|Year : 2015 | Volume
| Issue : 2 | Page : 95-101
Stress, anxiety, and depression among call handlers employed in international call centers in the national capital region of Delhi
Dinesh Raja Jeyapal1, Sanjiv Kumar Bhasin2, Anjur Tupil Kannan3, Manjeet Singh Bhatia4
1 Assistant Professor, Department of Community Medicine, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
2 Professor, UCMS and GTB Hospital, Delhi, India
3 Professor and Head, Departments of Community Medicine, UCMS and GTB Hospital, Delhi, India
4 Professor and Head, Department of Psychiatry, UCMS and GTB Hospital, Delhi, India
|Date of Web Publication||25-May-2015|
Dinesh Raja Jeyapal
Department of Community Medicine, Saveetha Medical College and Hospital, Chennai - 602 105, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Call handlers employed in call centers repeatedly undergo stress in their day-to-day lives and this can have deleterious effects on their health. Objectives: The objectives were to study the levels of stress, anxiety, and depression, and their predictors among call handlers employed in international call centers in the National Capital Region (NCR) of Delhi. Materials and Methods: A cross-sectional questionnaire-based survey was conducted among 375 call handlers aged 18-39 years. Depression Anxiety Stress Scale- 42 (DASS-42) was used to measure stress, anxiety, and depression along with a pretested sociodemographic questionnaire. Univariate analysis was done to find out the association of stress, anxiety, and depression with various factors. Variables with P < 0.25 were included in multiple logistic regression and three models were developed each for stress, anxiety, and depression. Results: The prevalence of stress, anxiety, and depression among call handlers was 46.7%, 57.1%, and 62.9% respectively. Abnormal sleep quality, prolonged travel time, and lack of relaxation facilities at the office were predictors of stress and depression. The presence of physical ailments, the absence of hobbies, temporary/part-time employment, and traveling long-distance to office were significant predictors of anxiety among call handlers. Conclusion: Call handlers face a high burden of stress, anxiety, and depression. Public health specialists need to pay adequate attention to their health problems.
Keywords: Anxiety, call centers, call handlers, depression, stress
|How to cite this article:|
Jeyapal DR, Bhasin SK, Kannan AT, Bhatia MS. Stress, anxiety, and depression among call handlers employed in international call centers in the national capital region of Delhi. Indian J Public Health 2015;59:95-101
|How to cite this URL:|
Jeyapal DR, Bhasin SK, Kannan AT, Bhatia MS. Stress, anxiety, and depression among call handlers employed in international call centers in the national capital region of Delhi. Indian J Public Health [serial online] 2015 [cited 2020 Feb 18];59:95-101. Available from: http://www.ijph.in/text.asp?2015/59/2/95/157508
| Introduction|| |
With newer occupations and changing workplaces, unique occupational health hazards are emerging in India. Emerging new occupations like those in call centers pose a host of new health challenges particularly those related to mental and social health. India is a leading destination of offshore services owing to a large population of well-educated English-speaking young people with computer skills.  International call centers are one of the most sought after workplaces for young graduates due to good work environment, attractive lifestyle, and remuneration packages.  The National Capital Region (NCR) like other metropolitan cities has become an important hub of call center industry.
When a company concentrates on the core business and out sources its noncore activities like payment services, customer services, and administration, then it is referred to as Business Process Outsourcing (BPO). A call center can be identified as the voice-based part of a BPO organization.  While employment in the BPO sector has meant that young adults are reaching their career milestones and financial goals much earlier than before, surveys and anecdotal evidence show that workers in the BPO sector experience high levels of stress and its related disorders. Brown more vividly characterizes the work as "repetitive brain strain." 
The available literature revealed many studies on Indian call centers in the domains of Sociology, Management, and Psychology, with very few in the public health domain mostly using small sample sizes. ,,,,,,,,,,, The present study was designed to study the levels of stress, anxiety, and depression, and their predictors among call handlers employed in international call centers in the NCR region with a fairly large sample size.
| Materials and Methods|| |
This was a cross-sectional, descriptive study conducted in the year 2012. Permission for carrying out the study was obtained from the institute's Ethics Committee. A call handler is an employee in an international call center involved in customer services whose job requires him/her to spend a significant proportion of his/her working time responding to calls on the telephone while simultaneously using Display Screen Equipment.  Call handlers in the age group of 18-39 years and employed for more than 2 months were included in the study.
At a 33% prevalence of stress,  95% confidence level, and 5% absolute precision, the sample size came out to be 354. Thus for the purposes of the present study, 375 subjects were studied. Sampling was done in two stages. In the first stage, three different lists of international call centers (in Delhi, Gurgaon, and Noida) were prepared. This constituted the sampling frame of international call centers. Five call centers were selected randomly from each list using random number tables. In the second stage, all call handlers entered in the attendance register of each call center were brought in from the manager and each call handler was numbered. This was our sampling frame. In each call center, 25 call handlers (sampling units) were interviewed. Out of each list, the first call handler was selected by using the last digit of a randomly picked currency note. Subsequently, using the required sampling interval, 25 call handlers were included in the study using systematic random sampling. Personal interviews were conducted at the respective call centers using structured questionnaires after obtaining informed consent.
Data were collected using a validated, self-administered Depression, Anxiety, and Stress Scale (DASS 42)  along with a pretested, self-prepared, structured questionnaire that consisted of sociodemographic details, lifestyle, dietary habits, and work conditions of call handlers. The DASS is in the public domain  and is a set of three self-report scales designed to measure the negative emotional states of depression, anxiety, and stress, the details of which are given in their website.  In each item, the respondents are to rate the extent to which they have experienced the given state over the past week, using a 4-point severity scale. Scores for depression, anxiety, and stress are calculated by summing the scores for the relevant items. Sleep quality was assessed using an 8-item Athens Insomnia Scale wherein each item was scored on a 4-point scale and a higher score indicated more severe sleep problems. The total score ranged 0-24 and was graded as follows: <4 = no sleep problem, 4 or 5 = some suspicion of insomnia, and ≥6 suspected insomnia. 
Data were analyzed using SPSS software (SPSS Inc., Released 2007. SPSS for Windows, Version 16.0. Chicago). Univariate analysis was done to find the association of stress, anxiety, and depression with various factors using the chi-square test. Variables with P < 0.25 were included in multiple logistic regression (backward likelihood ratio), and three models were developed each for stress, anxiety, and depression. Variables that were found to be collinear were not entered in the final regression model. The criterion for entering and removing the independent variables from the backward stepwise model was P < 0.05. The Hosmer-Lemeshow goodness of fit test was applied.
| Results|| |
Of the total of 375 call handlers studied, the majority (78%) were males and the rest were females. The mean age was 24.6 ± 2.4 years. Of the respondents, 83.5% were unmarried, 15% were married, and the rest were in live-in relationships or divorced. Regarding education, 82% call handlers were graduates and 8% were postgraduates, while none had reached an educational level less than senior secondary degree. The highest and lowest paid salaries were Rs. 40000 and Rs. 7000 per month respectively, with a vast majority (96.7%) earning >Rs. 10,000 per month. Of the call handlers, 49.3% were permanent employees, while the rest were either temporary or part-time employees. Most of them worked in either the night shift or a changing shift (51.5% and 28.3% respectively), and the rest in the day shift. Regarding work hours, 87.2% respondents worked for 9-12 h per day and 12.8% for 7-<9 h per day (mean 9.2 ± 0.7 h). A majority (74%) attended 100 or less calls per day, while the rest attended >100 calls per day.
The prevalence of stress, anxiety, and depression among call handlers employed in international call centers in Delhi NCR was 46.7%, 57.1%, and 62.9% respectively [Figure 1]. For the purpose of finding association stress, anxiety, and depression were dichotomized into two groups, i.e., the categories "mild," "moderate," "severe," and "extremely severe" were merged and renamed "present" while the category "normal" was renamed "absent." Variables found significant (P < 0.05) on univariate analysis for stress, anxiety, and depression are shown in [Table 1]. However, there was no statistically significant association was found between stress, anxiety, and depression among call handlers and their gender or their marital status (P > 0.25).
|Figure 1: Levels of stress, anxiety, and depression among call handlers (using DASS 42)|
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|Table 1: Variables found signifi cant for stress, anxiety and depression on univariate analysis (N = 375)|
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To find the predictors of stress, anxiety, and depression, multiple logistic regression was applied. Independent variables were selected by univariate method (chi-square), having P < 0.25, and three models were developed each for stress, anxiety, and depression. The following were the other variables included in the stress model: Salary of call handlers/month (P = 0.092), alcohol use (P = 0.214), facing verbal abuse at workplace (P = 0.131), physical ailments (P = 0.083), type of shift (P = 0.112), and availability of cab facility to office (P = 0.158). Nature of employment (P = 0.074), job tenure (P = 0.061), sleep quality (P = 0.083), alcohol use (P = 0.084), skipping food (P = 0.127), facing verbal abuse at workplace (P = 0.216), workload (P = 0.233), time for hobbies/games (P = 0.242), type of shift (P = 0.066), and shift duration (P = 0.238) were the other variables included in the anxiety model. Age of call handlers (P = 0.247), salary per month (P = 0.152), alcohol use (P = 0.221), smoking status (P = 0.160), skipping food (P = 0.080), physical ailments (P = 0.132), availability of cab facility to office (P = 0.084), distance traveled to office (P = 0.126), time spent per call (P = 0.222), and facing hostile customers on phone (P = 0.137) were other variables included in depression model. The final predictor variables of stress, anxiety, and depression among call handlers are depicted in [Table 2].
|Table 2: Predictors of stress, anxiety and depression among call handlers (regression analysis)|
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| Discussion|| |
It has been opined that stress is not only an individual problem, but is also located within "a framework that emphasizes the interrelationships between structural relations of power and the subjective interpretations and actions of employees."  Chronic exposure to stress can result in long-lasting changes in the brain's biology. These long-lasting changes may alter the functional states of various neurotransmitter and intraneuronal signaling systems, changes that may even include the loss of neurons and an excessive reduction in synaptic contacts. As a result, a person is at a high risk of undergoing subsequent episodes of depression, even without an external stressor. 
A significantly large proportion of call handlers were found to have high levels of stress, anxiety, and depression. Previous studies, too, have reported such high levels among call center employees. ,,,,,,,, Though the depression level reported by Suri et al.  was in concordance with our study, we did not employ any controls. Also, none of them have comprehensively assessed all three negative states together. Most of these studies have been done on different study areas (domestic and international call centers) employing smaller sample sizes and different study tools to measure stress, anxiety, and depression.
Most international call centers in Delhi NCR operate at night, corresponding to a time suitable to their international customers mostly from USA, UK, Australia, and Germany. Such erratic work timings are often called "graveyard shifts" or "UK-USA shift" by a few researchers. , This could challenge the individual's circadian rhythm because the sleep-wake internal clock setting is at odds with the sleep-wake cycle of the shift schedule. Sleep deprivation can further complicate his/her health as it can result in stress, fatigue, depression, irritability, and a predisposition to infections. ,, Some call handlers in order to cope with the physical and psychological stress develop poor eating habits in the form of junk foods, overeating, skipping meals, smoking, alcohol and narcotics use, and high intake of stimulants (tea, coffee, cola) in order to work through the night. Such peculiar food habits can result in frequent headaches, fatigue, sleepiness, and obesity. ,,, Night shift duties and long working hours negatively affect psychological health and can result in stress and anxiety among call center employees.  According to Vaid et al. among the various factors considered to cause stress at work, travel time was one major factor.  Standard Psychiatry textbooks have mentioned a strong association of physical ailments like musculoskeletal disorders with anxiety.  Honda et al. found that having breaks in between work involving computers is a protective factor against mental health disorders.  Therefore, the need for availability of adequate relaxation time and facilities at their offices stands substantiated. The study by Kuruvilla et al. that claimed that the number of call center employees seeking psychological and counseling help had increased owing to tremendous stress at work, stands further validated. 
Our study did have certain limitations. Since it was a cross-sectional study, the issue of temporality is a barrier in understanding the association of various factors like sleep quality and physical ailments with stress, anxiety, and depression. Whether stress, anxiety, and depression preceded or succeeded these factors is difficult to delineate. Ours was a quantitative, descriptive enquiry to document stress, anxiety, and depression levels in call handlers. We felt that alongside quantitative design, qualitative aspects like focus group discussions and in-depth interviews may have brought some more aspects of the disease to the fore. The NCR of Delhi consists of many satellite towns and other smaller towns, such as Gurgaon, Noida, Faridabad, Ghaziabad, Rohtak, and Meerut. For feasibility purposes, we included international call centers located only in Delhi, Noida, and Gurgaon. We wished we could have included other cities of NCR also to enable a more comprehensive documentation. The number of female call handlers in our study was only 22%. The investigator did not anticipate this at the beginning of the study, otherwise some changes could have been implemented in the methodology to get a reasonably fair representation of female call handlers.
Severe to extremely severe levels of stress, anxiety, and depression were found among 6.7%, 22.9%, and 16% call handlers respectively. We felt that these would be the subjects who might need counseling or medication in the immediate future. In view of a high prevalence of stress, anxiety, and depression among call handlers, there is a need for destressing and counseling facilities at the call centers. In the meantime, part-time counselors in liaison with a mental health facility can be appointed to help these call handlers. Periodic health examinations may be conducted for the early detection and treatment of psychological disorders and other lifestyle diseases among call handlers by engaging psychologists, psychiatrists, and public health physicians. However, a bigger challenge lies in formulating a preventive and promotive program for such a new occupation as call handling. At the initiation/orientation phase of the appointment of call handlers, simple and practical Information, Education and Communication (IEC) messages can lead to a healthy environment. The importance of a stress-free life, healthy lifestyle, exercise, and pursuit of hobbies should be stressed upon. Also, more such studies need to be conducted to add to the existing database to make a strong advocacy for better understanding of stress, anxiety, and depression among call handlers.
Traditionally, public health physicians have concentrated mainly on the conventional workforce, like agricultural and industrial workers. With the advent of new occupations like call handlers, there is a need to concentrate on this significant workforce and public health issues related to them, as well.
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[Table 1], [Table 2]