used in this study; (2) a history of major back or lower limb traumas;
(3) a history of abdominal surgery; (4) a history of an accident involving the low back; and (5)
were currently pregnant or planned to become pregnant in the next year.
The sample size needed to find hazard ratio (HR) of 2.0 with a 2-tailed α of 0.05 and 80%
power with an anticipated probability of exposure of 0.25 was calculated.16 At least 290 partici-
pants were required.

Baseline Measurements
All participants were asked to fill out a self-administered questionnaire and underwent physical
examinations by trained physical therapists following a standardized protocol. The questionnaire
inquired regarding individual, work-related, and psychosocial factors. Individual factors included
age, sleep duration, rest duration, gender, educational level, smoking status, frequency of exer-
cise, any ongoing chronic health conditions as well as history of LBP, and any musculoskeletal
symptoms in the last year. Work-related factors included current work position, years of employ-
ment, working task, working frequency, working posture, working duration, tapping level, expo-
sure to pesticides, and having second job(s). Psychosocial factors were measured using the
54-item Job Content Questionnaire–Thai version (TJCQ),17 which contains 6 subscales that
Udom et al 3

assess perceived control over one’s job, psychological job demands, physical job demands, per-
ceived job security, perceived social support, and perceived work hazards. Since perceived con-
trol over one’s job and psychological job demands were found to have a joint effect, the scores
from these 2 subscales were used to calculate job strain level.18 The participants were classified
into 1 of 4 groups: (1) low strain job (high control, low psychological job demands), (2) active
job (high control, high psychological job demands), (3) passive job (low control, low psychologi-
cal job demands), and (4) high strain job (low control, high psychological job demands). Median
value was used for dichotomization of each subscale. The scores greater than the median were
classified as having high control or high psychological job demands.19
Three physical examinations were carried out. First, body weight and height were measured
using a digital scale and a wall-mounted stadiometer, which were later computed as body mass
index (kg/m2). Second, back muscle endurance was examined using the Sorensen test.20 The dura-
tion that the participants could maintain their trunk in the horizontal position with the arms folded
across the chest was recorded. This test showed excellent reliability in this study ([intraclass cor-
relation] ICC(3,1) = 0.89). Third, performance of the back stabilizer muscle was assessed in prone
position using a pressure biofeedback unit.21 The participants were categorized as having normal
and abnormal responses when they could produce the pressure change from baseline ⩾4 mm Hg
and <4 mm Hg, respectively.21 The current study found this test to be reliable (κ = 0.69).

Outcome Measures
Participants were prospectively followed monthly via a telephone interview to determine whether
or not they had self-perceived LBP that lasted more than 24 hours in the past month. The partici-
pants who were uncontactable by phone were contacted in person by researchers. An incident
case was defined as a new episode of LBP within the 12 months of the study. The pain had to
localize between the lower margins of the 12th rib and inferior gluteal folds with no known
underlying pathology.4 Any participants who responded affirmatively was appointed to meet
with researchers for asking about their pain intensity. The pain intensity of 31 mm or more on a
100-mm VAS was deemed to have incident of LBP.22 The pain intensity greater than 70 mm was
considered as severe pain, while the pain between 31 and 70 mm was moderate pain.23 The par-
ticipants were followed until they completed the 12-month follow-up, became symptomatic, or
withdrew from the study.

Statistical Analysis
Demographic data were described using means and proportions. The 12-month cumulative inci-
dence of LBP was calculated as the proportion of new cases of LBP at each month of follow-up.
A univariate Cox regression analysis was performed to identify the predictors for the develop-
ment of LBP to be included in the final model. Any factor with a P value <.1 was considered as
a potential predictor in the planned multivariate Cox regression analysis. The HR and the 95%
confidence interval were calculated for each predictor. Statistical significance was set at P < .05.
All statistical analyses were performed using the SPSS statistical software, version 22.0 (SPSS
Inc, Chicago, IL).

Results
Incidence and Demographic Characteristics
Three hundred and twenty-seven participants consented to take part in the study. Thirteen partici-
pants dropped out, which left 314 participants for the final analyses (Figure 1). No participants
4 Asia Pacific Journal of Public Health 00(0)

Figure 1.  Flowchart of the participants’ recruitment.

had an ongoing condition that impeded them from performing physical examinations. Table 1
presents the baseline characteristics of the study population. A total of 110 (35%) participants
reported new onset of LBP during the 12-month period. On average, the pain intensity on the
VAS was found to be moderate (5.2 ± 1.6).

Predictors of LBP in Rubber Farmers

When univariate analysis was used, the results revealed that job strain level, history of LBP, cur-
rent work position, other musculoskeletal symptoms in the previous 12 months, engaging in
pushing and pulling motions at work, and perceived social support were the factors that showed
a P value <.1 (Table 2). Thus, these covariate factors were selected for further analysis. After
adjusting for potential confounders, Cox regression analyses showed that history of LBP (HR =
1.55, 95% CI = 1.05-2.30) and having an active job (HR = 1.98, 95% CI = 1.16-3.40) were the
significant predictors of LBP in the study sample (Table 2). A post hoc power analysis16 was
performed using the sample size of this study, there were 68.8% and 97.5% power to detect haz-
ard ratios of history of LBP and having an active job, respectively. Using low strain job as the
reference, an active job exhibited a lower survival curve than low strain job (Figure 2).

Discussion
This is the first prospective cohort study on the predictors of LBP in rubber farmers. The 12-month
incidence of LBP in rubber farmers was as high as 35%. The factors that contributed significantly
to the development of LBP in the study sample were having a history of LBP and an active job
(according to the job strain level of the JCQ).
To the best of the authors’ knowledge, no previous studies have examined the incidence of
LBP in rubber farmers. The incidence of LBP in this study was higher than previous research in
other manual laborers, wherein different tasks were performed.3,23-25 This high incidence of LBP
might support the high prevalence of LBP reported by previous studies investigating rubber
farmers.7,14 This information raises the need to find interventions for reducing the risk of LBP in
this population.
Udom et al 5

Table 1.  Baseline Characteristics of the Participants (n = 327).

Characteristics n (%) Mean ± SD Median

Individual factors
Age (years) 49.3 ± 10.8  
Body mass index (kg/m2) 24.7 ± 14.8  
Sleep duration (hours/day) 5.7 ± 1.7  
Rest duration (hours/day) 3.5 ± 2.0  
Gender
 Male 111 (33.9%)  
 Female 216 (66.1%)  
Educational levels
  Primary school 211 (64.5%)  
  Post–primary school 116 (35.5%)  
Smoking status
  Current smoker 76 (23.2%)  
  Former smoker 20 (6.1%)  
  Never smoker 231 (70.6%)  
Frequency of exercise
  At least 20 minutes per time, 3 times per week 109 (34.7%)  
  Less than 20 minutes per time, 3 times per week 205 (65.3%)  
History of LBP
 No 239 (73.1%)  
 Yes 88 (26.9%)  
Other MSDs in the previous 12 months
 No 160 (48.9%)  
 Yes 167 (51.1%)  
Work-related factors
Current work position
  Farm owner 181 (55.4%)  
 Employee 146 (44.6%)  
Years of employment 19.1 ± 13.5  
Working tasks
  Rubber collecting only 4 (1.2%)  
  Rubber tapping only 20 (6.1%)  
  Rubber tapping and collecting 288 (88.1%)  
  Rubber tapping, collecting, and sheeting 15 (4.6%)  
Working frequency
  1 day work and 1 day off 4 (1.3%)  
  2 days work and 1 day off 210 (66.9%)  
  3 days work and 1 day off 88 (28%)  
 Everyday 12 (3.8%)  
Duration at each task (hours/day)
 Tapping 4.0 ± 2.0  
  Collecting latex 2.0 ± 0.8  
  Collecting piece 2.5 ± 1.2  
 Sheeting 2.1 ± 1.2  
Current tapping levels
  Thoracic level and above 177 (54.1%)  
  Below thoracic level 150 (45.9%)  

(continued)
6 Asia Pacific Journal of Public Health 00(0)

Table 1. (continued)

Characteristics n (%) Mean ± SD Median

Working posture
 Sitting 183 (56.0%)  
 Standing/walking 327 (100.0%)  
 Bending 272 (83.2%)  
 Lifting 173 (52.9%)  
 Reaching 178 (54.4%)  
 Twisting 116 (35.5%)  
 Push/pull 71 (21.7%)  
Duration of each posture (hours/day)
 Sitting 1.3 ± 1.0  
 Standing/walking 3.5 ± 1.9  
 Bending 2.0 ± 1.6  
 Lifting 1.5 ± 1.1  
 Reaching 1.8 ± 1.6  
 Twisting 1.5 ± 1.4  
 Push/pull 1.9 ± 1.3  
Exposure to pesticides
 Yes 30 (9.2%)  
 No 297 (90.8%)  
Second job
 Yes 30 (9.2%)  
 No 297 (90.8%)  
Psychosocial factors
JCQ scores
  Perceived control over one’s job 39.2 ± 4.5 38.5
  High 181 (57.6%)  
  Low 133 (42.4%)  
  Psychological job demands 33.3 ± 4.9 33.0
  High 172 (54.8%)  
  Low 142 (45.2%)  
  Physical job demands 15.6 ± 3.0 15.0
  Perceived job security 15.6 ± 1.7 16.0
  Perceived social support 28.6 ± 11.1 24.0
  Perceived work hazards 14.1 ± 2.4 13.0
Job strain levels
  Low strain job 71 (22.6%)  
  Active job 110 (35.0%)  
  Passive job 71 (22.6%)  
  High strain job 62 (19.7%)  
Physical factors
Performance of back muscles endurance (seconds) 131.8 ± 81.5  
Performance of back stabilizer muscles  
  Normal response 107 (34.1%)  
  Abnormal response 207 (65.9%)  

Abbreviations: LBP, low back pain; MSD, musculoskeletal disorder; JCQ, Job Content Questionnaire.
Udom et al 7

Table 2.  Cumulative Incidence, Unadjusted and Adjusted HRs With 95% CIs of 12-Month LBP With
Respect to Factors in the Final Modeling (n = 314).
Incidence Unadjusted Adjusteda
of LBP (n =
Variables N 110), n (%) HR 95% CI P HR 95% CI P
Job strain levels
  Low strain job 71 18 (25.4%) 1.00 — 1.00  
  Active job 110 51 (46.4%) 2.04 1.19-3.50 .01 1.98 1.16-3.40 .013
  Passive job 71 18 (25.4%) 1.04 0.54-2.00 .91 1.01 0.52-1.94 .981
  High strain job 62 23 (37.1%) 1.59 0.86-2.95 .14 1.42 0.76-2.66 .268
History of LBP
 No 229 71 (31.0%) 1.00 — 1.00  
 Yes 85 39 (45.9%) 1.53 1.03-2.26 03 1.55 1.05-2.30 .029
Current work position
  Farm owner 172 52 (30.2%) 1.00 —  
 Employee 142 58 (40.8%) 1.47 1.01-2.14 .04  
Other MSDs in the previous 12 months
 No 154 45 (29.2%) 1.00 —  
 Yes 160 65 (40.6%) 1.51 1.03-2.20 .04  
Push/pull working posture 69 18 (16.4%) 0.59 0.32-1.07 .08  
Perceived social support 314 110 (35%) 1.08 0.99-1.17 .05  

Abbreviations: HR, hazard ratio; CI, confidence interval; LBP, low back pain; MSD, musculoskeletal disorder.
aAdjusted for job strain level, history of LBP, current work position, other musculoskeletal symptoms in the previous

12 months, engaging in pushing and pulling motions at work, and perceived social support.

The finding of having a history of LBP as a significant predictor for the occurrence of LBP
concurs with the results from previous research. It was reported that sedentary and manual work-
ers with a history of LBP were at risk of developing LBP.24,26,27 Those with a history of LBP of
high intensity were particularly at higher risk.28 In this study, rubber farmers who had a history
of LBP were 1.5 times likely to develop LBP more than those who had no such history. This
amount of risk is relatively lower than those reported in previous studies (1.9-10.3).24,26-28 The
discrepancy might be related to the difference in the inclusion criteria of the subjects at baseline.
The current study recruited participants who had no LBP in the previous 12 months whereas the
other studies only recruited participants who had no LBP at baseline. It is therefore possible that
the participants in the current study were relatively healthier. Although we did not record the
onset time of previous LBP in our participants, the finding suggests that having a history of LBP
even prior to the previous 12 months of recruitment should be considered in the management of
LBP in this population.
With history of LBP, several physical impairments have been demonstrated even when the
pain has subsided. Wasting and weakness of trunk muscles have been reported, especially in the
group that provides stability to the lumbar spine.21 Impaired motor control with delayed muscle
reflex response to sudden trunk loading was demonstrated.26 These impairments then lead to
abnormal stress and strain on lumbar structures that can cause pain. However, the finding of simi-
lar proportions of individuals with abnormal back stabilizer muscle performance between those
who did and did not develop LBP in this study did not support this notion in rubber farmers.
The possible explanation for the significant effect of history of LBP might be due to the effects
of prior pain experience. Fear of pain and fear of reinjury, which are associated with avoidance
behaviors and hypervigilance to bodily sensation and pain, are often reported in these individu-
als.29 The increase in body awareness and attentional focus toward pain and noxious body
8 Asia Pacific Journal of Public Health 00(0)

Figure 2.  The survival curve comparing low strain job group with other groups.

stimulus might make these persons with history of LBP to more likely to report pain. Although
history of LBP is a nonmodifiable predictor, this information is useful for health care profession-
als to realize who requires advice or preventive measures for LBP.
Among the studies that examined whether job strain is a risk factor of LBP, all reported that
those who were classified as having high strain jobs were at greater risk of LBP than the other
categories.30-33 With high strain work, the stress associated with high psychological job demands
in conditions that the persons cannot adjust their work variables (eg, environment, their work
load, and their speed of work) increases muscle tension and leads to LBP.34 Nevertheless, this
association between high strain job and LBP occurs only in the conditions of high physical expo-
sures31 and this appears to be bidirectional.32 The effects of high strain jobs were found to be
more prominent in women than men.33 Moreover, increasing high psychological job demands
without increasing perceived control over one’s job could also pose further risk of LBP.30
However, high strain job was not a risk factor for LBP in the current study. This difference might
be due to the differences in the work-rest cycle among studies. Due to the nature of rubber pro-
duction, tapping usually happens intermittently. The common cycle is a day off every 2 working
days. For those who had high perceived control over one’s job such as farm owners, this work-
rest cycle could vary. For other occupations, workers commonly have 2 days off and work 5
consecutive days. Although rubber farming is a strenuous task that requires high physical load,
the relatively frequent rest cycle allows more time for tissues to recover from musculoskeletal
symptoms related to LBP. Consequently, this may reduce the potential risk of LBP.
Surprisingly, this study found that high perceived control over one’s job accompanied with
high psychological job demands (active job) was a significant predictor of LBP. Those with
active jobs developed LBP at twice the number of those with low strain jobs. This finding is in
contrast with a study of the automobile industry that found active jobs tend to be a protective
factor of LBP.31 In general, it is deemed that high perceived control over one’s job allows them
Udom et al 9

to adjust their work procedure according to each individual’s own resources and decreases their
risk of getting LBP.18 Notably, high perceived control over one’s job under the condition of high
psychological job demands might not help decrease the risk of LBP in this population. This find-
ing suggests the dominant role of psychological job demands in LBP. Since rubber farming is an
agricultural occupation that relies heavily on climate and seasonal variations that are uncontrol-
lable, the products and income can fluctuate. This may cause stress to the rubber farmers that
differs from other industrial or sedentary workers. As a result, an occupation that has to encounter
these variations regularly might be at risk of LBP.
Several associated factors for LBP in rubber farmers have been reported in previous cross-
sectional research.7,8 However, all of these factors were not proven to be risk factors of LBP in
this study. This difference emphasizes the importance of reporting prospective studies when risk
factors are to be studied.

Strengths and Limitations

The strengths of the present study are that it is a prospective cohort study, which could establish
the causal relationship between predictors and LBP. The follow-up was conducted on the study
sample every month, which can reduce recall bias. This study determined multiple factors includ-
ing individual, work-related, and psychosocial factors, which can lead to clearly substantiating
the multifactorial nature of LBP. Furthermore, the interaction effects between the domains of the
job-related psychosocial factors were examined.
However, this study has some limitations. First, this study used a convenience sample that
restricts the external validity of the study. The results of rubber farmers might be similar to
manual laborers but generalization of the results from this study to other working populations
should be made with caution. The estimated incidence rate might also be different with different
cohorts. Second, LBP symptoms were identified based on subjective information only, which
may lead to inaccurate identification. To increase the accuracy of differentiation, further research
should consider the use of physical examination. Third, physical load in this study was assessed
using a subjective self-report via working posture and duration at work. To clearly determine the
amount of physical load, further studies should assess physical load using observation or objec-
tive examination. Last, this study used a study sample who had no LBP in the previous 12 months,
and the healthy worker effect (eg, unhealthy workers are more likely to change their job) may
affect these findings. To reduce the healthy worker effect, further studies should use a nested
case-control study design.

Conclusion
The current study found that history of LBP and active job are predictors for the occurrence of
LBP in rubber farmers. Such information is important in the prevention or reduction of new onset
or recurrent LBP in this population. Thus, workplace interventions aimed at reducing the inci-
dence of LBP should focus on these 2 predictors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-
cation of this article: This research has been supported by National Research University Project, Office of
Higher Education Commission (NRU59-009-HR).
10 Asia Pacific Journal of Public Health 00(0)

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