Abstract
Background:
University teachers are consistently exposed to various risk factors for stress and hypertension. This study aimed to estimate the prevalence and determine the factors associated with stress and hypertension among university teachers.
Methodology:
A cross-sectional survey of 234 university teachers was conducted. A cluster sampling approach was employed to select samples from two universities. Teachers Stress Inventory (TSI) was used to assess the occupational stress among teachers. The blood pressure of the participants was measured and participants were considered hypertensive when SBP was ≥140 mm Hg and DBP was ≥90 mm Hg. Descriptive statistics were employed to estimate the prevalence measures and logistic regression models were developed to determine the factors associated with stress and hypertension.
Findings:
Close to 84% of university teachers experience moderate to high levels of stress. About 21.4% of university teachers were hypertensive and only 12% of them had control of their blood pressure levels. Stress levels were found to have an association with younger age of up to 45 years (AOR = 14.48; 95% CI = 2.48–84.49) and inadequate physical activity (AOR = 3.64, 95% CI = 1.02–12.90). Furthermore, hypertension status showed an association with older age of 46 years and above (AOR = 3.01; 95% CI = 1.33–6.78), a student ratio of ≥41 per class (AOR = 2.79, 95% CI = 1.37–5.65), and a moderate level of stress (AOR = 2.78, 95% CI = 1.01–7.66).
Conclusion:
Long-term occupational stressors coupled with age may expose university teachers to a significant risk of hypertension. Workplace health strategies and stress management interventions are needed to facilitate the prevention of stress and hypertension in this occupational group.
Keywords: Hypertension, stress, teacher’s stress inventory, university teachers
INTRODUCTION
Hypertension is a major cause of premature death among adults, especially in low- and middle-income countries. Globally, among those who are hypertensive, only 42% are diagnosed and treated and <21% have it under control.[1] In India, it is estimated that 18.1% of individuals aged 15–49 years are hypertensive and among them, only 13.3% were treated and 7.9% had their blood pressure under control.[2] Furthermore, among the Indian states, Kerala has the highest prevalence of hypertension ranging between 32.3% and 72.3% among adults aged > 30 years.[3,4]
Along with several etiological factors including age, sex, lifestyle factors, and genetics, stress is also a significant risk factor for hypertension.[5,6] Psychological stressors are known to influence the physiological process resulting in elevated blood pressure.[7] Additionally, occupational stress increases the risk of lifestyle factors such as smoking, alcohol consumption, physical inactivity or more sitting time, and unhealthy food habits that can further lead to hypertension.[8,9,10,11] Evidence also suggests that hypertension is worsened when any of the risk factors are combined with other stress-producing factors.[5]
It was found that people working in the service sector are stressed mainly due to high expectations, targets, and stringent performance appraisals.[12] Higher education institutions such as universities face a similar scenario with a specific set of expectations, class work, education, research, and administrative tasks to be performed by the university teachers. The regulations of the University Grant Commission (UGC), All India Council for Technical Education (AICTE), and the Ministry of Education require the university teachers to function effectively across multiple forte with measurable indicators on the number of credits delivered, research supervisions, involvement in administration, extra-curricular activities, and research output.[13,14] These performance indicators play a crucial role in the career progression of university teachers and the grading of institutions. The multitude of teacher roles coupled with challenges such as human resource shortcomings, infrastructural challenges, and administration delays can induce stress among university teachers, especially at public universities.[15]
A recent study from Kerala among school teachers found that the age-adjusted hypertension prevalence was 14.6%.[16] However, considering the sedentary lifestyle of the university teachers in general along with the occupational stress, they are much more prone to have conditions like hypertension.[17,18] While there are studies examining stress and hypertension levels among school teachers, there is limited literature on hypertension among university teachers. Moreover, the available studies either focused on stress or hypertension individually but did not observe the intricate association between these in light of occupational factors specific to university teachers. Given that universities often tend to be their own microcosm, there is a potential to develop contextual and cost-effective strategies to tackle occupational stress and hypertension. In this regard, we conducted this study to estimate the prevalence of stress and hypertension and to find out the factors associated with stress and hypertension among university teachers.
MATERIALS AND METHODS
Study design and setting
This study was conducted as a cross-sectional survey of university teachers sampled from two public universities in Northern Kerala. We selected one central and one state university from Northern Kerala which together accounted for around 1200 university teachers working as lecturers, assistant professors, associate professors, and professors.
Sampling and sample size
University teachers who were regular/ad hoc/guest faculty of the universities with at least one year of working experience were included in the study. Adjunct faculty/visiting faculty/honorary professors were excluded from the study. A cluster sampling approach was employed considering each university as a cluster. From each cluster, participants were selected by visiting the randomly selected departments/affiliated colleges. A total sample of 234 was estimated with an anticipated hypertension prevalence of 14.6%,[16] a 95% confidence level, an absolute precession of 5%, a design effect of 1, and a nonresponse rate of 20% using Open-Epi (available at: https://www.openepi.com/SampleSize/SSPropor.htm).
DATA COLLECTION TOOLS AND TECHNIQUES
A survey questionnaire (in English) was administered to the participants employing the pen-and-paper approach. The questionnaire collected data on socio-demographics, work, behavior, family history, and comorbidity details. Stress was captured using the adapted version of the “Teacher’s Stress Inventory’’ (TSI) (Cronbach’s α =0.87). Stress was measured as a composite index of 33 items distributed under five dimensions (i) stressors, (ii) distress, (iii) discipline and motivation, (iv) emotional manifestation, and (v) physiological manifestation. The responses were captured in a 5-point Likert scale with responses ranging from never to always (never = 1, rarely = 2, sometimes = 3, often = 4, and always = 5). The items were then summed up to produce a composite score ranging from 46 to 121, with higher scores reflecting a higher level of stress.[19]
The blood pressure was measured using Omron HEM 7124 automatic digital blood pressure monitor (Omron Healthcare Europe, Hoofddorp, Netherlands). A Master of Public Health (MPH) student with a medical degree, took blood pressure readings and administered the survey. Two blood pressure measurements were taken with a gap of 30 min and a third blood pressure reading was taken for the participants who were recorded to have a 10 mm Hg variation between the first and second blood pressure readings.[20] After the survey, the filled questionnaires were collected from the participants, and verified for completeness of the questionnaire to ensure that there was no missing data.
Data analysis
The analysis was conducted using IBM Statistical Package for Social Science (SPSS) version 27. Initially, the survey data was entered, cleaned, coded, transformed, and prepared for the analysis. For assessing stress levels, the composite score of TSI was categorized into three categories using mean and standard deviation (SD). When the calculated score was <1 SD from the mean, it was categorized as a low level of stress (score of 46–68), the scores within the range of ±1 SD from the mean (score of 69-97) were categorized as a moderate level of stress, and score of >1 SD from the mean was categorized as a high level of stress (score of >98). Hypertension status was confirmed when the blood pressure was ≥140 mm of Hg systolic and/or ≥90 mm of Hg diastolic and/or when the participant reported to be using antihypertensive medication.[21] Descriptive statistics was carried out to calculate the mean, median, SD, frequency, and prevalence percentage of the study variables. Logistic regression models were used to identify the factors associated with stress and hypertension among university teachers. Adjusted odds ratios (AOR) and 95% CI of the AOR were computed. Omnibus tests were used to assess the significance of the regression models, and Hosmer-Lemshow tests showed an acceptable model fit.
Ethical considerations
The study was conducted with approval from the Institutional Human Ethics Committee (IHEC) of a central higher education institution (IHEC/CUK/2023/15). Permissions were also obtained from administrative heads of the participating institutions. Informed consent was taken from individual participants and the privacy and confidentiality of the study data were maintained during and after the study.
RESULTS
Characteristics of the university teachers
A total of 234 university teachers with a mean age of 40 years (±6.33) across the universities in Kasaragod and Kannur districts were sampled. Among the participants studied, 55.2% were females and 53% had a PhD degree. The majority of the university teachers were lecturers/assistant professors (79.1%), and who delivered up to three courses per semester (76.1%). More details on the socio-demographic, work, lifestyle, and health characteristics of the participants are given in Table 1.
Table 1.
Participant characteristics (n=234)
| Variables | n (%) |
|---|---|
| Gender | |
| Male | 105 (44.8%) |
| Female | 129 (55.2%) |
| Age Group | |
| Up to 45 years | 183 (78.2%) |
| 46 years and above | 51 (21.8%) |
| Education Status | |
| PG | 110 (47%) |
| PhD | 124 (53%) |
| Hours of working per day | |
| 1 to 5 h | 119 (50.9%) |
| 6 to 10 h | 115 (49.1%) |
| Sitting hours per day | |
| No sitting time | 17 (7.3%) |
| 15 min to 2 h | 150 (64.1%) |
| More than 2 h | 67 (28.6%) |
| Total class hours per day | |
| 1 to 4 h | 179 (76.5%) |
| More than 4 h | 55 (23.5%) |
| Job satisfaction | |
| Partially satisfied | 39 (16.7%) |
| Satisfied | 116 (49.6%) |
| Very much satisfied | 79 (33.8%) |
| Number of Courses delivered per semester | |
| Up to 3 | 178 (76.1%) |
| 4 and above | 56 (23.9%) |
| Average number of students in a class | |
| Up to 40 | 152 (65%) |
| 41 and above | 82 (35%) |
| Years of experience as a university teacher | |
| 1 to 9 years | 133 (56.8%) |
| 10 to 25 years | 101 (43.2%) |
| Designation | |
| Lecturers and assistant professors | 185 (79.1%) |
| Associate and professors | 49 (20.9%) |
| Physical activity | |
| Inadequate<60 min/day) | 175 (74.8%) |
| Adequate (≥60 min/day) | 59 (25.2%) |
| Sound sleep | |
| Yes | 153 (65.4%) |
| No | 81 (34.6%) |
| Diabetic mellitus | |
| Yes | 26 (11.1%) |
| No | 208 (88.9%) |
| Family history of hypertension | |
| Yes | 97 (41.5%) |
| No | 137 (58.5) |
Note: n=frequency; % = percentage; PG=Post-Graduation; PhD=Doctor of philosophy
Stress and hypertension status among university teachers
With respect to stress levels, about 83.7% of the university teachers had moderate to high levels of stress. It was observed that university teachers were having major stressors such as too much work, lack of preparation time, and administrative (paper) work. Moreover, there were issues of progress in job, recognition, promotion, and professional development opportunities [see Supplementary File].
More than 1/5th of the participants were identified to be hypertensive and 58% of them were aware of their hypertensive status. A quarter of the university teachers who were hypertensive were on anti-hypertensive medication and about 1/3rd of those who were on medication achieved hypertension control. See Table 2 for more details on stress and hypertension status among university teachers.
Table 2.
Stress and hypertension status among university teachers (n=234)
| Dimensions of TSI | Mean (SD) | |
|---|---|---|
| Stressors | 17.7 (4.8) | |
| Distress | 23.2 (5.8) | |
| Discipline and motivation | 13.8 (4.0) | |
| Emotional manifestations | 12.6 (4.9) | |
| Physiological manifestations | 15.6 (3.9) | |
|
| ||
| Stress levels (based on TSI) | n (%) | |
|
| ||
| Low level of stress | 38 (16.2) | |
| Moderate level of stress | 165 (70.5) | |
| High level of stress | 31 (13.3) | |
|
| ||
| Hypertension variables | n (%) | Prevalence (%) among hypertensive (n=50) |
|
| ||
| Hypertension prevalence | 50 (21.4) | - |
| Awareness about hypertension | 29 (12.4) | 58 |
| Medication for hypertension | 14 (6.0) | 28 |
| Hypertension control | 6 (2.6) | 12 |
Note: SD=standard deviation; n=frequency; % = percentage; TSI=Teachers Stress Inventory
Factors associated with stress and hypertension among university teachers
It was found that stress levels were associated with age, physical activity, designation, and sitting time. Lectures and assistant professors (AOR = 3.47, 95% CI = 1.14–10.57) showed higher odds for moderate levels of stress compared to those who are professors. It is also found that those who belong to the age group of up to 45 years (AOR = 14.48, 95% CI = 2.48–84.49) and those who have inadequate physical activity (AOR = 3.64, 95% CI = 1.02–12.90) had higher odds for a high level of stress [see Table 3].
Table 3.
Factors associated with stress among university teachers (n=234)
| Variables | Moderate Stress AOR (95% CI) | High Stress AOR (95% CI) |
|---|---|---|
| Age Group | ||
| 46 years and above (ref) | ||
| Up to 45 years | 2.39 (0.73–7.84) | 14.48 (2.48–84.49)** |
| Courses delivered | ||
| 4 and above (ref) | ||
| Up to 3 | 0.63 (0.23–1.73) | 0.40 (0.10–1.51) |
| Students per class | ||
| 41 and above (ref) | ||
| Up to 40 | 1.23 (0.56–2.71) | 3.13 (0.95–10.28) |
| Physical activity | ||
| Adequate (≥60 min/day) (ref) | ||
| Inadequate (<60 min/day) | 1.95 (0.82–4.59) | 3.64 (1.02–12.90)* |
| Years of experience as a university teacher | ||
| 10 to 25 years (ref) | ||
| 1 to 9 years | 0.36 (0.10–1.21) | 0.36 (0.08–1.60) |
| Hours of work in a day | ||
| 6 to 10 years (ref) | ||
| 1 to 5 years | 1.36 (0.61–3.02) | 2.18 (0.71–6.66) |
| Designation | ||
| Associate professors and professors (ref) | ||
| Lecturers and assistant professors | 3.47 (1.14–10.57)* | 0.99 (0.22–4.45) |
| Sitting time | ||
| More than 2 h (ref) | ||
| No sitting time | 0.23 (0.60–0.88)* | 0.10 (0.01–0.78)* |
| 15 min to 2 h | 0.99 (0.39–2.54) | 0.22 (0.06–0.76)* |
Note: Dependent Variable: Stress levels: low stress (ref), Moderate stress, high stress. Ref=Reference category, *P<0.05; **P<0.01
Factors such as education level, age, student ratio in class, and stress level showed an association with hypertension in university teachers. Those university teachers with a PhD (AOR = 2.61, 95% CI = 1.18–5.79), aged 46 years and above (AOR = 3.01, 95% CI = 1.33–6.78), higher student ratio (AOR = 2.79, 95%CI = 1.37–5.65) and moderate level of stress (AOR = 2.78, 95% CI = 1.01–7.66) showed greater odds for having hypertension [Table 4].
Table 4.
Factors associated with hypertension among university teachers (n=234)
| Variables | Hypertension AOR (95% CI) |
|---|---|
| Education Level | |
| Post-graduation (ref) | |
| Doctor of Philosophy | 2.61 (1.18–5.79)* |
| Age group | |
| Up to 45 years (ref) | |
| 46 years and above | 3.01 (1.33–6.78)** |
| Students per class | |
| Up to 40 (ref) | |
| 41 and above | 2.79 (1.37–5.65)** |
| TSI categories | |
| Low (ref) | |
| Moderate | 2.78 (1.01–7.66)* |
| High | 0.28 (0.30– 2.66) |
Note: Dependent variable: Hypertension status: a) non-hypertensive (ref), b) hypertensive; Ref=Reference category; Significance at *P<0.05 and **P<0.01
DISCUSSION
Among 234 university teachers studied, about 84% had moderate to high levels of stress. This result is consistent with a previous study from other south Indian states which reported the prevalence of occupational stress and burnout to be 74% and 86%, respectively.[17] Similarly, a meta-analysis including studies from more than 20 countries including India during COVID-19 reported a pooled prevalence of 62.6% for stress among teachers.[22]
Respondents who were lecturers/assistant professors and aged up to 45 years had higher odds of moderate to high levels of stress. It has been recorded that it is hard for young teachers to stay in the institution due to the high workload, limited decision-making capacity, and lack of recognition and support.[23] Other studies also agree that a demanding work environment can act as a significant stressor particularly for teachers in younger demographics as their career progression is dependent on their professional output.[24,25,26] Evidence also showed that the comprehensive manuscript publishing trend significantly increased stress levels among the academic fraternity.[26] Additional stressors reported in this study are similar to the ones stated in the other studies such as inadequate material and technical conditions at work, the feeling of uncertainty and anxiety dealing with classrooms, student behavior, and issues with work-life balance.[17,25,27] While recent recommendations for adapting and integrating the National Education Policy (NEP) outline specific measurable academic output, the public universities in India face major constraints with respect to infrastructure and human resources potentially manifesting as job stress among teachers.[27,28]
Apart from work and demographic factors, unhealthy lifestyles such as inadequate physical activity showed higher odds of having stress. Teachers who sit for longer times had higher odds of having moderate to high levels of stress. Other studies also showed the association between physical activity and stress levels.[11,29] Studies have also shown that occupational stress levels among teachers were observed to have significant effects on their personal health and prolonged stress can lead to unhealthy lifestyle choices such as physical inactivity which can cause cardiovascular diseases including hypertension.[30,31] Given that occupational stress and inadequate physical activity are closely associated, the measures to encourage adequate physical activity among university teachers can act as a means to both reduce stress and prevent chronic NCDs. Workplace physical activity initiatives and wellness programs are known to be effective in this regard.[32,33]
More than 21% of the university teachers were found to be hypertensive in this study. However, only 12% of them had their blood pressure under control. Compared to a recent survey conducted in Kerala among school teachers, it can be said that university teachers have a higher prevalence, and poorer levels of awareness, treatment, and control of hypertension.[16] Furthermore, the hypertension control rates among university teachers are very low compared to the general population of Kerala. This includes both the adults (>30 years) that is, 75.1%, and older populations (60 years and above) that is 24% even though the prevalence was high in these populations.[3,34]
University teachers aged 46 years and above showed higher odds of having hypertension concurring with the existing literature on age and hypertension.[35] Specific to occupation, high-stress levels and the need to manage more students in a class (>40 students) increased the odds of hypertension. Evidence has also shown that there is a significant association between high student-teacher ratios with stress due to increased work hours and workload for teachers.[36,37] Based on the findings it can be inferred that the occupational stress among the university teachers might be following an established pattern of chronicity resulting in hypertension. Younger teachers are at greater risk of exposure to moderate to high-stress levels, and even moderate stress levels coupled with other risk factors and aging processes can induce hypertension.
CONCLUSION
Four in five university teachers face moderate to high stress and one in five have hypertension. Moderate to high levels of stress is associated with hypertension among university teachers. The findings suggest the need for regular screening for hypertension among university teachers. Workplace health and wellness programs specifically those focused on improving physical activity could reduce stress and improve hypertension control among university teachers.
Conflicts of interest
There are no conflicts of interest.
Supplementary File.
Item wise analysis of the items of adapted version of Teacher’s Stress Inventory
| Items of adapted version of TSI | Never (1) % | Rarely (2) % | Sometimes (3) % | Often (4) % | Always (5) % | Mean (SD) |
|---|---|---|---|---|---|---|
| Stressors | ||||||
| Lack of preparation time | 10.7 | 33.8 | 23.9 | 22.2 | 9.4 | 2.8 (±1.16) |
| Personal priorities short changed | 8.1 | 32.1 | 35 | 20.9 | 3.8 | 2.8 (±0.90) |
| Too much work | 3.4 | 27.4 | 38.9 | 22.6 | 7.7 | 3.0 (±0.0.97) |
| Caseload too big | 5.6 | 29.5 | 32.9 | 23.5 | 8.5 | 3.0 (±1.04) |
| Pace of work day too fast | 1.7 | 26.9 | 42.7 | 23.1 | 5.6 | 3.0 (±0.89) |
| Too much paperwork | 6.4 | 28.2 | 35.9 | 21.4 | 8.1 | 2.9 (±1.03) |
| Distress | ||||||
| Lack of promotion opportunities | 8.5 | 31.2 | 38.9 | 15.4 | 6.0 | 2.7 (±1.0) |
| Lack of on-the-job progress | 9.0 | 32.1 | 41 | 15.4 | 2.6 | 2.8 (±0.9) |
| Need for enhanced status and respect | 15.4 | 32.1 | 44.9 | 5.1 | 2.6 | 2.4 (±0.9) |
| Lack of recognition | 20.1 | 32.5 | 37.2 | 9.4 | 0.9 | 2.3 (±0.9) |
| Attitudes and opinions remain unheard | 15.0 | 32.1 | 42.3 | 7.3 | 3.4 | 2.5 (±0.9) |
| Lack of adequate salary | 17.9 | 25.6 | 38.5 | 6.4 | 11.5 | 2.6 (±1.1) |
| Lack of control over university-related matters | 15.8 | 25.2 | 47 | 9 | 3 | 2.5 (±0.9) |
| Lack of on-the-job emotional stimulation | 12 | 40.2 | 39.7 | 7.3 | 0.9 | 2.4 (±0.8) |
| Lack of professional improvement opportunities | 16.7 | 26.1 | 38.9 | 13.2 | 5.1 | 2.6 (±1.0) |
| Discipline and motivation | ||||||
| Having to continually monitor behaviour | 20.1 | 36.8 | 33.8 | 8.1 | 1.3 | 2.3 (±0.9) |
| Discipline problems in the classroom | 27.8 | 33.8 | 32.5 | 6 | 0 | 2.1 (±0.9) |
| Teaching poorly motivated students | 20.1 | 32.1 | 29.5 | 15.8 | 2.6 | 2.4(±1.06) |
| Teaching students who would do better if they would try harder | 17.9 | 36.3 | 31.2 | 11.5 | 3 | 2.4(±1.01) |
| Lack of adequate discipline policies | 20.1 | 36.8 | 35.5 | 7.7 | 0 | 2.3(±0.87) |
| Authority rejected by students or staff | 23.1 | 43.2 | 31.2 | 2.1 | 0.4 | 2.1(±0.80) |
| Emotional Manifestation | ||||||
| Feeling insecure | 39.7 | 17.9 | 32.1 | 8.1 | 2.1 | 2.1 (±1.1) |
| Feeling unable to cope | 41.5 | 26.9 | 22.2 | 6.8 | 2.6 | 2.0 (±1.0) |
| Feeling vulnerable | 44.4 | 23.9 | 24.8 | 5.1 | 1.7 | 1.9 (±1.0) |
| Feeling depressed | 32.5 | 29.9 | 29.1 | 7.3 | 1.3 | 2.1 (±1.0) |
| Feeling anxious | 20.1 | 40.6 | 29.9 | 8.5 | 0.9 | 2.2 (±0.9) |
| Feeling helpless | 36.3 | 29.1 | 26.5 | 7.7 | 0.4 | 2.0 (±0.9) |
| Physiological Manifestation | ||||||
| Stomach pain of extended duration | 50.9 | 28.9 | 19.7 | 0.9 | 0 | 1.7(±0.8) |
| Headache | 20.5 | 29.9 | 28.6 | 15.8 | 5.1 | 2.5(±1.1) |
| Physical exhaustion | 11.1 | 22.6 | 32.9 | 29.9 | 3.4 | 2.9(±1.05) |
| Physical weakness | 3.8 | 23.9 | 35.0 | 33.3 | 3.8 | 3.0(±0.9) |
| Easily gets Fatigue | 5.6 | 26.9 | 29.1 | 35.9 | 2.6 | 3.0(±0.9) |
| Acidity/indigestion issue | 32.9 | 24.4 | 19.7 | 19.7 | 3.4 | 2.3(±1.2) |
| Total Score | 83.12 (±14.55) | |||||
TSI=Teacher’s Stress Inventory, SD=Standard Deviation
Funding Statement
Nil.
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