Templeton World Charity Foundation (TWCF) grantee Dr. Anant Bhan is working to help community health workers in rural India improve their delvery of routine primary care, including the treatments for depression. For this Grantee Spotlight, we asked Dr. Anant Bhan, and his colleagues at Sangath, a mental health NGO in India, to share a little about what they do in a brief Q+A session.
What is the main focus of your study, and how did you become interested in designing it?
Anant Bhan: Through our current study, we want to understand if the utilization of personal (‘character’) strengths can enable rural female frontline health workers to address routine work stress and burnout, and thereby, improve their service delivery. While building their abilities to recognize and use their strengths, we want to include culturally and contextually suitable coaching strategies, keeping in mind that our target group is comprised of rural traditional women who have domestic responsibilities and equally, obligations to address the healthcare needs of their complex village communities.
Sangath has conducted a number of earlier projects in the region focusing on integrating mental health services into primary care, and in that we have trained, supervised, and mentored frontline workers, including ASHAs. However, seeing the challenges of their daily work and reviewing the published evidence on work-stress among frontline workers, particularly women, we became interested in conducting a rigorous study. Moreover, ASHAs were instituted as a cadre in 2005 under India’s flagship National Health Mission program, but since then, there have been very few structured interventions designed to reduce their burnout by leveraging their character strengths. This spurred our interest in conceiving the study design and drafting a research proposal in 2021, currently funded by TWCF.
One of the sources of inspiration for this study has been the ‘ESSENCE’ project, being implemented in the same context. In this project, ASHAs were trained to deliver community-level first-line brief psychological treatment called the ‘Healthy Activity Program’ to address the needs of people identified with depression. Working closely with ASHAs who absorbed the training content, we observed the nature of their routine stress, and conversely, ASHAs also expressed that through such a training program, they began to understand their own mental health needs. We believe that the first discussions related to our current study were drawn from the learnings of ESSENCE.
Tell us more about India's ASHAs and how a character-based coaching program might assist them to negotiate mental-health challenges in work situations.
Anant Bhan: More than a million women across India’s villages, with an average of an 8th- to 10th-grade education, work as ‘Accredited Social Health Activists’ (ASHAs). They are married women, formally unsalaried, and typically paid a monthly incentive for tasks such as check-ups of pregnant women, or making sure that children receive vaccinations on time. They have to conduct routine multiple house-to-house visits, often on foot, often in difficult weather, in addition to substantial documentation work, and their own household responsibilities. Under immense pressure to deliver basic services, ASHAs have been experiencing significant stress and burnout, particularly during the pandemic. But given the relative shortage of doctors in rural areas and the financial and logistical constraints to accessing formal health facilities, the rural communities of India are dependent on frontline workers such as ASHAs who act as a ‘bridge’ between them and the facilities. Therefore, ASHAs are crucial to achieving the third Sustainable Development Goal (SDG) of ensuring healthy lives and promoting wellbeing for all at all ages.
Sangath's character-based coaching program has been developed after an extensive review of the best practices in the field (i.e., positive psychology-based coaching interventions for reducing workplace burnout), in-depth discussions with ASHAs to understand the perceptions, experiences, effects, and responses to work stress, and an assessment (or profile) of their current ‘character-strengths’. The program is significantly drawn from the literature and empirical grounded learnings. The coaching approach, at its core, helps an ASHA to realize her (known) strengths and their application in routine life. It enables her to use these strengths in a number of work-related situations, which can otherwise act as stressors. These situations may pertain to managing untimely and complex workloads, handling difficult workplace relationships, and balancing domestic chores with work tasks. In particular, we want to reduce the ‘emotional labor’ and ‘rumination’ that ASHAs often go through in the absence of strategies based on personal strengths to address, cope or negotiate with work stress.
How do you envision your research translating into practical tools people might use in their everyday lives and community?
Ameya Bondre: One of our research outputs includes a character-strengths-based coaching manual with practical strategies for ASHAs to use in routine stressful situations while delivering services at the village-level, straddling household work with professional duties, and dealing with interpersonal challenges at their workplaces (health facilities). We believe a number of our strategies (e.g., using personal strengths and thereby, regulating emotions, finding meaning in difficult situations, or planning and prioritizing to manage workloads) are applicable across various workplace contexts, and can prove to be useful for other related cadres such as nurse midwives in rural India, doctors, and other kinds of frontline workers who experience similar work stress issues. As our study is a randomized controlled (effectiveness) trial, the results of the study will pave the way for the adoption of the coaching program by the state government to scale up the intervention with a larger population of frontline workers.
What is an insight or learning you found that might affect future study in this area?
Deepak Tugnawat: Through our empirical investigations and particularly the in-depth discussions with ASHAs on the experiences of burnout, we have interpreted the roles of certain ‘background variables that can affect the a) realization of personal strengths, b) their perceived applicability and c) the application of these strengths. Examples of such variables include the ASHA’s age, years of experience, caste/religious community, economic status, level of education, degree of family support for her work, or communication skills. We want to explore the ways in which these variables influence the use of personal strengths, and to that end, we have started brainstorming on further longitudinal studies in this area.
The current coaching program at Sangath is titled AANAND, an acronym for ‘Addressing ASHA wellbeing and burnout for improving depression care’, referencing the word "aanand," which loosely translates in English as "happiness." Dr. Anant Bhan is Principal Investigator and Project Director for the project and works with Sangath at its Bhopal office, along with his colleagues Dr. Ameya Bondre, and Mr. Deepak Tugnawat.
