Abstract: Background　Under the contracted family doctor service model，doctors at township health centers and village clinics undertake different tasks facing different working environments，and they may have different levels of work stress from various sources. There is currently a lack of comparative research on the work stress of doctors at township health centers and village clinics. Objective　To understand the work stress of 182 doctors at township health centers and 176 doctors at village clinics under the contracted family doctor service model，and to analyze the differences of work stress between them，in order to improve the comprehensive understanding of the work stress among rural grassroots doctors. Methods　In July 2019，using a sampling method combining typical sampling，stratified sampling，and convenience sampling，doctors at township health centers and village clinics who participated in the contracted family doctor service from 18 townships in three counties（districts） of Jiangsu Province were selected for the questionnaire survey. The questionnaire included the basic information（practice area，job category，gender，age，education level，marital status，job title and working years） and the Challenge- and Hindrance-related Self-reported Stress Scale（C-HSS）. Data were analyzed using descriptive analysis，chi square test，rank sum test，and Ordinal regression analysis. Results　There were significant differences in gender，age，education level，job title and number of working years between doctors at township health centers and doctors at village clinics（P<0.05）. There was significant difference in challenge-related stress between doctors at township health centers〔3.83（0.71） points〕 and doctors at village clinics〔4.33（0.83） points〕（P<0.05），while there was no significant difference in the hindrance-related stress〔both were 2.80（1.00） points〕（P>0.05）. However，the differences between doctors at township health centers and doctors at village clinics in the term of "I cannot determine what my job responsibilities are" and "I need to go through a tedious process to complete the job" of hindrance-related stress were statistically significant（P<0.05）. After controlling for possible confounding factors such as practice area，gender，age，education level，marital status，job title and number of working years，the job category was the influencing factor of challenge-related stress and hindrance-related stress for grassroots doctors（P<0.05）. The challenging pressure and obstructive pressure of doctors in township clinics were 40%〔OR（95%CI）=0.60（0.47, 0.76）〕 and 27%
〔OR（95%CI）=0.73（0.58, 0.94）〕 respectively，lower than those in village clinics. Conclusion　Both doctors at township health centers and at village clinics are under great challenge-related stress，while the latter bear more. Therefore，it is necessary to pay attention to doctors' stress and reduce negative impact of challenge-related stress. Compared with doctors at township health centers，village clinic doctors bear more hindrance-related stress in their job responsibilities and working procedures，which shows that more training and education need to be strengthened.

Key words: Contracted family doctor services, Work pressure, Township health center, Village clinic

摘要： 背景　家庭医生签约服务模式下乡镇卫生院医生和村卫生室医生承担着不同的工作任务，面临着不同的工作环境，可能具有不同程度、不同来源的工作压力。现有研究缺乏对乡镇卫生院医生和村卫生室医生工作压力的比较。目的　了解家庭医生签约服务模式下镇村两级医生工作压力，分析乡镇卫生院医生和村卫生室医生工作压力的差异，提高对农村医生工作压力的全面认识。方法　于2019年7月采用典型抽样、分层抽样和方便抽样相结合的抽样方法，选取江苏省3个县（区）18个乡镇参与家庭医生签约服务的乡镇卫生院医生182例和村卫生室医生176例进行问卷调查，内容包括基本情况（所在地区、岗位类别、性别、年龄、文化程度、婚姻状况、职称及工作年限等）和挑战性-阻碍性压力量表（C-HSS）。采用描述性分析、χ2检验、秩和检验和广义线性回归对数据进行分析。结果　乡镇卫生院医生和村卫生室医生在性别、年龄、文化程度、职称、工作年限等方面的比较，差异有统计学意义（P<0.05）。乡镇卫生院医生和村卫生室医生在挑战性压力中位得分分别为3.83（0.71）分和4.33（0.83）分，二者比较差异有统计学意义（P<0.05）；阻碍性压力中位得分分别为2.8（1.00）分和2.8（1.00）分，二者比较差异无统计学意义（P>0.05），但在阻碍性压力的“我无法确定自身工作岗位职责是什么”“为完成工作我需要经历繁琐的流程”2个条目上的比较，差异有统计学意义（P<0.05）。在控制了地区、性别、年龄、文化程度、婚姻状况、职称、工作年限等可能混杂因素后，职业类别是基层医生挑战性压力、阻碍性压力的影响因素（P<0.05）。乡镇卫生院医生的挑战性压力、阻碍性压力分别比村卫生室医生低40%〔OR（95%CI）=0.60（0.47，0.76）〕和27%〔OR（95%CI）=0.73（0.58，0.94）〕。结论　镇村两级医生挑战性压力均比较大，村卫生室医生承担更大挑战性压力，需关注并减少其消极影响；村卫生室医生比乡镇卫生院医生在岗位职责和工作流程上承担更大的阻碍性压力，需加强培训教育。

关键词: 家庭医生签约服务, 工作压力, 乡镇卫生院, 村卫生室