Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 1 | 17 ORIGINAL RESEARCH Correlates of level of satisfaction among primary health care workers in Albania Alvi Naum1,2, Ervin Toçi3,4, Dorina Toçi3,4, Genc Burazeri1,3, Robin van Kessel1, Katarzyna Czabanowska1 1 Department of International Health, School CAPHRI (Care and Public Health Research In- stitute), Maastricht University, Maastricht, Netherlands; 2 Local Health Care Unit, Korça, Albania; 3 Faculty of Medicine, University of Medicine, Tirana, Albania; 4 Institute of Public Health, Tirana, Albania. Corresponding author: Alvi Naum, MSc; Address: Rr. 10 Korriku, Nr. 5, L. 13, 7001, Korça, Albania; E-mail: alvinaum@hotmail.com Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 2 | 17 Abstract Aim: The aim of this study was to explore the level of satisfaction of primary health care staff in Albania and the factors associated with it. Methods: A cross-sectional study was conducted in Tirana city, the Albanian capital, from 11 November 2020 until 25 November 2020. Among all health centers (HCs) and health centers of specialties (HCSs) of Tirana Municipality, there were selected randomly a HC in rural areas, a HC in urban areas and one HCS. All the staff (doctors and nurses) being present at the time of data collection was interviewed, using an international standardized tool (the Dartmouth- Hitchcock Medical Center instrument) assessing the satisfaction with various elements of the work in PHC, validated in Albanian. A total of 102 PHC staff were included in the study. Binary logistic regression was used to assess the association of staff satisfaction with independ- ent factors. Results: The aspects of work most appreciated by PHC staff (% satisfied or very satisfied) were: respectful treatment by colleagues (78.2%), staff morale and their positive attitude to- wards work (73.2%). The most disliked aspects of work by PHC staff (% dissatisfied or very dissatisfied) were: current salary (60.8%), stress at work (38.3%), physical and medical infra- structure in the institution (27%). Staff in rural HCs, older staff, females and nurses and family doctors are more likely to be satisfied compared to their respective colleagues. Conclusion: Our findings suggest various factors associated with the satisfaction of PHC staff in Albania. These findings could be guiding future efforts aiming to improve the work condi- tions of the professionals working in primary health care in Albania. Keywords: Albania, cross-sectional, primary health care, staff satisfaction. Conflicts of interest: None declared. Acknowledgment: This study was funded by the “Health for All Project” in Albania (hap.org.al), which is a project of the Swiss Agency for Development and Cooperation (SDC). Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 3 | 17 Introduction Primary health care (PHC) is the point of entry of individuals/patients/users or clients to the health system representing the stable point of care over time (1). The function of primary health care is to coordinate health care for people and their multiple health needs throughout life and throughout the continuity of care provided both in PHC in- stitutions and communities, and for individ- uals and human populations; thus, PHC is essential for the achievement of universal health coverage (1). PHC is the most com- prehensive, equitable, cost-effective and ef- ficient approach to enhancing people's physical and mental health, as well as social welfare (2). An optimized effective PHC is critical for making health systems resilient and more responsive to crisis situations or increased demand for services, such as with the COVID-19 pandemic (2). An effective PHC implies that users have easy and con- venient access to trusted providers (3). In- creasing the availability of primary health care is associated with increased patient sat- isfaction and reduces spending on health care (4). A stronger primary health care sys- tem tends to be more pro-poor, more equal and more accessible compared to health systems based on specialist care (4). The use of primary health care reduces costs by increasing patient satisfaction without ad- verse effects on the quality of care or patient treatment outcomes as compared to the pro- vision of services through specialist physi- cians; in addition, replacing the provision of some services from the secondary health level with those offered in PHC has demon- strated to be a more cost-effective approach (4). However, the expansion of PHC ser- vices may not always and necessarily be as- sociated with cost reductions due to the risk of re-identifying unmet needs, improving access and tendencies to increase and ex- pand service use (4), and, therefore a de- tailed analysis of the effects of the expan- sion of the PHC system is needed as well as an analysis to at what extent and depth this expansion should take place. Health care providers are of critical importance in as- suring the quality of PHC services because their contribution is essential to the effec- tiveness, safety, equality, and timeliness of PHC services (5). Therefore, in order to achieve the goals of the medical visit, in ad- dition to the satisfaction of patients, which refers to the fulfillment of patients’ expec- tations with the health encounter (6), it is also important for the medical staff to be satisfied and to be able to meet the relevant expectations in terms of self-realization, personal career objectives, income from the provision of care for patients or users of the health care system, etc. International literature suggests that the sat- isfaction of healthcare professionals is re- lated to both patient satisfaction and the quality of care provided and more favorable health outcomes (7-9). Moreover, the way medical staff communicates with patients seems to have a significant effect on the level of patient satisfaction, as evidenced by the international literature: not applying the dominant position, being caring and com- mitted to patients, and holding a positive at- titude, have a favorable impact on the smooth running of the relationship between health personnel and patients (10). On the other hand, the characteristics of physicians working in PHC (such as gender, work ex- perience, and specialty) seem to influence their relationship with patients (11), and subsequently to the quality of PHC. Also, non-verbal communication seems to be very important in the doctor-patient rela- tionship (12). The extent to which primary health care staff is satisfied is influenced by several factors, including salary, individual characteristics, infrastructure of health care institutions, time pressure, autonomy in de- cision making, professional relationships with colleagues, etc. (13-15). Work stress also reduces the satisfaction of health personnel and the ability to have con- trol over the schedule of visits and working hours seem to be associated with greater job Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 4 | 17 satisfaction (16). Likewise, job satisfaction or dissatisfaction is related to doctors' plans to leave work, where younger doctors were more likely to plan to leave medical prac- tice in the future, and then this indicator de- creased with the increasing age of doctors; likewise, dissatisfaction with current salary and the surrounding community was strongly linked to physicians' plans to leave work (17). The PHC staff has a very im- portant role to play in reducing health care costs, through the implementation of the “gateway” function by which individuals in need make contact with the health care sys- tem (18). This is an issue of critical im- portance for every country in the world, in- cluding Albania. The recently implemented reforms in PHC in our country aim pre- cisely at strengthening primary health care and increasing the ability of PHC to serve as a gateway to the health system by provid- ing quality service to people in need and, at the same time, reducing costs. In this con- text, it is important that staff working in PHC feels satisfied when carrying out day- to-day health care activities. Given that in Albania the information about PHC staff satisfaction and the factors associated with it is scarce, we carried out the current study in order to obtain a clearer picture and deeper analysis of these issues inextricably linked to the quality of health care in PHC. Methods A cross-sectional study was conducted in Tirana city, the Albanian capital, from 11 November 2020 until 25 November 2020. Study population The target population was the PHC staff, both doctors and nurses, working in the structures of primary health care in Tirana, Albania. The PHC system in Tirana is com- posed of Health Centers (HCs) and Health Centers of Specialties (HCSs). In total there are 31 HCs and 3 HCSs in the Tirana Municipality. Among 31 HCs, 11 HCs are located in urban areas and the re- maining 20 HCs are located in rural areas; HCSs, on the other hand cover HCs in both urban and rural areas, according to their ge- ographic location. Given that it was not possible to include all HCs and HCSs in the current study, then we decided to select one PHC facility from each level: urban HCs, rural HCs and HCSs. Among all the HSCs, one of them was randomly selected (the Health Center of Specialties No. 1); among all the urban HCs, one of them was ran- domly selected (Health Center No. 8) and among the rural HCs one of them was ran- domly selected (Farka Health Center) as well. A total of 102 PHC providers who were present at the included HCs and the HCS during the study timeframe, partici- pated in the study. These 102 individuals represent more than half of the entire staff working in the selected PHC facilities (n=182). Data collection Face-to-face interviews using a standard- ized instrument with the relevant PHC health personnel of these health institutions were carried out to obtain the data. A questionnaire adapted from the Dart- mouth-Hitchcock Medical Center instru- ment (19) was used to collect information on the satisfaction of health personnel working in PHC. This questionnaire covers various aspects of working in primary health care, including satisfaction with the work environment, health facility, equip- ment, workload, salary, etc., and can be used by physicians and nurses working at this level. The Primary Care Staff Satisfac- tion Questionnaire is also validated in Al- banian, through previous efforts of re- searchers (20). Similarly, in the question- naire used in the current study the answer options are built on the Likert scale with five options available, where the extreme values (1-5) mean 1- "strongly agree/very satisfied" and 5- "strongly disagree/very dissatisfied". The staff questionnaire also contained some general socio-demographic questions such as age, gender, place of res- idence, occupation, work experience in Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 5 | 17 general and experience in the current work- place, and participation in various scientific and training activities. Piloting of the questionnaire Before being applied on a large scale, the staff satisfaction questionnaire was piloted among a limited number of 7 providers. In general, the questions were understood quite well and there were no particular problems with the instrument. This is prob- ably because the questionnaire was previ- ously validated in the Albanian language, as mentioned earlier. Regarding the reliability of the staff satis- faction questionnaire in the pilot phase, the internal consistency coefficient (Cronbach’s alpha coefficient) was 0.822. Ethical considerations All participants were informed about the purpose and objectives of the study. They were assured of the confidentiality and an- onymity; in no case and under no circum- stances would it be possible to relate the an- swers to the specific person and it would be impossible to disclose the identity of the participants. All study participants gave their verbal approval to participate. This study was approved by the Medical Ethics Committee, with decision number 303/43, dated 12/10/2020. Statistical analysis Statistical analysis of the data was based on the type of variables used in the study. Measures of central tendency (mean) and dispersion (standard deviation) were used to describe numerical data. For categorical data, absolute numbers and corresponding percentages were used. To assess the relia- bility of the instruments in the study, the internal consistency assessment of the questionnaire was used based on the calcu- lation of Cronbach's alpha internal con- sistency coefficient. To study the relation- ship between categorical variables, the square hi test was used. In-depth statistical analysis consisted of binary logistic regres- sion test (where provider satisfaction score was dichotomized). A staff satisfaction summary score (includ- ing 9 questions) was calculated for each participant; then, this score was dichoto- mized into two categories: “satisfied” (un- der-the-median score) versus “dissatisfied” (over-the-median score). This categoriza- tion was then used to distinguish the per- centages of staff who were satisfied (or dis- satisfied) with different aspects of their work. This variable was used in binary lo- gistic regression models to identify factors related to staff satisfaction with PHC. In or- der to control the potential confounding ef- fect of age and gender, binary logistic re- gression models controlled for these factors and reported standardized odds ratios (OR) and corresponding 95% (95% CI) confi- dence intervals. In all cases, the correla- tions were considered statistically signifi- cant when if P ≤0.05. All statistical analyzes were performed us- ing the Statistical Package for Social Sci- ences (SPSS), version 21. Results Table 1 presents general data on the PHC staff in the study. The average age of the health staff included in the study was 42 years with about 30% belonging to the 31- 40 age group. More than 9 in 10 PHC staff were female (93.1%). The average work ex- perience in the profession was 16.9 years and participants had worked in the current job for 11.3 years on average. About 44% of respondents declared that they have been involved in scientific research, 33.8% had referred at national conferences and 7% at international conferences. About 6% were also engaged in writing scientific articles. Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 6 | 17 Table 1. General information about study participants Variable Absolute number Percentage Total 102 100.0 % PHC facility HCS Nr. 1 HC Nr. 8 HC Farkë 53 40 9 52.0 % 39.2 % 8.8 % Age (mean ± standard deviation) 42.0±10.6 Age-group 23-30 years 31-40 years 41-50 years >50 years 17 * 30 17 30 17.2 % 30.3 % 26.3 % 26.3 % Sex Male Female 7 95 6.9 % 93.1 % Profession General practitioner Family doctor Specialist doctor Nurse 8 16 11 67 7.8 % 15.7 % 10.8 % 65.7 % Work experience in profession (mean ± standard deviation) 16.9±10.6 Work experience at this work place (mean ± standard deviation) 11.3±8.6 Participation in various activities Scientific research Publication of scientific articles Presentations at national conferences Presentations at international conferences All the above 31 4 24 5 7 43.7 % 5.6 % 33.8 % 7.0 % 9.9 % * Any discrepancies with the total number is due to lack of information. Table 2 presents data on the distribution of opinions of PHC staff regarding the evalu- ation of various aspects of their work envi- ronment. Data are presented in percentages. The aspects of work most appreciated by PHC staff (percentage strongly agreeing or agreeing) were: respectful treatment by col- leagues (78.2%), staff morale and their pos- itive attitude towards work (73.2%), ease of asking others about the way the staff takes care of the patients (71%), the noticing from the others when the work is done well (61.9%), while for other aspects about half of the staff was very much satisfied or sat- isfied.Meanwhile, the most disliked aspects of work by PHC staff (percentage who re- ported dissatisfaction or a lot of dissatisfac- tion) were: current salary (60.8% were dis- satisfied or very dissatisfied), stress at work (38.3% were dissatisfied or very dissatis- fied), physical and medical infrastructure in the institution (27% were dissatisfied or very dissatisfied), and the fact that this in- stitution was not a better place to work com- pared to 12 months ago (24.2% were dissat- isfied or very dissatisfied). Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 7 | 17 Table 2. Satisfaction with different elements of the workplace Please tell us how satisfied or dis- satisfied you are with the following aspects related to your work or health institution in the last 12 months Strongly agree and/or very satis- fied 1 2 3 4 Strongly disagree and/or very dis- satisfied 5 1. I am treated with respect every day by everyone that works in this prac- tice 36.6% 41.6% 18.8% 1.0% 2.0% 2. I am given everything I need— tools, equipment, and encourage- ment—to make my work meaningful to my life 9.0% 30.0% 34.0% 16.0% 11.0% 3. When I do good work, someone in this practice notices that I did it 32.0% 29.9% 24.7% 10.3% 3.1% 4. Working in this health institution is very stressful 7.8% 14.7% 39.2% 24.5% 13.7% 5. It is very easy to ask anyone about how we care for patients 25.8% 45.4% 16.5% 9.3% 3.1% 6. The morale of the staff and their attitudes to work here are very posi- tive 35.6% 37.6% 16.8% 6.9% 3.0% 7. This health institution is a better place to work than it was 12 months ago 15.2% 39.4% 21.2% 14.1% 10.1% 8. I would recommend this health in- stitution as a very good place to work 26.7% 26.7% 32.7% 10.9% 3.0% 9. I am satisfied with my salary - 6.2% 33.0% 37.1% 23.7% * Row percentages. Table 3 shows the information on PHC staff satisfaction level by the characteristics of the participants. The percentage of staff sat- isfied with their working environment is significantly higher among employees of HC Farka (88.9%) compared to much lower percentages in HCS No. 1 (42.3%) and HC Nr. 8 (46.7%), P=0.035. Meanwhile, the differences in the proportions of satisfied staff according to other socio-demographic characteristics were not statistically signifi- cant (P>0.05 in each case); however, clini- cal significance suggests that the percent- age of those satisfied increases with in creasing staff age (from 40% among staff aged 23-30 years, to 68.2% among staff aged>50) and among females (48.8%) com- pared to males (42.9%). In terms of profes- sion or specialty, it seems that higher per- centages of nurses (57.6%) and family doc- tors (42.9%) are satisfied with their work while the most dissatisfied are the general practitioners of PHC (only 12.5% are satis- fied while 87.5% are dissatisfied) and spe- cialist doctors working here (only 30% sat- isfied and the remaining 70% were dissatis- fied). These differences have borderline statistical significance (P=0.053). Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 8 | 17 Finally, higher percentages of staff who gave presentations at international scien- tific conferences (60% of them) and na- tional conferences (52.4%) and staff en- gaged in publishing scientific articles (50% of them) seem to be satisfied with their work compared to colleagues of other cate- gories (Table 3). Table 3. Distribution of staff satisfaction level according to their basic characteristics Variable Overall score (9 items)* P-value Dissatisfied Satisfied PHC facility HCS Nr. 1 HC Nr. 8 HC Farkë 30 (57.7) a 16 (53.3) 1 (11.1) 22 (42.3) 14 (46.7) 8 (88.9) 0.035b Age-group 23-30 years 31-40 years 41-50 years >50 years 9 (60.0) 17 (58.6) 12 (54.5) 7 (31.8) 6 (40.0) 12 (41.4) 10 (45.5) 15 (68.2) 0.211 b Sex Male Female 4 (57.1) 43 (51.2) 3 (42.9) 41 (48.8) 0.762 b Profession General practitioner Family doctor Specialist doctor Nurse 7 (87.5) 8 (57.1) 7 (70.0) 25 (42.4) 1 (12.5) 6 (42.9) 3 (30.0) 34 (57.6) 0.053 b Participation in various activities Scientific research Publication of scientific articles Presentations at national conferences Presentations at international conferences All the above 17 (65.4) 2 (50.0) 10 (47.6) 2 (40.0) 4 (57.1) 9 (34.6) 2 (50.0) 11 (52.4) 3 (60.0) 3 (42.9) 0.717 b * For each participant a summary score (including 9 questions) was calculated for the staff satisfaction level; then, the result was dichotomized into two categories: “satisfied” (below-the-median score) versus “dissatisfied” (above-the-median score). a Absolute number and row percentage (in parenthesis). b P-value according to chi square test. NOTE: Any discrepancies with the total number is due to lack of information. Table 4 presents data on the association of staff satisfaction level with the independent factors included in the study. After control- ling the confounding effects of age and gen- der, no independent factor was found to be statistically significantly related to the sat- isfaction of PHC staff with the work envi- ronment where they work. However, in terms of clinical significance, some differ- ences are worth noting. Thus, the most sat- isfied employees were those working in HC Farka (OR = 9.39) compared to the staff of HCS No.1, while the odds of satisfaction were almost similar among the staff of HCS Nr. 1 and HC No. 8.On the other hand, the likelihood of satisfaction with current work increased with increasing age of health per- sonnel (OR = 3.18 in staff aged >50 years), were higher among female staff (OR = 1.16), nurses (OR = 6.18) and family phy- sicians who work in PHC (OR = 3.57) [whereas general practitioners and special- ist physicians were the least likely to be sat- isfied with current work in PHC]. Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 9 | 17 Each year increase of experience in the cur- rent workplace was associated with a 1.04- fold increase in the likelihood of current job satisfaction at the PHC. Attendance at inter- national conferences, national conferences and writing scientific articles increased the likelihood of satisfaction with the current work in PHC by 2.02 times, 1.5 times and 1.5 times, respectively. Table 4. Association of staff satisfaction level with independent factors in the study – Odds Ratios (ORs) by Binary Logistic Regression Variable Model * OR ** 95%CI § P-value† PHC facility HCS Nr. 1 HC Nr. 8 HC Farkë 1.00 1.23 9.39 Reference 0.46-3.28 0.92-96.44 0.163 (2) - 0.674 0.059 Age-group 23-30 years 31-40 years 41-50 years >50 years 1.00 1.05 1.24 3.18 Reference 0.29-3.75 0.33-4.71 0.80-12.56 0.236 (3) - 0.941 0.749 0.100 Sex Male Female 1.00 1.16 Reference 0.23-5.70 0.860 Profession General practitioner Family doctor Specialist doctor Nurse 1.00 3.57 1.66 6.18 Reference 0.30-43.07 0.12-22.30 0.68-56.41 0.161 (3) - 0.316 0.703 0.107 Experience in profession (years) 0.99 0.91-1.07 0.717 Experience working here (years) 1.04 0.96-1.13 0.299 Participation in various activities Scientific research Publication of scientific articles Presentations at national conferences Presentations at international conferences All the above 0.71 1.50 1.50 2.02 1.00 0.724 (4) 0.12-4.26 0.12-18.89 0.24-9.56 0.17-24.03 Reference 0.718 (2) 0.709 0.752 0.669 0.578 - * Model: simultaneously adjusted for age and gender. Adjusted ORs. ** Odds Ratio (OR: satisfied vs. dissatisfied), according to Binary Logistic Regression test. § 95% Interval of Confidence (95% CI) for OR. † P-value according to Binary Logistic Regression test and degrees of freedom (in parentheses). Table 5 shows the information about spe- cific changes that, according to the opinions of the PHC staff, would make the current health institution a better place for patients and a better place to work. The majority of staff (68.6%) stated that in order to improve patient care there is a need for new working facilities and better equipment, followed by 10% who think that there is a need for addi- tional staff, 5.7% think that it is necessary increase the level of service, 4.3% suggest reducing the workload with patients, etc. Unexpectedly, only 1.4% of staff suggested salary improvement. Regarding the changes that would improve the work of the PHC staff, 67.2% stated that there is a need for Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 10 | 17 new working facilities and better equip- ment, followed by 7.5% who think that there is a need to strengthen anti-COVID protection measures and that many men- tioned salary increase, etc. Table 5. Changes that would make the current health facility a better place for patients and staff Variable Absolute number Percentage The kind of change that would make the institution a better place for patients New facilities and better equipment Collaboration with managers More staff Less work burden with patients Increasing the level of service Improving staff behavior Better salary Trainings and specializations Patient awareness Planning visits for the Family Doctor 48* 1 7 3 4 2 1 2 1 1 68.6 % 1.4 % 10.0 % 4.3 % 5.7 % 2.9 % 1.4 % 2.9 % 1.4 % 1.4 % The kind of change that would make the institution a better place for staff New facilities and better equipment Anti-COVID protection measure More staff Better salary Training Better job appreciation Additional services Group work More medications available Planning visits for the Family Doctor 45 5 2 5 2 1 2 1 1 3 67.2 % 7.5 % 3.0 % 7.5 % 3.0 % 1.5 % 3.0 % 1.5 % 1.5 % 4.5 % * Discrepancies with the total numbers are due to lack of information. Discussion The current study is one of the few studies in Albania that sheds light on the level of satisfaction and related factors with various aspect of primary health care practice from the perspective of the PHC staff. Our find- ings suggest that the overwhelming major- ity of PHC staff was satisfied with the rela- tionship with their colleagues in work set- tings but much less so with the healthcare infrastructure and equipment; on the other hand, more than six out of ten PHC profes- sionals were dissatisfied with the current salary. In addition, nurses and family doc- tors were more likely to be satisfied work- ing in PHC compared to general practition- ers and specialist doctors. A major problem for developing countries is bypassing the “gateway” function of PHC and direct ac- cess to the highest levels of the health care system (secondary and tertiary care), mak- ing the PHC “gateway” function often turn into something purely symbolic or dysfunc- tional (21). Such a problem has affected Al- bania in recent decades; so in the near past (7-8 years ago), patients had easy and free access to specialist doctors even at the ter- tiary level without the need for referral doc- uments or these were intentionally by- passed or overlooked for other reasons, Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 11 | 17 similarly with the situation of many former communist bloc countries of the Eastern bloc two decades ago (21). But the ener- getic interventions by the Ministry of Health and Social Protection (MSHMS) to- wards the regulation of the referral system and the implementation of the National Health Strategy 2016-2020 have had a con- siderable impact on the extraordinary mini- mization of this phenomenon, especially during last years. The fact that 50%-78% of PHC staff in the current study is satisfied or very satisfied with the working environ- ment in PHC or its specific elements, may have contributed to improving the quality of health care and consequently to increas- ing of patient satisfaction with PHC in our country. On the other hand, a high percent- age of PHC staff is dissatisfied with current salaries (61%) and stress at work (38%), implying the need for an increased attention by the authorities with regard to these ele- ments. Satisfaction of healthcare profes- sionals is very important for the quality of services, effectiveness at work and commit- ment to duties in the work environment, also having an impact on healthcare costs (22). A number of factors can affect the sat- isfaction of health care professionals with their work, including age, gender, level of education, work experience, way of organ- izing work, institution and medical infra- structure, etc. (22), salary, job security (not losing the job), adequate training, adequate workload, etc. (23). Regarding the factors related to the satisfaction of the staff work- ing in PHC, a study in Kosovo reported that family physicians were significantly more likely to be satisfied compared to nurses (20), whereas in our study we identified the opposite trend: nurses were more likely to be satisfied and general practitioners and specialist doctors working in PHC are among the most dissatisfied with the PHC system in Albania. Such a difference can be explained by several factors:  First, general practitioners and special- ist doctors working in PHC in our country think that they are not in the right place of work: the former are al- ways looking for a "better" specializa- tion and the latter are always looking for employment in the capital's hospital centers or in structures of the highest levels of the health system.  Second, family physicians feel more satisfied compared to the previous two categories as they have willingly (or not) received this specialization and consequently have "made up their minds" that they will work in primary health care, thus not being under the stress of seeking a specialization or other position at other levels of the health system.  Third, PHC nurses may be more under- paid than doctors, but they have more freedom in their work, especially in HCs in rural areas, they are in constant contact with the community, and may receive other benefits as a result of such close and constant contacts with the community, which doctors proba- bly do not have.  Fourth, physicians may feel less satis- fied compared to nurses as they are more pressured during their work and relatively feel that they are underpaid for the work they do compared to nurses. Higher satisfaction of nurses compared to physicians in primary health care has also been reported in other developing countries (24). The international literature suggests that the satisfaction of non-medical staff (nurses) has a strong impact on patient sat- isfaction (25,26). Although the interna- tional literature suggests that it is more common to consider nurses as additional staff than as substitute staff for physician care (27), and this reality may be quite prev- alent in Albania based on anecdotal data, the fact that nurses have more freedom in their work, have expanded contacts with the community and benefits from these contacts, may overcome their “dissatisfaction” regarding the considera- tion as additional staff, resulting in a more Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 12 | 17 satisfied staff category with their work compared to doctors. In our study, the increase in work experi- ence was always negatively associated with staff satisfaction with the work environ- ment (although the differences never reached statistical significance), while in Kosovo an opposite relationship was iden- tified (20). The negative association in our study can be explained by the assumption that over time health personnel, hoping to move to a better job at the highest levels of the system, have in fact "stuck" here and consequently tend to see from a negative perspective everything that happens in the PHC premises where he/she works. How- ever, this is only an assumption and further studies are needed to confirm this hypothe- sis. For example, a survey of general prac- titioners' satisfaction in 34 European coun- tries found that the age of general practi- tioners was positively correlated with their job satisfaction, explaining this with the "effect of a healthier worker": older general practitioners who feel more satisfied in PHC tend to stay longer at work, whereas dissatisfied doctors may retire earlier and therefore may not be adequately repre- sented in a particular study (28). In an at- tempt to explain this positive relationship between age and job satisfaction of PHC staff in Albania and the negative relation- ship between work experience and job sat- isfaction of PHC staff (i.e. two factors closely related to each other: increasing age and increasing work experience, linked in opposite directions to job satisfaction!), we carried out an additional analysis (not pre- sented in Tables) to look in detail at the structure of PHC categories within each age group in the study. And the solution laid right there! It turned out that 81% of the staff age >50 years old were nurses (re- member, nurses were the most satisfied cat- egory of PHC professionals in our study!) While specialist doctors and general practi- tioners occupied only 15.4% and 0% of pro- fessionals in this age group (specialist doc- tors and general practitioners turned out to be the most dissatisfied categories of PHC professionals in our study!). So, although specialist doctors and general practitioners are the most dissatisfied staff with PHC, the very high specific weight of the most satis- fied group of PHC staff (nurses) aged >50 is enough to overcome the effect of special- ist doctors and general practitioners produc- ing, overall, a positive correlation of staff satisfaction in general with increasing age. Meanwhile, a survey of health personnel in rural Iran reported that only 17% of them were satisfied with the work they were do- ing (29), and a survey of public primary health care physicians in Delhi, India, re- ported that all staff were dissatisfied with training policies and practices, with the level of salaries and opportunities to make a career in the system (30), findings and levels that are incomparable with the find- ings of our study, where over half of the staff were very satisfied or satisfied with the working environment and work spirit in PHC and the dimensions where dissatisfac- tion is relatively high were: salaries and work stress. A 2011 study on the satisfaction of public health care staff (hospitals) in Serbia used some questions similar to those used in our study (for example, satisfaction with avail- able medical equipment, personal relation- ships with colleagues, satisfaction with sal- ary, availability of protocols, etc.) (22). The most important factors related to the satis- faction of health staff in this study (ranked based on the most important factor) in- cluded: obtaining clear instructions on the objectives to be achieved in the workplace, the opportunity for professional develop- ment in the workplace, good relations with colleagues, satisfactory salary, appropriate clinical tools, suitable time to perform tasks, opportunity for continuing education in the workplace, etc. (22). It can be noticed that some of these factors were also con- firmed by the PHC staff in our study. In our study we found that 53.4% of PHC staff would recommend the current institu- tion where they work as a very good place Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 13 | 17 to work. In a study of PHC doctors in Lith- uania, 75.5% of them stated that they would not recommend their children to choose the profession of PHC doctor (31). Similar to our study where 78.2% of staff were satis- fied with relationships with colleagues, in Lithuania PHC doctors rated this aspect as one of the most important factors that af- fects their job satisfaction (31). In our study 22.5% of PHC staff agreed or strongly agreed with the fact that working in the cur- rent institution is very stressful; in Lithua- nia also stress at work and workload were considered as an important factor of job dis- satisfaction in PHC (30). Overall less than one fifth of PHC staff in Albania was dis- satisfied or very dissatisfied with the work- ing aspects of PHC, while the level of dis- satisfaction among PHC doctors in Lithua- nia were at much higher levels (31). Similar to our study, where 60.8% of PHC health personnel stated that they were dis- satisfied or very dissatisfied with their cur- rent salary and 27% with the available clin- ical medications, a study in Tanzania re- ported similar figures as 46% of the health staff in PHC there were dissatisfied with their salaries while 34.2% were dissatisfied with the available clinical tools (24). Two were the main factors related to staff satis- faction in Tanzania: the right medical equipment and infrastructure to provide health care and a supportive work environ- ment in terms of peer relationships (24). In Norway GPs turned out to be among the most satisfied professionals in this country, being on average more satisfied even com- pared to the doctors working in hospital; general practitioners were more satisfied with the ability to apply their skills, cooper- ation with colleagues, variation in work, and freedom to choose their method of work, while they were more dissatisfied with the official working schedule (32). These results are contrary to the findings of our study, where GPs were the most dissat- isfied in the PHC system. We have men- tioned the reasons for this dissatisfaction earlier during this discussion. The reason why general practitioners working at PHC in Norway are among the most satisfied health professionals is related to the fact that the Norwegian health system relies on a strong primary health care system, where administrative responsibilities are dele- gated to 434 municipalities (local govern- ment); general practitioners in this system are highly valued and well paid, and their per-capita based salary system (capitation) has not influenced the clinical autonomy of general practitioners in PHC (32). Lack of time, the high number of official working hours, administrative workload, heavy workload and lack of recognition of merit for the work done are some other fac- tors that reduce the satisfaction of general practitioners, according to literature reports (33). These factors are also present in the practice of PHC in our country, based on conversations with doctors and our experi- ence in the field with various studies in PHC, therefore it is necessary that these factors be taken into account in order to ad- dress them. Nevertheless, some elements identified in this study, such as the high workload of PHC staff or the increase of the staff working at this level of health care is already reflected and is part of the 2021- 2030 health care strategy. A study on job satisfaction of about 7400 general practitioners in 34 European coun- tries between 2010-2012 reported great di- versity of this indicator, where the level of satisfied general practitioners was highest in Denmark and Canada, Scandinavian countries and the Netherlands, and lower in Spain, Hungary, and the countries of South- ern Europe; the ability to implement tech- nical procedures, the provision of preven- tive care and health promotion, feedback from colleagues and patient satisfaction with the service received at the PHC were positively associated with the satisfaction of GPs at the PHC and the increase in work- ing hours was negatively related to their job satisfaction (28). However, comparing the working conditions and satisfaction of health staff with their work is very difficult Naum A, Toçi E, Toçi D, Burazeri G, van Kessel R, Czabanowska K. Correlates of level of satis- faction among primary health care workers in Albania (Original research). SEEJPH 2022, posted: 23 March 2022. DOI: 10.11576/seejph-5346 P a g e 14 | 17 due to changes in health systems and differ- ent tasks of PHC physicians in each coun- try. Still, salary turns out to be an important international determinant of job satisfaction of healthcare staff (31-35). Study limitations There may be several potential limitations of our study: first, the cross-sectional de- sign does not allow reaching final conclu- sions regarding the time sequence of events; as such, the study does not provide arguments for verifying the causal relation- ships between the variables and in this con- text, any finding of the study should be in- terpreted very carefully always keeping in mind its cross-sectional design. Second, se- lection bias cannot be ruled out given the small number of health facilities included in this study. The selection bias might have been decreased given the fact that health fa- cilities selected were representing all three kinds of health facilities: HCs in urban and rural areas and HCSs. Regarding the poten- tial bias of the selection of health care staff, we think that this bias has a low probability since the study was attended by over half of all health staff in the study centers. How- ever, limitations on the number of centers included in the study may limit the general- izability of outcomes related to health care staff as well! Third, information bias cannot be ruled out as well; however, we do not think of any reason for the untrue reporting of the PHC staff included in this study. Fourth, the current study was conducted in the context of the partial limitations of the COVID-19 pandemic and the heavy burden that this situation placed on the health sys- tem; it is possible that some aspects of the PHC work might have been perceived in a more negative light by the PHC staff due to the overload and/or increased work stress in this context. The actual study has some strong points as well: this is the first study shedding light on the level of satisfaction of PHC staff and the factors associated with it in Albania. As such, the current study can inform policy- makers and decision-makers about these factors by encouraging appropriate measures to improve the satisfaction of PHC staff with their work environment or other aspects of health care, leading to im- proving the quality of care provided. Sec- ond, the current study used a standardized and validated international instrument in the Albanian language, creating a unique opportunity to compare our findings with those of similar studies conducted in the in- ternational arena. Third, the current study has suggested a series of hypotheses and as- sumptions for discussion, paving the way for their scientific verification through other studies in the future! Conclusion In conclusion, there are several factors as- sociated with PHC staff satisfaction in Al- bania. Policy-makers and decision-makers might take advantage of the current find- ings as a starting point to initiate addressing them as a way to increase staff satisfaction and, subsequently, the quality of PHC ser- vices in Albania. References 1. World Health Organization. Qual- ity in primary health care. Tech- nical series on primary health care. WHO; 2018. 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