Musculoskeletal disorders and the affecting factors among teachers: An example from Turkey

1 Introduction

According to the International Commission on Occupational Health, musculoskeletal disorders (MSDs) are defined as the “diseases of the musculoskeletal system caused by working”, which are also known as the work-related upper extremity disorders or the “repetitive motion injuries” [1, 2]. It has been reported that approximately 30% of all musculoskeletal diseases are related to work due to poor working conditions [3]. Accordingly, MSD is one of the most common and important health problems in the working population [4, 5] and it is among the biggest causes of absenteeism [6]. In addition, it has been reported that labor and economic loss related to MSDs are higher compared to all other disease groups, due to the health reports, compensation costs and wage losses [6, 7].

Musculoskeletal disorders involve a wide variety of inflammatory and degenerative conditions affecting the muscles, ligaments, tendons, nerves, bones, and joints. They may develop due to a single trauma or cumulative trauma [1], and they usually have a specific pathology. There are multifactorial reasons in its etiology; however, it is basically stated that repetitive movements, inappropriate body posture or excessive use of force trigger these problems [8]. In addition to these factors, factors such as work stress, excessive workload, high-speed and repetitive monotonous work have been mentioned in the recent studies [9, 10]. MSDs are most common in the lower back, neck, hands, wrists, elbows and shoulders; and these complaints may continue as temporary or permanent conditions that cannot be treated [1]. Nonetheless, these health problems impair the quality of life of the individual, affect the job satisfaction, morale and productivity of the employee negatively, and cause workday losses [5]. It is predicted that MSDs will gradually become more common in the future, become a “new epidemic”, and constitute a health problem that needs to be investigated and resolved in the occupational diseases group [11].

In the literature, studies have emphasized that teachers are at risk in terms of MSDs [2, 12]. Teachers who have different working conditions in their work environment are faced with more physical and mental health risks compared to other occupational groups due to their certain working characteristics such as standing and sitting at a desk for a long time, as well as the increased workload demands [12, 13]. Preparing lecture notes in a fixed position, reading, evaluating, working in a standing position and performing different activities outside of the classroom are some of the physical activities of teachers while performing their duties [2]. In addition, the rapid changes in the educational environments introduced by the age of technology, the effort to meet the demands of the administrators, parents and students, and the continuous effort of the teachers may lead to increased physical and mental tension, triggering the musculoskeletal disorders [14].

In the teaching profession; there are various fields such as kindergarten, primary school, high school, vocational and special education. In general, there may be branch-specific health problems due to different age groups and different educational environments. Since providing the learning process of the individual is the main goal of education, teachers have to do the common behaviors required by the profession, even in different fields. In the literature, it is reported that the problems of MSDs among teachers are quite high due to the ergonomic problems specific to the profession. Studies show that although individuals may have incomplete recollection of their health problems, self-report is a more reliable source in identifying work-related hazards [15] because it does not qualify for clinical validation subjectively reported symptoms. In the literature, it is recommended to use a body map showing the extent and localization of pain to reduce the chance of incomplete recall of such health problems. However, it has been reported that the use of the human body diagram is a reliable method in studies conducted to determine the pain and work effect of MSDs symptoms [16]. In this study, it was aimed to evaluate the locations of musculoskeletal system disorders experienced by teachers, the severity of pain, the state of being prevented from working and some related factors.

2 Methods

3 Results

The mean age of the teachers who participated in the study was 40.4±9.06 years, and 62.7% were female. The mean years of working was determined as 16.67±9.28 (years), mean weekly working hours was 29.95±10.87 hours/week, mean time spent working in standing position per day was 617.58±530.10 min/day, and the mean time spent sitting at the desk was 177.70±194.35 min/day. The mean score obtained by the teachers from CMDQ was 135.79±209.26; the mean score obtained from the work stress was 31.15±5.45, and the total mean score of satisfaction with life was 16.88±3.96 (Table 1).

It was found that 64.9% of the participants experienced discomfort in some part of their bodies within the last week, and the parts where they experienced the most discomfort were the neck (55.5%), back (53.4%) and lower back (47.6%). The body areas with the least discomfort were the left elbow (6.5%) and the left forearm (8.7%). In addition, it was determined that the level of severe pain was mostly experienced in the right forearm (11.5%) as a result of the discomfort, and this pain strongly prevented 11.8% of the teachers from doing their job depending on the severity. It was reported that the pain was moderate in 22.6% of the patients with neck pain, and the pain mildly prevented 18.3% of the teachers from performing their activities (Table 2).

Mean CMDQ scores of the teachers were found to have a statistically significant difference when compared with gender, shoe preference and time devoted to housework outside of work (p < 0.05). Nonetheless, no significant difference was found between the mean CMDQ scores of teachers and their marital status, age groups, physical activity levels, body mass index and weekly working hours (Table 3).

In the correlation analysis on the relationship between the mean CMDQ scores of the teachers and work stress levels, there was a moderately significant and positive correlation (r = 0.453, p 0.000). In addition, there was a moderate and negative correlation between the scores obtained from CMDQ and Satisfaction with Life Scale (r = –0.350, p 0.000). It was determined that as the work stress level of the participants increased, the symptoms of MSD increased; and when their level of satisfaction with life decreased, the symptoms of MSD increased (Table 4).

A multiple regression analysis was performed by correlating the independent variables with the total CMDQ score, which was the dependent variable in the study (Table 5). The model, which explained the MSDs of the teachers (Model R = 0.486; R = 0.236; Adjusted R² = 0.225; F = 20.938), was found to be significant. In the model; the work stress score (β= 0.335, p≤0.001), the satisfaction with life score (β= –0.222, p≤0.001), the time spent sitting at a desk (β= –0.117, p≤0.05), the time devoted to housework (β= –0.181, p≤0.001), and shoe preference (β= –0.062, p≤0.05) were identified as the effective predictors. The model explained 23.6% of the variance (Table 5).

Musculoskeletal disorders have a minimal impact on mortality; however, they are among the major causes of pain and disability in the society. The most noteworthy finding that was also obtained in the present study was that 64.9% of the teachers experienced MSDs in any part of their body within the last week. According to the previous studies conducted in many countries on the occupational risk factors of MSD in teachers, it is observed that its prevalence varies between 30–88.9% [2, 22]. In the studies conducted with teachers, the prevalence of MSD was reported as 30% in Brazil [2], 40.1% and 61.7% in two different studies in Malaysia [10, 12], 53.5% in India [23], 55.9% in Turkey [21], 59.2% in Saudi Arabia [24], 66.7% in Estonia [25], 69.3% in Hong Kong [26], 85.5% in Taiwan and 88.9% in Pakistan [1]. The results indicated that the prevalence of MSD was higher in teachers, and the problems should not be ignored.

Similar to other studies, gender was found to be associated with MSD in the present study [3, 21]. In a study conducted by Alias et al. on female teachers, the prevalence of MSD was found to be 2.9 times higher compared to the male teachers [12]. According to the literature, the differences between the genders in terms of MSD are caused by biological factors, everyday lives and expectations. In addition to the differences in exposure, the fact that women’s response to the disease is different, and they present with more severe and a greater number of symptoms also had an effect. It is believed that the female participants, who reported a greater number of complaints, had to devote more time to chores such as housework and child care due to their traditional gender roles [27], and the conflicts between the work and the family were therefore effective [12]. Similarly, a significant relationship was found between the time devoted to the housework and the score obtained from CMDQ in the present study. The amount of time allocated to housework was higher in female teachers compared to the male teachers. Moreover, a significant relationship was found between MSD and the preference for high heels in the present study. Darwish and Zuhair [8] reported that there was a strong relationship between MSD and the female teachers who wore very high heels. This finding was explained with the fact that the impairment of walking and posture in the entire body caused severe load on the muscles and joints [8]. Looking at the results in general, we believe that the factors such as the more time devoted to housework and greater preference for high heels in the female participants compared to the male participants contributed to the prediction of the causes of MSDs.

In the present study, no significant relationship was found between MSD and the other sociodemographic characteristics such as the age, marital status, weekly working hours, exercising habits and the body mass index. There are similar findings in the literature [8]. Nonetheless, there are studies, which determined a significant relationship between MSDs and age, marital status, exercising habits and body mass index [10, 24]. In these studies, the reason for the relationship between MSDs and age was explained with physical degeneration, reduced tissue healing and thinning of joint cartilage at advanced ages [28]. In the present study, there was no significant relationship in terms of age, and we believe that this might be due to the sample of the study which consisted of young and middle age groups. In the previous studies, MSDs were reported to be more common in individuals who did not exercise regularly [10, 11]. Although there was no significant difference between those who exercised and those who did not exercise in this study, it can be said that MSDs were experienced less in teachers who exercised regularly due to the lower average CMDQ score. In the present study, the fact that the prevalence of MSD was high among the teachers, and that almost all of the participants did not exercise regularly could have affected the results. We are of the opinion that studies with different variables in large sample groups are needed for investigating the difference between other variables and MSD.

Similar to the other studies, it was found in the present study that the pain in the neck, lower back and shoulders had a higher prevalence among the MSDs. Among the primary school teachers employed in the Central Durban region, the prevalence of shoulder pain was 80.4%, and the prevalence of lower back pain was 68.0% [29]. It was reported that the prevalence of neck pain was 52.2% within the last 12 months among the teachers in Malaysia [26], and neck pain was the most common pain among the female teachers in Switzerland with 44.0% [30]. Due to their profession, teachers perform activities that require sitting, standing up, working on the computer and sitting behind a desk for a long time. As a matter of fact, a significant correlation was observed between the time spent sitting at a desk and the score obtained from CMDQ in the present study. In a study conducted on desk workers, back pain was detected with rate of 63.0%, and neck pain with 54.3% [3]. It was also demonstrated in the literature that these activities increased risk of lower back pain in teachers [31]. These activities also cause posture deterioration. In this context, increasing the awareness of teachers on this matter will contribute to the protection of their health.

According to the literature, MSDs constitute the group of diseases that cause the highest loss of working days in employees [3]. In the present study, the part of the body where the teachers experienced discomfort that would prevent them from working was found to be the right forearm. The prevalence of pain in the right forearm was lower compared to the pain in the neck; however, it caused greater loss of working days. This may be due to the educational activities of the teachers such as preparing lecture notes and reading. In addition, the increased use of developing technology in recent years such as the use of smartphones could be indicated as the cause of the pain in the arms, wrists and neck [32]. There are also different studies emphasizing that teachers are particularly vulnerable due to these professional activities [1, 29]. In one study, it was reported that the teachers experienced the discomfort of neck pain, and that 3.5% of the teachers with neck pain and 4.3% of the teachers with shoulder pain changed their jobs due to this reason [28]. With the use of hand tools in the literature, it has been determined by an experimental study that there are regional discomforts such as pain and muscle fatigue in the wrist and upper arm extremities [33]. Studies with larger sample groups are needed to determine the causes of musculoskeletal disorders in teachers.

One of the most important results of this study was the significant correlation between MSD found in teachers and high levels of work stress. In recent studies, it has been stated that stress developing due to physical and psychosocial risks in the workplace causes more frequent MSDs in employees [9, 10]. In the present study, it was found that the work stress levels of the teachers were above 30, which indicated that the individuals had dangerous/high level of work stress. The findings of the study are consistent with the findings of other studies. The MSDs are more common in teachers with high levels of work stress and low levels of satisfaction with life. In a study conducted by Malik and Bjorkqvist on academic instructors in Finland and Pakistan, both MSDs and mental disorders were found to have a clear correlation with occupational stress in both countries. Therefore, it was reported that occupational stress was a risk factor for the mental and musculoskeletal health regardless of the country’s level of development [9]. In another study, the teachers, who reported anxiety, stress and depression, were found to experience more MSDs. It has been stated that stress, anxiety and depression cause an increase in allergic substances in the muscles by changing blood flow and oxygen supply, as well as increasing the risk of muscle tension and pain. It is believed that the work stress caused by the working conditions, and the decreased level of hopelessness increase the risk of experiencing pain. In addition, it is emphasized that the stress experienced by teachers would affect their school performance, and suitable working conditions should be provided urgently in order to improve the education processes of future generations [8].

5 Conclusion

It was found that MSDs were common problems experienced by teachers and negatively affected satisfaction with life, and were correlated with gender, working conditions and work stress levels. Unlike the other studies, particularly the time spent sitting at a desk, the time devoted to housework, shoe preference, work stress and satisfaction with life were determined as significant predictors of MSDs in the present study. Nonetheless, further studies with larger study groups are needed to investigate other potential effects for drawing definitive conclusions regarding the causative correlations of MSDs with other factors. The impact of increased stress on education should certainly not be underestimated. There is a need for further studies on distant education carried out by constant sitting at a desk especially due to the COVID-19 pandemic in terms of its effects on MSDs in teachers.

There is a need for protecting the health of teachers, who prepare the future generations, in order to maintain effective and continuous educational activities. Accordingly, their problems should be identified, their working characteristics should be reviewed, and necessary measures should be taken. It is important to understand the relationship between MSDs and their causes, which are demonstrated in the present study. In addition, our study will assist school administrators in organizing, planning or implementing preventive intervention programs for reducing the risk of MSDs. Moreover, the present study will raise teachers’ awareness regarding MSDs, who work in the Ministry of National Education. In this context, the study will contribute to reviewing the working conditions of teachers, the preparation of instructions for appropriate ergonomic movements, and the modeling of health-promoting behaviors in order to reduce MSDs.