【作者】 丁宏；

【导师】 徐希平； 叶冬青；

【作者基本信息】 安徽医科大学 ， 流行病与卫生统计学， 2013， 博士

【摘要】 背景在卫生服务领域，研究揭示工作满意度（job satisfaction，JS）与卫生服务人员的离职倾向、服务的质量和效率以及患者的满意度相关。高满意度的卫生服务人员能够提供更满意和更好治疗效果的服务，有助于患者满意度的提高和医疗费用的下降。然而，长期以来社区卫生服务人员（community health workers，CHWs）工作满意度并未引起卫生政策设计者足够的关注。研究CHWs工作满意度，探讨关键影响因素，为社区卫生服务（Community Health Service，CHS）人力资源相关政策的设计与完善提供科学依据，对于维护和促进CHWs工作满意度，提高CHS质量具有重要意义。目的基于CHWs工作满意度定量测量，明确CHWs工作满意度水平及关键影响因素，探讨CHWs工作满意度与人口学特征关系，比较安徽省基层医药卫生体制综合改革（local comprehensive medical care reform，LCMR）前后CHWs工作满意度。为CHS人力资源相关政策的设计与完善提供科学依据。方法2009年，通过系统抽样的方法从安徽省12个城市抽取57个CHS中心作为研究调查现场，采用横断面调查方法，使用工作满意度量表（job satisfaction survey，JSS）对入选的813名调查对象（包括临床医学、临床护理、医疗技术及公共卫生服务领域的CHWs）进行了JS调查（获得有效问卷765人份，有效应答率94.1%）。安徽省实施LCMR2年后（2012年），从2009年抽取的57个CHS中心中随机抽取了30个CHS中心，对入选的536名调查对象再次使用JSS量表进行了JS横断面调查（获得有效问卷495人份，有效应答率92.4%）。分析方法包括：描述性分析、t检验、单因素方差分析，Logistic回归、非参数检验和协方差分析等。检验水准α=0.05。结果1．CHWs的总体工作满意度平均得分110.06±17.874分，处于满意度“一般”状态；17.0%的CHWs对总体工作满意度表示“满意”，70.7%的CHWs对总体工作满意度表示“一般”。同事关系（14.71±2.072分）和工作性质（14.50±2.679分）维度的满意度平均得分最高，均处于“满意”状态；77.6%的CHWs对同事关系维度表示“满意”，70.3%的CHWs对工作性质维度表示“满意”。薪酬（10.00±2.861分）、福利（10.25±3.070分）、晋升（10.84±2.919分）维度的满意度平均得分水平最低，三个维度均处于“不满意”状态；对薪酬、福利、晋升等维度表示“不满意”的CHWs比例分别为58.6%、55.8%、44.4%。2．高级职称CHWs的总体工作满意度平均得分（114.57±14.473分）高于初级和中级（P <0.05）；公共卫生岗位CHWs平均得分（114.51±21.490分）高于临床、护理及医疗技术岗位（P <0.05）。Logistic回归分析揭示：年龄是CHWs总体工作“不满意”的保护因素（OR=0.887，P <0.05），工作年限是危险因素（OR=1.107，P<0.05）。3.高级职称CHWs薪酬维度的满意度平均得分（10.62±2.439分）高于初级和中级职称（P<0.001）；公共卫生服务岗位平均得分（10.78±3.391分）高于临床医学、临床护理及医疗技术岗位（P<0.05）。Logistic回归分析揭示：工作岗位是CHWs薪酬维度“不满意”的危险因素（OR临床医学=2.493，P <0.05；OR临床护理=2.310，P<0.05；OR医疗技术=3.049，P<0.05）。4.中专及以下学历CHWs晋升维度的满意度平均得分（11.20±2.713分）高于大专、本科及以上学历（P<0.05）；高级职称平均得分（12.67±3.055分）高于初级和中级职称。Logistic回归分析揭示：学历（OR=1.480，P <0.05）、工作年限（OR=1.063，P<0.05）及医疗技术岗位（与公共卫生岗位相比）（OR=2.473，P<0.05）是CHWs晋升维度“不满意”的危险因素。5．不同性别、年龄、学历、职称、工作岗位、工作年限的CHWs领导维度的满意度平均得分差异无统计学意义（P>0.05）。Logistic回归分析揭示：CHWs领导维度“不满意”与人口学特征变量不相关（P>0.05）。6．无职称CHWs福利维度的满意度平均得分（11.09±3.462分）高于其他职称（P<0.05）。Logistic回归分析揭示：年龄是CHWs福利维度“不满意”的保护因素（OR=0.897，P<0.05），工作年限（OR=1.104，P<0.05）及临床医学岗位（与公共卫生岗位相比）（OR=2.126，P<0.05）是危险因素。7．50岁～组CHWs奖励维度满意度平均得分（12.37±2.805分）高于其他年龄组（P <0.05）；高级职称平均得分（12.86±2.414分）高于初级和中级（P<0.05）。Logistic回归分析揭示：CHWs奖励维度“不满意”与人口学特征变量不相关（P>0.05）。8．女性工作流程维度的满意度平均得分（11.75±2.213分）高于男性（P<0.05）；学历越高，平均得分水平越低（F=7.398，P=0.007）。Logistic回归分析揭示：学历（OR=1.449，P<0.05）和工作年限（OR=1.066，P<0.05）是CHWs工作流程维度“不满意”的危险因素。9．公共卫生工作岗位CHWs同事关系维度的满意度平均得分（15.33±2.126分）高于临床医学、临床护理及医疗技术岗位（P<0.05）。Logistic回归分析揭示医疗技术岗位（与公共卫生岗位相比）（OR=10.671，P<0.05）是CHWs同事关系维度“不满意”的危险因素。10．CHWs年龄分组越小，工作性质维度的满意度平均得分越低（F=7.759，P=0.005）；公共卫生工作岗位（15.06±2.739分）平均得分最高（P<0.05）；工作年限16-20年组平均水平（15.04±2.323分）最高（P<0.05）。Logistic回归分析揭示：CHWs工作性质维度“不满意”与人口学特征变量不相关（P>0.05）。11．工作年限30年以上组CHWs沟通维度的满意度平均得分（13.20±2.735分）最高（P<0.05）。Logistic回归分析揭示：年龄（OR=0.932，P<0.05）、学历（OR=0.705，P<0.05）是CHWs沟通维度“不满意”的保护因素。12．LCMR2年后，CHWs工作满意度平均得分水平发生了变化。总体工作满意度平均得分（112.74±23.157分）高于基线调查平均水平（P<0.05）；薪酬（10.88±4.147分）、奖励（13.47±3.908分）、工作流程（12.26±3.711分）和沟通（13.46±4.419分）等4个维度的满意度平均得分高于基线调查平均水平（P<0.05）；晋升维度的满意度平均得分（10.20±4.030分）低于基线调查平均水平（P<0.05）；领导、福利、同事关系和工作性质等4个维度的满意度平均得分差异无统计学意义（P>0.05）。13．LCMR2年后，CHWs对薪酬、奖励、工作流程、沟通等4个维度主观感觉“满意”的比例分别为27.1%、51.5%、38.4%、51.7%，高于基线调查水平（P<0.05）；对同事关系及工作性质等2个维度主观感觉“满意”的比例分别为62.4%、57.6%，低于基线调查水平（P<0.05）。结论1．CHWs总体工作满意度不高，处于满意度“一般”状态。比较而言，同事关系和工作性质2个维度的满意度水平较高，均处于“满意”状态；薪酬、福利和晋升等3个维度的满意度较低，均处于“不满意”状态。2．年龄、工作年限与CHWs总体工作“不满意”相关;工作岗位与薪酬、晋升、福利、同事关系维度“不满意”相关；学历与晋升、工作流程、沟通维度“不满意”相关；工作年限与晋升、工作流程维度“不满意”相关；年龄与福利、沟通维度“不满意”相关。3．实施LCMR2年后，CHWs总体工作满意度水平有一个较小的提高。无论是改革前还是改革2年后，薪酬、晋升及福利等三个维度的满意度平均得分均较低。薪酬、晋升及福利仍然是目前影响CHWs满意度的关键因素。政策设计者需要采取相应措施提高CHWs工资、福利待遇，关注CHWs职业发展。4．实施LCMR2年后，CHWs同事关系、工作性质等2个维度主观感觉“满意”的比例均下降显著，其原因值得我们进一步深入探究。更多还原

【Abstract】 BackgroundIn health service sector, job satisfaction (JS) is highly associated with staffs’ turnoverintention, quality and efficiency of services, and patients’ satisfaction. Reports indicatethat doctors with higher job satisfaction are more likely to provide more satisfactoryservices and produce better therapeutic effect than those with lower ones. However, fora long time, health service managers failed to pay enough attention to JS of communityhealth workers (CHWs).The objective of this study was to identify JS levels and theirinfluencing factors among CHWs employed at community health service institutions, inorder to provide policy suggestions for human resource manegement of communityhealth service (CHS), to maintain and promote CHWs’JS and improve the quality ofCHS.ObjectivesBased on quantitative measurement of CHWs’JS, the paper aims to find out the levelof CHWs’JS and the key influencing factors of the community health service personnel,to explore the relationship between CHWs’JS and demographic characteristics, and tocompare CHWs’JS before and after Anhui Province basic medical and health systemreform(LCMR), so as to provide policy suggestions for human resource manegement oflocal health service institutions.MethodsIn2009,57community health service centers (CHCs) were randomly selected in12cities in Anhui province by systematic and cluster sampling. A cross-sectional survey was conducted among813CHWs (including clinical medicine, clinical nursing,medicaltechnology,and public health staff) of57CHCs (response rate:94.1%) by the jobsatisfaction scale (JSS). After two years’implementation of the LCMR (2012),30CHCswere randomly selected from57CHCs which were selected in2009. A total of536anonymous questionnaires were handed out to the participants. Finally,495validquestionnaires were available, with an overall response rate of92.4%.Statistical and analyzing methods include descriptive statistics, t-test, One-WayANOVA, Logistic regression, Nonparametric Tests and Univariate Analysis of Variance,α=0.05.Results(1)The average score of total JS of CHWs was110.06±17.874, which was in“moderate” status;17.0%CHWs were satisfied with total JS, while70.7%CHWs werein “moderate” status. The average score of JS with coworkers (14.71±2.072) and natureof work (14.50±2.679) was the highest, which were both in “satisfied” status;77.6%CHWs were satisfied with JS with coworkers and70.3%CHWs were satisfied withnature of work. While the average score of JS with pay (10.00±2.861), benefits(10.25±3.070), and promotion (10.84±2.919) was the lowest, which were all in“dissatisfied” status;58.6%CHWs were dissatisfied with pay,55.8%CHWs weredissatisfied with benefits, and44.4%CHWs were dissatisfied with promotion.(2)The average score of senior CHWs in total JS (114.57±14.473) were higher thanthose with junior title and middle title (p<0.05); the average score of public health staffin total JS (114.51±21.490) were higher than clinical, nursing andmedico-technique(p<0.05). Logistic regression suggested: age is the protective factor(OR=0.887, p<0.05), and tenure was the risk factor (OR=1.107, p<0.05) for“dissatisfied” with total JS.(3)The average score of CHWs with senior title in pay (10.62±2.439) was higher than those with junior and middle title (p<0.05); the average score of public health staff inpay (10.78±3.391) were higher than clinical, nursing and medico-technique (p<0.05).Logistic regression suggested: job type was the risk factor for “dissatisfied” with pay(ORclinical=2.493, p<0.05; ORnursing=2.310, p<0.05;ORmedico-technique=3.049, p<0.05).(4)The average score of CHWs who have secondary school and below in promotion(11.20±2.713) was higher than the CHWs with educational level of over junior college(p<0.05); the average score of CHWs with senior title in promotion (12.67±3.055) washigher than those with junior and middle title (p<0.05). Logistic regression suggested:educational background (OR=1.480, p<0.05), tenure (OR=1.06, p<0.05) andMedico-technique job type(OR=2.473, p<0.05) were the risk factor for “dissatisfied”with promotion.(5)Gender, age, educational background, professional titles, job type and tenure (years)had no significant influence on job satisfaction with supervision (P>0.05). Logisticregression suggested: there were no relationship between demographic characteristic ofCHWs and “dissatisfied” with supervision (P>0.05).(6)The average score of CHWs with “no technical title” in benefits was higher thanthose with junior title, middle and senior title (p<0.05). Logistic regression suggested:age is the protective factor for “dissatisfied” with benefits (OR=0.897, p<0.05), whiletenure (OR=1.104, p<0.05) and clinical job type (OR=2.126, p<0.05) were the riskfactors.(7)The average score of CHWs whose age is50over in contingent rewards(12.37±2.805) was higher than other age groups (p<0.05); the average score of CHWswith senior title in contingent rewards (12.86±2.414) was higher than those with juniorand middle title (p<0.05). Logistic regression suggested: there were no relationshipbetween demographic characteristic of CHWs and “dissatisfied” with contingentrewards (P>0.05).(8)The average score of female in operating procedures (11.75±2.213) was higher than male (p<0.05); the higher the degree, the lower the average score in operatingprocedures (F=7.398, p=0.007). Logistic regression suggested: educational background(OR=1.449, p<0.05) and tenure (OR=1.066, p<0.05) were the risk factors for“dissatisfied” with operating procedures.(9)The average score of public health staff (15.33±2.126) in coworkers was higher thanclinical, nursing and medico-technique job type (p<0.05). Logistic regression suggested:medico-technique job type was the risk factors for “dissatisfied” with coworkers(OR=10.671, p<0.05).(10)The younger the age, the lower the average score in nature of work (F=7.759,p=0.005); the public health staff had the highest score (15.06±2.739) compared to theother jobs (p<0.05); tenure with16-20years had the highest score (15.04±2.323)compared to the other tenures (p<0.05). Logistic regression suggested: there were norelationship between demographic characteristic of CHWs and “dissatisfied” withnature of work (P>0.05).(11)Tenure with over30years had the highest score in communication (13.20±2.735)compared with other tenures (p<0.05). Logistic regression suggested: age (OR=0.932,p<0.05) and educational background (OR=0.705, p<0.05) are the protective factors for“dissatisfied” with communication.(12)After two years’implementation of the LCMR, the average score of total JS ofCHWs (112.74±23.157) was higher than the of the baseline survey (p<0.05); theaverage score of satisfaction with pay(10.88±4.147), contingent rewards (13.47±3.908),operating procedures(12.26±3.711) and communication(13.46±4.419) in the effectevaluation survey were higher than that of the baseline survey (P<0.05); However, theaverage score of satisfaction with promotion (10.20±4.030) was lower than that of thebaseline survey (p<0.05);there were no significant differences in the dimensions ofsupervision, benefits, coworkers and nature of work between the two surveys (p>0.05).(13)After two years’implementation of the LCMR,27.1%CHWs were satisfied with pay,51.5%CHWs were satisfied with contingent rewards,38.4%CHWs were satisfiedwith operating procedures, and51.7%CHWs were satisfied with communication, whichwere all higher than those of the baseline survey (p<0.05);62.4%CHWs were satisfiedwith coworkers and57.6%CHWs were satisfied with nature of work, which were bothhigher than those of the baseline survey (p<0.05).Conclusions(1)The total JS of CHWs was not high, which was in “imoderate” status.By comparison,the JS of CHWs in coworkers and nature of work was relatively high, which were bothin “satisfied” status; while the JS of CHWs in pay, benefits and promotion wasrelatively low, which were both in “dissatisfied” status.(2) Age and tenure were associated with CHWs’“dissatisfied” with total JS; Job typewas associated with the “dissatisfied” status of pay, promotion, benefits and coworkers;Educational background was associated with the “dissatisfied” status of promotion,operating procedures and communication; Age was associated with the “dissatisfied”status of benefits and communication.(3)After two years’implementation of the LCMR, The total JS of CHWs have a smallimprovement. However, CHWs have lower satisfaction in the dimensions of pay,promotion and benefits dimensions before and after the LCMR. Pay, promotion andbenefits are the key factors that are affecting the CHWs’JS presently. Policy-makersshould take corresponding measures to raise work reward of CHWs and pay moreattention to CHWs’professional development to increase their JS.(4)After two years’implementation of the LCMR, the proportion of CHWs “satisfied”with coworkers and nature of work significantly declined, with reason worthy of furtherstudy.更多还原