In China, village doctors refer to those who have obtained the "rural doctor qualification certificate" and work in village-level clinics, including those who have obtained the qualification of practicing (assistant) doctors and those who have not obtained the above qualification. China's Sixth National Population Census Data showed that the rural population accounts for 50.3% of the national population, still accounting for a large proportion. Village doctors are "guardians" of the health of rural residents, responsible for providing comprehensive and continuous basic medical and public health services for rural residents, including prevention, health care, rehabilitation and health management. Therefore, as the most grass-roots and most widely existing medical service providers in rural areas, village doctors play a very important role in ensuring and improving the health level of rural residents.
With the implementation of the new medical reform and the hierarchical medical system, the service mode of village doctors has changed from the passive "patient seeking medical treatment" to the active "health management service", and from the combination of prevention and treatment to the comprehensive and whole-of-the-life-cycle health services. The work of village doctors in village clinics is facing new challenges. They not only need to carry out daily medical treatment, but also public health, family doctor contract, family planning, chronic disease management and other services, which requires village doctors to continuously improve their service capacity and quality, and master a wider range of knowledge and skills. However, in recent years, the situation of village doctors in China is facing severe challenges, including the difficulty of obtaining the qualification certificate of practicing doctors due to the low level of overall education; the poor level of wages and treatment, the difficulty of ensuring old-age insurance; the low social status, the difficulty of introducing young talents, and the overall instability of the ranks. The above problems seriously affect the survival of village doctors and the stability of the overall team. A survey of 2,682 village doctors showed that village doctors had a low job satisfaction rate of 64.62%, especially in terms of income (24.98%), workload (39.34%), personal development (47.05%) and social status (50.34%). Poor satisfaction leads to high job burnout among village doctors. 68.60% of village doctors have moderate or above job burnout, and 45.3% of village doctors have high turnover intention. In 2019, there were two demission groups of village doctors in Henan province, once 36 and once 28.
In 2019, there were two resignation incidents of village doctors in Henan province, once 36 and once 28. As a result, the total number of village doctors and the number of rural clinics in China has been decreasing year by year. In May 2019, the statistical bulletin on the development of health undertakings showed that compared with 2017, China's village doctors decreased by 62,000 in 2018, and the number of village clinics decreased by 5,101. At the same time, there are 1022 administrative villages without clinics, 6,903 clinics without qualified village doctors. Thus it can be seen that the job satisfaction, job burnout and turnover intention of village doctors have been related to the stability of the village doctors, closely related to the health level of farmers and the steady development of rural health undertakings, and has become the weakness and weakest link of China's medical and health service system.
Burnout, known as the epidemic of medical personnel, has long become an international and universal research hotspot in the field of medical and health services. Maslach, in 2003, defined job burnout as a long-term, chronic response to work stress, and a persistent, harmful state syndrome related to work characteristics and working conditions. However, the most widely accepted definition is Maslach & Jackson's three-dimensional syndrome of burnout, including emotional exhaustion (EE), depersonalization (DP), and low personal achievement (PA). Among them, EE refers to a person who often shows a state of pessimism, depression, helplessness, hopelessness and depression at work; DP refers to a person who often treats patients or colleagues with negative, negative attitude and indifferent emotion at work; and PA refers to a person's slow decline in meaning and evaluation of the work performed and the feeling of being incompetent. By the World Health Organization (WHO) in June 2019," burnout "was included in its International Classification of Diseases Manual and defined as" a syndrome caused by the failure of successful management of long-term job stress ", and it was noted that if patients showed three symptoms, doctors could give the diagnosis of burnout: fatigue, cynicism about work, and difficulty in successfully completing work. This means job burnout has become an international occupational health problem and needs to attract people's attention.
Job burnout is a reflection of the long time mismatch between workers and work, which is manifested by the negative response of their work stress. Serious burnout of doctors usually cause negative self-image and psychological problems such as anxiety and depression; low attendance and efficiency; and reduce the communication time between doctors and patients, which will lead to the decline of the quantity and quality of medical services, as well as the increase of the incidence of medical disputes and risks. When job burnout cannot be well treated and intervened, it may force doctors to leave the doctor's post, long-term accumulation will be harmful to the doctor's psychosomatic and social interaction. Therefore, doctor's job burnout, as the focus of occupational medical health, is a great subject related to people's health and happiness. Current research suggests that the causes of doctors' job burnout stem from three dimensions: social system, organization and individual factors. Firstly, social factors include lack of social support, strict and cumbersome laws and regulations, aging, lack of social security, excessive income gap, patient satisfaction, etc. Secondly, organizational factors include management style, excessive workload, type of occupation, organizational change, fierce competition, endless overtime, inappropriate working conditions, low organizational efficiency, lack of sense of achievement, insufficient career development opportunities, and excessive working hours each time. Finally, individual factors include: gender, age, relationship between husband and wife, whether there are young children, role conflicts, personality, self-esteem, ways to deal with difficulties[5, 8-10], etc. However, the influence of personality and alexithymia on burnout of village doctors has not been studied. At the same time, although the study believes that work engagement is an effective measure to interfere with job burnout of village doctors, the impact of work engagement on burnout is still lack of empirical research. Meanwhile, existing studies have mostly used chi-square test, t-test, Analysis of Variance (ANOVA) and, multiple linear or multiple logistic regression analysis, to analyze the factors influencing job burnout[5, 10-16]. Compared with the above research, structural equation modeling (SEM) can not only measure the correlation between research variables, but also dig the correlation between potential variables, and even explain the causal relationship between variables. Therefore, the introduction of SEM to study the quantitative regression relationship can make up for the limitations of current research to some extent[17, 18].
Although burnout comes from three aspects, it does not occur in all people, even in the face of the same organizational and social factors, which is related to the individual factors of burnout. On the aspect of individual factors, Swider and Zimmerman believed that personality, the sum of characteristics such as temperament, ability and character， was closely related to burnout and turnover, and basing on modern personality theory, they assumed that individuals' personality can influence their cognition and response to the environment. For example, when team members conflict, individuals with neuroticism may have different assessments of conflict from other participating individuals.
Many researches usually adopt the famous personality model proposed by Costa and McCrae , namely five factor model, which defines five groups of interdependent personality traits: neuroticism, extroversion, openness, easygoing and conscientiousness. Neuroticism reflects a person's emotional instability and fear, people with high scores are usually worried, unhappy and insecure; Extroversion reflects a person's self-confidence and positive, and those with high scores tend to have better social abilities. People with open personalities tend to be curious and playful, and they like new and unconventional ideas; Agreeableness represent the individual's orientation to others' experience, interest and goal, the higher the score is, the more modest, kind and compassionate; Conscientiousness refers to a person with a cautious attitude to guide their daily behavior, therefore, serious people are often reliable and prudent. Many empirical studies have found that personality is negatively correlated with burnout and affects it directly and indirectly. Okan Taycan et al. through a survey of 139 doctors in semi-urban and rural areas in Turkey, found that their level of job burnout was slightly higher than that of urban doctors, and the neuroticism dimension in personality was a significant predictor of burnout. Doctors with personality characteristics such as high hostility, introversion, neuroticism, aimlessness, hostility, and unwillingness to accept new things had higher occupational burnout according to Cheng-Chieh Lin et al. found in a study of 2230 doctors in Taiwan. Further research found that neuroticism, agreeableness and friendliness, and openness and friendliness were found to be predictors of emotional exhaustion, and individual achievement was determined by neuroticism, openness, conscientiousness, and hostility. Personality can influence job burnout through the mediating effect of subjective well-being. Individuals with personality traits such as emotional instability, neuroticism, anxiety and irritability had lower levels of happiness and higher levels of emotional burnout.
As a multi-dimensional personality structure, alexithymia represents a defect in emotional cognitive processing ,which is frequently associated with major depression and anxiety disorders. Even some researchers suggest that alexithymia secondary to depression, and is a manifestation of "state dependence.". Many researches indicated that people with alexithymia are more likely to develop the feeling of tension when staying in a high-pressure working environment, which may lead to the heavier emotional exhaustion, depression and depersonalization[22, 24], and even physiological diseases such as gastroenterology and hepatology disorders. But no matter in the field of psychology or occupational health, few researches focus on the relationship and mechanism between burnout and alexithymia. In a few studies，A study of 95 nurses in Greece by Aikaterini Moulou et al. found that alexithymia was positively associated with depersonalization and emotional exhaustion in burnout and could influence overall burnout scores through personal achievement and family support. After investigating 159 nursing assistants in 10 nursing homes in northern Spain, Erkuden Aldaz et al found that, after strictly controlling the mixed effect of work characteristics, alexithymia made a moderate contribution to the depersonalization and personal accomplishment dimensions of burnout.
High level of work engagement is essential no matter what occupation you are engaged in. Work engagement is defined as a positive, fulfilling, work-related state of mind including three dimensions of vigor, dedication and absorption. Tatenda S.Mhlanga et al. believe that although researchers have now found many beneficial and positive consequences of work engagement，such as, improving work efficiency, however, few people know the multiple antecedents that lead to work engagement, in which personality is an important antecedent. A study covering 1,236 nurses showed that neuroticism was negatively correlated with work engagement, thus, extroversion, openness, easygoing and conscientiousness were positively correlated with work engagement. At the same time, a Chilean study found that people with higher personality scores tend to have higher work engagement, and such people gain a lower level of job burnout even when working under high pressure.
After a comprehensive analysis of the above-mentioned theories and literature conclusions, the research is the first attempt to propose assumptions among personality, work engagement, alexithymia and job burnout and construct a double mediation model presented in Table 1 and Figure 1. We hypothesize that village doctors' personality, work engagement and alexithymia could have direct effects on burnout. Furthermore, personality could influence indirectly on the rural medical staff’s burnout through work engagement and alexithymia.
The Theoretical Hypotheses
1. Village doctors' work engagement has a negative impact on burnout.
2. Village doctors' alexithymia has a positive impact on burnout.
3. Village doctors' personality has a positive impact on work engagement.
4. Village doctors' Personality has a negative impact on alexithymia.
5. Village doctors' Personality has a direct negative impact on burnout.
6. Village doctors' Personality has an indirect negative impact on burnout through the mediating effect of work engagement.
7. Village doctors' personality has an indirect negative impact on burnout through the mediating effect of alexithymia.