This study presented critical information regarding the current profile of financial satisfaction, turnover intention, social support, and burnout and their relationships among primary care providers in China. Our results showed that financial satisfaction was strongly related to turnover intention, and individuals who were dissatisfied with their financial situation had a higher risk for turnover intention However, this correlation occurred through both direct and indirect effects. Financial satisfaction had a significant indirect effect on turnover intention mediated by social support and burnout. Moreover, the pathway from social support to burnout played a mediating role between financial satisfaction and turnover intention.
The results showed that primary care providers were generally dissatisfied with their financial situation. This finding was consistent with a previous study that found primary care providers were the least satisfied with their income . Since 1980, primary care providers in China have been able to charge a 15% markup on drug sales, but this was abolished in 2017 because of over-prescribing of drugs. The government increased its subsidy for primary healthcare institutions, but this policy substantially reduced the incomes of primary care providers . The mean score for turnover intention was 14.16, which was similar to previous results for general practitioners . The possible interpretation for the high-level turnover intention among Chinese primary care providers is their heavy workload, low income level, and few professional development opportunities . Moreover, 11.3% of participants reported severe burnout, which was higher than that reported among Chinese primary care doctors  and primary care providers in the US . The mean score for social support in this study was 64.93, which was lower than reported in a previous study involving Chinese physicians .
To our knowledge, this is the first population-based study among Chinese primary care providers that investigated the relationship of financial satisfaction and turnover intention as well as the mediating roles of social support and burnout. Prior studies observed correlations between financial satisfaction and turnover intention [9, 28]. However, those studies used different participant groups (e.g., specialist physicians) or analysis methods (e.g., traditional regressions and correlations). Although those studies differed from ours in terms of specific details, the results regarding the negative relationship between financial satisfaction and turnover intention were consistent, which confirms the results of our study.
This study found that financial satisfaction was associated with an increased likelihood of high social support among primary care providers. A study conducted among primary healthcare patients in Brazil suggested that people with a high income were more likely to receive more social support than those with a low income . The workloads of primary care providers have surged since the introduction of the basic public health services program . Furthermore, compared with workers with a low income, those with a high income may be able to get more support from coworkers . However, income levels and workloads appear to be mismatched. Financial dissatisfaction may also reduce the desire for social intercourse, and increase pressure in family life. Support from social networks may therefore be reduced by financial dissatisfaction and lack of communication. We found a correlation between low social support and high risk for turnover intention, which was consistent with a previous survey of Chinese specialist physicians and emergency room nurses [25, 39]. Social relationships are established by primary care providers in daily life and also at work (e.g., physician–nurse, physician–leadership, and physician–patient relationships). Primary care providers can also receive encouragement and support from their daily life networks (e.g., family and friends) or from work networks (e.g., leaders and colleagues) when faced with increased workloads. These factors may explain the mediating role of social support in financial satisfaction and turnover intention observed in this study. Financial dissatisfaction may lead to decreased social support from family, friends, and colleagues because of lack of communication and increased life pressure, and turnover intention increases when there is a lack of social support.
Financial dissatisfaction means a higher level of burnout for primary care providers; although this has not been confirmed in primary care providers, it has been described in previous studies conducted among Korean doctors  and Chinese nurses . Moreover, an association between burnout and turnover intention was observed in this study, which was consistent with earlier findings for physicians in the United States . Factors predicting burnout include low reward, excessive workload, low organizational status, and low support . Medical and basic public health services provided by primary care providers that resulted in excessive workloads did not increase their income. Furthermore, there is no professional rank promotion system for primary care providers in China, which means it is difficult for them to gain a higher organizational status . This may explain the associations between financial satisfaction, burnout, and turnover intention in primary care providers in this study. A mediating role of burnout between financial satisfaction and turnover intention was found in our study. Financial satisfaction was a predictor factor of burnout, and low financial satisfaction was reflected in a high level of burnout; that is, the higher level of burnout, the greater risk for turnover intention. In addition, we found a multi-serial mediation role of burnout through social support between financial satisfaction and turnover intention. Financial dissatisfaction may reduce social support through decreased social intercourse and increased family life pressure. Decreases in social support, especially support from colleagues, may increase the risk for burnout, thereby leading to increased turnover intention.
We selected age, gender, and marital status as covariables to control potential confounding variables in the SEM. The direct and indirect effects were significant before and after the covariates were added in the model.
The strengths of this research include the use of SEM, which is an analytical method suitable for evaluation and measurement that can eliminate measurement errors for variables that are difficult to measure, such as social support, burnout, and turnover intention. This study also showed a direct effect among four study variables and the mediation linking financial satisfaction with turnover intention, which is the first time this has been shown among primary care providers.
This study had several limitations. First, the measurements of financial satisfaction, turnover intention, social support, and burnout were obtained using self-administered questionnaires, meaning self-report bias might have impacted the results. Second, this study was a cross-sectional study, and the interpretation of causal inferences on the results is limited. Finally, the sample was selected from one province, so the extrapolation of conclusions to the national level could be challenged. These limitations need to be addressed in further research.