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Health Issues Amongst Call Center Employees, An Emerging Occupational Group in India

Call center sector in India is a relatively new industry and one of the fastest growing sectors driving employment and growth in modern India today. While employment in the business process outsourcing (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, primarily due to its contemporary work settings. Safeguarding the health of youngsters employed in this new, growing economy becomes an occupational health challenge to public health specialists.


Introduction
In the last two decades, India has witnessed a very rapid economic growth. One of the most important factors related to this rising growth has been the Information Technology (IT) industry. Business Process Outsourcing (BPOs) companies have mushroomed and are a visible concrete expression of this IT revolution. The availability of cheap labor costs and the pool of skilled, Englishspeaking workforce are the foremost factors for the call center boom in the country. (1,2) 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 BPO. A call center can be identified as the voice-based part of a BPO organization. (3) Why call center jobs are attractive? The changing lifestyles, demand for luxury, and emergence of high-income spending groups coupled with a thoroughly cosmopolitan outlook of life are changing the modern Indian. As entry and exit in these call centers is easy as compared with other jobs, freshlyout young graduates who are on the verge of starting their career are easily attracted by the lucrative salaries, lavishing lifestyle, and other remuneration packages they offer. (4) Work environment in call centers Call centers in India are both domestic and international, but the prominence arises in transnational call centers wherein the clients are from developed countries like USA, UK, and elsewhere. (2,5) Due to the difference in time zones between India and such countries, most work is performed during night hours corresponding to a time suitable to their international customers. Such erratic work timings are often called "graveyard shift" or "UK-USA shift" by few researchers. (6,7) Most of them are forced to live as Indians by days and Westerners after sundown with changed identities and locations to suit their international customers. The burden of work along with dual identity creates severe personal dilemmas as well as might result in anxiety and related disorders. (2) Call center employees are expected to express positive emotions and suppress negative emotions like frustration, resentment, and anger, in their interactions with customers so as to create a desired state of mind in the customer. If not given a healthy expressive outlet, this emotional repression can profoundly affect a person psychologically. Zapf et al., (8) support this view and have indicated that in having to hide the call handlers' true feelings, this would have negative consequences such as depression and anxiety.
Call-time pressure, dealing with hostile customers, reading prescripted conversations on the phone endlessly, system monitoring of call activities, and difficulty in providing good customer service while simultaneously meeting time targets were found to be significant sources of job stress. (9) Brown (10) more vividly, characterizes the work as "repetitive brain strain."

Sleep Quality
Most call center workers work at times when they would normally be sleeping, this could challenge the individual's circadian rhythm because the sleep-wake internal clock setting is at odds with sleep wake cycle of the shift schedule ultimately resulting in circadian rhythm sleep disorders. (7) A majority of workers in night duties are unable to sleep adequately during daytime and hence may develop cumulative sleep debt leading to significant sleep deprivation. Sleep deprivation can further complicate their health as it can result in fatigue, mood changes like depression, decreased cognitive functioning, poor executive functioning, impaired vigilance, and a predisposition to infections. (7) Occupational health experts of Bangalore opined that permanent night shift duties resulted in serious health concerns for call center employees, wherein sleep disorders were observed among 83% as compared with industry average (IT enabled Services) of 39.5%. (11) Burn out stress syndrome which included chronic fatigue, insomnia, and altered biological rhythm was also commonly observed among them. (12) In a study conducted in Delhi-NCR, 51.4% BPO employees were found to be sleepier as compared with non-BPO workers (20.5%). (7) Another study from Bangalore too reiterated that sleepiness was significantly higher among night shift workers as compared with day shift workers in BPOs. It also revealed a startling finding that night shift workers have an increased risk of developing cardiovascular disease as compared with day shift workers. (13) Food habits and addictions Call center employees are a distinct class in themselves and by Indian standards such employment is considered unconventional-night shift, a young employee base and western lifestyle including holidays. With high disposable incomes at a young age, they easily resort to smoking and drinking,. Smoking was considered by many to be a quick-fix solution to their stress problems. (14)(15)(16)(17) A study in Kolkata observed that 63% employees had multiple addictions (smoking, chewing tobacco, alcohol, and other forms). As much as 56% of the ''more than one pack-a-day'' smokers and 61% of the ''more than one peg-a-day'' drinkers worked in call centers. (18) Poor eating habits like skipping meals, overeating, and excessive drinking of coffee and other beverages were also reported. (15,17) Drug use and risky sexual behavior were also apparent among them. (2) Another study reported 42% employees resorted to adopt 'new lifestyle patterns' like late night partying, smoking, boozing, drug-addiction, staying away from family or live-in relationships. (19) Social life Call center employment not only demands cultural transformation, nocturnal labor, and hours of monotonous work from its employees but also brings with it insecurities and vulnerabilities by diminishing their interpersonal familial and social interactions. Many employees felt socially alienated, completely cut-off from their family and friends circuit owing to nocturnal labor. Some also complained of having little time to spend with their family members even though they were physically present at home during daytime. (17) A study in Delhi-NCR found that 90% employees were not able to balance between their work and family life. Interestingly, the main hobby of most employees was to sleep for as long as they could due to the high fatigue levels of the night duties. Disruption in family life and lack of socialization due to odd shift timings were reported more among women employees as they had to balance between the dual burden of work and home. (17) Physical and mental health of call center employees A case-control study in New Delhi found that BPO employees were more stressed (58.3% vs. 19.3%); more depressed (62.9% vs. 4.6%); and more anxious (33.9% vs. 1.4%) as compared with non-BPO workers. (7) Another study in Delhi too revealed a very high level of stress (66%) among them. (2) Higher levels of stress of more than 65% have also been reported by researchers from call centres in other metropolitan cities. (3,4,14,20) Anxiety levels were also found to be higher (45%) among them. (14) Various studies have reported a wide range of physical ailments among call center workers. Backache, shoulder pain, digestive problems, overweight, headache due to eye strain and dryness of eyes were some of the commonly reported ailments. (2,4,14,17) According to a study in Mumbai, 70.4% females and 55.6% males were found to be suffering from headache almost every day. (4) Women-centered studies like the one conducted by Associated Chambers of Commerce and Industry of India (ASSOCHAM) reported high blood pressure (60%) accompanied by sleep disorders (60%), menstrual-related problems (50%), respiratory illness (45%), and digestive problems (50%) to be the major health-related problems among women. (17)

Conclusion
It has been observed that call center workers are exposed to a volley of problems in all three domains of health viz. physical, mental, and social, owing to their unique job profile. A thorough search of literature revealed ample studies on Indian call centers in the domains of sociology, management, and psychology with very few studies in the public health domain. Most of the studies, barring a few, have relied mainly on self-reported health status of individuals without using any validated measuring tools for measuring their physical, mental, and social health. (2,4,5,14) Also, very few studies have used statistically sound methodology in conduct of their studies and analysis of results, thus failing to give scientifically valid explanations for possible reasons for poor health profile of call center workers. Thus, there is a need to conduct bigger epidemiological studies for better understanding and to create a database for health problems among call center workers.
There is also a need for destressing facilities like gymnasium, games, yoga, meditation, library, and counselling facilities at the respective work places. Periodic health examination may be required for early detection and treatment of psychological disorders and other lifestyle diseases by engaging physicians, psychologists, psychiatrists, and public health experts. The importance of having a stress-free and healthy lifestyle should be stressed upon through regular IEC (Information, Education and Communication) activities.
Traditionally, public health physicians have concentrated mainly on the conventional workforce for example, agricultural and industrial workers. With the coming up of new occupations like call center workers , there is a need to concentrate on this significant workforce and public health issues related to them as well.