Hope, Not Confidence, Drives How Support Boosts Primary Care Workers’ Pay Satisfaction

China’s primary healthcare system has a retention problem. Community health stations, township health centers, and village clinics—the front line of the world’s largest health system—struggle to attract and keep qualified staff, a shortage that threatens both the sustainability of healthcare delivery and the health of the populations those facilities serve. Since the landmark 2009 healthcare reform, policymakers have rolled out a series of reward policies designed to make frontline medical work more attractive. Yet most primary healthcare providers remain dissatisfied with the incentives their organizations offer. A new study published in BMC Health Services Research offers a fresh clue to why, and it comes from an unexpected direction: the inner psychological resources of the workers themselves.

The research, led by Jing Wang, Xiaoting Wang, and colleagues at the School of Health Service Management of Anhui Medical University, set out to untangle the relationship between social support—how much emotional and practical backing employees feel from colleagues, supervisors, family, and friends—and reward satisfaction, the degree to which workers feel their pay and benefits are fair and fulfilling. Crucially, the team did not treat this as a simple two-variable question. Instead, they asked whether psychological capital, a well-established construct in positive organizational psychology, acts as a bridge between the two. And rather than treating psychological capital as one undifferentiated score, they broke it into its four canonical sub-dimensions: self-efficacy, hope, resilience, and optimism.

That methodological choice turned out to be the study’s most consequential decision. Much of the existing literature has modeled psychological capital as a single composite indicator, on the assumption that its components work in concert. The Anhui team suspected that the four dimensions might instead travel along distinct pathways, some of which could even pull in opposite directions. Their results, drawn from 1,154 valid questionnaire responses collected across five types of primary healthcare institutions in Anhui Province, confirmed that suspicion in striking fashion.

The statistical backbone of the study is mediation analysis, a technique for testing whether an observed relationship between two variables flows through a third. The researchers ran correlation and mediation analyses using SPSS 21.0, Amos 22.0, and the widely used PROCESS macro tool. Across two model specifications, the direct association between social support and reward satisfaction was robustly positive: a standardized beta of 0.257 in Model 5 and 0.178 in Model 6, both significant at p < 0.001. In plain terms, primary healthcare workers who perceive more social support tend to be more satisfied with their rewards, even after the analysis accounts for the indirect routes through psychological capital.

The surprises emerged when the four sub-dimensions were examined separately. Hope—the goal-directed, pathway-oriented component of psychological capital, reflecting a person’s belief that they can generate routes to desired outcomes and sustain the willpower to pursue them—showed a significant positive partial mediating effect, with an indirect effect of 0.077 and a 95 percent confidence interval of [0.042, 0.115], which excludes zero. In other words, part of the reason social support translates into reward satisfaction is that supported workers feel more hopeful, and hopeful workers rate their rewards more favorably. This is the intuitive story most organizational theorists would predict: support from others fuels a sense of possibility, and possibility colors how one evaluates what the organization gives back.

Self-efficacy told a very different story. The confidence component of psychological capital produced a negative indirect effect of -0.033, with a 95 percent confidence interval of [-0.057, -0.009], again excluding zero. In mediation terminology, this is called a masking effect: rather than carrying the positive influence of social support forward, self-efficacy appears to suppress part of it. One plausible reading is that highly confident workers hold elevated expectations of what their rewards should be, so the same objective incentive package feels less satisfying to them. The authors are careful, however, to flag an important statistical caveat. This negative indirect effect appeared only in the parallel mediation model, in which all four sub-dimensions are entered simultaneously, and it may partly reflect statistical suppression arising from the high correlations among the psychological-capital dimensions themselves. Because self-efficacy, hope, resilience, and optimism are conceptually and empirically intertwined, disentangling their unique contributions is inherently delicate, and the masking effect should be interpreted with that limitation in mind.

The remaining two dimensions stayed on the statistical sidelines. Optimism produced an indirect effect of 0.019 with a confidence interval of [-0.014, 0.051], and resilience an indirect effect of -0.009 with a confidence interval of [-0.040, 0.021]. Both intervals include zero, meaning neither dimension showed a statistically significant mediating role. For administrators hoping for a simple prescription—boost all four psychological resources and satisfaction will follow—the data say otherwise. Only hope and self-efficacy carried statistically significant indirect signals, and they pointed in opposite directions.

These findings diverge from prior results in the literature, and that divergence is itself informative. Studies that collapse psychological capital into a single composite can obscure offsetting effects: a positive pathway through hope and a negative pathway through self-efficacy can partially cancel each other, leaving a composite score that looks uniformly benign. By modeling the dimensions in parallel, the Anhui team exposed structure that composite approaches would have averaged away. The study also fills a contextual gap. Most previous work on these relationships has been conducted in hospitals, corporations, or general workforce samples; few investigations have probed the differential mechanisms of the four psychological-capital dimensions specifically within primary healthcare settings, where pay is often modest, career ladders are short, and workload is heavy.

The practical implications are aimed squarely at health administrators. If social support raises reward satisfaction partly by raising hope, then interventions that strengthen goal-setting, mentoring, and collegial networks in township and community facilities may pay a double dividend—improving both the social climate and the perceived value of existing reward packages without requiring new money. Conversely, the self-efficacy masking effect suggests that simply exhorting workers to feel more capable, without adjusting incentive structures, could backfire by inflating expectations that current rewards cannot meet. Flexible incentive systems, the authors argue, should be designed with these distinct psychological pathways in mind rather than treating workforce morale as a single dial to turn.

The study, funded by key scientific research projects of universities in Anhui Province and related provincial education department grants, was approved by the Ethics Committee of Anhui Medical University and conducted in line with the Declaration of Helsinki, with informed consent from all participants. As with any cross-sectional design, the usual caution applies: the data capture associations at a single point in time and cannot definitively establish the direction of causality between support, psychological capital, and satisfaction. Longitudinal and intervention studies will be needed to confirm that building hope actually lifts reward satisfaction over time. Still, for a health system grappling with chronic staffing shortages at its grassroots, the message is a compelling one: the road from support to satisfaction runs through the mind, and hope may be the most valuable currency on it.

Subject of Research: The mediating role of psychological capital sub-dimensions in the relationship between social support and reward satisfaction among Chinese primary healthcare providers

Article Title: Exploring the association between social support and reward satisfaction: the mediating role of multi-dimensional psychological capital

Article References: Wang, J., Wang, X., Qiu, L., Li, M., Chen, R., Yan, J., Cheng, J., Wang, L., Zhang, Y., Ding, H., & Chen, G. (2026). Exploring the association between social support and reward satisfaction: the mediating role of multi-dimensional psychological capital. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15850-y

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15850-y

Keywords: social support, reward satisfaction, psychological capital, primary healthcare, mediation analysis, hope, self-efficacy, resilience, optimism, China, health workforce, incentives