Psychological distress among ASHA workers serving zero-dose and non-zero-dose UPHC catchments in Malegaon, Maharashtra: a cross-sectional study

Background: ASHA workers support immunization and community outreach, yet evidence on their psychological well-being in zero-dose programme settings is limited. This study compared psychological distress among ASHA workers serving zero-dose and non-zero-dose UPHC catchments in Malegaon Municipal Corporation, Maharashtra. Methods: A cross-sectional analytical study included 184 ASHA workers nested within 14 UPHCs (88 in six zero-dose and 96 in eight non-zero-dose catchments). DASS-21 scores were reconstructed directly from the 21 questionnaire items. Group differences were assessed using Welch tests with Mann-Whitney sensitivity analyses; mean differences, 95% confidence intervals and Cohen’s d were reported. Adjusted linear models used family type and religion, with small-sample cluster-robust CR2 inference at UPHC level. Results: Mean stress was 15.34 versus 8.96 (difference 6.38, 95% CI 3.95-8.82; d=0.78), anxiety 13.89 versus 8.98 (difference 4.91, 95% CI 2.59-7.22; d=0.62), and depression 8.66 versus 6.00 (difference 2.66, 95% CI 0.49-4.83; d=0.37) in zero-dose versus non-zero-dose groups. Adjusted CR2 coefficients were +7.47 for stress (p=0.033), +6.01 for anxiety (p=0.068) and +3.20 for depression (p=0.305). Conclusions: ASHA workers serving zero-dose catchments had higher observed stress and anxiety scores. Stress showed the most consistent evidence across analyses, whereas anxiety was less precise at cluster level and depression remained exploratory. The findings represent cross-sectional associations, not causal effects, and should be interpreted in light of only 14 UPHC clusters and fieldwork conducted after programme expansion.