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Chronic Lower Back Pain Among Women in India: Evidence-Based

Approach to Risk Factors and Interventions
Aelita Matosova
aelita.ne@gmail.com

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 1

Chronic Lower Back Pain Among Women in India: Evidence-Based Approach

to Risk Factors and Interventions

Aelita Matosova

School of Nursing and Health Professions, University of San Francisco

MPH-683: Integrated Learning Experience

August 13, 2023

Glossary
 2

CBT – Cognitive-Behavioral Therapy

CLBP – Chronic Lower Back Pain

CP – Chronic Pain

EBI – Evidence-Based Interventions

LBP – Lower Back Pain

MSD - Musculoskeletal Disorders

NHPI – National Health Portal of India

NSAID - Nonsteroidal Anti-Inflammatory Drugs

PHC – Primary Health Care

SEM – Socio-Ecological Model

 3

I. Introduction

II. Background

a. Chronic Lower Back Pain

b. Prevalence of Chronic Lower Back Pain among women in India

c. Existing interventions addressing Lower Back Pain

d. Gap Analysis

III. Methods

a. Search strategy

b. Study Selection

c. Data Extraction and Analysis

d. Socio-Ecological Model

IV. Risk factors analysis for developing Chronic Lower Back Pain using Socio-Economic

Model

a. Individual-level analysis

b. Interpersonal analysis

c. Community analysis

d. Public Policy

e. Summary

V. Interventions addressing CLBP

 4

a. History

b. CLBP Interventions available in India

c. Interventions recommendations

d. Public Health Impact

VI. Conclusion

VII. References

VIII. Appendixes

IX. MPH Competencies Checklist

 5

Abstract

Chronic lower back pain (CLBP) is a prevalent issue worldwide, affecting about 1.71 billion

people, with a significant proportion being women. CLBP is a major health concern in India,

particularly among women, which were 80% reported experiencing this condition. Several

factors, such as personal beliefs, sociocultural norms, restricted healthcare access, repetitive

movements, and psychological aspects, contribute to this high prevalence leading to severe

health and economic implications, including reduced work productivity and income. Although

there have been several reports on prevalence and risk factors of CLBP, to our knowledge, there

has not been enough work focusing on evidence-based interventions to decrease the burden of

CLBP in India.

This paper applied the Socioecological model to examine the determinants of CLBP among

Indian women and suggest evidence-based interventions. We reported that despite research on

the prevalence and single-level risk factors of CLBP, there's a gap in analyzing the complex

interactions of these risk factors and creating effective interventions to address these interactions.

CLBP constitutes a significant health burden among Indian women. Addressing chronic pain is

not only a fundamental human right but also an ethical responsibility of healthcare systems. s.

Interventions to address lower back pain should evolve from focusing on symptomatic relief to a

multidimensional, patient-centered approach. These include self-management strategies,

multidisciplinary care, and technological advancements like digital health solutions.

 6

Introduction

Alarming statistics reveal the substantial impact of chronic pain on a global scale. It affects a

significant proportion of the population, with an estimated prevalence of 20%, accounting for

15% to 20% of physician visits (Treede et al., 2008). The Global Burden of Disease analysis in

2019 demonstrated that musculoskeletal conditions, including low back pain, neck pain,

fractures, osteoarthritis, and rheumatoid arthritis, affect approximately 1.71 billion people

worldwide (Cieza et al., 2021).

Chronic musculoskeletal disorders, specifically chronic lower back pain (CLBP), are significant

health issues for women, who experience these conditions more frequently than men (Casale et

al., 2021; Sushil et al., 2023).. This high prevalence can be attributed to an intricate web of

factors such as personal beliefs, sociocultural norms, restricted healthcare access, repetitive

movements, and psychological aspects linked to enduring pain (Till et al., 2019; Gupta et al.,

2015; Das et al., 2018; Paramjot et al., 2019; Hemavati, 2014).

Research shows that the extent of CLBP among Indian women is alarmingly high, with

approximately 79% of women between 20 to 50 years suffering from chronic pain. Lower back

pain alone affects around 80% of women compared to 59% of men (Bang et al., 2021).

Apart from health implications, CLBP has severe economic repercussions on individuals and

society at large in India. Costs linked to healthcare services, such as consultations, diagnostics,

medication, and rehabilitation, add significantly to the economic strain (Shetty et al., 2022).

Moreover, women afflicted with CLBP often experience reduced work productivity and income,

further adding to the indirect costs of lost earnings and work absenteeism (Bang et al., 2021).
 7

The overall financial stress due to chronic pain can severely impact household budgets and

socioeconomic stability.

Recognizing the substantial influence of CLBP on the health and quality of life of women

in India necessitates a comprehensive understanding of its contributing factors to formulate

effective interventions. Although previous research has explored the prevalence and single-level

risk factors of CLBP among women in India, those studies have not adequately analyzed the

complex interactions of these factors (Priyanka, 2023). Therefore, this paper will use the

Socioecological model to examine the determinants of CLBP among women in India and suggest

appropriate interventions considering various levels of influence, including individual,

interpersonal, community, and policy factors. This multi-layered approach could help to mitigate

the burden of lower back pain, improve women's health outcomes, and contribute to their overall

well-being.

Background

Chronic lower back pain is a prevalent health issue that significantly affects individuals

worldwide (Sá et al., 2019). This condition can have debilitating effects on physical,

psychological, and social well-being, leading to a reduced quality of life and functional

impairment (Smith & Osborn, 2008). Characterized by pain that extends beyond the expected

healing time, chronic pain poses unique challenges as it lacks the acute warning function

typically associated with physiological nociception (Treede et al., 2008). Traditionally, pain is

considered chronic when it persists or recurs for more than 3 to 6 months (Treede et al., 2008).

According to a systematic review and meta-analysis of global studies, the prevalence of

CLBP in the general population ranges from 4.2% to 80.2% (Hoy et al., 2012). The prevalence
 8

can vary based on factors such as age, gender, occupation, and geographical region. 619 million

people globally were affected by CLBP in 2020 according to WHO and this number is expected

to increase up to 823 million by year 2050 (WHO, 2023).

These conditions are also the leading contributor to years lived with disability (YLDs),

accounting for 149 million YLDs globally, or 17% of all YLDs (Williams et al., 2018).

Specifically, low back pain contributes significantly to the burden of musculoskeletal conditions,

with 570 million prevalent cases worldwide and responsible for 7.4% of global YLDs

(Hartvigsen et al., 2018.; WHO, 2019).

Additionally, CLBP is associated with psychological distress, including depression, anxiety, and

reduced social functioning (Till et al., 2019; Paramjot et al., 2019). The long-lasting nature of

chronic pain further contributes to decreased sleep quality, fatigue, and overall diminished

health-related quality of life (Saxena et al., 2019). These health impacts highlight the urgent need

for effective interventions to address CLBP among women.

Chronic lower back pain can lead to various health consequences, including physical discomfort,

functional limitations, decreased mobility, and impaired daily activities (Dipika et al., 2020).

Associations have been observed between chronic pain and conditions such as depression,

anxiety, sleep disturbances, sexual dysfunction, and impaired quality of life (Meena et al., 2019;

Verma et al., 2020). These comorbidities contribute to a cycle of pain and psychological distress,

significantly affecting women's physical and mental health. Additionally, the impact of chronic

pain extends beyond the individual, affecting familial relationships, work productivity, and

socioeconomic stability (Chandwani et al., 2018). A comprehensive understanding of these risk

factors can inform targeted interventions and policies to alleviate the burden of chronic pain

among women.
 9

Within primary healthcare settings, chronic pain is a prevalent issue, with nearly one third

of patients presenting pain as their chief complaint (Sá et al., 2019). The recognition of chronic

pain as a pressing global health concern is of utmost importance, as adequate pain treatment is

not only a fundamental human right but also an ethical responsibility of healthcare systems. It is

crucial to address this complex issue and prioritize access to effective pain management on a

global scale to uphold the well-being and rights of individuals suffering from chronic pain.

Women in India and Chronic Lower Back Pain

The women population in India is a diverse and significant segment of the country's

society. As of 2021, the estimated female population in India stood at around 662 million,

accounting for approximately 48.5% of the total population (World Bank, 2021).

Chronic lower back pain (CLBP) constitutes a significant health burden among Indian

women, with prevalence rates surpassing those seen in men. Current research indicates that

around 79% of Indian women aged 20 to 50 years experience some form of chronic pain, with

CLBP being one of the most commonly reported forms (Bang et al., 2021). Specifically, the

prevalence of CLBP among women stands at around 80%, in comparison to 59% among men

(Bang et al., 2021). A comprehensive meta-analysis of 97 studies examining the prevalence of

lower back pain in India highlighted an even higher rate of CLBP among certain subgroups,

notably women, rural populations, and elementary workers, surpassing global averages and other

ethnic populations (Shetty et al., 2022). Moreover, mothers face a particularly high risk, with

nearly 50% reporting moderate to severe pain, and an established positive correlation between

pain intensity and parity (Saxena et al., 2019).

 10

However, it is important to note that there are significant regional variations in the sex

ratio, with some states experiencing a disproportionately lower number of females due to cultural

preferences for male children (Office of the Registrar General & Census Commissioner, India,

2021).

Education is crucial for empowering women and promoting gender equality. Over the

years, there has been progress in women's education in India, but gender disparities persist.

According to the National Family Health Survey (NFHS-5) data, the literacy rate among women

in India is lower compared to men, with significant variations across states (International

Institute for Population Sciences, 2020). Initiatives like the Beti Bachao, Beti Padhao (Save the

Girl Child, Educate the Girl Child) campaign have aimed to address these disparities and

promote girls' education (Ministry of Women and Child Development, Government of

India).Women's workforce participation in India remains relatively low. According to the World

Bank (2021), the female labor force participation rate in India stood at around 20% in 2020.

Various factors, including cultural norms, societal expectations, limited employment

opportunities, and gender-based discrimination, contribute to this low participation rate

(International Labour Organization, 2020).

Women in India face various social challenges and gender-based inequalities. Issues like

gender-based violence, child marriage, dowry system, and limited decision-making power persist

in many parts of the country (National Crime Records Bureau, 2020; United Nations Children's

Fund, 2020). Efforts to address these challenges include legislative measures such as the

Protection of Women from Domestic Violence Act and the Prohibition of Child Marriage Act, as

well as awareness campaigns and empowerment initiatives (Ministry of Women and Child

Development, Government of India).

 11

Women in India face unique challenges and disparities that significantly influence their

health and well-being. In Indian society, cultural norms, traditional gender roles, and limited

access to resources often contribute to gender inequality and impact women's health outcomes

(Mishra et al., 2009; Nagendra et al., 2018). Women's healthcare is sometimes prioritized less

than men's, leading to delays in seeking treatment and inadequate access to healthcare services

(Mishra et al., 2009).

Socioeconomic factors also play a crucial role in shaping women's health in India. Low

socioeconomic status and educational disparities limit opportunities for women, impacting their

overall health and well-being (Rao et al., 2017). 64% of the Indian population live in the rural

areas as estimated by World Bank staff based on data from the United Nations Population

Division's World Urbanization Prospects (World Bank, 2022.; Appendix 2). Women in rural areas

face additional challenges due to limited infrastructure, lack of transportation, and cultural

barriers that restrict their access to healthcare services (Venkatesan et al., 2022). These factors

contribute to health disparities and hinder the timely management of health issues, including

chronic conditions like lower back pain. Moreover, gender-based violence and discrimination

pose significant threats to women's physical and mental health in India. Domestic violence,

sexual assault, and harassment are prevalent issues that can have long-lasting consequences on

women's well-being and quality of life (Nagendra et al., 2018). These experiences can lead to

psychological distress, trauma, and increased vulnerability to health problems.

Given the considerable impact of CLBP on the well-being of women in India, it is

essential to understand the multitude of contributing factors to develop effective interventions.

Utilizing the socio-ecological model facilitates this understanding, as it allows for a

 12

comprehensive examination of the problem at multiple levels of influence (individual,

interpersonal, community, and policy), as proposed by Bronfenbrenner (1977).

Interventions addressing Lower Back Pain

Chronic lower back pain (CLBP) is characterized by persistent or recurrent pain in the

lower back region that lasts for at least three months. It is a common musculoskeletal condition

that can significantly impact an individual's quality of life and daily functioning. CLBP can range

in intensity from mild to severe and may be accompanied by other symptoms such as stiffness,

reduced range of motion, muscle spasms, and impaired physical function (WHO, 2019).

The history of addressing lower back pain spans several decades, with ongoing efforts to

understand its causes and develop effective interventions. Early approaches to managing lower

back pain focused primarily on symptomatic relief through bed rest and medication (Waddell,

2004). However, as research advanced, a shift occurred towards a more comprehensive and

multidisciplinary approach.

One notable development in the management of lower back pain is the recognition of the

biopsychosocial model, which considers biological, psychological, and social factors in

understanding and treating the condition (Main et al., 2012). This model acknowledges the

complex interplay between physical and psychosocial aspects of pain, highlighting the

importance of addressing not only the physical symptoms but also the psychological and social

factors that contribute to the experience of pain.

In recent years, there has been a growing emphasis on self-management strategies and

patient empowerment in the management of lower back pain. Self-management programs, such

as education, exercise, and behavioral techniques, have shown promising results in improving
 13

pain outcomes and enhancing patients' ability to cope with their condition (Nicholas et al., 2019).

These programs aim to empower individuals to take an active role in managing their pain and

promoting self-care.

Furthermore, the use of multidisciplinary pain clinics and rehabilitation programs has

gained traction in the management of chronic lower back pain. These programs involve a team of

healthcare professionals, including physicians, physical therapists, psychologists, and

occupational therapists, who collaborate to provide comprehensive care tailored to the individual

needs of patients (Von Korff et al., 2005). This integrated approach recognizes that effective pain

management requires a holistic approach that addresses the physical, psychological, and

functional aspects of pain.

In recent years, technological advancements have also played a role in the management

of lower back pain. Telemedicine and digital health solutions have facilitated remote

consultations, delivery of interventions, and monitoring of patients' progress (Cottrell et al.,

2020). These innovations have the potential to improve access to care, provide real-time support,

and enhance self-management strategies for individuals with lower back pain.

Overall, the approach to addressing lower back pain has evolved from primarily focusing

on symptomatic relief to adopting a multidimensional and patient-centered approach in the

developed world. The incorporation of the biopsychosocial model, self-management strategies,

multidisciplinary care, and technological advancements has contributed to a more comprehensive

and personalized approach to managing lower back pain.

 14

This paper attempts to provide a comprehensive analysis of the determinants of CLBP

among Indian women using a socioecological model and suggesting potential interventions

specifically for the female Indian population that correspond to each level of identified risk

factors. This study emphasizes the substantial proportion of the population affected by chronic

pain, with women being particularly vulnerable, especially regarding lower back pain. The

significance of chronic lower back pain calls for comprehensive risk analysis in order to create

suitable interventions that address these issues within a socioeconomic model.

Methods

Chronic lower back pain (CLBP) is a significant public health issue affecting women in

India. Understanding the risk factors associated with CLBP and identifying suitable interventions

is crucial for addressing this prevalent condition. This paper uses a qualitative approach to

examine the determinants of chronic lower back pain among women in India and propose

suitable interventions based on using a socioecological model.

By examining the multifaceted nature of CLBP in Indian women through the

socioecological lens, this review aims to provide insights into the various levels of influence and

propose comprehensive strategies to effectively tackle this public health challenge.

Literature Search Strategy

A comprehensive literature search was conducted to identify relevant studies on chronic

lower back pain risk analysis among women in India and suitable interventions. The search was

performed in electronic databases, including PubMed, Scopus, Google Scholar, WHO, World

Bank, Stata web site, Indian government official web site and the Indian Journal of Pain. The

following search terms were used: “chronic pain”, "chronic lower back pain," "women," "India,"
 15

"risk factors," "prevalence," and "interventions,". Boolean operators (AND, OR) were used to

combine the search terms appropriately. The search was limited to articles published in English

from the past 15 years (2008-2023) to ensure the inclusion of recent research. This paper

includes peer-reviewed journals, official government websites, statistics websites and NGO

organizations’ information.

Study Selection

The initial search yielded a total of approximately 150 articles. After removing

duplicates, the titles and abstracts of the remaining articles were screened for relevance. Studies

were included if they focused on chronic lower back pain among women in India, assessed risk

factors associated with the condition, and existing interventions based on the socioecological

model. Studies that primarily focused on other musculoskeletal conditions or did not provide

sufficient data on chronic lower back pain were excluded. The full texts of potentially relevant

articles were then reviewed for final inclusion in the literature review.

Data Extraction and Analysis:

Information from listed resources was analyzed and key findings related to the risk

factors and interventions associated with chronic lower back pain among women in India were

extracted. The socioecological model was used as a framework to categorize and analyze risk

factors and interventions at multiple levels, including individual, interpersonal, community, and

public policy factors.

Socioecological Model:

The socio-ecological model, developed by Urie Bronfenbrenner in the mid-1970s, has

served as an invaluable tool in understanding health behaviors and outcomes in the context of
 16

their social and environmental influences (Bronfenbrenner, 1977). This model emphasizes the

role of five interconnected systems, namely, the individual, interpersonal, organizational,

community, and policy levels, which together shape individuals' health behaviors and outcomes

(McLeroy et al., 1988). The application of the socio-ecological model to chronic lower back pain

(CLBP) in Indian women allows for a comprehensive understanding of the diverse factors

contributing to this prevalent health concern (Appendix 1). By organizing the risk factors

according to the socioecological model, this literature review emphasizes the multifaceted nature

of chronic lower back pain among women in India and highlights the need for interventions

targeting multiple levels of influence to effectively address this public health issue.

Risk factors analysis for developing Chronic Lower Back Pain using Socio-

Economic Model

The socio-ecological model allows for a holistic understanding of the multi-layered risk

factors contributing to CLBP among Indian women, thereby informing the development of

effective preventive and intervention strategies. Based of the model, we will discuss these levels:

Individual level

Age has been identified as a significant factor in CLBP among women, with studies

showing a higher prevalence in older age groups (Gupta et al., 2020). According to the study by

Koley and Sandhu (2009), there is an association between increasing age and the risk of

developing low back pain among menopausal patients in Tarn Taran, Punjab, India. The findings

suggest that as age advances, there is a higher likelihood of experiencing low back pain in this
 17

population. Research indicates that women in India may experience accelerated aging compared

to their counterparts in other regions. A study by Dey and Chakraborty (2018) found that Indian

women exhibited signs of advanced aging. The findings suggest that factors specific to the Indian

context may contribute to accelerated aging in women, placing them at a higher risk of

developing LBP as well.

Parity, or the number of pregnancies and childbirths a woman has experienced, has also

been associated with CLBP. Research suggests that multiparity increases the risk of CLBP due to

the physical stress placed on the lower back during pregnancy and delivery (Khalil et al., 2019).

Despite recent trends showing a decrease in the number of multiple births in India, the burden on

the woman's body during pregnancy still poses a risk factor for contracting lower back pain and

needs to be addressed. Inequities in accessing maternal health services, particularly in rural areas,

further compound the challenges faced by the female population (Dongarwar & Salihu, 2020).

Obesity plays a crucial role in CLBP among women in India, with excess weight placing

additional strain on the spine. Studies have highlighted a positive correlation between obesity

and CLBP (Lakshman et al., 2018). Physical inactivity, characterized by a lack of regular

exercise or a sedentary lifestyle, is another contributing factor. Insufficient physical activity

weakens the supporting musculature of the back, making women more susceptible to CLBP

(Gupta et al., 2020). The prevalence of obesity in India, particularly among women in rural areas,

is concerning (Venkatrao, 2020). The Indian National Family Health Survey-4 reported a

significant increase in obesity among women aged 15 to 49 years in India, reflecting the growing

burden of obesity in the country (Pradeepa et al., 2015). Psychological factors, such as stress and

depression, are known to influence CLBP. High levels of chronic stress and depression can

exacerbate pain perception and increase the likelihood of developing CLBP (Machado et al.,
 18

2017). Mental health is not addressed adequately in India due to the luck of mental health

professionals, disadvantaged position of women, lack of awareness and stigma (Bohra,

Srivastava, & Bhatia, 2015). The relationship between these factors and CLBP among women in

India highlights the importance of addressing mental health alongside physical well-being.

Interpersonal level

Studies have shown that social support plays a crucial role in managing and coping with

chronic pain. The absence of strong social support networks can contribute to increased

vulnerability and poor outcomes for women experiencing chronic lower back pain (Palmer,

Heitkemper, & Jarrett, 2019). In the context of India, where gender dynamics and roles can be

distinctly marked, the relationship between social support for women and chronic pain is

noteworthy. Women, especially in rural areas, often lack access to appropriate healthcare, and

social stigma can prevent them from seeking help for conditions like chronic pain (Rao, K., &

Finnoff, J. T., 2017). Traditional support structures such as joint families can play a role in

providing instrumental and emotional support. However, these systems may also perpetuate

stigmas and inhibit women from seeking external medical help. Many times, such support may

be inadequate or inappropriate for managing chronic pain effectively (Bennett, M. I., et al.,

2017).

Additionally, family dynamics and gender roles within Indian society can influence the

experience of chronic pain among women. Cultural expectations and traditional gender roles

may limit women's autonomy in seeking help, receiving appropriate treatment, and engaging in

self-care practices for managing their pain (Mittal et al., 2019). The article about the risk of

musculoskeletal disorders (MSDs) associated with kitchen platform tasks found that repetitive

and prolonged kitchen tasks, such as cooking, washing dishes, and chopping, were significantly
 19

associated with an increased risk of developing musculoskeletal disorders, including lower back

pain, among women (Sonal et al., 2019). Statistically in India only about 11% of the urban

families go out to eat or order food delivery once a week (Statista, 2023.; Appendix 3).

Therefore, burden of everyday kitchen tasks falls mostly on women putting them at higher risk of

developing MSD.

Socio-cultural factors also contribute to the prevalence of LBP among women in India.

Gender roles and societal expectations often place a burden on women to perform household

chores and caregiving responsibilities without adequate support or assistance (Gupta et al.,

2015). This can lead to prolonged periods of physical strain and repetitive movements, increasing

the risk of LBP. Cultural norms may discourage women from seeking medical help or expressing

their pain, further exacerbating the problem (Till et al., 2019).

Moreover, Gender-based issues in India, including domestic violence, persist as

significant challenges that impact the well-being and rights of women. These issues are rooted in

deep-seated gender inequalities, cultural norms, and social structures. Domestic violence, in

particular, has detrimental effects on women's physical, mental, and emotional health, and is a

violation of their human rights.

Domestic violence refers to any form of violence, including physical, sexual, emotional,

or economic abuse, that occurs within the context of an intimate or family relationship. In India,

domestic violence remains alarmingly prevalent. According to the National Family Health

Survey (NFHS-5) data, around 30% of ever-married women aged 15-49 have experienced some

form of spousal violence (International Institute for Population Sciences, 2020.; Appendix 4).

Additionally, the COVID-19 pandemic has further exacerbated the issue, with reports of
 20

increased instances of domestic violence during lockdown periods (United Nations Women,

2020).

The causes of domestic violence in India are complex and multifaceted. Deep-rooted

gender inequalities, patriarchal norms, and cultural beliefs that perpetuate male dominance and

control contribute to the prevalence of domestic violence (Kishor, 2004). Economic factors, such

as women's limited financial independence and dependence on their partners, can also contribute

to the perpetuation of violence (Jejeebhoy, 1998).

Challenges connected to domestic violence farther exaggerate health issues affecting women

from mental and physical sides and prevent women from seeking medical help feared to be

abused.

It is imperative to challenge gender norms, promote gender equality, and provide comprehensive

support to survivors of domestic violence to ensure the well-being and rights of women in India.

Community Level

Occupational hazards and workplace conditions can significantly contribute to the

development of chronic lower back pain, especially in developing countries like India where

labor laws and work safety regulations may not be as strictly enforced as in developed countries.

Jobs involving heavy physical labor, repetitive tasks, and prolonged sitting or standing are

particularly risky (Bernard, 1997). In India, many women are involved in these types of work,

including agriculture, construction, and in the informal economy, where working conditions are

often unregulated and precarious.

Agricultural work, a significant employer of women in rural India, often involves

repetitive, strenuous tasks such as bending, lifting heavy loads, and long hours of work, which
 21

are known risk factors for lower back pain (Gupta, et al., 2015). Overall rural women in India

stand for 75.7% of agricultural workers in India according to the recent report by the Ministry of

Statistics & Programme Implementation (2023). Accordingly, it is a major number of women

who suffer from job-related psychological and physical problems as discussed above. Such as,

rice farmers in West Bengal India report increased number of lower back pain due to monotony

in work, awkward working positions, lifting, pulling loads (Das, 2022. Similarly, women

working in construction, another major employment sector, face similar physical demands, as

well as the added risk of accidents due to inadequate safety measures (Dong, et al., 2017.,

Gangopadhyay, at al., 2015). For example, the study in India among female brick field workers

revealed results of 70% women suffering from LBP due to manual material handling (45%) and

due to unsafe lifting objects like bricks (Das, 2017).

Women working in the informal economy, such as domestic work or home-based

piecework, may face poor ergonomic conditions, lack of breaks, and psychosocial stressors, all

of which can contribute to chronic lower back pain (Das, 2017). Work-related psychosocial

stressors, such as job dissatisfaction, high job demands, and low decision latitude, are also

associated with lower back pain (Das, 2017, Gangopadhyay, at al., 2015). These factors may be

particularly relevant in the Indian context, where gender inequality can result in higher levels of

job-related stress for women.

When chronic pain is already exists women again face multiple challenges to seek help

while insurance in India has specific limitations for females. First of all workers typically lack

access to healthcare services and benefits, compounding the problem. 83% of rural housewife’s

reported LBP in the study in Kanpur, India (Gupta & Nnandini, 2015). These women have a

significant impact of social burden due to their LBP.

 22

India's healthcare structure overall consists of a three-tiered system comprising primary,

secondary, and tertiary levels of care. At the primary level, primary health centers (PHCs) and

sub-centers serve as the first point of contact for healthcare services. The health insurance sector

has expanded significantly, with various insurers offering individual and group health insurance

policies (IRDAI, 2021). However, there are challenges in terms of the availability of skilled

healthcare professionals, inadequate infrastructure, and uneven distribution of healthcare

facilities, particularly in rural areas (Ministry of Health and Family Welfare, Government of

India, 2019). These limitations impact women's access to primary healthcare services creating

significant challenges for healthcare access.

Specifically, women in India face multiple barriers to accessing healthcare services.

These include cultural norms, limited financial resources, lack of transportation, gender-based

discrimination, and low awareness of available services (International Institute for Population

Sciences, 2020). These barriers can significantly impact women's ability to seek timely and

appropriate healthcare, resulting in delayed diagnoses, limited preventive care, and poorer health

outcomes. Moreover, certain women-specific health needs may not always receive adequate

coverage. For example, maternity-related expenses, such as prenatal care, delivery, and postnatal

care, may have limited coverage or specific waiting periods before becoming eligible (Gupta &

Indrayan, 2018). Additionally, health insurance in India is the practice of gender-based pricing,

where women may be charged higher premiums compared to men. This pricing disparity is often

based on actuarial considerations related to women's higher utilization of healthcare services,

including maternity-related expenses (Gupta & Indrayan, 2018). The gender-based pricing can

make health insurance premiums more expensive for women, potentially limiting affordability

and access to coverage.

 23

Health insurance policies also impose exclusions or waiting periods for pre-existing

conditions. Some women-specific conditions, such as breast cancer, cervical cancer, reproductive

disorders or chronic pain, including LBP may be considered pre-existing conditions and may

have waiting periods before coverage kicks in which discourage women to seek medical help and

expand struggling period (Gupta & Indrayan, 2018).

Finally, health insurance policies often do not fully cover preventive services, requiring

women to bear the cost out of pocket (Gupta & Indrayan, 2018). Preventive care, such as regular

health check-ups, screenings, and vaccinations, is crucial for maintaining women's health and

preventing future complications.

Public Policy Level

India's healthcare system, while extensive, is fraught with barriers that particularly impact

women's access to healthcare services, among which chronic conditions like lower back pain are

a major concern. Notably, the lack of gender-sensitive policies stands out as a fundamental issue.

Chronic lower back pain, which is closely associated with strenuous labor, pregnancy, and

childbirth, disproportionately affects women. Despite this, the healthcare policies in India often

overlook the specific health needs of women, thereby creating a disconnect in the provision of

effective treatment and prevention efforts for conditions like lower back pain (George, A., 2008).

Exacerbating this situation is the shortfall in healthcare infrastructure. Particularly in rural areas,

where most of the far women who do farmer work live the healthcare system lacks the necessary

amenities and specialist services, such as orthopedic consultations, that are crucial in managing

lower back pain (Rao, M., et al., 2011). Affordability presents another significant challenge.

While there have been strides to improve accessibility to affordable healthcare, out-of-pocket
 24

expenses persist as a substantial hurdle. Statistics show that rate of women living in poverty is

significantly higher than the same among men (Kanwal, 2022). This is 45.3 million women

compared to 37.77 million men live in poverty in India (Appendix 5). For women suffering from

chronic conditions like lower back pain, this barrier is all the more prominent due to the need for

ongoing treatment, physiotherapy, and medications (Balarajan, Y., et al., 2011).

Furthermore, the existing health insurance policies often fall short in meeting the needs of

women. Often, the coverage for treatments and therapies necessary for managing chronic

conditions, such as lower back pain, are insufficient. This gap in the system places a substantial

financial burden on women who are seeking the required treatments (La Forgia, G., & Nagpal,

S., 2012). Notably, the proportion of women in national parliament is significantly low, which

also affect decisions on female health sensitive policies (World Bank, 2022.; Appendix 6).

Lastly, the lack of adequate education and awareness plays a crucial role. Without

appropriate policies and programs that raise awareness about health issues and available services,

particularly targeting women in rural or marginalized communities, the timely diagnosis and

treatment of conditions like lower back pain become even more difficult (Scott, K., et al., 2018).

Often women are no aware of the condition like chronic pain can be treated and just learn how to

live with it (Scott, K., et al., 2018). Additionally, not only access to education but specific

knowledge about the condition is not adequate among the Indian women. Study among college

student showed that majority of participants had false believes in the domains about CLBP

(Suhail et al., 2021).

In essence, policy-level barriers pose significant challenges to women's access to

healthcare in India, notably influencing the management and treatment of conditions like chronic

lower back pain. Addressing these barriers necessitates a holistic, gender-sensitive, and inclusive
 25

approach to policymaking. Efforts to address these disparities and provide equal educational

opportunities for all women remain crucial for achieving sustainable programs to address CLBP

among women in India.

Intervention approach addressing CLBP

History

Over the years, the development of interventions for chronic lower back pain (CLBP) has

undergone a significant transformation, reflecting a growing understanding of the complexity of

this condition. Initially, the focus was primarily on biomedical approaches such as medication,

injections, and surgeries (Chou et al., 2017). While these interventions aimed to alleviate pain

and restore functionality, their effectiveness in providing long-term relief was often limited.

As research advanced, it became evident that CLBP is influenced by various factors,

including physical, psychological, and social aspects. This led to a shift towards a more holistic

approach in addressing CLBP. Physical therapy and exercise emerged as crucial components of

CLBP management, focusing on improving strength, flexibility, and posture while reducing pain

and disability (Oliveira et al., 2012). These interventions encompassed a wide range of exercises,

including aerobic activities, strengthening exercises, and mind-body practices like yoga and tai

chi.

Alongside physical interventions, cognitive-behavioral therapy (CBT) gained recognition

as a valuable tool in managing chronic lower back pain. CBT aims to address maladaptive

thoughts, behaviors, and emotions associated with pain, empowering individuals to develop

coping strategies, relaxation techniques, and problem-solving skills (Morley et al., 2019). By
 26

targeting the psychological aspects of pain, CBT contributes to improved pain management and

psychological well-being.

Recognizing the multidimensional nature of CLBP, multidisciplinary programs emerged

as an integrative approach to its management. These programs involve collaboration among

healthcare professionals from various disciplines, including physical therapists, psychologists,

and pain specialists. By combining biomedical, physical, and psychological components,

multidisciplinary interventions provide comprehensive care and personalized treatment plans

tailored to individual needs (Chou et al., 2017). Such programs have demonstrated positive

outcomes in reducing pain intensity, improving function, and enhancing quality of life.

In recent years, self-management interventions have gained prominence in the

management of CLBP. These programs empower individuals to take an active role in managing

their pain through education, self-care strategies, and behavior change (Lorig et al., 2006). Self-

management interventions, including self-help books, online resources, and group-based

programs, have shown positive outcomes in reducing pain-related disability and improving self-

efficacy.

Furthermore, the integration of complementary and alternative medicine (CAM) therapies

expanded the range of options available for CLBP management. Therapies such as acupuncture,

massage, chiropractic care, and mindfulness-based approaches have shown potential benefits in

pain reduction and improving quality of life (Chou et al., 2017).

Overall, the evolution of CLBP interventions reflects a paradigm shift towards a more

comprehensive and patient-centered approach. Recognizing the multidimensional nature of

CLBP, interventions now encompass physical, psychological, and social aspects, aiming to
 27

improve overall well-being and functional outcomes. By addressing various factors contributing

to CLBP, these interventions offer a more holistic and personalized approach to pain

management.

CLBP Interventions available in India

Chronic lower back pain is a widespread problem that has a significant impact on

individuals' physical, psychological, and social well-being. It is characterized by pain that lasts

for more than 3 to 6 months. Chronic pain, including chronic lower back pain, affects a

substantial proportion of the global population and is a leading cause of years lived with

disability.

In India, multiple interventions exist to address chronic lower back pain (CLBP) among

women. These interventions, which span across traditional, medical, and complementary

modalities, demonstrate the multi-pronged approach necessary to handle this pervasive

condition.

Addressing chronic lower back pain (CLBP) among women in India requires a

comprehensive and multifaceted approach due to the complexity of the condition. Interventions

ranging from medical, traditional, and complementary modalities to psychosocial and

technological methods are currently in use.

The most common medical approach for CLBP in India is the use of Nonsteroidal Anti-

Inflammatory Drugs (NSAIDs). They are widely used due to their ability to provide immediate

relief from pain (Kanukula et al., 2014). However, the relief is temporary, and SAIDs are not

effective for long-term pain reduction, necessitating other interventions (Kanukula et al., 2014).

Physical therapy is another vital component of medical approach. It incorporates various exercise
 28

modalities, such as rehabilitation using International Classification of Function-based tools

(Ganesh et al., 2016), resistance exercises (Kristensen & Franklyn-Miller, 2012), and yoga

(Anheyer et al., 2022), all of which have demonstrated positive outcomes (Grooten et al., 2022).

However, these approaches may need to be adapted to better cater to the unique needs of Indian

women and their lifestyles.

India's rich tradition of Ayurveda and Yoga offers additional interventions for managing

CLBP. Ayurveda includes the use of herbal medicines, diet regulation, and detoxification

procedures, while yoga involves physical postures, breathing exercises, and meditation, which

have shown effectiveness in improving pain, disability, and quality of life among women with

CLBP (Telles et al., 2016). Complementary and alternative medicine (CAM) modalities, such as

acupuncture, massage, and homeopathy, are also employed (Naik et al., 2018). These

interventions, despite having varying levels of scientific evidence backing their effectiveness,

enjoy widespread use due to cultural acceptance and perceived lower side effects.

Mindfulness meditation is gaining recognition as a psychosocial intervention in CLBP

management. Research indicates that mindfulness meditation can help shift focus away from

pain, promote relaxation, and significantly reduce pain-related fear and anxiety (Kikuchi, 2017;

Elma et al., 2022; Woodley et al., 2020). Moreover, emerging technologies such as telemedicine

and digital health solutions offer innovative platforms for managing CLBP increased use during

the COVID-19 pandemic. They provide accessible and affordable care, including virtual

physiotherapy sessions, online pain education programs, and digital behavior change

interventions (Kumar & Sachdeva, 2020).

At the policy level, the National Health Portal of India provides general guidelines for

managing back pain, including NSAIDs, hot and cold treatments, relaxation techniques, and
 29

supervised exercise sessions (Government of India, 2020). However, significant challenges in

terms of accessibility and individualizing these interventions for women, especially in rural

regions, remain.

Collectively, these interventions underline the necessity of a multidisciplinary approach

to pain management. Effective CLBP management involves various healthcare professionals and

a combination of treatments that address different aspects of pain, as echoed by multiple studies

(Hwang, 2017).

Addressing chronic lower back pain in India requires comprehensive interventions that

consider the socio-ecological model. This model examines the problem at multiple levels of

influence, including the individual, interpersonal, community, and policy levels. Interventions

should focus on preventive strategies, early identification of risk factors, and targeted treatments.

Exercise interventions, rehabilitation programs, mindfulness meditation, and multidisciplinary

approaches to pain management have shown positive outcomes in managing chronic lower back

pain. A comprehensive and multifaceted approach that addresses risk factors at different levels of

the socio-ecological model is necessary to effectively manage chronic lower back pain among

women in India.

Gap Analysis

Upon an analysis of the existing literature and healthcare landscape for chronic lower

back pain (CLBP) among Indian women, several gaps emerge, delineating areas for potential

improvement and further research.

• Significant research gap: While the high prevalence of CLBP among Indian

women is established, specific research pertaining to this group remains limited

 30

(Bang et al., 2021). Studies often fail to disaggregate data by sex, resulting in an

absence of gender-specific insights (Shetty et al., 2022). Furthermore, there is a

scarcity of robust longitudinal and qualitative studies that might elucidate the

temporal trends and lived experiences of women with CLBP in India.

• Healthcare services gap: Accessibility to quality healthcare services, particularly

for chronic pain management, is unequally distributed, with urban areas being

favored over rural areas (Venkatesan et al., 2022). Especially in rural regions,

women lack access to necessary diagnostic services and effective interventions for

CLBP.

• Awareness and education gap: There is an inadequate level of awareness about

CLBP, its risk factors, and prevention strategies among Indian women. This lack

of knowledge often leads to underestimation of the importance of early detection

and timely management of CLBP, consequently resulting in delayed or inadequate

treatment.

• Policy gap: Current health policies often do not prioritize non-communicable

diseases like CLBP, with no specific policies or guidelines addressing this

condition, particularly for vulnerable groups such as women (World Health

Organization, 2019).

• socio-cultural gap: Societal and cultural norms often prevent women from seeking

and receiving healthcare in India (Mishra et al., 2009). The stigma associated with

chronic pain conditions and traditional gender roles often preclude women from

prioritizing their health needs.

 31

• intervention gap: Existing interventions for CLBP often do not consider the

specific needs and context of Indian women (Rao et al., 2017). Aspects such as

lifestyle, occupational hazards, cultural practices, and particular psychosocial

stressors are not adequately addressed in intervention design and implementation.

• technological gap: Despite the increasing application of digital health solutions

for chronic pain management globally, their utilization in managing CLBP among

Indian women is still limited (Cottrell et al., 2020). This is a considerable issue,

especially in the context of the COVID-19 pandemic, which has highlighted the

importance of remote delivery of healthcare services.

In conclusion, addressing these identified gaps requires a comprehensive, multifaceted

approach, integrating strengthened research, enhanced healthcare services, improved awareness

and education, developed targeted policies, strategies to tackle socio-cultural barriers, tailored

interventions, and leveraging digital health solutions.

Recommendations/public health impact

Chronic lower back pain (CLBP) among women in India is influenced by various risk

factors at different levels of the socio-ecological model.

To effectively address the high prevalence of CLBP among women in India, interventions

should target the significant risk factors identified. Evidence-based interventions should include

promoting physical activity, weight management, gender equality, social support networks,

workplace safety measures, and equitable healthcare policies. A comprehensive approach that

addresses risk factors at multiple levels of the socio-ecological model is crucial for reducing the

burden of CLBP and improving the overall health and well-being of women in India.
 32

Interventions addressing lower back pain (CLBP) among women in India should adopt a

multidisciplinary approach that encompasses a range of evidence-based strategies to effectively

address the complex nature of the condition. One recommended intervention is the

implementation of a comprehensive multidisciplinary program that combines various

components, such as exercises, mindfulness-based practices, and psychosocial support, in a

series of community workshops. These workshops can be facilitated by a team of healthcare

professionals including physical therapists, psychologists, and pain specialists. The program can

include tailored exercise regimens that focus on improving core strength, flexibility, and posture,

which have been shown to be effective in managing CLBP (Oliveira et al., 2012). Besides, the

women who are in risk zone can be invited to workshops for preventative measures of CLBP.

The workshops should include classes educating and empowering women about the

problem overall and specific solutions, as well as information of facilities, organizations and

closest medical hospitals that can help addressing CLBP along with associated challenges.

Workshop series must include at least one class where women come with the family. Choice can

be partner, parents, friends or any other close personal surrounding woman feel comfortable with

or feel need to educate about CLBP and support associated with it. This addition can help

educate not only women, but family and close community about the challenges and problems

women suffering from CLBP face. This will also help to break a chain of cultural norms

affecting the development or exaggeration of CLBP. Moreover, the intervention such as

workshop will possibly increase social support among women and help develop new connections

based on the mutual problem, therefore empowering women and increasing confidence.

Next, proposing and teaching a variety of exercises during the workshops, such as

aerobic activities, strengthening exercises, and mind-body practices like yoga and Pilates, can
 33

provide women with a range of options that suit their individual preferences and capabilities.

Those exercises should be developed in a way when women do not need to spend too much time

for workout and can easily incorporate it in the everyday life, choosing what of the options of the

exercises work best for each person. Additionally, this type of exercises are know to be a part of

Indian culture and will go along with cultural norms (Naik et al., 2018).

Finally, the workshops can have an option of joining online, which will help to increase

the accessibility to intervention. Furthermore, for distanced areas workshops should be recorded.

Next, with a collaboration of local community workers, recordings can be shown on the more

rural areas among the communities of women who has no access to new technologies, devises or

the internet.

In addition to physical interventions, incorporating mindfulness-based interventions can

be beneficial in managing CLBP among women. Mindfulness-based stress reduction (MBSR)

programs, which combine mindfulness meditation, body awareness, and yoga, have

demonstrated effectiveness in reducing pain intensity, improving functional status, and

enhancing psychological well-being in individuals with CLBP (Cherkin et al., 2016). These

interventions can help women develop self-awareness, relaxation skills, and coping mechanisms

to manage pain, reduce stress, and improve overall well-being.

Collaboration with non-governmental organizations (NGOs) that focus on women's

support and empowerment is crucial in addressing CLBP among women in India. For example,

partnering with organizations such as the Self-Employed Women's Association (SEWA) and the

Women's India Trust (WIT) can provide access to resources, advocacy, and support specifically

tailored to women with CLBP. These NGOs have extensive experience in addressing women's

health issues and can contribute to the development and implementation of community-based
 34

workshops, peer support groups, and educational initiatives that focus on CLBP management

(SEWA, n.d.; WIT, n.d.). These collaboration should also raise awareness of women rights and

bring up women voices regarding violence and inequalities not only in the family or community

but importantly in work environment as well.

Advocating for policy changes is another important aspect of addressing CLBP among

women. This can involve advocating for the inclusion of ergonomic practices in workplaces to

prevent and manage CLBP. Raising awareness among employers about the importance of

providing ergonomic workstations, promoting regular breaks, and implementing measures to

reduce prolonged sitting or standing can help alleviate the physical stress on the lower back.

Furthermore, employees should include a break for exercise where all the workers collectively

can do exercises or stretching before coming back to work. This intervention can include a

collaboration with community worker as well who will lead the exercises or teach work team

leader to provide guidance during the exercises time. Additionally, advocating for flexible work

arrangements, such as the option to alternate between sitting and standing, can contribute to the

prevention and management of CLBP among working women. Collaborating with policymakers,

labor unions, and occupational health organizations can help drive policy changes that prioritize

the well-being and rights of women in the workforce. Also, advocating for CLBP should bring up

the issue of formalizing a protocol of treating chronic pain among women, and CLBP

specifically, as chronic pain should be managed in a tailored way for women specifically.

Furthermore, advocating for an increased number of female policy makers in the Indian

government can have a significant impact on addressing women's health issues, including CLBP.

Having women in decision-making positions can bring a gender-sensitive perspective to policy

development and implementation, leading to better recognition and support for women's health
 35

concerns. For example, women perspective on health policies can change gender inequities in

insurance pricing. Also, using an Affordable Care Act example which significantly increased

population health coverage (Patient Protection and Affordable Care Act, 2009), Indian policies of

excluding preexisting conditions need a change. Collaborating with other countries and

international organizations can facilitate knowledge exchange and the adoption of best practices

in CLBP management, leading to improved interventions and policies.

The comprehensive, multidisciplinary intervention program proposed to address chronic

lower back pain (CLBP) among women in India promises broad and potentially transformative

public health impacts. At the individual level, such an intervention can lead to a significant

improvement in the physical and mental well-being of the affected women. By teaching effective

exercise routines, mindfulness practices, and providing psychosocial support, women would gain

tools and skills to manage their pain effectively and improve their quality of life. The improved

physical health can also reduce the risk of obesity and subsequent related health issues such as

cardiovascular diseases and diabetes, given that regular exercise is a key preventive measure for

these conditions (Fletcher et al., 2018).

Beyond individual health benefits, the intervention can create positive ripple effects at the

interpersonal level. Involving family members and close friends in workshops can enhance

understanding, empathy, and support within families and social circles. This approach can also

help shift societal norms and attitudes regarding CLBP, fostering a more supportive environment

for women with this condition. Additionally, by creating a space for women to connect over

shared experiences, the workshops can contribute to building supportive networks and

community solidarity, thereby further enhancing psychological well-being (Sturgeon, 2014).

 36

At the community level, interventions aimed at reducing CLBP can lead to significant

economic and productivity gains. Chronic pain conditions, including CLBP, often result in

reduced work productivity and increased absenteeism (Dagenais et al., 2008). By helping women

manage their CLBP more effectively, the intervention could potentially increase workforce

participation and productivity, thereby contributing to the broader economic development of the

community and the country. Furthermore, advocating for ergonomic practices and flexible work

arrangements can improve the working environment, making it more appealing for potential

employees and reducing the physical stress experienced by workers.

The promotion of gender equality is another critical impact of the proposed intervention.

By advocating for more female representation in policymaking, the intervention contributes to

fostering a more inclusive, gender-sensitive approach to public health policy. Women in

decision-making roles can bring unique insights and advocate for policies that directly address

women's health issues, including CLBP. For instance, the issue of gender inequity in insurance

pricing can be addressed more effectively with women's input. This will also set the stage for

future research, policy changes, and program developments that can continue to address CLBP

and other women's health issues effectively (World Health Organization, 2019).

However, while the potential benefits of the intervention are substantial, there are also

important challenges and limitations to consider. Firstly, the accessibility and implementation of

the program may be affected by various factors such as regional disparities in healthcare

infrastructure, literacy rates, and socio-cultural attitudes towards women's health. It's also worth

noting that while online workshops increase accessibility for some, digital divides in certain

areas could limit the reach of these interventions (Fitzpatrick et al., 2020). Similarly, addressing

structural issues like workplace ergonomics and policy changes may involve overcoming
 37

resistance from employers or dealing with slow-moving bureaucratic processes. Additionally,

interventions require careful planning in terms of cultural topics while aim to address some

changes in this area not to harm authenticity and avoid westernizing of Indian women. Finally,

intervention implementation needs to include multilevel evaluation which involving program

evaluation specialist.

Despite these challenges, the proposed intervention can make a significant contribution to

alleviating the public health issue of CLBP more generally. The multidisciplinary and holistic

approach not only addresses the physical aspects of CLBP but also considers psychological,

social, and structural factors that contribute to the condition. In this way, the intervention can

help to reduce the prevalence of CLBP, improve the health and well-being of affected women,

and create more supportive and inclusive environments for them.

Ultimately, the impacts of this intervention could pave the way for further research,

policy, and programmatic developments. Future research can build upon this intervention by

assessing its effectiveness, exploring ways to enhance its reach and impact, and adapting it to

address other health conditions. On the policy front, the success of this intervention can

encourage the development of more gender-responsive health policies and workplace practices.

Programmatic next steps may involve expanding the scope of the intervention, such as

incorporating additional components like nutritional education, and replicating the program in

other regions or countries.

Overall, the multidisciplinary intervention recommended for addressing CLBP among

women in India holds significant potential for improving individual and community health,

promoting gender equality, and inspiring further research, policy changes, and programmatic

developments. Despite potential challenges in implementation and access, the broad-reaching

 38

impacts of the intervention make it a promising approach for managing CLBP and improving

women's health in India.

Conclusion

This paper has addressed the significant public health issue of chronic lower back pain

(CLBP) among women in India. The analysis trough SEM identified several gaps and challenges

related to the prevalence, healthcare services, awareness, policy, socio-cultural barriers,

interventions, and technology surrounding CLBP. These gaps highlighted the need for a

comprehensive, multi-level approach to address the complex nature of CLBP among women in

India.

To address the identified gaps and implement these recommendations, collaboration among

various stakeholders is essential. Healthcare providers, policymakers, NGOs, researchers, and

community leaders must work together to overcome barriers and ensure the successful

implementation of interventions. Monitoring and evaluation of the interventions' effectiveness

are crucial to continuously improve and adapt the programs. Scaling up successful interventions

to reach a larger population, addressing regional disparities, and promoting inclusivity and

accessibility should be key considerations in the next steps.

The recommendations put forth in this paper propose a multidisciplinary intervention program

that considers individual, interpersonal, community, and policy factors. The interventions aim to

improve the well-being of women, reduce the risks of obesity and related diseases, strengthen

family connections, enhance work productivity, and promote gender equality. The potential

impacts of these recommendations are far-reaching at each level of SEM – individual,

interpersonal, community and public policy level.

 39

In conclusion, this paper highlights the urgency of addressing CLBP among women in India.

Continued research, policy changes, and programmatic developments are essential to ensure the

sustainability and effectiveness of these interventions and to further advance the understanding

and management of CLBP among women in India.

 40

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Appendix 1
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Appendix 2
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Appendix 3

Frequency of food ordering or eating out among millennials in India as of 2019

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Appendix 4
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Appendix 5
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Appendix 6
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MPH Competencies Checklist

Integrative Learning Experience – ILEX
Aelita Matosova

CEPH Foundational Competencies

Competency Choose at least 2 foundational
competencies and briefly note
why you feel it is relevant to your
ILEX paper or presentation.

(Note: all students can choose

Competency #19, and mention
your specific audience)

Evidence-based Approaches to Public Health

1. Apply epidemiological methods to the breadth of settings

and situations in public health practice

2. Select quantitative and qualitative data collection methods

appropriate for a given public health context

3. Analyze quantitative and qualitative data using biostatistics,

informatics, computer-based programming and software as
appropriate

4. Interpret results of data analysis for public health research, Will be used when doing literature
policy and practice review and interview analysis to
understand the background of health
issue

Public Health & Health Care Systems

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5. Compare the organization, structure and function of health

care, public health and regulatory systems across national
and international settings

6. Discuss the means by which structural bias, social Will be used when researching,
inequities and racism undermine health and create challenges analyzing and discussing risk factors
to achieving health equity at organizational, community and of CLBP among women in India
societal levels

Planning & Management to Promote Health

7. Assess population needs, assets and capacities that affect Will be used when doing gap
communities' health analysis and proposing interventions

8. Apply awareness of cultural values and practices to the

design or implementation of public health policies or programs

9. Design a population-based policy, program, project or

intervention

10. Explain basic principles and tools of budget and resource

management

11. Select methods to evaluate public health programs

Policy in Public Health

12. Discuss multiple dimensions of the policy-making process,

including the roles of ethics and evidence

13. Propose strategies to identify stakeholders and build

coalitions and partnerships for influencing public health
outcomes

14. Advocate for political, social and economic policies and

programs that will improve health in diverse populations

15. Evaluate policies for their impact on public health and

health equity

Leadership

16. Apply principles of leadership, governance and

management, which include creating a vision, empowering
others, fostering collaboration and guiding decision making

17. Apply negotiation and mediation skills to address

organizational or community challenges

Communication

18. Select communication strategies for different audiences

and sectors
 62

19. Communicate audience-appropriate public health content, Will be used in final presentation and
both in writing and through oral presentation writing ILEX paper about women
health in India

20. Describe the importance of cultural competence in

communicating public health content

Interprofessional Practice*

21. Perform effectively on interprofessional teams

Systems Thinking

22. Apply systems thinking tools to a public health issue Will be used when
creating/suggesting intervention for
women in India

MPH - Community and Public Health Practice Competencies

Competency If CPHC is your program
concentration, choose at least 2
competencies you plan to draw on
and mention how it is relevant.

1. Apply qualitative methods to assess community assets for Will be used when analyzing existing
addressing public health and environmental issues intervention and programs for women
in India

2. Analyze how issues of power, race and ethnicity, sex and
gender identify, and socioeconomic factors affect the
development, implementation, and evaluation of community-
based projects
Since I will work with specific
population – women in India I will be
using sex, race and socioeconomic
factors when analyzing the issue and
suggesting changes

3. Develop a research project proposal using mixed methods

to address a public health problem
4. Apply project management strategies to improve the quality
of programs and services in public health settings

5. Identify environmental health risks in vulnerable

communities and examine strategies to reduce exposures

MPH – Health Policy Leadership Competencies

 63

Competency If HPL is your program

concentration, choose at least 2
competencies you plan to draw on
and mention how it is relevant.

1. Predict how health policies may impact risks and drivers

of health outcomes at the health system and public health
sector level

2. Synthesize evidence from literature review and/or

databases to write a policy paper for a specific audience,
identifying a problem and proposing alternative approaches
to meet health needs in underserved communities

3. Design a leadership plan and strategies to manage

stakeholders and related political processes, addressing
conflict, resistance, and cooperation in the implementation
process

4. Communicate recommendations to improve

organizational strategies and capacity to implement health
policy

5. Advocate and make recommendations on legislation or

regulation related to a current environmental health issue,
drawing on risk assessment evidence

MPH – Behavioral Health Competencies

Competency If BH is your program
concentration, choose at least 2
competencies you plan to draw on
and mention how it is relevant.

1. Plan a health education training, curriculum, or workshop

including stakeholder identification, resource planning and
timeline, volunteer recruitment and marketing, strategy
selection, and monitoring process.
2. Effectively deliver evidence-based health education and
behavior change intervention skills such as motivational
interviewing, health coaching, peer education, mindfulness, or
social media messages to individuals or groups.
3. Analyze the impact of chronic conditions and propose I will work on chronic pain among
strategies to address prevention and management across all women in India and use this
levels of the Socioecological Model. competency to analyze the impact of
this condition on my population and
propose a solution
 64

4. Formulate strategies for mental health and substance

abuse prevention and treatment in community settings.
5. Develop a data collection and analysis plan including
measures and methods for research on behavioral health.