Psychosocial factors at work and teachers’ illness: a systematic review

The aim of the present study is to analyze scientific evidence about associations between psychosocial factors at work and teachers’ illness. A systematic literature review based on the PRISMA statement was conducted. Biblioteca Virtual em Saúde, Medical Literature Analysis and Retrievel System Online, Cumulative Index of Nursing and Allied Health Literature, Scopus, Web of Science, PsycINFO, and Excerpta Medica Database databases were searched. Articles in Portuguese, English and Spanish, published in the past 11 years, were of interest. In total, 861 articles were identified, but only 15 of them met all the eligibility criteria and were included in the review. Eleven articles (73.3%) used validated instruments to assess psychosocial factors, and the Job Content Questionnaire was the most cited one. Low social support, heavy workload, high job demands, and low job control were the most commonly investigated factors and showed statistically significant associations with teachers’ illness.


INTRODUCTION
The International Labor Organization (ILO) 1 defines psychosocial factors at work as those referring to work environment interactions, job content, organizational factors and skills, and individual features of labor that may have a negative influence on individuals' health and satisfaction with their jobs.It is worth highlighting that, in order to better understand that concept, we must also consider individual labor perceptions and experiences influenced by the socioeconomic context. 1 The teaching task has affective value in the teaching profession. 2 Environments with a positive organizational climate are more likely to promote the sense of well-being.However, professional satisfaction can be influenced by different job-routine factors, such as participation in decision-making, autonomy, social support, and remuneration, among others. 3pidemiological data about teachers' illness and absence from work due to health issues have shown that morbidities often observed in this population are linked to mental, physical, and vocal health. 4,5sychological demands, such as low control and lack of social support, cause distress and are likely to damage workers' health; moreover, they can embody different meanings for labor force groups within their cultural, social, and occupational contexts.The literature has also demonstrated that social support has a positive influence on the health of individuals and their satisfaction with their jobs. 6iven the importance of including psychosocial factors in the list of triggers and aggravating factors for the development of diseases, it is necessary to better understand those that negatively influence the health of teachers.With that approach, this literature review may contribute to scientific knowledge by assessing the psychosocial aspects of labor that trigger teachers' illness.
Consequently, results in the current review may help guide further improvements in labor conditions and the elaboration of practices focusing on teachers, in order to prevent losses in these workers' health.Accordingly, the aim of the present study is to analyze scientific evidence about associations between psychosocial factors at work and teachers' illness.

METHODS
A systematic literature review of articles on psychosocial factors at work and teachers' illness published in the last 11 years (2011-2021) was conducted.Study protocol was recorded at the International Prospective Register of Systematic Reviews (PROSPERO), under number CRD42021234983.Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 7 recommendations were followed and used to build this review.

ELIGIBILITY CRITERIA
Criteria used for article selection were I -to be published in Portuguese, English, or Spanish; II -to have investigated psychosocial factors at work; III -to have included teachers who act at any teaching level, except for higher education, as assessed population; IV -to have assessed the presence of morbidities in teachers; and V -to be available for full-text access.
Qualitative methodology studies, article reviews, editorials, opinions, comments, dissertations and theses in repositories, and articles with methodological quality classified as "weak" by the Quality Assessment Tool for Quantitative Studies (QATQS) 8 were excluded from the review.

BIBLIOGRAPHICAL SEARCH STRATEGY
The following electronic databases were consulted: Biblioteca Virtual em Saúde (BVS), Medical Literature Analysis and Retrievel System Online (Medline), Cumulative Index of Nursing and Allied Health Literature (Cinahl), Scopus, Web of Science (WoS), PsycINFO, and Excerpta Medica Database (Embase).The search strategy combined selected descriptors (Descritores em Ciências da Saúde/Medical Subject Headings [DeCS/MeSH]) that are described in Chart 1. Electronic searches started in February 2021 and finished in April 2021.

STUDY SELECTION
After removing duplicate publications in the first stage, initial screening consisted of reading all titles and abstracts in order to select the ones meeting the eligibility criteria.Subsequently, selected articles were fully read for extraction of the following data: authors, publication year, country where the study was conducted, sample features, investigated psychosocial factors, instrument for psychosocial factors' evaluation, main findings, health outcome, and methodological quality assessment.

STUDY QUALITY ASSESSMENT
Collected data were recorded and organized in an Excel database.All selection processes in this review were conducted by independent peers.Disagreements were solved by consensus and, whenever reaching a consensus was not possible, the case was assessed by a third researcher.
The methodological quality of the selected articles was individually and independently analyzed by two raters.The QATQS tool, which was developed by the Effective Public Health Practice Project (EPHPP) research group, 8 was used in the analysis.
QATQS presents 22 items that are divided into 8 blocks, labeled from A to H.The following items are assessed: A -selection bias; B -study design; Cconfounders; D -blinding; E -data collection method; F -withdrawals and dropouts; G -intervention integrity; and H -analyses.Each block can be classified as 1 -strong (no weak ratings), 2 -moderate (one weak rating), or 3 -weak (two or more weak ratings).A global index that classifies the study based on one of the categories is found by the end of the evaluation process.
Only one publication (6.6%) 17 did not show significant statistical associations of demand-control factors and social support with teachers' illness.Overall methodological quality features of studies and publications included in the present review are described in Table 1.

DISCUSSION
Scientific evidence suggests an association between psychosocial factors at work and teachers' illness.Studies showing the presence of mental and physical illness among teachers who reported low social support, heavy workload, high job demand, and lower job control prevailed in the sample.][23] Results from different countries reinforce the relevance of acknowledging psychosocial factors related to the workplace when analyzing teachers' health.Different definitions for psychosocial factors were used, as well as a large number of data collection instruments (most of them were validated).It is worth highlighting that using validated instruments provides more consistent results about the object being measured and opens room for comparisons between results from several studies.
Based on the present review, low social support, heavy workload, high job demand, and low job control are associated with the presence of mental disorders, 9,13,16,[19][20][21] MSP, 15,17,18,23 and burnout syndrome. 11,22Social support is indicative of social environment quality at work, of the relationship between employees and managers, and of the relationship among workmates. 24According to Araújo & Karasek, 6 this aspect is now assessed within the demand-control model, based on the model proposed by Johnson & Hall. 25It has been identified as an important mediator between demand and control effects and impacts on workers' health.
Accordingly, our findings reinforce such data by showing that not receiving social support is associated with MSP, depression symptoms, and professional exhaustion.][28] This result is pertinent to the discussion as it reveals the importance of this support in the teaching profession, whether from colleagues or from managers and workmates.Thus, this finding allows us to direct and suggest practices that can contribute to dealing with the lack of time to update, prepare classes, correct activities, and discuss planning with peers, in addition to the administrative demands of the school, social situations regarding the students, and precarious working conditions.
Frutuoso & Cruz 29 associated workload with a permanent tension between job demands and workers' physical and psychological ability to fulfil them.It is clear that the intense work linked to teaching is not limited to the number of hours working at the school but to other labor features that teachers must perform out of the classroom, 30 resulting in physical and mental exhaustion due to work factors. 31vertime, changes in the teaching process due to educational reforms have caused important transformations in teachers' actions. 32Demands from social context, productivity due to pedagogical and managerial demands, and responsibility for the students' and schools' performance are some of the factors influencing work overload.
High job demands perceived by teachers are closely related to low levels of mental health 13 and high prevalence of MSP. 23Social and professional relationships along with responsibilities and commitments beyond the organizational aspects of the job are determining elements in the health conditions of teachers.When work permeates the school environment and functions, schedules are disregarded, and thus daily life becomes more exhausting.
These findings make us rethink the importance of balancing activities based on teachers' workload in order to make sure that they have enough time to carry them out.It is necessary to rationalize work/rest time, eliminate excessive out-of-class workloads, and promote the updating of academic training and the use of new technologies.Thus, the accumulation of tasks that lead to CMDs and other illnesses experienced by teachers, such as depression and anxiety, can be avoided.
Control over work is related to workers' ability to be autonomous at decision-making about their own activities.The literature 33 points to an association between job demands and job control, revealing that individuals exposed to high demands and low control had greater emotional exhaustion and more complaints related to dissatisfaction with work.
The present review, supported by Jones-Rincon & Howard 20 and Ng et al., 16 shows that low control is closely related to anxiety disorders and MSP in teachers.It can be assumed that teachers' overwork may lead them to dedicate additional efforts to some tasks that appear to be coherent with the time available to perform them, reducing control over their own work with consequent physical and psychological symptoms in the face of this conflict.
Although they are still poorly discussed in the literature, psychosocial factors such as organizational climate, 11,19 effort reward, 9 family support, 14 teacherstudent relationship, 11 and intimidation at work 12 were found to be associated with teachers' illness in this review.Many of these professionals also reported a lack of recognition for their work and working in environments where they are even physically threatened.That loss of the sense of work, which has an impact on professional devaluation and dropout, 34,35 is among the consequences of the psychological assault experienced by teachers. 36ome limitations of the present review should be highlighted.For example, there was a lack of studies with high methodological quality, based on QATQS assessment.
Although the cross-sectional design does not allow us inferring a cause-effect relationship between the assessed variables, the present findings enable observing and rethinking the importance of knowing the factors contributing to illness in this group for health surveillance purposes.
The evaluations were conducted by two researchers, who were blinded and independent, in an attempt at minimizing all selection and classification biases in the current review.Although the researchers used combinations and keywords for the bibliographic search, articles related to the topic of interest may not have been reached by the adopted search strategy.One example regards work-related voice disorders, which are some of the most prevalent issues among teachers but were not addressed in any of the selected articles. 37iven the evidence provided herein, we suggest that additional studies are performed, based on different research designs and focusing on identifying psychosocial factors and those affecting teachers' health conditions.This will allow proposing measures and actions related to work organization, social support (both from managers and workmates), as well as making improvements in teachers' relationships with students and their parents in a more effective and broader way.

CONCLUSIONS
The investigation about the psychosocial aspects of labor and teachers' health has been amplified in recent years.Mental illness, MSP, and burnout syndrome are associated with low social support, heavy workload, high job demands, low job control, organizational climate, role ambiguities, low family support, teacherparent-student relationships, intimidation, and safety at work.
Flowchart describing the study selection process.Created by the authors, adapted from Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).* MEDLINE results were excluded from the following databases: BVS and EMBASE.BVS = Biblioteca Virtual em Saúde; CAPES = Coordenação de Aperfeiçoamento de Pessoal de Nível Superior; CINAHL = Cumulative Index of Nursing and Allied Health Literature; Embase = Excerpta Medica Database; Medline = Medical Literature Analysis and Retrievel System Online; WoS = WEB OF SCIENCE.

Table 1 .
General features of articles published between 2011 and 2021 about psychosocial factors and teachers' illness