Relationships between actual and desired workplace characteristics and job satisfaction for community health workers in China: a cross-sectional study

China introduced the concept of general practice in the 1980s and began to build community health services in urban areas in the 1990s. In 2009, a new set of health system reforms, officially introduced by China's central government, called for the development of community health services. The state established basic public health service items, which focused on providing basic public health services for urban and rural residents. These services were provided by general practitioners, nurses, and public health physicians from community health centers (CHCs) and community health stations.

Heilongjiang Province is located in Northeast China and has a population of approximately 38.1 million. There were 410 urban CHCs and 366 community health stations as of December 31, 2012 [ 1]. The integrated management of CHCs and their affiliated community health stations was adopted by the Heilongjiang Provincial Health Bureau, providing unified management to CHC and community health station employees.

There are 5,416 general practitioners working in community health institutions in the province. When this number is compared to the reference population, based on human resource planning ratios, there is a shortfall of approximately 30% in the number of general practitioners (5,416 vs. 7,620) [ 2]. Since the introduction of CHCs, these institutions have encountered difficulties due to limited resources, an insufficiency of staff members, and inadequate staff training [ 3]. Recent reforms have expanded the scope of public health services and increased workload without increasing the number of staff members [ 4],[ 5]. Moreover, it has been demonstrated that work motivation can influence job satisfaction, which influences job performance [ 6]-[ 9]. Consequently, it is critical that healthcare managers and policy decision makers motivate current staff and improve their job satisfaction.

Increasing workers' job satisfaction is a topic that has been studied extensively by researchers and managers [ 10]. Job satisfaction refers to the relationship between what workers desire from their jobs and their perceptions regarding what their jobs offer [ 11]. Some researchers have also proposed that job satisfaction is a function of the discrepancy between needs and outcomes [ 12]-[ 14]. In addition, job satisfaction can affect job performance, retention, and turnover [ 15]-[ 17]. Therefore, it is important that managers understand their employees' needs, how the discrepancy between those needs and perceived incentives relates to job satisfaction, and how to motivate employees and increase their job satisfaction.

There are various workplace incentive policies in existence, such as those of financial and in-kind rewards, professional development, training opportunities, and positive working environments [ 18]-[ 21]. The value of an incentive depends on its actual content and the extent to which it matches what is desired by individuals [ 22],[ 23]. There is extensive literature concerning factors affecting job satisfaction and motivation. Herzberg's research results created the dual-factor theory of motivation [ 24]. Content theories were developed to link employee motivation and desired satisfaction [ 25]. Existence, relatedness, growth (ERG) theory, which reduced Maslow's five levels of need to three categories (Existence, Relatedness, and Growth), was proposed by Clayton P. Alderfer [ 26]. Alderfer maintained that the three ERG areas are not hierarchical levels, and an employee's behavior is motivated by more than one need level operating simultaneously. This theory included a frustration-regression process, in which inability to satisfy a higher need causes frustration and a regression to the level of need that is one step lower in a hierarchy of needs. ERG theory also suggested that the fulfillment of one need would enhance one's desire. Process theories focused on the influence of subjective expectation, or the value that is placed on staff, on employees' work efforts [ 27]. The crowding-out effect proposes that extrinsic rewards have a negative impact on intrinsic motivation [ 28]. Previous researches have suggested that both desired workplace incentives and perceived actual incentives affect job satisfaction, either directly or indirectly [ 23],[ 29]. For example, Linz and Semykina assessed the relationship between job satisfaction and anticipated reward [ 29].

The purpose of this study was to assess the determinants of job satisfaction in community health workers in one Chinese province. A cross-sectional survey was conducted to measure actual and desired workplace characteristics and job satisfaction. Factor analysis was used to identify the main factors involved in workplace incentive. The key determinants of job satisfaction in community health workers were assessed, with particular attention directed toward actual and desired workplace characteristics.

The socioeconomic and demographic status of respondents was examined. Subsequently, eight subscales of DWC were derived based on the factor analysis; for each of the eight subscales, DWC, AWC and GWC were measured, and the determinants of job satisfaction were assessed.

This study was one of the most recent efforts to focus on gaps between workers' desires and perceptions of workplace incentives and analyze the determinants of job satisfaction in urban community health workers in China. An eight-subscale structure of workplace characteristics was derived via factor analysis. The mean value of each DWC subscale was higher than the associated AWC subscales, and some AWC subscales predicted DWC, either positively or negatively. We also found that five GWC subscales and some socioeconomic characteristics significantly predicted job satisfaction.

In this study, overall job satisfaction was higher than extrinsic job satisfaction and lower than intrinsic job satisfaction. This finding is consistent with previous research on job satisfaction in Chinese community health workers [ 35]. To account for variations in job satisfaction, four distinct multiple regression models were assessed, with specific consideration of AWC and GWC. The socioeconomic characteristics of workers were included in all models, and each model accounted for a significant proportion of the variation in job satisfaction. While the AWC subscales were significant when used alone (Model 1), which replicated previous research [ 17],[ 29], this model was dominated by Model 2, which only used GWC subscales. In this context, occupation, years worked, and five subscales (system & policy; fringe benefits; working relationship; professional development; and remuneration.) were significant determinants. The result was quite similar to those of previous studies [ 12],[ 14]. When AWC and GWC were combined (Model 3), none of the individual AWC subscales were significant determinants of job satisfaction. Further, the interaction between AWC and GWC was included in Model 4, and while the subscales of both the interaction variable (AWC*GWC) and the AWC accounted for a larger proportion of the variance, none were significant individually. Therefore, Model 2 was the superior model. This was consistent with Longest's study, which indicated that only needs that were not yet fulfilled influenced behavior [ 36].

These findings have significant implications for policy makers and CHC managers in their efforts to improve workers' job satisfaction. First, they should pay more attention to narrowing the gaps between the AWC and DWC, as five subscales of the GWC were negative predictors of job satisfaction. These findings were consistent with Locke's study, which linked job satisfaction with discrepancy between actual and expected rewards and facets of the job [ 37]. The results also indicated that there was considerable room for improvement in narrowing these gaps in order to improve job satisfaction, as the mean scores for each subscale of the AWC were significantly lower than those of the associated DWC subscale. Longest's study proposed that individuals are beings of desire, whose needs depend on what they already have [ 36]. ERG theory suggested that the fulfillment of one need would enhance one's desire for a higher-level need [ 26].

In the present study, remuneration (stable income, pay equity, and performance bonus) ranked highest for DWC and GWC [ 29]. According to Herzberg's motivation-hygiene theory, remuneration is a hygiene factor that is required to ensure that an employee is satisfied. Previous studies have revealed that adequacy of pay and perceived equity via others influenced job satisfaction and behavior [ 38]. Studies in most developing countries have shown that job dissatisfaction in health workers is primarily accounted for by low salaries [ 16],[ 39]. Therefore, managers should provide fair pay to reduce the gap between desired and actual remuneration to improve job satisfaction [ 40],[ 41].

Second, financial incentives are not the sole means of stimulating motivation and improving job satisfaction [ 42],[ 43]. Other factors, particularly working relationships, professional development, and system and policy subscales of GWC, were negative predictors of job satisfaction [ 44],[ 45]. These findings were congruous with previous studies and highlighted the importance of packaging financial and nonfinancial incentives [ 46],[ 47]. In addition, the regression equation for DWC showed that general practitioners, public health physicians, and workers with 6-15 years in the profession expressed greater desire for professional development.

Third, managers and policymakers should consider DWC and AWC comprehensively, as subscales of AWC can influence subscales of DWC positively or negatively. In our study, we found that actual remuneration was a positive predictor of desired fringe benefits, and actual fringe benefits were a positive predictor of desired remuneration. Consequently, an increase in actual fringe benefits would increase the gap between desired remuneration and actual remuneration. Similarly, an increase in actual remuneration would enlarge the gap between desired and actual fringe benefits. Therefore, to improve job satisfaction, care should be taken to balance the relationship between remuneration and fringe benefits.

Results also revealed that the working relationship subscale received the lowest ranking in GWC and the highest ranking in AWC. Three reasons accounted for this result. First, CHC is a simply structured organization employing fewer workers relative to general hospitals; therefore, managers enjoy greater opportunity to tailor incentives to individual staff members and provide employees with timely guidance if required. Second, it was easier for employees to communicate and form positive relationships in CHCs [ 16],[ 48],[ 49]. Third, as ERG theory indicates, if a higher-level need appears too difficult to fulfill, the person may regress to lower-level needs [ 26]. In our study, actual remuneration and fringe benefits were both low-level needs; therefore, financial needs increased, and desire for working relationships decreased. Therefore, working relationships were ranked in the lowest position in GWC.

In this study, we found that general practitioners and public health physicians reported higher job satisfaction compared with administrative staff. In community health institutions, general practitioners and public health physicians were the main providers of basic public health and medical services. They earn higher salaries and would be afforded more opportunities to join conferences and receive in-job training. The results also indicated that health workers who had worked in the position for 11-15 years displayed lower levels of job satisfaction. Most of these workers faced difficulties with respect to promotion, because it was difficult for community health workers to achieve promotion, as there were limited annual promotion quotas in CHCs in Heilongjiang Province. This would exert a negative influence on job satisfaction.

It is important that health-care managers and policy decision makers improve and maintain the job satisfaction of health workers in low-resource settings. We analyzed the relationship between desired and actual workplace characteristics comprehensively, and the key determinants of job satisfaction were assessed using multiple regression analysis. The results indicated that subscales of AWC affect subscales of DWC both positively and negatively. Five subscales of GWC, comprising system and policy, fringe benefits, working relationship, professional development, and remuneration were significant negative predictors of job satisfaction. The study findings suggest that managers should endeavor to reduce the gap between DWC and AWC to improve job satisfaction. The results also suggest that some subscales representing the gaps (i.e., between DWC and AWC) are more important than others as determinants of job satisfaction. Two methods could be used to reduce this gap. One is to improve actual workplace incentives, and the other is to dampen DWC. It is difficult for managers to help every staff member to meet all of their needs, due to limited resources. However, subscales of AWC predicted subscales of DWC both positively and negatively. Therefore, in order to formulate incentives suitable for their own organizations, managers should consider determining which incentives they can provide and which workers desire, in addition to examining the relationship between workplace characteristics and job satisfaction.

LL was responsible for the study design, data collection, data analysis, the drafts and the final manuscript. ZZ and XYL contributed equally as the first author to this article for study design and the drafting of the manuscript. HZ provided statistical expertise. XYL and HZ performed data collection and technical support. ZNS provided questionnaire translation and literature review. LHF provided administrative support. PC made critical revisions to the paper for important scientific content and reviewed various drafts as well as the final manuscript. All authors read and approved the final manuscript.