| BackgroundPrimary health workers are direct providers of health services. Thus, their quantity and competency directly decide the quantity, quality and outcomes of primary health services. In recent years, the overall educational level and professional title of primary health workers in China have improved. However, the overall competency of primary health workers in China is still at a low level. The small proportion of primary health workers who are well-educated and have relatively high professional title greatly limits the quality of primary health services. One of the major causes that lead to this situation is that primary health institutions have their difficulties in recruiting and retaining primary health workers with high competency. On one hand, students from medical schools are not willing to work in primary health institutions. On the other hand, primary health workers are not stable. Research shows that those primary health workers who leave primary health institutions tend to be more experienced and qualified. As a consequence, stabilizing primary health workers and alleviating primary health institutions’difficulties in recruiting and retaining qualified primary health workers are of great significance to improve the overall competency of primary health workers and to improve the quality of primary health services.Facing the problem that primary health institutions have difficulties in recruiting and retaining qualified primary health workers, researchers have conducted plenty of relative studies. Most of these studies are descriptive studies about human resources of primary health. There are also studies on incentive mechanisms and work-related attitudes of primary health workers. Few studies are found which focused on turnover intention and job preferences of primary health workers. There are some limitations of existing studies:Firstly, those descriptive studies about human resources of primary health can only find existing problems, but they are unable to find insightful reasons and thus can not give specific suggestions. Secondly, the aim of those studies on incentive mechanisms of primary health workers is to find an effective way to motivate their passion and enthusiasm, and to improve the efficiency of health services. Thus the findings of these studies are not so relevant on consideration of stabilizing primary health workers. Thirdly, most of the studies on primary health workers’work-related attitudes, such as job pressure, job burnout and job satisfaction, are focused on one attitude and its influencing factors. Systematic studies on work-related attitudes and their relationships are scarce. Last but not least, studies on turnover intention and job preferences of primary health workers are also scarce. The study methods of existing studies are traditional methods, such as descriptive study, univariate analysis and multivariate analysis.Based on existing relative studies, this study analysed the relationship among work-related attitudes and turnover intention of primary health workers in China. This study used structural equation model to establish the internal mechanism of turnover intention and work-related attitudes. Thus, the findings of this study are valuable to understand primary health workers’turnover intention and to propose effective solutions. Moreover, this study used discrete choice experiment to analyse primary health workers’ job preferences. Relative studies both at home and abroad are scarce. Thus, this study has both academic significance and practical significance.ObjectivesThe overall objective of this study is to systematically analyse primary health workers’ turnover intention and job preferences and their influencing factors, offering policy recommendations on stabilizing primary health workers. Specifically, the research objectives of this study include:to describe primary health workers’basic information and work-related problems; to analyse primary health workers’job pressure, job burnout, job satisfaction and their influencing factors; to analyse primary health workers’turnover intention and its influencing factors, to explore the internal mechanism of turnover intention and work-related attitudes, and to establish structural equation model of primary health workers’turnover intention; to analyse primary health workers’job preferences and its influencing factors; to propose policy recommendations on improving primary health institutions and stabilizing primary health workers.Data and MethodsThe data of this study are derived from the project "Study on Public Health Workers’ Behavior, Payment and Outcomes" that was funded by National Natural Science Grant awarded by National Natural Science Foundation of China. This study used a multistage sampling design. First, five provinces, namely Jilin, Shandong, Anhui, Chongqing and Shaanxi were selected in consideration of geographical location and economic development. Then, within each province, one urban district and two rural counties were chosen based on the representativeness of their socioeconomic status and health care development. Finally,5community health organizations were chosen in each urban district and3township health centers were chosen in each rural county. All the doctors, nurses and public health workers were investigated in these institutions. The final sample consists of308primary health workers in community health organizations and403primary health workers in township health centers.The major contents of the investigation of this study include:primary health workers’ personal attributes (demographic factors such as gender, age), primary health workers’ work attributes (work-related factors such as monthly income, living condition), primary health workers’job pressure, job burnout, job satisfaction, turnover intention and job preferences. Data analysis methods consist of:descriptive analysis was used to analyse the basic information of primary health workers’personal attributes, work attributes, job pressure, job burnout, job satisfaction and turnover intention; univariate analysis was used to compare the differences of primary health workers’job pressure, job burnout, job satisfaction and turnover intention among different personal attributes and work attributes; multivariate analysis was used to analyse the influencing factors of primary health workers’job pressure, job burnout, job satisfaction and turnover intention; structural equation model was used to establish and verify the structural relationship among primary health workers’ job pressure, job burnout, job satisfaction and turnover intention; discrete choice experiment was used to analyse primary health workers’job preferences.Stata12.0was used to conduct most of the analysis in this study, including descriptive analysis, univariate analysis, multivariate analysis, exploratory factor analysis and discrete choice experiment analysis. Amos17.0was used to conduct structural equation model.Results(1) The overall competency of primary health workers was still low:Similar with the finding of relative studies, the educational level and professional title of the primary health workers that participated in this study were not high. The major proportion of primary health workers have a primary professional title (64.12%), no more than10%of primary health workers have an associate senior professional title or a senior professional title. In terms of educational level, the major proportion of primary health workers have college degrees or lower, while only around20%have bachelor degrees or higher.(2) Primary health workers faced problems such as poor income and welfare benefit, heavy workload, poor opportunities for training and career development:Primary health workers’ income and welfare benefit were rather poor. The average monthly income of the primary health workers that participated in this study was about1900 RMB; half of them did not have pension insurance,65%of primary health workers in township health centers had no pension insurance. In terms of workload, more than60%of primary health workers considered their workload as heavy or very heavy, hardly any primary health workers thought their workload as light. Opportunities for training and career development of primary health workers were also poor. About60%of primary health workers considered their opportunities for training as insufficient, only10%considered their opportunities for training as sufficient; more than half of primary health workers considered their opportunities for career development as insufficient.(3) Primary health workers’job pressure and job burnout:The proportion of primary health workers who felt heavy job pressure was high, around10%felt fairly heavy pressure in work, while around40%felt heavy job pressure. The three dimensions of job burnout are emotional exhaustion, depersonalization and reduced personal accomplishment. There were no significant differences in job pressure and job burnout between primary health workers in community health organizations and township health centers. Respect from the community, workload and living conditions are the major influencing factors of primary health workers’job pressure and job burnout.(4) Primary health workers’job satisfaction:From the11terms of job satisfaction, primary health workers’satisfaction on interpersonal relationships at work and respect from the community were the highest, and their satisfaction on salary and welfare benefit were the lowest. From the3dimensions of job satisfaction, primary health workers’ satisfaction on relationship was the highest, followed by satisfaction on personal development, their satisfaction on basic needs was the lowest. There were no significant differences in job satisfaction between primary health workers in community health organizations and township health centers.(5) Primary health workers’turnover intention:There were almost half of the primary health workers that participated in this study who did not want to leave their current jobs, about one third of them had turnover intention. There were significant differences in turnover intention between primary health workers in community health organizations and township health centers. The proportion of primary health workers who wanted to leave their current jobs in township health centers was higher than those in community health organizations. In terms of age, primary health workers older than30and younger than50had the highest turnover intention, and those older than50had the lowest turnover intention. Primary health workers with higher professional title (associate senior or higher) and higher educational level (bachelor degree or higher) had higher turnover intention. Primary health workers’turnover intention was positively correlative with their job pressure and job burnout, and was negatively correlative with their job satisfaction. Controlling for personal attributes and work attributes, primary health workers’job pressure, emotional exhaustion and job satisfaction affected their turnover intention significantly. Primary health workers’ job burnout played as a mediator between job pressure and job satisfaction, and job satisfaction played as a mediator between job burnout and turnover intention.(6) Primary health workers’ job preferences:All the six job attributes that were included in this study significantly influenced primary health workers’job choices. In other words, primary health workers considered not only monetary factors but also nonmonetary factors such as working conditions and respect from the community when choosing a job. Other than salary, respect from the community, welfare benefit and working condition were major factors that influenced primary health workers’job preferences, the impact of opportunities for training and career development on primary health workers’job preferences were small.Conclusions and Policy ImplicationsThe overall competency of primary health workers are still low, and primary health workers confront problems such as poor income and welfare benefit, heavy workload, poor opportunities for training and career development.Primary health workers’job pressure was at a high level, respect from the community, workload and living conditions were the major influencing factors of primary health workers’job pressure and job burnout. Moreover, primary health workers’satisfaction on relationship was the highest, their satisfaction on basic needs was the lowest. This study also found that about one third of primary health workers had turnover intention, which implied the potential instability of primary health workers. Besides, those who had turnover intention tended to be younger and more qualified. The relationship of job pressure, job burnout, job satisfaction and turnover intention are tight, job satisfaction is the direct antecedent variable of turnover intention; job burnout has both direct effect on turnover intention and indirect effect on turnover intention through job satisfaction; job pressure has both direct effect on turnover intention and indirect effect on turnover intention through job burnout and job satisfaction.When choosing a job, primary health workers considered not only monetary factors but also nonmonetary factors such as working conditions and respect from the community. Respect from the community, welfare benefit and working condition were major factors that influenced primary health workers’job preferences.The following policy implications can be drawn and proposed based on the findings of this study:(1) Improving primary health workers’income and welfare benefit should be the priority of health investments;(2) Primary health institutions should make efforts to offer primary health workers with convenient living condition, such as building staff lounge and staff canteen, launching staff bus and so on;(3) In order to lighten primary health workers’workload to an appropriate level, policy makers should assess primary health workers’competency of providing primary public health services and distribute some of the services to other related health institutions (such as center for disease control, tuberculosis dispensary and so on);(4) In order to increase patients’trust on primary health institutions and primary health workers, policy makers should try to improve the competency of primary health institutions and primary health workers, such as improving the infrastructure and equipment of primary health institutions, and improving primary health workers’ opportunities for training;(5) Policy makers should also formulate policies on career development that are more suitable for primary health workers. Innovations and LimitationsThe innovations of this study:(1) This study laid the stability of primary health workers as the springboard, analysed primary health workers’ turnover intention and job preferences systematically. No similar studies have been found;(2) This study established the structural framework of primary health workers’ turnover intention using structural equation model, thus is of great importance to understand the generation mechanisms of primary health workers’ turnover intention;(3) This study investigated and analysed primary health workers’ job preferences using discrete choice experiment, thus can remedy the limitations of traditional methods. Similar studies are scarce.The limitations of the research:(1) In this study, the investigation of job pressure and turnover intention both used single question, this may lead to instability of the results. Future studies can add investigation questions from different perspectives to improve reliability of the results;(2) Due to the limitation of discrete choice experiment, we included only6job attributes when analysing primary health workers’ job preferences, as a result, we are unable to know the effects of other job attributes on job preferences. Meanwhile, as with all stated preference studies, the job choices we presented to the respondents were hypothetical, and further research needs to compare these results with results based on actual behavior. |
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