The POISE Study: Qualitative findings from a mixed methods study investigating burnout in family physicians in low-and middle-income countries

Problem

Burnout is highly prevalent among physicians globally and has far-reaching consequences impacting on physician health, physician performance, and the workforce. The World Health Organisation has identified primary care as essential for achieving Universal Health Coverage. Therefore, it is imperative to investigate burnout syndrome in family physicians, especially those in LMICs where data is lacking. This study explores the stressors experienced by family physicians working in LMICs, their burnout experiences, and their coping strategies, adding richness, depth, and context to the quantitative findings of the POISE study.

Approach

Online semi-structured interviews were conducted with 33 family physicians. Within the sample, there were four physicians from each of Pakistan, Malaysia, and Sri Lanka, eight from Zambia, and 13 from South Africa. Participants were recruited from those who had completed the POISE burnout survey and had consented to further contact; burnout scores were known. Sampling was purposive. A mix of baseline demographic, employment, and workplace characteristics was also sought. Interviews were analysed using a thematic approach as described by Braun and Clarke where units of meaning are coded, and then codes are organised into themes. Recruitment continued until data saturation.

Findings

Five themes were identified: ‘demands’, ‘resources’, ‘experience of burnout’, consequences of stress and burnout’, and ‘coping strategies’. Participants described demands including heavy workloads with long work hours and high numbers of patients; workplace conflict with both colleagues and patients; patient factors such as poverty, illiteracy and health beliefs; work-related travel; systems and regulation; and political and socioeconomic factors such as the wider economy. Within the theme of ‘resources’ participants discussed their training and career development opportunities; the availability of supplies, services, and staffing; the importance of support; rewards, both monetary and non-monetary; motivating factors and values; and their work-life balance. They also spoke about their personal burnout experiences mainly in terms of consequences to physical and mental health; relationships; and work performance. Many participants also spoke about the stigma of burnout in their settings, where the consequences of stress and burnout may be perceived as weakness. Coping strategies and solutions were also discussed In terms of personal strategies such as self-care and self-improvement; relational strategies such as socialising; and work-related strategies such as migration.

Consequences

These personal perspectives add depth and context to widely recognised factors associated with burnout such as heavy workloads, conflict, and a lack of resources. They also highlight some unusual context-specific stressors such as work-related travel, poverty, and illiteracy. The stigma associated with acknowledging burnout, expressed more strongly by participants from certain countries, is an important finding as it will influence help-seeking behaviour. These perspectives will add insight to the development of context-specific burnout interventions and work-related policies going forward.