Prevalence of Burnout Among Health Workers in Iran: A Systematic Review and Meta-analysis

Introduction: Burnout significantly impacts human service professions, reducing the sense of competence and successful performance of duties. This study aimed to investigate the prevalence of job burnout among healthcare workers in Iran. Methods: A systematic search was conducted according to the PRISMA checklist in databases such as PubMed, Scopus, Web of Science, PsycINFO, Magiran, Scientific Information Database (SID)


Introduction
Human resources are considered one of the most valuable organizational assets, the most critical competitive advantage, and the scarcest resource in the knowledge-based economy.They are considered the greatest asset of any organization in terms of possessing the power of thought, creativity, and innovation, as any improvement and progress in technical and organizational structures are carried out by human resources (1).Healthcare workers have close and intimate contact with other people and have a critical responsibility for the health and life of humans (2).Dealing with sick people, incurable diseases, and death puts this profession in, leading to their high-stress jobs, fatigue, and burnout.Job burnout is one of the issues first introduced in the 1970s (3).Job burnout is a psychological syndrome of three dimensions: Emotional or affective exhaustion, depersonalization, and reduced personal accomplishment (4).
The central feature of burnout is emotional exhaustion, which is a general stress response and Health Workers (Title/Abstract)] OR [Health Workers (Title/Abstract)] OR [Health Personnel (Title/Abstract)] AND [burnout (Title/Abstract)] AND [Iran (Title/Abstract)]}.This search yielded 45 potentially relevant papers from the mentioned electronic databases.After removing duplicates and excluding studies based on title and abstract review, several studies remained for full-text screening.Eighty-five studies were excluded due to unrelated topics, unsuitable design, and lack of access to the full text.The flowchart of the screening and study selection process is presented in Figure 1.For each electronic database, a search strategy was adopted using the POLIS model (Population, Outcome, Location, Index, and Study Design) for study selection (Table 1).This model is widely used for formulating empirical studies concerning evidence synthesis and ensures that the relevant aspects of the question are well-defined.

Inclusion and Exclusion Criteria
The inclusion criteria were studies that investigated the prevalence of burnout in healthcare workers in Iran (doctors, nurses, treatment assistants, health aides, faculty members of medical science universities, and students in related fields, dentists) and used the "Maslach Job Burnout Questionnaire" evaluation tool.No restrictions were applied regarding language, participant age, gender, or time period searched.Crosssectional empirical studies were included in this review.Case studies (series of case reports or individual case reports) were excluded.Additionally, studies without full text and those conducted on other target groups were excluded.

Quality Appraisal
To conduct this section, two observers independently used the modified version of the quality assessment checklist for prevalence studies (adapted from Hoy et al.) for cross-sectional prevalence studies.This tool consists of 10 questions designed to assess the risk of bias.For this study, and considering the specific study conditions, the questions of this tool were modified, and the quality assessment of the papers was performed based on it.Disagreements at any review stage were resolved through discussion with a third independent J Nurs Midwifery Sci.2024; 11(2): e144750.
3 reviewer.A data extraction and quality assessment form, which was previously designed in an Excel program, was provided to the two observers.

Study Selection and Data Extraction
Strictly following the inclusion and exclusion criteria, two reviewers retrieved and independently reviewed full-text papers after screening the titles and abstracts of all papers.The two reviewers independently evaluated every article for inclusion in this systematic review and meta-analysis.Any disagreements regarding article inclusion were resolved through discussion with a third reviewer to reach a consensus.Two independent reviewers performed data extraction.For data extraction, variables included the first author's name, publication year, research location, study design, sample size, mean age, target population, work experience, type of instrument used, the average score of occupational burnout, outcomes, and quality assessment score.

Occupational Burnout Assessment Tool
The MBI (Maslach burnout inventory) was developed in 1996 for use in healthcare workers.This tool assesses three dimensions of occupational burnout: Emotional exhaustion, depersonalization, and personal accomplishment.The scale consists of 22 items with Likert Scale responses, and the total scores can classify the respondent into different levels of occupational burnout (no burnout, mild burnout, moderate burnout, and severe burnout).

Synthesis
Using meta-analysis techniques with the "metaprop" command in STATA version 12, the data from studies that addressed the prevalence of occupational burnout in healthcare personnel in Iran were synthesized, and the results were reported with a 95% confidence interval.The I-squared test was used to identify heterogeneity among studies: I 2 < 25% indicates no heterogeneity, I 2 =

Characteristics of the Included Studies
The characteristics of the 63 articles systematically reviewed are reported in Table 2. Due to the large volume, Table 2 is not included in the article file but is attached separately.

Quality Assessment
Approximately 62.2% of the studies had a low risk of bias, and 33.3% had a moderate risk.Two articles were found to have a high risk of bias.A common weakness in most studies was the lack of explicit mention of the participants' exposure level and the sampling method (online or in-person) during the study (Table 3).

Mean Occupational Burnout
The primary outcome of interest, the prevalence of occupational burnout, was analyzed in 61 studies.Using a random-effects model, the mean score for occupational burnout was calculated as ES: [95% Confidence Interval = 0.36 (0.29 -0.42)].The heterogeneity was significant, reported as I 2 = 99.66%(P = 0.000), indicating high heterogeneity among these studies (Figure 2).To address this, subgroup analysis was performed based on study quality, levels of occupational burnout, and the duration of employees' activity before and after the COVID-19 pandemic.Despite this, severe heterogeneity persisted (Table 4).

Publication Bias
The Begg method was used to assess publication bias for this outcome.In Begg's chart, which examines the effect of small studies, P-value = 0.000 was reported.Since this value is significant, it indicates the presence of publication bias (adj.Kendall's Score (P-Q) = 885, SD = 160.70,z = 5.51, Pr > |z| = 0.000).

Discussion
Our study results indicate that the average job burnout score among healthcare workers in Iran is approximately 0.38 (95% CI 0.30 -0.46), suggesting a mild to moderate level of burnout in this population.Job burnout has emerged as a significant public health issue and challenge.Identifying risk situations and implementing preventive measures early on is crucial to prevent future damage (7).The combination of work environment stressors and personal fears related to the COVID-19 pandemic has placed a substantial psychological burden on healthcare teams.Providing care in high-risk units, interacting with infected patients, and being in stressful situations can contribute to psychological strain for healthcare workers, potentially leading to mental health issues such as depression, alcohol and substance addiction, and burnout syndrome (7,14).These conditions can adversely affect patient care quality and system efficiency (16).Consistent with our findings, a similar study reported that nearly half of healthcare workers in Iran experienced job burnout during the COVID-19 pandemic (17).
Another study in Iran found no significant difference in job burnout prevalence between COVID-19 and non-COVID healthcare workers (7).One of the key findings of this study was that the prevalence of job burnout increased with larger sample sizes.Larger studies tend to be more reliable than smaller ones (18) due to reduced sampling errors, making it easier to identify more cases of job burnout.
Compared to other studies, one of the strengths of our research is the use of the standardized "Maslach Burnout Inventory" to assess the severity of job burnout among Iranian healthcare workers.Many similar studies globally use various tools with different measurement criteria, leading to inconsistencies in cutoff points.Another strength is that all included studies were observational and predominantly cross-sectional.However, a notable weakness is the inclusion of a wide range of healthcare and educational staff, which might introduce variability.Additionally, since all studies included in this research were observational, they are susceptible to biases, such as selection bias, and their results can be influenced by confounding variables (18).
that training programs be developed to enhance resilience and moral intelligence among health system employees.

Conclusions
A combination of workplace stressors and personal fears associated with the COVID-19 pandemic appears to have placed a significant psychological burden on healthcare teams.To minimize burnout, it is suggested that supportive approaches, including access to psychosocial support services such as web-based platforms, psychological first aid, psychological support hotlines, and self-care techniques, be provided to individuals throughout their service years.

Demographic, Maslach burnout inventory, and semantic therapy
There was a significant relationship between meaning therapy and its effect on the frequency and severity of job burnout.Also, it means that therapy was effective in three areas of job burnout: Emotional exhaustion, depersonalization, and job conflict.These were effective, but they did not affect the dysfunction area.The level of burnout among nurses in the obstetrics and gynecology unit was reported to be significantly lower than that of nurses in intensive care units.
Torabi Parizi, M, Kerman, 2015 ( The frequency of job burnout among dentists of Kerman City

Crosssectional 145 Maslach burnout inventory
There was a significant relationship between marital status and employment with the depersonalization component.The total number of shifts during the pandemic had a significant positive correlation with emotional exhaustion.

Maslach burnout inventory, symptoms checklist for mental disorders
There was a positive and significant relationship between job burnout and all symptoms of mental disorders.
The effect of job burnout on social support and self-esteem of personnel health of Yazd city

Crosssectional 130
Maslach's burnout inventory, Eyseng's self-esteem, and Cassidy's social support There was a significant relationship between the dimensions of job burnout and the variables of work experience, marital status, gender, place of service, type of job, and personnel work experience.

Relationship between personality traits and burnout in oncology nurses
Crosssectional 106

Maslach burnout inventory, Personality questionnaire (NEO)
There was a significant relationship between all dimensions of job burnout with personality traits and anxiety and depression.The findings showed that there was no significant relationship between emotional intelligence and job satisfaction, but there was a significant relationship between emotional intelligence and burnout.
Nasrolah Beigi1, F, The relationship between human resources management functions and job burnout from the perspective of managers and staff in deputy of health at Iran University of Medical Sciences

Cross-sectional 242
Two questionnaires on burnout and human resources management functions.
Job burnout can be significantly reduced with the improvement of human resources management functions.

Figure 1 .
Figure 1.Identification of studies through databases and registries based on PRISMA fLOW diagram (2020)

Figure 2 .
Figure 2. Burnout in employees and subgroups

Table 1 .
The POLIS (Patients, Outcome, Location, Indicator and Study Design)

Table 4 .
Prevalence of Burnout in Employees and Subgroups

Table 2 .
The Characteristics of the Iranian Included Studies

Table 3 .
Evaluation of the Quality of Included Studies to Check the Risk of Bias Was the Study Instrument That Measured the Parameter of Interest (e.g., Prevalence of Burn Out) Shown to Have Reliability and Validity (if Necessary)?