Alabama Rural Health Programs
Burnout is a state of mental exhaustion that affects human service professionals, (public service, volunteer, medical, human social service, educational organizations). Participants and settingAll Behvarzes (227 subjects) working in the western part of Tehran province, were eligible to participate in this study.
This study was cross sectional; therefore, we included all Behvarzes, without using sampling methods. The study was conducted between October 2009 and March 2010.
The data were gathered by self-administered questionnaires which were provided to Behvarzes by mail. The study was approved by The Medical School Ethics Committee of Iran University of Medical Sciences approved. InstrumentsThe following questionnaires were completed by the participants.Demographic Questionnaire: included items about their background characteristics.Maslach Burnout Inventory (MBI): it was developed by Maslach and Jackson, and has three domains of emotional exhaustion (EE) depersonalization (DP) and personal accomplishment (PA). Burnout was defined according to the original Maslach high-degree definition of burnout syndrome: the combination of high emotional exhaustion (≥ 27 points), high depersonalization (≥ 10 points), and low personal accomplishment (≤ 33 points).
High levels of EE and DP and low levels of PA indicate increased risk of burnout. This instrument has been found to be reliable, valid, and easy to administer among health workers 5 with a reliability coefficient of 86% in the Iranian population.General Health Questionnaire-12: Psychological symptoms were measured using the GHQ-12. This instrument showed a high sensitivity and specificity in the previous validation studies. In this study, we used Goldenberg's original scoring method. In this method, response category score is 0 and 0 for the first and second levels, and 1 and 1 for the third and fourth levels of each question. The final score of the questionnaire ranged from 0 to 12.Subjects with a score of 4 considered as suspected of having a mental disorder.Stainmentz questionnaire: The Stainmentz Scale is a 36-question Likert-type instrument that measures work related stress.
Answer to each item has five point scale ranging from 0 to 4 (0=never, 1=seldom, 2=sometimes, 3=frequently, and 4=always. Past administrations of the Stainmentz Occupational Stress Scale have yielded a 0.90 reliability coefficient, and have also shown to be a valid measure of occupational stress 13. In our study internal reliability consistency had a cronbach's α of 0.94. Statistical analysisData were analyzed using the SPSS for windows, version 15.0. Univariate analysis between categorical variables was assessed by chi-square test.
We used student t-test to compare means between the two groups.There was some missing data for variablesMental health: 201 (95%) of the study subjects answered all the 12 items of GHQ-12; out of which 144 (71%) had a score 4 and less (within the normal range for mental health), and 57 (28.4%) were suspected (GHQ score 4) to have mental disorders (82.1% female and 17.9% male, (without significant difference); 18.5% of the study subjects had a history of visiting a psychiatrist.Job stress: 153 subjects (72.1%) responded to this questionnaire. The mean score was 42.8 (± 27.16) ranging from 1 to 134. The mean score for female and male subjects was 43.42 (±26.6) and 41.98(±28.6) respectively, with no significant difference.
It is shown that up to 75% of subjects had a score of 62 or lower. The first quartile for this score was 23.Burnout of the subjects: The frequency of distribution in dimensions of Maslach burnout inventory is shown in. The mean score for the emotional exhaustion subscale was 14.46 (±9.7) with a score of more than cutoff score in 12.3% of the respondents. The mean score of depersonalization/cynicism subscale was 2.20 (± 3.4) with a score of more than cutoff score in 5.3% of the subjects. The mean score of the personal accomplishment subscale was 33.82 (±10.8) and 43% showed a high degree of inefficiency by achieving a score of less than cutoff score. Among 175 study subjects who responded to the three questionnaires, 17.6% (31 subjects) had moderate to severe level of burnout.
16.6% (29 subjects) had moderate level (high scores in exhaustion and cynicism subscales) and only 1% (2 subjects) had severe level of burnout. The statistical analyses were carried out on the subjects with moderate and severe levels of burnout. It is shown that 29 (16.6%) of 175 respondents had moderate and severe burnout; of whom only 2 (1.08%) fulfilled the criteria for severe burnout (one 48 year- old married woman, and another 28 year – old married man).Correlation between burnout and other variables: No significant association was found between marital status, education level, and gender with burnout level of the subjects.In our study, work experience was one of the factors which had a significant association with burnout.
The result showed an average work experience of 14.6 years (±8.8) in the subjects with burnout versus 11.0 years (±7.19) in subjects without burnout (P=0.01).Overall burnout level was significantly associated with mental health status. The mean score of GHQ for subjects with and without burnout was 6.21± 3.56 and 2.45±2.84 respectively (P=0.001).There was a significant correlation between burnout level and job stress. The mean score for Steinmentz’ test in Behvarzes with overall burnout (70.1± 20.5) was significantly more than the other Behvarzes without burnout (37.7±24.8) (P=0.001).The overall burnout syndrome was significantly correlated with abnormal mental health status (GHQ-124) (P=0.001).
DiscussionCurrently, more than 94% of rural areas in Iran are covered by PHC network. It means that essential primary health care is delivered through PHC network by Behvarzes. Therefore, attending to physical and mental health of PHC staff is one of the important tasks of health officers and policy makers in Iran.The main finding showed that 28.4% of the study subjects are suspected to be affected by a mental disorder; their stress level was low, and 17% of the cases suffered from burnout syndrome.In the current study, the mean score of the burnout questionnaire was 42.8 (± 27.16) ranging from 1 to 134. Among them, 17.6% (31 subjects) had moderate to severe level of burnout, and 16.6% (29 subjects) had moderate level of burnout. Burnout had a significant correlation with job stress and having a mental disorder. What is already known and possible explanation of the resultsThe prevalence of mental disorder among Behvarzes in this study correlated with the results of a population based study on the prevalence of mental disorder 14; and it seems that it is rather higher among Behvarzes (28.4%) than the general population (21%).Few studies have been carried out on the burnout of Behvarzes. This study has been conducted to evaluate the burnout, job stress and mental health condition of Behvarzes in west district of Tehran, the capital.In spite of increasing trend of job assignment to Behvarzes during the last 30 years, the level of job stress is not high and its mean score is in the first quartile.
In one study conducted in Zahedan, south east province of Iran, 40.5% of the Behvarzes were satisfied with their jobs, in terms of “working conditions and their co-workers”. However, they were not satisfied with “work load”, “organizational structure”, “promotion” and “payment”.The main distressful sources of job among Behvarzes in Mashhad, in north east province of Iran, were “high workload”, “role ambiguity” and “physical environment”. Nevertheless, in this study, the level of job distress was not considered abnormal, which may be due to “low external accountability”. Feeling of usefulness for the people who are living with them, may dilute the severity of job demand and distress. The results of the study on Behvarzes in Gazvin, central province of Iran, and Sabzevar, north part of Iran, demonstrated that the study subjects were satisfied with “living in the same village”, “being effective for the health of the local people”, “having regular training courses” and “being accepted socially with respect”.
Rural Health Anna Il
However, managerial issues such as “meeting their authorities regularly”, “having opportunities for promotion”, “high working hours”, and “environmental condition” were the main sources of job distress for them (, ). Therefore, it seems that job satisfaction among Behvarzes was moderate to high 15, 17, 18 and job stress was not distressful. What this study addsReducing burnout among mental health personnel can be made possible by improving their interpersonal relationship. Regarding burnout syndrome in Behvarzes, we could not find any study carried out in Iran. However, several studies evaluated the burnout syndrome among other medical staff such as nurses and medical doctors in Iran (, ). Comparing the results of other studies with that of the current study, it can be concluded that burnout is more severe among nurses and other medical staff than among Behvarzes. A study conducted in Italy showed that high levels of job distress affected nearly two-thirds of the psychiatric staff, and one in five staff members suffered from burnout syndrome.
Psychiatrists and social workers reported the highest levels of burnout, and support workers and psychologists reported the lowest levels.Although the scores of “emotional exhaustion” and “depersonalization/cynicism” were low, 43% of the study subjects expressed “inefficiency” and low “personal accomplishment”. Being in control of the occupational changes has a positive relation with a sense of self-competency. Participation in planning to improve quality of care and receiving consultations by health authorities, provide a good sense of self-control and self-efficiency to Behvarzes. Providing fruitful interaction between health officers will reduce the burnout level of Behvarzes and other staff working in Health Centers.As a conclusion, it seems that in spite of the fact that during the last 30 years Behvarzes have been assigned to increasing duties, the job stress and overly burnout are not distressful.
Improvement of self accomplishment by providing support for occupation and promotion, reducing job ambiguity, participating in planning new programs, reducing job conflicts and promoting self control on daily activities may help Behvarzes to feel more comfortable, have less stress and experience less occupational burnout. Strengths and limitation of the studyThe strength of the current study are as follows: the first study on primary health workers in our setting, using standard and valid questionnaires, assessing burn-out, mental health, and occupation stress simultaneously, and high responsiveness.This study has some limitations. The questionnaires were sent to subjects by ordinary mail without the supervision of interviewers; therefore, there was some missing data for the variables. We tried to complete the missing data, but there was no response from some subjects. In addition, the other limitation was related to the method of gathering data; some questions were not clear for Behvarzes, although, we tried to make the necessary clarifications by a phone call.