The association between the adverse event reporting system and burnout and job satisfaction of nurses: Workplace violence as a mediator.

AIMS: This study aims to explore the association between the implementation of the adverse event reporting system (AERS), burnout, and job satisfaction among psychiatric nurses, with a focus on examining the mediating effect of workplace violence from patients. BACKGROUND: Many organizational and personal factors contribute to burnout and job satisfaction experienced by nurses. AERS, serving as a key component of organizational-level quality improvement system, impacts the overall workplace wellness of nurses. METHODS: A national sample of 9,744 psychiatric nurses from 41 psychiatric hospitals across 29 provinces in China participated. Burnout was measured by the Maslach Burnout Inventory. Job satisfaction was measured using the Minnesota Satisfaction Questionnaire. Workplace violence was assessed by nurses' experience of verbal and physical violence. Multilevel linear regression analyses were carried out to examine if AERS impacts burnout and job satisfaction and to identify the mediating role of workplace violence. RESULTS: AERS was positively associated with job satisfaction, but negatively with burnout and workplace violence. Workplace violence exhibited a positive association with burnout and a negative association with job satisfaction. Mediation analyses indicated that the associations between AERS, burnout, and job satisfaction were mediated by workplace violence. CONCLUSIONS: The application of AERS is associated with a reduction in workplace violence in hospitals, which contributes to the diminished burnout and heightened job satisfaction among psychiatric nurses. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY: The study highlights the importance of organizational efforts and mechanisms in promoting nurses' well-being. It is necessary for hospital management to create a safe workplace through the implementation of AERS.

Policy perception, job satisfaction and intentions to remain in rural area: evidence from the National Compulsory Service Programme in China.

BACKGROUND: Exploring factors that may influence general practitioners (GPs)' intentions to remain in rural area is necessary to inform the training and placement of future medical workforce in rural area. However, little is known about how GPs' perception towards the National Compulsory Service Programme (NCSP) and job satisfaction impact their turnover intention. This paper explores GPs' intentions to remain in rural China and how their policy perception and job satisfaction predict the intentions. METHODS: We conducted a cross-sectional, online survey from December 2021 to February 2022 to investigate GPs' perception towards NCSP, job satisfaction, and intentions to remain in rural area. Eligible participants were GPs who were required to provide health services as part of NCSP at township health centres of 9 provinces which could represent all NCSP GPs in China. Multinomial logistic regression analyses were performed to explore the associations between policy perceptions, job satisfaction, and intentions to remain. RESULTS: Of 3615 GPs included in the analysis, 442 (12.2%) would like to remain in rural area and 1266 (35.0%) were unsure. Results of the multinomial logistic regression analyses showed that compared with GPs who would leave, GPs with higher perception scores for the restriction on taking postgraduate exam (RRR: 1.93, 95% CI 1.72, 2.16) and the commitment to work for six years (RRR: 1.53, 95% CI 1.31, 1.78) were more likely to remain. In contrast, GPs who had higher perception scores for completing standardised residency training (RRR: 0.75, 95% CI 0.64, 0.88) and passing National Medical Licensing Examinations (RRR: 0.74, 95% CI 0.62, 0.87) were more likely to leave. GPs who were satisfied with the freedom of choosing work methods (RRR: 1.52, 95% CI 1.25, 1.84) and chances of promotion (RRR: 1.60, 95% CI 1.32, 1.94) were more likely to remain. CONCLUSIONS: This study highlights the significance of policy perception and job satisfaction on GPs' intentions to remain in rural area. Factors such as career advancement and the empowerment of GPs to build on and use their skills and abilities should be taken into account when designing rural placement programmes.

The moderating role of resilience in the association between workload and depressive symptoms among radiology residents in China: results from a nationwide cross-sectional study.

OBJECTIVES: The current study aimed to explore the moderating role of psychological resilience in the association between workload and depressive symptoms among radiology residents during standardized residency training (SRT) in China. METHODS: A nationwide cross-sectional online survey was conducted among radiology residents in China. Workload was measured by working hours per week and the frequency of frontline nightwork in the last month. Resilience was assessed by the 2-item Connor-Davidson Resilience Scale. Depressive symptoms were measured by the Depression Anxiety Stress Scales. The hierarchical regression and simple slope analyses were performed to examine the moderating effect of resilience. RESULTS: Among 3666 radiology residents, the mean age was 27.3 years (SD = 2.6) and 58% were female. About 24.4% of the participants reported medium to severe depressive symptoms. The hierarchical regression showed that working hours (ba = 0.11, 95%CI: 0.08, 0.14) and having frontline nightwork more than once (ba = 1.22, 95%CI: 0.67, 1.78) were positively associated with depressive symptoms; the moderating effect of resilience was significant in the association of depressive symptoms with working hours (ba = - 0.02, 95%CI: - 0.03, - 0.01) and having frontline nightwork more than once (ba = - 0.28, 95%CI: - 0.49, - 0.07). The simple slope test showed the association between workload-related variables and depressive symptoms was only significant in those with a relatively lower level of resilience. CONCLUSIONS: The study found that resilience was an important modifier buffering the positive association between workload and depressive symptoms among radiology residents in China. Future medical training programs are suggested to include effective intervention components to increase personal resilience. CLINICAL RELEVANCE STATEMENT: Heavy workload in clinical setting may pose adverse effect on mental health and job performance of radiology residents. The study investigated whether psychological resilience would mitigate the association between workload and depressive symptoms among Chinese radiology residents. KEY POINTS: • Radiology residents with a heavier workload presented a higher level of depressive symptoms in China. • Psychological resilience mitigated the positive association between workload and depressive symptoms. • The association between workload and depressive symptoms was only statistically significant in radiology residents with a relatively lower level of resilience.

Perceptions of medical error among general practitioners in rural China: a qualitative interview study.

BACKGROUND: Medical error (ME) is a serious public health problem and a leading cause of death. The reported adverse incidents in China were much less than western countries, and the research on patient safety in rural China's primary care institutions was scarce. This study aims to identify the factors contributing to the under-reporting of ME among general practitioners in township health centres (THCs). METHODS: A qualitative semi-structured interview study was conducted with 31 general practitioners working in 30 THCs across 6 provinces. Thematic analysis was conducted using a grounded theory approach. RESULTS: The understanding of ME was not unified, from only mild consequence to only almost equivalent to medical malpractice. Common coping strategies for THCs after ME occurs included concealing and punishment. None of the participants reported adverse events through the National Clinical Improvement System website since they worked in THCs. Discussions about ME always focused on physicians rather than the system. CONCLUSIONS: The low reported incidence of ME could be explained by unclear concept, unawareness and blame culture. It is imperative to provide supportive environment, patient safety training and good examples of error-based improvements to rural primary care institutions so that ME could be fully discussed, and systemic factors of ME could be recognised and improved there in the future.

Radiology Residents' Perceptions of Artificial Intelligence: Nationwide Cross-Sectional Survey Study.

BACKGROUND: Artificial intelligence (AI) is transforming various fields, with health care, especially diagnostic specialties such as radiology, being a key but controversial battleground. However, there is limited research systematically examining the response of "human intelligence" to AI. OBJECTIVE: This study aims to comprehend radiologists' perceptions regarding AI, including their views on its potential to replace them, its usefulness, and their willingness to accept it. We examine the influence of various factors, encompassing demographic characteristics, working status, psychosocial aspects, personal experience, and contextual factors. METHODS: Between December 1, 2020, and April 30, 2021, a cross-sectional survey was completed by 3666 radiology residents in China. We used multivariable logistic regression models to examine factors and associations, reporting odds ratios (ORs) and 95% CIs. RESULTS: In summary, radiology residents generally hold a positive attitude toward AI, with 29.90% (1096/3666) agreeing that AI may reduce the demand for radiologists, 72.80% (2669/3666) believing AI improves disease diagnosis, and 78.18% (2866/3666) feeling that radiologists should embrace AI. Several associated factors, including age, gender, education, region, eye strain, working hours, time spent on medical images, resilience, burnout, AI experience, and perceptions of residency support and stress, significantly influence AI attitudes. For instance, burnout symptoms were associated with greater concerns about AI replacement (OR 1.89; P<.001), less favorable views on AI usefulness (OR 0.77; P=.005), and reduced willingness to use AI (OR 0.71; P<.001). Moreover, after adjusting for all other factors, perceived AI replacement (OR 0.81; P<.001) and AI usefulness (OR 5.97; P<.001) were shown to significantly impact the intention to use AI. CONCLUSIONS: This study profiles radiology residents who are accepting of AI. Our comprehensive findings provide insights for a multidimensional approach to help physicians adapt to AI. Targeted policies, such as digital health care initiatives and medical education, can be developed accordingly.

The impact of multiple non-pharmaceutical interventions for China-bound travel on domestic COVID-19 outbreaks.

Objectives: Non-pharmaceutical interventions (NPIs) implemented on China-bound travel have successfully mitigated cross-regional transmission of COVID-19 but made the country face ripple effects. Thus, adjusting these interventions to reduce interruptions to individuals' daily life while minimizing transmission risk was urgent. Methods: An improved Susceptible-Infected-Recovered (SIR) model was built to evaluate the Delta variant's epidemiological characteristics and the impact of NPIs. To explore the risk associated with inbound travelers and the occurrence of domestic traceable outbreaks, we developed an association parameter that combined inbound traveler counts with a time-varying initial value. In addition, multiple time-varying functions were used to model changes in the implementation of NPIs. Related parameters of functions were run by the MCSS method with 1,000 iterations to derive the probability distribution. Initial values, estimated parameters, and corresponding 95% CI were obtained. Reported existing symptomatic, suspected, and asymptomatic case counts were used as the training datasets. Reported cumulative recovered individual data were used to verify the reliability of relevant parameters. Lastly, we used the value of the ratio (Bias2/Variance) to verify the stability of the mathematical model, and the effects of the NPIs on the infected cases to analyze the sensitivity of input parameters. Results: The quantitative findings indicated that this improved model was highly compatible with publicly reported data collected from July 21 to August 30, 2021. The number of inbound travelers was associated with the occurrence of domestic outbreaks. A proportional relationship between the Delta variant incubation period and PCR test validity period was found. The model also predicted that restoration of pre-pandemic travel schedules while adhering to NPIs requirements would cause shortages in health resources. The maximum demand for hospital beds would reach 25,000/day, the volume of PCR tests would be 8,000/day, and the number of isolation rooms would reach 800,000/day within 30 days. Conclusion: With the pandemic approaching the end, reexamining it carefully helps better address future outbreaks. This predictive model has provided scientific evidence for NPIs' effectiveness and quantifiable evidence of health resource allocation. It could guide the design of future epidemic prevention and control policies, and provide strategic recommendations on scarce health resource allocation.

Mental health status of mental health nurses in China: Results from a national survey.

INTRODUCTION: It has been acknowledged in China that actions should be taken immediately to ease the critical shortage of psychiatric nurses. However, with national data lacking, little is known about nurses' mental health status. AIM: To evaluate psychiatric nurses' mental health status by measuring their burnout, depression, anxiety and stress. METHODS: All psychiatric nurses in the 41 selected hospitals in China were invited to participate in the survey. The Maslach Burnout Inventory-Human Service Survey and Depression Anxiety Stress Scale were used to assess variables of interest. RESULTS: 38.6% of psychiatric nurses met the criteria for burnout. The rates of depression, anxiety and stress were 26.3%, 36.4% and 12.5%, respectively. It was found that workplace region, educational level, working years, longer working hours and night shifts were associated with risk of burnout and DASS. CONCLUSIONS: More than a quarter of psychiatric nurses are suffering from burnout, depression or anxiety in China. Policymakers and hospital administrators should design a flexible schedule and restrict working hours for psychiatric nurses to achieve work-life balance. IMPLICATIONS FOR PRACTICE: The study informs policymakers and administrators on addressing the nursing shortage by identifying nurses immersed in negative emotions and preventing mental health problems.

The satisfaction with radiology residency training in China: results of a nationwide survey.

BACKGROUND: National data on the satisfaction of radiology residents enrolled in standardized residency training (SRT) are rather scarce in China. This study identified a set of potential factors concerning SRT satisfaction among radiology residents as well as the association between SRT satisfaction and post-competency and well-being. METHODS: A total of 3666 radiology residents who were receiving SRT during 2020 in China were recruited across all 31 provinces. The cumulative odds logistic regression was used to examine the potential factors associated with SRT satisfaction as well as associations between satisfaction and well-being, burnout, professional identity and competency. RESULTS: The prevalence of satisfaction with SRT was 68.6%. Participants who were male, worked in central China, aged more than 28 years old, had long working hours and claimed increased workload during the COVID-19 pandemic were more likely to be unsatisfied with the SRT program. Participants who were more satisfied with the radiation protection were more likely to report higher degree of SRT satisfaction (OR = 3.00, 95% CI 2.58-3.50). In addition, SRT satisfaction was positively associated with well-being, professional identity, competency and lower burnout. CONCLUSIONS: Perceived satisfaction can be introduced into hospital management, as it may reflect the overall situation of the residents during residency training and influence radiologists' well-being, professional identification and competency. Appropriate measures should be taken to reduce the risk of radiation exposure, ensure employee safety (such as risk assessment system and paid time off), provide radiology residents with fair treatment and guarantee the time out of working for optimizing their professional ability.

Gender differences in income among psychiatrists in China: Findings from a national survey.

Background: Gender income disparity in healthcare settings is a longstanding issue around the globe, but such evidence among Chinese psychiatrists is scarce. This study investigated whether gender income differences exist among physicians in China. Methods: Data came from the 2019 national survey data of 4,520 psychiatrists in major public psychiatric hospitals across China. Self-reported monthly income after tax (in Chinese Yuan, CNY) by participants at all professional ranks was assessed. Average monthly income by gender was reported. Adjusted income differences between male and female psychiatrists were examined using multivariable regression models, adjusting with inverse probability of treatment weights and controlling for psychiatrist demographics (e.g., gender, professional rank, marital status, educational level, and work hours) and hospital fixed effects. Results: The unadjusted mean difference in monthly income after tax by gender was 555 CNY (about $86; 95% CI, -825 to -284; mean [SD] for men: 8,652 [4,783] CNY and for women: 8,097 [4,350] CNY) in all psychiatrists. After regression adjustments, the income difference by gender among all psychiatrists reduced substantially and became insignificant. However, gender income difference was still observed among senior-level psychiatrists, where female psychiatrists earned 453 CNY (about $70; 95% CI, -810 to -95) significantly less than male psychiatrists. Conclusion: China achieved gender equity in income for psychiatrists overall, the observed income differences among senior level psychiatrists, however, reveal the persistence of gender inequity at the highest level of professional hierarchy. These findings call for policy attention to the issue of gender income disparity among psychiatrists in China's healthcare system.

Stressors, coping strategies and intention to leave the nursing profession: A cross-sectional nationwide study in China.

AIMS: This study aims to investigate the association between stressors, coping strategies and intention to leave the nursing profession among nurses. BACKGROUND: Job stressors and coping strategies are believed to affect turnover intention among nurses, but no large-scale study has been conducted on these associations in China yet. METHOD: A cross-sectional secondary analysis was conducted among 51,406 nurses from 1858 hospitals. Univariable and multivariable logistic regression analyses were carried out, and odds ratios were reported. RESULTS: Overall, 49.58% nurses had an intention to leave the profession. It is found that stress from health condition, family, occupational injuries, nurse-patient tension, high job demands, strict leaders and colleague relationships were significantly associated with higher intention to leave. Coping strategies such as talking to family and friends, talking to leaders, doing outdoor activities, engaging in hobbies and attending on-the-job training were significantly associated with lower intention, but social gathering, psychological counselling and suffering in silence had an opposite effect. CONCLUSIONS: Our study provides new insights into the association between stressors, coping strategies and turnover intention among nurses in China. IMPLICATIONS FOR NURSING MANAGEMENT: Evidence from this study indicates that policies promoting a safe and supportive work environment should be developed to help nurses cope with stress.

Gender differences in the association between lifestyle behaviors and mental health among psychiatrists in China.

INTRODUCTION: Mental health symptoms are common among health professionals and the influence of lifestyle behaviors on psychiatrists' mental health is insufficiently understood. Based on a nationwide sample, we aimed to survey the lifestyle behaviors and mental health status among psychiatrists, and to identify the co-occurrence and gender differences in lifestyle behaviors. METHODS: Data were collected through an anonymous questionnaire among psychiatrists in China. Depression, Anxiety and Stress Scale - 21 (DASS-21) was used to evaluate mental health symptoms. Latent class analysis (LCA) was used to explore the co-occurrence of lifestyle behaviors. The multivariate logistic regression model was used to examine the effects of demographic and lifestyle factors. RESULTS: 4520 psychiatrists were included in the analysis with 11.5 % of them reporting smoking, 10 % reporting alcohol misuse, 35.2 % reporting physical inactivity, and 23.1 % reporting insomnia. The prevalence of depression, anxiety and stress symptoms were 29.2 %, 34.5 %, and 12.2 %, respectively. Significant gender differences were found in smoking (P < 0.001), alcohol misuse (P < 0.001), and physical inactivity (P < 0.001), but not in insomnia. Based on these four high-risk health behaviors above, three lifestyle behavior clusters with huge gender differences were identified through the LCA. Accordingly, the unhealthy lifestyle classes, though defined differently for males and females, were significantly associated with depression, anxiety, and stress. CONCLUSIONS: The co-occurrence and significant gender differences in multiple lifestyle behaviors exist in this group, highlighting the need for gender-specific comprehensive interventions against mental health symptoms and the urgency of promoting their well-being.

Workplace Violence and Turnover Intention Among Psychiatrists in a National Sample in China: The Mediating Effects of Mental Health.

Background: Workplace violence (WPV) in healthcare has received much attention worldwide. However, scarce data are available on its impact on turnover intention among psychiatrists, and the possible mechanisms between WPV and turnover intention have not been explored in China. Methods: A cross-sectional survey was conducted among psychiatrists in 41 tertiary psychiatric hospitals from 29 provinces and autonomous regions in China. A stress-strain-outcome (SSO) model was adopted to examine the effects of WPV on mental health and turnover intention. The association and mediation by burnout and stress were examined by multivariate logistic regression (MLR) and generalized structure equation modeling (GSEM). Results: We invited 6,986 psychiatrists to participate, and 4,520 completed the survey (64.7% response rate). The prevalence of verbal and physical violence against psychiatrist in China was 78.0 and 30.7%, respectively. MLR analysis showed that psychiatrists who experienced verbal violence (OR = 1.15, 95% CI = 1.10-1.21) and physical violence (OR = 1.15, 95% CI = 1.07-1.24) were more likely to report turnover intention. GSEM analysis showed that burnout (ß = 4.00, p < 0.001) and stress (ß = 1.15, p < 0.001) mediated the association between verbal violence and turnover intention; similarly, burnout (ß = 4.92, p < 0.001) and stress (ß = 1.80, p < 0.001) also mediated the association between physical violence and turnover intention. Conclusions: Experience of WPV is a significant contributor to turnover intention among psychiatrists. Mental health status, such as burnout and stress level significantly mediated the association. Policy makers and hospital administrators need to be aware of this association. Action is needed to promote mental health among the psychiatrists to improve morale and workforce sustainability.

The association of state-level drug and opioid overdose deaths with the capacity of behavioural health professionals in the United States.

As behavioural health occupations have diversified, more specialists such as social workers and counsellors are involved in providing substance use disorder treatment services. This study examined the association between changes in the number of different types of behavioural health professionals and changes in drug and opioid overdose deaths in the United States. Using publicly available state-level data from 2008 to 2017, we constructed multivariate linear regression models with state- and year fixed-effects to examine the effect of changes in the number of different types of behavioural health professionals (i.e. psychiatrists, psychologists, social workers and counsellors) on changes in drug and opioid overdose deaths at the state level, controlling for state population characteristics and other state-level factors. After controlling for confounding factors, a 1% increase in the number of social workers and counsellors at the state level was significantly associated with a 0.215% reduction in drug overdose deaths per 100,000 state population and with a 0.358% reduction in opioid overdose deaths per 100,000 state population. We did not find statistically significant associations between changes in drug overdose death rates and increases in the number of psychiatrists or psychologists alone. Our findings suggest efforts to facilitate a prepared and skilled workforce, such as expanding the capacity of social workers and counsellors, to maximise access to substance use disorder treatment services.

Workplace Violence, Workforce Stability, and Well-being in China's Psychiatric Hospitals.

INTRODUCTION: Workplace violence against psychiatric professionals is a growing problem, yet nationally representative data in China are lacking. This study examines workplace violence against psychiatrists and psychiatric nurses in China as well as its association with workforce stability and well-being . METHODS: Data came from a 2019 national survey of 14,264 participants (including 4,520 psychiatrists and 9,744 nurses) from 41 psychiatric hospitals across China. The occurrence of physical and verbal assaults among psychiatrists and psychiatric nurses was reported. Logistic regression models were constructed to examine the participants' characteristics associated with encountering workplace violence and the association of encountering violence with self-reported quality of life, health status, turnover intention, and career satisfaction. Analyses were performed during 2020. RESULTS: In 2019, among 14,264 psychiatrists and psychiatric nurses in China, 81% reported encountering workplace violence during the past year. Psychiatrists were 0.68 (95% CI=0.55, 0.83) times less likely to report an encounter of violence than nurses. Male and younger nurses were 2.20 (95% CI=1.72, 2.81) and 1.21 (95% CI=1.01, 1.45) times more likely to report violence. Psychiatrists who had a higher educational degree or a higher professional rank were more vulnerable to violence. Encountering violence was significantly associated with poor quality of life, less satisfaction with health status, greater intention to leave the current job, and career dissatisfaction. CONCLUSIONS: Workplace violence against psychiatrists and psychiatric nurses are common in China, indicating that China's psychiatric professionals are facing a significant threat to occupational safety. To maintain psychiatric workforce stability, actions are needed to reduce the prevalence of workplace violence at the system, institutional, and individual levels.

Burnout and job satisfaction of psychiatrists in China: a nationwide survey.

BACKGROUND: Despite a significant shortage of psychiatrists in China, an ever-increasing number of psychiatrists in China are experiencing burnout and job dissatisfaction and considering leaving their jobs. Yet, to our knowledge, there have been no nationwide studies to date that examined both burnout and job dissatisfaction of psychiatrists in China. Therefore, this study evaluated burnout and job dissatisfaction of psychiatrists in China, and identified relevant characteristics. METHODS: We conducted a nationwide, cross-sectional survey in March 2019. Psychiatrists from all tertiary psychiatric hospitals in China were invited to participate. The Maslach Burnout Inventory-Human Service Survey and the short version of the Minnesota Satisfaction Questionnaire were used to measure burnout and job satisfaction. Data on socio-demographic and occupational characteristics were collected. Multivariate logistic regression was conducted to identify socio-demographic and occupational characteristics associated with burnout and job satisfaction. RESULTS: In total, 4520 psychiatrists from tertiary psychiatric hospitals in China completed the questionnaire. Overall, 38.4% of respondents met the criteria for burnout and 35.6% were dissatisfied with their jobs. Being male, more years of practice, having no leadership role, and longer working hours per week were significantly associated with burnout and job dissatisfaction. Lower monthly pay was significantly associated with job dissatisfaction but not burnout. Moreover, burnout was significantly associated with job dissatisfaction. CONCLUSIONS: Our data suggest a high rate of burnout and job dissatisfaction among psychiatrists in China. In order to preserve and strengthen the mental health workforce, proactive measures are urgently needed to mitigate burnout and job dissatisfaction among psychiatrists in China.

Community health workers' job satisfaction in Ebola-stricken areas of Sierra Leone and its implication for COVID-19 containment: a cross-sectional mixed-methods study.

OBJECTIVES: Community health workers (CHWs) played important roles in supplementing scarce healthcare workforce in Sierra Leone during the Ebola outbreak, causing the government to launch the National Community Health Worker Policy 2016-2020. This study evaluated this ambitious policy and examined CHWs' sustainability through their job satisfaction and the underlying factors to inform new policy recommendations, especially the implication for COVID-19 containment. DESIGN: A mixed-methods approach applying structured questionnaires and semistructured interviews. SETTING AND PARTICIPANTS: 188 CHWs in Bombali District (key Ebola-stricken areas) of Sierra Leone, 184 of them participated in follow-up interviews. PRIMARY AND SECONDARY OUTCOME MEASURES: Quantitative and qualitative elements were triangulated to improve robustness of investigation: job satisfaction was measured by the Minnesota Satisfaction Questionnaire (MSQ), and factors associated with job satisfaction were identified through thematic analysis and multivariable logistic regression. RESULTS: The MSQ score of CHWs in Sierra Leone was 65.09, extremely low even among low-income and middle-income countries. Five themes (grouped from 16 subthemes) emerged through the semistructured interviews and were tested quantitatively. Payment was CHWs' top concern. Low stipend and payment tardiness were significantly associated with dissatisfaction. Those with Ebola experience were 5.20 times (95% CI 1.51 to 17.95, p=0.009) more likely to be dissatisfied. This study also found that working conditions, medical material supplies and career development were far from what the CHW policy promised. CHWs' commitment was the only 'positive' theme, and their intrinsic job satisfaction (mean=3.61) was much higher than the extrinsic job satisfaction (mean=2.72). CONCLUSIONS: Some critical components of the 2016 National Community Health Worker Policy, aiming to promote CHWs and strengthen primary healthcare, have severe shortfalls in practice. The Sierra Leone government should address the underlying factors that have impaired CHWs' job satisfaction to ensure sustainability of its CHW network, especially during the combat against COVID-19.

Factors affecting thyroid volume in adolescent students attending a rural middle school in East Hangzhou, China.

OBJECTIVE: To investigate the thyroid volume (Tvol) and to explore factors that affects it among 12 to 15-year-olds attending a rural middle school in east Hangzhou, China. METHODS: A cross-sectional survey of middle school students attending a rural middle school in east Hangzhou, China was conducted. Height, weight and other physical development related indicators in middle school students were measured. The thyroid size was measured using ultrasound, and the thyroid volume calculated. RESULTS: The median (P25, P75) of the thyroid volume in 596 middle school students from a rural middle school in east Hangzhou, China was 6.69 (5.66, 7.98) mL. Our study enrolled 305 male students (51.2%) and 291 female students (48.8%). The height, weight and thyroid volume of middle school students increased with age. Univariate analysis revealed that height, weight, body mass index (BMI) and body surface area (BSA) were positive correlated with thyroid volume (p<0.01).The correlation between BSA and thyroid volume was significant (Spearman's rho=0.473, p<0.01). Multiple linear regression analysis revealed that BSA was positive and significantly correlated with the thyroid volume (p<0.05). Regression equation was Y=-2.532 + 6.186×BSA. CONCLUSION: The thyroid volume is not only affected by age, but it is also affected by growth and development. Goiter cannot only be assessed based on age, gender and thyroid volume. However, this study established that BSA not only presented the strongest correlation with thyroid volume (Spearman's rho=0.473), but also had a strong correlation with physical development, taking into account the growth and development of middle school students, and showed greater stability. Therefore, we recommend inclusion of BSA as a reference standard in the measurement of the thyroid volume.