Effectiveness of Awareness Package on Occupational Health Hazards among Ragpickers of New Delhi, India.

BACKGROUND: Ragpickers are informal workers who collect recyclable materials to earn a small wage on daily basis. They work in vulnerable conditions and awareness regarding occupational and environmental hazard is essential for them.
OBJECTIVE: To study the effectiveness of awareness program on various occupational health hazards among the ragpickers.
MATERIALS AND METHODS: This interventional study was conducted from May through October 2016 among the ragpickers living near field practice area of Department of Community Medicine and those living in slum areas around HAHC Hospital, New Delhi, India. The awareness regarding occupational and environmental health hazards was assessed using a pretested and predesigned pro forma. Snowball sampling technique was used to select the ragpickers from the various areas. Health awareness and education package was designed for the ragpickers. The package was delivered by medical officers and health workers. A posttest assessment was done 2 weeks after the awareness activity. RESULT: Among 150 ragpickers, there was significant improvement in knowledge immediate post training on knowledge of occupational hazard and hygiene.
CONCLUSION: Efforts should be put to develop training materials on occupation and environmental health and injury issue relating to waste management.

INTRODUCTION

Ragpicker or Chiffonnier is a term for someone who makes a living by rummaging through refuse in the streets to collect material for salvage.[1] They are informal workers who collect recyclable materials to earn a small wage on daily basis. India's booming urbanization brings the problem of waste management. The amount of waste is increasing at a high pace and waste management is likely to become a critical issue in the coming years. Ragpickers play an important, but usually unrecognized, role in the waste management system of Indian cities. They collect garbage in search of recyclable items that can be sold to scrap merchant (paper, plastic, tin, etc.). This activity requires no skills and is a source of income for a growing number of urban poor.[2] Due to the extremely unorganized and scattered nature of the waste picking activity, it is difficult to give an accurate estimate of the population involved in waste picking. Rough estimates give the number of waste pickers in Delhi as ranging between 80,000 and 100,000.[3]

The occupational health hazards of waste pickers arise from two aspects: poverty and their occupation itself. Because they belong to the poorest and most deprived section of the urban population, diseases are very common among waste pickers. These make them all the more susceptible to occupational health hazards. Child ragpickers are working in filthy environments, surrounded by crows or dogs under any weather conditions and have to search through hazardous waste without gloves or shoes. They often eat the filthy food remnants they find in the garbage bins or in the dumping ground. Using the dumping ground as a playing field, the children run the risk to come upon needles, syringes, used condoms, saline bottles, soiled gloves, and other hospital wastes as well as ample of plastic and iron items.[4] They work in vulnerable conditions and knowledge and awareness regarding occupational and environmental hazards are essential for them. Keeping the above points in mind, the following study was conducted to study the awareness of various occupational and environmental health hazards among the ragpickers, to generate awareness among them on environmental and occupational health hazards and to assess the effectiveness of the awareness program.

MATERIALS AND METHODS

Study type: Quasi experimental pre and post test Interventional study.

Study duration: May through October 2016.

Study setting: The study was conducted in the field practice area of Department of Community Medicine (Hamdard Institute of Medical Sciences and Research, New Delhi) and the area around HAHC Hospital, New Delhi, India.

Study population: Ragpickers were defined as those informal workers who collected recyclable materials to earn a small wage on daily basis in the study area.

Inclusion criteria: Ragpickers who consented to participate were included. In case of minors, one adult member of their family was contacted and consent was taken.

Exclusion criteria: Those who could not understand the language used by the interviewers.

Sample size and sampling: Nonprobability sampling (Snow ball technique) was used to approach the ragpickers. After one ragpicker was identified he/she was further asked for help to locate other ragpickers. A total of 161 ragpickers living near Urban Health Training Centre (Pul Prahladpur), Rural Health Training Centre (Madanpur Khadar), and those living in slum areas around HAHC Hospital, New Delhi were approached. Eleven ragpickers refused to participate or had to go for some other job for daily wage, hence could not spare time for the study. Thus 150 consented to participate.

Tool for data collection

Data collection was done by self-administered structured knowledge questionnaire. It consisted of items on demographic variables such as age, gender, income per month, hours of work, and literacy status and on awareness of various occupational and environmental hazards. Awareness material was designed in local language with pictorial representations for the ragpickers.

Data collection and awareness generation

Four to five ragpickers were asked to gather in a common place. After explaining the purpose of the study, the baseline data and pretest information from the participants were recorded before beginning the awareness program.

Demonstration of hand washing technique was done.

Awareness was imparted by medical officers, medico-social workers, and health inspector.

Those who possessed a phone, their contact details were recorded and 2 weeks later the awareness activity posttest assessment was done. Those who did not have a phone the contact details of someone living nearby to them were recorded for contacting them.

Operational definitions

Effectiveness: It refers to difference between pretest and posttest awareness of ragpickers regarding hand hygiene practices, as revealed by statistical tests.

Awareness package: Refers to planned instruction regarding knowledge on various environmental and occupational health hazards.

Awareness: Refers to awareness of ragpickers regarding occupational and environmental health hazards as revealed by self-administered questionnaire.

Data analysis

Frequency and percentage distribution was used to analyze demographic data. Chi-square test was used to determine the association of awareness before and after the intervention. P value was considered significant at <0.05.

Ethical consideration and consent

Ethical clearance was taken from the institute before beginning the study.

RESULTS

Table 1 shows that 62% of the ragpickers were males and more than half were illiterate (53%), while 33% had completed primary schooling. Majority of illiterates were males (60%) Adolescent and youth age group (14–20 years) constituted 27% of the ragpicker population and 25% were above 35 years of age. More than half (51.3%) of age >35 years of ragpickers was constituted by females. Majority (65%) were earning Rs. 2000–5000 through ragpicking. However, males earned in majority (79.2%) higher daily income (>5000 INR) as compared to females and this distribution was statistically significant (P = 0.003). It was also observed that 64% of less than 5 h of daily time spent on this occupation was by females. A higher duration of working hour was spent in majority by males (75%) and this distribution was statistically significant (P< 0.0001).

Table 1

Gender-wise distribution of sociodemographic profile of rag pickers

Table 2 shows the effectiveness of the awareness program on various hazards. During ragpicking 43% of the ragpickers mentioned that they were vulnerable to pricks by sharps (including improper syringe disposal). Among them, only 13% were immunized for tetanus as per the Universal Immunization Program (UIP). When asked about the diseases caused by sharp pricks during ragpicking before the awareness program, only 8% knew about a disease called tetanus, 27% knew about HIV/AIDS, while none knew about hepatitis B or C. After the intervention the awareness level increased significantly about all the three diseases (P< 0.0001).

Table 2

Effectiveness of awareness program on various hazards

Significant improvement was observed on awareness of diseases caused by mosquito bites and awareness of infections caused due to not using proper hand hygiene practices after the education program (P < 0.001). However, there was no significant difference found between awareness on hand washing practice before each meal before and after the education program [Table 2].

DISCUSSION

In the present study, majority (62%) of the ragpickers were males. Studies in Brazil [5] and Delhi [4] have shown that more than 50% of the ragpickers are males; the findings are similar to our study. Males are expected in our country to be the breadwinners for the family, however, a good proportion of females are also involved in this work. Also, in the current study in the age group >35 years, majority were females; probably because one person's wage is not enough for a family in the current situation, hence females are also engaging themselves in this occupation.

Majority of the study population belonged to middle aged (21–35 years). Similar findings were found by a report submitted on ragpickers of Kathmandu.[6] A study from Paletos in Brazil reported that majority of the ragpickers (58%) belonged to the age group 18–39 years.[5] The present study reported that ragpickers consisted of 53% of illiterate people of which majority were males, and similar to the findings of Shrestha et al.[6] from Nepal. However, another report from Nepal also found that majority of the ragpickers are literate.[7]

Most (67%) of the waste collectors were reported to work for more than 5 h daily in the current study and among them males contributed to the maximum proportion. Menon et al.[8] found that 73% of ragpickers worked for a period of 5–8 h daily and 21% more than 8 h in Thiruvananthapuram district. Shrestha et al.[6] also found that majority of these ragpickers were working 7 h per day. Hence the major part of the daily working hours were spent in this work, making it their predominant occupation to earn their living mainly by the males. Females have to perform their household chores too and then proceed out for earning wages; also they cannot work in odd hours due to safety constraints.

From the study the average monthly income of 65% ragpickers is found to be 2000–5000 INR. Also, a higher monthly wage (>5000 INR) was earned by a major proportion of males. In a study by Sarkar et al., it was found that adult waste pickers earn meager Rs. 45–80 per day. A child waste picker earns Rs. 10–15 when he is assisting his parents. If he is working independently, the child earns Rs. 20 or 30 as he can then devote more time to his activity. Also, they reported that waste picker with a cycle earns Rs. 50–80 per day and one with a tricycle earns Rs. 150–200 per day.[3]

Ragpickers are vulnerable to environmental and occupational health hazards. Awareness regarding the various diseases caused by these hazards was assessed. A study in Delhi found that waste pickers were likely to suffer from diarrhea and helminth infections too.[9] In the present study, significant increase was observed on awareness of diseases caused due to nonusage of proper hand hygiene practices after the education program. Hand hygiene practices were found to be poor, both before and after the awareness program and the major reason mentioned was nonavailability of water. The reason could be that most of these ragpickers belong to migrant population and accessibility to basic necessities such as water and electricity are a concern for them.[10] These problems have also been stated by Eswaran et al.[11]

Cut from sharp materials in the waste is a further direct health hazard. The knowledge about the diseases caused due to pricks due to sharp waste was nil to very low. In our study also, 70% were not aware of this disease and its transmission through pricks. Tetanus resulting from sharp pricks and infection of wounds has been reported as a significant cause of illness and death among the children.[12] In a study by Mote et al.,[13] 60% of ragpickers had not heard about HIV/AIDS. Significant increase of awareness level was observed after the education program regarding the diseases caused by sharp pricks in our study. In Bangkok, cuts were commonly experienced; most were caused by glass, discarded needles, bamboo, and metal.[14] In another survey from Hyderabad, it was indicated that 82% of ragpickers suffered wounds or injuries.[4] A study by Batool et al.[15] in Pakistan showed that 79% of ragpickers faced hurdles of sharps and broken glasses during ragpicking.

Disease vectors also breed in and feed near solid waste. Many waste pickers complain about flies and mosquitoes act as a nuisance while working.[15] More than half of study population (baseline) had awareness regarding vector-borne diseases arising from these waste. Solid waste is associated with several specific vector-borne diseases. When discarded buckets, pots, bottles, and even bottle tops are filled with rainwater, they form potential habitats for the Aedes aegypti mosquito which transmits dengue fever. Significant increase of awareness level was observed after the education program regarding the diseases caused by vectors.

Limitations of the study

The data were cross-sectional, which limits the ability to determine the directionality of the relations. The small sample size of the analysis limits us to generalize the findings to all the ragpickers of the country. The data collected from interview of respondents may be subjected to response bias. People tend to provide socially desirable responses and, moreover, there are differences in levels of perception of the questions asked. Also posttest assessment was only done once and that too after 2 weeks of awareness activity.

CONCLUSION AND RECOMMENDATIONS

In the present study there was significant improvement in knowledge immediate posttraining about occupational hazards and hygiene. Very few studies have been conducted to see the effectiveness of such awareness programs on the ragpickers.[16] Large-scale studies involving multicentric centers are warranted and efforts should be put to develop training materials on occupation and environmental health and injury issue for this vulnerable section. Government and nongovernment organizations play a key role for targeting this population and ensure provision of accessible health care services.

Though the waste pickers play a significant role in the entire process of waste management, yet their services go unnoticed and issues concerning their livelihood go unaddressed. Issue of protective equipments, immunization, and focusing on the vulnerable population among the ragpickers such as women and children should be an issue of prime concern.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.