Call Centers and Associated Health Hazard for Women Employees: A Review of Health Implications for Women Employees of Transnational Call Centers in India

Indian women are fast moving from conventional jobs to night-shift jobs in transnational call centers. Women working at night is a relatively new phenomenon and stands apart from the usual Indian lifestyle. Night work and the dual burden of work and family have adverse implications on women employees’ physical and psychological health. The paper highlights the occupational health hazards of women employees of international call centers through a systematic review of 38 articles published between 2000 and 2018. Data and evidence from studies on women employees of international call centers in India reveal that odd working hours against the biological clock make women employees suffer from several health problems. Women were more prone to health problems as compared to their counterparts. The responsibility of balancing work and family leads to high levels of stress. Despite the attractive salary package, most women employees suffer health hazards and psychological disorders.


Introduction
The socio-economic and political developments during the past decades have resulted in a change in the position of women, mainly in the area of education and labor force participation.The age-old customs, barriers, and prejudices governing the employment of the Indian women in particular occupations are gradually getting diluted.Women are breaking barriers of stereotypes and are actively participating even in non-traditional occupations (Hota, 2000).Women are now gainfully employed in almost all the sectors of India's economy.Indian women are increasingly employed in the international call centers, where working at night is a prerequisite.Nightwork for women in India is still regarded as taboo.Working at the night in call centers of the international business process outsourcing (BPO) is a significant step in moving away from the patriarchal control over women's mobility.The other night-based jobs for women such as nursing, defense, and hospitality industry alternate between day and night, but work at the international call centers is primarily at night.Employment at the international call centers offers women a means to break the taboos and reject the patriarchal norms controlling their mobility (Mattingly, 2012).
The digital revolution, accompanied by a sharp drop in international telecommunications costs and advances in information and communication technology, has led to the development of outsourcing industry in developing countries such as India (Bailly and Farrell, 2004).Outsourcing allows companies to complete peripheral and repetitive tasks performed by contracted labor from developing countries, while the headquarters can consider its core business functions (Nadeem, 2009).A BPO is a delegation of one or more information technology (IT) intensive business processes to an external provider, which in turn administers and manages the processes based on defined and measurable performance metrics (Gartner, Inc, 2003).Owing to the dependence of the BPO sector on IT, it is also known as the information technology-enabled services (ITES) (National Statistical Coordination Board [NSCB], 2007).
The growth of the BPO industry in India has its roots in the liberalization and globalization policy of the Government of India.Since its inception in the late 1990s, it has reached stunning heights, claiming more than half of the global outsourcing share (S.Singh, 2012).India is one of the prominent electronic housekeepers to the world taking care of a host of routine activities of transnational companies globally.BPO has become India's new sunshine sector (Chengappa & Goyal, 2002;Seshu, 2003).India remains a prominent location for outsourced business activities through offering an unbeatable mix of low cost, in-depth technical knowledge, language skills, mature vendors, and supportive government policies (Amoribieta et al., 2001;NASSCOM and McKinsey, 2005;Ramesh, 2004;Vaid, 2009).
Based on the type of work performed, BPOs are categorized into back office outsourcing or non-voice sector, and front office outsourcing or voice-based sector.The back office outsourcing includes work such as data encoding, database development, market research, handling of credit billing problems, etc.The front office outsourcing is often interchangeably referred to as the ''call center industry,'' ''contact center industry'' or ''customer service industry'' as the service entails interactive communication with the client or customers (Tara & Ilavarasan, 2009).Call centers in India serve domestic firms as well, but their prominence arises in case if they are transnational or international call centers (N.Singh, 2007).In the international call centers due to the difference in time zones between India and client country such as the UK or the USA, most works are performed at night (Poster, 2007).As the work involves interactive communication with the clients or the customers, work during the day is almost absent and starts only in the late evening hours.In contrast, the non-voice service workers can do their work during the daytime as most of their compatriots (Ofreneo et al., 2007).This paper takes into consideration only the women employees of international call centers due to the requirement of night work.

Work Environment and Associated Challenges
Call center employment is associated with a high pay package, use of the latest technologies, fancy designations, innovation, and flexibility in the workplace but in practice, the work is quite inflexible, eroding even the elementary rights at work (Ramesh, 2004).The work is repetitive, routinized, highly pressurized, carefully monitored, limited call handling time and breaks, no interaction between the employees while at work, and with predefined scripts for dealing with customers (Nadeem, 2009;Ofreneo et al., 2007).Indian call center industry makes specific demands on its labor force regardless of their skill level.The employees have to endure monotonous work, respond quickly to orders and undergo certain changes to adapt to the workplace environment (McMillin, 2006).Due to the high work pressure, the employees at times have to work nonstop without any break in between the calls (Arora & Kaul, 2005).The work demands long working hours, permanent night shifts, incredibly high work targets, isolation, and pseudo-identity all of which have implications on health and work-life balance (Taylor et al., 2008).As compared to the United Kingdom, the Indian call center employees work in a more pressurized environment (Taylor & Bain, 2005).
The work at the international call centers demands a cultural alteration among its employees (Ramesh, 2004).Most of the call centers require their employees to change their names, modify their accents as per the client country thereby creating the problem of dual identities (McMillin, 2006).They are forced to live as Indians during the day and as westerners after sunset (Ramesh, 2004).During the day, they use their Indian identitytheir name and accent while in the evening when at work they have to switch to their pseudo-identity.At work, the employees are required to speak with the accent of the client country, use pseudo names and geographical location and greetings as per the client country (Mirchandani, 2005;Noronha & D'Cruz, 2009;Ramesh, 2004).The masking of identity and nationality creates severe personal dilemmas among the employees (Ofreneo et al., 2007).The nature of work, along with the use of dual identities further aggravates the difficulties of working at odd hours (Tara & Ilavarasan, 2009).
The non-traditional work processes at the call centers such as the absence of face-to-face interaction with clients, extended technology interface, electronic performance, and monitoring bring about a plethora of challenges for its employees.An integral component of call center employment is to control negative emotions during customer interactions (Machado et al., 2013).The control of negative emotions may lead to the added pressure of emotional labor.The interactive service work has given rise to a work demand called emotional labor, a mechanism by which the service employees are required to manage their feelings at work (Hochschild, 1983).Emotional labor can be defined as expressing organizationally desired emotions during service transactions (Morris & Feldman, 1996).The employees at the call center are expected to remain cheerful, welcoming, pleasant, polite, positive, and tactful while dealing with the customers over the phone.The employees are required to control their negative emotions and remain calm and polite even in the case of rude and abusive customers.Emotional labor can, in turn, lead to psychological effects such as dissonance, inauthenticity, self-alienation, and burnout (Hochschild, 1983).The work also results in social isolation, health problems, stress, and work-life imbalances (McMillin, 2006;Taylor et al., 2008).A major problem faced by the employees is to manage time to socialize.The mismatch of the timings is the key reason the employees are hardly left with any time to socialize ( Arora & Kaul, 2005).The job considerably reduces the time that the employees can spend with their family and friends.The usual social patterns which operate during the day exclude the call center employees due to their job timings resulting in difficulties in structuring family and social interactions (Wilson et al., 2007).The call centers follow the calendar of the client country and their holidays are also planned accordingly.This makes it difficult for the employees to celebrate the Indian festivals with their loved ones ( Arora & Kaul, 2005).
The call centers employees in India earn a relatively high wage given their educational qualification.The appeal of the high pay packages at the call centers in India is somewhat lost when it is compared with the opportunity cost.Most of the employees enter the call centers after graduation and entering into a well-paid job right after college may restrict their scope for higher education.The opportunity cost of the job in the long term can become even higher.The employees end up doing low-end work which does not lead to any skill upgradation except getting an upper hand at communication skills and English language.The lack of skill development may act as a deterrent for the employees wanting to switch to other sectors (Ramesh, 2004).
Taking into account both the prospects and the vulnerabilities, call center employment is associated with various connotations.The BPO sector is termed as the ''sunshine sector'' as it has emerged as one of the fastestgrowing sectors in India, generating enormous revenues and providing employment avenues to the Indian youths (Chengappa & Goyal, 2002).Along with being called the sunshine sector, they are also compared to sweatshops.The term sweatshops are often used for factories that have poor working conditions, low wages, odd and long working hours, and lack of proper benefits for the workers.The call centers have been termed ''electronic sweatshops'' (Budhwar et al., 2009), and ''new age sweatshops'' (George, 2005) due to the pressurized work environment and the nature of the job.The employees are under constant surveillance, required to maintain dual identities, work in odd hours, limited breaks during shifts.The rigid work organization system, monitoring, and control at the call centers have led to the intensification of work so much that the employees are reduced to ''cyber coolies.''Coolie is a term used for poorly paid baggage handlers at the train station in India.The Indian call center employees represent a group of educated, English speaking graduates who are burning out formative years of their career doing repetitive, low-end work, without any skill development (Ramesh, 2004) while earning a relatively lower pay package as compared to their American counterparts (Batt et al., 2005) and thus justifying the metaphor ''cyber coolies.''According to Taylor et al. (2008), the ''cyber coolies'' metaphor may be overdrawn, but many call center employees report their work as pressurizing and contributing to exit and burnout.

Challenges for Women Employees
The participation of women in the call center workforce is a critical enabling factor for the continued growth of the industry (NASSCOM and Mercer, 2009).Women are the preferred workforce as they are supposed to be more reliable and compliant as compared to men (Kelkar et al., 2002).Women are deemed to be more hardworking, patient, attentive, loyal, possessing better interpersonal skills, and less aggressive than men (Pradhan & Abraham, 2005).The ability to empathize with customers is an indispensable competency for call centers (D'Cruz & Noronha, 2008) and women are considered to be better at this skill (Goleman, 2011).
Along with the alluring opportunities the call center employment in India also brings about challenges for its women employees.The unique work atmosphere at the call centers stands apart from the traditional Indian work culture due to its work timings, exposure to the western culture and lifestyle, and a young employee base (Tara & Ilavarasan, 2009).Women working at night is a relatively new phenomenon in the socio-cultural scenario of traditional work patterns for women in India (P.Singh & Pandey, 2005).The call centers by making the women work at night act as catalysts for social change in India through intersecting with the pre-defined constructs of gender.India, by and large with all its diversity, has a classic patriarchal social system.The Indian patriarchal society has well-defined rules for women's mobility (Kandiyoti, 1988;Medora, 2007).Patriarchy creates and enforces the feminine and masculine characteristics, strengthens the public and the private divide, limits the mobility of the women, and reinforces male dominance (Uberoi, 2000).In India, it is considered improper and unsafe for women to be out at night.Therefore, to make the night shift participation feasible for the women, the call centers use corporate strategies such as the use of shuttle vans with male guards to transport women to work and back home.The changes in women's mobility brought out by the employment reflects a dichotomy that provides women with a means to step outside the house at night in ways not experienced by previous generations, but at the same time, it is based on maintaining gendered access to spaces outside the home.Although the presence of middle-class women in the urban landscape represents a break in the traditional patriarchal control on mobility, their mobility, and spatial access is based on regimes of surveillance and control.An example of this surveillance and control is the journey of the women to work and back home which is controlled by the transport provided by the company.Women are escorted by guards on their journey to work and back home and their mobility is put under close surveillance through the means of advanced technologies such as Global Positioning System tracker.Within the call centers, the space that the women occupy is closely monitored through the surveillance systems such as cameras, call records, and identity cards (Patel, 2006).
Indian society has stringent rules for women's mobility and hence the working hours at the call center negatively affect the women's image in society and the family's reputation as well (Patel, 2006).But on a brighter note, the scenario has changed to a large extent during the recent decade.The Indian women are gradually coming out of patriarchal control and are willing to work at night for the transnational call centers.Despite the stigmas attached, call centers are one of the most sought-after workplaces for young graduate and undergraduate women due to the appealing work environment, pay package, incentives, and conveyance facilities (P.Singh & Pandey, 2005).
The call center employment has adverse implications on the work-life balance and the social life of the women employees.In a study on the women call center employees, the women considered the reduction in their family time as one of the major ill-effects of the job.As the women were working at night and sleeping during the day, they are hardly left with any time to spend with their family.The women were not able to be a part of most of the family events, festivals, and other social events due to their work timings, strict leave policy, and the holidays being scheduled as per the client country (Mattingly, 2012).
The women employees work at night and during the day they have to take rest as well as manage the family and household responsibilities.Most of the women especially the married ones found it difficult to balance work and family responsibilities.Managing work-life balance was easier for the women who were unmarried and were staying with their parents as compared to the married women employees especially the ones with children or dependents.Rest during the daytime was easier for unmarried women as their parents took care of the household responsibilities.The married women, on the other hand, had to struggle to fulfill their household responsibilities as well as manage time to rest during the daytime.Some of the married women employees were even stressed because they did not get proper support from their spouses in carrying out household chores (P.Singh & Pandey, 2005).
The predominant patriarchal society in India has prescriptions and preferences related to women's mobility and their role in the domestic sphere.The situation is changing over time with women coming out of the strict norms of conservative society governing its mobility to the extent that they are working at night for the international call centers-which is still regarded by certain sections of the society as not respectable and safe.Women who enter into occupations traditionally reserved for men have to struggle hard and face many barriers and encounter stigma, stress, and strain.The reversing of the body's biological clock has a negative implication on the health, social life, and well-being of the employees.Regardless of the capabilities of its employees, the job makes specific demands from its employees such as night work, ability to withstand long hours of repetitive work, emotional labor, change in diction, identity, handling irate customers with the predefined script, and limited time.The high work pressure and demands from the organization result in severe stress and burnout among the employees.Previous studies on international call centers in India have focused on various dimensions of the employment.However, the implications of the employment on the health of the employees especially the women employees have been relatively less explored.The work culture of call centers and an increasing number of women employed in this sector emphasize the need for examining the impact of odd working hours on the health of women employees.To that end, the broad objective of the paper is to assess the physical, occupational, and psychological health problems of the women employees of international call centers in India, via systemic review.The study explores the occupational health hazards that women face in transnational call centers through reviewing the evidence available from various studies carried out on women call center employees in the Indian cities.
Figure 1 presents the conceptual framework for the study.The framework outlines the various dimensions of call center employment.The job makes the women financially independent at a young age and also helps in their personality development.Financial independence helps the women in supporting themselves as well as their families financially.The job enables the women in becoming more assertive and also helps in learning new skills such as communication, interpersonal skills, and technical competency.
Along with the benefits, the job also has several challenges.The work at the call centers also makes specific demands from its employees such as night work, change in accent, identities, and lifestyle.The night work results in the disruption of the normal functioning of the body.The work at the call centers is highly pressurized, routinized, and monotonous in nature.The employees require to follow a predefined script while handling the clients within a limited time.The employees find it difficult to handle the customers within the stipulated time limit.The employees and their work performance are closely monitored through call recordings and cameras.The call pressures are so high at times that the employees are not even able to take breaks in between the calls.The job timings also alter the social life of its employees and they find it difficult to participate in their social life effectively.This environment leads to social alienation and physical and psychological health problems

Methodology
The study is based on the major studies carried out on the women employees of transnational call centers in India with an emphasis on the health impact of the employment.The paper highlights the occupational health hazards of women employees of international call centers through a systematic review of 38 articles published between 2000 and 2018.The main source of data for the study is the published research papers in various journals broadly covering the dimension of the health of women call center employees.The other sources of data for the study include information available in various print and electronic media such as newspapers, magazines, data provided on company websites, and online studies.The search items that were used ''night work for women in India,'' ''women in international call centers in India,'' ''work environment at international call centers,'' work challenges at internal call centers', ''health and social problems of women call center employees,'' ''physical health problems of women call center employees,'' ''mental health problems of women call center employees,'' ''social support for women call center employees.''The search items were used separately.Only the articles dealing with the international call centers, and women employees of international call centers in India were included in the present study.Among the selected studies the data on health problems were collected and illustrated through suitable figures with the help of Microsoft Excel.
Table 1 presents some of the major studies conducted on call center employees in India.Though a large number of studies have been carried out on call center employees, only a few studies (Banu & Gomathi, 2014;Machado et al., 2013;P. Singh & Pandey, 2005;Subbarayalu, 2013;Suri & Rizvi, 2008;Vaid, 2009), have dealt explicitly with the health problems of the women employees.

Results
The utmost challenge that call center employment brings about is a plethora of health problems.Night shift is the most disruptive of all shift timings, affecting physiological adjustment, sleep, and well-being (Peter, 2011).Night work adversely affects circadian rhythm, concentration, alertness, motivation, memory, overall health, job performance, and accident rates (Harrington, 2001;Occupational Health Clinics for Ontario Workers, 2005).Night work is also linked with a higher risk of miscarriage, spontaneous abortion, delayed fetal development, pre-term delivery, low birth weight, breast cancer, and lower rates of pregnancies (Occupational Health Clinics for Ontario Workers, 2005).Sleep restriction even at moderate levels affects the stress hormone levels which in turn can impair neurobehavioral functions (Van Dongen et al., 2003).Over the years, the body's ability to compensate for the sleep deficit drops, perhaps permanently (Meerlo et al., 2002).

Physical Health Problems
In India, women's employment in the international call centers is looked at and represented in diverse ways; some consider it is a crucial instrument for women's empowerment by increasing mobility and financial independence, while others believe that the employment results in exploitation of women and adversely affects their health and social life.Women are particularly affected by odd working hours, work demands, domestic and social responsibilities (Taylor & Bain, 2005).The job has a direct and negative effect on women's health (P.Singh & Pandey, 2005).The women employees, though initially find the job comfortable but within a year, start facing numerous health concerns.Over time the women found it challenging to continue with the work timings, long working hours, and rigid monitoring (Clark & Sekher, 2007).The primary physical health problems among the women employees are digestive disorders, high blood pressure, fatigue, musculoskeletal, sleep, visual, voice and ear-related issues, menstrual-related problems, and frequent headaches, cough, and cold (Banu & Gomathi, 2014;Naveen & Joseph, 2012;P. Singh & Pandey, 2005;Subbarayalu, 2013).
The employment makes the women empowered and financially independent at a young age but also brings about insecurities and vulnerability such as the risk of traveling at night, social stigma, social alienation, health hazards, and work and family life imbalance.Some of the women even compared themselves with ''security guards'' who remained awake at night to perform their duty and slept during the day.The majority of the women employees regarded the job as a potential health hazard (P.Singh & Pandey, 2005).The major physical health problems reported by the employees were throat related ailments, musculoskeletal, sleep, eye and ear related problems.Throat related problems was the highest reported ailment by the women employees.More than three-fifths of the women suffered from throatrelated problems such as sore throat, voice loss and breathlessness.The next most reported health problem was musculoskeletal problems (61%).The musculoskeletal disorders included pain in the lower back, neck, wrist, and hands, and shoulders.A substantial proportion of the employees also reported ear and eye related problems.The ear-related problems included pain in the ears and acoustic shock while eye related problems included eye strain, dry or burning eyes, frequent tearing and watering eyes, and blurred vision.Around twothirds of the women employees were prone to anxiety like symptoms while at work while a little over half were depressed due to the nature of the work (Figure 2).
In a study on women call center employees in Mumbai it was found that the effect of night work on health was felt by more than four-fifths of the respondents.The employees suffered from a wide range of health problems ranging from headaches to high blood pressure.Musculoskeletal disorders (83%) were the highest reported health problem followed by voice-related problems (72%), digestive disorders (63%), and earrelated ailments (44%).The other health ailments included frequent cough and cold, headache, respiratory ailments, and hypertension.Seventeen percent of the women suffered from menstrual-related problems like irregular menstrual cycles and heaving bleeding.More than four-fifth of the women who suffered from health ailments believed that the health problems that they were currently suffering from were a result of their job and the resultant lifestyle (Gupta, 2018).Weight gain was also a problem faced by women employees.To remain awake during the night, the employees resort to smoking and drinking tea and coffee, which further adds up to their health problems (P.Singh & Pandey, 2005).
There are persistent gender differentials in health problems among the call center employees.A study conducted on call center employees in Chennai, Coimbatore, and Bangalore, by Subbarayalu (2013) highlighted significant gender differentials in the prevalence of occupational health problems.The women employees were more prone to health ailments as compared to their male counterparts.Figure 2 shows the gender differentials in health problems among the employees.A higher proportion of women suffered from health ailments as compared to men.Though a higher proportion of women suffered from health ailments, this differential was especially high for psychological health issues.A probable explanation for this gender differential in health problems could be that women may not able to get proper sleep as the majority of them have to devote their daytime to domestic chores.For married women living with families sleeping during the day becomes difficult due to household responsibilities and children.Thus, the lack of proper sleep along with work pressure and odd working hours leads to health problems.Night work also creates problems for the women employees for performing their social obligations and meeting social expectations.They are unable to spend time with family, friends, and relatives resulting in being alienated from their social life (ASSOCHAM, 2005).
Most of the health problems that the women experience may be linked to their work and the resultant lifestyle.The job demands long hours of constrained sitting and minimal opportunity for variation in work performed.The employees have to use computers continuously during the calls along with juggling with the pressure of sticking to the time limits and performance monitoring.Due to the massive workload and the short breaks, the employees are hardly left with any time to move out of their cabin/workstations, therefore, hindering their body movements.Extended periods of constrained sitting with continuous use of computers can be a possible explanation for the high prevalence of musculoskeletal disorders.The continuous use of the computer keyboard and mouse leads to pain in the hand and wrist.Constant sitting in one position and staring at the screen of the computer also leads to pain in the neck and leg cramps (Buckle, 1994;Hagberg & Wegman, 1987;Punnett & Bergqvist, 1997;Subbarayalu, 2013).The employees have to continuously interact with customers without adequate rest in between resulting in various voice-related problems.Continuous use of the computer and irregular and incomplete sleep may be the contributing factors for eye-related issues.The incessant use of headsets and exposure to loud noise at work might be the probable reason for the ear-related problems.Lifestylerelated factors such as lack of proper sleep and exercise, and irregular and faulty eating habits may also be a contributor to digestive disorders and lifestyle diseases such as hypertension and obesity among the employees.

Psychological Health Problems
The call center employment puts its employees under enormous stress due to the unique working conditions.In a study on occupational problems across 26 occupational groups, six occupations including call centers were identified as having worse than the average scores for job satisfaction, physical and psychological well-being (Johnson et al., 2005).Job stress can lead to health problems such as insomnia, depression, behavioral issues such as addiction to alcohol and drug use, and interpersonal conflicts (Kalimo & Mejman, 1987;Levi, 1996).
High levels of stress is one of the negative aspects of call center employment which acts as a catalyst for inducing physical and psychological health problems among the employees.Some studies have brought out the high levels of occupational stress among call center employees (Annamalai & Nandagopal, 2013;Johnson et al., 2005;Latha & Panchanatham, 2011;Nadeem, 2009;Shahnawaz, 2006;Subbarayalu, 2013;Suri & Rizvi, 2008).The psychological health problems reported by the women employees were sleep disturbance, depression, anxiety, and stress (Banu & Gomathi, 2014;Hossain et al., 2016;Subbarayalu, 2013).Women employees are more vulnerable to psychological distress as compared to men (Bhuyar et al., 2008;Hossain et al., 2016;Machado et al., 2013;Ramesh, 2004;Subbarayalu, 2013).Subbarayalu (2013) in his study found that anxiety and depression were especially high among women employees.Women employees experience greater work-related anxiety and are more prone to depression and sleep-related disturbances.More than half of the women employees reported psychological health concerns, such as depression and anxiety, which can be a reflection of the stressful work environment.
More than half of the women employees showed signs of psychological distress in a study conducted on women call center employees of Mumbai.The important predictors of psychological distress among the women employees were marital status, living arrangement, dependent at home, and years of employment.Unmarried women employees were significantly less likely to experience psychological distress as compared to married women.Women with no dependents to take care of were less likely to experience psychological distress as compared to those with dependents.Women with 2 to 5 years of work experience were less likely to experience psychological distress compared to women with less than 2 years of work experience (Gupta, 2018).
The call centers are known for their high employee turnover.The high employee turnover rate among the women employees is also a reflection of the stress that they face at work (Mitter et al., 2004).High levels of routinization and standardization within the call centers result in monotony, job dissatisfaction, poor job performance and high employee turnover (Batt, 2002;Batt & Moynihan, 2002).Some of the major reasons for high employee turnover rates in call centers are the repetitive and stressful work, hostile working conditions and lack of sufficient career development opportunities (Budhwar et al., 2009).Quitting the job is often the preferred option for the employees dissatisfied with their job, growth prospects and opportunities within the organization (Batt et al., 2005).One way to improve employee stability is through offering better vertical growth opportunities, greater discretion in handling the clients, reduced use of scripts, and electronic monitoring (Batt et al., 2005;Zito et al., 2018).These steps taken by the organizations would help to bring down monotony and employee turnover rates besides improving overall work performance of the employees.
The work patterns in call centers are standardized, repetitive, and relatively uniform which weakens the employee's independence and enhances the potential for management control.Loss of control is associated with work-related stress (Bhuyar et al., 2008).The monotonous, intensive, and pressurized work environment, stringent performance monitoring, unrealistic work targets, multiple levels of controls, customer induced stress, the requirement of emotional labor, etc. result in a highly demanding, challenging, and emotionally stressful work environment which in turn leads to in employee burnout (Bhuyar et al., 2008;Surana et al., 2011).Maslach defined burnout as ''a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do 'people work' of some kind'' (Maslach, 1982).The type of work, the work pressure, and the prolonged combination of stress and fatigue in call centers lead to burnout stress syndrome (BOSS) among the employees (Latha & Panchanatham, 2011;Nadeem, 2009).BOSS can also result from personal frustrations and inadequate coping mechanisms for stress.It can lead to at least four types of stress-related consequences-depletion of energy reserves, inefficiency at work, reduced resistance to diseases and increased dissatisfaction, absenteeism, and pessimistic attitude (Pandey, 2005).Symptoms of BOSS include chronic fatigue, insomnia poor judgment, cynicism, guilt, the feeling of ineffectiveness, and a sense of disconnection with fellow workers (Bittner et al., 2011;George, 2005).Guidance and physical and mental coordination to cope up with the high demanding job helps to cope up with the BOSS syndrome (Sudhashree et al., 2005).There is a significant inverse relationship between social support available at work and job burnout.The support received from the supervisor was most significantly related to job burnout.The inverse relationship highlights that the social support available to the employees at work from supervisors, peers and other people at work can be instrumental in reducing burnout (Surana et al., 2011).
The Dataquest (DQ) and International Data Corporation (IDC) BPO Employees Satisfaction Survey showed that insufficient holidays were the primary cause of stress among the employees.The leaves are as per the client country, and therefore the employees are not able to enjoy Indian festivals and celebrations which in turn affect their personal and social life.The other reasons for stress among the employees were the long working hours, repetitive nature of work, workload, travel time, health issues, the pressure to perform, overtime, and the high volume of calls to attend (DQI Bureau, 2005).According to the DQ-IDC BPO Employee Satisfaction Survey, 2007, the primary reasons for stress among the employees were travel time, work timings, insufficient holidays, workload, and long working hours (DQI Bureau, 2007).Another key reason for stress among the employees was the abuse from the angry and irritated customers which ranged from rude and abusive language to sexual and racial abuse as well (Baliga, 2005;The Hindu, 2005).The gender-stereotyped work culture, gender discrimination at the workplace, security issues, and the presence of a glass ceiling were the major stressors for the women employees (Pathak & Sarin, 2015).
Along with the work environment and organizational factors, societal factors also play an important role in making the job stressful for women employees (Latha & Panchanatham, 2011).Working hours and maintaining a work-life balance also stood as a major source of stress.Work-life imbalances serve as a potential source of stress for the women, in particular for the married ones.Stress adversely affects the job performance and has a positive association with employee turnover.The women employees also believed that high level of stress triggered problems such as insomnia, cardiovascular disease, lower appetite, depression, and anxiety among them (Pathak & Sarin, 2015).Nearly three-fourths of women considered the job as a potential health hazard (P.Singh & Pandey, 2005).

Call Center Employment and Associated Lifestyle Changes
The call center job alters the lifestyle of the women employees considerably.The work embraces nightwork, smoking, drinking, and pub culture, etc. which are in opposition to the values, traditions, and beliefs of the Indian urban middle class (Mishra et al., 2010).Call centers, unlike other industries, provide openings for employment opportunities at a young age, high disposable income, and quick promotion avenues at low educational qualifications.As a result, women are reaching their career goals and financial targets much earlier than expected.With high disposable incomes at a young age, the employees fall easy prey to habits such as smoking, drinking alcohol, and interestingly most consider these habits as a style statement (Arora & Kaul, 2005;Batt et al., 2005).Tobacco use among women varied from smoking cigarettes, hookah, and chewing tobacco (Mishra et al., 2010).Though substance use is prevalent among both men as well as women, it is lower among the latter (Mishra et al., 2010;Vaid, 2009).Substance use among the call center employees was highlighted by a study conducted in Gurgaon.More than two-fifths of the women employees smoked while around two-third reported alcohol consumption and 4% even reported drug use (Vaid, 2009).Stress and peer pressure were the principal reasons for the initiation and continuation of tobacco use among the employees (Mishra et al., 2010).Most of the women initiate smoking with a notion that it is glamorous and will act as a quick-fix solution to their problems and stress, oblivious that it could lead to a risk of cardiovascular diseases, low birth-weight babies, lower gestation periods, and higher rates of stillbirth (India Infoline News Service, 2010).Evidence also suggests that young call center employees are adopting risky sexual behavior along with drug, and alcohol use (Vaid, 2009).

Discussion and Conclusions
Along with being caregivers, the Indian women are now also playing the role of breadwinners.The participation of women in the workforce is visible in all sectors of the economy.The patriarchal Indian society has stringent rules governing the mobility of women but the Indian women breaking all the stereotypes and the prejudices are working in the night for the international call centers.The call center employment provides an opportunity for the young graduates to earn a relatively high pay package at minimal educational qualification.The job is very alluring to the Indian youths due to the high salary, requirement of low educational qualification, attractive lifestyle, and various benefits provided.Employment in the call centers along with high salaries and attractive facilities that an ordinary graduate could never imagine in India also brings along insecurities and vulnerabilities.The work is intensive, monotonous, highly pressurized, and closely monitored and supervised.The employees are required to attend to the customers within a limited time with predefined scripts and pseudo identities.The burden of work along with pseudo names and nationality that the employees have to use creates personal dilemmas and even the problem of dual identities (Ofreneo et al., 2007).
Women are the preferred workforce in the call centers as they possess qualities such as patience and empathy which are critical in dealing with the customers.The call center employment attracts Indian women with its high pay packages at minimal educational qualifications and skills, attractive lifestyle, increased financial independence, and mobility.The job is helping the women in learning new skills, becoming financially independent at a young age, and increasing their mobility.The employment provides the women with a means to increase their mobility and financial independence and also helps them in breaking the patriarchal control on their mobility.Along with providing alluring opportunities to the women the employment stands apart from the usual employment for women in India due to the requirement of night work, exposure to the western lifestyle, and a young employee base.Due to the requirement of night work, the employment is not considered by some as a respectable profession and is associated with various stigmas and negative connotations.The scope of the women in call centers is restricted due to the work timings, patriarchal control on mobility along the dual burden of work and family as a result of which they find it difficult to continue in the employment in the long run (Ramesh, 2004).Another major challenge that nightwork brings along with it is a plethora of health problems.The present study tries to understand the implication of call center employment on the physical and psychological health of women employees in India.
The odd working hours and the highly pressurized work environment along with the burden of western accent changed lifestyles and identities, and the dual burden of work and family responsibilities lead to health problems among the employees.The majority of the women considered their health to be affected by night work.The major health problems among the women employees were voice-related, musculoskeletal disorders, digestive disorders, eye, and ear problems, and frequent cold and cough.The majority of the women considered these health problems a result of the nightwork.There were marked gender differentials in the prevalence of health problems among the employees.The women employees had a higher prevalence of health problems as compared to the male employees.
The call center employment brings with it high levels of stress, which is further intensified as the women employees are cut off from their family and friends.Undoubtedly, the physical balance and well-being of most of these women employees are thrown out of gear.The women employees suffered from psychological health ailments such as sleep disturbance, depression, anxiety, and stress.The gender differentials were especially prominent for the psychological health ailments such as anxiety and depression.Among the women, the unmarried ones were significantly less likely to experience psychological distress as compared to the married women employees.The nature of work at the call center leads to burnout among its employees.The women to survive in this occupation require support from their family, friends, and colleagues.The social support available to the employees at work especially the support from the supervisor was significantly related to reducing burnout among the employees.
The call center employment provides the women employees with a means to increase their mobility and financial independence and helps them in breaking the patriarchal control on their mobility.The findings of the study point out that the call center employment helps women to become financially independent at a young age and also helps them in increasing their mobility.However, several areas of concern were also observed, and these concerns call for a variety of interventions for youth in this sector.The job brings about physical and psychological ailments, and work-life imbalance, and thus the women require proper support to survive in the occupation.Taking into consideration the growing number of women joining the call centers some of the emerging issues that will have future policy implications have been mentioned below.
The psychological distress among the women employees was very high, and the firms should pay proper attention to their employee's psychological health.Roundthe-clock counseling services should be available for both workplace and non-work place-related stress.There should be some kind of psychological support for the women who face any kind of abuse at the workplace be it from people at the workplace or abusive customers.The over-ambitious performance targets, strict deadlines, close monitoring, overtimes, stringent leave policies may not be sustainable in the long run.The call centers must encourage their youth to engage in activities that would help them in relieving stress such as engaging in recreational activities, yoga, and meditation.The organizations should frequently organize stress-relieving interventions such as integrated fun and games at work, parties and outings, and other fun activities.Health check-ups at regular intervals should be provided by employers.These activities should be managed during working hours and should be made mandatory for the employees.Along with it, there should be proper channels through which the employees can express their stress to the supervisors, managers, and councilors to help them reduce their stress.The organizations should ensure that proper and healthy food is available for the employees at the office.Along with the organizations, the employees should also try to maintain a healthy lifestyle, proper food, and sufficient rest.The employees should be made aware of the benefits of having a healthy and proper diet, adequate sleep, and physical activities.They should also be counseled regarding the ill effects of tobacco and alcohol consumption.
Though the call center employment helps in attracting women to join the job, it fails in retaining the employees which result in high employee turnover.The high employee turnover is also a reflection of the high level of stress among the employees.Internal marketing interventions such as employee harassment prevention programs, cultural sensitivity training, employee welfare programs, family involvement, fun in the workplace, industryspecific training programs, etc. can go a long way in increasing job satisfaction and reducing the employee turnover in the call centers (Budhwar et al., 2009).In addition to these measures, the job would be more appealing to the women if their wages and other financial benefits are on par with their counterparts in the other developed nations such as the USA or UK.For making the night work attractive for the women employees, some steps should be taken by the organizations like flexible work timings, on-campus care centers for children, reduced overtime, flexible leave policies, relaxation zones, proper support from supervisors, and a friendly work environment.Organizations should also encourage family engagement programs.Inviting the parents and family members to the campus would help in creating a better image of the call centers along with helping the family members understand more about the work atmosphere and the work done at the call center.This would also help the women in gaining respect from their family members about the call center work which has lots of stigmas attached.

Limitations of the Study and Scope for Future Research
The present study brings out the health implication of the employment on the women employees.Being a systematic review there were restrictions on the interpretation of the results.The study could not provide the treatment-seeking behavior, coping mechanisms that they utilized for the psychological health problems, and the support that they received from their organization and family to deal with their health problems.
It would be interesting to understand treatmentseeking behavior and the coping mechanism employed by the women to deal with the physical and psychological health problems.A comparison between the women employees of call centers and the other nightbased jobs such as nursing can be also done to bring out the relative situation of the women working in call centers as compared to the other night-based employments.These are some relevant issues to explore in future research.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figure 1 .
Figure 1.Linkages between aspects of call center employment and health implications among women employees.

Table 1 .
Studies on International call Centers in India.