Intrinsic and extrinsic motivational factors of frontline health workers in Ghana

Moses Aikins; Samuel Amon; Samuel Agyei Agyemang; Patricia Akweongo; Kaspar Wyss

doi:10.12688/f1000research.126824.1

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Research Article

Intrinsic and extrinsic motivational factors of frontline health workers in Ghana

[version 1; peer review: 1 approved with reservations, 1 not approved]

Moses Aikins ¹, Samuel Amon¹, Samuel Agyei Agyemang¹, Patricia Akweongo¹, Kaspar Wyss^2,3

Moses Aikins ¹, Samuel Amon¹, [...] Samuel Agyei Agyemang¹, Patricia Akweongo¹, Kaspar Wyss^2,3

PUBLISHED 13 Apr 2023

Author details Author details

¹ Department of Health Policy Planning and Management, School of Public Health, University of Ghana, Accra, Ghana
² University of Basel, Basel, Switzerland
³ Swiss Tropical and Public Health Institute, Basel, Switzerland

Moses Aikins
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Samuel Amon
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Samuel Agyei Agyemang
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Patricia Akweongo
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Kaspar Wyss
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

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Abstract

Background: Human resources are vital for delivering health services, and health systems cannot function effectively without enough skilled, motivated, and well-supported health workers. Even though several studies have addressed job satisfaction among healthcare professionals in different parts of the world, there is limited research examining intrinsic and extrinsic motivational factors involved in job satisfaction, particularly in low-and-middle-income countries.
Methods: This was a facility-based quantitative cross-sectional study conducted in 34 primary health care facilities, across three out of the 26 districts in the Eastern Region of Ghana, between February and March 2018, analyzing job satisfaction and underlying factors. Randomly selected public health workers (n=287) from health facilities were included in the study. The two-factor theory was adopted as the measurement model for this study.
Results: The odds of staff that had received management training in the past 12 months being intrinsically satisfied was 3.73 (95% CI:2.03,6.86) times higher than staff with no management training (p<0.001). Compared to staff working in hospitals, Community-based Health Planning and Services (CHPS) staff showed lower levels of satisfaction on factors relating to intrinsic motivation. Technical staff had higher odds of being intrinsically and extrinsically satisfied compared to non-technical staff.
Conclusions: Public healthcare workers working at primary health facilities in Ghana, at higher levels of service delivery, showed higher satisfaction compared to lower-level staff, both in terms of intrinsic and extrinsic factors underlying satisfaction. Thus, to enhance healthcare services, health facilities’ administrators should take measures to improve the working conditions of staff at all levels of service delivery, since the hierarchy of service delivery in the health system makes the contributory role of all staff critical in improving the quality of primary healthcare.

Keywords

Job satisfaction, intrinsic, extrinsic, primary healthcare workers, Ghana

Corresponding author: Moses Aikins

Competing interests: No competing interests were disclosed.

Grant information: This work was supported by the European Union’s Horizon 2020 research and innovation programme (733360 [Strengthening management at district level to support the achievement of Universal Health Coverage - PERFORM2scale]).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2023 Aikins M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Aikins M, Amon S, Agyemang SA et al. Intrinsic and extrinsic motivational factors of frontline health workers in Ghana [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2023, 12:396 (https://doi.org/10.12688/f1000research.126824.1) First published: 13 Apr 2023, 12:396 (https://doi.org/10.12688/f1000research.126824.1) Latest published: 13 Apr 2023, 12:396 (https://doi.org/10.12688/f1000research.126824.1)

Introduction

Job satisfaction has been defined as “the balance between factors of working stressors and rewards”.¹ Job satisfaction has been also described as: “A pleasurable or positive emotional state which is the result of someone’s working assessment or someone’s working experience. Job satisfaction results from the perception that [someone’s] job fulfills or allows the fulfillment of important values, given that these values are in accordance with individual needs”.²

Previous literature on the job satisfaction of health workers has demonstrated that access to training, ability to perform key tasks, recognition and shift schedule were associated with job satisfaction.³^–⁵ A study on developing countries also found that job dissatisfaction results from key attributes such as adverse work environment, leadership problems, inadequate equipment and supplies, lack of recognition, stress due to heavy workloads, and limited opportunities for career development and advancement.⁶

Studies on intrinsic and extrinsic factors of job satisfaction over the years have shown mixed results. Some studies indicate that both intrinsic and extrinsic factors can be sources of satisfaction and/or dissatisfaction.⁷^,⁸ Furthermore, both intrinsic and extrinsic motivational factors in various degrees impact the work performance of nurses in Ghana.⁹ Additionally, Goetz et al. observed that even though both intrinsic and extrinsic issues are essential for dentists, intrinsic motivating factors have the most positive impact on their job satisfaction.¹⁰

Other studies have shown that intrinsic and extrinsic factors are important when measuring job satisfaction,¹¹ and intention to leave employment.¹²^,¹³ However, studies by Djordjević et al. and Ayalew et al. also found out that health workers place a higher value on extrinsic motivation.¹⁴^,¹⁵ Conversely, Tung et al. noted that a healthcare work environment that supports intrinsic motivation and improves work hours may reduce physician burnout and job dissatisfaction.¹⁶ In the education sector, private basic school teachers were more dissatisfied with their intrinsic factors of job satisfaction than their counterparts in the public sector.¹⁷

In this study, intrinsic factors are issues that relate to health worker’s need for a sense of self-actualization and self-accomplishment on the job. Intrinsic job satisfaction is derived from multiple intrinsic factors experienced in the job, such as the responsibility, commitment, self-directiveness, and skill development associated with doing the work. On the other hand, extrinsic factors define the external context and reward system within which the health worker carry out roles and responsibilities. Extrinsic factors include working conditions, supervision, support systems, company policies, work recognition, and external rewards such as allowances and salaries etc.

Health systems cannot function effectively without an adequate number of skilled and motivated health workers.⁴ Developing highly motivated, skilled and supported health workers is vital in advancing health in every health system and consequently, achieving national and universal health goals.¹⁸^,¹⁹ Thus, work climate and motivated human resources are critical for adequate health service provision.²⁰ The World Health Organization (WHO) estimates that shortages of about 12.9 million health care workers will be encountered by 2035 in South Eastern Asia and Africa (47% and 25%, respectively) and will represent only 1% of health care workers in the Europe region. The same report further postulates that an estimated 40% of health care workers in the world will vacate their jobs in the next decade due to lack of incentives.²¹

Developing countries like Ghana face serious issues with health professionals. Recently, Ghana was included in the list of countries with severe health worker challenges by the World Health Organization (WHO). The WHO further predicted that the persistence of the challenges can significantly affect quality health service delivery.²² The undesirable features of the healthcare systems of many developing countries including Ghana coupled with poor living conditions, lack of professional development opportunities and work overload among other factors, causes health workers to migrate to developed countries,²³^,²⁴ where they have better remuneration and conditions of work, easy access to technology and opportunities for intellectual growth.²⁵ Driving factors for workforce shortages are insufficient numbers of new health cadres joining the health workforce, as well as losses due to out-of-country migration and abandonment. As a consequence, Ghana is not only losing skilled professional staff but it is also losing investments made in educating and training nurses.²⁶ Further negative impacts of job dissatisfaction include non-conformance with medical and work procedures and policies, increases in work accidents, and organizational conflicts,²⁷ which may increase the rate of medical errors, hence jeopardizing patient safety.²⁸

Few studies have investigated intrinsic and extrinsic job satisfaction at the primary care level in Ghana. Realizing the significance of job satisfaction for health workers’ performance, this study was conducted to assess the overall job satisfaction of healthcare workers in primary healthcare facilities in the Eastern Region of Ghana, to highlight various factors that cause job satisfaction and make recommendations that might improve the current statistics on job satisfaction.

Methods

Ethical considerations

Prior to data collection, ethical approval for the study was obtained from was the Research Ethics Committee of the Liverpool School of Tropical Medicine, United Kingdom (LSTM; ID No.: 17-046) and the Ghana Health Service Ethical Review Committee, Ghana (ID No.: GHS-ERC:009/12/17). As mentioned, written informed consent was also obtained from the study participants. The privacy, confidentiality, and anonymity rights of participants were always observed.

Study design and setting

This was an institution-based quantitative cross-sectional study conducted in 34 primary health care facilities across three out of the 26 districts in the Eastern Region of Ghana, between February and March 2018. The region is located approximately 80 kilometers north of Accra, the capital of Ghana. These selected primary health care facilities provide services for about 343,236 inhabitants. The study is part of the baseline assessment of the PERFORM2Scale project (P2S), which sought to scale up district healthcare management, strengthening intervention.²⁹

Study participants

The main characteristics of the PERFORM2Scale project (P2S) study districts are shown in Table 1. Randomly selected public health workers from these health facilities were included in the study. This study included all categories of health staff – clinical and non-clinical, who had served for more than a year in the health facility at the time of the data collection.

Table 1. Study setting characteristics.

Item	Districts
Item	Yilo Krobo	Fanteakwa	Suhum
Population (2010 estimates)	104,888	130,295	108,053
Sub-districts	6	7	9
Geographical setting	Urban	Rural	Semi-Urban
Health Facilities:	62	40	32
District hospitals	0	1	1
Health centers	13	2	5
Maternity homes	3	2	0
Community-based Health Planning and Services (CHPS)	46	35	26

Sample size and sampling techniques

The sample size calculation was based on a published sample size table by Israel (2009). With an estimated number of clinical health staff (i.e., professional groups) within the three districts at 600, a precision level of ±5%, confidence level of 95% and degree of variability of 0.5, and a potential non-response rate of 5%, the estimated sample size of health workers was 287. Apart from the district hospitals which were purposively selected, health centers and Community-based Health Planning and Services (CHPS) were randomly selected using a simple random sampling approach. The calculated sample size was proportionally allocated to the four health facilities. Therefore, the 287 study participants were selected from district hospitals (119), health centres (119), and CHPS (49).

The study participants were randomly selected. By this, full list or register of clinical and non-clinical staff was obtained from each study facility. Thus, the staff register constituted the sample frame, grouped into clinical and non-clinical staff. To anonymize participants, each eligible staff member was given a code, which was written on a piece of paper and placed in an opaque box, grouped into clinical and non-clinical staff. The required number of staff were then randomly picked for each category. Clinical and non-clinical staff who participated in the study included physicians; nurses and midwives; pharmacists and associated professionals; community health workers and managers. Casuals and auxiliary staff were excluded from the study. The research team contacted selected participants by phone to briefly inform them about the study and seek consent for their participation. To ensure participation, suitable dates for interviews were agreed for participants who consented to be part of the study and follow up confirmation phone calls were made a day before the interviews. When a selected participant refused to be part, he/she was replaced by a randomly selected participant, using the same sampling approach. Overall, three clinical staff approached refused to be part of the study.

Data collection

Data were collected between February and March 2018. A self-administered paper-based questionnaire was used for data collection. The questionnaire was pre-tested with 15 health workers (5% of the planned sample) at a health facility outside of the study area and results were assessed by the researchers. Pre-testing was done with the aim of checking the language, comprehension of the questions, and sequence of question among the participants and over the duration of an interview. Assessment of the pre-test findings confirmed suitability of language used, understanding of questions and estimated interview duration. However, the sequence of sections was fine-tuned to make it more logically fit for purpose. By this, sections pertaining to district and facility levels management as well as specific job satisfaction (Sections III, IV, and V respectively) were moved to the later part of the questionnaire (VII, VIII, and IX respectively).

Prior to data collection, the aim of the study was explained to the participants face-to-face. Written informed consent was obtained from all study participants. To ensure the internal validity of collected data, three research assistants were trained on the data collection tool. All questionnaires were completed in English. Data collected included the background and job characteristics of health workers, and job satisfaction indicators. The reliability and internal consistency of the tool was again checked using Cronbach’s alpha test and was found to be acceptable. The measure of internal consistency of job satisfaction scales found a good internal reliability for overall job satisfaction (α=0.87), intrinsic job satisfaction (α=0.70) and extrinsic job satisfaction (α=0.83). Returned questionnaires were checked for completeness and accuracy every day after field work by the field supervisor. All data were stored in a locked compartment at the University of Ghana School of Public Health, Department of Health Policy Planning and Management - and only the core research team had access to the forms. The underlying and extended data of this study are available on Figshare.⁵²

Measurements

The Herzberg two-factor theory³⁰ was modified/adapted as the measurement model for this study (see Figure 1). This theory was chosen because it is one of the most commonly used theories in job satisfaction research.³⁰ The model establishes two distinct sets of factors for job satisfaction. The satisfiers/motivators or the intrinsic factors such as work methods, work variations, skills application, responsibility, commitment, and client respect, result in satisfaction when adequately fulfilled. Whereas dissatisfiers or extrinsic factors (e.g., those associated with physical working conditions, work recognition, remuneration, working hours, management support, conflict resolution, job description), as in this study, cause dissatisfaction when deficient. The intrinsic factors typically are largely administered by the health worker and the extrinsic factors are under the control of the management.

Figure 1. Measurement model for the determinants of health workers’ job satisfaction.

A five-point Likert scale with a value ranging from 1 (very dissatisfied) to 6 (very satisfied) was used to measure the intrinsic and extrinsic factors relating to satisfaction. The participants indicated their feeling for 20 items, as elicited by the questionnaire.⁵² These items were re-grouped into intrinsic and extrinsic job satisfaction factors afterwards. Participants answered in terms of how ‘satisfied’ or ‘dissatisfied’ they were with a few intrinsic (n=6) and extrinsic (n=14) job-related items. A summary of items covered in the questionnaire relating to intrinsic and extrinsic job satisfactions are shown in Table 2. These key influencing items were derived from the literature. In this study, to determine the general satisfaction level, respondents with a composite average score equal to or less than 3.5 (on a scale of 1–5) were classified as dissatisfied, and those with a composite average score above 3.5 were considered as satisfied.

Table 2. Elements of intrinsic and extrinsic job satisfaction.

Factors

Variable

Intrinsic:

1. Freedom to choose work methods
2. Variety in work
3. Opportunities to use abilities
4. Amount of responsibility
5. Commitment to quality work
6. Sense of client respect

Extrinsic:

1. Physical working conditions
2. Co-workers relationship
3. Work recognition
4. Remuneration
5. Hours of work
6. Acceptance of staff suggestions
7. Disagreements resolution
8. Colleagues’ support
9. Team coordination
10. Support for knowledge updates
11. Management support
12. Personnel problem resolution
13. Conflict resolution
14. Job description all-encompassing

Data analysis

The 20 items questionnaire data collected were entered into EPI INFO version 7.2.2.2 and all statistical analyses were performed using STATA (https://www.stata.com/) version 13.1. A freely accessible software that can also complete this analysis would be R (programming language) (https://www.r-project.org/). Descriptive analysis of continuous variables (i.e., variables that take infinite set of values) was estimated using means and deviations while that of categorical variables (nominal or ordinal variables with characteristics that cannot be quantifiable) was assessed using frequencies and proportions. Based on responses to the 5-point Likert scale factors of intrinsic and extrinsic satisfaction, composite mean scores (CMS) were calculated and classified into “satisfied” (CMS=3.5+) and “dissatisfied” (CMS<3.5). Univariate and multivariate logistic regression analysis was done to test association between outcome variables (i.e., intrinsic and extrinsic job satisfaction) and staff background factors. For all measures of association, significance levels were set at 0.1%, 1% and 5%.

Results

Background characteristics of primary healthcare workers

Table 3 shows the background characteristics of the 287 primary healthcare worker respondents in this study. The majority were men (75.3%). Most of them were aged 30-39 years (53.6%). The majority were technical staff (78.4%). More than half of the healthcare workers (58.6%) had been working for more than two years. Most of them worked in either a hospital (41.5%) or a health centre (41.5%).

Table 3. Background characteristics of primary healthcare workers.

Variable	N (%)
Sex:
Female	71 (24.7)
Male	216 (75.3)
Age (years):
<30	98 (37.0)
30–39	142 (53.6)
40+	25 (9.4)
Professional status:
Technical staff	225 (78.4)
Non-technical staff	62 (21.6)
Working duration (years):
<1	75 (26.1)
1–2	44 (15.3)
>2	168 (58.6)
Facility type:
Hospital	119 (41.5)
Health center	119 (41.5)
Community-based Health Planning and Services (CHPS)	49 (17.0)
Management training in last 12 months:
Trained	55 (19.2)
Not trained	232 (80.8)
Total	287 (100.0)

Level of job satisfaction among primary healthcare workers

Figure 2 shows job satisfaction levels differentiated by technical staff, sex, work duration and facility type. The majority of both technical (physicians; nurses and midwives) and non-technical staff (pharmacists and associated professionals; community health workers and managers) were extrinsically and intrinsically satisfied. Most of the primary health care workers were more extrinsically satisfied than intrinsically satisfied. Also, most males and females were more extrinsically satisfied than intrinsically satisfied. There was no significant difference in the proportion of staff working in the hospitals who were extrinsically and intrinsically satisfied, compared to those working at other facilities. However, most staff working at CHPS facilities were more extrinsically satisfied.

Figure 2. Job satisfaction of primary healthcare workers by selected background factors.

Predictors associated with intrinsic and extrinsic job satisfaction

As shown in Table 4, there was a statistically significant relationship between management training and intrinsic job satisfaction (<0.01), as well as extrinsic job satisfaction (<0.001). However, there was no statistically significant relationship found between all other background characteristics of primary healthcare workers and job satisfaction.

Table 4. Intrinsic and extrinsic job satisfaction.

Variable	Intrinsic satisfaction [n(%)]			Extrinsic satisfaction [n(%)]
Variable	Satisfied	Dissatisfied	χ^{2^a}	Satisfied	Dissatisfied	χ^{2^a}
Sex:
Female	41 (24.4)	30 (25.2)	0.876	45 (23.4)	26 (27.4)	0.468
Male	127 (75.6)	89 (74.8)		147 (76.6)	69 (72.6)
Age (years):
<30	60 (38.2)	38 (35.2)	0.475	71 (39.7)	27 (31.4)	0.396
30–39	85 (54.1)	57 (52.8)		91 (50.8)	51 (59.3)
40+	12 (7.7)	13 (12.0)		17 (9.5)	8 (9.3)
Professional status:
Technical staff	135 (80.4)	90 (75.6)	0.338	153 (79.7)	72 (75.8)	0.450
Non-technical staff	33 (19.6)	29 (24.4)		39 (20.3)	23 (24.2)
Working duration (years):
<1	50 (29.8)	25 (21.0)	0.247	52 (27.1)	23 (24.2)	0.664
1–2	24 (14.3)	20 (16.8)		27 (14.1)	17 (17.9)
>2	94 (55.9)	74 (62.2)		113 (58.8)	55 (57.9)
Facility type:
Hospital	73 (43.5)	46 (38.7)	0.93	77 (40.1)	42 (44.2)	0.527
Health center	72 (39.5)	47 (39.5)		84 (43.8)	35 (36.8)
Community-based Health Planning and Services (CHPS)	23 (13.7)	26 (21.9)		31 (16.1)	18 (19.0)
Management training in last 12 months:
Trained	21 (12.5)	34 (28.6)	0.001^*	23 (12.0)	32 (33.7)	0.000^*
Not trained	147 (87.5)	85 (71.4)		169 (88.0)	63 (66.3)

a Chi-square test.

* p<0.001,

** p<0.01,

*** p<0.05 significant levels.

Table 5 shows the staff background factors associated with intrinsic job satisfaction. A univariate logistic regression found a statistically significant association between intrinsic job satisfaction and management training (p<0.001). After controlling for observed confounding factors, multivariate logistic regression analysis found a statistically significant association between intrinsic job satisfaction and management training in the past 12 months (p<0.01) as well as the gender of primary health care worker (p<0.05). Those health workers who benefitted from management training in the past 12 months, rated intrinsic factors associated to satisfaction significantly higher at 2.8 (95% CI: 1.53,5.13) than those who had not undergone management training (p<0.001). Compared to staff working in hospitals, CHPS staff were less satisfied. Technical staff had higher odds of being satisfied compared to non-technical staff.

Table 5. Association between background characteristics and intrinsic factors associated to job satisfaction.

Variable	Intrinsic job satisfaction
Variable	Crude OR (95% CI)	p-value	Adjusted OR (95% CI)	p-value
Sex:
Female	Ref	0.876	Ref	0.024^***
Male	1.04 (0.61,1.80)		1.11 (0.60,2.07)
Age (years):
<30	Ref	0.481	Ref	0.435
30–39	0.94 (0.56,1.60)		1.01 (0.58,1.76)
40+	0.58 (0.24,1.41)		0.57 (0.22,1.46)
Professional status:
Technical staff	Ref	0.340	Ref	0.325
Non-technical staff	0.76 (0.43,1.34)		0.71 (0.35,1.41)
Working duration (years):
<1	Ref	0.242	Ref	0.122
1–2	0.60 (0.28,1.29)		0.53 (0.24,1.21)
>2	0.64 (0.36,1.12)		0.52 (0.27,1.00)
Facility type:
Hospital	Ref	0.197	Ref	0.058
Health center	0.97 (0.57,1.62)		0.79 (0.43,1.46)
Community-based Health Planning and Services (CHPS)	0.56 (0.28,1.09)		0.38 (0.17,0.85)
Management training in last 12 months:
Not trained	Ref	0.000^*	Ref	0.003^**
Trained	2.80 (1.53,5.13)		2.71 (1.42,5.18)

* p<0.001,

** p<0.01,

*** p<0.05 significant levels.

Table 6 shows the staff background factors associated with extrinsic job satisfaction. Similar to intrinsic satisfaction, a univariate logistic regression found a statistically significant association between extrinsic factors associated to job satisfaction and management training (p<0.001). After controlling for observed confounding factors, multivariate logistic regression analysis found a statistically significant association between extrinsic job satisfaction and the gender of the primary health care worker (p<0.05). The odds of staff that had received management training in the past 12 months being intrinsically satisfied were 3.73 (95% CI: 2.03, 6.86) times higher than staff with no management training (p<0.001). Compared to staff working in hospitals, CHPS staff were less extrinsically satisfied. Compared to non-technical staff, technical staff had higher odds of being extrinsically satisfied.

Table 6. Association between background characteristics and extrinsic factors associated to job satisfaction.

Variable	Extrinsic job satisfaction
Variable	Crude OR (95% CI)	p-value	Adjusted OR (95% CI)	p-value
Sex:
Female	Ref	0.470	Ref	0.016^***
Male	1.23 (0.70,2.16)		1.28 (0.67,2.45)
Age (years):
<30	Ref	0.392	Ref	0.386
30–39	0.68 (0.39,1.19)		0.66 (0.43,1.46)
40+	0.81 (0.31,2.09)		0.74 (0.27,2.07)
Professional status:
Technical staff	Ref	0.453	Ref	0.943
Non-technical staff	0.80 (0.44,1.43)		1.03 (0.50,2.13)
Working duration (years):
<1	Ref	0.668	Ref	0.355
1–2	0.70 (0.32,1.53)		0.55 (0.23,1.28)
>2	0.91 (0.51,1.63)		0.88 (0.45,1.74)
Facility type:
Hospital	Ref	0.525	Ref	0.193
Health center	1.31 (0.76,2.26)		1.59 (0.83,3.06)
Community-based Health Planning and Services (CHPS)	0.94 (0.47,1.88)		0.85 (0.37,1.95)
Management training in last 12 months:
Not trained	Ref	0.000^*	Ref	0.000^*
Trained	3.73 (2.03,6.86)		3.31 (1.74,6.31)

* p<0.001,

** p<0.01,

*** p<0.05 significant levels.

Discussion

In this study, we analysed intrinsic and extrinsic factors related to job satisfaction and among primary healthcare staff in Ghana. Overall, most of the primary healthcare workers were intrinsically and extrinsically satisfied irrespective of the professional category they belong to. The perception of overall job satisfaction was higher than in a similar study in Ghana,³ as well as reports from other low-and-middle-income countries.³¹^–³⁶ On the other hand, it is lower than results from Nigeria.³⁷ The potential reasons for the discordance might be due to: variations in the working context investigated; health infrastructure; administrative dynamics; organizational culture, values and setup; socio-demographic characteristics; study geographical areas, as well as the study time and tools used to measure the outcome variable.³⁸

Evidence from this study suggests that most primary healthcare workers were more satisfied extrinsically than intrinsically, which is contrary to other studies.³⁹^,⁴⁰ Contextual dynamics could be the reason for the differences in the findings. According to Herzberg’s (1959)⁴¹ two-factor theory, the presence of motivator elements such as achievement, recognition, good working conditions, responsibility, advancement, and personal growth drive staff to work harder towards actualization of personal and organizational goals, without any external reward or coercion.³⁰ Similar to findings from other studies,⁴² this study found a strong relationship between management training (or capacity development) and intrinsic job motivation, as well as extrinsic motivation.

Similar to findings of this study, previous reports have alluded to a directly proportional relationship between age and, intrinsic and extrinsic factors related to job satisfaction.³⁹^,⁴³^,⁴⁴ Evidence from this study also corroborates that of others³⁹^,⁴⁵ in which older health workers had a lower likelihood of job satisfaction compared to younger ones. This could be attributed to the sense of privilege associated with being young and employed in Ghana, given the high level of unemployment among the youth. Older primary health staff in Ghana tend to be dissatisfied mainly due to issues pertaining to compensation, working conditions, and diminished intrinsic values over time. Thus, the results of this study corroborate the discovery by Hatinoğlu and Ergün⁴⁵ that age has an effect on both intrinsic and extrinsic job motivation.

The study results show that more experienced primary health care staff were intrinsically and extrinsically satisfied with their job than less experienced staff. This finding concurs with reports from other African countries⁴⁶^,⁴⁷ as well as Asia.⁴⁸ Existing literature cites helping sick patients as the main source of job satisfaction for technical staff.⁴⁰ By this, a majority of health staff tend to be intrinsically satisfied due to the fulfillment that emanates from assisting patients and working for the public good, which outweighs dissatisfaction related to compensation and working conditions.⁴⁰ Although not statistically significant, the majority of male staff are more intrinsically and extrinsically satisfied than their female counterparts. This finding concurs with those by Alshmemri.⁴⁹ This can be ascribed to the emotional stress related to societal issues like the family and social responsibilities borne by women.³⁹^,⁵⁰

Furthermore, most primary healthcare staff working at lower-level facilities (i.e., CHPS) were less satisfied, both in terms of intrinsic and extrinsic factors, compared with those in higher-level facilities. Working conditions have been cited in the literature as very important for job satisfaction in public health facilities.³⁹ Meanwhile, most staff working at lower-level facilities in Ghana have relatively poor working conditions, which may have accounted for the lower level of intrinsic and extrinsic job satisfaction among CHPS health workers compared to their counterpart at higher levels. Prestige and social recognition are typically higher for staff working at higher levels. Also, institutional efforts directed at increasing employees’ motivation differ by the demographic characteristics of employees and the organization’s structure, values and types of duties.⁵¹

Strengths and limitations

The authors of this study are not aware of any other national study looking at job satisfaction among primary health workers and its associated factors. This study fills that important knowledge gap. A possible limitation relates to social desirability of a study such as ours, which could lead to artificially inflated and/or deflated responses. However, a self-administered questionnaire was used to mitigate this effect. Additionally, the use of one out of sixteen regions, and six districts out of thirty-three districts in the selected region (Eastern Region) limits the generalizability of the present findings. Also, the sample did not include private sector staff, which may have shed more light on the context. Furthermore, these results were not triangulated with qualitative data, which may have provided rich context to the quantitative findings.

Conclusions

In conclusion, public healthcare workers at primary health facilities in Ghana, at higher levels of service delivery, were intrinsically and extrinsically more satisfied compared to lower level staff. Thus, to enhance healthcare services, health facilities’ administrators should take measures to improve intrinsic and extrinsic working conditions of staff at all levels of service delivery, since the hierarchy of service delivery in the health system makes the contributory role of all staff critical in improving the quality of primary healthcare. Additionally, staff training has a significant effect on both intrinsic and extrinsic job motivation of primary healthcare workers. Hence, regular staff training must be institutionalized to contribute to the sustenance of job motivation.

Data availability

Underlying data

Figshare: ‘Raw/Expanded-Data_Health Worker Job Satisfaction’. https://doi.org/10.6084/m9.figshare.21433035.v2.⁵²

This project contains the following underlying data:

– Expanded-Data.xlsx. (Anonymised job satisfaction dataset with data processing extensions).
– Raw-Data.xlsx. (Anonymised job satisfaction raw dataset).
– Explanation-of-variables.xlsx. (Explanation of variable codes used in dataset).

Extended data

Figshare: ‘Raw/Expanded-Data_Health Worker Job Satisfaction’. https://doi.org/10.6084/m9.figshare.21433035.v2.⁵²

This project contains the following extended data:

– Health-worker-satisfaction-survey-tool_Ghana.pdf. (Questionnaire used as data collection. tool).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgements

The authors wish to express their profound gratitude to all participants of the study at the national, regional, district, sub-district, and community levels in Ghana’s health sector.

References

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2. Tovey EJ, Adams AE: The changing nature of nurses’ job satisfaction: An exploration of sources of satisfaction in the 1990s. J. Adv. Nurs. 1999; 30: 150–158. Publisher Full Text
3. Bonenberger M, Aikins M, Akweongo P, et al.: The effects of health worker motivation and job satisfaction on turnover intention in Ghana: A cross-sectional study. Hum. Resour. Health. 2014; 12: 43. PubMed Abstract | Publisher Full Text | Free Full Text
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17. Adu-Baffoe E, Bonney D: A Study of Job Satisfaction and Retention Amongst Public and Private Basic School Teachers in Ghana. J. Educ. Pract. 2021; 12.
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Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 13 Apr 2023

Author details Author details

¹ Department of Health Policy Planning and Management, School of Public Health, University of Ghana, Accra, Ghana
² University of Basel, Basel, Switzerland
³ Swiss Tropical and Public Health Institute, Basel, Switzerland

Moses Aikins
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Samuel Amon
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Samuel Agyei Agyemang
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Patricia Akweongo
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Kaspar Wyss
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This work was supported by the European Union’s Horizon 2020 research and innovation programme (733360 [Strengthening management at district level to support the achievement of Universal Health Coverage - PERFORM2scale]).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (1)

version 1

Published: 13 Apr 2023, 12:396

https://doi.org/10.12688/f1000research.126824.1

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© 2023 Aikins M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Aikins M, Amon S, Agyemang SA et al. Intrinsic and extrinsic motivational factors of frontline health workers in Ghana [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2023, 12:396 (https://doi.org/10.12688/f1000research.126824.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Open Peer Review

Version 1

VERSION 1

PUBLISHED 13 Apr 2023

Views

6

Reviewer Report 15 Sep 2023

Cornelia Van Diepen, Department of Socio-Medical Sciences, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands

Not Approved

https://doi.org/10.5256/f1000research.139272.r204612

General comment

Although the premise is interesting. The statistical analyses is flawed and the conclusion do not fit. The analysis created odds ratios that do not seem to match with the descriptive table. Table 4 provides a ... Continue reading

General comment

Although the premise is interesting. The statistical analyses is flawed and the conclusion do not fit. The analysis created odds ratios that do not seem to match with the descriptive table. Table 4 provides a skewed representation of the data by taking column percentages instead of row percentages.

Table 4 should show the row percentages as for example this will reveal the division of satisfaction/dissatisfaction among women and among men. This would show that for both intrinsic and extrinsic satisfaction the prevalence as very similar. (women; intrinsically satisfied 57.7%; men: 58.8%).

Similarly, on the question of trained/not trained, 147 out of the total 287 participants were untrained and satisfied. That is 51.2% of the sample. Table 4 even shows that the trained participants were more dissatisfied than satisfied and the odds of 2.8 shows has trained as a reference not the other way around. These are just the results I have recalculated and I am not sure if the rest is done correctly.

The main results (as presented in the abstract) are therefore based on faulty calculations. This is luckily not unsalvageable and the authors can redo table 4 (with row percentages) and analyse the odds ratios again to make sure they are correct.

The redone analyses will then affect the discussion, conclusion and abstract. So I will not further comment on those.

There are a few other things, I think can be improved:

The title does not include 'job satisfaction' even though that is the main outcome so it should be in there.
The definitions in the first paragraph are nice but could be better incorporated in the introduction text.
You apply the Herzberg two factor theory, this needs to be explained in more detail in the introduction to help the reader understand how you are looking at job satisfaction.
The aim should be the same everywhere.
The sequence of the methods is a bit odd as you start with the ethics even though the reader doesn't know yet what you are doing (so they don't know what you need ethical review for).
Figure 2 is of poor quality and does not really add anything when you have table 4.

So the study is interesting but the results need to be correct.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Work-related health of healthcare professionals; Person-centred care

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

CITE

Report a concern

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Views

3

Reviewer Report 05 Jul 2023

Matilda Aberese-Ako, Institute of Health Research, University of Health and Allied Sciences, Hohoe, Ghana

Approved with Reservations

https://doi.org/10.5256/f1000research.139272.r169560

General comments

This is an interesting study, it is timely and well written. However, I have a few comments that can help to strengthen the quality of the paper.

Gaps in the study ... Continue reading

General comments

This is an interesting study, it is timely and well written. However, I have a few comments that can help to strengthen the quality of the paper.

Gaps in the study

The authors suggest that extrinsic factors are mostly caused by management issues. This implies that other contextual factors such as national activities, health care policies, labour policies and environmental factors are not in any way linked to intrinsic and extrinsic motivation?
The authors refer to motivation and job satisfaction throughout the manuscript as if they mean the same, authors need to clarify.
Authors refer to management training as an indicator, it will be interesting to know whether all health workers in Ghana undergo management training.

Why were the three districts out of the of the lot in the Eastern region of Ghana?
The use of etc in several places including in one of the figures, the use of i.e, eg, missing articles such as “a”, connectors such as “to” among others need to be worked on.

Ethical consideration

Some information is missing from the first sentence

Study design and setting

The last sentence is a bit confusing, kindly rephrase
The information on the PERFORM2Scale project is too scanty

Sample size and sampling techniques

What are the authors referring to in the following statement: “The calculated sample size was proportionally allocated to the four health facilities.”?

Measurements

The authors state the following: “The satisfiers/motivators or the intrinsic factors such as work methods, work variations, skills application, responsibility, commitment, and client respect, result in satisfaction when adequately fulfilled. Whereas dissatisfiers or extrinsic factors (e.g., those associated with physical working conditions, work recognition, remuneration, working hours, management support, conflict resolution, job description), as in this study, cause dissatisfaction when deficient. The intrinsic factors typically are largely administered by the health worker and the extrinsic factors are under the control of the management.”

Are authors implying that satisfiers/motivators are intrinsic factors only and dissatisfiers are extrinsic only?

Predictors associated with intrinsic and extrinsic job satisfaction

Authors report figures using two decimal places and others three decimals?
Authors indicate gender as a factor in the results but fail to elaborate.

Discussion

In the entire section the authors compare several studies to theirs without giving a brief on those studies

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Anthropology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

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Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 13 Apr 2023

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Version 1 13 Apr 23	read	read

Matilda Aberese-Ako, University of Health and Allied Sciences, Hohoe, Ghana
Cornelia Van Diepen, Erasmus University Rotterdam, Rotterdam, The Netherlands

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Reviewer Report

6 Views

15 Sep 2023 | for Version 1

Cornelia Van Diepen, Department of Socio-Medical Sciences, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands

6 Views Cite this report Responses(0)

Not Approved

General comment

Although the premise is interesting. The statistical analyses is flawed and the conclusion do not fit. The analysis created odds ratios that do not seem to match with the descriptive table. Table 4 provides a skewed representation of the data by taking column percentages instead of row percentages.

Table 4 should show the row percentages as for example this will reveal the division of satisfaction/dissatisfaction among women and among men. This would show that for both intrinsic and extrinsic satisfaction the prevalence as very similar. (women; intrinsically satisfied 57.7%; men: 58.8%).

Similarly, on the question of trained/not trained, 147 out of the total 287 participants were untrained and satisfied. That is 51.2% of the sample. Table 4 even shows that the trained participants were more dissatisfied than satisfied and the odds of 2.8 shows has trained as a reference not the other way around. These are just the results I have recalculated and I am not sure if the rest is done correctly.

The main results (as presented in the abstract) are therefore based on faulty calculations. This is luckily not unsalvageable and the authors can redo table 4 (with row percentages) and analyse the odds ratios again to make sure they are correct.

The redone analyses will then affect the discussion, conclusion and abstract. So I will not further comment on those.

There are a few other things, I think can be improved:

The title does not include 'job satisfaction' even though that is the main outcome so it should be in there.
The definitions in the first paragraph are nice but could be better incorporated in the introduction text.
You apply the Herzberg two factor theory, this needs to be explained in more detail in the introduction to help the reader understand how you are looking at job satisfaction.
The aim should be the same everywhere.
The sequence of the methods is a bit odd as you start with the ethics even though the reader doesn't know yet what you are doing (so they don't know what you need ethical review for).
Figure 2 is of poor quality and does not really add anything when you have table 4.

So the study is interesting but the results need to be correct.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Work-related health of healthcare professionals; Person-centred care

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

3 Views

05 Jul 2023 | for Version 1

Matilda Aberese-Ako, Institute of Health Research, University of Health and Allied Sciences, Hohoe, Ghana

3 Views Cite this report Responses(0)

Approved With Reservations

General comments

This is an interesting study, it is timely and well written. However, I have a few comments that can help to strengthen the quality of the paper.

Gaps in the study

The authors suggest that extrinsic factors are mostly caused by management issues. This implies that other contextual factors such as national activities, health care policies, labour policies and environmental factors are not in any way linked to intrinsic and extrinsic motivation?
The authors refer to motivation and job satisfaction throughout the manuscript as if they mean the same, authors need to clarify.
Authors refer to management training as an indicator, it will be interesting to know whether all health workers in Ghana undergo management training.

Why were the three districts out of the of the lot in the Eastern region of Ghana?
The use of etc in several places including in one of the figures, the use of i.e, eg, missing articles such as “a”, connectors such as “to” among others need to be worked on.

Ethical consideration

Some information is missing from the first sentence

Study design and setting

The last sentence is a bit confusing, kindly rephrase
The information on the PERFORM2Scale project is too scanty

Sample size and sampling techniques

What are the authors referring to in the following statement: “The calculated sample size was proportionally allocated to the four health facilities.”?

Measurements

The authors state the following: “The satisfiers/motivators or the intrinsic factors such as work methods, work variations, skills application, responsibility, commitment, and client respect, result in satisfaction when adequately fulfilled. Whereas dissatisfiers or extrinsic factors (e.g., those associated with physical working conditions, work recognition, remuneration, working hours, management support, conflict resolution, job description), as in this study, cause dissatisfaction when deficient. The intrinsic factors typically are largely administered by the health worker and the extrinsic factors are under the control of the management.”

Are authors implying that satisfiers/motivators are intrinsic factors only and dissatisfiers are extrinsic only?

Predictors associated with intrinsic and extrinsic job satisfaction

Authors report figures using two decimal places and others three decimals?
Authors indicate gender as a factor in the results but fail to elaborate.

Discussion

In the entire section the authors compare several studies to theirs without giving a brief on those studies

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Anthropology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Respond to this report

Responses (0)

[1] 1. Corey-Lisle P, Tarzian AJ, Cohen MZ, et al.: Healthcare reform: Its effects on nurses. J. Nurs. Adm. 1999; 29: 30–37. Publisher Full Text

[2] 2. Tovey EJ, Adams AE: The changing nature of nurses’ job satisfaction: An exploration of sources of satisfaction in the 1990s. J. Adv. Nurs. 1999; 30: 150–158. Publisher Full Text

[3] 3. Bonenberger M, Aikins M, Akweongo P, et al.: The effects of health worker motivation and job satisfaction on turnover intention in Ghana: A cross-sectional study. Hum. Resour. Health. 2014; 12: 43. PubMed Abstract | Publisher Full Text | Free Full Text

[4] 4. Deriba BK, Sinke SO, Ereso BM, et al.: Health professionals’ job satisfaction and associated factors at public health centers in West Ethiopia. Hum. Resour. Health. 2017; 15: 36. PubMed Abstract | Publisher Full Text | Free Full Text

[5] 5. Kebriaei A, Moteghedi MS: Job satisfaction among community health workers in Zahedan District, Islamic Republic of Iran.2009.

[6] 6. Vujicic M, Zurn P, Diallo K, et al.: The role of wages in the migration of health care professionals from developing countries. Hum. Resour. Health. 2004; 2: 3. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. O’Reilly CA, Caldwell DF: Job choice: The impact of intrinsic and extrinsic factors on subsequent satisfaction and commitment. J. Appl. Psychol. 1980; 65: 559–565. Publisher Full Text

[8] 8. Wernimont PF: Intrinsic and extrinsic factors in job satisfaction. J. Appl. Psychol. 1966; 50: 41–50. Publisher Full Text

[9] 9. Aduo-Adjei K, Emmanuel O, Forster OM: The Impact of Motivation on the Work Performance of Health Workers (Korle Bu Teaching Hospital): Evidence from Ghana. Hosp. Pract. Res. 2016; 1: 45–50. Publisher Full Text

[10] 10. Goetz K, Campbell SM, Broge B, et al.: The impact of intrinsic and extrinsic factors on the job satisfaction of dentists. Community Dent. Oral Epidemiol. 2012; 40: 474–480. Publisher Full Text

[11] 11. Sansgiry SS, Ngo C: Factors Affecting Job Satisfaction among Hospital Pharmacists. Hosp. Pharm. 2003; 38: 1037–1046. Publisher Full Text

[12] 12. Chang Y-C, Yeh T-F, Lai I-J, et al.: Job Competency and Intention to Stay among Nursing Assistants: The Mediating Effects of Intrinsic and Extrinsic Job Satisfaction. Int. J. Environ. Res. Public Health. 2021; 18: 6436. PubMed Abstract | Publisher Full Text | Free Full Text

[13] 13. Hegney D, Plank A, Parker V: Extrinsic and intrinsic work values: their impact on job satisfaction in nursing. J. Nurs. Manag. 2006; 14: 271–281. Publisher Full Text

[14] 14. Ayalew F, Kibwana S, Shawula S, et al.: Understanding job satisfaction and motivation among nurses in public health facilities of Ethiopia: Across-sectional study. BMC Nurs. 2019; 18: 46. Publisher Full Text

[15] 15. Djordjević D, Petrović D, Vuković D, et al.: Motivation and job satisfaction of health workers in a specialized health institution in Serbia. Vojnosanit. Pregl. 2015; 72: 714–721. PubMed Abstract | Publisher Full Text

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Intrinsic and extrinsic motivational factors of frontline health workers in Ghana

Abstract

Keywords

Introduction

Methods

Ethical considerations

Study design and setting

Study participants

Table 1. Study setting characteristics.

Sample size and sampling techniques

Data collection

Measurements

Figure 1. Measurement model for the determinants of health workers’ job satisfaction.

Table 2. Elements of intrinsic and extrinsic job satisfaction.

Data analysis

Results

Background characteristics of primary healthcare workers

Table 3. Background characteristics of primary healthcare workers.

Level of job satisfaction among primary healthcare workers

Figure 2. Job satisfaction of primary healthcare workers by selected background factors.

Predictors associated with intrinsic and extrinsic job satisfaction

Table 4. Intrinsic and extrinsic job satisfaction.

Table 5. Association between background characteristics and intrinsic factors associated to job satisfaction.

Table 6. Association between background characteristics and extrinsic factors associated to job satisfaction.

Discussion

Strengths and limitations

Conclusions

Data availability

Underlying data

Extended data

Acknowledgements

References

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