Malaysian Family Physician

Official Journal of the Academy of Family Physicians of Malaysia

and Family Medicine Specialist Association of Malaysia

ORIGINAL ARTICLE

Prevalence of personal, work-related and

patient-related burnout during the COVID-19
pandemic and its associated factors among
healthcare workers in health clinics in the district
of Manjung, Perak: A cross-sectional study
Yee Theng Lau, Hui Teng Chia, Nadia A Hadi, Mohd Shaffari Marzuki, Liliwati Ismail,
Noor Syazana Che Ismail
Lau YT, Chia HT, Nadia AH, Mohd Shaffari M, Liliwati I, Noor Syazana CI. Prevalence of personal, work-related and patient-related burnout during
the COVID-19 pandemic and its associated factors among healthcare workers in health clinics in the district of Manjung, Perak: A cross-sectional study.
Malays Fam Physician. 2024;19:44. [Link]

Keywords: Abstract
Burnout, Copenhagen Burnout Introduction: Burnout is a syndrome characterised by physical, emotional and mental exhaustion
Inventory (CBI), Healthcare that results from a long period of involvement in an overwhelming work condition. It is prevalent
workers, Social support among frontline workers. This study aimed to identify the prevalence of burnout among primary
healthcare workers in the district of Manjung, Perak and determine the factors associated with
burnout.
Authors: Methods: This cross-sectional study was conducted among healthcare workers in seven health
clinics located in the district from August to September 2022. The self-administered validated Malay
Yee Theng Lau version of the Copenhagen Burnout Inventory and the Malay version of the Multidimensional
(Corresponding author) Scale of Perceived Social Support were used. These instruments consisted of 31 questions rated
MD, MMed Fam Med on a 5-point Likert scale. The scores were then summed up to determine the burnout level. Data
Klinik Kesihatan Lekir, Batu 8 Lekir, were analysed using SPSS version 20. Simple logistic regression analysis was performed. Thereafter,
Sitiawan, Perak, Malaysia. multiple logistic regression analysis was conducted to determine the factors associated with burnout.
Email: alysse_lyt@[Link] Results: A total of 224 participants were included. Among them, 61.6% were nurses; 21.4%,
doctors; and 17.0%, assistant medical officers. The prevalence of personal burnout was 31.3%;
Hui Teng Chia work-related burnout, 16.5%; and patient-related burnout, 5.4%. The factors associated with
MD, MMed Fam Med burnout were the highest educational level, financial difficulties and low perceived social support
Klinik Kesihatan Ayer Tawar, Jalan from friends and significant others.
Besar, Pekan Ayer Tawar, Ayer Conclusion: Healthcare workers in Manjung health clinics have a higher prevalence of personal
Tawar, Perak, Malaysia. burnout than work- and patient-related burnout. The findings of this study provide early insights
and guidance for possible interventions.
Nadia A Hadi
MD, MMed Fam Med
Klinik Kesihatan Pulau Pangkor, Introduction 12-item General Health Questionnaire, the
Jalan Pasir Bogak, Pulau Pangkor, Burnout is a syndrome due to stress from prevalence of mental health problems among
Perak, Malaysia. chronic workplace conditions that has not the general adult population was reported
been managed successfully, characterised to be 29.2%.4 Burnout is found to be a risk
Mohd Shaffari Marzuki by physical and emotional exhaustion, factor for suicide and low quality of life, as
MD, MMed Fam Med increased mental distance from one’s job and affected individuals are prone to experiencing
Klinik Kesihatan Sitiawan, Jalan decreased professional efficacy according depression, anxiety and sleep difficulties.5 It
Datuk Ahmad Yunus, Kg Serdang, to the 11th Revision of the International is associated with sleep deprivation, family
Sitiawan, Perak, Malaysia. Classification of Diseases.1,2 It can result in issues and feelings of being overwhelmed by
negativity in relation to one’s job, especially assigned tasks.5 Therefore, measures aimed at
Liliwati Ismail when dealing with patients, thus resulting reducing the stress levels of healthcare workers
MD, MMed Fam Med in decreased professionalism and work are needed to improve their general well-being
Klinik Kesihatan Pantai Remis, efficacy.3 Burnout is prevalent among and quality of life, consequently enhancing
Jalan Tangki Air, Kg Sungai Batu, healthcare workers, especially frontliners.3 In their efficiency at work.5
Pantai Remis, Perak, Malaysia. the National Health and Morbidity Survey
conducted in 2015 in Malaysia using the COVID-19 has emerged as a global health

Malays Fam Physician 2024;19:44 1

 ORIGINAL ARTICLE

Noor Syazana Che Ismail issue, which has resulted in an unprecedented a lack of self-perceived social support at the
MD, MMed Fam Med demand for healthcare workers worldwide. workplace and inadequate childcare support.19
Klinik Kesihatan Beruas, Beruas, It has caused a significant burden on the Working experience and working in different
Perak, Malaysia. healthcare system.6 medical departments are also associated with
burnout.17 This information is important to
The disease has been associated with a facilitate the planning of interventions to
remarkable rise in reported feelings of reduce the prevalence of burnout and further
burnout. During the pandemic, healthcare prevent progression to multiple implications
Open Access: This is an Open workers faced issues such as insufficient related to personal and patient care, such as
Access article licensed under the personal protective equipment, risk of decreased professionalism, lack of empathy,
Creative Commons Attribution exposure to the disease, shortage of manpower, increased medical errors, compromised
(CC BY 4.0) license, which permits a lack of childcare, limited resources and patient safety and lack of teamwork. To date,
others to distribute, remix, adapt lengthy working hours.6–8 Long working there is a paucity of research on burnout
and build upon this work, for hours might cause physical exhaustion and among staff in health clinics during the
commercial use, provided the increase the susceptibility to psychological pandemic, especially in Malaysia. Awareness,
original author(s) and source distress. Consequently, these factors could preventative strategies and early diagnoses can
are properly cited. See: http:// worsen the quality of life and reduce the improve burnout among healthcare workers
[Link]/licenses/ confidence and efficacy to perform well under and thus improve their quality of life.
by/4.0/ extended working hours.6,7 Healthcare workers
perceived that the quality of care and patient Methods
safety might be affected when their workload This cross-sectional study was conducted from
is increased and working hours are extended.8 August to September 2022 among healthcare
workers in seven health clinics in Manjung
A systematic review of studies conducted District. Manjung District is located in the
among healthcare workers in India south-western part of Perak State. It covers an
demonstrated a prevalence of burnout ranging area of 1113 km2 with a population of nearly
from 23% to 27%.9 In another study, the 250,000 people and a population density of
prevalence of burnout among healthcare 200/km2. The district has few hundreds of
providers in hospitals in Taiwan was reported primary care frontliners. Due to this large
to be 40.3%.10 A study in Indonesia reported number, Manjung District was deemed an
a prevalence of burnout ranging from 70% to appropriate location for this study. Healthcare
88.3%.11 Some studies conducted on burnout workers such as doctors, assistant medical
among healthcare workers in Singapore officers and nurses were included as the study
showed burnout rates ranging from 40% to population because they were the frontliners
60%, with most studies using the Maslach who dealt with patients most of the time
Burnout Inventory.12–14 In a study conducted during the pandemic. In particular, doctors,
in Malaysia, the prevalence of burnout assistant medical officers and nurses who
was 51.3% among emergency healthcare were aged 18–60 years and were practising
workers.15 Another study performed in Sabah in health clinics in Manjung District were
showed that the prevalence of personal, work- included. Conversely, healthcare workers
related and client-related burnout was 61.2%, who had pre-existing psychotic disorders,
48.8% and 39.8%, respectively.16 There are had a bipolar mood disorder, used illicit
many inventories used to assess burnout. drugs, had alcohol dependence, were from
In this study, the Copenhagen Burnout other agencies doing attachment in the health
Inventory (CBI) was used to assess burnout clinics temporarily and were doing further
among healthcare workers, as it is a valid and studies (e.g. degree or post-basic studies) were
reliable instrument that can be easily applied excluded. The response rate was 100% among
among medical professionals compared to all categories of healthcare workers including
other inventories.17 doctors, assistant medical officers and nurses.

The factors associated with burnout are job The formula for sample size calculation for
overload, frequent involvement with angry prevalence studies,15 with a finite population
or difficult clients, stereotyped notion of size of 234 and precision of 0.025, was
underpaid work and lack of clear guidelines.18 used. The sample size of 204 was calculated
Other factors significantly associated with using the simple proportion formula for
burnout include younger age, underlying finite populations based on a prevalence
medical conditions, long working durations, of burnout among healthcare workers of
direct dealing with patients with COVID-19, 51.3%. Considering a 10% drop out rate,

2 Malays Fam Physician 2024;19:44

 ORIGINAL ARTICLE

224 participants were recruited. A total of the scores for all 12 items. The greater the
234 healthcare workers fulfilled the inclusion score, the higher the level of social support.
criteria. Among them, 224 were chosen using Items 1, 2, 5 and 10 relate to support from
the simple random sampling function in the significant others; items 3, 4, 8 and 11,
EpiCalc 2000 software (Brixton Health, www. from family; and items 6, 7, 9 and 12, from
[Link]). friends. The item scores are summed and then
divided by 4 to calculate the subscale scores.
A data collection form that was used has 3 The total scale score is calculated by adding
parts. It was pretested among five healthcare all 12 item scores and then dividing the
workers to assess its feasibility in the local sum by 12. A total score of 1–2.9 indicates
setting. The results of the pretesting were low support; 3–5, moderate support; and
not included in the final analysis. The 5.1–7, high support. The instrument showed
questionnaire used had three parts, and good internal consistency (Cronbach’s alpha
permission was sought to use them. The coefficient=0.89), parallel-form reliability
first part of the questionnaire collected (0.94) and test–retest reliability (0.77)
basic sociodemographic and clinical data (Spearman’s rho, P<0.01).21 All participations
including age, race, sex, religion, marital were voluntary, and written consent was
status, highest educational level, occupation, obtained before questionnaire completion.
monthly household income, number of
dependants, duration of service, distance Permission to conduct this study was acquired
between the house and workplace, medical from the NMRR [approval number: NMRR
conditions, working shift, working hours in 22-01231-B0J (IIR)]. Data were analysed
a week, financial problems, problems with using SPSS version 20. Descriptive analysis
colleagues and family issues. The second part was performed using frequencies and
consisted of the self-administered validated percentages. Age, monthly household income,
Malay version of the CBI. The CBI is used duration of service, number of dependants,
to measure occupational burnout, with distance of the workplace from the house and
excellent psychometric properties, and is total working hours per week were presented
available in the public domain.19 It has three as medians, as these data were not normally
dimensions including personal (six items), distributed. Simple logistic regression was
work-related (seven items) and patient- used to select variables for further analysis. All
related burnout (six items) (Cronbach’s variables with P-values of <0.25 and clinically
alpha coefficient=0.83–0.87 for the three significant variables were included in multiple
dimensions).19 Each question is scored logistic regression. This P-value was set higher
on a 5-point Likert scale (never, seldom, than the level of significance to allow for more
sometimes, often and always). Each item is important variables to be included in the
rated as follows: always/to a very high degree model. The independent factors associated
(score=100), often/to a high degree (score=75), with burnout were identified via multiple
sometimes/somewhat (score=50), seldom/to logistic regression. P-values less than 0.05
a low degree (score=25) and never/to a very were considered statistically significant.16
low degree (score=0). The score for the set
of questions for each of the three burnout Results
dimensions was added, and the average of The median age of the participants was
the scores was calculated. An average score 37 years (IQR=10.0). Majority of the
of ≥50% is considered to indicate burnout. participants were Malays (87.5%), followed
The CBI was also validated in the pandemic by Indians (6.7%) and Chinese (4.0%). There
context, with a Cronbach’s alpha coefficient were more female participants (80.8%) than
of 0.94.20 The third part comprised the self- male participants (19.2%). Most participants
administered validated Malay version of the held a diploma (47.8%). Approximately
Multidimensional Scale of Perceived Social 61.6% of the participants were nurses. The
Support (MSPSS-M). The MSPSS-M is used sociodemographic and clinical characteristics
to assess social support from three sources: of the participants are detailed in Table 1.
family, friends and significant others. It has
12 items, with four items for each source of
support. Each item is scored on a 7-point
Likert scale ranging from very strongly disagree
(score=1) to very strongly agree (score=7).
The total social support score is the sum of

Malays Fam Physician 2024;19:44 3

 ORIGINAL ARTICLE

Table 1. Sociodemographic and clinical characteristics of the participants.

Variables n (%) Median (IQR)
Age 37 (10.0)
Sex
Female 43 (19.2)
Male 181 (80.8)
Race
Malay 196 (87.5)
Chinese 9 (4.0)
Indian 15 (6.7)
Others 4 (1.8)
Religion
Islam 198 (88.4)
Buddha 3 (1.3)
Hindu 14 (6.3)
Others 9 (4.0)
Marital status
Single 15 (6.7)
Married 203 (90.6)
Divorced 4 (1.8)
Widow/widower 2 (0.9)
Highest educational level
Secondary 64 (28.6)
Diploma 107 (47.8)
Degree and above 53 (23.7)
Occupation
Doctor 48 (21.4)
Medical assistant 38 (17.0)
Staff nurse/community nurse 138 (61.6)
Monthly household income (RM) 5000 (4000)
Duration of service (month) 59.5 (91)
Number of dependants 3 (2)
Distance from the house to the workplace (km) 10 (16.48)
Working shift
No 195 (87.1)
Yes 29 (12.9)
Total working hours in a week 45 (0)
Underlying chronic medical illnesses
No 183 (81.7)
Yes 41 (18.3)
Financial problem
No 201 (89.7)
Yes 23 (10.3)
Colleague-related problem
No 214 (95.5)
Yes 10 (4.5)
Family problem
No 213 (95.1)
Yes 11 (4.9)

The prevalence of personal burnout among the participants was 31.3%; work-related burnout,
16.5%; and patient-related burnout, 5.4%. The assistant medical officers and staff nurses had
3.93 times higher odds of developing personal burnout than the community nurses [95%
confidence interval (CI)=1.55, 10.01; P=0.004]. The doctors had 8.36 times higher odds of
experiencing personal burnout than the community nurses (95% CI=3.05, 22.95; P=0.000).
The participants with financial problems had 5.93 times and 4.96 times higher odds of
developing personal burnout (95% CI=2.13, 16.52; P=0.001) and work-related burnout (95%
CI=1.98, 12.42; P=0.001) than those without, respectively. The participants with low perceived
social support from significant others had 14.91 times higher odds of experiencing personal
burnout than those with high perceived social support from significant others (95% CI=1.42,
157.03; P=0.024). The participants with low perceived social support from friends had 49.50
times higher odds of developing patient-related burnout than those with high perceived social
support from friends (95% CI=4.45, 550.32; P=0.010) (Table 2).

4 Malays Fam Physician 2024;19:44

 ORIGINAL ARTICLE

Table 2. Multiple logistic regression analysis of the factors associated with burnout among the
participants.
Multivariate analysis
Variables
aOR 95% CI Wald statistic df P-value
Personal burnout
Highest educational level 0.000
Secondary 1.00 2
Diploma 3.93 (1.55, 10.01) 8.257 1 0.004
Degree and above 8.36 (3.05, 22.95) 16.984 1 0.000
Financial problem 0.000
No 1.00
Yes 5.93 (2.13, 16.52) 11.562 1 0.001
Support from significant others 0.044
High 1.00 2
Moderate 1.55 (0.81, 2.98) 1.732 1 0.188
Low 14.91 (1.42, 157.03) 5.059 1 0.024
Work-related burnout 0.000
Financial problem
No
Yes 4.96 (1.98, 12.42) 11.664 1 0.001
Patient-related burnout 0.013
Support from friends
High 1.00 2
Moderate 3.57 (0.74, 17.20) 2.512 1 0.113
Low 49.50 (4.45, 550.32) 10.082 1 0.010

aOR, adjusted odds ratio; CI, confidence interval

Discussion of experiencing personal burnout than those

The overall prevalence of personal burnout who completed secondary school only. The
among the healthcare workers in health healthcare workers who held a diploma were
clinics in Manjung District was 31.3%; the assistant medical officers and staff nurses.
work-related burnout, 16.5%; and patient- The participants who held a degree and above
related burnout, 5.4%. This finding is had 8.4 times higher odds of developing
consistent with that of a study conducted personal burnout than those who completed
in Japan, wherein the overall prevalence of secondary school only. Similarly, Font et al.
burnout was 31.4%.22 However, the study was showed that doctors faced higher levels of
performed in a tertiary hospital. Conversely, burnout than nurses in Spanish oncology
the prevalence noted in the present study is units.24 Another study found that workers
much lower than that reported in a study on employed in government service had relatively
Malaysian healthcare workers: 53.8%, 39.1% lesser job flexibility and autonomy than those
and 17.4% for personal, work-related and employed in the private sector.25 Healthcare
patient-related burnout, respectively.18 This workers who held a diploma encountered
could be because this study was conducted higher job demands surpassing resources.25
when Malaysia was in its third month under Increased workload among healthcare workers
a movement control order during the initial including multitasking during the pandemic
phase of the COVID-19 pandemic; in has resulted in higher risks of burnout by
comparison, our study was performed among depleting the capacity of workers to meet their
doctors, assistant medical officers and nurses job demands.26 Further, negative emotions
in health clinics in a district during the end of patients and colleagues have triggered
of the pandemic, when the number of cases similar emotions in healthcare workers with
had significantly dropped and movement a diploma, making them more susceptible to
control measures were eased. Even before burnout.27
the pandemic, high levels of personal, work-
related and patient-related burnout were also We also found that personal and work-
found in a study conducted among doctors related burnout were associated with financial
in Sabah, with rates of 57.1%, 48.8% and difficulties. This is consistent with the findings
30.4%, respectively.23 of a study among radiology trainees, wherein
financial constraint was a risk factor for
The current study showed that the healthcare burnout.26 Similarly, financial difficulties were
workers who held a diploma had higher odds found to be associated with high burnout

Malays Fam Physician 2024;19:44 5

 ORIGINAL ARTICLE

levels among a female general population in insights into burnout among healthcare
another study.25 These findings indicate that workers in the country.
further attention is needed to assess and help
healthcare workers with financial constraints Conclusion
through, for example, training in financial Burnout is prevalent among healthcare workers
planning via courses.28 If financial problems are in Manjung District. Several measures could
solved, the risk of personal and work-related be implemented to reduce the mental health
burnout can be reduced. impact of burnout on healthcare workers,
including mental health screening, immediate
Social support from friends and significant access to mental healthcare services, early
others plays an important role in reducing intervention and establishment of support
the risk of burnout by acting as a buffer. groups. Further studies can be conducted in
Providing support can be an essential the country to better identify the issues and
psychological approach with better efficacy contributing factors of burnout.
than pharmacological therapy. A lack of social
support is related to increased burnout levels. Acknowledgements
Social support from friends is associated with We would like to acknowledge the Director
lower work-related burnout levels.28 This General of the Ministry of Health for granting
suggests the importance of creating policies permission to publish this paper.
that do not mandate separating frontline
healthcare workers from their friends or Author contributions
significant others. Healthcare workers can Conception and design: LYT, CHT, NAH, LI,
easily seek psychological support from their MSM and NSCI
family members to relieve stress from work Analysis and interpretation of the data: LYT
instead of feeling isolated or helpless.26 and CHT
Drafting of the article: LYT
According to a systematic review, decreased Critical revision of the article for important
social support is a vital risk factor for the intellectual content: LYT
development of psychological issues among Final approval of the article: LYT
healthcare workers, especially during disasters.29 Provision of the study materials or patients:
Support from families, friends, colleagues and LYT, CHT, NAH, MSM, LI and NSCI
healthcare organisations can provide healthcare Statistical expertise: LYT
workers the opportunity to alleviate negative Administrative, technical or logistic support:
feelings and emotions, which can then reduce LYT
the risk of burnout syndrome.29,30 Individuals Collection and assembly of the data: LYT,
can cope with difficulties by receiving support CHT, NAH, MSM, LI and NSCI
from their significant others.28 Several studies
have shown that strong social support during Ethical approval
the COVID-19 pandemic can reduce feelings of All forms used in this study were anonymised.
isolation and, consequently, the risk of burnout The data were stored on a password-protected
among healthcare workers.28,30 computer and could be accessed only by
the research team. All participations were
A limitation of this study is that the voluntary.
findings might not be generalised to other
healthcare workers, as their job scopes differ. Conflicts of interest
Nonetheless, the study provides an estimation None.
of the prevalence of burnout among healthcare
workers in a similar workplace setting in Funding
Malaysia. Another limitation is the possibility None.
of reporting bias, as the burnout data were
obtained using a self-administered instrument. Data sharing statement
Despite the limitations, the findings provide Raw data are available only upon request.

6 Malays Fam Physician 2024;19:44

 ORIGINAL ARTICLE

How does this paper make a difference in general practice?

• This study examined the determinants of burnout among healthcare workers in primary
care in Manjung District.
• The findings could assist public healthcare authorities in designing a targeted promotional
and intervention programme to reduce the risk of burnout among healthcare workers in
primary care.

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