Low back-pain among school-teachers in Southern Tunisia: prevalence and predictors

Background

The World Health Organization has characterized “work-related” diseases as multifactorial to indicate that several risk factors, such as physical, work organizational, psychosocial, individual, and sociocultural that contributed to initiating these diseases or disorders [1]. As one of the most prevalent work-related diseases and the most disabling condition affecting people in their productive years, musculoskeletal disorders are major health issues that have a substantial influence on the general population’s quality of life [2].

The changes in the education and school systems have led to more pressures on teachers, predispose them to both stress and ergonomic risks that may affect their physical health, which includes musculoskeletal disorders [3]. The National Institute for Colombian Occupational Safety and Health defined musculoskeletal disorders as a group of conditions that involved the nerves, tendons, muscles and supporting structures of the body [1]. Teaching is a job requiring a lot of mental and physical efforts as well as concentration, since it does not only include teaching, but also preparing lessons at home, evaluating students’ homework, preparing, and correcting exams and sometimes teachers were asked to assure other extra activities. Consequently, teachers are faced to various types of both physical and psychological health problems, which could be related to professional factors and work conditions [4].

Low back pain (LBP) is one of the most prevalent musculoskeletal diseases that affects the working population, including teachers, and is a leading cause of disability in both developed and developing countries [5]. It has been shown that LBP is an important health and socio-economic problem of occupational diseases, which touched a large section of occupational population especially teachers [6]. It represented one of the major reasons for consulting in both primary care and emergency setting and one of the most common reasons for absenteeism and loss of productivity [7]. LBP could certainly affect activities of daily living and this fact was reported by previous data [8, 9]. It could reduce mainly the work ability and sexual function [8].

LBP lifetime prevalence has been estimated at nearly 70 % among the general population [10]. Among teachers, a highly exposed population to this problem, several previous data focused on studying this health concern among school-teachers. The prevalence of LBP was variable and ranged between 20 % in Japan in 2002 [6], 40 % in Philippines in 2020 [4], 50 % in Malaysia in 2020 [11] and 90 % as reported in an international systematic review in 2011 [12].

In Tunisia, medical visits for teachers at the workplace to ensure their control and health monitoring are still insufficient and missing. On the other hand, the material conditions are unfavorable and the workload in Tunisian schools could promote or aggravate the occurrence of LBP among teachers. Quantifying this problem among teachers in the local area and determining its risk factors seems to have a permanent importance. However, only limited studies have been conducted considering all these factors among teachers.

In light of this, this study aimed to estimate the LBP prevalence among school-teachers in Southern Tunisia and to identify their main determinants.

Methods

Results

Discussions

To the best of our knowledge, this is the first study examining the magnitude and the risk factors of work-related LBP among South-Tunisian school-teachers. The global prevalence of LBP was 71.8 %. As there had not been any similar study in Tunisia conducted on teachers, on other professions or on general population, the results could only be compared with those from other countries. The prevalence rates of back and neck pain were extremely variable across the world. They were about 26 % in Austria, 47 % in the European Union [18], 41 % in Brazil [19], 62 % in Italy [20] and 46 % in China [21]. The previous reported rates of LBP among school-teachers were lower than our results. This could be related to the fact that in developed countries material and work conditions in schools were more favorable and suitable for teachers [22]. As well, the workload could be an additional argument, given the small number of teachers and the relatively high number of students, related probably to the demographic characteristics of the Tunisian population and the scarcity of the resources [23]. In the developing countries, limited data evaluated LBP among school-teachers; it was about 55 % in Jordan [24], 75 % in Turkey [25] and 40 % in Malaysia [26]. All these frequencies are far from being negligible or benign. Therefore, these alarming rates indicated the urgent necessity to pinpoint the determinants and the factors associated with this pathologic symptom among teachers to develop preventive strategies to restrict LBP among teachers.

The first underlined determinant was female gender. This fact was in line with a previous large-scale survey from Philippines in 2020 [6] and with other international data from Malaysia, Japan and Brazil [27]. The possible reasons of this independent association were firstly the difference between males and females in terms of practicing physical regular exercise, which was universally known as a protective factor from LBP. In fact, among Tunisian general population, males were reported to be more likely involved in regular physical activity [28]. Secondly, the overload that female teachers must face daily compared with males could be another explanation. Indeed, apart from teaching and other school activities, women were also called to do many domestic households after work [4]. Another explication could be attributed to this was that women had more likely suffered from physical and psychological pain, compared with men and this was related to physiologic differences between genders [21].

Another interesting result in the present study was that advanced age was an independent factor of LBP, which was in line with previous studies [4, 21, 29]. Age was largely known as an associated factor with musculoskeletal disorders. A possible explanation of this fact was that senior teachers had more responsibilities than recently recruited ones, such as supervising, teaching terminal classes, and preparing exams, so that they were more at risk to develop LBP [4]. In addition, the physiologic degradation of muscle tonicity as well as bone force and density could be another reason for aged teachers to have more LBP [21].

The present study showed that a history of chronic diseases was independently associated with LBP. This finding was similarly reported in a recent published study from Germany [30]. This could be related to the increased vulnerability of teachers with chronic diseases to more perceive pain. This fact was considered not only for osteoarticular diseases specifically but also for internal diseases psychological, neurological, respiratory, and oncological diseases [30, 31].

Working ≥4 h/day was another predictive factor. Several precedent data were harmonized with this result. In fact, this might be because of the physical efforts during teaching, including prolonged standing in an inappropriate way for more than a few hours inside the classroom [31]. Consequently, encouraging break times during working hours and performing regular daily exercises could reduce the extent of this problem.

Working at primary schools was also an independent factor of LBP. Results reported previously were controversial [21, 32, 33]. It seems that teachers in primary schools in our country had higher work-load and more inadequate working conditions. Furthermore, primary school teachers had more physically demanding work, such as long hours of standing, sitting, pliable and uncomfortable posture [34], so that they experienced more LBP.

Inadequate ergonomic conditions at work were found to be an independent predictor of LBP. This fact was illustrated previously [21, 33, 35]. In fact, inappropriate work conditions such as uncomfortable chairs with proper back support deficiency or lack of adapted boards could make teachers adopting bad postures [29].

Distance home-institution (in kilometer) ≥10 was also an independent factor of LBP. Increased LBP among teachers that spent a daily long-distance home-institution could be explained by the extra time spent to arrive at the workplace, which could intensify the fatigue level for teachers and could be an additional factor of bad postures.

This study was original and valuable highlighting the prevalence and the determinants of LBP among South Tunisian teachers. This study could be used as a referent document, since it was carried out on a representative randomized sample of teachers. Furthermore, the detailed and clear methodology of this work gave an added value because it provided clarity and reproducibility. Nevertheless, there are few limitations. Specifically, the cross-sectional design of this study does not necessarily determine cause and effect; only associations between risk factors and LBP can be established. Moreover, the data collection was a time-demanding process, and it was difficult to estimate the prevalence of neck-shoulder pain simultaneously to the LBP. Besides, the low likelihood of significant multiplicity issues should be considered due to multiple comparisons performed in this study. Further adjustment methods are required to have more accurate results. Lastly, although the used instrument contains validated scales both internationally and locally, there was still a possibility of bias results since the data collection tool was self-administered.

Conclusions

The findings of this study pointed up an alarmingly high prevalence rate of LBP among Tunisian teachers. Several individual, ergonomic, and occupational factors were potential predictors of this symptom. This survey underlined the need to promote rational strategies for LBP prevention among teachers, starting firstly from the improvement of working conditions, with a special accent on the most vulnerable categories and the exposed to predictors as well. Given the noble and the major purpose of education towards the progress of nations, teachers’ well-being should be a priority for policymakers to ensure a good education quality for future generations.