Chronic pain is now understood as a multidimensional personal experience influenced by biological, psychological and social factors and chronic pain is commonly defined as pain that persists or recurs for longer than 3 months [1]. Low back pain is the leading cause of disability worldwide and the musculoskeletal condition for which the largest number of people may benefit from rehabilitation [2,3]. Beyond direct treatment costs, musculoskeletal disorders impose a major indirect economic burden through absenteeism, reduced productivity and long-term functional limitation [4-10].   Hospital housekeeping is a physically demanding occupation. Daily work commonly involves repetitive bending, twisting, reaching, pushing, pulling, lifting, handling mattresses and cleaning equipment and prolonged standing. These exposures can increase lumbar mechanical loading and may contribute to chronic low back pain and other work-related musculoskeletal disorders [11-16]. Prior studies among cleaners and housekeepers have repeatedly shown high rates of low back pain and have linked symptoms to awkward posture, repetitive bending, extended work hours, insufficient rest and cumulative work exposure [11-16].   Pain self-efficacy refers to a person's confidence in performing meaningful activities despite pain [5]. In chronic musculoskeletal pain, lower self-efficacy has been associated with greater disability, higher pain intensity, poorer coping and less favorable functional recovery [7-10]. Importantly, self-efficacy represents a potentially modifiable factor within the biopsychosocial model of chronic pain and may therefore complement ergonomic interventions in occupational settings.   Despite the relevance of both physical workload and psychological coping, hospital housekeepers remain underrepresented in the chronic low back pain literature, especially in Middle Eastern healthcare settings. Most available occupational studies focus on prevalence and biomechanical risk factors, whereas fewer address how pain self-efficacy relates to disability in this workforce [11-16].   The present study therefore examined the association of pain self-efficacy with pain intensity and disability among hospital housekeepers with chronic low back pain, while also describing work-related factors associated with worse outcomes.   Aim and Objectives The primary aim of this study was to assess the association of pain self-efficacy with pain intensity and disability among hospital housekeepers with chronic low back pain.   Secondary objectives were to describe the distribution of pain intensity, disability and self-efficacy in the study population and to explore whether selected demographic and work-related factors were associated with disability level and self-efficacy.

This study was conducted as a cross-sectional electronic survey from February 2025 to May 2025 among hospital housekeepers. The manuscript originally contained proposal-tense wording; this was corrected to past tense to reflect completed data collection. Because the original file did not provide the final ethics approval number, the authors should insert the approval identifier in the final submission.   Adults working as hospital housekeepers who reported chronic low back pain were included. For reporting clarity, chronic low back pain was defined as self-reported pain in the lower back persisting or recurring for more than 3 months. The original manuscript did not provide a detailed exclusion list; this should be added by the authors in the final version if such exclusions were applied (for example pregnancy, prior spinal surgery, major trauma, radiculopathy, or red-flag conditions).   Data were collected using a self-administered online questionnaire. The questionnaire included three components: (1) demographic and work-related items; (2) the Oswestry Disability Index (ODI), a widely used measure of back-related disability [6]; and (3) the Pain Self-Efficacy Questionnaire (PSEQ), a 10-item instrument that measures confidence in functioning despite pain [5]. Because the uploaded manuscript did not specify the language version used, the authors should explicitly state whether validated Arabic, English, or bilingual versions were administered.   The ODI assesses disability across ten activities of daily living. Each item is scored from 0 to 5 and converted to a percentage, with higher scores indicating greater disability [6]. The PSEQ comprises ten items scored on a 0-6 scale, with higher total scores indicating stronger pain self-efficacy beliefs [5].   Data were exported to Microsoft Excel, screened for duplication and analyzed in SPSS version 23 (IBM Corp., Armonk, NY, USA). Frequencies and percentages were used for descriptive analysis. Associations between categorical variables were examined using Pearson's chi-square test or Fisher's exact test, as appropriate. The original manuscript included a logistic regression model for severe disability; however, because only three participants fell into the severe-disability category, these estimates should be regarded as exploratory and statistically unstable. A p value <0.05 was considered statistically significant.

A total of 365 participants were analyzed. The majority were older than 29 years (70.1%), 71.5% had permanent employment, 56.4% had more than 5 years of work experience in the same work area and 55.1% worked more than 8 hours per day. Reaching/overstretching and repetitive bending were reported by 87.4 and 89.0% of participants, respectively (Table 1).   Table 1: Sociodemographic and Work Related Characteristics Variables Variables N Percentage Age < = 24 years 12 3.3 Age 25-29 years 97 26.6 Age >29 years 256 70.1 Gender Female 178 48.8 Gender Male 187 51.2 Chronic diseases None 326 89.3 Chronic diseases Diabetes 16 4.4 Chronic diseases Hypertension 19 5.2 Chronic diseases Others 4 1.1 Are you currently take any medication No 309 84.7 Are you currently take any medication Yes 56 15.3 Employment pattern Temporary 104 28.5 Employment pattern Permanent 261 71.5 Specific Work experience in this work area <2 years 37 10.1 Specific Work experience in this work area 2-5 years 122 33.4 Specific Work experience in this work area >5 years 206 56.4 Body Mass Index (BMI) Underweight 51 14.0 Body Mass Index (BMI) Normal 234 64.1 Body Mass Index (BMI) Overweight 71 19.5 Body Mass Index (BMI) Obese 9 2.5 Hours worked per day ≤8 hours 164 44.9 Hours worked per day >8 hours 201 55.1 Rest break taken per day (excluding lunch break) >3 times (15 min/60 min work) 13 3.6 Rest break taken per day (excluding lunch break) Twice (30–45 min) 147 40.3 Rest break taken per day (excluding lunch break) Once for <30 min 205 56.2 The job require reaching/over stretching No 46 12.6 The job require reaching/over stretching Yes 319 87.4 The job require repetitive bending No 40 11.0 The job require repetitive bending Yes 325 89.0   Mild low back pain was reported by 67.7% of participants, minimal disability by 89.9% and very high self-efficacy by 60.8% (Table 2). No participant was classified as crippled or bed-bound/exaggerating.   Table 2: Distribution of Lower Back Pain Intensity, Disability Levels and Pain Self-Efficacy Among Participants Lower back pain intensity Mild (0-3) N Percentage 247 67.7 Lower back pain intensity Moderate (4-6) 101 27.7 Lower back pain intensity Severe (7-10) 17 4.7 Disability Minimal 328 89.9 Disability Moderate 34 9.3 Disability Severe 3 .8 Disability Crippled 0 0 Disability Bed-bound/Exaggerating 0 0 Self-efficacy Very low 64 17.5 Self-efficacy Low 7 1.9 Self-efficacy Moderate 14 3.8 Self-efficacy High 58 15.9 Self-efficacy Very high 222 60.8   Disability level varied significantly by sex, with female participants showing higher proportions of moderate and severe disability than male participants (p = 0.008). Other demographic and work-related comparisons were directionally informative but should be interpreted cautiously because severe disability was rare in the sample (Table 3).   Table 3: Association of Disability Levels with Sociodemographic and Work-Related Characteristics Variables Variables Disability Disability Disability Total P-value Variables Variables Minimal Moderate Severe Age ≤24 years 12 (100.0%) 0 (0.0%) 0 (0.0%) 12 (100%) 0.315 Age 25–29 years 84 (86.6%) 13 (13.4%) 0 (0.0%) 97 (100%) 0.315 Age >29 years 232 (90.6%) 21 (8.2%) 3 (1.2%) 256 (100%) 0.315 Gender Female 151 (84.8%) 25 (14.0%) 2 (1.1%) 178 (100%) 0.008 Gender Male 177 (94.7%) 9 (4.8%) 1 (0.5%) 187 (100%) 0.008 Chronic Disease None 298 (91.4%) 25 (7.7%) 3 (0.9%) 326 (100%) 0.115 Chronic Disease Diabetes 12 (75.0%) 4 (25.0%) 0 (0.0%) 16 (100%) 0.115 Chronic Disease Hypertension 15 (78.9%) 4 (21.1%) 0 (0.0%) 19 (100%) 0.115 Chronic Disease Others 3 (75.0%) 1 (25.0%) 0 (0.0%) 4 (100%) 0.115 Employment Pattern Temporary 94 (90.4%) 10 (9.6%) 0 (0.0%) 104 (100%) 0.545 Employment Pattern Permanent 234 (89.7%) 24 (9.2%) 3 (1.1%) 261 (100%) 0.545 Specific Work Experience <2 years 37 (100.0%) 0 (0.0%) 0 (0.0%) 37 (100%) 0.130 Specific Work Experience 2–5 years 111 (91.0%) 11 (9.0%) 0 (0.0%) 122 (100%) 0.130 Specific Work Experience >5 years 180 (87.4%) 23 (11.2%) 3 (1.5%) 206 (100%) 0.130 BMI Underweight 46 (90.2%) 5 (9.8%) 0 (0.0%) 51 (100%) 0.380 BMI Normal 213 (91.0%) 20 (8.5%) 1 (0.4%) 234 (100%) 0.380 BMI Overweight 62 (87.3%) 7 (9.9%) 2 (2.8%) 71 (100%) 0.380 BMI Obese 7 (77.8%) 2 (22.2%) 0 (0.0%) 9 (100%) 0.380 Hours Worked per Day ≤8 hours 143 (87.2%) 18 (11.0%) 3 (1.8%) 164 (100%) 0.091 Hours Worked per Day >8 hours 185 (92.0%) 16 (8.0%) 0 (0.0%) 201 (100%) 0.091 Rest Break per Day (excluding lunch) >3 times 13 (100.0%) 0 (0.0%) 0 (0.0%) 13 (100%) 0.385 Rest Break per Day (excluding lunch) Twice 131 (89.1%) 16 (10.9%) 0 (0.0%) 147 (100%) 0.385 Rest Break per Day (excluding lunch) Once for <30 min 184 (89.8%) 18 (8.8%) 3 (1.5%) 205 (100%) 0.385 Job Requires Reaching/Overstretching No 42 (91.3%) 4 (8.7%) 0 (0.0%) 46 (100%) 0.792 Job Requires Reaching/Overstretching Yes 286 (89.7%) 30 (9.4%) 3 (0.9%) 319 (100%) 0.792 Job Requires Repetitive Bending No 37 (92.5%) 2 (5.0%) 1 (2.5%) 40 (100%) 0.291 Job Requires Repetitive Bending Yes 291 (89.5%) 32 (9.8%) 2 (0.6%) 325 (100%) 0.291 Self-efficacy level showed significant associations with work experience (p = 0.010), daily working hours (p = 0.014), rest-break pattern (p = 0.025), reaching/overstretching (p = 0.001) and repetitive bending (p<0.001) (Table 4).   Table 4: Association of Self-Efficacy Levels with Sociodemographic and Work-Related Characteristics Variables Variables Self-Efficacy Levels Self-Efficacy Levels Self-Efficacy Levels Self-Efficacy Levels Self-Efficacy Levels Total p-value Variables Variables Very Low Low Moderate High Very High Age ≤24 years 1 (8.3%) 0 (0.0%) 0 (0.0%) 2 (16.7%) 9 (75.0%) 12 (100%) 0.495 Age 25–29 years 11 (11.3%) 1 (1.0%) 5 (5.2%) 19 (19.6%) 61 (62.9%) 97 (100%) 0.495 Age >29 years 52 (20.3%) 6 (2.3%) 9 (3.5%) 37 (14.5%) 152 (59.4%) 256 (100%) 0.495 Gender Female 34 (19.1%) 4 (2.2%) 6 (3.4%) 36 (20.2%) 98 (55.1%) 178 (100%) 0.142 Gender Male 30 (16.0%) 3 (1.6%) 8 (4.3%) 22 (11.8%) 124 (66.3%) 187 (100%) 0.142 Chronic Disease None 54 (16.6%) 6 (1.8%) 14 (4.3%) 48 (14.7%) 204 (62.6%) 326 (100%) 0.081 Chronic Disease Diabetes 2 (12.5%) 1 (6.3%) 0 (0.0%) 4 (25.0%) 9 (56.3%) 16 (100%) 0.081 Chronic Disease Hypertension 5 (26.3%) 0 (0.0%) 0 (0.0%) 6 (31.6%) 8 (42.1%) 19 (100%) 0.081 Chronic Disease Others 3 (75.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (25.0%) 4 (100%) 0.081 Employment Pattern Temporary 14 (13.5%) 2 (1.9%) 6 (5.8%) 14 (13.5%) 68 (65.4%) 104 (100%) 0.429 Employment Pattern Permanent 50 (19.2%) 5 (1.9%) 8 (3.1%) 44 (16.9%) 154 (59.0%) 261 (100%) 0.429 Specific Work Experience <2 years 7 (18.9%) 1 (2.7%) 0 (0.0%) 2 (5.4%) 27 (73.0%) 37 (100%) 0.010 Specific Work Experience 2–5 years 12 (9.8%) 0 (0.0%) 3 (2.5%) 23 (18.9%) 84 (68.9%) 122 (100%) 0.010 Specific Work Experience >5 years 45 (21.8%) 6 (2.9%) 11 (5.3%) 33 (16.0%) 111 (53.9%) 206 (100%) 0.010 BMI Underweight 2 (3.9%) 0 (0.0%) 1 (2.0%) 11 (21.6%) 37 (72.5%) 51 (100%) 0.277 BMI Normal 50 (21.4%) 5 (2.1%) 10 (4.3%) 31 (13.2%) 138 (59.0%) 234 (100%) 0.277 BMI Overweight 10 (14.1%) 2 (2.8%) 3 (4.2%) 15 (21.1%) 41 (57.7%) 71 (100%) 0.277 BMI Obese 2 (22.2%) 0 (0.0%) 0 (0.0%) 1 (11.1%) 6 (66.7%) 9 (100%) 0.277 Hours Worked per Day ≤8 hours 18 (11.0%) 2 (1.2%) 8 (4.9%) 33 (20.1%) 103 (62.8%) 164 (100%) 0.014 Hours Worked per Day >8 hours 46 (22.9%) 5 (2.5%) 6 (3.0%) 25 (12.4%) 119 (59.2%) 201 (100%) 0.014 Rest Break per Day (excluding lunch) >3 times (15 min/60 min work) 7 (53.8%) 0 (0.0%) 1 (7.7%) 0 (0.0%) 5 (38.5%) 13 (100%) 0.025 Rest Break per Day (excluding lunch) Twice (30–45 min) 26 (17.7%) 1 (0.7%) 5 (3.4%) 27 (18.4%) 88 (59.9%) 147 (100%) 0.025 Rest Break per Day (excluding lunch) Once for <30 min 31 (15.1%) 6 (2.9%) 8 (3.9%) 31 (15.1%) 129 (62.9%) 205 (100%) 0.025 Job requires reaching/ overstretching No 17 (37.0%) 2 (4.3%) 0 (0.0%) 2 (4.3%) 25 (54.3%) 46 (100%) 0.001 Job requires reaching/ overstretching Yes 47 (14.7%) 5 (1.6%) 14 (4.4%) 56 (17.6%) 197 (61.8%) 319 (100%) 0.001 Job requires repetitive bending No 17 (42.5%) 1 (2.5%) 1 (2.5%) 1 (2.5%) 20 (50.0%) 40 (100%) <0.001 Job requires repetitive bending Yes 47 (14.5%) 6 (1.8%) 13 (4.0%) 57 (17.5%) 202 (62.2%) 325 (100%) <0.001   Some counterintuitive distributions were observed in small subgroups and may reflect sparse cells, coding issues, or reverse causation; these findings should therefore not be overinterpreted.   Self-efficacy was strongly associated with disability category (p<0.001), with very high self-efficacy being most common among participants with minimal disability (Table 5).   Table 5: Association of Self-Efficacy Levels with Disability Disability Self-efficacy Self-efficacy Self-efficacy Self-efficacy Self-efficacy Total p value Very Low Low Moderate High Very High Minimal 59 (18.0%) 7 (2.1%) 6 (1.8%) 39 (11.9%) 217 (66.2%) 328 (100%) <0.001 Moderate 4 (11.8%) 0 (0.0%) 6 (17.6%) 19 (55.9%) 5 (14.7%) 34 (100%) <0.001 Severe 1 (33.3%) 0 (0.0%) 2 (66.7%) 0 (0.0%) 0 (0.0%) 3 (100%) <0.001   Mean pain intensity also differed significantly across disability groups and across self-efficacy strata (p<0.001) (Table 6).   Table 6: Comparison of Lower Back Pain Intensity with Disability and Self-Efficacy N Mean Std. Deviation p-value Disability Minimal 328 2.36 1.820 <0.001 Disability Moderate 34 5.85 1.374 <0.001 Disability Severe 3 4.67 3.215 <0.001 Self-efficacy Very low 64 2.28 2.465 <0.001 Self-efficacy Low 7 2.29 2.984 <0.001 Self-efficacy Moderate 14 6.07 1.859 <0.001 Self-efficacy High 58 4.83 1.365 <0.001 Self-efficacy Very high 222 2.07 1.417 <0.001   An exploratory logistic regression model is retained in Table 7 because it formed part of the original analysis. Nevertheless, the model should be interpreted with extreme caution because the outcome of severe disability was present in only three participants, making odds ratios unstable and unsuitable for strong inferential claims.   Table 7: Exploratory Logistic Regression Model Predicting Severe Disability (Interpret with Caution; n = 3 Severe Cases) Independent Variables Odds Ratio (OR) 95% CI for OR p-value Age (Reference: ≤24 years) 25–29 years 1.35 (0.85–2.13) 0.202 >29 years 1.98 (1.21–3.24) 0.006 Gender (Reference: Male) Female 0.90 (0.35–1.55) 0.501 Chronic diseases (Reference: None) Diabetes 2.56 (1.40–4.70) 0.812 Hypertension 1.85 (1.10–3.12) 0.220 Others 1.40 (0.65–3.02) 0.384 Currently taking medication (Ref: No) Yes 1.74 (1.12–2.70) 0.813 Table 7: Continue Employment pattern (Ref: Temporary) Permanent 0.85 (0.54–1.33) 0.474 Work experience (Reference: <2 years) 2–5 years 1.55 (0.95–2.52) 0.081 >5 years 1.96 (1.22–3.15) 0.005 BMI (Reference: Normal) Underweight 0.88 (0.40–1.94) 0.747 Overweight 1.07 (0.34–1.69) 0.132 Obese 2.90 (1.72–4.89) <0.001 Hours worked per day (Reference: ≤8 hours) >8 hours 2.24 (1.47–3.42) <0.001 Rest breaks per day (Reference: >3 times) Twice (30–45 min) 1.45 (0.83–2.53) 0.190 Once (<30 min) 2.05 (1.22–3.43) 0.137 Job requires reaching (Reference: No) Yes 1.15 (0.36–2.40) 0.123 Job requires repetitive bending (Ref: No) Yes 1.92 (1.20–3.05) 0.006 Self-efficacy (Reference: Very high) Very low 1.10 (0.45–1.98) 0.211 Low 0.40 (0.10–1.02) 0.424 Moderate 2.20 (1.22–3.97) 0.129 High 1.25 (0.65–2.40) 0.500 Lower back pain (Reference: Mild, 0–3) Moderate (4–6) 1.25 (0.42–2.94) 0.681 Severe (7–10) 6.50 (3.85–10.95) <0.001

This study found that most hospital housekeepers with chronic low back pain reported mild pain, minimal disability and high pain self-efficacy. Even within this relatively low-disability sample, lower self-efficacy was associated with worse disability and higher pain intensity. These findings are consistent with previous work showing that pain self-efficacy is closely related to functional status in chronic low back pain and may mediate the relationship between pain and disability [7-10].   The occupational profile of the sample also supports the importance of work exposures. Long work hours, longer work experience, repetitive bending and reaching/overstretching were associated with poorer self-efficacy distributions. This is biologically and ergonomically plausible, because repetitive and awkward movements can sustain pain, reinforce guarded movement behavior and reduce workers' confidence in remaining active while symptomatic [11-16].   Female participants had higher disability levels than male participants, although sex was not significantly associated with self-efficacy in this sample. This pattern may reflect differences in symptom burden, pain reporting, task allocation, or unmeasured psychosocial variables rather than a direct sex effect alone. Because the present design was cross-sectional, the study cannot determine whether low self-efficacy contributed to disability or whether greater disability eroded self-efficacy over time.   The original manuscript presented the regression model as if it definitively identified predictors of severe disability. That interpretation is too strong. With only three severe cases, the model is statistically fragile and several estimates may be unreliable. For this reason, the regression has been explicitly reframed as exploratory. Similarly, the unexpected subgroup patterns for rest breaks and some task-exposure categories should be interpreted as hypothesis-generating rather than confirmatory.   From a practical perspective, the findings still support a combined occupational-health approach. Housekeeping staff with chronic low back pain may benefit from ergonomic modification, reduction of repetitive bending, appropriate work-rest scheduling, training in safer movement strategies and pain self-management interventions that strengthen confidence in functioning despite pain. This interpretation is aligned with the biopsychosocial view of chronic low back pain and with occupational studies emphasizing both physical and psychosocial contributors [7-17].   The study has several limitations. It was conducted in a single hospital, relied entirely on self-reported data, did not provide objective clinical assessment and did not specify the survey language version in the uploaded manuscript. Most importantly, the severe-disability subgroup was extremely small, limiting subgroup analysis and making the regression model unstable. These issues should be acknowledged transparently in the final submission.

In this cross-sectional sample of hospital housekeepers with chronic low back pain, pain self-efficacy was significantly associated with both pain intensity and disability. The results support workplace strategies that combine ergonomic risk reduction with education and confidence-building self-management support. Because the study was single-center and cross-sectional and because severe disability was rare, the findings should be interpreted as associative rather than causal.   Tables Table 1 reproduces the original descriptive distribution of sociodemographic and work-related variables.   Tables 2-6 are retained from the submitted manuscript, with interpretation revised in the text.   Table 7 is retained as an exploratory model only because the severe-disability category contained just three participants.