Primary Health Care: Open Access

Job Satisfaction and Associated Factors among Rural Health Extension Workers in East Shoa Zone, Oromia Regional State, Ethiopia

Waju Beyene salgedo^1*, Mekonen Ayele² and Gelila Abraham^{1 *}Correspondence: Waju Beyene salgedo, Department of Health policy and Management, Faculty of public Health, Health institute, Jimma University, Ethiopia, Tel: 947211385, Email:

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Introduction

Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low and middle-income countries (LMICs) [1]. The umbrella term “community health worker” embraces a variety of community health aides selected, trained and working in the communities from which they come. The use of community health workers has been identified as one strategy to address the growing shortage of health workers, particularly in lowincome countries [2].

Equivalent to Community health workers (CHWs) in Ethiopia is called Health Extension workers (HEWs). HEWs are the backbone for the health extension program (HEP) made it possible to target those who mostly need improvement in their access to services [3-5].

Ethiopia launched Health Extension Program (HEP) in 2004 GC to expand the national health program by expanding community based health interventions as a primary component of the Health Sector development program (HSDP). Rapid expansion of HEP services, which is a core component of the broader health system, became one of the strategies adopted with a view to achieving universal coverage of primary health care to the rural population, in a context of limited resources. The HEP has shown substantial outcome in areas related to disease prevention, family health, hygiene and environmental health. The program has improved the skewed distribution of health facilities and human resources. As a result of deployment of health extension workers, the human resources for health doubled within few years [3-8,13,14].

The implementation design of HEP involves deployment of two trained and salaried female HEWs at each kebele/village. These health extension workers are posted to rural communities across Ethiopia, where they provide a better and more equitable access to health services for the poor, women, and children in a sustainable manner [6,7]. HEWs were meant to spend 75% of their time by visiting families in their homes and performing outreach activities in the community and the remaining 25% time spent by providing essential family health services including immunizations and contraceptives at the health posts. To address strong community demands for basic curative care, HEWs are trained to provide first aid and to treat malaria, dysentery, intestinal parasites and other ailments and refer complicated and other cases to the nearest health center as needed [3-9]. Each kebele has a health post that serves 5,000 people and functions as an operational center for a health extension worker [6,7].

HEP has made important contributions to Ethiopia’s achievements in the area of health. For example, reducing wasting, increase in improved sanitation facilities, access to modern family planning, maternal and newborn health care practices; expanded vaccination services; malaria control and prevention and reduction of new HIV infection [4-9].

However the country recognized Human Resource for Health (HRH) had been facing challenges including urban/rural and regional disparities, poor motivation, retention and performance [8,12]. In HEP implementation, irregular/no supply of drugs and lack of adequate skill, poor infrastructure, lack of carrier development and low remuneration were among the contributing factors for the poor motivation and low performance of HEP [13-16].

Anecdotal evidences show that high attrition, low motivation and job satisfaction of health extension workers has been recognized as a challenge for the region. Thus, this study tried to explore level of job satisfaction and factors affecting it among the HEWs in the study area.

Methods

The study was conducted among rural HEWs in east shoa zone, centeral Ethiopia from January 15 to 24, 2018 . The zone was divided into 10 rural and one urban disticts. It was meant to serve for a total population of 1,440,144 (705,671 males and 734,473 females) nearly in a 1:1 female ratio.There were 2 hospitals, 59 health centers and 292 health posts in the zone. The health workforce of the zone was 2360 of which 559 (26.2%) were health exstention workers.

A facility based Cross-sectional study design was employed.

Eighty percent of the district (8 out of 10 districts) and 50% (N=132) of the available health posts were included in the study to get a good deal of sample size acceptable for operational recommendation. As 2 health extension workers were assigned to each health post as a standard that makes a total of 264 HEWs. Thus, we included all the HEWs in the selected health posts as it is nearer to the calculated sample

The dependent variable was job satisfaction while the independent variables of measurement were: Socio demographic characteristic (Age, Marital status, education, Service year, Living house, Monthly income, Residence), infrastructures (water supply, electricity, telephone service, transport service), Job and individual related factors (Job content, service provided, ability/ skill, prospect for future career), Work Load related factors (Time for family, work interference, routine Vs additional work, expected work), benefit related factor (salary), Management & leadership related factors(supervision, fairness/transparency, feedback, recognition),Promotion and training subscale (in-service training, upgrading, opportunity to improve skills, promotion), Environment & community related factors (relations with health center staff, support from kebele, availability of equipment and materials, community trust).

Data was collected using a pretested self-administered structured questionnaire. The questionnaire was prepared in English and translated to local language “Afan Oromo” for easy understanding by the respondents. Eight trained data collectors and 2 supervisors collected the data. The questionnaire was pre-tested on 5% of the study population in district out of the study area before the actual data collection began and adjusted.

The mean score for job satisfaction was computed using a five point Likert scale with a value ranging from 1(very dissatisfied to 5(very satisfied) was used. Discriptive statistics was used to summarize the data and the results were represented using frequency tables , mean ,standard deviation and percentages.

Bivariate analyses between dependent and independent variables were performed using chi-square (x²). The correlations between the variables was measured on an interval scale analyzed computing the product-moment correlation coefficients (i.e., Pearson’s r) which showed the intensity and direction of the relationships between the variables. A mulivariate logistic regression analysis was emloyed to identfy the sociodemographic predictor variables of job satisfaction. Odds ratio with 95% CI was used to determine presence of association between explanatory variables and level of job satisfaction. To determine the overall job satisfaction level, respondents with average score of less than mean value were classified as dissatified and those with average score of mean value and above were considered as satisfied.

Ethical clearance was secured from ethical review board of Health Institute, official letter written from the universty to the regional health bureau and the zonal health office was wrote a cooperation letter to woreda health offices. Verbal consent at spot of data collection was obtained from the study participants.

Result

Socio-demographic characteristics of the respondents

The study covered 132 HPs and 260 HEWs filled the assessment questionnaires. The age of the study participants ranged from 19 to 38 year with mean of 25.94 years and SD ± 3.071 years. The service year ranged from 1 to 13 years with mean of 7.61 and SD ± 3.345 years.

Regarding education among the respondents 155 (59.6%) were level III and 105 (40.4%) were level IV. One hundred and twenty three (47.3%) HEWs were within in the range of 26-30 years of age and 122 (46.9%) them were serving for 6-10 years. About 172 (66.5%) of the study participants were married. Six hundred and sixty five (63.5%) of the respondents were living out of their catchment population. The study reveals 165 (63.5%) of the respondents were recruited from another kebele/Village. Regarding infrastructure 143(55.5%) and 128 (49.2%) of HEWs are working where there is no water supply and transport service respectively (Table 1).

Table 1: Socio-demographic characteristics of health extension workers at Health posts of East Shoa Zone, Oromia regional state, April 2018. 

Out of 260 respondents, 119 (45.8%) were satisfied with the contents of their job description. One hundred and eighty eight (72.3%) of HEWs believe as they have significant contribution in improving the health of the community they serve. Similarly 148 (56.9%) and 170 (65.4%) believe that they are satisfied with their ability to meet the health needs of the community and their contribution to the organizational goal respectively. Regarding their future perception for their career development and other chances 217 (83.5%) was dissatisfied.

With regard to workload and benefit subscales, 85.8% of HEWs were not satisfied with the workload and time they have for their family, 92.3% of HEWs were not satisfied with the work load they are perform and the salary they were paid. Most of HEWs, 231(88.8%), were dissatisfied with the interference in their work schedule and assignment of additional works while only 29 (11.2%) were satisfied with it.

Regarding to support from management, supervisors and catchment Health centers they were poorly satisfied. Only 20.4%, 27.7% and 30.8% of them were satisfied with the support they were getting from their management, supervisors and health centers respectively. About 80.4% of the respondents were believed that their work was not appreciated and recognized by management. Regarding feedbacks from their supervisors they were poorly (36.9%) satisfied.

The study revealed that, 79.2% were dissatisfied by the level of support from kebele for their routine work while 156 (60%) of them satisfied by community trust for them and services they were providing. The study also identified that they were poorly satisfied (22.7%) with the availability of equipment’s and materials for services they provide. One hundred and twenty six (48.5) HEWs were satisfied by relationship with health center staffs while only 102 (39.2%) were satisfied with their supervisors relationship.

Out of the total respondents only about 20.8% and 14.2% of them were satisfied with the opportunity for in-service training and by chances they have to improve their skill respectively. They were highly dissatisfied (82.7%) with the opportunity for upgrading. Similarly 188(72.3) were dissatisfied with the chances for promotion (Table 2).

Table 2: Frequency distribution of responses on job satisfaction of health extension workers at Health posts of East Shoa Zone, Oromia regional state, April 2018.

Factors associated with level of job satisfaction

To assess bivariate associations among satisfaction determinants, Spearman’s rank order correlation analysis was carried out. In addition, to assess the relationships between satisfaction determinants and general job satisfaction, after controlling for other factors, multivariate regression models were estimated. Overall job satisfaction was estimated with the dependent variable being a dichotomous indicator equal to 2 if the respondent reported being either satisfied or very satisfied with her job and 1 if the worker either has no opinion, dissatisfied, or strongly dissatisfied.

Before multivariate logistic regression binary logistic regression was computed to identify candidate predictors for Sociodemography as predictors of factors associate with level of job satisfaction. The only candidate predictors of job satisfaction after others controlled at first step were marital status, education, from where (kebele/village) Recruited, transport service and availability of electric services were analyze by multiple logistic regression. As a result marital status and availability of electricity were the significant predictors for overall job satisfaction of HEWs (Table 3). This model of parameter estimate scored the hosmer and lemshow test of model with the prediction capacity of 74.8%. Accordingly those HEWs working in where there is no electricity service were 59.3% less likely to be satisfied with overall job satisfaction compared to those working where there was electricity service ((AOR: 0.407 [95% CI: (0.175, 0.947)], (P<0.05). Those married HEWs were two times more likely satisfied with aspects of their job satisfaction when compared to those who were single ((AOR: 2.533 [95% CI: (1.256, 5.107)], (P<0.01)(Table 3).

Table 3: Multiple logistic regression analysis of predictors of job satisfaction HEWs at HPs East Shoa Zone, Oromia regional state, April, 2018.
Significant at **P<0.01, *P<0.05

Pearson’s correlation was done to measure the correlations between overall job satisfaction and each dimensions of job satisfaction. The correlation between the different aspects was found to be significant.

These differences suggest that satisfaction was not independent of the individual job aspect. General satisfaction and all the individual dimensions of job satisfaction had a positive medium relationship with each other at a low to medium level.

The result indicated that the job satisfaction dimension shows significant correlation with each other (0.096–0.526) and was correlated with the total (overall) satisfaction score (0.07–0.471) (Table 4).

Table 4:  Pearson correlation between overall job satisfaction and dimensions of job satisfaction.

Discussion

Job satisfaction of health extension workers plays a great role in implementing health extension program. It contributes to achieve HSTP in the country. Overall, only 18.1% of the study participants reported they were satisfied with their job. While more than two third of the study participants were dissatisfied in their job. This result is worse than the study finding conducted by Mulugeta Mekuria Mengistu1, Ayele Geleto Bali2, (2015) in west shoa zone which showed 34.9% of the study participants satisfied by their job [18]. This difference might be due to additional work assignments and over burden of HEWs by different responsibilities.

The finding of this study indicated that 148 (56.9%) of the study participants were satisfied with their job content and believe that they were satisfied with their ability to meet the health needs of the community. This result was little high from a research report by the society for human resource management (SHRM) finding which was 51% [19]. Similarly, a time motion qualitative study of HEWs conducted in 2015 has identified a pride of serving the community and seeing positive change were among Motivating factors frequently mentioned among HEWs [16]. This implies that HEWs were encouraged and satisfied by the changes they see in their communities as a result of their work.

Management issues are one of the major sources for employee satisfaction/dissatisfaction. Good leadership and management system can create good attitude toward achieving common organizational goal. It is effective to give recognition to an employee for a well done job to make them satisfied with their job. This study reveals that level of satisfaction with management and supportive supervision in problem solving was 53 (20.4) and 72 (27.7) respectively. This result was higher than the study result conducted on “Job satisfaction and associated factors among health care providers at public health institutions in Harari region, eastern Ethiopia, 2015 ” which was 44.3% for management style and communication modality. By strengthening relationship and communication with HEWs and being supportive and problem solving type of management may makes HEWS be more likely satisfied.

Nearly two third of respondents (80.4%) reported that they were dissatisfied with the recognition and rewards for their outstanding work and contribution. This finding may implies that Management’s recognition and acknowledging of employee based on their job performance is very important to their job satisfaction.

Out of the total respondents 92.3% and 85.8% were dissatisfied in workload and time for their family respectively. This finding is two times higher than the study result conducted on community health workers in Rwanda which shows 47% for workload and 33% time for their family [17].

This difference might be due to additional work assignments and over burden by different responsibilities of HEWs.

In this study, HEWs reported low level of satisfaction with professional development opportunities and in-service trainings. Only 20.8% and 17.3% of the respondents were satisfied with the opportunities for training and upgrading chances respectively. The finding supported by the finding of a qualitative study conducted in Ethiopia, where, slow professional career growth and inadequate in-service refresher training were among demotivating factors [16]. This finding also in line with the finding of Mulugeta Mekuria Mengistu1, Ayele Geleto Bali2, 2015, Where 76.6% of the respondents reported that they were dissatisfied to this aspect [20]. The implication of these findings is that even though, services are available at health posts the quality of health care provided at health posts might be highly compromised because it is not complemented with current evidence based practices. In-service training and upgrading opportunity may build up the confidence of HEWs and increases their skill and help them to gain necessary information to perform their job and as a result increase their satisfaction. It also motivates as it is related with benefit.

With regard to fairness in chances of being promoted the study result show that 188 (72.3%) of the respondents were dissatisfied. The possible explanation given why HEWs dissatisfied with this aspect may be bias by managers in recognition for performance and unfair screening of individuals.

Satisfaction with availability of equipment and materials in this study was relatively very low (22.7%). This study results was in consistent with the finding of Hotchkiss et al. Human Resources for Health, 2015 [17].

Regarding satisfaction in relationship with health center staff and supervisors the study shows only 126 (48.5%) and 102 (39.2%) were satisfied respectively. This result was a little lower than the study result conducted in at public health institutions in Harari region, eastern Ethiopia, 2015” which was 51.5% [21-26]. This difference might be complained about a fault-finding attitude of supervisors and health center staff and lack of supportive and problem solving approaches.

Out of the total respondents, 92.3% of HEWs were not satisfied with the work load they are perform and the salary they were paid. This result is high from the study finding of Health Extension program Evaluation [14,27-32] which was 79%. This difference might be because of time difference.

This study revealed that about 165 (63.5%) of HEWs were living out of their catchment area. This may be resulted in unavailability HEWs in the community [33-36] to provide services in the community and at the Health Posts which has negative implication on their performance.

Overall dissatisfaction among health extension workers at east Shoa zone of Orormia Regional State is a cause for concern, given that job satisfaction has implications for the efficiency, effectiveness and sustainability of the program in the region.

Limitation

The study was not covering all districts. Two districts were excluded due to security problem at the study period.

Conclusion

In conclusion health extension workers working in East shoa zone have showed low level of job satisfaction. HEWs were less satisfied with management and supportive supervision in problem solving, in-service training and upgrading opportunities, recognition and rewards for their performance, workload and time for their family and technical support from the health centers.

Thus, it was recommended that the managers of health services at all level should take measures to establish continuous need based in-service trainings, planned capacity building trainings for health extension program supervisors and develop recognition and reward mechanisms for best performers in order to improve the job satisfaction of the HEWs.

Conflict of Interest

We, all the authors declare that we have no conflict of interest of any sort.

Funding

The data collection of this study was funded by Jimma University

Authors’ Contributions

All authors contributed to conception and design of the study, acquisition of data, data analysis and interpretation, funding acquisition, drafting and revising the manuscript.

Acknowledgement

We would like to acknowledge Jimma University for funding the data collection of this study. We are also thankful for all the study participants, data collectors and supervisor.

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