The Effect of Mindfulness-based Cognitive Behavior Therapy on Occupational Stress Management

The Effect of Mindfulness-based Cognitive Behavior Therapy on Occupational Stress Management Among Community Secondary School Teachers in Kathmandu

Occupational stress is one of the leading work-related factors that influence the health of employees and their ability to work. Stress at work is unavoidable due to changing and increasing demands and types of work. The teaching profession is one of the most stressful jobs with a high level of psychological morbidity globally. Stress may occur together with common mental disorders, which are one of the leading causes of disability worldwide. However, very little is known about the occurrence of occupational stress among schoolteachers. Several interventions have been designed to help school teachers to cope with stress. However, lifestyle modification intervention is not well explored, therefore, this study aims to evaluate the impact of lifestyle modification intervention on occupational stress management among community-level schoolteachers. Through effective intervention tools, workplace health can be enhanced, and the well-being of schoolteachers could be maintained.

Background Stress is the feeling of being overwhelmed or unable to cope with mental or emotional pressure which can happen together with mental health problems, such as depression. In 2019, depressive disorders were the sixth leading contributor to disability-adjusted life years (DALYs) among 25-49-year-olds. Occupational stress is the most common form of stress, and the degree of stress varies among different occupations. A study from the UK found that teaching was one of the most stressful occupations, because of its direct human-oriented nature. Likewise, a follow-up study in West England reported a higher level of psychological distress among a cohort of teachers than among comparable professionals from the general population. Potential stressors for teachers are low job support, student apathy, overcrowded and noisy working environments, excessive paperwork, low wages, unsupportive parents, and changing curricula. Lacking management of chronic workplace stress may result in Burnout syndrome. Prolonged stress becomes permanent, over time, because it is hard to recover and as a result, the individual faces chronic fatigue, dementia, musculoskeletal problems, cardiovascular disease, and professional burnout syndrome. The range of job stress may vary from job to job and profession to profession. Largo-Wight, Moore, and Barr have shown some different roots of job stress pertaining to physical or biological and psychological or behavioral in nature. Notwithstanding, exploring the level of job stress in the working population, and their lifestyle modification practices to reduce the stress level have a significant implication. The large number of schoolteachers teaching at different levels may have multifaceted stresses due to various reasons, such as less pay, high job demands, job insecurity, lack of professional opportunity, and safety. An earlier study by Kumar et. al. stated that occupational stress is increasingly common in the teaching profession due to increased occupational complexities and economic pressure on individuals. The reason behind the increased distress among the teachers is the result of the failure of the school to meet the social needs and job demands of the teachers. With most adults spending around half of their waking hours at work, the workplace is therefore an important setting to promote health and well-being. Various national and international bodies (e.g. ILO, WHO) are responsible for ensuring the health and safety of employees, with a focus on identifying physical, chemical, and biological hazards in the workplace. Increasingly, attention is also being paid to the psychosocial work environment, with a major focus on work stress. Therefore, promoting awareness of the link between stress and health among both employers and workers is an important component of workplace health promotion. Several interventions are tested to help teachers to reduce their stress levels and to improve their well-being and student outcomes at organizational and individual levels. Organizational-level interventions are directed at changing the organization's culture and work practices, whereas individual-level interventions are the most common approaches that include psychological relaxation or meditation, cognitive behavioral techniques to improve active coping skills, and lifestyle modification activities. Evidence shows that individual-level intervention improves teachers' health and well-being. In this regard, a study carried out by Naghieh et al. concluded that organizational interventions led to improvements in teacher well-being and retention rates. However, these lifestyle modification knowledge and practices have not been well explored among community-level schoolteachers. Therefore, this study aims to evaluate the impact of lifestyle modification intervention on occupational stress management among community-level schoolteachers. This individual-level intervention may affect teachers' own health behaviors, inspire others to review their own lifestyle activities, and support in developing a positive impact on community health practices. Research aims and objectives The overarching aim of this project is to investigate the effect of mindfulness-based cognitive behavior therapy on occupational stress management among secondary school teachers in Kathmandu, Nepal. The study has the following specific objectives: To assess the prevalence of occupational stress and the associated factors among schoolteachers. To evaluate the effect of the intervention on the occupational stress of teachers at post-intervention. To evaluate the effect of the intervention on the occupational stress of teachers in three months of follow-up after the intervention. Subjects and methods Study population and design: This research project plans to utilize an experimental study design focusing on community school settings and the prevailing numbers of teachers. Secondary-level teachers teaching at community schools from the Kathmandu district are the study population. The list of all schools in Kathmandu district (n=167) will be prepared and using 40 schools will be selected and 5 teachers from each school, totaling 200 teachers from these schools. Among them, teachers from 20 schools will be selected for the control group and another 20 will be for the intervention. Sample size and power calculation: The estimated sample size will be proportional to the prevalence of occupational stress among schoolteachers. This study will try to use the power of 80%. There is a need for a sample of 90 teachers in each study group and 180 in total and assuming 10% attrition rate, the participants per study group will be 100 and in total 200 teachers. Intervention: The content of the intervention has developed based on the previous literature. Cognitive behavior therapy (CBT) and Mindfulness-based stress reduction (MBSR) programs will be used combinedly. Data collection tools: The Maslach Burnout Inventory-Educators Survey (MBI-ES) will be used to measure the stress level of the teacher, as well as the effectiveness of intervention simultaneously. Demographic information of the participants will be collected using a separate set of questionnaires. The MBI-ES consists of 22 items including three sub-scales viz. Emotional Exhaustion (EE-9 items), Depersonalization (DP-5 items), and Personal Accomplishment (PA-8 items). These 22 items have different and unique values. The EE-9, and the DP-5, subscales, exhibit that the greater value the higher the stress they imply, however the PA-8 displays that the greater score the lower stress it indicates. The data collection will be carried out in three stages - at the baseline survey (T1), immediately after treatment (T2), and a follow-up measurement (T3) is scheduled for three months after the T2. The PI of the current project has prepared the first draft of the translation of this tool into the Nepali language. Two professional experts checked and corrected the translation of the tool. Further modifications in the tools will be carried out after using the tools for the pilot study and a final version will be prepared and ready for use. Ethical considerations: The permission to conduct this workplace intervention study has been taken from the concerned authorities and the ethical clearance was obtained from the Nepal Health Research Council (NHRC) (ethical approval number 147). Written/verbal consent was obtained from the study participants and their schools. In addition, the privacy and confidentiality of the participants will be maintained in the study according to scientific norms.

Cognitive behavior therapy (CBT) and Mindfulness-based stress reduction (MBSR) programs will be used together.

Participants in the Intervention arm will receive Cognitive behavior therapy (CBT) and Mindfulness-based stress reduction (MBSR) programs based intervention.

The control will work normally with intervention. The intervention material will be provided to the controls once the follow-up surveys are conducted after the intervention is given to the intervention arm.

Cognitive behavior therapy (CBT) and Mindfulness-based stress reduction (MBSR) programs will be used combinedly. CBT will be constructed based on the CBT model of Beck, (2021) and mindfulness practice will be implemented based on the MBSR program developed by Williams et. al. (2011).

Baseline, change in the outcome will be assessed at post intervention (at 1 month), and in a 2 month of follow-up after the intervention

Inclusion Criteria: In community schools, teachers who are employed at least one year before the survey and have a work contract of more than one year until the time of the survey; Teachers teaching in grades 9 and 10; Teacher of working age between 18 and 60 years; Teacher with any educational background and level; and Teacher who teaches any subjects at the secondary level (grades 9 and 10). Exclusion Criteria: Teacher with a short-term contract (less than 1 year); Teacher employed for extra class or substitute; Currently pregnant or those are on maternity leave; and Teacher who is on study leave or absence due to long-term sickness.

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