5-Nasiripour

JRHS 2009; 9(1): 48-51

Copyright © Journal of Research in Health Sciences

Occupational Stress among Rural Health Workers in Mashhad District, Northeast Iran

Nasiripour AA (PhD)a, Raeissi P (PhD)b, Shabanikiya HR (MSc)c

aSchool of Management, Health Administration Department, Islamic Azad University, Science andResearch Branch, Tehran, Iran

bSchool of Management and Medical Information Services, Research Department, Iran University of Medical Sciences, Tehran, Iran

cHealth Services Administration, School of Management and Medical Information Services, Iran University of Medical Sciences, Tehran, Iran

*Corresponding author: Dr Pouran Raeissi, E- mail: praeissi@yahoo.com

Received: 15 December 2008; Accepted: 10 May 2009

Abstract

Background: This study explores the level of Occupational Stress and main sources of occupational and personal stress among Rural Health Workers (RHW) of the health network of Mashhad district.

Method: The first part of the Occupational Stress Inventory (OSI) (called the Occupational Roles Ques­tion­naire (ORQ)) was used to measure the Rural Health Workers occupational stress (N=172). A num­ber of extra questions were also added to measure their specific sources of stress. The question­naires were distributed among RHW in a meeting held in the Health District Center in the city of Mash­had.

Results: The mean score of stress for the investigated subjects on OSI and all of its dimensions was within the normal range. On some dimensions such as role overload and role ambiguity however, about 40% of the Health Workers had middle to sever stress. Type of employment, distance of the vil­lage to the nearest city, number and combination of Health Workers in rural health clinics showed to have a significant impact on the RHW stress as well.

Conclusion: As the RHW Job is concerned, role overload and role ambiguity are the main sources of stress, which may have an adverse effect on the quality of their services. Type of employment, dis­tance of the village to the nearest city, number and combination of Health Workers at the health cen­ter also put pressure on RHW that need to be taken under consideration in planning for improv­ing RHW qual­ity of work Life.

Keywords: Occupational Stress, Health workers, Health Network, Iran

Introduction

Occupational Stress (OS) among health work­ers has been a matter of much scientific in­quiry in literature over the past decades (1-3). High level of stress at work is a major threaten­ing factor to both physical and psy­chological health of individuals (4-6) and af­fects their cog­nitive processes involving mem­ory, recall of knowledge and attention (7-8). In the as­pects of organizational and managerial affairs, a strong negative rela­tion­ship has been found between nurses' oc­cupational stress and job satisfaction (9) and it has been reported that high levels of OS re­sults in increasing turn­over rates and causes more and more nurses to leave their jobs (10). Also a high level of OS caused by heavy workload has been found to reduce nursing quality, and can threaten the lives and security of patients (11). The avail­able sta­tistics reveal that occupational stress has be­come more and more prevalent and costly over the past decades (12-13). Direct medi­cal costs of stress related problems are esti­mated to be between $150 to $300 billion an­nually in the United State (14). It was found that job stress causes health problems that lead to decrease productivity (15) as well.

The literature indicates that there is a rela­tion­ship between age, gender, marital status, educational level, position, length of service and working experience with occupa­tional stress (16-21), but the results of a study that was con-ducted on urban police of­ficers in the USA, showed that dynamic fac­tors such as work envi­ronment and cop­ing mechanisms, contrib­uted more to explain variance of police stress than static factors such as race and gen­der (22).

In several studies income, heavy workload, lack of workspace, lack of resources (includ­ing eq-uip­ment and material to do tasks), ab­sence of proper company procedures, insuf­fi­cient time to perform duties, meeting dead­lines imposed by others, have been intro­duced as stressors re­lated to work envi­ronment (23-25). In other studies ex­ternal ac­countability, responsibility, work re­la­tion­ships, insufficient consultation, commu­nica­tion, inadequate feed­back on performance and organizational chan­ges have been intro­duced as sources of oc­cupational stress (26).

In spite of a good amount of statistics avail­able in this area (27-30), very little attention has been paid to OS among rural health work­ers. The RHW are called Behvarz in the Iranian culture.

Health services in Iran are publicly financed. The health policy has been based on primary health care, with particular emphasis on ex­pan­sion of health networks and referral pro­ce­dures. In both towns and villages, a cen­tral Rural Health Center1 that performs its func­tions (delivery of primary health care) through a large number of rural health clinics2 (RHCs) and help of RHW. RHCs are mainly re­sponsible for public health such as com­mu­nity care, preventive care, vaccina­tion, health education, family planning, mater­nity care, child health care, school health care, primary diagnosis and treatment of some prevalent com­municable diseases. In addition, RHCs play an important role as a demographic and health statistic collector from their areas. RHW are health personnel who work in these RHCs and are in charge of delivering the stated services. RHW are trained in a Behvarzy School for 2 years to work in RHCs and are native to the village. In recent years however, some health techni­cians and midwives have replaced typical RHW and these are usually non-natives to the villages. We have called both of these RHW (Behvarz) in this study. If patient from rural ar­eas are also in need of special care and ser­vices beyond whatever RHW are re­sponsible for, they will be send to the special­ist and hos­pitals in city and towns and this will be done by RHW through referral pro­cedure. Overall, RHW have a key role in maintain­ing and promoting the rural popula­tion health.

The goal of the present study was to explore the level of OS among RHW of the health net­work of Mashhad district and to deter­mine the main sources of personal and occupa­tional stress of them.

Method

Participants and procedure

One hundred seventy two RHW from the Mashhad health network affiliated with Mash­had University of Medical Sciences lo­cated in the northeast of Iran were chosen to par­tici­pate in this survey. The data were col­lected through a self-report questionnaire. The data were gathered by the researcher at the Ru­ral Health Center where the RHW had gath­ered for a workshop. The questionnaires were distributed at the beginning of the work­shop and collected at the end of the ses­sion. Due to the limited number of RHW, no sampling was done in this research.

Variables and Instruments 

The survey questionnaire contained 4 parts and 83 questions as follows: Socio-demo­graphic characteristics of RHW (9 items), Charac­ter­is­tics of rural health clinics (7 items), occupa­tional stressors (60 items), and Job and per­sonal problems of RHW (7 items).

The characteristics of Rural Health Clinics (RHC) were evaluated by 7 questions includ­ing the population size covered by the RHCs, distance from the village to the near­est city (in kilometers), existence or non-exis­tence of satellite villages, safe water pip­ing, electricity and heating and/or cooling fa­cilities, enough space for rural health clinic ac­tivities, and num­ber and combination of RHW working in the RHCs (e.g. single, cou­ple, etc.).

The first part of the Occupational Stress In­ventory (OSI) (41) was used to measure the RHW occupational stress. This part was called Occupational Roles Questionnaire (ORQ). The ORQ was validated by Raeissi and Mona­jemy (21) and consisted of six sub­scales in­cluding 1) Role overload, 2) Role in­suffi­ciency, 3) Role ambiguity, 4) Role boundary, 5) Role re­sponsibility, and 6) Physi­cal environ­ment. Each subscale con­tained 10 questions, and 60 items. All ques­tions in the ORQ were scored on a 5-point Likert scale ranging from 1= never to 5= always. The score on each subscale was ob­tained from summing the score of a set ques­tions belong to that specific sub­scale. The total occupational stress score was also obtained from summing the scores of the stated sub­scales in above. The cut score for the distri­bu­tion of the stress score on five sub­scales was as fallows: 10-16= Without Stress, 17-30= Nor­mal Stress, 31-38 = Mod­er­ate Stress and 39-45= Severe Stress (e.g. 1-Role overload, 2-Role insuffi­ciency, 3-Role ambiguity, 4-Role bound­ary, 5- Role re­spon­sibility) and for physical envi­ronment subscale, 10-24 considered Nor­mal, 25-32= Moderate and, 33-40= Se­vere.

For the total stress score distribution, the cut scores used were as follows: 60-107= With­out Stress, 108-203= Normal Stress, 204-251= Moderate Stress and 252-300= Severe Stress.

A checklist of 10 items was used to measure RHW specific personal and occupational prob­lems too and, for the ease of communica­tion, we called them RHW spe­cific personal and oc­cupational stressors in this research. These items were as follows:

1- Lack of collaboration between rural health clinics and higher levels of the health net­work (e.g. Rural Health Centers, District Health Centers, and District Hospitals), 2- Lack of co­ordination between Rural Health Clinics (RHCs) and sectors out of the health system such as Rural Councils, Schools etc., 3- Lack of coordination with RHCs about the time of workshops set by higher levels, 4- Delay in re­ceiving formal letters, sched­ules and pro­ce­dures, 5- Inadequate salary, 6- Problems in commuting for non-resident RHW, 7- Family problems related to RHW jobs such as in­ade­quate and poor educational facilities and op­portu­nities for their children. The stated items were measured as a "yes" and "no" question where 1=Yes and 0= No. Each item of this part was evaluated independ­ently. Since the stated items were checking the facts, its validity was grantee through judgment of the experts and no esti­mate of reliability was considered.

Data Analysis

Total stress was measured by the Osipow and Spokane (41) questionnaire.

The impact of socio-demographic variables, ru­ral health clinic characteristics or specific personal and occupational stressors on rural health workers' total stress was tested using one-way ANOVA or independent t-test. The data were analyzed by SPSS version 15.

Results

A total of 172 rural health workers partici­pated in this study of whom 77.7% were fe­male and 22.3% male. The majority of the par­tici­pants (86.6%) were married and 57% of them did not have a high school diploma.  Al­most all of them (94.8%) were graduated from Behvarzy schools. Their average length of em­ployment was about fourteen years (X= 13.65, SD= 7.33). Ninety percent of the re­spondents were official employees of the RHCs and 10% were provisional employees.  About 60% of RHW were native to the vil­lages and were liv­ing in the same area. From the investigated RHW 71.4% were settled in their own houses among the village commu­nity and 28.6% in dormito­ries attached to the Rural Health Clinics. The mean score of their age was 34.78 yr. Table (1) presents rural health workers' socio-demo­graphic infor­mation.

Table 1: Descriptive statistics of social Demo­graphic variables

Variables

N

%

Age (yr)



20-29

50

29.6

30-39

77

45.6

40-49

29

17.2

50-59

13

7.7

Marital status



Single / Divorced/ Widow

23

13.4

Married

149

86.6

Educational level



Primary School

24

14

Junior high school

74

43

High school

36

20.9

Diploma

36

20.9

Junior community college

2

1.2

Major



Primary health care in Behvarzy School

163


Others

7


Years of employment



<=1

4

2.4

2-10

64

38.8

11-19

63

38.2

20-30

34

20.6

Residence status



Resident in village and native

102

59.3

Resident in village but non- native

17

9.9

Resident out of village but native

22

12.8

Resident out  of village and non-native

31

18.0

For nonresident Rural Health Workers

In this research the average population cov­er­age for each Rural Health Clinic was 1,941 persons and the villages on average were 34.41 km away from the nearest city (SD= 23.40). In addition to their own vil­lages, 67.8% of the rural health workers had to provide health care services to some satel­lite villages as well. Almost half (48.5%) of the RHCs were managed by a female rural health work­ers, and 19.3% by both a male and a female. Forty five percent of the RHW reported that they were dealing with a short­age of space in their RHCs. From the stated RHCs 33% did not have safe water piping and 55.3% elec­tricity or air con­di­tioning facili­ties. Table (2) presents demo­graphic in­formation of the Rural Health Clinics.

Table 2: Descriptive Statistics on Rural Health Centers' characteristics

Characteristics

N

%

Population coverage of a Rural Health Clinic



< 500

6

3.6

500-1499

72

43.6

1500-2499

48

29.1

2500-3499

16

9.7

3500-4999

15

9.1

>= 4500

8

4.8

Distance of village(Rural Health Clinic) to the nearest city(km)



< = 9

21

13.1

10-29

53

33.1

30-49

42

26.3

50-69

24

15.0

70-90

20

12.5

Number and combination of Rural Health Workers  in  the  Rural Health Clinic 



A female

83

48.5

A male

3

1.8

A couple (wife and a husband)

22

12.9

Two females

12

7.6

A male and a female

33

19.3

Two Rural Health Workers who are relatives

3

1.8

More than two Rural Health Workers

14

8.2

Having satellite villages *

116

67.8

Insufficient space in Rural Health Clinic

88

55.3

Lack of safe water piping

52

32.9

Lack of electricity and / or air conditioning facilities

71

44.7

Satellite villages dont have any Rural Health Clinic and they receive their health care services from a mobile team who is sent to them by the nearest Rural Health Clinic 

The findings of the present study on RHW spe­cific personal and professional stressors re­vealed that inadequate salary, interference of job obligations with family affairs, delay in re­ceiving official letters, and commuting be­tween village and city were the four top stressors for RHW in this research (Table 3).

Table 3: Special Personal/Occupational stressors for Rural Health Workers

Variables

N

%

Lack of coordination with health houses about the time of work­shops

56

35.4

Delay in receiving official letters, …                                                              

102

65.0

In adequate Salary

132

84.6

Difficulties with shuttling between village and city

30

56.6

Interference of family affairs with Rural Health Workers job

113

76.4

Lack of collaboration between health house and higher levels

76

49.4

Lack of coordination between health houses and sectors out of health system

66

41.8

In regard to the occupational stress of RHW measured by OSI, the findings of the present study revealed that the mean scores of RHW stress on all the OSI dimensions and as a whole fell within the normal range. How­ever, 40% of the respondents had middle or se­vere stress on the "Role Overload" dimen­sion and 30% of them gained a score higher than normal on the "Role Ambiguity" dimen­sion (Table 4).

Table 4: Distribution of Rural Health Workers' Total Stress on (OSI) and its Dimensions

       Level of stress


Subscales

Without  stress

Normal stress

Middles Stress

              Sever stress

n

%

n

%

n

%

n

%

Role Overload

3

1.7

97

56.4

63

36.6

8

4.7

Role Insufficiency

19

11

149

86.6

1

0.6

0.0

0.0

Role Ambiguity

12

7

103

59.9

42

24.4

11

6.4

Role Boundary

4

2.3

132

76.7

32

18.6

1

0.6

Role Responsibility

36

20.9

114

66.3

12

7

1

0.6

Physical Environment

0.0

0.0

127

73.8

32

18.6

6

3.5

Total Stress

11

6.9

142

89

1.0

0.6

0.0

0.0

Type of employment, distance of the village to the nearest city, and number and combina­tion of RHW in RHCs had a significant im­pact on RHW total OS (Table 5).

Concerning the number and combination of RHW working in a RHC, a single male gained the highest score for total stress. The second highest score was gained by a combina­tion of a male and a female (X̅=154, SD=24) who did not have any fam­ily relationship but were just colleagues. A rural health workers who were couple achieved one of the two lowest total stress scores (X̅=139, SD=18) and finally, two RHW who were relatives (but not spouses) had the least total stress score (X̅=96, SD= 1).

Regarding type of employment, we found that of­ficial employees gained higher total scores than provisional employees (X̅=139, SD=15).

With regard to distance, the findings re­vealed RHW who worked in faraway RHCs experi­enced more OS.

Table 5:  Statistical Results for impact of Socio-demo­graphic variables or Characteristics of health houses on Rural Health Workers Occupational Stress

Variables

F-value

P-value

Age

0.823

0.486

Marital status

0.526

0.666

Educational level

2.230

0.075

Major

1.457

0.232

Years of service

0.498

0.685

Type of employment

3.154

0.049*

Residence status

0.974

0.411

Place of living in the vil­lage

0.161

0.690

Population coverage by health house

0.786

0.564

Distance from village to nearest city

3.738

0.009**

Having satellite villages

0.068

0.769

Number and combination of Rural Health Workers in a health house

3.635

0.004**

* Significant at P<0.05, ** significant at P<0.01

Discussion

The findings of the present study revealed that overall; RHW had normal levels of stress. These findings could be due to the char­ac­teristics of the job such as low levels of ex­ternal accountability. Our findings in this area are in agreement with the findings of Byrne (9). On "role overload" however, we had a large number of RHW who had ex­perienced severe to moderate stress in their work en­vironment. These findings support McGrath & Reid (6) and Adib-Saeedi (25). The stress of RHW on this dimension could be due to the following factors: 1) The aver­age population coverage for each RHC is no­ticeably higher than the standard (i.e. 1,949 vs. 1,500), 2) As time passes, new health care programs add to the current programs and this adds to RHW work load.

A large number of RHW had moderate to se­vere stress on "role ambiguity". These find­ings support the results of Elovainio and Kivi­maki (32). RHW stress on this dimen­sion could be due to lack of unity of com­mand at the RHCs-one of the classic princi­ples of management. As it was men­tioned previously, RHCs are supervised by Ru­ral Health Centers and a ge­neral practitio­ner (MD) is usually in charge of running the Rural Health Center. In these cen­ters, differ­ent health experts are responsible for differ­ent fields of health care services and when they supervise RHCs every one of them puts pressure on the RHW to allot their work pri­or­ity to their own fields. The GPs as the man­agers also expect that RHW allot their job pri­orities to curative rather than preven­tive ser­vices. Therefore, RHW are often faced with confusing conditions and they sometimes do not know exactly what their job priorities and ex­pectations are.

The number and combination of RHW who work together in RHCs have an impact on RHW occupational stress. These findings sup­port the findings of Landa et al. (16). The job stress for those who were relatives and worked as couples in the RHCs was the least com­pared with others. This might be due to the supports that RHW who are rela­tives, receive from each other.

The distance of the village to the nearest city had a significant impact on RHW occupa­tional stress. One possible explanation for these findings is that the remote RHCs do not re­ceive sufficient support from the Rural Health Cen­ter or District Health Center for run­ning their health service activities. For ex­ample, as the dis­tance of the RHCs with the Rural Health Center or District Health Center increases RHW are faced with more problems in terms of having transportation fa­cilities to conduct their job obligations at the RHCs and this may impose more stress on the RHW working in these RHCs than oth­ers.

The findings also indicated that type of em­ployment (official vs. provisional) has an im­pact on RHW occupational stress. That is per­manent or official employees had higher levels of stress than provisional employees did. One possible explanation for these find­ings is that the permanent employees feel to be tight up with limited income and little pro­motion for long time while, the provi­sional employees may not have such a feel­ing to their job. Landa et al. (16) also found that younger employees with shorter length of service experienced less stress.

The overall RHW occupational stress score fell within the normal range in this research. On "Role Overload" and "Role Ambiguity" di­men­sions, however, they showed to have moder­ate to severe levels of stress. These find­ings are important for planning to pro­vide a stress free environment for RHW at the RHCs and improving the quality of their work life.

There was a relationship between RHW occu­pational stress and the 1) number and combi­nation of RHW in a RHC, 2) type of em­ploy­ment, and 3) distance of the village from the nearest city. In conclusion, these findings can be used for future planning to as­sist RHW and possibly to increase their job satisfaction.

Acknowledgments

Our sincere thanks go to all the authorities and staff of the Health Network of Mashhad district who kindly helped us to collect the data for this research. The authors declare that there is no conflict of interests.

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