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Spine (Phila Pa 1976). 2012 March 15; 37(6): 508–514. doi:10.1097/BRS.0b013e318221e83f.
Back Pain among Farmers in A Northern Area of China

Xiaotong Liu1, Limin Wang, MD, MPH2, Lorann Stallones, PhD3, Krista K. Wheeler, MS1,
Weiyan Zhao, MD, PhD1, Gary A. Smith, MD, DrPH1, and Huiyun Xiang, MD, PhD1
1Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital,
The Ohio State University College of Medicine, Columbus, Ohio, USA

2Division
of Disease Surveillance, National Center for Chronic Disease Control and Prevention,
Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
3Colorado Injury Control Research Center, Department of Psychology, Colorado State University,
Fort Collins, Colorado, USA
Abstract
Study Design—This was a population-based survey conducted in 2008 in a northern area of

China.
Objective—To investigate back pain prevalence and to examine the associations between
potential risk factors and back pain among Chinese farmers.
Summary of Background Data—Few studies have investigated back pain and its associated
risk factors among farmers in low-income and developing nations.
Methods—Farmers ages 15 years and older were chosen from 800 families in Heilongjiang
Province of People’s Republic of China using cluster sampling methods. Complete survey data
were obtained from 2045 farmers. The prevalence of self-reported back pain during the previous
three-months was reported. Associations between back pain and potential risk factors were
examined in logistic regression models which included age, gender, education levels, perceived
stress, main farm activities, smoking, and drinking status.
Results—A total of 786 (38.4%) farmers reported back pain. Two-thirds of those with back pain
(66.0%) reported that back pain affected work quantity and quality. The adjusted odds ratios of
reporting back pain increased with advancing age. Females and farmers who experienced stress
regularly were also more likely to report back pain.
Conclusion—Back pain is a common problem among Chinese farmers and is reported more
frequently by females. Significant positive associations of gender, age, and perceived stress with
back pain warrant additional study.
Keywords
back pain; stress; farmers; agricultural work; China; epidemiology
Corresponding author Huiyun Xiang, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s
Hospital, Columbus, Ohio, 43205. Huiyun.Xiang@nationwidechildrens.org Telephone: 614-722-2400, Fax: 614-722-2448.
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Liu et al. Page 2
INTRODUCTION
Among working adults, low back pain (LBP) is one of the principal causes of disability in
industrialized nations.1 Occupational risk factors contribute to 37% of LBP worldwide.2

Moreover, back pain leads to substantial losses in financial revenue and to reductions in
quality of life. Farming has become increasingly recognized as an occupation that poses a
high risk for back pain. The risk of back and joint pain has been found to be higher among
farmers when compared with workers from other occupational sectors, including manual
workers.3
A number of contributing factors have been associated with back pain among farmers.
Potential risk factors include physical occupational demands such as manual handling,
repetitive motion, and whole body vibration and mechanical shock from farming
equipment.4-6 Additionally, several studies in industrialized nations have shown that people
with mental distress and people who smoke are more likely to suffer from back pain.7-9
While there has been research in the United States 4,10 and other developed countries,5,11
less is known about the factors associated with back pain among farmers in low-income and
developing nations. In the past three decades, the still-developing People’s Republic of
China (PRC) has emerged as a prevailing force on the world market. Producing 30% of the
world’s rice, 20% of the world’s corn, 25% of the world’s cotton, an estimated 37% of the
world’s fruit and vegetables, and half of the world’s pork, China has become the largest
agricultural producer and consumer.12 Not only does China export to the rest of the world, it
must also sustain its own population of 1.3 billion. It is thus imperative to investigate and to
address the issue of back pain among China’s vast agricultural workforce.
The objectives of this study were to: 1) describe the prevalence of back pain among Chinese
farmers by selected demographic characteristics and 2) examine the associations between
potential risk factors (perceived stress, smoking and alcohol drinking) and back pain among
Chinese farmers.
MATERIALS and METHODS

Data Source
We analyzed data from a population-based survey conducted in 2008 that was a
collaborative effort between the Center for Injury Research and Policy (CIRP) of the
Research Institute at Nationwide Children’s Hospital, the Colorado Injury Control Research
Center (CICRC) of the Psychology Department at Colorado State University, and a research
team from the School of Public Health of Qiqihar Medical University. These data were
previously used by Wang et al. in a study investigating the association between alcohol
consumption and work-related injuries among Chinese farmers. The survey procedures and
study methods were described in detail in their study.13
Study Design and Sampling

Qiqihar is a population center located in China’s northernmost province, Heilongjiang
Province. Approximately 59% of Qiqihar’s population lives in surrounding agricultural
areas. Information about residents was obtained from Qiqihar’s mandatory registration of
residents. The following procedures were utilized to select the sample for this study. First,
800 families were selected through systematic sampling from 9 villages with similar soil and
farming techniques. Using cluster survey sampling methods, rural residents 15 years of age
and older were surveyed.
Liu et al. Page 3
With help from CIRP and CICRC, the research team at the School of Public Health of
Qiqihar Medical University developed the survey questionnaire. After obtaining approval
from the Colorado State University Institutional Review Board and the Scientific Research
Committee of the Qiqihar Medical University, the study was officially launched.
Trained in May 2008 by the principal investigator, 25 students from the School of Public
Health of Qiqihar Medical University served as interviewers. Student interviewers filled in
all questionnaires by conducting face-to-face interviews. Data collection began on May 7
and was completed by May 25 in 2008. The principal investigator at the university randomly
chose 25 questionnaires following completion of the initial survey and met with the
respondents to verify the consistency of the data collected. Data agreement was greater than
90%, and so the previously collected data were considered reliable.
Definition of Back Pain

A specific question about back pain was asked in the survey: “During the past three months,
that is, February to April, 2008, did you have back pain that lasted for a full day or more?”
In this study, a positive response (yes) to this question was defined as back pain. To those
who self-reported back pain, another question was asked: “Did any of the back pain you had
during the past three months affect your work quality or quantity?” Respondents who
answered “yes” were defined as having back pain that affected work.
Potential Risk Factors

The potential risk factors examined in this study were gender, age, education, main
agricultural activities, perceived life stress, cigarette use, and alcohol consumption. Subjects
were asked to evaluate the overall level of stress they felt in relation to external factors, as
well as whether they perceived stress in their family and neighbor relationships. Subjects
were asked whether they smoked or drank, as well as a detailed history of their use.
Statistical Analysis
EpiData 3.02 was used to collect and store the data.13 Both SPSS 13.0 and SAS 9.1 were
used in the data analysis. Our analysis was completed in phases. First, the prevalence of self-
reported back pain was compared across gender, age, education, and main agricultural
activities using Pearson Chi-square tests.. Similarly, comparisons in back pain prevalence
were considered across stress, smoking, and alcohol consumption variables. Finally, logistic
regression models were fitted with back pain and back pain that affected work as the
outcome variables and gender, age, education , main farm activities, perceived stress,
smoking, and alcohol use status as independent variables. Odds ratios (ORs) with 95%
confidence intervals (CIs) were reported. We also evaluated the use of the Generalized
Estimating Equation (GEE) to account for non-independence because more than one adult
could participate from the each family (using the SAS GENMOD procedure). The original
survey did not include a cluster variable, but we could identify clusters using phone numbers
for just over 43% of our sample. On average, 2 individuals from each family (i.e. with the
same phone number) participated in our survey. Our statistical results from the standard
logistic regression analysis and the GEE that accounted for clustering effects were similar,
and the conclusions were the same. Therefore, we choose to present the results of logistic
regression models, so we could utilize the full dataset.
RESULTS
Of the 2264 respondents initially selected, only 15 (0.7%) declined to participate in the
survey, and another 51 (2.3%) provided incomplete information. After data collection, we
found that 148 persons actually spent little time performing farm work so they were
Liu et al. Page 4
excluded from the study. Therefore, 2045 farmers were included in the final analyses. There
were 786 (38.4%) farmers who reported having experienced general back pain and 518
(25.4%) who reported having experienced back pain that affected work within the 3 months
preceding the survey. Two-thirds of those with back pain (66.0%) reported that back pain
affected work quantity and quality. Because patterns and potential risk factors were similar
for back pain and back pain that affected work, the results and discussion in this article focus
primarily on general back pain.
Demographic Variables
As shown in Table 1, 40.7% of females reported back pain compared with 36.3% of males
(P=0.041). Additionally, farmers ages 25 and older reported significantly higher rates of
back pain relative to younger farmers (15-24 year olds) with those over age 35 reporting
back pain over 40% more often than the younger farmers. Farmers whose main farm activity
was crop cultivation were more likely to report back pain than farmers whose main activity
was breeding livestock, although this difference was not statistically significant (42.1% vs.
37.9%, P=0.092).
Perceived Stress, Smoking and Alcohol Consumption

Of the 584 farmers who reported experiencing stress “regularly,” 53.9% reported back pain
compared with 31.3% of farmers who reported back pain among those that said they never
experienced stress (P<0.001) (Table 2). Overall, less than 2% of respondents reported stress
in their familial and neighbor relationships, but those with familial stress reported back pain
more often than those without that stress (P=0.003). Back pain was self reported more often
among smokers than among non-smokers (P=0.008). Current and former drinkers reported
back pain more often than those abstaining from alcohol.
Multivariate Analyses
Gender, age, and stress were statistically significant in the multivariate model (Table 3). The
associations of smoking and drinking with back pain were not statistically significant after
controlling for other variables in the multivariate model. Females were more likely to
experience back pain than males (OR 1.22; 95% CI: 1.09-1.36). The odds ratios of back pain
increased with increasing age among farmers. Farmers with regularly perceived stress had
an increased odds ratio of reported back pain (OR 2.51; 95% CI: 2.00-3.16) compared with
farmers who “never or rarely” experienced stress.
DISCUSSION
The overall prevalence of self-reported back pain in the preceding 3 months among Chinese
farmers in Qiqihar was 38.4%; back pain affected the quantity and quality of work for over a
quarter of the farmers. Though comparisons to other studies face limitations because of
differences in reference periods, study population, and back pain definitions, the results of a
U.S. study and several other Chinese studies provide context for our results. In the United
States, a study using a large nationally representative dataset, reported a previous 3 month
prevalence of LBP (with and without neck pain) of 26.3%.14 Studies of LBP among farmers,
mostly males in the U.S. have sometimes reported higher levels of prevalence.4,15 Several
studies have described self-reported LBP prevalence rates in Chinese populations. Nearly
67% of farmers in eastern China self-reported back pain in the previous 12 months, and the
prevalence rate among women was consistently higher than that among men until age 60.16
Jin, et al. reported an annual LBP prevalence rate of 50% for 3 types of workers in
Shanghai: teachers, battery/ kiln factory workers, and garment workers.17 A cross-sectional
study of villages in Tibet found a point prevalence rate of LBP of 34.1% and a 12-month
prevalence of 41.9%. 18 In our multivariate modeling, sex, age, and perceived stress were
Liu et al. Page 5
statistically associated with back pain while controlling for education, farm activity,
smoking, and alcohol use, but gender had only a weak association in the multivariate logistic
model. Greater back pain reported among women has been seen in other large population
based studies.14,19 Of the 4 identified studies about back pain among Chinese general
populations or workers, 16-18,20 only one study of a rural population in Tibet reported no
gender-related difference in prevalence of back pain.18 The three other previous studies and
our study suggest that females have slightly higher prevalence of back pain.16-18,20 This
higher prevalence of back pain among Chinese females may be due to reporting bias (i.e.,
females may be more likely to report back pain than males) or pain among females due to
menstruation.16,17
In the multivariate modeling, advancing age and perceived stress were more strongly
associated with back pain than gender. Close to half of Chinese farmers older than 45 years
of age reported back pain, and those farmers with regular stress reported back pain more
often than those who never or rarely perceived stress. There are a number of literature
reviews regarding back pain and psychosocial factors at work21,22 and in private life.23,24
More recently, a review of review studies has been published.25 While there appears to be
value in including psychosocial factors in studies of back pain,25,26 associations should be
viewed cautiously.22 It is not possible to determine the direction of causality between pain
and stress in this cross-sectional survey.
In the univariate analysis, we observed that smokers were significantly more likely to have
self-reported general back pain, and individuals with 20 or more years of smoking cigarettes
had a significantly higher prevalence of general back pain. In addition, former drinkers were
significantly more likely to report general back pain and back pain that affected work quality
and quantity. The prevalence of self-reported back pain that affected work also increased
with years of alcohol drinking. Our results further suggested that years of alcohol drinking
has a larger impact on back pain that affected work than on general back pain. These results
could be caused by the confounding effects of age. We found a strong association between
age and both general back pain and back pain that affected work in this study. Older
individuals are more likely to be former alcohol drinkers and smokers than young
individuals in China. Cigarette smoking and alcohol drinking were not associated with back
pain in the multivariate model controlling for confounding effects of age. These results
suggest that association between years of cigarette smoking/alcohol drinking and self-
reported back pain could be explained by the confounding effects of age. According to a
systematic literature review of original research reports published between 1987 and 1995,
there is no positive association between alcohol consumption and low back pain.27
However, one recent prospective study suggests that moderate alcohol consumption had a
protective effect on back pain.28 A meta-analysis of 40 studies published prior to February
2009 indicates that the association between smoking and low back pain was fairly modest.29
This study has several limitations. First, because of the variability of estimates and their high
sensitivity to various factors, such as inquiry phrasing, setting and cultural differences,
comparison of prevalence rates of back pain among various populations and countries can be
problematic.3,30 In future studies, standard definitions of back pain for use in
epidemiological studies developed and agreed upon by a group of international experts
should be used.31 Their use will facilitate comparisons among back pain studies
internationally.32 Second, results were based on self-reports of back pain and the potential
risk factors and may have been affected by recall bias. Also, due to cultural stigmatization
regarding alcohol consumption and cigarette usage, it is possible that participants
underreported actual usage. Third, although the study questionnaire asked a general question
about whether subjects “perceived life stresses,” the more detailed questions focused only on
familial and neighbor relationships, not allowing assessment of other sources of stress, such
Liu et al. Page 6
as job, economic and other life pressures. In addition, the psychometric properties of the
stress questions used in the study have not been validated. Finally, because our study was
cross-sectional, causality cannot be evaluated.
Conclusions
This study found a high prevalence of self-reported back pain among farmers in this
northern area of China. Because two-thirds of those with back pain (66.0%) reported that
back pain affected work quantity and quality, back pain is an important public health issue
among agricultural workers in China. Future research should address remaining important
questions regarding prevalence of back pain, risk factors, and effective interventions.
Acknowledgments
Dr Limin Wang was a trainee of the USA-China Agricultural Injury Research Training project. Grant sponsor:
National Institutes of Health Fogarty International Center (PIs: L Stallones and H Xiang; Grant #:
1D43TW007257-01A2). The findings and conclusions in this report are those of authors and do not necessarily
represent the views of the funding agency.
We thank researchers and students at the School of Public Health, Qiqihar Medical University for data collection.
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Liu et al. Page 8
Key Points
• The overall prevalence of self-reported back pain in the preceding 3 months
among Chinese farmers in Qiqihar was 38.4%.

• Back pain affected the quantity and quality of work for over a quarter of the
farmers.
• In multivariate logistic models, gender, age, and perceived stress were
associated with back pain while controlling for education, farm activities,
cigarette and alcohol use.
• Females and older farmers were more likely to report back pain.
• Farmers under regular stress reported back pain significantly more often than
those without perceived stress.
Liu et al. Page 9
Mini Abstract
We investigated back pain and back pain that affected work among Chinese farmers in a
northern area of China. Both were self-reported in face-to-face interviews in this

population-based survey. High prevalence of back pain was found among farmers,
especially among females, older farmers, and those reporting perceived stress.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 1
Demographics and Perceived Stress of Chinese Farmers with Self-reported Back Pain and Back Pain that Affected Work
Back Pain that

Liu et al.
Back Pain
Affected Work
Total n %* P n %* P
Total 2045 786 38.4 519 25.4

Sex
Male 1073 390 36.3 Ref. 252 23.5 Ref.
Female 972 396 40.7 0.041 267 27.5 0.042
Age (Yrs)
15-24 195 31 15.9 Ref. 17 8.7 Ref.
25-34 438 130 29.7 <0.001 63 14.4 0.048
35-44 515 213 41.4 <0.001 135 26.2 <0.001
45-54 426 203 47.7 <0.001 154 36.2 <0.001
55-64 326 145 44.5 <0.001 102 31.3 <0.001
65-74 105 49 46.7 <0.001 37 35.2 <0.001
75-84 29 14 48.3 <0.001 11 37.9 <0.001
Education
Elementary or Below 828 348 42.0 Ref. 248 30.0 Ref.
Middle School 1049 374 35.7 0.005 220 21.0 <0.001
High School and Above 168 64 38.1 0.345 51 30.4 0.807
Main Farm Activities
Livestock Breeding 1271 482 37.9 Ref. 311 24.5 Ref.
Crop Cultivation 573 241 42.1 0.092 167 29.1 0.034
Other 201 63 31.3 0.073 41 20.4 <0.001
*
Row percentages; Ref.- Reference Group
Page 10
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 2
Perceived stress, Cigarette and Alcohol Use in Chinese Farmers Self-reporting Back Pain and Back Pain that Affected Work
Back Pain that

Liu et al.
Back Pain
Affected Work
Total n %* P n %* P
Perceived Stress
Never or Rarely 785 246 31.3% Ref. 152 19.4% Ref.
Sometimes 667 223 33.4% 0.395 144 21.6% 0.294
Regularly 584 315 53.9% <0.001 222 38.0% <0.001
Familial Stress
No 2003 763 38.1% Ref. 501 25.0% Ref.
Yes 33 21 63.6% 0.003 17 51.5% <0.001
Neighbor Stress
No 2005 769 38.4% Ref. 506 25.2% Ref.
Yes 31 15 48.4% 0.255 12 38.7% 0.115
Smoker
No 1214 438 36.1% Ref. 297 24.5% Ref.
Yes 831 348 41.9% 0.008 222 26.7% 0.251
Years Smoking†
Less than 10 152 50 32.9% Ref. 31 20.4% Ref.
10 to 19 201 77 38.3% 0.294 40 19.9% 0.909
20 or More 478 221 46.2% 0.004 151 31.6% 0.764
Drinker
Never (Abstainer) 1358 495 36.5% Ref. 333 24.5% Ref.
Former (Quit) 76 39 51.3% 0.005 27 35.5% 0.031
Current 611 252 41.2% 0.015 159 26.0% 0.477
Years Drinking†
Less than 5 56 21 37.5% Ref. 7 12.5% Ref.
5 to 9 89 31 34.8% 0.744 16 18.0% 0.379
10 to 14 149 55 36.9% 0.938 36 24.2% 0.068
15 or More 391 182 46.6% 0.204 126 32.2% 0.003
Page 11
Row percentages; Ref.- Reference Group;
Liu et al. Page 12
Approximate figures from self-reports

*
†
Liu et al. Page 13
Table 3
Logistic Regression Model of Self-reported Back Pain and Back Pain that Affected Work among Chinese
Farmers
Back Pain that

Back Pain
Affected Work
OR 95% CI * OR 95% CI *
Sex
Male 1.00 1.00
Female 1.22 1.09-1.36 1.16 1.03-1.32
Education
Elementary or Below 1.00 0.69-1.43 0.82 0.56-1.21
Middle School 1.07 0.75-1.53 0.77 0.52-1.12
High School and Above 1.00 1.00
Age (Yrs)
15-24 1.00 1.00
25-34 2.12 1.36-3.30 1.72 0.97-3.04
35-44 3.29 2.14-5.07 3.31 1.92-5.70
45-54 4.16 2.67-6.48 5.01 2.89-8.69

55-64 4.00 2.52-6.35 4.46 2.53-7.87
65-74 4.97 2.82-8.75 5.96 3.08-11.55
75-84 5.43 2.32-12.73 6.73 2.66-16.99
Perceived Stress
Never or Rarely 1.00 1.00
Sometimes 1.16 0.92-1.46 1.22 0.94-1.59
Regularly 2.51 2.00-3.16 2.52 1.96-3.25
Main Farm Activities
Livestock Breeding 1.00 1.00
Crop Cultivation 1.11 0.90-1.37 1.18 0.93-1.49
Other 0.78 0.56-1.09 0.82 0.56-1.20
Smoker
No 1.00 1.00
Yes 1.19 0.97-1.47 1.04 0.83-1.31
Drinker
Never (Abstainer) 1.00 1.00
Current 1.26 0.99-1.61 1.11 0.85-1.46
Former (Quit) 1.64 1.00-2.68 1.49 0.88-2.51
*
CI: confidence interval

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Spine (Phila Pa 1976). 2012 March 15; 37(6): 508–514. doi:10.1097/BRS.0b013e318221e83f.

Back Pain among Farmers in A Northern Area of China

The Ohio State University College of Medicine, Columbus, Ohio, USA

Study Design—This was a population-based survey conducted in 2008 in a northern area of

industrialized nations.1 Occupational risk factors contribute to 37% of LBP worldwide.2

MATERIALS and METHODS

Study Design and Sampling

Definition of Back Pain

Potential Risk Factors

Perceived Stress, Smoking and Alcohol Consumption

2000; 25:1148–56. [PubMed: 10788861]

among Chinese farmers in Qiqihar was 38.4%.

northern area of China. Both were self-reported in face-to-face interviews in this

Back Pain that

Total 2045 786 38.4 519 25.4

Back Pain that

Approximate figures from self-reports

Back Pain that

45-54 4.16 2.67-6.48 5.01 2.89-8.69

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