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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 26-32

Analysis of job satisfaction and factors affecting dentists' retention in rural and remote areas of indonesia


1 Nusantara Sehat's Dentist, Public Health Center Kayoa, Indonesia
2 Nusantara Sehat's Dentist, Public Health Center Laiwui, Indonesia
3 Temporary Employees as Dentist, Public Health Center Labuha, Indonesia
4 Temporary Employees as Dentist, Public Health Center Gandasuli, South Halmahera, North Maluku, Indonesia

Date of Submission13-Nov-2019
Date of Acceptance12-Jan-2020
Date of Web Publication7-Feb-2020

Correspondence Address:
Dr. Tiara Oktavia Saputri
Public Health Center Kayoa, South Halmahera, North Maluku
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SDJ.SDJ_55_19

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  Abstract 


Background: Maldistribution of health workers, including dentists, is a global issue faced by not only poor and developing countries but also developed countries due to the mobility of health workers, who prefer working in urban areas. The World Health Organization (2012) released global policy recommendations that cover education, regulation, incentives, and personal and professional support to overcome this issue. However, they have not been able to completely solve the issue, as is shown by a description of Indonesia's Health Profile (2018), which highlights that 43.53% of public health center lack of dentists. The number of studies concerning the real condition experienced by dentists working in rural and remote areas of Indonesia is still limited. Objectives: To analyze job satisfaction and factors affecting dentists' retention in rural and remote areas of Indonesia. Methods: This study used questionnaire to collect data which was designed based on seven major themes and inserted in Google Form. The link was distributed to dentists who work in rural and remote areas of Indonesia. The sample was selected based on random sampling techniques. Result: The study showed that 45.90% of respondents were not satisfied working in rural and remote areas. Most of the respondents claimed that working conditions, incentives, career and professional development, living conditions, and personal characteristics influenced their interest in working permanently in remote and rural areas. However, political and cultural factors did not give a high impact. Conclusion: The description of job satisfaction and factors affecting dentists' retention in rural and remote areas of Indonesia is expected to have a positive impact on formulating policy regarding dentists' maldistribution.

Keywords: Dentists, factors affecting retention, rural and remote areas, satisfaction


How to cite this article:
Saputri TO, Noorkhakim A, Tangkere H, Inna M. Analysis of job satisfaction and factors affecting dentists' retention in rural and remote areas of indonesia. Sci Dent J 2020;4:26-32

How to cite this URL:
Saputri TO, Noorkhakim A, Tangkere H, Inna M. Analysis of job satisfaction and factors affecting dentists' retention in rural and remote areas of indonesia. Sci Dent J [serial online] 2020 [cited 2020 Sep 18];4:26-32. Available from: http://www.scidentj.com/text.asp?2020/4/1/26/277879




  Background Top


Health is a basic human right; everyone should have opportunities to access standard health services. However, the effectiveness of health services depends on the availability and distribution of health workers. Indonesia is the fourth populous country in the world, with a population of about 261 million.[1] Because of this, Indonesia should have a balanced distribution of health workers too. However, due to geographical conditions, half of the Indonesian population lives in rural and remote areas in which standard health services are less accessible.[2]

Maldistribution of health workers, including dentists, is a global issue faced by not only poor and developing countries but also developed countries such as America and Canada. The cause of this maldistribution is mobility; most health workers prefer working in urban areas.[3] Indonesia, a big country with varied geographical conditions, definitely faces the same issue. In 2016, the Indonesian Medical Council reported that the eastern area of Indonesia, including the provinces of North Maluku and West Papua, has the lowest number of dentists.[4] Wijaya et al. in 2017, reported that there was a tendency of dentist to avoid placement in rural areas induced the accumulation of dentists in big cities.[5] In 2010, the World Health Organization (WHO) released global policy recommendations to overcome this issue. The key aspects of the recommendations cover education, policy, incentives, and personal and professional support.[6] However, these recommendations have not completely solved the issue, as shown by a 2018 description of Indonesia's health profile, which highlights that 43.53% of public health center lack of dentists.[7] However, the population, regardless of location, has the same right to access standard health services. Consequently, the availability of qualified health workers in rural and remote areas is an important issue that must be resolved.[8] National Basic Health Research (2018) reported that 57.60% of the Indonesian population has a dental problem, but only 10.20% get treatment.[9] This implies that the availability of dentists in all areas in Indonesia, both urban and rural, is crucial.

Currently, the number of studies concerning the real conditions experienced by dentists working in rural and remote areas in Indonesia is limited. Therefore, this research was conducted to analyze job satisfaction and other factors affecting dentists' retention in these areas. This research is expected to contribute positively to the development of policies regarding dentist maldistribution.


  Materials and Methods Top


This research is a descriptive study using questionnaire for data collection. The questionnaire was designed based on seven major themes covering incentives, career and professional development, working conditions, living conditions, personal characteristics, and political and cultural factors. These themes were adopted from a literature review study entitled “Facilitators and Barriers to Health Workforce Retention in Rural and Remote Setting of Indonesia: A Literature Review,” which was conducted by Kartika.[2] These seven major themes are divided into subthemes listed in [Table 1].
Table 1: Selected themes and subthemes for questionnaire factors affecting dentists' retention

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The questionnaire was designed and inserted in Google Form, and the link was distributed to the population by private message or by communication group. The population of the individual was 1359 dentists who work in rural and remote areas of Indonesia following the Ministry of Health's Report (2018).[10] The sample was selected based on random sampling techniques with the following inclusion criteria: dentists working in rural and remote areas of Indonesia for more than 30 days and filled out all the sections of the questionnaire. The exclusion criteria were dentists working in rural and remote areas of Indonesia for <30 days and did not fill out all the sections of the questionnaire. The sample size was estimated through a sample survey calculator that can be accessed at www.surveysystem.com with a confidence level of 95% and 10% margin of error. Then, the obtained sample from the calculator was 90 dentists. The number of dentists who completed the questionnaire were 113. However, only 111 questionnaires could be analyzed because two respondents did not meet the inclusion criteria.


  Results Top


Individuals were distributed over 27 provinces in Indonesia, as shown in [Figure 1]. The highest number of individuals was in North Maluku. The category of the individuals' workplaces was divided into three: remote, very remote, and special areas that refer to the regulation of the Ministry of Health number 90 of 2015 concerning the implementation of health service in health facilities in remote and very remote areas which categorized based on eight criteria including the location of the area (mountains, inland, and coastal); the location of the island (in a group of islands or small islands); disaster vulnerability; access to regular public transportation; distance to district capital; occasional transportation; level of difficulty in fulfillment of staple; and regional security conditions. The number of individuals from remote areas, very remote areas, and special areas was 64, 44, and 3, respectively.
Figure 1: Distribution of individuals

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The highest employment status of individuals was from Nusantara Sehat, with 52 individuals. The lowest was from honorary workers and regional public service agency employees, with only one of each. The other employment statuses were civil servants (27), temporary employees (24), and contract workers, the Indonesian Army, and private workers, with two individuals in each.

Overall, 45.90% of respondents claimed that they were not satisfied working in rural and remote areas. Many factors could have affected this level of satisfaction. The percentage of factors affecting dentists' retention to work permanently in rural and remote areas is shown in [Table 2]. The factors that had high impact included working conditions, incentives, living conditions, career and professional development, and personal characteristics. Meanwhile, cultural and political factors did not have high impact.
Table 2: Percentage of major themes affecting dentists' retention

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  Discussion Top


Analysis of satisfaction level

Job satisfaction is a positive attitude toward someone's job as a result of the evaluation.[11] Ivancevich et al. have said that job satisfaction can be obtained from several dimensions, including rewards, the job itself, promotion opportunities, supervision, co-workers, working conditions, and job security.[12] In this study, 45.90% of respondents claimed that they were not satisfied working in rural and remote areas. Ilahi et al. have stated that job satisfaction is positively related to work discipline and organizational commitment.[13] Therefore, it was necessary to conduct a re-evaluation if some workers were dissatisfied. In this case, the presence of dentists who were dissatisfied working in rural and remote areas could affect the interest in working permanently in rural and remote areas. To overcome this dissatisfaction issue, a deeper analysis of factors influencing interest in working permanently is needed.

Analysis of factors affecting retention

Knowing factors affecting dentists' retention in rural and remote areas is a milestone that must be achieved if policies to improve quality health are to be designed. The WHO Director-General has reported the importance of increasing communities' access to health services to realize Millennium Development Goals and to provide equal health services. Several countries began designing various policies to overcome the maldistribution of health workers 30 years ago, and it has resulted in continuous improvement of public health status. However, an unequal quantity and quality of health workers are still reported in rural and remote areas in developing countries. The decision to work and live in rural and remote areas is quite complicated. Personal and professional factors must be considered. Health workers working in rural and remote areas need to think of their families' safety and welfare. Furthermore, they need broader and deeper skills to be able to deal with emergencies and other patients' complex conditions, which typically need to be treated by specialist teams in large cities.[14] The existence of dentists who feel dissatisfied working in rural and remote areas has to be considered by policymakers to overcome the maldistribution issue.

[Table 2] shows the factor that most affecting dentists' retention in rural and remote areas was working conditions, with 81.10% of respondents claiming that working conditions affect their interest in working permanently in this area. The next most important factor was incentives, at 80.20% of respondents; followed by living conditions, at 79.30% of respondents; career and professional development, at 71.20% of respondents; and personal characteristics, with 67.60% of respondents willing to work and live in rural and remote areas due to this factor. Meanwhile, cultural and political factors did not have high impact. Only 45.90% of respondents claimed that cultural factors affected their interest in working rural and remote areas, while a mere 17.10% of respondents said political factors affected their decision concerning where to work.

Working conditions

Working conditions or working environment affect job satisfaction and productivity.[15] The study revealed that 74.80% of respondents stated that working conditions were not the reason they worked in the area. Poor facilities without basic supplies, such as running water, gloves, basic medicines, and basic equipment, limited their ability to practice their knowledge and skills.[6] Working conditions are not a recruitment factor, but it is a crucial factor in increasing dentist retention in remote areas. This is evidenced by 81.10% of respondents claiming that working conditions affect their interest in working permanently in an area. As a consequence, if working conditions were improved, 84.70% of respondents said they would choose to work permanently in a remote or rural area. In addition, improving working conditions should improve health workers' performance and productivity. As a result, the performance of the health system can be improved too.

Some conditions affecting working conditions include facilities, tools and materials, management, health safety, and relationships with coworkers. However, only 16.20% of respondents said that they were satisfied with the working conditions in their workplace. Ensuring safe working conditions, including appropriate equipment and supplies and supportive supervision and assistance, could improve the recruitment and retention of health workers in remote and rural areas.

Incentives

Incentives are one of the factors affecting a person's decision to choose a workplace.[16] The study showed that 59.50% of respondents stated that incentives were a reason for working in rural and remote areas. However, 42.30% of respondents were dissatisfied with the incentives they received. Meanwhile, 80.20% of respondents claimed that incentives affected their interest in working permanently in rural and remote areas. If the incentives were increased, 82.90% of respondents claimed that they would be willing to work permanently in rural and remote areas. Mkoka et al. stated that adequate and transparent incentives that were paid on time could increase motivation to work permanently in a rural or remote area.[17] The geographical conditions of rural and remote areas and the lack of opportunities to earn other income should be considered to provide adequate incentives for dentists working in rural and remote areas. In a meeting conducted in Uganda in 2008, the Global Health Workforce Alliance announced the Kampala Declaration, which highlights the importance of adequate incentives and safe working condition for the effectiveness of retention and balanced distribution of health workers.[18]

Besides incentives, other facilities such as housing, transportation, and health insurance increased dentists' interest in working and staying in rural and remote areas.[19] This is in line with the result of this study, in which 78.40% of respondents claimed that improvement in other facilities such as housing, transportation, and health insurance could increase their interest in working permanently in rural and remote areas. However, 63.10% of respondents claimed that they were dissatisfied with the provided facilities. This result should be considered for policymakers, who need to offer more and better incentives, as well as housing and transportation facilities, to the dentists working in rural and remote areas to increase retention.

Living conditions

Living conditions can be affected by many factors, such as geographical location, public facilities, food, housing, safety, and social interaction. Ideal living conditions will fulfill these factors.[20] In Indonesia, infrastructure development has not been equal in all areas. The development in rural and remote areas is slow. Because Indonesia is an archipelago country, geographical conditions become the main challenge in development.[21] Hence, the inequality of development, which has caused a great number of areas to have poor living conditions or less-than-ideal living conditions.[20] Other living conditions that affect health worker retention include distance from family, security, social interaction, and facilities such as water, electricity, transportation, and education for children.[22] Furthermore, 79.30% of respondents claimed that living conditions affected their interest in working and living in their workplace at this time. This percentage implies that living conditions are the main consideration of dentists working and living in rural and remote areas. On the other hand, 70.30% of respondents claimed that they were unsatisfied with the facilities, such as housing, water, electricity, security, transportation, and education for children, provided by their current workplace. Therefore, improving facilities in rural and remote areas is essential and considered to be the main focus to improve dentist retention.

Career and professional development

Career and professional development is one of the factors affecting the retention of health workers. So far, the opportunity to progressively improve careers and opportunities to attend regular training has been much easier for workers in urban areas. One individual, in a study concerning the retention of doctors and nurses in rural and remote areas in Bangladesh conducted by Darkwa, stated, “Sometimes, when you arrive in this place, it will be difficult to develop your career. Then, when you come back to the city, your colleague's progress is far ahead of you.”[23] This finding is in line with the results of this study, which found that only 36.90% of respondents claimed that they were satisfied with career and professional development in rural and remote areas. In contrast, 70.30% of respondents claimed that career and professional development could affect their interest in working permanently in an area.

The opportunity to attend training and seminars relates to career and professional development. Hou et al. have said that health workers working in Timor Leste claimed that working in rural and remote areas gave them fewer opportunities to attend training and seminars compared to those working in urban areas. However, the demand for training and seminars in both areas is almost the same.[24] The results of this study illustrate the same condition, with only 31.50% of respondents claiming satisfaction with the training and seminar opportunities in their workplace. In contrast, 80.20% of respondents stated that increasing the opportunity for training and seminars could increase their interest in working in rural and remote areas.

Besides the opportunities for attending training and seminars, job security affected workers' motivation to work permanently in rural and remote areas as well.[20] Purohit and Bandyopadhyay have stated that working as a public worker has the highest job security.[25] As a public worker, the job is permanent and the chance of losing it is very small. In this study, it was found that 54.10% of respondents were satisfied with the job security in their workplace, as the employment status was mostly Nusantara Sehat, followed by civil servants. However, the increase in job security did not significantly affect the health workers' interest in working in rural and remote areas, as only 57.70% of respondents stated that job security could increase their interest in working in rural and remote areas permanently.

Personal characteristics

Every human has different characteristics which differ from one another. Personal characteristics cover age, sex, marital status, working interest, and personal dedication. All of them may affect dentists' interest in working and living in remote and rural areas.[1] The personal characteristics of dentists' who choose to work and live in rural and remote areas should be considered by the government, with the goal of increasing the number of dentists who have the appropriate personal characteristics and thus the distribution of dentists in rural and remote areas. This study showed that 67.60% dentists who claimed that they were willing to work and live in rural and remote areas were influenced by their personal characters and the moral reason such as dedication, humanity, and devotion become dominant factors affecting dentists' interest in living in the rural and remote areas (90.10%). Based on the result, it can be concluded that developing moral values in dentistry educational program is crucial to support the success of dentists' distribution in Indonesia. Besides moral reason, career option to work in rural areas has contributed to increasing the dentists' interest in working and living in rural and remote areas.

Cultural factors

Indonesia is a multicultural country with varied races, tribes, religions, and groups.[26] As such, 79.30% of respondents stated that cultural differences did not obstruct them from working in rural and remote areas, and 60.40% of respondents stated that cultural factors did not affect their satisfaction level when working in rural and remote areas. Widiastuti (2013) has analyzed the varieties of Indonesian culture using Strengths Weaknesses Opportunities and Threats analysis and found that more than 1128 tribes living on thousands of islands in Indonesia, from Sabang to Merauke with varied geographical conditions, flora, and fauna, are becoming this country's strength.[27] Many aspects of Indonesia's multiculturalism affect dentists' retention in rural and remote areas, including unique cultures (such as the kinship system), social ethics, traditional clothes, varied culinary practices, handcrafts, woven fabric, batik, carvings, and other arts such as architecture, dance, and literature. However, each community has different cultural values and cultural backgrounds, which could stimulate an excessive sense of belonging and cause political and economic conflicts. A National Socioeconomic Survey (2015) found that 85.16% of households allowed members of the family to interact with individuals from other tribes or races.[28] This is in accordance with the results of this study, in which 54.10% of respondents stated that culture did not affect their interest in working and living in rural and remote areas. Moreover, 51.40% of respondents stated that they wanted to stay in their current workplace due to cultural differences.

Political factors

Shah et al. have stated that political factors affect the placement of health workers in remote areas. In their study, one doctor said, “Every patient is the same in our eyes, we cannot provide special services to someone just because they play an important role in politics. Despite the fact that they are trying to intervene in and will transfer us to remote places if it is not in their way.”[20] However, the results of this study contrast this finding. Only 9% of respondents stated that there was political intervention in the selection of their current place of work. Furthermore, only 17.10% of respondents stated that political factors affected their interest in working permanently in an area, and only 10.80% of respondents stated that political factors affected the choice of their current workplace.

Concerning the existing bureaucracy and administration system, 17.10% of respondents said they believe that the current system affected their decision to choose their current workplace. However, 68.50% of respondents said they are dissatisfied with the existing bureaucracy system. Thus, it will be better if the government evaluates and improves the existing bureaucracy and administration system in remote areas. In addition, local government support played an important role in increasing dentists' retention in remote areas, with 83.30% of respondents stating that the increasing level of local government support has improved their interest in working permanently in rural and remote areas. However, 69.40% of respondents said that they were not satisfied with local government support. Therefore, evaluation and improvement in this sector are needed. This finding is in line with Leonardia et al., who have stated that local government support plays an important role in the retention of health workers in an area.[29]


  Conclusions Top


Some respondents feel dissatisfied working in rural and remote areas in Indonesia. Working conditions, incentives, living conditions, career and professional development, and personal characteristic affect dentists' interest in working permanently in rural and remote areas. However, cultural and political factors did not have high impact on the dentists' interest in working permanently in rural and remote areas. The descriptions of job satisfaction level and factors affecting dentists' retention investigated in this study are expected to have a positive impact on how policy is designed to solve the dentist maldistribution problem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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