Factors associated with burnout amongst healthcare workers providing HIV care in Malawi

Autoři: Maria H. Kim aff001;  Alick C. Mazenga aff001;  Xiaoying Yu aff003;  Katie Simon aff001;  Phoebe Nyasulu aff001;  Peter N. Kazembe aff001;  Thokozani Kalua aff004;  Elaine Abrams aff005;  Saeed Ahmed aff001
Působiště autorů: Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi aff001;  Baylor College of Medicine International Paediatric AIDS Initiative, Texas Children’s Hospital, Houston, Texas, United States of America aff002;  University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America aff003;  Ministry of Health, Department of HIV and AIDS, Lilongwe, Malawi aff004;  ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America aff005;  College of Physicians and Surgeons, Columbia University, New York, New York, United States of America aff006
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222638



High rates of burnout have been reported in low and medium income countries and can detrimentally impact healthcare delivery. Understanding factors associated with burnout amongst health care workers providing HIV care may help develop interventions to prevent/treat burnout.


We sought to understand factors associated with burnout amongst health care workers providing HIV care in Malawi.


This was a sub-study of a larger cross-sectional study measuring burnout prevalence amongst a convenience sample of healthcare workers providing HIV care in 89 health facilities in eight districts in Malawi. Burnout was measured using the Maslach Burnout Inventory. Anonymously administered surveys included questions about sociodemographics, work characteristics (work load, supervisor support, team interactions), depression, life stressors, assessment of type D personality, and career satisfaction. We performed univariable and multivariable regression analyses to explore associations between variables and burnout.


We received 535 responses (response rate 99%). Factors associated with higher rates of burnout on multivariable regression analyses included individual level factors: male gender (OR 1.75 [CI 1.17, 2.63]; p = 0.007), marital status (widowed or divorced) (OR 3.24 [CI 1.32, 7.98]; p = 0.011), depression (OR 3.32 [CI 1.21, 9.10]; p = 0.020), type D personality type (OR 2.77 [CI 1.50, 5.12]; p = 0.001) as well as work related factors: working at a health center vs. a rural hospital (OR 2.02 [CI 1.19, 3.40]; p = 0.009); lack of a very supportive supervisor (OR 2.38 [CI 1.32, 4.29]; p = 0.004), dissatisfaction with work/team interaction (OR 1.76 [CI 1.17, 2.66]; p = 0.007), and career dissatisfaction (OR 0.76 [CI 0.60, 0.96]; p = 0.020).


This study identified several individual level vulnerabilities as well as work related modifiable factors. Improving the supervisory capacity of health facility managers and creating conditions for improved team dynamics may help reduce burnout amongst healthcare workers proving HIV care in Malawi.

Klíčová slova:

Careers – Finance – Malawi – Personality – Psychological stress – Supervisors – Burn management


1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Annals of family medicine. 2014;12(6):573–6. doi: 10.1370/afm.1713 25384822

2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet (London, England). 2016;388(10057):2216–7. doi: 10.1016/S0140-6736(16)31332-0

3. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory. Evaluating stress: A book of resources. 1997;3:191–218. Lanham, MD, US: Scarecrow Education. [cited 2019 Mar 12]. https://www.researchgate.net/publication/277816643_The_Maslach_Burnout_Inventory_Manual

4. Poghosyan L, Clarke SP, Finlayson M, Aiken LH. Nurse burnout and quality of care: cross-national investigation in six countries. Research in nursing & health. 2010;33(4):288–98. doi: 10.1002/nur.20383 20645421

5. Salyers MP, Bonfils KA, Luther L, Firmin RL, White DA, Adams EL, et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Journal of general internal medicine. 2017;32(4):475–82. doi: 10.1007/s11606-016-3886-9 27785668

6. Seo HS, Kim H, Hwang SM, Hong SH, Lee IY. Predictors of job satisfaction and burnout among tuberculosis management nurses and physicians. Epidemiology and health. 2016;38:e2016008. doi: 10.4178/epih/e2016008 26971698

7. Suñer-Soler R, Grau-Martín A, Flichtentrei D, Prats M, Braga F, Font-Mayolas S, et al. The consequences of burnout syndrome among healthcare professionals in Spain and Spanish speaking Latin American countries. Burnout Research. 2014;1(2):Pages 82–9. doi: 10.1016/j.burn.2014.07.004

8. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. Journal of internal medicine. 2018;283(6):516–29. doi: 10.1111/joim.12752 29505159

9. Dugani S, Afari H, Hirschhorn LR, Ratcliffe H, Veillard J, Martin G, et al. Prevalence and factors associated with burnout among frontline primary health care providers in low- and middle-income countries: A systematic review. Gates open research. 2018;2:4. doi: 10.12688/gatesopenres.12779.3 29984356

10. Salvagioni DAJ, Melanda FN, Mesas AE, Gonzalez AD, Gabani FL, Andrade SM. Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PloS one. 2017;12(10):e0185781. doi: 10.1371/journal.pone.0185781 28977041

11. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Internal Med. 2002;136(5):358–67. doi: 10.7326/0003-4819-136-5-200203050-00008 11874308

12. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995–1000. doi: 10.1097/SLA.0b013e3181bfdab3 19934755

13. West MA, Guthrie JP, Dawson JF, Borrill CS, Carter M. Reducing patient mortality in hospitals: the role of human resource management. J Organ Behav. 2006;27(7):983–1002. doi: 10.1002/job.396

14. Kim MH, Mazenga AC, Simon K, Yu X, Ahmed S, Nyasulu P, et al. Burnout and self-reported suboptimal patient care amongst health care workers providing HIV care in Malawi. PloS one. 2018;13(2):e0192983. doi: 10.1371/journal.pone.0192983 29466443

15. Anyangwe SC, Mtonga C. Inequities in the global health workforce: the greatest impediment to health in sub-Saharan Africa. International journal of environmental research and public health. 2007;4(2):93–100. 17617671

16. Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ quality & safety. 2015;24(10):608–10. doi: 10.1136/bmjqs-2015-004160 26038586

17. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet (London, England). 2016;388(10057):2272–81. doi: 10.1016/S0140-6736(16)31279-X

18. Dieleman M, Biemba G, Mphuka S, Sichinga-Sichali K, Sissolak D, van der Kwaak A, et al. 'We are also dying like any other people, we are also people': perceptions of the impact of HIV/AIDS on health workers in two districts in Zambia. Health policy and planning. 2007;22(3):139–48. doi: 10.1093/heapol/czm006 17400577

19. Kruse GR, Chapula BT, Ikeda S, Nkhoma M, Quiterio N, Pankratz D, et al. Burnout and use of HIV services among health care workers in Lusaka District, Zambia: a cross-sectional study. Human resources for health. 2009;7:55. doi: 10.1186/1478-4491-7-55 19594917

20. Lasebikan VO, Oyetunde MO. Burnout among nurses in a Nigerian General Hospital: Prevalence and associated factors. ISRN nursing. 2012;2012:402157. doi: 10.5402/2012/402157 22619733

21. McAuliffe E, Bowie C, Manafa O, Maseko F, MacLachlan M, Hevey D, et al. Measuring and managing the work environment of the mid-level provider—the neglected human resource. Human resources for health. 2009;7:13. doi: 10.1186/1478-4491-7-13 19228391

22. Perry L, Rech D, Mavhu W, Frade S, Machaku MD, Onyango M, et al. Work experience, job-fulfillment and burnout among VMMC providers in Kenya, South Africa, Tanzania and Zimbabwe. PloS one. 2014;9(5):e84215. doi: 10.1371/journal.pone.0084215 24802260

23. Malawi Ministry of Health: Integrated HIV Program Quartely Report July-September 2018. Lilongwe: Department of HIV and AIDS; 2018.

24. Jordaan I, Spangenberg JJ, Watson MB, Fouchè P. Emotional stress and coping strategies in South African clinical and counselling psychologists. South African Journal of psychology,. 2007; 37(4):835–55. doi: 10.1177/008124630703700411

25. Khamisa N, Oldenburg B, Peltzer K, Ilic D. Work related stress, burnout, job satisfaction and general health of nurses. International journal of environmental research and public health. 2015;12(1):652–66. doi: 10.3390/ijerph120100652 25588157

26. Olley BO. A comparative study of burnout syndrome among health professionals in a Nigerian teaching hospital. African journal of medicine and medical sciences. 2003;32(3):297–302. 15030092

27. Pienaar J, Wyk Dv. Teacher burnout: construct equivalence and the role of union membership. South African Journal of Education. 2006;26 (4):541–51.

28. Thorsen VC, Tharp AL, Meguid T. High rates of burnout among maternal health staff at a referral hospital in Malawi: A cross-sectional study. BMC nursing. 2011;10:9. doi: 10.1186/1472-6955-10-9 21605379

29. Rothmann S, Essenko N. Job characteristics, optimism, burnout, and ill health of support staff in a higher education institution in South Africa. South African Journal of psychology. Vol 37, (Issue 1):135–52. doi: 10.1177/008124630703700110

30. Beusenberg M, Orley JH. A User’s guide to the self reporting questionnaire (SRQ). Geneva: World Health Organization; 1994. [cited 2019 Mar 12]. https://apps.who.int/iris/handle/10665/61113.

31. Stewart RC, Kauye F, Umar E, Vokhiwa M, Bunn J, Fitzgerald M, et al. Validation of a Chichewa version of the self-reporting questionnaire (SRQ) as a brief screening measure for maternal depressive disorder in Malawi, Africa. J Affect Disord. 2009;112(1–3):126–34. doi: 10.1016/j.jad.2008.04.001 18504058

32. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: the Alcohol Use Disorders Identification Test: guidelines for use in primary health care. World Health Organization. 2001, 2nd ed. [cited 2019 Mar 12]. https://apps.who.int/iris/handle/10665/67205.

33. Peltzer K, Davids A, Njuho P. Alcohol use and problem drinking in South Africa: findings from a national population-based survey. Afr J Psychiatry. 2011;14(1). 21509408

34. Zverev Y. Problem drinking among university students in Malawi. Coll Antropol. 2008;32(1):27–31. 18494185

35. Berman A, Bergman H, Palmstierna T, Schlyter F. The Drug Use Disorders Identification Test (DUDIT) Manual. Stockholm, Sweden: Karolinska Institutet. 2003. [cited 2019 Mar 12]. https://paihdelinkki.fi/sites/default/files/duditmanual.pdf.

36. Armon G. Type D personality and job burnout: The moderating role of physical activity. Personality and individual differences 2014;58:112–5. doi: 10.1016/j.paid.2013.10.020

37. Denollet J. DS14: standard assessment of negative affectivity, social inhibition, and Type D personality. Psychosomatic medicine. 2005;67(1):89–97. doi: 10.1097/01.psy.0000149256.81953.49 15673629

38. Polman R, Borkoles E, Nicholls AR. Type D personality, stress, and symptoms of burnout: the influence of avoidance coping and social support. British journal of health psychology. 2010;15(Pt 3):681–96. doi: 10.1348/135910709X479069 19930789

39. Tekin A, Karadag H, Yayla S. The relationship between burnout symptoms and Type D personality among health care professionals in Turkey. Archives of environmental & occupational health. 2017;72(3):173–7. doi: 10.1080/19338244.2016.1179168 27120565

40. Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. Jama. 2009;302(12):1338–40. doi: 10.1001/jama.2009.1385 19773573

41. Ahola K, Honkonen T, Isometsä E, Kalimo R, Nykyri E, Aromaa A, et al. The relationship between job-related burnout and depressive disorders—results from the Finnish Health 2000 Study. J Affect Disord. 2005;88(1):55–62. doi: 10.1016/j.jad.2005.06.004 16038984

42. Marcelino G, Cerveira JM, Carvalho I, Costa JA, Lopes M, Calado NE, et al. Burnout levels among Portuguese family doctors: a nationwide survey. BMJ Open. 2012;2(3):e001050. doi: 10.1136/bmjopen-2012-001050 22710131

43. Smith HK. Testing work characteristics as mediating factors in the relationships among nurse leadership, burnout, and engagement. 2012.

44. UNICEF. 2017/18 Health Budget Brief: Towards Universal Health Coverage New York; 2017. [cited 2019 Mar 12]. https://www.unicef.org/malawi/media/411/file

45. World Health Organization. Global Health Expenditure Database. Geneva; 2018. [cited 2019 Mar 12]. https://www.who.int/health_financing/topics/resource-tracking/ghed-update/en/

46. Coetzee SK, Klopper HC, Ellis SM, Aiken LH. A tale of two systems—nurses practice environment, well being, perceived quality of care and patient safety in private and public hospitals in South Africa: a questionnaire survey. International journal of nursing studies. 2013;50(2):162–73. doi: 10.1016/j.ijnurstu.2012.11.002 23218020

47. Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, et al. Why did I stop? Barriers and facilitators to uptake and adherence to ART in Option B+ HIV care in Lilongwe, Malawi. PloS one. 2016;11(2):e0149527. doi: 10.1371/journal.pone.0149527 26901563

48. Llorent VJ, Ruiz-Calzado I. Burnout and its relation to sociodemographic variables among education professionals working with people with disabilities in Cordoba (Spain). Ciencia & saude coletiva. 2016;21(10):3287–95. doi: 10.1590/1413-812320152110.00732015 27783801

49. Canadas-De la Fuente GA, Ortega E, Ramirez-Baena L, De la Fuente-Solana EI, Vargas C, Gomez-Urquiza JL. Gender, marital status, and children as risk factors for burnout in nurses: A meta-analytic study. International journal of environmental research and public health. 2018;15(10). doi: 10.3390/ijerph15102102 30257449

50. Ramirez-Baena L, Ortega-Campos E, Gomez-Urquiza JL, Canadas-De la Fuente GR, De la Fuente-Solana EI, Canadas-De la Fuente GA. A multicentre study of burnout prevalence and related psychological variables in medical area hospital nurses. Journal of clinical medicine. 2019;8(1). doi: 10.3390/jcm8010092 30650557

51. Guidroz AM, Wang M, Perez LM. Developing a model of source-specific interpersonal conflict in health care. Stress and health: journal of the International Society for the Investigation of Stress. 2012;28(1):69–79. doi: 10.1002/smi.1405 22259160

52. Hana J, Maleta K, Kirkhaug R, Hasvold T. “PHC leadership: are health centres in good hands? Perspectives from 3 districts in Malawi”. Malawi medical journal: the journal of Medical Association of Malawi. 2012;24(3):46–51. 23638273

53. Chikaphupha KR, Kok MC, Nyirenda L, Namakhoma I, Theobald S. Motivation of health surveillance assistants in Malawi: A qualitative study. Malawi medical journal: the journal of Medical Association of Malawi. 2016;28(2):37–42. 27895826

54. Manafa O, McAuliffe E, Maseko F, Bowie C, MacLachlan M, Normand C. Retention of health workers in Malawi: perspectives of health workers and district management. Human resources for health. 2009;7:65. doi: 10.1186/1478-4491-7-65 19638222

55. Muula AS, Maseko FC. How are health professionals earning their living in Malawi? BMC health services research. 2006;6:97. doi: 10.1186/1472-6963-6-97 16899130

56. Schmiedeknecht K, Perera M, Schell E, Jere J, Geoffroy E, Rankin S. Predictors of workforce retention among Malawian nurse graduates of a scholarship program: a mixed-methods study. Global health, science and practice. 2015;3(1):85–96. doi: 10.9745/GHSP-D-14-00170 25745122

57. Chimwaza W, Chipeta E, Ngwira A, Kamwendo F, Taulo F, Bradley S, et al. What makes staff consider leaving the health service in Malawi? Human resources for health. 2014;12:17. doi: 10.1186/1478-4491-12-17 24641840

58. West CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA internal medicine. 2014;174(4):527–33. doi: 10.1001/jamainternmed.2013.14387 24515493

59. Spector PE, Jex SM. Development of Four Self-Report Measures of Job Stressors and Strain: Interpersonal Conflict at Work Scale, Organizational Constraints Scale, Quantitative Workload Inventory, and Physical Symptoms Inventory. Journal of occupational health psychology. 1998;3(4):356–67. doi: 10.1037/1076-8998.3.4.356 9805281

60. Coetzee B, Kagee A, Vermeulen N. Structural barriers to adherence to antiretroviral therapy in a resource-constrained setting: the perspectives of health care providers. AIDS care. 2011;23(2):146–51. doi: 10.1080/09540121.2010.498874 21259126

61. Gorgens-Ekermans G, Brand T. Emotional intelligence as a moderator in the stress-burnout relationship: a questionnaire study on nurses. Journal of clinical nursing. 2012;21(15–16):2275–85. doi: 10.1111/j.1365-2702.2012.04171.x 22788561

62. Leiter MP, Maslach C. Six areas of worklife: a model of the organizational context of burnout. Journal of health and human services administration. 1999;21(4):472–89. 10621016

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