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Chronic fatigue syndrome among nurses and healthcare workers in a research hospital in Turkey.

Chronic fatigue syndrome (CFS) among nurses and healthcare workers was evaluated via a questionnaire examining CFS, sociodemographic factors, lifestyle, work capacity and education. The criteria of the Centers for Disease Control were applied. One hundred and eighty-three nurses and 18 healthcare workers (mean age 29.04 [+ or -] 5.31 years) participated. More than half of cases (n = 116, 57.7%) complained of fatigue. Thirty-six cases (17.9%) fully matched the criteria of the CDC for CFS. High income level (> $400/month) (p = 0.005) and overworking (> 8 hr/day) (p = 0.017) had a significant effect on CFS [high income (OR: 9.60, CI, 95%: 1.98 - 46.54) and overworking (OR: 7.66, CI, 95%: 1.44 - 40.92), respectively]. CFS was also related to being under 35 years old.

Keywords: chronic fatigue syndrome, stress, workload, health occupations, health personnel, Turkey.

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Fatigue among the working population is well recognized and its prevalence is estimated to be 22% (Bultmann, Kant, Kasl, Beurskens, & Van Den Brandt, 2002). The experience of fatigue can vary widely, from mild complaints of fatigue to severe, persisting, disabling fatigue disorders such as chronic fatigue syndrome (CFS) (Bultmann et al.). CFS is an exhausting and complex disease characterized by the presence of at least four of the following criteria: red throat, insufficient memory or concentration, tender lymph nodes, myalgia, arthralgia, headache, sleep disturbance, fever and muscle weakness. These symptoms accompany deep fatigue, remain present for at least six months and do not improve with bed rest. The reported prevalence ranges from 0.006% to 3.0% in the general adult population (Atari & Buchwald, 2003).

Fatigue in the working population has been the subject of growing interest because of its high prevalence and the adverse consequences of severe fatigue (Lewis & Wessely, 1992). Considering professional stress factors, nursing is a profession with a high risk for physical disease (Wagner & Jason, 1997) but the level of impact of stress on CFS needs to be investigated.

The aim of this study was to estimate the frequency of CFS in nurses and healthcare workers in a university hospital and to look for any relationship with sociodemographic factors, lifestyle, working status and educational level.

METHOD

This cross-sectional study was conducted in the Research Hospital of Dicle University, Diyarbakir, Turkey. The study was approved by the Dicle University Ethics Committee. A total of 201 respondents (183 nurses and 18 healthcare workers) participated in this study from March 1st to April 28th, 2006. The questionnaire included open-ended and multiple-choice questions about CFS, sociodemographic factors, lifestyle, working status and education. Four researchers (two medical doctors and two nurses) from Dicle University used the questionnaire to conduct face-to-face interviews with participants.

The CFS criteria defined by the Centers for Disease Control (CDC; National Center for Infectious Diseases, 2006) and the Hamilton Depression Rating Scale (HAM-D) (Turkish version: Akdemir et al., 2001) with 17 items were included in the interview. HAM-D scores range from 0 to 52, with higher scores indicating higher levels of depression. The cut off point for clinical depression is assessed as 16 when using this scale.

Participants were divided into CFS and non-CFS groups, and evaluated by gender (male, female), age ([less than or equal to] 35, > 35), BMI (kg/[m.sup.2]) ([less than or equal to] 25, > 25), educational level (high school vs. university graduate), marital status (single, married, divorced or widowed), income (low ([less than or equal to] $400/month), high (> $400/month)), working time ([less than or equal to] 8, > 8 hours/day), working place (intensive care, regular service), night shift (Yes, No), total years of work (< 15, [greater than or equal to] 15), status of employment (nurse, healthcare worker), social life (sufficient, insufficient) and status of habits (alcohol and smoking).

Data were analyzed using SPSS version 11.0 (SPSS Inc). Analyses included descriptive statistic, one-way ANOVA (Post-hoc bonferroni), chi-square (Fisher's exact) and logistic regression. Level of significance was set at p = 0.05.

RESULTS

Participants had the following characteristics (Table 1). A total of 116 (57.7%) participants complained of fatigue. The group (n = 36, 17.9%) which fully matched the criteria for CFS was named the CFS group, with the remaining participants becoming the non-CFS group (n = 165). Prolonged or idiopathic fatigue was evident in 35 (17.4%) and 45 (22.4%) had a chronic condition: major depression (24, 11.9%), obesity (9, 4.5%), diabetes (4, 2.0%), hepatitis (4, 2.0%), cancer (2, 1.0%), hypothyroidism (2, 1.0%) or an autoimmune disease (1, 0.5%). In terms of minor depression the non-CFS group (34, 20.6%) outnumbered the CFS group (14, 38.9%) (p = 0.020).

The comparison of sociodemographic factors, lifestyle, working status and education in CFS and non-CFS groups revealed statistically significant differences in only income (p = 0.017), working duration (p = 0.033), and being under 35 years old (p = 0.05). The logistic regression analysis showed high income status of more than $400/month (p = 0.005) and working more than 8 hours a day (p = 0.017) as having a significant impact on CFS (high income status OR: 9.60, CI, 95%: 1.98-46.54 and working over 8 hours a day OR: 7.66, CI, 95%: 1.44-40.92, respectively).

The leading signs and symptoms in respondents with CFS versus non-CFS were unusual fatigue (100% vs. 48.5%, p < 0.0001), myalgia (77.8% vs. 38.8%,p < 0.0001), arthralgia (75.0% vs. 40.6%,p < 0.0001), sleep disturbance (75.0% vs. 46.1%,p < 0.0001), neurocognitive complaints (61.1% vs. 26.1%, p < 0.0001), sudden onset headache (61.1% vs. 35.2%, p < 0.0001), sore throat (44.4% vs. 24.8%, p < 0.017), muscle weakness (33.3% vs. 16.4%, p < 0.021), nausea (33.3% vs. 10.9%,p < 0.021), loss of weight (19.4% vs. 5.5%,p < 0.011), lymph node tenderness (5.6% vs. 7.3%, p < 0.526) and fever and/or chills (2.8% vs. 6.7%, p < 0.327).

DISCUSSION

Although fatigue is frequently found in the general population, the fulfillment of CFS criteria is rare. Price, North, Wessely, and Fraser (1992) associated tiredness with a decrease in daily activities. In their study with a general population, Price and colleagues asked "Did you have a period of feeling tired for two weeks or more?" A total of 23% of the participants answered "Yes". However, just 13.3% of the participants emphasized an observable decrease in daily activities, and only 4.4% said they had felt tired and decreased their daily activities.

In a study by Taylor, Jason, and Jahn (2003), participants with chronic fatigue had higher rates of mood disorder than did controls (60% vs. 22%) and women suffered from it more than did men (55% vs. 39%). Our CFS-group showed results similar to other studies, showing high frequency of psychiatric disorders in individuals with unexplained chronic fatigue. Psychiatric diagnoses with chronic fatigue have been reported in 12.5%-72% of individuals (Hickie, Lloyd, Wakefield, & Parker, 1990; Taylor & Jason, 1998). Jason, Taylor et al. (1993), and Jason, Wagner et al. (1998) estimated a minimum prevalence of CFS of 324/100,000 among a sample of nurses in 1993 and later performed a mail questionnaire in the US which revealed a prevalence of CFS of 1088/100,000 nurses. The same group (Wagner-Raphael, Jason, & Ferrari, 1999) reported a relation between CFS symptoms and physical and social dysfunction and general pain. With increased fatigue, physical and social dysfunction and general pain were higher, and with lower fatigue an improvement in general health status was observed. Huibers et al. (2003) showed a link between unexplained persistent fatigue and CFS in employees. Commonalities could be seen in both clinical presentations and 44% of participants met CFS criteria. The "CFS-like employees" were found to have stronger somatic attributions. In our study, 57.7% of participants complained of fatigue and 17.9% fully matched the criteria for CFS. Two factors had significant effects on CFS (high income OR: 9.60, CI, 95%: 1.98-46.54 and overworking OR: 7.66, CI, 95%: 1.44-40.92).

Symptoms such as prolonged and debilitating fatigue are frequently encountered in daily family practice (10 to 25%). Even though most of these patients do not fulfill CFS criteria, they might have an underlying chronic health condition or a psychiatric condition (Sharpe, Archard, Banatvala, & Borysiewicz, 1991). This possibility is supported by our results; some respondents did not fulfill CFS criteria but they did exhibit symptoms of minor depression.

Limitations of our study were its cross-sectional nature, a relatively low number of participants and the single location of the research, which might limit generalizability. Broader epidemiological studies involving different centers, well distributed throughout the country, are recommended.

In conclusion, participants with CFS shared the following features: severe fatigue, social and functional impairment, and long duration of complaints. We believe that contributing factors for health professionals who are prone to CFS include stressful working conditions, long working hours, being younger than 35, and having high economic status.

REFERENCES

Afari, N., & Buchwald, D. (2003). Chronic fatigue syndrome: A review. American Journal of Psychiatry, 160, 221-236.

Akdemir, A., Turkcapar, M. G., Orsel, S. D., Demirergi, N., Dag, I., & Ozbay, M. H. (2001). Reliability and validity of the Turkish version of the Hamilton Depression Rating Scale. Comprehensive Psychiatry, 42(2), 161-165.

Bultmann, U., Kant, I. J., Kasl, S. V., Beurskens, A. J. H. M., & Van den Brandt, P. A. (2002). Fatigue and psychological distress in the working population: Psychometrics, prevalence and correlates. Journal of Psychosomatic Research, 52, 445-452.

Hickie, I., Lloyd, A., Wakefield, D., & Parker, G. (1990). The psychiatric status of patients with the chronic fatigue syndrome. British Journal of Psychiatry, 156, 534-540.

Huibers, M. J. H., Beurskens, A. J. H. M., Prins, J. B., Kant, I., Bazelmans, B., van Schayck, C. P., et al. (2003). Fatigue, burnout and chronic fatigue syndrome among employees on sick leave: Do attributions make the difference? Occupational and Environmental Medicine, 60, i26-i31.

Jason, L. A., Taylor, S. L., Johnson, S., Goldston, S. E., Salina, D., Bishop, P, et al. (1993). Prevalence of chronic fatigue syndrome-related symptoms among nurses. Evaluation and the Health Professions, 16, 385-399.

Jason, L. A., Wagner, L., Rosenthal, S., Goodlatte, J., Lipkin, D., Papernik, M., et al. (1998). Estimating the prevalence of Chronic Fatigue Syndrome among nurses. American Journal of Medicine, 105, 91S-93S.

Lewis, G., & Wessely, S. (1992). The epidemiology of fatigue: More questions than answers. Journal of Epidemiology and Community Health, 46, 92-97.

National Center for Infectious Diseases. (2006, October 11). Surveillance-Chronic Fatigue Syndrome program, Program Update, 2002-2003. Retrieved from: http://www.ede.gov/neidod/diseases/ efs/program-updates/efs-uptdate-031703.htm

Price, R. K., North, C. S., Wessely, S., & Fraser, V. J. (1992). Estimating the prevalence of chronic fatigue syndrome and associated symptoms in the community. Public Health Report, 107, 514-522.

Sharpe, M. C., Archard, L. C., Banatvala, J. E., Borysiewicz, L. K., Clare, A. W., David, A. S., et al. (1991). A report--Chronic Fatigue Syndrome: Guidelines for research. Journal of Royal Society Medicine, 84, 118-121.

Taylor, R. R., & Jason, L. A. (1998). Comparing the DIS with the SCID: Chronic fatigue syndrome and psychiatric comorbidity. Psychology Health, 13, 1087-1104.

Taylor, R. R., Jason, L. A., & Jahn, S. C. (2003). Chronic fatigue and sociodemographic characteristics as predictors of psychiatric disorders in a community-based sample. Psychosomatic Medicine, 65, 896-901.

Wagner, L. I., & Jason, L. A. (1997). Outcomes of occupational stressors on nurses: Chronic Fatigue Syndrome-related symptoms. Nursing Connections, 10, 41-49.

Wagner-Raphael, L. I., Jason, L. A., & Ferrari, J. R. (1994). Chronic Fatigue Syndrome, chronic fatigue, and psychiatric disorders: Predictors of functional status in a national nursing sample. Journal of Occupational Health Psychology, 4, 63-71.

ISMAIL HAMDI KARA, DOGAN DEMIR, OZGUR ERDEM, GULFER TOPCU SAYIN, AND NURAN YILDIZ

Dicle University, Diyarbakir, Turkey

HAKAN YAMAN

Akdeniz University, Antalya, Turkey

Ismail Hamdi Kara, Dogan Demir, and Ozgur Erdem, Department of Family Practice, Medical Faculty, Dicle University, Diyarbakir, Turkey; Gulfer Topcu Sayin, Nurse, and Nuran Yildiz, Ataturk Healthcare College, Dicle University, Diyarbakir, Turkey; Hakan Yaman, MD, MS, Associate Professor of Family Medicine, Department of Family Medicine, Faculty of Medicine, Akdeniz University, Antalya, Turkey.

This study has been supported by the Akdeniz University Scientific Research Project Unit. Appreciation is due to reviewers including: Prof Ilhami Unluoglu, MD, Medical Faculty, Family Medicine Department, Eskisehir Osmangazi University, 26480 Eskisehir, Turkey, Email: iunluog@yahoo.com

Please address correspondence and reprint requests to: Hakan Yaman MD, MS, Associate Professor, Department of Family Medicine, Faculty of Medicine, Akdeniz University, 07059 Antalya, Turkey. Phone: +90 242 249 68 63; Email: hakanyaman@akdeniz.edu.tr
TABLE 1
DISTRIBUTION OF DETERMINANTS ACCORDING TO CFS GROUP AND NON-CFS GROUP

                         CFS group          Non-CFS group
Determinants               n = 36               n=165            p

Age (years)          28.5 [+ or -] 3.8    29.2 [+ or -] 5.6    0.502
BMI (kg/[m.sup.2])   22.5 [+ or -] 2.7    22.7 [+ or -] 3.1    0.769
Working duration
  (years)             8.9 [+ or -] 5.2     9.4 [+ or -] 6.9    0.672
Duration of
  fatigue (months)   21.7 [+ or -] 18.1   13.8 [+ or -] 24.9   0.06
HAM-D                 3.8 [+ or -] 4.2     4.7 [+ or -] 6.4    0.301
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Article Details
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Author:Kara, Ismail Hamdi; Demir, Dogan; Erdem, Ozgur; Sayin, Gulfer Topcu; Yildiz, Nuran; Yaman, Hakan
Publication:Social Behavior and Personality: An International Journal
Article Type:Report
Geographic Code:7TURK
Date:Jun 1, 2008
Words:2196
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