Burnout syndrome and abdominal adiposity among Primary Health Care nursing professionals

We conducted a confirmatory, cross-sectional, epidemiological study with Primary Health Care nursing practitioners of nine municipalities in Bahia, Brazil, namely, Anguera, Catu, Guanambi, Ibirapitanga, Igaporã, Inhambupe, Macaúbas, Pojuca, and Santa Barbara, linked to the multicenter project entitled “Síndrome de Burnout e Síndrome Metabólica em Profissionais de Enfermagem da Atenção Básica à Saúde do Estado da Bahia” (Burnout Syndrome and Metabolic Syndrome in Primary Health Care Nursing Professionals of the State of Bahia). The total amount of family health units (FHU), the study’s locus, corresponded to 73, and among the 211 nursing professionals, who have developed their working practices regularly, 195 met the inclusion criteria.

It is noteworthy that 16 professionals were excluded because of the following: being on medical leave, develop purely administrative activities, pregnant women, and professionals who reported a diagnosis of depression before entering the position assumed.

From the professionals included in the study, 189 (96.9%) participated and answered all the questions of the questionnaire, specifically designed for this study, containing information on sociodemographic and job conditions, lifestyle, and human biology as well as a tool to assess the presence of BS, called the Maslach Burnout Inventory (MBI) (Maslach et al 1996). We evaluated the internal reliability of the MBI instrument categories using the Cronbach’s alpha coefficient. Alpha values above 0.70 indicate acceptable internal consistency, maintaining the reliability of the instrument, with 0.82 for EE, 0.79 for DP, and 0.81 for LPA.

Data collection was conducted through interviews from January 2015 to March 2016, and all the PHC nursing professionals were invited to participate in the survey by telephone, on which occasion the scope and objectives of the survey were explained to them, emphasizing the nature of voluntary participation. Only six participants refused to participate in the study. We performed a pilot study to make the necessary adjustments in the questionnaire. Moreover, viewing to ensure a uniform application of the questionnaires, we opted for a calibration of the research’s assistants by means of the application of questionnaires in ten professionals of the hospitals’ field. This procedure was eligible to calculate the rate of agreement between them, using the Kappa index, finding a 0.87 value which is considered acceptable with an optimal classification (Seigel et al. 1992).

The main independent variable of this study was the BS; for the definition of the individual with BS, we remark that the MBI is a validated instrument which was translated into Portuguese in Brazil by Benevides-Pereira (2009). It is composed of 22 questions that explore the three dimensions: EE (1, 2, 3, 6, 8, 13, 14, 16, and 20), DP (5, 10, 11, 15, and 22), and LPA (4, 7, 9, 12, 17, 18, 19 and 21), scored by a Likert scale of five points which is as follows: “1” never, “2” rarely, “3” sometimes, “4” frequently, and “5” always.

From the sum of questions for each dimension, the score was obtained with the following cutoff points: EE, high (≥27 points), medium (19–26 points), and low (<19 points); DP, high (≥10 points), medium (6–9 points), and low (<6 points); and LPA, high (≤33 points), medium (34–39 points), and low (≥40 points) (Moreira et al. 2009). The BS was dichotomized according to the criteria by Ramirez et al. (1996), as present (yes) or absent (no), by considering the existence of high scores in the dimensions of EE and DP and low scores on the LPA.

The dependent variable was represented by abdominal adiposity, measured by the individual’s waist circumference. The most representative anthropometric verification of intra-abdominal fat, considered simpler measurement, is the measurement of abdominal circumference (AC) or waist circumference (WC) due to its high relation to the amount of visceral adipose tissue (Sociedade Brasileira de Endocrinologia e Metabologia 2005; Scarcela and Despres 2003). It is the best indicator of visceral fat mass being strongly related to cardiovascular complications (Martins and Marinho 2003).

The WC standardization and measurement followed the standards recommended by the Universidade de São Paulo, Laboratório de Avaliação Nutricional de Populações (2010) and the nutrition department. Thus, the WC measurement was obtained using an ISP® inelastic tape made of fiberglass material with a capacity of 150 cm and 1-cm accuracy. The measure was taken at the midpoint of the distance between the lower edge of the rib cage and the iliac, at horizontal plane. The surveyed professionals were measured in standing position, arms at their sides, feet together, weight divided between the legs, and eyes on the horizon. We requested the professionals to elevate their shirts to measure accurately (Habicht and Butz 1979).

The following cutoffs were used: normal WC (<88 cm for women and <102 cm for men) and high-risk WC (≥88 cm for women and ≥102 for men) (World Health Organization 2005).

After data collection, the questionnaires were examined, numbered to facilitate registering, entered, and processed, using the Statistic Package for Social Sciences (SPSS). We checked for errors and inconsistencies and validated the data presenting the percentage values, the means, and the standard deviations of the variables.

Subsequently, the statistical analysis of the data was carried out using SPSS 22.0 software for Windows and STATA for Windows, in order to assess the predictive conceptual model having AA as dependent variable and BS as an independent main variable. The independent variables (covariates) considered as potential effect modifiers were as follows: hypertension, diabetes mellitus, and alcohol consumption; the confounding variables were as follows: gender, education, working time at the Health Unit, physical activity, and anxiety.

Initially, we carried out a descriptive analysis by means of absolute and relative frequencies of all the variables of interest, enabling to estimate prevalence from the main independent variable (BS) and the dependent variable (AA). The bivariate analysis was performed to verify the associations of the independent variables with the dependent variable. Therefore, we calculated their prevalence ratios (PR), their respective confidence intervals (CI) of 95%, and p value through Pearson’s chi-square test or Fisher’s exact test to assess the statistical significance of the associations.

To confirm the modification of the effect, we calculated the PRs of the main association per stratum of each preselected covariate and their respective 95% CI. Verification of effect modification was done through the intuitive method (PR of a stratum should not be contained in the confidence interval of another stratum and vice versa) and the Breslow-Day homogeneity test with a p value ≤0.05. As for the confirmation of the confounding variables, we used the variation between crude PR and Mantel-Haenszel’s adjusted PR, taking as a selection criterion variation ≥20%. In processing the analyses, we found no effect modifying or confounding variables.

To assess the association between BS and AA, controlled by the covariates of interest in the predictive conceptual model, we used conditional logistic regression with the retrograde selection process (“Back Ward”), with analysis criterion value p ≤ 0.05. To obtain the final logistic regression model, we followed the procedures described by Hosmer and Lemeshow (2000).

It is noteworthy that the logistic regression model produced odds ratio measures (OR) which is not a suitable association measure for cross-sectional studies, and this measure overestimates associations in studies with high-prevalence outcomes (over 10%); therefore, the prevalence ratios (PR) and 95% confidence intervals were estimated using Poisson’s regression with robust variance (Coutinho et al. 2008; Francisco et al. 2008).

The adequacy of the final regression model was evaluated by the model’s goodness of fit test (Hosmer and Lemeshow) and the area under the receiver operating characteristic (ROC) curve.

The study was approved by the Ethics in Research Committee involving human beings of the State University of Bahia, in decree no. 872.365/2014. We highlight that all participants signed the consent form.

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