Job satisfaction and associated factors among Public Health Inspectors in Sabaragamuwa Province, Sri Lanka: pre-COVID-19 era

This article is published under the Creative Commons CC-BY-ND License (http://creativecommons.org/licenses/ by-nd/4.0/).This license permits use, distribution and reproduction, commercial and non-commercial, provided that the original work is properly cited and is not changed anyway. Abstract: Public Health Inspectors (PHIs) are key field health workers in Sri Lanka who are responsible for many preventive health functions in the community. Job satisfaction is one of the crucial factors which motivate field health care workers such as PHIs. The objective of this study is to examine the job satisfaction and its associated factors, and the problems and challenges faced by PHIs in the Sabaragamuwa Province while performing their duties. This descriptive cross sectional study was conducted in all 29 Medical Officer of Health (MOH) areas of the Sabaragamuwa Province. Study unit was a PHI working in the Sabaragamuwa Province at the time of the study. All 128 PHIs fulfilled eligibility criteria, consented and were recruited. Validated self-administered questionnaire assessing socio-demographic and work characteristics, job satisfaction based on Herzberg’s Two Factor Theory, factors influencing job satisfaction, and a diary for self-reporting of time utilisation were used for data collection. Out of the 128 PHIs recruited, 119 completed the questionnaire. Among intrinsic factors, responsibility showed highest level of satisfaction (n=100, 84%) and among extrinsic factors, it was interpersonal relationship (n=108, 90.8%). Highest percentage of dissatisfaction among intrinsic factors was shown for advancement (n=88, 73.9%) and among extrinsic factors, it was for income and payment (n=74, 62.2%). More PHIs were dissatisfied when their area population increased (p=0.04). PHIs who spent more time in the field were less satisfied compared to officers who spent less time in the field (p<0.01). Majority of the PHIs were not satisfied with their salary and allowances, system of promotion and training and thus, attention is needed on these areas to improve the job satisfaction of PHIs.


INTRODUCTION
Preventive health care plays a major role in delivery of health services in the country. At present, 347 MOH Offices provide preventive health care services at grassroot level (Family Health Bureau, 2019). MOHs are the primary service delivery point in preventive health, and act as the frontline preventive health units in Sri Lanka. There are a number of designated preventive health personnel attached to MOH offices, namely, Medical Officer of Health, who acts as team leader; Public Health Midwives (PHMs); Public Health Inspectors (PHIs), Community Dental Officers, and School Dental Therapists, as well as several supervisory staff (National Institute of Health Sciences, 2012). PHIs perform diverse field duties in preventive health which ranges from disease control to life skill development. This challenging nature of the duty influences the job satisfaction of the PHIs in a major way. The role of PHIs at present is critical due to the emergence of COVID-19 pandemic, as PHIs are responsible for prevention of the pandemic in the community (Sri Lanka, Ministry of Health, 2020). Therefore, understanding of the status of job satisfaction of PHIs is important for better preventive health services in Sri Lanka. This study was conducted prior to the current COVID-19 outbreak in Sri Lanka.

LITERATURE REVIEW
Public Health Inspectors are the main focal point in an MOH area to carry out disease surveillance and activities on prevention of communicable diseases. Public Health Inspectors are also involved in family planning activities in the MOH areas concerning the male partner. In addition, PHIs conduct life skills training workshops at schools and institutions. Furthermore, all school health activities are carried out by PHIs with the guidance and participation of MOHs. PHIs play the key role in maintenance of environment and occupational health in their respective MOH areas. The scope of activities of the PHI extends even further which includes functioning as the main focal point in food hygiene in the MOH area (Sri Lanka, Ministry of Health, 2010).
There are many challenges faced by PHIs while carrying out their duties as they interact with numerous sectors and perform field work. Therefore, effective interactions with different partners in the community are essential for smooth functioning. As per the report on Rapid Assessment of Essential Public Health Functions in Sri Lanka in 2006(World Health Organization, 2006, majority of the participants had not seen a PHI in their uniform coming to their close community for disease surveillance and communicable disease prevention activities. Furthermore, the participants were not aware that such a system functions in Sri Lanka to control communicable diseases. Only a very low percentage was able to recall any inquiry by health related officers at their houses or close proximities regarding a patient with a communicable disease (Fernando et al., 2006: p. 57-58).
The above report further mentioned that respondents did not recognise that the officials they had met or spoken to, were PHIs and therefore, were not aware of the functions of the PHI. In addition, only a few in the community have seen an officer during food handling place supervision. It is further stated that the community awareness of the disease surveillance system including detection of patients, follow up as well as environmental control and preventive activities were extremely weak. These findings highlight the challenges faced by the PHIs in effectively implementing public health strategies in their communities (Fernando et al., 2006: p. 57-58).
In addition, due to meagre resources and incentives that are in place, it is questionable whether PHIs' work has enough job satisfaction to motivate them. "Job Satisfaction" has been defined in many ways. One of the generally accepted definitions was forwarded by Locke in 1976 as follows: "A pleasurable or positive emotional state resulting from appraisal of one's job or job experience" (Locke, 1976).
Job satisfaction theories are manifold and they all assess the job satisfaction using different models depending on the circumstances. The most common and prominent theories include Herzberg's Two Factor Theory, Affective Event Theory, Equity Theory and Job Characteristics Theory. Two Factor Theory is one of the oldest theories of job satisfaction, and was first described by Herzberg (Herzberg et al.,1959). The first publication by Herzberg is one of the frequently referred articles in industrial and organisational psychology. Original publication work included the efforts of Bernard Mausner and Barbara Snyderman (Herzberg et al., 1959). In his original work, Herzberg (1959) stressed on the motivator-hygiene factors that would determine the job satisfaction level. Overall effects of these factors would lead to the satisfaction and dissatisfaction of an individual in a working place. Herzberg further explained that some characteristics of the job cause satisfaction and was named as motivation factors and some characteristics cause job dissatisfaction which were named as hygiene factors. Motivational factors are often referred to as intrinsic factors while hygienic factors are referred to as extrinsic factors. Intrinsic/Motivational factors are nature of work, recognition, responsibility, achievement and advancement. Extrinsic/Hygienic factors are supervision, income and job security, working environment and external influences, co-worker relationships and institutional policies (Herzberg, 2003).
Herzberg explained that the factors which determine the satisfaction or the dissatisfaction of the job are different.
"The opposite of job satisfaction is not job dissatisfaction but, rather, no satisfaction; and the opposite of job dissatisfaction is not job satisfaction but no dissatisfaction" (Herzberg, 2003).
Herzberg's Motivation Theory is classified as a content theory of motivation. Herzberg, through research, explores the causes that motivate individuals by identifying and satisfying their individual requirements, wishes and the aims pursued to fulfil these wishes. Both motivational and hygienic factors are important to prevent the discontent among the employees and for personnel development. Thus, less motivational factors will result in employees switching their focus to hygiene factors which in turn dissatisfy them (Ball, 2003).
Intrinsic factors and the satisfaction achieved through one's employment is the most essential component of job satisfaction and closer attention should be given to these factors compared to the environment. That does not mean environment/hygienic factors are not important. Thus, a job itself must be challenging, have scope for enrichment and be of interest to the job holder. Motivators lead to satisfaction as it expands the areas in which one could improve him/herself and also bring the feeling of inner happiness of the achievement. In contrast, the deficiency of these intrinsic factors will result in more attention given to hygienic/extrinsic factors which lead to discontent among the employees.
The concept hygiene factors arise out of the characteristic that they can be avoided or prevented by the use of 'hygienic' methods. The key feature is that attention to these hygiene factors prevents dissatisfaction but does not necessarily provide positive motivation. Hygienic/ extrinsic factors cause dissatisfaction among employees. Thus, it is important to identify the motivational factors and hygienic factors on an individual basis and as some of the factors may be difficult to alter, it is essential to focus on the modifiable factors which increase the satisfaction of a given individual (Ball, 2003).
Affective Event Theory explains the linkages between employees' internal influences such as cognition, emotions, mental status etc. and their reactions to incidents that occur in their work environment that affect their performance, organisational commitment and job satisfaction (Wegge et al., 2006). In support of their theory, research findings of Fisher & Ashkanasy show that the type of feedback on performance provided by managers can affect employee performance and job satisfaction (Fisher & Ashkanasy, 2000).
According to Equity Theory, employee ponders about what his/her qualifications contribute to the work and the job's contribution to him/her. This results in formation of an attitude of worker against the work he/she does. If the worker is overpaid for his work, he will feel guilty whereas if he is underpaid than what he deserves, the need for justice will rise within him. Through this comparison, where they perceive that their inputs are fairly rewarded by outputs, they feel satisfied and feel happier as well as motivated in their work. When employees feel the need for justice, they are demotivated to do their job and to work for their organisation, as they perceive that their ratio of inputs-outputs is less beneficial than the ratio enjoyed by referent others (Pritchard, 1969).
Hackman & Oldham in 1976 proposed a framework to study how particular job characteristics affect job outcomes and job satisfaction; it is named as Job Characteristic Theory. It is mentioned that there are a number of core job characteristics that impact on job outcomes. These are skill variety, task identity, task significance, job outcomes and job feedback (Hackman & Oldham, 1976). If a job is high on above characteristics, the theory assures that motivation, job satisfaction and performance will be positively affected and the likelihood of negative outcomes as absenteeism and turnover will be reduced (Steel, 2012).
Though some studies have shown high job satisfaction, many studies have revealed moderate to low job satisfaction levels among field health workers. A study conducted among Public Health Midwives (PHMs) in the Ratnapura district of Sri Lanka found out that 43.9% of the PHMs were satisfied/ strongly satisfied with intrinsic factors of job satisfaction, whereas overall percentage for job satisfaction was only 25.3% (Gamini, 2008). A study among rural public health nurses in America revealed high job satisfaction levels (Cole et al., 2010). Whereas, in China, a study among community health workers revealed 14.9% of satisfaction/ high satisfaction and 59.1% were in moderate to not full satisfaction (Wang et al., 2011). Further studies have been conducted among community and primary health care workers in different regions in the world, revealing different levels of satisfaction (Chew et al., 2013;Goetz et al., 2012). These studies show regional variability among job satisfaction as well as multifactorial influence in job satisfaction. The objective of this study is to describe the job satisfaction and its associated factors and the problems and challenges faced in work life among PHIs in the Sabaragamuwa Province.

METHODS
A descriptive cross-sectional study was carried out in Ratnapura and Kegalle districts of the Sabaragamuwa Province, Sri Lanka, prior to COVID-19 pandemic, following ethical clearance from the Ethics Review Committee of Faculty of Medicine, University of Colombo and administrative clearance from Provincial Director of Health Services of Sabaragamuwa. Study unit was a Public Health Inspector working in the Sabaragamuwa Province, who has worked more than 1 year in any area in Sri Lanka. Total number of PHIs in Sabaragamuwa Province at the time of the study period was 141 as per administrative branches of each Regional Director of Health Offices. Only 128 PHIs met the inclusion and exclusion criteria. The PHI population of Sri Lanka was 1304 (Sri Lanka, Ministry of Finance and Planning, 2012) excluding the Supervising Public Health Inspectors and the sample size covered 10% of this total population. Two study instruments were used for data collection; namely, a pre-tested, content-validated (in Sinhala), self-administered questionnaire based on Herzberg Two Factor Theory (Gamini, 2008) and a diary for self-reporting of time utilisation. The questionnaire consisted of 3 sections.
Sections 1 & 2 of the questionnaire were item related and were validated by an expert panel in Sociology, Psychology and Community Medicine (Gamini, 2008). Section on socio-demographic data and work related data consisted of 14 questions targeted on obtaining basic socio-demographic and work related data. Second section was based on job satisfaction rating scale on Herzberg Two Factor Theory. Final, 3 rd section consisted of 8 questions on specific factors likely to be associated with job satisfaction of PHIs in Sri Lankan setting. Diary consisted of 2 sections. First section covered the work of two weeks carried out by PHIs prior to the point of data collection and hereafter would be called as "Part 1 of the Diary of activities/work". Second section covered the work of two weeks carried out by PHIs from the point of data collection onwards and hereafter would be called as "Part 2 of the Diary of activities/work". The questionnaire and both part 1 & part 2 of the Diary were self-administered. PHIs were recruited at the Monthly Conferences of respective MOHs, following informed consent. Questionnaire was administered to PHIs & SPHIs at the 1 st point of contact, namely, at the Monthly Conference. Diary for self-reporting of time utilisation was handed over to the PHIs for completion. They were requested to hand over the completed part 1 and 2 of the diary to the Principal Investigator at the Monthly Conference, enclosed in a sealed envelope. A five point Likert scale was used to assess the job satisfaction based on intrinsic and extrinsic factors. Associations between total job satisfaction and socio-demographic and workrelated factors and amount of field & office work were analysed using chi-square test.

RESULTS
Out of the 128 PHIs enrolled, 119 responded to the questionnaire with a response rate of 92.7%. Out of 128 PHIs, 99 responded to 1 st part of the diary with a response rate of 77.3% and only 79 PHIs responded to 2 nd part of the diary with a response rate of 61.7%.
Mean age of the respondents was 40.5 years (SD=7.95). Majority of PHIs were Sinhalese (n=114, 95.8%) and Buddhists (n=114, 95.8%). The mean work experience of PHIs was 12.45 years (SD=6.1). More than 19% of PHIs were working in the same station for past 4 years or more (n=23). Only 16% of Public Health Inspectors resided in their respective PHI areas while more than 32% travelled in excess of 15 km daily to reach their PHI area. Majority of the PHIs have received official motor bicycles for transportation. More than 17% (n=21) of PHIs had an area population in excess of 15,000.
Majority of the PHIs were either dissatisfied or strongly dissatisfied on allowances and overtime payments they were receiving currently (n=91, 76.5%); facilities provided by the government to carry out their duties (n=86, 72.3%); level of consideration given in promotions on work & contributions rendered by the officers (n=76, 63.9%); transfer policy implemented at present (n=73, 61.3%); training they were currently receiving on new technologies and knowledge (n=66, 55.4%); the system in place in MOH offices/ RDHS offices for recognition & felicitation of hard working officers (n=64, 53.8%) and timely feedbacks they were receiving from Medical Officers of Health (n=61, 51.2%). However, majority of PHIs were satisfied with their working hours (n=107, 89.9%) and guidance provided by the Medical Officer of Health in performing their duties (n=79, 66.4%).
Most of the PHIs believed that legal provisions were inadequate for vector control activities to prevent Dengue (n=77, 64.7%) and sanitary facilities of new and existing buildings (n=80, 67.2%). Majority of PHIs were not happy with the facilities government had provided to implement the Food Act and the Mosquito Breeding Prevention Act (N=76, 63.9%) ( Table 2).
On average, out of total respondents of part 1 and 2 separately; one fourth of the time of PHIs' duties was spent on preventing communicable diseases (25% and 24.4%, respectively). Approximately, 15% of PHIs' time during work was spent on water and food safety (part 1-14.8% and part 2-14.6%). They spent least amount of time on Rabies control activities (part 1-0.5% and part 2-2.5%), inspection of institutions (part 1-0.5% and part 2-    (Table 3).
Field activities were defined as all types of work mentioned in Table 3, excluding legal action; training programmes & workshops; office and administrative work, and monthly conferences & other meetings. The PHIs who spent more than 50% of their time on field activities according to part 1 of the diary were considered as officers who spent more time in the field and vice versa. There was a statistically significant difference regarding job satisfaction, as officers who spent more time in the field were less satisfied compared to officers who spent less time in the field (p<0.01). More PHIs were dissatisfied when their area population increased (2.3% vs. 18.2%). This difference was statistically significant (p=0.03) ( Table 4).

DISCUSSION
In Sri Lanka, only few studies have been conducted to assess job satisfaction of health staff. Only a single solitary study was carried out among public health staff to determine their job satisfaction which was conducted among PHMs in Ratnapura district in year 2008 (Gamini, 2008  previously in Sri Lanka. This study was conducted in the Sabaragamuwa Province which has a PHI population of 10% out of total PHI population in Sri Lanka. However, findings from this study may not represent the national profile due to inter-provincial disparities of health services, geography and economy. Majority of the PHIs who took part in this study were dissatisfied with the transfer policy in practice. A recent attempt to implement a transfer scheme for PHIs in the Ratnapura district met with resistance. However, fouryearly transfers for PHIs are expected to be implemented isalnd-wide (Establishments Code, 1985). Nevertheless, more than 19% of PHIs were working in the same station for past 4 years or more, highlighting the doubts on the effectiveness of the said transfer scheme which was in place to improve the productivity of work and keep the staff motivated. Among Public Health Midwives in Ratnapura, only 41% were either dissatisfied or strongly dissatisfied with the transfer policy which is similar to PHIs (Gamini, 2008).
Political authority plays an important role in work of PHIs which was evident by the fact that more than one third of the PHIs claim that there was "political interference" at least once during past 6 months. Thus, it is important to further assess the specific scenarios in which such interferences were made to strengthen the PHIs to avoid/face such occasions effectively without downgrading their work.
Although PHI is a field-based profession, the results from this study showed that during the 1 st two weeks of the diary of activities, close to 40% of the time was spent on administrative work, meetings, monthly conferences, training and legal activity (39.3%). This raises the question; whether Public Health Inspectors spend adequate time in the field, as highlighted in the report by Fernando et al. (2006): "There was a general consensus among the participants that PHI has minimal contact with the communities and that being the main reason for sub optimal functioning". (Fernando et al., 2006: p. 57-58) Among intrinsic factors, responsibility shows highest level of satisfaction (84%), followed by official duty/ nature of work (47.9%) and among extrinsic factors, it is interpersonal relationship (90.8%), followed by supervision (41.2%). The importance of responsibility, nature of work, interpersonal relationships and supervision in job satisfaction in health workers were highlighted in many previous studies as well. Similar findings were shown in studies conducted in Iran and Vietnam (Kebriaei & Moteghedi, 2009;Tran et al., 2013).
Highest percentage of dissatisfaction among intrinsic factors was reported for advancement (n=88, 73.9%), followed by achievement (n=61, 51.3%), and among extrinsic factors, it was income and payment (n=74, 62.2%), followed by organisational policies (n=35, 29.4%). A study conducted in Turkey, using Minnesota Satisfaction Questionnaire among health care staff employed in primary health centres, revealed working environment and income as the most dissatisfying aspects of the job (Bodur, 2002). Furthermore, a study conducted among primary healthcare professionals in Malaysia revealed lowest satisfaction scores in pay and advancement (n=149). Study questionnaire used was Warr-Cook-Wall scale (Chew et al., 2013).
Supervision plays an important part in job satisfaction as an extrinsic/hygienic factor. Study finding shows that more than fifty percent were satisfied or strongly satisfied (60.5%) with regards to impartiality and completeness of the supervision. This is a positive aspect in job satisfaction of PHIs.
More than 75% of the PHIs were not satisfied with the allowances and overtime payments they were receiving (76.8%). Similar pattern was observed among PHMs as well (87.1%). Majority of PHIs were satisfied with their working hours (89.9%) and in comparison, 79% of the PHMs in Gamini's (2008) study were satisfied with the working hours. One of the reasons for high satisfaction rate for duty hours might be the fixed working hours with no duties at night time except in special situations. There was a general dissatisfaction with the facilities provided by the government to carry out their duties (73.7%). PHMs too showed similar response with 82.9% not being satisfied with the facilities (Gamini, 2008). These findings highlight the importance of providing adequate remuneration and facilities to the Sri Lankan grass root level health workers to motivate them for better performance. Such provisions might be critical in controlling the current outbreak of COVID-19 in Sri Lanka.
Officers who spent more time in the field compared to office and other duties were significantly dissatisfied than the officers who spent less time in the field (18.9% vs. 2.2%; p<0.01). This finding raises serious concerns regarding the practicability of the profession of PHIs. The fundamental nature of a PHI's work is based on field activities. However, if the field work causes dissatisfaction among them, it is a serious concern regarding effective fulfilling of their duties. Further, this raises the question of why PHIs who were engaged in field activities were less satisfied. Was it due to work load or more physical and psychological exertion? Further studies are needed to be conducted to find the root cause for above finding and whether the situation is similar nationally. In addition, it is important to find out the impact of COVID-19 on the job satisfaction of PHIs and whether the pandemic has positively or negatively influenced the job satisfaction.

CONCLUSIONS
Majority of Public Health Inspectors were satisfied with responsibility and about half were satisfied with the nature of the work. However, only a minority were satisfied with recognition, advancement and achievement gained from the job. Most were satisfied with interpersonal relationship and about one third were satisfied with supervision and working environment. However, only a minority were satisfied with organisational policies and income/pay. The study revealed that greater proportion of PHIs was dissatisfied with income/pay. In addition, legal provisions were perceived as inadequate for vector control activities to prevent Dengue and to address sanitary facilities of new and existing buildings, by a majority. More time spent in field work (p=0.03) and higher area population (p=0.03) were significantly associated with lower overall job satisfaction of the PHIs. However, experience of the PHI, age and exposure to unnecessary political influence did not significantly influence the overall job satisfaction of the PHIs. As this study investigated the job satisfaction of PHIs in the pre-COVID 19 era, further studies need to be conducted to examine the impact of COVID-19 on the job satisfaction of PHIs.

FUNDING & CONFLICTS OF INTEREST
This study was self-funded and we declare no conflicts of interest.