Decoding the "Body Present, productivity Reduced " Phenomenon among Primary Health Care Workers: A Study on the Impact Mechanism of Role Overload on Presenteeism

Decoding the "Body Present, productivity Reduced " Phenomenon among Primary Health Care Workers: A Study on the Impact Mechanism of Role Overload on Presenteeism | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Decoding the "Body Present, productivity Reduced " Phenomenon among Primary Health Care Workers: A Study on the Impact Mechanism of Role Overload on Presenteeism Kexin Wei, Guobiao Lou, Huanyi Zhong, Tianan Yang, Jianwei Deng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7990151/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Primary health care workers serve as a crucial human resource guarantee for the further improvement of the hierarchical medical system and constitute the backbone for forming a rational medical service pattern featuring "a slight illness be in the community, recovery be back to the community". This study aims to explore the impact mechanism of role overload on presenteeism in primary health care workers, and examine the mediating roles of occupational delay of gratification and work-family conflict in this relationship. Furthermore, by taking the occupation category of primary health care workers (doctors or non-doctors) as a moderating variable, the researchers constructed a mechanism mode. Methods Mature scales were adopted. Based on the Credamo data collection platform, 365 valid questionnaires from primary health care workers were collected through a two-wave questionnaire survey. Data analysis was conducted using SPSS 27.0 and Mplus 8.3 software. Results (1) Hindering mechanism: Role overload of primary health care workers exerted a significantly positive effect on work-family conflict (β = 0.569, p < 0.01); work-family conflict significantly increased presenteeism (β = 0.195, p < 0.01) and played a mediating role (β = 0.111, 95%CI = [0.431, 0.640]). (2) Facilitating mechanism: Role overload of primary health care workers had a significantly positive impact on occupational delay of gratification (β = 0.359, p < 0.01); occupational delay of gratification significantly reduced presenteeism (β = -0.854, p < 0.01), and played a mediating role (β = -0.307, 95%CI = [-0.287, -0.004]). (3) Boundary effect: Multi-group analysis results showed that the facilitating effect of occupational delay of gratification was more pronounced among non-doctors of primary health care workers (nurses, medical technicians, pharmacists) compared to doctors. Meanwhile, the hindering effect of work-family conflict is more pronounced in the doctors. Conclusion We confirmed the mediating roles of occupational delay of gratification and work-family conflict in the relationship between role overload and presenteeism, and the significant moderating role of the occupation category of primary health care workers (doctors or non-doctors). This study provides scientific evidence to reduce productivity loss among primary health care workers and offers a reference for managers of primary health institutions to formulate relevant intervention measures. Primary health care workers Presenteeism Role Overload Work-family conflict Occupation delays gratification Figures Figure 1 Introduction Primary health care (PHC) originated from the Declaration of Alma-Ata in 1978. The Declaration defines PHC as "essential health care based on practical, scientifically sound, and socially acceptable methods and technologies, made universally accessible to all individuals and families through their full participation and at a cost that the community and country can afford at each stage of their development in the spirit of self-reliance" [1]. Different countries adopt different primary health care models: the United Kingdom has established Accountable Care Organizations [2], Australia has initiated PHC networks [3], Family Medicine for America and so on [4]. China stands as a prominent example of PHC implementation, such as "barefoot doctors" [5]. As diverse rural health workers, they emphasized two core principles: their work was centered on rural rather than urban areas, and their services prioritized health care and prevention over treatment [6]. With the passage of time, "barefoot doctors" have gradually transitioned into professional rural doctors and general practitioners, while the philosophy of "prevention first and rooting in the grassroots" has been preserved. Currently, China is developing a rational hierarchical medical service pattern featuring "first consultation at the grassroots level, two-way referral, differential management of acute and chronic diseases, and vertical collaboration". However, against the backdrop of the rising prevalence of chronic diseases and population aging, in some regions, the demand for medical services has surged sharply, while the supply has failed to keep pace in a timely way. This has led to strained health care resources, and the challenges of difficulty in accessing medical care and high medical costs persist for Chinese patients. The mismatch between supply and demand remains a prominent issue [7]. The human resources crisis in primary health care institutions has become an urgent issue [8]. A study by Xin et al. [9] has indicated significant problems in the management and utilization of primary health human resources in China, such as rigid management systems and insufficient incentive mechanisms. Another study indicated that there is an inequality in the allocation of medical workforce between hospitals and primary health care institutions in China [10] This underscores the urgent need for healthcare workforce reform. Due to the unique nature of their profession, health care workers are generally recognized as a group facing high work pressure. Yiğit et al. [11] found that during the COVID-19 pandemic, a large number of health care workers perceived excessive workloads, which led to mental health issues such as anxiety and depression, ultimately impairing work quality. In addition to disease diagnosis and treatment, primary health care workers are also responsible for health education, referral services, and health management of patients with chronic diseases, thus bearing substantial role overload [12]. Role overload exerts significant negative impacts on employees’ work performance. For instance, a study by Zhang et al. [13] confirmed that role overload among nurses directly undermines their job performance. Notably, among health care workers, this decline in work performance often manifests as Presenteeism [14]. Presenteeism was defined as reduced productivity at work due to health problems and non-illness concerns such as stress and cognitive or emotional difficulties [15, 16, 17]. Although this behavior does not directly cause productivity loss in terms of attendance, the academic community generally regards presenteeism as a negative phenomenon. It is believed that presenteeism indirectly leads to reduced productivity by impairing employees’ work and quality of life, thus requiring intervention [18]. This phenomenon may be associated with factors such as job satisfaction [8] and mental health [19]. In a psychometric study on health care workers, Baldonedo et al. [20] further confirmed that the decision of health care workers to continue working while ill is closely related to factors including role overload, lack of supervisory support, mental health, and physical condition. Zhang et al. [21] confirmed that presenteeism exerts a potential negative impact on job burnout and health-related productivity loss among clinical nurses. Therefore, from the long-term perspective of national health, addressing the crisis of presenteeism among primary health care workers holds irreplaceable strategic value. Through literature review, firstly, we found that most studies have investigated the impact of role overload on job performance among specific groups such as nurses [22, 23] and doctors from top-tier hospitals [24, 25], while relatively few studies have focused on the influencing factors of role overload among primary health care workers. Secondly, as a typical work stressor, role overload may not only produce negative effects by consuming individuals’ psychological resources but also stimulate their coping potential in specific contexts. As the Challenge-Hindrance Stressor Framework proposed by Cavanaugh et al. [26] classifies work stressors into two types: Challenge stressors (stress within an employee's control that promotes personal growth when overcome) and hindrance stressors (stress beyond an employee's control that obstructs opportunities for personal development). This "double-edged sword" effect should have been a key focus of research; however, existing literature primarily examines the role of role overload as a hindrance stressor [27, 28, 29], leading to an insufficient understanding of its impacts. Thirdly, research on moderating variables also has limitations. Existing studies mostly focus on the moderating effects of individual traits: core self-evaluations [30], work engagement [13], mindfulness [31], and organizational environments: leader-member exchange [23], support systems [32]. Some scholars have identified demographic and individual characteristics—such as educational level, age, personal care experience, and computer literacy—as moderators of nurses’ acceptance of information systems [33]. However, few studies have explored basic demographic characteristics as moderating variables. Based on the above discussion, this study intends to introduce two mediating variables—occupational delay of gratification and work-family conflict—from the perspective of a dual mechanism (that is, the coexistence of facilitating and hindering effects). Additionally, the occupation category of primary health care workers (doctors or non-doctors) is included as moderating variable. Structural equation modeling (SEM) is employed to effectively analyze and validate the studied variables. hypothesis development Role Overload and Work-family conflict According to the theory proposed by Greenhaus and Beutel [34], role overload leads to states such as fatigue and distraction in individuals, which in turn causes mutual interference between their role performance in the work and family domains, ultimately triggering conflict. As a form of role conflict, work-family conflict is rooted in the mutual exclusivity of role pressures in the work and family domains—when an individual engages in one role, the fulfillment of the other role is significantly hindered [35]. A study by Wang J et al. [36] further confirmed that work-family conflict plays a mediating role in the relationship between workload and job burnout. When work demands exceed an individual’s capacity, the boundary between work and family gradually becomes blurred, prompting employees to develop a tendency to avoid the workplace. An analysis by Michel et al. [37] verified that role stressors (e.g., role overload) are core antecedents of work-family conflict. Scholars such as Matthews et al. [38] have provided new insights into the relationship between role overload and work-family conflict using boundary theory. They argue that "inter-domain transitions" are an important strategy for individuals to cope with role stress—within a reasonable range, individuals can reallocate physical or psychological resources (e.g., time and energy transfer) between different roles (e.g., worker, family member). However, "inter-domain transitions" may also disrupt boundary balance and trigger conflict. This association was also observed during the COVID-19 pandemic: Savu et al. [39] found that work-family conflict is a potential factor affecting the sustainability of health care work. Based on the above theories, this study proposes the following hypothesis: H1: Role overload of primary health care workers is positively correlated with work-family conflict. Work-family conflict and Presenteeism Presenteeism refers to the situation where employees continue working while being ill or physically unwell [40]. The Conservation of Resources (COR) theory posits that individuals strive to acquire, retain, nurture, and protect core valuable resources. When resources are severely overused, individuals enter a defensive mode and may exhibit irrational decision-making behaviors to maintain the survival of core resources [41]. When work-family conflict threatens individuals with the loss of resources in both professional and family roles, individuals may choose to continue working (rather than taking leave) to avoid further loss of work resources or due to financial pressure. A survey of hotel employees in Turkey showed a significant positive correlation between work-family conflict and presenteeism [42].The work characteristics of primary health care workers (e.g., long working hours, emergency response requirements) easily lead to excessive consumption of core resources (such as time, energy, and emotions) in the work domain, which in turn results in insufficient resource supply in the family domain (e.g., reduced time spent with family, failure to fulfill family responsibilities), exacerbating psychological stress and resource depletion. When individuals face dual resource loss in work and family, presenteeism becomes a defensive resource maintenance strategy—by continuing to participate in work, they avoid immediate resource losses (e.g., salary, job security). Therefore, this study proposes the following hypotheses: H2: Work-family conflict of primary health care workers is positively correlated with presenteeism. H3: Work-family conflict plays a mediating role in the relationship between role overload and presenteeism among primary health care workers. Role Overload and Occupation delays gratification Liu et al. proposed the concept of "occupational delay of gratification", which provides a new perspective for alleviating productivity loss caused by role overload. This concept refers to individuals’ delay of gratification in their career development—it represents a decision-making orientation where individuals are willing to give up immediate gratification opportunities that are not conducive to current work (such as rest, entertainment, or impulsive behaviors) in order to better complete work tasks, obtain more benefits, and achieve higher career goals (i.e., more valuable long-term outcomes) [43]. Occupational delay of gratification is a form of delay of gratification in work and career development, and it is more manifested as a type of behavior [44]. Challenge stressors refer to stress factors that are within employees’ control and can promote personal growth once overcome. Self-Determination Theory (SDT) argues that individuals’ motivation stems from the satisfaction of three basic psychological needs: autonomy, competence, and relatedness, and self-regulation ability is crucial for achieving goals [45]. In specific contexts, role overload may act as a challenge stressor. Unlike hindrance stressors, this type of stressor does not directly hinder employees’ work performance or career development; instead, it can stimulate employees’ intrinsic motivation. As individuals gradually overcome stress, their sense of autonomy and competence is enhanced, which in turn exerts a positive impact on occupational delay of gratification. Based on the above discussion, this study proposes the following hypothesis: H4: Role overload of primary health care workers is positively correlated with occupational delay of gratification. Occupation delays gratification and Presenteeism Existing studies have confirmed that individuals with high occupational delay of gratification exhibit many positive outcomes. For example, it helps reduce employees’ emotional exhaustion, improve their work adaptability [46], and foster positive psychological capital [47]. Through surveys, DiBenedetto and Bembenutty [48] found a direct relationship between self-efficacy and delay of gratification, and delay of gratification may act as a mediating or moderating variable for positive outcomes such as academic success. Studies have also shown that career delay of gratification has a significant positive effect on job performance: by strengthening employees’ long-term goal orientation, it encourages them to proactively engage in work, reduce distractions, and thus achieve adaptive development in complex workplace environments [49]. Individuals with high occupational delay of gratification have a stronger intrinsic identification with long-term goals and higher self-regulation efficacy. They are more willing to endure current discomfort, fatigue, or temptations for the sake of long-term career goals, while still maintaining a certain level of work engagement and sense of responsibility, thereby reducing the occurrence of "physical presence but mental absence" (i.e., presenteeism). Conversely, individuals with low occupational delay of gratification are more likely to be driven by immediate negative emotions (e.g., burnout, irritability) [50], leading to more presenteeism behaviors. Meanwhile, due to their high self-regulation efficacy, they perceive a reduction in external temptations over time [51]. Individuals with strong occupational delay of gratification tend to view role overload as a challenge for career growth rather than a threat; they proactively adjust work priorities and optimize task allocation to enhance their sense of competence, thereby mitigating the negative impacts of role overload. Therefore, this study proposes the following hypotheses: H5: Occupational delay of gratification of primary health care workers is negatively correlated with presenteeism. H6: Occupational delay of gratification plays a mediating role in the relationship between role overload and presenteeism among primary health care workers. Multi-Group Paths At the same time, occupational differences among primary health care workers (doctors or non-doctors) may also lead to variations in the association between role overload and presenteeism. Non-Doctors (nurses, pharmacists, etc.) typically have tasks that are clearly defined and relatively fixed in process, characterized by high structuralization and measurable outcomes. A study has shown that the workload of nursing professionals is highly measurable and outlines 94 relevant factors [52]. There are also strict correlation and measurability indicators for pharmacists as well [53]. Such tasks are more easily perceived by individuals as “this task I can complete with effort” and “completing this task can yield effective rewards”, thus individuals may choose to delay immediate gratification (such as giving up lunch breaks or shortening social time) to allocate time to cope, directly triggering the strategy of “delaying gratification to complete tasks”. In the context of an aging population and the prevalence of chronic diseases, nurses, medical technicians, pharmacists, and other non-doctor primary health care workers increasingly focus on nursing services, medication preparation, medication guidance, and so forth, and thus face unprecedented pressure and challenges. H7a: The profession of primary health care workers (doctors or non-doctors) positively moderates the impact of presenteeism on occupation delays gratification, meaning that compared to doctors, the promoting effect of role overload on occupation delays gratification is more pronounced in the non-doctors. H7b: The profession of primary health care workers (doctors or non-doctors) negatively moderates the impact of occupation delays gratification on presenteeism, indicating that compared to non-doctors, the inhibiting effect of g negatively gratification on presenteeism is particularly prominent in the doctors. To summarize, this study proposes a model of factors influencing presenteeism among primary health care workers (Figure 1). In this model, occupational delay of gratification and work-family conflict play mediating roles in the relationship between role overload and presenteeism; meanwhile, the occupational differences among primary health care workers (doctors or non-doctors) play moderating roles in this relationship. Methods Study design and data collection In this study, data were collected through the Credamo data collection platform, a leading crowdsourcing platform that ensures high-quality data collection through algorithmic participant selection [54]. To avoid common method bias and homologous data issues, questionnaires were distributed at two time points with a 1-week interval. Before completing the questionnaire, participants were informed that their participation was entirely voluntary and anonymous. In the first wave, a total of 518 questionnaires were distributed, and 516 were actually returned. Participants provided their basic personal information, the type of primary health institution they belonged to, and completed the role overload assessment. In the second wave, questionnaires were distributed to the 516 primary health care workers who participated in the first wave, and 365 valid questionnaires were recovered. Participants were asked to assess occupational delay of gratification, work-family conflict, and presenteeism. In total, 518 questionnaires were distributed, and 365 valid questionnaires were collected, resulting in an effective response rate of 70.5%. Construct measurements Role Overload The role overload of primary health care workers was assessed using the Role Overload Scale developed by Peterson et al. [55]. In this study, the scale consisted of 5 items: "I need to reduce my workload", "I feel overburdened at work", "I think I take on too many responsibilities", "My workload is too heavy", and "My workload affects the quality I want to maintain". Each item was scored on a 5-point Likert scale, with higher scores indicating more severe role overload. In this study, the scale demonstrated good internal consistency reliability, with a Cronbach’s alpha coefficient of 0.897. Work-family conflict The Work-Family Conflict Scale used in this study was based on a 6-item scale developed by Netemeyer et al. [56]. The scale showed good internal consistency, with a Cronbach’s alpha coefficient of 0.895. Each item was scored on a 5-point Likert scale (1 = "strongly disagree" to 5 = "strongly agree"), and higher scores indicated more severe work-family conflict among the participants. Occupation delays gratification The Occupational Delay of Gratification Questionnaire, developed by Liu et al. [57], was used in this study. The questionnaire consisted of 8 items and adopted a 7-point scale (1 = "strongly disagree" to 7 = "strongly agree"). A sample item was: "Compared with a job with a higher salary but limited development prospects, I am more willing to take a job with a lower starting salary and more hard work but greater development prospects in the future." The internal consistency reliability coefficient of this questionnaire in the present study was 0.713. Presenteeism The Perceived Ability to Work Scale (PAWS) has demonstrated good applicability and validity in the assessment of presenteeism both domestically and internationally [57, 58, 59, 60]. The scale includes 4 subjective items, requiring participants to rate their perceived physical capacity on a scale of 0 to 10 based on their actual situation—where 0 indicates a complete loss of work ability and 10 indicates that their current work ability is at the best level in their life. To ensure that the scoring results accurately reflect the degree of presenteeism, the original scores were reversed in this study (i.e., the original score reported by the participant was subtracted from 10) [59]. After this reversal, higher final scores indicated higher actual attendance rates and lower levels of presenteeism. The internal consistency reliability coefficient of this questionnaire in the present study was 0.824. In addition, basic demographic characteristics of the participants were collected, including gender, age, educational level, marital status, department, institution, and work experience. Data analysis SPSS 27.0 was used for data entry, descriptive statistics, and preliminary analysis. Amos 27.0 and Mplus 8.3 software were employed to establish structural equation models, conduct confirmatory factor analysis, test for common method bias, verify mediating effects, perform Bootstrap tests, and carry out multi-group path analysis. Results Demographic characteristics As shown in Table 1 , 68.5% of the participants were female, and 31.5% were male. Among all respondents, 37.8% of primary health care workers were under 25 years old, 35.3% were aged 26–35 years, 15.1% were aged 36–45 years, 8.5% were aged 46–55 years, 2.7% were aged 56–60 years, and only 0.5% were over 60 years old. Regarding educational level, 16.7% of the respondents had a college degree or below, 66.8% had a bachelor’s degree, and 16.4% had a postgraduate degree. A total of 45.8% of the participants were married, divorced, or widowed, while 54.2% were unmarried. Among the primary health care workers, 67.1% worked in community health service centers, and the remaining worked in township health centers. Approximately half of the participants had less than 5 years of work experience (58.6%), 18.1% had 6–10 years of work experience, 13.4% had 11–20 years of work experience, and 9.9% had more than 20 years of work experience. Table 1 Demographic Characteristics of the Respondents (n = 365) Characteristics Sample (n = 365) % Occupation Category Doctors 181 49.6 Nurse 87 23.8 Medical Technician 72 19.7 Pharmacist 25 6.8 Institution Community Health Service Center 245 67.1 Township Health Center 120 32.9 Gender Male 115 31.5 Female 250 68.5 Age Under 25 years 138 37.8 26–35 years 129 35.3 36–45 years 55 15.1 46–55 years 31 8.5 56–60 years 10 2.7 Over 60 years 2 0.5 Educational Level College or below 61 16.7 Bachelor’s degree 244 66.8 Postgraduate degree 60 16.4 Marital Status Married/Divorced/Widowed 167 45.8 Unmarried 198 54.2 Work Experience Less than 5 years 214 58.6 6–10 years 66 18.1 11–20 years 49 13.4 More than 20 years 36 9.9 Common method bias The Harman single-factor test was used to check for common method bias. The results showed that five factors with eigenvalues greater than 1 were extracted, which together explained 62.48% of the total variance, and the variation explained by the first principal factor was only 27.28% which are below the 40% threshold. Therefore, there is no serious common method bias issue [ 61 ]. Correlations among study variables Table 2 presents the means, standard deviations, and correlation matrix of the main variables. The results showed that role overload was significantly positively correlated with work-family conflict (β = 0.569, p < 0.01), supporting H1. Work-family conflict was significantly positively correlated with presenteeism (β = 0.195, p < 0.01), supporting H2. Role overload was significantly positively correlated with occupational delay of gratification (β = 0.359, p < 0.01), supporting H4. Occupational delay of gratification was significantly negatively correlated with presenteeism (β = -0.854, p < 0.01), supporting H5. Table 2 Means, Standard Deviations, and Correlations Among Variables (n = 365) Variable M SD 1 2 3 4 Role Overload 3.344 0.986 1 Work-Family Conflict 5.367 0.676 .569 ** 1 Occupational Delay of Gratification 2.827 1.289 .359 ** − .104 * 1 Presenteeism 3.432 0.951 .059 ** .195 ** − .854 ** 1 Note:*p<0.05, **p<0.01, *** p<0.001 Mediating Model Test A structural equation model was established with role overload as the predictor variable, work-family conflict and occupational delay of gratification as mediating variables, and presenteeism as the outcome variable. The results showed that all fit indices of the model met psychometric standards: χ²/df = 1.477, GFI = [value omitted in original], CFI = 0.94, NFI = 0.89, IFI = 0.94, TLI = 0.94, RMSEA = 0.04. A bias-corrected nonparametric percentile Bootstrap method with 2000 resamples was used to test the mediating effects and estimate the confidence intervals. The results indicated that both work-family conflict and occupational delay of gratification had significant mediating effects on presenteeism, with 95% confidence intervals of [0.431, 0.640] and [-0.287, -0.004], respectively (neither interval included 0), supporting H3 and H6. Multi-Group Comparison of the Mediating Model by Occupation Category (doctors or non-doctors) This study conducted a multigroup path analysis of the model based on occupational category among primary health care workers (doctors or non-doctors). As shown in Table 3 , the comparison of path coefficient differences indicates that the Critical Ratios for Differences between Parameters exceeds 1.96 [ 62 ], confirming that the occupation category of primary health care workers (doctors or non-doctors) had a significant moderating effect on the path "role overload → occupational delay of gratification" and "occupational delay of gratification → presenteeism". Specifically, the inhibitory effect of occupational delay of gratification on presenteeism was more prominent in the doctors, while the promoting effect of role overload on occupational delay of gratification was more significant in the non-doctors, supporting H7a and H7b. Table 3 Comparison of Path Coefficient Differences of the Mediating Model Between Groups by Occupation (doctors or non-doctors) Path Doctors Non-Doctors Comparison Result β P β P RO→ODG .062 .001 .241 .033 -2.621 ODG→Prent -1.563 .002 − .532 .001 6.374 RO→WFC .588 .001 .611 .001 − .539 WFC→Prent .190 .018 .183 .012 .367 Discussion Theoretical implications Addressing the human resource crisis in primary health care institutions and comprehensively improving the quality of talent development for primary health care workers in China has become an urgent task. Therefore, this study aimed to explore the impact mechanism of role overload on presenteeism among primary health care workers, examine the mediating roles of occupational delay of gratification and work-family conflict in this relationship, and investigate the moderating role of the occupation category of primary health care workers (doctors or non-doctors). The theoretical contributions are as follows. First of all, existing research on role overload has largely confined its understanding to “hindrance stressors”. This study empirically demonstrates that role overload can enhance occupational delayed gratification levels, introducing a novel perspective that it may function as a “challenge stressor”. This provides a new theoretical framework for examining the relationship between role overload and presenteeism. This aligned with research by Rosen et al. [ 63 ] and Kern et al. [ 64 ] on “challenging stressors,” enriching the Challenge-Hindrance Stressor Framework for role overload. Based on this, the study constructs a dual mediation mechanism, explicitly confirming the mediating roles of occupational delayed gratification and work-family conflict in the influence of role overload on presenteeism. It establishes dual mediation models: “role overload → occupational delayed gratification → presenteeism” and “role overload → work-family conflict → presenteeism”. This approach transcends the traditional binary perspective that views its effects as entirely beneficial or detrimental. Secondly, building upon Yu et al.'s [ 65 ] research on delayed gratification and Liu Xiaoyan et al.'s [ 44 , 57 ] studies on occupational delayed gratification, this research links occupational delayed gratification to reduced productivity loss. Individuals are willing to endure immediate hardships and sacrifice personal freedom to pursue long-term goals and gain others' respect and recognition. At the same time, we found that work-family conflict plays a mediating role in the relationship between role overload and presenteeism. Although there are few studies directly exploring the role of work-family conflict in the specific relationship between role overload and presenteeism, research on the relationship between work-family conflict and role overload is relatively mature. The burden of work demands will inevitably affect the role conflict between work and family experienced by individuals [ 66 ]. Work-family conflict has been confirmed to be associated with a variety of negative work outcomes, such as job burnout, reduced job satisfaction, and decreased work performance [ 59 , 67 , 68 ]. Balancing work-family conflict and reducing role overload can alleviate turnover intentions [ 69 ]. This also echoes the work-family interface theory [ 70 ]. The above two parts enrich the theoretical framework examining the relationship between role overload and presenteeism. Last but not least, this study broadens the research perspective on moderating factors. Unlike previous studies, we consider the occupation categories of primary health care workers (doctors or non-doctors) as a moderating variable. This makes the theoretical model more aligned with the occupational characteristics in China's primary health sector, expanding the depth of related theories' application among specific occupational groups. Practical implications This study provides insights for reducing the phenomenon of presenteeism among primary health care workers. From a management perspective, managers can improve primary health care workers' ability for occupational delay of gratification through enhancing training quality and capacity building, and establishing performance accountability systems, which can help them better cope with role overload and reduce presenteeism. Additionally, it is essential to strengthen humanistic care, value the balance between work and family for primary health care workers, and implement measures such as flexible work systems and providing family support services. Lastly, managers should develop different management strategies based on employee characteristics: reinforcing 'long-term goal orientation' among doctors and reasonably activating 'moderate overload incentives' among non-doctors. Ultimately, this will effectively curb presenteeism and improve the service quality and operational efficiency of primary medical institutions. From the perspective of primary health care workers, they should proactively enhance their self-management skills, scientifically prioritize work tasks, utilize time management tools and techniques, and allocate time and energy wisely to improve work efficiency. Secondly, attention should also be paid to mental health by developing healthy interests such as exercise and reading, actively participating in team-building activities, enhancing social interactions, and building psychological resilience. Furthermore, primary health care workers need to develop strong career planning skills, clarify their career development goals, actively engage in continuing education and skills training, and earn relevant professional certifications to improve personal professional competitiveness and face work challenges with greater ease, thereby achieving a positive cycle of personal value and career development. Limitations and future directions This study has several limitations that can be addressed in future research. Firstly, the valid samples were collected from primary health care workers through the Credamo data collection platform, and the stratified characteristics of different regions were not clearly covered. Thus, the samples may not fully represent the overall situation of primary health care professionals nationwide. Secondly, the questionnaire data relied on self-reports from participants, which may be subject to social desirability bias. For example, when evaluating presenteeism, participants may conceal their actual situation due to fear of negative evaluations, affecting the accuracy of the data. Finally, according to Self-Determination Theory, sustained high workload may lead to the impairment of individuals’ sense of autonomy and competence, thereby weakening their self-regulation ability [ 71 ]. How to ensure data accuracy and whether there will be a critical value for the positive correlation between role overload and occupational delay of gratification is a direction for future research. Conclusions This study investigated the relationships between presenteeism and role overload, occupational delay of gratification, and work-family conflict among health care professionals in primary health care institutions. The findings showed that role overload was positively correlated with occupational delay of gratification and work-family conflict; work-family conflict was positively correlated with presenteeism, while occupational delay of gratification was negatively correlated with presenteeism. In addition, this study confirmed the mediating roles of occupational delay of gratification and work-family conflict in the relationship between role overload and presenteeism, as well as the moderating role of primary health care workers’ occupation (doctors or non-doctors). These findings provide multi-dimensional insights for the management practice and policy formulation of primary health care workers, and emphasize that primary health care institutions should pay attention to the differential effects when implementing intervention measures for different types of primary health care workers, thereby providing a basis for formulating more targeted strategies. Abbreviations SEM: Structural Equation Modeling PHC: Primary Health Care RO: Role Overload WFC: Work-Family Conflict ODG: Occupational Delay of Gratification PAWS: Perceived Ability to Work Scale COR: Conservation of Resources Prent: Presenteeism SDT: Self-Determination Theory Declarations Statement of Interests Conflict of Interest Statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements The authors acknowledge the significant contributions of Professor Ran Liu, Dr. Yang, and Dr. Deng to this research. We also extend our gratitude to the Credamo data collection platform that assisted with recruitment, as well as to all participants who completed the questionnaires from which this study's data were derived. Authors' contributions KW, GL and RL conceived the study, designed the methodology, collected and analyzed the data, interpreted the findings, and drafted the manuscript. RL also played a key role in revising the manuscript to enhance its academic content and in approving the final submission. KW ang HZ contributed to the study by assisting with data collection, analysis, and interpretation. TY, JD and RL provided valuable insights during manuscript preparation and revision. All five authors reviewed and approved the final version of the manuscript for submission and agree to take responsibility for all aspects of the work. Funding This work was supported by the special project of Zhejiang Provincial Philosophy and Social Sciences Planning Project “Research and Interpretation of the Spirit of the Third Plenary Session of the 20th CPC Central Committee and the Fifth Plenary Session of the 15th CPC Provincial Committee”, the Zhejiang Province Soft Science Research Program (2024C35008), the National Natural Science Foundation of China (72474022, 71974011, 72574023, 72174022), the Higher Education Teaching Reform Project of Wenzhou Medical University (JG2025062), and the “BIT think tank” Promotion Plan of Science and Technology Innovation Program of Beijing Institute of Technology (2025CX13015). Availability of data and materials The data are available from authors upon reasonable request. Ethics approval and consent to participate The Ethical approval of this study is compliant with the Helsinki Declaration (https://www.wma.net/policies-post/wma-declaration-of-helsinki/) and obtained ethics approval by Ethics Committee of Beijing Institute of Technology (approval number: BIT-EC-H-2024275; date of approval: October 26, 2024). At the same time, the research process strictly adheres to confidentiality and privacy principles, ensuring participants' voluntary involvement and their right to withdraw at any time. Informed consent was obtained from all of the participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1 School of Medical Humanities and Management, Wenzhou Medical University, Wenzhou 325035, China. 2 Key Research Center of Philosophy and Social Sciences of Zhejiang Province (Institute of Medical Humanities), Wenzhou Medical University, Wenzhou 325035, China. 3 School of Management, Beijing Institute of Technology, Beijing 100081, China. 4 Sustainable Development Research Institute for Economy and Society of Beijing, Beijing Institute of Technology, Beijing 100081, China. References International Conference on Primary Health Care, 1978. Declaration of Alma-Ata. WHO chronicle, 32(11), 428-430. Shortell, S., Addicott, R., Walsh, N., & Ham, C., 2014. Accountable care organisations in the United States and England. King’s Fund Brief. 1-17. https://assets.kingsfund.org.uk/f/256914/x/74b750cdcd/accountable_care_organisations_us_and_england_2014.pdf. Booth, M., Hill, G., Moore, M. J., Dalla, D., Moore, M. G., & Messenger, A., 2016. 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1","display":"","copyAsset":false,"role":"figure","size":8352,"visible":true,"origin":"","legend":"\u003cp\u003eResearch Framework\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7990151/v1/37d8f7906e6d7cc0573f2b4e.png"},{"id":104427310,"identity":"243a0968-a021-4469-9d70-5792f3b72616","added_by":"auto","created_at":"2026-03-11 14:57:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":968024,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7990151/v1/78713afb-f390-40fe-98dd-71c9a7f7969e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Decoding the \"Body Present, productivity Reduced \" Phenomenon among Primary Health Care Workers: A Study on the Impact Mechanism of Role Overload on Presenteeism","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary health care (PHC) originated from the Declaration of Alma-Ata in 1978. The Declaration defines PHC as \u0026quot;essential health care based on practical, scientifically sound, and socially acceptable methods and technologies, made universally accessible to all individuals and families through their full participation and at a cost that the community and country can afford at each stage of their development in the spirit of self-reliance\u0026quot; [1]. Different countries adopt different primary health care models: the United Kingdom has established Accountable Care Organizations [2], Australia has initiated PHC networks [3], Family Medicine for America and so on [4]. China stands as a prominent example of PHC implementation, such as \u0026quot;barefoot doctors\u0026quot; [5]. As diverse rural health workers, they emphasized two core principles: their work was centered on rural rather than urban areas, and their services prioritized health care and prevention over treatment [6]. With the passage of time, \u0026quot;barefoot doctors\u0026quot; have gradually transitioned into professional rural doctors and general practitioners, while the philosophy of \u0026quot;prevention first and rooting in the grassroots\u0026quot; has been preserved. Currently, China is developing a rational hierarchical medical service pattern featuring \u0026quot;first consultation at the grassroots level, two-way referral, differential management of acute and chronic diseases, and vertical collaboration\u0026quot;. However, against the backdrop of the rising prevalence of chronic diseases and population aging, in some regions, the demand for medical services has surged sharply, while the supply has failed to keep pace in a timely way. This has led to strained health care resources, and the challenges of difficulty in accessing medical care and high medical costs persist for Chinese patients. The mismatch between supply and demand remains a prominent issue [7]. The human resources crisis in primary health care institutions has become an urgent issue [8]. A study by Xin et al. [9] has indicated significant problems in the management and utilization of primary health human resources in China,\u0026nbsp;such as rigid management systems and insufficient incentive mechanisms.\u0026nbsp;Another study indicated that there is an inequality in the allocation of medical workforce between hospitals and primary health care institutions in China [10]\u0026nbsp;This underscores the urgent need for healthcare workforce reform.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to the unique nature of their profession, health care workers are generally recognized as a group facing high work pressure. Yiğit et al. [11] found that during the COVID-19 pandemic, a large number of health care workers perceived excessive workloads, which led to mental health issues such as anxiety and depression, ultimately impairing work quality. In addition to disease diagnosis and treatment, primary health care workers are also responsible for health education, referral services, and health management of patients with chronic diseases, thus bearing substantial role overload [12]. Role overload exerts significant negative impacts on employees\u0026rsquo; work performance. For instance, a study by Zhang et al. [13] confirmed that role overload among nurses directly undermines their job performance. Notably, among health care workers, this decline in work performance often manifests as Presenteeism [14]. Presenteeism was defined as reduced productivity at work due to health problems and non-illness concerns such as stress and cognitive or emotional difficulties [15, 16, 17]. Although this behavior does not directly cause productivity loss in terms of attendance, the academic community generally regards presenteeism as a negative phenomenon. It is believed that presenteeism indirectly leads to reduced productivity by impairing employees\u0026rsquo; work and quality of life, thus requiring intervention [18]. This phenomenon may be associated with factors such as job satisfaction [8] and mental health [19]. In a psychometric study on health care workers, Baldonedo et al. [20] further confirmed that the decision of health care workers to continue working while ill is closely related to factors including role overload, lack of supervisory support, mental health, and physical condition.\u0026nbsp;Zhang et al. [21] confirmed that presenteeism exerts a potential negative impact on job burnout and health-related productivity loss among clinical nurses. Therefore, from the long-term perspective of national health, addressing the crisis of presenteeism among primary health care workers holds irreplaceable strategic value.\u003c/p\u003e\n\u003cp\u003eThrough literature review, firstly, we found that most studies have investigated the impact of role overload on job performance among specific groups such as nurses [22, 23] and doctors from top-tier hospitals [24, 25], while relatively few studies have focused on the influencing factors of role overload among primary health care workers. Secondly, as a typical work stressor, role overload may not only produce negative effects by consuming individuals\u0026rsquo; psychological resources but also stimulate their coping potential in specific contexts. As the Challenge-Hindrance Stressor Framework proposed by Cavanaugh et al. [26] classifies work stressors into two types: Challenge stressors (stress within an employee\u0026apos;s control that promotes personal growth when overcome) and hindrance stressors (stress beyond an employee\u0026apos;s control that obstructs opportunities for personal development). This \u0026quot;double-edged sword\u0026quot; effect should have been a key focus of research; however, existing literature primarily examines the role of role overload as a hindrance stressor [27, 28, 29], leading to an insufficient understanding of its impacts. Thirdly, research on moderating variables also has limitations. Existing studies mostly focus on the moderating effects of individual traits: core self-evaluations [30], work engagement [13], mindfulness [31], and organizational environments: leader-member exchange [23], support systems [32]. Some scholars have identified demographic and individual characteristics\u0026mdash;such as educational level, age, personal care experience, and computer literacy\u0026mdash;as moderators of nurses\u0026rsquo; acceptance of information systems [33]. However, few studies have explored basic demographic characteristics as moderating variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the above discussion, this study intends to introduce two mediating variables\u0026mdash;occupational delay of gratification and work-family conflict\u0026mdash;from the perspective of a dual mechanism (that is, the coexistence of facilitating and hindering effects). Additionally, the occupation category of primary health care workers (doctors or non-doctors) is included as moderating variable. Structural equation modeling (SEM) is employed to effectively analyze and validate the studied variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ehypothesis development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole Overload and Work-family conflict\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the theory proposed by Greenhaus and Beutel [34], role overload leads to states such as fatigue and distraction in individuals, which in turn causes mutual interference between their role performance in the work and family domains, ultimately triggering conflict. As a form of role conflict, work-family conflict is rooted in the mutual exclusivity of role pressures in the work and family domains\u0026mdash;when an individual engages in one role, the fulfillment of the other role is significantly hindered [35]. A study by Wang J et al. [36] further confirmed that work-family conflict plays a mediating role in the relationship between workload and job burnout. When work demands exceed an individual\u0026rsquo;s capacity, the boundary between work and family gradually becomes blurred, prompting employees to develop a tendency to avoid the workplace. An analysis by Michel et al. [37] verified that role stressors (e.g., role overload) are core antecedents of work-family conflict.\u0026nbsp;Scholars such as Matthews et al. [38] have provided new insights into the relationship between role overload and work-family conflict using boundary theory. They argue that \u0026quot;inter-domain transitions\u0026quot; are an important strategy for individuals to cope with role stress\u0026mdash;within a reasonable range, individuals can reallocate physical or psychological resources (e.g., time and energy transfer) between different roles (e.g., worker, family member). However, \u0026quot;inter-domain transitions\u0026quot; may also disrupt boundary balance and trigger conflict. This association was also observed during the COVID-19 pandemic: Savu et al. [39] found that work-family conflict is a potential factor affecting the sustainability of health care work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the above theories, this study proposes the following hypothesis:\u003c/p\u003e\n\u003cp\u003eH1: Role overload of primary health care workers is positively correlated with work-family conflict.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWork-family conflict and Presenteeism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePresenteeism refers to the situation where employees continue working while being ill or physically unwell [40]. The Conservation of Resources (COR) theory posits that individuals strive to acquire, retain, nurture, and protect core valuable resources. When resources are severely overused, individuals enter a defensive mode and may exhibit irrational decision-making behaviors to maintain the survival of core resources [41]. When work-family conflict threatens individuals with the loss of resources in both professional and family roles, individuals may choose to continue working (rather than taking leave) to avoid further loss of work resources or due to financial pressure. A survey of hotel employees in Turkey showed a significant positive correlation between work-family conflict and presenteeism [42].The work characteristics of primary health care workers (e.g., long working hours, emergency response requirements) easily lead to excessive consumption of core resources (such as time, energy, and emotions) in the work domain, which in turn results in insufficient resource supply in the family domain (e.g., reduced time spent with family, failure to fulfill family responsibilities), exacerbating psychological stress and resource depletion. When individuals face dual resource loss in work and family, presenteeism becomes a defensive resource maintenance strategy\u0026mdash;by continuing to participate in work, they avoid immediate resource losses (e.g., salary, job security).\u003c/p\u003e\n\u003cp\u003eTherefore, this study proposes the following hypotheses:\u003c/p\u003e\n\u003cp\u003eH2: Work-family conflict of primary health care workers is positively correlated with presenteeism.\u003c/p\u003e\n\u003cp\u003eH3: Work-family conflict plays a mediating role in the relationship between role overload and presenteeism among primary health care workers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole Overload and Occupation delays gratification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLiu et al. proposed the concept of \u0026quot;occupational delay of gratification\u0026quot;, which provides a new perspective for alleviating productivity loss caused by role overload. This concept refers to individuals\u0026rsquo; delay of gratification in their career development\u0026mdash;it represents a decision-making orientation where individuals are willing to give up immediate gratification opportunities that are not conducive to current work (such as rest, entertainment, or impulsive behaviors) in order to better complete work tasks, obtain more benefits, and achieve higher career goals (i.e., more valuable long-term outcomes) [43]. Occupational delay of gratification is a form of delay of gratification in work and career development, and it is more manifested as a type of behavior [44].\u0026nbsp;Challenge stressors refer to stress factors that are within employees\u0026rsquo; control and can promote personal growth once overcome. Self-Determination Theory (SDT) argues that individuals\u0026rsquo; motivation stems from the satisfaction of three basic psychological needs: autonomy, competence, and relatedness, and self-regulation ability is crucial for achieving goals [45]. In specific contexts, role overload may act as a challenge stressor. Unlike hindrance stressors, this type of stressor does not directly hinder employees\u0026rsquo; work performance or career development; instead, it can stimulate employees\u0026rsquo; intrinsic motivation. As individuals gradually overcome stress, their sense of autonomy and competence is enhanced, which in turn exerts a positive impact on occupational delay of gratification.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the above discussion, this study proposes the following hypothesis:\u003c/p\u003e\n\u003cp\u003eH4: Role overload of primary health care workers is positively correlated with occupational delay of gratification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOccupation delays gratification and Presenteeism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExisting studies have confirmed that individuals with high occupational delay of gratification exhibit many positive outcomes. For example, it helps reduce employees\u0026rsquo; emotional exhaustion, improve their work adaptability [46], and foster positive psychological capital [47]. Through surveys, DiBenedetto and Bembenutty [48] found a direct relationship between self-efficacy and delay of gratification, and delay of gratification may act as a mediating or moderating variable for positive outcomes such as academic success. Studies have also shown that career delay of gratification has a significant positive effect on job performance: by strengthening employees\u0026rsquo; long-term goal orientation, it encourages them to proactively engage in work, reduce distractions, and thus achieve adaptive development in complex workplace environments [49].\u0026nbsp;Individuals with high occupational delay of gratification have a stronger intrinsic identification with long-term goals and higher self-regulation efficacy. They are more willing to endure current discomfort, fatigue, or temptations for the sake of long-term career goals, while still maintaining a certain level of work engagement and sense of responsibility, thereby reducing the occurrence of \u0026quot;physical presence but mental absence\u0026quot; (i.e., presenteeism). Conversely, individuals with low occupational delay of gratification are more likely to be driven by immediate negative emotions (e.g., burnout, irritability) [50], leading to more presenteeism behaviors. Meanwhile, due to their high self-regulation efficacy, they perceive a reduction in external temptations over time [51]. Individuals with strong occupational delay of gratification tend to view role overload as a challenge for career growth rather than a threat; they proactively adjust work priorities and optimize task allocation to enhance their sense of competence, thereby mitigating the negative impacts of role overload.\u003c/p\u003e\n\u003cp\u003eTherefore, this study proposes the following hypotheses:\u003c/p\u003e\n\u003cp\u003eH5: Occupational delay of gratification of primary health care workers is negatively correlated with presenteeism.\u003c/p\u003e\n\u003cp\u003eH6: Occupational delay of gratification plays a mediating role in the relationship between role overload and presenteeism among primary health care workers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMulti-Group Paths\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the same time, occupational differences among primary health care workers (doctors or non-doctors) may also lead to variations in the association between role overload and presenteeism. Non-Doctors (nurses, pharmacists, etc.) typically have tasks that are clearly defined and relatively fixed in process, characterized by high structuralization and measurable outcomes. A study has shown that the workload of nursing professionals is highly measurable and outlines 94 relevant factors [52]. There are also strict correlation and measurability indicators for pharmacists as well [53]. Such tasks are more easily perceived by individuals as \u0026ldquo;this task I can complete with effort\u0026rdquo; and \u0026ldquo;completing this task can yield effective rewards\u0026rdquo;, thus individuals may choose to delay immediate gratification (such as giving up lunch breaks or shortening social time) to allocate time to cope, directly triggering the strategy of \u0026ldquo;delaying gratification to complete tasks\u0026rdquo;. In the context of an aging population and the prevalence of chronic diseases, nurses, medical technicians, pharmacists, and other non-doctor primary health care workers increasingly focus on nursing services, medication preparation, medication guidance, and so forth, and thus face unprecedented pressure and challenges.\u003c/p\u003e\n\u003cp\u003eH7a: The profession of primary health care workers (doctors or non-doctors) positively moderates the impact of presenteeism on occupation delays gratification, meaning that compared to doctors, the promoting effect of role overload on occupation delays gratification is more pronounced in the non-doctors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH7b: The profession of primary health care workers (doctors or non-doctors) negatively moderates the impact of occupation delays gratification on presenteeism, indicating that compared to non-doctors, the inhibiting effect of g negatively gratification on presenteeism is particularly prominent in the doctors.\u003c/p\u003e\n\u003cp\u003eTo summarize, this study proposes a model of factors influencing presenteeism among primary health care workers (Figure 1). In this model, occupational delay of gratification and work-family conflict play mediating roles in the relationship between role overload and presenteeism; meanwhile, the occupational differences among primary health care workers (doctors or non-doctors) play moderating roles in this relationship.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, data were collected through the Credamo data collection platform, a leading crowdsourcing platform that ensures high-quality data collection through algorithmic participant selection [54]. To avoid common method bias and homologous data issues, questionnaires were distributed at two time points with a 1-week interval. Before completing the questionnaire, participants were informed that their participation was entirely voluntary and anonymous. In the first wave, a total of 518 questionnaires were distributed, and 516 were actually returned. Participants provided their basic personal information, the type of primary health institution they belonged to, and completed the role overload assessment. In the second wave, questionnaires were distributed to the 516 primary health care workers who participated in the first wave, and 365 valid questionnaires were recovered. Participants were asked to assess occupational delay of gratification, work-family conflict, and presenteeism. In total, 518 questionnaires were distributed, and 365 valid questionnaires were collected, resulting in an effective response rate of 70.5%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstruct measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole Overload\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe role overload of primary health care workers was assessed using the Role Overload Scale developed by Peterson et al. [55]. In this study, the scale consisted of 5 items: \"I need to reduce my workload\", \"I feel overburdened at work\", \"I think I take on too many responsibilities\", \"My workload is too heavy\", and \"My workload affects the quality I want to maintain\". Each item was scored on a 5-point Likert scale, with higher scores indicating more severe role overload. In this study, the scale demonstrated good internal consistency reliability, with a Cronbach’s alpha coefficient of 0.897.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWork-family conflict\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Work-Family Conflict Scale used in this study was based on a 6-item scale developed by Netemeyer et al. [56]. The scale showed good internal consistency, with a Cronbach’s alpha coefficient of 0.895. Each item was scored on a 5-point Likert scale (1 = \"strongly disagree\" to 5 = \"strongly agree\"), and higher scores indicated more severe work-family conflict among the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOccupation delays gratification\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Occupational Delay of Gratification Questionnaire, developed by Liu et al. [57], was used in this study. The questionnaire consisted of 8 items and adopted a 7-point scale (1 = \"strongly disagree\" to 7 = \"strongly agree\"). A sample item was: \"Compared with a job with a higher salary but limited development prospects, I am more willing to take a job with a lower starting salary and more hard work but greater development prospects in the future.\" The internal consistency reliability coefficient of this questionnaire in the present study was 0.713.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePresenteeism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Perceived Ability to Work Scale (PAWS) has demonstrated good applicability and validity in the assessment of presenteeism both domestically and internationally [57, 58, 59, 60]. The scale includes 4 subjective items, requiring participants to rate their perceived physical capacity on a scale of 0 to 10 based on their actual situation—where 0 indicates a complete loss of work ability and 10 indicates that their current work ability is at the best level in their life. To ensure that the scoring results accurately reflect the degree of presenteeism, the original scores were reversed in this study (i.e., the original score reported by the participant was subtracted from 10) [59]. After this reversal, higher final scores indicated higher actual attendance rates and lower levels of presenteeism. The internal consistency reliability coefficient of this questionnaire in the present study was 0.824.\u003c/p\u003e\n\u003cp\u003eIn addition, basic demographic characteristics of the participants were collected, including gender, age, educational level, marital status, department, institution, and work experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS 27.0 was used for data entry, descriptive statistics, and preliminary analysis. Amos 27.0 and Mplus 8.3 software were employed to establish structural equation models, conduct confirmatory factor analysis, test for common method bias, verify mediating effects, perform Bootstrap tests, and carry out multi-group path analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eDemographic characteristics\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 68.5% of the participants were female, and 31.5% were male. Among all respondents, 37.8% of primary health care workers were under 25 years old, 35.3% were aged 26\u0026ndash;35 years, 15.1% were aged 36\u0026ndash;45 years, 8.5% were aged 46\u0026ndash;55 years, 2.7% were aged 56\u0026ndash;60 years, and only 0.5% were over 60 years old. Regarding educational level, 16.7% of the respondents had a college degree or below, 66.8% had a bachelor\u0026rsquo;s degree, and 16.4% had a postgraduate degree. A total of 45.8% of the participants were married, divorced, or widowed, while 54.2% were unmarried. Among the primary health care workers, 67.1% worked in community health service centers, and the remaining worked in township health centers. Approximately half of the participants had less than 5 years of work experience (58.6%), 18.1% had 6\u0026ndash;10 years of work experience, 13.4% had 11\u0026ndash;20 years of work experience, and 9.9% had more than 20 years of work experience.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic Characteristics of the Respondents (n\u0026thinsp;=\u0026thinsp;365)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSample\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;365)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation Category\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoctors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e181\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Technician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstitution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity Health Service Center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e245\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTownship Health Center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e250\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnder 25 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u0026ndash;35 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36\u0026ndash;45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e46\u0026ndash;55 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e56\u0026ndash;60 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOver 60 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostgraduate degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried/Divorced/Widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e167\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWork Experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 20 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eCommon method bias\u003c/h2\u003e\u003cp\u003eThe Harman single-factor test was used to check for common method bias. The results showed that five factors with eigenvalues greater than 1 were extracted, which together explained 62.48% of the total variance, and the variation explained by the first principal factor was only 27.28% which are below the 40% threshold. Therefore, there is no serious common method bias issue [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eCorrelations among study variables\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the means, standard deviations, and correlation matrix of the main variables. The results showed that role overload was significantly positively correlated with work-family conflict (β\u0026thinsp;=\u0026thinsp;0.569, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), supporting H1. Work-family conflict was significantly positively correlated with presenteeism (β\u0026thinsp;=\u0026thinsp;0.195, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), supporting H2. Role overload was significantly positively correlated with occupational delay of gratification (β\u0026thinsp;=\u0026thinsp;0.359, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), supporting H4. Occupational delay of gratification was significantly negatively correlated with presenteeism (β = -0.854, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), supporting H5.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMeans, Standard Deviations, and Correlations Among Variables (n\u0026thinsp;=\u0026thinsp;365)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRole Overload\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.344\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.986\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWork-Family Conflict\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5.367\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.676\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.569\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupational Delay of Gratification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.827\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.359\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.104\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresenteeism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.432\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.951\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.059\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.195\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.854\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote:*p\u0026lt;0.05, **p\u0026lt;0.01, *** p\u0026lt;0.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eMediating Model Test\u003c/h2\u003e\u003cp\u003eA structural equation model was established with role overload as the predictor variable, work-family conflict and occupational delay of gratification as mediating variables, and presenteeism as the outcome variable. The results showed that all fit indices of the model met psychometric standards: χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;1.477, GFI = [value omitted in original], CFI\u0026thinsp;=\u0026thinsp;0.94, NFI\u0026thinsp;=\u0026thinsp;0.89, IFI\u0026thinsp;=\u0026thinsp;0.94, TLI\u0026thinsp;=\u0026thinsp;0.94, RMSEA\u0026thinsp;=\u0026thinsp;0.04. A bias-corrected nonparametric percentile Bootstrap method with 2000 resamples was used to test the mediating effects and estimate the confidence intervals. The results indicated that both work-family conflict and occupational delay of gratification had significant mediating effects on presenteeism, with 95% confidence intervals of [0.431, 0.640] and [-0.287, -0.004], respectively (neither interval included 0), supporting H3 and H6.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eMulti-Group Comparison of the Mediating Model by Occupation Category (doctors or non-doctors)\u003c/h2\u003e\u003cp\u003eThis study conducted a multigroup path analysis of the model based on occupational category among primary health care workers (doctors or non-doctors). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the comparison of path coefficient differences indicates that the Critical Ratios for Differences between Parameters exceeds 1.96 [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], confirming that the occupation category of primary health care workers (doctors or non-doctors) had a significant moderating effect on the path \"role overload \u0026rarr; occupational delay of gratification\" and \"occupational delay of gratification \u0026rarr; presenteeism\". Specifically, the inhibitory effect of occupational delay of gratification on presenteeism was more prominent in the doctors, while the promoting effect of role overload on occupational delay of gratification was more significant in the non-doctors, supporting H7a and H7b.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Path Coefficient Differences of the Mediating Model Between Groups by Occupation (doctors or non-doctors)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eDoctors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eNon-Doctors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eComparison Result\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRO\u0026rarr;ODG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.033\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-2.621\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eODG\u0026rarr;Prent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-1.563\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.532\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e6.374\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRO\u0026rarr;WFC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.588\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.611\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.539\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWFC\u0026rarr;Prent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.367\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003eTheoretical implications\u003c/h2\u003e\u003cp\u003eAddressing the human resource crisis in primary health care institutions and comprehensively improving the quality of talent development for primary health care workers in China has become an urgent task. Therefore, this study aimed to explore the impact mechanism of role overload on presenteeism among primary health care workers, examine the mediating roles of occupational delay of gratification and work-family conflict in this relationship, and investigate the moderating role of the occupation category of primary health care workers (doctors or non-doctors). The theoretical contributions are as follows.\u003c/p\u003e\u003cp\u003eFirst of all, existing research on role overload has largely confined its understanding to \u0026ldquo;hindrance stressors\u0026rdquo;. This study empirically demonstrates that role overload can enhance occupational delayed gratification levels, introducing a novel perspective that it may function as a \u0026ldquo;challenge stressor\u0026rdquo;. This provides a new theoretical framework for examining the relationship between role overload and presenteeism. This aligned with research by Rosen et al. [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] and Kern et al. [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] on \u0026ldquo;challenging stressors,\u0026rdquo; enriching the Challenge-Hindrance Stressor Framework for role overload. Based on this, the study constructs a dual mediation mechanism, explicitly confirming the mediating roles of occupational delayed gratification and work-family conflict in the influence of role overload on presenteeism. It establishes dual mediation models: \u0026ldquo;role overload \u0026rarr; occupational delayed gratification \u0026rarr; presenteeism\u0026rdquo; and \u0026ldquo;role overload \u0026rarr; work-family conflict \u0026rarr; presenteeism\u0026rdquo;. This approach transcends the traditional binary perspective that views its effects as entirely beneficial or detrimental.\u003c/p\u003e\u003cp\u003eSecondly, building upon Yu et al.'s [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] research on delayed gratification and Liu Xiaoyan et al.'s [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] studies on occupational delayed gratification, this research links occupational delayed gratification to reduced productivity loss. Individuals are willing to endure immediate hardships and sacrifice personal freedom to pursue long-term goals and gain others' respect and recognition. At the same time, we found that work-family conflict plays a mediating role in the relationship between role overload and presenteeism. Although there are few studies directly exploring the role of work-family conflict in the specific relationship between role overload and presenteeism, research on the relationship between work-family conflict and role overload is relatively mature. The burden of work demands will inevitably affect the role conflict between work and family experienced by individuals [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Work-family conflict has been confirmed to be associated with a variety of negative work outcomes, such as job burnout, reduced job satisfaction, and decreased work performance [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Balancing work-family conflict and reducing role overload can alleviate turnover intentions [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. This also echoes the work-family interface theory [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. The above two parts enrich the theoretical framework examining the relationship between role overload and presenteeism.\u003c/p\u003e\u003cp\u003eLast but not least, this study broadens the research perspective on moderating factors. Unlike previous studies, we consider the occupation categories of primary health care workers (doctors or non-doctors) as a moderating variable. This makes the theoretical model more aligned with the occupational characteristics in China's primary health sector, expanding the depth of related theories' application among specific occupational groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003ePractical implications\u003c/h2\u003e\u003cp\u003eThis study provides insights for reducing the phenomenon of presenteeism among primary health care workers.\u003c/p\u003e\u003cp\u003eFrom a management perspective, managers can improve primary health care workers' ability for occupational delay of gratification through enhancing training quality and capacity building, and establishing performance accountability systems, which can help them better cope with role overload and reduce presenteeism. Additionally, it is essential to strengthen humanistic care, value the balance between work and family for primary health care workers, and implement measures such as flexible work systems and providing family support services. Lastly, managers should develop different management strategies based on employee characteristics: reinforcing 'long-term goal orientation' among doctors and reasonably activating 'moderate overload incentives' among non-doctors. Ultimately, this will effectively curb presenteeism and improve the service quality and operational efficiency of primary medical institutions.\u003c/p\u003e\u003cp\u003eFrom the perspective of primary health care workers, they should proactively enhance their self-management skills, scientifically prioritize work tasks, utilize time management tools and techniques, and allocate time and energy wisely to improve work efficiency. Secondly, attention should also be paid to mental health by developing healthy interests such as exercise and reading, actively participating in team-building activities, enhancing social interactions, and building psychological resilience. Furthermore, primary health care workers need to develop strong career planning skills, clarify their career development goals, actively engage in continuing education and skills training, and earn relevant professional certifications to improve personal professional competitiveness and face work challenges with greater ease, thereby achieving a positive cycle of personal value and career development.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eLimitations and future directions\u003c/h2\u003e\u003cp\u003eThis study has several limitations that can be addressed in future research. Firstly, the valid samples were collected from primary health care workers through the Credamo data collection platform, and the stratified characteristics of different regions were not clearly covered. Thus, the samples may not fully represent the overall situation of primary health care professionals nationwide. Secondly, the questionnaire data relied on self-reports from participants, which may be subject to social desirability bias. For example, when evaluating presenteeism, participants may conceal their actual situation due to fear of negative evaluations, affecting the accuracy of the data. Finally, according to Self-Determination Theory, sustained high workload may lead to the impairment of individuals\u0026rsquo; sense of autonomy and competence, thereby weakening their self-regulation ability [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. How to ensure data accuracy and whether there will be a critical value for the positive correlation between role overload and occupational delay of gratification is a direction for future research.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study investigated the relationships between presenteeism and role overload, occupational delay of gratification, and work-family conflict among health care professionals in primary health care institutions. The findings showed that role overload was positively correlated with occupational delay of gratification and work-family conflict; work-family conflict was positively correlated with presenteeism, while occupational delay of gratification was negatively correlated with presenteeism. In addition, this study confirmed the mediating roles of occupational delay of gratification and work-family conflict in the relationship between role overload and presenteeism, as well as the moderating role of primary health care workers\u0026rsquo; occupation (doctors or non-doctors). These findings provide multi-dimensional insights for the management practice and policy formulation of primary health care workers, and emphasize that primary health care institutions should pay attention to the differential effects when implementing intervention measures for different types of primary health care workers, thereby providing a basis for formulating more targeted strategies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSEM: Structural Equation Modeling\u003c/p\u003e\n\u003cp\u003ePHC: Primary Health Care\u003c/p\u003e\n\u003cp\u003eRO: Role Overload\u003c/p\u003e\n\u003cp\u003eWFC: Work-Family Conflict\u003c/p\u003e\n\u003cp\u003eODG: Occupational Delay of Gratification\u003c/p\u003e\n\u003cp\u003ePAWS: Perceived Ability to Work Scale\u003c/p\u003e\n\u003cp\u003eCOR: Conservation of Resources\u003c/p\u003e\n\u003cp\u003ePrent: Presenteeism\u003c/p\u003e\n\u003cp\u003eSDT: Self-Determination Theory\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConflict of Interest Statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the significant contributions of Professor Ran Liu, Dr. Yang, and Dr. Deng to this research. We also extend our gratitude to the Credamo data collection platform that assisted with recruitment, as well as to all participants who completed the questionnaires from which this study\u0026apos;s data were derived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKW, GL and RL conceived the study, designed the methodology, collected and analyzed the data, interpreted the findings, and drafted the manuscript. RL also played a key role in revising the manuscript to enhance its academic content and in approving the final submission. KW ang HZ contributed to the study by assisting with data collection, analysis, and interpretation. TY, JD and RL provided valuable insights during manuscript preparation and revision. All five authors reviewed and approved the final version of the manuscript for submission and agree to take responsibility for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the special project of Zhejiang Provincial Philosophy and Social Sciences Planning Project \u0026ldquo;Research and Interpretation of the Spirit of the Third Plenary Session of the 20th CPC Central Committee and the Fifth Plenary Session of the 15th CPC Provincial Committee\u0026rdquo;, the Zhejiang Province Soft Science Research Program (2024C35008), the National Natural Science Foundation of China (72474022, 71974011, 72574023, 72174022), the Higher Education Teaching Reform Project of Wenzhou Medical University (JG2025062), and the \u0026ldquo;BIT think tank\u0026rdquo; Promotion Plan of Science and Technology Innovation Program of Beijing Institute of Technology (2025CX13015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are available from authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethical approval of this study is compliant with the Helsinki Declaration (https://www.wma.net/policies-post/wma-declaration-of-helsinki/) and obtained ethics approval by Ethics Committee of Beijing Institute of Technology (approval number: BIT-EC-H-2024275; date of approval: October 26, 2024). At the same time, the research process strictly adheres to confidentiality and privacy principles, ensuring participants\u0026apos; voluntary involvement and their right to withdraw at any time. Informed consent was obtained from all of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eSchool of Medical Humanities and Management, Wenzhou Medical University, Wenzhou 325035, China. \u003csup\u003e2\u003c/sup\u003eKey Research Center of Philosophy and Social Sciences of Zhejiang Province (Institute of Medical Humanities), Wenzhou Medical University, Wenzhou 325035, China. \u003csup\u003e3\u003c/sup\u003eSchool of Management, Beijing Institute of Technology, Beijing 100081, China. \u003csup\u003e4\u003c/sup\u003eSustainable Development Research Institute for Economy and Society of Beijing, Beijing Institute of Technology, Beijing 100081, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eInternational Conference on Primary Health Care, 1978. 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Motivation and Emotion. 37: 93-105. https://doi.org/10.1007/s11031-012-9290-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Primary health care workers, Presenteeism, Role Overload, Work-family conflict, Occupation delays gratification","lastPublishedDoi":"10.21203/rs.3.rs-7990151/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7990151/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePrimary health care workers serve as a crucial human resource guarantee for the further improvement of the hierarchical medical system and constitute the backbone for forming a rational medical service pattern featuring \"a slight illness be in the community, recovery be back to the community\". This study aims to explore the impact mechanism of role overload on presenteeism in primary health care workers, and examine the mediating roles of occupational delay of gratification and work-family conflict in this relationship. Furthermore, by taking the occupation category of primary health care workers (doctors or non-doctors) as a moderating variable, the researchers constructed a mechanism mode.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eMature scales were adopted. Based on the Credamo data collection platform, 365 valid questionnaires from primary health care workers were collected through a two-wave questionnaire survey. Data analysis was conducted using SPSS 27.0 and Mplus 8.3 software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e(1) Hindering mechanism: Role overload of primary health care workers exerted a significantly positive effect on work-family conflict (β\u0026thinsp;=\u0026thinsp;0.569, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01); work-family conflict significantly increased presenteeism (β\u0026thinsp;=\u0026thinsp;0.195, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and played a mediating role (β\u0026thinsp;=\u0026thinsp;0.111, 95%CI = [0.431, 0.640]). (2) Facilitating mechanism: Role overload of primary health care workers had a significantly positive impact on occupational delay of gratification (β\u0026thinsp;=\u0026thinsp;0.359, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01); occupational delay of gratification significantly reduced presenteeism (β = -0.854, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and played a mediating role (β = -0.307, 95%CI = [-0.287, -0.004]). (3) Boundary effect: Multi-group analysis results showed that the facilitating effect of occupational delay of gratification was more pronounced among non-doctors of primary health care workers (nurses, medical technicians, pharmacists) compared to doctors. Meanwhile, the hindering effect of work-family conflict is more pronounced in the doctors.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWe confirmed the mediating roles of occupational delay of gratification and work-family conflict in the relationship between role overload and presenteeism, and the significant moderating role of the occupation category of primary health care workers (doctors or non-doctors). This study provides scientific evidence to reduce productivity loss among primary health care workers and offers a reference for managers of primary health institutions to formulate relevant intervention measures.\u003c/p\u003e","manuscriptTitle":"Decoding the \"Body Present, productivity Reduced \" Phenomenon among Primary Health Care Workers: A Study on the Impact Mechanism of Role Overload on Presenteeism","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-17 10:30:38","doi":"10.21203/rs.3.rs-7990151/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5d7d23b-efa0-4024-a8fd-2b2a4e3e9252","owner":[],"postedDate":"November 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T14:56:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-17 10:30:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7990151","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7990151","identity":"rs-7990151","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}