The elementary and secondary education systems have been heavily impacted by the coronavirus disease 2019 (COVID-19) pandemic. In many jurisdictions, part of the public health response to slow the community spread of COVID-19 involved closing schools for in-person learning for extended periods. For example, in Ontario, Canada, schools were initially closed for 2 weeks following March break (between March 14 and April 5, 2020), with in-person learning subsequently suspended until the end of the school year in June 2020. Schools were reopened for in-person learning at the start of the 2020–2021 school year in September, with additional safety measures put in place. These included the mandatory wearing of masks for students in grades 4 through 12, with encouragement to wear masks for students in kindergarten to grade 3; enhanced self-screening protocols for parents and students; and enhanced cleaning practices within the school. In addition, medical masks and face shields were to be provided to all teachers, with masks to be worn by all on-site education workers unless they had medical exemptions.1
There is a rapidly growing evidence base on the potential advantages and disadvantages of school closures as they relate to the mental and physical health of students, their families, and the broader community.2,3 Whereas much of the debate around school closures (and reopenings) has centered on the lower risk of contracting COVID-19 and lower risk of adverse COVID-19 outcomes among school-aged children,2–6 less research has focused on the experiences of educators who remain engaged in in-person learning. Yet, these frontline education workers may be at increased risk of COVID-19 because of both working outside of the home and being in close proximity to students, coworkers, and members of the public throughout the course of their workday. Advisory bodies recommending returning to (or maintaining) in-person learning also recognize that it should be accompanied by strong commitment to a range of safety practices.7 As such, it is important to identify modifiable work factors that might be associated with both COVID-19 transmission risk and mental health outcomes among these workers.8
Inadequate access to resources to effectively control hazards in the workplace has been associated with adverse physical and mental outcomes among workers.9,10 The mechanisms that lead to inadequate access to protections and mental health are likely through perceptions of increased risk, more negative work experiences, and greater stress.11 Specifically related to COVID-19, inadequate provision of personal protective equipment (PPE) and infection control practices (ICPs) has been associated with higher levels of symptoms of anxiety among both health care10,12 and non–health care workers.13,14 The objectives of this article were to extend this work into the elementary school setting, to examine both the adequacy of ICPs and PPE among a sample of education workers in Ontario during the first 4 months of schools reopening in the province during the 2020–2021 school year, and to examine the relationship between the adequacy of ICPs and provision of PPE and symptoms of anxiety.
In early November 2020, an online survey was developed by the Occupational Health Clinics for Ontario Workers in collaboration with the Elementary Teachers' Federation of Ontario (ETFO). The ETFO represents more than 83,000 teachers, occasional teachers, and education professionals employed in the public elementary schools of Ontario. The survey content was also informed by two previous surveys conducted among health care workers12 and non–health care workers13 during the first phase of the COVID-19 pandemic (April to June 2020).
The survey was open from November 23 to December 21, 2020. Multiple e-mails to ETFO members were sent out over this time period encouraging them to complete the survey. In addition, posts were made on ETFO's social media channels. Between November 23 and December 21, 5774 responses to the survey were recorded. The current article focuses on respondents to the survey who were working at the school worksite for the whole workweek (n = 4947). The study received approval from the University of Toronto Research Ethics Board.
Main Outcome: Symptoms of Anxiety
Symptoms of anxiety were assessed using the seven-item Generalized Anxiety Questionnaire (GAD-7). The GAD-7 is a seven-item survey assessing the frequency of symptoms of generalized anxiety disorder over the previous 2 weeks. The scale has demonstrated excellent internal consistency and test-retest reliability.15 Scores on the GAD-7 range from 0 to 21. Scores of 10 and higher have a sensitivity of 89% and specificity of 82% to detect the presence of generalized anxiety disorder using a structured psychiatric interview, whereas scores of 15 and higher have a sensitivity of 48% and a specificity of 95%.15 The developers of the GAD-7 have suggested that scores can be divided into four levels of anxiety: minimal (0 to 4), mild, (5 to 9) moderate, (10 to 14), and severe (15 to 21). 15 Examination of the relationships between the GAD-7 items in the current sample indicated excellent internal consistency (standardized Cronbach α = 0.91).
Main Independent Variables: Perceived Adequacy of COVID-19 Infection Control Programs
Respondents were asked a series of questions about the adequacy of implementation of 13 different types of ICPs and the adequacy and supply of nine different types of PPE to reduce COVID-19 transmission. Infection control practice items included adjusting ventilation to improve air circulation, presence of physical barriers between the worker and others, physical distancing procedures for coworkers, physical distancing procedures for students/visitors, staggered or adapted schedules, cohorting of students to minimize contacts, screening workers for COVID-19 symptoms, screening students/visitors for COVID-19 symptoms, workers wearing face coverings, students wearing face coverings, cleaning procedures, laundry for work-related materials (eg, towels), and waste disposal practices. For each type of ICPs, respondents indicated if it was appropriate and adequately implemented, appropriate but inadequately implemented, inappropriate, lacking, “not sure/don't know” what is appropriate, and “not applicable.” We defined a perceived need for a given ICP as when respondents endorsed one of the first four categories (as opposed to “not sure/don't know” or “not applicable”). We defined that a need was met when respondents endorsed the first category (appropriate and adequately implemented).
Personal protective equipment items included gloves, eye protection/goggles, face shields, gowns or coveralls, hand sanitizer, soap and running water, surgical masks, and N95 masks. Response options were appropriate type and adequate supply, appropriate type but inadequate supply, inappropriate type but adequate supply, inappropriate type and inadequate supply, needed but not available at all, “not sure/don't know” what is appropriate, and “not applicable.” We defined need for a given PPE as when respondents endorsed one of the first five categories (as opposed to “not sure/don't know” and “not applicable”). We defined that need being met when respondents endorsed the first category (appropriate type and adequate supply).
Respondents were grouped based on the proportion of their perceived ICP and PPE needs that were met: those who had all their needs met, those who had more than half of their needs met, those who had less than half of their needs met, and those who did not have any of their needs met. Groupings were done separately for ICPs and PPE.
Study variables were identified that may be associated with (but not a consequence of) the proportion of ICP and PPE needs meet and that could be associated with anxiety symptoms. These measures crossed three main domains: sociodemographic, occupational, and workplace characteristics, and COVID-19–specific measures. Survey date was also included as a covariate in all models to account for temporal trends in anxiety associated with general COVID-19 case counts in Ontario over the survey period.
Sociodemographic measures included self-reported gender, age (grouped in 10-year age brackets), and whether the respondent was identified as a member of an aboriginal/first nations or racialized group (yes/no). Occupational and workplace characteristics included the number of years the respondent had worked in the Ontario public elementary school system; his/her employment relationship (permanent teacher, long-term occasional teacher, short-term occasional teacher, or support personnel); whether the respondent was working full-time or part-time; the grades he/she usually taught (kindergarten, primary, junior, intermediate, other); whether the respondent had engaged in any virtual learning activities since September 2020 (yes/no); and how many employees were at his/her school. COVID-19–specific measures included the number of workers at his/her school who had been infected with COVID-19 (suspected/presumed or confirmed) (none, one, more than one, don't know); the number of nonworkers who had been infected (none, one, more than one, don't know); whether the respondent was currently working at his/her usual job (yes/no); whether the respondent had contact with someone at work who was later diagnosed with COVID-19; whether the respondent had contact with someone outside of work who was later diagnosed with COVID-19; whether the respondent experienced COVID-19 symptoms; whether the respondent had been told to self-isolate; whether the respondent had been tested for COVID-19; whether the respondent worked within 2 m of other coworkers; whether the respondent worked within 2 m of others (members of the public or students); whether the respondent's household had lost income since the pandemic started; and whether the respondent took public transport (bus/streetcar/subway/train) to work in the last week.
Among the 4947 respondents who were currently at the worksite, 2946 (60%) had complete information on all study variables, whereas five respondents (0.1%) were missing information on all variables apart from work status and were removed from the analytical data set, leaving an analytical sample of 4942 respondents. To minimize bias in parameter estimates and standard errors (SEs), missing information on all variables was handled through multiple imputations.16–19 Variables with the highest level of missing information were race (34% missing), gender (23% missing) and age, teacher type, grades taught, full-time/part-time status, and whether the respondent took public transit to work (all 18% missing). Variables with the lowest level of missing data were whether the respondent had engaged in virtual learning since September 2020 (less than 1% missing), GAD-7 score (4% missing), and whether the respondent had close contact with coworkers or students in a usual day (both 6% missing). In general, variables with higher proportions of missing data were located toward the end of the survey and variables with lower proportions toward the start of the survey.
Imputation models included all analytical variables, as well as the following auxiliary variables: symptoms of depression as measured by the two-item Patient Health Questionnaire, exposure to bullying or harassment in the previous 12 months (yes/no), burnout symptoms, sleep disturbance, work pace, quantitative demands, predictability, role conflict, supervisor support, and coworker support all measured using the Copenhagen Psychosocial Questionnaire.20 In addition, we included measures of fear about the pandemic (0- to 10-point scale), whether the respondent would exercise his/her right to refuse work in particular situations, whether his/her employer had an infection control program, whether his/her temperature was being checked before entering the school, whether attendance policies at the school encouraged or discouraged workers from coming to the workplace, and their perception of the adequacy of training in relation to working safety in the context of COVID-19. Each of these measures were considered auxiliary variables as they are either potential mediators in the pathway between our main exposures and outcome (eg, in the case of psychosocial work exposures or adequacy of training) or could be considered secondary outcomes (eg, in the case of depressive symptoms, sleep disturbance, fear, and burnout). Therefore, these measures could provide information on likely levels of missing values among analytical variables of interest but were not candidate measures for the analytical models.18,19 Imputation was undertaken using a fully conditional specification approach, with 50 imputation cycles.18
Initial analyses examined the distribution of all analytical variables and the relationships between variables to ensure lack of collinearity in regression models. The relationship between perceived adequacy of ICPs and PPE and the proposed levels of anxiety was examined as reflected by GAD-7 scores: (minimal [0 to 4], mild, [5 to 9] moderate, [10 to 14], and severe [15 to 21]). For this analysis, we initially considered multinomial logistic regression models, given the four-level outcome. However, because of the high proportion of respondents defined as having moderate or severe anxiety with the GAD-7, we opted against this approach, given the odds ratios would not approximate the relative risk.21,22 Instead, we ran models to estimate the relative risk associated with our independent measures and the four levels of anxiety defined by GAD-7. We did this in two ways. First, we ran log-binomial models restricting our sample to two anxiety groups at a time (ie, minimal and mild anxiety groups, minimal and moderate anxiety groups, and minimal and severe anxiety groups). Although this approach is less statistically efficient compared with the multinomial logistic model, we felt this trade-off was warranted to aid in the interpretation of estimates as relative risks compared with odds ratios that would have been inflated. Our log-binomial models ran into convergence issues given the number of covariates; instead, we estimated relative risks using general regression models assuming a Poisson distribution, with a log link function.22 Although SEs using this method are potentially inflated, we did compare these models to log-binomial models where we used an stabilized inverse probability weight to account for confounding,23 enabling these models to converge. Estimates from both models were similar. We also examined the relationship between perceptions of ICP and PPE needs and the GAD-7 score modeled as a continuous outcome. Given the absolute GAD-7 score in our sample was relatively normally distributed (mean, 11.5; median, 11.0; skew, −0.01; kurtosis, −0.95), we used linear regression models for these analyses. We have included only Poisson models in this article (log-binomial models are available on request). Separate models were run for ICP and PPE measures. Models including all covariates were run with the SURVEY procedures in SAS (SURVEYPHREG and SURVEYREG) (SAS Institute Inc, Cary, NC) with SEs estimated using Taylor series approximation. PROC MI was used to generate 50 imputation data sets, and PROC MIANALYZE was used to pool estimates and SEs. We further checked the appropriate regression diagnostics in each of the 50 regression models to confirm that modeling assumptions were met.
Table 1 presents the distribution of the main study outcome and independent variables. High levels of anxiety symptoms were observed in the sample, with 27.4% (95% confidence interval [CI], 26.2% to 28.7%) of the sample reporting symptoms consistent with moderate anxiety and 32.1% of the sample (95% CI, 30.8% to 33.5%) reporting symptoms consistent with severe anxiety. In general, provision of PPE was more adequate than the implementation of ICPs, with 29.4% (95% CI, 28.1% to 30.8%) of the sample reporting 100% of their PPE needs met, whereas only 4.5% of the sample (95% CI, 3.9% to 5.1%) reported that all their ICP needs were met. Approximately two-thirds of the sample had less than half of their ICP needs meet, whereas 17.5% of the sample had less than half their PPE needs met. Descriptive information for study covariates is presented in Table S1 in the supplementary material to this article (https://links.lww.com/JOM/B193).
TABLE 1 -
Distribution of GAD-7 Categories and ICP and PPE Adequacy, Educators in Ontario, Canada, November to December 2020 (n = 4942)
|ICP needs met
| 100% of ICP needs met
| 50%–99% of ICP needs met
| 1%–49% of ICP needs met
| 0% of ICP needs met
|PPE needs met
| 100% of PPE needs met
| 50%–99% of PPE needs met
| 1%–49% of PPE needs met
| 0% of PPE needs met
CI, confidence interval; GAD, 7-item Generalized Anxiety Questionnaire; ICP, infection control practice; PPE, personal protective equipment.
Table 2 presents the proportion of unmet needs across different types of ICPs and PPE. Numbers of respondents in Table 2 reflect the proportion of the sample who responded to questions on ICP and PPE needs (approximately 87% of the sample). The ICP types with the highest unmet needs were physical barriers, physical distancing from students, screening of students and visitors, cohorting of students, and students wearing face coverings, all of which were reported by more than 60% of the sample. For PPE, the highest unmet needs were reported for eye protection, N95 masks, face shields, and soap and running water, which were reported by 25% or more of the sample.
TABLE 2 -
Prevalence of Unmet Needs across Types of Infection Control and PPE Categories, Educators in Ontario, Canada, November to December 2020
|ICP Type (n = 4301)
||% With Unmet Need
||PPE Type (n = 4294)
||% With Unmet Need
|Physical distancing (coworkers)
|Physical distancing (students)
|Cohorting of students
||Soap and running water
|Screening for workers
|Screening for students/visitors
|Workers wearing face coverings
|Students wearing face coverings
|Laundry for work-related material
|Waste disposal practices
ICP, infection control practice; PPE, personal protective equipment.
Table 3 presents results from the Poisson and linear regression models examining the association between adequacy of ICP and PPE needs and GAD-7 scores, adjusted for all study covariates. Unadjusted estimates are presented in Table S2 in the supplementary material to this article (https://links.lww.com/JOM/B194). For ICP needs, Poisson regression results demonstrated a graded relationship between lower proportion of ICP needs being met and increased likelihood of mild, moderate, and severe anxiety. In addition, the strength of the relative risks increased when examining mild anxiety compared with moderate and severe levels of anxiety. For example, compared with respondents with 100% of their ICP needs being met, respondents with 1% to 49% of their ICP needs met had a 3.10 increased risk of moderate anxiety (95% CI, 2.21 to 4.34) and 3.21 increased risk of severe anxiety (95% CI, 2.28 to 4.51). For respondents with none of their ICP needs met, the associated relative risks were 3.19 (2.27 to 4.49) for moderate anxiety and 3.41 (2.42 to 4.80) for severe anxiety. In linear regression models, we observed similar relationships with respondents with 50% to 99% of their ICP needs met having GAD-7 scores 2.52 points (1.66 to 3.37) higher than respondents with 100% of their ICP needs met, with respondents with 1% to 49% and 0% of their ICP needs having GAD-7 scores 4.97 (4.13 to 5.80) and 6.34 (5.42 to 7.27) points higher, on average, respectively.
TABLE 3 -
Adjusted* RRs for Mild, Moderate, and Severe Anxiety and ICP and PPE Needs and Linear Regression Models for ICP and PPE Needs With Absolute GAD-7 Scores, Educators in Ontario, Canada, November to December 2020 (n = 4942)
|ICP needs met
| 100% of ICP needs met
| 50%–99% of ICP needs met
| 1%–49% of ICP needs met
| 0% of ICP needs met
|PPE needs met
| 100% of PPT needs met
| 50%–99% of PPT needs met
| 0%–49% of PPT needs met
*Adjusted for date of survey, age, gender, race, experience, employment relationship, work hours, grades taught, virtual learning, number of employees at school, number of employees infected with COVID-19, number of students infected with COVID-19, currently working normal job, contact with COVID-19 at school, contact with COVID-19 outside of school, COVID-19 symptoms, required to self-isolate, tested for COVID-19, usually work within 2 ft of other workers, usually work within 2 ft of students, household lost income, and taking public transport to work.
†Model fit statistics for linear regression models with ICP needs met. Given the 50 imputed data mean, minimum and maximum values are reported: R2 mean = 0.159, minimum = 0.148, maximum = 0.166; RMSE mean = 5.22, minimum = 5.19, maximum = 5.26. Model fit statistics for linear regression models with PPE needs met. Given the 50 imputed data mean, minimum and maximum values are reported: R2 mean = 0.127, minimum = 0.118, maximum = 0.136; RMSE mean = 5.32, minimum = 5.29, maximum = 5.35.
CI, confidence interval; COVID-19, coronavirus disease 2019; GAD-7, 7-item Generalized Anxiety Questionnaire; ICP, infection control practice; PPE, personal protective equipment; Ref, reference; RMSE, root mean square error; RR, relative risk.
For models examining the relationship between PPE adequacy and GAD-7 scores, respondents with 1% to 49% of PPE needs met and 0% of PPE needs met had to be grouped because of the small number of respondents with none of their PPE needs met. In general, results were similar for PPE needs and the GAD-7, although the sizes of the estimates were attenuated compared with models examining ICP adequacy.
Education workers who are engaged in in-person learning represent a group of workers with a potentially high level of exposure to COVID-19. In this study of just under 5000 educators who were currently working on site in the Canadian province of Ontario in November to December 2020, we observed very high levels of anxiety symptoms, with almost 60% of the sample being classified with symptoms of moderate or severe anxiety as assessed by the GAD-7. In addition, we observed a clear graded relationship between the proportion of unmet needs related to ICPs and PPE with increasing risk of more severe symptoms of anxiety. Unmet needs related to ICPs were higher than for PPE measures. The relationship between unmet ICP needs and anxiety symptoms was stronger than observed for PPE and anxiety symptoms. Taken together, these results point to the importance of adequate ICPs in particular, in addition to PPE, within the context of keeping schools open, and draw attention to the elevated symptoms of anxiety among educators in Ontario and the relationship between the symptoms and inadequate ICPs and PPE.
The results of this study should be interpreted given the following strengths and limitations. Although we have a large sample of educators in this study, ETFO, which disseminated links to the survey, has more than 83,000 members. As such, the 5774 respondents to our survey represent less than 7% of the total ETFO membership. We examined the distribution of age, gender, full-time status, and years of experience in our sample compared with information available from the ETFO membership database (which contains the information on 31,251 ETFO members). Compared with the ETFO membership database, our sample had fewer men (9% vs 16%), people 35 years or younger (12% vs 15%), educators with less than 5 years of experience (10% vs 18%), and part-time employees (8% vs 15%). However, we note that we have adequate numbers of respondents in each of these underrepresented groups and good distribution of responses across all analytic variables. As such, these selection effects may not necessarily bias the relationships presented in this article.24 Our study also only examined the experiences of elementary teachers. The work context of elementary and secondary teachers differs in important ways, in relation to the age of students, and time spent with the same group of students. In addition, in Ontario, elementary and secondary settings addressed COVID-19 with different controls. For example, almost all students at the secondary level were all required to wear masks and did not require as much supervision and instruction for hand hygiene as elementary school students. Secondary schools also rearranged class schedules and eliminated lunch at schools. As such, our findings should not be extended beyond the elementary setting. All measures in our study were based on self-report, and it is possible that respondents who reported more symptoms of anxiety could also overreport needs related to ICPs and/or PPE, which could inflate the association between unmet needs and anxiety symptoms. To examine this potential for bias further, we ran additional models that also included the number of needs a person had identified as an additional covariate, which could be a proxy for a generally negative disposition toward infection control in the workplace. The inclusion of this measure did not meaningfully change our estimates (results not presented, but available from authors on request). Our study also has strengths, which include the use of multiple imputations to handle missing values across study variables and providing collapsible risk estimates (as opposed to odds ratios). Our principled approach to missing data increases confidence in the risk estimates and associated SEs describing the relationships between our independent variables and outcomes.
Given the rapidly changing environment due to COVID-19, the survey responses only reflect a particular point in time in Ontario. To put these findings into context, between the start of September and the end of December 2020, there were 7484 cases of COVID-19 in schools in Ontario, with 70% of these being among students, 15% among staff, and 15% unspecified.25,26 Cases were highest in November and December, which mirrored the total number of cases in the Ontario population over this period. School outbreaks (where two or more people in a school were infected in a 14-day period, and at least one case could have been reasonably acquired at the school) represented just over 40% of all cases in schools in this time period.25
Comparing the results of our study to other studies is hampered by the lack of attention on the mental health of education workers during the COVID-19 pandemic to date. A few studies have identified elevated mental health concerns among teachers,8,27,28 with a large convenience-based sample in China observing that improper mask wearing was associated with a higher odds of anxiety (defined as GAD-7 scores >10).27 In this Chinese sample, the proportion of respondents with GAD-7 scores of 10 or higher was 13.5% overall, although higher (14.1%) among primary and junior school teachers, compared with high school and university teachers (11.8%).27 This prevalence is considerably lower than the 60% of our sample who met this criterion. It is unclear whether this difference reflects cultural differences between samples or levels of protections in place between samples or is due to other factors. Among a convenience-based sample of 90 female and 25 male teachers from Philadelphia, collected at the start of the COVID-19 pandemic (April to July 2020), authors reported that 50% of female and 16% of male teachers had Hospital Anxiety and Depression Scale scores of 11 or higher.29 The Hospital Anxiety and Depression Scale and GAD-7 have been demonstrated to be highly correlated with each other,30 and the corresponding prevalence rates of moderate and severe anxiety in our sample were 60.1% among women and 49.1% among men. Our results are consistent with a recent systematic review that documents the importance of employer-based infection control strategies to reduce psychological ill health among health care workers31 and other studies on PPE and ICP adequacy and mental health among health care10,12 and non–health care workers.13,14
Our study offers important insights into ICPs in Ontario during the reopening of schools. Within a hierarchy of controls, ICPs and PPE sit across different locations, with PPE referring to items worn by workers to prevent infection, whereas ICP refers to changes in how workers perform their duties, administrative controls to increase distancing, or the use of engineering controls in the workplace.32 Generally, it is thought that ICPs will be more effective in reducing risk than will PPE32; however, in our sample, two-thirds of respondents reported having less than half of their ICP needs met, compared with 18% who had less than half of their PPE needs met. In addition, the association between ICP needs and symptoms of anxiety appeared stronger than for PPE. Areas of ICPs where there were high proportions of unmet needs included screening of students and visitors, installation of physical barriers, and procedures to enable physical distancing from students, cohorting students, and having students wear face coverings. Taken together, this suggests that more resources should be directed toward the implementation of organizational measures, such as the effective screening of students and visitors and enabling adequate physical distancing between students and teachers within the school setting.
In this sample of just under 5000 education workers in Ontario, 6 in 10 respondents reported symptoms consistent with moderate or severe anxiety, as evaluated by the GAD-7, passing the suggested threshold for clinical follow-up. We also observed two-thirds of our sample currently had less than half of their perceived needs met in relation to ICPs. There was a graded relationship between higher perceived unmet needs related to ICPs and greater symptoms of anxiety. These findings highlight the importance of implementing and communicating the adequacy of administrative and engineering controls in schools, in addition to maintaining adequate supply of PPE, both as potential ways to reduce risk of COVID-19 infection and also to potentially reduce symptoms of anxiety among education workers. This will, in turn, improve educational outcomes for students. Educators, school administrators, and policy makers should work collaboratively to design school environments that enable more physical distancing between educators and students and allow greater compliance with student masking and cohorting. In addition, providing ongoing mental health individual support for educators and addressing organizational factors is warranted.
The authors thank Tracie Edward from ETFO for her help in the survey design and dissemination of the survey.
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