Abstract:

The study aimed to identify multiple exposures to the risk of work absenteeism among Brazilian schoolteachers, independently of the reasons reported by teachers (n = 6,510). The data came from a telephone survey on health, working conditions, and absenteeism among schoolteachers in Brazil (Educatel Study, 2015/2016). Exposures were identified and studied by principal components analysis and Poisson regression, with a focus on working conditions and quality of school administration. Three components of risk factors for work absenteeism were identified. Component 1 featured lack of opportunities for new learning experiences, insufficient time for performing tasks, constraints on teachers’ autonomy, and little or no social support in the school environment; component 2 was characterized by the perception of heavy demand from tasks and an agitated classroom environment due to students’ lack of discipline and intense noise; and component 3 by the experience of verbal or physical violence from students. All three components were specially associaed with stress-related work absenteeism in relation to reported stress at school (aPR = 3.87; 95%CI: 2.93-5.10; p < 0.05/aPR = 3.18; 95%CI: 2.47-4.09; p < 0.05/aPR = 3.31; 95%CI: 2.58-4.25; p < 0.05; respectively) and emotional problems (aPR = 2.28; 95%CI: 1.93-2.70; p < 0.05/aPR = 2.43; 95%CI: 2.05-2.87; p < 0.05/aPR = 2.09; 95%CI: 1.78-2.45; p < 0.05; respectively). The identification of these risk components highlighted the need for systemic changes in Brazilian Basic Education schools.

Keywords:
Absenteeism; School Teachers; Risk Factors; Occupational Health

Introduction

Studies based on the classic Fordist model that target workers on jobs where they are exposed to measurable environmental risks have proven insufficient for addressing current relations between health, work, and employment ¹1. Gomez CM, Lacaz FAC. Saúde do trabalhador: novas-velhas questões. Ciênc Saúde Coletiva 2005; 10:797-807.. In recent decades, progress in research and knowledge on workers’ health indicate gaps in the Fordist paradigm. The field of workers’ health is based on research concepts and methods that examine the links between the macro social structural level (income, schooling, and adults’ position in the workforce) and the unique level of the health-disease process (physical and psychosocial working conditions, morbidity, mortality, and disability in adult workers) ²2. Barnay T. Health, work and working conditions: a review of the European economic literature. Eur J Health Econ 2016; 17:693-709..

Teachers in preschool, primary, and secondary schools (the stages comprising “Basic Education” in Brazil) are considered internationally as one of the professions most vulnerable to work-related illness ³3. Kovess-Masféty V, Sevilla-Dedieu C, Rios-Seidel C, Nerrière E, Chee CC. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 2006; 6:101.^,44. Scheuch K, Haufe E, Seibt R. Teachers' health. Dtsch Arztebl Int 2015; 112:347., including sick leave from work ⁵5. Shirom A, Rosenblatt Z. A panel study of the effects of school positions and promotions on absenteeism in the teaching profession. J Occup Organ Psychol 2006; 79:623-44.. Although voice problems are highly prevalent in schoolteachers ⁶6. Medeiros AM, Assunção AA, Barreto SM. Absenteeism due to voice disorders in female teachers: a public health problem. Int Arch Occup Environ Health 2012; 85:853-64., they are not covered by Brazil’s specific social security or workers’ compensation laws. Appalling situations such as aggression between members of the school community have come to dominate daily teaching work ⁷7. Araújo TM, Carvalho FM. Condições de trabalho docente e saúde na Bahia: estudos epidemiológicos. Educação & Sociedade 2009; 30:427-49.. An extensive literature addresses the factors related to teachers’ absence from schools when they should be expected to appear, a process known as absenteeism ⁵5. Shirom A, Rosenblatt Z. A panel study of the effects of school positions and promotions on absenteeism in the teaching profession. J Occup Organ Psychol 2006; 79:623-44.. Work absenteeism for health reasons are an indicator not only of population groups’ health ⁸8. Kausto J, Pentti J, Oksanen T, Virta LJ, Virtanen M, Kivimäki M, et al. Length of sickness absence and sustained return-to-work in mental disorders and musculoskeletal diseases: a cohort study of public sector employees. Scand J Work Environ Health 2017; 43:358-66., but also of working conditions ⁹9. Laaksonen M, Pitkaniemi J, Rahkonen O, Lahelma E. Work arrangements, physical working conditions, and psychosocial working conditions as risk factors for sickness absence: bayesian analysis of prospective data. Ann Epidemiol 2010; 20:332-8., the sector’s overall characteristics ¹⁰10. van Vilsteren M, van Oostrom SH, de Vet HCW, Franche RL, Boot CR, Anema JR. Workplace interventions to prevent work disability in workers on sick leave. Cochrane Database Syst Rev 2015; (10):CD006955., and the organizational culture ¹¹11. Antai D, Oke A, Braithwaite P, Anthony DS. A 'balanced' life: work-life balance and sickness absence in four Nordic countries. Int J Occup Environ Med 2015; 6:205-22..

Although complex and multifactorial causality of this process is known to researchers, the vast majority of studies analyze risk factors separately ¹²12. Santos MN, Marques AC. Condições de saúde, estilo de vida e características de trabalho de professores de uma cidade do sul do Brasil. Ciênc Saúde Coletiva 2013; 18:837-46.^,1313. Pereira EF, Teixeira CS, Andrade RD, Bleyer FTS, Lopes AS. Associação entre o perfil de ambiente e condições de trabalho com a percepção de saúde e qualidade de vida em professores de educação básica. Cad Saúde Colet (Rio J.) 2014; 22:113-9.. In order to broaden the analytical perspective, some authors have suggested innovating the approaches to identify the dynamics by which the multicausal risks and outcome intertwine ¹⁴14. Steele EM, Claro RM, Monteiro CA. Behavioural patterns of protective and risk factors for non-communicable diseases in Brazil. Public Health Nutr 2013; 17:369-75.. However, this strategy has apparently not been used in studies on factors related to work absenteeism, which still form the basis for the Fordist paradigm.

The current study’s relevance consists of analyzing a nationwide database of Brazilian schoolteachers using a methodology that has rarely been explored in the field of workers’ health. The proposal was developed to identify and link the multiple risks of work absenteeism in Brazilian schoolteachers in Basic Education.

The study aimed to identify the multiple exposures to the risk of work absenteeism, independently of the reasons reported by the teachers.

Methods

This was a cross-sectional study using primary data from a probabilistic sample of schoolteachers (Educatel Study 2015/2016), a telephone survey on health, working conditions, and absenteeism among Brazilian schoolteachers.

Study population, sampling, and data collection

The minimum sample was set at 6,500 teachers, considering a 95% confidence interval (95%CI) and 0.99% of the maximum error predicted for the estimation of the prevalence of absenteeism for the entire population of teachers in Brazil. More detailed information has been published in a complementary methodological study ¹⁵15. Vieira MT, Claro RM, Assunção AA. Desenho da amostra e participação no Estudo Educatel. Cad Saúde Pública 2019; 35 Suppl 1:e00167217.. Access to data from the 2014 School Census¹⁶16. Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Censo Escolar da Educação Básica 2014. http://portal.inep.gov.br/basica-levantamentos-acessar (acessado em 16/Set/2016).
http://portal.inep.gov.br/basica-levanta... allowed stratification of the total population of schoolteachers (2,229,269) in Basic Education in Brazil according to geographic location (geographic region and census area, i.e., urban versus rural), demographic variables (age brackets and gender), and position in the school system (school administrative affiliation, type of teaching contract, and grade level). Next, the teachers were selected to be interviewed by simple random sampling in each stratum. A total of 13,243 teachers were selected, thereby ensuring the minimum number of interviews. The inclusion of a large number of teachers in the initial selection round was necessary to offset the expected losses from refusal to participate (approximately 20%) and discrepancies between the administrative data (2014 School Census) and the reality in the field.

Considering the logistic complexity and high cost of conducting face-to-face interviews in such a large sample, the decision was made to use telephone interviews. Data were collected from October 2015 to March 2016. Schoolteachers were considered ineligible if they were not affiliated with the school at the time, if they worked in schools without telephones, or if the telephone listed in the original data source was not working. There were two possible situations for eligible teachers: to interview the teacher during the first contact at the school itself or later, by appointment, if the teacher preferred. A maximum of 15 attempted contacts were made for each selected teacher (on different days and at different times, including night school and weekends). Teachers that had not been located after these 15 attempts were considered ineligible. The results were: 119,378 telephone calls, 7,642 eligible teachers (57.7% of the list of selected teachers), and 6,510 interviews (85.2% success rate).

The Educatel questionnaire was developed in keeping with the telephone survey’s specificities and based on a review of Brazilian and international experiences in the health field and more specifically that of workers’ health or teachers’ health. The instrument was a multiple-theme questionnaire, the adequacy of which was confirmed by assessment of each question as to understanding of the statement and its objective. The terminology, internal organization of the questionnaire, production of the answers, duration of interview, format of the questions (open or closed), and possible answers were confirmed by applying a pilot test in a convenience sample (n = 15). More details have been published in a complementary theoretical and methodological study ¹⁷17. Assunção AA, Medeiros AM, Claro RM, Vieira MT, Maia EG, Andrade JM. Hipóteses, delineamento e instrumentos do Estudo Educatel, Brasil, 2015/2016. Cad Saúde Pública 2019; 35 Suppl 1:e00108618..

The interviews’ results were associated with weighting factors to ensure that the weighted sampling totals coincided with the known population totals of Brazilian schoolteachers. These weighting factors took the study’s sampling design into account, i.e., the inverse of the selection probabilities for each teacher (study unit), the influence of non-response cases on the Educatel estimates, and an additional factor to fit the sample to that recorded by the 2014 School Census according to the distribution of variables used in the survey’s sampling plan (post-stratification) ¹⁵15. Vieira MT, Claro RM, Assunção AA. Desenho da amostra e participação no Estudo Educatel. Cad Saúde Pública 2019; 35 Suppl 1:e00167217..

Organization of the data

Overall absenteeism was measured by the question “In the last 12 months, have you missed work on at least one day (for whatever the reason)? (no/yes)”. An affirmative answer to this question triggered six questions on the reasons for work absenteeism, of which only three were included in the current study (referring to the most prevalent problems and the internal school environment): “Have you missed work for family reasons? (no/yes)”, “Have you missed because you experienced something stressful in school? (no/yes)”, “Have you missed because of problems with your own health? (no/yes)”. Finally, teachers who answered the last question in the affirmative (related to absenteeism due to illness) were asked six more questions. Of these, only the questions related to the three most prevalent problems were included in the current study: “Emotional problems (e.g., depression, stress, anxiety)? (no/yes)”, “Voice problems (e.g., hoarseness, loss of voice)? (no/yes)”, “Respiratory problems (e.g., asthma, bronchitis, rhinitis, sinusitis)? (no/yes)”. Seven dichotomous indicators on work absenteeism were elaborated on the basis of these questions.

Indicators related to the quality of school administration and working conditions in the schools were used. Quality of administration was measured with the following questions: “Does your work demand too much of you?”, “Do you have the possibility of learning new things at your work?”, “Do you have sufficient time to complete all the tasks in your work?”, “Does the school give the teaching staff the opportunity to participate actively in decisions?”, “Is there a calm and pleasant environment where you work?”, “At work, does everyone get along well with each other?”, “Can you count on support from your coworkers?”, “If you’re not having a good day, do your coworkers understand?”, “At work, do you get along well with your superiors?”, and “Do you enjoy working with the other teachers?”. The possible answers to these questions were “often/sometimes/rarely/never or almost never”. Five indicators on the quality of administration, with dichotomous answers, were elaborated: often, sometimes/rarely, never or almost never. The last six above-mentioned questions were used to build the indicator “social support at school” with a score based on the sum of the answers (1 point in the score for each answer “often”, 2 for “sometimes”, 3 for “rarely”, and 4 for “never or almost never”). Teachers that scored more than 7 (50th percentile) were defined as not counting on social support at school ¹⁸18. Alves MGM, Chor D, Faerstein E, Lopes CS, Werneck GL. Versão resumida da "job stress scale": adaptação para o português. Rev Saúde Pública 2004; 38:164-71..

Indicators related to working conditions were elaborated using the following questions: “How often is your workplace agitated because of students’ lack of discipline? (often/sometimes/rarely/never or almost never)”, “How often is noise at work so loud that you have to raise your voice to talk to someone? (often/sometimes/rarely/never or almost never)”, “In the last 12 months, have you suffered verbal violence from students? (never/once/twice or more)”, “In the last 12 months, have you suffered physical violence from students? (never/once/twice or more)”. At the end, based on the frequency of these events, four indicators on working conditions, with dichotomous answers, were elaborated: often, sometimes/rarely, never or almost never; or never/once, twice or more.

The demographic, geographic, and school system characteristics were analyzed: gender (male/female), two brackets for teachers’ educational level (primary or secondary - complete or under way/university - complete or under way), four age brackets (≤ 34 years/35-44 years/45-54 years/≥ 55 years), five geographic regions (North/Northeast/Central/Southeast/South), census area (urban/rural), size of school (≤ 10 teachers/11-20 teachers/21-30 teachers/> 30 teachers), teaching level (preschool/primary/secondary/youth and adult education/vocational/two or more levels); and type of teaching contract (based on public admissions, tenured, stable/temporary/private system with contract covered by labor legislation/stable and private system).

Data analysis

The demographic, geographic, and school system characteristics were described first. Next, the prevalence rates were estimated for the seven indicators on reasons for work absenteeism, as well as the prevalence of nine risk factors related to quality of the school administration or working conditions for teacher absenteeism in the Brazilian schools.

The dimensions in the exposure to work absenteeism were identified by principal components analysis (PCA), an exploratory analytical model that allows identifying study units based on similarities between individuals according to the study variables ¹⁹19. Hair JF, Black WC, Barry JB, Anderson RE. Multivariate data analysis. 7th Ed. Englewood Cliffs: Prentice Hall; 2010.. In this study, information on teachers’ working conditions and quality of the school administration were used (dichotomous variables). The definition of the number of components (or dimensions) to be extracted was defined in three stages: Kaiser criterion (eigenvalue > 1.0), scree plot, and interpretation of the components’ composition ¹⁹19. Hair JF, Black WC, Barry JB, Anderson RE. Multivariate data analysis. 7th Ed. Englewood Cliffs: Prentice Hall; 2010.. The analysis was based on a polychoric correlation matrix, and promax oblique rotation was applied to achieve a simpler structure and facilitate interpretation of the results. The larger the variable’s load, the greater its contribution to the component, and only those greater than 0.30 (in module) were considered significant ¹⁹19. Hair JF, Black WC, Barry JB, Anderson RE. Multivariate data analysis. 7th Ed. Englewood Cliffs: Prentice Hall; 2010.. Negative loads indicate an inverse association with the component and positive loads a direct association. The three extracted components account for about 60% of the model’s total variability. The first component represents the largest share of variability in the set of variables (largest explanatory force in the model), the second component, independently of the first, explains the maximum possible remaining variability, and so on, with no correlation between the components ¹⁹19. Hair JF, Black WC, Barry JB, Anderson RE. Multivariate data analysis. 7th Ed. Englewood Cliffs: Prentice Hall; 2010..

Each individual’s score for each component identified in the previous stage was analyzed as an independent variable, while the reasons for work absenteeism were dependent variables in the models. The variables containing the individuals’ score for each component (originally continuous variables) were transformed into dichotomous ones, considering the median of their distribution as the cutoff (dividing the score in “high” as above the median and “low” as below the median), in order to simplify the coefficient’s interpretation. The association between each of the components and the reasons for work absenteeism was studied with Poisson regression models, used to calculate crude (cPR) and adjusted prevalence ratios (aPR). Demographic, geographic, and school system characteristics were considered potential confounding variables in the adjusted models. Variables that were significant in the bivariate model (p < 0.20) were kept in the analyses and included stepwise in the multivariate model according to level of significance (p-value). At the end, all the confounding variables showed p < 0.05. The available weighting in Educatel (corrected for non-response) was used for the all the analyses except PCA. Data processing and all the analyses used Stata version 13.1 (http://www.stata.com), taking the complex sample design in the Educatel Study into account.

The Educatel Study was approved by the Ethics Research Committee of the Federal University of Minas Gerais (CAAE: 48129115.0.0000.5149 and review n. 1.305.863).

Results

The Educatel Study population consisted of 6,510 Brazilian schoolteachers, mostly women (80.28%) and with university education (90.56%). One out of three teachers were under 34 years of age (32.97%), and slightly more than one out of ten were 55 or older (10.55%). About two-thirds of the teachers worked in three regions of Brazil (Central 7.17%; Southeast 40.51%; and South 15.11%), and nearly one-sixth worked in rural areas (15.92%). As for school size, the majority worked in schools with more than 30 teachers (54.94%). Half (49.79%) were working in more than one level of Basic Education, and about two-thirds had formal employment contracts (39.56% based on public admission/tenured/stable and 26.27% stable and private system) (Table 1).

About 70% of the sample reported work absenteeism of at least one day in the year preceding the survey. Problems related to the teacher’s own health were the most frequent cause of absenteeism, affecting more than half (53.34%) of the teachers (Table 2). Among the risk factors for work absenteeism, the perception of heavy demand from teaching tasks was the most prevalent (81.59%), followed by agitated classrooms due to students’ lack of discipline (70.17%) and intense noise in the workplace (64.02%). Another frequently reported risk factor was the perception of low social support at school (40.63%) (Table 2).

PCA identified three significant components of risk factors. After rotation, the three components explained 23%, 23%, and 16% of the total variability, respectively. Component 1 was characterized as the lack of new learning opportunities, insufficient time to finish tasks, perception of constraints on teachers’ autonomy, and little or no social support in the school environment; component 2 featured the perception of heavy demand from tasks and agitated classrooms due to students’ lack of discipline and perception of intense noise; and component 3 featured the experience of verbal or physical violence from students (Table 3).

The three components showed a positive association with the different reasons for work absenteeism (Table 4). In general, components 1, 2, and 3 showed a stronger association with work absenteeism due to stressors at school (aPR = 3,87; 95%CI: 2.93-5.10; p < 0.05/aPR = 3.18; 95%CI: 2.47-4.09; p < 0.05/aPR = 3.31; 95%CI: 2.58-4.25; p < 0.05; respectively) and emotional problems (aPR = 2.28; 95%CI: 1.93-2.70; p < 0.05/aPR = 2.43; 95%CI: 2.05-2.87; p < 0.05/aPR = 2.09; 95%CI: 1.78-2.45; p < 0.05; respectively). Components 1 and 3 also showed a stronger association with work absenteeism due to respiratory problems (aPR = 1.59; 95%CI: 1.36-1.86; p < 0.05/aPR = 1.51; 95%CI: 1.29-1.76; p < 0.05; respectively), and the component 2, due to voice problems (aPR = 2.14; 95%CI: 1.85-2.47; p < 0.05) among Brazilian schoolteachers.

Discussion

The unprecedented data on health, working conditions, and absenteeism allowed identifying risk factors for work absenteeism in a nationally representative sample of Brazilian schoolteachers. By assuming that teachers’ absenteeism is a multifactorial event, the study identified a typology of factors (components 1, 2, and 3) associated with work absenteeism at school. The results highlight the coherence of each component’s internal composition and the association with the different reasons for failing to appear for work at school.

Distress and illness are associated with insufficient time for rest and recovery. This is likely the case of schoolteachers whose formal workday is augmented by leadership duties, faculty meetings, and additional non-classroom demands. Teachers commonly prepare their teaching materials and grade the students’ exercises and tests outside their formal working hours. Teaching tasks compete with the teachers’ time for rest and recovery from physical and mental fatigue ²⁰20. Assunção AA, Oliveira DA. Intensificação do trabalho e saúde dos professores. Educação & Sociedade 2009; 30:349-72.^,2121. Borrelli I, Benevene P, Fiorilli C, D'Amelio F, Pozzi G. Working conditions and mental health in teachers: a preliminary study. Occup Med 2014; 64:530-2.. Insufficient time, constraints on autonomy, and little or no social support are psychosocial dimensions that remained in component 1, expressing increased risk of work absenteeism for health reasons (respiratory and emotional problem) and stressful experiences at school. One can conjecture on the manifestations of a situation that generally reflects a system with deteriorated working conditions where the physical environment, lack of discipline, and demands from tasks would have negative effects on health and wellbeing and likely jeopardize the capacity to perform functions ²²22. Rugulies R, Christensen KB, Borritz M, Villadsen E, Bültmann U, Kristensen TS. The contribution of the psychosocial work environment to sickness absence in human service workers: results of a 3-year follow-up study. Work Stress 2007; 21:293-311.. Absenteeism under such conditions feeds back into its determinants, increasing the workload for teachers substituting for those who have missed work or breaking the ties of solidarity towards the absent coworker. This means a cycle of deteriorating working conditions, jeopardizing teachers’ health and students’ learning ²³23. Penteado RZ, Pereira IMTB. Qualidade de vida e saúde vocal de professores. Rev Saúde Pública 2007; 41:236-43.^,2424. Bowers T. Teacher absenteeism and ill health retirement: a review. Cambridge Journal of Education 2001; 31:135-57..

Heavy demand from tasks, the perception of low social support, exposure to the agitated classroom environment, and intense noise are factors associated with work absenteeism in school both in wealthier countries ²⁵25. Ervasti J, Kivimäki M, Kawachi I, Subramanian SV, Pentti J, Oksanen T, et al. School environment as predictor of teacher sick leave data-linked prospective cohort study. BMC Public Health 2012; 12:770.^,2626. Notenbomer A, Roelen CAM, Van Rhenen W, Groothoff JW. Focus group study exploring factors related to frequent sickness absence. PLoS One 2016; 11:e0148647. and in Brazil ¹²12. Santos MN, Marques AC. Condições de saúde, estilo de vida e características de trabalho de professores de uma cidade do sul do Brasil. Ciênc Saúde Coletiva 2013; 18:837-46.^,1313. Pereira EF, Teixeira CS, Andrade RD, Bleyer FTS, Lopes AS. Associação entre o perfil de ambiente e condições de trabalho com a percepção de saúde e qualidade de vida em professores de educação básica. Cad Saúde Colet (Rio J.) 2014; 22:113-9.. Intense noise is the environmental risk most cited by the teachers and simultaneously results from multiple sources in the surroundings: recess on the schoolyard or games on the sports courts, heavy vehicle traffic on neighboring streets, machinery, and even classroom activities themselves ²⁷27. Woolner P, Hall E. Noise in schools: a holistic approach to the issue. Int J Environ Res Public Health 2010; 7:3255-69.. The noise interferes in communication between teachers and students, hampers short-term memory, decreases motivation, compromises reading and language skills, and jeopardizes learning in general ²⁸28. Jiménez-Tejada MP, Hódar JA, González-García F. Noise, what noise? Raising awareness of auditory health among future primary-school teachers. Teach Teach Educ 2012; 28:1083-90.. Tests of the noise intensity in Brazilian school have shown levels exceeding the recommended technical limits ²⁹29. Batista JBV, Carlotto MS, Coutinho AS, Pereira DAM, Augusto LGS. O ambiente que adoece: condições ambientais de trabalho do professor do ensino fundamental. Cad Saúde Colet (Rio J.) 2010; 18:234-42.. Noise and lack of classroom discipline are interrelated events, placing a heavy demand on teachers to recuperate the necessary tranquility to conduct their teaching activities. Consistently, the variables expressing these three situations remained in component 2, with increasing risk of work absenteeism due to health problems (especially voice and emotional problems). The physical, emotional, and cognitive responses required of teachers by this type of demand (teaching in an unruly, chaotic, and noisy environment) are associated with illnesses ³⁰30. Klatte M, Lachmann T, Meis M. Effects of noise and reverberation on speech perception and listening comprehension of children and adults in a classroom-like setting. Noise Health 2010; 12:270-82. and a probable break in their ability to appear for work.

The Educatel results are consistent in associating component 3, characterized by the teacher’s exposure to episodes of verbal or physical violence from students, with work absenteeism due mainly to contact with stressful events in the school and emotional and respiratory problems. Episodes of violence in school lead to teachers’ demotivation and illness, sick leave, and abandonment of the profession. Fear, anxiety, and isolation are reactions identified in exposed groups ³¹31. Wilson CM, Douglas KS, Lyon DR. Violence against teachers: prevalence and consequences. J Interpers Violence 2011; 26:2353-71.. Emotional symptoms were identified in 84% of a sample of Canadian teachers that reported experiencing violence at school ³¹31. Wilson CM, Douglas KS, Lyon DR. Violence against teachers: prevalence and consequences. J Interpers Violence 2011; 26:2353-71.. Violence at work itself is considered an occupational stressor ³²32. Barling J, Dupré KE, Kelloway K. Predicting workplace aggression and violence. Ann Rev Clin Psychol 2009; 60:671-92.. In Brazil, common mental disorders were significantly associated with reports of violence ³³33. Gasparini SM, Barreto SM, Assunção AA. Prevalência de transtornos mentais comuns em professores da rede municipal de Belo Horizonte, Minas Gerais, Brasil. Cad Saúde Pública 2006; 22:2679-91.. Importantly, emotional problems can harm teachers’ health directly or indirectly, making them more vulnerable to psychosomatic diseases. Among these, respiratory illnesses like brinchial asthma and anxious dyspnea are highlighted ³⁴34. Contaifer TRC, Bachion MM, Yoshida T, Souza JT. Estresse em professores universitários da área de saúde. Rev Gaúch Enferm 2003; 24:215-25..

Although the multifactorial nature of work absenteeism is known to researchers, the classic “one risk factor for each health outcome” analysis prevails in the specialized literature ³⁵35. Catalina-Romero C, Sainz JC, Pastrana-Jiménez JI, García-Diéguez N, Irízar-Muñoz I, Aleixandre-Chiva JL, et al. The impact of poor psychosocial work environment on non-workrelated sickness absence. Soc Sci Med 2015; 138:210-6.^,3636. Fernandes C, Pereira A. Exposure to psychosocial risk factors in the context of work: a systematic review. Rev Saúde Pública 2016; 50:24.. The approach adopted in the current study not only reflects trends in international studies to analyze known multicausal outcomes ³⁷37. Seghers J, Rutten C. Clustering of multiple lifestyle behaviours and its relationship with weight status and cardiorespiratory fitness in a sample of Flemish 11- to 12-year-olds. Public Health Nutr 2010; 13:1838-46., but also favors the elaboration of strategies for workers’ health promotion. However, since the approach is unprecedented in occupational studies, caution is recommended when interpreting the results, since it is not possible to draw comparisons.

Some study limitations deserve mentioning. Inconsistencies were found in the information from administrative data on the telephone numbers for contacting the selected teachers. But it should be noted that the school areas (the initial point of contact with teachers) have better telephone coverage than the corresponding residential areas. At any rate, post-stratification weighting was used to correct for gaps in coverage ³⁸38. Bernal RT, Malta DC, Morais Neto OL, Claro RM, Mendonça BCA, Oliveira ACC, et al. Vigitel - Aracaju, Sergipe, 2008: the effects of post-stratification adjustments in correcting biases due to the small amount of households with a landline telephone. Rev Bras Epidemiol 2014; 17:163-74.. Self-reported information obtained by telephone interview are subject to biases. Note, however, that this strategy has been used in Brazil ³⁹39. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2017. and elsewhere ⁴⁰40. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS). http://www.cdc.gov/mmwr/pdf/ss/ss6309.pdf (acessado em 28/Nov/2016).
http://www.cdc.gov/mmwr/pdf/ss/ss6309.pd... , due to the low cost, speed, and relative simplicity of data collection when the sample is distributed across a vast territory. From the instrument’s construction to the statistical analyses, the procedures were elaborated so as to diminish the likelihood of possible biases. Tests with the instrument sought to guarantee the data’s consistency ¹⁷17. Assunção AA, Medeiros AM, Claro RM, Vieira MT, Maia EG, Andrade JM. Hipóteses, delineamento e instrumentos do Estudo Educatel, Brasil, 2015/2016. Cad Saúde Pública 2019; 35 Suppl 1:e00108618..

Various measures have been developed to improve Basic Education in Brazil ⁴¹41. Dourado LF. Políticas e gestão da Educação Básica no Brasil: limites e perspectivas. Educação & Sociedade 2007; 28:921-46.. The measures to value teachers feature the Brazilian National Plan for Education (PNE), which includes targets for structuring career plans and pay scales and support for democratic workplace relations. According to the PNE, effective measures are needed for health promotion, prevention, care, and treatment and to support schoolteachers’ physical, mental, and emotional integrity in order guarantee improved quality of educational services ⁴²42. Brasil. Plano Nacional de Educação 2014-2024: Lei no 13.005, de 25 de junho de 2014, que aprova o Plano Nacional de Educação (PNE) e dá outras providências. http://www.observatoriodopne.org.br/uploads/reference/file/439/documento-referencia.pdf (acessado em 16/Set/2016).
http://www.observatoriodopne.org.br/uplo... . By identifying the increase in teachers’ work absenteeism when exposed to unfavorable conditions in the physical and organizational school environment, the results of the Educatel Study reinforce the PNE targets.

The results call attention to the seriousness of the problem, since the study detected the harmful effects of noise on the school community’s health ²⁸28. Jiménez-Tejada MP, Hódar JA, González-García F. Noise, what noise? Raising awareness of auditory health among future primary-school teachers. Teach Teach Educ 2012; 28:1083-90.. The main source of noise is activities involving the teachers and students themselves. Class size, students’ age, and teacher’s inexperience are significant determinants of exposure to noise, besides inadequate school acoustics ⁴³43. Kristiansen J, Lund SP, Nielsen PM, Persson R, Shibuya H. Determinants of noise annoyance in teachers from schools with different classroom reverberation times. J Environ Psychol 2011; 31:383-92.. Thus, in order to decrease noise pollution and other preventable risk factors, classroom walls and ceilings should be covered with acoustic insulation in order to reduce the effects of sound reverberation ⁴³43. Kristiansen J, Lund SP, Nielsen PM, Persson R, Shibuya H. Determinants of noise annoyance in teachers from schools with different classroom reverberation times. J Environ Psychol 2011; 31:383-92..

Healthy hearing and violence in school are relevant themes for life in society that can be included in school texts. For hearing, it is possible to modify behaviors that signal tolerance to sound pollution inside and outside the school environment. Planning specific educational programs can be helpful for educating future teachers about the effects of environmental noise on individuals’ physical and mental health ²⁸28. Jiménez-Tejada MP, Hódar JA, González-García F. Noise, what noise? Raising awareness of auditory health among future primary-school teachers. Teach Teach Educ 2012; 28:1083-90.. Such measures expand the ways for continuous learning and improvement in the school community. In relation to violence, knowledge on human rights and peace should be incorporated into the class content. It is important to identify the school surroundings that are most vulnerable to violence in order to act on different fronts. Creating student clubs to promote peace in the school ⁴⁴44. Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura. Poner fin a la violencia en la escuela: guía para los docentes. http://unesdoc.unesco.org/images/0018/001841/184162s.pdf (acessado em 30/Ago/2017).
http://unesdoc.unesco.org/images/0018/00... , defining the concept of violence in schools, and drafting and publicizing overall guidelines on the promotion of more just environments are workable proposals ⁴⁵45. International Labour Organization. Code of practice on workplace violence in services sectors and measures to combat this phenomenon. Geneva: International Labour Organization; 2003.. When a violent event does occur, it is reasonable for school administrators, together with the school community, to guarantee the situation’s confidentiality in order to avoid further exposing the victims and witnesses. Since violence is a problem with a national scope, teachers’ health services should incorporate the guidelines issued by agencies and social organizations in order to be better prepared to support victims and promote their recovery under humane conditions. The prevention of violence helps increase autonomy and expand the support for teachers, since it relates to the way policies are developed for interpersonal relations with dignity and mutual respect. A fundamental resource for teachers to cope with occupational stress is for them to feel supported to the extent that there is room in school to share concerns with coworkers and to rely on the administration’s leadership in positive experiences vis-à-vis similar situations ⁴⁶46. García-Herrero S, Mariscal MA, Gutiérrez JM, Ritzel DO. Using Bayesian networks to analyze occupational stress caused by work demands: preventing stress through social support. Accid Anal Prev 2013; 57:114-23..

Coping with the risks of work absenteeism at school is a way of observing and complying with workplace health and safety legislation as provided by the International Labor Organization ⁴⁵45. International Labour Organization. Code of practice on workplace violence in services sectors and measures to combat this phenomenon. Geneva: International Labour Organization; 2003.. Including information on violent incidents in the existing systems (the School Census, for example) will facilitate risk assessment aimed at implementing preventive measures. These forms of social support in the face of distress experienced by the school community expand the biological explanatory limits in order to establish a broader and more effective platform for teachers’ health promotion ⁴⁷47. Reblin M, Uchino BN. Social and emotional support and its implication for health. Curr Opin Psychiatry 2008; 21:201-5.. Finally, teachers’ time limitations have to do with planning and administration and multiple teaching jobs. To change this situation involves the school’s own organization and the educational system as a whole, since official national school guidelines have set a nationwide minimum wage for teachers that has not been implemented in the entire country.

Conclusion

The hypothesis of coexistence of multiple exposures to the risk of work absenteeism was proven, reinforcing the importance of goals for valuing Brazilian schoolteachers in Basic Education and the development of school resources. These feature the need to decrease noise pollution in schools, ensure discipline, and prevent violence. Encouragement is needed for multiple simultaneous changes in the quality of administration and working conditions, benefiting not only the teachers but the entire school community.

Acknowledgments

The authors are grateful to the Department of School Systems Linkage of the Brazilian Ministry of Education, the Brazilian National Research Council (CNPq), and the Brazilian National Institute for Educational Studies and Research “Anísio Teixeira” (INEP).

References

Additional informations

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