Prevalence of neck pain and its associated factors in Africa: a systematic review and meta-analysis protocol

Abstract

Introduction
Neck pain is one of the most prevalent musculoskeletal pain conditions with multifactorial impact including pain, disability and reduced quality of life. To the best of our knowledge, no systematic review and meta-analysis is available to provide reliable data on the pooled prevalence of neck pain and its associated factors in Africa. Thus, the objective of this study is to describe a protocol for a systematic review and meta-analysis on the prevalence of neck pain and its associated factors in Africa.

Methods
This systematic review protocol has been designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). A systematic search will be conducted among six key electronic databases including PubMed/MEDLINE, Scopus, African Journals Online, EMBASE, CINAHL and Web of Science, from inception onwards. Population-based cross-sectional studies reporting prevalence of neck pain in the African continent will be included. The primary outcome will be the prevalence of neck pain, whereas the secondary outcomes will be the factors associated with neck pain prevalence. Two independent reviewers will screen the titles/abstracts and relevant full-text articles of potentially relevant studies. Data from eligible studies will be extracted using a customised data extraction form. The risk of bias and methodological quality of the included studies will be assessed using the Newcastle–Ottawa Scale and critical appraisal tool, respectively. A narrative synthesis will be used to summarise the prevalence estimates of neck pain and associated factors. However, if feasible, random-effects meta-analysis will be conducted with Revman V.5.4 software. Additionally, subgroup, sensitivity and publication bias analyses will be conducted.

Discussion
This will be the first systematic review and meta-analysis to systematically identify and synthesise available literature on the prevalence of neck pain and its associated factors in Africa. The results of this review may assist health professionals and policymakers to plan and implement evidence-based strategies that will lessen the burden of neck pain.

Ethics and dissemination
Data from previously published studies will be collected and analysed and hence ethical approval will not be sought for this study. The results of this review will be disseminated through publication in a peer-reviewed academic journal and presentation at relevant academic conferences.

PROSPERO registration number
CRD42021273585.

Full text

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MukhtarNB, etal. BMJ Open 2023;13:e074219. doi:10.1136/bmjopen-2023-074219
Open access
Prevalence of neck pain and its
associated factors in Africa: a systematic
review and meta- analysis protocol
Naziru Bashir Mukhtar,1,2 Aminu Alhassan Ibrahim ,3 Jibril Mohammed 1
To cite: MukhtarNB,
IbrahimAA, MohammedJ.
Prevalence of neck pain and its
associated factors in Africa: a
systematic review and meta-
analysis protocol. BMJ Open
2023;13:e074219. doi:10.1136/
bmjopen-2023-074219
►Prepublication history and
additional supplemental material
for this paper are available
online. To view these les,
please visit the journal online
(http://dx.doi.org/10.1136/
bmjopen-2023-074219).
Received 31 March 2023
Accepted 30 August 2023
1Department of Physiotherapy,
Faculty of Allied Health
Sciences, College of Health
Sciences, Bayero University,
Kano, Nigeria
2Department of Physiotherapy,
School of Health Sciences,
Maryam Abacha American
University of Nigeria, Kano,
Nigeria
3Department of Physiotherapy,
School of Basic Medical
Sciences, Skyline University
Nigeria, Kano, Nigeria
Correspondence to
Dr Aminu Alhassan Ibrahim;
amenconafs@ gmail. com
Protocol
© Author(s) (or their
employer(s)) 2023. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Introduction Neck pain is one of the most prevalent
musculoskeletal pain conditions with multifactorial impact
including pain, disability and reduced quality of life. To
the best of our knowledge, no systematic review and
meta- analysis is available to provide reliable data on the
pooled prevalence of neck pain and its associated factors
in Africa. Thus, the objective of this study is to describe
a protocol for a systematic review and meta- analysis on
the prevalence of neck pain and its associated factors in
Africa.
Methods This systematic review protocol has been
designed in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta- Analyses
Protocols (PRISMA- P). A systematic search will be
conducted among six key electronic databases
including PubMed/MEDLINE, Scopus, African Journals
Online, EMBASE, CINAHL and Web of Science, from
inception onwards. Population- based cross- sectional
studies reporting prevalence of neck pain in the African
continent will be included. The primary outcome will be
the prevalence of neck pain, whereas the secondary
outcomes will be the factors associated with neck pain
prevalence. Two independent reviewers will screen
the titles/abstracts and relevant full- text articles of
potentially relevant studies. Data from eligible studies
will be extracted using a customised data extraction
form. The risk of bias and methodological quality of the
included studies will be assessed using the Newcastle–
Ottawa Scale and critical appraisal tool, respectively.
A narrative synthesis will be used to summarise the
prevalence estimates of neck pain and associated factors.
However, if feasible, random- effects meta- analysis will
be conducted with Revman V.5.4 software. Additionally,
subgroup, sensitivity and publication bias analyses will be
conducted.
Discussion This will be the rst systematic review and
meta- analysis to systematically identify and synthesise
available literature on the prevalence of neck pain and its
associated factors in Africa. The results of this review may
assist health professionals and policymakers to plan and
implement evidence- based strategies that will lessen the
burden of neck pain.
Ethics and dissemination Data from previously
published studies will be collected and analysed and
hence ethical approval will not be sought for this study.
The results of this review will be disseminated through
publication in a peer- reviewed academic journal and
presentation at relevant academic conferences.
PROSPERO registration number CRD42021273585.
INTRODUCTION
Musculoskeletal disorders are common and
burdensome health problems contributing
to disability,1 2 with about 1.71 billion people
being affected globally.3 Neck pain, being
second only to low back pain as the most
prevalent musculoskeletal pain condition,4
is a complex disorder with a multifactorial
impact including pain, disability and reduced
quality of life.5 Neck pain causes a substantial
burden not only to sufferers and their families
but also to society due to the costs associated
with healthcare, insurance, work absenteeism
and loss of productivity.5 6
The occurrence and chronicity of neck
pain are believed to be multifaceted,7 with
individual/personal (eg, age, sex, body mass
index and smoking), biomechanical (eg,
strenuous physical activity, faulty postures)
and psychosocial (eg, stress, anxiety and
depression) factors being commonly impli-
cated.8–10 However, the development and
impact of neck pain are likely to vary signifi-
cantly between and within population groups
owing to social, economic, cultural and envi-
ronmental influence.
According to the most recent Global
Burden of Disease estimates, the global
prevalence and incidence of neck pain have
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒This protocol denes the rst systematic review
with meta- analysis to synthesise the prevalence of
neck pain and its associated factors in Africa.
⇒Findings of this review will provide information to
health professionals and policymakers in planning
and implementing evidence- based strategies for
lessening the burden of neck pain in Africa.
⇒The plan to conduct a meta- analysis, subgroup and
sensitivity analyses, as well as inclusion of all age
groups, are the strengths of this review.
⇒Language restriction to studies published in English
or French may be a limitation.
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increased from 124.4 million and 276.5 million cases
in 1990 to about 222.7 million and 475.2 million cases
in 2019, respectively.11 Neck pain remained one of the
leading causes of disability in most parts of the world in
2015.1 Moreover, among different conditions, it contrib-
utes to the highest healthcare expenditure related to
musculoskeletal disorders, where about $134.5 billion
was reported to have been spent in the USA in the year
2016.12 This poses a serious problem to the contemporary
society.
The burden of neck pain in terms of years lived with
disability is higher in women than in men, but increases
with age in both genders, peaking at 45–54 years of age,
before declining around the age of 70–74 years.11 This is
indicative of the significant role of ageing as a contributing
factor to the burden of the disease, which unfortunately,
is likely to be increasingly overwhelming in the coming
decades. In low- income countries, especially those on the
African continent, where population growth and ageing
are increasing at a very fast pace, this may be an issue to
contend with in the future.13 Moreover, the current wide-
spread limited healthcare resources, low socioeconomic
status, and ineffective or lack of preventive strategies in
these countries also make the situation even more dire.14
In sub- Saharan Africa, the point prevalence of neck
pain is high (males 4.1–4.7%; females 6.0–6.8%) and
only outranked by the USA (males 5.3%; females 7.6%),
Western Europe (males 5.2%; females 7.4%) and East
Asia (males 4.8%; females 7.0%).5 Unless effective
prevention strategies are implemented, the burden of
neck pain in Africa is likely to be disturbing in the next
few years. Unfortunately, despite the staggering impact
of neck pain, it is generally less prioritised and empiri-
cally presented,5 15 possibly due to the overwhelming inci-
dence of life- threatening conditions such as malaria and
HIV/AIDS.16 However, epidemiological challenges and
unavailability of reliable data on the prevalence estimates
could possibly explain why disabling musculoskeletal
conditions are generally less prioritised in Africa. Thus,
to have a better understanding of the impact of neck pain
for policymaking, resource allocation and effective trans-
lation of research findings into clinical practice in this
continent, reliable data on the pooled prevalence of neck
pain and its associated factors are warranted.
As is the usual trend globally, low back pain is mostly
prioritised over neck pain in research despite the huge
global burden of both disorders.5 17 In this regard, a
systematic review and meta- analysis on the prevalence
of low back pain in Africa was conducted in 201718 and
updated in 2018.19 This review has opened doors for
low back pain- related research and policies. However, a
similar review on neck pain in Africa, despite its burden
and a plethora of published cross- sectional studies, is
lacking.
Following our preliminary search in the International
Prospective Register of Systematic Reviews (PROSPERO),
MEDLINE, PEDro and the Cochrane Database of System-
atic Reviews, it is apparent that no current or underway
systematic review and meta- analysis on the prevalence of
neck pain and its associated factors in Africa exits. There-
fore, the objective of this study is to describe a protocol
for a systematic review and meta- analysis on the preva-
lence of neck pain and its associated factors in Africa.
Specific objectives of this review are:
►To provide accurate and contemporary prevalence
estimates of neck pain in Africa according to existing
published studies.
►To examine the factors associated with neck pain
prevalence in Africa according to existing published
studies.
►To critically appraise the methodological quality of
the prevalence studies to identify gaps in the litera-
ture and highlight areas for improvement in future
research.
METHODS
Systematic review registration and reporting
This review protocol has been registered with the PROS-
PERO database on 14 September 2021 (registration
number CRD42021273585) and designed in accordance
with the Preferred Reporting Items for Systematic Reviews
and Meta- Analyses Protocols (PRISMA- P) statement20
(online supplemental appendix 1) and Meta- analysis
Of Observational Studies in Epidemiology (MOOSE)
reporting guideline.21 In the event of an amendment to
this protocol, a description of the amendment along with
the rationale will be updated in PROSPERO.
Data sources and search strategies
Six key electronic databases will be systematically searched
from inception to obtain and export relevant articles
reporting the prevalence of neck pain in the African
continent. The databases are PubMed/MEDLINE,
Scopus, African Journals Online, EMBASE, CINAHL
and Web of Science. Appropriate search strategies will
be used for each of the databases to ensure maximum
number of relevant articles. The keywords will be ‘preva-
lence’, ‘neck pain’, ‘musculoskeletal disorders/pain’ and
‘Africa’. Logically, we anticipate that there will be a lack
of the word ‘Africa’ quoted in the title of body of most
potentially relevant African prevalence studies. Hence, all
individual African countries names will be included in the
search strategies. For studies reporting musculoskeletal
disorders/pain, neck pain prevalence has to be reported
for the study to be included. The full search strategy is
presented online supplemental appendix 2.
Eligibility criteria
Studies will be included in the review according to the
following criteria: participants, condition or outcome(s)
of interest, study design and context. The primary focus of
the review is to estimate the prevalence of neck pain in the
African continent. Therefore, studies that were conducted
in any of the African countries and have reported data on
the prevalence of neck pain will be eligible for inclusion.
Eligible studies will be population- based cross- sectional
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studies reporting prevalence data using validated or
non- validated questionnaire/scale and conducted in the
African continent.
Due to the frequency of studies conducted on muscu-
loskeletal disorders and musculoskeletal pain among
African researchers, such studies will be included due
to the presence of neck pain in the data of such studies.
This will be in addition to studies reporting primarily
on neck pain. To be included, studies have to report
on prevalence (often proportion) of neck pain in the
population of interest. Parameters such as age, gender,
language or ethnic group of the participants will not be
a barrier for inclusion. However, only studies published
in English or French will be eligible since these are the
common languages used in scholarly communication in
Africa.19 22 Studies published in French will be translated
by a French- speaking African native and will be validated
by cross- checking the French translations with the English
abstract of the article, which is often available online,
before inclusion. Studies published in other languages
other than English and French will be excluded. Lastly,
reviews, conference abstracts, commentaries/letter to
editors, non- human articles and other grey literature will
also be excluded.
Condition or outcome(s) of interest
Primary outcome for the present review will be preva-
lence proportion of neck pain, defined according to the
author’s reported definition. Secondary outcomes will be
to identify the factors (eg, individual/personal, biome-
chanical and psychosocial factors) associated with neck
pain prevalence. In the event that neck pain prevalence
is not directly reported in proportion and associated
95% CI, estimates from the number of cases and sample
size mentioned in each single study will be calculated, if
permissible.
Study screening and selection
Relevant articles will first be exported to Zotero soft-
ware (https://www.zotero.org), where articles will be
sorted and duplicates removed before being exported
to the Rayyan software (https://rayyan.qcri.org) for
screening. The first author (NBM) who is experienced
in conducting and publishing systematic reviews as first
and coauthor, together with the second author (AAI)
who recently completed an intensive course on how to
conduct systematic reviews and meta- analyses, will inde-
pendently screen the articles. In case of unresolved
conflict, the third author (JM) will help in resolving the
conflict. JM has published a number of systematic reviews
as first author. Additional co- authors with experience in
conducting systematic reviews will be invited depending
on the amount of work load encountered from the data-
bases search. Both title/abstract and full- text screening
will be performed using the Rayyan software. A planned
PRISMA flow chart showing details of the included and
excluded studies at each stage of the study selection
process is provided in figure 1.
Data extraction and management
Information to be extracted from the eligible studies will
include author name(s), year of publication, country of
publication, study design, data collection tool/outcome
measure tool(s), population, study setting, sample size,
age group/age (range and/or mean±SD), gender,
data collection period, neck pain definition, neck pain
recall period, reliability/validity of measurement tools,
response rates, neck pain prevalence rates (point, period,
lifetime) and associated or risk factors of neck pain with
their OR. The corresponding authors will be contacted
through mail when necessary for any difficulties encoun-
tered during data extraction. A prepared customised
data extraction form will be used for entering the rele-
vant publication details. The findings of the review will be
illustrated through tables and figures.
Risk of bias and methodological quality assessment
The Newcastle–Ottawa Scale (NOS) which consists of
three domains (selection, comparability and outcome)
will be used in assessing the risk of bias (ROB) in
the included studies. A checklist and coding manual
language specific to the current review topic will be
prepared to aid the two independent raters during ROB
assessment. When a primary study meets the method-
ological expected standard, one star will be awarded
for each item in selection and outcome domains, and a
maximum of two stars will be awarded for the compara-
bility domain. In the end, studies with star scores from
0 to 4 points will be considered as having high ROB,
Figure 1 Flow chart depicting study selection process.
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5 to 6 points will be considered as having moderate
ROB, while 7 to 9 points will be considered as having
low ROB.23
Additionally, the quality of the included studies will
also be appraised using a critical appraisal tool as modi-
fied by Morris et al19 (online supplemental appendix 3)
where low back pain prevalence in Africa was reviewed
and methodological quality of the included studies was
appraised using the same tool. We consider this tool to be
additionally appropriate for our review due to the simi-
larity of both reviews. Both low back pain and neck pain
are types of spinal pain and in both reviews, Africa is the
target scope while observational/cross- sectional studies
are the designs of interest. In our review, the only modi-
fication to the appraisal tool will be to replace low back
pain with neck pain. The tool has 10 questions that will
be weighed and scored equally. Each question is to be
answered by either a ‘yes’ or ‘no’ or ‘unclear’. An option
of ‘yes’ will be scored as 1 point, while an option of either
‘no’ or ‘unclear’ connotes 0 point.
Two assessors (most probably NBM and AAI) will inde-
pendently score the ROB (using NOS) and methodolog-
ical quality of the included studies. In case of conflicts, a
meeting will be organised between the two assessors and
where a conflict remains unresolved after the meeting,
the last author (JM) will be invited to make the final
decision.
Strategy for data synthesis
A descriptive table summarising the key characteristics
of each of the included studies will be presented. Meta-
analysis will be planned with sufficient clinically and statis-
tically homogeneous and comparable reported outcomes
among studies by pooling data using Revman V.5.4 soft-
ware. The pooled prevalence estimates of neck pain in
Africa and associated 95% CI will be calculated. Similarly,
for the factors associated with neck pain prevalence, OR
and associated 95% CI will be computed. Random- effects
model will be used since heterogeneity in the popula-
tions of included studies is expected. Statistical hetero-
geneity will be assessed using I² statistic and its 95% CI,
with values of 25, 50, and 75% signifying mild, moderate,
and severe heterogeneity, respectively.24 25 Pooled preva-
lence estimates will be graphically depicted using forest
plots. In case meta- analysis is not possible due to insuffi-
cient homogeneous studies, a narrative synthesis will be
performed.
Assessment of publication bias
Potential publication bias will be assessed subjectively
using funnel plots, with a symmetrical funnel shape indi-
cating no publication bias while an asymmetrical funnel
plot indicating a publication bias.26 Objective assessment
of publication bias will be performed using Egger’s linear
regression test, with p<0.1 indicating statistically signifi-
cant publication bias.27
Subgroup and sensitivity analyses
Based on the study and population characteristics,
subgroup analyses will be performed for age group (adults
and children/adolescents), gender (male and female),
study setting (community, industry, hospital, professional
and school) and country status (low income, low middle
income and upper middle income) as also examined in
previous reviews in Africa.18 19 For sensitivity analyses,
studies with lower methodological quality studies will be
excluded to assess if their exclusion would change the
results of the analyses.
Patient and public involvement
This study involves a review of publicly available published
peer- reviewed papers; hence, patients and the public were
not involved.
Ethics and dissemination
Ethical approval will not be sought for this study, as no
human subject participants will be involved. Data from
previously published studies will be collected and anal-
ysed. The results of this review will be disseminated
through publication in a peer- reviewed academic journal
and presentation at relevant academic conferences.
DISCUSSION
Neck pain remains one of the common health problems
affecting the contemporary society. However, despite
the significant disability and socioeconomic burden
imposed by neck pain, still, less is known about its impact
in the African context, perhaps because it is not a life-
threatening condition.28 To our best knowledge, this will
be the first review to systematically identify and synthe-
sise available literature on the prevalence and associated
factors of neck pain in the African continent. Therefore,
this will be the first systematic review and meta- analysis
to provide a pooled prevalence of neck pain and its asso-
ciated factors on the African continent, which may assist
health professionals and policymakers to plan and imple-
ment evidence- based strategies for lessening the burden
of neck pain. Furthermore, the review will identify the
methodological shortcomings of published African
studies on neck pain prevalence for improvement of
future research quality.
The plan to conduct a meta- analysis, subgroup and
sensitivity analyses are the major strengths of our review.
Additionally, the inclusion of all age groups will increase
the generalisability of the findings. However, we antici-
pate limitations to our review due to potential publica-
tion bias and heterogeneity among studies, as well as the
inclusion of only published studies in English or French.
Contributors NBM conceived the research question and designed the study with
the help of other authors. AAI developed and edited the protocol. NBM and AAI will
design the search strategy, participate in the search process, appraise the quality of
the articles and extract needed data independently. NBM and JM will analyse and
interpret the results. JM will supervise the review. All authors read and approve this
protocol before sending it for publication.
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Open access
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer- reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Aminu AlhassanIbrahim http://orcid.org/0000-0002-5711-1639
JibrilMohammed http://orcid.org/0000-0001-7466-7973
REFERENCES
1 Vos T, Allen C, Arora M. Global, regional, and national incidence,
prevalence, and years lived with disability for 310 diseases and
injuries, 1990- 2015: a systematic analysis for the Global Burden of
Disease Study 2015. Lancet 2016;388:1545–602.
2 Kyu HH, Abate D, Abate KH, etal. Global, regional, and national
disability- adjusted life- years (DALYs) for 359 diseases and injuries
and healthy life expectancy (HALE) for 195 countries and territories,
1990- 2017: a systematic analysis for the Global Burden of Disease
Study 2017. The Lancet 2018;392:1859–922.
3 Cieza A, Causey K, Kamenov K, etal. Global estimates of the need
for rehabilitation based on the global burden of disease study 2019:
a systematic analysis for the Global Burden of Disease Study 2019.
Lancet 2021;396:2006–17.
4 March L, Smith EUR, Hoy DG, etal. Burden of disability due to
musculoskeletal (MSK) disorders. Best Pract Res Clin Rheumatol
2014;28:353–66.
5 Hoy D, March L, Woolf A, etal. The global burden of neck pain:
estimates from the Global Burden of Disease 2010 study. Ann Rheum
Dis 2014;73:1309–15.
6 Haldeman S, Carroll L, Cassidy JD. Findings from the bone and joint
decade 2000 to 2010 task force on neck pain and its associated
disorders. J Occup Environ Med 2010;52:424–7.
7 Blanpied PR, Gross AR, Elliott JM, etal. Neck pain: revision 2017. J
Orthop Sports Phys Ther 2017;47:A1–83.
8 Hogg- Johnson S, van der Velde G, Carroll LJ, etal. The burden and
determinants of neck pain in the general population: results of the
bone and joint decade 2000- 2010 task force on neck pain and its
associated disorders. Spine (Phila Pa 1976) 2008;33:S39–51.
9 Croft PR, Lewis M, Papageorgiou AC, etal. Risk factors for
neck pain: a longitudinal study in the general population. Pain
2001;93:317–25.
10 Kazeminasab S, Nejadghaderi SA, Amiri P, etal. Neck pain: global
epidemiology, trends and risk factors. BMC Musculoskelet Disord
2022;23:26.
11 Shin DW, Shin JI, Koyanagi A, etal. Global, regional, and national
neck pain burden in the general population, 1990–2019: an
analysis of the Global Burden of Disease Study 2019. Front Neurol
2022;13:955367.
12 Dieleman JL, Cao J, Chapin A, etal. US health care spending by
payer and health condition, 1996- 2016. JAMA 2020;323:863.
13 Kibirige JS. Population growth, poverty and health. Soc Sci Med
1997;45:247–59.
14 Azevedo MJ. The state of health System(S) in Africa: challenges
and opportunities. In: Historical perspectives on the state of health
and health systems in Africa, Volume II. Cham: Palgrave Macmillan,
2017: 1–73.
15 Wanyonyi NEN, Frantz J. Prevalence of work- related musculoskeletal
disorders in Africa: a systematic review. Physiotherapy
2015;101:e1604–5.
16 Moszynski P. WHO report highlights Africa’s health challenges. BMJ
2006;333:1088.
17 Hoy D, March L, Brooks P, etal. The global burden of low back pain:
estimates from the Global Burden of Disease 2010 study. Ann Rheum
Dis 2014;73:968–74.
18 Louw QA, Morris LD, Grimmer- Somers K. The prevalence of low
back pain in Africa: a systematic review. BMC Musculoskelet Disord
2007;8:105.
19 Morris LD, Daniels KJ, Ganguli B, etal. An update on the prevalence
of low back pain in Africa: a systematic review and meta- analyses.
BMC Musculoskelet Disord 2018;19:196.
20 Moher D, Shamseer L, Clarke M, etal. Preferred reporting items for
systematic review and meta- analysis protocols (PRISMA- P) 2015
statement. Syst Rev 2015;4:1.
21 Stroup DF, Berlin JA, Morton SC, etal. Meta- analysis of
observational studies in epidemiology: a proposal for reporting.
Meta- analysis of observational studies in epidemiology (MOOSE)
group. JAMA 2000;283:2008–12.
22 Ondari- Okemwa E. Scholarly publishing in sub- Saharan Africa in the
twenty- rst century: challenges and opportunities. FM 2007;12:10.
23 Mamikutty R, Aly AS, Marhazlinda J. Selecting risk of bias tools for
observational studies for a systematic review of anthropometric
measurements and dental caries among children. Int J Environ Res
Public Health 2021;18:8623.
24 Higgins JPT, Thompson SG, Deeks JJ, etal. Measuring
inconsistency in meta- analyses. BMJ 2003;327:557–60.
25 Huedo- Medina TB, Sánchez- Meca J, Marín- Martínez F, etal.
Assessing heterogeneity in meta- analysis: Q Statistic or I2 index
Psychol Methods 2006;11:193–206.
26 Sterne JA, Egger M. Funnel plots for detecting bias in meta- analysis:
guidelines on choice of axis. J Clin Epidemiol 2001;54:1046–55.
27 Egger M, Davey Smith G, Schneider M, etal. Bias in meta- analysis
detected by a simple, graphical test. BMJ 1997;315:629–34.
28 Woolf AD, Brooks P, Akesson K, etal. Prevention of musculoskeletal
conditions in the developing world. Best Pract Res Clin Rheumatol
2008;22:759–72.
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