Job satisfaction and associated factors among health care staff in township health centers——a cross-sectional survey in rural Central China

ABSTRACT Township health centers play a cornerstone role in the primary healthcare in China while it’s development is largely limited by the brain drain. Job satisfaction is closely related to brain drain, investigating the relevant factors of job satisfaction can provide strategies to reduce brain drain. This research was conducted in Huangpi, China. Convenience sampling methods and self-administereded questionnaires were used. We collected 1370 valid samples, with an effective rate of 97.72%. Descriptive statistics are used to describe sociodemographic information. The Pearson Chi-square statistical was used to test the binary association between job satisfaction and another categorical variable. All the sociodemographic information was applied to the binary logistic regression model using the stepwise selection method. The mean age was 36.98 (SD = 9.84), factors that affect job satisfaction include educational background (x2 = 7.99, p< 0.05), marital status (x2 = 8.96, p< 0.05, monthly income (x2 = 51.43, p< 0.01), hire form (x2 = 7.64, p< 0.05), hours worked per week (x2 = 33.48, p< 0.01), parent had a stable job (x2 = 10.65, p< 0.01). Government and management should consider the impact of current policies on job satisfaction. Increasing the welfare of healthcare staff and promoting equity are potential strategies for improving low levels of job satisfaction.


Background
The shortage of professionals in healthcare centers will eventually affect the health of the rural population and exacerbate health inequality. Improving job satisfaction is crucial for reducing turnover intention in township health centers (Fang et al., 2014;Wen et al., 2018). Job satisfaction originated from Hawthorne's experiment to study the work efficiency of workers (Gillespie, 1991). After years of development, there are aplenty concepts and measurement methods of job satisfaction, which reflects the work-related psychological behavior has become a consensus.
A previous study on healthcare staff in township health centers showed that job security, reward and promotion opportunities were important factors affecting job satisfaction (Liu et al., 2010). For healthcare staff, low job satisfaction is detrimental to physical and mental health and reduces well-being (Faragher et al., 2005;Jarosova et al., 2017). For medical institutions, decline in the quality of medical services, increased doctor-patient conflict are associated with poor job satisfaction (Patel et al., 2008). Chinese government launched a new medical reform to strengthen primary healthcare and promote the public welfare in 2009. While the reform has benefited service users, it has been accompanied by a decline in the income of healthcare staff and a brain drain from township health centers (Zhou et al., 2014). Huangpi first put forward the concept of health management, and became the national health management demonstration area. We are concerned about the job satisfaction of healthcare staff and its influencing factors in this composite context.

Settings and participants
A cross-sectional survey and convenience sampling methods were used. The investigation was conducted anonymously with informed consent. Eligible participants met the following inclusion criteria: (1) Time of service was more than one year. (2) Individuals who have no history of mental illness or who have not suffered mental damage recently.
(3) Participants were voluntary. The total number of healthcare workers in township health centers in Huangpi is around 2400. We distributed 1402 questionnaires with 97.72% (1370/1402) effective rate .

Measures
The original questionnaire was developed by Fudan University (Zhang, 2011). Sociodemographic characteristics include gender, age, educational background, marital status, professional status, occupation, monthly income, hire form, hours worked per week, years of service, night shift frequency, parents had a stable job or not. The questionnaire of job satisfaction includes 18 items which evaluate satisfaction with work environment, remunerations, management and the work itself. A five-point Likert scale was adopted, all questions were positive scoring. The mean score of job satisfaction more than 3.5 points (out of 5 points) was classified as good (Lu et al., 2016) (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree).
The value of Kaiser-Meyer-Olkin(KMO) is 0.96, and Bartlett's test was significant at x 2 (0.05,153) = 34 832.83 (p< 0.01). Cronbach's alpha was used to evaluate the reliability of the questionnaire, exploratory factor analysis was performed to test the construct validity. The value of Cronbach's alpha reflects the internal consistency of the questionnaire. As shown in Table 1, the Cronbach's alpha value of each dimensions ranged from 0.89 to 0.98, which indicated the reliability of the questionnaire is good. The construct validity was acceptable if the factor loading of each item was greater than 0.40 (Lu et al., 2016), and the factor loading of each item met the criteria. The four factors were named as 'working environment', 'management rules', 'remunerations' and 'the work itself', respectively.

Statistical analysis
SPSS version 20.0 was used to analyze the data. Descriptive statistics are used to describe sociodemographic information. The Chi-square test was used to test the binary association between job satisfaction and another categorical variable. The Odds Ratio (OR) and 95% Confidence Interval (CI) of the association between different factors and job satisfaction were analyzed via binary logistic regression model using the stepwise selection method. All tests were conducted at the 0.05 level of statistical significance.

Descriptive of sociodemographic characteristics
The sociodemographic characteristics of respondents are tabulated in Table 2. In this sample, 31.09% of participants were male. Their average age was 36.98 ± 9.84 years, the largest proportion of participants (35.77%) was in the less than 31 years old group. The educational background of 46.42% of staff surveyed was junior college. The proportion of respondents who were married was 77.29%. Most of participants had primary professional status (52.85%). The majority were clinicians (42.77%). There were 519 respondents (37.88%) with a monthly income of 3001-4000 RMB, and 759 workers were permanent staff. The respondents worked for 31-40 hours per week (h/wk) account for 71.02%, and only 1.31% worked for less than 31 h/wk. Participants' average years of

Discussion
The average score of healthcare staff is 4.24. A survey conducted in township health centers in poor rural areas of China used a similar measurement with a score equivalent to 4.17 (Liu et al., 2010). The slightly lower score in the survey may be related to worse work pay and working conditions in poor rural areas. Divorced or widowed staff report significantly lower levels of satisfaction than married (living with a spouse), a previous study confirmed our results (May, 2003). The average time spent with spouse daily has a positive effect on marriage quality and job satisfaction, which could be a potential explanation for the results. Although previous studies have shown a significant correlation between marriage and job satisfaction, deeper reasons such as whether lives with spouse, work-family conflict, and marital quality remain to be explored (Al-Enezi et al., 2009;Shahnazi et al., 2014).
Healthcare staff with high professional status and high salary were more likely to be satisfied, which is consistent with the previous research (Yoshiaki et al., 2018). However, a study conducted in Guangdong Province found the opposite (Lu et al., 2016). Their survey included tertiary public hospital healthcare staff, who undertake the heaviest workload at different levels of care. It adversely affect the overall job satisfaction and may develop higher stress levels and burnout syndrome (Zhou et al., 2018). This also explains why staff with low educational background and staff who work too long hours per week are less satisfied in our study. The potential reason that temporary healthcare staff are more likely to have low satisfaction is that temporary contracts increase vulnerability to work-related stress (De Simone et al., 2018). There was no significant difference between personnel agents and long-term employees, we surmise this may be related to the fact that personnel agents are close to regular employees in many aspects such as salary and benefits in public medical institutions. It was found that higher satisfaction was associated with parents had stable jobs. Those whose parents had stable jobs often mean less time and financial cost in caring for elderly parents. In addition, work-family conflict is less and more internal support is obtained from family (Chan et al., 2020).
Limitations lie in study type, single-district aspect, less representative research subjects, making the results difficult to be generalized. Nevertheless, the results are still meaningful.

Conclusion
Job satisfaction was significantly related to work, personal and family factors. Increasing welfare security, promoting equity, and focusing on individual characteristics are potential strategies for improving job satisfaction.