health care workers in Lusaka District , Zambia : a cross-sectional study

Background: Well-documented shortages of health care workers in sub-Saharan Africa are exacerbated by the increased human resource demands of rapidly expanding HIV care and treatment programmes. The successful continuation of existing programmes is threatened by health care worker burnout and HIV-related illness. Methods: From March to June 2007, we studied occupational burnout and utilization of HIV services among health providers in the Lusaka public health sector. Providers from 13 public clinics were given a 36-item, selfadministered questionnaire and invited for focus group discussions and key-informant interviews. Results: Some 483 active clinical staff completed the questionnaire (84% response rate), 50 staff participated in six focus groups, and four individuals gave interviews. Focus group participants described burnout as feeling overworked, stressed and tired. In the survey, 51% reported occupational burnout. Risk factors were having another job (RR 1.4 95% CI 1.2–1.6) and knowing a co-worker who left in the last year (RR 1.6 95% CI 1.3–2.2). Reasons for co-worker attrition included: better pay (40%), feeling overworked or stressed (21%), moving away (16%), death (8%) and illness (5%). When asked about HIV testing, 370 of 456 (81%) reported having tested; 240 (50%) tested in the last year. In contrast, discussion groups perceived low testing rates. Both discussion groups and survey respondents identified confidentiality as the prime reason for not undergoing HIV testing. Conclusion: In Lusaka primary care clinics, overwork, illness and death were common reasons for attrition. Programmes to improve access, acceptability and confidentiality of health care services for clinical providers and to reduce workplace stress could substantially affect workforce stability. Published: 13 July 2009 Human Resources for Health 2009, 7:55 doi:10.1186/1478-4491-7-55 Received: 20 February 2009 Accepted: 13 July 2009 This article is available from: http://www.human-resources-health.com/content/7/1/55 © 2009 Kruse et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Human Resources for Health 2009, 7:55 http://www.human-resources-health.com/content/7/1/55 Page 2 of 10 (page number not for citation purposes) Background Over the past decade, access to antiretroviral therapy (ART) has grown at an unprecedented rate in sub-Saharan Africa, with tremendous health gains observed among those utilizing these services [1-3]. As programmes have expanded, availability of trained health personnel has become an important limiting factor in the provision of services [4-6]. Nowhere is the shortage more noticeable than in subSaharan Africa, where patient: provider ratios fall significantly below World Health Organization recommendations. In 2006, for example, an estimated 2.3 health care workers served every 1000 people in the region. This figure is below the worldwide average of 9.3 per 1000 and below the level defined as a critical shortage: 2.5 per 1000, at which populations fail to achieve 80% coverage of services such as deliveries and vaccinations [7]. Numerous approaches have been implemented to compensate for the shortage. These include task shifting [8,9], employment of lay health workers [10,11] and use of technology (e.g. mobile phones or the Internet) to facilitate care and consultation [11,12]. Few strategies, however, have focused on maintaining the well-being of existing workers [13]. It is crucial that this human resource foundation be kept intact if service provision is to continue in these resource-constrained settings. In settings with high HIV prevalence, related morbidity and mortality are responsible for health provider absenteeism and attrition. In Zambia, mortality rates are high and before ART was available, death was a common cause of attrition among district health care workers [14,15]. A recent South African survey measured HIV prevalence among health care workers at 12% [16]. In Malawi, the death rate among health care workers was 2%; the most common causes were TB and other chronic illness attributable to AIDS [17]. Perhaps more overlooked is the issue of occupational burnout among health personnel, a phenomenon characterized by exhaustion, depersonalization and inefficacy [18]. The emotional intensity of caring for HIV-infected patients, along with the high patient volumes seen at many ART centres, may place health providers at particular risk for burnout [19]. The consequences can be severe and include exhaustion, reduced productivity, decreased empathy for patients, absenteeism and desire to search out other occupations [20,21]. Methods We designed a two-part study to describe occupational burnout and utilization of HIV services among providers in the primary care centres of the Lusaka, Zambia, public health sector, where services for HIV care and treatment have rapidly expanded since 2004 [3]. We recruited physicians, clinical officers (the equivalent of physician assistants in the United States and Europe), nurses, midwives and pharmacy staff employed at government clinics. Thirteen sites were chosen, all providing long-term HIV care and treatment. At each facility, other primary care services are provided, including general outpatient care, antenatal services, child health services and tuberculosis treatment. Characteristics of each facility and catchment size are shown in Table 1. This study included qualitative and quantitative study components. Our qualitative methods consisted of six focus group discussions and four key-informant interviews. One group session was held for each of the following: midwives, physicians, clinical officers and pharmacy staff. Two groups of nurses were convened, as they comprise the vast majority of health care workers. Participants were stratified according to clinic of employment and professional cadre, and then randomly selected. Overall, 13 invitations were sent out for each group (i.e. one representative per clinic). Discussions were held in a private conference room at a local nongovernmental organization and each lasted approximately 90 minutes. Trained study staff served as facilitators; written notes and tape recordings were transcribed. Key informants were identified by physicians based at the study clinics and were recruited to participate in one-onone interviews. The four interviews included two providers living with HIV, one HIV-negative and one with unknown HIV status. Each lasted approximately 60 minutes. Data were analyzed by manually compiling common themes and matrices and discussing these data between investigators, study staff and representatives from the Lusaka District Health Management Team. In parallel, we surveyed active health care providers across the 13 clinics to quantify their perceptions of occupational burnout and HIV service utilization. All staff reporting to work over a three-week window were asked by their supervising nurse managers to complete a 36-question survey. Each questionnaire had a statement of consent attached; completion of this consent was necessary for inclusion in the analysis. Drop boxes were provided so that participants could return their questionnaires anonymously. In the survey, prevalence of occupational burnout was based on a single question that has been validated against Human Resources for Health 2009, 7:55 http://www.human-resources-health.com/content/7/1/55 Page 3 of 10 (page number not for citation purposes) a full occupational burnout scale [22]. Respondents were asked to quantify their level of burnout from a five-item scale: (1) "I have no symptoms of burnout"; (2) "Sometimes I am under stress, but I don't feel burned out"; (3) "I am definitely burned out and have occasional symptoms of burnout"; (4) "The symptoms of burnout I'm experiencing won't go away"; and (5) "I feel completely burned out and I am at the point where I need to make some changes or seek some sort of help". If respondents selected (3), (4), or (5) from the scale, they were categorized as having occupational burnout. We also asked numerous supporting questions to better understand types of burnout in this population. To determine utilization of HIV services, we relied primarily on use of HIV testing services over the past 12 months. Information regarding demographic characteristics, employment history and HIV knowledge and perceptions was also collected. In our statistical analysis, we calculated unadjusted and adjusted relative risks (RR) with 95% confidence intervals (95% CI) to identify predictors of occupational burnout and HIV service utilization [23]. We adjusted for individual and clinic-level variation in hierarchical logistic models by means of the SAS GLIMMIX Procedure [24]. Covariates included demographics and other independent variables associated with the outcome at p < 0.10 in unadjusted models. All analyses were performed with SAS version 9.1.3 for Windows (Cary, North Carolina, United States of America). All participants provided written informed consent to participate. This study was approved by the University of Zambia Research Ethics Committee and the University of Alabama at Birmingham Institutional Review Board. Results In May 2007, 78 individuals were invited for focus group discussions. Fifty (64%) participated: 18 nurses, eight midwives, nine clinical officers, five medical officers and 10 pharmacy staff. Key informants comprised two registered nurses, one nurse manager and one clinical officer. From March to July 2007, 483 of 573 active health care providers in the 13 clinics completed the study questionTable 1: District health facilities in Lusaka, Zambia, that served as sites for this study, March 2007 to July 2007 Clinic Clinic catchment size Staff per 10 0