Association between job burnout and depressive symptoms in rural primary healthcare workers: The indirect role of sleep quality

doi:10.5498/wjp.122230

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World Journal of Psychiatry

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2220-3206

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Observational Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Psychiatry. Oct 19, 2026; 16(10): 122230
Published online Oct 19, 2026. doi: 10.5498/wjp.122230

Association between job burnout and depressive symptoms in rural primary healthcare workers: The indirect role of sleep quality

Lian Nan, Ye Wang, Nicha Wareesawetsuwan, Muhammad Sanan, Xiao-Feng Zhao, Lei Yang, Wen-Li Zhu

Lian Nan, Muhammad Sanan, Xiao-Feng Zhao, Lei Yang, Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China

Ye Wang, Department of Psychiatry, Shenyang Mental Health Center, Shenyang 110000, Liaoning Province, China

Nicha Wareesawetsuwan, Department of Medicine Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02108, United States

Wen-Li Zhu, Department of Psychiatry, The Fourth People’s Hospital of Wuhu, Wuhu 241002, Anhui Province, China

Co-corresponding authors: Lei Yang and Wen-Li Zhu.

Author contributions: Nan L contributed to conceptualization, study design, project coordination, data interpretation, supervision, and drafting of the original manuscript; Wang Y contributed to data collection, data curation, preliminary analysis, and manuscript revision; Wareesawetsuwan N contributed to manuscript review, editing, and critical revision for important intellectual content; Sanan M contributed to data analysis, data interpretation, and manuscript revision; Zhao XF contributed to data acquisition, investigation, and data verification; Yang L contributed to data acquisition, statistical support, and data interpretation; Zhu WL contributed to study supervision, project administration, data interpretation, and critical revision of the manuscript. All authors read and approved the final manuscript. Yang L and Zhu WL were designated as co-corresponding authors because they made complementary and substantial contributions to the study and share responsibility for its integrity and communication. Yang L contributed significantly to data acquisition, statistical support, interpretation of the results, and coordination of issues related to the dataset and analytical methods. Zhu WL provided overall study supervision, project administration, interpretation of the findings, and critical revision of the manuscript for important intellectual content. Their respective expertise enables them to respond appropriately to questions concerning both the methodological and administrative aspects of the study. In addition, they represent the principal institutions involved in conducting and supervising the research. Both authors approved the final version of the manuscript and agreed to share responsibility for correspondence with the journal, responses to reviewers, provision of study materials, and any questions arising after publication. Therefore, co-corresponding authorship accurately reflects their shared leadership, accountability, and continuing responsibility for this work.

AI contribution statement: During the preparation of this manuscript, artificial intelligence assisted tool (Chatgpt) was used only for language polishing and grammar improvement. The authors reviewed, edited, and approved all AI assisted content and take full responsibility for the accuracy, integrity, and originality of the manuscript.

Supported by Anhui Province Clinical Medical Research Transformation Special Project, No. 2022-04295107020065, No. 2022-04295107020006, and No. 2022-04295107020028; and Henan Province Science and Technology Research and Development Program, No. 242102311050.

Institutional review board statement: This study was approved by the Institutional Review Board of the Ethical Committee of the Fourth People's Hospital of Wuhu, No.[2023]-KY-18.

Informed consent statement: The requirement for written informed consent was waived by the Institutional Review Board of the Ethical Committee of the Fourth People's Hospital of Wuhu because this was an anonymous questionnaire based observational study involving minimal risk. Participation was voluntary, and completion of the questionnaire was considered implied informed consent.

Conflict-of-interest statement: The authors declare that they have no conflicts of interest.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Corresponding author: Lei Yang, MD, PhD, Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou 450000, Henan Province, China. 355280249@qq.com

Received: April 16, 2026
Revised: May 28, 2026
Accepted: August 25, 2026
Published online: October 19, 2026
Processing time: 180 Days and 7.2 Hours

Abstract

BACKGROUND

Primary healthcare workers (PHWs) in township health centers are the backbone of rural healthcare in China. High rates of job burnout and depression among PHWs adversely affect patient care quality and increase turnover, contributing to the persistent shortage of PHWs. Although job burnout is a recognized risk factor for depression, the underlying mechanisms are not fully understood.

AIM

To examine the association between job burnout, depressive symptoms, and sleep quality among PHWs, and to explore whether sleep quality may partly explain the association between job burnout and depressive symptoms.

METHODS

A cross-sectional study was conducted between January and September 2023 among PHWs working in township health centers in Anhui Province, China. A total of 450 self-administered questionnaires were distributed, collecting data on sociodemographic characteristics, job burnout (using the Maslach Burnout Inventory), depressive symptoms (using the Self-Rating Depression Scale), and sleep quality (using the Pittsburgh Sleep Quality Index). Descriptive statistics, Spearman correlation analysis, structural equation modeling, and the bootstrap method were employed.

RESULTS

A total of 421 valid responses were collected, with an effective response rate of 93.6%. The mean age of participants was 37.7 ± 10.1 years, and 61.3% were female. Job burnout, depressive symptoms, and most components of sleep quality were significantly positively correlated. In the exploratory mediation model, job burnout showed a significant total association with depressive symptoms, B = 0.792 [95% confidence interval (CI): 0.638-0.950]. After accounting for sleep quality, the direct association between job burnout and depressive symptoms remained significant, B = 0.589 (95%CI: 0.418-0.768). Sleep quality showed a significant indirect association in the relationship between job burnout and depressive symptoms, B = 0.203 (95%CI: 0.110-0.318), accounting for 25.6% of the total association.

CONCLUSION

Sleep quality may partly explain the association between job burnout and depressive symptoms among PHWs. These findings underscore the need for strategies that address sleep quality and job burnout to help reduce depressive symptoms among PHWs, although causal inference cannot be made due to the cross-sectional design.

Keywords: Depressive symptoms; Job burnout; Sleep quality; Primary healthcare workers; Rural areas

Core Tip: This cross-sectional study among rural primary healthcare workers demonstrates that sleep quality partially mediates the relationship between job burnout and depressive symptoms, accounting for 25.6% of the total effect. These findings highlight sleep disturbance as a modifiable pathway linking occupational stress to depression. Targeting sleep quality may offer a practical and scalable strategy to reduce depressive symptoms and improve workforce retention in resource-limited primary care settings.