The relationship between effort–reward imbalance and job satisfaction among primary care general practitioners in Gansu of China: the mediating role of public service motivation

Abstract

Background

With the development of society and the economy, along with the aging population, the demand for primary health care services is growing. As the core providers of primary healthcare services, the job satisfaction of general practitioners (GPs) directly affects the quality of healthcare services and patient satisfaction, and it is one of the key indicators for assessing the effectiveness of relevant policy implementations. However, the heavy workload of Chinese primary care physicians, their low income levels, and their weak sense of professional identity may lead to an effort–reward imbalance (ERI). Therefore, analyzing the mechanisms behind ERI in relation to GPs’ job satisfaction is crucial for advancing their professional growth. This is particularly relevant in less developed regions, as it can significantly boost the performance of healthcare services, elevate the standard of primary healthcare, and ultimately contribute to the realization of universal health coverage.

Methods

This study, conducted from December 2023 to March 2024, employed a cross-sectional analysis of primary care GPs in Gansu Province, China, based on social exchange theory, to investigate whether and how ERI affects job satisfaction among primary care GPs. An electronic questionnaire survey was distributed to resident doctors who had completed their training through standardized residency training bases to test the theoretical hypotheses.

Findings

This study found that the ERI among primary care GPs in China was relatively significant (3.57/5.00). The ERI negatively affected primary care GPs’ job satisfaction (B = − 0.381, p < 0.01), explaining 23.6% of the variance in job satisfaction. Additionally, public service motivation (PSM) fully mediated the relationship between ERI and primary care GPs’ job satisfaction (mediation effect of − 0.500, 95% bootstrap confidence interval [− 0.818 to − 0.156]). The study also revealed that GPs in primary hospitals had higher job satisfaction, while rural order-oriented GPs experienced lower job satisfaction.

Conclusion

This study examines the detrimental effects and underlying mechanisms of ERI on the job satisfaction of primary care GPs, thereby contributing to the body of research on the factors influencing their job satisfaction. The findings underscore the importance of considering PSM as a critical intermediary when addressing ERI among primary care GPs. The conclusions offer practical insights for enhancing the job satisfaction of GPs, which, in turn, may lead to improved medical service performance in underdeveloped regions of China.

Introduction

Employees with high satisfaction create higher performance and the organization grows in a healthy way. Job satisfaction, as one of the notable indicators of job well-being [1], is related to job performance, burnout and career retention [2, 3]. The job satisfaction of primary care general practitioners (GPs) affects not only their own health, but also the quality of healthcare services and the quality of care perceived by patients. In some countries, there is widespread dissatisfaction among GPs, whose share of the physician workforce is declining despite the growing importance of primary care [4]. A cross-sectional study of 34 countries showed that job satisfaction varied across countries and GPs, with large differences between countries, with GPs in countries with higher GDP per capita being more satisfied; health system characteristics were not associated with GPs’ job satisfaction; colleague feedback and patient satisfaction were positively associated with GPs’ job satisfaction, whereas longer working hours were negatively correlated [5].

In recent years, the reform of China’s healthcare system has focused on “strengthening the grassroots”, and the construction of grassroots healthcare personnel, especially the construction of the GPs workforce, is the core content of “strengthening the grassroots”. The free medical student program is currently an important measure to train a large number of qualified GPs in China. In the program, they undergo five years of undergraduate and three years of residency training, and then return to the grassroots level to work as GPs after passing the assessment. Despite the fact that the focus of the new healthcare reform has been continuously tilted towards primary care and the government has been introducing various policies that are conducive to stabilizing the GPs workforce, GPs in China are still facing the problems of talent shortages and difficulties in staff retention, which greatly affect the level and quality of primary healthcare services. In fact, the problems of talent shortage and turnover of primary care GPs are closely related to the job satisfaction of this occupational group [6]. By combing through the literature, it was found that Chinese scholars had only begun to pay attention to the job satisfaction of primary care family physicians roughly since the last decade, and the results of the study showed that job pressure, job needs, job duties, satisfaction with supervisor’s support, and opportunities for training and career development were the main factors affecting the job satisfaction of primary care GPs in China [7, 8].

In China, Gansu Province, as an economically underdeveloped region in western China with unique geographical characteristics, faces healthcare challenges that differ from those in other regions. Firstly, Gansu’s economic level is relatively low, with its GDP ranking among the lowest in the country, leading to a shortage and unequal distribution of medical resources [9, 10]. Medical resources are concentrated in the provincial capital, Lanzhou, and a few large cities, while primary healthcare facilities are extremely weak, with a shortage of doctors and insufficient service capacity in rural areas. Gansu’s geographical layout is long and narrow, with a large regional span, resulting in significant disparities in medical resources across different areas. Primary healthcare services face considerable pressure. As the population ages and public health emergencies increase, the inadequacy of primary healthcare services has become more evident, not only affecting the health of residents across the province but also hindering progress toward achieving comprehensive health.

According to the 2023 National Health and Wellness Development Statistical Bulletin, there are 3.99 GPs per 10,000 people in China [11]. Meanwhile, a report on the construction of the medical and health service system from the Gansu Provincial People’s Government points out that in the past three years, the province has introduced 14,204 various talents, and the number of general practitioners per 10,000 people has increased from 2.48 to 3.32. Despite this improvement, the number of GPs per 10,000 people in Gansu Province is still below the national average [12]. This disparity will inevitably increase the workload, leading to an effort–reward imbalance (ERI) [13]. This model focuses on an individual’s efforts to achieve balance in the workplace through a comparison of inputs and outcomes with others, and it states that work characterized by high efforts and low rewards creates perceptions of imbalance that result in employee strain reactions and impaired well-being, which are the core indicators of job stress [14]. Chinese GPs face a strong workload and greater physical and mental pressure [15], but there are still relatively few research results on the ERI of primary care GPs.

Among the ranks of Chinese public officials, street bureaucrats are the group with the largest number and the most frequent interactions with citizens, playing an important role in grassroots governance and grassroots services, and assuming the responsibility of implementing national policies and mediating grassroots social interests and conflicts [16]. Scholarly research on the public service motivations (PSM) of street bureaucrats has been a hot topic of study. The theory of PSM originates from the public sector management practice under the influence of the new public management trend in the U.S. It is a reflection and reform of traditional public employee management tools such as performance appraisal. The theory argues that focusing only on external constraints and incentives will lead to the dilution of public values and moral consciousness, and therefore needs to emphasize the intrinsic driving force of motivation. PSM is rooted in an individual’s desire to contribute to society, and it is an intrinsic motivation based on the special interests and preferences of the public service career, which is difficult to change [17, 18].

As one of the street bureaucrats, primary care GPs are mainly responsible for the integrated services of diagnosis and treatment of common diseases and multiple diseases and referrals, preventive health care, patient rehabilitation and chronic disease management at the grassroots level [19]. They play an extremely important role in basic medical and health care services, and are known as the “gatekeepers” of the residents’ health, and their behaviors have a direct bearing on the well-being, accessibility and satisfaction of the citizens, as well as on citizens’ trust in the government. Providing basic medical services to the people is a basic function of the government, and shaping the public service spirit of GPs is of great significance. However, their monthly income is significantly lower than that of ordinary clinical graduates, with the absolute value of the difference increasing year by year [20], leading to difficulties in realizing their material and spiritual needs, and generating somatic and spiritual slackness [21]. The reform of supporting incentive mechanisms such as remuneration, rewards and punishments is relatively lagging behind, leading to burnout and willingness to leave in some GPs, and these phenomena reflect the decline of GPs’ motivation for public service and enthusiasm for work [15, 20, 22]. A number of studies have focused on the outcomes of PSM, such as its impact on occupational well-being, job satisfaction, work engagement, work evaluation and counterproductive work behavior [23–28]. However, information about the level of PSM among primary care GPs and the mediating role of PSM on ERI and job satisfaction deserves further exploration.

Social exchange theory is based on the principle of reciprocity, which suggests that individuals, after evaluating costs and benefits, enter into relationships that minimize costs and maximize benefits [29]. Such exchanges can be either negotiated or reciprocal. Negotiated exchanges involve explicit bargaining, whereas reciprocal exchanges rely on the behavior of the other party and, once initiated, may create a self-reinforcing cycle of behavior. Such reciprocal relationships based on trust can promote cooperation and efficiency within an organization and increase employee job satisfaction and loyalty [30]. The core of social exchange theory lies in individuals’ evaluation of inputs versus rewards, where perceived imbalance triggers psychological and behavioral responses. In the healthcare context, physicians’ efforts (workload, occupational stress) can be viewed as inputs, while compensation, professional recognition, and career development opportunities represent rewards. According to social exchange theory, when physicians experience prolonged high-effort–low-reward conditions, their psychological contract is breached, potentially diminishing intrinsic motivation and thereby reducing positive evaluations of their work [31].

In summary, based on social exchange theory, this study will explore whether and how the ERI at work affects the job satisfaction of grassroots GPs of Gansu. The questionnaire survey method was used to analyze the process mechanism of ERI affecting the job satisfaction of primary care GPs, and verify the mediating effect of PSM. The findings of the study are intended to provide a useful reference for improving the job satisfaction of primary care GPs and creating a primary care GPs workforce with a high level of public service spirit.

Theoretical foundations and research hypotheses

Effort–reward imbalance and job satisfaction

Effort–reward imbalance (ERI) refers to the work-related stress that arises when an individual’s effort exceeds the rewards they receive. This theory suggests that when employees’ efforts surpass the rewards they receive, their stress levels increase, which in turn affects employee turnover [14, 32, 33]. GPs work in high-pressure environments, handling large patient volumes, administrative tasks, and critical decisions while maintaining high care standards. However, their efforts often outweigh the rewards, leading to stress, burnout, and dissatisfaction potentially driving turnover. As frontline healthcare providers, GPs also face challenges like long hours, limited resources, and emotional exhaustion, underscoring the need to examine the impact of ERI on job satisfaction and retention.

Job satisfaction tends to decline when employees feel an imbalance between payoffs and rewards. Studies have shown that excessive workloads and inadequate rewards can lead to burnout, anxiety, and dissatisfaction among employees, thus reducing their job satisfaction [14, 34]. In both the public and private sectors, this imbalance may lead to employees’ lack of enthusiasm for their jobs and affect their performance. The ERI may also lead to an increase in job stress, which further affects job performance and satisfaction. In a relatively balanced situation, employees tend to have higher job satisfaction. Managers can mitigate the ERI by providing appropriate support, fair pay, and recognition to enhance employees’ job satisfaction and motivation. This balance not only contributes to the well-being of employees, but also enhances their sense of engagement at work.

At present, the imbalance between effort and reward for GPs at the grassroots level in China is becoming increasingly prominent. This imbalance not only affects the job satisfaction of GPs, but also the quality and sustainable development of primary care services. The main effort status is manifested in the fact that GPs need to undertake more patient consultation tasks, work long hours, and often need to provide services in extreme working environments. They are not only responsible for the diagnosis and treatment of diseases, but also take on multiple responsibilities, such as health management and chronic disease management, and face high occupational pressure [35]. Compared with urban hospitals, primary care GPs have fewer opportunities for professional training and development, and it is difficult to improve professional skills [36]. Moreover, compared with the efforts of GPs, their rewards are relatively low. Although the government has gradually increased the salaries of primary care doctors, it is still difficult to meet their living needs, especially when the cost of living is gradually rising [37]. The professional value of primary care GPs is often underestimated, and the public does not have a high degree of recognition and respect for them, which affects their sense of professional pride [38]. Due to the lack of space for career advancement and opportunities for continuing education, many GPs feel that their career development prospects are slim. The long-term imbalance has led to a general feeling of exhaustion and frustration among primary care GPs, and serious burnout [39]. Because of the lack of sufficient incentives and support, the motivation of primary care GPs and the quality of their services have been affected, which in turn affects the patients’ experience of care. Many excellent GPs choose to leave their primary care positions and turn to urban hospitals or other professions, resulting in a shortage of primary care talent [15]. Based on the cost–reward trade-off principle of social exchange theory, when physicians’ efforts substantially outweigh their rewards, the imbalance in their psychological contract directly reduces job satisfaction [40]. Based on this, this study proposes hypothesis 1:

H1: There is a significant negative effect of ERI on the job satisfaction of primary care GPs.

The mediating role of public service motivation

Rainey and Steinbauer define PSM as “an altruistic motivation to serve the interests of a group, locality, nation, or humanity as a whole” [41]. This motivation is strong enough to inspire individuals to dedicate themselves to public service and continuously enhance their enthusiasm [42]. Vandenabeele, based on the integration of multiple perspectives, proposed a comprehensive definition, stating that PSM is a belief, value, and attitude that goes beyond personal and departmental interests, focusing on the broader interests of political organizations and inspiring individuals to take appropriate actions when necessary [43]. When public service workers perceive insufficient rewards (e.g., recognition, promotions), their motivation and job satisfaction decline, increasing burnout and turnover intent [14, 17]. Public Service Motivation (PSM), driven by expected social rewards (not just financial), weakens when efforts lack acknowledgment from superiors or the public. Effort–reward imbalance (ERI) exacerbates emotional exhaustion, further eroding PSM, motivation, and creativity.

PSM is a key endogenous factor that enhances positive organizational behaviors such as job satisfaction, occupational well-being, and organizational citizenship behaviors and reduces burnout among public employees [44, 45]. A high level of PSM tends to enhance public officials’ job satisfaction. Public officials are more likely to find meaning and value in their work due to their own sense of mission and responsibility. This intrinsic motivation enables public officials to remain positive in the face of challenges, thus increasing overall job satisfaction [17]. Social exchange theory emphasizes the role of intrinsic motivation in sustaining exchange relationships. Public service motivation (PSM), as an intrinsic driver for physicians to serve the public, depends on individuals’ perception of social rewards (patient recognition, professional value). When ERI weakens physicians’ perceived rewards, their PSM declines, thereby impacting satisfaction. Based on this, this study proposes Hypothesis 2:

H2a: ERI has a significant negative effect on PSM of primary care GPs.

H2b: PSM plays a mediating role in the effect of ERI on job satisfaction of primary care GPs.

Based on the above analysis, this study constructs a theoretical model, as shown in Fig. 1.

Fig. 1.

Conceptual framework of the study

Methods

Setting

The questionnaire was discussed and formulated by experts. Ten experts were invited, including two managers from health administration departments, two hospital administrators, three managers from community health service centers, and three GPs. In the first round, opinions were anonymously collected using the Delphi method. In the second round, only those items with over 80% consensus were retained. Based on expert suggestions, related questions were merged. The final questionnaire included basic personal information, effort–reward imbalance, job satisfaction and public service motivation. According to the pre-set questionnaire validity determination related issues, the validity of the returned questionnaires was determined [46].

The GP data come from 12 prefecture-level cities and 2 autonomous regions in Gansu Province, China. All the GPs were clinically active, full-time state employees of the hospitals and community medical institutions. Three categories were included: rural orders directed to general practitioners, transfer to general practitioners, and staff engaged in general practice.

Convenience sampling was used in this study, which was conducted from December 2023 to March 2024. An electronic questionnaire was distributed to resident doctors who had completed training at standardized residency training bases or who were from community medical institutions. 431 questionnaires were received in total. After verification of answers to validity questions, the final valid questionnaires were 420 (with a validity rate of 97.45%). Participants completed the online survey voluntarily and anonymously; their identity and responses were kept strictly confidential.

Variables

Effort–reward imbalance

Van Yperen’s scale is widely used to assess effort–reward imbalance in the workplace. Its items cover core dimensions such as work pressure, responsibility load, and time pressure, effectively reflecting the high workload and low reward perception faced by Chinese general practitioners (GPs). The scale demonstrates high reliability and validity in healthcare settings, aligning with the measurement needs of ERI in this study. So ERI was measured using van Yperen’s six-item 5-point scale (1 = “strongly disagree”, 5 = “strongly agree”). Sample items include “I experience significant time pressure due to heavy workloads”, “There are many obstacles and disturbances in my work”, “I bear substantial responsibilities in my job”, “I am often forced to work overtime”, “My job demands have increased significantly over the past few years”, and “My work is physically demanding” [14]. The Cronbach’s alpha coefficient was 0.880.

Job satisfaction

Job satisfaction was assessed using a two-item 7-point scale (1 = “extremely dissatisfied”, 7 = “extremely satisfied”). Despite its brevity, this unidimensional two-item scale has proven efficient in resource-constrained studies. The first item directly measures individual overall satisfaction, while the second indirectly reflects organizational environmental influences through colleagues’ satisfaction. Together, they effectively capture GPs’ subjective experiences while minimizing respondent fatigue from lengthy questionnaires and reducing the likelihood of nonresponse [47]. The items were “Overall, I am very satisfied with this job” and “Most of my colleagues are very satisfied with this job”. The Cronbach’s alpha coefficient was 0.947.

Public service motivation

PSM was assessed using a revised version, which was adapted and validated in the Chinese context, aligning with the cultural connotations of “public service spirit”, by Bao and Li using an eight-item 5-point scale.(1 = strongly disagree; 5 = strongly agree). It accurately captures GPs’ PSM. The scale demonstrated high reliability in pre-tests, and its four dimensions comprehensively cover the theoretical framework of PSM, ensuring measurement robustness. The questionnaire included four categories: public engagement, public value commitment, compassion and self-sacrifice. A sample item is “It is important to me to do meaningful public service” [48]. The Cronbach’s alpha coefficient was 0.896.

Analyses

In this study, SPSS 21 software was used for descriptive statistical analysis and correlation analysis of data. The mediation test method is the Bootstrap confidence interval (CI) method.

Results

Demographic characteristics

Participants ranged in age from 21 to 60 years, with a mean age of 32.51 years, and a standard deviation of 7.56 years. 58.33% were women; 95.00% were Han, the remaining 5.00% were of other ethnic groups (i.e., Dongxiang ethnic or Hui group). 63.81% were married, 35.24% were unmarried and 0.95% were divorced. 10.95% were only-child. 40.24% were from hospitals, and 49.76% were from community medical institutions. The details are shown in Table 1.

Table 1.

Demographic characteristics of general practitioners (n = 420)

Demographic characteristics		Frequency(%)/mean ± SD
Gender	Male	175(41.67)
	Female	245(58.33)
Age		32.51 ± 7.56
Nationality	Han	399(95.00)
	Other	21(5.00)
Marital status	Married	268(63.81)
	Unmarried	148(35.24)
	Other	4(0.95)
Only-child	Yes	46(10.95)
	No	374(89.05)
Title	Primary	296(70.48)
	Medium	113(26.90)
	Senior	11(2.62)
Work unit	Community medical institution	209(49.76)
	Hospital	211(40.24)
GP category	Rural orders directed to general practitioner	201(47.86)
	Transfer to general practitioner	55(13.10)
	Staff engaged in general practice	164(39.04)

Common method bias test

In this study, data were collected by questionnaire method and all items were self-administered by GPs, so there may be common method bias. Therefore the collected data were first subjected to Harman’s One-factor Test, which yielded that the factors with eigenvalues > 1 were three, and the variance explained by the first factor was 42.417, which is less than 50%. According to the theory of Podsakoff and Organ, it is considered that the common method bias is not serious if the variance explained by the single factor obtained with EFA (unrotated) does not exceed 50% [49].

Descriptive statistics and correlation analysis results

Table 2 shows the mean and standard deviation of each variable and the correlation coefficient between variables. The results showed that PSM was positively correlated with job satisfaction (r = 0.474, p < 0.01), and ERI was negatively and statistically significantly correlated with job satisfaction (r = − 0.164, p < 0.01) and public service motivation (r = − 0.481, p < 0.01).

Table 2.

Descriptive statistics and the correlation analysis of the variables

Variables	1	2	3
1 ERI	1.000
2 PSM	− 0.481**	1.000
3 Job satisfaction	− 0.164**	0.474**	1.000
Mean	3.574	3.673	4.760
SD	0.779	0.756	1.639

^**p < 0.01

The results of the mediation effect analysis

Model 1 examines the total effect of ERI on job satisfaction without considering PSM. Model 2 tests the effect of ERI on PSM. Model 3 investigates the mediating role of PSM between ERI and job satisfaction. Other basic characteristics, such as gender, age, and marital status, are included as control variables.

Model1 in Table 3 showed that ERI had a significant negative effect on job satisfaction (B = − 0.381, p < 0.01); under the condition of considering control variables, ERI can explain 23.6% of the variance in job satisfaction. This aligns with social exchange theory, where unmet expectations of effort–reward reciprocity generate frustration and perceived injustice, ultimately deteriorating work attitudes. The results indicate that the more serious the ERI was, the lower the job satisfaction was, and Hypothesis 1 was verified.

Table 3.

The results of the mediation effect analysis (n = 420)

Variables	JS (Model1)				PSM(Model2)				JS (Model3)
	B	SE	t	p	B	SE	t	p	B	SE	t	p
Constant term	3.667**	1.128	3.250	0.001	2.981**	0.517	5.765	0.000	0.488	1.025	0.476	0.634
Control variables
Gender	− 0.045	0.151	− 0.298	0.766	0.005	0.069	0.079	0.937	− 0.051	0.132	− 0.385	0.700
Age	− 0.006	0.014	− 0.396	0.693	− 0.012	0.006	− 1.887	0.060	0.007	0.012	0.600	0.549
Marital status (Married)	− 0.039	0.741	− 0.053	0.958	− 0.328	0.340	− 0.965	0.335	0.310	0.648	0.479	0.632
Marital status (Unmarried)	− 0.166	0.763	− 0.218	0.828	− 0.472	0.350	− 1.350	0.178	0.338	0.668	0.505	0.614
Only-child	− 0.112	0.227	− 0.491	0.624	0.046	0.104	0.444	0.657	− 0.161	0.199	− 0.810	0.418
Title (Medium)	0.235	0.178	1.322	0.187	0.152	0.082	1.856	0.064	0.074	0.156	0.472	0.637
Title (Senior)	0.213	0.483	0.440	0.660	− 0.027	0.221	− 0.121	0.904	0.241	0.422	0.571	0.568
Work unit	0.463**	0.156	2.968	0.003	− 0.131	0.072	− 1.834	0.067	0.603**	0.137	4.406	< 0.001
GP category (Rural orders directed to general practitioner)	− 1.437**	0.175	− 8.201	< 0.001	− 0.179*	0.080	− 2.232	0.026	− 1.246**	0.154	− 8.091	< 0.001
GP category (Transfer to general practitioner)	0.020	0.268	0.076	0.939	0.139	0.123	1.133	0.258	− 0.128	0.234	− 0.547	0.585
Independent variable ERI	− 0.381**	0.092	− 4.126	< 0.001	− 0.469**	0.042	− 11.062	< 0.001	0.118	0.092	1.287	0.199
Mediating variable PSM									1.067**	0.094	11.305	< 0.001
R 2	0.256				0.264				0.434
Adjusted R 2	0.236				0.245				0.417
F Value	12.782***				13.332***				26.008***

The coefficient is the unstandardized coefficient

^*p < 0.05, **p < 0.01,***p < 0.001

Model 2 demonstrated a significant negative effect of ERI on PSM (B = − 0.469, p < 0.001), with ERI explaining 24.5% of PSM variance under control variables. This supports the mechanism that chronic effort–reward imbalance induces burnout and erodes intrinsic motivation, thereby diminishing individuals’ enthusiasm for public service contributions. These findings confirm that ERI significantly and negatively affects primary care GPs’ PSM, verifying Hypothesis H2a.

Following Baron and Kenny’s mediation test [50], Model 3 revealed that when both ERI and PSM predicted job satisfaction, the regression coefficient of ERI became non-significant (B = 0.118, p > 0.05), while PSM showed a strong positive impact (B = 1.067, p < 0.01). This complete mediation underscores PSM’s critical role in buffering ERI’s detrimental effects: ERI indirectly reduces job satisfaction by depleting PSM, which itself serves as a key enhancer of job satisfaction. To rigorously validate this, a Bootstrap test with 5000 resamples was conducted via SPSS21.0 Process. As shown in Table 4, the mediation effect of PSM was − 0.500, with a 95% Boot confidence interval (− 0.818 to − 0.156) excluding zero, further confirming the significance of PSM’s mediating role and solidifying Hypothesis H2b.

Table 4.

Summary of the mediation effect test results

	c total effect (95% CI)	a (95% CI)	b (95% CI)	a*b mediation effect	a*b (Boot SE)	a*b (z value)	a*b (p value)	a*b (95% BootCI)	c' direct effect (95% CI)
ERI =  > PSM =  > JS	− 0.381** (− 0.563 ~ − 0.200)	− 0.469** (− 0.552 ~ − 0.386)	1.067** (0.882–1.251)	− 0.500	0.245	− 2.039	0.041	− 0.818 ~ − 0.156	0.118 (− 0.062 ~ 0.299)

c: the regression coefficient of ERI on JS, that is, the total effect

a: the regression coefficient of ERI on PSM

b: the regression coefficient of PSM on JS

a*b: the product of a and b, which is the mediation effect

c': the direct effect

^**p < 0.01

Regarding control variables, organizational differences significantly influenced job satisfaction. GPs in hospitals exhibited higher satisfaction than those in community health centers (likely due to superior resources and career development opportunities), while rural order-oriented GPs reported lower satisfaction, potentially attributable to heightened workload pressures and resource limitations. Notably, no other control variables impacted job satisfaction beyond institutional type and GP status classification.

Discussion and conclusion

This study investigated the effects and mechanisms of ERI on primary care GPs’ job satisfaction, using a questionnaire survey method and empirical data analysis. The main conclusions are as follows: ERI significantly and negatively predicted primary care GPs’ PSM and their job satisfaction, and PSM fully mediated the relationship between ERI and primary care GPs’ job satisfaction. This study enriches the research on antecedent variables of job satisfaction and becomes a new research perspective on how to improve primary care GPs’ job satisfaction from the perspective of PSM.

The findings of this study validate the applicability of Social Exchange Theory in healthcare contexts. The direct negative effect of ERI on job satisfaction corroborates the theoretical expectation that “input-reward imbalance undermines psychological contracts”. Furthermore, the full mediating role of PSM reveals that physicians’ evaluation of rewards extends beyond material dimensions to the preservation of intrinsic values. When ERI erodes such intrinsic motivation, even improvements in external incentives struggle to restore satisfaction, highlighting the distinction between social exchange and economic exchange from social exchange theory.

This study confirmed that higher ERI was associated with lower levels of job satisfaction among primary care GPs. This finding is consistent with previous studies in other populations such as physicians and teachers [1, 13]. A study from the Netherlands found that high effort, low pay, and ERI all contributed to lower job satisfaction [51]. A systematic review had shown that the issue of ERI among health workers was widespread, with many health workers contributing more than they were rewarded for, especially in some Asian and European countries. The systematic review also suggested that one of the reasons for the ERI was the new institutional system, and another explanation might be due to the increased workload required of health workers as a result of the increased demand for health care by the population [30].

In alignment with the reciprocity principle, policy design should integrate extrinsic rewards and intrinsic motivation. Recognizing grassroots physicians’ public service contributions could enhance their perceived gains within exchange relationships, thereby mitigating the adverse effects of ERI. This approach is in line with the social exchange theory’s focus on fostering long-term reciprocal relationships. Our findings also demonstrated that PSM fully mediated the relationship between ERI and job satisfaction. Therefore, it was important to focus on the key role of PSM as a bridge while focusing on the ERI of primary care GPs. It has been argued that PSM, defined as the altruistic desire for the common interest, to serve others and to help patients and their families regardless of financial or external rewards, has been shown to be key to the performance of public servants [52].

Also, the study concluded that daily interactions with patients promote emotional motivation (empathy and self-sacrifice) among healthcare providers, which is a core element of PSM [52]. Therefore, when applied to healthcare scenarios in China, it can be found that primary care physicians, as the “gatekeepers” of the population’s health, need to have a strong belief in their willingness to be rooted at the grassroots level in order to serve the people, in order to enhance their job satisfaction. This study also found that the job satisfaction level of rural order-targeted GPs was low. However, they often face unfavorable factors such as low pay, difficulty in development and promotion, poor working environment, and a high rate of leaving the profession at the end of their service period [20, 21, 53]. Public officials with high levels of PSM have the potential to promote the quantity and quality of public services. The stability, overall quality, and service quality of the GP workforce determine the level of primary healthcare services, which plays an important role in the health protection of the population and has a significant impact on the realization of the Healthy China 2030 goal [22]. Therefore, our research evidence on the balance between effort and reward of primary care physicians is needed to draw policymakers’ attention, and the reasons for the ERI need to be clarified. The current regulatory sector of the Chinese healthcare system needs to be improved in order to assist the nationwide implementation of GP services and to strengthen its gatekeeping role [54]. Primary care GPs also need “motivation for public service”, which brings both intrinsic and extrinsic incentives, such as material rewards, development opportunities, and a stronger welfare and security system to enhance job satisfaction. These incentives are expected to retain rural order-oriented GPs, enabling them to better serve at the grassroots level. By optimizing resource allocation through policy support and building talent development and incentive mechanisms tailored to regional needs, this approach will further activate the intrinsic motivation of primary healthcare services. It will improve healthcare service performance in underdeveloped areas, promote the balanced, high-quality development of public hospital services, and ultimately achieve the strategic goal of universal access to quality healthcare.

Introducing public service motivation as a mediating variable to analyze the relationship between effort–reward imbalance and job satisfaction can deeply reveal the internal psychological process of the formation of GPs’ job satisfaction. This indicates that the general practitioners’ internal pursuit and motivation for public service play a crucial bridging role between effort–reward imbalance and job satisfaction, enriching the theoretical understanding of the influencing factors of GPs’ job satisfaction. Although the theory of public service motivation has been studied to some extent in the field of public administration, applying it to the specific occupational group of GPs further expands the application scope of this theory. General practitioners are at the grassroots level of medical and health services, and their work has a strong public service attribute. The research findings show that public service motivation plays an important role in the formation of their work attitudes, indicating that this theory also has applicability and explanatory power in the medical and health field. It helps to have a more comprehensive understanding of the manifestations and action mechanisms of public service motivation among different occupational groups.

This study has several limitations. Although the sample size meets empirical requirements for mediation analysis, the uncertainty inherent in the sampling process necessitates cautious interpretation of statistical power. Participants who volunteered for the study may possess higher baseline levels of PSM, potentially attenuating the observed negative impact of ERI on PSM and leading to an underestimation of the mediation effect. Furthermore, convenience sampling risks excluding physicians in specific organizational cultures where the mediating role of PSM might operate distinctly, thereby limiting the contextual transferability of the findings.

So, firstly, the sample size needs to be increased to enhance the representativeness and external generalizability of the findings, particularly in regions with different socio-economic conditions. Secondly, the reliance on cross-sectional data limits the interpretation of causal relationships; future research should adopt longitudinal designs or multi-source data collection to track dynamic changes and explore causality. Thirdly, although this study identifies PSM as a mediator, other potential pathways (such as organizational support and job autonomy) have not been explored and merit further investigation. The unique cultural factors in China may also influence the relationship of ERI and job satisfaction, so cross-cultural comparisons are needed to validate the generalizability of these findings. Finally, the brevity of the questionnaire may oversimplify complex constructs like PSM; combining qualitative insights with mixed methods could provide a deeper understanding of the nuances of motivation. Addressing these limitations will help strengthen future research and provide a foundation for policies aimed at improving the well-being of GPs.

Abbreviations

GPs

General practitioners

PSM

Public service motivation

ERI

Effort–reward imbalance

Author contributions

HJW, JH and JHW conducted the literature search, and HJW wrote the main manuscript text. HJW made substantial contributions in drafting and revising the manuscript, submitted the manuscript to the journal. JHW contributed to the data interpretation, prepared tables. All the authors have participated in the design of the study, have commented critically on the initial manuscript and have reviewed and approved the final version. HC and YW are corresponding authors.

Funding

This publication was funded by and developed under the Natural Science Foundation of Gansu Province Assistance Agreement No. 22JR5RA692 and 22JR11RA257 awarded by the Science and Technology Department of Gansu Province. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability

All data generated or analyzed during this study are included in this published article [and its tables and figure].

Declarations

Ethics approval and consent to participate

All participants provided informed consent instructions on the electronic questionnaire.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.