Prevalence of work-related musculoskeletal symptoms among tea garden workers in Bangladesh: a cross-sectional study.

OBJECTIVES: Occupational health is still in the developmental stage in Bangladesh. There is a lack of focus on agricultural workers. Statistics on musculoskeletal symptoms (MSS) of any occupational group can assist in developing intervention and ergonomics-based prevention. This study aimed to assess work-related MSS among tea garden workers.
SETTING: This cross-sectional study was done in one tea garden in Moulvibazar district which has the highest number of gardens in Bangladesh. DESIGN AND PARTICIPANTS: 346 tea garden workers were interviewed using the Nordic Musculoskeletal Questionnaire Extended Version 2. Workers 18-60 years of age and of both sexes were interviewed individually. OUTCOME MEASURES: Prevalence of MSS among the tea garden workers, MSS in different body regions and MSS related informations. Sociodemographic and work-related factor associated with MSS.
RESULTS: Among the tea garden workers, 276 were female and 70 were male. The study showed 80.9% had symptoms in the past 12 months while 80.1% and 76.6% had in the past 4 weeks and on the day of the interview, respectively. Symptoms were most commonly reported at the shoulder (78.2%) followed by upper back (56.1%) and lower back (32.5%). Workers engaged with plucking operation were found to be significantly associated with symptoms compared with non-pluckers (p<0.05). Female workers were more likely to display symptoms in the neck (p<0.05) than male workers. Increased work hours were significantly associated with symptoms in the lower back (p<0.05). Overtime was responsible for symptoms in the elbow and hip/buttock (p<0.05). Statistics from relevant studies in India, Malaysia and Thailand were compared with the results of this study.
CONCLUSIONS: The prevalence of MSS among tea garden workers was found to be very high, and ergonomic interventions like reduction of weight load, job rotation and small breaks can reduce these symptoms. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

This study focused on musculoskeletal symptoms (MSS), which is an important aspect of occupational health but is less investigated in the workplace.

The information regarding MSS in the past 12 months relies purely on recall and the prevalence may be overestimated.

Musculoskeletal problems were recorded by asking questions, not by observation and the respondents may intentionally modify the actual problem behaviour by them.

The causative factors of MSS were not investigated in this study using methods like the Rapid Entire Body Assessment and the Assessment of Repetitive Tasks analysis.

The thorough medical examination was beyond the scope of the study and the MSS were taken from the reviewed articles.

Introduction

Tea plants are evergreen shrubs that reach 30 feet in height if not pruned regularly. A subtropical climate is most suitable for the growth of tea plants and they mostly cultivated in Asian and African countries. They are grown for their leaves, which are dried, then wilted, oxidised and fermented leading to the production of drinkable tea. Bangladesh is the twelfth largest producer of tea in the world.1 Tea is produced all year long in Bangladesh but mostly between June and November. The colonial British administration came up with the idea of tea plantations in the Indian subcontinent at the very beginning of the nineteenth century. Since then, in the subcontinental region, the progress of the tea industry was going at a slow rate but now it is one of the major industries in this region. Now many tea gardens are successfully running in Bangladesh. Tea is cultivated on 115 629.76 hectares of land.2 There is a total of 164 tea gardens present in the country. Over 100 000 workers are registered in these tea gardens3 and most of them live under a 1$ per day income.4 Their activities throughout the year include plucking tea tree leaves and buds, weeding, dressing tea plants, applying fertilisers and pesticides, clearing the forest land for the extension of plantation areas, pruning vulnerable tea trees, repairing canals and roads, and doing domestic chores at the households of the managers. Among all agricultural works, tea-related works are one of the most labour-intensive occupations. The factory, which makes tea, is mechanised and uses less than 10% of the population. All other workers work in the field with activities related to hoeing, weeding, pruning and plucking tea tree leaves and buds, and so on.5 After plucking the tea leaves, the workers have to carry the load on their back. They maintain an awkward static posture, repetitive movements, poor lifting and carrying techniques while plucking tea for long periods.6 In Bangladesh, plucking is done manually which is the most labour-intensive part of tea production. Plucking of leaves is done by both hands in a fast-paced, short-cycled and highly repetitive manner. Plucked leaves are delivered in a wide basket. For increasing work efficiency, the basket is carried on the back. It is hung from the head with the help of a belt/rope/cloth and is supported at the back of the pluckers. During plucking, they flex their trunk and neck. Tea pluckers have to work in varying climatic conditions like high temperatures and rain. They have to maintain an awkward static work posture while plucking with repetitive hand movements. The working condition also imposes physical demands on the pluckers. They also carry plucked tea on their heads until they weigh and unload in the carrying vehicle. Moreover, the work is performed the whole day. Literature on the physical demands of different occupations is in general agreement that the greater the physical demand, the greater the probability of musculoskeletal injury. There is a relationship between repetitive movement and musculoskeletal disorders.7 Repetitive movement in an awkward posture has also been described as a causal factor in different musculoskeletal symptoms (MSS).8 Tea garden workers work in similar postures and perform similar activities. Studies about MSS in tea garden workers in Assam, India showed workers were suffering most in the shoulder (71.8%), neck (66.4%) and upper back (65.6%).9 Another study in Tamil Nadu, India assessed MSS among tea pluckers and found a high prevalence (83.6%) among them.10 MSS among Cambodian fruit farm workers was found to be 80.4%.11 Search for literature on MSS among tea garden workers in Bangladesh was done but none was found. MSS among tea garden workers of Bangladesh ask for special attention. This study, therefore, focuses on assessing work-related MSS among tea garden workers. All information from this study may therefore help the provision of better health monitoring practice among tea garden workers in Bangladesh. The objectives of this research are to investigate the prevalence of MSS in nine body regions and any possible demographic or work-related factor correlations among the tea garden workers.

Materials and methods

Settings and sample

The study was carried out in the largest tea-producing district, Moulvibazar, in the north-east part of Bangladesh. A random tea garden from a list of 91 in the district was selected for this study using simple random sampling. The total population working in the tea garden was 4000 as per the company census. The workers were either permanent or contractual employees in the tea garden. All the tea garden workers, both male and female, aged between 18 years and 60 years were considered to be the sampling unit. Workers who were working since less than 12 months or had a history of accidents that might cause muscle or joint pain were excluded from the study. The sample size was calculated with a 95% CI and relative precision of 5%. A total of 346 tea garden workers was interviewed for this study who volunteered to make themselves available.

Data collection tool

The interview had three parts: sociodemographic details of the workers, work-related questions and the extended Nordic Questionnaire Version 2 to assess MSS in different parts of the body. The whole questionnaire was translated into the Bangla language. A pilot testing on 15 tea garden workers was done. Minor changes in the language of the Bangla questionnaire were done and a page showing nine body parts according to the Nordic Questionnaire was added. This was created to help participants show their specific body area where they have symptoms. Sociodemographic details included age, gender, marital status, religion, area of residence, educational qualification, monthly income and family size of tea garden workers. Work-related questions included type of work, work experience, working hours per day, working days per week, duration of overtime, break during work, the number of breaks and duration of the break. The extended Nordic questionnaire included MSS in nine body regions, namely neck, shoulder, elbow, wrist/hand, upper back, lower back, hip/buttock, knee and ankle/foot. The term MSS was used to address the presence of any symptoms such as ache, pain or discomfort during the last 12 months, the past 4 weeks and on the day of the interview. It also included questions regarding the length of symptoms in the past 12 months, hospitalisation, change of work, reduction or prevention of work and leisure activities, attending physician, taking sick leave, subjective perception regarding symptoms having any relation to present work, and reporting of MSS to the employer.

Data collection method

Data were collected by direct face-to-face interviews of the tea garden workers who fulfilled the selection criteria. The interviews were taken without disturbing their routine work. The purpose and objectives of the study were explained to the respondents before the interview. If the participant agreed to participate then a written consent form was explained before the interview. Assurance was given regarding confidentiality and secrecy of the information they provided. Then the study participants were requested to answer the questions according to the developed format of questions. To prevent comprehensive difficulties, the questions were read to the subjects, and answers were filled one by one. First sociodemographic and work-related questions were asked. To identify their symptoms, they were provided with a diagram of the human body with nine different regions shaded and identified in a different colour to help them distinguish the regions where they have experienced symptoms. Each interview for each body region started with the question, for example, ‘have you ever had neck trouble (pain, ache, or discomfort)?’ If the answer is ‘yes’, then the interview continued to the other questions related to that body region. If the answer is ‘no’, then the interview moved to the next body region. The average time of one interview was calculated to be about 30 min.

Data analysis

For analysis purposes data were grouped as follows: age was grouped as ≤30 years, 31–40 years, 41–50 years and ≥51 years; educational qualifications were grouped as illiterate and literate; work experience was grouped as ≤10 years, 11–20 years and ≥21 years; work hours per day was grouped as ≤7 hours, 8 hours and ≥9 hours. For significance, the χ2 test was used to see the relation between MSS and associated factors. Data were analysed using SPSS V.24.

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of this study.

Result

The questionnaire was used to collect data from 346 respondents. Sociodemographic information of the tea garden workers is presented in table 1. About 20.2% of the workers were male and 79.8% were female. Among the workers 35.3% were ≤30 years, 26.3% between 31 years and 40 years, 17.9% between 41 years and 50 years, and 20.5% were ≥51 years of age. The majority of the sample was found to follow the Hindu (89.9%) religion and 81.5% of them were married; 88.7% of the workers were illiterate.

Table 1

Sociodemographic information of the tea garden workers

Variable	Category	Frequency	Percentage
Age (years)	≤30	122	35.3
	31–40	91	26.3
	41–50	62	17.9
	≥51	71	20.5
Sex	Male	70	20.2
	Female	276	79.8
Religion	Hindu	311	89.9
	Muslim	24	6.9
	Christian	11	3.2
Marital status	Unmarried	31	9.0
	Married	282	81.5
	Widowed	33	9.5
Education	Illiterate	307	88.7
	Literate	39	11.3

Work-related information about the tea garden workers is presented in table 2. Among the workers 80.1% of them were directly related to plucking work from the garden while the rest of the workers were engaged in other works like spraying fertilisers and pesticides, weeding and pruning vulnerable tea trees, and domestic chores. Most of the workers (52%) had ≤10 years of experience, 30.7% had 11–20 years of experience and 17.3% had ≥21 years of work experience. Almost all workers (87.3%) had an 8-hour working day while a small proportion (10.1%) had ≤7 hours of work and 2.6% of workers had ≥9 hours of work every day. Among the workers, 92.5% did not do overtime work and 7.5% stated that they did overtime work; 70.2% of the workers took one break during work and 29.8% took no break during work.

Table 2

Work-related information of the tea garden workers

Variable	Category	Frequency	Percentage
Type of work	Pluckers	277	80.1
	Non-pluckers	69	19.9
Work experiences (years)	≤10	180	52.0
	11–20	106	30.7
	≥21	60	17.3
Work hours per day	≤7	35	10.1
	8	302	87.3
	≥9	9	2.6
Overtime work	Overtime	26	7.5
	No overtime	320	92.5
Break during work	Break	243	70.2
	No break	103	29.8

MSS-related information of the tea garden workers is presented in table 3; 80.9% of the workers reported MSS in the last 12 months while 80.1% reported suffering from MSS in the last 4 weeks and 76.6% reported that they had MSS on the day of the interview. Almost a sixth of the workers (16.1%) required hospitalisation due to MSS in their local tea garden hospital. Every worker suffering from MSS in the past 12 months required consultation with a doctor/physiotherapist; 80.6% of the respondents had taken medication due to MSS and 78.3% of participants had to take sick leave in the past 12 months. A small number of participants (11.6%) had to change their jobs. Of the respondents, 77.7% think MSS had reduced their work activity and 76.6% think MSS had reduced their leisure activity.

Table 3

Musculoskeletal symptoms (MSS) information of the tea garden workers

Variable	Frequency	Percentage
MSS prevalence in the past 12 months	280	80.9
MSS prevalence in the past 4 weeks	277	80.1
MSS prevalence on the day of the interview	265	76.6
Hospitalisation	56	16.1
Consultation with doctor/physiotherapist	280	80.9
Medication due to MSS in the past 12 months	279	80.6
Sick leave in the past 12 months	271	78.3
Change of jobs	40	11.6
Reduced work activity in the past 12 months	269	77.7
Reduced leisure activity in the past 12 months	265	76.6

Table 4 demonstrates the MSS information in nine body regions as reported by the tea garden workers. The participants mostly suffered from MSS in the shoulder (78.2%) followed by upper back (56.1%), lower back (32.5%), neck (32.1%), wrist/hand (30%), hip/buttock (25.7%), elbow (20.7%), knee (10.7%) and ankle/foot (6.8%).

Table 4

Musculoskeletal symptoms (MSS) information according to body regions of the tea garden workers

Body regions	MSS frequency	MSS percentage
Neck	90	32.1
Shoulder	219	78.2
Elbow	58	20.7
Wrist/hand	84	30.0
Upper back	157	56.1
Lower back	91	32.5
Hip/buttock	72	25.7
Knee	30	10.7
Ankle/foot	19	6.8
Any body region	280	80.9

Factors associated with MSS of the tea garden workers are presented in table 5. Workers who were directly related to plucking work in the garden had a higher (83.4%) proportion of MSS (p=0.019). Female workers suffered more than male workers (p=0.028) in the neck region. Plucking workers reported suffering more from MSS in the neck (p=0.015), shoulder (p=0.032) and wrist/hand (p=0.034) compared with non-puckers. Tea garden workers who worked 9 hours or more every day had MSS more in the lower back (p=0.036) compared with workers who had fewer work hours. Workers who did overtime suffered more in the elbow (p=0.047) and hip/buttock (p=0.021) than those who did not do overtime.

Table 5

Factors associated with musculoskeletal symptoms (MSS) of the tea garden workers

Type of work	Musculoskeletal symptoms		Test of significance
	Present	Absent
Plucking	231 (83.4)	46 (16.6)	p=0.019
Non-plucking	49 (71)	20 (29)

Discussion

MSS is a very common health problem among agricultural workers. In this study, most of the tea garden workers were female (79.8%). Traditionally most of the tea garden workers in Bangladesh are female which reflects among the respondents in this study. A similar study in India also reported 92.6% female respondents.9 Most participants were illiterate and belonged to the ≤30 years age group. Dihingia and Dewangan in their study found 91.2% illiterate, and 8.8% educated respondents in Assam, India, which is similar to this study.9 The prevalence of MSS for the past 12 months was found to be 80.9%. In a similar study in Tamil Nadu, India the prevalence of MSS among tea garden workers was found to be 83.6% which is quite similar.10 This is probably due to similar geographical, socioeconomic and work-related factors in neighbouring countries. Another study among Cambodian fruit farm workers shows the prevalence of MSS to be 80.4%, which is also similar to this study.11

In this study participants were found mostly suffering from MSS in the shoulder (78.2%) followed by upper back (56.1%), lower back (32.5%), neck (32.1%), wrist/hand (30%), hip/buttock (25.7%), elbow (20.7%), knee (10.7%) and ankle/foot (6.8%). Vasanth et al10 in a similar study found the prevalence of MSS mostly in the shoulder (59%) followed by the lower back (58%), neck (49.1%), knee (43.9%), elbow (41.5%), upper back (37.3%), wrist (25.9%), ankle (7.1%) and hip (3.3%); the result of this study has some similarities with the current study. A similar study in Malaysia showed the prevalence of tea garden workers having MSS for the past 12 months in different body parts on the neck (34.6%), shoulder (24.8), elbow (22.2%), wrist (38.5%), upper back (26.9%), lower back (35%), hip (24.4%), knee (32.9%), ankle (18.4%) and feet (24.4%).6 In Malaysia plucking is done by sheer and machine rather than conventional hand plucking in basket method in most parts of the world. This can be the reason for the lower prevalence of MSS compared with Bangladesh. A study done by Dihingia and Dewangan showed that the symptoms were most commonly reported in the shoulders (71.8%) followed by the neck (66.4%), upper back (65.6%), wrists/hands (50.4%), lower back (47.2%), elbows (39.4%), knees (10.0%), hips/buttocks (5.4%) and ankles/feet (2.6%); this study also has some similarities with the results of the current study.9 Since the amount of tea plucked depends on the number of tea leaves and buds plucked per cycle of hand movements and frequency of movement, therefore to increase output, pluckers increase hand movement cycles, which increases the load on the shoulders. This can explain why the shoulder is the prime region of MSS found in these studies.

There are many pieces of literature explaining that MSS is multifactorial.7 8 12 The symptoms may be influenced by working techniques, characteristics, types of work, and individual and sociodemographic characteristics. Psychosocial factors can also play role in developing MSS. The role played by age, job experience, breaks and overtime are of great importance in developing MSS. Here, the researchers tried to find out whether some sociodemographic and work characteristics were associated with MSS among tea garden workers.

In the neck region, the female workers (28.6%) suffered more than the male workers (15.7%), which was statistically significant (p=0.028). Plucking workers (83.4%) were suffering more from MSS than non-pluckers (71%) (p=0.019). Also, plucking work was associated with MSS in the neck (p=0.015), shoulder (p=0.032) and wrist/hand (p=0.034). All the participants who worked ≥9 hours per day were associated with MSS in the lower back (p=0.036). Overtime was also associated with MSS in the elbow (p=0.047) and hip/buttock (p=0.021).

The information regarding MSS in the past 12 months relies purely on recall and the answers may be subjective. MSS were recorded by asking questions, not by observation. Posture analysis and measuring repetition of work were not done in this study. These limitations can be pursued to obtain further information to identify causative factors for developing MSS among tea garden workers.

MSS prevalence was found to be very high among tea garden workers. Working in awkward postures should be avoided; also workers need to reduce excessive force and repetitive movements and minimise static unsupported postures. Workers should take small breaks such as stretching, sitting or change of posture, if possible, to avoid prolonged awkward posture and repetitive motion.

Tea is mostly cultivated in developing and underdeveloped countries. So occupational problems of tea workers have always been neglected. Musculoskeletal problems are now being studied in all occupational settings all over the world, yet it is not enough. This study adds research to that small number of studies.