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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 156-162

Evaluation of perceived social stigma and burnout, among health-care workers working in covid-19 designated hospital of India: A cross-sectional study


1 Department of Psychiatry, GMERS Medical College and Civil Hospital, Ahmedabad, Gujarat, India
2 Department of Obstetrics and Gynecology, GMERS Medical College and Civil Hospital, Ahmedabad, Gujarat, India

Date of Submission15-Jun-2021
Date of Decision08-Aug-2021
Date of Acceptance24-Aug-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Bhumika Rajendrakumar Patel
37/A, Rajanpark Society, Opp. Brahmjyot School, Mogri Janta Road, Post: Mogri, Anand, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/shb.shb_54_21

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  Abstract 


Introduction: The coronavirus disease 2019 (COVID-19) pandemic has notably changed the working and community environment for health-care workers (HCWs) leading to burnout and feeling of being stigmatized by the community due to their work. This study aims at assessing the prevalence of burnout, perceived social stigma, and their demographic and work-related predictors. Methods: A cross-sectional study using Oldenburg Burnout Inventory and perceived stigma scale was carried out among 348 HCWs in COVID-19 designated hospital at Ahmedabad about 6 months after the onset of the outbreak in September 2020. The prevalence of burnout was assessed in two dimensions: disengagement and exhaustion. Severity of each was measured on low, moderate, and high levels. Results: Total 348 HCWs participated in study with a mean age of 28.05 ± 6.75 years. Two hundred and sixty-five (76.15%) HCWs experienced burnout and 200 (57.47%) high levels of perceived stigma. The level of burnout was measured on three severities. Factors which predict high burnout are female gender, lower education, unmarried status, living in a nuclear family, and high perceived stigma. Work characteristics such as duty hours, days of working, monthly income, and work experience does not predict burnout. Intern doctors had high burnout (87.25%, χ2 = 28.067, P < 0.001) while nurses had high perceived stigma (70.97%, χ2 = 14.307, P < 0.05). Perceived stigma is positively correlated with burnout (r = 0.26, P < 0.001) with its both components, disengagement (r = 0.19, P < 0.001) and exhaustion (r = 0.30, P < 0.001). Conclusion: Burnout and stigmatization are prevalent among HCWs. Psychological interventions needed to reduce their burden and improve quality care during pandemic.

Keywords: Burnout, COVID-19, health-care worker, social stigma


How to cite this article:
Patel BR, Khanpara BG, Mehta PI, Patel KD, Marvania NP. Evaluation of perceived social stigma and burnout, among health-care workers working in covid-19 designated hospital of India: A cross-sectional study. Asian J Soc Health Behav 2021;4:156-62

How to cite this URL:
Patel BR, Khanpara BG, Mehta PI, Patel KD, Marvania NP. Evaluation of perceived social stigma and burnout, among health-care workers working in covid-19 designated hospital of India: A cross-sectional study. Asian J Soc Health Behav [serial online] 2021 [cited 2021 Oct 24];4:156-62. Available from: http://www.healthandbehavior.com/text.asp?2021/4/4/156/326956




  Introduction Top


The novel coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China, in December 2019. The World Health Organization (WHO) officially declared it a pandemic on March 11, 2020. According to the data available on October 25, 2020, confirmed cases and deaths across globe are 42,512,186 and 1,147,301, respectively.[1] Respiratory infectious disease outbreaks prompt international response involving thousands of health-care workers (HCWs). This response is known to increase the risk of developing mental health problems among them in both short and long term. Numerous studies show that the prevalence of anxiety, burnout, depression, posttraumatic stress disorder, somatization, and sleep disorders among HCWs working during COVID-19 pandemic is higher than normal.[2],[3],[4] Such outbreaks were associated with significantly high morbidity and mortality among HCWs. Practicing social distancing which is necessary to prevent transmission of pathogen can give rise to stigma and discrimination.[5]

Social stigma in the context of coronavirus disease 2019

Stigma in the context of health refers to as labeling; stereotyping and discrimination against people because of illness. Stigma attached to disease can be as minor as avoidance or as dramatic as physical aggression. Main drivers of such stigmatization include fear of infection and lack of awareness about spread. Lack of adequate research on transmission and therapeutic approaches increases fear among the public leading to mistrust in health-care services.[6] As the number of cases increases, incidences of stigmatization toward HCWs, patients, and survivors also increase. In India, media reports claimed incidents where HCWs faced difficulty in finding accommodation and public transport. They were asked to vacate the rented houses, denied basic essential goods at shops, and even physical violence was reported against them.[7] Stigma shown by the community leads to creating a nonsupportive environment for HCWs, adding to their burden. Stigma has high impact on HCWs outcome. They start experiencing symptoms of fatigue, burnout,[8] and depressive symptoms as well.[9]

Burnout and its impact on health-care workers

Burnout was first described by American-German psychologist Herbert Freudenberger in 1974.[10] According to the international classification of diseases-11, the WHO described burnout as occupational phenomenon characterized by feeling of energy depletion or exhaustion, increased mental distance from one's job (disengagement), reduced professional efficacy.[11] Usually, burnout occurs following long-term exposure to occupational risk factors but in emergencies like pandemic, HCWs can easily experience symptoms of burnout within a short period. Work factors (increased workload, long duty hours),[12],[13] personal factors (work life imbalance, poor mental health, sleep deprivation, disrupted social support, and stigmatization),[8],[12],[13] and organizational factors (shortage of personal protective equipment, lack of preparedness and emotional support, workload expectations, insufficient rewards)[12],[13],[14] are identified as risk factors for burnout. In addition, allotted duties with insufficient training,[14] direct exposure to COVID-19 patients, are associated with increased stress and burnout in HCWs.[15] Such psychological distress and burnout affect HCWs decision-making, attention, and execution. They became prone to experience somatic symptoms,[16] depression, increase in substance use.[17],[18] These consequences will lead to reduced work productivity, quality of patient care and their satisfaction, and increase medical errors.[17]

One-fourth of Indian HCWs are suffering from burnout symptoms.[19] India is currently in the second position globally in terms of confirmed cases of COVID-19. Burden on HCWs is at peak now. Due to such increasing workload, symptoms of burnout tend to increase in intensity. In India, we have limited data on such psychological disturbances faced by HCWs working currently in COVID-19 pandemic.[20],[21],[22] Therefore, it is necessary to quantify stigmatization and burnout faced by HCWs. This will help our nation to build a healthy workforce in the current pandemic.


  Methods Top


Study design

We conducted a cross-sectional study during COVID-19 pandemic to evaluate the perceived social stigma and level of burnout among HCWs who were taking care of COVID-19 patients at GMERS Medical College and Civil Hospital, Sola located in Ahmedabad, Gujarat, India. The study was conducted on online platform using Google Forms, about 6 months after the onset of the outbreak.

Participants

Participants were recruited from a government-designated hospital for COVID-19 in Sola, Ahmedabad from 1 to September 25, 2020, using purposive sampling method according to inclusion criteria. The study population included physicians or specialist doctors, resident doctors (including junior residents, postgraduate students, and senior residents), intern doctors, registered nurses, and other HCWs (allied health-care professionals [including ayurvedic doctor, homeopathic doctors, physiotherapists, clinical psychologists], technicians [laboratory and radiology technicians], clerical staff, maintenance workers) who had taken care of COVID-19 patients at any time during the outbreak and who were willing to participate in study. Exclusion criteria were those unwilling to take part.

Ethical consideration

The institutional ethics committee, GMERS Medical College and Civil Hospital, Sola, having DCGI registration number ECR/404/Inst/GJ/2013/RR-20 granted approval for the study. A researcher then sent the online link containing study pro forma to potential participants. After opening link, the first section explained about the purpose of the study, its voluntary nature, anonymity, and the maintenance of confidentiality. If they agreed to take part, they were asked to give consent by clicking to the next section to move forward and to complete questionnaires. We converted questionnaires into vernacular languages in Gujarati and Hindi for those who have difficulty with English language.

Measures

The data collection instruments included three parts:

The first part of the tool asked questions on sociodemographic and work-related characteristics. Sociodemographic characteristics include age, sex, religion, education, marital status, type of family, and staying with family or not during COVID duty. Work characteristics include work category, years of work experience, and monthly income. This section also asked whether the respondent had been involved in care of COVID-19 patients, their duty hours per day, and days of working per month.

The Stigma Scale – The second part of the tool asked questions about perceived social stigma. A stigma scale, which measures the perceived stigma of HCWs regarding COVID-19, was prepared by Uvais et al.[22] He prepared this scale based on the questionnaire used to study stigma among nursing staff during Middle East respiratory syndrome coronavirus outbreak.[23] The stigma scale includes 13 items, each of which is scored on 5-point Likert-type scale from strongly disagree (0) to strongly agree (4). The total score ranges between 0 and 52, with a higher score indicating that HCWs perceived greater stigma. Cutoff score for perceived stigma is set at 26.[22]

Oldenburg burnout inventory (OLBI) – Third part of the tool asked questions about burnout using OLBI. To limit the study to burnout related to COVID-19, the phrase “due to COVID-19” was added to each item. Positive and negative wording overcomes the shortcoming of Maslach Burnout Inventory (MBI) and makes OLBI a better alternative to widely used MBI. OLBI was shown to be simple, comprehensive, self-explanatory with excellent psychometric properties to measure burnout in HCWs.[24],[25]

The OLBI has two dimensions – Exhaustion and disengagement. Each subscale consists of eight items, and four are positively worded and four negatively. The positive and negative exhaustion and disengagement items were presented in mixed order. The questionnaire has 16 items, and each item is responded to on four Likert scales; strongly agree – 1, agree – 2, disagree – 3, strongly disagree – 4. Reverse scoring is applied to the items marked with an “R” in the instrument such that strongly agree is scored-4 and strongly disagree-1. In all instances, higher scores show higher exhaustion and disengagement. Threshold values for the classification of burnout into “high,” “moderate,” and “low” levels were calculated by splitting the raw scores into quartiles. The data collection was divided into percentiles of 25th, 50th, and 75th. The returned thresholds for the total OLBI scale were 33, 37, 42, respectively. As such, the burnout scores were classified into low, moderate, and high.[26] We defined “burnout” as obtaining a moderate or high score in either disengagement or exhaustion components.

Statistical analysis

Objectives for study were to know the prevalence of burnout and perceived stigmatization. Measuring severity of burnout and predictors of burnout was also an objective. Data entry and analysis were done using the Statistical Package for the Social Sciences software version 26 (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp). Continues variables were summarized using mean and standard deviation (SD) while categorical variables were summarized using proportions. Correlational statistics between the variables in study was done by Pearson correlation. After categorizing into severity, we get two groups, burnout present and absent, similarly, considering cutoff of ≥26 for stigma, two groups of stigma, present and absent. Chi-square test was done to find correlation between these groups with their sociodemographic and work characteristics. Furthermore, regression analysis was performed to find predictors for burnout. The predictor variables were forcedly entered into the regression analysis in order, based on researcher's presumptions from various findings of other related studies.[4],[8],[16],[27],[28] The level of significance was decided by P < 0.05.


  Results Top


[Table 1] shows demographic characteristics of participants. The mean (± SD) scores of the disengagement, exhaustion components, total burnout, and perceived stigma questionnaire were 18.3 ± 4.22, 19.03 ± 4.44, 37.33 ± 8.20, and 26.65 ± 9.55, respectively. The mean exhaustion component of burnout score was higher than the disengagement component.
Table 1: Demographic characteristics of participants (n=348)

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The psychometric validation of scales (reliability statistics)

The psychometric validation of scales used in the present study was conducted using Cronbach's alpha coefficient, which should be higher than 0.8. Cronbach's α value for Oldenburg burnout and perceived stigma scale was 0.909 and 0.853 which indicates high internal consistency.

Prevalence of burnout and stigma

Prevalence of burnout was 76.1% (n = 265) and of perceived social stigma was 57.47% (n = 200). The prevalence of disengagement was 77% (n = 268) and of exhaustion was 81% (n = 282). Frequency with its percentages among each severity category is shown in [Table 2].
Table 2: Distribution according to severity of burnout

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Descriptive statistics and correlations among variables of study

[Table 3] shows that perceived stigma is positively correlated with burnout (r = 0.26, P < 0.001) and its both components, disengagement (r = 0.19, P < 0.001) and exhaustion (r = 0.30, P < 0.001). Furthermore, stigma is positively correlated with duty hours (r = 0.10, P < 0.05). Age and work experience are negatively correlated with burnout and its components.
Table 3: Pearson correlation statistics among variables in study

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Predictors of burnout

For disengagement component of burnout, Chi-square test reveal significant differences in demographic characteristics of education level (χ2 = 12.200, P < 0.05), marital status (χ2 = 7.76, P < 0.05), type of family (χ2 = 19.42, P < 0.001), and staying with family during COVID duty (χ2 = 4.61, P < 0.05). Hence, education level of up to graduation, unmarried status, living in nuclear family, and staying with family during COVID duty show more disengagement.

For exhaustion component of burnout, Chi-square test reveals significant differences in demographic characteristics of gender (χ2 = 16.32, P < 0.001), education level (χ2 = 20.81, P < 0.001), marital status (χ2 = 8.58, P < 0.05), type of family (χ2 = 10.96, P < 0.05), and staying with family during COVID duty (χ2 = 5.43, P < 0.05). Therefore, females, higher education level, unmarried status, living in joint family, and staying with family during COVID duty show more exhaustion.

Accordingly, significant findings for burnout were found in female gender (χ2 = 14.6, P < 0.001), among graduated (χ2 = 18.17, P < 0.05), unmarried (χ2 = 10.18, P < 0.05) HCWs, those who are living in nuclear family (χ2 = 17.46, P < 0.001) and those staying with family during their COVID duty (χ2 = 7.08, P < 0.05).

HCWs designation posts significantly correlated with burnout level (χ2 = 28.067, P < 0.001) and its both disengagement (χ2 = 22.70, P < 0.001) and exhaustion (χ2 = 21.82, P < 0.001) components. Interns have more burnout. For perceived stigma, only designation (χ2 = 14.307, P < 0.05) of HCWs shows significant differences. Nurses have more perceived stigma.

Regression analysis was done to predict these sociodemographic and work-related predictors for burnout. [Table 4] shows that gender, education level, marital status negatively predict burnout whereas type of family and perceived stigmatization positively predict burnout. All these variables predict burnout for 21% of variance.
Table 4: Multiple regression analysis of various sociodemographic and work characteristics on burnout

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  Discussion Top


The objective of our study was to highlight the prevalence of perceived social stigma and burnout among HCWs and to evaluate impact of sociodemographic and work-related factors on burnout. Key findings in the study reveal that there is a high level of perceived social stigma and burnout among HCWs working in the current COVID-19 pandemic.

We found that significantly higher prevalence of burnout in HCWs than was reported by the studies conducted across India before the onset of pandemic. A systematic review and meta-analysis of 15 studies done in various parts of India during pre-COVID-19 era which includes 3845 HCWs showed the prevalence of 24% in emotional exhaustion and 27% in depersonalization domain.[19] In comparison, our study found that 81% of HCWs have moderate to severe exhaustion and 77.3% of HCWs have moderate to severe disengagement. These findings suggest a considerable rise in burnout levels of HCWs due to the pandemic. We also found high levels of perceived social stigma (57.47%) faced by HCWs during their work in pandemic. These results are novel, as to our knowledge, burnout and perceived social stigma among HCWs during pandemic has been studied only in few studies in India.[21],[22]

A global survey to find factors contributing to burnout during COVID-19 pandemic which included HCWs from 60 countries reports that the prevalence of burnout was 51% which is higher than previously reported rates and more in high income countries.[14] Studies done during pandemic among 1422 Spanish HCWs show that 41.1% were emotionally drained.[2] Two studies were conducted on 1132 intensive care unit specialist and 468 emergency physicians in France[3] and Canada,[27] respectively. Both studies reported high levels of burnout among them. Another study done in Iran after 2 months of pandemic showed 53% burnout among HCWs.[28] Studies among 393 physician trainees in Japan[15] and 100 resident doctors in Romania[29] show average burnout of 43.6% and 76%, respectively. Most of these studies used MBI to measure burnout.

A first Indian study on burnout among HCWs using Copenhagen Burnout Inventory during ongoing pandemic includes 2026 HCWs reports 44.6% personal burnout, 26.9% work-related burnout, and 52.8% pandemic-related burnout.[21]

Regarding severity of burnout, findings in our study show that 193 (55.46%) had moderate and 76 (21.84%) had high levels of disengagement; 200 (57.47%) had moderate and 82 (23.56%) had high levels of exhaustion. Similar findings were noted in a study done in Italy. They found moderate and severe emotional exhaustion in 35.7% and 31.9% subjects, respectively. Similarly, 14% and 12.1% experience moderate and severe level of depersonalization, respectively.[4] A Chinese study on all front-line staff including HCWs, community workers, commanders, police, journalists, market administrators also suggests 75.7% and 18.7% experienced symptoms of moderate and severe fatigue, respectively.[30]

As age is negatively correlated with burnout, younger the age more is the burnout as was noticed in the index study. Female gender, lower education, unmarried status, and living in a nuclear family were some of sociodemographic factors identified as predictors for burnout. Furthermore, females are prone to experience more exhaustion than males. Numerous studies also support our findings. Higher severity of burnout in younger age groups may possibly be due to higher proportion of them working in the pandemic, lower resilience, and less work exposure.[28],[30] Females are proved to experience burnout symptoms[8],[30] more in emotional exhaustion.[4],[16],[28] Depersonalization was also found more in females in one study.[2] Lack of family support has been shown to be a precipitating factor for experiencing early fatigue.[30]

Among work characteristics, years of work experience, hours of working per day, and days of working in a month were not predicts burnout and perceived stigma. These findings were different from some of the studies where they find more burnout in less experienced HCWs.[4],[28],[30] Working in shift duty, weekly working hours, daily workload have not shown any association with burnout and stigmatization in some of the studies.[8],[28] Greater number of shifts per week was associated with high exhaustion in emergency physicians.[27]

Among various designations, burnout was found at higher levels among intern doctors. Nurses have experienced more perceived stigma than any other HCWs. Similar findings suggestive of high burnout and other psychological disturbances in nurses during pandemic have been shown in a global study.[14] Nurses tend to develop more frequent somatic symptoms during pandemic.[16] Possible factors causing high prevalence of burnout in intern doctor in our study were worries about career, being not involve in decision-making process and frequent rotation with changing patient profile.

Various other factors contributing in experience of psychological distress during pandemic included increased workload, fear of infection, lack of perceived support from family due to isolation,[4] limited organizational support,[14] exposure to COVID-19 patients,[4],[15] fear of carrying infection to home.[21]

Our study also found that the prevalence of perceived social stigma was 57.47%. Correlation analysis in our study confirmed positive correlation between stigma and burnout. A correlation study done in southern Italy during the current pandemic on 260 HCWs shows stigma negatively impacts satisfaction and positively impacts burnout and fatigue among HCWs.[8]

Burnout and stigmatization negatively affect HCWs outcome. Emotional exhaustion and depersonalization were positively and significantly related to symptoms of posttraumatic stress, anxiety, depression,[2] and frequent experiences of somatic symptoms.[16] Another study conducted in India on 58 HCWs also shows high level of perceived stigma (62.1%) and it was significantly associated with high level of perceived stress (63.8%) among HCWs.[22]

Physician burnout is associated with sub-optimal patient care, more patient safety incidents and less patient satisfaction. This was observed in a systematic review and meta-analysis having 47 studies.[17] High baseline burnout levels in HCWs are likely to be aggravated by acute stress posed by pandemic which not only risk their mental health but also affects their health-care delivery adversely. These would lead to increased turnover, early retirement, and decreased percentage of professional efforts, which is not desirable especially during the pandemic.[18]

Therefore, it is necessary to study predictors of burnout and perception of stigma during pandemic as this would help in providing training and information to our frontline workers to ensure adequate levels of satisfaction and to prevent burnout. Increasing awareness, ensuring better mental health services, and improving organizational policies are some of evidence-based approaches for intervening to mitigate the psychological impact of COVID-19.[31] Some institutions encourage interventions such as stress management and relaxation skills, yoga, mindfulness, grief counseling, music and art therapy, and improving communication skills.[32]

Limitations

Cross-sectional design of study, lack of control group, single academic medical center, and limited sample size are some of the limitations in our study. Longitudinal study in the future might provide more information because of the ongoing nature of pandemic. Multicentric study involving larger sample size with control group for comparison will make the study result more generalizable.


  Conclusion Top


Major findings in our study represent high prevalence of burnout and stigma among HCWs. Burnout is prevalent at higher than previously reported rates among them during their work in pandemic. Few nonmodifiable factors which predict burnout are gender, age, and education. Social factors such as marriage and living in joint family reduce experience of burnout symptoms. As stigma positively predicts burnout, impact of stigmatization is serious. The information presented is relevant in an order to build healthy workforce and to improve mental health of our frontiers in future waves of COVID-19 and similar situations. More specific early interventions and comprehensive support are required both from administrators and society.

Acknowledgment

  • We are thankful to Dr. N.A. Uvais, Department of Psychiatry, Iqraa International Hospital and Research Center, Calicut, Kerala, India, for providing perceived stigma scale for use
  • We are thankful to Dr. Pradhyuman Chaudhry, assistant professor, MD psychiatry, GMERS Medical College and Civil Hospital, Sola, Ahmedabad, for their constant support
  • We would like to express our deepest appreciation to all HCWs for their time and effort to take part in study in a pandemic situation.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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