Formal education and back-related disability: In search of an explanation

Study Design. The present study is a 2-year prospective study with repeated measurements. Objectives. To examine the association of education with back-related disability along with four sets of variables that might explain this relationship: clinical, behavioral, and environmental factors; occupational variables; health care use; and interactions between stressful events and coping strategies. Summary of Background Data. Although education has been found to be associated with back-related disability in previous reports, this relationship remains to be explained. Examination of this association may yield a better understanding of the causes and natural history of disability resulting from back pain. Methods. Subjects were 1213 enrollees of a Health Maintenance Organization (HMO) who consulted a primary care physician for back pain in 1989-1990, completed a baseline telephone interview, and had a follow-up evaluation after 1 and 2 years, using a modified version of the Roland-Morris Scale to measure disability. Results. Subjects who completed 13 years or more of schooling had less disability and a greater decline in their disability over time than those who completed less schooling. Occupational characteristics and somatization were among the strongest explanatory factors. Cigarette smoking contributed to the explanation of the cross-sectional association. Conclusions. Education is associated cross-sectionally and longitudinally with disability resulting from back pain. A wide range of variables may mediate the education-back- related disability association, including a propensity to report diffuse physical symptoms (somatization), lifestyle (e.g., cigarette smoking), and occupational factors.