Study design
A descriptive, cross-sectional, nationwide study was performed using an online questionnaire.
Setting And Participants
Ecuador is a country located on the equator and situated on the eastern most coast the South American continent. With a territory of approximately 283,560 km2, the Ecuadorian territory is divided into four geo-climatic regions: Coast, Andes (highlands), Amazonia and Galapagos Islands. Politically it is divided into 24 provinces.
Ecuador's health system is divided into three sectors: social security, which is responsible for providing care to members; the private sector, which consists of self-financed, for-profit health institutions; and the public sector, which consists of government-funded health institutions. The public sector, in turn, is divided into four levels of health care which are available to provide health care to the entire population of Ecuador [23]. In 2019, Ecuador had a total of 40,230 physicians, the majority of which work in the public sector (73.6%) [24]. Within the first level of care are included several professionals such as family medicine specialists, dentists, nursing graduates, primary health care technicians, and recently graduated professionals. These recent graduates are employed for a one-year mandatory residency in rural and remote areas. The number of these medical residents vary from generation to generation depending on the total number of professionals graduating each year [25].
The sample group employed for the present study consisted of recent medical graduates enrolled in the national registry of obligatory social service (rural medicine). Study participants were eligible to participate if they had graduated in medicine and were legally performing their year of obligatory social service in Ecuador. Consent was obtained from participants at the beginning of the questionnaire with an explanation of the purpose of the study. Participants could continue with the entire questionnaire only after obtaining an anonymous consent (by electronically marking) a "Terms and Conditions" and "Participation Agreement" assent form.
Data Measurement And Questionnaire
A structured questionnaire was designed to assess the perceptions and level of job satisfaction of rural doctors in Ecuador with respect to compulsory social service. Initially, a pilot survey was undertaken with 20 recently graduated rural physicians to identify understanding difficulties or errors in the structure of the questions. After editing errors detected by the pilot study, a 37-question questionnaire was consolidated in Spanish, revised, and validated by a Public Health expert. Additionally, an English translation of the questionnaire was created to be presented in this manuscript (Additional file 1).
The final version of the online questionnaire consisted of three sections:
Section 1: Comprises 3 questions about participant demographics, including gender, age, and marital status.
Section 2: Is composed of 11 questions that evaluated characteristics and perceptions regarding compulsory social service (rural medicine), including: type of health unit of work, geographical region of work, work schedule, difficulty in accessing the workplace, the existence of delays in remuneration and the use of one's own salary or other personal income to finance the materials or supplies needed during the compulsory social service work. Perceptions about the election system used to access compulsory social service positions in terms of fairness and functionality, the adequacy of academic orientation during university training, the professional usefulness of compulsory social service work, the sufficiency of the induction for compulsory social service, and the perceived experience (positive, indifference, and negative) during compulsory social service for their professional future.
Section 3: Includes 23 questions belonging to the job satisfaction questionnaire S20/23, which evaluate the level of job satisfaction of recently graduated physicians with respect to their work during their mandatory social service. In this evaluation the "organization" role was played by the Ministry of Public Health of Ecuador [26].
The questionnaire was distributed through a single link belonging to the Google Forms platform via official dissemination groups of rural physicians throughout Ecuador. In all cases, a brief explanation of the purpose of the study and the guarantee of data confidentiality was ensured in the initial section of the questionnaire. All questionnaires were anonymous, and no identifiable data were requested.
Bias
To avoid duplicate response bias, using the properties of the “Google Forms” tool, the number of responses for the questionnaires was limited to one response for each IP device.
Likewise, this research could be exposed to a selection bias since part of the potential participants could be busy or performing working activities in areas of Ecuador without internet access, however, we tried to reduce the effects of this bias by conducting the collection process for 30 days, in which the professionals who are performing the mandatory social service had access to their monthly rest days.
Study Size
According to official data, the total number of medical professionals in Ecuador who are completing their mandatory social service year during the period 2021–2022 is 2012 professionals [27]. From this population, the necessary sample size was calculated using the following equation [28].
$$n=\frac{\left(N.{Z}^{2}\right). \left(p.q\right)}{{d}^{2}\left(N-1\right)+{Z}^{2}.(p.q)}$$
Where, the total population (N = 2012), the expected proportion of unknown response was (p = 0.5), confidence level (Z = 95%, or Z = 1.96) and a precision or margin of error allowed of (d = 6%). Complete surveys from 236 participants (recently graduated physicians) were obtained.
Data Management
Work characteristics in the compulsory social service can be categorized by the complexity of services of the health units employing the graduates. These include the Type of Health Care Unit which can be classified according to the level of as follows: Health post (the least complex, with limited resources for health promotion and prevention), Type A Health Center (promotional, preventive, and rehabilitative care for communities of up to 10.000 inhabitants), Type B Health Center (promotional and preventive care for communities between 10.001 to 50.000 inhabitants), Type C Health Center (promotional, preventive and rehabilitation care, performs as a short stay maternity and emergency clinic for communities between 25.000 to 50.000 inhabitants) and Basic Hospital (a health care unit of secondary level that has outpatient service, emergency, clinics and basic surgery specialties) [29]. The remoteness of ease of access to compulsory social workplace was classified as: easy access to the Health Care Units, (the doctors have roads accessible by land throughout year), difficult access to the Health Care Unit (the doctors only have passable roads during the summer or through walking trails), and very difficult access to the Health Care Units (requiring River or air transport for health center access) [30].
In the evaluation of residents’ perceptions, the variable “election system” captures the perceived fairness of process of choosing (choice by means of an online platform) the health care unit in which recently graduate physicians would perform the compulsory social service. The variable “adequate academic orientation” assess whether the physicians consider that their formation in university was adequate for their rural medical experience. The variable “usefulness for professional practice” evaluates the graduate’s perception regarding whether social compulsory service will be useful for their future professional life. The variable “sufficient induction” assesses if the period of de preparation (7 days) before starting their social service was enough to develop their work activities optimally. Finally, the variable "marked experience" evaluates the physician's perception of the possible effect of the professional practice during the mandatory social service on his or her future professional life, whether positive (the experience increased the professional's mood towards future medical practice), indifferent, and negative (the experience decreased the professional's mood towards future medical practice).
The evaluation of job satisfaction was performed using the job satisfaction S20/23 questionnaire originally formulated in Spain by Meliá y Peiró in 1989. The adequacy of the questionnaire was validated on external workers in the health area, with a Cronbach’s alfa coefficient (α = 0.897), conformed by 23 questions with 7 answer options, using a Likert scale (1 = completely dissatisfied, 2 = quite dissatisfied, 3 = somewhat dissatisfied, 4 = indifferent, 5 = somewhat satisfied, 6 = quite satisfied, 7 = completely satisfied) permitting a minimum score of 7 and maximum score of 163 points. Job satisfaction was evaluated across five factors: satisfaction with participation (q19-q21), intrinsic satisfaction (q1, q2, q3, q5), satisfaction with benefits and remuneration (q4, q11, q12, q22, 23), satisfaction with the physical work environment (q6 – q10) and with the quality of supervision (q13 – q18) [26, 31]. The level of satisfaction was calculated by computing the mean of the total scores and the overall level determined by grouping the mean responses by three possible general satisfaction levels. The groups were denoted: dissatisfied for the scores between 1.0 to < 3.5 points, indifferent between 3.5 to < 4.5 and satisfied between 4.5 to 7.0 points.
Statistical Methods
The descriptive analysis of the qualitative variables was carried out using frequencies and percentages. For satisfaction level value, quantitative measures of mean and standard deviation (SD) were used. The Chi-Square test was used to search for an association between qualitative variables. Values p < 0.05 were accepted as statistically significant. In addition, Cronbach's alpha reliability analysis was performed to assess the validity of the S20/23 questionnaire in medical professionals. All the analysis of results was carried out in the IBM SPSS version 24.0 software.