The present study showed that sleep problems were prevalent among community health workers in China. In addition, we found a higher risk of sleep disorder among those who were males, had chronic illness, had authorized strength contracts, worked night shifts, and had worked ≥ 30 years. More importantly, the study indicated that as health workers’ ERI ratios increased, sleep quality became progressively worse (Table 1). It has been recognized that job stress affects the sleep quality of health workers [6, 8, 30].
Our research showed that community doctors perceived higher levels of effort and overcommitment and lower levels of rewards than community nurses. This is inconsistent with other research [31, 32]. The rewards score comprises three components: financial and career-related aspects, esteem-related rewards, and the gratification of job security [22]. As the primary providers of health services, doctors have a heavy burden. Some general practitioners (GPs) came from general hospitals, and they are exposed to a range of factors that are inferior to those of general hospitals, such as work overload, time pressures, role conflicts, lower compensation and fewer career development opportunities. Promotions and other normal conditions also limit GPs’ development and effort-reward imbalances, so they experience more job stress than nurses, and their job satisfaction is not high. In contrast, the jobs of nurses are relatively clear in the community, so their job satisfaction is higher than that of GPs [26, 33]. Regardless of the unsafe clinical environment, health workers are always committed to providing timely health services without any hesitation or reservations in China, which contributes to the imbalance between effort and rewards and contributes to higher job stress [34, 35]. Our results showed that the ERI ratio of the community health workers was 1.17 ± 0.22, indicating that the community health workers generally perceived more effort than rewards. We found a higher ERI ratio among those with the following demographic characteristics: males, 35–44 years old, undergraduate, married, chronic illness, doctors, worked night shifts, working ≥ 30 years, intermediate job title, group leader, and monthly income > 10,000 yuan. This is consistent with other studies [36, 37]; the occupational task and stress response for males were higher than those for females and higher in those with a high education level than in those with a low education level. The scores on the overcommitment dimension were 17.03 ± 2.28, which was higher than the scores found in previous research [37, 38]. Inadequate compensation is a concept incorporated into the ERI model: high effort and low compensation lead to high stress [30]. In the present study, 370 (78.39%) health workers had a high ERI (ERI ratio > 1), which was associated with insomnia, consistent with previous studies [39]. Moreover, a large number of previous studies have shown that effort–reward imbalance can lead to adverse health outcomes [28, 40].
With health system reforms, the connotation and work volume of community health workers have continuously increased, and occupational stress will inevitably increase. The participants in this study had higher levels of occupational stress, possibly because of the study being conducted in southwestern China, which is less economically developed; thus, the rewards for community health workers are far lower than those in coastal areas. In addition, doctor-patient relationships are becoming increasingly fragile in China [41]. It is unfair to use doctor-patient relationships to evaluate the costs and rewards of a doctor’s professional and emotional investment, as these fragile relationships results in resource depletion, which is closely related to job stress, burnout and depression in health workers [42]. Therefore, managers should take measures to reduce the incidence of occupational stress among health workers in community hospitals.
The results of this study showed that health workers with poor sleep quality had higher levels of perceived effort, higher levels of perceived overcommitment, and higher ERI ratios than those with good sleep quality (Table 3). This is consistent with existing research [43]. Table 4 shows that the ERI ratio was the main risk factor for sleep disturbances in community health workers (P = 0.000, OR = 34.334). Further analysis indicated that age, education, type of work, shift work and job title were the main risk factors for a higher ERI ratio in community health workers (Table 5). If the efforts and rewards at work cannot be balanced, professionals will find their jobs difficult, which will cause occupational stress and affect sleep quality. Overcommitment and effort–reward imbalance have been identified as important occupational stress factors that negatively contribute to the psychological and physical health and well-being of employees [44]. Community health workers report higher levels of ERI, resulting in occupational stress, which leads to sleep disorders. Therefore, organizational interventions such as increasing rewards and improving doctor-patient relationships should be considered in China.