Prevalence, Patterns, and Risk Factors of Work-Related Musculoskeletal Diseases Among Teachers in the Eastern Province, Saudi Arabia: A Community-Based Retrospective Cross-Sectional Survey

Background and objective Work-related musculoskeletal diseases (WMSDs) are one of the most common occupational health concerns among teachers. They refer to a variety of degenerative and inflammatory disorders that can be triggered by the work environment of the people affected. Teachers’ health is substantially significant as it impacts their productivity at work. The aim of this study was to determine the prevalence, patterns, implications, and risk factors of WMSDs among teachers in the Eastern Province of Saudi Arabia. Methods This study involved a survey based on a cross-sectional questionnaire that was distributed to 404 random school teachers located in the Eastern province of Saudi Arabia. Information such as sociodemographic characteristics, workplace characteristics, characteristics of WMSDs experienced, associated factors, and impact of the symptoms experienced was collected. Questions related to symptoms were obtained from the Nordic Musculoskeletal Questionnaire and Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ). The collected data were then analyzed using the SPSS Statistics version 23.0 (IBM Corp., Armonk, NY). Results Among the participants, back pain, shoulder pain, and knee pain were the most reported symptoms of WMSDs in the past 12 months, while elbow pain was the least experienced; 41.1% had pain, discomfort, or numbness that prevented them from performing regular daily activities. The regression analysis revealed a relationship between moderate to severe pain and a pain duration of more than 12 months (p=0.001). Additionally, those who were able to perform lighter work and were not having depression had a low probability of pain persistence and were able to carry out their usual work while experiencing pain (p=0.002). Conclusions In the Eastern province of Saudi Arabia, WMSDs were commonly reported by school teachers. The prevalence of WMSDs among teachers was 41.1%. The pain was described as disabling and causing a negative impact on performance. The most common locations of symptoms were the back, shoulder, and knees. Risk factors for severe pain were female gender, sleeping for six to seven hours, and pain located in the neck shoulder, elbow, hand, thigh/hips, back, knees, and ankles. Furthermore, severe pain was associated with pain duration of more than 12 months, affecting sleep, causing anxiety, and mild depression. The impact of severe pain seriously affected the daily activities of teachers.


Introduction
Work-related musculoskeletal diseases (WMSDs) encompass a wide range of inflammatory and degenerative conditions that affect the muscles, ligaments, tendons, nerves, bones, and joints among people who engage in a variety of occupations, and can be caused by a single incident of or cumulative trauma [1]. WMSDs have been recognized as primary factors contributing to physical impairment, early retirement, and work-related absences and limitations, with an associated peak observed in the most productive period (middle age) in life, and can be financially burdensome for the individual, community, family, and the government [2].
WMSDs are the second major cause of disability globally, impacting almost all types of workers [3,4]. Among 1 1 1 1 these affected working sectors is the teaching sector. Teachers perform a demanding job that involves more than just the act of teaching; it also entails planning classes, grading assignments, and participating in school activities that are not necessarily performed in a favorable environment with a head-down position [5,6]. Due to these factors, WMSDs have been reported to impact 39-95% of teachers [5]. Pain often leads to other issues, including persistent fatigue, sleep disturbances, excessive need for rest, withdrawal from activities, weakening of immunological function, and mental disorders [7].
Various risk factors for WMSDs have been described in the literature [8]. They range from patient-related (older age, female gender, number of children in the family, smoking history, sleeping habits) to workrelated (working environment, workload, and the type of school where the teacher is employed). However, the literature also contains some conflicting data/information regarding certain contributing risk factors. For example, while some studies suggest that working for a longer period increased the chance of having WMSDs, other studies have stated that new teachers are more prone to getting WMSDs. On the contrary, some factors were found to play a major role in limiting and reducing the impact of WMSDs, such as a satisfactory working environment and performing regular exercise [9][10][11].
A recent study in Kenya by Elias et al. [2] has reported that being female and having low supervisor support are risk factors for getting WMSDs. A study by de Souza et al. [12] has found that bad sleep quality is highly associated with WMSDs in teachers in Brazilian public schools. In a more recent study, Kraemer et al. [13] found that teachers at federal institutes were exposed to several ergonomic risk factors, the most common of which were prolonged sitting and standing, sharp edges on work surfaces, having to use a laptop touchpad rather than a mouse, and incorrect screen height.
The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ), developed by Linton and Halldén, is one of the most widely used tools for screening pain [14]. ÖMPSQ was created to aid in the identification of people at risk of acquiring chronic pain by looking into their attitudes, beliefs, and behavior in reaction to pain [15]. Management is mainly focused on physiotherapy for prevention and treatment, along with shortterm use of non-steroidal anti-inflammatory medications [8,16].
The literature investigating WMSDs in Saudi Arabia has identified that the prevalence of low back pain symptoms among teachers is 63.8% [13]. A previous study conducted among Saudi female secondary school teachers in Al Khobar City, Saudi Arabia, found a high prevalence of musculoskeletal pain disorders (79.17%) [11]. However, none of the studies in the literature have discussed patterns and risk factors related to this condition. In light of this, this study aims to determine the prevalence, patterns, and risk factors of WMSDs among teachers in Saudi Arabia.

Study design and setting
This was a community-based retrospective cross-sectional study conducted in the Eastern Province of Saudi Arabia between December 2021 and March 2022.

Ethical approval
Prior to conducting the survey, ethical approval was obtained from the Institutional Research Board and the Ethics Committee of King Faisal University in Al Ahsa city after fulfilling all the required ethical criteria (Research Number: KFU-REC-2021-DEC-EA000300).

Study size and population
The study population included teachers employed in Eastern Province's schools, including both public and private sectors, with at least one year of experience. Teachers with physical disabilities, malignant tumors, inflammatory joint diseases, pregnant teachers, and those who had undergone orthopedic surgery or/and retired were excluded from the study.
According to the Ministry of Education, the total number of school teachers in the Eastern Region was 67,765 in 2021 [17]. Therefore, a sample of at least 377 teachers was required to participate in our study as calculated by Raosoft with a 95% level of confidence and a 5% margin of error [18]. We ultimately included 404 school teachers in our study. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) flow chart illustrating the selection procedure is shown in Figure 1.

Data collection
A survey was employed to collect data regarding the following aspects from participants; sociodemographics, workplace characteristics, characteristics of WMSDs experienced, associated factors, and impact of the symptoms experienced. Questions related to symptoms were obtained from the Nordic Musculoskeletal Questionnaire and ÖMPSQ [14,15].
The survey was conducted in Arabic, the primary language of the targeted population. The predesigned questionnaire was distributed among the community via a Google Forms link to enable better access to the population. Consent from the participants was taken prior to their filling out the form.

Statistical analysis
The descriptive statistics of the collected data were presented using numbers and percentages. The relationship between the severity of pain and sociodemographic and other related pain characteristics of school teachers was assessed using the Chi-square test. A p-value <0.05 was considered statistically significant. All data analyses were performed using the SPSS Statistics version 23.0 (IBM Corp., Armonk, NY).

Demographics and habits
A total of 404 school teachers participated in the study. The most common age group was 40-49 years (49.8%); more than half (52.2%) were female and nearly all (89.9%) were working in governmental institutions. Married participants constituted 84.7% of the sample. With respect to education, 90.3% were university or higher degree holders. Of note, 91.6% of the teachers earned more than 2,000 Saudi Riyals (SAR) per month. Nearly half of the teachers (49.3%) weighed between 70 and 89 kg, and 56.2% of the teachers reported having one to four children. Approximately 72.3% stated that the amount of sleep they get daily on average ranged from six to seven hours. In addition, a significant majority of the respondents (91.8%) were wearing medical shoes or shoes without heels ( Table 1).

Teaching load
Regarding the workplace characteristics of participants, half of the teachers (50%) had 20-30 years of teaching experience with approximately 60.9% of them teaching one to four classes per day or 10-19 classes per week (46.3%), with a total workload of three to six hours per day of classes (51.5%). Also, 62.4% indicated having 20-34 students per class ( Table 2).

Location of WMSDs experienced
The prevalence in terms of the location of the pain experienced by participants in the past 12 months was as follows -back pain: 80.2%, shoulder pain: 69.8%, knee pain: 62.9%, and elbow pain: 33.7% ( Figure 2); in nearly half of the participants (46.8%), the pain, discomfort, or numbness lasted for more than a year ( Figure  3).  The characteristics of school teachers in dealing with pain, discomfort, and numbness in terms of dealing with pain, discomfort, and numbness is presented in Table 3. Pain, discomfort, or numbness preventing carrying out daily activities for the past 12 months was observed in 41.1% of teachers with 45.8% rating their pain as moderate. Nearly two-thirds reported that they can still do light work for an hour and sleep at night with the pain because it is not severe (64.9% and 60.9%, respectively). Additionally, the severity of the pain did not affect the ability to sleep at night. The proportion of teachers who were stressed or anxious for a week prior to filling out the questionnaire was 54.5% while that of teachers who felt severely depressed was 7.9%. Approximately 53.2% of the teachers believed that there is a low probability that the current pain will persist while 55.2% believed that there is a high probability that they can carry out daily activities normally for the next three months. Among the participants, 52.5% agreed that whenever the pain increases, they should stop what they usually do in order to reduce the pain, and 32.4% agreed that they should not be doing their usual work with their current pain ( Table 3).

Variables N (%)
Characteristics of pain

Risk factors for severe pain
We used the Chi-square test to determine the influence of pain severity on the sociodemographic characteristics of the teachers. The analysis revealed that the prevalence of moderate-severe pain was significantly more common among females (p<0.001), those who slept for six to seven hours, (p=0.036), and those who experienced musculoskeletal pain in the neck (p<0.001), shoulder (p<0.001), elbow (p<0.001), hand (p<0.001), thigh/hips (p<0.001), back (p<0.001), knees (p<0.001) and ankles (p<0.001) (

Factors associated with severe pain
Additionally, moderate to severe pain showed a statistically significant relationship with the following factors: having a duration of pain of more than 12 months (p<0.001), being able to perform light work because the pain is not severe (p<0.001), being able to sleep at night (p<0.001), feeling stress or anxiety in the past week (p<0.001), and feeling mildly depressed (p<0.001) ( Table 5).

Perception of pain and its impact
When assessing the perception of those with moderate to severe pain, there was a statistically significant association with the expectation of pain persistence (p<0.001) as well as a perceived low probability of carrying out daily activity normally in the next three months (p<0.001). Finally, experiencing moderate to severe pain had a statistically significant relationship with teachers having neutral expectations as to whether they should or should not continue working while experiencing pain (p=0.002) (  Association between the severity of pain and the characteristics of school teachers in dealing with pain, discomfort, and numbness (n=404) § P-value has been calculated using the Chi-square test; *significant at p<0.05 level

Discussion
The main purpose of the study was to determine the prevalence of WMSDs among school teachers. We also sought to assess the risk factors for pain and their impact on the study participants. There have been 28 previous studies investigating WMSDs among teachers. The survey demonstrated that among 404 participants, back pain was the most reported WMSD (76.5%), and the highest number of participants (49.8%) was in the age group of 40-49 years. A study conducted in Qassim has reported the highest prevalence of WMSDs in the age group of 40 years and above (60.2%), and in Hail, the age group of 41-45 years accounted for 24.4% [4,16]. Moreover, back pain was the most common complaint, as reported by the Qassim study (68.8%) and the study from Hail (74.4%) [4,16]. These findings are in accordance with the previously reported literature from other countries, such as Sweden (72.5%), Brazil (95.1%), and Japan (62.7%) [19][20][21][22]. Of note, the study findings correlate with other papers in terms of pain being more prevalent in certain age groups, as teachers who work for a long time may develop WMSDs compared to their counterparts with less experience.
However, our finding that the shoulders (69.8%) and knees (62.9%) constituted the second and the third most affected regions contrasted with other previously published studies in Brazil, North Ethiopia, and other developing countries, which indicated the neck as the second most affected [6][7][8][9][10]13], and with studies in Hong Kong, Brazil, and Sweden where they reported upper limbs as a third most affected region [4,19,[21][22][23][24][25][26]. These differences can be attributed to differences between countries/regions in certain specific aspects related to the profession and workload itself. In this survey, most of the teachers stated that they have to stand for long hours while teaching, which puts high pressure on the lower back, shoulders, and knees. Meanwhile, in Brazil, North Ethiopia, and other developing countries, most participants reported that they spend more hours in a sitting position with their necks flexed and their upper limbs not supported, which causes pain in those regions.
Among the participants, 52.2% of female teachers reported WMSDs, which aligns with several studies suggesting that WMSDs are more prevalent among women and are strongly related to the female gender [27]. The female gender has been found to be associated with different musculoskeletal disorders [28]. Regarding WMSDs, researchers have hypothesized that women are more likely to experience pain primarily due to their weaker physical capabilities, greater family obligations, and different career prospects compared to men; alternatively, men and women may simply report pain differently [21]. In a previous study, it was found that women experienced higher pain intensities, more disabilities, and greater difficulties in functioning than men. Furthermore, anxiety, depression, and self-efficacy among female teachers have been reported to be worse when compared to their male counterparts [3,29]. It has been reported that the above-mentioned differences are associated with several biochemical and biological characteristics [30].
Afferents C and Aẟ in male and female muscles are mechanically sensitive and respond to mechanical distortion, but females have a higher number of afferents and produce higher levels of cytokines as a result of tissue damage, which would indicate a stronger inflammatory response than their male counterparts [28,29].
In terms of the impact of WMSDs, about (12.2%) of teachers in our study complained of difficulty sleeping due to the severity of the pain. This finding demonstrated the huge impact WMSDs have on their lives. Similarly, a study conducted in Kenya showed that 52% of the participants had a decline in daily activities in the past 12 months due to low back pain. Half of those who experienced low back pain (51.5%) had suffered the pain in the past week [5]. In our study, 41.1% of teachers faced difficulties in carrying out their daily activities for the past 12 months and 54.5% of teachers were stressed or anxious in the week prior to filling out the questionnaire. This is consistent with a study conducted in North Ethiopia, which reported a comparable percentage of 60.9% [10]. The prevalence of teachers who felt depressed or severely depressed in our study was discovered to be 7.9% and 38.6%, respectively. Similar findings were observed in a study done in France that recognized major depressive disorder among male and female teachers to account for 23.2% and 40.8%, respectively [31]. Moreover, our study reported a probability of 75.8% of carrying out activities normally in three months, which is higher compared to the study done in Al Khobar city by 22.5% [11]. Such a finding can be explained by the fact that our study covered a larger geographical area.
Based on the findings of this study, we strongly recommend that the concerned authorities take immediate actions to prevent the factors significantly associated with WMSDs in order to reduce the incidence of pain and associated disability. Changes in the types of schools, methods of teaching, and other variables may be difficult to bring about. As a result, educational programs for raising awareness of WMSDs and preventive methods such as regular exercise, as well as physiotherapy and medical treatment, should be implemented to alleviate pain in school teachers [8,32].

Limitations
There are several limitations to our study that can be avoided in future research. Recall bias and selfreporting can be considered limitations of several studies of this nature given that many of these use anonymous surveys for data collection. Data were collected through online surveys due to constraints related to time, and this may have introduced certain participant-related biases to these questionnaires. Consequently, generalizing the results of this study should be done with caution. Moreover, it is not possible to separate cause from effect in a cross-sectional study design, resulting in weak evidence linking exposure and outcomes.

Conclusions
The current study showed a high prevalence of work-related musculoskeletal pain disorders among teachers in the Eastern Region of Saudi Arabia. The majority of teachers regarded pain as disabling, which had a negative impact on their workplace attendance. Risk factors for severe pain were female gender, sleeping for six to seven hours, and pain located in the neck, shoulder, elbow, hand, thigh/hips, back, knees, and ankles. Furthermore, severe pain was associated with pain duration of more than 12 months, affecting sleep, causing anxiety, and mild depression. The impact of severe pain limited daily activities. To prevent this, teachers must be encouraged to participate in health-awareness programs. Regular exercise should be included in these programs, as it may be the most effective way to relieve pain and suffering, resulting in fewer WMSDs. More importantly, to reduce the risk of long-term disability, appropriate measures are required. These actions can be linked to changes in personal and environmental factors, which will help teachers improve their health. Further studies are needed to gain deeper insights into factors such as gender differences in the incidence and severity of WMSDs as well as WMSDs' association with the number of years in terms of teaching experience as a risk factor on a larger scale.
Human subjects: Consent was obtained or waived by all participants in this study. Research Ethics Committee at King Faisal University issued approval KFU-REC-2021-DEC-EA000300. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.