Knee pain and knee pain related disability in adults of the Western Development Region of Nepal ...

368 Pages·2017·4.72 MB·English

by  Dan Bahadur Baidwar-kshetri

Knee pain and knee pain related disability in adults
of the Western Development Region of Nepal

By

Dan Bahadur Baidwar Kshetri

A thesis submitted in partial fulfilment for the requirements for the
degree of Doctor of Philosophy at the University of Central
Lancashire

July 2017
Student Declaration

I declare that while registered as a candidate for the research degree, I have
not been a registered candidate or enrolled student for another award of the
University or other academic or professional institution.

I declare that no material contained in the thesis has been used in any other
submission for an academic award and is solely my own work

-------------------------------------------
Signature of Candidate

Type of Award Doctor of Philosophy (PhD)

School School of Dentistry
Acknowledgements

Firstly, I would like to express sincere gratitude to my supervisory team Prof.
Paola Dey, Prof. James Selfe and Dr. Chris Sutton for their continuous support
of my PhD study and related research and for their patience, motivation, and
immense knowledge. Their guidance helped me throughout the time of the
research and writing of this thesis. I could not have imagined having a better
set of advisors and mentors for my study.

I would like to thank my wife Mira and son Aayam for supporting, encouraging
and taking care of me during this long journey. I would also like to thank my
mother Bhim for her encouragement for my study.

I appreciate the invaluable support and help from the participants, community
people, and staff of different offices of Nepal for their valuable time and support
to make a success of this survey.

I would like to thank administrative staff at the UCLan’s Research Student
Registry, particularly Claire Altham, for their support. Thanks to my colleagues
and friends: Chukwuemeka Onyebuchi Ibeachu, Victoria Appleton, Neil Cook,
Bikash M Bhattarai, for their sharing of moments during my academic and non-
academic life.

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Abstract

Background
Knee pain and related disability are important public health problems
worldwide. In a systematic review, the prevalence of knee pain varied between
2.4% to 49.2% worldwide and disabilities were greater in those with knee pain
compared to those without. The prevalence of knee pain may be higher in
mountainous regions. The research student is from Nepal. He has a clinical
interest in musculoskeletal disorders and had found at the time of the thesis
that there had been no study undertaken across Nepal. Such a study would
inform Nepalese health policy.

Objectives
To estimate the prevalence of knee pain and knee related disability, overall
and in different ecological zones, of one region of Nepal.

Methods
A cross-sectional multistage cluster survey was undertaken using a
questionnaire in Nepali delivered face to face to adults aged over 18 years in
seven sites across the three ecological zones (plain, hilly and mountainous) of
the Western Development Region of Nepal. Crude weighted and age
standardised period and point prevalence rates of knee pain were estimated.
The prevalence of disability was compared between those who had knee pain
and those who did not have knee pain. Binary logistic regression was used to
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investigate potential independent risk factors for the prevalence of knee pain
and knee pain related disability.

Results
In total 694 participants were recruited; 52.6% were women, the mean age
was 41 years and 14.1% lived in the mountainous zone. The period prevalence
of knee pain was 22.3% (95% CI 19.2% - 25.5%) and of chronic knee pain
was 12.1% (95% CI 9.5 – 14.7%). The point prevalence was 7.6% (95% CI
5.7%-9.6%). Knee pain was higher in the mountainous zone compared to the
plain zone. Overall 25.6% of the 694 participants had disability, as measured
by the WHO DAS 2.0, and this was significantly higher in those with knee pain
compared to those without (81.2% vs. 9.5%). Disability was highest among
those with knee pain in the mountainous zone, with all having disability.
Despite this only 54.8% of those with knee pain sought advice for their
condition, those in the mountainous zone were less likely to seek advice,
access hospital treatment or take oral medications.

Conclusion
Knee pain is highly prevalent in Nepal. Just under half who suffer do not
access services for pain management, even though knee pain is associated
with high levels of disability. Rates of knee pain are highest in the mountainous
areas where access to services is lowest. This demonstration of unmet need,
particularly in the poorest and most remote areas of the country, is of
importance to policymakers who should focus on raising awareness and
improving access to services.
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Acronyms

AMED: Allied and Complementary Medicine
DI: Disability Index
EMBASE: Excerpta Medica database
HAQ: Health Assessment Questionnaire
HRL : Hilly rural site
HUA : Hilly urban affluent
HUD : Hilly urban deprived
KOOS: Knee Injury and Osteoarthritis Outcome Score
KP: Knee pain
KPD; Knee pain related disabilities
MEDLINE: Medical Literature Analysis and Retrieval
MRL : Mountain rural site
MZ : Mountainous zone
PRL : Plain rural site
PSU: Primary sampling unit
PUA: Plain urban affluent site
PUD : Plain urban deprived site
PZ : Plain zone
SF; Short Form Questionnaire
SSU: Secondary sampling unit
WDR: Western Development Region
WHODAS 2.0: World Health Organization Disability Assessment Schedule 2.0
WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index

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Table of contents

Student Declaration ..................................................................................................... ii
Acknowledgements ..................................................................................................... iii
Abstract ....................................................................................................................... iv
Acronyms..................................................................................................................... vi
Table of contents ....................................................................................................... vii
List of Tables .......................................................................................................... xiv
List of Figures ........................................................................................................ xvii
Chapter 1: Introduction................................................................................................ 1
1.1 Background of study ........................................................................................... 1
1.1.1 Why is knee pain important? ....................................................................... 2
1.1.2 Measuring knee pain in populations ........................................................... 4
1.1.3 Knee pain and knee pain related disability in developed countries............ 6
1.1.4 Knee pain and knee pain related disability in developing countries ........... 7
1.1.5 Knee pain in Nepal ....................................................................................... 8
1.1.6 Rationale for the study .............................................................................. 10
1.1.7 Element of originality................................................................................. 11
1.2 Brief introduction to the study country and region ......................................... 11
1.2.1 Nepal .......................................................................................................... 11
1.2.2 Administrative divisions ............................................................................. 13
1.2.3 Western Development Region .................................................................. 14
1.2.4 Study sites .................................................................................................. 16
1.3 Help seeking behaviour .................................................................................... 17
1.4 Thesis aims and objectives ............................................................................... 18
1.4.1 Aims and objectives of the thesis .............................................................. 18
1.4.2 Outline of the thesis .................................................................................. 20
1.5 Summary ........................................................................................................... 21
Chapter 2: A review of studies of the prevalence of knee pain and knee pain related
disability ..................................................................................................................... 22
2.1 Objectives ......................................................................................................... 23
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2.2 Methods ........................................................................................................... 23
2.2.1 Selection criteria ........................................................................................ 23
2.2.2 Search strategy .......................................................................................... 24
2.2.3 Outcomes and outcome measures ............................................................ 27
2.2.4 Assessment of risk of bias in included studies........................................... 27
2.2.5 Data extraction .......................................................................................... 29
2.2.6 Approach to analysis of the studies ........................................................... 29
2.3 Results .............................................................................................................. 30
2.3.1 Findings of the search strategy .................................................................. 30
2.3.2 Findings of the prevalence of knee pain .................................................... 33
2.3.2.1 Characteristics of the eligible studies ............................................................ 33
2.3.2.2 Settings of eligible studies for review ............................................................ 36
2.3.2.3 Risk of bias assessment .................................................................................. 36
2.3.2.4 Point prevalence of knee pain ....................................................................... 41
2.3.2.5 Commonly used questions to assess period prevalence of knee pain .......... 43
2.3.2.6 Period prevalence of knee pain by study ....................................................... 44
2.3.2.7 Period prevalence of knee pain by continent ................................................ 45
2.3.2.8 Period prevalence of knee pain by gender .................................................... 47
2.3.2.9 Period prevalence of knee pain by age .......................................................... 48
2.3.2.10 Prevalence knee pain by residency .............................................................. 48
2.3.2.11 Prevalence of knee pain in mountainous zone ............................................ 49
2.3.2.12 Prevalence of knee pain by social class ....................................................... 50
2.3.2.13 Period prevalence of knee pain by occupation............................................ 50
2.3.3 Findings of knee pain related disability ..................................................... 51
2.3.3.1 Characteristics of eligible studies................................................................... 51
2.3.3.2 Setting of the studies ..................................................................................... 53
2.3.3.3 Risk of bias assessment .................................................................................. 54
2.3.3.4 Knee pain related disability ............................................................................ 56
2.4 Discussion of review ......................................................................................... 63
2.5 Strengths and limitations of review ................................................................. 64
2.6 Implications of the findings of the review ........................................................ 66
2.7 Summary ........................................................................................................... 67
Chapter 3: Prevalence Study Questionnaire Development ....................................... 68
3.1. Aims and objectives ......................................................................................... 68
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3.2 Overview of questionnaire design ................................................................... 69
3.2.1 General questions ...................................................................................... 70
3.2.2 Knee pain questions ................................................................................... 71
3.2.3 Knee pain related disability questions ....................................................... 74
3.2.4 Questions related with health seeking behaviour for knee pain .............. 78
3.2.5 Invitation letter to the participants in English ........................................... 79
3.2.6 Finalization of the questionnaire in English ............................................... 79
3.3 Translation of the questionnaire into Nepali ................................................... 80
3.3.1 Overview of translation process ................................................................ 80
3.3.2 Identification of translators ....................................................................... 82
3.3.3 Forward translation of questionnaire (English to Nepali) ......................... 83
3.3.4 Synthesis of translated Nepali questionnaire ............................................ 83
3.3.5 Backward translation of questionnaire (Nepali to English) ....................... 84
3.3.6 Examination of the backward translated version questionnaire .............. 85
3.4 Pre-test of questionnaire ................................................................................. 87
3.5 Piloting of questionnaire .................................................................................. 88
3.6 Summary ........................................................................................................... 89
Chapter 4: Prevalence - survey methods ................................................................... 90
4.1 Objectives ......................................................................................................... 90
4.2 Methods ........................................................................................................... 91
4.2.1 Study design ............................................................................................... 91
4.2.2 Study population ........................................................................................ 92
4.2.3 Sampling Strategy ...................................................................................... 92
4.2.3.1 Selection of study districts ............................................................................. 93
4.2.3.2 Selection of study sites within district ........................................................... 95
4.2.3.3 Selection of village or Tole ............................................................................. 96
4.2.3.4 Selection of households ................................................................................. 98
4.2.4 Data collection ........................................................................................... 99
4.2.5 Measures ................................................................................................. 101
4.2.6 Sample size .............................................................................................. 102
4.3 Ethical and other approvals ............................................................................ 104
4.3.1 Co-ordination with the Governmental organizations ............................. 104
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4.3.2 Co-ordination with local bodies in Nepal ................................................ 105
4.3.3 Feedback to local community .................................................................. 106
4.4 Data management .......................................................................................... 107
4.4.1 Errors in statistical data ........................................................................... 107
4.4.2 Measures applied to reduce errors ......................................................... 109
4.4.2.1 Data collection ............................................................................................. 109
4.4.2.2 Data verification ........................................................................................... 110
4.4.2.3 Validation ..................................................................................................... 112
4.5. Statistical analysis .......................................................................................... 113
4.5.1 Prevalence rates ...................................................................................... 113
4.5.1.1 Prevalence of knee pain ............................................................................... 113
4.5.1.2 Prevalence of knee pain related disability ................................................... 114
4.5.2 Adjustment of prevalence rates due to study design ............................. 115
4.5.2.1 Stratification due to multistage design ........................................................ 115
4.5.2.2 Clustering ..................................................................................................... 116
4.5.3 Adjustment of prevalence rates to allow direct comparison between
ecological zones and residences ....................................................................... 117
4.5.4 Estimation of weighted prevalence rate ................................................. 118
4.5.5 Logistic regression ................................................................................... 120
Chapter 5: Results - Prevalence of Knee Pain .......................................................... 122
5.1 Introduction .................................................................................................... 122
5.1.1 Variation in altitudes of study area ......................................................... 122
5.1.2 Population data for ecological zones and study sites ............................. 123
5.2 Survey response ............................................................................................. 124
5.2.1 Surveyed households in each study site .................................................. 124
5.2.2 Surveyed participants in each of the study sites ..................................... 125
5.2.3 Adult population by age and gender ....................................................... 127
5.3 Demographic characteristics of the participants ........................................... 129
5.3.1 Gender ..................................................................................................... 129
5.3.2 Age ........................................................................................................... 129
5.3.3 Marital status ........................................................................................... 130
5.3.4 Employment status .................................................................................. 130
5.3.5 Occupation ............................................................................................... 130
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