Luciana Cristina Machado; Jean Ezequiel Limongi
BACKGROUND: Association analysis between common mental disorders (CMD) and working conditions is necessary to achieve a better understanding of the reasons for physical and mental illness among teachers.
OBJECTIVE: In the present cross-sectional study we sought to establish the prevalence of CMD among teachers in public municipal elementary schools in Uberlândia, Minas Gerais, Brazil, and its correlation with sociodemographic, environmental and occupational aspects. Methods: A random sample of 330 teachers from 36 schools responded the General Health Questionnaire-12 and a structured questionnaire designed to investigate risk and protective factors for CMD. The collected data were first subjected to bivariate, then to multiple logistic regression analysis.
RESULTS: The results indicate that the following characteristics were associated with CMD: female sex, permanent employment relationship, working double shifts, previous experience with school violence and use of sleep disorder drugs.
CONCLUSION: We conclude that the mental health of teachers does not receive the proper attention and care even though it has direct impact on the teaching-learning cycle. Decreasing the rates of absenteeism, presenteeism, turnover, early retirement and sick leave reduces the government's costs, while positive impacts extend to society at large.
Keywords: faculty; mental disorders; occupational health; mental health.
INTRODUÇÃO: O estudo sobre a associação de transtornos mentais comuns (TMC) em docentes e as condições em que seu trabalho é realizado é necessário para melhor compreender as razões de adoecimento físico e mental dessa categoria.
OBJETIVO: Este estudo pretende estimar a prevalência de TMC em professores da rede pública de ensino fundamental de Uberlândia (MG) e associá-los a condições sociodemográficas, ambientais e laborais.
MÉTODOS: Uma amostra aleatória de 330 professores lotados em 36 escolas foi explorada neste estudo transversal. Foram utilizados dois instrumentos de coleta de dados: o General Health Questionnaire-12 (GHQ-12) e um questionário estruturado com questões relativas aos possíveis fatores de risco e proteção no desenvolvimento de TMC. Os dados foram analisados por meio de análise bivariada e, posteriormente, por regressão logística.
RESULTADOS: Foram indicados como fatores de risco associados ao desenvolvimento de TMC o sexo feminino, vínculo efetivo de trabalho, lotação em dois turnos, experiência com violência no ambiente escolar e uso de medicamentos para distúrbios do sono.
CONCLUSÃO: Os resultados apontam que a saúde mental do professor carece de cuidados e comprometimento nas ações, visto que a saúde desses profissionais afeta diretamente os ciclos de ensino-aprendizagem. A redução do absenteísmo, presenteísmo, rotatividade, aposentadorias precoces e licenças médicas diminuem os custos para o Estado e trazem benefícios que se estendem para toda a sociedade.
Palavras-chave: docentes; transtornos mentais; saúde do trabalhador; saúde mental.
Changes in the world of work cause variations in the epidemiological profile of workers. Production restructuring and globalization have direct impact on the everyday routine, leading to substantial modifications in the prevalence of work-related diseases1. Occupational diseases previously caused by musculoskeletal disorders and dysphonia are giving way to mental disorders related to exhaustion, work overload, hectic pace of work and interpersonal conflict2. Within this context, the health of teachers is i gaining increasing visibility for being one of the most stressful jobs3.
Mental disorders are characterized as clinically significant impairments in cognition, emotional regulation or behavior. These conditions derive from imbalance between the psychological, biological or development processes which underlie mental functioning. Mental disorders are frequently associated with significant distress or disability, having impact on social, professional and other relevant activities4.
Common mental disorder (CMD) is the diagnosis attributed to individuals who exhibit signs and symptoms such as irritation, anxiety, depression, sleeplessness, fatigue, difficult concentration and forgetfulness. These conditions have biological, cultural, social, political and social impacts and high global prevalence5. Affected individuals might also exhibit changes in their mood and thoughts, leading to excessive sadness and continuous anguish, with consequent effects on their personal, social and occupational lives6. Since mortality and lethality are low, CMD have been long neglected as a public health concern to only become acknowledged as a serious problem starting in 19966.
CMD are frequent among teachers. Teaching demands proper preparation and commitment, and thus teachers are frequently overloaded and might develop physical or mental diseases as a result. Also other factors might lead to illness, such as low salary, lack of motivation and scarce investment in the education system. Violence in schools is one further factor to consider, inasmuch as it became a serious social problem that contributes to cause exhaustion and stress among teachers, since learning institutions are no longer safe and protected environments, but are involved on local conflicts7.
CMD are the main reason for long sick leave, threaten well-being and influence behaviors and emotions8. According to the International Labor Organization, teaching is a high-risk occupation and teachers are the second leading occupational group in terms of frequency work-related diseases worldwide9.
The mental status of teachers has direct impact on the quality of teaching and of the education system as a whole. In addition, it might further pose a social problem, since it determines organizational and personnel costs as a function of, e.g. high turnover and absenteeism rates and effects on productivity, among others10. A study performed in Uberlândia, Minas Gerais, Brazil, on early retirement revealed an alarming situation in regard to chronic diseases, including CMD, among the teachers in the municipal public school network11. The authors attributed such situation to lack of investment and effective health promotion, mental health and rehabilitation programs for workers.
Analyzing teachers within their proper context, including individual psychosocial and environmental factors and their correlation with CMD, is essential to achieve a more thorough understanding of and approach teaching work. The aim of the present study was to establish the prevalence of CMD among public municipal elementary school teachers in Uberlândia and investigate its correlation with sociodemographic, health and occupational characteristics.
The present cross-sectional study was performed with public municipal c elementary school teachers in Uberlândia. According to the Brazilian Institute of Geography and Statistics, the population of Uberlândia was 676,000 in 2017. There are 127 schools distributed across urban and rural areas, including 69 kindergartens, 56 elementary schools, one vocational school and one center for studies and educational projects. We included in our study the 36 municipal elementary schools with more than 40 teachers. For sample size calculation, we considered a maximum permissible error of 5%, 95% of confidence and prevalence of 50% of CMD among teachers (this cut-off point was selected to maximize the number of possible samples). As a result, the number of participants had to be 330. At a later time we performed proportionate stratified sampling based on the number of teachers in each included school.
Instruments for data collection were two structured questionnaires. One included questions on sociodemographic and health aspects (age, sex, marital status, number of children, educational level, income, smoking, physical activity, alcohol consumption, use of medications for high blood pressure, diabetes and sleep disorders, and presence of chronic diseases); occupational characteristics (second job, second job in education, reallocation, commute mode share, years of experience in teaching, weekly working hours, daily shifts and type of employment relationship); and workplace violence (from students, parents, other teachers). This questionnaire was based on that administered by Gasparini et al.7 with the addition of items "presence of chronic diseases," "employment relationship" and "violence outside school premises." Variables related to violence were stratified for both physical and psychological abuse.
The other was the General Health Questionnaire 12 - GHQ-12 - a 12-item validated screening instrument for mental disorders in the general population. The original version comprises 60 items responded on a four-point Likert scale. As a result of its wide application several shortened versions were also developed (with 30, 28 and 12 items) all of them validated and with adequate reliability and consistency12. Response options are: "Better/more than usual," "Same as usual," "Less than usual" and "Much less than usual"-with some modifications according to the item wording. There are four possible methods to calculate scores. In the present study we followed the method recommended by the questionnaire developer, according to which the two former response options are scored 0 and the latter two 1. All the participants who scored ≥4 were considered as with some mental problem.
For recruitment, we first requested authorization from the Municipal Secretariat of Education and obtained a signed document to present to school principals. The questionnaires were then delivered to each teacher individually to respond them anonymously to ensure greater reliability to the responses. The participants received information on the study aims and associated risk and signed an informed consent form.
A dataset was created with software Epi Info version 7.1.3, which also used for analysis and included:
Frequency distribution of variables and data consistency: we first tested the consistency of the data, then we analyzed the frequency distribution of all the analyzed variables to characterize the sample according to demographic and socioeconomic aspects and factors related to CMD;
Bivariate analysis: to investigate possible relationships between CMD and demographic and socioeconomic factors. The χ2 or Fisher's exact test were used to compare two proportions (α=5%). Measures of dispersion were calculated for continuous variables, which were compared by means of Student's t-test or the Wilcoxon-Mann-Whitney (U) test according to whether the normality assumption was met or not. Association between factors related to CMD was expressed as odds ratio (OR). Logistic regression analysis was performed to compare variables with more than two categories.
Multivariate analysis involved fitting a logistic regression model as follows:
We first included variables with p<0.20 on bivariate analysis;
Then we fitted several intermediate models for various subgroups (demographic and social variables, teaching career, health behaviors, working conditions). Variables with p<0.15 were kept in these models;
Next we fitted the final model, which only included significant variables for p<0.05.
The present study was approved by the research ethics committee of Federal University of Uberlândia, ruling no. 1,776,717/2016.
The sample comprised 330 teachers, most of whom were female (88.2%), aged 22 to 70 years old, mean 43.5±9.73. Most were married/had a stable partner (64.6%), followed by the single (18.6%), divorced (15.2%) and widowed (1.6%) teachers. The largest proportion of participants had completed specialization courses (68.7%), 23.1% higher education, 7% had earned a master's degree and 9% a PhD; 0.3% had attended secondary school only. About 58.5% of the sample reported to exercise regularly, 26.9% up to twice and 31.6% three or more times per week. About 87% of the participants reported not to smoke, 6.1% were smokers and 6.9% former smokers. About 79.6% of the sample reported not to drink alcohol. About 6% of the participants had diabetes, 17.5% hypertension, 9% thyroid disease and 2.4% some neoplasm. Medications for diabetes were used by 6% of the participants, antihypertensive drugs by 19.6 and 15.3% reported to take sleep disorder drugs. About 38.1% of the sample had a second job at another school, 5.2% were retraining and 22% had a second job in another sector. Most participants worked two daily shifts (66%), 32% only one and 2% three shifts. Most teachers had permanent employment relationship (75.3%), 11.1% term contracts and 13.5% both. About 77.6% of the participants drove their own car to work. The mean working hours were 30 hours/week and the participants had worked in teaching 16.2 years, on average. About 30.6% of the teachers reported to had been physically abused by students (more than once: 16.7%), 11.2% by parents (more than once: 4.2%) and 7.6% by coworkers (more than once: 3.3%). Psychological abuse from students was reported by 42.2% of the participants (more than once: 26.6%), 32.8% from parents (more than once: 18.8%) and 20% by coworkers (more than once: 13.9%).
The largest proportion of participants stated they had considerable autonomy at work (41.6%) and possibilities to develop creativity (63.5%) while these aspects were judged just reasonable by 48.6 and 35.3%, respectively. The time available to correct homework and prepare for lessons was rated reasonable by 61 and 65.3%, insufficient by 26.5 and 17.3% and considerable by 12.5 and 17.3%. Most teachers reported to use TV and video resources (86.1%) and that their students had Internet access (59%). However, 59.2% of the participants observed that the number of computers available to students at school was insufficient. Noise in the classroom, in the school in general and outside the school premises was rated from neglectable to reasonable by most of the sample (58.7, 87.1 and 56.7%, respectively) and too loud or unbearable by the rest of the participants. Ventilation was considered reasonable by 42.8%, satisfactory by 33.3% and poor by 23.9%. Lighting and walls were rated reasonable by 43.3 and 49.5%, satisfactory by 42.1 and 31.3% and poor by 14.65 and 19.2%.
Based on the results on GHQ-12, the estimated prevalence of CMD was 43.9%.
On bivariate analysis we found association between CMD and female sex, monthly family income BRL 3,001.00-4,500.00, use of sleep disorder drugs, thyroid disease (Table 1), more than 20 years in teaching and having permanent or both types of employment relationship (Table 2). CMD were more frequent among the participants who had experienced psychological/moral harassment from students, parents or coworkers once or more times (Table 2). Also reasonable autonomy, loud noise in and outside the classroom, reasonable or poor ventilation and reasonable lighting behaved as risk factors (Table 3).
On separate multiple logistic regression analysis per subgroup of variables, CMD remained associated with the aforementioned demographic variables (female sex and monthly family income BRL 3,001.00-4,500.00). Among health variables, also use of sleep disorder drugs and thyroid disease remained associated with the outcome. Of the occupational variables, double shift and permanent employment relationship remained in the model. Of the forms of workplace violence only psychological/moral harassment from students remained associated with CMD. None of the aspects related to perceived working conditions, physical environment and available resources was associated with the outcome (Table 4).
In the final regression analysis we considered all the variables and their simultaneous effects. CMD were found to have significant relationship with female sex and use of sleep disorder drugs, double shift and permanent employment relationship, and psychological/moral harassment from students more than once, which thus behaved as risk factors (Table 5).
The prevalence of CMD found in the present study was lower than that reported for Brazilian municipal teachers in Belo Horizonte (50.3%)7 and Paraná (75%)13 and similar (44%) to that for public and private kindergarten teachers in Victoria da Conquista, Bahia14.
This prevalence rate is quite high, particularly among the women, who exhibited 2.6 higher odds of CMD compared to the men. Female teachers predominated in the analyzed sample, which can be explained as a function of changes in the Brazilian education system from the second half of the nineteenth century onward. Better access to education was associated with increasing need for teachers, while teaching, as also nursing, was then seen as a typically female occupation since it involves providing care to others and thus as an extension of childcare, i.e. a sort of "educating mothers14." This higher prevalence of CMD among female workers might also be accounted by their double burden (paid job and home), feelings of guilt for not having enough time for household chores and job tasks, lack of time for leisure activities and rest, little professional recognition and personal involvement with the social demands of students14.
CMD were more frequent among the participants who used sleep disorder drugs, with permanent jobs, second jobs and having been subjected to psychological abuse from students more than once. CMD were not associated with any variable related to perceived working conditions, available resources or physical environment. Sleep disorders are an early warning sign of CMD, together with other manifestations such as stress, anxiety, physical and mental exhaustion, tiredness and irritability7. This situation might account for the relationship found between CMD and use of sleep disorder drugs in the present and other studies7,13,15. Job stability grounded on a permanent employment relationship is usually seen as a favorable aspect, since it ensures some degree of financial security. Yet the results of the present study indicate it might also contribute to the occurrence of CMD. Job stability might lead to professional stagnation and lack of motivation to look for other jobs more likely to satisfy personal needs and pose new challenges, whence dissatisfied teachers may choose to remain in their jobs without developing their full potential10.
A low salary might result in the need for teachers to work more than one shift, sometimes in different schools and education systems (public and private) with consequent work overload. This situation also hinders interpersonal relationships with coworkers likely to provide support and reinforcement16. These factors might explain the higher frequency of CMD among the teachers who worked double shifts. In addition, work overload interferes with the practice of physical activity, which also contributes to the occurrence of CMD. In a study with university professors, physical activity behaved as protective factor against this type of disorders2. Effective health promotion programs for teachers might be beneficial provided they are implemented in the workplace at specifically appointed times.
Threats of violence at school and constant fear triggered in the participants a continuous stress reaction. Student misbehavior extends outside the school environment to the police and judicial spheres and leaves physical and psychological scars among teachers17. School violence reflects an external social reality daily experienced by students18. In the present study, psychological/moral harassment remained associated to CMD in the final regression model. This finding indicates that this type of violence, often overshadowed by physical abuse, has a considerable role in the mental health of teachers. The inclusion of psychologists in school staffs to approach social and emotional issues which interfere with learning has been long discussed since it might improve interpersonal relationships in schools. The results of the present and other studies performed in Brazil indicate that including psychologists in the education system is absolutely necessary.
Most participants had attended higher education. This finding might be related to the fact that the Grounds and Guidelines for Education Law - passed in 1996 as part of an educational reform - demands a higher education diploma from all new teachers19. As a result, the qualification of teachers improved, in addition to boosting higher education teaching.
Although no variable related to the physical environment of schools exhibited statistically significant association with the outcome on multivariate analysis, poor ventilation, excessive noise, classroom walls in bad conditions and poor lighting make the working environment uncomfortable. Work under unfavorable conditions might impair the quality of teaching7. As a rule, the infrastructure at municipal schools in Uberlândia is rather good by comparison to state-run schools, which fact might have contributed to the lack of association between this variable and CMD.
Autonomy and creativity are related to the personal cognitive resources mobilized to respond to job demands. Individuals make schematic representations of their actual situation, which serve as grounds for decision making on appropriate actions to achieve the intended daily goals20. In the present study, both variables were associated with occurrence of CMD on bivariate analysis, but lost this relationship on logistic regression analysis. Nevertheless, they are relevant as concerns personal accomplishment and the development of subjectivity among teachers.
As limitations of the present study, we did not perform a proper diagnosis of CMD. Since this was not our aim, we merely investigated signs indicative of mental distress or disorders by means of GHQ-12. We neither analyzed sick leaves granted for CMD nor the rate of teachers who decided to leave the profession for this reason.
The mental health of teachers does not receive the proper attention and care although it has direct impact on the teaching-learning cycle. The various factors liable to cause illness and mental exhaustion among teachers should be duly acknowledged, and empowerment strategies should be developed for this population of workers to be better able to cope with the various situations in and outside schools. Actions to provide support and understand better the problems of teachers within their social context should be implemented by school managers and the government to empower teachers, in addition to strategies to improve their working conditions to prevent disease and consequently improve the quality of teaching.
Periodic medical examinations including assessment of mental health have paramount importance, since interventions may be implemented before the onset of CMD. Teachers should receive clear orientation on how to seek help when they need psychological or management support so they can feel safe and protected whenever they perceive their working conditions interfere with their work. Health care and labor relations should become more humane to reduce the occurrence of CMD, with benefits for both teachers and managers. Decreasing the rates of absenteeism, presenteeism, turnover, early retirement and sick leave reduces the government’s costs, while positive impacts extend to society at large.
In the present study we had resource GHQ-12, which is easy to administer, well accepted, extremely useful in the screening for CMD and does not demand too many resources. Proper diagnosis by duly trained professionals is necessary to advance in this line of research.
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5 de Abril de 2019.
Aceito em 5 de Setembro de 2019.
Fonte de financiamento: nenhuma