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

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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

Table 1 Sociodemographic characteristics of the participants

Variables	n (%)	Job burnout¹		Depressive symptoms²		Sleep quality³
Variables	n (%)	Median (IQR)	P value	Median (IQR)	P value	Median (IQR)	P value
Total	421 (100)	22.0 (12.0-35.0)		33.0 (29.0-40.0)		5.0 (3.0-7.0)
Gender
Male	163 (38.7)	22.0 (12.0-34.0)	0.637	32.0 (29.0-39.0)	0.227	4.0 (3.0-6.0)	0.050
Female	258 (61.3)	22.5 (12.0-35.0)		34.0 (29.0-41.0)		5.0 (3.0-8.0)
Age, years
≤ 30	134 (31.8)	26.0 (16.8-36.0)	0.001^b	35.0 (30.8-41.0)	0.021^a	5.0 (3.0-8.0)	0.667
31-40	127 (30.2)	23.0 (14.0-35.0)		34.0 (29.0-40.0)		5.0 (3.0-7.0)
41-50	113 (26.8)	17.0 (8.0-30.0)		32.0 (28.0-38.0)		4.0 (3.0-7.0)
51-60	47 (11.2)	20.0 (9.0-38.0)		34.0 (30.0-42.0)		5.0 (3.0-8.0)
Marital status
Single	80 (19.0)	27.5 (15.3-39.8)	0.036^a	35.0 (29.3-40.8)	0.216	5.0 (3.0-8.0)	0.283
Married	327 (77.7)	21.0 (10.0-33.0)		33.0 (29.0-39.0)		5.0 (3.0-7.0)
Divorced	10 (2.4)	17.0 (10.8-70.3)		34.0 (27.8-50.3)		5.0 (2.8-8.3)
Widowed	4 (1.0)	34.5 (19.3-37.8)		41.0 (34.8-46.5)		7.0 (7.0-8.5)
Education
Junior high school	9 (2.1)	31.0 (9.5-36.0)	0.038^a	43.0 (28.0-46.5)		3.0 (2.5-5.5)	0.005^a
Highschool	72 (17.1)	17.0 (7.3-30.0)		33.0 (29.0-39.8)		4.0 (2.0-6.0)
Bachelor’s degree	306 (72.7)	24.0 (13.0-35.0)		33.5 (29.0-40.0)		5.0 (3.0-8.0)
Master’s degree or above	34 (8.0)	20.0 (11.8-40.3)		35.0 (30.5-40.3)		4.0 (3.0-8.0)
Working years
≤ 5	103 (24.5)	23.0 (16.0-36.0)	0.001^b	33.0 (30.0-39.0)	0.105	5.0 (3.0-7.0)	0.914
6-10	77 (18.3)	29.0 (16.0-37.0)		37.0 (30.0-42.0)		5.0 (3.0-8.0)
11-20	94 (22.3)	20.0 (12.0-32.5)		33.0 (29.0-40.0)		5.0 (3.0-7.3)
> 20	147 (34.9)	18.0 (9.0-32.0)		33.0 (28.0-38.0)		5.0 (3.0-7.0)
Monthly income, CNY
< 2000	23 (5.5)	33.0 (19.0-37.0)	0.120	38.0 (32.0-45.0)	0.003^b	5.0 (3.0-7.0)	0.171
2000-3000	97 (23.0)	21.0 (11.5-32.0)		33.0 (30.0-37.5)		4.0 (2.5-7.0)
3001-5000	218 (51.8)	23.5 (12.0-36.0)		34.0 (29.0-41.0)		5.0 (3.0-8.0)
> 5000	83 (19.7)	18.0 (10.0-32.0)		31.0 (27.0-37.0)		5.0 (3.0-7.0)

¹Job burnout is represented by the total burnout score.

²Depressive symptoms are represented by the Self-Rating Depression Scale.

³Sleep quality is represented by the Pittsburgh Sleep Quality Index.

^aP < 0.05.

^bP < 0.01.

Exchange rate: 1 USD = 7.27 CNY (as of April 2025). IQR: Interquartile range.

Full Size Table

Table 2 Spearman’s correlation coefficients of job burnout, depressive symptoms, and sleep quality

Variables	TBS	Qua	Lat	Dur	Med	Eff	Dis	Dys
Qua	0.310^b	1
Lat	0.219^b	0.565^b	1
Dur	0.126^b	0.370^b	0.270^b	1
Med	0.094	0.319^b	0.318^b	0.400^b	1
Eff	0.230^b	0.414^b	0.380^b	0.190^b	0.154^b	1
Dis	0.124^a	0.172^b	0.125^a	0.052	0.051	0.183 ^b	1
Dys	0.462^b	0.534^b	0.387^b	0.286^b	0.122^a	0.370^b	0.166^b	1
SDS	0.537^b	0.442^b	0.371^b	0.201^b	0.194^b	0.377^b	0.174^b	0.439^b

^aP < 0.05.

^bP < 0.01.

TBS: Total burnout score; Qua: Subjective sleep quality; Lat: Sleep latency; Dur: Sleep duration; Med: Use of sleep medication; Eff: Sleep efficiency; Dis: Sleep disturbance; Dys: Daytime dysfunction; SDS: Self-Rating Depression Scale.

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Table 3 Comparison of model fit indices between unconstrained and constrained (nested) models

Fit index	Unconstrained model	Constrained (nested) model¹	Acceptable fit range
χ² (df)	50.83 (17)	158.41 (23)	-
χ²/df	2.99	6.89	< 3
CFI	0.98	0.91	> 0.90
IFI	0.98	0.91	> 0.90
NFI	0.97	0.90	> 0.90
RMSEA	0.07	0.12	< 0.08
Δχ² (Δdf)	-	107.58 (6)	-

¹The constrained nested model constrained the paths from total burnout score to the seven PSQI components to be equal, whereas the unconstrained model allowed these paths to be estimated freely.

CFI: Comparative Fit Index; IFI: Incremental Fit Index; NFI: Normed Fit Index; RMSEA: Root Mean Square Error of Approximation.

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Table 4 Path coefficients of the unconstrained model

Independent variable		Dependent variable	Estimate (B)	SE	CR	P value
Total burnout score	→	Subjective sleep quality	0.050	0.007	7.315	< 0.001^c
Total burnout score	→	Sleep latency	0.043	0.008	5.630	< 0.001^c
Total burnout score	→	Sleep duration	0.029	0.006	5.235	< 0.001^c
Total burnout score	→	Use of sleep medication	0.017	0.006	2.754	0.006^b
Total burnout score	→	Sleep efficiency	0.029	0.005	6.259	< 0.001^c
Total burnout score	→	Sleep disturbance	0.012	0.004	3.009	0.003^b
Total burnout score	→	Daytime dysfunction	0.093	0.009	10.540	< 0.001^c
Subjective sleep quality	→	Depressive symptoms	1.580	0.551	2.867	0.004^b
Sleep latency	→	Depressive symptoms	1.047	0.444	2.357	0.018^a
Sleep duration	→	Depressive symptoms	-0.319	0.573	-0.557	0.578
Use of sleep medication	→	Depressive symptoms	0.691	0.509	1.359	0.174
Sleep efficiency	→	Depressive symptoms	2.359	0.649	3.633	< 0.001^c
Sleep disturbance	→	Depressive symptoms	0.740	0.688	1.074	0.283
Daytime dysfunction	→	Depressive symptoms	-0.016	0.433	-0.036	0.971

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

The arrow (→) represents a direct causal path from the independent variable to the dependent variable. CR: Critical ratio.

Full Size Table

Table 5 The indirect association of sleep quality in the relationship between job burnout and depressive symptoms

Pathway	Estimate (B)	Lower 95%CI	Upper 95%CI	P value	% mediated
Total effect	0.792	0.638	0.950	< 0.001^c	-
Direct effect	0.589	0.418	0.768	< 0.001^c	-
Total indirect effect	0.203	0.110	0.318	< 0.001^c	25.631
Subjective sleep quality	0.079	0.029	0.147	0.003^b	-
Sleep latency	0.045	0.008	0.099	0.015^a	-
Sleep duration	-0.009	-0.049	0.023	0.575	-
Use of sleep medication	0.012	-0.003	0.040	0.120	-
Sleep efficiency	0.069	0.028	0.133	0.001^b	-
Sleep Disturbance	0.009	-0.004	0.035	0.181	-
Daytime dysfunction	-0.001	-0.091	0.082	0.931	-

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

% Mediated: Proportion of the indirect effect relative to the total effect; CI: Confidence interval.

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Citation: Nan L, Wang Y, Wareesawetsuwan N, Sanan M, Zhao XF, Yang L, Zhu WL. Association between job burnout and depressive symptoms in rural primary healthcare workers: The indirect role of sleep quality. World J Psychiatry 2026; 16(10): 122230
URL: https://www.wjgnet.com/2220-3206/full/v16/i10/122230.htm
DOI: https://dx.doi.org/10.5498/wjp.122230

Nan L, Wang Y, Wareesawetsuwan N, Sanan M, Zhao XF, Yang L, Zhu WL. Association between job burnout and depressive symptoms in rural primary healthcare workers: The indirect role of sleep quality. World J Psychiatry 2026; 16(10): 122230 [DOI: 10.5498/wjp.122230]

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