Gender, caste discrimination, mistreatment by superiors: Mental stress takes a toll on ASHA workers, shows study

“I started feeling anger in my body, I started shouting at children, because I have to do household chores as well. I even have fights at home, as a result of what happens at work.”

“Sometimes I feel frustrated and tense. I start thinking that I should not work anymore and it's better to just leave the job.”

“There are times we are not able to eat as well; we fall sick, we feel dizzy, or some or the other thing. But who is looking after us?”

These are some of the distressed anecdotes shared by Accredited Social Health Activists (ASHA) workers of Sehore district, Madhya Pradesh during a study. 

Most published evidence on ASHAs has focused on their workplace challenges, without sufficiently probing into the nature of individual-level work stress and their responses to stress, according to the study led by Ritu Shrivastava, research coordinator at Sangath, a Goa-based not-for-profit working on psychological and social interventions. 

Moreover, over 50 per cent of the articles in a review of 122 articles found that 10 years of research on ASHAs’ work included only the health system perspective, according to findings published recently in the journal Social Science and Medicine

This study, however, elicited responses from ASHAs employed by the National Rural Health Mission on the high stress levels they face due to their demanding job as the country’s frontline healthcare workers.

Six focus groups of 59 ASHA workers talked about their individual experiences of work stress, particularly in terms of workload, perceptions as a result of caste, gender as well as relationships, and psychological symptoms, among other interrelated factors. 

Focus group discussions were conducted between December 2021 and March 2022 at neutral locations such as the Sangath project office, and other block-level offices. 

The women narrated instances when they experienced discrimination based on their caste. One of them recollected a time when she was not allowed inside the home of residents belonging to a higher social caste. In another instance, an ASHA described a similar instance during which she was allowed to enter such a house but was still not allowed to sit on the bed or chair.

Another issue commonly brought up by the frontline healthworkers was disrespectful behavior by community members when they are seen in public with men who are not their family members. They are often subjected to derogatory comments, they shared.

The women are questioned about their character when they communicate with male relatives of a patient, they complained. This also happens when they counsel male clients on reproductive health or family planning.

“Being a woman, some people laugh at us and say that we provide condoms to people, to which we tell them that it is our work,” an ASHA said.

On occasions, ASHAs were visited by men staying in the village at night for unnecessary reasons such as asking for family planning advice.

Most ASHAs have described their working experience with the ASHA supervisor, auxiliary nurse midwife (ANM), medical officer and supporting hospital staff as unhealthy, bordering on toxic, the researchers described.

In a harrowing instance, an ASHA worker narrated that during an emergency, when a hospital bed was not available, she helped a patient find accommodation in a nearby hotel. After this, an ANM filed a police complaint without listening to an explanation.

Insensitivity is the common thread. The worker said, “I told Ma’am (supervisor) that I was sick, and would not be able to come. She responded that I will have to come to the PHC and write down the reason why I cannot perform the day’s duties …’’

Societal expectations make work-life balance difficult for these caregivers, they become unhealthily accustomed to the dual nature of work stress and domestic stress, the researchers said.

Many reported conflicts at home because of the nature of work, sometimes leading to divorce threats. An ASHA worker shared that her mother-in-law had once told her, “We have married you to this family, not to the village.”

This study is part of a larger randomised controlled trial to be published this year that aims to assess the effectiveness of a coaching program that improves the mental health of ASHAs. 

ASHAs provide primary healthcare services ranging from reproductive, maternal, neonatal and child health, to nutrition, basic sanitation, immunisation, hygienic practices and disseminating awareness.

“While their professional and social constraints persist, ASHAs could potentially be coached to use strategies, including coping mechanisms, the use of personal strengths, and /or spiritual recourse mechanisms to manage stress,” the researchers wrote.

In the Sehore district in Madhya Pradesh, there are 15 primary health centres, nine civil hospitals, one district hospital and 1,524 ASHAs, according to the National Rural Health Mission of 2013.

Despite all of the aforementioned hurdles, ASHA workers felt a social responsibility and happiness in helping others, according to the report. They said they have learned to handle situations that can cause them anger, with some amount of tact.

Since its inception in 2005, the ASHA cadre has been deprived of a structured, contextually-rooted intervention to strengthen their abilities in coping with recurrent work stress, the researchers said. Identifying and documenting such challenges was thus key to finding solutions, they added. 

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