臺灣博碩士論文加值系統

Background: Leaving intentions is the preferred predictor of actual turnover (Yang & Chen., 2020). This is an issue which many healthcare systems view as vital and should be addressed in order for them to maintain a functional sustainable workforce. The use of evidence-based data in the determination of factors which impact the leaving intentions of public health employees, is important for the purpose of putting in the place the key strategies and policies that are required to mitigate possible losses and also to regain and retain the workforce. Through the experiences of going through a global pandemic which exposed weaknesses within health institutions, environments and services, more research is required to gain specific useful data to decrease the loss of this vital workforce.
Objective: This study assessed the trends and important individual, organizational, environmental, along with other important factors, which impacted the turnover intentions of the Public Health Workforce in the United States of America (USA) in both 2021 and 2017.
Methods: A cross-sectional study design was used with quantitative methods, in order to assess the effect of various factors on the leaving intentions of public health employees within the USA, in 2021 and 2017. This was done via a nationally fielded Public Health Workforce Interest and Needs Survey (PHWINS), for the comprehension of the requirements of state and local governmental workforce. Statistical assessments were done via Stata/MP 18.0 to establish the correlation between the variables.
Results: The results determined that the odds of turnover intention were the same in 2021 as in 2017, however this was insignificant (OR=1.00, p=0.429). Gender, age, racial category/ethnicity, education level and tenure were each significantly associated with turnover intention with p-values of <0.001. Of these, being a woman in 2021 and 2017 (OR=0.82, p<0.001; OR=0.87, p<0.001 respectively) had significantly decreased odds of considering to leave, while those who identified as other (OR=1.42, p<0.001; OR=1.55, p=0.001 respectively) had significantly greater odds. Those who were over the age of 30 had significantly decreased odds of turnover intention with p-values of <0.05, except for those over 60 in the year 2017 (OR=1.05, p=0.252). Those who identified as having two or more races when compared to white had significantly increased likelihood of considering to leave in both 2021 and 2017 (OR=1.43, p<0.001; OR=1.28, p<0.001 respectively) and in both bivariate and multivariate analysis. Those respondents with an associate’s degree or above had significantly higher odds of leaving intentions when compared with those without a college degree with p-values of <0.05. The amount of years that a respondent worked had varying significant results between the analyses, in terms of the odds of turnover intention when compared with 0-5 years. Those who were employed full-time had decreased odds of turnover intention when compared with those who worked part-time in 2021 and 2017 (OR=0.94, p=0.138; OR=0.94, p=0.126 respectively), however this was insignificant. Pay (p=0.044), work overload/burnout (p<0.001) and job satisfaction (p<0.001) as the most important reason for turnover intention, were each significantly associated with the period before (2017) and after (2021) the COVID-19 pandemic. Better/other opportunities outside of the agency (p=0.466) as the top reason for turnover intention, was not associated with the period before (2017) and after (2021) the COVID-19 pandemic.
Conclusion: There will always be a necessity to sustain the public health workforce as long as there are possible future pandemics and varying factors that impact the employee’s intention to leave. These being those related to the socio-demographic characteristics of individuals or those viewed as key reasons for leaving intentions. It is therefore vital to seek and investigate evidence-based data in varying environments, to gain the specific knowledge needed to put policies and strategies in place to create a sustainable future workforce. This study adds to that knowledge.
Keywords: Turnover intention, intention to leave, public health workers, healthcare workers, COVID-19 pandemic

Background: Leaving intentions is the preferred predictor of actual turnover (Yang & Chen., 2020). This is an issue which many healthcare systems view as vital and should be addressed in order for them to maintain a functional sustainable workforce. The use of evidence-based data in the determination of factors which impact the leaving intentions of public health employees, is important for the purpose of putting in the place the key strategies and policies that are required to mitigate possible losses and also to regain and retain the workforce. Through the experiences of going through a global pandemic which exposed weaknesses within health institutions, environments and services, more research is required to gain specific useful data to decrease the loss of this vital workforce.
Objective: This study assessed the trends and important individual, organizational, environmental, along with other important factors, which impacted the turnover intentions of the Public Health Workforce in the United States of America (USA) in both 2021 and 2017.
Methods: A cross-sectional study design was used with quantitative methods, in order to assess the effect of various factors on the leaving intentions of public health employees within the USA, in 2021 and 2017. This was done via a nationally fielded Public Health Workforce Interest and Needs Survey (PHWINS), for the comprehension of the requirements of state and local governmental workforce. Statistical assessments were done via Stata/MP 18.0 to establish the correlation between the variables.
Results: The results determined that the odds of turnover intention were the same in 2021 as in 2017, however this was insignificant (OR=1.00, p=0.429). Gender, age, racial category/ethnicity, education level and tenure were each significantly associated with turnover intention with p-values of <0.001. Of these, being a woman in 2021 and 2017 (OR=0.82, p<0.001; OR=0.87, p<0.001 respectively) had significantly decreased odds of considering to leave, while those who identified as other (OR=1.42, p<0.001; OR=1.55, p=0.001 respectively) had significantly greater odds. Those who were over the age of 30 had significantly decreased odds of turnover intention with p-values of <0.05, except for those over 60 in the year 2017 (OR=1.05, p=0.252). Those who identified as having two or more races when compared to white had significantly increased likelihood of considering to leave in both 2021 and 2017 (OR=1.43, p<0.001; OR=1.28, p<0.001 respectively) and in both bivariate and multivariate analysis. Those respondents with an associate’s degree or above had significantly higher odds of leaving intentions when compared with those without a college degree with p-values of <0.05. The amount of years that a respondent worked had varying significant results between the analyses, in terms of the odds of turnover intention when compared with 0-5 years. Those who were employed full-time had decreased odds of turnover intention when compared with those who worked part-time in 2021 and 2017 (OR=0.94, p=0.138; OR=0.94, p=0.126 respectively), however this was insignificant. Pay (p=0.044), work overload/burnout (p<0.001) and job satisfaction (p<0.001) as the most important reason for turnover intention, were each significantly associated with the period before (2017) and after (2021) the COVID-19 pandemic. Better/other opportunities outside of the agency (p=0.466) as the top reason for turnover intention, was not associated with the period before (2017) and after (2021) the COVID-19 pandemic.
Conclusion: There will always be a necessity to sustain the public health workforce as long as there are possible future pandemics and varying factors that impact the employee’s intention to leave. These being those related to the socio-demographic characteristics of individuals or those viewed as key reasons for leaving intentions. It is therefore vital to seek and investigate evidence-based data in varying environments, to gain the specific knowledge needed to put policies and strategies in place to create a sustainable future workforce. This study adds to that knowledge.
Keywords: Turnover intention, intention to leave, public health workers, healthcare workers, COVID-19 pandemic

Table of Contents

Acknowledgements I
Abstract II
Table of Contents IV
List of Tables VII
List of Figures VIII
List of Abbreviations IX
Chapter 1 Introduction 1
1.1 Background 1
1.2 Statements of the Problem 4
1.3 Research Questions 5
1.4 Significance of the Study 6
1.5 Objectives of the Study 7
Chapter 2 Literature Review 8
2.1 Introduction of the importance of studying Turnover Intention 8
2.2 Turnover Intentions 9
2.3 Individual Factors that Impact Turnover Intentions 11
2.3.1 Gender 11
2.3.2 Age 11
2.3.3 Racial Category/Ethnicity 12
2.3.4 Educational Level 13
2.3.5 Tenure 13
2.3.6 Employed Full-time or Part-time 14
2.4 Organizational Factors that impact Turnover Intentions 15
2.4.1 Pay 15
2.4.2 Organizational Culture/Climate 16
2.4.3 Work Overload/Burnout 18
2.5 Environmental Factor that impact Turnover Intentions 20
2.5.1 Better/Other Opportunities outside of the Agency 20
2.6 Job Satisfaction 21
2.7 Summary 23
Chapter 3 Methods 24
3.1 Empirical Research used as basis for the Conceptual Framework 24
3.2 The Conceptual Framework 25
3.3 Operational Definitions of Variables 26
3.4 Research Hypotheses 31
3.5 The Study Design 31
3.6 The Study Population 32
3.7 Data Source and the Survey Instrument 32
3.8 Processing Data and Statistical Analyses 33
3.9 Ethical Considerations 34
Chapter 4 Results 35
4.1 Descriptive Statistics 35
4.1.1 Characteristics of the respondents 35
4.1.2 Socio-demographic description of the respondents 38
4.1.3 Description of the participants’ responses for the dependent variable 40
4.1.4 Description of the independent variables examined as the most important reason for the respondents’ turnover intention 41
4.2 Results of the bivariate analysis of the variables 43
4.2.1 Binary logistic regression of turnover intention and survey year 43
4.2.2 Chi-Squared (Χ²) test of the dependent variable and independent variables 43
4.2.3 Chi-Squared (Χ²) test of the survey year and independent variables (organizational factors, environmental factors and job satisfaction) as the top reason for turnover intention 47
4.2.4 Binary logistic regression of the dependent variable and independent variables 47
4.3 Results of the multivariate analysis of the variables 52
4.3.1 Multiple logistic regression of the dependent variable and independent variables 52
4.4 Summary of the Results 56
Chapter 5 Discussion 61
5.1 Main research findings 61
5.1.1 The probability of turnover intention of public health workers in 2021 verses 2017 61
5.1.2. The relationship between individual factors and turnover intention 61
5.1.3 The relationship between pay as the principal reason for turnover intention and the period before (2017) and after (2021) the pandemic. 64
5.1.4 The relationship between work overload/burnout as the principal reason for turnover intention and the period before (2017) and after (2021) the pandemic 65
5.1.5 The relationship between better/other opportunities outside of the agency as the principal reason for turnover intention and the period before (2017) and after (2021) the pandemic 65
5.1.6 The relationship between job satisfaction as the principal reason for turnover intention and the period before (2017) and after (2021) the pandemic 66
5.2 Policy Implications 66
5.3 Strengths and limitations of the study 67
5.4 Suggestions for future research 67
5.5 Conclusion 67
References 69
Appendix 74
Appendix 1 - 2021 Survey Instrument 74
Appendix 2 - 2017 Survey Instrument 95
Appendix 3 - Certificate of the TMU-JIRB 112

List of Tables
Table 1 Herzberg’s Motivation and Hygiene Factors 21
Table 2 Operational Definitions of Variables 26
Table 3 Descriptive statistics of the socio-demographic characteristics 39
Table 4 Descriptive statistics of the turnover intention of public health workers 41
Table 5 Descriptive statistics of the most important reason for turnover intention of the respondents 42
Table 6 Results of the binary logistic regression of turnover intention and the survey year 43
Table 7 Results of the Chi-squared (Χ²) test of turnover intention and individual factors in 2021 and 2017 44
Table 8 Results of the Chi-squared (Χ²) test of the survey year and the most important reason for turnover intention 47
Table 9 Results of the binary logistic regression of turnover intention and individual factors 50
Table 10 Results of the multiple logistic regression of turnover intention and individual factors 54
Table 11 Summary of the results of the analysis of the hypotheses 58













List of Figures
Figure 1 The Conceptual Framework of this study 25
Figure 2 Flow chart of the 2021 population 36
Figure 3 Flow chart of 2017 population 37

 
List of Abbreviations
BCHC - Big City Health Coalition
BIPOC - Black, Indigenous and People of Color
EU - European Union
HHS - Health and Human Services
LHDs - Local Health Departments
PHWINS - Public Health Workforce Interest and Needs Survey
SHAs - State Health Agencies
SHA-COs - State Health Agencies-Central Offices
US - United States
USA - United States of America

 

References
Alenazy, F. S., Dettrick, Z., & Keogh, S. (2023). The relationship between practice environment, job satisfaction and intention to leave in critical care nurses. Nursing in Critical Care, 28(2), 167-176. https://doi.org/10.1111/nicc.12737
Arslan Yurumezoglu, H., & Kocaman, G. (2016). Predictors of nurses’ intentions to leave the organization and the profession in Turkey. Journal of Nursing Management, 24(2), 235-243. https://doi.org/10.1111/jonm.12305
Asegid, A., Belachew, T., & Yimam, E. (2014). Factors Influencing Job Satisfaction and Anticipated Turnover among Nurses in Sidama Zone Public Health Facilities, South Ethiopia. Nursing Research and Practice, 2014, 1-26. https://doi.org/10.1155/2014/909768
Bae, S. H., Cho, M., Kim, O., Pang, Y., Cha, C., Jung, H., Kim, S., & Jeong, H. (2021). Predictors of actual turnover among nurses working in Korean hospitals: A nationwide longitudinal
survey study. Journal of Nursing Management, 29(7), 2102-2114. https://doi.org/10.1111/jonm.13347
Beck, A. J., Leider, J. P., Coronado, F., & Harper, E. (2017). State Health Agency and Local Health Department Workforce: Identifying Top Development Needs. American Journal of Public Health, 107(9), 1418-142 https://doi.org/10.2105/AJPH.2017.303875
Borkowski, N., Amann, R., Song, S; & Weiss, C. (2007, April). Nurses’ intent to leave the profession: Issues related to gender, ethnicity, and educational level. Health Care Management Review. 32(2), 160-167. DOI: 10.1097/01.HMR.0000267793.47803.41
Bracarense, C. F., Costa, N. D. S., Raponi, M. B. G., Goulart, B. F., Chaves, L. D. P., & Simoes, A. L. A. (2022). Organizational climate and nurses' turnover intention: a mixed method study. Revista Brasileira Enfermagem, 75(4), e20210792. https://doi.org/10.1590/0034-7167-2021-0792
Brewer, C. S., Kovner, C. T., Greene, W., Tukov-Shuser, M., & Djukic, M. (2012). Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. J Adv Nurs, 68(3), 521-538. https://doi.org/10.1111/j.1365-2648.2011.05753.x
de Vries, N., Boone, A., Godderis, L., Bouman, J., Szemik, S., Matranga, D., & de Winter, P.(2023). The Race to Retain Healthcare Workers: A Systematic Review on Factors that Impact Retention of Nurses and Physicians in Hospitals. Inquiry, 60, 469580231159318. https://doi.org/10.1177/00469580231159318
Degen, C., Li, J., & Angerer, P. (2015). Physicians' intention to leave direct patient care: an integrative review. Human Resources for Health, 13, 74. https://doi.org/10.1186/s12960-
015-0068-5
Hamburg, M. A., Cohen, M., Desalvo, K., Gerberding, J., Khaldun, J., Lakey, D., Mackenzie, E., Palacio, H., & Shah, N. R. (2022). Building a National Public Health System in the United States. New England Journal of Medicine, 387(5), 385-388. https://doi.org/10.1056/nejmp2207374
Hammig, O. (2018). Explaining burnout and the intention to leave the profession among health professionals - a cross-sectional study in a hospital setting in Switzerland. BioMed Central Health Services Research, 18(1), 785. https://doi.org/10.1186/s12913-018-3556-1
Herzberg, F., Mausner, B., & Snyderman, B.B. (1959). The motivation to work. Wiley.
Hussien, M., Yitayal, M., Abaynew, Y., Minyihun, A., (2020). Rural health extension workers’ intention to leave their jobs and associated factors, North Wollo, Zone, northeast Ethiopia. Ethiopian Journal of Health Development, 34(2). https://www.ajol.info/index.php/ejhd/article/view/201323
Kachi, Y., Inoue, K., & Toyokawa, S. (2010). Associations between contractual status, part-time work, and intent to leave among professional caregivers for older people: results of a national cross-sectional survey in Japan. International Journal of Nursing Studies, 47(8), 1028-1036. https://doi.org/10.1016/j.ijnurstu.2010.01.006
Kim, H., Kim, H., & Oh, Y. (2023). Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BioMed Central Nursing, 22(1), 55. https://doi.org/10.1186/s12912-023-01212-0
Koch, P., Zilezinski, M., Schulte, K., Strametz, R., Nienhaus, A., & Raspe, M. (2020). How Perceived Quality of Care and Job Satisfaction Are Associated with Intention to Leave the Profession in Young Nurses and Physicians. International Journal of Environmental Research and Public Health, 17(8). https://doi.org/10.3390/ijerph17082714
Lee, B., Lee, C., Choi, I., & Kim, J. (2022). Analyzing Determinants of Job Satisfaction Based on Two-Factor Theory. Sustainability, 14(19). https://doi.org/10.3390/su141912557
Leider, J. P., Castrucci, B. C., Robins, M., Hare Bork, R., Fraser, M. R., Savoia, E., Piltch-Loeb, R., & Koh, H. K. (2023). The Exodus of State And Local Public Health Employees: Separations Started Before And Continued Throughout COVID-19. Health Affairs(Millwood), 42(3), 338-348. https://doi.org/10.1377/hlthaff.2022.01251
Leider, J. P., Pineau, V., Bogaert, K., Ma, Q., & Sellers, K. (2019). The Methods of PH WINS 2017: Approaches to Refreshing Nationally Representative State-Level Estimates and Creating Nationally Representative Local-Level Estimates of Public Health Workforce Interests and Needs. J Public Health Manag Pract, 25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl), S49-S57. https://doi.org/10.1097/PHH.0000000000000900
Leider, J. P., Shah, G. H., Yeager, V. A., Yin, J., & Madamala, K. (2023). Turnover, COVID-19,
and Reasons for Leaving and Staying Within Governmental Public Health. Journal of
Public Health Management and Practice, 29(Suppl 1), S54-S63. https://doi.org/10.1097/PHH.0000000000001634
Liss-Levinson, R., Bharthapudi, K., Leider, J. P., & Sellers, K. (2015). Loving and Leaving Public Health: Predictors of Intentions to Quit Among State Health Agency Workers. Journal of Public Health Management and Practice, 21 Suppl 6(Suppl 6), S91-101. https://doi.org/10.1097/PHH.0000000000000317
Liu, J., Zhu, B., Wu, J., & Mao, Y. (2019). Job satisfaction, work stress, and turnover intentions among rural health workers: a cross-sectional study in 11 western provinces of China. BioMed Central Family Practice, 20(1), 9. https://doi.org/10.1186/s12875-019-0904-0
Majeed, M., Irshad, M., & Bartels, J. (2021). The Interactive Effect of COVID-19 Risk and Hospital Measures on Turnover Intentions of Healthcare Workers: A Time-Lagged Study. International Journal of Environmental Research and Public Health, 18(20). https://doi.org/10.3390/ijerph182010705
McFarlane, T. D., Dixon, B. E., Grannis, S. J., & Gibson, P. J. (2019). Public Health Informatics in Local and State Health Agencies: An Update From the Public Health Workforce Interests and Needs Survey. Journal of Public Health Management and Practice, 25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl), S67-S77. https://doi.org/10.1097/PHH.0000000000000918
Nashwan, A. J., Abujaber, A. A., Villar, R. C., Nazarene, A., Al-Jabry, M. M., & Fradelos, E. C. (2021). Comparing the Impact of COVID-19 on Nurses’ Turnover Intentions before and during the Pandemic in Qatar. Journal of Personalized Medicine, 11(6), 456. https://doi.org/10.3390/jpm11060456
Peter, K. A., Meier-Kaeppeli, B., Pehlke-Milde, J., & Grylka-Baeschlin, S. (2021). Work-related stress and intention to leave among midwives working in Swiss maternity hospitals - a cross-sectional study. BioMed Central Health Services Research, 21(1), 671. https://doi.org/10.1186/s12913-021-06706-8
Poku, C. A., Donkor, E., & Naab, F. (2022). Impacts of Nursing Work Environment on Turnover Intentions: The Mediating Role of Burnout in Ghana. Nursing Research and Practice, 2022, 1310508. https://doi.org/10.1155/2022/1310508
Pourshaban, D., Basurto-Davila, R., & Shih, M. (2015). Building and Sustaining Strong Public Health Agencies: Determinants of Workforce Turnover. Journal of Public Health Management and Practice, 21 Suppl 6, S80-90. https://doi.org/10.1097/PHH.0000000000000311
Ran, L., Chen, X., Peng, S., Zheng, F., Tan, X., & Duan, R. (2020). Job burnout and turnover intention among Chinese primary healthcare staff: the mediating effect of satisfaction. British Medical Journal Open, 10(10), e036702. https://doi.org/10.1136/bmjopen-2019-036702
Robins, M., Leider, J. P., Schaffer, K., Gambatese, M., Allen, E., & Hare Bork, R. (2023). PH WINS 2021 Methodology Report. J Public Health Manag Pract, 29(Suppl 1), S35-S44. https://doi.org/10.1097/PHH.0000000000001632
Rotenstein, L. S., Brown, R., Sinsky, C., & Linzer, M. (2023). The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-023-08153-z
Sasso, L., Bagnasco, A., Catania, G., Zanini, M., Aleo, G., & Watson, R. (2019). Push and pull factors of nurses' intention to leave. Journal of Nursing Management, 27(5), 946-954. https://doi.org/10.1111/jonm.12745
Sellers, K., Leider, J. P., Gould, E., Castrucci, B. C., Beck, A., Bogaert, K., Coronado, F., Shah, G., Yeager, V., Beitsch, L. M., & Erwin, P. C. (2019). The State of the US Governmental Public Health Workforce, 2014-2017. Am Journal of Public Health, 109(5), 674-680. https://doi.org/10.2105/AJPH.2019.305011
Shah, S. H. A., Haider, A., Jindong, J., Mumtaz, A., & Rafiq, N. (2021). The Impact of Job Stress and State Anger on Turnover Intention Among Nurses During COVID-19: The Mediating Role of Emotional Exhaustion. Frontiers Psychology, 12, 810378.
https://doi.org/10.3389/fpsyg.2021.810378
Silverman, H., Wilson, T., Tisherman, S., Kheirbek, R., Mukherjee, T., Tabatabai, A., McQuillan, K., Hausladen, R., Davis-Gilbert, M., Cho, E., Bouchard, K., Dove, S., Landon, J., & Zimmer, M. (2022). Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center. BioMed Central Medical Ethics, 23(1), 45. https://doi.org/10.1186/s12910-022-00775-y
Steinmetz, S., Vries, D. H. D., & Tijdens, K. G. (2014). Should I stay or should I go? The impact of working time and wages on retention in the health workforce. Human Resources for Health, 12(1), 23. https://doi.org/10.1186/1478-4491-12-23
Tabur, A., Choudhury, A., Emhan, A., Mengenci, C., & Asan, O. (2022). Clinicians' Social Support, Job Stress, and Intent to Leave Healthcare during COVID-19. Healthcare (Basel), 10(2). https://doi.org/10.3390/healthcare10020229
Thomas-Hawkins, C., Flynn, L., Zha, P., & Ando, S. (2022). The effects of race and workplace racism on nurses' intent to leave the job: The mediating roles of job dissatisfaction and emotional distress. Nursing Outlook, 70(4), 590-600. https://doi.org/10.1016/j.outlook.2022.03.001
Wang, H., Jin, Y., Wang, D., Zhao, S., Sang, X., & Yuan, B. (2020). Job satisfaction, burnout, and turnover intention among primary care providers in rural China: results from structural equation modeling. BioMed Central Family Practice, 21(1), 12. https://doi.org/10.1186/s12875-020-1083-8
Wynen, J., & Op de Beeck, S. (2014). The Impact of the Financial and Economic Crisis on Turnover Intention in the U.S. Federal Government. Public Personnel Management, 43(4), 565-585. https://doi.org/10.1177/0091026014537043
Yan, S., Shen, X., Wang, R., Luo, Z., Han, X., Gan, Y., & Lv, C. (2021). The prevalence of turnover intention and influencing factors among emergency physicians: a national observation. Human Resources for Health, 19(1). https://doi.org/10.1186/s12960-021-00688-8
Yang, Y., & Chen, J. (2020). Related Factors of Turnover Intention Among Pediatric Nurses in Mainland China: A Structural Equation Modeling Analysis. Journal of Pediatric Nursing, 53, e217-e223. https://doi.org/10.1016/j.pedn.2020.04.018
Zhang, C., Hu, L., Ma, J., Wu, S., Guo, J., & Liu, Y. (2019). Factors determining intention to leave among physicians in tertiary hospitals in China: a national cross-sectional study. British Medical Journal Open, 9(3), e023756. https://doi.org/10.1136/bmjopen-2018-023756
Zhang, F., Luo, Z., Chen, T., Min, R., & Fang, P. (2017). Factors affecting turnover intentions among public hospital doctors in a middle-level city in central China. Australia Health Review, 41(2), 214-221. https://doi.org/10.1071/AH15238