Assessment of job satisfaction and contributing factors among community health officers in Chhattisgarh, India

INTRODUCTION

Globally, there is a growing shift toward delivering effective primary healthcare (PHC) by utilizing mid-level health providers (MLHPs) to support or independently provide services, especially in resource-limited settings. This approach addresses the shortage of healthcare professionals in both high-and low-income countries.¹ The world health organization (WHO) believes that primary health care (PHC) is the best strategy for ensuring equitable and effective access to healthcare.² In fact, countries that have integrated MLHPs into their health systems have shown improved service coverage, better health outcomes, and increased efficiency in service delivery.³

Primary healthcare is a cornerstone of India’s healthcare system, with CHOs playing a pivotal role in HWCs. Introduced under the Ayushman Bharat initiative, CHOs bridge the gap between the formal healthcare system and underserved communities by providing clinical and preventive care.⁴ The Ayushman Bharat program's HWCs strategy prioritizes comprehensive PHC (CPHC), with mid-level providers central to delivering screenings, diagnostics, and treatments while strengthening frontline health systems.³ CHOs are typically trained in public health and community medicine and are positioned to manage common illnesses, promote health awareness, and facilitate timely referrals. Their role is especially critical in rural and tribal areas where doctor shortages are most acute. Evidence suggests that well-trained and supported MLHPs can deliver care that is comparable in quality to that provided by physicians, and help achieve more equitable access to health services.⁵

In the absence of CHOs, rural medical assistants, crucial to Chhattisgarh's initial HWCs rollout, now serve dual roles as clinical providers at primary health centers and part-time mid-level providers, managing biweekly clinics at sub-health center-based wellness centers.⁶

Job satisfaction is defined as the degree to which an individual feels positive or negative about their job.⁷ It is a subjective evaluation of one’s contentment towards their job, not only emotionally but also physically and mentally. Which may vary from person to person working in the same organization.

The ERG theory of motivation (Alderfer, 1972) categorizes human needs into existence, relatedness, and growth.⁸ Basic needs like salary, fringe benefits, and physical working conditions come under existence, while social needs like relationships with coworkers and communication come under Relatedness and personal growth and development needs like learning, advancement, and achievement under growth. If the lower-level need is not met, it becomes the primary focus but once an individual is satisfied with the lower-level need, the higher level becomes the focus. Whereas if higher-level need is not met, an individual may relapse to lower-level needs. This theory is an alternative to Maslow’s hierarchy of needs offering a more dynamic understanding of human motivation at the workplace.

For CHOs, inadequate rewards and poor working conditions can hinder job satisfaction, shifting focus back to basic needs such as monetary compensation. This study explores the challenges and satisfaction levels of CHOs in both tribal and non-tribal settings in Chhattisgarh.

METHODS

Type of study

This research adopts a mixed-methods approach that combines both quantitative and qualitative methodologies to comprehensively assess job satisfaction of CHOs in Chhattisgarh.

Quantitative component

A descriptive cross-sectional study was conducted to assess the levels of job satisfaction (in percentage terms) among CHOs across the selected districts. The quantitative phase aimed to measure the degree of satisfaction through structured data collection and numerical analysis, providing a broad overview of satisfaction levels.

Qualitative component

A qualitative explanatory design was employed to explore the underlying factors influencing job satisfaction among CHOs. This phase facilitated an in-depth understanding of the determinants and contextual influences that shape satisfaction levels. A comparative analysis was carried out between Bijapur-a tribal, conflict-affected district with challenging terrain-and Raipur, the state’s capital and a non-tribal urban district, to highlight the contrasts and similarities in professional experiences.

Study setting and participants

The study was conducted between August and November 2023 in two districts of Chhattisgarh.

Raipur: Represented a non-tribal, urban context with better infrastructure and accessibility.

Bijapur: Represented a tribal, conflict-affected district characterized by difficult terrain and limited resources.

A total of 100 CHOs participated in the quantitative component, while 16 in-depth interviews were conducted for the qualitative phase to capture detailed narratives and perspectives.

Inclusion criteria

Quantitative component

All CHOs currently posted in the selected districts at the time of the study were included. This ensured that the data represented the existing workforce actively engaged in service delivery.

Qualitative component

CHOs with more than one year of service were included under the assumption that their extended tenure provided them with a deeper understanding of the roles, responsibilities, and contextual challenges associated with their position compared to newly appointed officers.

Exclusion criteria

Quantitative component

CHOs who had resigned or were not actively employed at the time of data collection were excluded from the study to maintain data relevance and validity.

Qualitative component

CHOs with less than one year of experience were excluded, as it was assumed that they might not yet have sufficient exposure or insight to provide comprehensive reflections on the job satisfaction and the influencing factors.

Sampling and data collection

Quantitative component

A pre-tested Likert scale was utilized to measure job satisfaction across seven key domains: working conditions, supervisor relationships, coworker support, monetary and non-monetary benefits, available resources, and self-appraisal. The use of a standardized tool ensured consistency and comparability of results.

Qualitative component

Semi-structured interviews were conducted in Hindi, the local language of communication, to ensure comfort and clarity among participants. All responses were recorded, transcribed, and thematically analyzed to identify patterns, themes, and subthemes that explained the underlying factors affecting job satisfaction.

Data collection tools

Quantitative tool

A 5-point Likert scale was developed to assess job satisfaction, drawing on relevant literature and adapted to the local context and population. The development of the tool was guided by expert input, and the scale was pre-tested prior to its final implementation. The final instrument consisted of 21 items, grouped into seven subscales, with three questions per subscale. These subscales were designed to capture the multifaceted dimensions of job satisfaction among CHOs. The seven subscales included working conditions and workplace safety, supervisor relationship, co-worker interactions, non-monetary benefits, resources and other organizational factors, monetary benefits, and self-appraisal.

Qualitative tool

An interview guide was developed in collaboration with program implementers from the AB-HWC program to gather comprehensive insights from the participants. The guide included questions capturing key socio-demographic details such as marital status, religion, current address, work location, population served, years of experience as a CHO, and work schedule.

The semi-structured interview explored multiple aspects of the participants’ professional experience, focusing on their work environment, roles and responsibilities (both facility-based and community-based), challenging and rewarding aspects of their job, relationships with coworkers and supervisors, availability of infrastructure, and family and work-life balance.

Ethical considerations

Ethical approval was obtained from the Indian institute of public health-Bhubaneswar. Written consent was taken for qualitative interviews, and verbal consent was recorded for telephonic quantitative interviews.

RESULTS

Data was collected using Microsoft excel and analysis was done using SPSS version 22. The average score of the seven sub-groups was calculated and presented under seven different headings.

Quantitative findings

Out of 100 participants, 61% reported dissatisfaction with their jobs. The highest dissatisfaction (89%) was observed in monetary benefits, while the highest satisfaction (80%) was in self-appraisal.

District comparison

CHOs from Bijapur reported higher job satisfaction (56.5%) than those from Raipur (33.8%).

Qualitative findings

Several themes emerged from the qualitative interviews:

Workload and safety concerns

CHOs reported being overwhelmed with tasks, especially with administrative duties. Many expressed concerns about safety in remote centers. One CHO stated: “I feel more like a data entry operator than a clinician.”

Monetary and non-monetary incentives

Dissatisfaction with salaries was prominent, particularly in Raipur: “My salary is insufficient given my responsibilities, especially compared to other states.”

Support from coworkers and supervisors

Positive relationships with coworkers, especially Mitanins (community health workers), emerged as a source of job satisfaction. However, relationships with auxiliary nurse midwives (ANMs) were mixed, with some CHOs reporting conflicts.

Challenges in infrastructure and resources

Issues like lack of essential drugs and poor internet connectivity were reported. A CHO from Bijapur shared: “It is hard to fulfill teleconsultation targets due to poor network connectivity.”

Impact on personal life

The work environment impacted CHOs' personal lives, especially those working away from home: “It is difficult managing work with a one-year-old child.”

DISCUSSION

Significant levels of employment dissatisfaction among CHOs in Chhattisgarh are highlighted by this mixed-methods study, especially with regard to workload, financial benefits, and workplace safety. These results are in line with both national and international research that has looked at the motivation and working conditions of mid-level healthcare professionals in environments with limited resources.

Monetary dissatisfaction

With 89% of CHOs in this study indicating dissatisfaction with their salary, financial benefits were the main cause of their discontent. This is consistent with earlier studies that highlighted financial incentives as a key factor influencing community health workers' (CHWs') job satisfaction. Insufficient compensation was identified as a demotivating factor in a qualitative study conducted in Delhi, which even caused some CHWs to resign from their positions. ⁹ In a similar way, CHWs in a multi-country study stressed the importance of prompt and adequate remuneration in order to sustain retention and motivation.¹⁰

Infrastructure and resource challenges

The provision of services, particularly teleconsultations, was adversely affected by a shortage of resources, including medications and digital infrastructure. Previous investigations on mid-level provider environments support these logistical concerns.

For instance, a study conducted in Malawi found that low resource availability, restricted control over work, and insufficient staffing all substantially predicted decreased job satisfaction among healthcare professionals.¹¹

Altruism and community motivation

Despite external stressors, many CHOs remained motivated by the perceived value of their contribution to community health. This intrinsic motivation, tied to social recognition and self-worth, has also been noted among CHWs undergoing mental health training in Madhya Pradesh. Pride in work and community respect served as strong anchors for job satisfaction.¹²

Work-life balance and gendered experiences

Qualitative narratives revealed that female CHOs are emotionally burdened by balancing work and family duties like childcare. Similar results were found in a study conducted in Delhi, where female medical officers had more severe work-life imbalances that impacted their general level of satisfaction.¹³

Education, acknowledgment, and professional identity

The yearning for development and official acknowledgment was a less addressed but equally important issue. Although they felt limited in their ability to advance in their careers, CHOs found importance in their responsibilities. Research indicates that position clarity and professional growth pathways enhance retention and satisfaction.

Given the changing significance of CHOs in India's primary healthcare system, more robust frameworks are required to support this new workforce.¹⁴

Synthesis

The findings of this study closely match the information currently available from India and other comparable LMICs. Relationship and altruistic elements reduce fatigue and give meaning, even when financial and infrastructure deficiencies continue to be major sources of discontent.

To encourage long-term involvement among CHOs, policy changes that address internal (recognition, role clarity) and extrinsic (pay, safety, training) motivators will be crucial.

Strengths

Mixed-methods design

By combining quantitative and qualitative methods, a thorough grasp of CHO work satisfaction was made possible, offering not only statistical trends but also contextual information on underlying problems.

District-level comparison

The study was able to capture geographic inequalities by included participants from both a tribal (Bijapur) and a non-tribal (Raipur) district. This allowed for a more thorough examination of contextual difficulties and incentive variables.

Thematic richness

The qualitative interviews revealed subtle elements that are sometimes overlooked in studies that are only survey-based, such as interpersonal dynamics, administrative load, and emotional pressures.

Policy relevance

The study is realistically helpful to policymakers as it directly contributes to current discussions on Ayushman Bharat initiative and deployment of MLHPs (CHOs).

Limitations

Sample size

A bigger sample spanning more districts would enhance statistical power and generalizability, even though the study included 100 CHOs for the quantitative arm.

Cross-sectional nature

Inferences on causality or changes in work satisfaction over time are not possible due to the study's methodology.

Social desirability bias

Out of allegiance to the system or fear of consequences, some CHOs may have underreported workplace conflicts or discontent.

Geographic limitation

Only two districts in Chhattisgarh were used to gather data, which would restrict the findings' generalizability to other areas with distinct sociopolitical dynamics or healthcare systems.

CONCLUSION

This study identifies significant inequalities in CHOs' job satisfaction in Chhattisgarh, particularly with regard to financial compensation, workload, and workplace safety. Strong interpersonal ties and a feeling of purpose in one's work are important for sustaining morale, but they are not enough to counteract systemic issues. The results demand immediate legislative changes with an emphasis on higher wages, more precise job descriptions, infrastructural assistance, and organized professional advancement routes. In India's tribal and non-tribal contexts, addressing these problems is crucial to boosting motivation, lowering attrition, and guaranteeing long-term, high-quality healthcare delivery at the local level.

ACKNOWLEDGEMENTS

Authors would like to thank to Dr. Upasona Ghosh and Mr. Narayan Tripathi for their guidance. I also extend my gratitude to Dr. Pritam Kumar Roy, Aspirational District Consultant, UNICEF Bijapur, the State Health Resource Center, Raipur, and the Indian Institute of Public Health-Bhubaneswar for their support.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee IIPH-Bhubaneswar (IIPHB/IEC/2023/04).

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