Determinants Stress among Civil Servants of the Ministry of Health Republic of Indonesia

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1 Available online at GlobalIlluminators Full Paper Proceeding ITMAR-2014, Vol. 1, FULL PAPER PROCEEDING Multidisciplinary Studies ISBN: ITMAR-14 Determinants Stress among Civil Servants of the Ministry of Health Republic of Indonesia Besral 1 and Winne Widiantini 2 1 University of Indonesia Jakarta, 2 Ministry of Health Republic of Indonesia - Jakarta Abstract This study aimed to determine the prevalence of stress and determinant of stress among Civil Servants of the Ministry of Health of Republic of Indonesia in This cross-sectional study was conducted on 230 respondents that was selected randomly. The measurement of stress was using a questionnaire with 17 items modified from Hamilton Anxiety Rating Scale (HARS). It indicates stress if score reaches 28 or more. Multiple logistic regression was used to determine determinant of stress. The results showed that very high level prevalence of stress among Civil Servants of the Ministry of Health Republic of Indonesia in 2013 was 79%. The multiple logistic regression showed that the risk of stress was higher among obese respondents with adjusted OR is 1.9 (95%CI= ), age group less than 40 years old with adjusted OR 2.1, tribe Sudanese with adjusted OR is 3.1 (95%CI= ), position staff with adjusted OR is 2.0 (95%CI= ), middle educational level (high school or diploma) with adjusted OR is 2.5 (95%CI= ), women who are lacking physical activity with adjusted OR is 8.2 (95%CI= ). Recommendations for Ministry of Health are performing activities such as public awareness about healthy lifestyles and the prevention of stress, as well as occasionally doing a gathering or outbound scene that can decrease stress, conducting regular exercise every Friday morning and using sports facilities (fitness center) to reduce obesity and stress The Authors. Published by Global Illuminators. This is an open access article under the CC BY-NC-ND license ( under responsibility of the Scientific & Review committee of MTAR Keywords: Stress, Obesity, Physical Activity, Ministry Of Health, Indonesia Introduction Stress is a condition of distress experienced by a person who is the impact of the psychosocial work environment and adverse environment (Brunner et al, 2007). Stress is an adjustment response mediated by individual differences and or psychological process that is a consequence of any action from the outside, environment, situations, or events that define the psychological and or physical demand excessive to someone. (Gibson, 1996) Stress can be defined as a threat to the physiological or psychological integrity of an individual, it could be real or just interpreted, that resulting in physiological and behavioral responses, it could be good or bad responses. In some Eastern cultures, stress has been viewed as an absence of inner peace. On the other hand, in some Western culture has viewed stress as a loss of control. Stress is the respondents' statements about the conditions outside and inside job factors that can disrupt the balance of psychological, physiological, and characterized by psychological symptoms, physical symptoms, and behavioral symptoms. *All correspondence related to this article should be directed to Besral 1 University of Indonesia Jakarta besral@yahoo.com 2014 The Authors. Published by Global Illuminators Publishing. This is an open access article under the CC BY-NC-ND license ( Peer-review under responsibility of the Scientific & Review committee of ITMAR-2014.

2 Stress response is associated with manifestations of various psychosomatic and psychiatric disorders. Hence, it is important to understand the underlying mechanisms that influence this association. Moreover, men and women tend to react differently with stress both psychologically and biologically. These differences also need to be studied in order to have a better understanding in the gender differences. Such an understanding would have a significant impact on our understanding about how civil servant health is set during their life and how health staff could promote healthy life style. Ministry of Health of the Republic of Indonesia (MOH RI) is one of the ministries that has the task to assist the President in conducting the affairs of government in the health sector. Employees at the MoH RI have often recommended to perform health checks to hospitals, but have never done study related on stress and it s determinant. The objective of this study was to describe the magnitude of stress and determinants of stress among civil servants at the Ministry of Health Republic of Indonesia Jakarta. Method This research is a quantitative analytical approach using a cross-sectional survey design, the measurement of the dependent variable stress and their determinant variables is done at the same time. This study was conducted in May-June, The population in this study were all civil servants Secretariat General of the Ministry of Health, whose status has been a Civil Servant (PNS) as many as 1,119 employees. Inclusion criteria were an employee who has been a civil servant for at least two years and exclusion criteria are employees who have physical problems (illness or disability), as well as employees who are pregnant. Minimum sample size was computed using formula based on hypothesis testing two different proportions (Lemeshow, 1991), using a significance level of 5% and a power of test is 90%, the minimum required sample was 210 respondents. The sample was selected in this study were 230 respondents that randomly selected by systematically. Data collection, measurement of stress, measurement of nutritional status, and interviews about physical activity performed by 2 (two) health workers who are already trained. The study uses a structured questionnaire measuring of psychological concept that have been well-publicized in the stress literature. The stress experienced by the respondents has been measured using a well-designed pretested scale that is Personal Stress Inventory which is modified from Hamilton Anxiety Rating Scale, using a 17 item questions. Interview process was conducted by the health workers that has been trained for this study. The responses on the scale was given using a three-point Likert-modified type scale ranging from "Never", sometimes, and "Always". The codes 1, 2, 3 were assigned to all the negative statements which indicate the stress, whereas the positive statements were coded reversely. The respondent remind stress if the total score rich 28 or higher. Measures used to determine a person suffering from obesity is based on body weight and height, using an index based on the weight in kilograms divided by height in meter square, which is called the Body Mass Index (BMI). BMI is a simple and easy measurement to monitor the nutritional status of adults aged 18 years or more. BMI cut-off points had been modified by the Indonesian Ministry of Health, based on clinical experience and research in developing countries. BMI categories for Indonesia are as follows: 1) Underweight (BMI <18.5); 2) Normal (IMT18,5-25,0); 3) Obese or overweight (> 25.0).Weight measurements 114

3 performed with a digital scale to the nearest 0.1 kg and height measurements using a tape measure to the nearest 0.1 cm. Measurement of daily physical activity undertaken by respondents answering the Baecke questionnaire. Multiple logistic regression was used to determine determinant of stress adjusted for respondents characteristics and other potential confounding variables. Results Table 1 shows the personal inventory stress probe 17 parameters, the big problems related stress among among civil servants at the Ministry of Health Republic of Indonesia were they have not regular diet (85%), they feel tired (78%), they have a fight with their partner (72%), the have insomnia or frequent waking sleep time (69%), they feel tense or uncomfortable (68%), they feel stiff and sore (63%), they feel weak, tired, or lethargic (63%), and they made a lot of mistakes in the work (62%). Table 1. Personal Inventory Stress among Civil Servants in the Ministry of Health Republic of Indonesia year 2013 (n=230) No Personal Inventory Stress Answering Yes (%) 1 My diet is not regular I feel tired I fight with my partner I am insomnia or frequent waking sleep time I feel tense or uncomfortable I feel stiff and sore that I can not describe clearly I feel weak, tired, lethargic for no apparent reason I made a lot of mistakes in the work I feel slow finish the job I am having problems at work Everything is running as it should (% no) The quality of my work is less well I fight with my friends I fight with my family members I was not able to finish my work I have a good sense of humor (% no) I feel happy (% no) 36.5 Another issue which is rise in this study was happiness. Most of the respondents feel happy, only 36% reported their feel not happy. Half of the respondents reported have a good sense of humor, and able to finished their work. In contrast, half of the respondents have a fight with their friends or have a fight with their family members. 115

4 Using cut off point score 28 or higher as stress, the results showed that 79% of 230 respondents civil servants in the Ministry of Health of Republic of Indonesia in year 2013 having stress (Table 2). Table 2: The Prevalence of Stress among Civil Servants in the Ministry of Health Republic of Indonesia year 2013 Stress n % No (score <28) % Yes (score >=28) % Total The socio-demographic respondents shows that most of the respondent was aged years old (72%), male respondents was higher (54%) than female, undergraduate school (46%) was higher than graduate school, tribe Javanese is the highest group (53%), most of their position is staff or structural (89%). As much as 48% of respondents was obese and 36% have a medium physical activities. Being obese is a risk factor for the occurrence of stress, the risk of stress in the obese group was higher than non-obese group. The prevalence of stress among obese group reached 82%, whereas in the non-obese group only 75%. Once controlled by other variables in the multivariate logistic regression analysis, it was found that the obese group had almost twice the risk of experiencing stress than non-obese (adjusted OR 1.9). The prevalence of stress varies by age group, the younger the age the higher the risk of stress. The prevalence of stress in the age group below 31 years to reach 83%, among the age of years to reach 81%, among the age of years was 77%, and among the 51 years old or more only 74% prevalence of stress. Once controlled by other variables in the multivariate logistic regression analysis, it was found that the age group of 40 years old or less had a two times greater risk (adjusted OR 2.1) to experience stress as compared to the age group of 50 years old or more. The prevalence of stress differ by sex group, women have a higher prevalence of stress than men. The prevalence of stress in women reaches 81%, whereas in males the prevalence of stress is only 77%. Once controlled by other variables in the multivariate logistic regression analysis, it was found that women had a 1.2 times greater risk for experiencing stress compared with men. This relationship was not statistically significant since crude analysis was not control yet for the confounding variables, hence further analysis showed that the effect of gender on the stress differs according to physical activity, or there is an interaction between the sexes with physical activity in the risk of developing stress. Table 3: The Determinant Stress among Civil Servants in the Ministry of Health Republic of Indonesia year 2013: Crude and Adjusted Odds Ratio* Norma l Stress Tota l (n=92) (n=138) n % Obese No Tota l crudeor 95%CI adjor 95%CI 116

5 Yes Age <=30 years old years old years old years old Sex Male Female Position Supporting Staff /Structural Educational level High school Diploma Undergraduate Graduate Race Others Javanese Sundanese Betawi Physical activity Low Moderate High *Adjusted OR was controlled for demographic characteristic and all potential confounders (age, sex, education, obesity, position, race, and physical activity) The prevalence of stress also differ according to the position, the prevalence of stress was higher among structural than supporting staff. The prevalence of stress among structural reaches 80%, whereas the prevalence of stress among supporting staff is only 68%. Once controlled by other variables in the multivariate logistic regression analysis, it was found that the staff or structurally officials have 2.3 times greater risk for developing stress as compared to supporting staff. The prevalence of stress vary according to level of education, the lower the level of education the higher the risk of stress. The prevalence of stress among high school group reached 81%, among the diploma was 86%, among the undergraduate school was 80%, and among the graduate school was only 67% prevalence of stress. After controlled by other variables in the multivariate logistic regression analysis, it was found that a group of high school or diploma have a risk respectively 2.8 and 2.4 times more likely to experience stress as compared to a group of graduate school education. The prevalence of stress also differ by race or ethnicity, race Sundanese are at greater risk for experiencing stress. The prevalence of stress among Sundanese reached 91%, whereas in other parts of stress events is only about 74% to 78%. Once controlled by other variables in the multivariate logistic regression analysis, it was found that the Sundanese 117

6 ethnic group has 3 times greater risk for experiencing stress than Betawi or Other ethnic group. The prevalence of stress also varies according to the level of physical activity, the lower the level of physical activity the higher the risk of stress. The prevalence of stress in mild physical activity group reached 90%, among the group of moderate physical activity was 74%, and among heavy physical activity group was only 73% of stressful events. Once controlled by other variables in the multivariate logistic regression analysis, it was found that mild physical activity group has a 3.6 times greater risk for experiencing stress as compared to the heavy physical activity. Table 4. The Risk of Stress among Female according to physical activity The Risk of Stress among Female as compared to Male Physical activity index OR adj 95%CI Mild Moderate Heavy Table 4 showed the Risk of Stress among Female as compared to Male that stratified by physical activity index. It shows that the Female with mild or lacking physical activity were eight times higher risk to develop stress as compared to male respondents. If the female have a moderate or high physical activities, the risk of stress almost the same as male respondents. Discussion This results shows that very high prevalence of stress among Civil Servants in the Ministry of Health Republic of Indonesia year 2013 as compared to other research in Indonesia (Ministry of Health RI, 20013). We used the modified Hamilton Anxiety Scale to measure stress because Maier et al (1988) suggested that the applicability of the Hamilton Anxiety Scale in anxiolytic treatment studies is therefore limited and more specific anxiety scales are needed to develop. High prevalence of stress could impact on health status. Schneiderman (2005) stated that stress have a major influence on mood, on our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the longterm effects of stressors can damage health. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases. The prevalence of stress was vary according to demographic characteristics of age, sex, and educational level. The same results was reported by Nhundu and Tichatonga (1999) which assessing the occupational stress in teaching by investigating the sources, prevalence and intensity of administrative stress among head teachers in Zimbabwe. The results of a survey of a sample of 95 head teachers showed that the sample experienced relatively high levels of administrative stress compared with previous findings. In addition, the study revealed several demographic characteristics and school variables which influenced the stress. 118

7 A high prevalence of stress, excessive workload and long hours may increase risks of health problems, lead to reduced productivity, and impact significantly on the performance of Ministry of Health and the community as a whole. The prevalence of stress in head teachers in West Sussex is significantly increased compared to recent studies of workers in the UK. The recurring theme in existing studies of workload as a main stressor is confirmed in the findings of this study. Gender and type of school does affect outcome and female head teachers have more reported stressors than their male colleagues (Sen D and McNamee R, 2007). The results of this study was the same as research reported by Ireton, LaFond, and Kunian (1989) who conducted research on personal stress inventory in the screening and evaluation of family practice patients. They found that About 15% of these patients were seriously concerned about their marriages, sexual problems or personal habits (eating, drinking, smoking, rest, exercise). Moderately high levels of stress and anxiety were reported. Patients with psychological symptoms showed the highest levels of stress, anxiety, depression, anger, and confusion and the lowest levels of emotional support and coping skills. Psychosomatic patients reported more depression, anger, and confusion and less emotional support than their physically ill counterparts. The individual brings certain characteristics to work and these individual characteristics determine how the individual will respond to stress. An individual s perception of stress is influenced by factors including personality characteristics, personality types, social support, gender, age, sense of self-esteem, and sense of self-efficacy (Harris and Hartman, 2002). Consequently responses to potentially stressful situations may vary greatly from person to person and will depend on the complex interaction between their personality, values, skills and the relevant conditions (Ngidi and Sibaya, 2002) Stress response is associated with manifestations of various psychosomatic and psychiatric disorders. Hence, it is important to understand the underlying mechanisms that influence this association. Moreover, men and women tend to react differently with stress both psychologically and biologically. This study shows that women with low or lacking physical activity were eight times higher to develop stress as compared to male respondents. If women have a moderate or high physical activities, the risk of stress almost the same as man respondents. These differences also need to be explored in order to have a better understanding. Such an understanding would have a significant impact on our understanding about how stress could be prevented in men and women. De Vogli (2003) reported that risky behaviors tended to be interrelated with weak associations. A healthy lifestyle was less prevalent among those with lower social class even controlling for demographic and other socioeconomic factors. The association between social class and health behaviors was neither linier nor consistent across all health behaviors. Psychosocial stress partially mediated the focal relationship among the lowest social classes. Psychosocial stress varied in mediating the focal relationship according to the specific behavior and social class considered. The limited applicability of his findings on the social gradient of health behaviors and the mediating effect of psychosocial stress is surprising. This may be due to the macroeconomic context of the respondents by having a relatively low income inequality, a small percentage of people living below the poverty level. Palos and Viscu (2014) reported that psychological anxiety is positively correlated with automatic negative thoughts, while unconditional self-acceptance is negatively correlated with both psychological anxiety and somatic anxiety as well as with automatic negative thoughts. Intervention on these variables through support and counseling can lead to 119

8 reducing anxiety and stress, to altering the coping styles, and, implicitly, to improving the patients' quality of life. Mkumbo (2014) found that three factors have been identified as particularly associated with work stress among academic staff. These are lack of staff involvement in institutional reform processes, lack of necessary support systems related to their work and high workload levels. Highly qualified and experienced staff reported lower levels of stress than staff with low qualifications and less experienced. These results indicate that work stress is a common phenomenon among both education institution and ministry of health institution. Conclusion The results showed that the higher prevalence of stress omong Civil Servants of the Ministry of Health Republic of Indonesia in 2013, it was 79%. The prevalence of stress was vary according to individual characteristics such as age, sex, race, educational level, obesity, and phisical activity. The multiple logistic regression confirmed that risk of stress was higher among obese respondents with adjusted OR is 1.9 (95%CI= ), age less than 40 years old as compared to age 51 years old and above with adjusted OR 2.1, tribe Sundanese with adjusted OR is 3.1 (95%CI= ), position as staff or structural with adjusted OR is 2.0 (95%CI= ), middle educational level (high school or diploma) as compared to graduate school with adjusted OR is 2.5 (95%CI= ), women who are lacking physical activity as compared to men with adjusted OR is 8.2 (95%CI= ). Recommendation Recommendations for Ministry of Health are performing activities such as public awareness about healthy lifestyles and the prevention of stress, as well as occasionally doing a gathering or outbound scene that can decrease stress, conducting regular exercise every Friday morning and using sports facilities (fitness center) to reduce obesity and stress among Civil Servant at the Ministry of Health Republic of Indonesia. More research needs to explore the determinants of the working environmental influence on stress. Better planned and designed interventions would help individuals deal more effectively with stress in their lives. References De Vogli, Roberto. De Vogli, R. (2003). Socioeconomic determinants of healthy lifestyles: does psychosocial stress matter?. UCLA. A Dissertation University of California at Los Angeles Proquest Dissertation and Theses. Harris, O. J. and S. J. Hartman Organizational behavior. New York: Best Business Books. Ireton HR, LaFond N, Kunian A. Personal stress inventory in the screening and evaluation of family practice patients. Fam Pract Res J Spring-Summer;8(2): PubMed PMID: Maier W, Buller R, Philipp M, Heuser I. The Hamilton Anxiety Scale:reliability, validity and sensitivity to change in anxiety and depressive disorders. J Affect Disord Jan- Feb;14(1):61-8. PubMed PMID:

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