Work motivation and job satisfaction among health workers of primary health facilities: a mixed-methods study from Nepal

Background Work motivation and job satisfaction are linked with the performance and retention of health workforce. Primary health facilities, mostly comprising of mid-level health workers, serve majority of the population in Nepal. The aim of the study was to assess the determinants of job satisfaction in relation to socio-demographics, job characteristics and work motivation status among health workers working in primary health facilities. Methods A mixed-methods study was conducted in Jhapa district in Eastern Nepal covering 40 primary health facilities. The data collection involved 151 self-administered questionnaire interviews and 16 in-depth interviews with the health workers. Mean differences in work motivation among those satised and unsatised with their job was examined using t tests. Logistic regression with 95% condence interval at p<0.05 was used for identifying associated factors with job satisfaction. Thematic analysis was done for qualitative data. Results Among the study participants, 78.2% were either auxiliary health workers or auxiliary nurse midwives. The median employment period of health workers was 174 months. In the likert scale of ve points, the mean score of work motivation was highest for team work (3.99) and lowest for nancial motivation (2.21). Age of health workers and satisfaction with career development, and nancial motivation were signicantly associated with job satisfaction. The qualitative ndings also revealed that majority of the health workers were not satised with the existing career development opportunities, availability of resources in health facility and nancial motivation. Conclusions Dissatisfaction with career development and nancial motivation was signicantly associated with lower odds of job satisfaction among health workers. Additionally, resource availability in health facility, recognition management support affected job A focus on improving work through increased nancial motivation and career development opportunities as as health with support is recommended to improve job satisfaction. of health workers working in primary health facilities. The evidence will be useful for informing human resource management policy in Nepal and other countries that share similar settings.

supportive leadership and management and professional development [4]. Though both job satisfaction and motivation cannot be directly observable, they are critical to the retention and performance of health workers [8,9].
Nepal is a country among 57 global and six South East Asia Region (SEAR) nations [6]with critical shortage of HRH [10]. Nepal has only 0.17 physicians and 0.50 nurses per 1000 population and the health workforce mainly comprises of non-clinical supporting personnel (37.65%) and paramedical practitioners (18.16%) [11]. Primary health facilities comprise of 198 Primary Health Centers (PHCs) and 3808 Health Posts (HPs) throughout the country and are based in community level [12]. The PHCs have sanctioned post for one medical doctor, one staff nurse, one lab personnel and paramedical practitioners while HPs have paramedical practitioners only [13]. The paramedical practitioners include Health Assistants (HAs), Auxiliary Health Workers (AHWs) and Auxiliary Nurse Midwives (ANMs). The vocational training period of HAs, AHWs and ANMs includes 36 months, 15 months and 18 months, respectively.
Similarly, staff nurses and medical laboratory technician had a three-year of training each in their respective areas. There are also cadres like Village Health Workers (VHWs) and Maternal and Child Health Workers (MCHWs) who are responsible for community-based services in the area of maternal and child health including immunization, and reproductive health.
Before the implementation of federalism in 2017, District Public Health O ces (DPHOs) had central role in managing primary health facilities, which are now overseen by local governments with the technical support from health o ces in district level [14]. Health workers working in primary health facilities cater to the need of majority of people. The performance of health workers depends on their work motivation and job satisfaction. There is inadequate evidence to guide performance management of health workers in Nepal and other similar settings [15,16]. Though several studies have been conducted on motivation and job satisfaction in other developing countries [6], very little is known about health workers of Nepal. Similarly, job satisfaction of those working in primary health facilities are often missed out from such studies. This study addresses the research gap by identifying the determinants of job satisfaction of health workers working in primary health facilities. The evidence will be useful for informing human resource management policy in Nepal and other countries that share similar settings.

Study design and setting
This was a health facility based mixed-methods study conducted in Jhapa district in the Eastern Nepal. Jhapa district was chosen because health sector performance of the district ranked in average among 75 districts of Nepal. Concurrent triangulation method was adopted to triangulate the findings from quantitative and qualitative data. According to the census of 2011, the district had a population of 812,650 [17]. There were 246 health workers in 50 primary health facilities (six PHCs and 44 HPs) in Jhapa. Additionally, Jhapa has one secondary hospital, as well as private sector hospitals and clinics.

Sampling and study participants
Among the total six PHCs and 44 HPs, 5 PHCs and 35 HPs were randomly selected. The study participants included all the health workers working in the selected health facilities at the time of study.

Study tools
For quantitative study, a structured self-administered questionnaire was used comprising of three sections (i) socio-demographic characteristics and job related information; (ii) 21 likert scale items under seven domains to measure work motivation and (iii) one item questionnaire to measure job satisfaction . Since, no tool was developed for specific context, the tool to measure work motivation was developed based on motivational theories [5,[18][19][20] and earlier work done by Li L et al [21] and Willis-Shattuck M et al. [6]. Based on Herzberg's two factor theory of work motivation [19,20], seven domains were identified to measure work motivation. Three domains namely recognition, responsibility and career development were related to motivators or intrinsic factors while four domains namely organization and management support, financial motivation, team support, and resource availability were related to extrinsic factors. We included 21 items under these domains.

The
Cronbach's alpha was calculated 0.72 which was considered sufficient for consistency [22].
The 21 items of work motivation were grouped across seven domains: career development (three items), recognition (three items), responsibility (three items), financial motivation (two items), organization and management support (four items), availability of resources (two items) and team support (four items). Study participants were asked to indicate their level of work motivation on a five-point likert scale: strongly disagree (1), disagree (2), neither agree nor disagree (3), agree (4) and strongly agree (5). Job satisfaction was the outcome variable and assessed on a four-point Likert scale: strongly dissatisfied (1), dissatisfied (2), satisfied (3) and strongly satisfied (4). Extensive literature review, pretesting of the tool and consultation with subject experts was done to refine the tool.
Guideline was provided to the study participants for filling self-administered questionnaire.
To minimize the response bias, balance of negatively worded questions was maintained in Likert scale items.

Data collection
Before data collection, we conducted a meeting with the respective in-Charges and health workers of the selected health facilities to share study objectives and seek permission. The questionnaire was distributed to health workers in their office at the early office hours and filled questionnaires were collected the same day or the next day. A total of 151 out of 175 health workers (86.3%) completed the questionnaire. In-depth interviews were conducted concurrently and included in-depth interview with 16 health workers who were selected purposively including different professional categories -one District Public Health Officer, two health assistants, two staff nurses, two ANMs and nine AHWs.
For qualitative study, in-depth interviews were conducted using interview guideline.
Exploration with health workers was done on the motivating factors present in the job, job satisfaction status and actions required to improve work motivation and job satisfaction.
Data collection was done during January -March in 2016.

Data management and analysis
Data entry was done in EpiData (version 3.1) and were analyzed using IBM SPSS Statistics 20. Descriptive statistics were presented as frequencies, percentages, mean and median.
Work motivation for individual items and each domain was determined by mean value and standard deviation. In case of domains of work motivation, the value equal to or above the mean score was categorized as 'satisfied' and those below as 'not satisfied'. The difference in work motivation among participants those who were or who were not satisfied with their job were assessed by independent t-test. Chi-square test was done to observe the association between categorical independent variables and categorical dependent variable.
Thereafter, those variables significant in bivariate analysis were fitted in logistic regression model to measure the predictors of job satisfaction. To check collinearity, we calculated the variance inflation factor (VIF) and detected no problem among the independent variables (highest, VIF, 2.02) that would bar their inclusion in analysis. Both unadjusted and adjusted Odds Ratio (OR) were calculated. Statistical significance was set at p < 0.05.
The in-depth interviews were transcribed from audio scripts and then translated from Nepali into English. Transcripts were studied and analyzed under three main themes (Table   1).

Results
Socio-demographic and job related characteristics The median age of the study participants was 38 years and 50.3% were male. Ethnicity pursued agriculture to supplement their income. (Table 2). The mean score of work motivation for individual items was higher for 'team work' (4.17) , 'relationship between co-workers' (4.15), and 'clear work roles' (3.97) while it was lower for 'training' (1.90), 'available equipment' (2.10) and 'salary' (2.13) ( Table 3).
Work motivation as per domains was higher for team work (3.99) and responsibility (3.50) while it was lower for financial motivation (2.21) and career development (2.41). Work motivation was higher among health workers who were satisfied with their job than those not satisfied across all domains except availability of resources (Table 4).   Recognition Some health workers were dissatisfied with the higher authorities due to lack of proper recognition of their work. They complained that performance of health workers was not assessed and reward system was non-functional. They however expressed happiness with the support received from the community people.
'There is no appreciation and encouragement from the DPHO. Performance of health workers is not assessed. What cost will it take to give a certificate to recognize the work done by us?'[AHW] Management support Health workers demanded the need of regular supervision and feedback system, evaluation of performance, availability of office operation expenses and encouragement from the DPHO.
'Health system in district level is running as it is. Through review meeting, we are given feedback but this does not help much'. [AHW] Besides mentioned above, the other factors that affected work motivation was low priority given to the health sector by the local governments, trade union politics in case of transfer and those close to power receiving training opportunities, and seniority row between health assistant and Sr. AHW in taking leadership of the health facility.
In qualitative analysis, permanent nature of the job was perceived as a factor for job satisfaction. However, health workers expressed that there was inadequate investment of government in primary health facilities and the government was focusing only on the health indicators and not on the health system issues. Moreover, they were burdened with administrative works. They also expressed dissatisfaction with the transfer system and government attention towards health workers working in primary health facilities.
'If there is anything to motivate about the job, it is the permanent job. Once you enter into the service, it will be difficult to leave the job. Only ambitious people leave their job. In our context, at least for paramedics, very few leave their job'. [Health Assistant]

Discussion
Higher age, career development and nancial motivation were the determining factors of job satisfaction in our study population. Motivational score was the lowest for nancial motivation. The qualitative ndings also identi ed that the existing remuneration was inadequate to cover health worker's living expenses including schooling for their children. A signi cant proportion of service providers in our study worked in private clinics for additional income. This shows that health workers perceived that the existing salary and incentives were inadequate. Financial factor has been reported of associated with job satisfaction in studies around the world including China [21], Kenya [23], Ethiopia [24] and South Africa [25]. As remuneration is linked with meeting personal and family needs, we suggest the government for salary adjustment of health workers to improve job satisfaction.
In this study, career development was associated with job satisfaction which are in line with previous studies conducted in Nepal [15,26]. Unpaid leave and lack of quotas for government staffs for further studies has affected the career ladder for these health workers. Interestingly, there are government quotas only for pursuing post-graduate studies which has hampered the professional growth of mid-level health workers. Health workers perceived training opportunity as scarce and not equitable in our study which was similar to the nding from a previous study done in Nepal in 2012 [27]. Inadequate career development opportunities affects the job satisfaction and ultimately the performance of health workers and health system as a whole which are supported by previous studies done in Nepal [28], India [29], Pakistan [30] and Ethiopia [24] . We thus suggest the need of in-service interventions such as further education and training opportunities for health workers working in primary health facility settings. Health workers of older age were more satis ed than younger health worker in our study which might be due to less expectation as compared to younger ones. Studies from China [21], Cyprus [31] and Nepal [26] showed similar ndings while younger health workers were more satis ed in Ethiopia [32].
The HRH in primary health facilities are the major service providers for rural Nepal. This is also true for other developing countries including Tanzania, Malawi and South-Africa [33]. The job satisfaction of these cadres is essential for obtaining desired health outcomes especially because specialized health workforce like doctors are scarce and are more likely to work in private hospitals [11], urban areas or migrate to foreign countries because of limited opportunities [34,35]. Health workers of primary health facilities stayed longer in the job. Similar phenomena were observed in Tanzania and Malawi where health workers worked for more than 10 years in their position [33]. They are less likely to migrate to other countries too because of the permanent nature of the job and non-transferable degree which is better suited to the local context [3].
Nepal's National Health Policy 2019 [36] has identi ed further education, in-service training and professional development opportunities for HRH development. However, little is focused when it comes to improving the working conditions and providing management support [37] and it is more pronounced in primary health facilities and its health workers where the burden of health system lies [38]. Lack of formal motivation scheme can leave these health workers abandoned [39]. A motivated and satis ed health workforce is thus crucial to attaining policy objectives and efforts should be made to design interventions taking into account the contextual realities of the country. In the context of federal governance in Nepal, provincial and local governments (municipalities) can play an important role for addressing HRH issues with focus on nancial and non-nancial motivation, and distribution [40,41].
Additionally, from the qualitative study, health workers perceived inadequate availability of resources as factors affecting their work motivation. Health workers were not satis ed with the infrastructure, shortage of drugs, equipments and supplies, which in turn has affected community trust on them. This spells out the need of investing in primary health facilities for improving work environment and work morale of health workers, and increasing community trust. The study ndings are in accordance with the published research in developing countries suggesting that the identi ed issues are genuine and demand appropriate interventions.

Strengths and limitations
This paper provides a comprehensive perspective regarding the effect of socio-demographics and work motivation on job satisfaction among primary health workers by employing mixed methods in a low resource setting. Moreover, the study measures work motivation by considering socio-economic and health system context and by adapting motivational theories. The study limitations include small sample size and heterogeneous nature of health workers that hindered quantitative analysis by professional groups. Also, self-reported bias might have occurred in the responses.

Conclusion
Age of health workers and satisfaction with career development and nancial motivation was signi cantly associated with job satisfaction among health workers. Additionally, resource availability in health facility, recognition of work and management support is also required to improve job satisfaction.
A focus on improving work environment through increased nancial motivation and career development opportunities as well as investing in primary health facilities with increased resource support is recommended to improve job satisfaction.
in data analysis and reviewing the manuscript. All the authors reviewed, read and nalized the manuscript.