Background

Community health service (CHS) mainly involves general medical service. It is a basic health service [1] that is economical, convenient, highly comprehensive, and full of human interest. It can increase the fairness and efficiency of the health care service. It can also control the increase in medical costs and raise the health level of residents [2]. Many countries have established a relatively complete and stable CHS system to meet the people’s basic medical care demands [3]. For example, the United Kingdom and Australia have established a strict training and entrance system for their community general medical practitioners (or general practitioners) to provide satisfactory basic medical services to residents by producing well-trained community general medical practitioners. Therefore, only emergency patients or those who require medical treatment, as assessed by the community general medical practitioner, are moved to hospitals [4, 5]. However, in China, most medical colleges and universities do not offer general medicine specifically. Thus, CHS workers consist mainly of common medical practitioners [6]. A CHS work team is still under development.

In 1997, the Decision on Health Reform and Development by the Chinese government proposed the active development of CHS for the first time. In 2002, the Chinese Government issued Opinions on Accelerating Development of Urban Community Health Services, which requires the establishment of an urban CHS system to meet the health care demands of residents. In the following 3 years, the Chinese government built the foundation of the CHS system [7]. The Guidance on Developing Urban Community Health Services, issued in 2006, requires that all cities at the prefecture level or above and all county-level cities around China must build a relatively complete CHS system by 2010. The Chinese government also issued Guidance on Enhancing Building of Urban Community Health Talent Team, which requires the enhancement of the development of a CHS workforce, improvement of the CHS work team quality as a whole, completion of the training system, and completion of the development of general medical and community nursing sciences. In 2009, to meet the increasing health service demands of the residents and mitigate “the difficulty in obtaining medical service and high cost of medical treatment,” the Chinese government initiated a new medical and health system reform by successively issuing the Opinions on Further Medical and Health System Reform and the Implementation Scheme for Further Medical and Health System Reform from 2009 to 2011, both of which took the development of the CHS system as the foundation for future health work, presented applicable measures, and set the goal of cultivating, developing, and stabilizing CHS talent [8].

Currently, the object of the service provided by the Chinese CHS is the entire community of residents. The Chinese CHS provides basic diagnostic and treatment services [9] for disease prevention, keeping fit, recuperating health, health education, family planning technical service, common diseases, frequently encountered diseases, and chronic diseases. CHS organizations mainly comprise CHS centers and CHS stations. By June 2012, a total of 33,736 CHS organizations were established in China, of which 20,050 were founded by the government, and 396,476 CHS workers were recorded [10]. These numbers indicate that the CHS work team is sufficient in terms of quantity [11]. However, studies on the residents show that only about half of the residents have ever availed of CHS and less than 30 % are willing to choose CHS as a first option for treatment. As a whole, residents who received services from CHS were not very satisfied [12, 13]. The reason is that the residents do not have enough confidence in CHS [14] and think that the technical capability of CHS is insufficient [15, 16]. The results of the investigation on CHS workers show that CHS workers have a relatively high demission rate [17, 18], are not well educated, [19], possess poor professional skills [20], and are inefficient [21], among others. CHS workers are crucial for the excellent performance of the CHS [22]. A stable and high-quality CHS work team is the basis for ensuring CHS quality, meeting the basic health service demands of the residents, and ensuring the sustainable development of CHS [23]. Thus, probing into the current factors that influence the turnover intention of CHS workers is very important.

Scholars and government management departments focus on studying CHS capacity development. They pay more attention to cultivating community general medical practitioners and training in-service CHS workers than to the factors that result in CHS worker turnover intention. As turnover intention has a significant positive correlation with demission behavior [24], an investigation on the turnover intention can effectively facilitate the prediction of future talent stability. Generally, the desire of medical workers to resign depends on how much of their work demands are met [25, 26].

The purpose of this study is to analyze the related factors that result in CHS worker turnover intention by investigating CHS workers from five Chinese provinces, including their individual characteristics, turnover intention, and degree of work satisfaction, to determine the main factors that result in CHS worker turnover intention according to the results. The discussion aims to create a strategy for increasing CHS worker stability and CHS workers’ degree of work satisfaction. We aim to provide a stable human resource foundation for the capable development of CHS organizations to meet the basic health service demands of community residents.

Methods

Study Population

CHS organizations were chosen through sampling in several stages. First, because China is very large, five provinces in East, South, West, North, and Central China, namely, Zhejiang, Guangdong, Guizhou, Hebei, and Hubei, respectively, were chosen according to geographical location and level of economic development. Second, a capital and a common city were chosen from each of the five provinces. Ten cities were chosen in total. Third, 10 CHS organizations were randomly chosen from the 10 cities; thus, 100 CHS organizations were chosen.

All health workers in the selected CHS organizations, such as medical practitioners, nurses, public health workers, and medical technicians (pharmaceutical personnel and inspectors), were considered objects of the study, excluding administrators and logistical personnel. A total of 3,212 CHS workers were studied, of which 610 were from Zhejiang, 652 from Guangdong, 617 from Guizhou, 583 from Hebei, and 750 from Hubei. The Ethics Committee, Tongji Medical College, Huazhong University of Science and Technology (IRB No: FWA00009618) approved this study. All investigated CHS workers were aware of this study and were willing to participate in the investigation. The privacy of the investigated CHS workers was strictly protected.

Questionnaire

The CHS worker questionnaire has three parts: socio-demographic information, demission intention and causes, and degree of work satisfaction. The socio-demographic information contains data on sex, age, educational qualifications, post, title, and work seniority. Included in the questionnaire were questions on the intention of CHS workers to be dismissed and the factors that cause demission intention, such as pay packets, learning and training opportunities, promotion and individual development space, interpersonal relationships, work stress, influences of busy work, work conditions, family life environment, individual value embodiment, and scientific research atmosphere. The investigation on the degree of work satisfaction of CHS workers addresses the fullness and stability level of jobs, decision-making ability of managers, opportunities to exercise one’s abilities fully in work, how superiors treat employees, amount of stress given by leaders, opportunities for work autonomy, job achievement, methods and measures for implementing organization policies, promotion opportunity, and balance between remuneration and work quantity. For these aspects, we provided five options (numbered from 1 to 5) for the CHS workers to express their work satisfaction: “1” represents very dissatisfactory, “2” represents dissatisfactory, “3” represents moderate (not too bad), “4” represents satisfactory, and “5” represents satisfactory.

Statistical Analysis

EpiData3.1 was used to establish a database, and the collected data were entered into the computer using duplex computers. PASW18.0 (SPSS) was used for related statistical data analysis. The socio-demographic factors of the investigated CHS workers were summarized using a descriptive statistical analysis method. The Pearson Chi square statistical method was employed to assess whether the socio-demographic and other factors were related to CHS worker turnover intention. Binary logistic regression was used to judge significantly related factors that result in CHS worker turnover intention. The variant is whether the CHS workers want (1) or do not want (0) to resign. To select and substitute significant variants into the regression model for calculation, we only substituted significant variants discovered from the Pearson Chi square statistical test into the Binary logistic regression model (p < 0.05). The odds ratio (OR) was reported with 95 % (CI) where applicable. All tests were conducted at the 5 % level of significance.

Results

Socio-demographic Features of the Investigated CHS Workers

Overall, 99.32 % of the questionnaires were accomplished and returned. A total of 3,234 CHS workers were investigated and 3,212 valid answer sheets were returned. The average age of the investigated CHS workers ranged from 25 to 34 (38.3 %), and most of the investigated CHS workers were female (72.8 %). The highest educational qualification of the investigated CHS workers was junior college (43.3 %), and the titles of the investigated CHS workers were mainly junior titles (52.5 %) (Table 1).

Table 1 Socio-demographic features of the investigated CHS workers in five Chinese provinces and cities
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Turnover Intention of CHS Workers

According to the results of the investigation conducted in five Chinese provinces, 61.3 % of the CHS workers did not plan to leave the organization in which they were currently employed but 38.7 % considered leaving. More than one-third of CHS workers intended to resign.

Socio-demographic Factors Related to CHS Workers’ Turnover Intention

The Chi square test method was employed to test the correlation between all indexes of socio-demographic factors and CHS worker turnover intention. The value 1 was set for CHS workers who are “considering to leave the current employing CHS organization and go to other medical organization” and 0 for those who “do not consider leaving their current employing CHS organization.” The results show that among the socio-demographic factors of CHS workers, age, post, title, and work seniority were related to CHS worker turnover intention (p < 0.05) (Table 2).

Table 2 Univariate analyses of socio-demographic factors related to CHS workers’ turnover intention
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Assessment on the Factors Resulting in CHS Workers’ Demission Intention

According to the results, 74.2 % of investigated CHS workers chose pay packets as the main factor that results in CHS worker turnover intention. Learning and training opportunities, promotion and individual development space, and work stress are also main factors that may result in the demission intention of CHS workers. The proportion of investigated CHS workers that chose these options is 41.0, 29.5, and 29.5 %, respectively. The Pearson Chi square test was used to analyze the factors that influence turnover intention. The analysis results show that pay packets, learning and training opportunities, promotion and individual development space, and work stress are significantly related to CHS worker turnover intention (p < 0.05) (Table 3).

Table 3 Assessment and analysis on the factors resulting in turnover intention of CHS workers
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Analysis on the Multiple Factors Influencing CHS Workers’ Turnover Intention

To further analyze the factors that influence CHS worker turnover intention, we analyzed the significantly related factors (p < 0.05) taken from a previous study using the binary logistic regression method. Analysis results show that age and post are significantly related to CHS worker turnover intention. Compared with that of CHS workers younger than 24, the turnover intention probability of CHS workers older than 55 is the lowest. The turnover intention probability of CHS workers older than 55 is 0.518 times that of CHS workers younger than 24 (OR 0.518, 95 %CI = 0.296–0.905, p = 0.021). Compared with that of doctors, the turnover intention probability of medical technicians is lower and is 0.796 times that of doctors (OR = 0.796, 95 %CI = 0.645–0.982, p = 0.021). Factors that influence turnover intentions, namely, pay packets and learning and training opportunities have a positive correlation with the turnover intention of CHS workers. The turnover intention probability of CHS workers who consider that pay packets may result in turnover intention is 1.351 times that of other CHS workers (OR = 1.351, 95 %CI = 1.114–1.639, p = 0.002). The turnover intention probability of the CHS workers who consider learning and promotion opportunities may influence turnover intention is 1.549 times that of other CHS workers (OR = 1.549, 95 %CI = 1.189–2.019, p = 0.001) (Table 4).

Table 4 Analysis on the multiple factors influencing the turnover intention of CHS workers
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Work Satisfaction Degree of CHS Workers

According to the statistical results of the work satisfaction degree scores of the investigated CHS workers in various aspects, CHS workers are more satisfied with work fullness (3.75 ± 0.859), work stability (3.67 ± 0.850), and the decision-making ability of managers (3.61 ± 0.946), and are less satisfied with the balance between remuneration and work quantity (2.97 ± 1.047), promotion opportunities (3.14 ± 0.896), and work conditions (3.35 ± 0.967). CHS workers are most satisfied with work fullness and least satisfied with the balance between remuneration and work quantity (Table 5).

Table 5 Satisfaction degree of CHS workers in all aspects
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Discussion

In the past decades, the Chinese government paid increasing attention to developing the CHS. As the new medical and health system reform began in 2009, the Chinese government has started to take CHS development as a foundation task for promoting medical and health system reform and mitigating the difficulty of obtaining medical service and its high costs. The government has also modified the basic medical insurance system and the national system for basic drugs to ensure the healthy development of CHS. Moreover, the Chinese government is focusing on developing CHS to establish a complete preliminary health care system and a basic public health service system. Both the central government and the local governments at all levels are investing more funds for CHS, which significantly increases the number of CHS organizations and CHS workers. The geographical coverage rate of CHS organizations and CHS workers reaches almost over 98 % [27]. The goal of CHS development is to make CHS meet the basic health service demands of the residents. The stability and suitable work positioning of the CHS work team is the foundation for ensuring the realization of this goal. However, this study shows that 38.7 % of the CHS workers want to resign. Therefore, we need to further analyze the factors that influence CHS worker turnover intention to provide a basis for completing CHS development in the future.

Let us study the results of related studies by country and region before discussing the findings of this study. In the analysis of socio-demographic factors that influence the turnover intention of medical workers, some studies show that sex, age, work seniority, educational qualification, and so on are related to the turnover intention of medical workers [28]. In terms of the other factors that influence the turnover intention of medical workers, some studies show that dissatisfaction with job income, lack of development opportunity, exceedingly high job quantity, individual job burnout, conflict between job and family, and dissatisfaction with the work environment, among others, can result in the demission intention of medical workers [29, 30]. The gap between expected income and actual income influence the satisfaction of medical workers with regard to their salary, and the degree of salary satisfaction and job stress influence the degree of work satisfaction and organization identification [31]. Some studies also show that turnover intention has a significant negative correlation with the degree of work satisfaction and organization identification [32, 33], and has a significant positive correlation with a subscale of the burnout syndrome and emotional exhaustion [34]. The higher the degree of work satisfaction and job identification is, the lesser the probability of having demission intentions. Specifically, the lower is the income satisfaction, work environment satisfaction, degree of organization management satisfaction, and other aspects of work satisfaction, the lower the individual value realization and the stronger the demission intention [35].

The conclusions drawn in this study are similar to those drawn scholars from other countries and regions. According to the results of the analysis on the data, among the socio-demographic factors of investigated CHS workers, age, post, title, and work seniority are the factors that influence the existence of CHS worker turnover intention. In other aspects, pay packets, learning and training opportunities, promotion and individual development space, and work stress are the factors that influence the existence of turnover intention of CHS workers. The probability of CHS workers younger than 24 years possessing turnover intention is relatively high. Compared with that of doctors, the turnover intention probability of medical technicians is lower. Specifically, the probability of doctors possessing turnover intention is higher than that of medical technicians. Pay packets and learning and training opportunities are significantly correlated with CHS workers’ turnover intention. To enhance the stability of CHS workers, effectively cut and control their turnover intention, and make CHS workers determined to provide good medical services to community residents, the government should pay attention to the work situations and status of CHS workers as well as their demands, especially rational demands. The government should also balance the income and technical and labor value of medical workers and the income and work quantity. More learning and training opportunities should be provided to CHS workers, and their professional level should increase continuously and their individual development requirements met.

According to the results on the work satisfaction degrees of CHS workers in all aspects, CHS workers are more satisfied with the fullness and stability of their job and the decision-making ability of managers and are less satisfied with the balance between payment and work quantity, promotion opportunity, and working conditions. CHS workers are the least satisfied with the balance between remuneration and work quantity and are less satisfied with promotion opportunities. These findings indicate that CHS workers think that their current remuneration does not match the quantity of their work and are therefore dissatisfied with their remuneration. CHS workers are also not satisfied with the current promotion opportunities and think that the learning and training opportunities that are currently provided to them do not meet their requirements. Therefore, the results of the investigation on the work satisfaction degrees of CHS workers also respond to the factors that influence the turnover intention of CHS workers. The government should pay attention to these factors, increase the income of CHS workers, and provide them with more learning and training opportunities to increase their degree of work satisfaction. Increasing the degree of work satisfaction can avoid turnover intention because the work degree of satisfaction has a negative correlation with turnover intention [36]. Therefore, it can ensure the stability of the CHS work team.

Conclusions

According to the analysis, after the new medical reform was initiated, CHS development gained some achievements. Many patients have gradually become accustomed to choosing CHS first if they feel ill. Moreover, the government has given importance to CHS infrastructure construction and service capability development, especially in cultivating community general medical practitioners. However, the demission rate of the CHS work team is still high. The results of this study show that over one-third of the investigated CHS workers want to resign. The main reason for this finding is their dissatisfaction with their pay packets, learning and training opportunities, and promotion and individual development space, among others, which do not meet their requirements. This finding is also caused by the socio-demographic factors of CHS workers. We suggest that the government and organizations attach importance to the work situation and status of CHS workers; pay attention to and meet the various work-related demands of CHS workers, especially their demand for a reasonable income; balance the income and technical and labor value of medical workers as well as income and work quantity; provide more learning and training opportunities to increase their professional level continuously and meet their individual development requirements;and improve their work environment and conditions to increase their degree of work satisfaction, avoid turnover intention, cut down the demission rate, enhance their stability, and make them determined to provide high-quality and efficient medical services to community residents. Government departments and organizations must prioritize these steps and fully understand the significance of maintaining the stability of the CHS work team for CHS development.