Hrev_master [Healthcare in Low-resource Settings 2016; 4:5482] [page 29] Occupational hazards correlates of ocular disorders in Ghanaian fisheries Samuel Kyei,1 Andrew Owusu-Ansah,1,2 Samuel Bert Boadi-Kusi,1 Dennis Nii Abbey,1 Emmanuel Kwasi Abu1 1Department of Optometry, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana; 2Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China Abstract The study examined the ocular health of agricultural workers in the fisheries sub sector with the aim of establishing a possible correla- tion between the work place hazards and their ocular health. A multi-stage random sampling (involving 683 subjects, 358 fishmongers and 325 fishers) was employed. Ocular hazards encountered at the work place included seawa- ter, sand or dust, heat, sunrays and smoke. Exposure to these hazards were found to be associated with ocular irritation (P<0.001), tearing (P<0.001), red eye (P<0.001), gritty sensation (P<0.001), blurred distant vision (P=0.001) and blurred near vision (P=0.001). The development of pterygium was associated with the exposure to sunrays (P=0.042) and heat (P=0.001) among fishmongers. Further analysis using multivariate logistic regression indicated exposure to heat as the most impor- tant predictive factor for pterygium (OR=1.951, P=0.003). Exposure to seawater was found to be associated with the develop- ment of cataract (P=0.022) among fishermen/fishers. Cataract among fishmon- gers was rather associated with exposure to heat (P=0.005), sunrays (P=0.035) and sand/dust (P=0.002). Exposure to work place hazards is associated with ocular disorders in the fishing industry of Ghana. Introduction Comparative statistical records on fatalities in fisheries around the globe put fishing as one of the most dangerous jobs ahead of driv- ing, fire fighting, policing and others who ply their work on land and remains history’s most dangerous occupation.1 Globally, it is estimat- ed that 24,000 fatalities occur in the fisheries industry annually. In coastal countries of West Africa, artisanal canoe fatality rates range from 300 to 1000 per 100,000 fishermen. In Nordic countries where there is evidence of best practices regarding accident prevention, survival training, search and rescue services, fatality rates still persist between 90 and 150 per 100,000 people. This underscores the like- lihood of under estimation of fisheries fatali- ties in countries where there are no data.2,3 Reports of non fatal injuries are rather too common in spite of evidence of under report- ing attributable to paucity of and unsatisfacto- ry documentation from several countries of the world.4,5 Apart from the vast evidence of fatali- ties and injuries among workers in the fish- eries industry, ocular injuries, most of which are sight threatening, have been specifically cited.6-8 These injuries are commonly associat- ed with the hazardous working environment in most fisheries which include the use of fishing hooks, lures, weights, biofuels and excessive reflection of extraneous sun rays.6,7 The speci- ficity and diversity of hazards, depending con- siderably on geographical-climate and cultural factors, make the differentiation of problems and solutions important in different zones of fishing. Ghana has a marine coastline of 550 km, which extends from Aflao in the East to Half Assini in the West; the fishing industry serves as a source of livelihood for some 10% of Ghanaians.9 The sector has seen a decline in its contribution to the Nation’s gross domestic product (GDP) over the past decade. It is esti- mated to contribute some 1.5% of the Agriculture GDP (GSS, 2013 Budget).10 Most fish consumed in Ghana comes from the marine fishing industry and it remains the favorite and cheapest source of animal protein with about 75 per cent of total annual produc- tion being consumed domestically.11,12 An aver- age of 500,000 fishermen, fish processors, traders and boat builders are employed in the fishing industry.13 A canoe census conducted for the marine fisheries estimated the number of artisanal fishermen at 124,000.14 Artisanal fishing involves the use of dugout canoes pro- pelled by outboard motors. Ghana’s coastline stretches along the Atlantic Ocean providing rich grounds for artisanal marine fishing.3 The Central Region has long been noted as a fish- ing hub.15 Historical records trace the subsis- tence of the fishing industry in the Central Region as early as 1471,15 operating in house- hold-based entities and utilizing small vessels. Notwithstanding the importance of the fishing industry to the overall economy and nutritional needs of the country, players within the indus- try are exposed to several workplace hazards with long term consequence for their health especially their eye health. Recent data from the International Labor Organization (ILO) and the World Health Organization (WHO) indicate that overall occupational accident and disease rates are slowly declining in most industrialized countries,16 but are on level or increasing in developing countries. Generally, there are several hazards associ- ated with the fishing industry but those that directly pose threats to the eye as outlined in the literature include dust/sand, plants, chem- icals, decomposing leaves, micro-organisms in the fishing environment, smoke, radiations and heat, equipments and machines with sharp and pointed edges.17 It has been noted that there is a dearth of information on the potential effect of such exposures on the eyes of workers of the fishing industry mainly fish- ermen and fishmongers. We therefore sought to evaluate the correlations between these hazards and ocular disorder in the fishing industry of Ghana. Healthcare in Low-resource Settings 2016; volume 4:5482 Correspondence: Samuel Kyei, Department of Optometry, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana. Tel: +233243309718. E-mail: skyei@ucc.edu.gh; samdollar2@yahoo.com Key words: Cataract; Artisanal fishing; Fishmongers; Atlantic Ocean; Pterygium. Contributions: SK conceived the idea and designed the study. AOA and SBB were also involved in the design of the study. DNA and EKA wrote the protocol, managed the literature searches and collected data. SK and DNA wrote the first draft of the manuscript. SK, DNA, SBB and AOA managed the analyses and interpreta- tion of the data. SK, AOA, EKA critically revised the content. All authors read and approved the final manuscript. Conflict of interest: the authors declare no poten- tial conflict of interest. Acknowledgements: the authors are grateful to Mrs Esther Kyei, Mrs Alice Abu, Mrs Mary Boadi- Kusi and Mrs Jennifer Owusu-Ansah for their immense support and encouragement. Received for publication: 9 August 2015. Revision received: 29 May 2016. Accepted for publication: 19 October 2016. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright S. Kyei et al., 2016 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2016; 4:5482 doi:10.4081/hls.2016.5482 Non co mmerc ial us e o nly Materials and Methods Study area The Central Region of Ghana has the widest continental shelf and the longest coastline of 150km spanning eight (8) coastal districts18 (Figure 1). There are 43 coastal towns and vil- lages from Gomoa Nyanyano in the East to Kafodzidzi in the West with a total of 103 land- ing sites. The two main types of marine fishing are; artisanal or Canoe Fisheries and inshore Fisheries. There are 46,513 artisanal fisher- men working with 4675 canoes as against 1500 inshore fishermen operating over 100 inshore motor fishing vessels. The fishermen in the region dock about 36% of the Nation’s fish pro- duction.19 These include some exportable species of marketable value such as: lobsters, squids and octopuses, shrimps, soles, sea breams, mackerels, groupers, skipjack tunas, yellow fin tunas, round and flat sardinellas and sailfish.19 Sampling technique Multi-stage random sampling was employed. Four out of the eight coastal districts were ran- domly selected of which a fishing town or vil- lages each was also randomly selected (Figure 1). In each of the four fishing towns or villages, two landing sites were randomly selected. A register of fishers /fishermen and fishmongers for each chosen landing site was then obtained from the chief fishermen and the queen fish- mongers as per their records. A total of 683 (involving 358 fishmongers and 325 fishers) people within these four major communities were sampled. The minimum sample size for the survey was determined as quoted by Glenn using the formula developed by Cochran (1963).20 The minimum sample size computed was 374. However, the sample size was adjust- ed to 683 to include 358 fishmongers and 325 fishers to reduce the incidence of reporting false positive responses. Subject selection/data collection procedure The subjects were systematically selected (every nth person) based on the number of participants needed for that area for interview using a pretested interview-based question- naire and subsequent routine ophthalmic examination (external and internal eye exams) by four experienced optometrists, ODs. Inclusion/exclusion criteria The study participants included fishers/fish- ermen and fishmongers who had been engaged in the fishing industry not less than 3 years and were aged 18 years and older at the time of the study. All fishers/fishermen or fish- mongers who had other part time engage- ments outside of the fishing industry were excluded. Data analysis procedure Data collected was analyzed using SPSS ver- sion 19 (Statistical Package for Social Sciences) and reported as frequency tables, percentage tables, bar charts and cross tabula- tion. Goodness of fit-test was calculated to compare the frequency levels between fish- mongers and fishermen. Chi-square model was performed to measure the association between categorical variables. Multivariate logistic regression was also conducted to measure the predictive ability of the independ- ent variable (hazards) to the dependent vari- ables (prevalent ocular diseases and symp- toms). The alpha level was set at P=0.05, thus association existed between categorical vari- ables when P≤0.05. Ethical consideration The research was done according to the Helsinki Declaration on Research Regarding Human Subjects. A detailed rationale for the study was given to respondents, after which respondents signed a consent form or verbal consent depending on their educational back- ground. Confidentiality was ensured and a forum was organized to educate participants on basic safety measures regarding their work- place. Those with ocular disorders were treat- ed and some referred to eye clinics for further attention. Results Socio-demographic characteristics A total of 683 participants comprising 325 fishers and 358 fishmongers were interviewed and examined in this study. All the participat- ing fishers/fishermen were males while 354females and 4 males were fishmongers. Majority of the fishmongers (181, 51.0%) and fishermen (158, 48.8%) were in the age range of 36-59 years (adult). Those aged between 18 and 35 (Youth) were 102 (28.7%) for fishmon- gers and 126 (38.9%) for fishermen and those aged 60 and older were 72 (20.3%) for fish- mongers and 40 (12.3%) for fishermen. Goodness of fit test showed no significant dif- ference (P=0.236) between the total partici- pants of fishers/fishermen and fishmongers. The results indicated that the majority of the fishermen and fishmongers had no form of for- mal education and only one person each among the fishermen and fishmongers had had tertiary education. The most frequent income range for both fishermen and fishmon- gers was GH� 1000-1999 (US$ 350-699) and the least number of the respondents had an income range of GH� 4000-4999 (US$ 1400- 1749) (Table 1). Ocular hazards There were 623 and 717 responses (due to multiple responses) to ocular hazards identi- fied at the workplace by fishermen and fish- mongers respectively. Sun rays was the main ocular hazard reported among the fishermen (299, 36.8%). The fishmongers on the other hand, reported smoke 357 (49.8%) as the main Article Figure 1. A map of the Central Region showing the study districts and communities. [page 30] [Healthcare in Low-resource Settings 2016; 4:5482] Non co mmerc ial us e o nly ocular hazard (Table 2). Ocular symptoms after exposure to hazards Ocular symptoms after exposure to hazards during smoking of fish by fishmongers indicat- ed 1126 responses (due to multiple responses) with irritation of the eyes being the highest and redness being the least. The most preva- lent symptom among fishmongers included photophobia, 222 (62.2%), 217 (60.8%) com- plaints of burry distance vision, 201 (56.3%) complaints of tearing, 154 (43.1%) complaints of ocular pain, 143 (51.3%) complaints of burn- ing sensation. Ocular symptoms after expo- sure to hazards during fishing by fishermen indicated 997 responses with blurry distance vision being the highest 273 (72.70%). The others were irritation 138 (61.1%), gritty sen- sations 232 (71.2%), ocular pains 162 (49.7%), photophobia 211 (64.7%) and tearing 225 (78.2%) (Table 3). Players within the fishing industry were more prone to suffer ocular irritation (P<0.001) than burning sensation. There was significant association between ocular irrita- tion and some identified workplace hazards such as smoke (P=0.001), heat (P=0.002), dust/sand (P=0.047) and seawater (P=0.016). Complaints of ocular pain were found to be associated with workplace hazards such as sunrays (P=0.001), heat (P<0.001) and smoke (P=0.047), Gritty sensation, tearing and pho- tophobia were associated with sunrays (P≤0.001, 0.015, 0.000). Photophobia was also associated with seawater (P=0.000). Anterior segment eye examination Anterior segment eye examination using a handheld slitlamp revealed pterygium was the most prevalent ocular surface disorder and trichiasis the least prevalent. The total number of cases (abnormalities detected) was 396 among the fishermen but 501 among the fish- mongers (Figure 2). There was association between some work- place hazards experienced by fishmongers such as sunrays (P=0.042) and heat (P=0.001) and pterygium but there was no such associa- tion between hazards and pterygium among fishermen. Multivariate logistic regression between workplace hazards indicated that exposure to heat was a very significant factor associated pterygium among fishmongers (Table 4). Internal eye examination Direct ophthalmoscopic examination revealed 169 posterior segment disorders among the fishermen, 66 (39.1%) were glauco- ma suspects, 53 (31.4%) had cataract, 32 (18.9%) had other posterior segment diseases like retinal degeneration, retinal scars and other retinal disorders, 8 (4.7%) had Article Table 1. Distribution of educational levels and annual income. Level of education/annual income Fishermen, n (%) Fishmongers, n (%) Level of education No formal education 123 (37.8) 170 (47.5) Elementary/primary 110 (33.8) 83 (23.2) Middle/junior 87 (26.8) 94 (26.3) Secondary/technical 4 (1.2) 10 (2.8) Tertiary 1 (0.3) 1 (0.3) Annual income° Less than GHȻ1000 57 (17.5) 81 (22.6) GHȻ1000-GhȻ1999 87 (26.8) 111 (31.0) GHȻ2000-GHȻ2999 82 (25.2 90 (25.1) GHȻ3000-GHȻ3999 39 (12.0 49 (13.7) GHȻ4000-GHȻ4999 25 (7.7) 14 (3.9) Greater than GHȻ5000 35 (10.8) 13 (3.6) Total 325 (100.0) 358 (100.0) °The exchange rate as time of the study was US$ 1:GHȻ 2.86 Table 2. Ocular hazards reported among fishermen and fishmongers. Hazard Type of occupation Total Fishermen Fishmongers N=623 (%) N=717 (%) N Smoke 7 (1.1) 357 (49.8) 364 Heat 10 (1.6) 153 (21.3) 163 Sunrays 229 (36.8) 118 (16.5) 347 Dust/sand 161 (25.8) 87 (12) 248 Sea water 216 (34.7) 2 (0.2) 218 [Healthcare in Low-resource Settings 2016; 4:5482] [page 31] Figure 2. Prevalence of anterior segment disorder as detected upon slit lamp examination in fishermen (A) and fishmongers (B). Non co mmerc ial us e o nly [page 32] [Healthcare in Low-resource Settings 2016; 4:5482] retinopathies, 5 (3.0%) had toxoplasmosis scar, 3 (1.8%) had optic atrophy and 2 (1.2%) had maculopathies. Fishmongers on the other hand had 213 posterior segment disorders. Ninety-nine (46.5%) had cataract, 49 (23.0%) were glaucoma suspects, 48 (22.5%) had other posterior segment diseases like retinal degen- eration, retinal scar and other retinal disor- ders, 5 (2.3%) had retinopathies, 4 (1.9%) had maculopathies and toxoplasmosis scar, 2 (0.9%) had optic atrophy and posterior uveitis. No association was found between any of the workplace hazards and suspicion of glaucoma among fishermen and fishmongers, neverthe- less, exposure to seawater was found to be associated with the development of cataract (P=0.022) among fishermen. Cataract among fishmongers was associated with exposure to heat (P=0.005), sunrays (P=0.035) and dust (P=0.002). Discussion The study employed multi-stage random sampling which was most suitable since the communities studied were diverse (8 coastal districts with 43 coastal towns and villages and a total of 103 landing sites) in a bid to ensure representativeness.21 The male dominance in fishing has long been documented as it is deemed as a risk prone and adventurous task reserved for the males while females are more often than not discouraged and excluded.22 However, fish mongering is an agricultural processing activity known to involve both males and females.23 In Africa, market systems are customarily seen as compatible with the female gender’s role as housekeepers and caregivers hence the few men (1.2%) involved in these post-harvesting activities of the fish- ing industry.24 A greater proportion of fisher folks were illiterates with nearly half of the fishmongers (47.5%) having no formal education at all. Recent studies have highlighted this high pro- portion of illiteracy among fishing communi- ties in Africa with Females being the most affected. This phenomenon is attributable to the remote locations, marginalization and mobility of most fishing communities affecting access to education and even health.25-31 Their reported income levels, though only one of the various indices for the determination of socioeconomic status,32,33 were generally low especially among fishmongers who were pre- dominantly females. It is common knowledge that poverty is prevalent among artisanal fish- eries of which Ghana is no exception.34 The adult population dominating the fishing indus- try presupposes that they are in their active age and need to earn to keep their homes. The arduous nature of the work also favors the active working population. Due to the ubiquity of hazards in the fishing industry, fishing has been tagged as one of the most dangerous occupations in the world.35-37 At the same time, those involved in the pro- cessing of the fish are also not spared. The top three most common hazards among the fisher- men were sunlight, seawater and dust/sand. These have been reported as major eye health risks among fishermen.38,39 Half of the reports from the fishmongers identified exposure to smoke as the single most important ocular hazard at their workplace due the use of biofu- el (i.e. fire wood).40 Excessive heat was also found to be a worrisome hazard among fish- mongers. The most prevalent complaint of ocu- lar irritation was found to be associated with exposure to hazards such as smoke, heat, dust/sand and seawater.39-41 Other ocular com- Article Table 4. Multivariate logistic regression between workplace hazards and pterygium. Hazards Exp (B) P 95% CI for Exp (B) Lower Upper Smoke 1431268.01 0.999 0.0 Heat 1.951 0.003* 1.252 3.038 Sun rays 1.356 0.203 0.848 2.166 Constant 0.00 0.99 CI, confidence interval. Table 3. Ocular symptoms among fishmongers and fishermen. Symptoms Type of occupation Total P Fishermen Fishmongers N (%) N (%) N Irritation No 188 (41.1) 269 (58.9) 457 0.000* Yes 138 (61.1) 88 (38.9) 226 Burning sensation No 190 (47.0) 214 (53.0) 404 0.659 Yes 136 (48.7) 143 (51.3) 279 Ocular pains No 164 (50.3) 203 (56.9) 367 0.086 Yes 162 (49.7) 154 (43.1) 316 Blurred distance vision No 89 (27.3) 140 (39.2) 229 0.001* Yes 273 (72.7) 217 (60.8) 490 Blurred near vision No 12 (3.7) 36 (10.1) 48 0.001* Yes 314 (96.3) 321 (89.9) 635 Foreign body sensation No 44 (13.5) 65 (18.2) 109 0.096 Yes 282 (86.5) 292 (81.8) 574 Redness No 32 (9.8) 14 (3.9) 46 0.002* Yes 294 (90.2) 343 (96.1) 637 Gritty sensation No 94 (28.8) 205 (57.4) 299 0.000* Yes 232 (71.2) 152 (42.6) 384 Photophobia No 115 (35.3) 135 (37.8) 250 0.491 Yes 211 (64.7) 222 (62.2) 433 Tearing No 71 (21.8) 156 (43.7) 227 0.000* Yes 255 (78.2) 201 (56.3) 456 *Significant values at the 0.05 alpha level. Non co mmerc ial us e o nly [Healthcare in Low-resource Settings 2016; 4:5482] [page 33] plaints associated with workplace hazards were ocular pain, gritty sensation, photopho- bia and tearing which are mostly symptoms of conjunctivitis.42 Conjunctivitis was the second most prevalent ocular surface disease after pterygium. Pterygium was the most prevalent ocular surface disorder and was found to be associated with exposure to smoke and heat which are the two most common hazards encountered by fishmongers relative to fisher- men. Fishmongers, most of whom are predom- inantly women, are frequently exposed to bio- fuels, mainly firewood and charcoal, which have been implicated in adverse consequences to the human eye.40,43 The continuous use of biofuel in poor communities such as fishing communities has been observed despite its decline in use on the global scene.44,45 Multivariate logistic regression indicated heat as the single most important predictor of developing pterygium (P=0.003). Other stud- ies elsewhere have indicated a high preva- lence of pterygium among agricultural workers due to exposure to heat. The linkage between heat and the pathogenesis of pterygium has been predicted previously.40,46 The association between cataract and some workplace hazards in the fisheries sector was implied but has been difficult to establish. Epidemiologists were unable to establish a simple realistic causal model for cataract because each risk factor could be a component cause.47 The multiple risk factors of the work- place environment including heat, sunrays, and dust/sand may wholly or partly be involved in the pathogenesis of age-related cataract commonly found among fishmongers.41,48 The seawater is said to be a good reflector of sun- light and may be indirectly involved in causing cataract among fishermen.38 This study high- lights the fact that the continuous engagement in fishing and post harvest activities as an occupation exposes workers to potential risks which have implications for their eye health.49 It is worthy to note that several of these risk factors are manageable through the use of pro- tective eye wears, photoprotective lenses, and re-orientation of fishers and fishmongers on modern fish processing methods. It is there- fore recommended that these fishers and fish- mongers be educated on safety practices and provision of first aid kits and adequate train- ing be implemented by stakeholders in the fisheries industry. Conclusions In conclusion, this study found some associ- ation between workplace environments and ocular disorders in the fishing industry of Ghana. These associations are of worthy note in the context of public health intervention. References 1. Symile MA. Perilous catch: the history of commercial fishing. Dublin: The History press Ireland; 2015. 2. FAO. The state of the World Fisheries and Aquaculture. Rome: Food and Agriculture Organization; 2000. 3. Eliasen S, Sverdrup-Jensen S, Holm P, Johnsen JP. Nordic experience of fisheries management seen in relation to the reform of the EU Common Fisheries Policy. TemaNord 2009;2009:579. 4. El-Saadawy ME, Soliman NE, El-Tayeb IM, Hammouda MA. Some occupational health hazards among fishermen in Alexandria city. 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