Analysis of the difference between urban and rural areas in job satisfaction of primary health care workers

doi:10.21203/rs.3.rs-5237886/v1

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Analysis of the difference between urban and rural areas in job satisfaction of primary health care workers

https://doi.org/10.21203/rs.3.rs-5237886/v1

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Background: The purpose of this study is to investigate the influencing factors of job satisfaction and urban-rural differences among grassroots health workers in Anhui Province, and to provide a basis for the formulation of relevant health policies.

Methods: A multi-stage sampling method was used to survey 8135 primary health care workers in Anhui Province. Data were analyzed using chi-square test, t-test, and logistic regression analysis to analyze the influencing factors of job satisfaction of primary health personnel and its urban-rural differences in Anhui Province. In addition, Fairlie decomposition analysis was used to quantify the contribution levels of different influencing factors.

Results: Out of 8135 primary health workers, 3161 (38.9%) primary health workers were dissatisfied with their jobs. The percentage of job dissatisfaction was higher among rural primary health workers (39.8%) than urban primary health workers (36.7%).Fairliedecomposition analysis showed that 13.12% of the urban-rural difference in job satisfaction could be explained mainly with gender (24.00%), average annual income (-12.22%), overtime pay (8.94%), job-reward match (- 15.76%), unit-family support (-4.24%), and burnout (15.07%) differences.

Conclusion: The results of the study will help the Chinese government to provide a basis for improving the job satisfaction of primary health care personnel, narrowing the gap between urban and rural primary health care personnel's job satisfaction, formulating relevant health policies, and promoting the better development of primary health care.

Primary Health Care Workers

Job Satisfaction

Rural-Urban Differences

and Fairlie Decomposition Analysis.

Primary healthcare institutions play a crucial role in providing essential medical and public health services to people, consistently playing a vital role in safeguarding the health and well-being of residents [1]. According to the "China Health Statistics Yearbook 2023," in 2022, the number of health personnel in China's primary medical and healthcare institutions was 4.551 million (31.6%), providing a total of 4.27 billion visits (50.7%) to the Chinese population. Currently, with the deepening of population aging and the increase in chronic diseases, the demand for primary healthcare services is expected to significantly rise. However, there is a severe global loss of primary healthcare professionals, and a crisis in primary healthcare human resources has become an urgent issue [2].

Job satisfaction is defined as the degree of positive, negative, or emotional feelings health workers have towards their work [3]. The job dissatisfaction of primary healthcare personnel significantly impacts their intention to leave, exacerbating the shortage of primary healthcare human resources [4]. Furthermore, job dissatisfaction among primary healthcare personnel also affects the quality of medical services and patient satisfaction [5]. Therefore, continuous monitoring of the job satisfaction of primary healthcare personnel is crucial. Numerous studies on the job satisfaction of healthcare workers indicate an overall dissatisfaction rate of 20%-40% [6-8], with some reports showing levels exceeding 40% [9,10].

In studies on the factors influencing healthcare workers' job satisfaction, the work environment and income of medical staff at the Turkish Public Health Center are identified as the most important factors leading to dissatisfaction [11]. In Serbia, the main factors affecting dissatisfaction among healthcare professionals are wages, equipment, opportunities for continuing medical education, and professional development [12]. A survey of primary healthcare personnel in China revealed that the most dissatisfying factors in their work are income levels and benefits [13].

Is there a difference in job satisfaction among primary healthcare personnel in urban and rural areas? Some studies suggest that job dissatisfaction is higher in rural areas compared to urban areas [14, 15], while others indicate no difference between urban and rural areas [16, 17]. However, there are also studies showing higher job dissatisfaction in urban areas compared to rural areas [18]. Disparities in job satisfaction among healthcare workers in urban and rural areas vary depending on the practice environment, possibly due to the diversity of job satisfaction assessment scales in different countries, cultural beliefs, economic levels, and differences in political and medical environments.

However, there is a lack of research that further analyzes the reasons for the urban-rural differences in job satisfaction among primary healthcare personnel. Quantitative studies on the contribution of each influencing factor are limited. Therefore, our study aims to identify and analyze the factors influencing the job satisfaction of primary healthcare personnel in urban and rural areas. We will use FDA (Fairlie decomposition analysis) to quantify the contribution of each influencing factor. This research aligns with the spirit of the 20th National Congress of the Communist Party of China, implements the new era party's health work policy focusing on the grassroots, improves the job satisfaction of primary healthcare personnel, narrows the urban-rural gap in the job satisfaction of primary healthcare personnel, provides higher quality and more efficient primary healthcare services, and offers evidence-based support for formulating relevant health policies in China.

Data sources

Community health centers and township health centers are the primary institutions that provide basic medical and public health services to urban and rural residents. This study employed a multi-stage sampling method to select research subjects. Firstly, a province in central China (with 16 prefecture-level cities) was chosen as the sample province. Secondly, through typical sampling, 10 township health centers and 10 community health service stations were selected from each prefecture-level city, totaling 320 primary healthcare institutions. Finally, from March to May 2022, a cluster sampling method was used to survey all primary healthcare workers in the sample primary healthcare institutions who met the inclusion criteria (including general practitioners, nurses, public health physicians, pharmacists, etc.). The inclusion criteria for participants were: (1) having worked in primary healthcare services for 1 year or more; (2) being informed and voluntarily agreeing to participate in this study.

Once contact was established with the survey sites, with the cooperation of the grassroots health department's head of primary healthcare at the municipal level, electronic online questionnaires were distributed to the survey sites through "WeChat Survey Star" (WeChat is a widely used social media application in China, and "Survey Star" is a mini-program within the WeChat ecosystem).

This survey was conducted anonymously among all medical staff who met the inclusion criteria in the primary healthcare institutions. A total of 8,339 questionnaires were collected, and after IP verification, duplicate questionnaires were discarded. The completeness and standardization of the filled questionnaires were validated (54 duplicates and 150 with missing key information), resulting in 8,135 valid questionnaires, with an effective response rate of 97.5%. All procedures complied with the ethical standards of Anhui Medical University (Approval No. 83220442).

Job satisfaction scale

This study developed a satisfaction scale based on the Minnesota Satisfaction Questionnaire (MSQ) compiled by Weiss et al. [19] and according to relevant theories and research on satisfaction [20, 21]. After expert discussions, a satisfaction scale was created, consisting of 17 measurement items such as "compensation for primary healthcare personnel," "work hours and intensity," and "talent incentive mechanisms." The results were dichotomized using the median score method for each item. The satisfaction scale utilized a 5-point Likert scale, with scores ranging from 1 to 5, representing "very dissatisfied" to "very satisfied" respectively. The item scores ranged from 17 to 85 points. The total score for each respondent was calculated, with the dependent variable (job satisfaction) categorized as 0 (satisfied: score less than or equal to 51) and 1 (dissatisfied: score higher than 51). The Cronbach's α coefficient for the scale in this study was 0.90.

Grouping variables

The respondents were categorized as rural and urban primary healthcare personnel based on the nature of the location of the primary healthcare institutions during the survey.

Covariates

To meet the research requirements, demographic information and job characteristics of primary healthcare personnel were collected, including gender, age, educational level, professional qualifications, job title, years of experience, average annual income, and average daily working hours. Additionally, data on organizational-family support, professional identity, and occupational burnout were gathered and organized. The Work-Family Support Questionnaire, developed by Li and Zhao et al. [22], consists of two dimensions (work domain support and family domain support) with a total of 26 items, and the scale's Cronbach's α coefficient was 0.97. The professional identity scale was adapted from the Nurse Professional Identity Scale [23] and the Medical Staff Professional Identity Scale [24]. After discussions among the research team and experts, a professional identity scale suitable for primary healthcare workers was formulated, comprising 12 items, with a Cronbach's α coefficient of 0.90. The occupational burnout scale utilized the Maslach Burnout Inventory-General Survey (MBI-GS) [25], encompassing three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment, totaling 15 items, with a Cronbach's α coefficient of 0.88.

Statistical analyses

The research will utilize descriptive statistical analysis to investigate demographic characteristics and job features of primary healthcare personnel in rural and urban areas. Chi-square tests and t-tests will be employed to assess the distribution of job satisfaction among rural and urban primary healthcare personnel. A binary logistic regression model will be applied to explore the primary factors influencing job satisfaction among primary healthcare workers in rural and urban settings. These statistical analyses will be carried out using SPSS 26.0 software. Furthermore, factors contributing to disparities in job satisfaction among rural and urban primary healthcare personnel will be examined using the FDA model in Stata MP17.0 software. The significance level for statistical tests is set at 0.05.

Fairlie decomposition analysis

Due to the dependent variable being a binary variable, the FDA nonlinear decomposition method is employed to decompose the urban-rural differences in job satisfaction among primary healthcare personnel into contributions from various factors. The FDA utilizes StataMP 17.0 statistical software to identify and quantify the intergroup differences in job satisfaction among urban and rural primary healthcare personnel. The research findings are divided into two parts: the explained part and the unexplained part. The formula can be expressed as:

The total difference is composed of the explained part, which is caused by the observed variables in the study, and the unexplained part, which is caused by the differences between the measured grouping variables and unmeasured variables [26-28].

Characteristics of the participants

Table 1 presents the results of the descriptive statistical analysis for primary healthcare personnel. The results indicate that 38.9% of primary healthcare personnel are dissatisfied with their work. Specifically, the proportion of rural primary healthcare personnel dissatisfied with their work (39.8%) is higher than the proportion of urban primary healthcare personnel dissatisfied with their work (36.7%) (p < 0.05). Chi-square test results reveal differences in the distribution of 10 covariates—gender, age, education level, professional title, years of service, average annual income, average daily working hours, frequency of overtime work, overtime pay, and job competency—between rural and urban primary healthcare personnel.

Comparison of variable distribution across Job satisfaction

Table 2 displays the differences in the distribution of job satisfaction variables among primary healthcare personnel based on urban and rural settings. The results indicate statistically significant differences in the distribution of job satisfaction variables based on urban and rural settings. Among rural primary healthcare personnel, there are statistically significant differences in the distribution of job satisfaction variables related to gender, age, professional qualifications, professional title, and years of service. However, these differences are not statistically significant among urban primary healthcare personnel.

Logistic model results

Table 3 presents gender, average annual income, years of service, overtime pay, job fit, family support, professional identity, and occupational burnout as factors influencing job satisfaction among primary healthcare personnel. Simultaneously, there are differences in the factors influencing job satisfaction between urban and rural primary healthcare personnel. Notably, the years of service categories of 11-20 years and ≥21 years reach significance only among urban primary healthcare personnel.

FDA results

The specific results of the decomposition of urban-rural differences in job satisfaction among primary healthcare personnel are presented in Table 4. The results indicate that 13.12% of the differences in job satisfaction among primary healthcare personnel are attributable to observed variables, while the differences caused by the urban-rural "binary" structure and unmeasured variables account for 86.88%. Among the variables contributing to the explainable portion of the differences, gender, income, overtime pay, job-reward fit, organizational and family support, and occupational burnout are significant influencing factors (p < 0.05), with contribution levels of 24.00%, -12.22%, 8.94%, -15.76%, -4.24%, and 15.07% respectively.

The study investigated the factors influencing job satisfaction among urban and rural primary healthcare personnel in Anhui Province. Additionally, the research quantitatively analyzed the contribution levels of various influencing factors to explain these urban-rural differences. This study can provide theoretical references for relevant departments to formulate policies to improve the job satisfaction of primary healthcare personnel.

Our research results indicate that among primary healthcare personnel in Anhui Province, 38.9% are dissatisfied with their work. It was found that there are urban-rural differences in job satisfaction, with rural primary healthcare personnel having a higher proportion of dissatisfaction compared to their urban counterparts. This aligns with the findings of studies on rural doctors in Pennsylvania reporting higher rates of professional dissatisfaction compared to urban settings [29], as well as congruent results from studies on healthcare worker satisfaction in Serbia [15] and Southeast Iran [14].

Results from both univariate and multivariate analyses show that gender, years of service, average annual income, overtime pay, job fit, occupational burnout, professional identity, and organizational family support are factors influencing job satisfaction among rural and urban primary healthcare personnel, with job satisfaction exhibiting urban-rural disparities.

Table 4 FDA of Job Satisfaction difference between urban and rural areas.

In both rural and urban primary healthcare personnel, women have a lower probability of being dissatisfied with their work. Our analysis reveals that a majority of primary healthcare personnel are female, consistent with existing research indicating evolving gender roles in the medical field, particularly in nursing and pharmacy professions [30]. The 2022 China Health Statistics Yearbook shows that women accounted for 72.4% of healthcare technical personnel in China in 2020. In terms of gender differences in job satisfaction, female physicians in the United States commonly report satisfaction with their careers [31], while studies in Canada and Finland found that male psychiatrists had lower job satisfaction compared to their female counterparts [32], aligning with our findings. This may be attributed to women contributing to their families and society through economic activities, feeling proud of their work-family balance, and finding fulfillment in their professional accomplishments [33].

In urban primary healthcare personnel, those with 11-20 and ≥21 years of work experience have a higher probability of job dissatisfaction. This could be due to increased age and experience leading to repetitive and monotonous work, resulting in decreasing job satisfaction among employees. This finding is consistent with the perspective of R. L. McNeely et al., suggesting that younger primary care physicians and those new to practice are more satisfied than older colleagues with longer tenures [34]. However, contrary to survey results in Saudi Arabia [35], healthcare providers with more experience exhibit higher job satisfaction, likely due to their enhanced understanding of their work environment and ability to adjust it. Moreover, experienced healthcare providers receive more recognition, leading to higher satisfaction levels.

Our study demonstrates that an increase in average annual income reduces the likelihood of dissatisfaction among rural and urban primary healthcare personnel, while the absence of overtime pay increases the likelihood of dissatisfaction. Previous research has shown that compensation (including wages and additional benefits) is a crucial motivator[36, 37], with low pay and high workload being significant factors contributing to low job satisfaction among primary healthcare personnel, especially in low- and middle-income countries [38]. However, the prominence of non-monetary incentives makes it challenging to significantly boost healthcare workers' motivation solely through higher salaries, a topic that has been discussed in previous studies [39].

Mismatch between job requirements and responsibilities increases the likelihood of job dissatisfaction among rural and urban primary healthcare personnel. Studies in the field of education have shown that achieving a good job fit quality results in higher job satisfaction [40]. However, there is limited literature in the public health domain explaining the negative impact of job mismatch on job satisfaction.

Our study reveals that occupational burnout, professional identity, and organizational family support influence job satisfaction among rural and urban primary healthcare personnel. Previous research indicates that occupational burnout has a direct negative impact on job satisfaction [41, 42], while professional identity and organizational family support have direct positive effects on job satisfaction [43-45], aligning with our findings. The complex relationships among occupational burnout, professional identity, organizational family support, job satisfaction, and other relevant scales among healthcare providers have been further studied [43-47].

Our research shows that the urban-rural differences in job satisfaction among primary healthcare personnel are influenced by gender (24.00%), income (-12.22%), overtime pay (8.94%), job-reward fit (-15.76%), organizational and family support (-4.24%), and occupational burnout (15.07%), all of which are statistically significant. Except for gender, all other factors are modifiable. Improving these intervention factors could reduce the disparities in job satisfaction between urban and rural primary healthcare personnel.

Our study can offer meaningful policy recommendations. Firstly, there should be a shift in healthcare investment structures to improve investment in primary healthcare personnel, with a focus on their income and welfare, especially in rural areas. Secondly, efforts should be made to enhance the psychological well-being of primary healthcare personnel, dynamically monitor their mental states, and provide emotional care and social support. Thirdly, both mental and material incentives should be implemented to enhance job satisfaction among primary healthcare personnel, thereby increasing the stability of this workforce.

Limitations

Our study has several limitations. Firstly, our examination of job satisfaction among grassroots health workers is based on a cross-sectional design, limiting our ability to establish causal relationships. Secondly, the multitude of factors influencing job satisfaction among these workers was not fully explored in our study, as we only considered a subset of indicators, impacting the model's explanatory power. Future research endeavors will involve gathering additional pertinent data to enhance the model's explanatory capacity, thereby increasing its practical significance and scientific robustness. Moreover, given the regional focus of our study, it may not be generalizable to the entire country of China, necessitating further research with a broader scope for validation.

This study identified disparities in job satisfaction among grassroots health workers between urban and rural areas, with rural workers reporting significantly higher levels of job dissatisfaction compared to their urban counterparts. The key factors contributing to these urban-rural differences include gender, income, overtime pay, job-reward alignment, organizational and family support, and occupational burnout. The relevant departments of the Chinese government should prioritize attention to these factors. The findings of this study can serve as a foundation for the Chinese health authorities to enhance job satisfaction among grassroots health workers, narrow the urban-rural gaps in job satisfaction, deliver higher quality and more efficient grassroots health services, and develop pertinent health policies.

FDA :Fairlie decomposition analysis

Data availability

Considering the anonymity of the participants and the fact that the datasets are being used in other unpublished studies, the datasets for this article are not publicly available. However, if a reasonable request is made, please contact the corresponding author to obtain our datasets.

Acknowledgements and funding

Funding for this work was provided by a grant by National Health Commission, China , which contributed a lot to study design, data collection, analysis of data and a grant by Open Program of Health Policy Research Center;This study was supported by Grants for Scientific Research of BSKY( No. XJ202011 ) from Anhui Medical University;Anhui Medical University (Project number: 2022wszc09), which made contribution to some part of this study design.The sponsors and funding agencies had no role in design and implementation of this study or the preparation of this article.

Author information

Authors and Affiliations

School of Health Service Management, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China

Sicheng Liu,Ming Yang,Jiayi Sun & Jinxia Yang,Guixia Fang

School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China

Yuan Xu

Contributions

SL and MY contributed equally. SL, MY, JS ,JY and GF participated in the survey and data collection. SL, MY and YX analyzed the data and drafted the manuscript. SL, GF and JY designed the study. JY,GF, SL, MY, JS, YX discussed the methodology and revised the paper. All authors critically reviewed the manuscript and approved the final manuscript.

Corresponding author

Correspondence to Jinxia Yang.Guixia Fang is a tied corresponding author.

Ethics declarations

Ethics approval and consent to participate

Informed consent was obtained from all respondents, and all respondents voluntarily participated in the study.

Consent for publication

The studies involving human participants were reviewed and approved by Biomedical Ethics Committee of Anhui Medical University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. All relevant participants agree to the publication.

Competing interests

The author reports no conflicts of interest in this work.

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Tables 1 to 4 are available in the Supplementary Files section

No competing interests reported.

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Analysis of the difference between urban and rural areas in job satisfaction of primary health care workers

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Abstract

Background

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Discussion

Conclusion

Abbreviations

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Supplementary Files

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