The hidden burden of cervical and low back pain among women in conflict-affected Yemen

Background: Musculoskeletal disorders, particularly cervical and low back pain (CLBP), are leading causes of disability worldwide. However, evidence from conflict-affected and low-resource regions such as Yemen remains scarce. This study aimed to determine the prevalence, associated risk factors, and radiological patterns of CLBP among women attending a tertiary hospital in Sana'a, Yemen.

Methods: A hospital-based cross-sectional study was conducted among 470 adult female patients at Al-Gumhori Teaching Hospital, Sana'a, from January to March 2025. Participants completed structured questionnaires covering sociodemographic characteristics, lifestyle behaviors, psychological stress, and musculoskeletal symptoms. CLBP was defined according to European Guidelines as non-traumatic spinal pain persisting ≥12 weeks. Radiological assessments (x-ray and MRI) were performed in clinically indicated cases. Multivariable logistic regression identified independent factors associated with CLBP.

Results: The prevalence of cervical and/or low back pain was 69.4% (95% CI: 65.2–73.3). Independent factors associated with CLBP included obesity (aOR = 2.56; 95% CI: 1.54–4.25), physical inactivity (aOR = 1.91; 95% CI: 1.13–3.24), prolonged screen time >4 h/day (aOR = 1.73; 95% CI: 1.01–2.98), and moderate-to-severe anxiety symptoms (aOR = 3.12; 95% CI: 1.79–5.45). Radiological findings revealed cervical muscle spasm in 62%, vertebral osteophytosis in 33%, and lumbar disc prolapse in 28%.

Conclusion: CLBP is highly prevalent among Yemeni women, with multiple modifiable risk factors linked to lifestyle and psychological distress. Targeted, integrated public health strategies are urgently needed to reduce musculoskeletal disability among women in conflict-affected regions.

1 Introduction

Musculoskeletal disorders (MSDs) are among the most common causes of chronic disability globally, particularly affecting women in low-resource and conflict-affected settings. Cervical and low back pain (CLBP) contribute substantially to years lived with disability and lost productivity. Despite extensive research in developed countries, data from conflict zones such as Yemen remain scarce.

The ongoing humanitarian crisis in Yemen has intensified psychosocial stress, disrupted healthcare access, and altered daily activity patterns—factors that may amplify musculoskeletal burden. Women in Yemen, often balancing physical labor with caregiving responsibilities, are especially vulnerable to both physical strain and emotional stress.

This study aimed to estimate the prevalence of CLBP among women in Sana'a, identify associated sociodemographic, lifestyle, and psychological factors, and assess radiological findings to provide evidence for preventive and therapeutic interventions.

2 Methods

2.1 Study design and setting

A hospital-based cross-sectional study was conducted at Al-Gumhori Teaching Hospital, one of the largest tertiary referral centers in Sana'a, Yemen, between January 1 and March 30, 2025.

2.2 Ethical approval

Ethical clearance was obtained from the Institutional Review Board of 21 September University for Medical and Applied Sciences (IRB Approval No: 100001644). Written informed consent was obtained from all participants.

2.3 Participants

Eligible participants were female patients aged ≥18 years attending outpatient clinics for non-emergency complaints.

2.3.1 Exclusion criteria

• Recent spinal or major trauma

• Diagnosed spinal tumors or infections

• Neurological deficits suggesting systemic pathology

2.4 Sampling

A systematic convenience sampling approach was applied to recruit consecutive eligible women during the study period until the target sample size (n = 470) was reached. This hospital receives referrals from multiple districts, making the sample representative of the urban female population in conflict-affected Sana'a.

2.5 Measurement and definitions

Data were collected via structured face-to-face interviews using a validated questionnaire covering:

• Sociodemographics: age, marital status, education, occupation

• Anthropometrics: height, weight, BMI (classified per WHO)

• Lifestyle: physical activity, sedentary time, daily screen use

• Psychological stress: assessed by GAD-7 scale (categorized as none <5, mild 5–9, moderate–severe ≥10)

• Musculoskeletal pain: assessed by Visual Analog Scale (VAS) and duration ≥12 weeks

2.6 Radiological evaluation

Plain x-rays were performed for all participants presenting with moderate-to-severe or chronic pain (>3 months). MRI was ordered for those with neurological symptoms or red flags. All imaging was interpreted by a senior radiologist blinded to clinical data, following standardized diagnostic criteria for osteophytosis, disc prolapse, and muscle spasm.

2.7 Statistical analysis

Data were analyzed using SPSS version 26.

• Descriptive statistics summarized participant characteristics.

• Univariate associations were tested using chi-square and t-tests.

• Variables with p < 0.10 were included in a multivariable logistic regression model.

• Model fit was verified using the Hosmer–Lemeshow test (p > 0.05 indicates good fit), and multicollinearity was checked (VIF < 2).

• A p-value < 0.05 was considered statistically significant.

3 Results

3.1 Participant characteristics

A total of 470 women were included (mean age 34.8 ± 9.6 years). Sociodemographic and behavioral characteristics are shown below.

3.1.1 Analytical comment

Most participants were overweight or obese, physically inactive, and had high daily screen exposure. One-third demonstrated moderate-to-severe anxiety symptoms, indicating a high psychosocial burden among women in this population.

3.2 Prevalence and risk factors

The overall prevalence of cervical and/or low back pain was 69.4% (95% CI: 65.2–73.3) (see Tables 1, 2).

• Cervical pain only: 29.1%

• Lumbar pain only: 24.7%

• Both sites: 15.6%

Table 1

Table 1. Demographic and Behavioral Characteristics (N = 470).

Table 2

Table 2. Multivariable Logistic Regression for Factors Associated with CLBP.

3.2.1 Analytical comment

Anxiety and obesity showed the strongest associations with CLBP, suggesting a biopsychosocial interaction where both mental and physical factors contribute significantly to pain persistence.

3.3 Radiological findings (n = 420)

• Cervical muscle spasm: 62%

• Vertebral osteophytosis: 33%

• Lumbar disc prolapse: 28%

• Normal imaging: 12%

3.3.1 Analytical comment

Radiological abnormalities confirmed the clinical diagnosis in most cases. The predominance of muscular spasm highlights chronic strain rather than acute injury as the primary mechanism.

4 Discussion

This study provides important evidence on the high prevalence and multifactorial nature of cervical and low back pain (CLBP) among women in conflict-affected Yemen. The overall prevalence of 69.4% observed in this study aligns with regional estimates from low- and middle-income countries in the Middle East and North Africa (MENA), where musculoskeletal disorders (MSDs) represent a growing cause of disability (1). The findings confirm that women in fragile contexts experience a disproportionate burden of musculoskeletal pain due to combined physical, psychosocial, and socioeconomic pressures.

Our results identified obesity, physical inactivity, prolonged screen time, and anxiety as significant correlates of CLBP. These associations reflect a biopsychosocial model in which both physical and psychological determinants contribute to chronic pain persistence. Similar risk factors were reported in Syrian and Iraqi studies, where obesity and anxiety symptoms were independently linked with chronic spinal pain (2–4). Furthermore, comparable epidemiological patterns have been documented in recent analyses of musculoskeletal conditions across the Middle East, highlighting sedentary lifestyles, poor ergonomics, and stress exposure as shared contributors (1, 5).

Conflict-related disruptions play an essential role in shaping these risk profiles. Evidence from Syria demonstrates that ongoing conflict limits healthcare access, reduces physical activity, and heightens psychological distress—factors that collectively increase chronic pain prevalence [2,4]. Among displaced and refugee populations, chronic pain syndromes are further aggravated by prolonged stress, inadequate rehabilitation, and restricted access to pain management services (6). Yemen shares these contextual vulnerabilities, where healthcare infrastructure damage and economic instability likely exacerbate musculoskeletal morbidity among women.

The strong link between anxiety and CLBP observed in this study is consistent with prior research demonstrating that psychological distress amplifies both pain perception and disability (7). Chronic stress may alter central pain processing pathways, leading to increased muscular tension and prolonged recovery times. This underscores the need to incorporate mental health assessment and stress management strategies into musculoskeletal care programs in conflict-affected regions.

Radiological findings in this study—particularly cervical muscle spasm and vertebral osteophytosis—support the predominance of chronic strain rather than acute trauma as the underlying mechanism of pain. Similar radiological patterns have been described in studies from low-resource environments, where occupational load, domestic labor, and inadequate postural ergonomics are common (4, 5). Addressing these factors through ergonomic education and workplace awareness campaigns may substantially reduce musculoskeletal pain incidence.

Despite its valuable insights, this study has several limitations. The cross-sectional design restricts causal inference, and being single-center may limit generalizability beyond urban women in Sana'a. Selective imaging could have biased radiological prevalence estimates. Additionally, self-reported behavioral and psychological data are prone to recall bias. Nevertheless, the combination of clinical assessment, imaging, and psychological screening enhances the internal validity of the findings.

In summary, the present study adds to the limited body of literature on musculoskeletal pain in conflict-affected settings and emphasizes the interplay between physical, mental, and environmental determinants of health. Integrating public health interventions targeting physical activity, ergonomic behavior, weight management, and psychological resilience could substantially mitigate the musculoskeletal burden among women in Yemen and comparable regions.

5 Conclusion

Cervical and low back pain are highly prevalent and disabling among women in Yemen, driven by modifiable lifestyle and psychological factors. Integrated, gender-sensitive public health strategies addressing physical inactivity, ergonomic habits, and mental well-being are essential to mitigate the burden of musculoskeletal pain in conflict-affected settings.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of 21 September University for Medical and Applied Sciences, Sana'a, Yemen (Approval No: [100001644]). Written informed consent was obtained from all participants prior to enrollment.

Author contributions

HM: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. MB: Funding acquisition, Writing – review & editing.

Funding

The author(s) declare no financial support was received for the research and/or publication of this article.

Acknowledgments

The authors thank the participants and the Radiology Department staff at Al-Gumhori Teaching Hospital for their cooperation.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declare that no Generative AI was used in the creation of this manuscript.

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