Assessment of happiness among ASHAs, the grass root level health workers in post-COVID era in Eastern India: a cross-sectional study

INTRODUCTION

The world health organization (WHO) mentions that the health system framework consists of six building blocks, one of which is the health workforce.¹ The health workforce is at the core of every health system (Anand and Bärnighausen, 2012).² At the grassroot level, in our country, ASHA ,or the accredited social health activists , has been the backbone of our health care delivery services ever since they have been inducted in a bid to build bridge with the marginalised community in 2005.³ The nation has pinned many hopes on the ASHA s, who are 25-45 years old, expected to have studied till tenth grade, selected through a rigorous process, belongs to the community they need to cater to, armed with continued training and a drug kit, aims to be the first port of call, and promote different health care programs and their services.⁴

Amid all the scheduled expectations and responsibilities bestowed upon the ASHAs, COVID-19 pandemic unleashed a never before scenario, that added the role of frontrunners to role. They were entrusted to spread awareness regarding COVID-19 and relevant safety protocols, identify and track the positive cases and promote the vaccination drive often in the absence of any personal safety gear.⁵

The COVID pandemic has gone through various transitions, from lockdown periods, several variants surfacing, massive vaccination drive and now that the world is trying to normalise life, positive psychologists emphasise the understanding of an individual’s happiness and well-being and its influence on their ability to achieve full potential in terms of productivity and optimal functionality.⁶ Happiness is the state of feeling or showing pleasure or contentment.⁷ The United Nations (UN) recognises pursuit of happiness as an essential human goal.⁸ With happiness perceived as an individual as well as a public endeavour, the policy makers are increasingly encouraged to incorporate utilitarianism approach to happiness in process of policy development and implementation aiming to achieve ‘greater happiness for the greater numbers’ within their populations.⁹ Mental health research among healthcare workers reveal increased prevalence of mental distress, depression, burnout, and suicidal ideations compared to other professionals.^10-13 Along with this, it is essential to recognize the optimistic aspects of their mental health. Positive attitudes and experiences act as a protective buffer for healthcare professionals.¹⁴ The happiness of healthcare professionals is said to be positively affecting quality of health care and the services provided by them.¹⁵

In these changing circumstances, happiness that is often put forward as one of the driving forces to peoples’ choices and actions, the present study intends to assess the happiness among the key grassroot level workers, ASHAs in the post-COVID era and the factors affecting their happiness.¹⁶

The objectives being to find the level of happiness among the ASHA in the study area and to ascertain the factors that affect their happiness the most.

METHODS

Study type

Cross-sectional, observational study type was used.

Study setting

Selection of districts was done by purposive sampling technique. The ASHAs working at the village level being the study subjects, the study was carried out among the ASHA working in the Budgebudge I and II block of district 24 parganas south, encompassing Rajibpur, Uttar Raipur, Nischintapur, Buita,Satgachia, Dongaria Raipur, Burul, North Bawali, Naskarpur, and Kashipur Alampur.

Study population and sample size

Multistage sampling design adopted for assessment of ASHA by national health systems resources centre (NHSRC), ministry of health and family welfare, India, would be followed. According to sequential sampling scheme the districts and blocks were chosen for covering study population, comprise of all consenting ASHAs working in below mentioned gram panchayat within the Budgebudge I and II block, of South 24 Parganas district of West Bengal, that has one of the highest literacy rates in state at 80.57 and 79.1%. All 122 ASHAs of selected gram panchayat were selected as the study subjects.

Sequential flow

West Bengal→South 24 Parganas→Budgebudge II, I→Satgachia, North Bawali, Naskarpur, Kashipur alampur, Dongaria Raipur, and Burul; Buita, Nischintapur, Uttarraipur and Rajibpur.

Inclusion criteria

All the ASHAs in the villages, within the above-mentioned gram panchayats consenting to participate in the study after duly explaining the study objective as well as the methodology adopted were included in the current study.

Exclusion criteria

ASHAs who were unwell or unwilling were excluded.

Study period

Study carried out over period of 3 months, July-September 2023.

Study tool

A happiness index comprising of 10 questions framed in vernacular, pre-designed and pre-tested through a pilot study on 15 ASHAs, in Bakrahat village, South 24 Parganas.¹⁷ It is a modified form of short version of the Oxford happiness questionnaire, a widely used instrument to assess happiness that in fact is an improved version of Oxford happiness inventory (OHI), a tool developed in the 80s (Bekhet et al) that was devised using discriminant analysis of the 29 point OHQ scale.¹⁸ Based on a pilot study, ten items were found to be adequate to classify participant scores having an accuracy of 90%, and correlation between results of short scale and modified one was greater than 0.90 and highly significant at p<0.01. Questions 1, 3, 12, 13, 16, 18, 21, 29 from the 29 point OHQ are taken into account in the 8 point short version. In present study to exclude physicality of appearance from happiness, question 13 was omitted and question number 8, 19 and 28 concerning commitment, involvement, control of own life, and their health was taken into consideration. A questionnaire in vernacular to assess factors affecting happiness.

Procedure

The study commenced with permission from administrative authorities, who are reporting authorities of ASHA and due approval was taken from Institutional ethical review committee (Reg No.ECR/1331/ Inst/WB/2019 vide JIMSH-IEC-F/33-2023). Prior to data collection, written informed consent was obtained from the participating ASHAs after detailed explanation of the content and purpose of the study. Anonymity of the study subjects were maintained throughout the study. Before field work was done, a pilot study was conducted among 15 ASHAs of Bakrahat village, South 24 Parganas for testing the feasibility of the questionnaire. Data collection was performed by using a well-structured short version of Oxford Happiness Index Level Questionnaire which is ten item measure of happiness that utilizes a six-point Likert rating scale of agreement ranging from 1 (strongly disagree) to 6 (strongly agree). The subjects were interviewed and responses recorded in google doc form. The response summary was prepared and was followed up with a questionnaire-based interview of these ASHAs to assess factors governing their state of happiness/ psychological wellbeing as reflected through happiness questionnaire.

RESULT

The data collected using the questions in Table 3 were put into a scoring system of 1 to 6 and the scores of each individual responders were added up from all the questions The mean score was found to be 40.4 and a median of 41. Accordingly, the responders with scores higher than 41 (exclusive range) was taken as happy and the rest as unhappy. In this modified scale, highest score possible was 60 and lowest possible was 10. It was found that the range of scores were between 43 and 38, having mean±SD of 40.4±1.65. Based on that 61.6% were happy, while 38.4% were unhappy among ASHAs. The summary response revealed that the variables like having commitment to work, mental alertness and ability to find beauty in many natural things had no disagreement, with agreement varying from slight, moderate to strong, and nearly 80% found life to be rewarding. While not feeling healthy, or whether they find time for everything wanted have large responses under disagree to strongly disagree. Interestingly, almost 87.5% felt they were not especially control of their lives and 41% were not being well satisfied with everything in life. More than half of them (55.3%) were not pleased with the way they were.

Distribution of study population according to age and residence. *All the ASHAs were local residents belonging to rural area. Majority (85.7%) of the ASHAs belonged to the age category 26-34years. More than 2/3^rd of them were educated till class X, and only 4.5% were graduates. Of the ASHAs studied, 78.5% were from Upper-lower socio-economic class, rest belonging to lower-middle class.

1=strongly disagree; 2=moderately disagree; 3=slightly disagree; 4=slightly agree; 5=moderately agree; 6=strongly agree.

Multiple response.

DISCUSSION

On correlating the happiness score with socio-demographic factors (Table 2), no linear correlation was found with age, while positive correlation was noted with socio-economic scale (Pearson r=0.67) and educational level (r=0.71). When the ASHAs were interviewed to find out the facilitators and barriers as perceived by the ASHAs (Table 4), one of the major facilitating factors to happiness was professional pride of being a social role model which 95.5% ASHAs agreed upon.

An altruistic attitude that involves ability to help others, came across as one of the most reported attributes that facilitated happiness with 97.3% of all ASHAs mentioning it.

An Iceland ethnographic study involving paediatricians, nursing personnel and an American one with physiotherapists also noted altruism through professional healthcare, professional pride as positive determinants of happiness.^14,19 Incidentally Altruism came across as an important theme governing happiness among health care workers based on systematic review spanning ten years.²⁰ Quality of life, a cognitive concept, that closely associates with happiness as social construct came across as a strong facilitator.²¹ Almost 97.1% of the “happy” ASHAs and 51.1% of “unhappy” ASHAs identified quality of life, that is ability to spend time with family, having time to socialise, doing recreational activities, self-care, etc as an important facilitating factor to ensure happiness. An American study by Gannotti et al also had similar findings that revealed getting to spend quality time with family and friends and engage in recreational activities are facilitating factors for happiness. Financial satisfaction was a factor favouring happiness with 69.6% of all ASHAs mentioning it, but it was not as universal as professional pride or altruism. A narrative inquiry in Thailand among nurses, identified lack of achievement, inadequate support systems and an imbalanced work life as deterring factors towards happiness, while being a role model, positive time management, having professional pride, being patient, etc were found to be facilitators.²² A very important facilitator that emerged was how one is treated at workplace by senior health care workers with 90% of the ASHAs expressing it. Nearly half (53.5%) of the unhappy ASHAs found inadequate support systems at work place as a barrier to their happiness.^23-25 In resonance with several other studies among healthcare professionals, the present study involving ASHAs recognised inability to maintain work–life balance as a major barrier of happiness. The inability to cope with stressful family issues (79%) was an important barrier to their happiness along with negative work experience (48.8%). Inadequate rest was also an important factor hindering happiness among many of them (74.4%).

Limitations

Lack of prior comparable research studies on the ASHAs was a limiting factor, and the happiness was assessed at a point of time, and have scopes of longitudinal follow up to understand the dynamics of happiness even better.

CONCLUSION

This study revealed that the pivotal work force at the ground level, the ASHAs were in need of positive reinforcement in terms of better workplace environment, time management skill enhancement, to strike a better work-life balance to ensure a happier version of themselves. Though a positive correlation was noted with socio-economic scale, and educational level, and financial satisfaction found to be a facilitating factor towards happiness, professional pride and altruism emerged stronger facilitator highlighting positive attitudes among the ASHAs which is very heartening to note. They are the prime motivators at the community level and their happiness is a very important aspect that needs to be looked into at a wider scale to ensure they keep thriving at health care delivery at the grass root level of our country.

ACKNOWLEDGEMENTS

Author would like to thanks to consenting participants, and the MSWs of the institution for their contribution.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee Reg No.ECR/1331/Inst/WB/2019 vide JIMSH-IEC-F/33-2023.

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