ORIGINAL ARTICLES
Musculoskeletal Pain, Job Satisfaction, Depression, and Anxiety Among Spanish Podiatric Physicians Marta Elena Losa Iglesias, PhD* Ricardo Becerro de Bengoa Vallejo, DPM, PhD† Background: There is a high prevalence of musculoskeletal complaints related to dayto-day work among podiatric physicians. We sought to determine the relationships among musculoskeletal pain, job satisfaction, depression, and anxiety in Spanish podiatric physicians. Methods: A convenience sample of 421 Spanish podiatric physicians was administered a survey that included questions about sociodemographic variables, musculoskeletal pain, job satisfaction, depression, and anxiety. Results: On average, respondents were found to have a high level of pain, a moderate level of job satisfaction, and low-to-moderate levels of depression and anxiety. Young single women had the highest levels of pain and anxiety. Analysis with the Student t test indicated significant differences between the sexes for levels of pain (P , .0001) and anxiety (P , .014). Job satisfaction was inversely related to depression and anxiety. Conclusions: These findings, particularly the increased levels of pain, job dissatisfaction, anxiety, and depression in young single female podiatrists, indicate a need for strategies to reduce the risks posed by the work environment in podiatric medicine, thus minimizing the negative psychological and physical consequences of participating in the profession. (J Am Podiatr Med Assoc 104(2): 191-197, 2014)
People who work in service professions may be at higher risk than those in other professions for burnout, stress, distress, anxiety, and other psychological problems. This may result from the emotional demands of working with patients, and the effects can be exacerbated by working alone and without the support of professional colleagues.1-3 Podiatric physicians are exposed to four main risk factors daily: poor posture, repetition of activity, extended duration of activity, and psychological stressors.4,5 The psychological stressors are various and include clinician inexperience, multiple workplaces, work overload, financial pressures, practice management problems, and societal issues.6 All of these factors can have a negative influence on podiatrists’ perceptions of and attitudes toward their work. *Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain. †Escuela Universitaria de Enfermerı´ a, Fisioterapia y Podologı´a, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain. Corresponding author: Marta Elena Losa Iglesias, PhD, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avda. Atenas s/n-Alcorco´n, 28922-Madrid, Spain. (Email: [email protected])
One additional factor is involved: the nature of podiatric medical care. The care of the feet is still considered by many to be a low-status profession. This perception can lead to low self-esteem among podiatric medical practitioners. It also helps explain the low level of job satisfaction reported by many podiatric physicians.7 A study involving dentists found a reciprocal relationship between anxiety, burnout, and depressive symptoms. In addition, it demonstrated that job strain causes a predisposition to depression related to burnout.8 These results may be applicable to the podiatric medicine profession as well. In addition, there is a high prevalence of musculoskeletal complaints related to day-to-day work among podiatric physicians.9 Psychological factors (notably distress, depressive mood, and somatization) have been implicated in the transition from acute to chronic low-back pain.10 Mitchell et al11 found that stress and difficulty coping contributed independently to the presence of low-back pain. However, few empirical data on musculoskeletal pain in Spanish podiatric physicians have been reported, and no studies have examined anxiety, depression, and job satisfaction in this population.
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Therefore, this study was undertaken to explore the relationships among musculoskeletal pain, job satisfaction, depression, and anxiety in Spanish podiatric physicians.
Methods We conducted a survey via e-mail of podiatric physicians across Spain. Contact information for this sample was obtained from a database created for podiatric physicians who voluntarily provided contact details to receive information relevant to meetings, courses, and so on. To be eligible for participation, individuals had to be Spanish podiatrists (either self-employed or salaried) with at least 1 year of experience, work at least 20 hours per week, and see at least five patients per working day. A total of 783 podiatric physicians were contacted, and 421 questionnaires were returned in April and May 2010, for a response rate of 54%. There were no penalties or rewards related to participation, and the participants were free to answer the questions to the best of their ability. Informed consent was obtained from each participant via a form enclosed with the online questionnaire. To maintain privacy and confidentiality, we did not collect individual names or addresses. Before data collection, we obtained approval for the study from the Ethical and Research Commission (Podiatry Section) of the Asociacio´n Espan˜ola de Medicina y Salud Escolar y Universitaria (Madrid, Spain). Survey Instrument Demographic Variables. The survey instrument included specific questions concerning sociodemographic variables (sex, age, and marital status). Musculoskeletal Pain. The survey instrument contained questions about the intensity of musculoskeletal pain directly related to day-to-day podiatric medical work, such as pain in the back, neck, wrists, and so on. Perceived pain was rated on the day the questionnaire was completed using the Borg CR10 scale category ratio. This is a numeric scale ranging from 0 to 10, with 0 indicating no pain at all and 10 indicating the most extreme pain.12 This scale has been previously shown to be highly reliable.13 Job Satisfaction. The survey investigated job satisfaction using the Job Satisfaction Scale (JSS) devised by Warr et al,14 which was adapted for a Spanish population.15 The Castilian Spanish version was obtained by means of the translation and backtranslation method and was adapted following the
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recommendations proposed for cross-cultural adaptation of health-related questionnaires.16,17 The JSS consists of 15 items on different aspects of working conditions (responsibility, variety, collaborators, physical conditions, possibility of using one’s skills, choice of work methods, positive feedback for good work, pay, and work hours), with items rated on a 7point Likert scale ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied). The total score, which is obtained by summing the scores for the separate responses, ranges from 15 to 105. The authors of the scale distinguish between intrinsic satisfaction (even-numbered items are associated with satisfaction with aspects of the job itself, such as positive evaluations of the variety in one’s job or the opportunity to use one’s skills) and extrinsic satisfaction (odd-numbered items pertain to working relationships with the person’s immediate boss or coworkers and satisfaction with the work environment). The last item on the scale provides an opportunity to express overall job satisfaction, also on a scale from 1 to 7. The reliability and validity of the JSS have been evaluated. Specifically, Warr et al14 reported a test-retest correlation coefficient of 0.63, and the scale has been used extensively in a variety of surveys in different countries. Depression. Depression was measured using the Beck Depression Inventory (BDI). The revised BDI,18 which exists in a Spanish version,19,20 is a 21-item self-report questionnaire in which each item consists of four statements (scored from 0 to 3) indicating different levels of severity of a particular symptom experienced during the past week. Scores for all 21 items are summed to yield a single depression score. The internal consistency of the BDI, based on a variety of clinical samples, is 0.86.18 The conventional cutoff scores are as follows: nondepressed, 10 or less; mildly depressed, 11 to 16; and moderately to severely depressed, 17 or greater. Factor analytic studies of the BDI have revealed three principal factors reflecting cognitiveaffective symptoms and attitudes, impaired performance, and somatic symptoms.21,22 Anxiety. Anxiety was measured using the Beck Anxiety Inventory (BAI).23 The BAI is a 21-item selfreport questionnaire in which each item is rated on a 4-point severity scale (from 0 to 3) reflecting the individual’s experience of anxiety symptoms during the past week, with 0 indicating ‘‘not at all’’ and 3 indicating ‘‘severely; I could barely stand it.’’ Scores for the 21 items are summed to yield a single anxiety score ranging from 0 to 63. The BAI was developed to better discriminate between depres-
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sion and anxiety and has been shown to do so more effectively than other widely used anxiety measures.24 The internal consistency of the BAI across a variety of samples has been found to be in the range of 0.85 to 0.94.23 In this study, we used the Spanish version of the BAI developed by Sanz and Navarro.20 Statistical Analysis We analyzed the data with a software program (IBM SPSS Statistics 19; IBM Corp, Chicago, Illinois). Basic descriptive statistics (means, standard deviations, and percentage distributions) were calculated for sociodemographic characteristics (sex, age, and marital status) and perceived pain. Student t tests and one-way analyses of variance (ANOVAs) with Bonferroni post hoc analyses were performed to determine whether there were statistically significant relationships between the Borg CR10 scale score and the sociodemographic variables. Pearson product moment correlation analysis was used to determine whether there were any statistically significant relationships among the Borg CR10 scale score, job satisfaction, depression, and anxiety.
Results The final sample consisted of 274 women (65%) and 147 men (35%), for a total of 421 podiatric physicians. The mean age of the sample was 31 years (95% confidence interval, 23–58 years). Regarding marital status, 57% were married and 43% were unmarried (Table 1). Borg CR10 Scale, JSS, BDI, and BAI Scores The descriptive statistics for the Borg CR10 scale, JSS, BDI, and BAI are shown in Table 2. In this Table 1. Characteristics of the 421 Study Participants Characteristic
Participants (No. [%])
Sex Female
274 (65)
Male
147 (35)
Age (years) 30
246 (58)
31–45
155 (37)
46
20 (5)
Marital status Married
241 (57)
Unmarried
180 (43)
Table 2. Descriptive Statistics for the Borg CR10 Scale, JSS, BDI, and BAI Measure Borg CR10 scale
Mean 6 SD
Range
4.78 6 1.73
1–9
71.33 6 18.13
28–102
BDI
8.22 6 7.43
0–30
BAI
9.38 6 9.38
0–41
JSS
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; JSS, Job Satisfaction Scale.
population of Spanish podiatric physicians, the results for the Borg CR10 scale indicated a high level of pain, with 246 of the 421 participants having scores ranging from 5 to 10 points. Analysis of the data for the JSS indicated moderate satisfaction for the sample overall. Finally, total scores for the BDI and BAI indicated low-to-moderate levels of depression and anxiety, respectively (Table 2). Relationship of Borg CR10 Scale, JSS, BDI, and BAI Scores with Demographic Variables Analysis with the Student t test revealed no significant differences by sex for JSS and BDI scores (P . .05). However, it did show significant differences by sex for Borg CR10 scale (P , .0001) and BAI (P , .014) scores, with women having higher levels of pain and higher anxiety scores than men (Table 3). The ANOVA indicated no statistically significant differences among age groups for all of the measures (Table 3). For the JSS, age group differences were significant at P , .0001. The Bonferroni post hoc tests showed that podiatric physicians aged 30 years and younger scored significantly lower than did those 46 years and older. In addition, the differences between the group aged 31 to 45 years and the other two age groups were significant (P , .05). The ANOVA for the BDI scores showed significant differences between age groups (P , .0001). Bonferroni post hoc tests indicated that podiatrists aged 46 years and older scored significantly lower than those 30 years and younger. However, no significant difference was found between those aged 31 to 45 years and those 46 years and older (P . .05). Finally, the ANOVA for the BAI indicated significant differences by age (P , .0001). Bonferroni post hoc tests indicated that podiatric physicians aged 46 years and older and those aged 31 to 45 years scored significantly lower than podiatric
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Table 3. Borg CR10 Scale, JSS, BDI, and BAI Scores by Podiatric Physician Sex, Age, and Marital Status
Variable
Borg CR10 Scale Participants (No.) Mean SD P1 P2 P3 Mean
JSS SD
BDI
BAI
P1 P2 P3 Mean SD P1 P2 P3 Mean
SD
P1 P2 P3
Sex Group A: female
274
5.09 1.71
Group B: male
147
Group A: 30 Group B: 31–45
a
71.69 18.48 NS
8.18 7.16 NS
4.19 1.59
70.69 17.5
8.3
246
4.73 1.68 NS
68.79 19.18
155
4.85 1.82
10.2
7.94
9.72
7.86
a
8.53
Age (years)
Group C: 46
20
4.8
NS
1.5
b b
73.72 16.08 NS 84
5.68 5.25 a
11.22
a
10.09 8.25 5
11.2 NS a
3.24
10.86
7.01
6.12
5.4
3.53
11.1
10.33
a b a
Marital status Group A: married
241
4.47 1.73
Group B: unmarried
180
5.18 1.64
a
71.61 17.1
NS
70.95 19.46
a
9.45 7.85 6.58 6.85
7.08
a
7.35
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; JSS, Job Satisfaction Scale; NS, not significant; P1, difference between groups A and B for sex, age, and marital status; P2, difference between groups B and C for age; P3, difference between groups C and A for age. a P , .01. b P , .05.
physicians 30 years and younger. A significant difference was also found between those aged 31 to 45 years and those 46 years and older (P , .05). Using an independent Student t test to compare married with unmarried podiatrists, significant differences were found for the Borg CR10 scale, the BDI, and the BAI (P , .0001 for all), with married podiatrists having a lower intensity of pain and higher scores for depression and anxiety. No significant difference was found for the JSS (P . .05) (Table 3). Correlations Among Borg CR10 Scale, JSS, BDI, and BAI Scores The results of the Pearson product moment correlation analysis of the Borg CR10 scale, JSS, BDI, and BAI are shown in Table 4. Positive and negative correlations were found between the values of each construct. There was a significant negative correlation between scores on the JSS and the BDI (r ¼ 0.451, P , .01) and between scores on the JSS and the BAI (r ¼ 0.211, P , .01). In addition, there was a significant negative correlation between scores on the Borg CR10 scale and the JSS (r ¼ 0.101, P , .05). Positive correlations were found between scores on the Borg CR10 scale and the BDI (r ¼ 0.265, P , .01) and between scores on the Borg CR10 scale and the BAI (r ¼ 0.210, P , .01). A significant positive
194
correlation was also found between the total scores for the BDI and the BAI (r ¼ 0.781, P , .01).
Discussion This study investigated relationships between musculoskeletal pain related to day-to-day podiatric medical work and the psychological variables of job satisfaction, anxiety, and depression. Overall, the study sample was young and exhibited a ‘‘strong’’ work-related pain level as measured by the Borg CR10 scale, moderate work satisfaction, a moderate level of anxiety, and a low level of depression. The results of this study show that women had higher levels of musculoskeletal pain and higher levels of anxiety than men. For job satisfaction, we found differences among all of the age groups, but the Table 4. Pearson Product Moment Correlation Analysis Among Borg CR10 Scale, JSS, BDI, and BAI Scores Borg CR-10 Scale Borg CR10 scale
JSS
BDI
BAI
1
1
JSS
0.101a
BDI
0.265b
0.451b
1
BAI
0.210b
0.211b
0.781b
1
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; JSS, Job Satisfaction Scale. a P , .05 (two-tailed). b P , .01 (two-tailed).
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results were strongest in the comparison of podiatric physicians aged 30 years and younger with the older groups, with the youngest group expressing the greatest dissatisfaction. Also, we found an inverse correlation between pain intensity and job satisfaction, suggesting that increased musculoskeletal pain leads to reduced job satisfaction among podiatric physicians. Epidemiologic, clinical, and experimental evidence points to sex differences in musculoskeletal pain. Adult women are more likely to have musculoskeletal problems than are men.25 Moreover, studies have shown that compared with men, women respond more emotionally to pain, tending to become more worried and bothered by it.26 Rollman and Lautenbacher25 suggested that a state of increased pain sensitivity with a peripheral or central origin predisposes individuals to chronic muscle pain conditions and that there are sex differences in the operation of these mechanisms, causing women to be more vulnerable to the development and maintenance of musculoskeletal pain conditions. People who have worked in podiatric medicine and dentistry commonly report musculoskeletal disorders and pain,9,27 with the pain often being related to fatigue as well as to common psychological disorders, such as anxiety.27 Job satisfaction may help to protect against the development of chronic pain and disability.28 The present results indicate that the youngest podiatric physicians have the most job dissatisfaction. This finding is in agreement with other studies that have found lower job satisfaction among young adults.29 Research involving medical professionals has proved that role conflict, inexperience, selfemployment, professionalism, anxiety, and younger age can lead to low levels of job satisfaction.30-33 The results of the present study show a clear association between lower job satisfaction and a higher score on the BDI. A recent study in the general population found that dissatisfaction was significantly associated with a depressive state.34 Another study demonstrated that health professionals (physicians, nurses, and assistants) with the highest dissatisfaction rate were between the ages of 25 and 29 years (70.0% of the total sample).35 Shields and Ward36 also found that younger nurses were less satisfied with their jobs compared with older nurses. Ruggiero37 demonstrated that psychological symptoms may adversely affect job satisfaction in health-care professionals such as nurses. Another study by Ernst et al38 found that age and
experience are inversely correlated with job satisfaction among nurses. Studies indicate that depression and anxiety are increasing in prevalence in the general population, although the causes of this historical change are not well understood.39,40 The present results indicate that depression and anxiety are especially prevalent among female podiatric physicians. It is not surprising to find that women are more anxious at work than men. Previous studies have demonstrated that women report higher levels of anxiety than men, possibly due to biological and psychosocial factors.41,42 This may help explain the persistence of women’s anxiety even after obtaining greater opportunities. Greater opportunities often lead to greater expectations and, thus, more stress.40 Twenge,40 in a study of a similar young sample of working women and men, found a relationship between psychological job demands and increased risk of major depression and generalized anxiety disorder. The present data for the BDI and the BAI indicate that married and older podiatric physicians scored significantly higher than the unmarried and younger age groups and also correlated with the total scores for the BDI and the BAI. These results are consistent with previous findings showing anxiety and depression to be highly correlated.43 Anxiety and depression disorders are common in the general population, with evidence of a decline in prevalence with increased age.44 When age is considered, most studies have found that depression has a higher prevalence in women from young adulthood to the mid-50s who are unmarried, separated, or divorced.45 The present study has several limitations. First, the survey response rate was moderate. Second, there may have been a selection bias favoring podiatrists who had pain from musculoskeletal disorders, dissatisfaction at work, or any kind of psychological problem. A third limitation is the nature of the sample population. It is better to obtain data from a completely random sample; however, we believe that the sample represented a diverse population of podiatric physicians that was adequate. The final limitation is an absence of other related studies involving a podiatric medical population. Thus, we cannot compare these findings with those of previous research; however, the results of this study can help increase knowledge about the topics addressed and how they affect the podiatric medicine profession. Future research should include other variables, such as stress, and should involve a larger sample of young podiatric physi-
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cians to more accurately measure the impact of all of the variables. 11.
Conclusions The levels of pain intensity, job dissatisfaction, anxiety, and depression found in this study, particularly among young single women, underline the need for a variety of strategies to reduce risks posed by podiatric medical work, thus, avoiding psychological and physical consequences. Further research is needed to identify risk factors in podiatric medical practice and to develop methods to minimize risk. Moreover, research is needed on these topics in other countries and occupational settings to shed more light on, and possibly confirm, these findings.
12.
13. 14.
15.
16.
Financial Disclosure: None reported. Conflict of Interest: None reported. 17.
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29. STEIN JA, SMITH GM, GUY SM, ET AL: Consequences of adolescent drug use on young adult job behavior and job satisfaction. J Appl Psychol 78: 463, 1993. 30. BLEGEN MA: Nurses’ job satisfaction: a meta-analysis of related variables. Nurs Res 42: 36, 1993. 31. CHU CI, HSU HM, PRICE JL, ET AL: Job satisfaction of hospital nurses: an empirical test of a causal model in Taiwan. Int Nurs Rev 50: 176, 2003. 32. LU KY, LIN PL, WU CM, ET AL: The relationship among turnover intentions, professional commitment, and job satisfaction of hospital nurses. J Prof Nurs 18: 214, 2002. 33. TURNER S, ROSS MK, IBBETSON RJ: Job satisfaction among dually qualified dental hygienist-therapists in UK primary care: a structural model. Br Dent J 210: E5, 2011. 34. KAWADA T, YOSHIMURA M: Results of a 100-point scale for evaluating job satisfaction and the occupational depression scale questionnaire survey in workers. J Occup Environ Med 54: 420, 2012. 35. YAMI A, HAMZA L, HASSEN A, ET AL: Job satisfaction and its determinants among health workers in Jimma University Specialized Hospital, Southwest Ethiopia. Ethiop J Health Sci 21 (suppl 1): 19, 2011. 36. SHIELDS MA, WARD M: Improving nurse retention in the National Health Service in England: the impact of job satisfaction on intentions to quit. J Health Econ 20: 677, 2001. 37. RUGGIERO JS: Health, work variables, and job satisfaction among nurses. J Nurs Adm 35: 254, 2005. 38. ERNST ME, MESSMER PR, FRANCO M, ET AL: Nurses’ job
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Musculoskeletal Pain, Job Satisfaction, Depression, and Anxiety Among Spanish Podiatric Physicians Marta Elena Losa Iglesias, PhD* Ricardo Becerro de Bengoa Vallejo, DPM, PhD† Background: There is a high prevalence of musculoskeletal complaints related to dayto-day work among podiatric physicians. We sought to determine the relationships among musculoskeletal pain, job satisfaction, depression, and anxiety in Spanish podiatric physicians. Methods: A convenience sample of 421 Spanish podiatric physicians was administered a survey that included questions about sociodemographic variables, musculoskeletal pain, job satisfaction, depression, and anxiety. Results: On average, respondents were found to have a high level of pain, a moderate level of job satisfaction, and low-to-moderate levels of depression and anxiety. Young single women had the highest levels of pain and anxiety. Analysis with the Student t test indicated significant differences between the sexes for levels of pain (P , .0001) and anxiety (P , .014). Job satisfaction was inversely related to depression and anxiety. Conclusions: These findings, particularly the increased levels of pain, job dissatisfaction, anxiety, and depression in young single female podiatrists, indicate a need for strategies to reduce the risks posed by the work environment in podiatric medicine, thus minimizing the negative psychological and physical consequences of participating in the profession. (J Am Podiatr Med Assoc 104(2): 191-197, 2014)
People who work in service professions may be at higher risk than those in other professions for burnout, stress, distress, anxiety, and other psychological problems. This may result from the emotional demands of working with patients, and the effects can be exacerbated by working alone and without the support of professional colleagues.1-3 Podiatric physicians are exposed to four main risk factors daily: poor posture, repetition of activity, extended duration of activity, and psychological stressors.4,5 The psychological stressors are various and include clinician inexperience, multiple workplaces, work overload, financial pressures, practice management problems, and societal issues.6 All of these factors can have a negative influence on podiatrists’ perceptions of and attitudes toward their work. *Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain. †Escuela Universitaria de Enfermerı´ a, Fisioterapia y Podologı´a, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain. Corresponding author: Marta Elena Losa Iglesias, PhD, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avda. Atenas s/n-Alcorco´n, 28922-Madrid, Spain. (Email: [email protected])
One additional factor is involved: the nature of podiatric medical care. The care of the feet is still considered by many to be a low-status profession. This perception can lead to low self-esteem among podiatric medical practitioners. It also helps explain the low level of job satisfaction reported by many podiatric physicians.7 A study involving dentists found a reciprocal relationship between anxiety, burnout, and depressive symptoms. In addition, it demonstrated that job strain causes a predisposition to depression related to burnout.8 These results may be applicable to the podiatric medicine profession as well. In addition, there is a high prevalence of musculoskeletal complaints related to day-to-day work among podiatric physicians.9 Psychological factors (notably distress, depressive mood, and somatization) have been implicated in the transition from acute to chronic low-back pain.10 Mitchell et al11 found that stress and difficulty coping contributed independently to the presence of low-back pain. However, few empirical data on musculoskeletal pain in Spanish podiatric physicians have been reported, and no studies have examined anxiety, depression, and job satisfaction in this population.
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Therefore, this study was undertaken to explore the relationships among musculoskeletal pain, job satisfaction, depression, and anxiety in Spanish podiatric physicians.
Methods We conducted a survey via e-mail of podiatric physicians across Spain. Contact information for this sample was obtained from a database created for podiatric physicians who voluntarily provided contact details to receive information relevant to meetings, courses, and so on. To be eligible for participation, individuals had to be Spanish podiatrists (either self-employed or salaried) with at least 1 year of experience, work at least 20 hours per week, and see at least five patients per working day. A total of 783 podiatric physicians were contacted, and 421 questionnaires were returned in April and May 2010, for a response rate of 54%. There were no penalties or rewards related to participation, and the participants were free to answer the questions to the best of their ability. Informed consent was obtained from each participant via a form enclosed with the online questionnaire. To maintain privacy and confidentiality, we did not collect individual names or addresses. Before data collection, we obtained approval for the study from the Ethical and Research Commission (Podiatry Section) of the Asociacio´n Espan˜ola de Medicina y Salud Escolar y Universitaria (Madrid, Spain). Survey Instrument Demographic Variables. The survey instrument included specific questions concerning sociodemographic variables (sex, age, and marital status). Musculoskeletal Pain. The survey instrument contained questions about the intensity of musculoskeletal pain directly related to day-to-day podiatric medical work, such as pain in the back, neck, wrists, and so on. Perceived pain was rated on the day the questionnaire was completed using the Borg CR10 scale category ratio. This is a numeric scale ranging from 0 to 10, with 0 indicating no pain at all and 10 indicating the most extreme pain.12 This scale has been previously shown to be highly reliable.13 Job Satisfaction. The survey investigated job satisfaction using the Job Satisfaction Scale (JSS) devised by Warr et al,14 which was adapted for a Spanish population.15 The Castilian Spanish version was obtained by means of the translation and backtranslation method and was adapted following the
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recommendations proposed for cross-cultural adaptation of health-related questionnaires.16,17 The JSS consists of 15 items on different aspects of working conditions (responsibility, variety, collaborators, physical conditions, possibility of using one’s skills, choice of work methods, positive feedback for good work, pay, and work hours), with items rated on a 7point Likert scale ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied). The total score, which is obtained by summing the scores for the separate responses, ranges from 15 to 105. The authors of the scale distinguish between intrinsic satisfaction (even-numbered items are associated with satisfaction with aspects of the job itself, such as positive evaluations of the variety in one’s job or the opportunity to use one’s skills) and extrinsic satisfaction (odd-numbered items pertain to working relationships with the person’s immediate boss or coworkers and satisfaction with the work environment). The last item on the scale provides an opportunity to express overall job satisfaction, also on a scale from 1 to 7. The reliability and validity of the JSS have been evaluated. Specifically, Warr et al14 reported a test-retest correlation coefficient of 0.63, and the scale has been used extensively in a variety of surveys in different countries. Depression. Depression was measured using the Beck Depression Inventory (BDI). The revised BDI,18 which exists in a Spanish version,19,20 is a 21-item self-report questionnaire in which each item consists of four statements (scored from 0 to 3) indicating different levels of severity of a particular symptom experienced during the past week. Scores for all 21 items are summed to yield a single depression score. The internal consistency of the BDI, based on a variety of clinical samples, is 0.86.18 The conventional cutoff scores are as follows: nondepressed, 10 or less; mildly depressed, 11 to 16; and moderately to severely depressed, 17 or greater. Factor analytic studies of the BDI have revealed three principal factors reflecting cognitiveaffective symptoms and attitudes, impaired performance, and somatic symptoms.21,22 Anxiety. Anxiety was measured using the Beck Anxiety Inventory (BAI).23 The BAI is a 21-item selfreport questionnaire in which each item is rated on a 4-point severity scale (from 0 to 3) reflecting the individual’s experience of anxiety symptoms during the past week, with 0 indicating ‘‘not at all’’ and 3 indicating ‘‘severely; I could barely stand it.’’ Scores for the 21 items are summed to yield a single anxiety score ranging from 0 to 63. The BAI was developed to better discriminate between depres-
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sion and anxiety and has been shown to do so more effectively than other widely used anxiety measures.24 The internal consistency of the BAI across a variety of samples has been found to be in the range of 0.85 to 0.94.23 In this study, we used the Spanish version of the BAI developed by Sanz and Navarro.20 Statistical Analysis We analyzed the data with a software program (IBM SPSS Statistics 19; IBM Corp, Chicago, Illinois). Basic descriptive statistics (means, standard deviations, and percentage distributions) were calculated for sociodemographic characteristics (sex, age, and marital status) and perceived pain. Student t tests and one-way analyses of variance (ANOVAs) with Bonferroni post hoc analyses were performed to determine whether there were statistically significant relationships between the Borg CR10 scale score and the sociodemographic variables. Pearson product moment correlation analysis was used to determine whether there were any statistically significant relationships among the Borg CR10 scale score, job satisfaction, depression, and anxiety.
Results The final sample consisted of 274 women (65%) and 147 men (35%), for a total of 421 podiatric physicians. The mean age of the sample was 31 years (95% confidence interval, 23–58 years). Regarding marital status, 57% were married and 43% were unmarried (Table 1). Borg CR10 Scale, JSS, BDI, and BAI Scores The descriptive statistics for the Borg CR10 scale, JSS, BDI, and BAI are shown in Table 2. In this Table 1. Characteristics of the 421 Study Participants Characteristic
Participants (No. [%])
Sex Female
274 (65)
Male
147 (35)
Age (years) 30
246 (58)
31–45
155 (37)
46
20 (5)
Marital status Married
241 (57)
Unmarried
180 (43)
Table 2. Descriptive Statistics for the Borg CR10 Scale, JSS, BDI, and BAI Measure Borg CR10 scale
Mean 6 SD
Range
4.78 6 1.73
1–9
71.33 6 18.13
28–102
BDI
8.22 6 7.43
0–30
BAI
9.38 6 9.38
0–41
JSS
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; JSS, Job Satisfaction Scale.
population of Spanish podiatric physicians, the results for the Borg CR10 scale indicated a high level of pain, with 246 of the 421 participants having scores ranging from 5 to 10 points. Analysis of the data for the JSS indicated moderate satisfaction for the sample overall. Finally, total scores for the BDI and BAI indicated low-to-moderate levels of depression and anxiety, respectively (Table 2). Relationship of Borg CR10 Scale, JSS, BDI, and BAI Scores with Demographic Variables Analysis with the Student t test revealed no significant differences by sex for JSS and BDI scores (P . .05). However, it did show significant differences by sex for Borg CR10 scale (P , .0001) and BAI (P , .014) scores, with women having higher levels of pain and higher anxiety scores than men (Table 3). The ANOVA indicated no statistically significant differences among age groups for all of the measures (Table 3). For the JSS, age group differences were significant at P , .0001. The Bonferroni post hoc tests showed that podiatric physicians aged 30 years and younger scored significantly lower than did those 46 years and older. In addition, the differences between the group aged 31 to 45 years and the other two age groups were significant (P , .05). The ANOVA for the BDI scores showed significant differences between age groups (P , .0001). Bonferroni post hoc tests indicated that podiatrists aged 46 years and older scored significantly lower than those 30 years and younger. However, no significant difference was found between those aged 31 to 45 years and those 46 years and older (P . .05). Finally, the ANOVA for the BAI indicated significant differences by age (P , .0001). Bonferroni post hoc tests indicated that podiatric physicians aged 46 years and older and those aged 31 to 45 years scored significantly lower than podiatric
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Table 3. Borg CR10 Scale, JSS, BDI, and BAI Scores by Podiatric Physician Sex, Age, and Marital Status
Variable
Borg CR10 Scale Participants (No.) Mean SD P1 P2 P3 Mean
JSS SD
BDI
BAI
P1 P2 P3 Mean SD P1 P2 P3 Mean
SD
P1 P2 P3
Sex Group A: female
274
5.09 1.71
Group B: male
147
Group A: 30 Group B: 31–45
a
71.69 18.48 NS
8.18 7.16 NS
4.19 1.59
70.69 17.5
8.3
246
4.73 1.68 NS
68.79 19.18
155
4.85 1.82
10.2
7.94
9.72
7.86
a
8.53
Age (years)
Group C: 46
20
4.8
NS
1.5
b b
73.72 16.08 NS 84
5.68 5.25 a
11.22
a
10.09 8.25 5
11.2 NS a
3.24
10.86
7.01
6.12
5.4
3.53
11.1
10.33
a b a
Marital status Group A: married
241
4.47 1.73
Group B: unmarried
180
5.18 1.64
a
71.61 17.1
NS
70.95 19.46
a
9.45 7.85 6.58 6.85
7.08
a
7.35
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; JSS, Job Satisfaction Scale; NS, not significant; P1, difference between groups A and B for sex, age, and marital status; P2, difference between groups B and C for age; P3, difference between groups C and A for age. a P , .01. b P , .05.
physicians 30 years and younger. A significant difference was also found between those aged 31 to 45 years and those 46 years and older (P , .05). Using an independent Student t test to compare married with unmarried podiatrists, significant differences were found for the Borg CR10 scale, the BDI, and the BAI (P , .0001 for all), with married podiatrists having a lower intensity of pain and higher scores for depression and anxiety. No significant difference was found for the JSS (P . .05) (Table 3). Correlations Among Borg CR10 Scale, JSS, BDI, and BAI Scores The results of the Pearson product moment correlation analysis of the Borg CR10 scale, JSS, BDI, and BAI are shown in Table 4. Positive and negative correlations were found between the values of each construct. There was a significant negative correlation between scores on the JSS and the BDI (r ¼ 0.451, P , .01) and between scores on the JSS and the BAI (r ¼ 0.211, P , .01). In addition, there was a significant negative correlation between scores on the Borg CR10 scale and the JSS (r ¼ 0.101, P , .05). Positive correlations were found between scores on the Borg CR10 scale and the BDI (r ¼ 0.265, P , .01) and between scores on the Borg CR10 scale and the BAI (r ¼ 0.210, P , .01). A significant positive
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correlation was also found between the total scores for the BDI and the BAI (r ¼ 0.781, P , .01).
Discussion This study investigated relationships between musculoskeletal pain related to day-to-day podiatric medical work and the psychological variables of job satisfaction, anxiety, and depression. Overall, the study sample was young and exhibited a ‘‘strong’’ work-related pain level as measured by the Borg CR10 scale, moderate work satisfaction, a moderate level of anxiety, and a low level of depression. The results of this study show that women had higher levels of musculoskeletal pain and higher levels of anxiety than men. For job satisfaction, we found differences among all of the age groups, but the Table 4. Pearson Product Moment Correlation Analysis Among Borg CR10 Scale, JSS, BDI, and BAI Scores Borg CR-10 Scale Borg CR10 scale
JSS
BDI
BAI
1
1
JSS
0.101a
BDI
0.265b
0.451b
1
BAI
0.210b
0.211b
0.781b
1
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; JSS, Job Satisfaction Scale. a P , .05 (two-tailed). b P , .01 (two-tailed).
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results were strongest in the comparison of podiatric physicians aged 30 years and younger with the older groups, with the youngest group expressing the greatest dissatisfaction. Also, we found an inverse correlation between pain intensity and job satisfaction, suggesting that increased musculoskeletal pain leads to reduced job satisfaction among podiatric physicians. Epidemiologic, clinical, and experimental evidence points to sex differences in musculoskeletal pain. Adult women are more likely to have musculoskeletal problems than are men.25 Moreover, studies have shown that compared with men, women respond more emotionally to pain, tending to become more worried and bothered by it.26 Rollman and Lautenbacher25 suggested that a state of increased pain sensitivity with a peripheral or central origin predisposes individuals to chronic muscle pain conditions and that there are sex differences in the operation of these mechanisms, causing women to be more vulnerable to the development and maintenance of musculoskeletal pain conditions. People who have worked in podiatric medicine and dentistry commonly report musculoskeletal disorders and pain,9,27 with the pain often being related to fatigue as well as to common psychological disorders, such as anxiety.27 Job satisfaction may help to protect against the development of chronic pain and disability.28 The present results indicate that the youngest podiatric physicians have the most job dissatisfaction. This finding is in agreement with other studies that have found lower job satisfaction among young adults.29 Research involving medical professionals has proved that role conflict, inexperience, selfemployment, professionalism, anxiety, and younger age can lead to low levels of job satisfaction.30-33 The results of the present study show a clear association between lower job satisfaction and a higher score on the BDI. A recent study in the general population found that dissatisfaction was significantly associated with a depressive state.34 Another study demonstrated that health professionals (physicians, nurses, and assistants) with the highest dissatisfaction rate were between the ages of 25 and 29 years (70.0% of the total sample).35 Shields and Ward36 also found that younger nurses were less satisfied with their jobs compared with older nurses. Ruggiero37 demonstrated that psychological symptoms may adversely affect job satisfaction in health-care professionals such as nurses. Another study by Ernst et al38 found that age and
experience are inversely correlated with job satisfaction among nurses. Studies indicate that depression and anxiety are increasing in prevalence in the general population, although the causes of this historical change are not well understood.39,40 The present results indicate that depression and anxiety are especially prevalent among female podiatric physicians. It is not surprising to find that women are more anxious at work than men. Previous studies have demonstrated that women report higher levels of anxiety than men, possibly due to biological and psychosocial factors.41,42 This may help explain the persistence of women’s anxiety even after obtaining greater opportunities. Greater opportunities often lead to greater expectations and, thus, more stress.40 Twenge,40 in a study of a similar young sample of working women and men, found a relationship between psychological job demands and increased risk of major depression and generalized anxiety disorder. The present data for the BDI and the BAI indicate that married and older podiatric physicians scored significantly higher than the unmarried and younger age groups and also correlated with the total scores for the BDI and the BAI. These results are consistent with previous findings showing anxiety and depression to be highly correlated.43 Anxiety and depression disorders are common in the general population, with evidence of a decline in prevalence with increased age.44 When age is considered, most studies have found that depression has a higher prevalence in women from young adulthood to the mid-50s who are unmarried, separated, or divorced.45 The present study has several limitations. First, the survey response rate was moderate. Second, there may have been a selection bias favoring podiatrists who had pain from musculoskeletal disorders, dissatisfaction at work, or any kind of psychological problem. A third limitation is the nature of the sample population. It is better to obtain data from a completely random sample; however, we believe that the sample represented a diverse population of podiatric physicians that was adequate. The final limitation is an absence of other related studies involving a podiatric medical population. Thus, we cannot compare these findings with those of previous research; however, the results of this study can help increase knowledge about the topics addressed and how they affect the podiatric medicine profession. Future research should include other variables, such as stress, and should involve a larger sample of young podiatric physi-
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cians to more accurately measure the impact of all of the variables. 11.
Conclusions The levels of pain intensity, job dissatisfaction, anxiety, and depression found in this study, particularly among young single women, underline the need for a variety of strategies to reduce risks posed by podiatric medical work, thus, avoiding psychological and physical consequences. Further research is needed to identify risk factors in podiatric medical practice and to develop methods to minimize risk. Moreover, research is needed on these topics in other countries and occupational settings to shed more light on, and possibly confirm, these findings.
12.
13. 14.
15.
16.
Financial Disclosure: None reported. Conflict of Interest: None reported. 17.
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