Job Satisfaction and Associated Factors among Health Care Staff in Township Health Centers—— A Cross-Sectional Survey in Rural Central China


 Background:Township health centers play a cornerstone role in the work of primary health care 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. The aim of this study was to explore job satisfaction and associated factors among health-care staff in township health centers in Huangpi District. Methods: This research was conducted in Huangpi, China. Convenience sampling methods and self-administereded questionnaires were used. 1370 of valid samples were collected with 97.72% effective rate. 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. Results: The mean age was 36.98 (SD=9.84), Factors that affect job satisfaction include educational background (χ2= 7.99, p=0.046), monthly income (χ2= 51.43, p<0.001), hire form (χ2=7.64, p=0.049), hours worked per week (χ2=33.48, p<0.01), parent have had a stable job (χ2= 10.67, p<0.01). Conclusions: Government and management should consider the impact of current policies on job satisfaction to reduce staff’s personal job dissatisfaction, Reducing staff workload, increasing salary and overtime benefits, and promoting the fairness of wage distribution are potential strategies to ameliorate low levels of job satisfaction.


Background
Primary health care is widely perceived to be the backbone of a national health care system (1), and township health centers serve as a central role in primary health care to ensure the implementation of many functions of health service at the grass-roots level in rural areas (2). However, for a long time, the shortage of personnel is prominent due to di culties in recruitment and serious wastage in rural health institutions, especially township health centers (3). A study conducted by Yang et al (4) indicated that China's rural health resources are extremely de cient, compared with other types of human resources for health. The shortage of professionals in health care centers will eventually affect the health of the rural population and exacerbate health inequality. Some studies (5,6) have shown that improving job satisfaction is crucial for reducing turnover intention among personnel in township health centers.
Job satisfaction originated from Hawthorne's experiment to study the work e ciency of workers. Hoppock (7) rst put forward the concept of job satisfaction, with the de nition of a subjective evaluation of their work status from a personal point of view. Locke (8) believes that job satisfaction represents the emotional state generated by the achievement of one's job value in the work situation. After years of development, Scholars have put forward the de nition of job satisfaction from different angles and enriched its connotation and dimension. In this study, we are prefer to use the de nition: The psychological state in which an individual has a benign feeling about the work itself and its related parties in the process of working within the organization, including working environment, working status, working style, work stress, challenge, interpersonal relationship at work, etc (9).
In 1935, Hoppock used the attitude scale for the rst time to evaluate job satisfaction, but he focused more on the material level of work, lacking the in uence of internal factors on employees. Later scholars developed a number of relatively mature evaluation scales on this basis, most of which include promotion opportunity, salary, colleague relationship and work itself (10)(11)(12). Although there are a variety of concepts and measurement methods of job satisfaction, almost all scholars agree that the concept of job satisfaction can re ect job-related psychological behavior.
The health personnel in township health centers are the practical practitioners of rural health services and the promoters of health policies, relating to the sustainable development of rural health services closely. A survey conducted by Shahnazi H (13) indicated that the quality of health services decreases with the decline of satisfaction. For health care staff, low job satisfaction can cause damage to their physical and mental health, and reduce well-being (14)(15)(16). For medical institutions, there will be an increase in doctor-patient con icts and a decline in performance with the increase of low satisfaction. Thus, assessment of job satisfaction among health personnel is essential.
Huangpi District rst put forward the concept of health management association, and became a demonstration area of national health management association in 2013. People have obtained more convenient, effective and inexpensive medical services, with the deepening of the system. However, the research on the satisfaction of health care workers after the innovation are few in Huangpi. Previous studies have focused more on patient satisfaction and less on doctors' satisfaction. The purpose of this study was to investigate job satisfaction and its related in uencing factors in the context of health management consortium among health care staff.

Settings and Participants
A cross-sectional survey was used. The research was based on the programme which named "Third party evaluation of comprehensive effect of medical and health institutions in Huangpi district". The programme was conducted from March 2018 to June 2019. Convenience sampling methods was used. We utilized data of medical staffs from township health centers in the rural areas. Eligible participants met the following inclusion criteria: (1) Time of service was more than one year. (2) There had been no mental damage recently. (3) Medical personnel must have quali cations. (4) Participants were voluntary. The exclusion evaluate satisfaction with work environment (facility, cooperation, interpersonal relationship, and leadership), remunerations, management and the work itself. A ve-point Likert scale was adopted, all questions were positive scoring (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 signi cant at χ 2 (0.05,153) = 34832.83 (p < 0.01). Cronbach's alpha was used to evaluate the reliability of the questionnaire, exploratory factor analysis (EFA) was performed to test the construct validity. The value of Cronbach's alpha re ects the internal consistency of the questionnaire. It is generally considered that a value above 0.90 is excellent, above 0.80 is good and above 0.70 is acceptable. 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 (21), 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. Table 1 Factor loading of items using the exploratory factor analysis and Cronbach's α of the questionnaire

Statistical analysis
Job satisfaction of healthcare staff was transformed into a binary categorical variable based on the mean score of all items. Job satisfaction was regarded as the dependent variable (Y), and it was divided into two groups: 1 "satis ed" (a mean score higher than or equal to 3.50(21)) and 0 "unsatis ed" (a mean score lower than 3.50 (21)). The sociodemographic information was regarded as independent variable (X). Gender was divided into two groups, 1 "male" and 0 "female". Age was divided into four groups: less than 30 years, 31-40 years, 41-50 years and more than 50 years. Educational background was divided into four groups: university and above, junior college, high school or technical school, junior high school and below. Marital status also was divided into four groups: married (living with spouse), married (not living with spouse), unmarried, divorced or widowed. Professional status was divided into four groups: senior/deputy, intermediate, primary, lower than primary (22). Occupation was divided into four groups: clinicians, nurse, public health staff, other occupation.
Monthly income was divided into ve groups: less than 2000 RMB, 2001-3000 RMB, 3001-4000 RMB, 4001-5000 RMB, more than 5000 RMB. Hire form was divided into three groups: personnel agent staff, permanent staff, temporary staff. Hours worked per week was divided into four groups: less than 31 hours, 31-40 hours, 41-50 hours, more than 50 hours. Years of service was divided into ve groups: 1-5 years, 6-10 years, 11-15 years, 15-20 years, more than 20 years. Night shift frequency was divided into three groups: 0 times, 1-3 times and more than3 times. The last group of each independent variable was used as a reference group to set the dummy variable.
Using EpiData (version 3.0) to establish a database for data entry and conversion. Double machine imputing method was used to enter the collected data into the computer. 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. Odds Ratio (OR) and 95% Con dence Interval (CI) of the variables were reported. Using SPSS version 20.0 (IBM Corp, Armonk, NY, USA) to analyze data, all tests were conducted at the 0.05 level of statistical signi cance.

Descriptive of Sociodemographic Characteristics
The sociodemographic characteristics of the respondents are tabulated in Table 2 with the number (n) and the corresponding percentages. In this sample, 31.09% of the participants were male and 68.91% were female. The average age of the respondents was 36.98 ± 9.84 years, the largest proportion of participants (35.77%) was in the less than 31 years old group, and the least proportion of participants (7.74%) was in the more than 50 years old group. The educational background of 46.42% of the staffs surveyed was junior college. 77.29% of the respondents was married, and 72.26% of them lived with their spouse. Most of the participants had primary professional status (52.85%), followed by lower than primary professional status (28.83%).    Table 4 shows the relationship between individual factors and job satisfaction. Marital status, professional status, monthly income, hire form, hours worked per week, parents have had a stable job or not were signi cantly associated with the job satisfaction of the respondents from township health centers in rural areas of Huangpi (see Table 4).  who worked 31 to 40 hours per week were more likely to be satis ed with their job than staff who worked more than 50 hours per week (OR = 2.343, 95%CI= (1.517,3.619), p < 0.01). Respondents whose parents have had a stable job were more likely to be satis ed with job than those whose parents did not have stable job (OR = 1.373, 95%CI= (1.040, 1.814), p < 0.05).

Disscussion
Previous studies (23,24) have shown that many factors, such as age, remuneration, educational level, working pressure, are in uencing factors of job satisfaction. This study aimed to review the satisfaction of township health center staff and the associated factors in Huangpi. Township health centers serve as a central hub in primary health care in rural areas of China. Improving satisfaction is of great signi cance for the provision of high-quality medical services.
In the present study, there was a signi cant correlation between marital status and job satisfaction. Married (living with a spouse) had the highest satisfaction, followed by married (not living with a spouse), and the lowest was divorce or widowhood. The study results of Mirzraie was in accordance with our study (25).
Similar study have shown that young age, being female and being married were signi cantly associated with a higher level of job satisfaction by Narge et al (26). However, there was no signi cant correlation between marital status and score of overall job satisfaction in the study of Hossein (27). Hossein divided marital status into three categories (married, single, other), while we subdivided it into four categories including married (living with spouse), married (not living with spouse), unmarried, divorced/widowed. The single status is divided into unmarried and divorced / widowed, these are two different states and the corresponding age groups varies greatly, the married state are classi ed as living with the spouse or not. We infer that simply dividing marital status into married and single is not conducive to nding the relationship between marital status and job satisfaction.
The result that staff who are employed on a long-term basis are more satis ed than those employed on a temporary basis was in line with other study (35).
According to Simone's research (36), temporary contracts form can increase worker's vulnerability to work-related stress and therefore in uence the job satisfaction. Thereby, we speculate that temporary contracts are linked to higher job insecurity. There was no signi cant difference in job satisfaction between personnel agents and long-term employees, combined with the actual situation of China's public medical institutions, we surmise that it is likely to be related to the fact that personnel agency system in many aspects, such as salary, performance, and bene ts, has no obvious difference with long-term employees.
In terms of the association between the parents' job stability and job satisfaction, it was found that higher satisfaction with parents having a stable job. Those whose parents have stable jobs often mean less time and nancial cost in caring for elderly parents. Similar results are reported in Linda' s study (37). Another explanation is that parents with stable jobs partly means less work-family con ict and can provide more internal support from family, thereby, job satisfaction is higher than those whose parents' job is not stable.
Employees who has a moderate working hours per week reported higher levels of job satisfaction than those who work too long. Previous studies (38,39) have also shown a negative correlation between extended work hours and job satisfaction as a whole. A possible explanation is that long working hours tend to be associated with higher workloads and higher stress levels. And compared with working too few hours, moderate working hours promote proper work enthusiasm and positive work stress.
There are a few limitations we must be open to acknowledge in this study. First, the representativeness of this sample is limited, as our sample was from the health centers in each township. Second, the questionnaire used in this study was self-administrated according to the conditions of Huangpi and has only been used in this district. Third, some of the questions such as income and work hours asked in this study were self-reported and may have generated less reliable responses. Fourth, the results only re ected the situations in Huangpi, and might not adapt to other regions due to differing implementation of policy and health system reforms across. However, the results were useful for re ecting the satisfaction situation of Huangpi especially under the reform background of health union in Huangpi District. Fifth, as the study was a cross-sectional design, the causal effects of job satisfaction could not be determined. Further study is perhaps needed for measuring the effects.

Conclusion
Healthcare staffs' job satisfaction was signi cantly associated with monthly income, weekly working hours, employment form, parents' work status and sociodemographic factors, including professional and marital status. As health care staff in townships are essential in providing primary services in China, the government and administrators could consider ways to enhance staff's personal job satisfaction. Given the health care staff shortage, there should be action taken to create a better balance between the number of patients and staff to reduce the workload of medical staff appropriately. Increasing personnel income especially by promoting wage equity and improving overtime allowance as well as shift work allowances is a potential strategy to ameliorate low levels of job satisfaction. Besides, scienti c performance appraisal and salary distribution, professional development supporting and nancial incentives are also make sense. Further research can be conducted to investigate the possible explanations.

Declarations
Ethics approval and consent to participate As the project is in cooperation with the government of Huangpi District, the government departments have helped us to obtain the informed consent of the participants in advance, and the consent was verbal. The ethics committee of Wuhan University School of Medicine (WUSM) reviewed it, and veri ed it to comply with the Declaration of Helsinki and its revised version, as well as the relevant regulations of biomedical journals, and approved the research (No.2018YF0080).

Consent for publication
Not applicable.

Availability of data and materials
The data that support the ndings of this study are available from the CDC of Huangpi district but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the CDC of Huangpi district.