Job Satisfaction and Associated Factors among Health Professionals Working at Public and Private Hospitals in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study

Introduction Job satisfaction is a pleasurable or positive emotional state resulting from evaluating one's job or job experiences. However, knowledge of workplace factors that either satisfy employees to keep working or dissatisfy them making them leave their jobs or working places is essential for decision-making. Thus, this study is aimed at assessing job satisfaction and associated factors among healthcare professionals working at public and private hospitals in Bahir Dar city, northwest Ethiopia. Methods An institution-based comparative cross-sectional study design was conducted from 10 February 2020 to 29 May 2020. A total of 520 health professionals were selected from public and private health facilities using stratified systematic random sampling techniques. Data were collected using structured pretested self-administered questionnaires. A binary logistic regression model with Huber-White robust standard error was fitted to identify job satisfaction and associated factors among healthcare professionals working at public and private hospitals. A less than 0.05 p value and an Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were considered to have a statistically significant association with the outcome variable. Results The overall magnitude of job satisfaction was 55.2% (95% CI: 51.0, 59.4%). At public and private hospitals, the provider's satisfaction was 29.0% (95% CI: 23.2, 35.1%) and 81.23% (95% CI: 76.6, 85.8%), respectively. Working at private hospital (AOR: 8.89; 95% CI: 5.14, 15.35), pleasant nature of work (AOR:  1.82; 95% CI: 1.05, 3.15), autonomy (AOR: 2.37; 95% CI: 1.29, 4.33), adequate supportive supervision (AOR: 2.42; 95% CI: 1.33, 4.40), good reward and recognition (AOR: 3.04; 95% CI: 1.37, 6.75), and high normative commitment (AOR: 2.57; 95% CI: 1.48, 4.43) were factors affecting the overall job satisfaction of health professionals. Conclusions The magnitude of job satisfaction was relatively low in private and public hospital health professionals and severe among health professionals working in public hospitals. Healthcare policy-makers and hospital managers need to develop and institutionalize evidence-based satisfaction strategies considering the predictors of health professional's job satisfaction.


Introduction
The Ethiopian healthcare system promotes public-private partnerships to ensure equity and quality of healthcare delivery. The public sector is composed of government health organizations that primarily serve the poor segment of the population. In contrast, the private sector is composed of private health facilities for-profit and serves the population segment who can afford out-of-pocket payment [1]. To ensure equity and quality of healthcare provided, availability and accessibility of highly committed and well-performing healthcare professionals are paramount [1][2][3]. Consequently, healthcare professionals' job satisfaction is a fundamental issue in improving access and quality healthcare for the population [4]. Job satisfaction is a pleasurable or positive emotional state resulting from evaluating one's job or job experiences [3,5].
The job satisfaction of healthcare professionals is highly important in building up employee interest and efficiency. Higher job satisfaction determines better employee performance and a higher level of patient satisfaction ultimately to gain competitive advantage and greater productivity of the organization [4,6]. Researchers found that employees satisfied with their job prefer to stay with their employers [7].
Several studies showed a significant and positive relationship between demographic factors such as age, working experience, profession, level of education, and gross monthly salary with job satisfaction [4,22]. According to the level of education, job satisfaction levels of healthcare staff with high school and technical school degrees were lower than healthcare staff with university degrees and master's and above degrees. Specialist doctors, practitioner doctors, and health officers tended to show greater job satisfaction than nurses [23].
According to different studies, opportunities for reward, nature of work, supervision, relations, contact with colleagues, training, and benefit status of the organization were factors affecting employees' job satisfaction [8,24,25]. Employees feel satisfied in organizations that allow them to participate in decision-making processes, improve their skills and knowledge, and enhance work autonomy [3], whereas too many working hours, administrative burdens, heavy workload, lack of time, poor performance evaluation system, and lack of recognition were factors identified as decreasing job satisfaction [26][27][28].
Employee job satisfaction is also influenced by working space and responsibility, opportunity to develop, staff relations [4,29], quality of the working environment, and organizational commitment [30]. In particular, a study done in the United States hypothesized that "organizational commitment is directly related to job satisfaction," and the study results confirmed that job satisfaction was strongly interrelated and associated with organizational commitment in a study done in Iran [31,32].
Similarly, previous researchers found that health workers in Ethiopia tend to be unsatisfied with many aspects of their job, for instance, training opportunities, decision-making autonomy, poor working environment, and their chances of promotion [33][34][35][36].
Furthermore, there are limited studies on job satisfaction and associated factors in the study area as to our search. Besides, no comparative study is conducted at all in the study area. Therefore, this study is aimed at assessing job satisfaction and associated factors among healthcare professionals working at public and private hospitals in Bahir Dar city, northwest Ethiopia.
Thus, this study will let managers better understand the underlying issues to implement strategies to improve health organization policy and principles.

Study Design and Settings.
A facility-based comparative cross-sectional study was conducted from 10 February 2020 to 29 May 2020 to assess job satisfaction and associated factors among healthcare professionals working at public and private hospitals in Bahir Dar city. Bahir Dar city is the Amhara National Regional State's capital city, Ethiopia, located 565 km from Addis Ababa to the northwest. Based on Ethiopia's 2007 Central Statistical Agency (CSA) report, Bahir Dar city had 339683 [37]. The city had been divided into six subcities and 24 kebeles (the smallest administrative units in Ethiopia). The city has three public hospitals, ten public health centers, four private hospitals, and thirty private clinics. According to the Amhara National Regional State health bureau performance report of 2019, there were 1653 and 504 health professionals in public and private hospitals in Bahir Dar city who provide services [37]. Information obtained from these hospitals' administrative offices provides different outpatient, inpatient, and operation room theatre services.

Population and Sampling
This study's source population was all health professionals working at public and private hospitals in Bahir Dar city. Likewise, all health professionals who were working for at least six months at public and private hospitals in Bahir Dar city during the study period were the study populations. Contract and voluntary employees were excluded from the study.
The sample size for the proportion of job satisfaction was determined using a double population proportion formula. An assumption of 95% confidence level, 80% power, P1 (proportion of patient satisfaction at public hospitals) 31.7% [25], P2 (proportion of patient satisfaction at a private hospital) 50%, and 10% nonresponse rate was considered. The final sample size for n1 ðfor public hospitalsÞ = 271 and n2 ðfor private hospitalsÞ = 271 yielded a total of 542.
The participants were identified by using a systematic sampling technique. The list of health workers was taken from payroll in the human resource management department.

Variables and Measurement
3.1.1. Health Professional. A health professional is anyone who has earned a diploma and/or bachelor's degree or higher in health science from an accredited college or university.
The dependent variable for this study was job satisfaction. It was measured by a five-point Likert scale (1: very dissatisfied to 5: very satisfied) of 20 items. Respondents 2 BioMed Research International who scored 60% and above the sum of the satisfaction scales were considered satisfied [38].

Organizational Commitment.
Organization commitment is a health professional's degree of attachment towards their employer. Three dimension scales measured it; a score with more than 60% of the commitment scales' sum represented a high organizational commitment [39]. Affective commitment is a health professional's attitude regarding the alignment of personal and organizational goals. This was measured by using three items, and a 5point Likert scale scored each item from one, denoting "strongly disagree," to five "strongly agree." 3.1.3. Continuance Commitment. Continuance commitment is a health professional's desire to stay with the organization in light of costs associated with leaving (i.e., seniority and pension plans). This was measured by using three items, and each was scored on a 5-point Likert scale with one denoting "strongly disagree" and five representing "strongly agree." 3.1.4. Normative Commitment. Normative commitment is a health professional's decision to stay with an organization because he or she feels obligated. This was measured using three items; each was scored on a 5-point Likert scale, with one denoting strongly disagree and five strongly agree.
3.1.5. Work Environment. Work environment describes the quality of the working environment, both its physical attributes and the degree to which it provides meaningful work. It was measured by using four items; each was scored on a 5point Likert scale.
3.1.6. Supervisor Support. Supervisor support describes the supervisors' responsibility both in preventing and in solving employee problems. It was measured by using ten items, each scored on a 5-point Likert scale.
3.1.7. Recognition and Reward. Recognition and reward describe employee perception about the way they are encouraged. It was measured by 5-point Likert scale questions with one denoted very disagree and five very agree.
3.1.8. Coworker Relationship. Coworker relationship describes the participants' interpersonal relationships within their workplace. It was measured by using four items, each scored on a 5-point Likert scale.
3.1.9. Pay and Benefit. Pay and benefit describe employees' expectations of fairness and adequate compensation on a day's pay for a day's work. It was measured by using four items, each scored on a 5-point Likert scale.
3.1.10. Educational Opportunity. Educational opportunity describes the availability of advancement opportunities for employees within the organization. It was measured by using four items, each scored on a 5-point Likert scale.
3.1.11. Organizational Policy. The organizational policy describes the way how an organization implements policy and strategy. It was measured by using four items, each scored on a 5-point Likert scale.
3.1.12. Autonomy. Autonomy reflects participants' autonomy in initiating and continuing their work behaviors and processes, such as making decisions about work methods, pace, and effort. It was measured by using two items, each scored on a 5-point Likert scale.
3.1.13. Performance Appraisal. Performance appraisal describes the participants feeling on the measurement of their actual performance. It was measured by using three items, each scored on a 5-point Likert scale.
3.1.14. Nature of Work. Nature of work describes the type of work the participants do (variety, meaningfulness). It was measured using nine items each scored on a 5-point Likert scale.
3.1.15. Workload. Workload describes the participant's work requirement, the amount of time, and resources for this requirement. It was measured by using six items, each scored on a 5-point Likert scale.

Data Collection Tools and
Procedure. Data were collected using a Minnesota Satisfaction Questionnaire (MSQ) and a pretested and structured self-administered questionnaire and adopted from previously published literature [38]. The questionnaire was prepared in English and translated to Amharic, then returned to English to check its consistency. The tool's reliability for each subscale was checked using Cronbach's alpha reliability test with a score of greater than 0.83.
To ensure the data quality, two diploma nurses and one BSc public health professional were recruited as data collectors and supervisors, respectively. Also, training regarding the study objectives and data collection process was given to data collectors and supervisors for one day. Moreover, the questionnaire was pretested among 5% of the sample size in Gondar Referral Hospital. Participants were informed that the codes were used to facilitate tracking of the completeness of their respective questionnaires. The supervisors and the principal investigator were responsible for checking on the completeness of the data on-site. Incomplete questionnaires were put in offices arranged for this purpose so that participants completed their questionnaires. Furthermore, intensive supervision was done by the supervisors and principal investigators throughout the data collection period. All participants were acknowledged for their time and assistance.

Data Processing and Analysis.
After the data was checked for its consistency and completeness, data were entered into EpiData version 4.6 and exported to SPSS version 20 for further analysis. Descriptive analysis was done for each variable in the study by running frequencies and percentages. Tables and charts were used for presenting results to give a clear picture of the magnitude and relationships of various study variables. Binary logistic regression and multiple logistic regression analyses were used to determine the significant association between the independent and dependent variables. In the logistic regression model, an estimator with the Huber-White robust standard errors was used. Variables with a p value of less than 0.2 in the binary logistic regression analysis were candidates for multiple logistic regression analysis. Association between the independent and dependent variables was considered significant when the p value was less than 0.05 from multiple logistic regression analysis.

Sociodemographic Characteristics of the Respondents.
A total of 520 study participants were involved in this study, with a response rate of 95.9%. Two hundred fifty-nine participants with a response rate of 95.9% were from the public hospitals, and 261 respondents with a 96.3% response rate were from the private hospitals. The median age of the participants was 26 (IQR = 25-31) years. Half of the respondents were male, 260 (50%), and most of the respondents were married 318 (61.2%). Three hundred nineteen (61.3%) of the respondents had a bachelor's degree, and two hundred forty-six (47.3%) of the respondents had 1-5 years of work experience. The median monthly salary of the respondents was 5294 (IQR = 2300-22180) Ethiopian birr. Around 423 (81.3%) and 493 (94.8%) of respondents were Orthodox Christian followers and Amhara in their ethnicity, respectively.
The majority of respondents were male, 132 (51%), and more than half of the respondents were married 173 (66.8%). One hundred seventy-nine (69%) of the respondents had a bachelor's degree, and one hundred ten (42.5%) of the respondents had 6-10 years of work experience. The respondents' median monthly salary was 5294 Ethiopian birr with an interquartile range (2411-13140). The median age (IQR) of the study participants was 27 (24)(25)(26)(27)(28)(29)(30) years, ranging from 21 to 50 years, and the greatest number of study participants, 183 (70.1%), is under the age category between 20 and 29 years. The majority of respondents were female 133 (51%), and more than half of the respondents were married 145 (55.6%). One hundred forty (53.6%) of the respondents had a bachelor's degree, and one hundred forty-seven (56.3%) of the respondents had 1-5 years of work experience. The respondents' median monthly salary was 4646 Ethiopian birr with an interquartile range (3500-6700) and ranges from 2300 to 22180 (Table 1).

Organizational and Job-Related Characteristics of
Respondents. Overall, 51.0% and 59.6% of respondents worked in a pleasant and safe working environment, respectively. Around 48.5% and 60.8% of respondents got adequate supportive supervision and freedom on their jobs, respectively. Only 21.6% and 37.5% of the participants were given a clear job description and used their annual leave in public hospitals.
The majority of the respondents, 88.4% at the public and 87% at private hospitals, had a high workload. About 37.5% and 69% of public and private hospitals had got short-term training. Twelve and 17.4% of participants were satisfied with recognition, reward, and pay and benefit in public hospitals. Similarly, most of the respondents 87.7%, 63.6%, and 82.8% had good coworker relationships, adequate supportive supervision, and high affective commitment in private hospitals, respectively (Table 2).

4.3.
Magnitude of Job Satisfaction. In this study, among job satisfaction items, the highest respondents' value was for the praise they get for doing a good job (67.1%), whereas the lowest respondents' value was for the way their coworkers get along with each other (47.9%). Healthcare professionals' overall magnitude of job satisfaction was 55.2% (95% CI: 51.0, 59.4%). However, the magnitude of job satisfaction at the public hospital was 29.0% (95% CI: 23.2, 35.1%) and at the private hospitals was 81.23% (95% CI: 76.6, 85.8%) ( Table 3).

Factors Associated with Health Worker Job Satisfaction
in Public and Private Hospitals. The multivariable logistic regression analysis, age, performance appraisal, reward and recognition, and normative commitment were significant variables for job satisfaction in public hospitals. Respondents aged greater than or equal to 30 years were 13 times more satisfied (AOR: 13.06; 95% CI: 4.83, 35.34) compared to respondents aged less than 30 years. Healthcare professionals who agree with the performance appraisal practice were 86% less likely to be satisfied than those who disagree with the performance appraisal practice (AOR: 0.24; 95% CI: 0.09, 0.63). Healthcare professionals who got good rewards and recognition were 4.09 times more likely to be satisfied compared to those who did not get good rewards and recognition (AOR: 4.9; 95% CI: 1.17, 14.29). Study participants with high normative commitment were 3.14 times more likely to be satisfied than those with low normative commitment (AOR: 3.14; 95% CI: 1.30, 7.61) ( Table 4).
Job description, nature of work, and autonomy were significant variables for job satisfaction in private hospitals. Accordingly, the respondents who got clear job descriptions were 5.59 times more likely to be satisfied than their counterparts (AOR: 5.59; 95% CI: 1.28, 24.31). Healthcare professionals working in the pleasant nature of work were 71% less likely to be satisfied than those working in unpleasant work (AOR: 0.29; 95% CI: 0.10, 0.85). Healthcare professionals who had autonomy in decision-making were 3.0 times more likely to be satisfied compared to their counterparts (AOR: 3.00; 95% CI: 1.01, 8.95) ( Table 4).

Factors Associated with Overall Health Professional Job
Satisfaction. In the final multivariable logistic regression analysis model, workplace work, job description, nature of work, autonomy, supportive supervision, reward and recognition, and normative commitment were factors associated with overall job satisfaction (p < 0:05). Subsequently, health professionals working in private hospitals were 8.89 times more likely to be satisfied as compared to those who work in public hospitals (AOR: 8.89; 95% CI: 5.14, 15.35).
Healthcare professionals working in the pleasant nature of work were 1.82 times more likely to be satisfied than those working in the unpleasant nature of work (AOR: 1.82; 95% Healthcare professionals who got good rewards and recognition were 3.04 times more likely to be satisfied compared to those who did not get good rewards and recogni-tion (AOR: 3.04; 95% CI: 1.37, 6.75). Study participants with high normative commitment were 2.57 times more likely to be satisfied than those with low normative commitment (AOR: 2.57; 95% CI: 1.48, 4.43) ( Table 5).

Discussion
In this study, the magnitude of overall job satisfaction was found to be 55.2 (51.0, 59.4)%. The finding showed that the health professionals working at private hospitals were more satisfied 81.2% (76.6, 85.8%) than those working at  The feeling of accomplishment I get from the job    (23.2, 35.1%). This discrepancy could have resulted from differences in infrastructure in the health institutions, administrative issues, socioeconomic characteristics, and healthcare workers' organizational setup.
In this study, the magnitude of job satisfaction at the public hospitals was lower than studies done in Vietnam, 41.8% [10]; Pakistan, 41% [11]; Ghana, 36.4% [15]; Harari region in Ethiopia, 44.2% [6]; Jimma University Specialized Hospital, 60.3% [19]; and Amhara region, 46.9% [18]. The magnitude of job satisfaction in private hospitals in this study was higher than in a study conducted in Nepal (76%) [12]. On the other hand, it was lower than a study conducted in Nigeria (90.4%) [14]. However, it is higher than studies done in Ethiopia [11,17,19,20]. Possible reasons for this variation might be the differences in infrastructure in the health institutions, study area differences, and the tools used to measure the outcome variable that The odds of job satisfaction were higher among healthcare professionals who work in private hospitals. This was supported by other studies conducted in China and New York [7,23].
Healthcare professionals working in a pleasant nature of work were more likely to be satisfied than those who are working in an unpleasant nature of work. This finding is supported by other studies carried out elsewhere [8,40]. This can be the fact that if employees are engaged with a kind of work and they labeled it as worthwhile, are with pride, and are able to see results, it is likely that they will be satisfied with their job. Study participants who had autonomy for decision-making were more likely to be satisfied as compared to those who had no autonomy for decisionmaking. This finding is congruent with other studies conducted in India and Chicago [3,26]. This can be explained as when employees had freedom of decision to accomplish their assigned task and chance to control scheduling of their work, they are likely to be satisfied.
Besides, in this study, health professionals who got adequate supportive supervision were more likely to be satisfied with their job as compared to those who did not get supportive supervision. This finding was consistent with a study from the western Amhara region [25]. These factors were opportunities for reward, nature of work, supervision, and benefit status of the organization [8]. Health professionals who got rewards and recognition were more likely to be satisfied with their job than those who did not get rewards and recognition. Also, those working in a pleasant nature of work were more satisfied than those who worked in the unpleasant nature of work. This finding was in line with a study conducted elsewhere [8]. Finally, healthcare professionals who reported a high normative commitment were more likely to be satisfied with their job than their counterparts. This was consistent with a study conducted elsewhere [41]. This was because if employees feel a sense of belongingness or are involved and linked emotionally with the organization, they are likely to be satisfied.

Strength and Limitations of the Study
The possible limitation of the study was social desirability and a recall bias which may lead to artificially inflated variables. To minimize this effect, a self-administered questionnaire was used. Besides, variables were categorized, which may probably hide information. Furthermore, this study was not triangulated with a qualitative method.

Conclusions
The magnitude of job satisfaction was relatively low in both private and public hospital health professionals and severe among health professionals working in public hospitals. This study revealed that healthcare professionals' job satisfaction was relatively low in private and public hospitals and somehow severe in the public hospitals at Bahir Dar city. The pleasant nature of work, good reward and recognition system, and high affective commitment were positively associated with healthcare professional's job satisfaction at the private hospitals. Being a medical doctor and pharmacy professional, a safe work environment, and adequate supportive supervision positively influence public hospitals' job satisfaction. In light of this finding, healthcare policymakers and hospital administrators should consider the identified factors to improve healthcare professionals' job satisfaction in private and public hospitals.