Job Satisfaction and Intention of Primary Healthcare Workers to Leave: A Cross-Sectional Study in a Local Government Area in Lagos, Nigeria

The increased intention of healthcare workers to leave the health sector is one of the many negative impacts of job dissatisfaction and poor working conditions among healthcare workers in Nigeria. This study assessed the level of job satisfaction and the intention of leaving the country or medical practice among primary healthcare workers in Lagos, Nigeria. The study was a descriptive cross-sectional among 235 respondents, selected using a multistage sampling method. An adapted self-administered questionnaire from the Minnesota questionnaire short form and the Job Description Index (JDI) was used for data collection. Data were analyzed with Statistical Package for Social Sciences (SPSS) version 22.0. Descriptive statistics were performed while Chi-square was used to determine the association between categorical variables and the level of significance was set at p <0.05. About half (50.6%) of the healthcare workers were satisfied with their jobs. Highest score 37.00 (32-40) for job satisfaction was found in the domain of management process; while the lowest score 16.00 (13-20) was found in the salary domain. The majority of the healthcare workers 201(85.5%) had the intention of leaving Nigeria for a better opportunity abroad. Healthcare workers were satisfied with the management process but dissatisfied with pay. Targeted interventions to improve the morale of healthcare workers at the primary healthcare level is recommended.


Introduction
Healthcare professionals constitute one of the most important factors in the component of the health system as a human resource for health. Job satisfaction is defined as the pleasurable emotional state resulting from the appraisal of one's job (Chaudhury, 2004;Thompson, 2012). Job satisfaction refers to the degree to which an individual feel positive or negative about his or her job. Health workers' dissatisfaction with jobs poses significant public health implications, as this will most likely adversely affect the clinical management of patients (Pathman et al., 2002). Job satisfaction and morale of medical practitioners is of concern as satisfied healthcare workers usually perform well and have reduced absenteeism (Zuger, 2004). Continuous and effective productivity of healthcare workers has been linked to job satisfaction. Hence, satisfied hospital staffs have been observed to be more contented and productive while those who were not happy with their job are likely to encounter job stress, occupational burnout and stress-related physical and psychological health disorders (Pindar, Wakil, & Coker, 2015) (retirement, promotion, training) (Adeoye, 2014).
The increased intention of healthcare workers to leave the health sector is one of the many negative impacts of job dissatisfaction among healthcare workers, which results in the shortage of health workers and increased work pressure on the remaining few leading to poor health care delivery, declining health indices, incessant strike actions, and impairment of the psychological health of the workers (Liu & Wang, 2010). In sub-Sahara Africa, the constant emigration of trained medical personnel is on the rise as a result of dissatisfaction with either the extrinsic or/and intrinsic factors of the job (Sieleunou, 2011). A major factor responsible for the poor health indices and disparities in the health outcomes in Low Middle-Income Countries (LMIC) is the mass emigration of healthcare workers to countries with better health indices (Janus, Amelung, & Gaitanides, 2007). In Nigeria, incessant strike actions have also been linked to job dissatisfaction (Akinyemi & Atilola, 2013). Burnout has been found to occurs with increasing exposure to job stressors resulting from inconsistency and mismatch between the job and healthcare workers (Amiri et al., 2016;Kabir et al., 2016). Other negative results of job dissatisfactions experienced by health workers include exhaustion, frustration, anger, and negative attitudes towards work and patients (Bawakid et al., 2017). The role of occupation in the dynamics of health and diseases has long been recognized. Workers who are satisfied with their work are known to be healthier than those who do not (Ofili, Asuzu, & Isah, 2004). There is a paucity of data about job satisfaction among primary health workers in Lagos, Nigeria. Lagos is a megacity with an increasing healthcare and workforce demands, hence the need for this study which determined the level of job satisfaction, factors affecting job satisfaction and intentions to leave job among healthcare workers in selected primary health facilities in Alimosho Local Government Area (LGA), Lagos, Nigeria.

Study Setting
Alimosho is one of the twenty local government area (LGA) in Lagos State, Nigeria, established in 1991. It is an urban and the largest LGA in Nigeria with about two million residents according to the 2006 population census. The LGA has five divisions into Local Community Development Areas (LCDA) namely Mosan Okunola, Ikotun/Igando, Egbe/Idimu, Ayobo/ Ipaja and Agbado/Oke-Odo.

Study Design and Population
The study was a descriptive cross-sectional among healthcare workers in primary health care centres in Alimosho LGA. Only healthcare workers on permanent employment with the Lagos State Health Service Commission including doctors, nurses, pharmacist, technicians, community health officers, community health extension workers and laboratory technologists were included in the study.

Sample Size Determination
Sample size was calculated using a Cochran formula (n=z 2 pq/d 2 ) where n was the estimated minimum sample size; z-level of significance at 95% confidence level (1.96); p-proportion from a previous study of 83.3% (0.406) (Liu, & Wang, 2010) q=(1-p), d=level of precision (0.05%). The calculated minimum sample size was 213, which was increased to 235 to make up for non and incomplete responses.

Sampling Technique
Multistage sampling method was used for the study. In stage one, three of the five LCDAs were selected by random sampling by ballot, in stage 2, three PHCs were selected from the list of PHCs in each LCDA including the comprehensive health centres by simple random sampling via ballot. In each primary health centre, all eligible health workers who met the inclusion criteria were recruited until the sample size was attained.

Data Collection Tool
An adapted self-administered questionnaire from the Minnesota questionnaire short form and the Job Description Index (JDI) (Measuring Job Satisfaction -Tools, Scales, Methods,) (https://iedunote.com/measuring-job-satisfaction) was used for the study. It is a psychometric and most popular tool that measures job satisfaction. The JDI is based on subscales as a present job; present pay; promotion; supervision and relationship with the co-workers. The questionnaire was divided into six sections; section A consisted of socio-demographic characteristics of the respondent, section B-E was made up of questions on factors affecting job satisfaction and section F, had questions on intentions of the health workers to leave the job.

Data Analysis
were used to assess job satisfaction, each question had five Likert scale items; very satisfied (5), satisfied (4), neutral (3), disagree (2) and very disagree (1). Responses were scored based on the median (IQR). Scores below and above the median (IQR)were categorized as unsatisfied and satisfied respectively. Categorical variables were presented as percentages or proportions while continuous variables were presented as mean ± standard deviation (SD). Chi-square was used to determine the association between categorical variables. Level of significance was set at p <0.05.

Ethical Consideration
Clearance was gotten from the Department of Community Health and Primary Healthcare, Lagos State University College of Medicine and the office of the Medical Officer of Health at the Alimosho LGA to carry out this study. Informed consent was verbally obtained from each respondent with the assurance of confidentiality of the information and their right to withdraw from the study at any point in time. The participants were made to understand that involvement was voluntary. Table 1 shows the socio-demographic characteristics of respondents. The mean ± SD age of respondents was 37.25± 9.73. Most of the respondents were female (66.4%), married (75.7%) and have practised for less than 10 years (55.7%) with a mean ±SD of the practice of 10.25±8.4. Most (31.9%) were nurses by profession.  Table 2 shows the respondent`s job satisfaction according to different domains of the scale. About half (50.2%) of the respondents were satisfied with job security, while 61.3% were satisfied with opportunities for advancement, less than half (48.5%) were satisfied with support for additional training and education, (47.6%) were satisfied with hours of work, and (48.1%) were satisfied with recognition for work. About 49% were satisfied with the rate of promotion and delegation of duties. About half (52.8%) of the respondents were satisfied with the physical working condition, 48.5% were satisfied with physical surroundings, 35.7% were satisfied with the necessary equipment, 34.5% were satisfied with the availability of PPE while 46.0% were satisfied with the methods of waste disposal. Above half (59.1%) of the respondents were satisfied with the spirit of cooperation, most (64.3%) were satisfied with coworker getting along with each other, About 60% were satisfied with the relationship with the supervisor. Less than half were satisfied with the relationship with subordinates (46.8%), while 58.3% were satisfied with the commitment of colleagues to work and 52.8% were satisfied with the working relationship. Few (36.2%) of the respondents were satisfied with the salary, while 31.1% were satisfied with the amount of pay for work done, 37.2% were satisfied with the comparison of pay to that for a similar position in other health facilities, 51.1% were satisfied with the benefits of the job and few (30.2%) of the respondents were dissatisfied with salary increment.     Table 4 shows no statistically significant association between the respondents' overall level of job satisfaction and their socio-demographic characteristics (p>0.05). Most 54 (72%) of nurses and doctors 11(44%) were unsatisfied with their jobs. A statistically significant association was found between the job designation and the overall level of job satisfaction of respondents. A higher proportion of nurses (72%) were unsatisfied with their jobs compared to others (p<0.05).   Table 5 shows the association between the respondents' overall level of job satisfaction and the intention to leave their jobs. Most 40 (80%) of the respondents who were unsatisfied with their jobs either had the thought of leaving the health sector, or leaving their current organization 44 (84.6%), or leaving Nigeria for abroad 107 (53.2%). The differences observed were statistically significant (p<0.05).

Discussion
The majority of the respondents in this study were between 30-39 years with a mean ± SD age of 37.25±9.73 years, similar to the report of a study among resident doctors in Northern Nigeria (Yakasai & Ugwa, 2013), nurses in Ekiti state (Ayamolowo & Irinoye, 2013), and oral health workers in Nigeria (Ezeja et al., 2010), however, this finding differs from other studies in Nigeria which reported higher mean ages (Omolase, Seidu, & Omolase, 2010;Kalamawei, & Abeki, 2016). Overall, about half of the respondents (50.6%) in this study were satisfied with their job, which is higher compared to similar studies among medical doctors in Benin, Nigeria (30%) (Ofili, Asuzu, & Isah, 2004), nurses in Ekiti (29.8%), (Ayamolowo & Irinoye, 2013) physicians in Pakistan (34%) (Ghazali, Shah, & Zaidi, 2007), health workers in Ethiopia (34.9%), (Mulugeta, 2015) and a University-specialized hospital of Ethiopia (41.4%) (Yami, Hamza, Hassen, & Jira, 2011). On the other hand, the finding is lower when compared to some other studies in Nigeria. A study among radiographers in South-Eastern, Nigeria (56.3%) (Okaro, & Eze, 2010) physicians and nurses in Yenagoa, (57.5%) (Kalamawei & Abeki, 2016), Jos (64.8%) (Gyang, et al, 2018), Ekiti (67.1%), (Ayamolowo & Irinoye, 2013), North-Eastern, (68.2%) (Chirdan, et al, 2009), Owo, (78.5%), (Omolase, Seidu, & Omolase, 2010) and Kano (80.1%), (Yakasai & Ugwa, 2013). Likewise, a study on job satisfaction among clinical and non-clinical hospital staff in a teaching hospital in Lagos, Nigeria reported that the majority of respondents were satisfied with their job (Coker & Coker, 2011). Studies in Vientiane reported 65.0%, (Khamlub et al., 2013) and Indian (66%) (Singh, Kaur, & Verma, 2019) job satisfaction among study respondents. The variations in findings could be due to the fact that most of the studies which reported higher level of satisfaction were conducted among medical doctors only who were practicing in either secondary or tertiary healthcare institutions as opposed to the present study which was conducted among all cadres of healthcare providers in primary health care centres. The high level of dissatisfaction among healthcare providers in this study however, demands further assessment, as this could lead to reduced overall efficiency, effectiveness, and sustainability of the country healthcare system most especially at the primary health care level which is the closest to the people in the community.
This study revealed the highest satisfaction median (1QR) score of 37.00 [32][33][34][35][36][37][38][39][40] of 50 points in the job satisfaction domain in relation to management duties. This implying that respondents had a good perception of their job security, opportunities for advancement, support for additional training, recognition at work and all other management duties. This finding is similar to that of other studies (Yakasai & Ugwa, 2013;Kalamawei & Abeki, 2016;Jadoo et al., 2015). However, contrary to the study in Plateau, Nigeria which reported that the staff were not satisfied with management and training issues (Gyang et al., 2018). The lowest satisfaction median (1QR) score was in the domain of pay with 16.00 [13-20] of the 25 obtainable points. This relates to salary, pay for work done, pay compared to the same position in other health facilities, job benefits and salary increment, similar to the study in Plateau, Nigeria which reported that staff were not satisfied with salary issues and benefits. (Gyang et al., 2018). A study has reported that workers at Vientiane were generally satisfied with their job except for salary (Khamlub et al., 2013). A study in Ethiopia among healthcare workers at public hospitals found that the major reason for dissatisfaction among health workers was poor payment scheme, lack of training opportunity, lack of incentives, bureaucratic management style, poor performance evaluation system, and poor working conditions (Mulugeta & Bali, 2015). Similarly, another study in Ethiopia among healthcare workers at a teaching hospital reported motivation, inadequate salary, insufficient training opportunities, and an inadequate number of human resources were responsible for their dissatisfaction (Yami et al., 2011). "Motivating factors like pay, fringe benefits and contingent rewards need to be met for an employee to be satisfied with work" (Singh, Kaur, & Verma, 2019). Quality of services has been linked to skills, motivation, and satisfaction of healthcare workers and it has been documented about the factors affecting the satisfaction of healthcare workers that managers who devote their time to work are more likely to gain improved performance (Singh, Kaur, & Verma, 2019).
The median (1QR) score for job satisfaction as related to working facilities was 17.00 [14-20] of 25 points. This refers to the physical working condition, physical surroundings, necessary equipment, availability of PPE and means of waste disposal, similar to a study in the South-Eastern, Nigeria which reported that respondents were mostly dissatisfied with the environmental working conditions (Okaro & Eze, 2010). The effect of the working environment, coworkers support and team dynamics, team leader qualities, and nature of work assigned to workers has been reported by various studies as determinants of job satisfaction (Merga et al., 2018).
This study found a statistically significant association between job designation and job satisfaction, whichh is similar to a study in Zaria, Nigeria which reported a statistically significant association between categories of profession and job satisfaction (Judge, Thoresen, & Bono, 2001). Also, this study showed that job satisfaction was higher among younger respondents of less than 30 years of age, and this differs from the report of a study in Indian which found that job satisfaction was similar across all age groups. However, other studies have reported higher satisfaction in older professionals compared to the younger ones (Carrillo-García et al., 2013;Alcaraz Mor, Vigouroux, & Urcun, 2019). Also, female respondents were more satisfied with their job compared to males in the present study. This is similar to the finding of a Spanish study (Carrillo-García et al., 2013), but different from another study in Indian (Jadoo et al., 2015), and a survey conducted among German physicians (Behmann et al., 2012). However, a previous study reported that gender is not a strong independent predictor for job satisfaction (Keeton, Fenner, & Johnson, 2007). The differences may be ascribed to cultural differences. In Nigeria, women comprise 47.9% of the workforce (World Health Organization, 2014).
This study found less satisfaction among nurses (28%), similar to the study in Lagos (Coker & Coker, 2011), and Plateau, Nigeria which reported that the nurses were least satisfied with their salaries but most satisfied with the work itself and supervision (Ofili, Asuzu, & Isah, 2004). However, this finding is different from the higher job satisfaction scores reported among nurses in Calabar, Nigeria (82.4%), (Samson-Akpan, Edet, & Neji, 2015) and a study from Indian among nurses (Khamlub et al., 2013). The lower satisfaction reported by the present study may be due to the shortage of nurses in the primary health centres with resultant work stress among the few available.
Highest job satisfaction was found among the technicians in the present study, contrary to a study in a tertiary care institute of Delhi which found technicians to be the least satisfied (Jaiswal et al., 2015). Above half (56%) of medical doctors in the present study were satisfied with their job, similar to the study in Lagos, (Coker & Coker, 2011) and Benin, Nigeria (Ofili, Asuzu, & Isah, 2004) where 54% of doctors were satisfied with their job. Another study from Ondo state, Nigeria found 46.8% and 51.3% of doctors were dissatisfied with their medical skills and research opportunities respectively (Omolase, Seidu, & Omolase, 2010). The differences observed in the level of satisfaction may be due to the different roles assigned to the different professionals. Generally, dissatisfaction among healthcare workers has been attributed to the presence of several cadres for the same job but diverse pay scales, lack of autonomy regarding professional decisions, stagnation and in-commensurate remuneration (Jaiswal, et al., 2015;Hwara, 2009). The findings of our study showed that about two-thirds (65%) of the pharmacists were satisfied with their job compared to other clinical staff, similar to previous study findings (Murawski & Payakachat, 2008).
Our study showed that majority of respondents who were unsatisfied with their jobs either wanted to leave the health sector 40(80%) or leave the current organization 44(84.6%) or leave Nigeria for abroad 107(53.2). A study in the Eastern region of Ethiopia reported a positive relationship of high intention to leave and job satisfaction (Getie & Betre, 2013). Another study in Southwest Ethiopian health institutions reported that more than half (59.4%) of the healthcare professionals had intended to leave their job (Gesesew, Tebeje, & Alemseged, 2016). The World Health Organization had reported a global concern for the shortage of human resource in health care (WHO, 2014). Unsatisfied job is one of the significant and persistent predictors of intention to leave the job and migration of healthcare workers. A significant relationship between pay, promotion opportunity, and job satisfaction has been reported and health system were encouraged to consider these to prevent brain drains (Singh, Kaur, & Verma, 2019).
Job dissatisfaction among health workers can also be accredited to poor or lack of necessary equipment, limited office spaces, longer working hours, the uncertainty of roles, home and work stress interface, work overload, lack of autonomy, frequent night shift duties, job insecurity, limited resources, communication and interpersonal relationship problems among colleagues, perceived lack of support from hospital authority and bureaucracy (Coker & Coker, 2011). Regular capacity building, timely medical intervention for sick staff, frequent job reward to enhance a sense of work pride and team blend among others by hospital management and other stakeholders has also been encouraged to prevent job dissatisfaction among health workers (Coker & Coker, 2011). Job satisfaction in healthcare providers has been documented to have a direct consequence on quality, effectiveness, work efficiency and the health-care costs. Also, healthcare worker job satisfaction is directly linked with work absenteeism, human relations and organization of work. (Dragana, Arandjelovic, & Maja, 2008).

Limitations of the Study
This study was cross-sectional and self-report, hence, there might have been biases in the answers to the questions. Also, the results may not be representative of all the healthcare workers in Lagos State.

Conclusion
The overall job satisfaction among primary healthcare workers was 50.6%. Healthcare workers were not satisfied with pay and physical working condition, physical surroundings, necessary equipment, availability of PPE and waste disposal mechanism. Majority of respondents who were unsatisfied with their jobs had the intention to leave the job.

Recommendations
Targeted interventions to increase job satisfaction among primary healthcare workers by the state government and involvement of relevant stakeholders to plan and implement necessary measures at the healthcare facilities to improve the level of satisfaction and well-being of the healthcare personnels are recommended.