INTRODUCTION

Burnout is characterised as "a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed" by the International Classification of Diseases (ICD-11). It involves (i) sensations of physical or mental tiredness; (ii) a growing mental detachment from one's employment; (iii) emotions of pessimism or cynicism about one's career; and (iv) a decline in professional effectiveness. It is not categorised as a medical issue but rather as an occupational phenomena [1]. Despite various initiatives implemented throughout the globe, mental illness remains extremely stigmatized due to the presence of negative stereotypes in the community [2]. Numerous campaigns have paid particular attention to changing the attitude of healthcare providers, as they usually carry the same negative stigma towards mental illnesses as the community. This not only adds to the disease burden by averting the public from seeking medical help, but it also inflicts this stereotype in the culture of the medical society, thus causing future medical professionals to have the same mindset [3]. The major obstacle to the effective management of mental illnesses includes the stigma associated with mental illness [4, 5]. Detriment, incomprehension, and discrimination are the three main components of the stigma linked with such illnesses [6].

Mental illness stigma can be a barrier to grasping many opportunities in life and being deprived of equal chances in society [7]. Stigma can affect the campaign that supports the need for treatment. As a result of this, few people turn up for the treatment and the majority remain undiagnosed which in turn reduces the quality of life and increases the burden on the individual as well as the community [8]. Healthcare providers are generally perceived as empathetic with a positive mindset towards the patients offering them solicitous care. However, this might not always be the case, and the healthcare system itself might be adding to this stigma in some settings [9].

Mental illnesses are seen to be commonly linked with burnout in professionals. A study conducted in Japan explained the association of burnout with mental illnesses-related stigma. The findings showed that mental illness, associated stigma, and occupational exhaustion are all inversely correlated. Therefore, strict action must be taken against mental illness-related stigma to refrain from developing burnout [10]. A study conducted in USA and Lithuania showed a higher level of burnout in the US sample compared to Lithuania, the study concluded that the Lithuania sample was also found more resilient and adaptable to harsh working environments [11]. A qualitative study carried out in Ghana concluded that primary healthcare professionals mainly encounter job-related stress and experience burnout, which may act as a factor for the high turnover of staff and dissatisfaction of both patients and caregivers [12]. A study conducted in France examined the association between borderline personality depression and burnout. In females, burnout was associated with the “affective insecurity” and “impulsiveness” components of Borderline Personality [13]. A study conducted in Bahrain evaluated the link between mental illness stigma and evidence-based care provision and showed healthcare professionals who approved acquiring evidence-based practices reflected less stigma directed toward patients with mental illness [14].

Over the past few years, WHO has categorized “Burnout” as an officially diagnosable syndrome that results from chronic work environment stress. It affects almost a quarter of the workforce worldwide [15]. While due to mental illness specifically depression, 264 million people are affected around the globe. In low- and middle-income countries, 76% to 85% of people with mental illness receive no treatment. Burnout costs around $125-$190 billion every year in the US [16]. In Pakistan, the prevalence of mental illness is rising as it is considered a social taboo, so most cases go undiagnosed. The ever-increasing job burden on healthcare professionals is affecting their work productivity and increasing the chances of developing burnout as well as the stigma of mental illnesses hinders work productivity in such challenging environments. A research done in Pakistan highlighted that no considerable association was found between burnout and the doctor-patient relationship [17]. Another cross-sectional survey conducted in Pakistan on gynecological residents concluded high levels of burnout in government institutes as compared to private institutes [18].  A study conducted in Lahore concluded that the prevalence of high-degree burnout in physicians was higher than those reported internationally [19]. A study conducted on nurses of a tertiary care hospital in Pakistan signified that burnout in nurses was very common because of increased workload which can negatively affect their quality of life leading to compromised patients [20].

Burnout is a result of occupational workplace stress and the underpaid labor market. Keeping in view the inflation rate in Pakistan, healthcare professionals have to work more due to low salaries. Non-conducive work environment and long working hours add to the mental fatigue resulting in decreased quality of life. Mental illness is considered a societal taboo due to which most of the cases go undiagnosed and unreported. Society does not accept healthcare professionals to be suffering from any mental illness or stigma which adds to the misery of the professionals as they try to cope with their stressors and burn out on their own resulting in low productivity and compromised professional services provided to the patients. Limited studies have been conducted in Pakistan to identify the barriers associated with burnout and mental health among healthcare professionals. Therefore, the present study was designed to assess burnout and mental illness-related stigma among healthcare professionals in Pakistan.

MATERIALS AND METHODS

To examine burnout and stigma associated with mental illness among healthcare professionals in Pakistan, a descriptive cross-sectional study design was utilised. The correlation between burnout and the stigma associated with mental illness was discovered by this study. The Hamdard University's Ethical Committee granted permission for the current study to be conducted (Ref. No. HU/DRA/2022/085).  The study sites included hospitals (district headquarters, tertiary care hospitals), public and private health care facilities, medical institutes, industries, regulatory affairs departments, sales and marketing departments, and pharmacies in Pakistan. Doctors, nurses, and pharmacists were the respondents. As there was no updated or validated record of all healthcare professionals in Pakistan, convenience sampling technique was used for this study, and all respondents available at the time of data collection who were willing to participate were included in the study. The sample size was calculated using Rao soft at a 95% confidence interval and a 5% margin of error, which came out to be 382. Three pre-validated questionnaires Maslach Burnout Inventory (MBI) were used to assess the level of burnout in healthcare professionals. MBI has three sections: the first section explores emotional exhaustion; the second section assesses depersonalization, and the third section deals with personal achievement. It has 22 items which are scored on a Liker scale of 0 to 6, (0 = Never, 1= A few times per year, 2 = Once a month, 3 = A few times per month, 4 = Once a week, 5 = A few times per week and 6 = Every day). Each section was separately scored and then a total score of the entire questionnaire was calculated [10]. The generalized Anxiety Disorder Scale (GAD-7) was used to assess anxiety symptoms. It has 7 items and an additional subsidiary question. The 7 items are scored on a liker scale of 0 to 3, (0 = Not at all, 1 = Several days, 2 = More than half the days, and 3 = Nearly every day). The total is then calculated by adding all scores together. It is a widely used screening tool for assessing anxiety symptoms in an individual [21]. The Occupational Depression Inventory (ODI) was used to generate preliminary diagnoses of job-attributed depression and to assess the severity of work-related depressed symptoms. There are nine things in the ODI, plus a question about turnover intention. The 7 items are scored on a liker scale of 0 to 3, (0 = Never or almost never, 1 = A few days only, 2 = More than half the days, and 3 = Nearly every day). The total is calculated by adding all scores together [13]. Data was collected from January to May 2022 and all the collected data was then checked, cleaned, coded, entered, and statistically analyzed using Statistical Package for Social Science (SPSS) version 21. Descriptive statistics comprising frequency and percentages were calculated. Non-parametric tests as well as correlation and regression were performed to find out the differences as well as associations among different variables.

RESULTS AND DISCUSSION

of the 382 respondents, 51.3% (n=196) were men and 49.7% (n=186) were women. The majority of the respondents 38% (n=145) were from the age group of 25-30 years. Of the total respondents, 34% (n=130) were single and 63.1% (n=241) were married. The income level varied across respondents where the majority of the respondents 40.8% (n=156) earned between Rs 51,000- Rs 100,000. Of the total respondents, 38% (n=145) were Doctors, 34.6% (n=132) were Pharmacists and 27.5% (n=105) were Nurses. A detailed description is given (Table 1).

The mean score for MBI was 60.32 (± 15.58) that indicated a high level of burnout, GAD-7 was (7.7, ± 4.53) which indicated a mild level of anxiety among healthcare professionals, ODI was 9.91 (±5.86) indicating a moderate level of occupational depression (Table 2).

No considerable variation (p > 0.05) in Maslach Burnout Inventory scores was seen among healthcare professionals in association with gender, setting, age, years of experience, income, profession, and working setting. A considerable difference (p ≤ 0.05) in Generalized Anxiety Disorder scores was observed among healthcare professionals in relation to gender. Male healthcare professionals were found to have relatively more generalized anxiety disorder in comparison to female healthcare professionals. However, there wasn’t a considerable difference (p > 0.05) between other demographic characteristics for healthcare professionals. A significant difference (p ≤ 0.05) in Occupational Depression Inventory scores was observed among healthcare professionals in relation to gender, years of experience, profession, and working setting. Male healthcare professionals had comparatively more occupational depression than female healthcare professionals. Moreover, healthcare professionals with experience greater than 20 years had more occupational depression. Nurses were found to have more occupational depression in comparison to doctors and pharmacists. In relation to the work setting, community pharmacists were found to have more occupational depression. However, no significant difference (p > 0.05) was observed among other demographic characteristics for healthcare professionals. The analysis reported Spearman’s relationship amongst burnout dimensions as well as occupational depression. Burnout and ODI showed a shaky positive association. All of the burnout dimensions were connected (Table 3).