Abstract:
Background: Wellbeing of healthcare workers (HCWs) is important for the effective functioning of health systems; it impacts the health service quality and patient outcome. HCWs are at an increased risk of stress and burnout both the nature of their work and their context of their work, but this has been little investigated in low income countries. The aim of this study was to: (1) explore the conceptualisations of wellbeing, stress and burnout, (2) assess the level of burnout and, professional satisfaction and (3) evaluate the short-term outcome of burnout and associated factors in the context of mental health service provision among HCWs providing healthcare in a rural districts in Southern Ethiopia. The study has followed a mixed methods approach divided into three overlapping studies. Study one (conceptualisation of burnout) Methods: was a qualitative study conducted in the Silti zone. A total of 52 frontline primary HCWs participated in either the in-depth interviews (n=18) or Focus Group Discussions (FGDs) (4 groups, total n=34). Data were analysed using thematic analysis. Results: Most participants conceptualised wellbeing as absence of stress rather than as a positive state. Many threats to wellbeing were identified. For facility-based workers, the main threats to wellbeing were inadequate supplies leading to fears of acquiring infection and concerns about performance evaluation. For community -based health workers, the main threat was role ambiguity. Workload and economic inefficiency were concerns for both groups. Burnout and its symptoms were recognised and projected by most as a problem of other healthcare workers. Derogatory and stigmatising terms, such as, “chronics”, were used to refer to those who had served for many years and who appeared to have become drained of all compassion. Most participants viewed burnout as inevitable if they continued to work in their current workplace without career progression. Structural and environmental aspects of work emerged as potential targets to improve wellbeing, combined with tackling stigmatising attitudes towards mental health problems. An unmet need for intervention for healthcare workers who develop burnout or emotional difficulties was identified. Study two (level of burnout) Methods: was a sequential, mixed quantitative and qualitative methods study of HCWs working in all 66 rural primary healthcare facilities (n=145) of the Sodo district, South Ethiopia, where a new integrated mental health service was being implemented. First a quantitative cross-sectional survey was conducted. The Maslach Burnout Inventory (MBI) was the primary measure of burnout, comprising three domains: emotional exhaustion, cynicism and reduced feeling of personal accomplishment. Cynicism was excluded from most analysis because of poor internal consistency of the domain. A set of instruments measuring professional satisfaction and psychosocial stress were also included. All instruments were self-administered. To assist understandings of the quantitative findings, four FGDs were conducted with 17 community and 16 facility-based HCWs. Results: A total of 145 HCWs who had worked for a median of 5.0 (25 th and 75 percentiles or interquartile range (IQR) 0.4, 12) years participated in the study. Most participants were female (62.1%; n=90) and working in healthcare facilities (65.5%; n=86); a third were community-based health extension workers. The median score (IQR) on the MBI was 3 (0, 8) for emotional exhaustion, and 34 (24, 40) for reduced personal accomplishment. High depression symptom scores (adjusted Odds Ratio (aOR) 1.19, 95% CI 1.05, 1.34), poor social support (aOR 1.45, 95% CI 1.12, 1.86), and experiencing two or more stressful life events (aOR 1.41, 95% CI 1.12, 1.95) were associated with higher emotional exhaustion. Only about half (50.8%) reported a high level of job satisfaction. FGD participants spoke of high levels of burnout and job-related stress, which the participants believed was under-reported in the quantitative study due to the overwhelming expectations to be strong and exemplary in the eyes of the community. Study three (short-term outcome of burnout) Methods: was a longitudinal follow up of the study two participants (145 primary HCWs working in the Sodo district). Burnout was assessed at baseline (when the new service was being introduced), as part of the initial cross-sectional survey, and after six months. Multivariate logistic regression and generalised estimating equations (GEE) were used to assess the association between burnout and relevant work-related and psychosocial factors. Results were considered statistically significant whenever p-value was less than 0.05. th Results: A total of 136 (93.8%) of PHC workers were re-interviewed after six months. There was a non-significant reduction in the burnout level between the two time points. In GEE regression models, high depression symptom scores (adjusted mean difference (aMD) 0.56, 95% CI 0.29, 0.83 p<0.01), experiencing two or more stressful life events (aMD 1.37, 95% CI 0.06, 2.14 p<0.01) , being a community health extension worker (aMD 5.80, 95% CI 3.21, 8.38 p<0.01) and perceived job insecurity (aMD 0.73, 95% CI 0.08, 1.38 p=0.03) were significantly associated with higher levels of emotional exhaustion. Conclusion: Ethiopian primary healthcare workers, particularly community health workers, face job-related stress and experience symptoms of burnout, which may contribute to the dissatisfaction of both patients and HCWs. However, the overall prevalence of burnout was lower than expected. There was also little change in severity score in the short-term. At least in the short-term, there is no apparent negative impact on burnout of adding mental healthcare into the care portfolio of PHC workers. Recommendation: Longer term and larger scale studies are required to substantiate these findings and understand the issue in depth. Future qualitative studies need to be done to understand the expression and impact of burnout in this setting and how barriers to detection may be overcome. Contextually relevant interventions also need to be developed and tested, giving priority to community health workers. Preventive works such as routine screening of HCWs for job related stress might help to prevent burnout. Improving awareness about mental health and self -care may have impact on preventing burnout.