Users Online: 804 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size


Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2020  |  Volume : 64  |  Issue : 4  |  Page : 351-356  

Occupational stress and coping strategy among community health workers of Mangalore Taluk, Karnataka

1 MPH Scholar, Department of Public Health, K S Hegde Medical Academy, Nitte (Deemed to be University), Mangalore, Karnataka, India
2 Assistant Professor, Department of Public Health, K S Hegde Medical Academy, Nitte (Deemed to be University), Mangalore, Karnataka, India

Date of Submission30-Nov-2019
Date of Decision01-Apr-2020
Date of Acceptance21-Jul-2020
Date of Web Publication11-Dec-2020

Correspondence Address:
Mackwin Kenwood D'mello
Department of Public Health, K. S. Hegde Medical Academy, Nitte (Deemed to be University) Mangalore - 575 018, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_549_19

Rights and Permissions

Background: Understanding the stress related to work among community health workers (CHWs) might be beneficial to plan intercessions to draw in and spur health-care professionals to toil in remote and disadvantaged region as well as to guarantee the quality of care. Objectives: This study was conducted to determine the prevalence, level, and sources of occupational stress among CHWs and coping strategies adopted by the CHWs. Methods: This cross-sectional study was conducted from January to April 2019 among 347 CHWs in 16 Primary Health Centres of Mangalore taluk, Karnataka. Occupational Stress Index and the Brief COPE scale were used to assess the stress level and coping strategy, respectively. Descriptive statistics and Chi-square test were used. The P = 0.05 was considered as significant. Results: The prevalence of occupational stress was found to be 40.5%. Stressors such as under participation, powerlessness, low status, and unprofitability were significantly associated with occupational stress. CHWs used various coping strategies such as self-distraction, active coping, denial, substance use, behavioral disengagement, venting, positive reframing, humor, and self-blame to manage their stress. Conclusion: Stress intercession programs could be conducted on a regular interval to make CHWs “stress-free”. Higher stress level might impede the performance of the workers, and hence addressing this is necessary. Similarly, positive coping strategies, such as active coping, should be promoted to manage stress.

Keywords: Auxiliary nurse midwife, accredited social health activist, community health workers, coping strategy, Mangalore Taluk, multipurpose workers, occupational stress

How to cite this article:
Aryal S, D'mello MK. Occupational stress and coping strategy among community health workers of Mangalore Taluk, Karnataka. Indian J Public Health 2020;64:351-6

How to cite this URL:
Aryal S, D'mello MK. Occupational stress and coping strategy among community health workers of Mangalore Taluk, Karnataka. Indian J Public Health [serial online] 2020 [cited 2022 Aug 12];64:351-6. Available from:

   Introduction Top

Community health-care broadens the healthcare services which ensure that the masses access them at the lowest level. Their presence at grassroots-level helps in “effective, democratic, and sustainable delivery” of health care to the remotest of areas.[1] Notably, in low- and middle-income countries, they have become “part and parcel” of health systems and their involvement is viewed as a strategic response to the shortage of health personnel. They provide many services, starting from general health promotion and education services to more advanced and specialized care such as maternal and child health, tuberculosis, and HIV/AIDS care, implementing National Programs at grass-root levels or malaria control.[2],[3],[4],[5] The establishment of primary health care mainly focused on providing wide ranges of services such as prevention, treatment, management, rehabilitation, and palliation along with achieving sustainable development goals (SDGs) and universal health coverage. Well trained and highly motivated health-care providers are essential for making robust primary health care.[6],[7],[8],[9]

More than 50 years ago, stress was implanted in our daily lives, and the term is now in popular parlance and co-existed as a perplexing as well as dynamic transaction amongst people and their environment.[10] Stressors, as a whole, can be termed as circumstances or else actions that can influence wellbeing.[11] Stress can be seen as a psychological threat, in which an individual perceives a situation as a potential danger.[12] Extreme strain can be harmful to overall performance, and health professional whose stress levels is high seems to become more depressed. As a result, this depression can prompt other psychological wellbeing issues, for example, overindulgence in alcohol or disproportionate substance use or not coordinating well in working as well as in the personal environment.[13] Thus, occupation-related stressors summons the entire region of acquiring plus accomplishing and acclimating to another condition, where much substance must be acclimatized in a brief period.[14]

Many reports have emerged from worldwide, saying that occupation-related stress is increasing at an exponential rate. Health-care professionals who tend to involve in community services also face stress which is not evaluated. The possible reason of occupational stress might be attributed to working hours, the compensation for execution of the work; the structure and the atmosphere of the association where work is done; the vocation advancement (troubles of promotion and the risk of joblessness), the job inside the association (obligation in connection to individuals) and the working relationships with bosses, partners, and subordinates.[15],[16],[17],[18] The entire perspective remained less studied, particularly in different geographical areas of the country. In this context, the present study was conducted to determine the prevalence, the sources, the level and coping strategy of occupational stress among community health workers (CHWs) in an area of Karnataka.

   Materials and Methods Top

Study design and study setting

This cross-sectional study was conducted in selected Primary Health Centers (PHCs) of Mangalore Taluk, Karnataka, over a period of 4 months from January to April 2019.

Study population and sampling strategy

CHWs, i.e., accredited social health activist (ASHA), auxiliary nurse midwives (ANM), and multipurpose workers (MPWs) working in the PHCs constituted the study population. A two-stage sampling technique was used to select the study subjects. In the first stage, 16 PHCs (50%) were selected through the lottery method out of total thirty-one PHCs. In the second stage, all the CHWs working in the selected PHCs were included in the study. The comprehensive list of health workers was obtained from District health office of Mangalore. In Mangalore taluk, there were 362 CHWs in 16 selected PHCs. Finally, a total sample of 347 CHWs was studied.

Data collection – Tools and techniques

A self-administered pretested structured questionnaire was used as a tool for data collection. The questionnaire was translated into the Vernacular language (Kannada) for convenience and easy understanding among participants.

The tool consisted three parts: First part contains sociodemographic characteristics of the study population (age, sex, marital status, years of experience, types of residence, monthly salary, etc.); second part - Occupational Stress Index (OSI); and the third part - Brief COPE Scale:

Occupational Stress Index

A well developed and widely used OSI in the Indian context (Srivastava and Singh 1981) was chosen to assess the occupational stress of the subjects. The questionnaire consists of 46 statements with five alternative responses based on 5-point Likert scale, for example, score 5 for strongly agree, score 4 for agree, score 3 for undecided, score 2 is for disagreeing, and score 1 for strongly disagree. The total score on this scale was considered for the assessment of occupational stress. Higher the score on OSI, higher is the level of stress. Forty-six items were further categorized into 14 divisions, namely role overload, role ambiguity, role conflict, unreasonable group and political pressures, responsibility for persons, under participation, powerlessness, poor peer relations, intrinsic impoverishment, low status, strenuous working conditions, unprofitability.[19] According to the scale scores, the CHWs occupational stress was divided into a low level of occupational stress (total score: 46–122), moderate level of occupational stress (overall score: 123–155), and high level of occupational stress (total score: 156–230). This categorization of the score was based on mean ± standard deviation and with the reference of the study conducted in Egypt.[20]


The Brief COPE, developed by Dr Charles Carver, was used to assess a broad range of coping behaviors among adults with or without clinical conditions. It comprises of 28 items, and each item was appraised on a 4-point Likert scale running from “I have not been doing this at all as Never (score 1),” “I have been doing this a little bit as Rarely (Score 2),” “I have been doing this in a medium amount as Occasionally (Score 3), and “I have been doing this a lot as Frequently (Score 4).” The higher score demonstrates greater coping by the respondents. The items were scored to deliver 14 measurements, each mirroring the use of coping technique: active coping, planning, acceptance, denial, self-distraction, use of the substance, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, humor, religion, and self-blame.[21]

Validity/reliability of the tools

The pilot study was conducted before the original study in a similar survey setting to check the feasibility of the study and reliability of the study tools. A total of 35 CHWs were included in the pilot study. Modifications of some of the questionnaires were done after the pilot study. The validity of the tool was maintained consulting two or more than two professionals, and Cronbach alphas were calculated for the reliability of scales. The Cronbach alpha for the OSI was found to be 0.711, whereas, for the Brief COPE scale, it was found to be 0.863.

Ethical considerations

The study was approved by the Institutional Ethics Committee of K S Hegde Medical Academy (Ref: INST.EC/EC/134/2018-19, date of approval: October 09, 2018). In addition, formal approval was also taken from the District Health Officer of Dakshina Kannada. After mentioning the purpose of the study, patient consent declaration form was distributed to the study subjects. Only those agreed to participate in the study were enrolled. CHWs were assured that participation would not affect their daily activities. Incomplete questionnaires were not included in the study.

Statistical analysis

The data were coded, entered, and analyzed using SPSS (Statistical Package for Social Science) version 23. Sociodemographic variables were described as frequency, percentage. The Shapiro-Wilk test was used to assess the normality of the data. Data were not normally distributed, so the test of association, such as Chi-square and likelihood ratio, was applied. The level of P = 0.05 was taken as statistically significant. The mean prevalence was calculated for moderate and severe stress using geometric mean formula (low stress was considered as normal stress for any work, hence was not considered).

   Results Top

A total of 347 health workers participated in this study. Among them, 238 were ASHA, 84 were ANM, and 25 were MPWs. The mean age of the participants was 39.86 ± 8.05 years, and 335 (96.5%) were female. The majority (335 [96.5%]) were married, 275 (79.3%) had a family size =5, and 276 (79.5%) were residing in their own house. Among married participants, 308 (91.9%) had children =2. Among 238 ASHA workers, 200 (84%) agreed that they received performance-based incentives, and the majority [98 [49%]) received less than Rs. 1000/month. All the participants reported that they had a vacant position in the PHCs where they were working, and they had to cover up the work of the vacant post as well. One-fourth (25%) of the ANM and 40% of MPW's attained graduation course prior to health professional training, while only 6.7% of ASHA workers had graduation degree and 12.4% had completed 10th standard.

[Table 1] shows the distribution of occupational stress among CHWs. The mean prevalence of occupational stress among CHWs was found to be 40.5%. The mean score for occupational stress was found to be 133.63 ± 13.78 with a range of 92–168. The total score of occupational stress was 230. The results showed that the majority (70.6%) of CHWs had a moderate level of occupational stress, followed by 23.3% and 6% with a severe and low level of occupational stress respectively.
Table 1: Prevalence and level of occupation stress (n=347)

Click here to view

[Table 2] represents the coping strategies adopted by CHWs. CHWs reported that they never use substance use and humor as the coping strategies to manage their stress.
Table 2: Coping strategies adopted by community health workers (n=347)

Click here to view

[Table 3] represents the association of occupational stress with various demographic factors. Occupational stress was found to be significantly associated with years of experience (P < 0.01), incentives received per month (P < 0.001), and monthly salary (P < 0.016). However, no evidence of association was observed between occupational stress and other socio-demographic factors such as age, gender, education, job position, the population covered, number of field visits, and monthly income. Occupational stress was significantly associated with various stressors such as under participation, powerlessness, low status, and unprofitability.
Table 3: Association of occupational stress with occupational factors and stressors (n=347)

Click here to view

The association between occupational stress and coping strategies was assessed. Statistically, a significant association was found between occupational stress and various coping strategies such as self-distraction, active coping, denial, substance use, behavioral disengagement, venting, positive reframing, humor, and self-blame, respectively. However, no evidence of association was found between occupational stress and coping strategies such as the use of emotional support, planning, acceptance, and religion.

   Discussion Top

The prevalence of occupational stress among CHWs was found to be 40.5%. Majority of CHWs had a moderate level (70.6%) followed by low level (23.3%) and high (6.1%) level of occupational stress in the present study. The mean scoring of occupational stress was 133.63 ± 13.77. The study conducted in Neelamangala found that majority of the frontline health workers have moderate stress (52.1%) followed by mild stress (37.1%), and severe stress (10.7%).[22] Although these findings were matched on the level of stress, statistics between these two studies differ.

The current study shows no significant association between demographic variables such as age, gender, job position, education, number of field visits in a week, and the total population covered under their jurisdiction with occupational stress. The study conducted by Spoorthy et al. also shows no significant association between socio-demographic variables with stress.[22] However, in the present study, years of experience, performance-based incentives received per month, and a monthly salary is significantly associated with occupational stress. Similarly, the study conducted in North Ethiopia found that socio-demographic variables such as sex, marital status, and work experience were significantly associated with work-related stress.[23]

A study conducted in Tamil Nadu reveals that women working in a health-care setting face higher stress than those working in communication, education, or retails service settings. Unexpected additional work, unscheduled time off work, and work-related pressure from various work spot were found to be the significant factors for higher stress.[24] Since, CHWs also work in healthcare settings, a higher level of stress among them is understandable. Similarly, the study conducted among women professionals in Bengaluru city reported that doctors were found to be more stressed in comparison to lawyers and engineers. Role overload, role conflict, and strenuous working condition were significant stressors among doctors.[25]

The study conducted in Allahabad city reveals that the women working in private sectors were found to be more stressed than women working in government sectors. Competitive nature of the job and higher pressure imposing to the employees were significant stressors. However, the working domain of women was not stated in the study.[26] Similarly, the study conducted in south Kerala reported that women police officers were found to be stressed because of staff shortage, and finding time to stay in good physical condition.[27]

In the present study, sources of occupational stress such as under participation, powerlessness, low status, and unprofitability were found to be significantly associated with CHWs. Similarly, a study conducted in the Netherlands and Ethiopia found that economic self-sufficiency was the major stressors among health workers, and it was significant.[28],[29] The major reason might be the difference in the health workforce and disparities between the health workers.

CHWs were found to be adopting various coping strategies to manage their occupational stress in the present study. Positive coping strategies such as active coping, venting, positive reframing, and humor were significantly associated with occupational stress. Similarly, avoidant coping strategies such as self-distraction, denial, substance use, behavioral disengagement, and self-blame was also significantly associated with occupational stress among CHWs.

The study conducted in Nigeria and Greece reported that health workers use positive re-appraisal, quitting, and looking for social support as coping strategies to manage their emotions as well as physical health.[23],[30] Similarly, a study conducted among social workers found that adopting a positive coping strategy leads to low occupational stress whereas negative coping strategy leads to more occupational stress.[31]

The strength of the current study was that a pretested standard questionnaire was used to assess occupational stress and a universal sample was taken for the study from the selected PHCs. However, the weakness of the study was that the nature of the causality in which occupational stressors is used to predict occupation stress was still unclear due to cross-sectional design. Furthermore, since the study used a self-administered questionnaire, recall bias could be predominant, and there was no means/tool to verify/validate the responses given by health workers were correct, accurate, and truthful.

   Conclusion Top

The prevalence of occupational stress among CHWs of Mangalore taluk was 40.5%. It was apparent from the study that predictors such as under participation, powerlessness, low status, and unprofitability were the primary sources of occupational stress. Improvement in remuneration, appreciation, and a structured career path could be ensured for better performance of CHWs. Subsequently, more in-depth analysis is needed to assess how usage of coping skills affects occupational stress.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Pandey J, Singh M. Donning the mask: Effects of emotional labour strategies on burnout and job satisfaction in community healthcare. Health Policy Plan 2016;31:551-62.  Back to cited text no. 1
Hazarika I. Health workforce in India: Assessment of availability, production and distribution. WHO South East Asia J Public Health 2013;2:106-12.  Back to cited text no. 2
The Lancet Global Health. Community health workers: Emerging from the shadows? Lancet Glob Health 2017;5:e467.  Back to cited text no. 3
Mills A. Health care systems in low- and middle-income countries. N Engl J Med 2014;370:552-7.  Back to cited text no. 4
Frenk J. Reinventing primary health care: The need for systems integration. Lancet 2009;374:170-3.  Back to cited text no. 5
Dugani S, Afari H, Hirschhorn LR, Ratcliffe H, Veillard J, Martin G, et al. Prevalence and factors associated with burnout among frontline primary health care providers in low- and middle-income countries: A systematic review. Gates Open Res 2018;2:4.  Back to cited text no. 6
Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.  Back to cited text no. 7
Campbell J, Dussault G, Buchan J, et al. Universal Truth: No health without a Workforce [Internet]. Available from: [Last cited on 2018 Dec 17].  Back to cited text no. 8
Guilbert JJ. The World Health Report 2006: Working together for health. Educ Health (Abingdon) 2006;19:385-7.  Back to cited text no. 9
Al-Sowygh ZH. Academic distress, perceived stress and coping strategies among dental students in Saudi Arabia. Saudi Dent J 2013;25:97-105.  Back to cited text no. 10
Sheidow AJ, Henry DB, Tolan PH, Strachan MK. The role of stress exposure and family functioning in internalizing outcomes of Urban families. J Child Fam Stud 2014;23:1351-65.  Back to cited text no. 11
Hamaideh SH. Gender differences in stressors and reactions to stressors among Jordanian university students. Int J Soc Psychiatry 2012;58:26-33.  Back to cited text no. 12
Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. The mental health of hospital consultants: The effects of stress and satisfaction at work. Lancet 1996;347:724-8.  Back to cited text no. 13
Ivancevich JM, Napier HA, Wetherbe JC. An empirical study of occupational stress, attitudes and health among information systems personnel. Inf Manage 1985;9:77-85.  Back to cited text no. 14
Purohit B, Vasava P. Role stress among auxiliary nurses midwives in Gujarat, India. BMC Health Serv Res 2017;17:69.  Back to cited text no. 15
Mkoka DA, Mahiti GR, Kiwara A, Mwangu M, Goicolea I, Hurtig AK. “Once the government employs you, it forgets you”: Health workers' and managers' perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania. Hum Resour Health 2015;13:77.  Back to cited text no. 16
Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews 2014;11:CD002892.  Back to cited text no. 17
Jaeger FN, Bechir M, Harouna M, Moto DD, Utzinger J. Challenges and opportunities for healthcare workers in a rural district of Chad. BMC Health Serv Res 2018;18:7.  Back to cited text no. 18
Srivastava AK, Singh AP. The Occupational Stress Index. Varanasi: Manovaigyanik ParikshanSansthan; 1984.  Back to cited text no. 19
Desouky D, Allam H. Occupational stress, anxiety and depression among Egyptian teachers. J Epidemiol Glob Health 2017;7:191-8.  Back to cited text no. 20
Carver CS. You want to measure coping but your protocol's too long: Consider the brief COPE. Int J Behav Med 1997;4:92-100.  Back to cited text no. 21
Sagar S, Ravish KS, Ranganath TS, Ahmed MT, Shanmugapriya D. Professional stress levels among healthcare workers of Nelamangala: A cross sectional study. Int J Community Med Public Health 2017;4:4685-91.  Back to cited text no. 22
Godifay G. Work-related stress among health care workers in Mekelle city administration public hospitals, North Ethiopia. J Health Med Nurs 2018;46:189-95.  Back to cited text no. 23
Thirumaleswari T. Exploring the evidence of occupational stress to burnout among working women in selected service sectors in Tamil Nadu. IJMS 2015;1:173-82.  Back to cited text no. 24
Srikumar A, Ravi V. A study of occupational stress among women professionals. Int J Sci 2015;4:16-18.  Back to cited text no. 25
Shobana S, Chacko N, Verma R, Mathur A. A comparative study on occupational stress among women working in Government and Private Sector. Int J Recent Sci Res 2016;7:12292-4.  Back to cited text no. 26
Vivek S, Varghese RG, Neethumol KS, Sameena SS, Reju RS, James P, et al. Occupational stress among female police officers in an urban setting in South Kerala. Int J Community Med Public Health 2019;6:325-9.  Back to cited text no. 27
Blekemolen JRM, Hulshof CTJ, Sluiter JK. The Prevalence of Work-Related Stress Complaints among Healthcare Workers for the Disabled Participating in a Workers' Health Surveillance Program. Occup Med Health Aff 2016;4:256.  Back to cited text no. 28
Selamu M, Thornicroft G, Fekadu A, Hanlon C. Conceptualisation of job-related wellbeing, stress and burnout among healthcare workers in rural Ethiopia: A qualitative study. BMC Health Serv Res 2017;17:412.  Back to cited text no. 29
Koinis A, Giannou V, Drantaki V, Angelaina S, Stratou E, Saridi M. The impact of healthcare workers job environment on their mental-emotional health. Coping strategies: The case of a local general hospital. Health Psychol Res 2015;3:1984.  Back to cited text no. 30
Gellis ZD. Coping with occupational stress in healthcare. Administ Soc Work 2002;26:37-52.  Back to cited text no. 31


  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Burnout and sleep quality among community health workers during the pandemic in selected city of Andhra Pradesh
Yella Tanuja, Mackwin K. Dmello
Clinical Epidemiology and Global Health. 2022; : 101109
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Materials and Me...
    Article Tables

 Article Access Statistics
    PDF Downloaded377    
    Comments [Add]    
    Cited by others 1    

Recommend this journal