Abstract
Aim
Professionals working at child advocacy centers (CACs) perform their duties under demanding professional, social, ethical, and legal conditions. This study aimed to compare job satisfaction, burnout, depressive symptoms, and dimensions of general psychiatric symptoms among CAC employees with those of a control group.
Methods
This cross-sectional study included 30 healthcare professionals working as forensic interviewers at five CACs in Türkiye and 30 healthcare professionals from the same occupational groups without CAC experience. Participants completed a structured socio-demographic questionnaire, the Symptom Checklist-90-Revised, the Beck Depression Inventory, and the Maslach Burnout Inventory. Data were collected between December 1 and December 10, 2018.
Results
Compared with controls, the Children’s Advocacy Center group had longer professional experience, lower job satisfaction, and higher depressive and overall psychiatric symptom scores, while burnout levels did not differ between groups.
Conclusion
Job satisfaction scores were found to be statistically significant predictors of depression scale scores, whereas age and length of service significantly affected burnout scale scores.
Introduction
Burnout was first introduced into the scientific literature in the 1970s by Freudenberger and Richelson (1). Recently, burnout has attracted increasing attention across various disciplines and is particularly prevalent in occupations involving intensive interpersonal interaction. Healthcare professionals are consistently among the groups most affected by burnout, a condition emerging as a prolonged response to chronic emotional and interpersonal stressors (2).
According to the World Health Organization’s ICD-11, burnout is defined as a syndrome resulting from chronic workplace stress that has not been successfully managed (3). Kristensen et al. (4) distinguished three dimensions of burnout: personal, work-related, and client-related. Research on employees in child protection units in the United States suggests that both work- and client-related burnout symptoms follow a curvilinear path over time, with job rotation providing a protective benefit during the first two years (5).
Burnout has adverse consequences for both employees and service recipients, being associated with chronic fatigue, sleep disturbances, impaired concentration, and psychological distress (6). Healthcare professionals experiencing burnout are more prone to depression, substance use, poor physical health, and even suicidal ideation (7). Furthermore, studies highlighting the alarmingly high prevalence of burnout among healthcare workers emphasize the importance of evaluating both individual coping strategies and interventions aimed at improving working conditions (8).
Child advocacy centers (CACs) represent stressful and demanding work environments where professionals are in direct contact with children exposed to trauma (9). Heavy workloads, staff shortages, secondary traumatic stress, legal pressures, and the severe psychological issues of children and families place substantial strain on these professionals, potentially leading to burnout and increased turnover intention (10).
We hypothesized that professionals working in CACs would exhibit higher levels of mental health problems, including burnout and depression, than their peers. This study aimed to compare burnout levels, job satisfaction, and psychiatric symptoms between CAC professionals and a control group and to examine socio-demographic factors to identify potential risk and protective factors.
Materials and Methods
Compliance with Ethical Standards
The study was conducted in accordance with the principles of the Declaration of Helsinki. The study was approved by the University of Health Sciences Türkiye, Antalya Training and Research Hospital Ethics Committee (approval number: 20/6, date: 12.09.2019).
Study Design and Setting
This cross-sectional comparative study was conducted between December 1 and December 10, 2018, at five CACs located in five provinces in Türkiye. These centers provide multidisciplinary medico-legal and psychosocial services to children suspected of being sexually abused.
The study population consisted of healthcare professionals who were actively working as forensic interviewers at five CACs in Türkiye at the time of data collection and had been in their current positions for at least six months. Forensic interviewers at CACs included social workers, nurses, child development specialists, psychologists, and midwives.
The study population consisted of healthcare professionals working as forensic interviewers at CACs, while the control group comprised professionals from the same occupational backgrounds who worked in other hospital departments and had no previous experience with CACs (Figure 1).
A total of 30 participants were included in each group. Participants were contacted either by direct on-site visits or by e-mail. All participants were informed about the study, and only those who volunteered and provided written informed consent were enrolled.
Physicians working at CACs were not included in the study because of different job roles, additional professional responsibilities, distinct motivational factors (such as other clinical duties and financial incentives), and exposure to different work-related stressors.
Background Information on the CACs: in Türkiye, CACs have become increasingly widespread and operate on a 24-hour on-call basis. Each center is staffed by specially trained professionals, including a physician responsible for coordination and trained healthcare personnel such as social workers, psychologists, child development specialists, and nurses. In 2011, the first CAC in Türkiye opened in Ankara. By September 2019, the number of CACs had reached 44 (11).
For the study planned in 2018, the article published by Oh and Lee (12) in 2009 was used as a reference, and a power analysis was conducted assuming an effect size of 0.5. With an alpha error probability of 0.05 and a power of 0.80, the total sample size was calculated to be 34.
Measures
A study-specific questionnaire, the Maslach Burnout Inventory (MBI), the Beck Depression Inventory (BDI), and the Symptom Checklist-90-Revised (SCL-90-R) were administered to assess burnout levels among professionals working in CACs and to identify variables associated with burnout.
Study-Specific Questionnaire: It comprised two sections. The first section included nine items, derived from the literature, to obtain socio-demographic information, including age, sex, profession, duration of professional experience, duration of work in the current unit or center, self-rated job satisfaction and happiness scores, and membership in professional organizations.
The second section consisted of 30 items designed to evaluate experiences related to working at CACs and perceptions of the centers and of referred cases. All items were developed specifically for this study to enable CACs’ staff to self-assess their working conditions and professional experiences. Responses were recorded using a three-point Likert-type scale. Because this section contained CACs-specific items, it was administered only to the study group.
The MBI consists of 22 items rated on a five-point Likert scale (six response options in the original version) and assesses burnout across three dimensions: emotional exhaustion (nine items), depersonalization (five items), and personal accomplishment (eight items). Unlike emotional exhaustion and depersonalization, the personal accomplishment subscale is reverse-scored. Higher scores on the emotional exhaustion and depersonalization subscales and lower scores on the personal accomplishment subscale indicate higher levels of burnout. No specific cut-off values are defined for the subscale scores (13, 14).
Beck Depression Inventory: The BDI is a 21-item self-report scale rated on a four-point Likert scale and used to assess the presence and severity of depressive symptoms. Total scores range from 0 to 63, and a cut-off score of 17 is commonly used to indicate clinically relevant depressive symptomatology (15, 16).
Symptom Checklist-90-Revised: The SCL-90-R is a 90-item self-report instrument developed to assess a broad range of psychological symptoms and distress. It can be used in both the general population and clinical settings. The scale gives scores for nine main symptom dimensions: somatization, obsessive-compulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. It also gives a global severity index that shows the overall severity of the symptoms (17, 18).
Procedure
After written informed consent was obtained, all participants completed the questionnaires and scales in a single session. Data collection was conducted over one week and completed on 10 December 2018. All data were collected anonymously, and no personally identifiable information was recorded.
Statistical Analysis
Data were analyzed using SPSS version 22.0 (Statistical Package for the Social Sciences). Categorical variables were compared using the chi-square test. The Shapiro-Wilk test was used to assess normality. For non-normally distributed continuous variables, the Mann-Whitney U test and Spearman’s correlation analysis were employed. For normally distributed data, independent samples t-tests and one-way analysis of variance with Tukey post-hoc tests were used. Additionally, multiple linear regression analysis was performed to identify independent predictors of burnout and depression scores. Statistical significance was set at p<0.05.
Results
Socio-demographic Data and Job Satisfaction
A total of 60 healthcare professionals were included in the study: 30 working at five CACs and 30 without CAC experience. The CACs group was older (38.76±9.03) and had longer (15.06±10.41) professional experience (p<0.05). Participants’ socio-demographic and professional characteristics are summarized in Table 1.
Job satisfaction scores were significantly lower in the CACs group compared with the control group (t=-3.68, p<0.05); professional association membership and non-professional hobbies did not differ between groups. Job satisfaction scores showed a significant negative correlation with BDI scores (r=-0.4, p<0.05), emotional exhaustion scores (r=-0.44, p<0.05), and SCL-90-R depression scores (r=-0.31, p<0.05) across all participants.
Evaluation of the Questionnaire Form
The CACs’ specific questionnaire was completed only by the CACs’ employees. Responses indicated high perceived importance of forensic and child psychiatric evaluations, high compatibility with colleagues, and a strong belief in the necessity and continuity of CACs. A considerable proportion of participants reported work-related stress and emphasized the negative impact of organizational deficiencies on their performance. The distribution of responses is shown in Table 2.
Responses to the questionnaire were analyzed by grouping CACs employees into psychologists, social workers, and other personnel. Multiple comparison tests revealed statistically significant differences in four items. Healthcare personnel working outside the psychologist and social worker groups were significantly more likely both to believe that cases of child abuse are increasing (χ2=11.74 , p<0.05) and to support the view that specially trained CACs personnel should assist physicians during forensic examinations (χ2=6.34 , p<0.05).
Regarding the statement, “The most appropriate social decision for our cases is made by the responsible Public Prosecutor,” social workers were significantly less likely to agree compared with other personnel (z=-2.4, p<0.05). Social workers were also more likely than other groups to support the opinion that “CAC staff should be renewed every three to four years” (z=-3.3, p<0.05).
Evaluation of Scale Scores
The median BDI score was significantly higher among CACs’ personnel than in the control group (p<0.05), whereas no statistically significant difference was found between the groups for mean MBI scores (p>0.05). In addition, the overall symptom median score on the SCL-90-R test and the median scores of the somatization, obsessive-compulsive, interpersonal sensitivity, depression, anger-hostility, and paranoid ideation subscales were statistically significantly higher in CACs’ employees than in controls (p<0.05). Comparisons of psychometric scale scores between groups are presented in Table 3.
In terms of socio-demographic variables, no significant effect on SCL-90-R scores was observed; however, the only parameter influencing the mean BDI score was the job satisfaction score. The group with the lowest job satisfaction had a significantly higher mean BDI score (F=7.85, p<0.05), and Tukey post-hoc analysis revealed a significant difference between the lowest and highest job satisfaction groups (p<0.05) (Table 4).
For the MBI, mean scores were affected by both professions and job satisfaction levels. Social workers had higher mean burnout scores than other professional groups (F=9.58, p<0.05). Similarly, job satisfaction scores influenced mean burnout scores in a manner comparable to that of the depression scale (F=5.89, p<0.05) (Table 5).
In the multiple regression model developed for the BDI, only the “job satisfaction score” emerged as a statistically significant predictor of total scale scores (p<0.05) (Table 6). Regarding the MBI, both age and length of professional experience had nearly equal, statistically significant impacts on burnout scores (p<0.05) (Table 7).
Discussion
Maslach et al. (13) emphasized that the primary determinants of burnout are the “areas of work life” and that burnout can be prevented only by systematically addressing and modifying these areas. These areas include workload, control, reward, community, fairness, and values. Time pressure also constitutes an important source of stress. Urgent medical examinations to prevent loss of forensic evidence, pressure related to detention or arrest decisions for alleged offenders, scheduling of forensic interviews and urgent placement of children into protective care represent major time-related stressors (19). Internal organizational factors, such as supervisor and colleague support, have been shown to reduce burnout (20). However, little is known about the impact of external organizational resources (e.g., therapists, advocates, police officers, and mental health professionals) on burnout. Some studies indicate that child abuse professionals who establish positive relationships with external professionals experience less frustration, feel less isolated, and are better able to fulfill their responsibilities, thereby potentially reducing burnout (21). There is broad consensus in the literature that professionals who work in the field of child neglect and abuse are at high-risk of burnout. However, more detailed studies are needed to better understand the specific challenges encountered in this field (22, 23).
Despite the specialized nature of this field, reduced job satisfaction and burnout have been identified as the main determinants of turnover among professionals working in CAC-like settings (2). Role conflict, role ambiguity and role overload, safety concerns, insufficient supervisory support, secondary traumatic experiences, and compassion fatigue have been reported as major risk factors affecting job satisfaction and burnout (2). Stressful working conditions may further increase vulnerability to depressive symptoms and substantially contribute to reduced job satisfaction and burnout (22). Burnout and job satisfaction are also reported to influence each other reciprocally (22), while individual characteristics and personal resilience may play either protective or vulnerability-enhancing roles (10, 22).
Depression is a multifactorial disorder resulting from interactions among genetic, developmental, and environmental factors. Burnout and reduced job satisfaction have been shown to be associated with depression and other mental disorders, with chronic psychosocial stress playing a central role in both conditions (24).
Individuals who are dissatisfied with their work and who cannot find a supportive organizational climate are more likely to experience marked declines in morale and motivation (25). Lower job satisfaction has been reported among professionals conducting abuse-related interviews in the literature (23, 26). In a study conducted among social workers employed in child protection services in the United Kingdom, role ambiguity and job satisfaction were identified as predictors of stress, while job satisfaction was suggested to be influenced by both perceived stress levels and role conflict (27). Consistent with the literature, the present study found that job satisfaction scores from the preliminary questionnaire were statistically significantly lower in CAC employees than in the control group. One possible explanation for this finding is longer professional experience among healthcare workers in the CAC group compared with controls. Although longer professional experience may increase competence and expertise, it may also lead to reduced motivational resources over time (28). Although no CAC-specific studies are available, findings regarding the relationship between age and job satisfaction in the literature are contradictory (29). In our study, no statistically significant difference in job satisfaction was found among age groups (p>0.05).
Moral distress and secondary traumatic stress may contribute to this situation, and workplace peer relationships should be considered. A study conducted among social workers working in child protection services in the United Kingdom reported that participants associated workplace friendships with a continuously increasing sense of well-being, higher job satisfaction, reduced stress, and a greater intention to remain in their roles (30). Furthermore, several studies have reported that individual factors such as higher educational level, specific work environments, and self-efficacy are positively correlated with job satisfaction (31). The literature also includes studies emphasizing the importance of strengthening employee well-being as a strong predictor of job satisfaction and positive work attitudes among social workers (32, 33).
In Türkiye, the lack of sufficiently developed regulations concerning CAC and the absence of a formal directive defining the division of duties among staff may contribute to decreased job satisfaction, since such legal uncertainties can limit the legal empowerment of professionals working under such conditions. Finally, previous studies have highlighted that job satisfaction plays an important role in maintaining psychological well-being and functional mental health (26).
In the present study, internal organizational factors other than colleague compatibility (93%) were not examined. Among external organizational factors, only perceptions regarding mental health professionals and legal professionals were assessed. Participants reported a very high level of belief in the importance of child psychiatry reports (97%), which may indirectly reflect trust in positive collaboration with these professionals. Healthcare personnel outside the psychologist and social worker groups were statistically more likely to believe that cases of child abuse are increasing and to support the view that specially trained CAC personnel should assist physicians during forensic examinations. However, compared with other personnel, social workers were more likely to support renewing CAC staff every three to four years while being less likely to endorse the view that the best social decisions for children should be made by public prosecutors. We consider that the difference between social workers (who are familiar with the field and receive specialized training prior to working at CACs and other personnel may be related to differences in training. Employing personnel who are not psychologists or social workers and who lack field-specific training may undermine workplace harmony, perceived social support, and the ability to cope with secondary traumatization.
No significant difference in burnout levels was observed between the study and control groups. This finding appears to be largely inconsistent with the existing literature, as higher burnout levels among professionals working with child abuse cases have been consistently reported (22). However, this result may be partly explained by the fact that during the study period CACs were established in relatively newer buildings compared with many hospitals (the oldest CAC had been in operation for only 7-8 years) and that the control group also consisted of healthcare professionals. Burnout syndrome among healthcare workers has been reported to be primarily characterized by frustration and depersonalization (34). In the regression model developed in our study, age and professional seniority were identified as the two most important parameters influencing the burnout scale. Although not statistically significant, a decrease in the mean scores of the MBI was observed as age increased, which is consistent with other studies conducted among healthcare workers in Türkiye (35, 36).
While most studies in the literature emphasize the change in burnout over time, they propose different perspectives regarding the trajectory of this change (37). According to the accumulation model, a continuous positive correlation develops between professional seniority and burnout over time. In contrast, the “onset effect” model suggests that burnout increases as employees adapt to their positions but decreases and returns to baseline levels once they become accustomed to the role (38, 39). These components are known to develop over time, and the mean duration of employment at CACs among participants in our study was 3.50±1.88 years. In another study, the peak period for workplace burnout was reported to be between 12 and 24 months (5). Considering that the average duration of employment in our study was well above this period and that change is more common than stability, the timing of the measurement point may not have been optimal.
It is also well known that unfavorable physical working conditions contribute to burnout (40). Moreover, social support mitigates workplace stressors such as high workload, exposure to trauma, and limited resources that may lead to burnout among child protection professionals (41). The level and nature of social support may vary across countries depending on administrative structures, organizational frameworks, and cultural and social contexts. In the literature, there is a study providing preliminary evidence that social workers’ participation in support programs—which encompass psychological protective factors such as mindfulness, acceptance, attention regulation/decentering, self-compassion, non-attachment, non-avoidance, and non-aversion—has the capacity to improve anxiety and rumination, thereby reducing stress, emotional exhaustion, and depersonalization (42). The fact that the newly structured CACs in Türkiye are newer buildings than those of other health institutions, have internal physical structures more suitable for the personal needs of health personnel, provide social support between individuals and supervisors, and offer facilitated opportunities for health personnel to participate in both in-service training and other educational events, such as congresses, may have contributed to the lack of difference in burnout scores between the two groups.
In this study, when socio-demographic characteristics were evaluated, social workers had significantly higher MBI scores than other professional groups. Studies focusing on social workers have identified workload and conflict between professional and family responsibilities as primary contributors to emotional exhaustion (43). In addition, lower professional satisfaction scores among healthcare personnel were statistically associated with higher mean scores on the MBI.
A study conducted in South Korea among child protection professionals suggested that depressive mood, identified as the second most common risk factor associated with intention to leave the job, reduces job satisfaction, increases emotional exhaustion, and diminishes the sense of personal accomplishment (22). Consistent with these findings, our study demonstrated a statistically significant difference in BDI scores between the study and control groups. Furthermore, healthcare personnel with lower professional satisfaction scores showed statistically significant increases in mean scale scores, a pattern similar to that observed in the MBI. Considering that the present study was conducted in newly established CACs, burnout levels may not have been fully captured; however, in line with the literature, the findings clearly indicate the presence of depressive symptoms and highlight the significant impact of professional satisfaction on both depression and burnout. Moreover, examination of the regression models demonstrating the negative linear relationships between job satisfaction scores and both the depression and burnout scales revealed that the contribution of the depression scale was nearly comparable to that of the burnout scale (Table 6).
The study found that median SCL-90 symptom scores, particularly the subscale medians for somatization, obsessive-compulsive symptoms, interpersonal sensitivity, depression, anger-hostility, and paranoid ideation, were significantly higher among CACs’ employees than in the control group. Higher levels of interpersonal sensitivity may reflect the search for social support, which has been described in the literature as a factor that helps reduce workplace stress (41). The presence of findings of somatization may also represent a natural psychological manifestation of stress. In professionals working in highly demanding fields such as child neglect and abuse, the emotional processes described as compassion fatigue may contribute to anger as a result of grief related to perceptions of the world’s safety and children’s protectability (44, 45).
Study Limitations
This study has several limitations. Because some questions were personal, response bias, particularly social desirability bias, may have occurred. Furthermore, participants were assessed cross-sectionally, and no longitudinal follow-up was performed; therefore, psychiatric symptom levels and scale scores may have been influenced by recent life events. Individual perceptions and attributions may also change over time depending on personal and professional circumstances. Repeating the study with the same sample at a later stage may provide additional insights. In addition, a substantial proportion of participants were not interviewed face-to-face; therefore, the impact of this on the honesty of responses remains unknown. Another limitation is that psychiatric symptomatology was assessed using self-report scales rather than structured or semi-structured psychiatric interviews. The relatively modest sample size and potential residual confounding related to baseline differences between the groups may also have influenced the findings. Despite these limitations, this study provides valuable preliminary evidence and contributes to the limited literature on healthcare professionals working in child monitoring centerss caring for children exposed to sexual abuse.
Conclusion
The present findings indicate that professionals working in CACs experience depressive mood states, a higher burden of psychiatric symptoms, and lower levels of job satisfaction. Given that reduced job satisfaction appears to be associated with both burnout and depression, further comprehensive quantitative and qualitative research addressing factors related to job demands, working system characteristics, and conditions, as well as individual-level determinants that may influence job satisfaction scores, may contribute to the literature. In addition, psychoeducational workshops focusing on stress management, mental health, self-care, personal strengths, and skill development and structured in-service training programs aimed at supporting professional development and advancement within the field may be encouraged.
