Table 2: Study results sorted by biomarker.
Sample type Study design Biomarkers Bias rating (biomarker & measurement) Stress construct & measure Bias rating (stress construct & measurement) Results Reference
 HPA axis
School teachers Cross-sectional Salivary cortisol;
ACTH; plasma		 Strong Occupational stress; ERI & OC scales Strong High OC relates to lower ACTH & salivary cortisol; HPA axis hyporeactivity in teachers high in OC [39]
School teachers Cross-sectional Salivary cortisol Strong ERI; vital exhaustion; burnout; ERI & OC scales Strong No associations between cortisol & burnout, exhaustion, or ERI [40]
Childcare workers Cross-sectional Salivary cortisol Fair Physical workload; experience and evaluation of work questionnaire (VBBA) Fair Higher cortisol, particularly at beginning of day, related to lower-quality caregiving behavior above & beyond other predictors [41]
Nursery & primary school teachers Experimental Salivary cortisol Fair Burnout; Spanish burnout inventory Fair CBT intervention reduced psychosomatic complaints & sig. increased cortisol levels pre- & post-intervention [42]
School teachers Experimental Salivary cortisol Fair Burnout; psychological distress; symptom checklist 90-R; MBI-ES Strong Mindfulness intervention reduced psychological symptoms & burnout, & increased cortisol. Control condition had decreases in cortisol functioning overtime & increases in burnout [43]
Childcare workers Cross-sectional Salivary cortisol Fair Perceived stress; TICS Fair Perceived stress predicted quality of care; cortisol did not differ between home- & center-based care [44]
Early career teachers Experimental Salivary cortisol; CAR Strong Perceived stress; burnout; MBI Strong Intervention showed decrease in perceived stress but not decrease in burnout; CAR & average resting cortisol decreased from baseline to week 6; pre- & post-session salivary cortisol levels show immediate decrease in cortisol for weeks 4 to 6 [45]
Middle school teachers Longitudinal Salivary cortisol Fair Perceived stress; burnout; MBI, PSS Fair Depersonalization & ambition were associated with less steep CAR. In contrast, ambition & perceived stress were associated with less steep sAA awakening response [46]
Middle school teachers Cross-sectional Salivary cortisol Fair Burnout; perceived stress Fair CAR was blunted in the spring compared to the fall; effective emotion regulation buffered this effect [14]
Secondary school teachers Cross-sectional Salivary cortisol; immune assay Fair Job strain Fair No association between job strain & salivary cortisol/sAA. Older teachers & special needs teachers exhibited higher stress levels with lower log salivary IgA levels [47]
School teachers Cross-sectional Salivary cortisol Fair Burnout; occupational stress Good No sig. associations between salivary cortisol or CAR with burnout or job satisfaction [48]
Early childcare workers Cross-sectional Salivary cortisol Strong Work demands & resources Fair Minor associations between cortisol activity & job resources & dem&s. Cortisol activity related to pedagogical work & teamwork; higher quality teamwork, the lower morning cortisol values [49]
Early childcare workers Cross-sectional Salivary cortisol; sAA Strong Burnout; work engagement; MBI Strong No associations among stress biomarkers, work engagement & burnout. No relation between cortisol & either burnout or job satisfaction. Teachers with high burnout showed lower job satisfaction but no cortisol differences [50]
Nursery schoolteachers Cross-sectional Salivary cortisol Fair ERI Strong No association between ERI or OC & biomarkers [51]
Nursery schoolteachers Cross-sectional Salivary cortisol; DHEA Strong Job strain; job content questionnaire Fair Negative association between DHEA & social support [52]
Kindergarten teachers Cross-sectional Hair cortisol Strong ERI; occupational stress Strong Positive relationship between ERI & hair cortisol [53]
Kindergarten teachers Cross-sectional Hair cortisol Strong NFR; job demands Strong NFR related to higher hair cortisol; seen as precursor to chronic fatigue [54]
Kindergarten teachers Cross-sectional Hair cortisol Strong Emotional labor Fair Emotional labor related to increased HPA axis activity in hair cortisol; NFR negatively related to hair cortisol [55]
School teachers Cross-sectional Salivary cortisol Strong Burnout; perceived stress; MBI, PSS, TBS Strong High levels of burnout associated with blunted cortisol.
Differential effects of chronic stress & burnout on HPA axis		 [56]
School teachers Experimental Salivary cortisol; BP; HR Strong burnout; MBI, TSI Strong Mindfulness intervention decreased depression, burnout, anxiety, & occupational stress. No sig. physiological changes 3 months later [57]
School teachers Cross-sectional Salivary cortisol; HR Strong Burnout; teacher self-efficacy; MBI, TSES, PANAS Strong Self-efficacy protective for biomarkers; improved HRV & attenuated morning cortisol [58]
Preschool teachers Cross-sectional Salivary cortisol Fair Subjective stress; fatigue; job demands Fair High stress teachers had higher CAR; high stress teachers engaged in more pedagogical preparation than low stress teachers, suggesting preparation & social support may be protective [59]
School teachers Longitudinal Salivary cortisol Fair Job strain Fair Burnout associated with blunted cortisol response; Job strain/work stress associated with elevated cortisol levels [60]
School teachers Longitudinal Blood sample Good Occupational stress; stress coping styles (adapted measures for teachers) Fair Sig. changes in blood chemistry, including cortisol & alcohol indicators over time; changes in physiological responses related to increases in stress. Blunted cortisol response at time 2 one year later [61]
Elementary school teachers Experimental Salivary cortisol Fair Occupational stress; perceived stress; anxiety; depression; OSI, ASS Strong Stress management intervention showed short-term reductions in depression, anxiety & stress. Both groups showed reduction in salivary cortisol at post-test [62]
Kindergarten teachers Person-centered cross-sectional Salivary cortisol Fair Occupational stress Fair Poorly-trained end-career teachers had blunted cortisol & flatter slopes compared to other teachers. Education & experience variation (combined with similar levels of well-being at work, own poverty risk, & class size) set teachers apart from each other [32]
Primary school teachers Cross-sectional Salivary cortisol; sAA; HRV Strong Perceived stress; TICS Strong Higher cortisol & perceived stress on workdays compared to free days; lower HRV on workdays compared to free days [63]
 Cardiovascular system
School teachers Cross-sectional BP; urinary hormone excretion Strong Occupational stress; JCQ Fair Teachers had lower BP & lower urinary hormone excretion than nurses; occupational stress not related to biomarkers [64]
Elementary school teachers Experimental BP; HR Fair Anxiety Poor Aromatherapy may have positive impacts on cardiovascular indicators of stress [65]
Primary school teachers Cross-sectional BP Poor Quality of life Poor A combination of chronic health conditions (obesity, hypertension) negatively impacts health among rural teachers [66]
Elementary school teachers Experimental BP; HRV Fair Workload; anxiety; BAI, objective number of classes taught each day Fair Older teachers benefit more from aromatherapy than younger teachers; BMI moderates aromatherapy impact on teacher anxiety & stress [67]
Preschool & primary school teachers Cross-sectional HRV Fair Work place location Poor Rural teachers had higher HRV than city teachers, indicating better autonomic control [68]
Secondary school teachers Cross-sectional BP Poor Stress cognitions; perceived stress; stress cognitions questionnaire, BFB, stress-short test Strong Strong relationships between BP & psychological features; Associations between lower BP & mood moderated by situational stress [69]
 Immune system
School teachers Experimental Immune assays, IL-6 Strong ERI; OC Strong Less effective anti-inflammatory regulation by IL-6 in teachers suffering from chronic work stress (ERI) [70]
School teachers Cross-sectional Immune assays; salivary cortisol Strong ERI; vital exhaustion; anxiety; depression Strong Increased pro-inflammatory activity in teachers high on ERI & OC [71]
High school teachers Experimental Immune assays; ATCH; blood cortisol; HR; BP Strong Daily hassles Fair No stressor effect on endocrine variables; increases in HR & BP blood pressure, with similar effect across high & low stress groups. Differences in NK & T cell responses in low & high stress groups [72]
Primary school teachers Cross-sectional Immune assays for IgA, IgG, IgM, C1-INH, C3; urine sample Strong Occupational stress; JSRS Fair In teachers, immunoglobin (IgA, IgG, & IgM) concentrations correlated with work-related problems [73]
School teachers Cross-sectional Immune assays for TNF; IL-4; IL-10 Strong Burnout; MBI Strong Higher total burnout symptoms relate to higher TNF levels & a higher TNF/IL-4 ratio. Higher levels of burnout relate to decrease IL-4 levels [74]
Note. ACTH = adrenocorticotropic hormone; ASS = anxiety and stress scale; BAI = beck anxiety inventory; BMI = body mass index; BP = blood pressure; CAR = cortisol awakening response; CBT = cognitive behavioral therapy; DHEA = dehydroepi & rosterone; ERI = effort reward imbalance; HPA = hypothalamic pituitary axis; HR = heart rate; HRV = heart rate variability; IgA = immunoglobulin A; IgG = immunoglobulin G; IgM = immunoglobulin M; IL = interleukin; JCQ = job content questionnaire; JSRS = job stress rating scale; MBI-ES = Maslach burnout inventory-educators survey; NFR = need for recovery; OC = overcommitment; OSI = occupational stress indicator; PANAS = positive and negative affect schedule; PSS = perceived stress scale; sAA = salivary alpha amylase; TBS = teacher burnout scale; TICS = trier inventory of chronic stress; TNF = tumor-necrosis-factor; TSES = teacher self-efficacy scale; TSI = teacher stress inventory.