Background

Primary health care (PHC) plays a crucial role in providing basic medical and public health services to the population, making it a key component of a country’s health care system. Proper allocation of human resources is essential to ensure the smooth functioning of the health system, increase health service accessibility, and improve health outcomes and equity [1]. The demand for PHC is expected to rise considerably due to the aging population and the increase in chronic diseases. However, the global human resource crisis for health in primary care institutions has become a pressing issue. A study predicts that the United States will face a shortage of 7,300 to 43,100 primary care physicians by 2030 [2]. In response, the Chinese government has introduced policies such as the Healthy China 2030 Plan aimed at strengthening the role of primary health care [3, 4], and has increased funding to relevant institutions more than tenfold since 2008 [5, 6]. Despite these efforts, the shortage of human resources in primary health care institutions in China remains a serious problem [7]. Turnover is a major cause of human resource shortages in primary health care, which not only significantly increases the cost of operating hospitals but may also compromise the quality of care [8]. According to the National Health Commission of the People’s Republic of China, the ratio of the number of primary health care workers to total number of health personnel in China decreased from 40.0 to 31.7% between 2010 and 2021 [9, 10].

Turnover intention is the likelihood that an employee will voluntarily leave their job in the future [11]. Numerous studies have shown that turnover intention is a reliable predictor of actual turnover behavior and reflects the management level of an organization [12]. High rates of turnover intention among health care professionals in teaching, tertiary, general, district, or acute hospitals have been observed in studies conducted in Iraq [13] and Italy [14]. Since the COVID-19 outbreak, studies have found that objective reasons such as increased workload, virus exposure, and isolation from family members have heightened the psychological stress experienced by health care workers [15], potentially contributing to separation issues [16]. A survey conducted in the United States revealed that 18% of health care workers left their jobs due to the COVID-19 pandemic [17], and health care workers in Singapore resigned due to fatigue during the COVID-19 outbreak [18]. Previous studies on turnover intention have largely focused on medical personnel in hospitals, with relatively little attention given to primary health care workers.

Numerous studies have investigated the factors that influence physicians’ willingness to leave their jobs, including external environmental factors such as the national medical system and occupational environment [29]. The effort-reward imbalance (ERI) model suggests that stress arises from a discrepancy between one’s high effort and commitment at work and the low rewards received in return [30]. The job demand-resources (JD-R) theory devised by Demerouti proposes that despite differences in job content across occupations, there are risk factors associated with job stress, including job demands and job resources [31].

Previous research on turnover intention among health care workers has primarily focused on the effect of job stress [32]. For example, a study conducted on 296 nurses in Iran showed that occupational stress was positively associated with nurses’ turnover intention [33]. This association has also been observed during the COVID-19 pandemic. A study revealed that nurses working in COVID-19 triage hospitals in Egypt experienced increased physical and psychological stress, leading to a higher likelihood of leaving their jobs [34].

Therefore, we postulate the following hypothesis:

H1: Primary health care workers’ job stress will have a positive association with turnover intention.

Job satisfaction and turnover intention

Job satisfaction is a multidimensional concept that refers to an employee’s evaluation and attitude toward various aspects of their job content and environment [12]. Mobley’s heuristic model of the employee withdrawal decision process suggests that job satisfaction is significantly associated with turnover intention [35]. Numerous studies have found that job satisfaction is a crucial antecedent variable that influences the turnover intention of medical staff, with a negative association between job satisfaction and turnover intention [36,29]. These results are consistent with a study by Chun, which found that presenteeism partially mediated the relationship between job stress and turnover intention among occupational therapists in Korea [48].

Our study also found that male primary health care workers and those in the doctor group had a higher rate of turnover intention. This finding is consistent with previous research conducted in China, which showed that male general practitioners were more likely to leave their jobs than their female counterparts [64]. However, Bardoel’s study found that female general practitioners were more likely to make unplanned turnover than males [70]. This could be related to the region of the research, and further research about the sex difference in primary health care workers’ turnover intention is needed to explore this issue in greater depth. In China, many studies have shown that doctors are more likely to be dissatisfied with their jobs due to workload and the doctor‒patient relationship [71], which could explain why the turnover intention of doctors tends to be higher, as observed in our study.

Our research has some limitations that need to be considered. First, the study population only included primary health care workers in Jilin Province, which may limit the generalizability of the findings to other regions of China. Second, the cross-sectional design of the study does not allow us to draw any causal inferences.

Conclusions

Our study investigated the relationship between turnover intention and job stress, job satisfaction, and presenteeism among health care professionals working in primary health care institutions in Jilin Province, China. We found that job stress and presenteeism had a positive association with turnover intention, while job satisfaction was negatively associated with turnover intention. Furthermore, our study confirmed the mediating role of job satisfaction and presenteeism in the relationship between job stress and turnover intention. These findings provide scientific evidence regarding the problem of turnover among primary health care workers and highlight the necessity of reducing job stress to improve job satisfaction and presenteeism. Therefore, it is crucial for managers to develop and implement effective measures to mitigate job stress among primary health care workers.