Introduction
Servant leadership, first articulated by Greenleaf (1970), redefines leadership as a service-oriented role that prioritizes the growth, well-being, and autonomy of followers. Unlike traditional hierarchical models, servant leaders emphasize altruistic behaviors such as active listening, empathy, stewardship, and commitment to others’ development (1,2). In public healthcare, where staff face high demands and emotional labor, this leadership approach can be particularly transformative in reducing burnout, enhancing job satisfaction, and fostering a supportive organizational culture (3,4).
In Indonesia, public hospitals operate under significant constraints including high patient-to-staff ratios, limited resources, and complex bureaucratic structures that often emphasize top-down decision-making. These conditions can lead to decreased staff morale, reduced quality of care, and elevated turnover intentions. Furthermore, the collectivist culture endemic to many Indonesian institutions values mutual cooperation and relational harmony, yet these cultural strengths are frequently underleveraged in conventional leadership models (5).
Implementing servant leadership in Indonesian public hospitals offers a pathway to address these challenges by fostering a more inclusive, participatory environment. By prioritizing servant leader behaviors such as supporting frontline staff, facilitating open communication, and modeling ethical stewardship public health administrators can enhance team cohesion, empower personnel to contribute ideas, and align organizational goals with community needs. Early studies in Indonesian healthcare settings indicate that servant leadership correlates with improved patient satisfaction, higher perceived organizational support, and increased resilience among clinical staff (6).
Empirical evidence suggests that servant leadership contributes to higher staff empowerment, increased psychological well-being, and stronger organizational commitment (7). Moreover, by cultivating eudaimonic well-being defined as the experience of meaning and purpose servant leaders can engage employees beyond transactional exchanges, leading to sustained performance and lower turnover intentions (8).
Although servant leadership has been widely studied in organizational and healthcare contexts globally, quantitative evidence from Indonesia’s public health sector remains limited. Most prior research has emphasized conceptual discussions or qualitative insights, leaving a gap in empirical studies that rigorously test servant leadership’s relationship with staff well-being and retention outcomes in this unique cultural and bureaucratic environment. Addressing this gap is particularly important given Indonesia’s ongoing health system challenges including high staff turnover, resource constraints, and the need for resilient frontline services (9,10). This study contributes by providing quantitative evidence on how servant leadership is associated with burnout prevention, empowerment, happiness, eudaimonic well-being, and motivation to retain employment among public health employees in Samarinda, Indonesia.

Materials and Methods
Study design
This study employs a quantitative research approach with a cross-sectional design. The research aims to analyze the impact of several independent variables burnout prevention, empowerment, happiness, eudaimonic well-being, and motivation to retain employment on servant leadership within the public health services. The cross-sectional design allows data collection at a single point in time, providing a snapshot of relationships among variable

Population and sample
The study population includes all employees working in public health services Samarinda Indonesia, encompassing 196 individuals across 15 divisions of the 196 eligible employees invited to participate, 188 completed the survey, yielding a response rate of 95.9%. These include both civil servant and non-civil servant staff. A stratified random sampling technique was adopted to ensure representative coverage of various organizational layers. Using the Slovin formula, the sample size was determined to be 188 respondents, maintaining a 10.42% margin of error.
Employees under manager level and those with at least one year of tenure who were willing to participate were included in the study. Higher officer staff, such as Heads of Division, and employees on leave or unavailable during the study period were excluded.

Study instruments
The study utilized a structured questionnaire comprising 13 items on burnout prevention, 10 items on empowerment, 12 items on happiness, 12 items on motivation to retain employment, and 12 items on eudaimonic well-being. Additionally, servant leadership was assessed through a series of related questions. All items were measured using a Likert scale, with the following scoring criteria: strongly agree=4, agree=3, neutral=2, disagree=1, and strongly disagree=0.
The validity tests revealed strong results, with item scores ranging from 0.467 to 0.881, all surpassing the r-table threshold of 0.36. Reliability analysis using Cronbach’s alpha confirmed high internal consistency across variables. The scores were as follows: Burnout Prevention (0.880), Empowerment (0.780), Happiness (0.924), Motivation to Retain Employment (0.903), Eudaimonic Well-Being (0.878), and Servant Leadership (0.924). These outcomes demonstrate the robustness and reliability of the questionnaire as an effective tool for data collection in this study.

Data collection 
This research was conducted at the Samarinda City Public Health Office Indonesia, from March to June 2024. Primary data were collected through questionnaires distributed to employees at the Public Health Office. The questionnaire focused on variables influencing servant leadership, ensuring alignment with the research objectives. Informed consent was obtained from all participants through the Informed Consent Form (ICF), ensuring their voluntary participation and understanding of the study’s purpose and procedures.

Data analysis
Descriptive statistics, including mean, median, and frequency distribution, were used to analyze the characteristics of the sample and variables. Spearman’s Rank Correlation test was used to evaluate the relationships between independent variables burnout prevention, empowerment, happiness, eudaimonic well-being, and motivation to retain employment and the dependent variable, servant leadership.
Multiple linear regression was conducted to determine the combined and individual impacts of independent variables on servant leadership. The regression model used was formulated as follows: Servant Leadership (SL) was analyzed as a function of Burnout Prevention (BP), Empowerment (EM), Happiness (HP), Eudaimonic Well-Being (EB), and Motivation to Retain Employment (MR). Specifically, the regression equation was:
SL=β+β1 BP+β2 EM+β3 HP+β4 EB+β5 MR+ε.
Here, SL (Servant Leadership) represents the dependent variable; BP (Burnout Prevention), EM (Empowerment), HP (Happiness), EB (Eudaimonic Well-Being), and MR (Motivation to Retain Employment) represent the independent variables. This model allowed for assessing both the collective and individual contributions of these predictors. 
The data was analyzed using the Statistical Package for the Social Sciences (SPSS) version 22.0. Sociodemographic characteristics were analyzed using descriptive statistics, including frequency and percentage for qualitative variables and mean and standard deviation for quantitative variables.
Adjusted R-square and standardized beta coefficients were interpreted to gauge the explanatory power and relative importance of each predictor variable

Results
The characteristics of the respondents in this study are presented based on demographic attributes, including age, gender, work tenure, and employment status. This information provides context for interpreting the subsequent analyses related to servant leadership levels among the respondents (Supplement Tables 1 and 2).

Supplement Table 1.  Distribution of servant leadership levels by variable

Supplement Table 2.  Characteristics of subjects based on servant leadership

Table 1. Distribution of respondents’ average based on age

Table 2. Spearman’s rank correlation coefficient results based on servant leadership

Table 3. Multiple linear regression analysis on servant leadership

Based on table 1, the average age of the 47 respondents is 38 years. The highest respondent age is 57 years, while the lowest respondent age is 26 years.
Figure 1 illustrates the distribution of servant leadership levels across demographic and organizational categories. The results show that servant leadership was more frequently rated as “good” or “very good” among female employees and non-civil servant staff, suggesting that these groups may perceive or embody servant leadership behaviors more strongly. Furthermore, employees with 1–10 years of tenure reported higher levels of servant leadership compared to longer-tenured staff, indicating that servant leadership practices may resonate particularly with newer cohorts in the organization. This pattern highlights potential differences in how leadership is experienced across gender, employment status, and tenure groups.
Figure 2 presents the average distribution of servant leadership scores across the five outcome variables. The results show that servant leadership was most strongly associated with happiness, where 27 respondents reported high levels of servant leadership. Burnout prevention, empowerment, eudaimonic well-being, and motivation to retain employment also showed substantial alignment with servant leadership, with 22–24 respondents rating leadership practices as “good” in these areas. These findings suggest that servant leadership behaviors are consistently reflected across multiple dimensions of employee well-being and motivation, reinforcing the results of the correlation and regression analyses.
Table 2 presents the Spearman’s Rank Correlation Coefficient, indicating that “Burnout Prevention” had a moderate relationship with Servant Leadership (r=0.381). The variable “Empowerment” showed a strong correlation with Servant Leadership (r=0.562), as did “Happiness” (r=0.642). “Eudaimonic Well-Being” exhibited a moderate correlation (r=0.442), and “Motivation to Retain Employment” had a moderate correlation (r=0.296). The implementation of Servant Leadership in public health services was positively associated with burnout prevention, empowerment, happiness, eudaimonic well-being, and motivation to remain in employment.
A positive correlation, as indicated by a positive coefficient value, signifies a direct relationship etween the variables. The implementation of servant leadership in the public healthcare sector is believed to enhance burnout prevention efforts, empower employees, improve happiness, promote eudaimonic well-being, and motivate employees to retain their roles within the organization. The VIF values for all predictors ranged from 1.213 to 1.873, well below the commonly accepted threshold of 5. This indicates that multicollinearity was not a concern in the regression model, and each predictor contributed independently to explaining servant leadership.
Table 3 presents a multiple linear regression model expressed as follows: Servant Leadership= 1.167+ 0.302 (Burnout Prevention) + 0.214 (Empowerment) +0.189 (Happiness)+0.408 (Eudaimonic Well-Being) +0.335 (Motivation to Retain Employment)+ε
The constant value of 1.167 indicates that when all predictors are held at zero, servant leadership has a baseline value of 1.167 units. The regression coefficients show that for each one-unit increase in burnout prevention, empowerment, happiness, eudaimonic well-being, and motivation to retain employment, servant leadership is expected to increase by 0.302, 0.214, 0.189, 0.408, and 0.338 units, respectively.

Discussion 
The findings of this study reveal the influence of burnout prevention, empowerment, happiness, motivation to retain employment, and eudaimonic well-being on servant leadership. Servant leadership has the potential to enhance employee motivation: leaders who provide support and prioritize the development of their employees are more likely to foster increased motivation and job satisfaction, thereby reducing the likelihood of employee turnover. This creates a positive feedback loop where motivated employees are more engaged and productive, further reinforcing the leader’s commitment to servant leadership principles and contributing to a healthier organizational culture (11,12). By prioritizing the well-being of their team members, servant leaders not only elevate individual performance but also cultivate a sense of community and shared purpose within the organization (13). 
The study of servant leadership in public health services highlights its significant influence on organizational and employee outcomes, emphasizing its role in enhancing well-being and culture. By prioritizing the needs of others and promoting ethical behavior, servant leadership mitigates burnout through supportive environments and engagement, fosters empowerment that boosts creativity and resilience, and enhances happiness via improved job satisfaction and mental health (14). Additionally, its supportive nature motivates employees to retain employment by addressing their professional growth and well-being, while promoting eudaimonic well-being through alignment of personal values and organizational goals, fostering purpose and fulfillment (14). However, the broader organizational context, including structure, resources, and external stressors, must be considered for optimizing leadership effectiveness, warranting further research into these dynamics (15).
Eudaimonic well-being emerged as the strongest predictor of servant leadership, which aligns with prior research emphasizing the role of meaningfulness and purpose in sustaining leadership behaviors (16). In collectivist contexts such as Indonesia, employees often evaluate leadership not only in terms of performance but also in how it resonates with shared values and social contribution. Servant leadership may therefore be particularly effective when it supports employees’ pursuit of meaning and alignment with organizational goals, reinforcing its impact on eudaimonic well-being (16).
Motivation to retain employment was also a strong predictor, suggesting that servant leadership is closely tied to retention dynamics in public health systems characterized by high turnover risk. This finding is consistent with studies showing that leaders who prioritize employee development and well-being foster loyalty and commitment. In Indonesia’s resource-constrained health sector, where stability of the workforce is critical, this association underscores the practical relevance of servant leadership (17,18).
By contrast, empowerment and happiness, while positively correlated, had relatively smaller contributions in the regression model. One possible explanation is that empowerment may be moderated by hierarchical organizational cultures, where decision-making authority remains limited regardless of leadership style. Similarly, happiness may fluctuate with short-term workplace conditions, making it a less stable predictor compared to the enduring sense of purpose captured in eudaimonic well-being. These differences suggest that servant leadership is most influential when it fosters deeper, value-driven forms of engagement rather than relying solely on surface-level satisfaction or autonomy.
Empowered employees are more likely to exhibit creativity and take initiative, aligning with the principles of servant leadership. However, the relatively lower contribution in the regression model suggests that empowerment must be carefully balanced with guidance to avoid potential ambiguities in leadership roles. Happiness was strongly correlated with servant leadership, contributing 0.189 units in the regression model. This underscores the importance of cultivating a positive work environment. Leaders who foster happiness among employees promote job satisfaction and emotional engagement, enhancing overall productivity and morale (19). While empowerment is crucial for fostering creativity and initiative, it is essential to balance it with adequate guidance to avoid role ambiguities (20). Additionally, the perception of empowerment can vary significantly across different organizational levels and sectors, which can impact its effectiveness (21). Understanding these dynamics is vital for effectively implementing empowerment strategies within the framework of servant leadership (21).
Servant leadership, first introduced by Greenleaf, emphasizes humility, stewardship, empathy, and the development of others, positioning leadership as service rather than authority (10). This model aligns well with collectivist values such as gotong royong (mutual cooperation) and relational harmony in Indonesia, but it also challenges entrenched bureaucratic and hierarchical traditions that dominate the public health system. While global evidence links servant leadership with empowerment, psychological well-being, and organizational commitment (5), its cultural fit and practical application within Indonesia’s healthcare context remain underexplored.
In public health services, where staff face high patient loads, limited resources, and emotionally demanding environments, servant leadership may be particularly relevant to addressing burnout, improving job satisfaction, and strengthening workforce retention. By fostering supportive and participatory environments, servant leaders can create resilience and shared purpose, potentially enhancing service delivery and equity (5,15). However, few empirical studies have examined how servant leadership operates within Indonesia’s healthcare system. 
The study’s implications are substantial for the public healthcare sector. Implementing servant leadership principles can lead to a holistic improvement in employee well-being and organizational culture (15,22). Leaders should integrate strategies that simultaneously address burnout prevention, empowerment, happiness, eudaimonic well-being, and motivation to retain employment. This integrated approach will ensure the sustainability and effectiveness of leadership practices (23,24).
This study has several limitations. First, the cross-sectional design restricts the ability to draw causal inferences; the findings indicate associations rather than directional effects. Second, the reliance on self-reported questionnaires may have introduced social desirability bias, as respondents could have overstated positive leadership behaviors or workplace well-being to align with perceived organizational expectations. Third, cultural factors may have influenced responses on the Likert scale, particularly within the Indonesian context where collectivist norms and deference to authority can shape how participants evaluate leadership. Such tendencies may inflate agreement levels and reduce variability in responses. Fourth, the study was conducted within a single municipal public health office, which may limit the generalizability of findings to other regions or healthcare settings with different organizational cultures or resource constraints. Finally, unmeasured confounding variables such as individual personality traits, external stressors, or organizational changes may also have affected the observed associations.
In conclusion, this study reaffirms servant leadership as a transformative approach that addresses critical challenges in public healthcare. By prioritizing employee well-being, fostering empowerment, and promoting meaningful engagement, leaders can enhance organizational outcomes while cultivating a culture of trust and shared purpose. These findings offer actionable recommendations for public health administrators seeking to implement effective leadership practices. 

Conclusion
This study highlights the transformative potential of servant leadership in Indonesia’s public health services. Beyond demonstrating associations with well-being and retention, the findings offer actionable guidance for practice. Public health administrators should consider embedding servant leadership principles into leadership training curricula, supervisory evaluations, and team management practices. Encouraging supervisors to model empathy, support staff autonomy, and align organizational goals with community values may help reduce burnout, strengthen motivation, and build a more resilient workforce. At the policy level, integrating servant leadership into organizational development frameworks and performance indicators could enhance service quality and employee retention in resource-constrained health systems. Future longitudinal and intervention-based studies are needed to establish causal relationships and guide large-scale implementation.

Ethics approval and consent to participate
Participant confidentiality and data privacy were strictly maintained throughout the study. All questionnaires were completed anonymously, and no identifying information was collected. This research received ethical approval from the Mutiara Mahakam School of Health, Indonesia. It was deemed ethically acceptable and complies with the seven standards established by WHO in 2011. The approval was granted under the reference number No. 843/KEPK-STIKES-MM/X/2024

Funding
This research received no external funding.

Acknowledgement 
The author expresses sincere gratitude to Universitas Muhammadiyah Kalimantan Timur and the Samarinda Public Health Office for their invaluable support in facilitating this research. The resources, collaboration, and academic environment provided by the university and the cooperation extended by the Samarinda Public Health Office were instrumental in the successful completion of this study. The research was ethically approved by the Ethics Committee of the Mutiara Mahakam School of Health, Indonesia (Approval No. 843/KEPK-STIKES-MM/X/2024). 

Conflict of Interest
All authors declare that they have no conflicts of interest.