Introduction

Degenerative lumbar spine disease is characterized by the progressive deterioration of the lumbar spine’s structural components, including intervertebral discs, facet joints, and ligaments1,2. Global estimates reveal 266 million new cases of degenerative lumbar spine disease annually, with the prevalence reaching as high as 27.3%3,4. In China, the incidence of the condition has also witnessed the rising trend with the growing aging population5,6. The condition not only undermines physical mobility and daily activities, but also extends to reduced psychological well-being7,8,9. Besides, the induced socio-economic burden has been on the rise, such as impaired work productivity and declined life quality10. To mitigate the health burden, patients’ responses to the disease and related management should be underscored. Since understanding the disease pathogenesis, its perceived impacts, and related treatment can impact patients’ involvement, exploring their knowledge, attitudes, and practices (KAP) is warranted to identify barriers11.

The KAP model has been widely employed to assess the understanding, beliefs, and actions of individuals or communities in relation to specific health issues12. The model operates on the assumption that knowledge influences attitudes, which in turn shape behaviors13. In the context of degenerative lumbar spine disease, knowledge includes the risk factors and related symptoms, facilitating prompt medical attention and diagnosis. Positive attitude towards rehabilitation exercises and physical therapy can enhance patients’ compliance with prescription. As regards practices, regular exercise and lifestyle modifications can slow the degenerative process of lumbar spine14,15. Also, routine check-ups allow for the early detection of degenerative changes and timely therapeutic implementation16. To our knowledge, previous KAP studies have mainly focused on spinal cord injury17 and intervertebral disc herniation11, and no KAP evidence has been available on degenerative lumbar spine disease. The research gap can thus materially impair the prevention and management of the disease.

This study aimed to explore the KAP among the patients, examine their interrelationships, and identify influential factors. The hypotheses for KAP framework were posited as follows: (1) Knowledge positively influences the attitudes toward degenerative lumbar spine disease; (2) Knowledge positively affects patients’ practices; (3) Attitudes positively impact patients’ practices. Our findings can provide KAP evidence of degenerative lumbar spine disease, and facilitate interventions to improve awareness and management for the disease.

Methods

Study design and participants

This cross-sectional study was conducted between December 2023 and January 2024 at Shanxi Bethune Hospital and enrolled patients with degenerative lumbar spine disease. The study has obtained ethical approval from The Medical Ethics Committee of Shanxi Bethune Hospital (approval No: 20231228) and written informed consent were provided from the research subjects. Inclusion Criteria: (1) Patients diagnosed with degenerative lumbar disc herniation, lumbar spinal stenosis, lumbar spondylolisthesis, discogenic low back pain, facet joint degenerative low back pain, and lumbar instability low back pain. (2) Patients who agreed to participate in the study. Exclusion Criteria: Patients who continued to refuse to participate in the survey or were unable to cooperate in answering the questionnaire.

Questionnaire introduction

The questionnaire design referenced guidelines and literature18,19,20,21,22. After designing the questionnaire, input from five experts in the field of spinal surgery was sought for modifications to ensure context validity. A small-scale pilot test (21 questionnaires) was conducted, achieving a Cronbach’s α of 0.893. During the pilot test, no patients reported that the contents of the questionnaire were difficult to understand, indicating good face validity. Thus, there is no need to edit the original questionnaire.

The final questionnaire, in Chinese, comprised four sections: demographic information (age, gender, residence, education, healthcare payment method, monthly income, duration of daily household chores, daily sedentary time, engagement in regular physical activity, annual expenditure on lumbar spine health, duration of lumbar and leg pain, and receipt of treatment), knowledge dimension, attitude dimension, and practice dimension. The knowledge dimension included 10 questions, with a score of 1 for a correct answer and 0 for an incorrect answer. The total score in the knowledge dimension ranged from 0 to 10 points. The attitude dimension comprised 8 questions, utilizing a five-point Likert scale ranging from “strongly agree” (5 points) to “strongly disagree” (1 point). The total score in the attitude dimension ranged from 8 to 40 points. The practice dimension included 9 questions, ranging from “always” (5 points) to “never” (1 point). The 9th question aimed to assess patients’ willingness to choose between open and minimally invasive lumbar spine surgeries. Because this question reflected personal preference rather than KAP scores, it was recorded descriptively and was not included in the scoring system. The total score in the practice dimension ranged from 8 to 40 points. A cutoff value of > 70% in each dimension was defined as adequate knowledge, positive attitude, and proactive practice, according to previous patient-centered research studies in China13,23.

Questionnaire distribution and quality control

Patients were recruited through convenience sampling via WeChat groups and face-to-face interactions in various departments. The online questionnaire was distributed using Questionnaire Star (https://www.wjx.cn/), allowing participants to scan a QR code through WeChat or follow a provided link to access and complete the questionnaire. In order to maintain data quality and ensure comprehensive responses, a one-submission-per-IP address restriction was applied, and all questionnaire items were marked as mandatory. The participants were guaranteed anonymity during the survey process. The research team, comprising 6 chief and deputy chief physician trained as research assistants, was responsible for questionnaire promotion and distribution and meticulously reviewed all submissions for completeness, internal consistency, and logical coherence. Any submissions with logical errors, incomplete answers, or uniform responses across all items were categorized as invalid.

Sample size calculation

The sample size calculation followed Cochran’s formula, a commonly used formula in KAP studies, which is suitable for cross-sectional surveys24:

$$\:n={\left(\frac{{Z}_{1-\frac{\alpha\:}{2}}}{\delta\:}\right)}^{2}\times\:p\times\:(1-p)$$

where n denoted the sample size, and p was assumed to be 0.5 to ensure the maximum sample size. α, also known as the type I error, was set to 0.05. In this case, \(\:{Z}_{1-\frac{\alpha\:}{2}}=1.96.\) Assuming an effective questionnaire recovery rate of 80%, the final target is to collect at least 480 completed questionnaires.

Statistical methods

Statistical analysis was conducted using SPSS 26.0 (IBM, Armonk, NY, USA) and STATA 14. The post hoc analysis of construct validity of the questionnaire was tested by the Kaiser-Meyer-Olkin (KMO) measure and confirmatory factor analysis (CFA). The demographic information of the respondents and the KAP scores were analyzed descriptively, and the continuous data were expressed using means ± standard deviations (SD). The categorical data were presented using number (%). Differences in the KAP dimension scores were compared among different demographic characteristics using Student’s t-test for comparisons between two groups and ANOVA for comparisons among three or more groups, and post hoc pairwise tests were conducted using the LSD method. Relationships between KAP scores were assessed by Pearson correlation analysis. In univariate and multivariate analysis, 70% of the total score was used as the cut-off value. Variables with P < 0.05 of univariate analysis were enrolled in multivariate analysis. Hypotheses regarding the influence of knowledge on attitude and practice, as well as attitude on practice, were tested through structural equation modeling (SEM). A two-sided P-value < 0.05 was considered statistically significant.

Results

In the initial stage, the study recruited 499 participants. One individual refused to respond and one participant was excluded for providing questionnaire with logical error. Additionally, 14 participants provided incomplete responses. No questionnaires were excluded due to uniform responses across all items. Finally, 16 questionnaires were excluded, and 483 valid questionnaires were included, with an effective response rate of 96.79%. The KMO measure was 0.881 (P < 0.001), indicating that the sample size was adequate for factor analysis, and the model fit indicators showed a good fit for the KAP model (Table S1and Figure S1).

The majority were aged 51 years and above (75.16%), male (50.1%), and residing in urban areas (51.35%). A daily household chores duration of 0–1 h was reported by 30.02%, while 24.64% indicated a daily sedentary time of 0–2 h. Concerning lumbar spine health, the majority had an annual expenditure of less than 1000 yuan (64.18%) and had undergone surgical treatment (94.41%). Significantly, 30.02% reported experiencing lumbar and leg pain for a duration exceeding 10 years (Table 1).

Table 1 Demographic characteristics and KAP scores.
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The mean scores for KAP were 7.43 ± 2.10 (possible range: 0–10), 32.69 ± 2.77 (possible range: 8–40), and 23.62 ± 5.96 (possible range: 8–40), respectively. Using 70% of the total score in each dimension as the cutoff value, 265 (54.87%) participants demonstrated adequate knowledge, 489 (98.00%) exhibited a positive attitude, and 101 (20.91%) demonstrated proactive practice. Significant variations in knowledge scores were observed across demographic factors, such as age (P < 0.001), residence (P < 0.001) and education (P < 0.001). Similarly, significant differences in attitude were observed concerning age (P < 0.001), education (P = 0.029), and the duration of lumbar and leg pain (P = 0.017). Additionally, practice displayed significant variations among groups, such as education (P < 0.001), monthly income (P < 0.001), and annual expenditure on lumbar spine health (P < 0.001) (Table 1).

The correct response rates for individual knowledge questions varied from 39.54 to 98.76%. A substantial majority (98.76%) demonstrated awareness that neglecting lumbar spine protection in daily life may exacerbate or lead to a recurrence of the disease (K10). In contrast, the lowest percentage (39.54%) possessed knowledge on how to prevent degenerative lumbar spine disease (K3). Furthermore, a limited proportion (62.94%) were familiar with the definition and causes of degenerative lumbar spine disease (K1). Additionally, a modest proportion (66.05%) possessed knowledge about medications used to treat degenerative lumbar spine disease, including analgesics and nerve nutrition drugs (K8) (Table S2).

Within the attitude section, positive response rates ranged from 70.40 to 99.80%. A substantial majority (99.80%) exhibited a positive attitude towards lumbar spine protection, expressing willingness to adjust posture, maintain a correct standing position, and avoid prolonged sitting or bending over (A4). Conversely, the lowest percentage (70.40%) believed that degenerative lumbar spine diseases could be improved through methods such as exercise (A7). Similarly, a limited proportion (77.84%) held the belief that the condition could be cured (A1) (Table S3).

Practice adherence rates ranged from 17.81 to 60.46%. The highest percentage (60.46%) involved individuals taking care to rest in bed and avoiding movements such as bending and twisting after being diagnosed with degenerative lumbar spine diseases (P4). Conversely, only 17.81% chose to engage in appropriate physical activities to strengthen the muscles of the lower back and abdomen (P2). Additionally, 21.74% made efforts to move their lumbar spine during prolonged computer use and watching TV (P3). An equivalent proportion (21.74%) underwent regular physical examinations to monitor the condition and progression of degenerative lumbar spine diseases (P8) (Table S4).

Pearson correlation analysis revealed significant positive correlations among knowledge and attitude (r = 0.1364, P = 0.0027), knowledge and practice (r = 0.4839, P < 0.001), as well as attitude and practice (r = 0.2931, P < 0.001).

In the multivariate analysis, possessing an education of high school/technical school (OR = 2.34, P = 0.007) and college/bachelor’s and above (OR = 3.14, P = 0.004), and an annual expenditure on lumbar spine health above 3000 yuan (OR = 2.19, P = 0.006) were positively associated with adequate knowledge. However, being 51 years and above (OR = 0.47, P = 0.043) was negatively associated with adequate knowledge (Table S5). Additionally, knowledge (OR = 1.66, P < 0.001) and attitude (OR = 1.27, P < 0.001) participants with education of junior high school (OR = 4.82, P = 0.007), high school/technical school (OR = 10.3, P < 0.001), and college/bachelor’s and above (OR = 6.61, P = 0.005) were positively associated with proactive practice (Table 2).

Table 2 Univariate and multivariate logistic regression analysis for practice.
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The SEM demonstrated a favorable model fit (RMSEA < 0.001, SRMR < 0.001, TLI = 1.000, CFI = 1.000) (Table S6). The SEM confirmed positive associations between knowledge and attitude (β = 0.20, P = 0.001), attitude and practice (β = 0.61, P < 0.001), and knowledge and practice (β = 1.22, P < 0.001) (Table 3; Fig. 1).

Table 3 The estimates of structural equation model.
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Fig. 1
figure 1

Structural equation model showing the associations between KAP scores. All variables are observed variables. Direction of causality is indicated by single-headed arrows. The standardized βs are presented alongside the arrows.

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Discussion

This study demonstrated adequate knowledge, positive attitude, and inappropriate practice among patients with degenerative lumbar spine disease in Shanxi, China. Moreover, positive associations were observed among their KAP scores. These results may have implications for tailored education and behavioral interventions to improve the KAP levels of patients.

Our observation of adequate disease knowledge among patients contrasted with previous findings in different populations. For instance, a cross-sectional study conducted among healthy individuals in China revealed inadequate knowledge regarding cervical spondylosis25. Similarly, a study from Malawi reported that many patients with low back pain (LBP) were not adequately knowledgeable about their condition26. Despite relatively high knowledge and positive attitudes in our cohort, inappropriate practices were further observed. This disconnection between KAP underscored the influence of systemic barriers. Access to healthcare services, cultural beliefs, and socioeconomic conditions critically shape patients’ ability to implement knowledge into action27,28. For example, previous research has shown that patients who perceive lumbar spine symptoms as a minor issue may delay seeking professional care29. Likewise, economic barriers or limited rehabilitation resources may further prevent patients from adopting preventive behaviors, such as engaging in regular exercise or attending routine check-ups30. Education campaigns should be combined with strategies that address financial, cultural, and accessibility barriers. Promoting affordable and community-based rehabilitation services, and greater integration of physiotherapy guidance into routine care could substantially improve patients’ practices.

In the knowledge dimension, the majority (98.76%) recognized that neglecting lumbar spine protection in daily life may exacerbate or lead to a recurrence of the disease. This high level of awareness could be attributed to the symptoms of lumbar spine issues, including low back pain, numbness and weakness31. Conversely, only 39.54% demonstrated knowledge on how to prevent the degenerative lumbar spine disease. Several factors may contribute to the low level of knowledge. Patient education programs may not be adequately disseminating information, or patients may face barriers in accessing educational resources32. Additionally, the lack of emphasis on preventive education during routine clinical encounters might be a contributing factor. Besides, the moderate proportion (62.94%) were familiar with the definition and causes of degenerative lumbar spine disease. Healthcare providers should prioritize education initiatives incorporating both preventive measures and comprehensive descriptions of the condition. Using routine clinical encounters and multimedia platforms for patient education can contribute to more effective dissemination of information33.

As for attitude, 99.80% of participants displayed positive attitudes toward lumbar spine protection. Most endorsed healthy behaviors such as posture correction and avoiding prolonged sitting. Tailored programs based on the existing positive attitude, such as practical guidance on posture adjustment and lumbar spine protection, can be instrumental in enhancing patient self-efficacy. However, only 70.40% believed that their condition could be improved through methods such as exercise. It raised concerns about potential barriers to adopting a crucial non-invasive and cost-effective intervention. Targeted exercise can alleviate pain, reduce inflammation, and improve functional outcomes for patients with degenerative lumbar spine disease34. Accordingly, evidence-based medicine should be emphasized in shaping patient perspectives. Incorporating rehabilitation specialists, physiotherapists, and other healthcare professionals into the patient education process can address misconceptions surrounding exercise for degenerative lumbar spine diseases. Similarly, a limited proportion (77.84%) held the belief that degenerative lumbar spine diseases could be cured. The chronic status of degenerative lumbar spine diseases, often involving structural changes and progressive degeneration, contributes to the perceived challenge of achieving a complete cure35. It is essential to foster realistic expectations among patients, emphasizing the potential for effective management, symptom control, and improved quality of life rather than an outright cure. Healthcare providers should provide clear information about degenerative lumbar spine disease, available treatment options, and the realistic goals of therapeutic interventions.

In the practice dimension, more than half (60.46%) of patients opted for bed rest and restricted movements like bending and twisting. While short-term rest may be recommended during acute exacerbations, prolonged bed rest can have detrimental effects, including muscle atrophy, joint stiffness, and psychological distress36,37. Encouraging a balance between rest and appropriate physical activity can contribute to better long-term outcomes. However, the low percentage (17.81%) choosing to participate in such activities was alarming. The result was consistent with research from Bangladesh, where gaps in practice, particularly in exercise engagement among patients with LBP, were identified38. Scientific evidence consistently supports the benefits of targeted exercises in improving muscle strength, stability, and reducing pain associated with degenerative lumbar spine diseases39. Only 21.74% of patients chose to move their lumbar spine during prolonged computer use and TV watching, highlighting a potential area for intervention. Prolonged static positions, such as sitting for extended periods, can contribute to stiffness and discomfort. Also, 21.74% underwent regular physical examinations to monitor the degenerative lumbar spine disease and its progression. These examinations (such as MRI or CT scans, pain and functional assessment) enable early detection of changes in the spine’s condition, assessment of disease progression, and timely adjustment of treatment plans40. Addressing the barriers to regular check-ups through enhanced education, psychological support, improved access, financial assistance, and systemic healthcare improvements is essential for optimizing patient outcomes.

Positive correlations between KAP scores were robustly observed in the Pearson correlation analysis and SEM. Participants with sufficient knowledge of the condition were more inclined to have positive attitude, which can promote the translation into proactive practice41. The influential factors were additionally identified. Firstly, the positive associations between higher education and adequate knowledge and proactive practice scores were observed. Individuals possessing higher education were more likely to understand health-related information42. Educational materials should be simplified, incorporating visual aids and accessible language to ensure comprehension. Secondly, being 51 years and above was negatively associated with adequate knowledge, possibly attributed to generational differences in health information accessibility and awareness. Interventions should prioritize user-friendly formats, including larger print, auditory content, and the involvement of caregivers or family members. Thirdly, the positive association between higher expenditure and knowledge scores underscored the role of financial commitment as a facilitator of health awareness and preventive measures. Low-cost or no-cost solutions are more recommended, such as online resources, public health campaigns, or collaborations with local healthcare provider.

The study had several limitations. First, the cross-sectional design posed challenges in establishing the causality of our findings. Although the analysis provided a surrogate measure of causality, it is statistically inferred rather than directly observed. This limitation warrants further investigation in future longitudinal or intervention-based studies. Second, self-reported data introduced the possibility of social desirability bias, potentially resulting in inflated scores43. Third, since convenience sampling can introduce selection bias, results may be more applicable to similar populations within the Shanxi region or other areas with comparable contexts. Future studies using random sampling methods or multi-site recruitment strategies could help improve the generalizability of the results. Fourth, we did not incorporate triangulation methods due to time and resource constraints. Further validation could incorporate quantitative and qualitative approaches, which not only enhance data validity but also help identify more nuanced intervention strategies tailored to the specific needs of patients.

Conclusions

Patients with degenerative lumbar spine disease demonstrated adequate knowledge and positive attitudes, but their practices were inadequate. Positive correlations were observed among KAP scores. Targeted educational programs and behavioral interventions are recommended, particularly for populations with lower educational levels, limited financial resources, and older age. Interventions should be tailored to address specific barriers such as low health literacy, limited access to healthcare, and physical or cognitive challenges in older patients, ensuring broader accessibility and effectiveness.