Khalid S. Al-Gelban, MD; SSCFM; CABFM; JBFM¹; Yahia M. Al-Khaldi, MD; CABFM²; Hasan S. Al-Amri, MD,SSC-Psych³; Ossama A. Mostafa, Dr.PH¹

(1) Dept. of Family and Community Medicine, College of Medicine, King Khalid University
(2) General Directorate of Health Affairs, Aseer Region
(3) Dept. of Medicine, Section of Psychiatry, College of Medicine, King Khalid University

Correspondence:
Khalid S. Al- Gelban
Department of Family and Community Medicine
College of Medicine,
King Khalid University
P.O. Box 641,
Abha, Kingdom of Saudi Arabia
Tel: 00966 7 2417738
Fax: 00966 7 2289300 Ext. 1791
Email: khalidgelban@hotmail.com

INTRODUCTION

There is an increasing concern about the interaction between mental health problems and the workplace⁽¹⁾. Mental disorders are among the most frequent causes of occupational disability⁽²⁾.

Amongst doctors, poor psychological health has been associated with significant impact on the quantitative and qualitative care of patients, leading to poor performance and the resulting effects on patients' satisfaction and adherence to treatment⁽³⁾.

Wall et al.⁽⁴⁾ examined a large sample of National Health Service workers in Britain and reported relatively high levels of minor psychiatric disorders among doctors, nurses, allied health professionals, and managers compared with rates in the general population⁽⁴⁾. In Pakistan, 39% of family physicians were shown to suffer from depression or anxiety⁽⁵⁾.

In Saudi Arabia the Ministry of Health (MOH) is the major government agency entrusted with the provision of preventive, curative and rehabilitative health care for the Kingdom's population. The Ministry provides primary health care (PHC) services through a network of health care centers (comprising 1,925 centers) throughout the Kingdom⁽⁶⁾, of which most health
professionals are expatriates.

High prevalence rates of anxiety, stress and depression were reported among Saudi secondary school teachers and students^(7,8). However; very limited evidence is available on the psychological issues among health care providers.

The aim of this study is to explore the prevalence of negative emotional states (i.e., depression, anxiety and stress) among PHC physician working in Aseer region.

During January 2006, this study was conducted on all physicians working in PHC centers in Aseer region (N=345). Aseer occupies a part of Southwest of Saudi Arabia with a total population of 1.6 million inhabitants and a total area that exceeds 185,000 km².

Physicians were assessed using the "Depression, Anxiety Stress Scale" (DASS). It is a 42-item mood state inventory designed to measure negative affective states. It has reliable, independent subscales of depression, anxiety, and stress. Gamma coefficients that represent the loading of each scale on the overall factor are 0.71 for depression, 0.86 for anxiety, and 0.88 for stress. Reliability of the test is considered adequate and test-retest reliability is likewise considered adequate with 0.71 for depression and 0.79 for anxiety and stress. Exploratory and confirmatory factor analyses have sustained the proposition of its factors (p<0.05)^(9,10).

Demographic and environmental data, as well as the presence of associated psychological factors, were collected via a questionnaire devised for the study. Participants were assured about the confidentiality of any provided data through a covering letter.

The questionnaire was distributed to all PHC physicians working in Aseer region. In order to answer the questionnaire properly, the technical supervisors in all sectors (16 sectors) supervised the assessment and were requested to return the responses to the General Directorate of Health Affairs within a maximum of one week.

Physicians who proved to have any of the three negative emotional states (i.e., depression, anxiety or stress) received the necessary consultation and psychiatric care from the psychiatrist researcher of this study.

Data of the completed questionnaire were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 15. Appropriate statistical tests were applied accordingly and results were considered significant if p<0.05.

A total of 305 questionnaires were returned giving a response rate of 88.4%. No reason was found to exclude any of them.

Table 1 shows that participant physicians were of middle age with a mean age of 39.1 years (SD = 6.2 years) with 4.2:1 male to female ratio. Most participants were married and live currently with their families (78%). Almost two-thirds of the physicians had been in general medical practice for over 10 years since graduation. However, the qualification of three-quarters of the physicians was the Bachelor degree. Among participants, there were only 8 Saudis (3%).

Table 2 displays that the prevalence rate of negative emotional states among PHC physicians in Aseer was 13.2%. Anxiety occupied the highest prevalence (26, 8.6%), followed by depression (23, 7.6%), and stress (22, 7.2%). High extent of overlap among the three negative emotional states is quite obvious (Figure 1).

Figure 1. Psychiatric morbidity among primary care physicians in Aseer region, Saudi Arabia, 2006 (n= 304)

Table 3 shows that depression, anxiety and stress were strongly, positively and significantly correlated.

Table 4 shows that depression was not significantly associated with any of the socio-demographic characteristics. Anxiety and stress were significantly higher among females than males (p=0.035 and p=0.032, respectively). Moreover, the 3 negative emotional states were shown to be higher among physicians with higher qualifications. However, this trend was statistically significant only as regards stress (p=0.035).

This study indicated that the prevalence of negative emotional states among primary care physicians in Aseer region is 13.2%. Differentially, the prevalence rates of depression, anxiety and stress were 7.6 %, 8.6% and 7.2%, respectively. These results are relatively lower compared with the results reported among Saudi secondary school teachers using the same tool⁽⁷⁾, as well as the prevalence of any depressive disorder in Saudi population which is 22.8%⁽¹¹⁾. This finding is not in accordance with that reported by several researchers, who indicated that mental disorders are significantly higher among general practitioners (GPs) than in the general population^(12,13).

There are possible reasons why the reported prevalence of negative emotional states are relatively low in this study. Some respondents with a 'felt negative' emotional state may experience personal concerns about the confidentiality of their responses (in spite of the clear written assurance accompanying the data collection sheets) or toward the social "stigma" commonly attached to psychiatric issues. In addition, frequently, some general practitioners might falsely believe that they, as physicians, are qualified enough for self-diagnosis and self-medication. Moreover, tight time constraints for delivering the physicians' response (one week only) might have contributed to this result⁽¹⁴⁾. Finally, the present study may have a limitation since the obtained data within this study were 'self-reported'. Hence, some degree of response bias, due to underreporting, is possible. Nevertheless, the fact remains that findings would reflect the prevalence of these disorders among the primary care physicians

The present study revealed a high extent of overlap among the negative emotional states and that studied negative emotional states are significantly and positively highly inter-correlated. This may indicate that the personal common vulnerability is universal, i.e., if a physician is susceptible to depression, he/she is also susceptible to anxiety and stress as well.

This study showed that participants' age group, nationality, marital status, and years of experience were not significantly associated with prevalence of negative emotional states. However, anxiety and stress were significantly higher among female than male physicians (15.5% vs. 6.9%, respectively, p=0.035 for anxiety and 13.8% vs. 5.7% for stress, respectively, p=0.032).

These findings are in accordance with those of Bekker and van Mens-Verhulst⁽¹⁵⁾, who reported a significantly higher prevalence of anxiety among females (16.3%) than males (7.8%). To explain this significant anxiety and stress predilection among females, Gianakos⁽¹⁶⁾ stated that males, compared to females, perceive greater levels of workplace support or at least report such support is effective in reducing their felt stress. Social support in the workplace likely buffers the impact of stress by providing actual assistance in problem solving or in feelings of attachment to others for emotional support. The present study showed that the higher the qualification of the PHC physician, the higher is the experienced stress. This finding is in agreement with that reported by Oubiña et al.⁽⁷⁾, who stated that academic qualifications make a difference to the recognition and experiencing of a stressful situation. This may be due to the fact that highly qualified physicians usually carry higher responsibilities.

In both the USA and Europe, 30-40% of the workforce is exposed to workplace stress, and levels of stress appear to have been rising over the last two decades⁽¹⁷⁾.

Several studies have evaluated the role of stressful or unsupportive workplaces in the genesis or maintenance of psychiatric symptomatology. Researchers have found that certain kinds of workplace stress are associated with a higher frequency of depression, anxiety and stress in employees^{(4,7,8,13,19)}.

In this study, almost all participating physicians were expatriates from different countries with different training backgrounds, different experiences in PHC, different cultural backgrounds and frequently different languages. These differences might create stresses at work that are added to the baseline stresses of working in a primary health care setting. The steady growth in health services in recent years in Saudi Arabia raises the demand for labor in the health sector, which cannot be easily met by Saudi nationals due to the insufficient number of Saudi graduates from the medical educational and training institutions.

In literature, important sources of psychosocial stress for GP's are mentioned. These comprise excessive paperwork, health reforms, bureaucratic interference, job demands, decision latitude, workplace location, job pressure, patient load, lack of organizational support, dealing with difficult patients and objective personal characteristics such as age, gender and workers' marital status^(4,7,18,19). Suicidal tendencies and alcohol dependence were reported to be higher among physicians than controls of a comparable social class⁽²⁰⁾. For the workplace, these conditions lead to increased absenteeism, conflict, higher turnover and reduced quality and quantity of work.

This study indicates that PHC physicians in Aseer experience some degree of burnout, manifested in variable forms of expressed negative emotional states (i.e., depression, anxiety and stress). This work provides some insight about the satisfaction levels of workplace characteristics, stress and its affect among physicians. It contributes to the acknowledged need for further research to explore sources of stress among PHC physicians, their possible solutions and preventive measures and also to determine the effects of any change secondary to implementation of preventive strategies at different levels.

Acknowledgements:
The authors would like to thank all primary health care physicians who participated in this study as subjects, as well as all staff of department of family and Community Medicine, College of Medicine, King Khalid University for helping in data collection and verification.

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