key: cord-0758112-w2b1653j authors: Kajjimu, Jonathan; Kaggwa, Mark Mohan; Bongomin, Felix title: Burnout and Associated Factors Among Medical Students in a Public University in Uganda: A Cross-Sectional Study date: 2021-01-25 journal: Adv Med Educ Pract DOI: 10.2147/amep.s287928 sha: dcae4f9a74829791976ef2aac50eec46fa0fe162 doc_id: 758112 cord_uid: w2b1653j BACKGROUND: Burnout is a well-recognized phenomenon that may manifest with feelings of stress, fatigue, or exhaustion. It is a common and emerging problem among healthcare workers. Medical students may be at increased risk of burnout given the rigorous nature of their training. However, there is a paucity of data on the burden of burnout among medical students in Africa. AIM: This study aimed to determine the prevalence of burnout, as assessed using the Maslach Burnout Inventory – Student Survey (MBI-SS) as well as factors associated with the development of burnout among students pursuing Bachelor of Medicine and Bachelor of Surgery (MBChB) degrees at Mbarara University of Science and Technology (MUST), Uganda. METHODS: A single-centre, cross-sectional, online survey was conducted among MBChB students of MUST. Burnout was assessed using the Maslach Burnout Inventory – Student Survey (MBI-SS) tool. Bivariate analysis and backward stepwise logistic regression analysis were performed to assess possible associations between variables related to participants’ demography, socioeconomic, personal, learning environment, outside school environment aspects and burnout prevalence scores. RESULTS: A total of 145 medical students, 102 (70.3%) male, with a median (range) age of 23 (18–40) years were studied. A total of 135 students (93.1%) presented with high levels of emotional exhaustion, 90 (62.1%) students had low levels of professional efficacy scores and 141 (97.2%) of the medical students had high levels of cynicism. Overall, 79 (54.5%) students had burnout, as defined by the MBI-SS tool. Choosing MBChB willingly appears to be an independent predictor of burnout (Adjusted odds ratio: 7.2; 95% CI: 1.4–36.9; p=0.018). CONCLUSION: More than one-half of medical students questioned at MUST do experience a degree of burnout. Preventative and interventional measures should be considered in the development of the medical curriculum. Burnout is, according to the 11 revision of the International Classification of Diseases (ICD-11), depletion or exhaustion; increased mental distance from one's job or feelings of negativism or cynicism related to one's job; and reduced personal efficacy." 1 Burnout is an increasingly recognised problem among medical professionals. 2 Previous studies in medical students found 14.8-79.9% of them experience burnout during their medical training. [3] [4] [5] [6] [7] Its prevalence has been found to increase with medical school academic progression 8, 9 but studies have suggested that by equipping medical students with evidence-based stress management approaches to their education, the incidence of burnout is reduced irrespective of their academic progression. 32 In working-class healthcare professions, burnout has been linked majorly to job-or work-related chronic stress. In medical students, it is most likely related to personal factors such as mental health disorder, physical activity, personal financial satisfaction, high parental expectations, alcohol consumption, and smoking status or individual learning environment. 1,10 A 2017 systematic review suggested that, on average, one medical student out of two suffered from burnout as defined by the ICD-11. Medical students from the Middle East and Oceania countries were found to have a higher prevalence of burnout than those from countries in other continents, with no African data available at the time of the review. 11 Higher levels of stress coupled with poor coping strategies may be the major factors responsible for the development of burnout among medical students, 3 due to the cyclic relation between stress and emotional exhaustion. 12 Medical students, when compared to age-matched members of the general public, have been shown to have a poorer psychological quality of life. 13 A 2015 systematic review showed that medical students displayed a variety of coping mechanisms for burnout such as personal engagement, extracurricular activities including mainly musical and physical activities, student autonomy, mentorship programs, evaluation systems, career counseling and life coaching. 3 The prevalence of burnout among medical students at Mbarara University of Science and Technology (MUST) was unknown. We sought to identify the degree of burnout and identify any causal factors such as learning environment, personal life factors and outside school life factors. This cross-sectional study aimed at investigating the prevalence and factors associated with burnout among medical students in their pre-clinical and clinical years of study at MUST. An online descriptive cross-sectional study was conducted between 6 th September 2020 until 20 th September 2020, using a Google form. The study was carried out at Mbarara University of Science and Technology, commonly called Mbarara University. It is a public university accredited by the National Council for Higher Education, offering both undergraduate and postgraduate programs. MUST Undergraduate students from first to final years at MUST, pursing a medical program of Bachelor of Medicine and Bachelor of Surgery, were surveyed using an enrollment criteria including students being in the official WhatsApp groups of the respective class years and voluntarily consenting to take part in the study (see Figure 1 ). Representatives of each class were contacted by the principal investigator and informed about the study procedures, ethical issues and data collection. The participants were enrolled using a consecutive sampling technique. Students were recruited into the study through class representatives. The survey tool was then disseminated through class official WhatsApp groups. The inclusion criteria were medical students at MUST enrolled for the academic year 2019/2020. Other health profession students were not eligible for enrollment in this study. The required sample size was calculated using the Kish-Leslie formula. The prevalence of burnout was taken to be an average of 0.5 since there had not been any previous study carried out at MUST. This point prevalence, of 50% was also found in a recent study assessing burnout among medical students in Ethiopia. 16 We used the modified Kish-Leslie equation 33 to calculate the available sample size; where K was the estimated overall population of the study population. To cater for non-correspondents assuming a response rate of 90%, a total of 10% of the sample size was added. This led to the required sample size of 229 students. We developed a questionnaire that would collect participants' characteristics (demography and socioeconomic factors) and their MBI-SS scores. We also asked about factors that might be associated with burnout among medical students. Participants' characteristics included sex, age, year of study, religious/spiritual affiliation, source of tuition funding, marital status, family income, agreement with the effectiveness of wellness initiatives at their institution, and family residence. Burnout was assessed using the Maslach Burnout Inventory -Student Survey tool which was adapted from 17, 18 and had been validated in Brazil. 19 The MBS-SS is a self-administered tool consisting of 15 questions. It is subdivided into three subscales: emotional exhaustion (five items), cynicism (four items), and professional efficacy (six items). All items are assessed by frequency using aL ikert scale ranging from never (0) to every day (6) . The tool has an internal consistency of each latent factor greater than 0.7 with values of 0.77, 0.72, and 0.81 for emotional exhaustion, professional efficacy, and cynicism, respectively. 20 A test-retest reliability determined at about 4 weeks later, a yielded reliability coefficients of 89, 84 and 67 respectively for exhaustion, cynicism and academic efficacy. 21 20 There are two validated calculation methods used to compare burnout scores among participants ie, the summation (SUM) and average (AVE) method. 17 Burnout is determined by the total score of the MBI-SS based on the participant's responses by using both the tridimensional and bidimensional diagnostic criteria for burnout syndrome as listed in the ICD-11. On a two-dimensional model, it is identified by high scores on both emotional exhaustion and cynicism subscales. In the three-dimensional model, lowlevel burnout was determined based on the following scores: emotional exhaustion (0 -9), cynicism (0 -1), and professional efficacy <27. Moderate level burnout was determined based on the following scores: emotional exhaustion (10 -14) , cynicism (2 -6) , and professional efficacy (23 -27) . At a high level, burnout was identified based on the following scores: emotional exhaustion >14, cynicism >6, and professional efficacy <23. 18 High scores on emotional exhaustion and cynicism with low scores on professional efficacy are indicative of burnout. 20 Factors associated with burnout among medical students were adapted from Haile et al, 16, 18, 22 and modified The questionnaire was piloted by 23 (10% of the sample size) Gulu University medical students. A Cronbach alpha of 0.8099 was obtained, demonstrating the high reliability of the tool in assessing the study outcomes. Data analyses were performed using StataCorp. 2019. Stata: Release 16. Statistical Software. College Station, TX: StataCorp LLC. Medical students' characteristics were summarized with proportions. The prevalence of burnout was determined from the total score of the MBI-SS tool using the tridimensional criteria based on the participants' responses to Likert scale questions related to emotional exhaustion, professional efficacy, and cynicism. Proportions were used to estimate the prevalence of burnout in the student sample. To quantify possible associations between the independent variable and dependent variables, we calculated crude odds ratios. Backward regression analysis was used to assess the predictive relationship between the associated factors obtained from the medical students and their respective burnout prevalence scores. One hundred and fifty (35.5%) responses were received. We removed one incomplete response and four duplicate responses, leaving behind 145 responses that were analysed (34.3% response rate). The participants included 102 (70.3%) male and 43 (29.7%), female medical students. The majority (49%, n=71) of the students were under government sponsorship and over 90% (n=134) had a religious affiliation. The majority of the students were aged less than 24 years, and the rest of the sociodemographic characteristics were comparable across the 5 years of studies as shown in Table 1 . Table 2 presents the prevalence of burnout among medical students. More than half (54.5%, n= 79) of the medical students fitted the definition of burnout using the tridimensional dimensional criteria. Of the 145 students, 93.1% (n= 135) had high emotional exhaustion scores, 62.1% (n= 90) had low professional efficacy scores and 97.2% (n= 141) had high cynicism scores. In the unadjusted logistic regression analysis, several factors were found to be independently associated with burnout. These including factors intrinsic to the student such as being optimistic about their future career (OR=2.70, 95% CI 1.11 to 6.55; p=0.028), feeling fulfilled and happy at work (OR=2.77, 95% CI 1. 31 Table 3 . In multiple logistic backward regression only one factor, choosing MBChB willingly (OR =7.20, 95% CI 1.40 to 36.93; p=0.018) was found to be independently associated with burnout. Table 4 contains more details. Our cross-sectional study looked at the prevalence of burnout among medical students at MUST, as well as possible associations. More than half of the students described burnout. Willingly choosing a career in medicine was the only identified associated factor. The high prevalence of burnout in our study is consistent with a similar study in Egypt which reported a burnout prevalence of 79.9%. 7 One possible reason could be that medical students were unaware of the issue of burnout. A 2010 systematic review, suggested that there existed an association between a lower level of tolerance for uncertainty or ambiguity and self-reported burnout among medical students. 23 Studies conducted among medical students in Ethiopia and Spain found low levels of burnout, 34% and 14.8%, respectively. 6, 16 Such discrepancies in the burnout prevalence in various studies may be attributed to the submit your manuscript | www.dovepress.com Advances in Medical Education and Practice 2021:12 different burnout measurement tools used. Additionally, students in different countries are exposed to different socio-economic, political, health, and conflict-related stress factors. 3 Burnout was higher among males (70.9%) compared to females (29.1%), a consistent finding with a systematic review that found male medical students to have a higher burnout prevalence. 15 This could be due to the many male medical student participants as indicated in most studies. However, whether these many male survey responders are a true representative of their various institutions' male medical student population, remains a question to answer to come up with a conclusive finding. It has been proposed, by some, that female medical students are at a high risk of burnout than their male counterparts. 14 Female students are more likely to suffer from stress factors than male medical students, 4 with more demands placed on them outside of the university. 8 Third and fourth-year medical students had the highest level of burnout in this study. This correlates with prior studies that showed a higher degree of burnout in senior medical students. 16, 17 The transition from preclinical years to clinical years of training appears to be a risk factor for DovePress academic stress in medical school. 5, 24 The low burnout prevalence of fifth years may be due to them having learned some coping strategies such as life coaching, reflective practice, self-care, musical and physical activities. One interesting finding in our study was that willingly choosing to undertake MBChB was found to be significantly associated with an increased risk of burnout. This is contrary to a Cameroonian study that reported that students who regretted choosing their medical studies had higher burnout scores than their peers. 25 Medical schools in countries like America have established wellness programs that could be adapted to address the "bio-psychosocial-spiritual burnout" epidemic among medical students. 23, 26 In Australasia, several wellness initiatives have been trialed. These include the integration of a wellbeing curriculum alongside the traditional medical curriculum such as the SAFE-DRS program at the University of Auckland 30 and the Health Enhancement Program at Monash University Medical School. 31 A U.S based study evaluating the success of a student-led program teaching stress management and self-care skills to first-year medical students, found it to be helpful (based on longevity, student participation, and student feedback). 27 Additionally, the GMC -UK has provided guidance to medical schools on the creation of peer support networks, group sessions on stress management, and mentoring schemes. 29 Medical schools promote competition rather than cooperation. Training-related stress factors including annual examinations, an inability to cope with academic demands, and pressure with an obligation to succeed all compound the problem. Additionally, a sense of helplessness coupled with sleep deprivation, financial challenges, and the emotional burden of witnessed suffering stress medical students. 5, 24 Other studies have found associations between burnout in medical students with not seeing coursework as a source of pleasure, feeling uncomfortable with course activities, not acquiring skills necessary to become a doctor, poor social support, being less than satisfied with the education system, selfperception of health, optimism, and motivation in studies. 16, 18, 22 Our study did not find any such associations. Burnout is not only harmful to the medical students, their relatives, medical schools, and peers but to also the patients they care for. There is thus a heightened need to address burnout among medical students to ensure that delivery of compassionate patient care is kept paramount. 4,5,28 Our study had several limitations. First, this was a cross-sectional study. It could not allow us to study the variation of burnout among medical students throughout their entire 5-year study period in medical school at MUST. Second, the small response rate might have led to a type 2 error. Census involving these students would reveal more reliable findings. Recall bias may also have occurred amongst students since, by the time the study was conducted, students were offcampus due to the cessation of educational activities due to the COVID-19 pandemic. This, in itself, may have also contributed. Our study findings should be generalizable to many other low-and middle-income countries. We used a standardised burnout measurement tool to increase the reliability and validity of our study findings. This has been the first study to be conducted among medical students in Uganda and it has revealed high levels of emotional exhaustion, cynicism, and low levels of professional efficacy. There needs to be an investment in the provision of mental health support to medical students through interventions to raise awareness, understanding, and prevention of the development of psychological distress, burnout, and mental health disorders like depression and anxiety among medical students. The efficacy Notes: Bolded to represent a significant p-value. *Omitted represents a p-value that could not be calculated due to having less than 5 observations. DovePress of this study could be measured by conducting a multi-centre, prospective longitudinal study. Some student life activities may be present at MUST but these activities are not united under a comprehensive wellness objective. We hope that this study will help drive the establishment of wellbeing interventions at MUST. Data are available upon reasonable request from the first author. The study was performed in accordance with the international ethical standards of the Declaration of Helsinki. This study was approved by the Mbarara University of Science and Technology Research Ethics Committee (Approval number: 19/07-20). We also sought administrative approval from the dean of the Faculty of Medicine at Mbarara University of Science and Technology. The participant's email and name were requested optionally for entering the participants into a raffle for participatory gift certificates as an incentive for completing the survey. Each study participant who opted to submit their details for enrollment into the raffle was assigned a random number, after which we randomly chose five study participants from the enrolled participants based on those random numbers. Burn-out an "occupational phenomenon": international classification of diseases [Internet]. WHO, World Health Organization Understanding the burnout experience: recent research and its implications for psychiatry -Maslach -2016 -world psychiatry Stress, burnout and coping strategies in preclinical medical students Burnout and its associated factors in medical students of lahore, pakistan. Cureus Personal life events and medical student burnout: a multicenter study Burnout risk in medical students in Spain using the Maslach Burnout Inventory-Student Survey Burnout syndrome: determinants and predictors among medical students of Tanta University Prevalence and predictors of burnout syndrome among medical students of Cairo University Stress among medical students and its association with substance use and academic performance A narrative review on burnout experienced by medical students and residents Burnout in medical students before residency: a systematic review and meta-analysis Stress, burnout and doctors' attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates Survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school Prevalence and correlates of burnout among undergraduate medical students -a cross-sectional survey Burnout in medical students: a systematic review of experiences in Chinese medical schools Prevalence and associated factors of burnout among Debre Berhan University medical students: a cross-sectional study Assessment of burnout in medical students using the Maslach Burnout Inventory-Student Survey: a cross-sectional data analysis Burnout syndrome and associated factors among medical students: a cross-sectional study Sao Paulo, Brazil). clinics (Sao Paulo) Características psicométricas do Maslach Burnout Inventory. Student Survey (MBI-SS) em estudantes universitários brasileiros Clinical validity and diagnostic accuracy of the Maslach burnout inventory-student survey in Sri Lanka The psychometric characteristics of Maslach Burnout Inventory Student Survey: a study students of Isfahan University Burnout among medical students during the first years of undergraduate school: prevalence and associated factors The role of "wellness" in medical education Study of psychological stress among undergraduate medical students of government medical college, Surat Burnout Syndrome amongst medical students in cameroon: a cross-sectional analysis of the determinants in preclinical and clinical students A comprehensive medical student wellness program-design and implementation at Vanderbilt School of Medicine Student-led stress management program for first-year medical students The relationship between spirituality and burnout among medical students Supporting medical students with mental health conditions SAFE-DRS: 5 years of a health and wellbeing curriculum in the medical programme at the University of Auckland The health enhancement program at Monash University medical school Strategies against burnout and anxiety in medical education -implementation and evaluation of a new course on relaxation techniques (Relacs) for medical students Israel determining sample size We thank all participants for their willingness and the time they took to participate in the study. We thank the following students for serving as class representatives who reached out to their classmates with study link messages during the data collection stage including Viola Nansimbe, Innocent Arinaitwe, Ruth Nakawungu, Janat Nakachwa, Jeremiah Habizana, Taremwa Norman, and Ssewanyana Ernest. We also thank Ronald Olum for his support during data analysis. Specially, we thank Dr. Andrew Tagg (Emergency Physician, Western Health, Melbourne, Australia) for his contributions including copy editing of the study manuscript and provision of financial support for purchasing a license for using the Maslach Burnout Inventory instrument. All authors made a significant contribution to the work reported, be it in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. This study was not funded. The authors declare that they have no conflicts of interest for this work. Advances in Medical Education and Practice is an international, peerreviewed, open access journal that aims to present and publish research on Medical Education covering medical, dental, nursing and allied health care professional education. The journal covers undergraduate education, postgraduate training and continuing medical education including emerging trends and innovative models linking education, research, and health care services. 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