Abstract
BACKGROUND:
Hajj is a series of rituals that are done in specific areas and periods in Mecca. Performing Hajj requires a great amount of physical demand which may result in musculoskeletal pain (MSP) in different age groups.
OBJECTIVE:
To estimate the prevalence of MSP and understand its pattern via exploring the factors that could be associated with muscular pain among pilgrims in the 2022 Hajj.
METHODS:
A web-based survey was distributed during the annual Hajj mass gathering. Pilgrims were recruited from Hajj ritual sites. The collected data included demographics, musculoskeletal pain at ten anatomical body sites, and physical activity (PA) level. Descriptive and inferential statistics were used to analyze the data at a 0.05 significance level.
RESULTS:
A total of 248 pilgrims participated in the study. The mean age of the sample was 43.49±12.70 years. Of all pilgrims, 78.6% had reported MSP in at least one anatomical body site during performing Hajj. Results revealed that Pilgrims were more likely to have MSP in the lower limb while performing Hajj rituals where the most prevalent reported pain was in the legs (46%), followed by the lower back (45%), knees (37%), and ankles/feet (30%). Age, sex, and PA were not significantly associated with MSP except the BMI was found to be a significant factor related to MSP among pilgrims (p <0.05).
CONCLUSION:
Many pilgrims exhibited pain in at least one body part. Although physical fitness recommendations are published in the Saudi Ministry of Health, MSP preventative measures need to be disseminated by organizations and interested parties worldwide.
Keywords
Introduction
Annually, Hajj season gathers around two to three million pilgrims worldwide in Mecca, Saudi Arabia (SA), and it happens once a year for 5 to 7 days [1]. Hajj is the Arabic term for pilgrimage [2], and Muslims are required to perform it at least once in their life [3] if they have physical and financial abilities [4]. The annual time of Hajj is determined based on the Islamic calendar which happens on the last month of the year which is nearly eleven days earlier than the Gregorian calendar [5].
Hajj is a series of rituals that are done in specific areas and periods in Mecca, and it consumes high physical demand in a mass gathering. Pilgrims are required to walk around 5 to 15 kilometers a day to accomplish a daily set of rituals that are required for Hajj [6, 7]. The total standing and walking time was roughly calculated to be 63 km during the Hajj period [8]. Most of the worship activities are performed physically such as standing, sitting, bowing, and kneeling, and those activities are repetitive throughout the day during the Hajj period [9]. Many individuals may not be used to those physical activities in their daily routine, so the sudden changes may result in pain at various body parts. Musculoskeletal pain (MSP) is defined as any pain that compromises the locomotor system including muscles, bones, joints, ligaments, and tendons [10]. According to the World Health Organization (WHO), 1.75 billion people around the world suffer from MSP, which accounts for 20 to 33% of the world’s total population. MSP is one of the most common types of pain that may lead to physical disability [11], and it is considered the “new epidemic” as reported by WHO [12]. MSP may cause a financial burden to the healthcare system due to the frequent need for healthcare services [13], and it was reported to be a serious health issue that reduces the productivity and quality of work among individuals in different occupational settings [14].
Numerous studies have been conducted to investigate different medical conditions that may occur to pilgrims during Hajj, including cardiovascular [15], neurological [16], infectious [17], and gastrointestinal [18] diseases. Based on the literature search, only one study was conducted to investigate MSP issues among pilgrims, and it was done before the global pandemic [8]. In 2020, the WHO announced COVID-19 as a pandemic, and quarantine was required [19]. Most of the countries implemented a quarantine as a preventive procedure to limit the COVID-19 spread, which has given rise to isolation and curfew enforcement [20]. The pandemic has led to multiple abrupt changes in the level of individuals’ physical activity (PA). These changes affected the daily routines, and drastically increased time spent at home which encouraged the sedentary lifestyle for a long period [21]. In 2020, Hajj was limited to one thousand individuals from different nationalities who lived inside SA only. Then, the number of pilgrims was increased to be around 58,000 pilgrims in 2021 according to the General Authority for Statistics in SA [22]. However, the pattern of MSP among individuals who performed Hajj and its contributing factors are not fully understood, particularly post-pandemic. The results of this study would help to better understand the extent of MSP pain that may affect completing the Hajj journey. Thus, the study aims to shed light on assessing the overall prevalence of MSP and its associated contributing factors among pilgrims in 2022. Additionally, the relationship between the prevalence of MSP, age, sex, body mass index (BMI), and PA level were aimed to be studied.
Methods
Participants
The participants were pilgrims aged 18 years and older who performed Hajj in July 2022. Pilgrims from both genders with any nationality were invited to participate voluntarily in the study. Non-probability convenience sampling was utilized to recruit the participants. G-power 3.1 software (University of Düsseldorf) was used to determine the minimum sample size required to achieve a power of 80%. In G-power, a logistic regression test was chosen to calculate the priori power and determine the sample size. The result of the G-power analysis indicated that 247 participants are the minimum required sample size to detect an effect in this study.
Study design and setting
This study was a cross-sectional survey utilizing an electronic survey, and the link was created using Google-forms. The electronic survey was distributed during the last few days of the Hajj period in all Hajj ritual locations including Mina, Arafa, Muzdalifah, and the Holy Mosque.
Instrument
The electronic survey was divided into three main sections. The first section was developed to capture the demographic traits of the pilgrims, including, age, sex, height, weight, nationality, and chronic diseases. The second section was to determine the exact site of the MSP at ten anatomical body parts. Respondents were able to select more than one body site. A back view of the human body figure was inserted in the survey to help the pilgrims in their selection of pain sites. For each body part, each respondent was able to choose either a “yes” or a “no,” showing the presence or absence of MSP. The last section questioned the PA level, and the questions were adapted from the International Physical Activity Questionnaire - Short Form (IPAQ-SF). The IPAQ-SF is a valid and reliable tool to assess the physical activity level, and it consists of seven questions asking the individuals about their different activity levels in the last seven days [23]. The first six items assess the vigorous, medium, and walking activity based on the frequency and duration of each type of activity while the last item assesses the sedentary behavior. A detailed survey can be accessed in supplemental file 1.
After completing the survey structure, the last version was sent to four experts in physical therapy and survey design to establish the face and content validity of the survey questions. Each expert was requested to evaluate each question based on its relevance, structure, and clarity. 80% of the agreement was sought among the experts’ responses. In the case of disagreement, a second round was conducted to reach the minimum percentage of agreement.
Procedure
Ethical approval was obtained from the Ministry of Health in Makkah to conduct the study (IRB No. H-02-K-076-0622-767), and it was conducted in accordance with the Declaration of Helsinki. Before publishing the survey, two physical therapists checked the online version and the link to the survey. A brief description about the purpose of the study along with a statement highlighting the confidentiality and anonymity of the information was posted in the survey preface. To obtain informed consent, a question about the agreement to participate in the study was required to be answered before proceeding to the survey sections. Data collection was started after the fourth day of the Hajj, and it was collected by the principal investigator (PI), Co-PI, and volunteers in the main Hajj sites. Volunteers were trained to go through the electronic survey with the approached pilgrims if they needed help using electronic devices such as mobile phones, iPads, and tablets. Also, multiple heads of the Hajj campaign were contacted to facilitate distributing the survey link among their campaign members (pilgrims) via their WhatsApp, Telegram, and Facebook groups.
Statistical analysis
After closing the survey, data were checked for completeness. Incomplete or missing data were not included in the analyses. Data were coded and entered in a spreadsheet using Microsoft Excel (2016 of Microsoft Corporation, United States). All statistical analyses were performed using the SPSS software (ver. 29.0, IBM Co., Armonk, NY, USA). The prevalence and categorical data were presented as frequencies and percentages; BMI and PA levels were calculated and categorized. The final scoring and categorizing of physical activity levels were calculated according to instructions that are given on the website of IPAQ (https://sites.google.com/site/theipaq/scoring-protocol). The point prevalence of MSP for each anatomical site, the overall MSP (pain at any anatomical site), and the MSP of the lower limb (pain at any anatomical site of thigh, knee, leg, ankle/feet) were calculated separately.
Bivariate associations were explored by the Chi-squared test to assess the relationship between MSP and the categorical variables; Followed by a binary logistic regression analysis to investigate the related factors that might affect MSP including age, sex, BMI, and PA level. Two models were performed to present unadjusted and adjusted odds ratios (ORs) along with 95% confidence intervals (CIs). The first model was a univariate regression analysis to estimate unadjusted ORs and their 95% CIs; the second model was a multiple regression analysis to estimate ORs and their 95% CIs with an adjustment for age, sex, BMI, and PA level. The significance level for all the statistical tests was defined as a P value≤0.05.
Results
Characteristics of the Hajj pilgrims’ participants
A total of 248 Hajj pilgrims were enrolled in the study. The study sample included 155 (62.50%) females and 93 (37.50%) males. The mean age of the pilgrims was 43.49±12.70 years. Only 71 (28.62%) had reported to have a history of chronic diseases. Overall, most of the pilgrims were either overweight 92 (37.09%) or obese 74 (29.83%); and 78 (31.45%) were in the normal weight category with only 4 (1.61%) underweight. In regards to the level of physical activity of pilgrims, 79 (31.85%) were in the low physical activity group, while 82 (33.06%) and 87 (35.08%) of pilgrims exhibited sufficient physical activity levels and were categorized as moderate and high physical activity groups, respectively. A detailed description of the demographic characteristics of the sample is plotted in Table 1.
Demographic characteristics
Demographic characteristics
Of all pilgrims, 195 (78.63%) of the participants had reported MSP in at least one anatomical body site during performing Hajj. The location of pain varied across the different anatomical sites. The anatomical sites with the most frequently reported pain were legs (n = 116, 46%), lower back (n = 112,45%), knees (n = 92,37%), and ankle/feet (n = 74, 30%) (Table 2).
Prevalence of musculoskeletal pain among Hajj pilgrims
Prevalence of musculoskeletal pain among Hajj pilgrims
A Chi-squared test was performed between total MSP and general characteristics including age, sex, BMI, and level of PA. No expected cell frequencies were less than 5. None of the pilgrims’ general characteristics was a significant factor at the bivariate level (P>0.05) (Table 3).
Bivariate analysis of factors with musculoskeletal pain among Hajj pilgrims
Bivariate analysis of factors with musculoskeletal pain among Hajj pilgrims
After adjustment for age, sex, BMI, and PA level, one factor was found to be a significant predictor of MSP (Table 4). BMI was found to be a significant predictor of MSP, as the rate of MSP was found to increase with increasing BMI (p<0.05). The rate of MSP increased in females; however, this was not statistically significant. The data also showed a non-significant increase in the risk of MSP with increasing age. Interestingly, similar rates of MSP were observed in both low and high physical activity (Table 4).
Unadjusted and adjusted odds ratio for independent risk factors of musculoskeletal pain
Unadjusted and adjusted odds ratio for independent risk factors of musculoskeletal pain
Numerous infectious diseases have been studied extensively during Hajj [11, 24–29] since it is an annual religious routine that gathers people from all over the world in one specific place which enhances the chance of transmitting viruses [30]. However, an evident gap still exists in the literature concerning muscle and/or joint pain. This study investigated the prevalence of MSP and its associated factors among pilgrims during Hajj 2022. In this study, a high percentage of the participants (78.6%) reported the occurrence of MSP in at least one body part, which is in agreement with studies that found MSP to be increased among the general population than before the pandemic [31]. The pandemic encouraged individuals to adopt a sedentary lifestyle due to the restrictions on leaving homes; subsequently, physical activities became limited to mostly household activities [32]. Post-pandemic research reported an increase in MSP prevalence from 45% to 60% [33, 34].
In this study, the most prevalent reported pain was in the legs (46%), followed by the lower back (45%), knees (37%), and ankles/feet (30%). That might be justified by the long distance of walking that pilgrims perform during Hajj, and that was consistent with the findings of previous studies that found MSP risk was common among individuals whose work required walking for long distances, and physical effort such as physical therapists [35], nurses [36, 37], and dentists [38]. Literature has very limited studies that assessed the commonness of MSP during mass gatherings. In 2014, a retrospective study was conducted to document the chief complaints of pilgrims after performing Hajj 2010, and the burden of MSP was less than 10% [39]. Another study found that joint pain was accounted for 28.2% among pilgrims [40]. These findings showed less burden of musculature pain than this study findings which exhibited more than 75% of pain among pilgrims. In those previous studies, MSP prevalence rates were collected retrospectively from healthcare facilities, whereas the data of this study was collected from pilgrims while they were doing Hajj rituals. So, this study would imply a more accurate snapshot of the MSP since many individuals may not seek the free healthcare facilities in Hajj camps for muscular pain complaints. Future data about MSP prevalence among pilgrims would be acquired from the healthcare centers in Mecca, SA to help support this study results.
Hajj is a form of worship that requires health and physical fitness. Only one pre-pandemic study was conducted to explore the prevalence of muscular pain among pilgrims in Hajj 2018 [8], and the results were consistent with this study findings which highlighted high rate of MSP complaints among pilgrims. In this study, PA level of the pilgrims was considered especially after diminishing the activity level among general population post-pandemic [32]. However, similar rates of MSP were found in both low and high PA individuals. In fact, the design of this study limited the understanding of MSP causality among pilgrims, so conducting other forms of studies is recommended to further understand the problem.
Physical exertion is required to perform hajj which makes it a tiring journey. Hajj health requirements and recommendations have been issued and posted on the Saudi Ministry of Health webpage annually [41], and it enforces the need for being physically in good condition to safely accomplish Hajj. Also, instructions to improve physical fitness before performing Hajj are published on the website, and some of these recommendations are exercising 20 to 60 minutes daily, doing some aerobic exercises such as cycling and swimming, and gradually increasing physical effort. However, although the Saudi Ministry of Health publishes healthcare recommendations and tips for having a safe Hajj, the governments of the countries that expect a high number of pilgrims are encouraged to enhance the pilgrims’ basic healthcare knowledge. Further investigation is called to be done to improve the dissemination of MSP protective instructions among travelers to SA for the purpose of Hajj through the responsible agencies or organizers in their countries.
However, less evident research has been found to detect how the risk of MSP is perceived at mass gatherings, particularly during Hajj. Studies to comprehend MSP are recommended to be conducted. Interviews could be performed with Pilgrims to acquire more information and deeply understand their perceptions and understanding of MSP preventative measures during this tiring journey.
The results of this study showed no significant association with sex and age factors. On the contrary, previous studies found sex [8, 42–47] and age [8, 47] were significant predictors of MSP. Other non-demographic variables could be predictors of MSP in the annual gathering since psychological, social, and biological factors contribute to muscle/joint pain after the COVID-19 pandemic. Understanding how individuals perceive MSP risks that could result from Hajj performance is a necessary element in raising awareness about preventative health measures among general individuals who intend to come for Hajj. It is recommended that global health authorities and governments give pilgrims the needed health education before coming for Hajj.
Limitations and strengths
There are several limitations for this study. First, this study utilized a self-administered survey which may contribute to bias in pilgrims’ responses. Second, the convenience sampling method may limit the generalizability of the study to this population. The sample size was small although an effort was made to collect the data by sharing the survey links with several Hajj agencies and organizations. Hajj gather people from all over the world who have different ethnicity and spoken language. However, the survey of this study was published in two languages (English and Arabic) which may limit the generalizability of the study findings to a broader population. Also, the causal relationship can not be drawn because the study is limited by its cross-sectional design. Future studies are suggested to be done on a larger sample. Also, further research is needed to determine which factors and measures could be considered to reduce MSP incidence among pilgrims. However, the collected data can serve as preliminary data for additional research and discussions about MSP among pilgrims by interested groups and parties. Also, a strength of this study was collecting the data from the Hajj sites in Mecca, SA since many pilgrims may not seek medical attention for the MSP at healthcare facilities during their ritual period.
Conclusion
This study demonstrated that the prevalence of musculoskeletal disorders was high among pilgrims, especially in the lower limbs. Additionally, the study highlighted the need to focus on the physical demand that is required for Hajj ritual activities and how it influences the MSP. Additionally, MSP risk perception and prevention strategies among pilgrims need to be addressed. To prevent individuals from having musculoskeletal deterioration, it is crucial to increase awareness about the negative impact of MSP among pilgrims and treat musculoskeletal disorders and ensure that pilgrims are aware of the importance of incorporating adequate exercise routine before the Hajj journey.
Ethical approval
Ethical approval was obtained from the Ministry of Health in Makkah to conduct the study (IRB No. H-02-K-076-0622-767)
Informed consent
The data has been collected anonymously. Informed consent was obtained from the respondents before participating in the study. A detailed explanation of the procedure is given in the methods section.
Footnotes
Acknowledgments
Authors acknowledge the Ministry of Health in Makkah, SA for giving the IRB approval. Also, the authors would like to thank all pilgrims for their participation in the study and volunteers who participated in the data collection at Hajj sites.
Conflict of interest
The authors declare that they have no conflict of interest.
Funding
No financial support was provided for this work.