How Does Extrinsic Motivation Influence Intrinsic Motivation? A Study on the engagement mechanism of primary healthcare Workers based on the “Crowding-Out” and “Crowding-In” Effects

Abstract This study aims to explore the synergistic influence mechanism of extrinsic motivations and intrinsic motivations on the work engagement of primary healthcare workers (PHWs), with a focus on the mediating roles of relative deprivation and career calling. It further examines the moderating effect of extrinsic motivations on the relationship between intrinsic motivation and work engagement, to reveal whether the two types of motivations function complementarily or competitively under different conditions. A cross-sectional survey was conducted among 962 PHWs from 62 community health service center or township health centers across three cities in Zhejiang Province.

Quantitative analyses revealed that both extrinsic and intrinsic motivations positively predicted work engagement. Among them, career advancement showed a stronger effect than material rewards, and job significance had a greater influence than job autonomy. Relative deprivation plays a fully mediating role in the process in which material rewards and career advancement affect work engagement.

Career calling plays a fully mediating role in the process where job autonomy influences engagement, and a partially mediating role in the process where job significance influences engagement. Furthermore, material rewards negatively moderated the effect of job autonomy on work engagement (a “crowding-out effect”), while career advancement positively moderated the effect of job significance on engagement (a “crowding-in effect”). The work engagement of primary healthcare workers is influenced by the complex interaction of extrinsic motivations and intrinsic motivations, among which the fairness perception and value recognition are the key psychological mechanisms.

Extrinsic motivations can either “crowd out” or “crowd in” extrinsic motivations, depending on the type of incentives and the working context. In practice, management should adopt an integrated incentive system that emphasizes developmental recognition, provides foundational material support, and integrates attention to fairness perception and value guidance, so as to effectively enhance engagement across the grassroots health workforce.