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Occupational Medicine Advance Access originally published online on March 26, 2007
Occupational Medicine 2007 57(3):194-202; doi:10.1093/occmed/kqm013
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© The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Factors associated with psychiatric morbidity in Spanish schoolteachers

Obdulia Moreno-Abril1, Juan de Dios Luna-del-Castillo2, Carmen Fernández-Molina1, Dolores Jurado1, Manuel Gurpegui3, Pablo Lardelli-Claret1 and Ramón Gálvez-Vargas1

1 Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
2 Department of Statistics, University of Granada, Granada, Spain
3 Department of Psychiatry and Institute of Neurosciences, University of Granada, Granada, Spain

Correspondence to: Obdulia Moreno-Abril, Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina, Avenida de Madrid 11, E-18012 Granada, Spain. Tel: 34 958 249617; fax: 34 958 249958; e-mail: omoreno{at}ugr.es


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background The relationship between psychiatric morbidity and characteristics of the work environment has been well-documented, and one of the professional groups in which psychiatric symptoms are most common is schoolteachers.

Aims The present study was designed to evaluate the association between psychiatric morbidity [measured with General Health Questionnaire (GHQ)-28 score] and workplace-, sociodemographic- and personality-related variables in schoolteachers.

Methods A sample of 498 non-university teachers in the city of Granada (southern Spain) were studied with a questionnaire comprising items that covered work-related variables (work and professional variables, as well as job perceptions), sociodemographic characteristics of the teachers and personality, evaluated with the Temperament and Character Inventory (TCI-125). The dependent variable was psychiatric morbidity, measured as scores >6 on the GHQ-28. Crude and adjusted odds ratios between each independent variable and psychiatric morbidity were obtained.

Results In the adjusted analysis, psychiatric morbidity was associated with heavy workload, physical assault from pupils, low appraisal by superiors, low job satisfaction, high stress, female gender and (regarding personal characteristics) high scores for harm avoidance and novelty seeking and low scores for self-directedness.

Conclusions When personality characteristics are taken into account, the effect of workplace and sociodemographic variables was limited, although workload, poor job satisfaction and female sex remained associated with psychiatric morbidity.

Keywords      Mental health; occupational stress; teachers


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Regardless of the controversy that still surrounds the definition of teaching stress, the existence of this problem has been well-documented the world over [1]. Teaching is considered a high-stress profession [1–5]: teachers are under a variety of stressors related with school ownership (i.e. whether a school is publicly administered or owned by a private concern, including religious institutions) [6], grade-level taught [3,6], working conditions [1,6], workload [4], students' aggressive behaviour [7] and bullying [4]. These stressors may interact with demographic factors [8,9]. Coping strategies [3], perceptions related to the workplace setting [10,11], colleague support [3,4] and personality [11–13] may modify the effects of stress on teachers' psychiatric morbidity.

Psychiatry morbidity in the general population and at the workplace can be measured with standard screening instruments. One such instrument is the General Health Questionnaire (GHQ), developed in 1972 by Goldberg for use as a self-administered screening test in epidemiological studies [14].

We designed the present study to analyse the relationship between psychiatric morbidity in Spanish primary and secondary schoolteachers (measured through GHQ-28 score) and variables related with workplace and professional variables, sociodemographic characteristics of the schoolteachers and personality-related variables.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
The population sample for this cross-sectional study consisted of 2913 schoolteachers employed during 2000 at 129 primary and secondary schools in Granada, a city with a population of 260 000 in the region of Andalusia in southern Spain.

Two-stage cluster sampling was used to obtain a random sample of schools in the city (first stage), and then a random sample of teachers at the schools (second stage). Sample size was determined to estimate the frequency of a dichotomous variable with 60% precision. The variable was assumed to be present in up to 50% of the population, assuming an intraclass correlation of 10% and a 95% confidence interval. On the basis of these conditions, the initial sample size was calculated as 602 teachers working at 47 different schools. The schools were stratified by ownership (public or private), grade-level taught (primary or secondary) and number of teachers (low, medium and high) to ensure that all types of schools were represented in the sample. A total of 498 teachers (response rate 83%) took part in the study.

During the months of October–December 2000, questionnaires were given to each school principal for distribution to teachers. To avoid consultation between participants, the principal asked teachers to complete the questionnaire and return it on the spot. The study was approved by the ethics committee of the University of Granada; the survey was anonymous and all participants gave informed consent for being included in the study. To ensure anonymity, no identifying information was recorded on the questionnaire. The questionnaire contained items on variables in the following categories.

Health status
Health status (the dependent variable) was evaluated with the GHQ-28, validated by Lobo and Muñoz [15] for use with Spanish speakers.

Variables related with work
We included in this group the following working place-related characteristics: ownership (private or public), level taught (primary or secondary), number of teachers (<15, 16–30, 31–45, >45), the workload of each teacher (teaching hours per week), the numbers of pupils in the classrooms (20, 21–30 or >30) and whether the teacher had received verbal or physical assaults from pupils. Another subgroup of variables related to professional characteristics: teacher's academic degree (doctorate, baccalaureate, graduate training, technical training or other studies), grade-level taught (primary, middle school, high school, last year of high school or technical school), the qualification needed for the teaching post, whether the teacher was overqualified for the post, the teaching experience (<5, 6–15, 16–25, 26–35, >35 years) and whether they had administrative responsibilities. Finally, we asked teachers about their perceptions about the job: job stress, job satisfaction and perceived appraisal by the principal, by the pupils and by the pupils' parents. These perceptions were rated on a scale from 0 to 6 as in a previous study of health care professionals [16]. Teachers also answered the question, ‘Would you like to change your job?’ (yes/no).

Sociodemographic characteristics
Gender, age (<30, 30–40, 41–50, 51–60, >60 years), marital status [single, married, widowed, separated, divorced, celibate (member of a religious order) or cohabiting], number of children and their ages.

Personality traits
A Spanish version of the short form of the Temperament and Character Inventory (TCI-125) [17] was used for personality self-assessment. The TCI is a battery of questions aimed at evaluating differences between persons on seven basic dimensions of temperament and character. In this self-administered questionnaire, the subject answers ‘true’ or ‘false’ to a series of statements about likes and dislikes, emotional reactions, interests, attitudes, ambitions and values. Temperament was evaluated on the dimensions of novelty seeking (NS) and harm avoidance (HA) in 20 items each (five for each of the four subscales), reward dependence in 15 items (five for each of three subscales) and persistence in five items. Character comprised three dimensions: self-directedness (SD) and cooperativeness (TC) in 25 items each (five for each of the five subscales) and self-transcendence in 15 items (five for each of three subscales).

Some variables were missing for some schoolteachers of our study sample, although the proportion of missing values was <10% for all variables, with the exception of the number of children, in which this proportion was 18% due to an editorial error in the relevant item of the questionnaire. To overcome this problem, we used logical imputations when possible, using information provided by alternate variables. For the remaining cases, the expectation and maximization imputation algorithm was applied [18]. Validation was performed after the imputation procedure to check if means and standard values of the samples were approximately equal before and after imputations.

Initial analysis consisted of a descriptive study of all variables. Some quantitative variables were re-categorized, as noted in the tables. Specifically, all dimensions of the TCI were categorized in terciles. For each category of the independent variables, we recorded mean score on the GHQ, and whether there were statistically significant differences between scores (analysis of variance). The dichotomous variable for probable cases (yes/no) was then defined considering as probable cases GHQ scores >6. An earlier study [19] estimated that with a cut off score of 6, the parameters of validity for the GHQ for the diagnosis of mental health disorder were specificity 90%, sensitivity 77%, positive predictive value 83% and negative predictive value 86%, although the two predictive values change depending on the prevalence of mental disorders in the population. The test has been shown useful for epidemiological purposes for screening to detect undisclosed psychological distress [19].

The presence of a probable case was used to construct logistic regression models to estimate odds ratios (OR) and their 95% confidence intervals for each category of the independent variables in the model. Univariate models were constructed first to obtain crude OR for each independent variable, then a multivariate model was constructed in which all variables were included. Adjusted OR values were obtained from this model for each category of each independent variable included in the model.

Because the sample of teachers was a cluster (school) sample, traditional analysis based on independence of observations was not suitable. Coefficients in the models were estimated with Taylor series linearization [20,21]. All analyses were done with the svy series of the Stata software package (v. 8.0) [22]. The svy logit commands were used for logistic regressions models, and the svy tab commands were used to obtain contingency tables for a cluster sample.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
The questionnaire was completed by 498 teachers, for a response rate of 83%. The response rate was significantly different (P < 0.001) between public (76%) and private (89%) schools, but was not influenced by the grade-level taught at different centres (P = 0.22). Tables 1–3 show descriptive statistics for each variable, the GHQ-28 score for each category and the association (measured as OR) between each variable and psychiatric morbidity (defined as GHQ-28 >6). Crude OR were obtained for all variables, while adjusted values were obtained only for those variables which were included in the multivariate model.


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  		Table 1. Crude and adjusted associations between GHQ-28 scores and variables related with workplace, profession and job perception

 

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  		Table 3. Crude and adjusted associations between GHQ-28 scores and personality-related variables of the schoolteachers

 
Regarding variables related with workplace, profession and job perceptions (Table 1), higher GHQ-28 scores and therefore higher frequencies of psychiatric morbidity, were significantly associated with working at a public school, higher academic qualification and higher experience. A stronger association was found between higher GHQ-28 scores and teachers who had received verbal or physical aggression from students, who wished to change jobs and who felt under-appreciated by their superiors, their colleagues, the students and students' parents, as well as for teachers who reported higher levels of stress and lower job satisfaction. Crude OR revealed the same patterns of association.

Sociodemographic characteristics of the schoolteachers are displayed in Table 2. The crude analysis reveals that higher GHQ-28 scores were significantly associated with female gender, greater age and being divorced. Crude OR for females and teachers >30 years old were also significantly >1.


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  		Table 2. Crude and adjusted associations between GHQ-28 scores and sociodemographic variables of the schoolteachers

 
The association of GHQ-28 score with TCI dimensions (stratified in terciles) is shown in Table 3. There was an association between higher terciles and higher GHQ-28 scores for the HA and NS subscales, whereas the opposite was found for the SD and TC subscales. Accordingly, the frequency of being a probable case was higher for the upper terciles for the HA and NS subscales and the lower terciles for the SD and TC subscales.

Multivariate logistic regression analysis showed that the only two workplace-related variables associated with a significantly higher frequency of psychiatric morbidity were workload (which yielded a non-significant association in the crude analysis) and, especially, physical assault by students (adjusted OR = 9.62). Furthermore, low perceived esteem by superiors, high perceived levels of stress and low job satisfaction also yielded significant adjusted associations with higher psychiatric morbidity (Table 1). The only sociodemographic variable that showed a significant association with GHQ-28 score >6 was female gender (Table 2). The patterns of association found for different dimensions of the TCI were similar to that seen in the crude analysis, with the exception of TC, which was not significantly associated with psychiatric morbidity in the multivariate model (Table 3).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
Our study found that the frequency of probable psychiatry morbidity in schoolteachers was closely dependent on factors related with temperament and a negative perception of the work environment. After adjustment for the effect of these factors, the influence of sociodemographic variables and objective conditions at the workplace was much weaker, with the exception of female gender and workload.

The schoolteachers in our study were similar to participants in other studies with regard to gender [3,8], marital status [3,8], age [23] and years of experience [8]. Regarding the number of children in the teacher's family, our findings are similar to those of one earlier study [8], but our teachers had more children on average than those in another study [3]. Regarding the work environment, the teachers in our sample worked mainly in public secondary schools, in contrast to the participants in an earlier study [3]. The workload in our sample was heavier than for the teachers studied by Griffith et al. [3].

Possible selection bias introduced by non-responders also needs to be considered. For example, non-participation in the study might be associated with other factors related to psychiatric morbidity. Some of the teachers who were on temporary leave and thus ineligible for participation were probably on sick leave because of mental illness. This bias would result in underestimation of the prevalence of psychiatric morbidity in our population of schoolteachers. However, the magnitude of the possible selection bias can be assumed to be modest, because the proportion of non-responders (17%) was relatively low.

Using a cut off point of >6 for the GHQ-28 score, the prevalence of possible psychiatric morbidity in our sample of schoolteachers (33%) was slightly higher than the 29% observed in general population of the province of Granada [24]. When we compared GHQ-28 scores according to work-related and professional variables, we found that scores >6 were significantly more frequent among teachers at public schools in the crude analysis. We have found no previous studies that examined this variable. The finding that teachers at private schools had lower GHQ scores may reflect their perception of sharing a solid ideology and system of support with their colleagues and superiors. This support may give teachers the feeling that they are protected by the educational system—a feeling lacking among teachers at public schools. This conclusion is consistent with the study by Griffith et al. [3], which found that good relations at the workplace had beneficial effects on psychological well-being.

We found no statistically significant differences between primary and secondary schoolteachers, in contrast to Griffith et al. [3], who reported greater stress among primary schoolteachers. Differences in GHQ scores have been reported in relation with workload [25], and Harden [26] suggested that heavy workload (hours of class per week), higher numbers of students per classroom and frequent interruptions had negative effects on the teacher's psychiatric well-being. However, we found no significant differences according to number of students in the classroom.

The association between female gender and high GHQ-28 scores was reported in earlier studies [9,27], and several hypotheses have been put forward to explain this association. Mausner-Dorsch and Eaton [28] found that women were more sensitive to psychological stress at the workplace, and were exposed to more job stress than men. According to earlier research, the greater tendency for women to suffer psychiatry morbidity than men is related to factors such as poor adaptation to life events [29] or to the family or work setting [30]. Personality characteristics and factors such as marital instability can also influence the likelihood of psychiatry morbidity [31]. Kessler [32] compared the prevalence of depression in women and men, and found a sex ratio of 2:1. Earlier research has found that a higher prevalence of depression in women can emerge during puberty, and that depression may be related with hormonal changes. However, hormonal changes had no significant influence on major depression [32]. Kessler suggested that the key to understanding the difference in the risk of depression between men and women lies in the effects of biological vulnerability and experiences triggered by the environment. However, in the present study, the effect of female gender persisted after adjustment for workplace characteristics and subjective perception of the workplace environment and for individual, personality-related characteristics.

Like other authors [9,25], we found an association between high GHQ scores and age in the crude analysis. However, this association disappeared in the adjusted analysis, which indicated that the apparent effect of age was probably dependent on other age-related variables [25]. Stordal et al. [23] found that depression increased with age even after multiple variables were controlled for.

Several studies have related personality characteristics with depressive symptoms [33–36]. The associations in the present study between depressive symptoms and scores on different dimensions of the TCI are consistent with earlier findings [33,36–38]. A study of French gas company employees [12] found an association between adverse psychosocial work conditions and depressive symptoms, independent of personality traits. Like Stansfeld et al. [13], we believe that there may be a positive interaction between some types of jobs and certain personality traits and that this interaction may make workers more vulnerable to the workplace environment.

Aside from non-responder bias, other methodological limitations also need to be taken into account. The main limitation is the study's cross-sectional design, which made it impossible to establish causal relationships between the variables we studied. For example, a negative perception of workplace conditions might be a consequence, rather than a cause, of higher GHQ scores. Another drawback may be the use of self-reported questionnaires. Because both the GHQ and the TCI have been validated for use in Spain, the findings obtained with these instruments can be considered valid. It is important to remember that the aim of this study was to identify probable cases of psychiatric morbidity with a well-known screening instrument such as the GHQ-28, but not to identify true cases.

This study has practical implications for the development of strategies to enhance both subjective well-being and occupational functioning of persons in the teaching profession. The identification of modifiable risk factors such as workload and lack of respect on the part of the pupils may be useful to guide actions intended to improve the work environment. The implementation, especially in the public schools, of policies intended to increase recognition by superiors, pupils and their parents of the important role of educators in society, will surely protect the teachers' well-being and performance. Awareness that personal characteristics such as certain personality traits or being a woman may be associated with greater vulnerability can orientate efforts to provide appropriate personal support or even professional help aimed at ensuring teachers' mental health and happiness.

In conclusion, we found that the frequency of probable cases of psychiatric morbidity among schoolteachers was closely related to workload, low job satisfaction, high job stress, female sex and personality characteristics of the teachers.


Key points
  • Our study found that teachers with certain temperament and character traits appeared to be more prone to psychiatric morbidity.
  • High workload, reported by more than one-third of the teachers, and female sex were associated with psychiatric morbidity.
  • Consideration of appraisal by superiors, job satisfaction and job stress is important if developing strategies to enhance well-being and occupational functioning in teachers.

 


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
The authors thank the Provincial Delegation of the Educational Council of the Andalusian Regional Government for their institutional and logistic support. We are also grateful to the participating teachers and administrative staff at the schools that took part in this study. Thanks are also due to K. Shashok for translating parts of the original manuscript into English.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

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