17 Ann. psychophysiol. ISSN 2412-3188 (Online)|2410-1354 (Print) APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v9.i1.2022.17-27 Original Article Assessment of Burnout Syndrome and Physical Activity of the University Teachers – A cross-sectional Observational Study Qazi Noor Ul Wahab1 , Zia Ud Din1, Muhammad Jahanzeb2, Saleem Ullah3 & Muhammad Abbas1 1Department of Human Nutrition, University of Agriculture, Peshawar-Pakistan 2Department of Psychology, University of Peshawar, Peshawar-Pakistan 3Department of Agricultural Chemistry and Biochemistry, University of Agriculture, Peshawar-Pakistan Abstract Background: Burnout and physical activity (PA) are two critical determinants of health. The burnout and PA of the university teachers in Pakistan are not well, established. The main objective of the present study is to determine the prevalence of burnout syndrome and the level of physical activity in university teachers. Methodology: The sample of university teachers (n=505) was drawn from 14 public/private universities in Peshawar using a partly convenient, non- probabilistic method based on an exhaustive and up-to-date database of all universities in Peshawar. Data were collected on these parameters: socio- demographics, anthropometrics (body weight, height, and body mass index: BMI), Burnout using Maslach Burnout Inventory (MBI-ES), and PA level. The global Physical Activity Questionnaire developed by WHO (GPAQ-WHO) was used. Results: The sample consisted predominantly of males (78%) with a mean (SD) age of 37.5 ± 7.9 (Range: 28 – 60). The results demonstrated that 19% of university teachers suffered from burnout syndrome, with most of those with job experience <10 years. The mean PA for all the respondents was 955.1 MET minutes/week, with significant differences in PA levels of male and female teachers from public vs. private universities (p, for all trends < 0.05). The proportion of physically active university teachers was 63.6% (95%CI 56.6 to 68.2), with a higher proportion of university teachers without Burnout Syndrome being physically active than those with Burnout Syndrome (73.5% (95%CI 68.1 to 79.3) vs. 21.6% (95%CI 16.5 to 24.6). Only a small number of university teachers could achieve the recommended levels of PA with differences between genders and university types. Conclusion: Work-related burnout is seen in teachers with poor physical activity, and females are mostly affected. Public sector universities showed a greater burnout rate. The public sector needs to revitalize the staff and train them to manage their workload efficiently. Keywords Burnout Syndrome, Physical Activity, University Teachers, Work Stress, Occupation. Citation: Wahab Q, Din Z, Jahanzeb M, Ullah S, Abbas M. Assessment of Burnout Syndrome and Physical Activity of the University Teachers – A cross-sectional Observational Study. APP. 2022;9(1):17-27 Corresponding Author Email: dr.qazinoor@gmail.com DOI: 10.29052/2412-3188.v9.i1.2022.17-27 Received 26/03/2022 Accepted 06/04/2022 Published 01/06/2022 Copyright © The Author(s). 2022. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The author(s) received no specific funding for this work. Conflicts of Interests: The authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v9.i1.2022.17 0000-0001-6589-1404 about:blank about:blank 18 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 Introduction Stress and burnout are common phenomena present among university teachers. Burnout is a typical form of chronic occupational stress characterized by three dimensions, i.e., emotional exhaustion, depersonalization (or cynicism), and reduced professional efficacy1,2. The term 'Burnout,' which can be translated as 'emotionally exhausted3, has been studied mainly in the health professions. There has been an increasing trend of investigating the burnout phenomena in other occupations, including teaching at the university level. Regular physical activity (PA) is a state of health4. In addition to its overall positive impact, it is now accepted that health also plays an essential role in maintaining regular exercise. World Health Organization (WHO) recommends 600 or more metabolic equivalent tasks (METs) minutes/week as at least sufficient to produce health benefits5. The forms of movement they suggest are walking, swimming, indoor cycling, low- intensity aerobics, running or jogging (only if this was done before pregnancy), maintaining a healthy body weight, and improving mental health6. It hypothesizes that regular physical activity and exercise may constitute a practical approach to reducing burnout in university teachers. Physical activity to minimize burnout syndrome and its associated symptoms include its ease of accessibility, lower costs, and positive "side effects," such as the reduced risk for cardiovascular diseases (CVD)7-9. As teachers in the university may face work stress and burnout that may affect their PA, it is logical to think about the association between burnout and low PA. Low PA may further deteriorate the state of burnout or vice versa. Therefore, the analysis of PA habits of university teachers in association with burnout is of great importance. The main aim of our study was to investigate the prevalence of burnout and level of PA in university teachers and the frequency, duration, and intensity of PA concerning stress and burnout. Methodology Study Design and Subjects’ Characteristics: This cross-sectional study considered university teachers working at different universities of Khyber Pakhtunkhwa (KP) of Pakistan, both in the public and private sectors. The sampling strategy used for the present study was partly convenience, non- probabilistic, and based on consecutive cases that met these inclusion criteria: (1) to be a formal institutional employee (university teacher/permanent basis), (2) of any age, (3) only morning shift, (4) from any area/subject of service, (5) serving the university at the time of the study (data collection) and not on leave, (6) with no chronic infectious/non-infectious diseases. Rotating personnel, visiting, teachers on probation, pregnant/lactating, diabetic teachers, etc., were omitted. The sample size was calculated using Cochran's equation10. Where, n= Sample size; z= z-score correspond to the 95% confidence level, i.e. 1.96; e= Acceptable margin of error assumed as 4% or 0.04; p= population proportion (assumed to be 50% or 0.5); N=Total teaching population = 2818; Putting the above values in the equation (1), the sample size was estimated 494. In this way, the required sample was 500. However, the sample size was increased to 510 to take care of non- response/dropped out. The university teachers were screened initially to ensure selection criteria. Data Collection Socio-demographics and Anthropometrics: Socio-demographic data were collected in a 19 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 pre-designed questionnaire. All methods of measurement were standardized, and the same persons collected data. Anthropometrics were measured for the weight (digital scale: Tanita Terraillon, 100g precision) and height (stadiometer; SECA 231, 0.1cm precision). Body mass index (BMI) was calculated (weight in kg divided by the height in meters squared). Using WHO criteria (2020), BMI was categorized as average weight (BMI: 18.5 to 24.9), overweight (BMI: 25.0-28.0), and obese (BMI>28.0). Burnout Assessment: Maslach Burnout Inventory (MBI)– Educators Survey is a well- known 22-item questionnaire. This includes evaluation of three sub-scores: (1) "Emotional exhaustion" (EE; including 9 items with a maximum score of 54 points with items 1,3,6,8,13,14,16,20); (2) "Depersonalization" (DP), including 5 items with a maximum score of 30 points (these are items 5,10,11,15,22) and (3) "Personal accomplishment" (PA), including 8 items with a maximum score of 48 points (items 4,7,9,12,17–19,21) (Maslach et al., 1996). In this manner, the total score for the whole scale could have a maximum value of 132. The 'EE' subscale assesses aspects of physical and/or mental exhaustion and includes characteristics like physical wear/tear, exhaustion, and loss of strength/energy. The 'DP' subscale showed negative aspects of the responses and attitudes of other individuals and main co-workers in a setting. The 'PA' subscale displays typical negative responses aimed at the respondent and the work itself. These responses are related to low morale, depression, low productivity, poor self- esteem .and inability to withstand pressure, etc., for the present study. The MBI score was dichotomized according to the criteria reported by Ramirez et al. (1996) as 'present' or 'absent' when considering high scores in the dimensions of 'EE' and 'DP' and low scores. In 'PAC .'Burnout was defined as: high score (>26) for 'EE' and 'DP' (> 9), low (< 34) score PAc11. In this way, burnout was defined in four levels: 1. No burnout, when all three dimensions are 'negative.' 2. Mild burnout, when only one of the three dimensions is 'positive.' 3. Moderate burnout, when two out of three dimensions are 'positive.' 4. Severe burnout, when all three dimensions are 'positive'12-14. A Cronbach's Alpha Coefficient was applied for MBI reliability analysis. Assessment of Physical Activity: Physical activity levels of the teachers was evaluated by using the 'global physical activity questionnaire (GPAQ).' The data collected through GPAQ was used to calculate the 'Metabolic equivalent of Task (METs)' score15. "MET is the ratio of 'working metabolic rate' relative to the 'resting metabolic rate. Briefly, GPAQ has 16 questions. These are grouped to assess PA in 3 distinct domains: 1. Work, 2. Transport, and 3. Discretionary activity (recreation/leisure). The last domain has questions that assess the frequency/duration of two different categories of PA defined by the energy requirement/intensity (vigorous/moderate- intensity PA). In the transport domain, the frequency/duration of all walking/cycling is taken. In addition, one question enquires explicitly about time spent in sedentary activities/week. The data extracted from GPAQ defines PA as 'high PA, moderate PA, and low PA. The GPAQ questionnaire was pre-tested. A pilot study was carried out on the university teachers (n=10) to check the validity, practicability, and interpretation of the responses. For statistical analysis SPSS version 20.0 was used for data analysis. Values were reported 20 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 in mean (SD). Means were compared using a student's t-test, and a value of p<0.05 was considered significant. Result Five hundred-five (505) university teachers from different universities in the Khyber Pakhtunkhwa (KPK) province of Pakistan completed the study. Some of the baseline socio-demographic characteristics are provided in Table 1. In general, the University teachers in the present study represent relatively young faculty, mainly with ages <35 years. A significant percentage of university teachers were male (67.9%). The mean family size was fairly large (7.5 ± 7.0). Lesser than two-thirds (30%) of the University teachers demonstrated their satisfaction with their monthly income. Most (75%) of the teachers from the study sample belonged to public sector universities (71%). The majority of the university teachers who participated in this study were from sciences, followed by a decent percentage from the Arts subjects. Table 1: Summary of demographics variables (N = 467). Personal and Socioeconomic Characteristics No./mean % Age <30 years 167 33.1 31 - 40 156 30.9 41-50 115 22.8 >50 53 10.5 Gender Male 343 67.9 Female 162 31.9 Family Type Joint 333 65.9 Nuclear 171 33.9 Income Status Sufficient 143 28.3 Partially Sufficient 311 61.6 Insufficient 51 10.1 Health status (any type of chronic disease) Diabetes (yes) 173 34.3 Cardiovascular vascular (yes) 123 24.4 Any chronic infectious disease (yes) 45 8.9 Health Status Any physical disability (yes) 23 4.6 Any other long-term health issue (yes) 10 2.0 Health status (any type of chronic disease) 147 29.1 Accommodation status Rental House 187 37.0 Own House 107 21.2 University House 122 24.2 21 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 Figure 1. Distribution of three dimensions of Burnout This Venn diagram is based on the number of University Teachers having a high level of these dimensions. This diagram has not considered the number with low and moderate levels on these dimensions. The numbers for each region represent the number of University Teachers in different situations; 97=had all three dimensions common in them; 11=had two dimensions, comprising 3 for 'EE' and 'DP,' 5 for 'DP' and 'PA,' and 3 for 'EE' and 'PA .'The number of University Teachers who had only high 'EE,' only 'DP,' and only 'Pac' were 6, 5, and 40. We defined burnout based on high scores on 'EE' (>26) and 'DP' (>9) and a low score on PAC (<34). So in this way, positive (higher than the cutoff score of any of the dimensions) number of respondents in three dimensions, we divided job burnout into four levels: no burnout (all the three dimensions are negative); mild burnout (only one of the three dimensions is positive); moderate burnout (arbitrary two of the three dimensions are positive); and severe burnout (all the three dimensions are positive). These results are shown in Figure 1. Table 2 represents PA among the study participants. Information on PA was calculated in three domains, i.e., PA while at work, PA while traveling, and PA during recreational activities. Total mean PA at work, travel, and recreation was 176.8, 277.6, and 500.8 MET minutes/week, respectively. Significant differences were noted in the mean physical activity of males and females (p< 0.05). Differences between PA of males and females were also pointed out in the three domains of physical activity (p, for all trends<0.05). 22 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 Table 2: PA among University Teachers. Physical Activity Total (n=505) With Burnout (n-97) Without Burnout (n=408) Mean SD Mean SD Mean SD Work Domain Vigorous 8.9 21.1 5.4 19.1 12.4 7.9 Moderate 167.9 26.8 134.7 24.8 201 23.6 Total activity at work* 176.8 23.5 140.1 21.5 213.4 20.3 Total Activity during Travel* 277.6 45.3 142.1 43.3 413 42.1 At Recreation Vigorous 116.6 43.2 34.5 41.2 198.7 40 Moderate 384.2 54.3 156.7 52.3 611.7 51.1 Total recreational activity* 500.8 44.8 191.2 46.5 810.4 45.3 Mean Total PA* 955.1 113.6 473.4 111.3 1436.8 107.7 *P<0.05 Figure 2: Proportion of Active and Inactive University Teachers According to burnout syndrome, figure 2 showed the proportion of physically active and inactive university teachers. The proportion of physically active university teachers in this study was 36.4% (95%CI 26.6- 44.2), with a higher proportion of university teachers without Burnout Syndrome being physically active than university teachers with Burnout Syndrome, 33.9% (95%CI 18.1-39.3) vs. 2.6% (95%CI 1.5-4.6). Table 3 showed the percentages of university teachers who achieved the recommended level of physical activity as recommended by WHO. When the study subjects’ PA level was disaggregated by the "WHO global recommendation on PA for health," males who achieved the recommended level (23.7%) were almost 52.6% lower than those who didn't achieve (76.3%). In 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Total With Burnout Without Burnout Physically Active Pysically In Active 23 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 comparison, the case of a female who reached the recommended PA level (12.7%) was 74.6% lower than those who didn't achieve t (87.3%). Similarly, only 11.2% of university teachers from public universities achieved the recommended PA level. A relatively higher percentage of university teachers from private universities (25.2%) achieved the recommended PA. In addition, there were comparatively more males than females who completed the recommended level of physical activity recommended by WHO (22.7% vs. 12.7; p<0.05). Similarly, significantly more teachers from private universities than those from public universities achieved the recommended level of physical activity as recommended by WHO (25.1% vs. 12.2; p<0.05). Table 3: Distribution of University Teachers who achieved/did not achieve the 'WHO recommendations on PA for health*. Male n(%) Female n(%) p-value A. Distribution by Gender Achieved the recommended level 81(23.7) 21(12.7) 0.014 Didn’t achieve the recommended level 262(76.3) 141(87.3) 0.005 B. Distribution by university type Public n(%) Private n(%) Achieved the recommended level 40(11.2) 38(25.1) 0.0001 Didn’t achieve the recommended level 313(88.8) 114(74.8) 0.0001 *Calculations were based on WHO guidelines that adults, 18–64 years, should accumulate at least 600. MET-minutes of physical activity per week (2); WHO, World Health Organization; p<0.05 Association between Burnout Syndrome and socio-demographic characteristics A Chi-square test of independence was performed to examine the relation between Burnout Syndrome and socio-demographic characteristics. Table 4 shows an association between Burnout Syndrome and some socio-demographic characteristics. The relation between these variables were mostly significant, X2 (1, N = 505) = 8.93-31.37). Burnout was present when the global score was ≥56 (median) and represented the primary outcome of bivariate and multivariate analysis. All other variables except 'gender' was significantly associated with burnout (p, for all trends <0.05). The analysis for other than socio-demographic variables shows that except for the subscales, 'stress symptoms,' 'good working conditions,' 'social support at work,' and 'promotion and development opportunities' were significantly associated with Burnout Syndrome (p, for all trends<0.05). A total of 19% subjects were reportedly suffering from burnout syndrome. 24 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 Table 4: Frequency, χ2 test results, p-value, prevalence ratio, and confidence interval for the association between primary outcome and socio-demographic, occupational, psychosocial, and health-related variables. Items Categories Respondents with Burnout Syndrome. (%) X2 p-value Age (yrs) <45 76 9.21 0.0023 >45 21 Sex Male 72 1.204 0.272 Female 25 Family Type Joint 47 9.27 0.0023 Nuclear 50 University Type Public 61 8.931 0.0027 Private 36 Field Discipline Sciences 84 32.21 <0.0001 Humanities/Art s 15 Higher Qualification MS/MPhil 70 31.37 <0.0001 PhD 27 Position/Job Title Lecturer 48 0.0021 Assistant Professor 22 Associate Professor 17 Professor 10 Job Experience (years) <10 yrs 61 7.142 0.0079 >10 years 36 Marital Status Married 15 7.211 0.0064 Unmarried 31 Stress Symptoms Yes 72 5.29 0.21 No 25 Good Working Conditions Yes 8 0.018 0.89 No 89 Social Support at Work’ Yes 6 2.93 0.087 No 91 Promotion and development opportunities Yes 11 0.204 0.651 No 86 Workplace bullying Yes 82 3.82 0.050 No 15 Job Satisfaction Yes 5 9.19 0.0024 No 92 Mental Health Yes 18 25.79 <0.0000 No 79 25 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 Discussion The present study shows that 19% of university teachers were affected by burnout syndrome. This is a high percentage considering that a relatively strict criterion for defining burnout was adopted in the present study. Burnout was determined based on high scores on 'EE' (>26) and 'DP' (>9) and a low score on ‘PAC'(<34). So in this way, based on the positive (i.e., higher than the cutoff score of any of the three dimensions) number of respondents in the three dimensions, burnout was divided into four levels12-14. According to this criterion, 19% (n=97) of university teachers had severe burnout syndrome, while the rest (n=408) were categorized as 'no burnout at all' (24%); mild burnout (41%), and 'moderate burnout' (16%). This study also demonstrated that the university teachers had low physical activity: mean (SD) 955.1 (113.6) MET- minutes/week. Furthermore, the physical activity of university teachers with burnout syndrome (Mean 473.4 SD 111.3 vs. Mean 1436.8; SD 107.7 MET-minutes/week) was significantly lower than the mean physical activity of university teachers without burnout syndrome (p,0.05). In addition, more females compared to males and more university teachers in public universities compared to those in private universities had physical activity levels much lower than the recommendations of WHO. A teacher at a university is usually regarded as a 'low-stress job .'In addition, job security, conducive working employment, and a high social standard are generally associated with teaching at the university level. Teaching at the university level is considered a job with great promotion opportunities and enhanced satisfying level16. However, over the past 20 years, perceptions about academic careers and the environment have changed drastically. For example, Akerlind and McAlpine reported the pressures for change acting upon academia17. This pressure includes substantial growth in student numbers/ institutions of higher learning, increased emphasis on research, concerns for equity and social benefits of education, and great emphasis on the job- training job training. As presented in the present work, university teachers with lower physical activity are more likely to suffer from burnout syndrome. These findings are in agreement with other studies7,8. In another study by Abos et al. demonstrated that two sessions of exercise in a week improved satisfaction at work and work-related outcomes7. Another study by Sane et al., who collected data from 81 university teachers from Iran, demonstrated a significant inverse correlation between PA and burnout syndrome18. In addition, a linear but inverse correlation between PA and its components with burnout represents the positive role of PA in the prevention or reduction of burnout. Although the relationship between PA and burnout investigated in the present study may be casual with no indication of whether low PA causes burnout or vice versa, the association between the two is essential to form from a nutrition and health point of view. Future studies should investigate the cause-effect relationship between the two. Nevertheless, a high level of burnout is associated with substantial losses to employees' health and well-being and, consequently also, economic losses. Employees with burnout show significantly reduced self-efficacyabout:blank - B5, poor sleep quality, reduced cognitive functioning, compromised workability, and are at relatively higher risk for developing CVD diseases. Employers, too, face the consequences such as leave and/or absence 26 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 and productivity time loss19. Given the high prevalence of burnout and its negative consequences, it is valuable to examine potential approaches and remedies to reduce it20. Conclusion In conclusion, university teachers who were physically more active were relatively less prone to burnout. PA thus may play an important role in enhancing the physical and mental health status of university teachers. Future studies must explore this (rewrite). Findings also showed a significant difference between the genders and types of universities concerning burnout prevalence and physical activity levels. These differences may be considered while designing rehabilitation programs for university teachers. Acknowledgment We are thankful to all academic institutes' authorities, participants of the research, and our colleagues, for helping in data collection. Moreover highly grateful to the authors of the scales for providing the scales free of cost. References 1. Stamper CL, Johlke MC. The impact of perceived organizational support on the relationship between boundary spanner role stress and work outcomes. Journal of Management. 2003 ;29(4):569-88. 2. MaslachC JS. Burnout syndrome in health professions: A social psychological analysis. Social Psychology of health and illness (3rd Ed., pp. 227-251). Hillsdale, NJ: Lawrence Erlbaum.1982. 3. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory. Scarecrow Education; 1997. 4. Dishman RK, Heath G, Schmidt MD, Lee IM. Physical activity epidemiology. Human Kinetics; 2021. 5. Armstrong T, Bull F. Development of the world health organization global physical activity questionnaire (GPAQ). J Pub Health. 2006;14(2):66-70. 6. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U, Lancet Physical Activity Series Working Group. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet. 2012;380(9838):247-57. 7. Abós Á, Sevil-Serrano J, Julián-Clemente JA, Generelo E, García-González L. Improving teachers' work-related outcomes through a group-based physical activity intervention during leisure-time. J Exper Edu. 2021;89(2):306-25. 8. Raditya M, Sutarina N. Relationship between burnout and physical activity level among pre-clinical medical students. JPMA. 2021;71(2):S62-8. 9. Warburton DE, Nicol CW, Bredin SS. Prescribing exercise as preventive therapy. CMAJ. 2006;174(7):961-74. 10. Ahmad H, Halim H. Determining sample size for research activities. Selangor Business Review. 2017;1:20-34. 11. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, Snashall DC, Timothy AR. Burnout and psychiatric disorder among cancer clinicians. BJC. 1995;71(6):1263-9. 12. Yongxin L, Yimin L. Developing the diagnostic ctiterion of job burnout. Psychol Sci Shang. 2006; 29(1):148. 13. Liu X, Chen J, Wang D, Li X, Wang E, Jin Y, Ma Y, Yu C, Luo C, Zhang L, Liu C. COVID- 19 outbreak can change the job burnout in health care professionals. Front in Psychi. 2020;11. 14. Zhou J, Yang Y, Qiu X, Yang X, Pan H, Ban B, Qiao Z, Wang L, Wang W. Serial multiple mediation of organizational commitment and job burnout in the relationship between psychological capital and anxiety in Chinese female nurses: A cross-sectional questionnaire survey. Int J Nur Stud. 2018; 1;83:75-82. 15. Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phy Act Health. 2009;6(6):790-804. 27 ISSN 2412-3188 (Online)| 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 16. Knight P. Being a teacher in higher education. McGraw-Hill Education (UK); 2002 Jul 1. 17. Akerlind G, McAlpine L. Academic Practice- how is it changing?.,2009. 18. Sane MA, Devin HF, Jafari R, Zohoorian Z. Relationship between physical activity and it's components with burnout in academic members of Daregaz Universities. Procedia- Social Behav Sci. 2012;46:4291-4. 19. Naczenski LM, de Vries JD, van Hooff ML, Kompier MA. Systematic review of the association between physical activity and burnout. J Occup Health. 2017;59(6):477-94. 20. Akhtar Malik N, Björkqvist K. An evidence- based framework for reducing occupational stress and burnout in Pakistani Universities. AJUE. 2021;17(1):19-32. about:blank