






































 Global Journal of Education and Allied  

Research (GJEAR) 
Volume.13, Number 10; October-2022; 

ISSN: 2837-3707 | Impact Factor: 6.79 

https://zapjournals.com/Journals/index.php/gjear  

Published By: Zendo Academic Publishing 

 

 

pg. 1 

CONTROL-BASED MANAGEMENT STRATEGIES AND THEIR IMPACT ON 

FLOUR MILL WORKERS' OCCUPATIONAL ASTHMA 

 
1Dr. Amina Mahmoud Abdelrahman, 2Prof. Samir Ahmed El-Masry and 3Dr. Fatima Ali Hassan   

 

Article Info  Abstract 

Keywords: Occupational 

asthma, flour dust, respiratory 

symptoms, prevalence, 

spirometric parameters. 

 Occupational asthma remains a significant global concern, particularly 

impacting workers exposed to grain and flour dust, which stands as the 

second most frequently cited cause of such asthma cases. Despite being 

prevalent, limited research has delved into the topic, with a focus on 

symptomatology. Notably, a study investigated the prevalence of 

occupational asthma in South Cairo's flour mills, revealing that a 

quarter of workers exhibited work-related asthma symptoms that 

manifested during work hours and subsided post work. Moreover, these 

asthmatic workers displayed inferior spirometric parameters compared 

to non-asthmatic counterparts. Similarly, studies conducted in other 

regions corroborate these findings. For instance, an investigation in Iraq 

among flour mill workers discovered a significantly high prevalence of 

occupational asthma, substantiated both by self-reports and investigator 

diagnoses. In Egypt, a study involving flour production mill workers 

highlighted complaints of asthma due to occupational exposure, 

coupled with diminished respiratory capacity. Additionally, Indian 

research unveiled that chronic exposure to flour dust led to pronounced 

respiratory symptoms, including cough, breathlessness, and wheezing, 

further compounded by substantial declines across various pulmonary 

function tests. In sum, these collective studies emphasize the link 

between flour dust exposure and the prevalence of occupational asthma, 

urging comprehensive measures to safeguard the respiratory health of 

workers. 
 

 

Introduction  

Occupational asthma is a global problem affecting a large number of workers. Exposure to grain and flour dust is 

the second most typical reported cause of occupational asthma. Few studies on occupational asthma in Egypt, 

focusing mainly on asthma symptoms. A study was done to investigate the presence of occupational asthma 

among workers at flour mills of south Cairo, which indicated that 25% of mills workers had asthma-related to 

                                                      
1,2,3Community Health Nursing Department, Faculty of Nursing, Cairo University, Egypt  

https://zapjournals.com/Journals/index.php/gjear


Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 2 

work; the asthma symptoms appeared during work and improved after leaving the workplace. Also, the asthmatic 

workers had lower spirometric parameters than non-asthmatic (El-Gewily et al., 2018). Therefore, many studies 

investigated the relationship between flour dust and the prevalence of occupational asthma among flour mill 

workers. One of those studies was done by Ajeel & Al-Yaseen (2015) in Iraq to study the prevalence of 

occupational respiratory disorders among flour mill workers and found that the prevalence of occupational asthma 

as reported by workers and diagnosed by one of the investigators was significantly high. In addition, a study done 

by Rafiee et al. (2015) to assess the effects of flour dust on the respiratory system among 400 workers of flour 

production mills in Assiut, Egypt, found that most workers complained of occupational exposure to asthma and a 

decrease in respiratory capacity. Another study done by Asia & Atram (2016) in India to evaluate the effect of 

chronic exposure to flour dust on pulmonary function test among flour mill workers concluded that cough and 

breathlessness were more pronounced among workers, wheezing is a commonly encountered sign, and all 

pulmonary function tests showed a significant decline.  

J. Multidiscip. Sci. 2021, 3(2), 34-41.                          https://doi.org/10.33888/jms.2021.324                     

www.multidisciplines.com Yawn et al. (2014) mentioned that the asthmatic flour mill workers need effective 

occupational asthma management to achieve clinical control of the disease and maintain that control through 

implementing a control-based management strategy. Control-based asthma management strategy is a worker-

focused, individualized, flexible approach to occupational asthma management that allows adjustments to 

regimens over time, thus considering the variable nature of the disease within each worker. Therefore, 

occupational health nurses in flour mills play an essential role in maintaining the health and safety of health care 

workers through the three levels of prevention. The primary level of prevention includes both health promotion 

and work-related injury or disease prevention; health promotion is applied when the occupational health nurse 

helps the workers to change their lifestyle to move toward a state of optimal health. Work-related injury or disease 

prevention began with recognition of health risk factors, a disease, injury, or an environmental hazard and was 

followed by measures to protect as many workers as possible from the harmful consequences of that risk (Neis & 

Ewen, 2014).  

The occupational health nurse should provide more frequent health surveillance at the secondary prevention level, 

including a respiratory questionnaire about work-related upper and lower respiratory symptoms. To identify 

sensitized workers or cases of occupational asthma at early and reversible stages of the disease and ensure that 

the workplace and working practices are investigated to identify potential causes and implement corrective actions 

(Buchta & Russi, 2017). Additionally, the occupational health nurse is often the key person in the rehabilitation 

program with the manager in the tertiary prevention level. Moreover, the affected workers she/he is responsible 

for completing a risk assessment and advising the affected workers with the rehabilitation program to reduce the 

consequences of occupational asthma, monitor its progress, and coordinate health care services for the affected 

workers from the onset of illness to a safe return to work or an optimal alternative (Ethridge et al., 2015). So, the 

study aimed to evaluate the effect of a control-based management strategy on occupational asthma control among 

flour mill workers in Giza Governorate. 

Materials and Methods   

Research design and areas  

A quasi-experimental one-group pretest-posttest design will be utilized to fulfill the aim of the study. A purposive 

sample of 122 flour mill workers from El-Haram flour mill constituted the subjects of the study. The sample size 

was calculated based on a G-power version 3.1.1 for power analysis. A Power of .95 (β = 1-.95 = .05) at alpha .05 

(one-sided) was used as the significance level, and effect size= 0.3 was utilized. The inclusion criteria were 

working full-time for at least one year in the flour mill (8 hours a day and six days per week). The exclusion 



Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 3 

criteria were having a history of bronchial asthma before joining the work or family history and having a present 

or history of severe respiratory infections as extensive pulmonary tuberculosis. These criteria were according to 

British Occupational Health Research Foundation (2017).     

Research setting  

This study was conducted at South Cairo & Giza Mills & Bakeries Company in 2019. It is the largest company 

in Egypt for the manufacture of flour and has the most significant number of workers. It includes 950 workers. 

El-Haram Mill Branch was selected to implement the study because it includes many workers. It includes 300 

workers out of 950 workers in all company mills. In addition, the El-Haram mill is the main branch of the 

company.   

Tools of data collection  

Data were collected using five tools: I: Occupational Asthma Questionnaire: It was structured by the researcher 

based on extensive literature reviews. It included three parts: (a) Workers' characteristics consisted of 9 questions 

(b) Occupational asthma symptoms: It included 22 questions related to reported asthma symptoms as wheezing 

and tightness in the chest, cough, and whether these symptoms improved when the worker was away from work. 

(c) occupational asthma flare-ups symptoms: It consisted of 3 questions related to reported sudden symptoms as 

coughing, shortness of breath, and wheezing.   

II: Worker's Inhaler Adherence and Satisfaction Questionnaire: It was developed by the researcher based on an 

extensive literature review. It included two parts 1st   part. Pre/ post worker's inhaler adherence.  This part assessed 

the worker's adherence to the use of an inhaler, and it included ten questions related to when to use the inhaler, 

using the inhaler only when feeling breathless, missing out on doses. 2nd part. Pre/ post worker satisfaction with 

the inhaler. This part assessed the workers' satisfaction regarding inhaler use. It included ten questions about 

inhaler preparation, using, keeping, carrying.  

III: Inhaler Technique Observational Checklist: It is adopted from Basheti et al. (2014). It consisted of ten steps 

that assessed the worker’s inhaler use. This tool was used as a pre/post-test.  

IV-Workplace Observational Checklist: It was developed by the researcher based on Stobnika & Gorny (2015). 

It included five preventive measures available in the workplace to minimize the risks of occupational asthma 

among workers: a) Flour dust control measures, b) Ventilation measures, c) Personal Protective Equipment, d) 

First aid facilities, and e) Waste management measures.  

V: Spirometry Test Record. Spirometry is a standard test used to measure how well patient lungs are functioning. 

The test works by measuring airflow into and out of the patient lungs using a spirometer. The patient sits and 

breathes into a small machine (spirometer) to take a spirometry test. This medical device records the amount of 

air a patient breathes in and out to measure the Forced Expiratory Volume in one second (FEV1) and the speed of 

the patient breath. The researcher recorded the readings. Spirometry tests are used to diagnose asthmatic patients.  

Ethical consideration  

The research proposal and the tools were submitted to the Committee of Research Ethics at the Faculty of Nursing, 

CairoUniversity. Approval to start the study was obtained on 28 May 2018. Written approval was obtained from 

the director of the medical sector at South Cairo & Giza Mills & Bakeries Company on 8 July 2018 to collect 

data from the workers working at the El-Haram flour mill. Also, written informed consents were obtained from 

the workers working at El-Haram flour mill after explaining the aim of the study, its benefits, and risks, if any, 

duration of the study, data collection tools, and the procedure of the study. The researcher informed the workers 

that all data gathered during the study would be confidential. Moreover, they had the right to withdraw without 

any reason and any pressure from the head of the department. Besides, workers were informed that the obtained 

data would be used for this study, and it would not be reused in other studies except with their permission.   



Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 4 

Results and Discussion  

Description of flour mill workers' characteristics  

Concerning the personal characteristics of flour mill workers, table (1) shows that 51.6% and 23% of workers 

aged 45 to less than 55 and from 25 to ˂ 45 years old respectively with a mean of 48.11 ± 8.61 years. In addition, 

the table reveals that 40.1% of workers had work experience of 20 to less than 30 years while 18% had work 

experience of 1 - ˂ 10 years with a mean of 17.86 ± 8.69 years. As for smoking history, 17.2% were moderate 

smokers, and 6.6% were heavy smokers. 

Table 1. Percentage distribution of flour mill workers' 

characteristics (n = 122).  

 

Personal characteristics  Frequency  %  

Age / year   

25 ˂ 35  13  10.7  

35 ˂ 45  15  12.3  

45 ˂ 55  63  51.6  

55 – 60  31  25.4  

x̅ ± SD  48.11 ± 8.61 years   

Duration of work:   

1 - ˂ 10    22  18  

10 - ˂ 20  39  32  

20 - ˂ 30  49  40.2  

30- 38  12  9.8  

x̅ ± SD  17.86 ± 8.69 years   

History of smoking:   

No          82  67.2  

Yes:  40  32.8  

˂ 10    cigarettes/day    (light 

smoker)             

11  9  

10-20 cigarettes/day   (moderate 

smoker)          

21  17.2  

˃ 20    cigarettes/day   (heavy 

smoker)              

8  6.6  

Description of occupational asthma and lung function among flour mill workers in pre, post, and follow-up 

tests. 

Regarding the prevalence of occupational asthma, Figure 1-2 reveals that all degrees of asthma percentages 

changed better. Moderate occupational asthma represented 31.1% of workers in the pre-test, which decreased to 

28.7% and 18% in post and follow-up tests, respectively. The percentage of severe asthma workers decreased 

from 22.1% in the pre-test to 20.5% and 12.3% in the post and follow-up tests, respectively. Also, mild asthma 

increased from 18.9% in the pre-test to 22.9% and 36.9% in post and follow-up tests. Also, intermittent asthma 



Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 5 

increased from 27.9% to 32% in the follow-up. In addition, Table 2-3 shows a significant reduction in 

occupational asthma degree in the post and follow-up tests (F = 31.16, P = 0.006).  

Table 2. Difference between airway obstruction scores in pre and follow-up tests 

among flour mill workers.  

 

Scores of airway obstruction  Mean  SD  Paired T-

Test  

P  

Pre  2.24  1.04  9.718  0.000*  

Follow-up  1.50  0.67  

Note. * Significant at the 0.05 level and n = 122.    

  

Table 3. Difference between the means of occupational asthma degree in pre, post, and 

follow-up tests among flour mill workers.  

Degree of occupational asthma  Mean 

(10)  

SD  F  P  

Pre  6.86  1.74    

31.16  

  

0.006*  Post  5.19  1.23  

Follow-up  3.52  1.45  

Note. *Significant at the 0.05 level and n = 122.  

      

 
Figure 1. Percentage distribution of pre, post, and follow-up occupational asthma degree among flour mill 

workers (n = 122).  

  

  

% 0.0 

% 5.0 

% 10.0 

15.0 % 

% 20.0 

% 25.0 

30.0 % 

% 35.0 

% 40.0 

Intermittent Mild Moderate Severe 

27.9 % 

18.9 % 

31.1 % 

22.1 % 

27.9 % 

% 22.9 

% 28.7 

20.5 % 

% 32.8 

36.9 % 

18 % 

12.3 % 

Degree of Occupational Asthma 

Pre Post Follow-up 



Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 6 

 
Figure 2. Percentage distribution of airway obstruction in pre, and follow-up tests through Forced Expiratory 

Volume (FEV1) among flour mill workers (n = 122).  

Figure 2 clarifies that the percentage of workers who had normal lung function increased from 27.9% in the pre-

test to 49.3% in the in-follow-up test. Moderate and severe airway obstruction represented 18% and 17.2% in the 

pre-test, respectively decreased to 9.8% in the follow-up test. Table 3 shows a highly statistically significant 

difference between the means of airway obstruction scores in pre and follow-up tests (T = 9.718, P = 0.000).  

Table 4. Correlation between flour mill workers' characteristics and scores of airway 

obstruction in pre, and followup tests.  

The score of airway obstruction  

Flour mill workers' 

characteristics  

Pre   Follow-up  

                                                                            

R  

P  R  P  

Age   0.105  0.250  0.088  0.3322  

Sex  0.211  0.020*  0.082  0.370  

Level of education  0.007  0.937  0.028  0.761  

Place of residence  0.161  0.076  0.194  0.033*  

Duration of work  0.033  0.721  0.119  0.192  

Income  0.082  0.370  0.071  0.439  

Smoking   -0.055  0.545  0.083  0.364  

Note. * Significant at the 0.05 level, R = Pearson correlation, P = Probability, and n = 

122.  

3.3. Workers’ compliance to prescribed management.   

As indicated in Figure 3 regarding adherence of workers to inhalers, it shows that 4.9% of them were adherent to 

inhalers in pre-test increased to 75.4% and 79.5% in post and follow-up tests, respectively. Nonadherence 

  

% 0.0 

% 5.0 

% 10.0 

15.0 % 

20.0 % 

25.0 % 

30.0 % 

35.0 % 

% 40.0 

% 45.0 

% 50.0 

Normal Mild Moderate Severe 

27.9 % 

36.9 % 

18.0 % % 17.2 

% 49.3 

31.1 % 

9.8 % 9.8 % 

Degrees of airway obstruction based on scores of lung function   

Pre Follow-up 



Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 7 

represented 95.1%, 24.6%, and 20.5% in pre, post, and follow-up tests, respectively. Regarding the worker’s 

satisfaction with an inhaler, figure 4 clarifies that only  

4.1% of them were satisfied with using inhalers in pre-test increased to 60.7% and 42.6% in post and follow-up 

tests, respectively. 

Table 5. Percentage distribution of non-pharmacological practice among flour mill workers 

in pre, post, and follow-up tests.  

Non-pharmacological 

practices  

Pre  Post  Follow-up  

  *N  %  *N  %  *N  %  

Smoking:  

Light smoker  11  9  10  8.2  8  6.5  

Moderate smoker                  21  17.2  20  16.3  15  12.2  

Heavy smoker                      8  6.6  5  4  3  2.4  

Physical activity  27  22.1  45  36.8  77  63.1  

Breathing exercises  8  6.5  82  67.2  105  86.1  

Influenza vaccine  0  0  7  5.7  7  5.7  

Weight reduction  15  12.2  50  40.9  50  40.9  

Healthy diet  56  45.9  110  90.1  110  90.1  

Avoidance of confirmed 

food allergy  

46  37.7  45  36.8  27  22.1  

Avoidance of the outdoor 

allergen  

20  16.3  60  50.8  60  50.8  

Avoidance of outdoor air 

pollutants  

82  67.2  115  94.2  115  94.2  

Note. *Responses are not mutually exclusive,  *N = Number, and n = 122.  

  

Regarding non-pharmacological management, Table 5 shows that 17.2% were moderate smokers in pre-test 

decreased to 16.3% and 12.2% in post and follow-up tests, respectively. Concerning physical activity, 22.1% of 

flour mill workers did a physical activity in pre-test increased to 36.8% and 63.1% in post and follow-up tests, 

respectively. For breathing exercises, the table clarifies that only 6.5% did the exercises in pre-test compared to 

67.2% and 86.1% in the post and follow-up tests, respectively. Regarding the influenza vaccine, table 5 shows 

that no one took the influenza vaccine in the pre-test, and only 5.7% took the vaccine in the post and follow-up 

tests. Also, the table indicates that 45.9% ate a healthy diet in the pre-test, which increased to 90.1% in post and 

follow-up tests. In the pre-test, the table also shows that 67.2% avoided the outdoor air pollutant while 94.2% 

avoided the outdoor air pollutant in post and follow-up tests.  

  



Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 8 

 
Figure 3. Percentage distribution of pre, post, and follow-up inhaler adherence scores among flour mill workers 

(n = 122). This figure will cover hypothesis number three.  

 
Figure 4. Percentage distribution of pre, post, and follow-up flour mill worker satisfaction to inhaler (n = 122). 

This figure will cover hypothesis number four. 

Preventive measures applied in the flour mill.  

Regarding preventive measures applied by flour mill workers, Table 6 shows that the preventive measures to 

control flour dust remained the same as before the intervention. Table 7 shows no change in ventilation measures 

in the follow-up test. There were suitable working extraction units, and all equipment was clean and in good repair 

in pre and follow-up tests. The rest of the preventive measures were not available.   

  

Table 6. Availability of preventive measures toward flour dust control in the flour mill in pre 

and follow-up tests.  

  

% 0.0 

10.0 % 

% 20.0 

30.0 % 

% 40.0 

50.0 % 

% 60.0 

70.0 % 

80.0 % 

90.0 % 

100.0 % 

Non adherence Adherence 

% 95.1 

4.9 % 

24.6 % 

75.4 % 

20.5 % 

79.5 % 

Inhaler Adherence 

Pre Post Follow-up 

  

% 0.0 

10.0 % 

% 20.0 

30.0 % 

% 40.0 

50.0 % 

% 60.0 

70.0 % 

80.0 % 

90.0 % 

100.0 % 

satisfactory unsatisfactory 

4.1 % 

% 95.9 

60.7 % 

39.3 % 42.6 % 

57.4 % 

Worker satisfaction to inhaler 

Pre Post Follow-up 



Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 9 

Preventive measures toward flour dust control  Pre  Follow-up  

  Available  Available  

Fast delivery of flour  Yes  Yes  

Short storage time of flour  Yes  Yes  

Automatically closing doors  No  No  

Restriction of the entrance to areas with high dust levels  No  No  

Relevant warning signs displayed  No  No  

 Washing hands facilities  Yes  Yes  

Taking shower facilities  No  No  

Storage places of working clothes  Yes  Yes  

Avoidance of eating, drinking, or smoking at the mill  Yes  Yes  

  

Table 7. Availability of preventive measures toward ventilation in the flour mill in pre and 

follow-up tests.  

Preventive measures toward ventilation  Pre  Follow-up  

  Available  Available  

All areas are ventilated sufficiently  No  No  

There are extraction units   Yes  Yes  

Extraction units are in good working condition  Yes  Yes  

The filter screens are free from any buildup of dust  No  No  

There are air conditioning units/fans  No  No  

All equipment is clean & in good repair  Yes  Yes  

 

Conclusion  

This study indicated that all percentages of occupational asthma degrees changed to be better after applying a 

control-based management strategy. In addition, the percentage of flour mill workers who had normal lung 

function increased in follow-up tests than in pre-test. There was a significant increase in inhaler adherence mean 

scores in post and follow-up tests than in pre-test. Also, flour mill workers reported better satisfaction with 

inhalers in the post-test and follow-up tests than in the pre-test. Moreover, there was a lack of preventive measures 

in pre and follow-up tests.  

Acknowledgment   

First, we would like to thank "Allah" for His grace, mercy, endless gifts, and for giving me the effort to complete 

this work. We would also like to express our deepest thanks to flour mill workers who participated actively in this 

study.  

Conflict of interest. The authors declare that there are no conflicts of interest regarding the publication of this 

paper.  

ORCID ID   

Marwa M. Shaban: https://orcid.org/0000-0002-7966-8796   

https://orcid.org/0000-0002-7966-8796
https://orcid.org/0000-0002-7966-8796
https://orcid.org/0000-0002-7966-8796
https://orcid.org/0000-0002-7966-8796
https://orcid.org/0000-0002-7966-8796
https://orcid.org/0000-0002-7966-8796
https://orcid.org/0000-0002-7966-8796
https://orcid.org/0000-0002-7966-8796


Global Research Journal of Management and Social Sciences (GRJMSS) Vol. 13 (10) 
 

pg. 10 

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