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ORIGINAL ARTICLE
Musculoskeletal pain and its correlates among secondary school
female teachers in Aljouf region, Saudi Arabia
Doaa M. Abdel-Salam
1,2
&Alanoud S. Almuhaisen
3
&Rahaf A. Alsubiti
3
&Nouf F. Aldhuwayhi
3
&Faridah S. Almotairi
3
&
Shikhah M. Alzayed
3
&Farah F. Bakri
3
Received: 27 May 2019 /Accepted: 17 July 2019
#The Author(s) 2019
Abstract
Background and objectives Musculoskeletal pain is considered to be one of the most prevalent occupational health problems in
the working environment. School teachers are at significant risk of developing this pain. The objective of this study is to assess
musculoskeletal pain and its correlates among secondary school female teachers in Aljouf region, Saudi Arabia.
Methods A descriptive cross-sectional study was carried out on 254 secondary school female teachers in Aljouf region, Saudi
Arabia. A structured, self-administered questionnaire was utilized in the present study to collect the required data. Data analysis
was performed using the SPSS program, version 21.
Results The prevalence of musculoskeletal pain among secondary school female teachers in Aljouf region, Saudi Arabia
was 68.50%. The main sites of musculoskeletal pain were low back (68.4%), knee (58.6%), shoulder (47.7%), neck
(45.4%), elbow (23.6%), and wrist (14.4%). Nearly 70% of the teachers had musculoskeletal pain in various sites. Days
of absenteeism per month because of musculoskeletal pain were one to five days among 89.7% of the teachers. Regarding
the severity of musculoskeletal pain, 64.4% had non-disabling pain and 35.6% had disabling pain. Factors that showed a
significant relationship with disabling musculoskeletal pain were age (p= 0.013), marital status (p= 0.043), practicing
exercise (p= 0.008), years of teaching (p= 0.020), daily hours of working (p= 0.039), number of classes per week (p=
0.013), and comfortableness of school furniture (p= 0.009). Logistic regression analysis showed that the significant
predictors of disabling musculoskeletal pain were age more than 40 years [odds ratio (OR): 2.08; confidence interval
(CI): 1.16–3.71], not practicing exercise (OR: 3.19; CI: 1.29–7.88), more than ten years of teaching (OR: 2.07; CI: 1.12–
3.84), and non-comfortableness of school furniture (OR: 2.16; CI: 1.21–3.88).
Conclusion Secondary school female teachers showed a high prevalence of musculoskeletal pain in most anatomic sites, such as
low back, knee, shoulder, neck, elbow, and wrist. Significant predictors of disabling musculoskeletal pain were age more than 40
years, not practicing exercise, more than ten years of teaching, and non-comfortableness of school furniture.
Keywords Musculoskeletal pain .Secondary school teachers .Saudi Arabia
Introduction
Musculoskeletal pain appears to be one of the most wide-
spread occupational health-related issues in the teaching
profession (Erick and Smith 2014a). It involves a broad
area of degenerative and inflammatory conditions affect-
ing the joints, muscles, tendons, ligaments, bones, and
nerves, which may be triggered by the work circum-
stances of the affected persons (Punnett and Wegman
2004). School teachers generally have been shown, rela-
tive to other occupational groups, to record high preva-
lence rates of musculoskeletal pain of between 40%
(Cardoso et al. 2009) and 79% (Darwish and Al-Zuhair
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s10389-019-01127-8) contains supplementary
material, which is available to authorized users.
*Doaa M. Abdel-Salam
dabdelsalam@ju.edu.sa; doodyas2004@yahoo.com
1
Family and Community Medicine Department, College of Medicine,
Jouf University, Aljouf 42421, Saudi Arabia
2
Public Health and Community Medicine Department, Faculty of
Medicine, Assiut University, Assiut 71526, Egypt
3
Medical student, College of Medicine, Jouf University,
Aljouf 42421, Saudi Arabia
Journal of Public Health: From Theory to Practice
https://doi.org/10.1007/s10389-019-01127-8
2013). The workload of school teachers includes many
duties, such as teaching students, preparing lessons,
evaluating students’homework, and extracurricular ac-
tivities (Chong and Chan 2010). As a result of these
extensive duties, school teachers may have physical
and mental health problems. Musculoskeletal pain is
the main reason for absenteeism and early retirement
among school teachers (Maguire and O’Connell 2007).
The most frequently encountered sites of musculoskele-
tal pain among school teachers were shoulder, neck, and
low back (Abdulmonem et al. 2014).Theliteraturere-
veals that the risk factors of musculoskeletal pain are
numerous (Erick and Smith 2011). Occurrence of mus-
culoskeletal pain has been proposed to relate to female
gender (Erick and Smith 2013,2014b), smoking, sleep
disturbances, and number of children (Beyen et al.
2013). Other studies showed that musculoskeletal pain
has been positively associated with longer length of em-
ployment, high workload, increased age, and school
type (Darwish and Al-Zuhair 2013). On the other hand,
practicing exercise and favorable work circumstances
may have a protective effect against musculoskeletal
pain among school teachers (Erick and Smith 2013). A
frequently used assessment of severity of musculoskele-
tal pain is the Örebro Musculoskeletal Pain Screening
Questionnaire (ÖMPSQ), developed by Linton and
Halldén (1998).TheÖMPSQwasdevelopedtohelp
identifying persons at risk for developing disabling pain
by investigating the attitudes, beliefs, and behavior in
response to pain (Brown 2008). To the best of the au-
thors’knowledge, no prior study has been conducted on
assessing musculoskeletal pain among secondary school
female teachers in Aljouf region, northern Saudi Arabia.
Therefore, the aim of the study was to assess musculo-
skeletal pain and risk factors of disabling musculoskel-
etal pain among secondary school female teachers in
Aljouf region, Saudi Arabia.
Participants and methodology
Study design
The present study was a descriptive, cross-sectional inves-
tigation carried out to assess musculoskeletal pain and its
correlates among secondary school female teachers in
Aljouf region, Saudi Arabia. Aljouf region is located in
the northern part of Saudi Arabia. Data collection was
conducted during the period from December 2018 to
March 2019. The sampling frame was a list of female
secondary schools in Aljouf region, which was obtained
through the Ministry of Education.
Sampling
Sample size calculation
Estimation of the sample size was done using the following
formula:
N¼P1−PðÞZ2
d2
Assuming the prevalence of musculoskeletal pain to be
79% (Darwish and Al-Zuhair2013), Z=1.96,d= 0.05, apply-
ing a confidence level of 95%, with 80% power of the study,
then the calculated sample size was 254.
Sampling technique
Using a multistage sampling methodology, we selected the
participants as follows:
First stage: Aljouf region has four governorates: Skaka,
Domat Al-Jandal, Alqurayat, and Tabargel. Skaka and
Domat Al-Jandal governorates were selected by a simple ran-
dom sample. Second stage: the total number of female sec-
ondary schools in Skaka and Domat Al-Jandal governorates is
42 (governmental: 32 and private: 10). Following a simple
random sampling technique, 15 schools were selected,
amongst which 11 governmental and four private schools
were chosen. All employed teachers in the selected schools
were invited to participate in the present study. The question-
naires were distributed by the researchers to all teachers of the
selected schools except those who were absent during survey
time or refused to participate in the study. Also, teachers with
pregnancy, recent fractures, and chronic illnesses were exclud-
ed from the study.
Data collection tool
A structured, self-administered, anonymous questionnaire
which consisted of three parts was used in the present study.
The first part of the questionnaire was about
sociodemographic characteristics, such as age, school type,
educational level, marital status, number of children, number
of sleeping hours, practicing exercises, and monthly income.
The second part of the questionnaire was about work circum-
stances of secondary schools female teachers, such as the
presence of a housemaid at home, type of shoes, number of
teaching years, method of getting to school, daily hours of
working, number of classes per day, number of classes per
week, having extracurricular activities, and the comfortable-
ness of school furniture. Also, the second part of the question-
naire inquires about the pattern and effect of musculoskeletal
pain experienced by the teachers during the last year, such as
its site, duration, and days of absenteeism per month because
J Public Health (Berl.): From Theory to Practice
of this pain. The third part was about the severity of muscu-
loskeletal pain, where an Arabic version of the ÖMPSQ was
used, which has been previously validated in some studies
(Linton and Boersma 2003; Westman et al. 2008). A cutoff
score of 105 in the ÖMPSQ has been found to predict those
who will have no disabling pain (< 105) and those who will
have disabling pain (> 105). A pilot study was carried out on
20 secondary school female teachers to test the clarity of the
questionnaire. Few modifications in the questionnaire were
made in order to avoid misunderstanding of some questions.
Data from the pilot study was not included in the study
sample.
Statistical procedure
The data was analyzed using the SPSS program, version 21.
Descriptive statistics such as frequencies and percentages for
qualitative variables and mean and standard deviation (SD) for
quantitative variables were performed. Chi-squared and
Fisher’s exact tests were applied. Logistic regression analysis
was done to detect significant predictors of disabling muscu-
loskeletal pain. The p-value was considered statistically sig-
nificant when it was less than 0.05.
Results
The study was carried out on 254 secondary school female
teachers in Aljouf region, Saudi Arabia. Table 1reveals the
sociodemographic features of the respondents. Their mean
age was 37.87 ± 1.53 years. Most of the respondents were
working in governmental schools (87%). Nearly 91% had
attained their bachelor degree. Most of the participants were
married (80.3%). Concerning the number of children, 39.8%
of them had more than four children. The sleeping hours were
6–8 hours among 66.1% of the teachers. Regarding practicing
exercise, 78.3% of them did not practice exercise. The month-
ly income exceeded 5000 RS among 88.6% of the respon-
dents. Table 2depicts the work-related characteristics of the
secondary school female teachers. Most of the respondents
had a housemaid at home (65.4%). Regarding the type of
shoes, most of the participants wore flat shoes (68.5%). The
number of years of teaching was more than ten years among
58.3%. Nearly all of the respondents got to their schools by car
(96.1%). Almost 42% had more than four classes per day.
Most of the teachers had 11 to 20 classes per week (45.3%).
The daily hours of working were 7 to 9 among 59.1% of the
teachers. In relation to extracurricular activities, 85% of the
participants reported their involvement. Also, 45.3% of the
participants considered the school furniture as uncomfortable.
The overall prevalence of musculoskeletal pain among sec-
ondary school female teachers was 68.5%, as shown in Fig. 1.
Table 3demonstrates the pattern and effect of musculoskeletal
pain among secondary school female teachers. The majority
had musculoskeletal pain for more than six months (45.4%).
Regarding the site of musculoskeletal pain, the present study
showed that the highest prevalence was low back (68.4%),
followed by knee (58.6%), shoulder (47.7%), neck (45.4%),
elbow (23.6%), and wrist (14.4%). The number of days of
absenteeism because of musculoskeletal pain was one to five
days among 89.7% of the respondents. Among 174 teachers
with musculoskeletal pain, 64.4% had an ÖMPSQ score less
than 105 (non-disabling pain) and 35.6% had a score more
than 105 (disabling pain). Table 4shows the relationship be-
tween disabling musculoskeletal pain and the
sociodemographic features of secondary school female
teachers. Disabling pain was significantly associated with
age, marital status, and exercise practicing (p= 0.013, 0.043,
and 0.008, respectively). Disabling pain was prevalent among
teachers with increased age (32.7%). Also, disabling pain was
higher among teachers who were divorced or widowed
Table 1 Sociodemographic features of secondary school female
teachers in Aljouf region, Saudi Arabia
Vari ab les No. ( %) (n=254)
Age (years)
≤40 153 (60.2)
> 40 101 (39.8)
Mean ± standard deviation (SD) (range) 37.87 ± 1.53 (29–55)
Type of school
Governmental 221 (87)
Private 33 (13)
Educational level
Diploma 15 (5.9)
Bachelor degree 230 (90.6)
Postgraduate studies 9 (3.5)
Marital status
Single 19 (7.5)
Married 204 (80.3)
Divorced or widowed 31 (12.2)
Number of children
None 34 (13.4)
1–4119(46.9)
> 4 101 (39.8)
Number of sleeping hours
< 6 76 (29.9)
6–8 168 (66.1)
> 8 10 (3.9)
Practice exercise
Yes 55 (21.7 )
No 199 (78.3)
Income per month (RS)
≤5000 29 (11.4)
> 5000 225 (88.6)
J Public Health (Berl.): From Theory to Practice
(41.9%) and not practicing exercise (28.1%). Table 5shows
the relationship between disabling musculoskeletal pain and
the work-related characteristics of secondary school female
teachers. Disabling pain was significantly associated with
years of teaching, daily hours of working, number of classes
per week, and comfortableness of school furniture (p=0.020,
0.039, 0.013, and 0.009, respectively). Disabling pain was
higher among teachers with more than ten years of teaching
(29.7%), 7–9 daily hours of working (28.7%), and more than
20 classes per week (48%). Also, disabling pain was higher
among teachers who considered their school furniture as un-
comfortable (32.2%). Multiple logistic regression analysis re-
vealed that the following factors were significantly associated
with disabling pain: age more than 40 years [odds ratio (OR):
2.08; confidence interval (CI): 1.16–3.71] (p= 0.014), not
practicing exercise (OR: 3.19; CI: 1.29–7.88) (p=0.012),
more than ten years of teaching (OR: 2.07; CI: 1.12–3.84)
(p= 0.021), and non-comfortableness of school furniture
(OR: 2.16; CI: 1.21–3.88) (p=0.010).
Discussion
Musculoskeletal pain is a common and serious occupational
complaint that influences the general public, particularly
working individuals. Musculoskeletal pain mostly influences
those in the teaching career and is considered to be linked to
adverse work circumstances (Arvidsson et al. 2016).
Table 2 Work-related characteristics of secondary school female
teachers in Aljouf region, Saudi Arabia
Variables No. (%) (n= 254)
Housemaid at home
Yes 166 (65.4)
No 88 (34.6)
Type of shoes
Flat 174 (68.5)
With heel 80 (31.5)
Years of teaching
< 10 106 (41.7)
≥10 148 (58.3)
Method of getting to school
On foot 10 (3.9)
By car 244 (96.1)
Daily hours of working
3–6 104 (40.9)
7–9 150 (59.1)
Number of classes per day
1–4 149 (58.7)
> 4 105 (41.3)
Number of classes per week
1–10 114 (44.9)
11–20 115 (45.3)
> 20 25 (9.8)
Have extracurricular activities
Yes 216 (85)
No 38 (15)
Furniture use at school is comfortable
Yes 139 (54.7)
No 115 (45.3)
68.50%
31.50%
Yes
No
Fig. 1 Prevalence of musculoskeletal pain among secondary school
female teachers in Aljouf region, Saudi Arabia
Table 3 Pattern and effect of musculoskeletal pain among secondary
school female teachers in Aljouf region, Saudi Arabia
Vari ab les N o. (% ) (n=174)
Duration of pain (months)
< 3 66 (37.9)
3–629(16.7)
> 6 79 (45.4)
Areas of pain
Single 54 (31)
Multiple 120 (69)
Site of pain*
Low back 119 (68.4)
Knee 102 (58.6)
Shoulder 83 (47.7)
Neck 79 (45.4)
Elbow 41 (23.6)
Wrist 25 (14.4)
Days of absenteeism per
month because of pain
1–5 156 (89.7)
6–10 18 (10.3)
Örebro Musculoskeletal Pain Screening
Questionnaire (OMPSQ) score
Non-disabling pain (< 105) 112 (64.4)
Disabling pain (> 105) 62 (35.6)
*More than one answer had been reported
J Public Health (Berl.): From Theory to Practice
Numerous studies revealed that secondary school teachers
may have a higher risk of suffering from musculoskeletal pain
than primary school teachers, mostly due to the more intensive
workloads and more stressful conditions, factors that favor the
occurrence of pain (Mohseni Bandpei et al. 2014; Yue et al.
2012). Various studies showed a positive association between
musculoskeletal pain and female sex in the teaching profes-
sion (Erick and Smith 2014b; Mohseni Bandpei et al. 2014;
Samad et al. 2010). This may be attributed to the fact that the
teaching profession is mostly composed of females (Ng et al.
2017). Also, Chong and Chan proposed that females might
have pain more frequently than males because females have
less physical strength and may be stressed by their families or
profession (Chong and Chan 2010). In the present study, the
prevalence of musculoskeletal pain was 68.5% among sec-
ondary school female teachers. The most prevalent site of
musculoskeletal pain in this study was low back (68.4%).
This was relatively higher in comparison with other studies.
In a study conducted in Hong Kong, 53.3% of secondary
school teachers reported low back pain (Chiu et al. 2006).
The prevalence of back pain among Chinese school teachers
was 40% (Jin et al. 2004). Low back pain has been experi-
enced by 34.8% of French school teachers in the last six
months prior to the study by Kovess-Masféty et al. (2006).
Also, the prevalence of low back pain in a study which sam-
pled almost the same study population is 63.8%, which is
lower than that reported in this study (Darwish and Al-
Zuhair 2013). The high prevalence of low back pain may be
attributed to the fact that most secondary school teachers
spend their time continuously standing to follow the educa-
tional process. Knee pain was the second most common mus-
culoskeletal pain among school teachers, with a prevalence of
58.6%. This was higher than a previous study conducted in
Turkey (Durmus and Ilhanli 2012) but still lower than another
study performed in Saudi Arabia (Abdulmonem et al. 2014).
The prevalence of shoulder pain in this study was 47.7%.
Chinese school teachers had reported the highest shoulder
pain prevalence (73.4%) (Chong and Chan 2010), while in
Turkey, 28.7% of school teachers had experienced pain in
theshoulderarea(Korkmazetal.2011). Regarding neck pain,
it was reported by 45.4% of the teachers in this study. This is
lower than that reported in Hong Kong, where the prevalence
Table 4 Relationship between
disabling musculoskeletal pain
and sociodemographic features of
secondary school female teachers
in Aljouf region, Saudi Arabia
Variable No or non-disabling pain Disabling pain p-Value
Age (years)
≤40 124 (81) 29 (19) 0.013*
> 40 68 (67.3) 33 (32.7)
Type of school
Governmental 171 (77.4) 50 (22.6) 0.087
Private 21 (63.6) 12 (36.4)
Educational level
Diploma 10 (66.7) 5 (33.3) 0.704
Bachelor degree 175 (76.1) 55 (23.9)
Postgraduate studies 7 (77.8) 2 (22.2)
Marital status
Single 16 (84.2) 3 (15.8) 0.043*
Married 158 (77.5) 46 (22.5)
Divorced or widowed 18 (58.1) 13 (41.9)
Number of children
None 28 (82.4) 6 (17.6) 0.153
1–4 94 (79) 25 (21)
> 4 70 (69.3) 31 (30.7)
Sleeping hours
< 6 55 (72.4) 21(27.6) 0.718
6–8 129 (76.8) 39 (23.2)
> 8 8 (80) 2 (20)
Practice exercise
Yes 49 (89.1) 6 (10.9) 0.008*
No 143 (71.9) 56 (28.1)
Income per month (RS)
≤5000 23 (79.3) 6 (20.7) 0.620
> 5000 169 (75.1) 56 (24.9)
*Statistically significant difference at p<0.05
J Public Health (Berl.): From Theory to Practice
of neck pain among secondary school teachers was 69.3%
(Chiu and Lam 2007). However, it is higher than the result
from Turkey, where 42.5% of school teachers reported that
they had neck pain in the last year (Korkmaz et al. 2011).
Regarding the severity of musculoskeletal pain in this study,
64.4% of the respondents had non-disabling musculoskeletal
pain, while 35.6% had disabling pain. In a study conducted by
Darwish and Al-Zuhair, 25.9% of their participants had non-
disabling pain, while 53.3% had disabling pain (Darwish and
Al-Zuhair 2013). Musculoskeletal pain is a multidimensional
disease affected by several factors, such as the
sociodemographic and work-related characteristics of the af-
fected people. In the present study, the prevalence of disabling
musculoskeletal pain was significantly higher among aged
teachers. This agrees with the results of the studies investigat-
ing Brazilian (Cardoso et al. 2009) and Turkish teachers
(Korkmaz et al. 2011), which revealed that teachers more than
40 years old were more likely to have musculoskeletal pain
disorders. Musculoskeletal pain disorders are likely to become
more apparent as the population increases in age all over the
world (Felson 2000). However, other studies showed that
younger teachers have been found to experience musculoskel-
etal pain disorders. This has been revealed in the results of a
Chinese study (Chiu and Lam 2007), where the age group
with the highest prevalence of musculoskeletal pain was 31–
35 years old. Disabling musculoskeletal pain was significantly
higher among divorced or widow teachers in this study, in
agreement with a study conducted by Abdulmonem et al.
(2014). Practicing exercise is a fundamental aspect of manag-
ing many musculoskeletal pain disorders (Geneen et al. 2017).
Table 5 Relationship between
disabling musculoskeletal pain
and work characteristics of
secondary school female teachers
in Aljouf region, Saudi Arabia
Variable No or non-disabling pain Disabling pain p-Value
Housemaid at home
Yes 127 (76.5) 39 (23.5) 0.641
No 65 (73.9) 23 (26.1)
Shoes
Flat 133 (76.4) 41 (23.6) 0.643
With heel 59 (73.8) 21 (26.3)
Years of teaching
< 10 88 (83) 18 (17) 0.020*
≥10 104 (70.3) 44 (29.7)
Method of getting to school
On foot 9 (90) 1 (10) 0.459
By car 183 (75) 61 (25)
Daily hours of working
3–6 85 (81.7) 19 (18.3) 0.039*
7–9 107 (71.3) 43 (28.7)
Number of classes per day
1–4 118 (79.2) 31 (20.8) 0.075
> 4 74 (70.5) 31 (29.5)
Number of classes per week
1–10 91 (79.8) 23 (20.2) 0.013*
11–20 88 (76.5) 27 (23.5)
> 20 13 (52) 12 (48)
Have extracurricular activities
Yes 161 (74.5) 55 (25.5) 0.351
No 31 (81.6) 7 (18.4)
Furniture use at school is comfortable
Yes 114 (82) 25 (18) 0.009*
No 78 (67.8) 37 (32.2)
*Statistically significant difference at p<0.05
Table 6 Logistic regression analysis of significant factors affecting
disabling musculoskeletal pain among secondary school female
teachers in Aljouf region, Saudi Arabia
p-Value OR 95% CI
Age > 40 years 0.014 2.08 1.16–3.71
Not practicing exercise 0.012 3.19 1.29–7.88
Years of teaching > 10 years 0.021 2.07 1.12–3.84
Not comfortable furniture at school 0.010 2.16 1.21–3.88
OR = odds ratio; CI = confidence interval
J Public Health (Berl.): From Theory to Practice
In the present study, disabling musculoskeletal pain was sig-
nificantly higher among teachers do not practice exercise. In
this study, there was a significant association between dis-
abling musculoskeletal pain and increasing number of teach-
ing years, in agreement with many studies (Cardoso et al.
2009;DarwishandAl-Zuhair2013;Chiuetal.2006). This
positive association with the length of employment may be
due to the longer time the teacher was exposed to adverse
conditions causing musculoskeletal pain. In a Chinese study
of secondary school teachers, high workload has been signif-
icantly associated with neck pain (Chiu and Lam 2007). This
agrees with the results of this study, which showed that dis-
abling musculoskeletal pain was significantly higher among
teachers with more daily hours of working and more classes
per week. On the other hand, other studies did not show a
significant relationship between musculoskeletal pain and
workload (Darwish and Al-Zuhair 2013;Abdulmonemetal.
2014). The present study showed that musculoskeletal pain
was significantly higher among teachers who reported non-
comfortableness of school furniture. This is in agreement with
a study conducted among Brazilian teachers which showed
that inappropriate furniture has been positively associated
with back pain (Cardoso et al. 2009).
Conclusion and recommendations
Secondary school female teachers showed a high prevalence
of musculoskeletal pain in most anatomic sites, such as low
back, knee, shoulder, neck, elbow, and wrist. Risk factors
associatedwith disabling musculoskeletal pain were age more
than 40 years, not practicing exercise, more than ten years of
teaching, and non-comfortableness of school furniture. Some
useful preventive measures can be executed atthe school level
to decrease the high prevalence of musculoskeletal pain, such
as proportional reduction of workload for aging teachers, op-
timizing working hours per day, and availability of comfort-
able furniture. Health promotion programs are recommended
to increase the awareness regarding the benefits of doing reg-
ular exercise.
Limitations
The administrative authorities in Saudi Arabia prevent female
researchers from conducting studies on male teachers.
Therefore, the researchers did not have the chance to deter-
mine sex-specific prevalence rates. Another limitation is that
this investigation was a cross-sectional study, which showed
the relation between musculoskeletal pain and some risk fac-
tors, without being able to determine a cause–effect
relationship.
Acknowledgements The authors would like to express their extreme
thanks to all the school teachers and principals of the selected schools
for facilitating conduction of the present study.
Author contributions AS, NF, and FS suggested the research topic. Data
collection and entry was done by AS, RA, NF, FS, SM, and FF. DM
performed the statistical analysis and data interpretation. DM and AS
wrote the first draft of the manuscript. All authors read and approved
the final draft of the manuscript.
Funding The present study did not receive any financial budgets from
national or international organizations.
Availability of data and materials Please contact the authors for data
requests.
Compliance with ethical standards
Ethical approval and consent to participate Reviewing the proposal
was executed by a Local Committee of Bioethics at Jouf University,
Saudi Arabia. Data were collected after ethical clearance.
Administrative approvals were completed from the Ministry of
Education and school management. The female teachers were invited to
participate in the study after describing the objectives of the study and
emphasizing the confidentiality of the collected data through anonymous,
self-administered questionnaires. Informed written consent was obtained
from participants who agreed to share in the study.
Consent for publication Consent to publish was acquired from the tar-
get population.
Conflict of interest The authors declare that there is no conflict of
interest.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link
to the Creative Commons license, and indicate if changes were made.
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