Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2):42-49   

 

 © The Author(s). 2018 This article is distributed under the terms of the Creative Commons Attribution 4.0 International License 

(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate 

credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons 

Public Domain Dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise 

stated. 

  eISSN: 3456-3546                                Journal homepage: www.jidhealth.com                                        Open Access 

Predictors of emotional exhaustion among physicians from Iraq - a 

descriptive cross-sectional multicentre study 

Saad Ahmed Ali Jadoo1*, Ilker Dastan2, Mustafa Ali Mustafa Al Samarrai3, Shukur Mahmood 

Yaseen4, Perihan Torun1 

      

     Abstract   
Background: Doctors and paramedics in countries suffering from long-acting conflicts, including Iraq, are working 
in severe and exceptional conditions, putting them under severe physical and psychological pressure, therefore 
examining burnout is important when dealing with the quality of care and working conditions. This study aimed to 
assess the point prevalence and to explore factors associated with emotional exhaustion (EE) among medical 

doctors in Iraq. 

Methods: Descriptive and a cross-sectional study was conducted (January to June 2014) among a randomly 
selected sample of medical doctors (n=576, 87.3% response rate) working in twenty large general hospitals and 
medical centers. In addition to EE, the self-administered questionnaire used was consisting of questions on 
sociodemographic, work-related characteristics, conflict-related variables, and job satisfaction. EE was measured 
using the emotional exhaustion subscale of the Maslach Burnout Inventory (MBI). 

Results: The prevalence of EE reported by 60.0% of the respondents. In multiple linear regression analysis, the 
emotional burnout was higher among doctors who were married, female, bearing children, being threatened, 
displaced internally, non-specialist doctors, working more than 40 hours per week, experienced unsafe medical 
practice, disagreed with the way manager handle the staff and those who reported that the doctor-patient 

relationship as not excellent.  

 Conclusion: Our findings suggest that job dissatisfaction, conflict, and violence-related factors were significantly 
associated with a high level of emotional exhaustion among Iraqi physicians.  

Keywords: Emotional exhaustion, burnout, workplace, doctors, job satisfaction, conflict, Iraq 

 

Background   

The burnout syndrome has widely discussed since its first time 

emerged in its three dimensions; emotional exhaustion, 

depersonalization, and low personal accomplishment [1]. Work-

related burnout is becoming increasingly recognized as a 

serious problem affecting many people working in human 

services, especially healthcare workers [2]. Work-related 

burnout found to be directly related to a considerable list of 

adverse outcomes, including absenteeism from work, increased 

turnover, and poor job performance [3]. Burnout has shown to 

have an impact on physicians and their mental and physical 

health [4,5]. Moreover, Burnout may reflect on clinical 

performance and the quality of care [6,7]. These features have 

been regularly reviewed and recognized over the past fifty years 

[8]. Literature suggests that burnout is a common health 

problem among doctors in different countries globally [9-12]. 

However, despite such full recognition in Western societies, the 

subject of burnout has not received the required attention from 

the Middle East researchers until the beginning of the 21st 

century, and to our knowledge, there is a lack of national 

studies on burnout among Iraqi health workers. This is a 

particular problem in Iraq, where the health care system has 

suffered a long-standing catastrophic collapse since 1991 and 

has overloaded since that time [13]. 

     Furthermore, after the US-led invasion of Iraq in 2003, the 

health system exposed to deliberate destruction of its 

infrastructure accompanied by a new exodus of brain drain, 

including the medical doctors [14]. The high level of violence 

___________________________________________________ 

drsaadalezzi@gmail.com 
1Department of Public Health, Faculty of Medicine, Bezmialem Vakif University, 

Istanbul, Turkey 

Full list of author information is available at the end of the article 

http://www.jidhealth.com/


                                                           Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2): 42-49                                                                              43 
 

  
 

 

in conflict zones such as Iraq produced chronic stress among 

health personnel, so that continuity in work became almost 

impossible [15]. Moreover, lack of services and the attempt of 

the government to spoil the doctor-patient relationship by 

directing the media to focus mainly on the performance of 

health care providers made them victims of unfortunate and 

unjustified incidents of different types of abuse [15,16]. Thus, 

the combination of lack of security, work, and violence-related 

and political factors has significantly contributed to raising the 

level of turnover intention and migration among Iraqi doctors. 

Consequently, the staying doctors, who are still working in Iraq, 

were not able to cope with the resultant weakness in the level of 

health service presented to the patients who already feel 

dissatisfied and carry a negative impression against this service 

[17-19].  As a result, the doctors are more likely to pass into a 

state of an inevitable physical and emotional exhaustion (EE) 

ending to an exaggerated motivation to leave the job and 

looking for a better opportunity outside their country [14-19].  

     This study aimed to predict the main factors related to 

emotional burnout among Iraqi doctors working in different 

health care centers during the eruption of armed conflict in 

2014. The study focused on Job satisfaction, violence-related 

variables, work-related variables, and socio-demographic 

factors to investigate their interrelationships with EE. 

 

Methods 

Study design and subjects 

This cross-sectional study was conducted among Iraqi medical 

doctors to test the impact of violence-related and workplace-

related variables on the Overall EE. The present study is part of 

a larger research initiative [14,15], in which we recruited a 

multistage sampling technique to drew a random sample of 660 

physicians from twenty large general hospitals and medical 

centers covering the main five geographically regions in Iraq 

(north, west, south, central, and the capital city). Design, 

sampling, and data collection have been reported in detail 

previously [14,15]. In the current analysis, responses received 

from 576 physicians (response rate of 87.3%). At the time of 

the survey, all Iraqi physicians working at the selected hospitals 

were included and received a copy of the self-administered 

questionnaire manually with a contact number and email of the 

data collector. The exclusion criteria included the chief medical 

officers (CMO), hospital managers, and their deputies. 

 

Outcome variable  

Emotional burnout assessed by nine items of EE subscale of the 

validated Maslach Burnout Inventory (MBI) [20-22]. EE 

answered in terms of frequency on a 7-point Likert scale 

ranging from 0 (never) to 6 (every day). The overall EE was 

measured by summing the scores of the nine items (in range of 

0 to 54). A higher score indicated greater emotional exhaustion 

[3] and, accordingly, a higher emotional burnout. The 

Cronbach’s alpha coefficient of the EE subscale reported in this 

study was 0.89.  

 

Independent variables 

Job satisfaction measured with the 10-item Warr-Cook-Wall 

(WCW) job satisfaction (seven-point Likert-type) scale ranging 

from 1 = "very dissatisfied" to 7 = "very satisfied". The overall 

job satisfaction was measured by summing the scores of the ten 

items (in range of 10 to 70). 

     The socio-demographic variables collapsed and coded as 

follows: age (more or less than 40 years old), gender (male or 

female), marital status (married or single), presence of children 

(yes or no), residency (Urban or rural). Variables of conflicts or 

war-related violence were collapsed and coded as either (1) 

"Yes" or (0) "No" in response to the following questions: 

"Because of war violence in Iraq, have you been lost a family 

member?"; "Have you been threatened?"; "Have you been 

displaced internally?"; "Do you think that medical practice is 

safe?" and "The doctor-patient-relationship is excellent?”.   

    Individual work-related variables were categorized as 

follows: the current professional level (specialist or not); the 

working hours per week (more or less than 40 hours/week); the 

number of years spent at their work or the same facility (more 

or less than ten years); the type of employment (government 

only or dual in government and private); the training and 

educational opportunities (yes or no); The way the senior 

manager handles the staff is effective (agreed or disagreed). 

 

Statistical analysis 

The Statistical Package for Social Sciences (SPSS) version 16.0 

used to analyze data in this study. A descriptive analysis of 

sociodemographic, conflict-related variables, work-related 

characteristics, and job satisfaction has performed. The nine 

items of emotional exhaustion subscale summed to obtain the 

total score (0 to 54). A high degree of emotional burnout 

determined based on the cut-off point of the emotional 

exhaustion subscale in the MBI (≥27) [3]. The test of normality 

of the total score of emotional exhaustion conducted, and the 

data presented as mean and standard deviation (SD). 

     Student’s 𝑡-test used to compare the mean of emotional 

burnout score across demographic variables, work-related 

characteristics, conflict-related variables, and job satisfaction.                                                           

Categorical data presented as numbers and percentages, and the 

chi-squared test used for statistical analysis. Multivariate linear 

regression using the "Backward" technique was employed to 

obtain factors associated significantly with emotional burnout 

scores. Variables that were significantly associated with burnout 

in the bivariate analysis included in the multivariate analysis. 

The accepted level of significance set below 0.05 (𝑃 < 0.05). 

 

Results  

Descriptive analyses  

Table 1 shows the descriptive characteristics of the socio-

demographic variables. The mean age (±SD) was 40.43 years 

(±8.59) (in range of 27-56). More than half of respondents 

(53.8%) were females, married (64.2%), living in urban regions 

(63.4%), and bearing children (51.2%). There was a significant 

difference in overall emotional exhaustion. Overall emotional 

exhaustion was higher among female doctors (95% CI = 0.79-

3.16, p=0.001), married (95% CI = 0.99-3.46, p=<0.000), and 

those who are bearing children (95% CI = 0.59-2.96, p=0.003). 

 



                                                           Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2): 42-49                                                                              44 
 

  
 

 

Table 1 Socio-demographic variables on overall emotional exhaustion (n=576) 

Variable Category N% Mean + SD t-test P-value 95% CI Upper-Lower 

Age > or=40 years old 291(50.5) 28.73±7.46 1.355 0.176 0.37-2.02 

 <40 years old 285(49.5) 27.90±7.12    

Gender Female 310 (53.8) 29.23±7.81 3.262 0.001 0.79-3.16 

 Male 266 (46.2) 27.26±6.51    

Marital status Married 370 (64.2) 29.11±7.32 3.542 0.000 0.99-3.46 

 Single 206(35.8) 26.89±7.05    

Presence of children Yes 295(51.2) 29.18±6.96 2.935 0.003 0.59-2.96 

 No 281(48.8) 27.41±7.55    

Residency Urban 365 (63.4) 28.49±7.34 0.747 0.456 0.77-1.71 

 Rural 211 (36.6) 28.02±7.24    

 

 

Emotional exhaustion (Burnout)   

The mean (±SD) value on the total emotional exhaustion score 

was 28.72 (±7.30). Three hundred and forty-five respondents 

(60.0%) experienced a high level of emotional burnout (Table 

2).  
 

Table 2 Descriptive statistics of the nine items and overall 

emotional exhaustion scale 

No. Emotional Exhaustion 

(Burnout)  

Mean S.D. Min. Max. 

1 I feel emotionally drained 

from the work 

3.18 1.63 0 6 

2 I feel used up at the end 

of the workday 

3.26 1.69 0 6 

3 I feel fatigued when I get 

up in the morning and 

have to face another day 

on the job 

3.10 1.71 0 6 

4 Working with people all 

day is really a strain for 

me 

3.12 1.66 0 6 

5 I feel burned out from the 

work 

3.07 1.70 0 6 

6 I feel frustrated by my 

job 

3.25 1.69 0 6 

7 I feel I'm working too 

hard on my job 

3.00 1.72 0 6 

8 Working with people 

directly puts too much 

stress on me 

3.43 1.72 0 6 

9 I feel like I'm at the end 

of my rope 

2.90 1.68 0 6 

10 Overall scale emotional 

exhaustion 

28.72 7.30 0 54 

 

Conflict-related variables on overall emotional exhaustion  

In table 3, about one-fourth (26.6%) had lost one or more of 

their close relatives, 54.3% have threatened, 39.1% have 

internally displaced at least once, 66.8% experienced unsafe 

medical practice; however, 70.7% of them described their 

relationship with the patient as excellent. Most of the conflict or 

war-related variables showed a significant difference in overall 

emotional exhaustion. Overall emotional exhaustion was higher 

among doctors who have been threatened or kidnapped (95% CI 

= 0.75-3.13, p=0.000), internally displaced (95% CI = 1.50-

3.91, p= <0.000), experienced unsafe medical practice (95% CI 

= 01.06-3.57, p=<0.000), and those who described the doctors-

patients relationship was unwell (95% CI = 1.40-3.99, 

p=<0.000).  

 

Work-related variables on overall emotional exhaustion 

In table 4, the vast majority (73.3%) of respondents spent more 

than ten years in the same health facility and were not being 

specialist yet (60.2%); however, more than half of them 

(55.7%) have a dual job (government and private) and were 

satisfied with the available training and educational 

opportunities. Overall emotional exhaustion was higher among 

doctors who were not specialist (95% CI = 0.72-3.14, p=0.002), 

disagreed with the way manager handles the staff (95% CI = 

0.72-3.14, p=0.003) and those who are working more than 40 

hours per week (95% CI = 0.59-2.97, p=0.003). 

 

Predictors of burnout  
Table 5 shows the results of multiple linear regression analysis 

to identify the associated variables with emotional burnout. In 

backward elimination (or backward deletion), the multivariate 

linear regression analysis (after excluding non-contributing 

variables) was statistically significant, and overall, explained 

24.8% of the variance in the overall emotional exhaustion, F 

(11, 16.845) = 680.670, P < .0005. The “Internally displaced" 

and the "doctor-patient relationship” appeared to be the 

strongest factors predicting the EE (Table 5). 

      Doctors who were internally displaced were more likely to 

have high EE (B = 0.269, P < .0005). Doctors who considered 

the doctor-Patient relationship is not excellent were more likely 

to have high EE (B = 0.267, P < .0005).  

      In general, the emotional burnout was higher among doctors 

who were married, female, bearing children, being threatened, 

displaced internally, non-specialist doctors, working more than 

40 hours per week, experienced unsafe medical practice, 

disagreed with the way manager handle the staff and considered 

the doctor-patient relationship as not excellent.



                                                           Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2): 42-49                                                                              45 
 

  
 

 

Table 3 Conflict and war-related variables on overall emotional exhaustion (n=576)

 

Table 4 Work-related variables on overall emotional exhaustion (n=576)

 

 

Table 5 Factors associated with emotional exhaustion in multiple linear regressions (n=576)        

Variables B S.E. Beta t-test Sig. 95% CI  

Lower-Upper 

Tolerance  VIF 

Constant 39.048 1.302 - 29.994 0.000 36.49-41.61    -    - 

Overall job satisfaction 0.048 0.023 0.098 2.115 0.035 0.03-0.93 0.626 1.598 

Working more than40 h/week 1.426 0.570 0.098 2.501 0.013 0.31-2.55 0.872 1.147 

40 h/week or less       Reference   

Female  1.261 0.552 0.078 2.283 0.023 0.18-2.35 0.928 1.078 

Male       Reference   

Non -Specialist  1.602 0.657 0.108 2.438 0.015 0.31-2.89 0.677 1.477 

Specialist      Reference   

Not agree with way manger handle staff 1.482 0.549 0.100 2.700 0.007 0.41-2.56 0.970 1.031 

Agree       Reference   

The doctor-patient relationship is not excellent 4.244 0.688 0.267 6.165 0.000 2.89-5.60 0.715 1.398 

Excellent       Reference   

Displaced internally 4.398 0.624 0.296 7.052 0.000 3.17-5.62 0.759 1.317 

Not      Reference   

Presence of Children  1.929 0.545 0.133 3.538 0.000 0.86-3.00 0.948 1.055 

Not       Reference   

Married  2.924 0.682 0.193 4.287 0.000 1.58-4.26 0.661 1.514 

Single, divorced, widow      Reference   

Have been threatened  1.928 0.582 0.132 3.314 0.001 0.79-3.07 0.838 1.193 

Not       Reference   

Medical practice is Not safe  4.036 0.715 0.261 5.642 0.000 2.63-5.44 0.625 1.601 

Medical practice is Safe      Reference   

Variable Category N% Mean+ SD t-test P-value 95%CI Upper-Lower 

Loss of family member No 423(73.4) 28.39±7.31 0.395 0.693 1.08-1.63 

 Yes 153 (26.6) 28.12±7.29    

Exposure to threat or kidnapped  Yes 313(54.3) 29.20±7.33 3.207 0.001 0.75-3.13 

 No 263(45.7) 27.26±7.13    

Internally displaced  Yes  225(39.1) 29.96±7.73 4.404 0.000 1.50-3.91 

 No  351(60.9) 27.26±6.82    

Medical practice in Iraq is safe. No  385 (66.8) 29.09±7.48 3.623 0.000 1.06-3.57 

 Yes  191(33.2) 26.77±7.48    

The doctor-patient relationship is 

excellent 

no 169(29.3) 30.22±7.02 4.096 0.000 1.40-3.99 

 Yes  407(70.7) 27.53+7.27    

Variable Category N% Mean+ SD t-test P-value 95%CI Upper-Lower 

 Current professional level Non-specialist 347(60.2) 29.08±6.97 3.124 0.002 0.72-3.14 

 Specialist 229(39.8) 27.16±7.63    

Way managers handle staff. Agreed (yes) 343(59.5) 27.56±7.37 3.034 0.003 0.66-3.07 

 Disagreed (no) 233(40.5) 29.43±7.07    

Training and educational opportunities Yes  316(54.9) 28.84±7.33 1.881 0.060 0.05-2.34 

 No  260(45.1) 27.79±7.23    

Years of service  >10 years 422(73.3) 28.55±7.37 1.283 0.216 0.50-2.20 

 < or = 10 years 154(26.7) 27.69±7.07    

Hours of work/week >40 h 267(46.4) 29.27±7.21 2.941 0.003 0.59-2.97 

 <or=40 h 309(53.6) 27.49±7.17    

Type of employment Government and private 321(55.7) 28.58±7.43 0.977 0.329 0.60-1.80 

 Government only 255(44.3) 27.98±7.13    



                                                           Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2): 42-49                                                                              46 
 

  
 

 

Discussion 

It was an interesting exercise to test several factors that may 

predict the EE among Iraqi doctors. However, it was not 

possible to capture all possible factors. Only 24.8% of the 

variation was explained; 75.2% of the variation remained 

unexplained, which indicated other factors might affect EE. In 

this study, the mean value of the total burnout score among 

Iraqi physicians found to be 28.72 (SD=7.3, range 0-54). 

Around 60% of the study participants revealed experiencing a 

high level of emotional burnout. This finding is consistent with 

other international studies. Elsewhere in the Middle East, 

burnout found to be quite common among health professionals 

in Tunisia [23]. In Saudi Arabia, a high prevalence of burnout 

among multinational health professionals has been reported 

[24]. A quarter of the health professionals had suffered from 

high levels of burnout in Egypt [25]. In contrast, a study 

conducted in Qatar found that only 12.6% of responding 

primary care physicians experienced burnout [26].  
     The first step in coping with burnout threats is to identify the 

most common causes. The results from previous studies show 

that among the doctors, burnout is the result of exposure to 

factors associated with both personal and work environments. 

Taking into consideration the conclusions from previous studies 

and the difference in the health system and culture in Iraq, in 

the current study, several factors (Table 1,2,3,4) were 

investigated for their association with burnout and aiming to 

reduce burnout among Iraqi doctors. Eleven of these factors 

maintained in the backward regression analysis. Thus, burnout 

is potentially multi-determined; therefore, any type of 

prevention or intervention will require multi-faceted 

approaches. 

     In our study, multivariate regression analysis of variables 

affecting burnout revealed that among the demographic factors, 

being female, having children or being married are significant 

predictors of burnout among the study population in Iraq. 

Regarding the role of gender in burnout, some papers found 

female doctors to be at a higher risk of burnout [27,28], which 

agrees with the findings of the present study. However, only a 

few studies reported burnout by sex, and a study conducted 

across Europe found burnout to be more prevalent amongst 

males [29]. In our study, married physicians and physicians 

having children expected to have a higher level of burnout than 

their counterparts. In a study in Turkey, the authors reported 

that problems with childcare were significantly associated with 

burnout [30]. Disequilibrium between family and work 

demands found to be one of the most critical factors 

contributing to burnout among Iraqi physicians [31]. In 

contrast, unmarried physicians found to have a higher level of 

burnout and more desensitization in a few other studies [32,33]. 

Physicians exposed to a variety of work-related factors that are 

important in creating burnout. 

      This study showed that the prevalence of burnout is higher 

in physicians reporting lower job satisfaction. The entire 

literature evaluating the correlation between job satisfaction and 

burnout has yielded the same result [34-38]. However, the 

majority of the literature is based on cross-sectional surveys as 

it does in this study, which makes it difficult to verify a 

causality. While the researchers suggest that low job 

satisfaction was a risk factor for burnout, it can be asserted that 

burnout is a risk factor for low job satisfaction, or poor job 

satisfaction may itself be a symptom of burnout. Further 

research is needed to clarify the negative relationship. 

     Among the work-related factors, work time and the doctor-

patient relationship are two other factors that shown to be 

related to burnout in both this and previous studies [39-42]. 

Physicians in the current study who worked more than 40 hours 

per week or reported dissatisfaction with the doctor-patient 

relationship had significantly higher burnout rates. The Iraqi 

healthcare system has faced a catastrophic collapse since 1991. 

Iraqi doctors have left the country due to falling wages and 

worsening security conditions during the sanction years and 

after the 2003 invasion [43]. Even though the migration rates 

have slowed more recently, about half of the doctors have 

estimated to be already left Iraq after the 2003 invasion, and 

most healthcare providers have significant turnover intentions 

or to leave the country [44]. Additionally, the health care 

system has been rapidly changing in recent years, which has 

increased many doctors' responsibilities, as well as the demands 

of their patients. As a result, doctors are working longer hours 

and taking less time to communicate with patients, and medical 

disputes often occur caused by patient dissatisfaction. These 

combined effects have created an increasing conflict between 

patients and doctors and damaged the doctor-patient 

relationship [14]. Consequently, organizational interventions 

such as reducing long working hours and developing doctor-

patient relationships should be considered in the new health 

care reforms. The doctor-patient relationship improved through 

the implementation of various measures, including malpractice 

insurance for physicians, and improving doctor-patient 

communication [45]. 

     There is broad acceptance that work satisfaction and burnout 

levels are strongly affected by the leadership skills of senior 

managers. Previous studies have shown that relationship with 

managers is an important factor that affects burnout [46,47]. 

Poor relationships with managers can lead to feelings of 

exclusion and loneliness among physicians that can easily turn 

into burnout [20]. Our study reported similar results; physicians 

who reported low managerial skills of their immediate 

supervisors have higher rates of burnout. The findings in this 

study contribute to the understanding that high levels of 

managerial support and skills have positive effects on fighting 

with burnout. The reduction of occupational stress, the 

development of managerial skills of supervisors, and 

strengthening relationship with managers can decrease burnout 

and improve the quality of life of physicians, as seen in other 

studies [48] [50]. 

     Further, non-specialist physicians found to be at high risk of 

burnout in our study group. Similar findings found in other 

studies, for example, in a Finnish study, the highest burnout 

scores were noted in general practitioners and non-specialists 

working in health centers, which may be related to heavy 

patient loads, long hours of work, low salaries, and professional 

identity issues [49]. Conflict-related factors and workplace 

violence have not systematically examined as a predictor of 

physician burnout except for a few studies. The present study 

results demonstrated that physicians who threatened, displaced 



                                                           Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2): 42-49                                                                              47 
 

  
 

 

internally, or believed the medical practice was not safe were 

more likely to have higher burnout rates in our studied sample. 

Previous studies in Egypt, Poland, Turkey, and a meta-sample 

of seven studies from different regions also demonstrated that 

workplace violence, conflicts, personal threats, or incivility 

were positively associated with the psychological conditions of 

physicians, including burnout [25,50,51]. 

     There are some limitations to this study. First of all, because 

the study design was cross-sectional, a causal relationship could 

not be established. Second, because we had no information 

about the non-respondents, response bias is a possible bias. 

Third, this study conducted during peak crises of conflict in 

2014, which affected the accessibility to the hospitals and 

districts, and consequently, selection bias is another possible 

bias. Fourth, “Although we have test piloted the English version 

of the questionnaire, the language barrier could be a limitation 

because the native language of the respondent is Arabic". 

 

Policy implication  

The above findings may be applied to the design and 

implementation of burnout reduction programs in Iraq and 

facilitate the development of rational strategies. For example, 

the results showed burnout in physicians to be higher in 

females, married, or individuals with children. Therefore, we 

suggest that the target group of burnout reduction programs 

should primarily focus on these physicians. Intervention 

strategies may cover communication skill training, stress, and 

time management. Further, burnout found to be associated with 

work-related factors: job satisfaction, working hours, being 

non-specialist, poor relationships with managers and patients. 

Improving working conditions of Iraqi doctors should be an 

essential goal for their job satisfaction and low burnout levels. 

Policy reforms can address these factors contributing to burnout 

by reducing workload, reasonable welfare, a healthier working 

environment, and senior-junior support groups. Increasing 

compensation can be an effective method to help to attract and 

retain good doctors. A large percentage of patients affect the 

quality of care and the doctor-patient relationship, and thus the 

burning of doctors. A comprehensive health care reform is 

needed to strengthen primary health care intended to address the 

overutilization of hospitals, which may involve government 

hiring and training more staff. Conflict and violence-related 

factors found to be significantly associated with burnout of Iraqi 

physicians in the current study. Measures to prevent violence in 

the workplace against doctors are needed to reduce risk and 

negative consequences.  Although health institutions, in general, 

have made considerable progress in the development of 

programs to prevent violence in Iraq, there are still 

shortcomings in the legislation prohibiting violence at work, 

and laws must be enacted to improve the medical environment 

and prevent violence at work. In order to effectively carry out 

these policies, government and health care organizations must 

develop, implement, and encourage a strong safety and security 

environment. [51]. 

 

Conclusion  

A high level of emotional exhaustion detected in about two-

third (60.0%) of participants. The findings of this study show 

that various socio-demographic, occupational, and conflict-

related factors are important determinants of the burnout of 

Iraqi doctors. The results of this study would, therefore, be of 

great interest to Iraqi policymakers and health care managers 

seeking to reduce physician burnout levels. The importance of 

burnout in physicians should not be underestimated, and many 

of the associated factors identified may potentially be reversed. 

This study may serve as a guide for setting effective 

interventions and treatment.  According to the results, the focus 

should not only be on providing financial incentives but also on 

extraordinary efforts to create a safe and acceptable work 

environment. 

 

Abbreviations 
EE: Emotional Exhaustion CMO: Chief Medical Officers   WCW: 

Warr-Cook-Wall SD: Standard Deviation CI: Confidence Interval OR: 
Odds ratio WHO: World Health Organization GDP: Gross Domestic 

Product 

 
Declarations  

Acknowledgment 

We render our special thanks to all directors of hospitals and medical 

centers we visited. We are also grateful to all the Iraqi doctors and the 

paramedical staff for their working every day to serve their public in the 
face of violence and for their time and openness during the data 

collection. 

 
Funding  

The author (s) received no financial support for the research, authorship, 

and/or publication of this article. 
 

Availability of data and materials  

Data will be available by emailing drsaadalezzi@gmail.com. 
 

Authors’ contributions  

SAAJ is the principal investigator of the study who designed the study 
and coordinated all aspects of the research, including all steps of the 

manuscript preparation. He is responsible for the study concept, design, 

writing, reviewing, editing, and approving the manuscript in its final 
form. ID, MA, SY, and PT contributed to the study design, analysis and 

interpretation of data, drafting the work, writing the manuscript and 

reviewed and approved the manuscript. All authors read and approved 
the final manuscript. 

 

Ethics approval and consent to participate  

We conducted the research following the Declaration of Helsinki, and 

the Ethics Committee of the Izmir University of Economics approved 

the protocol (Ref: B.30.2.IEU.0.05.05-020-014). Confidentiality was 
assured with signed informed consent.  

 

Consent for publication  

Not applicable 

 

Competing interest  

The authors declare that they have no competing interests. 

 

Open Access  

This article is distributed under the terms of the Creative Commons 

Attribution 4.0 International License 

(http://creativecommons.org/licenses/by/4.0/), which permits 
unrestricted use, distribution, and reproduction in any medium, 

provided you give appropriate credit to the original author(s) and the 

source, provide a link to the Creative Commons license, and indicate if 
changes were made. The Creative Commons Public Domain Dedication 

waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to 

the data made available in this article unless otherwise stated. 
 

Author Details 
1Department of Public Health, Faculty of Medicine, Bezmialem Vakif 
University, Istanbul, Turkey. 2Department of Economics, Izmir 
University of Economics, Izmir, Turkey. 3Department of Public Health, 
Faculty of Medicine, Anbar University, Anbar, Iraq. 4Department of 



                                                           Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2): 42-49                                                                              48 
 

  
 

 

Medical Biology and Anatomy, Faculty of Medicine, Diyala University, 

Diyala, Iraq. 
 

Article Info 
Received: 23 May 2018  

Accepted: 08 November 2018   

Published: 08 December 2018 

 
References  

1. Maslach C, Jackson SE. The measurement of experienced 
burnout. Journal of Occupational Behaviour 1981; 2:99-113.    

2. Sørgaard KW, Ryan P, Hill R, Dawson I; OSCAR Group. Sources 
of stress and burnout in acute psychiatric care: inpatient vs. 

community staff. Soc Psychiatry Psychiatr Epidemiol 
2007;42(10):794–802.  

3. Maslach CC, Schaufeli WB, Leiter MP. Job burnout. Annu Rev 
Psychol 2001; 52:397–422. 

4. Deary IJ, Blenkin H, Agius RM, Endler NS, Zealley H, Wood R. 
Models of job-related stress and personal achievement among 

consultant doctors. British Journal of Psychology1996: 87(1):3–
29. 

5. Deckard G, Meterko M, Field D. Physician burnout: An 
examination of personal, professional, and organizational 
relationships. Medical Care 1994; 32: 745– 754. 

6. McCue JD. The effects of stress on physicians and their medical 
practice. N Engl J Med 1982; 306:458–463. 

7. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-
reported patient care in an internal medicine residency program. 

Ann Intern Med 2002; 136:358–367. 
8. Felton JS. Burnout as a clinical entity- its importance in health 

care workers. J Occup Health1998; 48: 237–50. 

9. Balch CM, Freischlag JA, Shanafelt TD. Stress and burnout 
among surgeons: Understanding and managing the syndrome and 

avoiding the adverse consequences. Archives of Surgery2009; 

144:371–376. 
10. Houkes I, Winants Y, Twellaar M. Specific determinants of 

burnout among male and female general practitioners: A cross-

lagged panel analysis. Journal of Occupational and Organizational 
Psychology 2008; 81: 249–276. 

11. Schaufeli W, Enzmann D. The burnout companion to study and 
practice: A critical analysis. London: Taylor & Francis, 1998. 

12. Wu S, Zhu W, Li H, Wang Z, Wang M. Relationship between job 
burnout and occupational stress among doctors in China. Stress 

and Health 2008; 24: 143–149. 
13. Squires A, Sindi A, Fennie K. Health system reconstruction: 

perspectives of Iraqi physicians. Global Public Health2010; 
5:561–77.  

14. Ali Jadoo SA, Aljunid SM, Dastan I, Tawfeeq RS, Mustafa MA, 
Ganasegeran K, Aldubai SA. Job satisfaction and turnover 
intention among Iraqi doctors-a descriptive cross-sectional 

multicentre study. Hum Resour Health2015; 13: 21.  

15. Ali Jadoo SA, Torun P, Dastan I, Al-Samarrai M. Impact of 
conflict related and workplace related violence on job satisfaction 

among physicians from Iraq –a descriptive cross-sectional 

multicentre study. Journal of Ideas in Health 2018; 1(1): 14-22. 
16. Al-Samarrai M, Ali Jadoo SA. Iraqi medical students are still 

planning to leave after graduation. Journal of Ideas in Health 

2018;1(1):23-28. 
17. Sa’adoon A A, Hussien AH, Museher TR. Patients’ satisfaction 

for health care services at Thi-Qar province, Iraq. Thi-Qar 

Medical Journal (TQMJ) 2008; 2(1):39–45. 
18. Shabila NP, Al-Tawil NG, Al-Hadithi TS, Sondorp E: A 

qualitative assessment of the Iraqi primary health care system. 

World Health Popul 2012; 13(3): 18-27.  
19. Webster P. Reconstruction efforts in Iraq failing health care. 

Lancet 2009; 373: 617-620. 

20. Ozyurt A, Hayran O, Sur H. Predictors of burnout and job 
satisfaction among Turkish physicians. QJM 2006; 99(3): 161–

169.  

21. Beckstead JW. Confirmatory factor analysis of the Maslach 
Burnout Inventory among Florida nurses. International Journal of 

Nursing Studies 2002; 39 (8): 785–792. 

22. Al-Dubai SAR, Ganasegeran K, Perianayagam W, Rampal KG. 
Emotional burnout, perceived sources of job stress, professional 

fulfillment, and engagement among medical residents in Malaysia. 

Scientific World Journal 2013; 2013: 137620.  

23. Halayem-Dhouib S, Zaghdoudi L, Zremdini R, Maalej I, Béchir 
MB, Labbène R. Burnout en psychiatrie: une experience 
tunisienne [Burnout among mental health professionals: a 

Tunisian experience]. Rev Epidemiol Sante Publique 

2010;58(6):403–408.  
24. Al-Turki HA, Al-Turki RA, Al-Dardas HA, Al-Gazal MR, Al- 

Maghrabi GH, Al-Enizi NH, et al. Burnout syndrome among 
multinational nurses working in Saudi Arabia. Ann Afr Med 

2010;9(4):226–229.  

25. Abdo SAM, El-Sallamy RM, El-Sherbiny AAM, Kabbash IA. 
Burnout among physicians and nursing staff working in the 

emergency hospital of Tanta University, Egypt. East Mediterr 

Health J. 2016; 21(12): 906-915.   
26. Abdulla L, Al-Qahtani DM, Al-Kuwari MG. Prevalence and 

determinants of burnout syndrome among primary healthcare 

physicians in Qatar. South African Family Practice Journal. 
2011;53(4):380–383. 

27. Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, 
Freischlag J. Relationship between work-home conflicts and 
burnout among American surgeons: a comparison by sex. Arch 

Surg 2011; 146:211–217. 

28. Shanafelt TD, Oreskovich MR, Dyrbye LN, Satele DV, Hanks JB, 
Sloan JA, et al. Avoiding burnout: the personal health habits and 

wellness practices of US surgeons. Ann Surg 2012;255(4):625–

633. 
29. Soler JK, Yaman H, Esteva M, Dobbs F, Asenova RS, Katic M, et 

al. Burnout in European family doctors: the EGPRN study. Fam 

Pract 2008; 25:245–265. 
30. Demir A, Ulusoy M, Ulusoy MF. Investigation of factors 

influencing burnout levels in the professional and private lives of 

nurses. Int J Nurs Stud 2003;40(8):807–27. 
31. Lagerström M, Josephson M, Arsalan N, Fallahi-Khoshknab M. 

Striving for balance between family and work demands among 

Iranian nurses. Nurs Sci Q 2010;23(2):166–172.  
32. Prins JT, van der Heijden FM, Hoekstra-Weebers JE, Bakker AB, 

van de Wiel HB, Jacobs B, et al. Burnout, engagement and 

resident physicians’ self-reported errors. Psychol Health Med 
2009; 14: 654−66.  

33. Wang, Zhihui, Zhenyu Xie, Junming Dai, Liqian Zhang, Yunbiao 
Huang, and Bo Chen. "Physician burnout and its associated 
factors: a cross-sectional study in Shanghai." Journal of 

occupational health 56, no. 1 (2014): 73-83. 

34. McManus IC, Winder BC, Gordon D. The causal links between 
stress and burnout in a longitudinal study of UK doctors. Lancet 

2002; 359: 2089–90. 

35. Visser MRM, Smets EMA, Oort FJ, de Haes HCJM. Stress, 
satisfaction and burnout among Dutch medical specialists. CMAJ 

2003; 168(3): 271–75. 

36. Elit L, Trim K, Mand-Bains IH, Sussman J, Grunfeld E, and in 
conjunction with the Society of Gynecologic Oncology Canada. 

Job satisfaction, stress and burnout among Canadian gynecologic 
oncologists. Gynecol Oncol 2004; 94(1):134–139.  

37. Thomsen S, Soares J, Nolan P, Dallender J, Arnetz B. Feelings of 
professional fulfillment and exhaustion in mental health 

personnel: the importance of organizational and individual factors. 
Psychother Psychosom 1999; 68:157–64. 

38. Renzi C, Tabolli S, Ianni A, Di Pietro C, Puddu P. Burnout and 
job satisfaction comparing healthcare staff of a dermatological 
hospital and a general hospital. J Eur Acad Dermatol Venereol 

2005; 19:153–157. 
39. Maccacaro G, Di Tommaso F, Ferrai P, Bonatti D, Bombana S, 

Merseburger A. The effort of being male: a survey on gender and 

burnout. Med Lav 2011; 102:286–296. 

40. Piko BF. Burnout, role conflict, job satisfaction and psychosocial 
health among Hungarian health care staff: a questionnaire survey. 

Int J Nurs Stud 2006; 43:311–318. 
41. Wu H, Liu L, Wang Y, Gao F, Zhao X, Wang L. Factors 

associated with burnout among Chinese hospital doctors: a cross-

sectional study. BMC public health 2013; 13(1): 786. 
42. Al-Dubai SA, Rampal KG. Prevalence and associated factors of 

burnout among doctors in Yemen. J Occup Health 2010; 52:58–

65. 
 

43. Al-Dewachi O. The Professionalization of the Iraqi Medical 
Doctors In Britain. Ann Arbor, United States: Harvard University; 
2008. 



                                                           Ali Jadoo et al., Journal of Ideas in Health 2018; 1(2): 42-49                                                                              49 
 

  
 

 

44. Webster PC. Iraq’s health system yet to heal from ravages of war. 
Lancet. 2011;378(9794):863–6. 

45. Gong Y, Han T, Chen W, Dib HH, Yang G, Zhuang R, Lu Z. 
Prevalence of anxiety and depressive symptoms and related risk 

factors among physicians in China: a cross-sectional study. PloS 
one 2014; 9(7): e103242. 

46. Escribà-Agüir V, Martín-Baena D, Pérez-Hoyos S: Psychosocial 
work environment and burnout among emergency medical and 

nursing staff. Int Arch Occup Environ Health 2006; 80:127–133. 

47. Karasek R, Theorell T. Healthy work: stress, productivity, and the 
reconstruction of working life. New York: Basic Books; 1990. 

48. Wang H, Zhang N: Analysis on the status of occupational burnout 
among doctors. Zhong Guo Jian Kang Xin Li Xue Za Zhi 2008; 
16:397–399. 

49. Olkinuora M, Asp S, Juntunen J, Kauttu K, Strid L, Aärimaa M, et 
al. Stress symptoms, burnout and suicidal thoughts in Finnish 
physicians. Soc Psychiatr Epidemiol 1990; 25(2):81–86. 

50. Merecz D, Drabek M, Moscicka A. Aggression at the workplace– 
psychological consequences of abusive encounter with coworkers 

and clients. International Journal of Occupational Medicine and 

Environme tal Health2009; 22: 243–260. 
51. 51. Aytac S, Dursun S. The effect on employees of violence 

climate in the workplace. Work 41 Suppl 1;2012: 3026–3031.