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Research Article
Revised

A cross-sectional study on the pursuit of happiness among healthcare workers in the context of health systems strengthening: The case of Meru County, Kenya.

[version 2; peer review: 1 approved, 1 approved with reservations]
PUBLISHED 24 May 2021
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Abstract

Background: Happiness is one of the ultimate goals of every human being. Happiness is a significant factor of health system efficiency. Healthcare workers are at the core of every health system. However, up-to-date literature on happiness among healthcare workers is limited. The purpose of this study is to investigate the factors influencing the self-assessed happiness among healthcare workers in public and mission hospitals in Meru County, Kenya. 
Methods: Using a cross-sectional design, a total of 553 healthcare workers in 24 hospitals completed the Orientations to Happiness questionnaire between June and July 2020.  
Results: Healthcare workers’ overall happiness was significantly different between hospitals of public and mission ownership (p<0.05). The orientations to happiness mean scores of both pursuits of pleasure and meaning were significantly different between public and mission hospitals  (p<0.05). However, there were no statistically significant differences in the pursuit of engagement among the healthcare workers between public and mission hospitals (p<0.05).  In both public and mission hospitals, income and the type of toiletry facility were significant factors of overall happiness (p<0.05 or p<0.1). In mission hospitals, eight more variables were statistically significant factors of overall happiness namely type of employment, occurrence of water unavailability, safe drinking water, acceptable main source of water, type of toiletry facility, hospital disposal of garbage, availability of water for hand washing, and overall safety of the hospital working environment (p<0.05 or p<0.1). In public hospitals, additional statistically significant factors of overall happiness were qualification level, and a functional workplace safety and health committee (p<0.05 or p<0.1). 
Conclusion: Demographic, work-related, and physical work environment factors significantly contribute to healthcare workers overall happiness in both mission and public hospitals. The findings present possible areas of focus for policy and practical implications related to healthcare workers’ happiness aimed at health workforce and health systems strengthening in Kenya.

Keywords

Happiness, healthcare workers, human resources for health, physical work environment, health systems, Kenya

Revised Amendments from Version 1

In the new version, revisions in various sections have been made following the reviewers recommendations. Thus, the order of intext citations and references changed throughout the document.
Abstract: Following additional analysis, similar and different statistically significant factors were included according to hospital ownership. The conclusion was also slightly modified to in corporate the updated results of the study.
Introduction: For clarity, accuracy, and improvement of the flow, rearrangement of the content has been done and current literature, included. Following a question posed by the reviewer, objectives 3 and 4 were merged to form a single objective due to similarity.
Methods: As suggested by the reviewers, the following information is included in this new version: a brief description of the Meru County health system, clarification of the role of the COVID-19 pandemic in the study and globally, a descriptive summary of the variables assessed, and statistical information regarding the Welch’s T-test, and double-log regression.
Results: Following the reviewers recommendations, t-test results were included, clarification of the response rate was done, reduction of the descriptive results of demographic factors was done because they are presented in the methods section and regression results tables. Following sub-group regression analysis as suggested, Tables 6 and 7 present the results of mission and public hospitals separately because a statistically significant difference was found between hospital ownership and happiness. As recommended, the double-log regression results are included and show a significant relationship between income and happiness in both public and mission hospitals.
Discussion: After the additional results, information and references to relevant studies are included. Where appropriate as recommended, references to tables are presented in this version. Regarding the problem of the last sentence referring to the next paragraph, changes have been made to solve this problem.
Conclusion: Following the new results, updates were also made accordingly.

See the authors' detailed response to the review by Ian Couper
See the authors' detailed response to the review by Zhuo Chen and Wei Jiang

Introduction

Research on the growing epidemic of mental health-related issues among healthcare workers, such as anxiety, burnout, depression, and substance abuse, confirm the challenges they are experiencing15. In comparison, there is a dearth of research on healthcare workers’ positive mental health aspects such as happiness, especially in low- and middle-income countries1,2. According to the United Nations General Assembly consisting of 193 heads of state, happiness is a prime goal of each individual6. In this study, happiness is defined as, the collective experience of pleasure, positive emotions, engagement, and a sense of meaning in life7,8. Experiencing happiness most of the time does not mean eliminating the negative affect from all aspects of life, because both are important depending on the situation9. Happiness has been reported as a significant factor of health systems efficiency, which implies the importance of having enabling health systems that promotes the happiness of healthcare workers and to improve health service delivery and health systems performance10.

According to the World Health Organization (WHO) healthcare workers are the core of any health system11. Researchers often interchangeably use the terms healthcare professionals and healthcare workers; in this study we primarily refer to the latter. Healthcare workers are defined as individuals who have under gone clinical training to practice ethical and evidence-based medicine, in order to provide quality health services12. Healthcare workers’ happiness is often a neglected component in medical school curricula and in-service training, for example physicians are trained to always be stoic while providing healthcare services13. However, healthcare workers are human beings, and mental balance is essential for them to avoid mental illness, while enabling them to operate optimally at work and in their personal lives. To effectively develop and implement happiness policies and programs among healthcare workers, empirical research is necessary to capture empirical realities14.

The theoretical framework applied in this study is the authentic happiness theory. The authentic happiness theory by Seligman15 explains the pursuit of happiness in three orientations, namely, the pursuit of pleasure, pursuit of engagement, and pursuit of meaning8. The pursuit of pleasure is a basic level of happiness, characterized by an emotional expression such as smiling or laughter and short term activities that maximize pleasure and minimize pain15. The pursuit of engagement is the experience of flow16. Flow occurs when an individual utilizes all their cognitive and emotional resources, strengths, and skills when engaging in a task16,17. Csikszentmihalyi explains that, although joy is not experienced instantly while being engulfed in the activity, it is the aftermath of the flow experience that is energizing and elicits happiness8.

The third orientation to happiness is the pursuit of meaning, which, according to the authentic happiness theory, is the ultimate level of happiness15. Seligman believes when an individual serves something that is larger than themselves that is a positive institution, such as family, community, religion, organizations, among others, an individual stands to achieve a sense of meaning15. Peterson and colleagues8 stated the higher scores on all three orientations to happiness equate to a full life. A full life is experienced by pursuing all three orientations associated with a life driven by intrinsic goals and high self-control18. A low score on all three orientations equates to an empty life8. The sole pursuit of pleasure, also known as hedonism, is associated with an empty life and low self-control18.

The World Happiness Report (WHR) is published annually on International Happiness Day every 20th March since the year 201219. In the WHR, the state of happiness is reviewed globally20. Using the science of happiness, various factors affecting happiness of the general population are reported, to inform government policy20. Some of the identified factors of happiness in the general population include age, gender, income, work, governance, education, mental and physical health, values, and family experience21. In 2020, a systematic review reported both individual and organizational factors are significant for healthcare professionals’ happiness14. The factors identified were age, gender, positive attitude, altruism, a sense of meaning, mental and physical health, time management, work-life balance, and quality of life14. Both having a job and being happy at work are important, as people with jobs spend most of their lives at work22.

In the 2020 WHR, the environment quality significantly impacted individuals’ happiness23. Thus, this study aimed to assess the relationship between the physical work environment in the hospital and healthcare workers’ happiness. Previous studies assessing healthcare workers’ happiness reported that small sample sizes as a major limitation2426. Researchers have recommended more studies need to be done among larger and more heterogeneous samples exploring multidimensional aspects of happiness among healthcare workers in multiple health system contexts14. Hence, the present study was conducted on a relatively large sample, across different cadres of healthcare workers in Kenya, which is a lower-middle-income country in Sub-Saharan Africa27. According to World Health Assembly (WHA) resolution WHA69.19 titled “The Global strategy for human resources for health: workforce 2030”, urges the member states to actively address the health workforce needs through an intersectoral approach28. Since health systems are comprised of both the public and private health sectors29, this empirical study was conducted in both public and private not-for-profit (e.g., mission or faith-based) hospitals.

The objective of this study was to investigate the factors influencing the self-assessed happiness among healthcare workers in public and mission hospitals in Meru County, Kenya. To the best of our knowledge this is the first quantitative study investigating happiness among healthcare workers in public and mission hospitals in Kenya. This study will contribute to bridging knowledge gaps related to the role of healthcare workers’ happiness in the Kenyan health system. Empirical evidence is paramount in informing happiness policies related to the quantity and quality aspects of employment22. By investigating the role of demographic, work-related, and physical work environment factors on happiness, this study will also contribute to evidence-based happiness strategies and policies geared towards health workforce strengthening. For example, Blanchflower and Oswald reported that the higher the income the higher the levels of happiness among a random sample of American and European adults30. Frey and Stutzer stated that in addition to measuring the relationship between income and happiness, it is equally important for happiness research to capture empirical realities by assessing additional aspects, which should no longer be disregarded31. Hence, in this study, in addition to income, other factors were assessed and, their association with healthcare workers' overall happiness in public and mission hospitals in Kenya. The present study focuses on the following aims:

  • 1. To find the relative importance and strength of agreement of the orientations to happiness among healthcare workers.

  • 2. To assess the significant difference between healthcare workers’ overall happiness in public and mission hospitals.

  • 3. To identify the relationship between healthcare workers’ overall happiness and demographic, work-related, and physical work environment factors.

Methods

Study design

Using a cross-sectional design, this study was performed in public and mission hospitals in Meru County, Kenya. Meru County is a rural area with a total population of 1,545,714 persons32. By 2019, the human resources for health (HRH) within Meru County was 1872 with 954 clinically trained healthcare workers, distributed across 183 health facilities33,34. The focus of this study was on all the 24 sub-county and county referral service hospitals in Meru County, Kenya.

Study setting

In Meru County, the health system consists of five-levels namely: level 1: community health services; level 2: health dispensaries and clinics; level 3: health centers and maternity homes; level 4: sub-county and medium-sized private hospitals; and level 5: the county referral hospital34,35. This study was done in level 4 and 5 health facilities, where different cadres of healthcare workers are present.

The present study was done between June 15, and July 31, 2020, which was during the COVID-19 global pandemic. In Meru County, by the end of June 2020, 16 cases were reported and towards the end of July 2020, 32 cases were reported in a population of 1,545,714 people32. The COVID-19 pandemic did not negatively influence the data collection process of this study as the number of COVID-19 cases were relative few at the time. Despite the relatively low COVID-19 case load at the time in Meru County, researchers reported that the COVID-19 pandemic is a health system shock that has adversely affected healthcare workers' mental health during spikes of COVID-19 cases36. A scope review also revealed that the increased spread of the COVID-19 virus has resulted in healthcare workers reporting higher levels of anxiety, burnout, depression, and distress, consequently researchers have recommended the need of studies aimed at enhancing healthcare workers' well-being37.

Study sample

Participant selection within the hospitals was made among healthcare workers across different cadres using simple random sampling. To minimize selection bias, simple random sampling was selected as a sampling method because it allowed for each eligible respondent to have an equal probability of being selected. A list of clinically trained healthcare workers in each hospital was obtained from the hospital administration. Then respondents were selected according to a simple random number table. In person, respondents were invited and presented with an informed consent form explaining this study, subsequently the willing participants signed and voluntarily agreed to participate.

Data collection and data source

The Orientations to Happiness Questionnaire (OTH) was established and validated by Peterson et al., in 2005 to assess an individuals’ orientation to happiness (https://doi.org/10.1007/s10902-004-1278-z)8. The orientations constitute the three primary constructs that are measured in the 18-item questionnaire8. Each of the orientations to happiness has six items on a five-point Likert scale ranging from 1 representing “Not at all like me” to 5 representing “Very much like me”8. Respondents’ happiness index ranges from 18 (lowest possible), signifying an empty life, to 90 (highest possible score), signifying a full-life8. Various studies reported a Cronbach alpha for all the three orientations to range from 0.77 to 0.888,38,39. The OTH has been used in various countries such as Australia39, South Africa38,40, Italy41, Switzerland42, USA39, and Croatia18.

On a scale of 0 to 1, when the Cronbach’s alpha is greater than 0.70, this means the instrument is reliable43. In this study, the Cronbach’s alpha was 0.833, which shows that the instrument was reliable in measuring happiness among the respondents. The dataset analyzed in this study can be found in the Figshare repository44.

Statistical analysis

Statistical analysis was done using STATA® 15.1 (StataCorp., College Station, TX, USA). We calculated measures of central tendency, the relative importance index (RII), analysis of variance (ANOVA), Welch’s t-test, double-log regression, and used a multivariate linear regression model to determine statistical significance of slope coefficients at 90% and 95% confidence levels of each independent variable. To control for confounding variables, we used multivariate linear regression analysis which can handle multiple confounders at the same time45. The questionnaires that were had up to 50% missing data were excluded from the data analysis.

The RIIs were calculated using the following formula:

RII=WA×N(1)

The RII formula applied shows W represented the weighting as per each respondent on a five-point Likert scale where 1 implies lower happiness scores and 5 higher happiness score. A represented the highest weight, in this case 5 based on the five-point scale. N represented the entire sample. The RII score is between 0 and 1; thus, the high values were 0.8 ≤ RII ≤ 1, high-medium values were 0.6 ≤ RII ≤ 0.8, medium values were 0.4 ≤ RII ≤ 0.6, medium low values were 0.2 ≤ RII ≤ 0.4, and low values were 0 ≤ RII ≤ 0.246.

The mean of the median absolute deviation (MADM) was calculated in a four-step process involving: (a) calculation of the median value of each of the 18 happiness variables; (b) calculation of the absolute deviation for each dependent variable represented as (x) in the sub-formula [ximedian]; (c) calculation of the median absolute deviation; (d) calculation of the MADM47. The MADM classifications signify the following: values of < 1.08 indicates high agreement, 1.08 – 1.41 indicates moderate agreement and, > 1.41 indicates low agreement48.

Using Analysis of Variance (ANOVA), we examined if there was a statistical difference the orientations to happiness between participants working in public and mission hospitals In addition, a two-sample Welch’s t-test was used to compare overall happiness mean scores between public and mission hospitals with unequal sample sizes.

In this study, the independent variables assessed were demographic and work-related, and physical work environment namely: hospital ownership (0 = public or 1 = mission hospital), sex (0 = male or 1 = female), age (participants’ age in years), income per month in Kenyan Shillings (KES) (1 = ≤14,999, 2 = 15,000-24,999, 3 = 25,000-44,999, 4 = 45,000-64,999, 5 = 65,000-74,999, 6 = 75,000-84,999, 7 = 85,000-104,999, 8 = ≥105,999), marital status (0 = single, divorced, widowed, or 1 = married), level of qualification (0 = certificate and diploma or 1 = bachelor’s degree or higher), years of work experience, healthcare worker cadre, employment type (0 = part-time (i.e., ≤40 hours per week) or 1 = full-time (i.e., ≥40 hours per week)), in-service training (0 = no or 1 = yes), number of hours worked per week, household size, and staff housing (0 = no or 1 = yes)44,47,49.

The physical work environment variables were consistent supply of water (0 = no or 1 = yes), occurrence(s) of water unavailability (0 = no or 1 = yes), safe drinking water (0 = no or 1 = yes), acceptable primary source of water (0 = no or 1 = yes), type of toiletry facility (0 = flush or pour flush or 1 = pit latrine), risk when using toiletry facility (0 = no or 1 = yes), hospital disposal of garbage (0 = informal disposal or 1 = formal collection service), availability of water for hand washing (0 = no or 1 = yes), constant availability of soap for hand washing (0 = no or 1 = yes), hand washing station ≤ five meters from the toilet (0 = no or 1 = yes), workplace safety and health committee (0 = no or 1 = yes), perceived overall safety of hospital working environment44,47,49.

A multivariate linear regression analysis was performed to discover the significant factors that influence healthcare workers’ overall happiness in mission and public hospitals. Where happiness (Yk) was the dependent variable and the demographic, work-related, and physical work environment factors were the 24 independent variables (Xjk). The multivariate linear regression model applied was as follows50:

Yk=β0+β1X1k+β2X2k+...+β24X24k+k(2)

Where: β0 indicates the constant or intercept term capturing the unexplained variations in the dependent variable Y. β1 indicates the slope coefficient measuring the amount by which Y will change when X changes by a single unit. k goes from 1 to n, in this case the 24 independent variables. X1k= stands for the kth observation value for the independent variable X1. ∈k is the error (disturbance) term that captures errors in model specification and other factors that influence healthcare workers’ happiness but are not explicitly considered in the model.

In addition, a double-log regression model, was performed to measure the non-linear relationship between the dependent variable (overall happiness) and independent variable (income) which were transformed into logarithms then regressed according to hospital ownership. The double log regression formula applied in this study is50:

lnY=β0+β1 lnX1+β2 lnX2+є(3)

Where: lnY indicates the log of overall happiness. β0 refers to the intercept term capturing the unexplained variations in overall happiness Y. β1 indicates the slope coefficient measuring the amount by which Y will change when X changes by a single unit. ln X1 refers to the log of income as the independent variable. ∈ is the error term that captures errors in the model. The elasticities in a double-log equation are constant thus an indifferent curve can be produced based on the results50.

Ethical considerations

The protocol of this study was ethically approved by three institutions, namely:

  • 1. The Faculty of Health Sciences Research Ethical Committee, University of Pretoria, South Africa (Reference number: 718/2019).

  • 2. The Institutional Review Board (IRB), United States International University-Africa, Kenya (Reference number: USIU-A/IRB/130-2020).

  • 3. The National Commission for Science, Technology, and Innovation (NACOSTI), Kenya (Research license number: NACOSTI/P/20/4133 and reference number: 901924).

The Meru County Government Department of Health also provided clearance for the conduct of this study (CGM/COH/1/17(50). This was followed by hospital administrative approvals from each of the 24 hospitals. The investigator provided respondents with informed consent forms explaining: the purpose of the study; participation in the research study was voluntary; refusal to participate would not have negative effect on their job; s/he has the liberty withdraw from the study at any time; and this research poses no risk. Following this explanation, respondents in this study voluntarily signed the informed consent forms, agreeing to participate.

Results

In this study, from 566 questionnaires 553 were analyzed, thus the response rate was 97.7%, because 13 questionnaires were 50% incomplete thus excluded from analysis47,49. The study involved a sample of n= 553 healthcare workers44. This study revealed that majority of the healthcare workers under study worked in public hospitals (78.48%), were female (61.30%), worked as nursing professionals (30.56%), held a diploma (60.58%), were employed full-time (93.49%), had attended in-service training (66.00%), were married (63.11%), had 10.7 years of work experience, lived in a median household size of three individuals, were not accommodated within the hospital compound (86.62%), were between the ages 20 and 78 years (the mean age was 36.5 years), and earned between 46,000-65,000 Kenyan shillings (KES) which is about US$439-615 (at an exchange rate of US$1=107KES by May 13, 2021)).

Orientations to happiness and hospital ownership

Among all the participants (n=553), the mean overall happiness score was 64.59 (SD = 11.09). The mean overall happiness score in public hospitals was 65.14 (SD = 10.98), whereas the mean in mission hospitals was 62.57 (SD = 11.31). A two-samples Welch t-test showed a statistically significant difference between overall happiness scores and hospital ownership, t(184.579) = 2.208,p=0.0285.

Table 1 shows the mean scores and standard deviations of the three orientations to happiness by the overall sample (n=553) and hospital ownership sub-samples (public hospitals n=434 and mission hospitals n=119).

Table 1. Mean scores* (SD) (1–5 Likert scale) of the three orientation to happiness for the sample of n=553 healthcare workers by hospital ownership.

Orientation to
happiness
Overall
(N=553)
Public hospitals
(n=434)
Mission hospitals
(n=119)
Pursuit of pleasure3.30 (0.24)3.36 (0.23)3.07 (0.28)
Pursuit of engagement 3.29 (0.62)3.31 (0.61)3.23 (0.66)
Pursuit of meaning 4.18 (0.29)4.19 (0.28)4.12 (0.36)

*Reported on 1–5 scale with higher values are suggestive of higher happiness

Among the orientations to happiness, the pursuit of meaning had the highest mean scores. In the overall sample, the pursuit of pleasure had the second highest mean scores, followed by the pursuit of engagement. The opposite order was reported for the second and third highest mean scores in mission hospitals, where the pursuit of engagement was second and pursuit of pleasure third (as shown in Table 1). The overall happiness average score was 64.59; 65.14 in public hospitals and 62.57 in mission hospitals (on an 18–90 scale).

Orientation to happiness - MADM analysis

The MADM results showed that healthcare workers moderately agreed to the pursuit of pleasure items as an orientation to happiness. Three items were moderately supported, and the healthcare workers strongly supported three other items. The healthcare workers highly agreed that the pursuit of engagement contributed to their happiness. Four items of the six were strongly supported, and the remaining two had moderate and low support in terms of their contribution to happiness. The pursuit of meaning items were all strongly supported as contributors to the healthcare workers happiness, signified by the high levels of agreement (see Table 2).

Table 2. The median and mean absolute deviation from the median for the orientations to happiness items (n=553).

Orientations
to happiness
ItemsNumber (%)
rating <4
MedianMAD1MADM2
Pursuit of
pleasure
Life is too short to postpone the pleasures it can provide.271 (49.01)411.12
I go out of my way to feel euphoric (joyful).310 (56.06)311.12
In choosing what to do, I always consider whether it will be pleasurable.265 (47.92)411.10
I agree with this statement: “Life is short-eat dessert first.”356 (64.38)311.25
I love to do things that excite my senses.259 (46.84)411.10
For me, the good life is the pleasurable life.291 (52.62)311.16
Pursuit of
engagement
Regardless of what I am doing, time passes very quickly.260 (47.02)410.96
I seek out situations that challenge my skills and abilities.158 (28.57)410.80
Whether at work or play, I am usually “in a zone” and not conscious of
myself.
441 (79.75)211.13
I am always very absorbed in what I do.210 (37.97)410.87
In choosing what to do, I always consider whether I can lose myself in it.270 (48.82)411.08
I am rarely distracted by what is going on around me. 320 (57.87)310.99
Pursuit of
meaning
My life serves a higher purpose.123 (22.24)500.76
In choosing what to do, I always consider whether it will benefit other
people.
119 (21.52)410.82
I have responsibility to make the world a better place.92 (16.64)500.63
My life has a lasting meaning.106 (19.17)500.66
What I do matters to society.99 (17.90)500.65
I have spent a lot of time thinking about what life means and how I fit
into its big picture.
236 (42.68)410.95

1MAD: Median absolute deviation.

2MADM: Mean absolute deviation from the median.

Orientation of happiness - RII

The relative importance of the orientations to happiness showed the pursuit of meaning was the most important, followed by the pursuit of pleasure. The pursuit of engagement was ranked third important orientation to their happiness (as shown in Table 3).

Table 3. Relative importance of orientations to happiness among healthcare workers (n=553).

Orientations to happinessRelative Importance IndexImportance
Pursuit of pleasure0.6682
Pursuit of engagement0.6583
Pursuit of meaning0.8351

Factors of healthcare workers’ overall happiness

ANOVA analysis results. Hospital ownership explained 0.91% of the variance in overall happiness score among the healthcare workers. The ANOVA analysis results show there was a statistically significant difference between healthcare workers’ happiness and hospital ownership (p=0.2551) (as shown in Table 4).

Table 4. ANOVA of overall happiness and hospital ownership.

NR2Adjusted R2FSig. F change
Overall happiness5530.00910.0073 5.040.0251*

*p < 0.05 indicates statistical significance.

There was a statistically significant difference between the hospital ownership, in the mean scores of pursuit of pleasure (p<0.001) and pursuit of meaning (p=0.024) orientations to happiness. No statistically significant difference between the ‘pursuit of engagement’ scores and hospital ownership (p=0.241) were reported (as shown in Table 5).

Table 5. ANOVA results of orientations to happiness and hospital ownership (n=553).

Orientations to happinessHospital ownershipnMeanStd. dev.FSig.
Pursuit of pleasurePublic4343.360.23132.581 0.0001*
Mission1193.070.28
Pursuit of engagementPublic4343.310.611.5500.214
Mission1193.230.66
Pursuit of Meaning Public4344.190.285.1210.024*
Mission1194.120.36

Reported on 5-point Likert scale with higher values are suggestive of higher happiness.

*p < 0.05 indicates statistical significance.

Regression analyses results. In mission hospitals, according to the multivariate linear regression model, nine statistically significant variables namely income, type of employment, occurrence of water unavailability, safe drinking water, acceptable main source of water, type of toiletry facility, hospital disposal of garbage, availability of water for hand washing, and overall safety of the hospital working environment, explained the healthcare workers’ overall happiness (p < 0.05 or p < 0.1) (as shown in Table 6).

Table 6. Multivariate regression of overall happiness, and demographic, work-related and, physical work environment factors in mission hospitals (n=119).

Independent variablesSlope
Coefficient.
Standard
Error
T
value
Significance95% confidence
interval
Sex0.0812.2430.040.971-4.3724.535
Age-0. 0200. 143- 0.140. 890-0. 3050. 264
Income- 9.0313.136-2.880.005*-15.258- 2.804
Marital status-2.6042.357-1.100.272-7.2842.076
Level of qualification0.5222.3640.220.826-4.1735.216
Years of experience-0.1620.202-0.800.424-0.5640.239
Healthcare workers cadre-0.9452.772-0.340.734-6.4494.560
Type of employment 10.0823.9802.530.013*2.17917.986
In-service training 2.7352.4201.130.261-2.0717.541
Hours worked per week0.1250.0971.280.204-0.0690.318
Household size-0. 5310. 730-0. 730.468-1.9800.917
Staff housing -1.7242.772-0. 620. 536-7.2283.781
Consistent supply of water0.2333.963-0.060.953-8.1027.637
Occurrence of water unavailability -4.8642.388-2.040.044*-9.605-0.123
Safe drinking water-8.2344.055-2.030.045*-16.285-0.182
Acceptable primary source of water12.6875.3352.380.019* 2.09523.278
Type of toiletry facility7.1522.7192.630.010* 1.75412.550
Risk when using toiletry facility-0.4352.659-0.160.871-5.7134.844
Hospital disposal of garbage4.6692.5211.850.067**-0.3379.674
Availability of water for hand washing-11.7545.507-2.130.035*-22.688-0.819
Constant availability of soap7.6876.3371.210.228-4.89520.268
≤5 meters of hand washing station from the toilet3.8454.3000.890.374-4.69312.383
Workplace safety and health committee-2.2302.523-0.880.379-7.2402.779
Overall safety of hospital working environment1.4920.7801.910.059**-0.0573.040
Constant39.7919.2364.310.00021.45358.130

* p < 0.05 indicates statistical significance at 95% confidence level. ** p < 0.1 indicates statistical significance at 90% confidence level.

Table 7 shows, based on the multivariate linear regression model, three statistically significant variables namely level of qualification, type of toiletry facility, and the presence of a functional workplace safety and health committee, explained the overall happiness of healthcare workers employed in public hospitals (p < 0.05 or p < 0.1).

Table 7. Multivariate regression of overall happiness, and demographic, work-related and, physical work environment factors in public hospitals (n=434).

Independent variablesSlope
Coefficient.
Standard
Error
T
value
Significance95% confidence
interval
Sex-0.4681.083-0.430.666-2.5961.661
Age-0.1650.119-1.390.166-0.3990.069
Income-0.3031.4230.210.832-2.4953.100
Marital status0.3001.2540.240.811-2.1662.766
Level of qualification-2.1801.159-1.880.061** -4.4570.098
Years of experience0.080.1280.620.536-0.1730.332
Healthcare workers cadre1.4441.1681.240.217-0.8533.742
Type of employment 1.3692.2450.610.542-3.0455.783
In-service training 0.9661.1700.830.409-1.3333.266
Hours worked per week0.0390.0381.040.299-0.0350.113
Household size-0.1100.322-0.340.733-0.7440.534
Staff housing -0.6171.849-0.330.739-4.2523.018
Consistent supply of water0.4351.6240.270.789-2.7563.627
Occurrence of water unavailability -0.9741.162-0.840.403-3.2581.311
Safe drinking water-0.9791.327-0.740.461-3.5881.629
Acceptable primary source of water1.1681.5740.740.458-1.9264.262
Type of toiletry facility2.0721.2421.670.096** 0.3694.514
Risk when using toiletry facility-0.7321.263-0.580.563-3.2141.751
Hospital disposal of garbage1.4712.1320.690.490-2.7195.662
Availability of water for hand washing0.4891.7970.270.786-3.0444.022
Constant availability of soap1.4712.1320.690.490-2.7195.662
≤5 meters of hand washing station from the toilet-0.8672.082-0.420.677-4.9593.225
Workplace safety and health committee5.3751.2054.460.000* 3.0077.743
Overall safety of hospital working environment0.0070.2950.020.980-0.5730.587
Constant61.0324.82712.650.00051.54470.520

* p < 0.05 indicates statistical significance at 95% confidence level. ** p < 0.1 indicates statistical significance at 90% confidence level.

The results of the double-log regression model showed a statistically significant relationship between healthcare workers’ overall happiness and income (n = 553, p = 0.003). In mission hospitals, income explained 5.1% of the variance in healthcare workers’ overall happiness (adjusted R2 = 0.0429, df = 118, F = 6.28, p = 0.0136). Whereas in public hospitals, the double log regression model showed that 1.13% variance in healthcare workers’ overall happiness was significantly explained by income (adjusted R2 = 0.0090, df = 433, F = 4.93, p = 0.0269). Thus, income significantly contributes to the healthcare workers’ overall happiness in both mission and public hospitals.

Discussion

The authentic happiness theory guided the investigation of factors influencing the self-assessed pursuit of happiness among healthcare workers in public and mission hospitals in Meru County, Kenya. The results showed a statistically significant association between hospital ownership and the participants’ overall happiness scores, where those working in public hospitals reporting higher mean scores compared to those in mission hospitals. Hospital ownership significantly influenced the healthcare workers’ pursuit of meaning and pleasure (as shown in Table 5). However, in present study, there was insufficient evidence of hospital ownership influencing the pursuit of engagement in the overall sample of healthcare workers. To date, this is the first quantitative study to investigate the association between the pursuit of happiness and hospital ownership among healthcare workers in Kenya.

The predicting factors of overall happiness among the participants differed between public and mission hospitals, with the exception of income. Income was found to be a statistically significant predictor of overall happiness among healthcare workers in both public and mission hospitals. Similarly, a qualitative study in Kenya among senior managers in public and mission hospitals reported that both the amount of income and timely payment of salaries are important factors of healthcare workers' happiness51. This study’s results are concurrent with a study carried out in Iran that reported monthly income and satisfaction with income as predictors of happiness among nurses52. Frey and Stutzer, explained that happiness and economics research has shown that there is a positive relationship between income and happiness and well-being, this is irrespective of the country, location, or time31. This finding is paramount important because both inadequate remuneration and recurrent delayed payment of salaries are among the major causes of the perpetual health worker strikes in Kenya53. The findings in this study show the importance of health policy makers ensuring healthcare workers are adequately remunerated in a timely manner.

In public hospitals, in addition to income, the qualification or education level was a significant factor of the participants’ overall happiness. The more educated the respondents were, the lower their overall happiness scores. However, a study in India reported the more qualified the dentists were the higher the levels of happiness54. The difference between this study and the Indian study could be, the critical shortage of skilled health workers in Kenya11, which results highly skilled and qualified healthcare workers in Kenya experiencing heavier workload, thus leading to demotivation55 and unhappiness.

In mission hospitals, aside from income, the type of employment was positively associated with the participants overall happiness. The healthcare workers who were working full-time reported higher overall happiness scores compared to those working part-time. This could be attributed to the higher sense of job security associated with being employed full-time compared to part-time. According to the WHR 2017, job security was positively associated with higher levels of happiness22. Thus, health policy makers should consider employing more healthcare workers full-time, which will simultaneously contribute to increased happiness, and the reduction of the critical shortage and brain drain of skilled health workers, which are major problems in the Kenyan health system.

The current study portrays the significance of a clean, healthy, hygienic, and safe work environment in promoting healthcare workers’ overall happiness, in both public and mission hospitals. The availability of water from an acceptable primary source, functional flush toiletry facilities, safe drinking water, availability of water for hand washing, an overall safe working environment, and the presence of a functional workplace health and safety committee significantly contributed to the overall happiness of the healthcare workers. A study in Korea similarly revealed that by improving and creating an enabling work environment significantly increased nurses happiness index56. These results prove that the physical work environment plays significant role in the psychological attitude healthcare workers have, either positive or negative. According to the World Happiness Report, the riskier and more unsafe the work environment is, the lower the workers happiness22. It is critical for health authorities to recognize that the attitude of healthcare workers in the workplace impacts the quality of healthcare, patient outcomes, and overall safety57. Therefore, having a healthy and safe work environment should be prioritized in health facilities to enhance healthcare workers' happiness and to facilitate higher quality of care provided to patients.

This study contributes to the authentic happiness theory by revealing the significant factors of happiness, and the order of relative importance of the orientations to happiness in a health setting. The current study revealed, living a meaningful life was the most important pursuit of happiness among the healthcare workers. Similar findings have been reported regarding career meaning contributing to happiness among physicians58 and physiotherapists25. Our findings are also congruent with the African philosophy of happiness. Happiness in the African context stems from the meaningful aspect of human existence59. In African philosophy, the two ways the African people derive meaning and happiness are through the collectivist culture of communal bonds and believing in a higher supernatural being59. This signifies that attaining a sense of meaning through their work and collectivist activities, aimed at contributing to something larger than oneself, is important to healthcare workers.

In the current study, the pursuit of pleasure was the second most important orientation among the respondents. The pursuit of pleasure, also known as hedonism, is the desire to attain maximum pleasure with minimal pain and instant gratification15,18. Due to the short term nature of the pursuit of pleasure, it is therefore viewed as an impediment to long term happiness60. For instance, smoking among medical students61 for pleasure has been viewed as a risk-taking behavior at the price of longevity60. However, the negative or positive view of the pursuit of pleasure is dependent on the contextual meaning. In 2010, researchers reported that nurses derived pleasure in the workplace by working as a team to save lives, minimize the pain of their patients, and feeling valuable through providing quality care62. A positive pursuit of pleasure among healthcare workers involves organizational actions for instance reduced incidence of overtime and introducing leisure activity programs to promote healthcare workers’ happiness57. This implies that the pursuit of pleasure among healthcare workers can be considered as positive through maximizing pleasure and minimizing sources of pain. For example, through facilitation of collectivistic activities such as team building exercises will increase the spirit of teamwork in health facilities51. The teamwork would help healthcare workers cope with the burden of heavy workload, by providing organizational support thus, promote healthcare workers’ happiness, and enhance the quality of care51.

At work, the pursuit of engagement is also known as work engagement and is characterized by the experience of flow. According to Csikszentmihalyi, flow is attained through applying one’s signature strengths to perform challenging tasks, requiring high degree skill and dedication15,16. In the current study, the pursuit of engagement was the third most important orientation to happiness. Previous studies have reported positive, significant and strong associations between healthcare workers’ work engagement and high productivity63, high job performance64, better teamwork65, improved patient safety63, and a better quality of health care63,65. Clearly, work engagement strategies need to be developed and implemented, because the score in this pursuit was the lowest of the three orientations to happiness in the current study.

All orientations to happiness are essential in developing authentic happiness signified by a full life8. A full life is attained by the collective scores of all the orientations to happiness, while the opposite is true for the empty life8. Collectively, the healthcare workers’ happiness was moderate. The present study found the overall happiness scores were slightly higher among healthcare workers employed in public hospitals than those in mission hospitals (as shown in Table 1 and Table 5). In this study, as hospital ownership changes from public to mission the overall happiness scores decreased by 2.274. This could be attributed to the differences in hospital ownership, which have an impact on the health facility operations and availability of resources. The current findings show that there is an opportunity for empowering healthcare workers to achieve authentic happiness. Based on the findings of this study, healthcare workers’ happiness policies and programs are important because experiencing happiness at work enables individuals to optimally function in the workplace9. By developing happiness policies and strategies that are sensitive and solve the healthcare workers’ issues, significant progress in strengthening the health workforce and health system in Kenya can be achieved. Health systems strengthening would result in improved health workforce responsiveness, universal access to quality healthcare services, improved productivity, and better patient outcomes66.

Implications for policy and practice

Based on these findings we believe happiness of healthcare workers should be mainstreamed into the ‘Kenya Health Policy’ and ‘Kenya Health Sector Strategic Plan’. This suggestion is based on the results of this study, and the United Nations General Assembly resolution advocating for happiness and well-being policies to be mainstreamed into public policies which was passed by all heads of state including Kenya6. The Kenyan health system stands to benefit from happier healthcare workers due to the probability of increased health system efficiency. It appears that healthcare workers’ happiness could be increased by enhancing and solving challenges related to demographic, work-related, and physical work environmental factors. For example, healthcare workers’ qualification significantly contributed to their overall happiness. Thus, positive education can be mainstreamed into the healthcare workers’ pre-service curriculum and in-service training. Positive education would entail involving experts in the field to apply evidence-based approaches to teach healthcare workers how to be engaged, develop their signature strengths, cultivate healthy relationships, practice physical wellbeing, and achieve a sense of meaning67. Positive education programs could empower healthcare workers to be competent enough to achieve authentic happiness.

The Government of Kenya should also consider applying a formal health care appraisal (HCA) system. According to the Global Happiness and Well-being Policy Report, a formal HCA provides an opportunity for governments to perform needs assessment, cost-benefit analysis, impact, and post-hoc analysis of regulations and interventions in health settings, to optimize the scarce healthcare resources68. Thus, the Government of Kenya can set happiness metrics, targets, and indicators to monitor and evaluate the impact of implementing happiness policies among healthcare workers. The happiness policies and implementation of happiness interventions could boost the healthcare workers’ mental health and wellbeing and the quality of care provided to patients68. At a national level, this is likely to contribute to the improvement of health indicators in Kenya.

Happiness policies would promote the focus of developing mental health. To effectively develop and implement happiness policies, strategic plans, and programs, the World Health Organization (WHO) has published a report titled ‘Mental Health Policy, Plans and Programmes’69. In this report WHO explains the seven essential steps of developing mental health policies, the four steps of creating a mental health plan, plus how to develop a mental health program69. Most importantly, the seven-step process of implementing the policy, plans and programs69. Using the results from this study and guided by the WHO report69, policy makers and implementers should seriously consider developing happiness policies, plans, and programs aimed at strengthening the health workforce and health system, by promoting mental health among healthcare workers in Kenya. Lastly, the development and implementation of happiness within the health system should involve most stakeholders such as policy makers in government, health mangers, and healthcare workers in the public and private health sectors.

Limitations and areas for further research

The results from this study should be interpreted in view of the study’s shortcomings. This study utilized a cross-sectional design; hence correlational evidence was reported and not causal evidence. In future, the Government of Kenya should perform experimental design studies to assess costs and benefits of alternative healthcare workers’ happiness policies, programs and interventions geared towards health systems strengthening, at the national and county levels. Secondly, this study was based on self-assessed happiness data, which presents the possibility of response and social desirability biases. To reduce the tendency of response and social desirability biases, the researchers informed the respondents that anonymity would be upheld throughout the entire research process and encouraged them to be as honest as possible.

The scope of the present study did not assess the role of job characteristics on healthcare workers’ happiness. Future studies could explore the impact of job characteristics on happiness among healthcare workers. We also acknowledge that other quantitative and qualitative studies may produce different results due to contextual factors or methodological differences. Thus, more studies using different methodologies are necessary to bridge the knowledge gaps on healthcare workers’ happiness in Kenya. This study was done in one of 47 counties in Kenya, thus may limit the generalizability of the results. In future, research geared towards promoting healthcare workers’ happiness should be carried out in other counties, to provide evidence-based healthcare worker happiness policies nationwide. Finally, this study was done among healthcare workers who had gone through clinical training. Further studies applying similar or alternative research designs could be done among other staff such as non-clinical staff, auxiliary staff in health facilities and workers in other sectors. This would contribute to informing the formulation of happiness and well-being public policy and implementation plans nationally.

Conclusion

In Kenya, this is first quantitative study report the factors influencing the self-assessed happiness among healthcare workers in public and mission hospitals in Meru County, Kenya. The most important orientation to happiness among the participants was the pursuit of meaning, followed by the pursuits of pleasure and engagement. These results were contextually synchronized to the African philosophy of happiness, where the sense of meaning is believed to be a significant element of ultimate happiness. This means that happiness policies, strategies, and programs aimed at empowering healthcare workers to attain a sense of meaning will significantly contribute to promoting happiness. The MADM results showed that healthcare workers highly agreed that both the pursuit of engagement and meaning contributed more to their happiness than the pursuit of pleasure. These findings imply that health leaders and managers aiming to improve and effectively execute healthcare workers’ happiness strategies and programs need to consider all pursuits of happiness. Based on the OTH theory, this will enable healthcare workers to achieve authentic and long-term happiness, which are attributes of a full life. In both public and mission hospitals, income and the type of toiletry facility were significant factors of overall happiness. In mission hospitals, eight additional variables were statistically significant factors of overall happiness namely type of employment, occurrence of water unavailability, safe drinking water, acceptable main source of water, type of toiletry facility, hospital disposal of garbage, availability of water for hand washing, and overall safety of the hospital working environment. In public hospitals, qualification level, and a functional workplace safety and health committee significantly predicted the healthcare workers’ overall happiness. The findings provide an understanding that demographic, work-related and physical work environment factors influence healthcare workers’ overall happiness. The policy implications for the factors reported, show that an intersectoral approach in designing and implementing evidence-based happiness policies and interventions, needs to be done involving both the private and public sectors.

Data availability

Underlying data

Figshare: Data used to investigate healthcare workers’ pursuit of happiness in Kenya. https://doi.org/10.6084/m9.figshare.13655822.v144.

This project contains the following underlying data:

  • - Dataset used to investigate healthcare workers' pursuit of happiness in Kenya RNDKM.xlsx. (The dataset includes some demographic and work-related variables from variable 1 to 25 and, the results from the Orientations to Happiness (OTH) questionnaire (Var 26–43). The healthcare workers' overall happiness scores were calculated based on the responses from Var 26–43, which are presented in Var 44. Below the dataset on the same data spreadsheet are variable definitions. It includes the variable label e.g., Var 1, Var 2 etc.; the variable definitions and coding descriptions.)

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC BY 4.0).

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Muthuri RNDK, Senkubuge F and Hongoro C. A cross-sectional study on the pursuit of happiness among healthcare workers in the context of health systems strengthening: The case of Meru County, Kenya. [version 2; peer review: 1 approved, 1 approved with reservations]. F1000Research 2021, 10:163 (https://doi.org/10.12688/f1000research.51203.2)
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Zhuo Chen, Department of Health Policy and Management, University of Georgia, Athens, GA, USA;  University of Nottingham Ningbo China, Ningbo, China 
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Zhuo Chen, Department of Health Policy and Management, University of Georgia, Athens, GA, USA;  University of Nottingham Ningbo China, Ningbo, China 
Wei Jiang, University of Nottingham Ningbo China, Ningbo, China 
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This manuscript investigated the difference in healthcare workers’ happiness between public and mission hospitals, as well as the impact of demographic and work environment factors on self-assessed happiness. The study addressed an important topic, i.e., self-assessed happiness among healthcare workers, ... Continue reading
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Chen Z and Jiang W. Reviewer Report For: A cross-sectional study on the pursuit of happiness among healthcare workers in the context of health systems strengthening: The case of Meru County, Kenya. [version 2; peer review: 1 approved, 1 approved with reservations]. F1000Research 2021, 10:163 (https://doi.org/10.5256/f1000research.54345.r82106)
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  • Author Response 24 May 2021
    Rose Nabi Deborah Karimi Muthuri, School of Health Systems and Public Health, University of Pretoria, Pretoria, Pretoria 0002, South Africa
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  • Author Response 24 May 2021
    Rose Nabi Deborah Karimi Muthuri, School of Health Systems and Public Health, University of Pretoria, Pretoria, Pretoria 0002, South Africa
    24 May 2021
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Ian Couper, Ukwanda Centre for Rural Health, Stellenbosch, South Africa 
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A cross-sectional study on the pursuit of happiness among healthcare workers in the context of health systems strengthening: The case of Meru County, Kenya.

This study, which sought to measure health workers happiness in public and mission ... Continue reading
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Couper I. Reviewer Report For: A cross-sectional study on the pursuit of happiness among healthcare workers in the context of health systems strengthening: The case of Meru County, Kenya. [version 2; peer review: 1 approved, 1 approved with reservations]. F1000Research 2021, 10:163 (https://doi.org/10.5256/f1000research.54345.r81292)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 24 May 2021
    Rose Nabi Deborah Karimi Muthuri, School of Health Systems and Public Health, University of Pretoria, Pretoria, Pretoria 0002, South Africa
    24 May 2021
    Author Response
    Ref: Response to review report 1
    Firstly, thank you very much for reviewing our article and for all the constructive suggestions and comments. Please find below our response to the ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 24 May 2021
    Rose Nabi Deborah Karimi Muthuri, School of Health Systems and Public Health, University of Pretoria, Pretoria, Pretoria 0002, South Africa
    24 May 2021
    Author Response
    Ref: Response to review report 1
    Firstly, thank you very much for reviewing our article and for all the constructive suggestions and comments. Please find below our response to the ... Continue reading

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