Japan’s rapidly aging population is placing an increasingly serious burden on national agencies because of increased health care costs. Therefore, the importance of health promotion and disease/care prevention strategies in the community has recently become more widely recognized in Japan. One effective way to improve community health and empower the community is to use “natural helpers,” such as community health workers (CHWs) [1, 2]. They can offer help in a neighborly way and provide informal and spontaneous assistance [3, 4]. Provision of such help could contribute to solving the problems of an aging population. Many earlier studies about CHW activities have revealed behavioral modification; improved health status and health knowledge; access to health support among community members; and more cost-effective health and welfare services as outcomes of CHW interventions. In the past year, review articles on these topics have been published [5–7].

In Japan, health promotion volunteers (HPVs) perform activities similar to those of CHWs [8–10]. The purpose of HPV activities is to maintain and promote the health of community members. HPVs have acted as a natural helping resource in the community for many years. HPV activity originated at the end of World War II. Subsequently, HPV organizations have been established in many municipalities throughout the country to address public health problems most relevant to the times, such as high infant mortality and poor nutrition after the war, and lifestyle-related diseases recently. Like CHWs, they are expected to function as leaders in promoting the health of local residents. HPVs are members of the community who are trained and supported by public health nurses and dietitians affiliated with local municipalities. They are not paid for their services. HPV activities are performed in all areas of the community and take place through organized programs as well as through individual initiatives.

A number of previous studies have reported that volunteer activities provide workers with a sense of fulfillment and personal accomplishment [11, 12] as well as increased self-esteem and self-efficacy [13]. In contrast, it has also been reported that some volunteers experience and suffer from emotional overload and burnout because of their activities [11, 14]. Thus, working on community activities can affect volunteers both positively and negatively. Moreover, satisfaction and burden related to activities might not be necessarily opposing concepts. There are, in fact, some volunteers who feel both satisfied and burdened when performing their activities. It would be natural to think that those who feel less burdened also experience a higher degree of satisfaction. However, the relationship between satisfaction HPVs derive from their activities and the level of burden they feel has not been clearly delineated in previous studies.

It is important to examine the prevalence of differing levels of activity satisfaction/burden among volunteers and reveal characteristics of HPVs related to satisfaction and burden so that strategies can be developed to support their work. In addition, understanding how levels of satisfaction and burden affect HPVs’ involvement and work persistence in the community is essential. Indeed, the success of workers’ interventions is contingent on their involvement and persistence. It is also important to consider the impact of HPVs’ feelings on their daily lives. Several articles have reported that volunteer work can influence aspects of participants’ quality of life, such as life satisfaction [15–17].

Omoto and Snyder proposed a conceptual framework known as the Volunteer Process Model that specifies psychological and behavioral features associated with each of three sequential stages: antecedents, experiences, and consequences [18]. This model has been modified through empirical research [19–22]. Antecedents include individual variables such as personality, motivation for volunteering, and degree of social support. Experiences include feelings related to volunteer activity such as satisfaction. Finally, consequences include persistence and involvement in the volunteer activity. This model is useful in understanding multiple individual factors and circumstances surrounding volunteers, and in explaining factors that affect feelings about the activity (experiences) and involvement and persistence in the work (consequences), based on a three-stage process.

The purposes of this study were 1) to identify the prevalence of Japanese HPVs according to differing levels of activity satisfaction/burden; 2) to examine the association between satisfaction and burden, volunteers’ activity involvement and persistence, and life satisfaction; and 3) to explore associated factors according to levels of satisfaction/burden among these volunteers. Our specific research question was the following: What is the relationship between activity satisfaction and burden among HPV?

A total of 604 questionnaires were distributed, and 433 were returned (response rate, 71.7%). After excluding 11 questionnaires that did not have answers regarding activity satisfaction and/or burden, 422 were used for the analysis (valid response rate, 69.9%). Of these questionnaires, 352 were from Koka, and 70 were from Konan (valid response rates, 68.8% and 76.1%, respectively). All HPVs who participated in this study were women, and mean age was 54.2 years. Approximately 70% graduated from junior high school or high school (categorized as lower education in this study).

This study aimed to understand trends associated with Japanese HPVs through an analysis of satisfaction level and perceived burden, to examine how levels of satisfaction/burden affect them in their daily lives, and to explore factors associated with different levels. We obtained three main findings in accordance with our research purposes.

First, HPVs who enjoyed high satisfaction coupled with a low level of perceived burden made up the largest group (38.4%). However, it was notable that other combinations of satisfaction/burden levels were also prevalent. Because the response rate for this survey was good, we posit that the results realistically reflect actual HPV conditions. Daniels et al. implied the coexistence of positive feelings such as accomplishment, and negative feelings such as suffering in lay health workers because of the dual demands of caring for their families and working on community activities [11]. Similarly, satisfaction and burden related to HPV activities are not mutually exclusive. Understanding the characteristics of each group is important for organizational management. Surprisingly, approximately a quarter of participants (27.5%) were categorized into group D. Although HPVs in this group had low satisfaction and high burden, their years of experience did not statistically differ from those in the other groups. HPV activities are performed in all areas of the community, indicating the importance of organized programs as well as individual initiatives. However, major difficulties that HPVs experienced in their daily work included recruitment of new members and a decrease in number of members who could flexibly engage in activities because of an increasing number who had jobs [24]. Therefore, there may be times when HPVs cannot easily leave their volunteer work, even though they feel less satisfied and experience burden related to their activities.

Second, HPVs who were satisfied with their activities (groups A and B) had greater activity involvement, and those with high satisfaction and low burden (group A) had greater life satisfaction. In terms of activity involvement, being satisfied with their activities was important, whether or not HPVs felt the activity was a burden. This result is consistent with findings from a study of volunteers using the Volunteer Process Model [19]. However, from the aspect of quality of life, HPVs’ satisfaction with the activity as well as less perceived burden is even more desirable. Several longitudinal studies have reported that greater involvement in volunteer activities often increases the participants’ well-being and life satisfaction [15–17]. Both activity satisfaction and burden were possible confounding factors between activity involvement and life satisfaction. To our knowledge, there are no studies that have examined the association between levels of activity satisfaction and burden with quality of life among volunteer workers. We conclude that having high satisfaction and low burden related to the activity has a beneficial effect on not only activity involvement but also the volunteers’ quality of life, although an examination of causal relationships among these variables should be conducted in future studies.

Third, to understand the characteristics of the groups, we explored associated factors for each, setting group A as a reference group. We found that environmental factors related to HPV activities such as a more facilitative organizational climate, increased social support, and a more cooperative relationship with the neighborhood association were associated with high volunteer satisfaction and low burden (group A), as well as individual factors such as higher initial motivation. This implies that improvement of the activity environment increases HPVs’ satisfaction and decreases their sense of burden associated with the activity. Their relationship with the neighborhood association appears to be particularly important. HPVs in group A enjoyed a more cooperative relationship with the head of the neighborhood association compared with those in other groups. Because HPVs engage in community-based health promotion activities, volunteers are expected to mobilize community members and resources [3, 4, 25]. For HPVs to meet such expectations regarding their role, the relationship with the head of the neighborhood association is arguably highly important. Therefore, HPVs who enjoy a good relationship with that person feel more satisfaction and less burden related to their activities.

HPVs in groups B and D had lower initial motivation for activities than those in group A. Previous studies on HPV activity reported the importance of increasing initial motivation to enhance activity persistence and satisfaction, thereby decreasing perceived burden and strengthening community health outreach initiatives [8–10]. In addition to improving the organizational environment, the development of strategies to train highly motivated new volunteers is essential in energizing current HPVs.

Overall, we discovered one main, overriding answer to our research question. The ideal situation for HPVs is experiencing a high level of satisfaction coupled with a low level of self-perceived burden when participating in an activity. This is illustrated by the results in Table 2. Although this finding might seem obvious, until now there have been no studies undertaken to support this hypothesis. The study also showed that HPVs in the other three groups, in addition to HPVs in group A (high satisfaction/low burden), were present in each organization. Thus, it is important to assess the prevalence of members with differing individual satisfaction/burden levels in each organization and set a high-priority target group for intervention. Moreover, based on the characteristics of each group, development of strategies for each one could be effective.

Several limitations of our research should be noted. First, this was a cross-sectional study. Hence, we cannot explain causal relationships. In this study, we set the variables based on the Volunteer Process Model. However, a longitudinal study design could provide more robust and useful evidence. Second, we used combined data from Koka and Kona because the HPV organizations of those cities work in cooperation with each other. However, we adjusted for the differences between the two cities in the analysis. Third, this study was conducted only on Japanese HPVs, with the target HPV organizations limited to those in two areas. The activities of HPVs in Japan are similar to those performed by CHWs in the United States, but the cultural backgrounds of communities are different between the two countries. Although this study provides clear evidence regarding ways to encourage HPVs, to increase the generalizability of the findings future studies should include different settings (e.g., different countries or municipalities with different cultural backgrounds). Fourth, the study data were collected in 2005. Although there have not been any significant changes in HPV activities related to policy, organizational management, or their role in the community, we must carefully interpret the findings in this study, taking into consideration the data collection period.

Grassroots HPV activities have the potential to promote the health of the community. We confirmed that HPVs who feel satisfied and lightly burdened are instrumental in promoting HPV community-based activities. In addition, our study suggests the importance of improving activity environments surrounding HPVs. Thus, it is important to assess levels of activity satisfaction and burden among HPVs and develop policies that contribute to building better activity environments.

For this study, an anonymous, self-administered questionnaire was mailed directly to the participants. A statement attached to the questionnaire explained the purpose of the study, that participation was voluntary, and a promise of anonymity. Return of the questionnaire was taken as consent to participate in the survey. The survey was explained to and approved by the HPV associations of Koka and Konan and the municipalities of both cities. The study was conducted after obtaining approval from the Ethics Committee of the Graduate School of Medicine and Faculty of Medicine at The University of Tokyo (No. 1182, in 2005).