403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 oa 1_absenteeism among_rashmi paniye kumara.indd original articleijosh, volume 9, no, 2, 2019 (issn 2091 – 0878) 27international journal of occupational safety and health (ijosh) doi: https://doi.org/10.3126/ijosh.v9i2.25381 corresponding author dr. naveen ramesh associate professor. department of community health, st. john’s medical college, bangalore 560034. india. e-mail: drnaveenr@gmail.com orcid id: 0000-0001-5269-7186 available online at https://www.nepjol.info/index.php/ijosh international journal of occupational safety and health, vol. 9 no. 2 (2019), 27 – 30 this journal is licensed under a creative commons attributionnon commercial 4.0 international license. absenteeism among female pluckers in a tea plantation in south india kumara rp1, fathima fn2, fernandes s3, xavier v3, ramesh n4 1postgraduate, 2associate professor, 3medical interns, 4associate professor department of community health, st. john’s medical college, bangalore 560034. india. abstract background: the tea industry which is one of the world’s oldest agro-based industry provides direct employment to more than a million workers, of which most are women. two of the main causes for decreased tea production in india is due to shortage of pluckers and their absenteeism which impacts tea productivity. so, this study was undertaken to study absenteeism rates and the causes of absenteeism among female pluckers in a tea plantation in south india. methodology: this was a cross section study undertaken in tea estates located in anamalais, tamilnadu. all female pluckers working in the estates were eligible to part of the study. the study population consisted of 256 female tea pluckers who were selected at random and an interview schedule was used to collect the following information – socio-demographic status, nature of the job, job satisfaction and reasons for absenteeism. results: the study population consisted of 80.9% permanent workers and 19.1% temporary workers, with an average work experience of 21.6years.the main cause of absenteeism was health related (47.8%), followed by visit to native place (29.3%), then illness among family members (15.7%) and either lazy of bored to report to work (7.2%).there was an association between absenteeism and hospitalization in the past one year, increasing number of children in the family and the number of years of work experience. conclusion: majority of the pluckers were in the age group of 40-45 years. women in this age group are more vulnerable to health issues such as osteoporosis, osteoarthritis, work related musculoskeletal disorders and also probably time taken off to take care of dependents apart from house old chores. increasing age, illness of self or family member were the most important factors which contributed to increase absenteeism. key words: absenteeism, pluckers, tea plantations, causes, south india introduction india is the second largest producer and largest consumer of tea in the world.1,2 the tea industry which is one of the world’s oldest agro-based industry provides direct employment to more than a million workers, of which most are women. the tea sector in the country is largely organized, in early 1990’s, nearly 94% of india’s tea was produced in organized sector which reduced to about 66% by 2017.1,2,3as of 2015, 566.66 thousand hectares was under tea production in india and india’s tea export was valued at united states dollar 785.92 million.3 tea plantation labourers are paid as per the legal minimum wages announced by the respective state governments. labourers are paid based on the time spent working and amount of tea plucked per day. in addition, the workers are given an incentive wage for plucking leaves above their fi xed daily quota. the indian tea industry provides direct employment to over 1 million people and another 10 million persons derive their livelihood from tea associated activities.4 simply put, 1 out of 7 workers in the organised manufacturing sector works in tea sector.4,5,6 28 international journal of occupational safety and health (ijosh) kumara rp et al. absenteeism is habitual non-presence of an employee at his or her job. habitual non-presence is time away from work beyond the normal schedule.7 the labour department in india defi ned the absenteeism rate as the total man-shifts lost because of absences as a percentage of the total number of man-shifts scheduled.7,8,9 absenteeism is a crisis and has a major impact on labour productivity in tea plantations.7,8 the management is forced to employ temporary labourers or migrant laborers due to absenteeism of seasoned workers and it results in decreased productivity and increased cost to the management. the causes of absenteeism vary from place to place. they could be physical, psychosocial or environmental causes. the major causes of absenteeism apart from wages among the tea plantation labourers were illness in the worker or family member, alcoholism, workers morale, absence after social and cultural ceremonies and absence of adequate welfare facilities.9,10,11 the production of tea in india has come down in the recent years owing to several factors. two of the maincauses for decreased production is labour shortage and absenteeism. there are very few studies done on absenteeism and its causes among tea plantation labourers in india and other countries. through this study, we aim to measure absenteeism rate and determine the various causes of absenteeism. this will help to quantify the main reasons for absenteeism and thus to fi nd a way to reduce the absenteeism rate in tea plantations. the objective was to study absenteeism rates and the causes of absenteeism among female pluckers in a tea plantation in south india. methodology the study area consisted of tea estates in anamalais, tamilnadu. the tea estates had a total population of 2916. majority of the tea leaf plucking population comprised of females and all female pluckers working in the estates were eligible to part of the study. maintenance staff s, sundry workers and management were excluded from the study. the study design was cross-sectional. in the fi rst step, duty rosters of the workers in plantation were reviewed since the past one month and absenteeism rate was measured. absenteeism rate was calculated by using the formula: absenteeism rate = total number of man days lost x total number of workers total number of working days x total number of workers based on the previous study9, taking absolute precision to be 5%and 95% confi dence interval, sample size was calculated to be 256. thelist of all female pluckers was procured from the estate management. simple random sampling of the workers was done by computer generated random numbers. in case the individual fell into the exclusion criteria, the next person was selected. a pre-tested, structured interview was administered to 256 female pluckers. the interview schedule collected information regarding socio-demographic status, nature of the job, job satisfaction, reasons for absenteeism (owing to health and health associated factors, fi nancial causes, domestic violence, laziness, social and cultural causes, etc.). data were entered in microsoft excel and analysed by using standard statistical software (spss version 16)for proportions, frequencies and associations. we considered p value of less than 0.05 as signifi cant. results a total of 256 female pluckers were studied. the workforce consisted of 80.9% permanent workers and 19.1% temporary workers, with an average work experience of 21.6years. most of them were in the age group of 43.38 years, with a standard deviation (sd) of 9.98 years. majority of the pluckers lived in a nuclear families (80.5%), followed by extended (16%) and three generation families (3.5%). among the study population 98.5% were married, highest educational qualifi cation attained by the pluckers was high school (42.2%), 25.8% were uneducated, the average household income was rs.6283.20. wage per day per person was rs.210 (as the minimum wages act). the pluckers spent 9 hours per day in plantation, with free time of 1 hour per working day. they had one holiday in a week, and bonus was availed by workers who had minimum one year experience. the socio demographic details and job profi le of the study participants have been depicted in table 1. the hospital record review showed that the absenteeism rate is 4.19 person days per month. the absenteeism rate calculated after the interview revealed absenteeism rate to be 8.73person days per month. the total number of days absent was found to be 946 in the last month, with an inter-quartile range of4(0,4).the mean number of days absent for the last month was 7.19 days with a sd of 1.33 days. 29international journal of occupational safety and health (ijosh) absenteeism among female pluckers in a tea plantation in south india our study found that 35.5% of pluckers were absent for atleast one day in the last week, and 52.3% were absent for at least one day in the last month. the main cause of absenteeism was health related (47.8%), with most of the workers complaining about back pain (3.1%). majority of workers fell ill at least two times per month, with 20.3% being admitted in the last 30 days to the hospital owing to health issues. of the working population, 12.9% had chronic illnesses, the main being asthma (4.3%). pluckers also suff ered from physical injuries at workplace making them take leaves for more than 2 days (11.3%), of which most common was fracture. among the injured, 28 people were compensated. about a third (29.3%) took leave to visit native place once a year. another cause for absenteeism was owing to a family member’s ill health. workers were absent for a mean of 6.35 days in a year due to family member’s illness (15.7%). among the husbands of pluckers, 68.2% consume alcohol. however no physical abuse has been reported by the pluckers. some pluckers (7.2%) took leave for no reason or they were lazy or bored to report to work. the causes for absenteeism among the study participants are depicted in fi gure 1. the number of days of absenteeism was signifi cantly higher among those who were hospitalized in the past one year (chi square: 20.382; df3; p = 0.000). the number of days of absenteeism increased with the number of children in the family (chi square: 12.731;p= 0.048). we also found a positive correlation between absenteeism and the number of years of work experience (r=0.04, p<0.05). discussion in our study, we found that, most of the pluckers were in the age group of 40-45 years. this goes on to imply that majority of the women who were working belonged to older age group. this makes the women more vulnerable to health issues such as osteoporosis, osteoarthritis and so on. 10,11,12 it also makes them more vulnerable to work related musculoskeletal disorders.13 our study found that the monthly rate of absenteeism is 8.7%. another study, done in mancotta gardens at assam by goswami et. al.12, found that the annual rate of absenteeism was 27.4% and monthly rate of absenteeism which is found to be 2.28%. this higher rate of absenteeism may be due to better management and record keeping in the health care facilities in the estate where we conducted this study, as compared to mancotta estates, where the absenteeism was mainly self -reported and record review was not done. our study also found an interesting point, which was that as the work experience increased, there was increased absenteeism in the plantation. this could be possibly due to higher age of the working population. in addition, the study participants had dual responsibilities in the form of household chores and care of dependents at home including children, grand children, elderly parents and in-laws. table 1: sociodemographic details and job profi le of the study particpants variable age 43.3 + 9.9 years type of family nuclear (80.5%) marital status married (98.5%) highest educational qualifi cation high school (42.2%) average monthly household income rs. 6283.20 ± 2137.57 wages per day rs 210 working hours per day 9 holidays per week 1 mode of travel to work place walking sickness (self) 48% illness of a family member 16% place 29% boredom / laziness 7% figure 1: causes of absenteeism in the study population 30 international journal of occupational safety and health (ijosh) kumara rp et al. our study found that the reported absenteeism rate was almost twice the rate documented in the hospital records. one reason for this could be error in recall. the under recording could also be because of study participants availing permissions to attend to personal work on an informal basis and not applying formal leave. conclusion we conclude that the absenteeism rate among female pluckers in a tea plantation in south india is high. the main causes for absenteeism are increasing age, illness in self and among dependent family members. references 1. india brand equity foundation. tea statistics[internet]. india brand equity foundation. 2019[assessed on 2019/02/03]. available on https:// www.teacoff eespiceofi ndia.com/tea/tea-statistics 2. tea news. india records highest ever tea production during the fi nancial year 2015-16; exports breach 230 million kgs mark after 35 years. india: tea boards india, government of india; 2016[assessed on 2019/02/03]. available on http://www.teaboard. gov.in/teaboardpage/mtyx 3. tea board, ministry of commerce &industry department of commerce, government of india. a paper on tea industry in the organised sector in india[internet]. india:ministry of commerce &industry department of commerce, government of india; 2017[assessed on 2019/02/03].available on http:// teaboard.gov.in/pdf/press_release_paper_on_tea_ industry_pdf1181.pdf 4. bhowmik sk. productivity and labour standards in tea plantation sector in india. semantic scholar[internet]. 2003[assessed on 2019/02/03]. available on https://pdfs.semanticscholar.org/df8b/0 a545b76dec34a5f6bf5c0290172e03b0c00.pdf 5. ministry of agriculture, government of india and indian institute of foreign trade. tea industry[internet]. india: ministry of agriculture, government of in india and indian institute of foreign trade. available on http://agritrade.iift.ac.in/html/training/asean%20 % e 2 % 8 0 % 9 3 % 2 0 i n d i a % 2 0 f t a % 2 0 % 2 0 emerging%20issues%20for%20trade%20in%20 agriculture/tea%20export.pdf [cited on 03.02.2019]. 6. employment trends in indian and assam tea industry[internet]. available on http://shodhganga. i n f l i b n e t . a c . i n / b i t s t r e a m / 1 0 6 0 3 / 1 4 4 4 2 3 / 9 / chapter%20vii.pdf [cited on 03.02.2019]. 7. shah sk, patel av. tea production in india: challenges and opportunities, journal of tea science research. 2016;6(5):1-6. 8. kenton w. absenteeism. investopedia. 2019 jun 5(updated)[assessed on 2019/07/01]. available on https://www.investopedia.com/terms/a/absenteeism. asp 9. basariya sr. employee absenteesim in indian industries. international journal of science and research. 2015;4(10):141-56. 10. mishra dk, upadhyay v, sarma a. ‘crisis’ in the tea sector: a study of assam tea gardens. the indian economic journal[internet]. 2008;56(3):39-56[assesses on: 2018/11/18]. available on https://www.researchgate.net/ p u b l i c a t i o n / 2 8 4 7 2 9 3 4 9 _ ’ c r i s i s ’ _ i n _ t h e _ te a _ sector_a_study_of_assam_tea_gardens 11. bose pr. trouble’s brewing in india’s tea sector. the hindu businessline[internet]. 2017 april 20[assessed on 2018/11/18]. available on https:// www.thehindubusinessline.com/opinion/troublesbrewing-in-indias-tea-sector/article21979485.ece 12. goswami b. absenteeism among the tea garden labourers: a case study on mancotta tea garden[dissertation][internet]. dibrugarh, india: dibrugarh univeristy; 2009[assessed on 2018/11/18]. available on https://www.scribd.com/doc/62152741/ absenteeism-among-the-tea-garden-labourers-acase-study-on-mancotta-tea-garden 13. vasanth d, ramesh n, fathima fn, fernandez r, jennifer s, jospeph b. prevalence, pattern, and factors associated with work-related musculoskeletal disorders among pluckers in a tea plantation in tamil nadu, india. ijoem. 2015 jan;26(3):167-70. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /none /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /error /compatibilitylevel 1.4 /compressobjects /tags /compresspages true /convertimagestoindexed true /passthroughjpegimages true /createjdffile false /createjobticket false /defaultrenderingintent /default /detectblends true /detectcurves 0.0000 /colorconversionstrategy /cmyk /dothumbnails false /embedallfonts true /embedopentype 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(adobe) (common) (1.0) ] /othernamespaces [ << /asreaderspreads false /cropimagestoframes true /errorcontrol /warnandcontinue /flattenerignorespreadoverrides false /includeguidesgrids false /includenonprinting false /includeslug false /namespace [ (adobe) (indesign) (4.0) ] /omitplacedbitmaps false /omitplacedeps false /omitplacedpdf false /simulateoverprint /legacy >> << /addbleedmarks false /addcolorbars false /addcropmarks false /addpageinfo false /addregmarks false /convertcolors /converttocmyk /destinationprofilename () /destinationprofileselector /documentcmyk /downsample16bitimages true /flattenerpreset << /presetselector /mediumresolution >> /formelements false /generatestructure false /includebookmarks false /includehyperlinks false /includeinteractive false /includelayers false /includeprofiles false /multimediahandling /useobjectsettings /namespace [ (adobe) (creativesuite) (2.0) ] /pdfxoutputintentprofileselector /documentcmyk /preserveediting true /untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /usedocumentprofile /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice oa 2_prevalence of bullying _cency baburajan.indd original article ijosh, volume 9, no, 1, 2019 (issn 2091 – 0878) 8 international journal of occupational safety and health (ijosh) doi: https://doi.org/10.3126/ijosh.v9i1.25161 corresponding author dr. naveen ramesh division of occupational health services, department of community health, st. john’s medical college, bangalore 560034. india. phone: +91 9448927400 e-mail: drnaveenr@gmail.com available online at https://www.nepjol.info/index.php/ijosh international journal of occupational safety and health, vol. 9 no. 1 (2019), 8-12 this journal is licensed under a creative commons attributionnon commercial 4.0 international license. prevalence of bullying among nurses in a tertiary hospital, bangalore cency baburajan1, sakthi arasu2, ramesh naveen3 1dr. cency baburajan, mbbs, post graduate, md (community medicine) 2dr. sakthi arasu, mbbs, post graduate, md (community medicine) 3dr. ramesh naveen, mbbs, md (community medicine) orcid id: 0000-0001-5269-7186 institutional affiliation: division of occupational health services, department of community health, st. john’s medical college, bangalore 560034. india. abstract background: in the last decade, research conducted in different countries has shown that bullying in the health care sector especially among nurses is a widespread and serious problem. bullying of nurses at workplace affects their quality of life, hinders delivery of quality healthcare andcontributes to increase inworkplace stress.so, this study was conducted to assess the prevalence of work place bullying among nurses working in a tertiary care hospital in bangalore. methodology: this study was conducted among 300 staff nurses providing in-patient services in a tertiary health care hospital located in bangalore. the required sample was selectedutilizing the documents maintained in the office of chief of nursing services and using computer generated random numbers. the data was collected using self-administered questionnaire which comprised of socio-demographic factors and negative acts questionnairerevised. results: among the 297 respondents, 26.9% were victims of bullying in the past six months according to negative acts questionnaire-revised(naq-r). among the participants who were bullied, those exposed to work-related bullying, person-related bullying and physical intimidation were 80%, 60% and 21.3% respectively. conclusion: this study suggests existence of work place bullying among nurses which can adversely affect their performance as health care professionals and their quality of personal life. key words: bullying, distress, harassment, health care, nursing staff, violence introduction nurses are paramount in the provision of health care. they have a signifi cant impact on the health of individual and therefore the society. there is an increasing demand for nurses due to multiple factors viz; an aging population, greater diversifi cation in society, multiculturalism, marginalized populations and increasing technologies.1according to a study, “bullying is defi ned as a situation in which someone is exposed to hostile behavior on the part of one or more persons in the work environment which aim continually and repeatedly to off end, oppress, maltreat, or to exclude or isolate over a long period of time”.2 verbal abuse, threats, humiliation, intimidation, and behaviors that interfere with job performance are all considered workplace bullying. workplace bullying may also include accusations of incompetence in the area of practice, gossiping about co-workers, withholding information pertinent to patient care, constant feelings of stress and fear of additional bullying events.3workplace bullying has negative implications on the victim’s health and work performance.4there may be an increase in incidence and severity of harassment in the health 9international journal of occupational safety and health (ijosh) prevalence of bullying among nurses in a tertiary hospital, bangalore sector due to factors likeinadequate staffi ng, quality of servicesnot meeting the expectation of patients and demand of the patients family members can increase stress on health workers. such situations contribute to co-worker harassment and reduced staff morale. there are also instances where there is observed gender based harassment against nurses.5 intense stress and anxiety of bullying can cause a variety of physiological, psychological and social problems.2 individuals experiencing bullying at work have poor job satisfaction, work performance, motivation and effi ciency, while their social relations suff er both at work and home.2 according to who, bullying reported often from workplace has adverse impact on mental health like depression and anxiety.6the national health policy 2017 by government of india has identifi ed reduced stress and improved safety in workplace as one of the priority areas to improve the environment for health.7 bullying in the nursing workplace has been identifi ed as a factor that hinders the delivery of quality healthcare causing poor patient outcome. moreover, due to the occupational stress some choose to leave the profession.8recognizing the occurrence of bullying in workplace and early intervention to prevent it are important to avoid the various detrimental eff ects it has on nurses. anti-bullying policies are adopted by governments in many countries, the implementation of these policies isstill regardedineff ective.9accurately describing the phenomenon of bullying will be the fi rst step towards strengthening nursing as a considerate and sympathetic profession. policies that will help in reducing and ultimately eradicating the occurrence of bullying in the workplace should be implemented to protect the nurses.10 objectives to assess the prevalence of work place bullying among nurses working in a tertiary health care hospital in bangalore. methodology this was a cross-sectional study conducted over a period of six months. approval from the institution ethics committee and the chief of nursing services of the concerned hospital were obtained prior to the study. written informed consent was obtained from the participants. the required sample size was 270 (prevalence of bullying was taken as 30% based on a previous study).11 after obtaining the list of staff nurses, simple random sampling technique using computer generated random numberswas adopted to select the study participants. we distributed the questionnaire to 300 female nursing staff , providing in-patient services in medical and surgical wards in a tertiary hospital with a work experience of at least six months. excluding the three participants who returned incomplete questionnaire, the fi nal number was 297. we have adopted self-labeling method in this study which explicitly asks if the subjects are exposed to bullying. the defi nition of bullying was included in the questionnaire based on which the respondents were requested to answer. study tool study tool included demographic details and naq-r (negative acts questionnaire revised).12prior permission was obtained from the author to use naq-r which has a likert scale 1-5 (never, now and then, monthly, weekly, and daily). three subclasses of bullying are work-related bullying, personal bullying and physical intimidation. in order to do the analysis we have followed the leymann criteria according to which, bullying acts take place on regular basis (at least once a week) over a long period of time (at least once in six months). a person is called a bullying target if he/she has been subjected to two negative acts (mikkelsen and einarsen).8a pilot study was conducted among 50 nursing personnel to measure reliability and face validity of naq-r questionnaire. reliability was measured using cronbach’s alpha, which was 0.8.the pilot study data was not included in this analysis. data analysis data was entered in microsoft excel and analyzed using statistical package for social sciences (spss) version 16. categorical variables were expressed in terms of absolute and relative frequencies. quantitative variables were expressed in terms of mean, standard deviation and range. chi-square test was used to detect potential association between two categorical variables. chi-square value less than 0.05 was considered signifi cant. results the response rate in this study was 99%. socio-demographic profi le among the 297 participants, mean age was 21.6±5.526 years (range:21-53). the participants were from 14 diff erent states and majority, 158(53.2%) were from kerala. majority of them, 234(78.8%) were christians 10 international journal of occupational safety and health (ijosh) cency baburajan et al. and 233(78.5%) were unmarried. among those who were married, 26(40.6%) had no children, 21(32.8%) had one child, 15(23.4%) had two children and the rest had three children. majority 28(95.6%),spoke the local language which was kannada. table 1: demographic distributio n of the study participants. age distribution of the study participants age frequency percentages 21 25 202 68.0 26 – 30 58 19.5 31 – 35 16 5.4 36 – 40 07 2.4 41 – 45 08 2.7 > 45 06 2.0 study population by religion religion frequency percentages hindu 47 15.8 christian 234 78.8 muslims 01 0.3 others 15 5.1 marital status of the study population marital status frequency percentages unmarried 233 78.5 married 62 20.9 divorced 01 0.3 widow 01 0.3 predominant language spoken by study participants mother tongue frequency percentages malayalam 173 58.2 tamil 56 18.9 kannada 30 10.1 telugu 16 5.4 hindi 03 1.0 others 19 6.4 socio-economic classifi cation (based on modifi ed kuppuswamy classifi cation). socio-economic class frequency percentages upper class upper middle 169 56.9 lower middle 108 36.4 upper lower 18 6.1 lower 2 0.7 institution where studies (nursing course) class interval frequency percentages study institution 74 24.9 diff erent institution 223 75.1 work profi le of the participants among the study subjects, 132(44.4%) had work experience between six months to one year, 127 (42.8%) had up to two years and the rest had three or more years of experience working in the present hospital. among the participants, 121(40.7%) had experience of working in other private hospitals. qualifi cation wise, 133(44.7%) had completed general nursing and midwifery (gnm) course and 164(55.3%) had completed b.sc. nursing course. at the time of the study, 170(57.2%) and 127(42.8%) of nurses were working in medical and surgical related specialty wards respectively. out of the total participants, 282(95%) of them were staff nurses and the rest were head nurses. none of them ever got any warning or suspension for misconduct in the work place. all the staff nurses were on six hour shifts and head nurses were on eight hour shifts. we explored the health profi le of the participants in terms of any physical deformities, health problems and if they were on any medication for psychiatric illness. one participant had physical deformity and another reported being on psychiatric medication. lower back pain was the most common complaint among 25(8.4%) of participants who reported to have a health problem. negative acts questionnaire results a total of 80(26.9%) participants were targets of bullying, i.e., those who experienced two or more negative acts on a regular basis for the past six months. this was based on the response given by the subjects to the items in the questionnaire that were the examples of negative acts in the workplace. assessing the prevalence of types of bullying based on the sub classes of the 22 item questionnaire showed that among the 26.9% of participants who were victims of bullying, 64(80%) of the participants were subjected to work place bullying, 48(60%) reported personal bullying and 17(21.3%) had faced physical intimidation. concerning the 23rd item in the questionnaire stating “have you been bullied at work?” with a defi nition of bullying given along with it, 241(81.1%) subjects stated that they were never bullied at work in the past six months, 37(12.5%) stated that they were bullied rarely, 14(4.7%) stated that they were bullied now and then, 5(1.7%) subjects stated that they were bullied several times in a week. among the 56(18.9%) subjectswho were bullied based on the response to this question, 11international journal of occupational safety and health (ijosh) prevalence of bullying among nurses in a tertiary hospital, bangalore 2(3.6%) of them reported that they were bullied by their immediate superiors and patients, 2(3.6%) subjects were bullied by doctors and colleagues, 1(1.8%) by other superiors and the rest of them did not disclose who bullied them. based on gender, 7(12.5%) and 2(3.6%) of participants reported that they were bullied by female and male perpetrators respectively the rest reported that they were being bullied by both. during the process of bivariate analysis, no signifi cant association was found between bullying and sociodemographic factors like age, religion, state of origin, marital status, mother tongue, number of children if married and monthly family income. no statistically signifi cant association was found between bullying and work related factors of the participants including course completed, years of experience working in current /previous organization, department where the participant is posted, designation duty timings. no statistically signifi cant association was found between bullying and health related factors like presence of a health issue or physical deformity. discussion in this study among nurses working in a tertiary care hospital, prevalence of bullying using naq-r was 26.9% among the 297 respondents. majority were found to be the victims of work related and personal bullying. even though only a smaller percentage of nurses reported to be subjected to physical intimidation it is also an issue of signifi cance. there are not many studies done in similar settings to compare the results that we have obtained, but studies done across the globe portrays the similar results.13-15though the work conditions and exposure factors may vary, the presence of bullying in whatever form cannot be ignored. international labor organization reports that in the world of work there are several circumstances which increase the chance of harassment.14 these circumstances arise while working in contact with public, unsocial working hours like evening and night duties or working in areas providing public and emergency services. nurses encounter such circumstances daily in their working environment. in a study conducted in washington, 27.3% were victims of bullying experiencing 2 or more negative acts daily or weekly.15 studies report varying prevalence of bullying like, study conducted in northwest pacifi c reported 48% of bullying8, study conducted in public hospitals in greece reported a prevalence of 30.2%.11 underreporting of actual incidence of harassment is an actual fact16and which could be a reason for the diff erence in results between the present study and other studies. in our study, among those who were bullied, prevalence of workplace bullying is 80% and personal bullying is 60% which is similar to another study conducted in turkey17 where most nurses faced hostility towards their status at work place and personality there was no statistically signifi cant association with age group, position, education and years of study. the study done in turkey17 reports that depression symptoms of nurses were positively associated with experience of bullying.17study conducted in united kingdom on work place bullying reported that 29.6% of staff reported psychological distress.18 in the present study, the victims had faced bullying from their immediate senior, other seniors, colleagues and doctors. being an educated community these individuals are expected to have high social intelligence and empathy. work place bullying implies a lack of conscience and incapability to experience empathy which is dangerous for the nursing community who are supposed to be caring and show compassion to the community and their patients.19bullying victims are four times more likely to experience depression and three times more likely to report problems in sleeping and twice likely to experience stress.20our study has shown that bullying does exist, and the fi ndings are not very diff erent from other studies as mentioned above. limitation in our study, we were only able to understand whether the participants perceived themselves to be bullied by administering the questionnaire.this is subjective since individuals have diff erent threshold of dealing with circumstances. conclusion bullying among nurses is a problem that needs to be addressed with care and concern. work place bullying was the most common, followed by personal and physical intimidation. the perpetrators were either their immediate supervisors, doctors, patient or their attenders and colleagues and belonged to same or opposite gender. work place counseling, professional and/or peer support and healthy working environment are of paramount importance to tackle workplace bullying. 12 international journal of occupational safety and health (ijosh) cency baburajan et al. references 1. clarke c. the eff ects of bullying behaviors on student nurses in the clinical setting. 2009;148. 2. available from:http://scholar.uwindsor.ca/cgi/ v i e w c o n t e n t . c g i ? a r t i c l e = 1 3 7 1 & c o n t e x t = e t d [accessed 11th december 2017] 3. niedhammer i, david s, degioanni s. association between workplace bullying and depressive symptoms in the french working population. j psychosom res. 2006 aug;61 (2):251-9. available from:https://www. 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/leaveuntagged /untaggedrgbhandling /usedocumentprofile /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 oa 2_the effect of shift_suleiman k.indd original articleijosh, volume 10, no, 1, 2020 (issn 2091 – 0878) 11international journal of occupational safety and health (ijosh) doi: https://doi.org/10.3126/ijosh.v10i1.29877 corresponding author khaled suleiman rn phd associate professor, school of nursing, al-zaytoonah university of jordan, p.o.box 130, amman 11733, jordan phone: + 962 6 4291511, fax: + 962 6 4291432 email: khaledsuleiman@yahoo.com, ksuleiman@zuj.edu.jo orcid id: 0000-0002-8602-3670 available online at https://www.nepjol.info/index.php/ijosh international journal of occupational safety and health, vol. 10 no. 1 (2020), 11 – 17 this journal is licensed under a creative commons attributionnon commercial 4.0 international license. the effect of shift fluctuations on sleep quality among nurses working in the emergency rooms in amman, jordan suleiman k 1 , al-khateeb t 1 , al kalaldeh m 2 , sharour la 1 1school of nursing, al-zaytoonah university of jordan, p.o.box 130, amman 11733, jordan, 2faculty of nursing, the university of jordan-aqaba campus, jordan abstract  introduction: sleep quality disturbances are common among nurses especially those working in stressful situations such as emergency room. additionally, sleep quality disturbances were found to interfere with nurses’ quality of life and work performance. no studies have found the effect of fluctuated shifts on sleep quality among nurses. objectives: to examine the impact of shift fluctuations on sleep quality among nurses working in the emergency room. methods: a cross-sectional, descriptive design was employed. five emergency rooms were selected from public and private hospitals located in amman, jordan. the selected hospitals were also referral sites with capacity of more than 200 beds. a convenient sample of nurses who had a minimum of six months experience in the emergency room and working on rotating shifts were eligible for participation. nurses with known chronic respiratory problems and sleep apnea were excluded. a self-administered questionnaire including a demographic and work-related questions, and the arabic version of the pittsburgh sleep quality index were provided. shift fluctuations were clustered based on interchanging between morning, evening and night shifts. results: a total of 179 emergency nurses working in rotating shifts participated in the study. the majority of the nurses were poor sleepers. the study found no significant differences between different shifts interchange and sleep quality. however, interchange between morning and evening shift reported the highest sleep disturbance. sleep quality was positively correlated with the length of experience, while negatively correlated with the age and the number of monthly shifts. nurses who declared higher satisfaction and ability to work under pressure revealed better sleep quality. conclusion: emergency room nurses showed poor sleep quality. while there was no specific shift interchange cluster inducing poor sleep quality, some demographical and work-related characteristics indicated their influence on sleep quality. key words: emergency room, nurses, shift fluctuation, sleep quality date of submission: 25.03.2020 date of acceptance:21.06.2020 introduction  sleep quality (sq) disturbances are common among nurses1,2 especially nurses working in stressful situations such as emergency room (er).3,4 further, it was reported that up to 92% of nurses working in er complained of sq disturbances.3 additionally, sq disturbances were found to interfere with nurses’ quality of life and work performance.1,5 suleiman et al3 reported that jordanian nurses working in er had a mean sleep duration of 6.38 hours per funding: no fund was received to conduct this study. confl ict of interest: the authors report no confl ict of interest. acknowledgments: the authors would like to thank all nurses who participate in the study and nurses’ managers in emergency departments at the participating hospitals who facilitate the data collection process. 12 international journal of occupational safety and health (ijosh) suleiman k et al. night, and needed on average 29.63 minutes to fall asleep. although er nurses reported bad sq and 70% sleep effi ciency, they had moderate problems with daytime functioning and used less sleep medication.3 nurses comprise of health care providers who work round the clock so they need to work in shifts.6-8 shift work is recognized as working irregular hours organized into 2-shift or 3-shift systems and include rotation work, and night work.9,10 no studies found that examined the eff ect of fl uctuated shifts on sq among nurses, however, it was reported that work in shift precisely night shift 11 may contribute to sleep disturbances.12-14 sleep is regulated by sleep homeostasis and circadian rhythms.15 working in shifts may interfere with the circadian rhythm,8 this suggests that nurses who work in shifts may experience sq alterations. it was reported that 78% of nurses working in shifts had bad sleeping quality.1 unfortunately, no information describes nurses’ sq when they have fl uctuated shift and which shift is associated with sleep alterations. thus, there is a need for more studies to investigate the eff ect of fl uctuated shifts on sq among nurses. besides shift work, numerous factors were identifi ed that contribute to lower sq among nurses. sociodemographic variables such as age and gender have a variable relationship with sq among nurses. it was reported that nurses who are females,1,16 old in age,3 single and with a university degree were poor sleepers.5 in contrast, suleiman et al3 reported no relationship between demographic and sq among a sample of nurses working in the er. previous literature reported numerous work-related variables that have a relationship with sq include job satisfaction and the level of experience. cheng and cheng17 reported that nurses with high job satisfaction had low sleep disturbances. also, nurses with a lesser number of years of experience had poor sq.5,16 other studies found no relationship between work-related variables and sq among nurses.3 thus, these inconsistent fi ndings warrant further studies to investigate the relationship between sq and demographic and work-related variables. unfortunately, there is a lack of studies that examined sq among jordanian nurses working in fl uctuated shifts in er. also, factors that may infl uence sq such as demographics, work-related variables, and shift fl uctuations were neglected by the health institution administrations in jordan. the evaluation of nurses’ sq and the eff ect of fl uctuated shift may inspire the jordanian researchers to conduct interventional research that may help to improve nurses’ sq. thus, the current study aims to assess the sq disturbances and identify the relationship of shift fl uctuations and other demographic and work related variables with sq among er nurses in jordan. methods  2.1. design, settings, and participants a cross-sectional descriptive design was employed to meet the aims of this study. the study was carried out in ers at selected private and public hospitals in amman (jordan). the health system in jordan consisted of public and private clinical settings that provide medical care over 24 hours, 7 days a week. the hospitals were chosen based on their classifi cation as referral teaching hospitals and their capacity which exceeded 200 beds. the population of the study consisted of the registered nurses who are working at the er in jordan. for the current study, a non-probability convenience sample of nurses was chosen to recruit the sample. to calculate the sample size, the g*power version (3.0.10) was used.18 the total sample required for a two-tail test with medium eff ect size (α= 0.05), and power (= 0.80) was (168) subjects to fi nd signifi cant diff erences between the fl uctuated shift groups and sq. however, more participants were recruited to allow for (15-25%) attrition. therefore, all eligible nurses who met the inclusion criteria and on duty at ers in the chosen hospitals were asked to enroll in the study. the inclusion criteria were male and female nurses working on rotating shifts, with an associate degree and higher in nursing and had at least six months experience in er. any nurse with respiratory problems and sleep apnea were excluded from the study. 2.2. data collection a self-administered questionnaire package was given to the subjects that asked about demographic and work-related variables, in addition to the arabic version of the pittsburgh sleep quality index (psqi).19 the demographic sheet included questions about nurses’ age in years, gender as male or female, number of years of experience in nursing, income, the shift-type that aff ect their sleep, marital status, educational status, years of experience, number of shifts in one month, satisfaction about their work, work under pressure, 13international journal of occupational safety and health (ijosh) the effect of shift fluctuations on sleep quality among nurses working in the emergency room number of night shift during the month and hospital type either public or private. to measure “shift fl uctuations” the participants were asked which type of shift interchange interfere with their sleep using the following three categories as follows: morning to evening, evening to night and night to morning. morning shift was defi ned as working from 7 am to 3pm. evening shift was defi ned as working from 3pm to 11pm. while night shift was defi ned as working from 11pm to 7am. the psqi. the psqi is a 19 self-reported questions19 that examine numerous sq components. each item is rated on a 4-point scale ranges from 0 to 3 with higher scores indicate severe sleep diffi culty. the 19 items are joined to form seven component scores that also ranges from 0 to 3 with higher scores denote poor sleep. the components are: sleep latency, subjective sleep quality, sleep disturbances, sleep duration, habitual sleep effi ciency, sleep medications, and daytime dysfunction. the seven component scores are added to yield one global score that ranges from (0) to (21) with higher scores indicating poorer sq. buysse et al19 have established a cut-off for the global of (5) that has been used to identify poor sleepers. scores (< 5) refer to good sleepers; scores (>5) refer to poor sleepers. the psqi demonstrated good internal consistency reliability of 0.83 among 148 psychiatric patients.19 in the arabic psqi validation study, suleiman et al 20 reported acceptable internal consistency reliabilities of the global psqi (0.70) among 35 healthy arabic participants. the study was done from 1st april 2019 to 15th may 2019 2.3. data analysis the data was entered to the statistical package for the social sciences (spss) version (25). initially, the data was cleaned, sorted and screened for outliers and missing. description of the participant’s characteristics was examined by calculating descriptive statistics for the demographic and work-related variables (frequency, percentages, mean (m), and standard deviations (sd) based on the level of measurements either numeric or categorical variable. to detect the diff erences in sq in diff erent levels of demographic and work-related variables, three statistical methods including pearson correlation coeffi cient, an independent sample t-test, and the analysis of variance (anova) were conducted to explore the diff erences in the global psqi scores by demographic variables. additionally, to examine sq in diff erent levels of fl uctuated shifts, the analysis of variance (anova) was used to detect the diff erences between the groups in terms of sq. 2.4. study procedures and data collection the er head nurses were approached by the researcher in the selected hospitals under the study. a clarifi cation of the purpose and outcomes of the study and the nurses’ population that will be included in the study was explained for the head nurses. all nurses who met the inclusion criteria and who agree to participate in the study were approached by the researcher where the purpose and outcomes of the study explained for them. at the time of data collection, questionnaires were handed to the available nurses by the researcher. within one week of participation, the participants were contacted via a follow-up telephone call to remind them to answer the questionnaires and return them. the completed questionnaires were collected by head nurses and given together in an envelope to the researcher himself. the data collection extended over six weeks. 2.5. ethical considerations the approval to conduct the study was obtained from the irb committee from all hospitals included in the study. the researchers assured the participants that their participation in the study is voluntary and they have the right to withdraw at any point in the study without any penalties. further, the participants were informed that there are no fi nancial benefi ts from participation in the study. subjects’ return of the questionnaires implies consent. additionally, all the information including the participants’ names were kept confi dential by the researcher. results of 220 nurses who agreed to participate in the current study, 179 returned the questionnaires with a response rate of 81%. after examining each questionnaire package, 12 nurses did not complete the questionnaire, 24 nurses did not return the questionnaire and 5 nurses were not jordanians. 3.1. sample characteristics the mean age of the nurses who complete the study was 30.44 (sd= 8.16) ranging from 20 to 60. almost half of the sample were males (n=95, 53.1%), and worked in a governmental hospital (n=97, 54.2%). in terms of educational levels, nurses who had bachelor’s 14 international journal of occupational safety and health (ijosh) suleiman k et al. degrees compromised three fourth of the participants in the study (n= 138, 77.1%). the nurses in the current study reported mean experiences in the emergency room of 7.58 (sd=10.78) years. at the entry of the study, the monthly income of the nurses ranged from 350 jd to 450 jd (m= 428.79 jd, sd=124.74). about half of the respondents (n= 88, 54%) are satisfi ed with their work and can tolerate working under pressure (n= 123, 68.7%) (table 1). 3.2. nurses’ sleep quality in the current study, the total mean scores of psqi were 7.87 (sd= 3.86) which indicates more sleep problems among nurses (see table 2). when examining nurses’ scores according to the cut point score 5, about 84.4% of nurses had global scores ≥ 5 indicating poor sleep. although the subjects in the current study reported a sleep duration of 7.02 (sd= 1.83) hour during night, they reported bad subjective sq. also, they reported an average time of 30.29 (28.26) min to fall asleep and had >58.7% sleep effi ciency. moreover, the majority of nurses had not used sleep medication (n=125, 69.8%), while, 42.5% (n= 76) of the nurses reported little problems with daytime functioning. the most frequent reason for sleep disturbances was waking at midnight or in the early morning (m= 1.70, sd= 1.1). 3.3. fluctuated shi and sleep quality. in this study, all nurses worked in a rotating shift schedule. the categories of shift interchange were: morning to evening, evening to night and night to morning (table 3). most of the nurses in the current study reported that they had less sq disturbances when they turn shift from night to morning (mean= 7.71, sd= 3.7). while, the highest psqi scores reported by nurses who turn shift from morning to evening. there was no signifi cant diff erence in sq in terms of shift fl uctuation (f=0.84, p= 0.43) (table 3). 3.4. demographic variables and sleep quality. there was a statistically signifi cant correlation between global psqi and age (p=0.018) indicating that older nurses had higher sq disturbances. but, when categorizing age into 4 categories, there were no signifi cant diff erences between the groups, although the middle age group (41-50) years old reported the lowest psqi score (m= 6.3, sd= 3.1). however, there were no signifi cant correlations between global psqi scores and other numerical demographical variables. additionally, no other signifi cant diff erences were revealed in terms of other categorical demographic variables (table 1). 3.5. work-related variables and sleep quality. there was a statistically signifi cant correlation between sq and number of years’ experience (r= -0.15, p=0.04), and number of shifts (r= -0.18, p=0.017). however, there were no signifi cant correlations between global psqi scores and other numerical work-related variables. additionally, a signifi cant diff erence was observed in sq scores in terms of work satisfaction (t= -2.92, p=0.004) and the ability of nurses to work under pressure (t= -2.95, p=0.004) indicating that nurses who are satisfi ed with their work and can work under pressure had better sq scores. (table 1). table 1: demographic, work-related variables and sleep quality characteristics. variable total (n=179) sleep quality between demographic and work related variables mean (sd) t/f (p value) gender n (%) male 95 (53.1%) 8.09(3.83) 0.47(0.45) female 84 (46.9%) 7.64(3.90 marital status n (%) single 96 (53.6%) 8.03(3.61) 0.51(0.67)married 79 (44.1%) 7.80(3.98) divorced/widowed 4 (2.2%) 6.50(2.27) educational status n (%) diploma 32(17.9%) 6.79(3.42) 1.43(0.24)bachelor 138 (77.1%) 8.13(3.19) higher 9 (5%) 7.77(2.87) 15international journal of occupational safety and health (ijosh) the effect of shift fluctuations on sleep quality among nurses working in the emergency room job satisfaction n (%) yes 88 (54%) 7.17(2.94) -2.92(0.004) no 75 (46%) 8.94(4.44) work under pressure n (%) yes 123(68.7) 7.27(3.34) -2.92(0.004) no 56(31.3) 9.10(4.52) hospital type n (%) governmental 97 (54.2%) 8.28(3.37) 1.49(0.13) private 82(45.8%) 7.39(2.89) mean (sd) age (years) 30.44(8.16) experience (years) 7.58(7.32) monthly income (jd)* 428.79(124.74) *jd: jordanian dinar = 1.5 us dollars table 2: subjective and objective sleep measures of the participants psqi* components total possible scores mean(sd) range global psqi 0-21 7.87(3.86) 0-17 subject sleep quality 0-3 1.31(0.86) 0-3 sleep latency 0-3 1.41(0.92) 0-3 sleep duration 0-3 1.08(1.02) 0-3 sleep effi ciency 0-3 1.06(1.0) 0-3 sleep disturbance 0-3 1.44(0.76) 0-3 sleep medications 0-3 0.50(0.89) 0-3 daytime dysfunction 0-3 1.44(0.90) 0-3 *psqi: pittsburgh sleep quality index table 3: sleep quality scores for fl uctuated shifts categories. shift fluctuation n (%) mean (sd) for global psqi* for each group anova† f test value and sig morning to evening 45(25.1%) 8.62(3.7) f= 0.84, p= 0.43evening to night 34(19%) 8.10(3.8) night to morning 94(52.5) 7.71(3.78) *psqi: pittsburgh sleep quality index, †anova: analysis of variance. table 1 cont ... discussion the current study refl ected poor sq among nurses working in the er. the nurses reported a global psqi score above the cut-off score of >5. similar results were reported by other studies that examined sq among jordanian nurses working in the er. suleiman et al3 reported a global psqi score of 8.76 (3.18) among 186 nurses working in the er. this indicates that nurses working in er are poor sleepers. probably, the stressful nature of nursing work in the er with work overload and fatigue might be the reason for the poor sq. also, the results of this study were similar with previous studies that examined sq in other acute care settings such as icu or ccu.16 this emphasizes that critical care settings are similar to er in workload and may induce alterations in sq for nurses too. in the current study, all nurse was working in shift. the study did not reveal any diff erences in sq in terms of shift fl uctuations, although nurses fl uctuated from shift morning to evening had the highest global psqi scores which indicate poorer sq than other shift fl uctuations such as morning to night or evening to night. no previous studies have examined shift fl uctuations on sq. however, previous studies reported poor sq 16 international journal of occupational safety and health (ijosh) suleiman k et al. among nurses working in shift rotation. mcdowall et al13 reported poor sq among 78% (n=888) of shift working nurses as compared to 59% (n= 116) of nurses who work in non-shifts. also, they reported a statistically signifi cant diff erence in terms of sq between shiftworking nurses and non-shift working nurses (t=4.653, p<0.001). further, another study showed that nurses who are working in night shift sleep two to four hours less than daytime workers which may lead to sleep defi ciency, malfunctioning, and tiredness.5 this emphasizes that work in shifts does disturb the normal circadian rhythms that are why most of the nurses who work in shifts are more likely to suff er from sleep disturbances. in this study, there was a statistically signifi cant relationship between sq and age. additionally, the current study found no association between sq scores and other socio-demographic variables. the correlation between sq and age in the current study are consistent with previous studies.11,16 attia21 found that better sq scores were reported by older nurses in comparison to younger nurses. the reason that the older nurses mainly work on day shift and have more stability than the younger nurses. in terms of other demographic variables, the current study was consistent with suleiman et al3 study, but inconsistent with other studies that reported that gender, educational level, and marital status were among the most sociodemographic factors that have a relationship with sq.1,5,16 on the other hand, the results of the current study showed a statistically signifi cant relationship between sq and the number of shifts worked and the duration of experience as nurses in the er. additionally, there were signifi cant diff erences in sq in terms of working under pressure and job satisfaction. these results are congruent with other studies that revealed a signifi cant association between sq and experience as nurse, and shift work.1,5 dong et al1 found more sq disturbances in nurses with less experience (x2= 159.7, p<0.001), and working on night shift (x2= 29.2, p<0.001). also, other studies reported that nurses with high job satisfaction and a low number of years of experience had low sleep disturbances.5,16,17 this could be explained as nurses with more years of experience are more adapted to the stressful work condition in the er and by the time they became more satisfi ed with their work and consequently have low sq alterations. in contrast, other studies found no relationship between workrelated variables and sq among nurses.3 conclusions the aim of the current study was to examine the relationship between sq and shift fl uctuations among nurses working in the er in jordan. the study concluded that jordanian er nurses reported poor sq. further, there was no eff ect of shifts fl uctuation on sq. factors that infl uenced sq included age, years of experience, number of shifts worked in the er and the level of nurses’ satisfaction with their work. this may suggest appropriate education programs, and intervention studies that focus on sleep among nurses working in the er as the target population. therefore, it is hoped that the fi nding from the current study may be benefi cial to health facilities administrators in identifying the nurses’ level of sq and fi nd specifi c measures to try to modify some of the infl uencing factors that may interfere with sq. references 1. dong h, zhang q, sun z, sang f, xu y. sleep disturbances among chinese clinical nurses in general hospitals and its infl uencing factors. bmc psychiatry. 2017;17(1):241-50. 2. momeni b, shafi pour v, esmaeili r, charati j. the relationship between the quality of work life and sleep in nurses at the intensive care units of teaching hospitals in mazandaran, iran. j nurs midwifery sci. 2016;31(1):28-34. 3. suleiman k, hijazi z, al kaladeh m, abu sharour l. factors associated with sleep quality among emergency nurses in jordan. sleep vigilance. 2019; december:11-6. 4. wolf l, perhats c, delao a, martinovich z. the eff ect of reported sleep, perceived fatigue, and sleepiness on cognitive performance in a sample of emergency nurses. j nurs adm. 2017;47(1):41-9. 5. senol v, soyuer f, guleser g, argun m, avsarogullari l. the eff ects of the sleep quality of 112 emergency health workers in kayseri, turkey on their professional life. turk j emerg med. 2014;14(4):1728. 6. books c, coody l, kauff man r, abraham s. night shift work and its health eff ects on nurses. health care manag. 2017;36(4):347-53. 17international journal of occupational safety and health (ijosh) the effect of shift fluctuations on sleep quality among nurses working in the emergency room 7. dall’ora c, ball j, recio-saucedo a, griffi ths p. characteristics of shift work and their impact on employee performance and wellbeing: a literature review. int j nurs stud. 2016;57:12-27. 8. sun q, ji x, zhou w, liu j. sleep problems in shift nurses: a brief review and recommendations at both individual and institutional levels. j nur manag. 2019;27(1):10-8. 9. niu s, miao n, liao y, chi m, chung m, chou k. sleep quality associated with diff erent work schedules: a longitudinal study of nursing staff . biolo res nurs. 2017;19(4):375-81. 10. rheaume a, mullen j. the impact of long work hours and shift work on cognitive errors in nurses. j nur manag. 2018;26(1):26-32. 11. heckman c, kloss j, feskanich d, culnan e, schernhammer e. associations among rotating night shift work, sleep and skin cancer in nurses’ health study ii participants. occup environ med. 2017;74(3):169-75. 12. lim s, han k, cho h, baek h. shift-work nurses’ work environments and health-promoting behaviours in relation to sleep disturbance: a crosssectional secondary data analysis. j clin nurs. 2019;28(10):1538-45. 13. mcdowall k, murphy e, anderson k. the impact of shift work on sleep quality among nurses. occup med. 2017;67(8):621-25. 14. togo f, yoshizaki t, komatsu t. association between depressive symptoms and morningnesseveningness, sleep duration and rotating shift work in japanese nurses. chronobiol int. 2017;34(3):34959. 15. borbely a. a two process model of sleep regulation. hum neurobiol. 1982;1(3):195-204. 16. han y, yuan y, zhang l, fu y. sleep disorder status of nurses in general hospitals and its infl uencing factors. psychiatr danub. 2016;28(2):176-83. 17. cheng w, cheng y. night shift and rotating shift in association with sleep problems, burnout and minor mental disorder in male and female employees. occup environ med. 2017;74(7):483-88. 18. faul f, erdfelder e, lang a, buchner a. g*power 3: a fl exible statistical power analysis program for the social, behavioral, and biomedical sciences. behav res methods. 2007;39(2):175-91. 19. buysse dj, reynolds cf, monk th, berman sr, kupfer dj. the pittsburgh sleep quality index: a new instrument for psychiatric practice and research. psychiatry res. 1989;28(2):193-213. 20. suleiman k, yates b, berger a, pozehl b, meza j. translating the pittsburgh sleep quality index into arabic. west j nurs res. 2010;32(2):250-68. 21. attia f. eff ect of shift rotation on sleep quality and associated health problems among nurses at asser hospital ksa. int j nurs sci. 2016;6(2):58-65. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /none /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /error /compatibilitylevel 1.4 /compressobjects /tags /compresspages true /convertimagestoindexed true /passthroughjpegimages true /createjdffile false /createjobticket false /defaultrenderingintent /default /detectblends true /detectcurves 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/leaveuntagged /untaggedrgbhandling /usedocumentprofile /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 available online at http://www.nepjol.info/index.php/ijosh international journal of occupational safety and health, vol 5 no 2(2015) 23– 27 introduction mental illnesses are becoming increasingly common and are a growing global health concern. according to the estimates, by 2020 dalys loss due to mental disorders are expected to represent 15% of the global burden of diseases [1]. mental illnesses are one of the leading causes of morbidity in india, affecting different age groups and distributed over different geographic area, socio-cultural background [2, 3]. in india, the prevalence of mental disorders ranges from 1.8% 20.7%. the burden of mental disorders is maximal among young adults, who are the most productive section of the population [1]. studies in the past have revealed that the prevalence of mental illness among industrial workers ranges from about 14% 51%, which is more than that in the general population [4-6]. psychiatric disorders constitute one of the leading occupational health problems, with one-third of all workers reporting adverse psychological effects.[7] since an individual’s psychosocial functioning has an impact on work, there is a need to screen workers in different settings for mental illnesses [8]. in light of the above observation, this study was undertaken to screen workers in tea plantation setting in south india for probable prevalence of mental illnesses and their associated factors. limited number of studies has been conducted among tea plantation workers and their mental illness. objectives to assess the prevalence of probable mental illnesses among workers in two selected tea estates in south india to study the factors associated with probable mental illness among these workers. original article mental health status of workers in selected tea estates, tamil nadu, india abstract: introduction: the prevalence of mental illnesses among industrial workers ranged between 14% 51%, which is more than that of the general population. individual’s psychosocial functioning has an impact on the work efficiency and hence the current study was undertaken to screen workers in tea plantations. objective: to document the prevalence of probable mental illness and its associated factors among workers in selected tea estates in south india. methodology: a cross sectional study was done in two tea estates in tamil nadu from march to may 2012. the general health questionnaire (ghq) 28 was used to screen for mental health status. socio-demographic details, work profile and associated risk factors were also documented. results: among the 400 subjects interviewed, 75.5% were females. the mean age was 43.21 (±7.47) years and the mean work experience was 21.38 (±9.31) years. in this study 12.8% subjects screened positive for probable mental illness and 1%, 1%, 0.2% and 1.5% screened positive for the domains of somatic symptoms, anxiety/insomnia, social dysfunction and severe depression respectively. workers who screened positive for probable mental illness had availed significantly greater duration of leave in the previous year. there was no significant association of mental illness with age, gender, marital status, substance abuse, designation, co-morbidity and stressful life events. conclusion: the prevalence of probable mental illness was similar to other occupational settings. management of the associated risk factors may improve one’s work efficiency and productivity. key words: mental health status, tea estate, south india, ghq 28. ashwini g s*, naveen r##, navya c j*, joy j**, thomas a**, jyoti s# *post graduate student, **medical intern, #mbbs, dgo, medical officer -estate hospital, ##associate professor. department of community health, st john’s medical college, bangalore 560034. karnataka, india. corresponding author: dr. naveen ramesh email: drnaveenr@gmail.com © 2015 ijosh all rights reserved. original article / ijosh/ issn 2091-0878 24 methods a cross-sectional study was conducted from march to may 2012 in two selected tea estates located at the anamalai, tamil nadu, south india. all permanent workers between the age group of 18 – 60 years from both the estate were included in the study. workers who could not be contacted after two visits were excluded from the study population. ethical clearance for this study was obtained from the institutional ethical board. an interview schedule was developed which included socio-demographic details, work profile and other possible associated risk factors. data regarding the number of leaves availed in the last one year by the workers was also obtained from the records maintained in the estate office. the general health questionnaire 28 (ghq 28) was used to screen for probable mental illness. ghq28 has 28 item and was devised by goldberg, licensed to gl institute and has been validated in india. permission was obtained to use the ghq28 from gl institute. this tool is used to screen an individual with a probable mental illness. it has four domains namely: somatic symptoms, anxiety/insomnia, social dysfunction and severe depression. each question is scored as 0 and 1. a total score of ≥ 6 and/or a total score of ≥ 5 in any one of the four domains are considered to be positive. a survey team was formed, who were briefed and trained to administer the pretested interview schedule including the tamil version of ghq 28. after obtaining written consent from the participants, the schedule was administered to the workers. data was entered into microsoft excel and analyzed for measures of central tendency, proportions and chi-square test using spss 16. results of the 400 workers interviewed, 302 (75.5%) were females. the mean age of the study subjects was 43.21 years (± 7.47years). majority of them, 368 (92%) of them belonged to middle socio economic class as per standard of living index. the socio-demographic profile of the study population is shown in table1. work profile: the mean years of work experience was 21.38 years (± 9.31years). workers reported working for an average duration of eight hours/day. majority of them, 360 (90%) said that they were satisfied with their work and 120 (30%) reported being satisfied with their salary. little more than a quarter of the interviewed workers, 113 (28.2%) attributed their health problems to their work. when questioned about the interpersonal relationship at the workplace, 256 (64%) said that they had a fair relationship with their colleagues. majority, 379 (94.7%) workers had availed leaves for less than four days in the past year. history of reported mental illness and stress: in the study population, two (0.5%) gave past history of mental illness and one (0.2%) reported family history of mental illness. table1: socio-demographic profile of the study population an associated co-morbidity was reported by 93 (23.2%) subjects. one third 131 (32.75%) reported having some form of substance abuse. the most commonly abused substance was chewable forms of tobacco. among the married, 86 (31.9%) reported substance abuse in their spouse and 58 (67.4%) were worried about this, which can be a potential stressor for a mental illness. seventy (17.5%) reported a stressful life event in the past one year. the most common stressful events reported were marriage of children and/or death in the family. most of the workers reported having good family support. when asked about the reasons for worry in general, 134 (33.5%) said that they were worried regarding their work and 126 (31.5%) about the education and future of their children. most of them 329 (82.2%), did not have any sleep disturbance. nearly half, 176 (44%) reported experiencing happiness by attending place of worship like temples or church and 89 (22.2%) by spending time with their family members. variables male female total age (years) 21-30 6(6.1%) 13(4.3%) 19(4.8%) 31-40 17(17.3%) 115(38.1%) 132(33%) 41-50 46(46.9%) 133(44%) 179(44.8%) 51-60 29(29.6%) 41(13.6%) 70(17.5%) education illiterate 5(5.1%) 102(33.8%) 107(26.8%) <7 th standard 30(30.6%) 71(23.5%) 101(25.2%) 7-10 th standard 25(25.5%) 55(18.2%) 80(20%) >10 th standard 38(47.8%) 74(24.5%) 112(28%) designation pluckers 22(22.450 284(94%) 306(76.5%) pruners/ sprayers 43(43.9%) 1(0.3%) 44(11%) others 33(33.7%) 17(5.6%) 50(12.5%) marital status married 91(92.9%) 264 (87.4%) 355(88.8%) widowed 2(2%) 27(8.9%) 29(7.2%) divorced 1(1%) 8(2.7%) 9(2.3%) unmarried 4(4.1%) 3(1%) 7(1.8%) type of the family nuclear 80(81.6%) 244(80.8%) 324(81%) joint 4(4.1%) 3(1%) 7(1.8%) three generation 14(14.3%) 55(18.2%) 69(17.2%) international journal of occupational safety and health, vol 5 no 1 (2015) 23 27 r. naveen et.al. 2015 probable mental illness as found by using the ghq 28: in this study, 51 (12.8%) of the study subjects screened positive for mental illness using the ghq 28 and 4 (1%), 4 (1%), 1 (0.2%) and 6 (1.5%) screened positive for the domains of somatic symptoms, anxiety/insomnia, social dysfunction and severe depression respectively. distribution of demographic and work place variables across ghq positivity is depicted in table 2 and table 3 respectively. table 2: distribution of demographic variables with ghq positivity there was no significant association between ghq positivity and the factors listed above. however a significant association was found between number of days of leaves availed and ghq positivity as shown in table 4. table 3: distribution of work place variables with ghq positivity table 4: association between ghq positivity and leaves availed discussion the prevalence of probable mental illness among tea plantation workers in this study was 12.8% using ghq28. this is probably the first study to document the prevalence of probable mental health illness among tea plantation workers. in a study done on industrial workers in india using ghq12 the prevalence was found to be 51.7%[4]. a community based study in western nigeria using ghq12 found the same to be 18.9%. [10] a study done on a production organization employees in india using ghq28 showed that there was a positive correlation between perceived occupational health and mental health status.[8] in a study done in pakistan using ghq28, a high level of mental health disorders were present among the female workers and in the workers in age group of 20 to 25 years [11]. in a study done by dutta [9] on industrial workers, educational level, perceived stress, job satisfaction and stressful life events were identified as the independent determinants of psychiatric morbidity. however in this study, there was no statistically significant association found between the prevalence of probable mental illness and gender, age, education, occupation, socio-economic status, religion, marital status, type of family, substance abuse, spouse’s substance abuse, comorbidity, stressful life events and job or salary satisfaction. workers who had screened positive for ghq were found to have availed significantly more days of leave in the previous year, as compared to those who were ghq negative. this reiterates the finding from earlier studies that mental illness is associated with decreased productivity among workers.*1,7,8+ variable ghq positive n (%) age (years) 20-30 03 (15.8) 31-40 17 (12.9) 41-50 20 (11.2) 51-60 11 (15.7) gender male 16 (16.3) female 35 (11.6) education illiterate 09 (8.4) <7 th standard 13 (12.9) 7 th -10 th standard 09 (17.2) >10 th standard 20 (17.1) substance abuse not using 36 (13.4) tobacco 10 (11.9) alcohol 05 (19.2) tobacco use smoking form 02 (6.2) chewable form 08 (11) comorbidity presence 15 (16.1) absence 36 (11.7) spouse substance abuse worried 05 (8.6) not worried 07 (25) stressful life event in the past 1 year yes 10 (14.3) no 41 (12.4) variable ghq positive n (%) work satisfaction yes 44 (12.2) no 79 (17.5) salary satisfaction yes 10 (8.3) no 41 (14.6) sleep disturbance yes 8(11.3) no 43(13.1) leaves availed (n, %) total days >4 days total ghq 28 positive 44 (86.27) 7 (13.72) 51 (100) ghq 28 negative 335 (95.98) 14 (4.02) 349 (100) total 379 (94.75) 21(5.25) 400 (100) p < 0.005 international journal of occupational safety and health, vol 5 no 1 (2015) 23 27 r. naveen et.al. 2015 8. bhardwaj a, srivastava a. occupational health and psychological well-being of industrial employees. ind psychiatry j. 2008 oct; 17: 28-32. 9. oe amoran, oo ogunsemi, and vo lasebikan: assessment of mental disorders using the patient health questionnaire as a general screening tool in western nigeria: a community-based study: j neurosci rural pract. 2012 jan-apr; 3(1): 6–11 10. anwar khan, subhan ullah, kamran azam, dr. salim khan. individual differences and mental health disorders among industrial workers: a cross sectional survey of hayatabad industrial estate peshawar, pakistan. international review of business research papers (irbrp), (6), 30-39. conclusion the prevalence of probable mental health illness was found to be 12.8% using the ghq 28 screening tool among tea plantation workers, which is in comparison with prevalence among the general population. the six subjects detected with severe depression followed up with the psychiatrist and were initiated on treatment. workers who had screened positive for suspected mental illness were found to have availed significantly more days of leave in the previous year. there is a need to screen workers in different settings for probable mental illnesses and evaluate further for associated factors for the same, as mental health is known to affect one’s work efficiency. references 1. national mental health programme. http://www.nihfw.org/ ndc/documentation services/national health programme/ national mental health programme.html 2. reddy mv, chandrashekhar cr. prevalence of mental and behavioural disorders in india: a meta-analysis. indian j psychiatry. 1998; 40: 149–57. 3. murali ms. epidemiological study of prevalence of mental disorders in india. indian j commun med.2001; 9:34–8. 4. dutta s, kar n, thirthalli j, nair s. prevalence and risk factors of psychiatric disorders in an industrial population in india. indian j psychiatry 2007;49:103-8 5. kar n, dutta s, patnaik s. mental health in an indian industrial population: screening for psychiatric symptoms. indian j occup environ med. 2002; 6:86–8. 6. kiran kumar p.k., jayaprakash k., francis n.p. monteiro, prashantha bhagavath. psychiatric morbidity in industrial workers of south india. journal of clinical and diagnostic research. 2011 october; 5(5): 921-5. 7. sauter sl, murphy lr, hurrell jj jr. prevention of work-related psychological disorders. a national strategy proposed by the national institute for occupational safety and health (niosh). am psychol. 1990 oct; 45(10):1146-58. http://www.nihfw.org/ndc/documentation%20services/national%20health%20programme/national%20mental%20health%20programme.html http://www.nihfw.org/ndc/documentation%20services/national%20health%20programme/national%20mental%20health%20programme.html http://www.nihfw.org/ndc/documentation%20services/national%20health%20programme/national%20mental%20health%20programme.html international journal of occupational safety and health, vol 5 no 1 (2015) 23 27 r. naveen et.al. 2015 4. van vliet p, knape m, de hartog j, janssen n, harssema h, brunekreef b: motor vehicle exhaust and chronic respiratory symptoms in children living near freeways. environmental research 1997, 74:122-132. 5. waldron g, pottle b, dod j: asthma and the motorways – one district's experience. journal of public health medicine 1995, 17:85-89. 6. kim jj, smorodinsky s, lipsett m, singer bc, hodgson at, ostro b: traffic-related air pollution near busy roads: the east bay children's respiratory health study. american journal of respiratory and critical care medicine 2004, 170:520-526. 7. brunekreef b, janssen na, de hartog j, harssema h, knape m, 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histamine?evaluation in a community survey of the bronchialsymptoms questionnaire (1984) of the international union against tuberculosis and lung disease. int j epidemiol 1989; 18: 165–173. 17. burney p, malmberg e, chinn s, jarvis d, luczynska c, lal e. the distribution of total and specific serum ige in the european community respiratory health survey. j allergy clin immunol 1997; 99: 314-22. 18. chinn s, burney p, jarvis d, luczynska c. variation in bronchial responsiveness in the european community respiratory health survey (ecrhs). eur respir j 1997; 10:2495-2501. 19. european community respiratory health survey.variations in the prevalence of respiratory symptoms, self reported asthma attacks, and use of asthma medication in the european community respiratory health survey (ecrhs). eur respir j 1996; 9: 687-95. 20. devereux g, ayatollahi t, ward r, bromly c, bourke sj,stenton sc, et al. asthma, airways responsiveness and air pollution in two contrasting districts of northern england.thorax 1996; 51 : 169-74. 21. peat jk, haby m, spijker j, berry g, woolcock aj.prevalence of asthma in adults in busselton, western australia. bmj 1992; 305: 1326-9. 22. doug brugge, john l durant, christine rioux.nearhighway pollutants in motor vehicle exhaust: a review of epidemiologic evidence of cardiac and pulmonary health risks, environmental health 2007, 6:23. 23. mcconnell r, berhane k, yao l, jerrett m, lurmann f, gilliland f, kunzli n, gauderman j, avol e, thomas d, peters j: traffic susceptibility, and childhood asthma. environmental health perspectives 2006, 114:766-772. oa 2_examining the effect_sinku kumar singh.indd original articleijosh, volume 7, no, 2, 2017 (issn 2091 – 0878) 17international journal of occupational safety and health (ijosh) doi: https://doi.org/10.3126/ijosh.v7i2.22891 corresponding author dr. sinku kumar singh, head, department of educational sciences, srtm university nanded (ms), india e-mail: drsinkusingh@gmail.com © 2017 ijosh all rights reserved available online at https://www.nepjol.info/index.php/ijosh international journal of occupational safety and health, vol. 7 no. 2 (2017) 17 – 21 examining the effect of an aerobic exercise program on stress and triglycerides level in sedentary students a pilot study sinku kumar singh1, nadeem afroz2 1department of educational sciences, srtm university nanded (ms), india 2mission hospital, durgapur (wb), india abstract background: stress is a risk factor for developing hypertension and cardiovascular diseases. the increased risk of cardiovascular diseases from chronic stress has been linked to increased plaque build-up as a result of elevated cholesterol, hardening of the arteries, change in the blood pressure, and abnormal working rhythm of the heart. the primary aim of this study was to examine the effects of aerobic exercise on stress and triglycerides. methods: this study is a pre-experimental study one group pre-test post-test design. a group of 17 sedentary male students whose age ranged between 19-28 years was enrolled in the study. the respondents were free of any type of smoking habit, consumptions of alcohol and drugs before the study. the study respondents participated in aerobic exercise training program which was conducted for six weeks, four days a week and 45 minutes in a day. the pre-test and post-test were conducted before and after the intervention. results: the mean age, height and weight of the sedentary students were 24.34 years, 172.31 cm and 69.22 kg respectively. before an aerobic exercise program, 52.94% sedentary students reported mild stress, 29.41 % reported moderate stress and 17.64 % reported severe stress. whereas, after aerobic exercise program, 58.82% sedentary students reported mild stress, 23.52 % reported moderate stress and only 11.64 % reported severe stress. the pre-test mean score of triglycerides was 147.649 mg/dl and the post test was 113.483 mg/dl. conclusion: an aerobic exercise program may reduce stress and triglycerides levels in sedentary students. this research provides a platform for further research in this field with higher power and precision. key words: aerobic, stress, sedentary, triglycerides introduction a sedentary lifestyle is one of the major causes of lifestyle disease around the world. approximately two million deaths every year are attributable to sedentary lifestyle.1 the world health organization (who) study on risk factors and mayo clinic article suggest that sedentary lifestyle is one of the ten leading causes of death and disability in the world.2,3 physical inactivity increases the risk of mortality, doubles the risk of hyper and hypotension, cardiac related diseases, diabetes and obesity.4,5 the sedentary lifestyle is a type of lifestyle with no irregular physical activity. individuals working without any physical activity and they are sitting down all the time and usually, they only get up when its break time, meal time and going to the comfort room. they are always sitting down the whole day while doing their work. the sedentary life style (physical inactivity) is a seriously growing health problem in india.6anepidemiological study has shown that sedentary lifestyle will contribute to the early onset and progression of life style diseases such as cardiovascular disease, hypertension, diabetes and obesity.7stress is a contributing risk factor for developing cardiovascular diseases (cvd). the increased risk of cvd from chronic stress has been linked to increased plaque build-up as a result of elevated cholesterol, hardening of the arteries, change in the blood pressure, and abnormal working rhythm of the heart.8 triglyceride is an ester derived 18 international journal of occupational safety and health (ijosh) singh sk et al. from glycerol and three fatty acids.9 triglyceride is constituents of body fat in human’s bodies and other animals.10 triglycerides are present in the blood to enable the bidirectional transference of adipose fat and blood glucose from the liver.11triglycerides are fat in the blood, and a high triglyceride level can increase the risk of heart related disease. in the human body, high levels of triglycerides in the bloodstream have been linked to atherosclerosis and, by extension, the risk of heart disease(boston scientists) and stroke.12,13 there is a scarcity of research reports on stress and triglycerides of sedentary students and require a very extensive eff ort. the eff ort made by the investigator can prove very useful for reducing stress and triglycerides. methods in this study, the researchers followed the ethical guidelines, principles, and standards for studies conducted with human beings. the study included safeguards for protecting humans, which involve three major ethical principles: benefi cence, respect for human dignity, and human justice. only one group was targeted as an intervention group, there was no control group. the 17 male sedentary students from srtm university participated in the study and their age ranged between 19-28 years. this study is a pre-experimental study one group pre-test post-test design. for assessment of academic stress, the student-life stress inventory (ssi) was used.14 the inventory refl ected students’ life stress experiences, in addition, the blood sample collected from veins to measure triglyceride (a type of lipid) by the technician of sahyog pathology lab vishnupuri nanded. this study involves an experiment of sedentary students on quasi-experimental research design. the data was collected through respondents in the form of diff erent descriptive tests. the demographic information about, age, height, weight, daily smoking etc. was obtained before seeking responses. the national cholesterol education program has set guidelines for triglyceride levels.6 level interpretation (mg/dl) (mmol/l) < 150 < 1.70 normal range – low risk 150–199 1.70–2.25 slightly above normal 200–499 2.26–5.65 some risk 500 or higher > 5.65 very high – high risk these levels are tested after fasting 8 to 12 hours. for this study, the students studying in the academic year 2016-2017 of swami ramanand treeth marathwada university’s (naac ‘a’ grade government university) were selected as the study respondents. the study respondents participated in an aerobic exercise training program which was conducted for six weeks and four days in a week and 30 minutes in a day. before exercise pre-test was done by the departmental fi tness centre. triglycerides (td) were measured in sahyog pathological laboratory. after the pre-test was over, all the selected subject were exposed to six week exercise intervention program followed by post-test done by the departmental fi tness centre. the program consisted of the following exercises; jogging, skipping, front-side-back running, fl oor push-ups, pull-ups, situps, back extension, squat etc. data processing the data was checked for accuracy and completeness and was coded and put up into the statistical package for social sciences descriptive statistics for all studied variables, percentage, mean, standard deviation (sd) and t-test was perform and were considered statistically signifi cant at 0.05 level. results the results concerning this study were presented in the form of tables and suitable fi gures below. table 1: morphological characteristic of sedentary students s.no. morphological characteristics student mean standard deviation age (year) 24.34 3.60 weight (kg) 69.22 4.76 height (cm) 172.31 15.14 the mean age of sedentary student was 24.34+ 3.60, mean weight as 69.22 + 4.76 kg, and the mean height was 172.31 + 15.14 cm. the result revealed that 82.35% sedentary students used internet on regular basis. similarly, 11.76% sedentary students reported that they have smoked / drunk in the past. figure 1. shows the pre and post-test of rate of overall level of stress to sedentary students. result revealed that before an aerobic exercise intervention, 52.94% sedentary students reported mild stress, 29.41% sedentary students reported moderate stress and 17.64% sedentary students reported severe stress. 19international journal of occupational safety and health (ijosh) examining the effect of an aerobic exercise program on stress and triglycerides level in sedentary students a pilot study whereas, after aerobic exercise intervention, 58.82% sedentary students reported mild stress, 23.52% sedentary students reported moderate stress and only 11.64% sedentary students reported severe stress. the pre-test mean score of systolic blood pressure (sbp) was 127.67mmhg and the post test was 122.56 mmhg respectively for sedentary students. furthermore, the pre-test mean score of diastolic blood pressure (dbp) was 83.5 6mmhg and the post test was 81.67 mmhg respectively for sedentary students. the pre-test mean score of triglycerides was 147.649 mg/dl and the post test was 113.483mg/dl obtained respectively of sedentary students. the fi ndings of the study revealed that the mean values and sds of triglycerides decreased following an aerobic exercise intervention in sedentary students. figure 1: rate of overall level of stress of sedentary students 52.94% 29.41% 17.64% 58.82% 23.52% 11.64% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% mild moderate sever rate of overall level of stress of sedentary students pre –test post –test table 2: pre and post-test of blood pressure in sedentary students blood pressure stages no. mean scores standard deviations t-test p value systolic blood pressure pre test 17 127.67 8.60 1.78ns 2.02 post test 17 122.56 7.95 diastolic blood pressure pre test 17 83.56 6.43 1.23ns 2.02 post test 17 81.67 6.12 table 3: pre and post-test of triglycerides in sedentary students components test no. mean std. deviation t-value p value triglycerides pre-test 17 147.649 15.67 6.921* 2.02 post-test 17 113.483 12.34 discussion the fi ndings of the study indicates that though the mild stress level increased, the moderate and severe level stress of sedentary students have decreased after six weeks of an aerobic exercise intervention programme. preliminary evidence suggests that physically active people have lower rates of stress and anxiety. economos, hildebrant and hyatt, (2008), investigated that engaging in more physical activity improves psychosocial health and decreases stress.15 the several research have also shown that physical activity is an eff ective means of reducing anxiety and various indices of stress among adults.16,17 exercise and other physical activity produce endorphins—chemicals in the brain that act as natural painkillers—and also improve the ability to sleep, which in turn reduces stress (anxiety and depression association of america). furthermore, the fi ndings of the study revealed that the mean 20 international journal of occupational safety and health (ijosh) singh sk et al. values and sds of sbp and dbp have decreased, but there were no signifi cant eff ects of aerobic exercise intervention program on sbp and dbp of sedentary students. the fi ndings of the study revealed that aerobic exercises training intervention reduce triglycerides. regular participation in physical activity as well as an exercise can positively alter cholesterol metabolism. exercise is involved in increasing the production and action of several enzymes that function to enhance the reverse cholesterol transport system. exercise has been shown to maintain blood pressure, lower the risk of cardiovascular heart disease and lowers triglycerides.18 most important eff ect of exercise on human body is on metabolic system specially lipids. lipid and lipoprotein are risk factors for coronary heart diseases.18 exercise favourably changes serum lipid lipoprotein-cholesterol concentration. the hormone cortisol is released in response to stress. studies suggest that the high levels of cortisol from long-term stress can increase blood cholesterol, triglycerides, and blood pressure. these are common risk factors for heart diseases. this stress can also cause changes that promote the build-up of plaque deposits in the arteries.18-20 even minor stress can trigger heart problems like poor blood fl ow to the heart muscle. this is a condition in which the heart doesn’t get enough blood or oxygen. and, long-term stress can aff ect how the blood clots. this makes the blood stickier and increases the risk of stroke. an aerobic exercise program may reduce stress and triglycerides levels in sedentary students. this research provides a platform for further research in this fi eld with higher power and precision. limitation of the research results of this study are limited by a relatively small preliminary experimental group rather than a study of actual behaviour, which would be very diffi cult to achieve. a limitation of this study is that it refl ects the fi ndings of one institution; the data was collected in one institution, hence, the results may not be generalized to other institutions. future research is warranted on estimating the level of stress by psychometric instruments and large number of sample. acknowledgments we own unbounded gratitude to ph.d research scholar, dr.sandeip gadadane, dr. rahul sarode, rahul lahane, amol datar and gulnaaz. they spared much of their valuable time and provided all possible help whenever required. we are thankful for the cooperation given by all sedentary students. without their co-operation it was not possible for us to do the research on this sensitive topic. finally thanks to all who helped us directly or indirectly in completion of this work. references 1. bertrais s, beyeme-ondoua j.p, czernichow s, galan p, hercberg s, oppert, jm. sedentary behaviors, physical activity, and metabolic syndrome in middle-aged french subjects. obes. res. 2005, 13(5): 936–44. 2. world health organization (2008).urbanization and health. bulletin of the world health organization. cited on: july 13 2016. available from : https://www. who.int/bulletin/volumes/88/4/10-010410/en/ 3. mayo clinic. (2014). depression and anxiety: exercise eases symptoms. retrieved january 23, 2017. available from http://www.mayoclinic.org/ diseases-conditions/depression/indepth/depressionand-exercise/art-20046495 4. biddle sjh, pearson n, ross gm, braithwaite r. tracking of sedentary behaviours of young people: a systematic review. prev med (baltim) 2010;51:345– 51 5. briddle s.j, o‟connel s, braithwaite r.f. sedentary behaviour interventions in young people-analysis, british journal of sports medicine. 56(11): 2655–67. 6. singh s. k. cardiovascular fi tness among sedentary students, journal of exercise science and physiotherapy. 2012; 8( 2): 90-3. 7. banerjee ak, mandal a, chanda d, chakraborti s. oxidant, antioxidant and physical exercise. mol cell biochem 2003; 253(1:2): 30712. 8. dimsdale, j. e. psychological stress and cardiovascular disease. journal of the american college of cardiology (jacc). 2008;51(13), 1237-46 9. nomenclature of lipids. iupac-iub commission on biochemical nomenclature (cbn). european j. biochem. 2 (1967) 127-1. 10. nelson dl, cox mm. (2000). lehninger, principles of biochemistry (3rd ed.). new york: worth publishing. isbn 1-57259-153-6. 11. lampe, ma, burlingame al, whitney j, williams ml, brown be, roitman e, elias m. human stratum corneum lipids: characterization and regional variations. j. lipid res. 1983; 24 (2): 120– 30. pmid 6833889. 12. carolyn y. johnson. boston scientists say triglycerides play key role in heart health. the 21international journal of occupational safety and health (ijosh) examining the effect of an aerobic exercise program on stress and triglycerides level in sedentary students a pilot study boston globe. june18, 2014. cited on jan 14, 2017. available from : https://www.bostonglobe. com/news/science/2014/06/18/boston-researchersfi nd-that-triglycerides-play-pivotal-role-heart-health/ ynrm4qqwiq1fccorwmfoan/story.html 13. drummond, k. e.; brefere, l. m. (2014). nutrition for foodservice and culinary professionals (8th ed.). john wiley & sons. isbn 978-0-470-05242-6. 14. bernadette m. gadzella, william g. masten. an analysis of the categories in the student-life stress inventory. american journal of psychological research. jan 5, 2005; 1(1): 1-10. 15. economos c, hildebrant l, hyatt, r. college freshman stress and weight change: diff erences by gender. american journal of health behavior. 2008 jan-feb; 32(1)16-25. 16. kawachi i. stress and the heart: psychosocial pathways to coronary heart disease bmj. 2002 jan 19; 324(7330): 176. 17. dunn al, trivedi mh, o’neal ha. physical activity dose-response eff ects on outcomes of depression and anxiety. medicine & science in sports & exercise. 200133(6 suppl.), s587–s597; discussion 609–510. 18. durstine, jl, haskell wl. eff ect of exercise training on plasma lipid and lipoprotenis. exercise sports sci. rev1994; 22: 477-522. 19. krummel d, etherton td, peterson s. eff ects of exercise on plasma lipids and lipoproteins of women. procsoc exp biol med.1993; 204: 123–37. 20. superko rh. exercise training, serum lipids, and lipoprotein particles: is there a change threshold? med sci sports exerc.1991; 23: 667-85. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /none /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /error /compatibilitylevel 1.4 /compressobjects /tags /compresspages true /convertimagestoindexed true /passthroughjpegimages true /createjdffile false /createjobticket false /defaultrenderingintent /default /detectblends true /detectcurves 0.0000 /colorconversionstrategy /cmyk /dothumbnails false /embedallfonts true /embedopentype false /parseiccprofilesincomments true /embedjoboptions true /dscreportinglevel 0 /emitdscwarnings false /endpage -1 /imagememory 1048576 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/leaveuntagged /untaggedrgbhandling /usedocumentprofile /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 available online at http://www.nepjol.info/index.php/ijosh international journal of occupational safety and health, vol 4 no 1 (2014) 38 – 40 introduction mucoceles are defined as mucus-filled cavities that can appear in the oral cavity, appendix, gallbladder, paranasal sinuses or lacrimal sac. it is the result of accumulation of mucous due to the alteration in the minor salivary gland which causes limited swelling. it is seventeenth most common salivary gland lesions seen in the oral cavity [1]. mucocele are characterized by the accumulation of liquid or mucoid material, giving rise to a rounded, well-circumscribed, transparent and bluish-colored lesion of variable size. soft in consistency and fluctuant in response to palpation. these are painless and tend to relapse. mucoceles are usually asymptomatic, though in some patients they can cause discomfort by interfering with speech, chewing or swallowing. however, in most cases these lesions rupture spontaneously or traumatically a few hours after being formed, with the release of a characteristic viscous, mucoid fluid. this may give the mistaken impression of healing, since the lesion decreases in size or disappears. however, once the small perforation allowing release of the mucocele contents has healed, the secretions accumulate again, and the lesion relapses. on the other hand, in the case of repeated trauma, the lesion may become nodular and firm in response to palpation, with rupture in this situation being more difficult [2]. surgical excision of the lesion has been the main treatment option. however, other options have been reported in the literature such as the creation of a pouch (marsupialisation), freezing (cryosurgery), micromarsupialisation and laser vaporization. there are also some reports suggesting the use of corticosteroid injections as an alternative to surgery [3]. case presentation case 1: a 38 year old male patient reported to department of periodontology, rungta college of dental sciences and research, bhilai with chief complaint of swelling in the lower lip since 1 month. history revealed that the lesion began as a small nodular growth in the left commissural region, and gradually continues to grow to the present size. the patient was in a good systemic health and his family history, medical history was non-contributory. the dental history revealed that he had a habit of ghutkha chewing 3-4 packets a day since 20 years. he also reported habit of lip biting during stress. on intraoral examination, a pink colored, solitary swelling measuring about 2 x 2 cm in size was found. on palpation the swelling was soft, fluctuant and non-tender. on the basis of history and clinical presentation, a provisional diagnosis of mucocele was made and an excisional biopsy was planned with laser and the same was explained to the patient and his consent was taken. local anesthesia (2% lignocaine hcl with 1:80,000 adrenaline) was administered taking care not to directly infiltrate the lesion to avoid compromising the biopsy results. then the lesion was marked with the heamatoxlin pencil (fig 1). the lip was then everted with digital pressure to increase the lesion’s prominence. patient and staff used special eye glasses for case report surgical management of mucocele by using diode laser: two case reports abstract: mucoceles are benign, mucus-containing cystic lesions of the minor salivary glands. they are not true cysts since most of them lack an epithelial lining. these lesion occur most commonly in the lower lip. this case report presents two cases of mucocele on the lower and upper lips. this lesion was diagnosed based on history, clinical finding and histopathological examination. the excision of the lesion was planed using diode laser. after re-evaluation of both the patients healing was satisfactory. key words: mucocele; diode laser; mucus extravasation cyst; excision; recurrence. srinivasa t. s., sana farista, parul agrawal, priya jain, sushmita deonani, varsha goswami department of periodontology, rungta college of dental sciences and research, bhilai, chhattisgarh, india. corresponding author: dr. sana farista email: drsanas@yahoo.com © 2014 ijosh all rights reserved. original article / ijosh/ issn 2091-0878 39 protection and all the laser safety protocol was followed prior to and during the laser procedure. a 940 nm diode laser (ezlase, biolase, usa) was used to excise the lesion. a circular incision figure 1. pre-oprative photograph was made around the lesion with the capsule intact along with the thin border of healthy adjacent tissue. the enucleated area was further approximated and low level laser therapy was done (fig 2). then the exciseded tissue (fig 3) was stored in formaline and further sent for histopathological examination. figure 2. excised mass. figure 3. post-operative . a postoperative instruction was given to the patient and was instructed to stop the habit of lip biting. the patient was recalled after 15 days for postoperative checkup (fig 4). patient is under observation and so far there is no evidence of recurrence. figure 4. pre-operative. case 2: a 60 year old male patient visited to the department with a chief complains of swelling in the upper lip since 15 days. history revealed that the lesion began as a small growth at the left commissural region which was gradually growing over the past 15 days. the patient reported that swelling was interfering with the speech and also that he was edentulous since 1 year and wanted the replacement of the same. on clinical examination, the swelling was pink measuring 1 x 1 cm in size (fig.5). on palpation the swelling was soft, fluctuant and non-tender. on the basis of history and clinical presentation, a provisional diagnosis of mucocele was made and an excisional biopsy was planned with lasers and the same was explained to the patient and his consent was taken. the procedure was performed same as case 1. the patient was recalled after 15 days for postoperative checkup. figure 5. pre-operative . the histopathological report revealed normal minor salivary gland tissue and muscle fibres, thin epithelial lining is seen. a large portion of mucinophages with inflammatory cells and extravasted rbc’s was seen. considering the history, clinical feature and histopathological report, a final diagnosis of ‘extravasated mucocele’ was made (6). international journal of occupational safety and health, vol 4. no 1 (2014) 38– 40 srinivasa t. s et al. 2014 references 1. rao prasana, shetty s.r., chatra l, shenai p. oral mucocele – a mini review. dentistry 2: 153. doi:10.4172/2161-1122.1000153. 2. chawlaa kriti, lambab a.k. et al. treatment of lower lip mucocele with er,cr:ysgg laser – a case report. j oral laser applications 2010; 10: 181–185. 3. alves a levy, nicoló di rebeca et al. retention mucocele on the lower lip associated with inadequate use of pacifier. dermatology online journal 2010; 16(7): 9. 4. a.k. rashid, n. anwar, a.m. azizah, k.a. narayan. cases of mucocele treated in the dental department of penang hospital. archives of orofacial sciences (2008); 3(1): 7-10. 5. moraes pde c et al. liquid nitrogen cryosurgery for treatment of mucoceles in children. pediatr dent. 2012; 34 (2): 159-6. 6. reinhard a. neumann,robert m. knobler. treatment of oral mucous cysts with an argon laser. arch dermatol. 1990; 126 (6):829-830. 7. madan nidhi, rathnam arun. excision of mucocele: a surgical case report. biological and biomedical reports 2012; 2(2): 115-18. 8. pedron ig, galletta vc, azevedo lh, correa l. treatment of mucocele of the lower lip with diode laser in pediatric patients: presentation of 2 clinical cases. pediatr dent. 2010; 32(7): 539-41. figure 6. histopathological view discussion the mucocele is a salivary gland lesion of traumatic origin which is formed when the main duct of a minor salivary gland is torn with subsequent extravasation of the mucus into the fibrous connective tissue so that a cyst like cavity is produced and it is filled with mucin. salivary mucoceles are more common in the lower lip though they may develop in other areas such as the floor of the mouth, the cheek, the palate, retromolar fossa and the dorsal surface of the tongue. in our case report the mucoceles developed in the both upper and lower lip [4]. there are various different treatment options, including medication, gamma-linolenic acid, cryosurgery, intralesional corticosteroid injection, micromarsupialization, marsupialization of the mucocele, conventional surgical removal of the lesion [6]. the surgical removal of the lesion sometimes leads to temporary paresthesia, fibrous scar formation & recurrence of the lesion [8]. vaporization with argon and nd: yag lasers has been described for the treatment of mucoceles [7]. both laser procedures presented satisfactory results with low recurrence rates and were well-tolerated by the patients [8]. conclusion lasers apply a great technology and are useful for soft tissue surgery in modern dentistry. in spite of all these advantages of using lasers in soft tissue incisions dental lasers provide an easy and comfortable option of keeping the procedure efficacious as well as minimally invasive. in our cases, there was no bleeding during and after the procedure, no post operative swelling or any discomfort was noted. uneventful healing after laser therapy adds to patient satisfaction. 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 original 1 available online at http://nepjol.info/index.php/ijosh international journal of occupational safety and health, vol 1 (2011) 7 13 original article when the exchange rate makes a difference: noise monitoring of traffic police in the kathmandu valley, nepal william s. carter, 1 rupesh rauniyar 2 1 the university of findlay,findlay, oh 45840, 2 kathmandu university, dhulikel, kavre, nepal abstract: this study demonstrates that when measuring wide swings in noise over short time periods, time weighted average (twa) calculated results may vary significantly depending upon the exchange rate used. the 3 dba exchange rate, the acgih recommended criteria, results in statistically significant higher values than the 5dba exchange rate recommended by osha, when noise levels vary from 70 dba to 120 dba while measurements are taken. a field study of noise levels among the traffic police in the kathmandu valley was conducted in the spring of 2009. sampling was done at 5 high density traffic areas on and inside the ring road (valley perimeter road). to collect sufficient data, hourly integrated personal and area samples were simultaneously taken with a dosimeter to identify hazardous noise areas and work locations that should be included in a hearing conservation program. this study demonstrates the importance of taking several integrated samples over short periods of time when average noise levels vary. this study likewise illustrates that area samples may not accurately reflect personal exposure, particularly when there are large variations in temporal and areal measurements. this study is the first to collect personal noise data associated with traffic noise in nepal. key words: personal noise monitoring, integrated sampling, 3 dba exchange rate, traffic noise, nepal introduction united states and international standards for occupational noise level exposure have differed for several years. the international organization of standards (iso) recommends a threshold limit of 80 dba and exchange rate of 3 dba. the united states occupational safety and health administration (osha) established a threshold limit of 80 dba and exchange rate of 5 dba. the threshold limit is the minimum noise level measured. the exchange rate is the quantity by which the sound level may increase if the exposure time is reduced by one half. this discrepancy results in inconsistency when reporting noise levels. in 1994 the american industrial hygiene association (aiha) and since then others, including prince et.al. (1997), daniel et.al. (2007) and suter (2009), recommended an exchange rate of 3 dba and an 8 hour criterion level of 85 dba. in 1998, the national institute of occupational safety and health (niosh, 1998) recommended that for occupational noise exposure 1.) the exchange rate should be 3 dba rather than 5 dba and 2.) the maximum exposure should be 85 dba for 8 hours, consistent with international standards. these recommendations were based on a review of risk assessments conducted by the iso, the environmental protection agency (epa), and previous niosh data. continuous noise level exposure for 8 hours was the baseline for determining hearing loss. in the 1998 report, niosh encouraged ongoing efforts to develop monitoring strategies applicable to various occupational conditions. a 2001 world health organization (who, 2001) report states “an occupational corresponding author: professor william s. carter email: carter@findlay.edu © 2011 ohssn all rights reserved. original article / ijosh/ issn 2091-0878 8 exposure limit of 85 dba for 8 hours [and at a 3 dba exchange rate] should protect most people against a permanent hearing impairment induced by noise after 40 years of occupational exposure.” yet in 2007 dobie claims there is no evidence preferring a 3 dba exchange rate over the current 5 dba in the osha hearing conservation standard. this paper describes conditions under which the 3 dba exchange rate is preferable and should be employed in such calculations. a worker’s exposure may vary based on his/her activity surrounding activities. further, the worker may not be aware of significant noise variations. the findings in this paper demonstrate that when noise levels repeatedly range above and below the threshold limit, there can be a significant difference in the calculated time weighted average (twa) noise level when using the 3 dba versus the 5 dba exchange rate. traffic noise as an environmental pollutant and workplace hazard has unique characteristics that require specialized approaches to sample and characterize the hazard. in 1990 the iso stated noise produced by motorized transportation can adversely impact the health of both the general public and workers associated with traffic management. joshi et. al. (2003) used surveys to identify the effect of traffic noise on hearing loss in nepal, with particular emphasis on the kathmandu valley in nepal. traffic police are often in close proximity to traffic and therefore are exposed to relatively high levels of noise. motor vehicles were first introduced into the kathmandu valley in 1958. since then the number of motorcycles, automobiles, buses, and trucks has increased rapidly. sprawling urbanization, an inefficient public transportation system, inefficient operation of vehicles, and narrow roads and streets greatly increase the hazard of noise pollution. there are few electrical traffic control devices, so traffic police are deployed to control traffic in busy intersections. kathmandu, located at latitude 27° 40' 0 n and longitude 85° 20' 60 e, is the capital and largest metropolitan area of nepal. the city sits in a valley at an elevation of approximately 1400 meters surrounded by mountains, with two major rivers transecting the city. in 2009 the official population estimate for kathmandu valley was approximately 2,000,000 with a density of 2305 person per square kilometer. migration of rural workers seeking employment often swells the urban population. despite a complex terrain with several traffic restrictions, kathmandu has the most advanced infrastructure among urban areas in nepal. earlier studies by manandhar et. al. (1987) measured area environmental noise levels in some central city areas in the kathmandu valley. khanal and acharya (1994) further documented noise levels in all parts of the city. these studies employed environmental area monitoring and so did not reflect personal exposure of workers. the goal of this study was to investigate the personal exposure of traffic police in the kathmandu valley, and make recommendations regarding noise control to improve worker health and safety. methods to establish criteria for collecting data, we conducted an initial survey at selected traffic locations in kathmandu, using a simpson 886-type 2 sound level meter (slm) with a model 898 octave band filter (simpson electric, lac du flambeau, wi). the a weighting scale with slow response function was employed for frequency measurements. the octave band instrument was calibrated at 10 octave bands within 2 dba of the two point calibration of 94 dba and 114 dba. these measurements demonstrated that most dominant traffic frequencies fall within the 2 khz and 4kz range. we confirmed this by measuring a representative source, a commonly used bajaj avenger motorcycle, observing noise levels of 104 dba at 2 khz and 96 dba at 4 khz at a distance of 3.6 meters and height of 1 meter. to select monitoring sites, we conducted initial evaluations of traffic patterns at several intersections along the ring road, the major road which circles kathmandu, and at center city intersections. with the kathmandu metropolitan traffic police department (kmtpd) we selected five intersections as representative of traffic patterns in the valley. this included three intersections in kathmandu proper, bhotahity, thapathali, and jawalakhel, and two on the ring road, koteshwor and narayan gobal (figure 1). the kmtpd previously had identified peak traffic hours in the kathmandu valley to be from 8:30 to 11:00 am and 3:30 pm to 7:00 pm. at the five selected sites we collected hourly integrated samples between 8:30 am and 6:30 pm. figure 1. map of kathmandu valley with sampling intersections carter, rauniyar / international journal of occupational safety and health, vol 1 (2011) 7 13 integrated q-300 noise dosimeter sampling: the goal of this study was to determine the effect of vehicular noise on working traffic police. we therefore developed an integrated sampling strategy to conduct both (1) time averaged personal samples of traffic police and (2) time averaged area samples, employing a quest model q-300 noise dosimeter (quest technologies, oconomowoc, wi). the dosimeter was checked for accuracy prior to each use with a standard 114 dba calibration source. measurements were taken every minute and the results were integrated hourly. all data was analysed using the quest suite professional computer program (qspcp). three channels of the dosimeter were set as described in table i. table i settings of the quest-300 dosimeter representative of the exposure group, and monitored continuously for up to 8 hours. traffic police roam the intersection to manage traffic movement and are at varying risks for noise exposure since the distance from a source may vary. the data was logged in approximately one hour integrated intervals allowing for both peak hours and off-peak hours measurements. sampling was set on three channels of the dosimeter as described previously. prior to personal monitoring approval was obtained from the nepal health research council and the institutional review board at the university of findlay. area monitoring was conducted at five intersections. the dosimeter was placed on a traffic kiosk in the middle of the crossroads and at various traffic points to determine the range of noise in the intersection. in all cases it was placed at a height of one meter. at the end of each hour the area monitor was moved to a different traffic point. data was logged at each point to obtain a pattern of noise throughout the intersection. results this paper employs the 3 dba exchange rate, recommended by acgih, and the 5 dba, recommended by osha, to calculate the twa noise level exposures of traffic police at five intersections in the kathmandu valley. the results demonstrate that when noise levels vary from below the threshold limit to well above the threshold limit there is a significant difference between the time weighted average (twa) when using these exchange rates. personal monitoring: three intersections for personal monitoring were chosen because of differences in traffic flow and surrounding conditions. table 2 summarizes the results. koteshwor is an open area on the ring road at the junction of three routes where noise reflection is relatively low. average vehicle density was 40 light vehicles and 9.2 heavy vehicles per minute evenly distributed over the day with moderate increase between 2:30 and 6:30 pm. we collected personal noise data for 10 hours, from 8:30 am to 6:30 pm. narayan gopal, also on the ring road, is at a major crossroad of converging roads surrounded by several tall buildings. noise reflection is relatively high. average vehicle density was 72.4 light vehicles and 8.5 heavy vehicles per minute evenly distributed over the day with a decreasing pattern in the evening. typical setups threshold exchange rate criteron weighting response osha noise compliance 90 db 5db 90 db a slow osha hearing conservation 80 db 5 db 90 db a slow acgih criteria 80 db 3 db 85 db a slow at all sites measured, noise levels showed swings from approximately 70 dba to greater than 90 dba in less than 30 seconds. only noise exceeding 90 dba with an exchange rate of 5 dba was collected in the first channel, called oshanc. this allowed us to observe during the data collection period variations in louder noise sources. all noise above a threshold of 80 dba was collected in channels two and three. while some traffic police work more than an 8 hour day, we used projected 8-hour twa calculations. results reported in table 2 compare the acgih twa calculations with an exchange rate of 3 dba to the osha hearing conservation (oshahc) values with an exchange rate of 5 dba. during the monitoring periods we conducted a count of light and heavy vehicles for 5 minutes each hour. light vehicles include motorcycle, van, car, pick-up truck, microbus, tuk-tuk(threewheeled electric passenger vehicle), and tractor. heavy vehicles include bus, truck, construction vehicles, and fire vehicles. personal monitoring was conducted at three intersections. the microphone was clipped to the collar of a traffic police person, original article / ijosh/ issn 2091-0878 10 noise remained above 90 dba over the entire period measured, although it decreased in the afternoon. a review of this data in table 2 shows traffic police working at narayan gopal have significant noise exposure throughout the day. the bhotahity intersection is in the central city, where brick buildings in close proximity to the road reflect noise. frequent horn use, in addition to the average vehicle density, contributes to noise intensity at this intersection. average traffic density was 67 light vehicles and 5.7 heavy vehicles per minute. data shows maximum noise of 98 dba from 9:00 and10:00 am during rush hour traffic and relatively low noise levels in non-rush hours between 11:00 am to 2: 00 pm. personal noise data was collected from 9:15 am to 6:15 pm. figure 2 is representative of a one hour plot of personal noise exposure. the dark gray line reflects the running lavg for the oshahc, the black line reflects the running lavg for the acgih value and the light gray line reflects the oshanc running lavg. the wide swings in the oshanc show the noise level exceeded 90 dba for limited times each hour. noise levels returned to values in the low to middle 70 dba between the short higher traffic chowk intersection sampling time twa acgih (dba) twa osha (dba) % time exceeding 90 dba % time between 80 and 90 dba koteshwor 8:38-9:39 am 82.2 78.3 9:39-10:39 am 83.9 79.4 10:39-11:35 am 97.1 91.7 11:35 am12:35 pm 97.1 90.2 12:35 – 1:38 pm 94.6 86.7 1:382:36 pm 94.0 87.5 2:36-3:25 pm 87.1 80.1 3:36-4:37 pm 97.5 91.0 4:37-5:39 pm 94.6 87.4 5:39-6:36 pm 96.6 87.7 total day (lavg) 94.8 87.4 11 31 narayan gopal 9:23-10:26 am 106.2 102.5 10:26-11:31 am 99.3 95.7 11:31 am – 12:31 pm 97.1 93.1 12:31-1:36 pm 99.1 95.3 1:36-2:41 pm 101.6 98.0 2:41-3:38 pm 97.6 91.7 3:38-4:41 pm 101.8 97.2 4:415:49 pm 102.4 97.8 total day (lavg) 101.7 97.2 35 34 bhotahity 9:12-10:20 am 98.2 91.7 10:20-11:17 am 93.5 89.1 11:17 am-12:17 pm 87.8 79.9 12:17-1:20 pm 83.2 75.8 1:20-2:18 pm 90.9 87.2 2:18-3:26 pm 92.1 88.1 3:26-4:27 pm 94.4 91.3 4:275:28 pm 93.4 90.7 5:28-6:13 pm 91.1 86.3 total day (lavg) 93.3 88.2 17 38 table ii personal monitoring carter, rauniyar / international journal of occupational safety and health, vol 1 (2011) 7 13 figure 2. typical one-hour time plot of personal sampling at koteshwor lavg for oshahc(gray), oshanc(light gray) and acgih (black) figure 3. full day personal sampling at koteshwor lavg for oshahc(gray), oshanc(light gray) and acgih(black) noise periods. proximity to police, resulting in elevated noise exposure. it should be noted the acgih value, employing the 3 dba exchange rate, was consistently 6 to 8 dba higher than the oshahc value, employing the 5 dba exchange rate. figure 3 shows the full day measurements of the personal noise levels taken at koteshwor. we conducted a statistical analysis on the aggregated 52 personal samples employing a t-test. analysis for this data shows a statistically significant 5.27 dba (ci 95% 2.60-7.95) higher noise level when using the 3 dba exchange rate compared to the 5 dba exchange rate. area monitoring we conducted area monitoring at 5 intersections in an attempt to determine whether area samples would usefully enhance representative personal monitoring. in addition to koteshwor, narayan gobal and bhotahity, we sampled at thapatali and jawalakhel in the center of kathmandu. at each intersection we collected multiple noise samples at different points within the intersection. the dosimeter operated in the run mode for 1 hour during the day at each designated point. we collected area noise data in koteshwor at 6 different points in the intersection representative of the traffic pattern. we collected area noise data in narayan gopal at 5 points in the intersection. original article / ijosh/ issn 2091-0878 12 at bhotahity we collected data at 4 points. at thapathali, we collected data at 4 points which included the traffic kiosk. there is significant commercial and truck traffic at this major crossing of the bagmati river. at jawalakhel we collected data at 6 roundabout points along the crossroads and traffic kiosk. considerable commercial and truck traffic pass through this intersection as well. this data is shown in table iii in all we collected 48 area samples and conducted a statistical analysis on the aggregated samples employing a ttest. analysis of this data shows a statistical difference of 6.73 dba (ci 95% 4.02-9.43) higher average value with the 3 dba exchange rate compared to the 5 dba exchange rate. table iii area monitoring personal samples compared to area samples we then compared personal noise data to area noise data collected at the same intersections and times. data in table 2 and table 3 shows the comparison in noise levels. an analysis, employing a standard t-test for each intersection showed the acgih personal measurements varied from 6.8 dba lower to 22.5 dba higher, with an average difference of 11.55 dba (95% ci 9.46 – 13.64). this variation depends upon the positioning of the area monitor relative to the location of the traffic police wearing the personal monitor. the oshahc personal values varied from 2.1 dba lower to 24.3 dba higher during these same time comparisons, with an average difference of 13.10 dba (95% ci 11.01-15.19). this data demonstrates the importance of collecting personal samples in order to accurately measure personal exposure. traffic chowk intersection intersection point sampling time (approximate times) twa acgih (dba) twa osha (dba) koteshwor traffic kiosk 8:30-9:30 am 86.2 78.2 cross road 9:30-10:30 am 90.7 82.0 10:30-11:30 am 86.0 81.9 11:30am – 12:30pm 82.5 78.2 12:30-1:30 pm 80.4 74.6 bus stop 1:30-2:30 pm 84.0 72.8 total day (lavg) 86.3 79.0 narayan gopal traffic kiosk 9:30-10:30 am 83.7 78.2 cross road 10:30-11:30 am 84.2 78.2 11:30am-12:30pm 86.3 79.9 1:30-2:30 pm 81.3 76.5 2:30-3:30 pm 77.7 71.2 total day (lavg) 83.6 77.1 botahity cross road 11:00am-12:00pm 79.2 70.2 12:00-1:00 pm 81.0 75.8 1:00-2:00 pm 78.5 72.2 3:004:00pm 94.6 81.2 total day (lavg) 88.8 76.0 thapathali cross road 9:30-10:30 am 85.7 80.7 10:30-11:30 am 82.5 76.6 11:30 am-12:30 pm 77.5 70.4 2:30-3:30 pm 80.8 75.2 total day (lavg) 82.6 76.5 jawalakhel traffic kiosk 9:00-10:00 am 81.4 75.2 cross road 10:00-11:00 am 93.0 87.2 11:00 am-12:00pm 96.3 88.8 1:00-2:00 pm 82.2 76.0 2:00 – 3:00 pm 80.1 74.3 3:00-4:00 pm 81.5 74.3 total day (lavg) 90.6 82.3 carter, rauniyar / international journal of occupational safety and health, vol 1 (2011) 7 13 conclusion the average personal noise levels measured in this study ranged from 70 to 120 dba. when using the 3 dba exchange rate personal sampling noise levels at each intersection ranged between 80-109 dba for the following percentage of time: in koteshwor 42% of the time, bhotahity 55% of the time, and narayan gopal for 69% of the time. traffic police are exposed to these sound levels for most of their duty hours. therefore a hearing protection program has been recommended for all traffic police. where personal and area sampling were conducted simultaneously, the personal samples gave higher values than area samples. based on these investigations, two sites where area sampling only was conducted merit additional investigation with personal monitoring. recommendations the kmtpd study demonstrates that the current osha standard of 5 dba does not adquately protect workers against noise levels in the 85 to 90 dba range, particularly when there is frequent and rapid variation in noise levels. under cirumstances where there is varying noise level it is important to employ an exchange rate of 3 dba to obtain accurate time average noise levels. these conditions exist in many workplace environments. the american industrial hygiene association (aiha) has encouraged osha to lower the exchange rate to 3 dba and the criterion level to 85 dba from the current standard. this data demonstrates the more prudent approach is to use the 3 dba exchange rate when evaluating personal exposure. consideration should be given to employing the 3 dba exchange rate for all twa measurements and the 85 dba criterion level for all hearing conservation programs. additional studies concerning noise induced permanent threshold shift calculations should be conducted using data employing the 3 dba exchange rate. area sampling alone cannot properly represent potential noise exposure. as observed in this study, the discrepancy between area samples and personal samples is likely to be more prevalent where there are wide fluctuations in the noise levels. thus personal sampling is essential to comply with monitoring requirements and accurately determine when persons may be exposed to intermittent noise levels above 85 dba twa. likewise when noise levels vary widely over relatively short period of time and distance, integrated sampling is recommended to accurately determine potential exposure. acknowledgements this project was supported by the fulbright united states scholar program award #8507. the nepal health research council and the university of findlay institutional review boards approved this study. the cooperation of the kathmandu municipal traffic police department and dr. sanjay nath khanal, from kathmandu university, made this study possible. reference 1. daniell, w. e., s. s. swan, m. m. mcdaniel, j. e. cohen, and j. g. stebbins, “noise exposure and hearing loss prevention programmes after 20 years of regulations in the united states”, occupational and environmental medicine, 2006;63:343-351. 2. dobie, robert a., “noise-induced permanent threshold shifts in the occupational noise and hearing survey: an explanation for elevated risk estimates,” ear & hearing, 2007, vol. 28, no. 4, pages 580-591. 3. international organization for standardization (iso), “acoustics: determination of occupational noise exposure and estimation of noise-induced hearing impairment”, iso1999, geneva, 1990. 4. joshi, s.k., devkota, s., chamling, s., shrestha s., “environmental noise induced hearing loss in nepal”, kathmandu university medical journal (2003) vol. 1, no. 3, 177183. 5. khanal, g.k, acharya, a., “noise pollution in kathmandu valley”, a report submitted to youth in environment, nepal in technical co-operation with landesdund fur vogelschutz lbv, munich, germany, 1994 6. manandhar, m.s., ranjitkar, n.g., pradhan, p.k. and khanal, n.r.; “study on health hazard in kathmandu city”, report submitted to national committee for man and the biosphere, kathmandu, 1987 7. national institute of occupational safety and health (niosh), “criteria for a recommended standard: occupational noise exposure” publication no. 98-126, washington 1998. 8. occupational safety and health agency (osha), “what constitutes an effective hearing conservation program?” available from www.osha.gov/dts/osta/otm/noise/hcp/index.html, june 2010. 9. prince, mary m., leslie t. stayner, randall j. smith, and stephen j. gilbert, “a re-examination of risk estimates from the niosh occupational noise and hearing survey (onhs),” education and information division, national institute for occupational safety and health, the journal of the acoustical society of america, volume 101, issue 2, february 1997, pages 950-963. 10.suter, a “the hearing conservation amendment: 25 years after”, noise & health, jan-march 2009, vol. 11, pages 2-7. 11.world health organization, occupational and community noise, information fact sheet no. 258, 2001, available from apps.who.int/inf-fs/en/fact258.html 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 original 3 available online at http://nepjol.info/index.php/ijosh international journal of occupational safety and health, vol 1 (2011) original article occupational safety and health studies in nepal joshi sk 1 , shrestha s 2 , vaidya s 3 1 department of community medicine, kathmandu medical college, sinamangal, 2 medical officer, bhimphedi primary health center, makwanpur, 3 member, international commision on occupational health, nepal (icoh) abstract: occupational safety and health are key issues today, with growing industrialization and labor market. to introduce and maintain a high standard of safety and health at workplace, it is essential to have an overall picture of the present workplace scenario, different hazards and probable health effects. this is a review of all previously published articles on occupational safety and health in nepal. key words such as nepal, occupation, safety, and health were used to search for relevant articles in pubmed and google scholar. a total of 15 research articles were found, which dealt with different forms of work, like agriculture, health services, child labor, small scale household industries, brick kilns, and textile factories. the overall status of occupational safety and health does not look satisfactory. standard work situations and criteria have to be set up and regular monitoring should be done to ensure the maintenance of quality at work. key words: environment, exposure, hazards, labor, work place introduction occupational safety and health is the science of anticipation, recognition, evaluation and control of hazards arising in or from the workplace, which could impair the health and well-being of workers, and also impact the surrounding communities and the environment [1]. according to nepal labor force survey, 2008, the total number of currently employed persons increased from 9463 thousand in 1998/99 to 11779 thousand in 2008. likewise, the proportion of paid employees increased slightly from 16.0 percent in 1998/99 to 16.9 percent in 2008. moreover based on the classification of industry, 73.9 percent of people are working in the agricultural sector and 26.1 percent in non-agriculture. among the employed persons, nearly 68 percent worked 40 hours and more, 20 percent 20-39 hours, 11 percent 1-19 hours and an insignificant proportion reported that they did not work in the reference week in 2007/8. with such background, it is immensely important that workers have a healthy and safe environment at work, which should be of certain standards [2]. since 1919, the international labor organization has maintained and developed a system of international labor standards aimed at promoting opportunities for women and men to obtain decent and productive work, in conditions of freedom, equity, security and dignity. in today's globalized economy, international labor standards are essential components in the international framework for ensuring that the growth of the global economy provides benefits to all [3]. although occupational safety and health is a very important issue at an individual, social and national level, it has not received much attention so far in nepal. this is evidenced by the very limited literature available on the status of occupational safety and health in nepal. thus, this study is carried out to get a general outline of the status of occupational health and safety in nepal. corresponding author: sunil kumar joshi email: drsunilkj@gmail.com © 2011 ohssn all rights reserved. original article / ijosh/ issn 2091-0878 20 methods this is a review which summarizes all the original research articles on occupational safety and health in nepal, previously published in national and international scientific journals. pubmed and google scholar were used to search for relevant articles using the terms “nepal, occupation, safety, and health”. the main purpose of the review was to have an overall picture of occupational health and safety in nepal. this review included only original research articles, other articles such as reviews, editorial, comments, letters were excluded. the initial search gave 35 articles. five were reviews, two editorials, and two letters to the editor, and accordingly excluded. the remaining articles were screened for relevancy based on title and abstracts, which narrowed down the search to 12 articles. to ensure that no relevant article was missed, the reference lists of those 12 articles were scrutinized. this added three more relevant articles. thus, this review finally includes 15 original research articles on occupational safety and health in nepal published during the time period 2003 2011. the study was conducted in the month of april, 2011. results the 15 articles focus on workplace standards, different hazards present and their probable effects on health. table i list of articles included in the review atreya’s work mainly focused on safety measures and hazards of pesticides used in agriculture and their effect on human health. in one of his studies, he surveyed 291 households using insecticides in a rural area in nepal every week for seven months. he then correlated the act of spraying pesticides with acute health symptoms developed among the people who sprayed the pesticide. he noted that exposure to pesticides was clearly associated with problems like headache, muscle twitching/pain, chapped hands, excessive sweating, eye irritation, skin irritation/burn, weakness, respiratory depression, chest pain and throat discomfort. likewise, pesticide users adopted few protective measures while spraying, limited largely to wearing longsleeved shirts (68% of the application episodes) and long pants (58%). spraying was undertaken without any protection 15% of the time. when an individual applied pesticides on agricultural farms, the predicted probability of acute illnesses was 0.41 compared to 0.18 for exposure to the local environment among nonusers. the study also found that for the sample population, the average annual treatment costs and productivity losses from pesticide exposure were nepalese rupees (nrs) 172.54 for users and nrs 105.34 for nonusers for similar illnesses. the annual average cost of avertive actions for users was nrs 175. the average cost of exposure was estimated to be nrs 162.34 for a pesticide user and nrs 18.62 for a non user. atreya carried out another study in panchkhal and deubhumi baluwa village development committees of kavreplanchowk sn author year title 1. atreya k 4 2008 health costs from short-term exposure to pesticides in nepal 2. atreya k 5 2005 health costs of pesticide use in a vegetable growing area, central mid-hills, nepal 3. atreya k 6 2008 probabilistic assessment of acute health symptoms related to pesticide use under intensified nepalese agriculture 4. atreya k 7 2007 pesticide use knowledge and practices: a gender differences in nepal 5. joshi sk 8 2008 occupational health in small scale and household industries in nepal: a situation analysis 6. joshi sk 9 2003 possible occupational lung cancer in nepal 7. shrestha bp 10 2008 work related complaints among dentists 8. gurubacharya dl 11 2003 knowledge, attitude and practices among health care workers on needle-stick injuries 9. shrestha sk 12 2006 study of hepatitis b among different categories of health care workers. 10. pradhan a 13 2003 backache prevalence among groups with long and normal working day 11. joshi s 14 2011 health problems of nepalese migrants working in three gulf countries 12. pun k 15 occupational safety and health situation in industrial sector in nepal 13. murthy vk 16 occupational health and safety study (ohss) of brick industry in the kathmandu valley 14. paudyal p 17 2011 exposure to dust and endotoxin in textile processing workers 15. joshi et al 18 2009 child labour in nepal and associated hazards: a descriptive study joshi sk et al./ international journal of occupational safety and health, vol 1 (2011) 19 –26 district in the central hills of nepal. he interviewed 443 households using pesticide and 126 households not using pesticides as control. individuals were scheduled for weekly interviews. data was collected during 2005 by two methods: one-time and multiple visits. data on pesticide dose and exposure, appearance of acute symptoms, and use of safety gear were collected through multiple visits at one-week intervals over seven months. it was found that individuals were unwilling to wear personal protective equipments during the spraying of pesticides to reduce health hazards. the average magnitudes of insecticide and fungicide exposure to individuals (including ‘zero’ values of control events) were 0.22 ml/l and 2.37 g/l per hour, respectively. atreya also looked into the difference among male and female on the knowledge and practice of pesticide use. he interviewed a total of 325 males and 109 females during 2005 to assess gender differences on knowledge, attitude and practices of pesticide use. he found less than 8% individuals were trained for integrated pest management. none of the males and females smoked, drank and ate while spraying pesticides and all believed that table ii different industries and people working there pesticides were harmful to human health, livestock, plants and their environment. however, there were gender differences on knowledge on the effect of wind direction during spraying (p = 0.032), prior knowledge on safety measures (p = 0.016), reading and understanding of pesticides labels (p = 0.001), awareness of the labels (p = 0.001) and protective covers. almost all respondents were aware of negative impacts of pesticide use on human health and environment irrespective of gender; however, females were at higher risk due to lower level of pesticide safety awareness. in a different set up, joshi et al [8] conducted a cross sectional study in ten small scale industries of kathmandu valley; the industries were randomly selected from the list of the industries prepared by the researchers during a preliminary survey. there were 545 respondents, they were personally interviewed. among the workers, there were 135 children less than 16 years of age. a qualified physician conducted their physical examination and occupational health risk assessment using an assessment form developed by harrington jm et al [19]. the industries included: sn industry number of adult workers number of child workers 1. metal industry 30 10 2. paint (coating) industry 25 0 3. tent industry 60 0 4. drinking water bottling plant 48 0 5. brick kiln 78 35 6. stone crusher plant 67 25 7. construction industry 47 15 8. embroidery industry 32 18 9. instant noodle industry 72 0 10. carpet industry 86 32 total 545 135 original article / ijosh/ issn 2091-0878 22 majority of the workers were illiterate and earned less than nrs. 5000 a month. children were screened for health problems. except for lower respiratory tract infection, the prevalence of all selected diseases was found to be high. those selected conditions included ear problem (53%), upper respiratory tract infection (38.5%), musculoskeletal problem (33.3%), eye problem (33.3%), abdominal problem (31.1%) and skin problem (26%). in a similar set up,[13] pradhan a conducted a cross sectional study among 64 households from a ward in kirtipur to look at the prevalence of backaches among workers due to normal and long work hours. for the comparison, the working day of up to seven hours per day was defined as normal working day whereas more than seven hour was defined as long working day for the study. the study included participants from different kind of jobs like agriculture, factory work, cap/shawl/textile/carpet weaving, carpentry, catering, daily wage based work, electrician, shopkeeping, mechanic, service, student and rest with no specified job. sixty out of 64 were involved in agriculture. the study revealed that 25(75.8%) of respondents who work long hours experienced backache compared to 15(48.4%) who work normal hours. in another cross-sectional survey, joshi et al evaluated the health problems of nepalese migrants during their stay abroad. using a convenience sampling, participants who had just returned from gulf countries and migrants who were about to go to those countries after a vacation in nepal were recruited at the airport. the inclusion criteria for the study were: adult people who had work experience of at least six months in one of the three gulf countries (qatar, saudi arabia and united arab emirates), who were in nepal at the time of recruitment and who had returned to nepal within the last 12 months (on their annual leave or for any other reason). the total number of participants surveyed was 408. out of the respondents only 31 (7.6%) were female. the mean age of the respondents was 32±6.5 years. more than half of respondents, 224 (54.9%), were involved in various types of construction work such as laborer, scaffolder, general helpers and others. this survey found that more than half, 231 (56.6%), of the respondents suffered from some type of health problem during their last 12 months of stay abroad. among the 231 respondents who experienced a health problem, 71(30.7%) had fever or headache, 49 (21.2%) had respiratory symptoms, 46 (19.9%) had musculoskeletal problems, 45(19.5%) had gastrointestinal illness, and 32 (13.9%) had injuries/poisoning. a quarter of the total respondents, 102 (25.0%), reported experiencing some type of injury or accident at their workplace during their last job. different types of cuts, 41 (40.2%), and fractures or dislocations, 21 (20.6%), were the most common type of injuries. temperature related illness (17.6%) (such as heat stroke) and other accidents and falls (11.8%) were also common. the survey also found that only one third of the respondents, 149 (36.5%), were insured for health services in the countries where they were working. likewise, in a case control study, joshi et al [9] assessed the relation of lung cancer with possible occupational exposure. the study subjects consisted of all cases of lung cancer and the control group of all cases of colon cancer that attended bhaktapur cancer hospital from july to october 2001. using a structured questionnaire, they obtained information about their education, father’s occupation, family history of cancer, present and past medical history, diet pattern, smoking habit, history of alcohol intake, present and past heating and cooking system at home, intake of any carcinogenic drug, past and present occupational history. questionnaire about the occupation included information like location of different work places, duration of work in those occupations, types of industries and job duties. exposure prone occupations like agriculture, construction of buildings, construction of roads and bridges, manufacturing, and transport were categorized as exposed occupations. a detailed smoking history was also obtained for all subjects who had ever smoked regularly for more than six months. there were 85 cases of lung cancer and 40 cases of colon cancer. mean age for the lung cancer and colon cancer cases differed significantly between the groups, 59 and 42 years, respectively. 42.4% of the lung cancer cases and 20% of the colon cancer cases had consumed alcohol in the past. mean smoking pack year for the cases and controls were 19 and 3.1, respectively. variables like sex, diet, father’s history of occupation, family history of cancer, history of carcinogenic drugs, heating and cooking habit were not significantly different between the cases and the controls. among the cases 23 subjects had worked in non-exposed and 62 in exposed occupations whereas among the controls 27 subjects had worked in non-exposed and 13 in exposed occupations. the crude odds ratio (or) for the exposed workers was 5.59 (95% ci: 2.47-12.6). after adjustment for smoking habit alone and for smoking habit, alcohol habit, smoking pack year, education and age altogether the or was 4.8 (95% ci: 2.02-11.4) and 4.2 (95% ci: 1.4-12), respectively. likewise, three studies were found which assessed the work situations and health among health workers. joshi sk et al./ international journal of occupational safety and health, vol 1 (2011) 19 –26 shrestha et al conducted a cross-sectional study among 68 dental surgeons to assess the possible work related health problems. there were 39(57%) male surgeons with mean age 29.5, and 29(43%) female with mean age 24.9. the major problems were neck pain among 40 of them, shoulder pain among 32 and back pain among 54. fifty dentists (73.5%) thought they practiced the right posture and 18 (26.5%) thought they did not. fifty (73.5%) felt that their musculoskeletal complaints were significantly contributed to by their dental work. likewise, total number of days with shoulder pain was 0.71±0.84, back pain was 2.09±1.57, and neck pain was 1±1.18. meanwhile, total number of work days lost due to back pain was 0.64±1.73 days. in another study, gurubacharya et al evaluated the working situation in a tertiary health center by assessing the knowledge, attitude and practice of 70 nurses and paramedical staffs from different departments of that center. data collection was carried out using a standardized questionnaire. it was found that 54(77%) of the respondents didn't know their anti hbs, hiv, hbc status. 28 (40%) didn't have hbsag vaccination ever and 36(86%) didn't check anti hbs antibodies after hb vaccination. needle stick injury was reported in 54(74%), with a frequency of 1-2 per year among 27(52%), 3-4 among 12 (23%) and 5-6 among 13(25%). when inquired about the practice of using gloves during phlebotomy procedures, 43(63%) answered that they use gloves occasionally, while 11(16%) reported they never used gloves. twenty four (34%) of the respondents had no idea of universal precaution guidelines. likewise, none of the respondents knew about needleless safety devices. in one more study in hospital setting, shrestha et al estimated the frequency of hepatitis b virus (hbv) infection among different categories of health care workers. the cross-sectional study was conducted in a tertiary health center and included a total of 145 health workers. blood samples were tested for hbv surface antigen (hbsag), surface antibody (anti-hbs) and core antibody (anti -hbc). anti-hbc was positive in 14.5% and hbsag in 1.4% of health workers. little less than twenty one percent (20.9%) of non-professional staff, 19.2% of nurses, 5.6% of laboratory workers and 3.1% of doctors had evidence of past or present hbv infection. around fifty percent of health workers, with only 16.7% of laboratory workers and 27.9% of non-professional staff, had received a full course of hbv vaccination. the significant risk factors associated with past or present hbv infection were lack of hepatitis b vaccination (p<0.05) and being a nurse (p<0.05) and non-professional staff, who clean the used instruments (p<0.05). in a descriptive study, pun k collected relevant data from 10 labor offices under the ministry of labor and transportation management, which keep records pertaining to the occupational safety and health conditions in industrial establishments of nepal for the past 10 years. it was reported that nearly 12 million workers were engaged in employment in nepal. based on the classification of industry 73.9% were engaged in agriculture sector and only 26.1% were engaged in non-agriculture sector. it is estimated that each year approximately 20000 workers meet accidents at workplace which lead to about 200 lives lost in nepal. the major causes of occupational hazards found in different work sectors were: 1. unsafe working conditions 2. lack of supervision and training 3. use of old machinery and equipment 4. lack of sufficient maintenance 5. bad house-keeping practices 6. violation of safety rules 7. overcrowded production units with very congested space some work activities were noted to have high risks; 1. working with machine and equipment 2. use of electricity 3. building and construction works 4. use of chemicals in industries 5. dusty worksites the number of work places and the frequency of their inspections have been listed as: original article / ijosh/ issn 2091-0878 24 years 2001/ 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09 number of establishments 3617 3630 3473 3514 3425 3578 n/a 3599 number of workers 359373 307536 306430 310900 310145 311069 n/a 313190 number of inspections made 1581 1515 1131 992 699 959 n/a 1138 years 2001/ 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09 number of establishments 3617 3630 3473 3514 3425 3578 n/a 3599 number of workers 359373 307536 306430 310900 310145 311069 n/a 313190 number of accidents 46 36 39 38 33 50 n/a 68 fatal 6 6 6 10 6 13 n/a 13 serious 23 16 17 12 12 18 n/a 12 minor 17 14 16 16 15 19 n/a 43 table iii labor inspection records table iv trends of industrial injuries brick kilns are considered one of the most hazardous workplace. murthy et al conducted an observational study in factories following fixed chimney bull trench kiln (fcbtk) and vertical shaft brick kiln (vsbk) brick manufacturing technologies. total four factories were studied, two from each type of technology. the study was carried out in four different spells during a period of one year and it included surveillance of the working environment and of workers’ health. the work environment air monitoring to quantitatively assess the dust, gas and heat pollution was carried out by standard procedures using calibrated and sensitive monitoring equipments. simultaneous health examination of listed workers in each factory by qualified medical professionals on four occasions was also performed. the occupational safety aspect was evaluated by observation and assessment of existing safety practices in place. the dust and heat pollution was found to be higher at fcbtk brick technology compared to vsbk brick making technology. likewise, sulfur dioxide (so2) gas monitoring indicated that vsbk factories were associated with higher so2 levels; the average levels were within prescribed threshold limit value. the thermal stress (radiant heat) prevalent in fcbtk fireplaces was higher compared to the fireplace work at vsbk technology. the difference was statistically significant suggesting that fcbtk brick making technology exerted a higher thermal stress on the firemasters. the study also indicated that the proportion of workers complaining about health problems were higher in fcbtk. among workers with health problems, gastrointestinal tract, skin related illnesses, respiratory complaints and genitourinary tract problems were more prevalent for fcbtk workers than for vsbk workers. detailed blood pressure measurment indicated that the fcbtk technology induced higher blood pressure. the environmental monitoring data also definitively suggested prevalence of heat stress at fcbtk factories compared to vsbk factories. the study findings suggested the workers at vsbk factories were better organized; they were involved in work under roof and had a factory-like environment. in another study to evaluate the exposure to dust and endotoxin, paudyal et al conducted an cross sectional study in four sectors of textile industry in kathmandu, including garment making, carpet making, weaving and recycling. personal exposure to inhalable dust and airborne endotoxin was measured during a full-shift for 114 workers. personal exposure to cotton dust was generally low (geometric mean 0.81 mg/m 3 ) compared to the uk workplace exposure limit (2.5 mg/m 3 ) but nearly 18% (n = 20) of the workers sampled exceeded the limit. exposures were lowest in the weaving and the garment sector (gm = 0.30 mg/m 3 ), higher in the carpet sector (gm = 1.16 mg/m 3 ), and highest in the recycling sector (gm = 3.36 mg/m 3 ). endotoxin exposures were high with the overall data (gm = 2160 eu/m 3 ) being more than 20fold higher than the dutch health-based guidance value of 90 eu/m 3 . the highest exposures were in the recycling sector (gm = 5110 eu/m 3 ) and the weaving sector (gm = 2440 eu/m 3 ) with lower levels in the garment sector (gm = 157 eu/m 3 ). joshi sk et al./ international journal of occupational safety and health, vol 1 (2011) 19 –26 the highest endotoxin concentrations expressed as endotoxin units per milligram inhalable dust were found in the weaving sector (gm = 165 eu/mg). there was a statistically significant correlation between inhalable dust concentrations and endotoxin concentrations (r = 0.37; p < 0.001) and this was particularly strong in the garment (r = 0.82; p = 0.004) and the carpet sector (r = 0.81; p < 0.001). among all forms of labor, child labor is one of the most exploited forms. joshi et al conducted a qualitative observational study in 19 different work sectors, which employed child laborers below 16 years of age. after inspections of the workplaces, they listed different hazards they found in the workplace, which could severely affect the health of the child workers. 1. lack of hygiene in the workplace 2. airborne contaminants 3. chemicals at the workplace 4. noise and illumination of the workplace 5. work load (long work hours, heavy load or both) 6. work posture (sitting, standing, crowded work/machinery, etc.) 7. tools and equipment (sharp, hammering, power-driven) discussion this is a review of all the previously published articles on status of occupational safety and health in nepal. as it was found, there were very few researches pertaining to the area. even the few researches found were diverse in their field coverage, so, a cumulative analysis was not possible. poudel kc et al also stressed the lack of researches in this field [20]. there were four studies that dealt with use of pesticide and its effect in terms of health and cost. all the four studies were carried out by the same person. the results carry great significance because in nepal, 73.9 percent of the employed people work in the agriculture, which is a huge number [2]. so, anything related to agriculture have big implications and as atreya found out, farmers are less careful about the exposure to pesticide, which have led to different health conditions. so, people should be made aware about the safe and proper use of pesticide. specially, women should be educated more as atreya found a lower level of knowledge about pesticides among women than men. joshi et al [8] and pradhan a’s [13] works also highlighted different health problems among workers in small scale industries like carpet factories, construction works, etc, which are more manual. usually, people with low level of education are engaged in such works as they don’t demand much of technical skills. these workers have the least knowledge about occupational safety measures and health effects, while at the same time, they have to work in some of the most hazardous environments. so, they are disadvantaged from both the ends and thus, suffer the most. about the major health issues among laborers, joshi et al,[8] pradhan a,[13] joshi et al [14] had similar results, which include musculoskeletal problems, respiratory tract infections and abdominal problems. such problems are to be expected considering the hard and manual job they have to do and lack of hygiene at the work place, which was also pointed out in another study by joshi et al.[18] although that was a study about child workers, it provided general information on working conditions in different work sectors, similar to those in the studies of joshi et al,[8] pradhan a,[13] and joshi et al.[14] specifically, murthy et al[16] provided a picture of working condition in brick kilns where higher so2 levels and thermal stress were found. he also argued for better working condition and upgrading the technologies, which is a good way of controlling the hazards and minimizing the health effects. likewise, in the hospital based case control study, joshi et al convincingly pointed to the relation of occupational exposure to lung cancer. exposure prone occupations like agriculture, construction of buildings, construction of roads and bridges, manufacturing, and transport were categorized as exposed occupations.[9] the odds for lung cancer in those occupations was high also after adjusting for smoking habits. thus, workers at such places should be made aware about the risks and be taught about proper safety and precaution measures. many studies focused on manual and highly physical works, but, there were some which studied work environment among hospital workers. it is definitely surprising, when gurubacharya et al’s results showed that 40% of the participants (nurses and paramedical staffs) didn't have hbsag vaccination ever and 34% of the respondents had no idea of universal precaution guidelines. this was also supported by the findings of shrestha et al, who found that 1.4% of health workers had hbsag, and 20.9% of non -professional staff, 19.2% of nurses, 5.6% of laboratory workers and 3.1% of doctors had evidence of past or present hbv infection. original article / ijosh/ issn 2091-0878 26 hospitals and hospital workers are supposed to be the ones at high risk of transmission of contagious diseases like hepatitis. 40% of the respondents not being vaccinated against hepatits b indicates huge carelessness among the respondents as well as the hospital. the hospital should make it mandatory that their staffs are properly vaccinated and protected against such diseases. as for the severity of injuries and hazards at work places, pun k pointed out that approximately 20000 workers meet workplace accidents each year which lead to about 200 lives lost in nepal. this is a very high figure which requires serious attention from the relevant authorities, employers, labor unions and the employees themselves. conclusions there are few scientific studies conducted so far in occupational safety and health in nepal. summing up the limited literature available, it is found that the overall status of occupational safety and health in nepal is not satisfactory. most of the work places, especially the ones requiring more physical work and labor, do not possess proper safety and preventive measures, likewise, the workers do not have proper understanding of exposure to hazards and measures to minimize them. thus, in such conditions, there should be immediate and strong interventions at all levels including the government, employers and the employees. references 1.vaidya sn. occupational safety and health situation in nepal. (accessed 12 mar 2011). [online]. available from: http:// www.ttl.fi/en/publications/electronic_publications/ challenges_to_occupational_health_services/documents/ nepal.pdf 2.central bureau of statistics. report on nepal labor force survey, 2008. kathmandu: central bureau of statistics; 2009. 3.ilo. introduction to international labour standards. [online]. 2011 (accessed 20 mar 2011). available from: http://www.ilo.org/ global/standards/introduction-to-international-labour-standards/ lang--en/index.htm 4.atreya k. health costs from short-term exposure to pesticides in nepal. social science & medicine. 2008;67:511–9. 5.atreya k. health costs of pesticide use in a vegetable growing area, central mid-hills, nepal. himalayan journal of sciences. 2005;3(5):81-4. 6.atreya k. probabilistic assessment of acute health symptoms related to pesticide use under intensified nepalese agriculture. international journal of environmental health research. 2008;18(3):187–208. 6.atreya k. pesticide use knowledge and practices: a gender differences in nepal. environmental research. 2007;104:305– 11. 7.joshi sk, dahal p. occupational health in small scale and household industries in nepal: a situation analysis. kathmandu university medical journal. 2008;6(22):152-60. 8.joshi sk, moen be, bratveit m. possible occupational lung cancer in nepal. journal of nepal medical association. 2003;42:1-5. 9.shrestha bp, singh gk, niraula sr. work related complaints among dentists. j nepal med assoc. 2008;47(170):77-81. 10.gurubacharya dl, kc m, karki db. knowledge, attitude and practices among health care workers on needle-stick injuries. kathmandu university medical journal. 2003;1(2):91-4. 11.shrestha sk, bhattarai md. study of hepatitis b among different categories of health care workers. j coll physicians surg pak. 2006;16(2):108-11. 12.pradhan a. backache prevalence among groups with long and normal working day. kathmandu university medical journal. 2003;2(6):119-23. 13.joshi s, simkhada p, prescott gj. health problems of nepalese migrants working in three gulf countries. bmc international health and human rights. 2011;11:3. 14.pun k. occupational safety and health situation in industrial sector in nepal. [online]. 2011 (accessed 12 mar 2011). available from: http://www.scribd.com/doc/50002585/occupationalsafety-and-health-in-industrial-sector-in-nepal 15.murthy vk, khanal sn, giri d. occupational health and safety study (ohss) of brick industry in the kathmandu valley report. dhulikhel, kavre: kathmandu university; 2007. 16.paudyal p, semple s, niven r, tavernier g, ayres jg. exposure to dust and endotoxin in textile processing workers. ann occup hyg. 2011;55(4):403-9. 17.joshi sk, sharma sc, shrestha s. child labour in nepal and associated hazards: a descriptive study. asian-pacific newslett on occup health and safety. 2009;16:66–9. 18.harrington jm, gill fs, aw tc, gardiner k. risk assessment. in: occupational health. 4th ed. blackwell science; 2000. p. 237 -40. 19.poudel kc, jimba m, poudel-tandukar k, wakai s. lack of occupational health research in nepal. american journal of public health. 2005;95(4):550. 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 editorial available online at http://nepjol.info/index.php/ijosh international journal of occupational safety and health, vol. 2 no. 1 (2012) 1 editorial dr. somnath gangopadhyay consultant editor international journal on occupational safety and health (ijosh) the present issue of ijosh contains two review and five original articles in different dimensions of occupational health. these are starting from mental health and passing through green hazards, attitudes to occupational health and safety of vocational tutors, estimation of accidents in construction industry, health status of child laborers and ending to environmental safety during stone crushing in abbottabad. within the 2nd issue of the journal it attracts the global researchers as a responsible media to contribute their valuable observations. the review article of halder and mahato depicts the mental health in the view of continuous occupational stress at work place. less physical work intensive workplaces also may act as stressors to the occupants. dorothea lynde dix ‘s attempt to protect human being to become mentally ill has no use in these days, where work and time act as a conjugated factor for the development of such illness. halder and mahato suggest monitoring regularly the mental condition of the workers and stressing level at work place for their protection against the development of mental illness. another review from jaita mondal portrays the mechanical & physical hazards at domestic kitchen. domestic kitchen are having potential risk factors for accidents. jaita mondal prescribe the domestic kitchen should be follow the ergonomics principal and consider the anthropometric variation to avoid such accidents. sonika achalli, shishir ram shetty and subhas g babu explore in their article the most neglected occupational health hazard: the green tobacco sickness. as it is reported by the national institute of occupational health, ahmedabad that indian tobacco harvesters are highly affected with green tobacco sickness or gts. a global awareness campaign on the green tobacco sickness is urgently required. stavroula bibila presents an original article on the knowledge of and attitudes to occupational health & safety among tutors of a vocational training institute in greece. her objective is to identify the significant predictors of ohs knowledge. she has designated that “hours of ohs training” is the primary and the only predictor of ohs knowledge. her study is based on the analysis of responses in 9 item knowledge scale and 9 item attitude scale. in india, a similar “knowledge and attitude” study [1] was done among garment workers. a wide gap was observed between their knowledge level and attitude towards safety. more ohs training may be improved the safety attitude of workers. article of gholamhossein halvani et al on the estimation of accidents in construction industry use a specific model for the analysis of accidents. the general conference of the international labour organization on 1 june 1999 considered the need for the prohibition and elimination of child labour. but even now in most of the developing countries, a large number of children are directly involved in different hazardous occupations. child labour health should be the prime concerned of these countries. joshi et al compares the health status of nepalese child labourers with same aged school going children of nepal. on the basis of their result, they come in conclusion to give priority in improvement of child labour health. in the last article of this issue, brad muise suggests that youtube may currently be an inadequate source of information on confined space safety. this article conveys that, the safety professionals should verify youtube video content against trusted agencies such as osha before using them as a resource for confined space information. 1. parimalam p, kamalamma n, ganguli ak: knowledge, attitude and practices related to occupational health problems among garment workers in tamil nadu, india. j occup health. 2007, 49(6):528-34. 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 elancheliyan available online at http://nepjol.info/index.php/ijosh international journal of occupational safety and health, vol 3 no 2 (2013) 12 17 introduction noise: "any loud, discordant or disagreeable sound." noise intensity is measured in decibel units [1, 2]. the decibel scale is logarithmic; each 10-decibel increase represents at enfold increase in noise intensity [6]. human perception of loudness also conforms to a logarithmic scale; a 10-decibel increase is perceived as roughly a doubling of loudness. thus, 30 decibels is 10 times more intense than 20 decibels and sounds twice as loud; 40 decibels is 100 times more intense than 20 and sounds 4 times as loud; 80 decibels is 1 million times more intense than 20 and sounds 64 times as loud. noise can cause hearing loss, lack of sleep, irritability, heartburn, indigestion, ulcers, high blood pressure, and possibly heart disease [3, 4]. prolonged or frequent exposure to noise tends to make the physiological disturbances chronic. in addition, noise-induced stress creates severe stresses in daily living and contributes to mental illness. permissible noise exposure levels when the daily noise exposure is composed of two or more periods of noise exposure of different levels [5], their combined effect should be considered, rather than the individual effect of each. the permissible noise exposure levels with time [16] are given in table i. table i permissible noise exposures equivalent noise exposure factor noise levels are expressed in terms of the energy-equivalent continuous noise level, leq, which normalizes the leq to an 8 field report noise effects of generator sets at construction sites abstract: noise and vibration can be the cause of serious disturbance and inconvenience to anyone exposed to them and in certain circumstances noise and vibration can be a serious hazard to health, causing permanent damage to hearing system. noise exposure levels of construction workers are difficult to determine due to the day to-day variation in occupation and shift length of each worker and the itinerant and seasonal nature of the job. nevertheless, it is clear that the construction worker is exposed to very high sound levels for considerable lengths of time. different types and sizes of equipment's, machineries and tools are used by construction industries. diesel generator for power is a very important one among the equipment used in the construction industries, used in large numbers and as clusters and also located very near to the work area. the noise level produced by these generators is much higher than the permissible limit. but the construction work group took very little effort to avoid or minimize this noise level to permissible level. many people even though they may not need electricity for their work got in and exposed in this zone of danger. at this site eight generators have been used by various working groups. this paper assesses the potential noise impacts associated with power generators used in construction activities of the dct project site and the effective steps to control this noise. a 12-hour noise survey was conducted to establish background noise levels in the project area. key words: construction workers; noise; power generators; dct. sellappan elancheliyan hse manager, eversendai engineering qatar wll, p.o.box:35283. street no.41 new industrial area, doha qatar. corresponding author: er. sellappan elancheliyan email: elankani@gmail.com © 2013 ijosh all rights reserved. doi: http://dx.doi.org/10.3126/ijosh.v3i2.6145 sound level (dba) permitted duration per workday (hrs) sound level (dba) permitted duration per workday (hrs) sound level (dba) permitted duration per workday (hrs) 90 8.00 99 2.30 108 0.66 91 6.96 100 2.00 109 0.56 92 6.06 101 1.73 110 0.50 93 5.28 102 1.52 111 0.43 94 4.60 103 1.32 112 0.38 95 4.00 104 1.15 113 0.33 96 3.48 105 1.00 114 0.28 97 3.03 106 0.86 115 0.25 98 2.63 107 0.76 116 0.21 original article / ijosh/ issn 2091-0878 13 hour day. this could only be accomplished given a worker’s pattern of exposure to noise; workers switch to different jobs/ tools/sites, and their shift length is variable and seasonal. exposure to different levels for various periods of time shall be computed according to the formula [16]. leq = (t1 / l1) + (t2 / l2) + ............ + (tn / ln) where: leq = the equivalent noise exposure factor. t = the actual time of noise exposure by person at a constant noise level. l = the duration of the permissible noise exposure at the constant level (from table i). if the value of leq exceeds unity (1) the exposure exceeds permissible levels. noise exposure levels (daily leq) by construction activity the dct project construction will occur over a period of approximately 27 months. in various stages of construction we found a large variety of hand tools and other machinery contributing to a background level which is usually above 85 dba [7]. table.2 provides a list of trade, activity and equipment's that were used during project construction together with associated noise levels [8, 9, 17]. table ii noise from construction equipment & tools noise from power generators power generators are essential for use on construction sites where electricity is not supplied. power generators are used to power electric equipment, welding machines, for general and task lighting. the workers involved in various works has exposed to various levels of noise by the machinery which they used [10, 18]. apart from the noise by individual tool, the tools need electricity to work. in construction industries all the required electricity is supplied by the power generators, which also producing huge noise, the workers ultimately are exposed to double effect. project site and vicinity the project extends to larger area whereas this study limited to exhibition hall only. the exhibition hall spread over 140 meter length (east to west) and 90 meter breadth (south to north) gives 12600 m2 area. the distance between the mega columns was 90 meters and the distance between two grid lines was 18 meters. ambient noise measurements were made for two generators at locations g1 & g2 as shown in figure.1. this was done to measure the noise effect of individual generator. at the time the noise measurement equipment was set up, the sky was clear, temperatures were in the mid 22 ̊ c, and the wind speed was light and variable. the measurement showed the noise exposure decreased with distance. actually the noise environment fluctuated greatly from hour to hour and location to location, depending on work activity within the exhibition hall. so another measurement was made at six locations during a normal working day over a period of 12 day. hours. similar weather conditions were observed on the day when the measurement was taken down for exhibition hall. the measurement shows that the exhibition hall area is typically noisy throughout a normal working day. study work the usual sound sources of an electrical power generator are fan, bearing and sound radiation from the surface. in an electric generator the magnetic field produces the circumferential forces required for the energy transfer. in addition, the field creates radial forces. these forces interact with stator is in contact with the frame, which also is excited. the vibration of the frame accelerates the surrounding air, which is heard as noise [11]. to avoid excessive noise the designer of the generators needs calculate the vibration and noise levels [14]. in this work the noise emission of an electric generator used for power generation operations were studied. the experimental readings were taken from two standard caterpillar diesel generators, one generator with 365kva, 1500 rpm and 220v output (g1) placed at gl-15, near to mega column in north side and the other with 500kva, 1500 rpm and 220v output (g2) was located at gl-17, south side mega column no.17and placed 105 meter apart between them. plant/equipment noise (leq), dba trade/tools noise (leq), dba dozers, dumpers 89-103 plumber 90 front end loaders 85-91 elevator installer 96 excavators 86-90 rebar worker 95 backhoes 79-89 carpenter 90 scrapers 84-102 concrete form finisher 93 mobile cranes 97-102 steel stud installer 96 manlift 102-104 laborers – shovel hardcore 94 compressors 62-92 laborers – concrete pour 97 pavers 100-102 hoist operator 100 rollers (compactors) 79-93 pneumatic chipper/ chisel 108 bar benders 94-96 compactor 109 pneumatic breakers 94-111 electric drill 102 hydraulic breakers 90-100 air track drill 113 pile drivers (diesel) 82-105 concrete saw 90 international journal of occupational safety and health, vol 3. no 2 (2013) 12 17 elancheliyan 2013 the noise levels from construction activities will vary during the different activity periods, depending upon the activity location and the number and types of equipment being used. another set of readings were taken exactly the center point (i.e. 45 meter from each column) between the two mega columns of a grid line. six points were identified or selected to cover the entire exhibition hall area with one point for every three grids. the study locations were marked in figure.3, the points p1 to p6 covered from gridline 3 to grid line 18(i.e. multiple of three). all construction activities in this area were continued in order to account the cumulative noise effect of other work activities. the readings were taken on 25-02-2012 for every one hour for a period of 12 hours (7 am to 7 pm). the measured values are tabulated in table iv. figure 1. location markings of generators & study points the generators (g1 and g2) were not covered or provided with any acoustic shield; hence the entire noise generated will be transmitted to the environment. the exhibition hall was covered with building structure on north and south, covered with decking sheets and concrete on the roof. this makes the entire area to be considered as enclosed space. the noise generated by generators has to absorb and reflected and nothing will be transmitted, which increase the intensity of noise exposure by employees. all other activities in this area were stopped in order to eliminate the noise effect of other work activities. the noise level was observed on 21-02-2012 in a calibrated standard digital sound level meter with rs232 and noted from various distances. table iii presents the summary of noise levels measured at various distances from the source of noise, i.e. generators. original article / ijosh/ issn 2091-0878 15 table iii noise in dba from generator sets table iv cumulative noise effects during working hours, dba result and discussion based on the noise level observed from the generators, the noise level is higher than the permissible level, at 1.0 m from the generator; the values noted are 103.7 dba and 104.4 dba for g1 and g2 respectively. these values decreases with increase in distance and it reaches the permissible level of 90 dba at 7.0m for g1 and 10.5m for g2 generators. even though the permissible level is 90 dba; hearing damage begins at a much lower level, about 85 decibels. this value is observed at 15m and 16m for g1 and g2 generators respectively. the effect of distance on noise is given in figure.2 figue.2. effect of distance on noise level from generators construction noise would vary throughout the build-out of the project according to specific activities, location, orientation of the activities, and changing equipment operations. to study the noise effects in the exhibition hall during a normal working day, a total of 78 noise measurements were made and data obtained were analyzed. figure.3 presents a summary of graphical analysis of noise data. the overall average of noise level observed was 82.05 dba which exceeds the threshold of 70 dba. the measured noise levels increased with points nearby the generators. the maximum noise exposure noted was 92.5 dba at point p6. as shown in this graph, the majority of inhabited (community) receptor -related noise levels that would be from p4 to p6. for these locations, construction noise would be expected to be clearly audible during most of the daytime hours, depending on the actual, onsite construction activities. these points of perceptibility are not considered significant, however, based on the temporary nature of the construction phases and the intermittent duration of the worst-case activities. other locations p2 and p3, would have construction-related noise levels, but below to any other location. mitigation measures the cumulative noise impacts associated with the project were evaluated. the following mitigation measures will be implemented to reduce noise and ensure that project noise impacts are less than significant. • locate noisy machines away from main areas of activity. otherwise, screen plant from work areas by using noise distance from the welding generator (m) noise level, dba distance from the welding generator (m) noise level, dba generator g1, 360 kva generator g2, 500 kva generator g1, 360 kva generator g2, 500 kva max max 1.0 103.7 104.3 11.0 87.6 89.3 2.0 100.0 101.3 12.0 87.4 88.3 3.0 97.6 99.6 13.0 87.1 87.4 4.0 94.9 95.8 14.0 86.0 86.4 5.0 92.5 94.3 15.0 85.1 85.6 6.0 91.2 93.5 16.0 84.6 85.1 7.0 89.7 91.9 17.0 82.7 83.6 8.0 89.4 90.6 18.0 81.3 83.2 9.0 88.7 90.2 19.0 80.2 82.6 10.0 87.7 90.1 20.0 79.9 81.8 time (hrs) noise levels, dba point, p1 point, p2 point, p3 point, p4 point, p5 point, p6 7.00 am 85.4 79.3 78.6 85.7 82.4 89.1 8.00 am 86.5 78.9 77.8 86.8 83.5 92.5 9.00 am 81.3 80.6 78.0 83.2 80.5 88.1 10.00 am 80.5 79.7 78.9 83.5 82.6 89.5 11.00 am 79.8 79.4 81.8 83.0 81.1 85.2 12.00 noon 77.8 78.6 80.9 82.4 80.9 85.7 1.00 pm 81.4 79.6 84.1 83.2 80.1 85.9 2.00 pm 81.1 80.2 83.7 83.0 82.3 86.1 3.00 pm 80.3 78.8 83.5 82.0 80.2 86.4 4.00 pm 81.5 80.0 82.9 84.4 81.5 85.8 5.00 pm 81.6 79.9 80.8 81.4 82.1 82.7 6.00 pm 80.6 79.5 80.3 82.7 81.1 82.8 7.00 pm 79.1 76.2 79.5 80.1 79.8 82.5 international journal of occupational safety and health, vol 3. no 2 (2013) 12 17 elancheliyan 2013 screens, berms or material stacked to form barriers [12]. • fit silencers to combustion engines. ensure they are in good condition and work effectively [13]. • maintain machines regularly they will be quieter figure.3. graphical analysis of noise level at different locations in exhibition hall • keep machinery covers and panels closed and well fitted. bolts/fasteners done up tightly avoid rattles • during both construction and operation, post warning signs in high noise areas and implement hearing protection program for work areas where noise levels exceed 85 dba [15]. incorporate into the final design/procurement of project facilities and equipment noise attenuation measures that ensure compliance with the legal requirements. table v overall noise levels at study points surveyed conclusion noise was measured at various distances from the generator equipment. in this site the workers are working without any ear protection at a distance of about 2m from the generators and are exposed to a minimum noise of 100dba around 360 kva generators and 101.3dba around 500 kva generators. the study shows the permissible level of noise (90 dba) is reached at 7.0m for g1 and 10.5m for g2 generators. noise from generators can be controlled by an increase in distance between the generator and the worker or to introduce noise reduction screens or provide acoustic shield around. so a hard barricading is needed at a minimum distance of 7m and this distance is further increased to 10.5m for 500 kva generators, which provides protection and minimizes the workers exposure in noisy zone. an overall mean equivalent noise level of 82.05 dba was observed at 6 locations (78 measurements) in exhibition hall, which exceeds the threshold of 70 dba that represents a cautionary risk of hearing damage of construction workers of about 400 involved in this work area. the exposure ranged from a minimum of 76.2 dba to a maximum of 92.5 dba. this scenario might exists in any construction site wherever open generators are used for power generation. hence during construction phase of any site needs to, investigate, document, evaluate, and attempt to take all feasible measures to reduce the noise at the source and implement hearing protection program for work areas where noise levels exceed 85 dba. references 1. eaton s., “noise & vibration in work safe industries”, wcb of bc engineering report wcb-99006, 1999:2531. 2. bares l.f., salyers e.f., “a new material systems approach for controlling heavy equip. operator noise exposure”, 1980: 80-84. 3. suggs c.w. “noise problems of hand and power tools”, noise-con 81, 1981:339-342. 4. singh, p., noise pollution. every man’s science., 25 (1&2),1984: 231-235 5. ringen, k. and seegal, j. safety and health in the construction industry. annual review of public health,1995:165-188. http://dx.doi.org/10.1146/annurev.pu.16.050195.001121 (pmid:7639869) 6. the columbia encyclopaedia, sixth edition. columbia university press, 2008:105-133. 7. niosh, national occupational exposure survey (19811983). cincinnati, ohio 1998:17-23. 8. sinclair, j.d.n., and w.o. haflidson: construction noise in ontario. appl. occup. environ. hygene 1995:457-460. 9. greenspan, c.a., r. moure-eraso, d.h. wegman, and l.c. oliver: occupational hygiene characterization of a highway construction project: a pilot study. appl. occup. environ. hyg.1995:50-58. http://dx.doi.org/10.1080/1047322x.1995.10387611 10. neitzel, r., n. seixas, m. yost, and j. camp: an assessment of occupational noise exposures in four construction trades. ms thesis, department of environmental health, university of washington, seattle, 1998:49-57. point noise levels, dba minimum maximum mean standard deviation variance p1 79.1 86.5 81.3 2.33 5.45 p2 76.2 80.6 79.28 1.08 1.17 p3 77.8 84.1 80.83 2.22 4.93 p4 80.1 86.8 83.18 1.73 2.99 p5 79.8 83.5 81.39 1.12 1.25 p6 82.5 92.5 86.33 2.90 8.45 original article / ijosh/ issn 2091-0878 17 11. paul klinge. symposium on “modeling and simulation of multi technological machine systems”, espoo 2000, 2000:1724. 12. bartholomae, r.c., and r.p. parker: mining machinery noise control guidelines, u.s. department of the interior 1983:29-42. 13. toth, w.j.: noise abatement techniques for construction equipment.1979: 4579. 14. ingemansson, s.: noise control: principles and practice (part 7). noise/news int, 1995:237-343. 15. legris, m., and p. poulin: noise exposure profile among heavy equipment operators, associated labourers and crane operators. am. ind. hyg. assoc. j, 1998:774-778. http://dx.doi.org/10.1080/15428119891010947 16. osha, occupational noise exposure, safety and health regulations for construction, 1926.52(d) (1, 2), 2002. 17. anon., “exposure of construction workers to noise”, construction ind. research and information association, uk, 1984: 96-102. 18. ontario ministry of labour: regulations for industrial establishments (reg.851). toronto, canada: ministry of labour, 1986:122-27. type of the paper (article int. j. occup. safety health, volume 13, no 1 (2023), 119-125 https://www.nepjol.info/index.php/ijosh 119 original article internet gaming disorder among undergraduate health sciences students in the pokhara valley: a cross-sectional study shahi s1, baral yr1, mishra dk1 1manmohan memorial institute of health sciences, department of public health kathmandu, nepal abstract introduction: internet gaming disorder (igd) is an emerging public health impact of technological advancement and globalization. this study was conducted to assess the prevalence and factors associated with igd among undergraduate health sciences students. methods: a web-based cross-sectional study was conducted during a period of november 2019 to july 2020. a total of 412 college students from undergraduate health sciences colleges of pokhara metropolitan city in gandaki province, nepal were enrolled. online google forms were sent to all the eligible students through email and other social media sites like face book with the help of coordinator and class representative. collected data were analyzed using spss ibm v.22 results: the finding of the study shows that the prevalence of internet gaming disorder among undergraduate health sciences students was 7.1%. sex (p=0.027), loneliness level at home (p=0.019), number of close friends (p<0.001), types of game (p<0.001), time spent on play game (p<0.001) and, type of gamer (p<0.001) were the factors associated with internet gaming disorder among the participants. conclusion: sex of the participants, loneliness level at home, number of close friends, types of game, time spent on the game play, and type of gamer are the contributing factors for developing internet gaming disorder. it is important to focus on these factors to address internet gaming disorder and its psychological health effects. keywords: developing countries, internet addiction, internet gaming disorder, problematic gaming, video games introduction internet gaming disorder (igd) refers to the problematic use of online or offline video games. it is defined as persistent and recurrent use of the internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the nine criteria in a 12-month period.1 world health organization (who) defined gaming disorder as “a pattern of gaming behavior (digital-gaming or video-gaming) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences. gaming disorder was incorporated as a mental health problem in the 11th revision of the international classification of disease (icd-11) in 2018 and was recommended to the governments to formulate public health strategies and monitor igd trends.2 the american psychiatric association (apa) included igd in section iii of the diagnostic and corresponding author: dr. yuba raj baral associate professor, program coordinator, department of public health, manmohan memorial institute of health sciences, kathmandu, nepal email: baralyr3@gmail.com orcid id: https://orcid.org/0000-0002-01916278 date of submission: 16.01.2022 date of acceptance: 18.08.2022 date of publication: 01.01.2023 conflicts of interest: none supporting agencies: none doi: https://doi.org/10.3126/ijosh.v13i 1.42038 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://orcid.org/0000-0002-0191-6278 https://orcid.org/0000-0002-0191-6278 https://doi.org/10.3126/ijosh.v13i1.42038 https://doi.org/10.3126/ijosh.v13i1.42038 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ shahi et al. internet gaming disorder among undergraduate health sciences students in the pokhara valley: a cross-sectional study 120 statistical manual of mental disorers-5th edition (dsm-5) on the condition that it guaranteed more clinical research and experience.3 the essential feature of igd is engaging in gaming for typically 8 to 10 hours or more per day, typically in internetbased group games.4 gaming is considered as safe activity but in certain population adverse consequences of involving in this behavior is noticed.23 engaging in gaming activities may promote negative behaviors such as smoking and aggression and could be harmful to physical and mental well-being.24,25 increase in internet use and video-gaming contributes to public concern on pathological or obsessive play of video games among children and adolescents worldwide.22 global games market (ggm) has shown that there were more than 2.5 billion gamers in the world in 2016, which is almost one-third of the total population globally.5 a systematic review on igd has shown the prevalence of igd ranged from 0.7 percent to 27.5 percent.6 in the context of nepal, there has been very limited studies conducted on igd to date. a cross-sectional study conducted during covid-19 pandemic lockdown in 2020 showed that the prevalence of gaming disorder was 8.5% among 260 internet gaming users.20 a study conducted among university students of ilam on internet addiction showed that 42.84% of students played online games, as a major purpose of internet using.7 internet gaming disorder is a relatively new phenomenon, and all the studies on internet addiction that have been published in nepal have pointed out that further research needs to be done in this area. a scoping review showed that 10-20% of children and adolescents have mental disorders and half of them started at age by 14 years 8. however, internet gaming as a cause of these conditions has not been ruled out. hence, this study aimed to assess the status of igd and factors associated with it. data obtained from this study generates evidence and would guide to the development of appropriate interventions and policies to prevention of problematic gaming and its psychological health effects. methods a web-based cross-sectional study was conducted among students of undergraduate health sciences colleges of the pokhara metropolitan city, gandaki province of nepal. the study was conducted during november-july 2020. the study participants were undergraduate health sciences students. sample size was calculated using the formula {n= z2p (1-p)/d2} where z= level of confidence according to the standard normal distribution (for a level of confidence of 95%, z= 1.96), p= prevalence of igd= 50%= 0.5, q= 0.5, d= margin of error=0.05 and the sample size (n) was 424 after adding 10% non-response rate. the main instrument to collect data was online selfadministered questionnaires using google forms. the survey instrument was distributed to faculty members to assess its validity and reliability before pretesting among 42 (10% of sample) undergraduate students for relevance, clarity, and acceptability. changes such as shuffling the question patterns were made before the final questionnaire survey was distributed to the research participants. the study questionnaire consisted of the following two parts part a: general informative questionnaire to assess the socio-demographic profile, and part b: the english version of the dsm-5 short (9-item) dichotomous scale which compromises nine items, each reflecting one dsm5 criteria for igd. the psychometric properties of this instrument have been well-established.1,26 for those who did not respond, the forms were sent at a gap of two days. the study included undergraduate health sciences students of all semester and year studying in different medical colleges in pokhara metropolitan city. interns and post-graduate students were excluded from the study. ethical clearance was obtained from institutional review committee (irc) of manmohan memorial institute of health sciences (mmihs) kathmandu, nepal (ref no: 77/27) prior to the start of study. the study was conducted during a period of november 2019 to july 2020. questionnaire did not contain any identification detail such as email, name of the students and confidentiality was strictly maintained throughout the study. the participants had complete freedom to answer or decline the questionnaire. shahi et al. internet gaming disorder among undergraduate health sciences students in the pokhara valley: a cross-sectional study 121 the data were transferred from google form into a spreadsheet and again transferred it to microsoft excel 2016, analysis was done using the statistical package for social sciences software (spss ibm v. 22). data were presented in the form of frequency and percentage. chi-square test (at 5% level of significance and 95% ci) was done to show the association between dependent and independent variables. a p value of <0.05 was considered statistically significant for all the tests. results there were total of 424 students out of which 412 students participated in the study. table 1 denotes the demographic characteristics of the respondents. the mean age of the participants was 21.45 ± 2.11 years with the majority (80.6%) of females. most (94.2%) of them were unmarried and were (99.5%) above the poverty line. average income less than 1.90$ (dollars) per day is defined as below poverty line and equal or more than 1.90$ (dollars) per day is defined as above poverty line.21 table 1. some of the demographic criteria for participation variables frequency percentage age (in years) mean ± sd 21.45 ± 2.11 sex female 332 80.6 male 80 19.4 ethnicity janajati 101 24.5 brahmin 198 48.1 chettri 88 21.4 others 25 6.1 marital status unmarried 388 94.2 married 24 5.8 socio-economic status below poverty 2 0.5 above poverty 410 99.5 table 2. igd among the respondents was found to be (7.1%) variables frequency percentage prevalence of igd no 273 92.9 yes 21 7.1 table 3 shows the analysis of factors significantly associated with igd. sex was significantly associated with igd. the prevalence of igd was higher in males than females. the study shows that males were 3 times more likely to have igd than the female respondents (or=2.906, 95% ci= 1.1677.240). loneliness level at home was seen to be significantly associated with the igd of the respondents. the respondents who felt much lonely at home were 7 times more likely to have igd than the respondents who did not feel lonely at home (or= 6.583, 95% ci= 1.143-37.917). likewise, the respondents who felt a little lonely at home were 3 times more likely to have igd than the respondents who did not feel lonely at home (or= 3.199, 95% ci= 1.179-8.679). number of close friends was also associated significantly with igd. respondents who had 1 to 2 close friends were 3 times more likely to have igd than the respondents who had 7 or more close friends (or= 3.205, 95% ci= 1.085-9.472). likewise, respondents who had 3 to 6 close friends were less likely to have igd than the respondents who had 7 or more close friends (or= 0.393, 95% ci= 0.1161.329). shahi et al. internet gaming disorder among undergraduate health sciences students in the pokhara valley: a cross-sectional study 122 respondents who played action games were 13 times more likely to have igd than the respondents who played strategic games (or= 12.972, 95% ci= 3.600-46.746). likewise, respondents who played adventure games were 5 times more likely to have igd than the respondents who played strategic games (or= 4.556, 95% ci= 0.883-23.495). similarly, the respondents who played role-playing games were 4 times more likely to have igd than the respondents who played strategic games (or= 3.905, 95% ci= 0.381-40.054). time spent on games was also found to be significantly associated with igd. respondents who played game for 8 and more than 8 hours were 7 times more likely to have igd than the respondents who played games for 0 to 7 hours (or= 6.951, 95% ci= 2.686-17.989). respondents who were regular players were 8 times more likely to have igd than the respondents who were irregular players (or= 8.227, 95% ci= 3.037-22.284). table 3. bivariate analysis of factors significantly associated with igd factors prevalence of igd p-value or 95% ci (lowerupper limit) no yes sex female 217 (94.8%) 12 (5.2%) ref male 56 (86.2%) 9 (13.8%) 0.022 2.906 1.167-7.240 loneliness level at home none 158 (96.3%) 6 (3.7%) ref little 107 (89.2%) 13 (10.8%) 0.022 3.199 1.179-8.679 much 8 (80.0%) 2 (20.0%) 0.035 6.583 1.143-37.917 no. of close friends 1 to 2 39 (79.6%) 10 (20.4%) 0.035 3.205 1.085-9.472 3 to 6 159 (97.0%) 5 (3.0%) 0.133 0.393 0.116-1.329 7 or more 75 (92.6%) 6 (7.4%) ref types of game role-playing 14 (93.3%) 1 (6.7%) 0.251 3.905 0.381-40.054 action 59 (80.8%) 14 (19.2%) 0.000 12.972 3.600-46.746 adventure 36 (92.3%) 3 (7.7%) 0.070 4.556 0.883-23.495 strategy 164 (98.2%) 3 (1.8%) ref time spend on game 0 to 7 hrs. 212 (98.8%) 7 (3.2%) ref 8 and more hrs. 61 (81.3%) 14 (18.7%) 0.000 6.951 2.686-17.989 type of gamer irregular 254 (95.1%) 13 (4.9%) ref regular 19 (70.4%) 8 (29.6%) 0.000 8.227 3.037-22.284 discussion this study found that the prevalence of igd among undergraduate health sciences students was 7.1% whereas among 92.9% of the respondents there was no igd. in the context of nepal, a comprehensive literature review showed a study on gaming disorder in nepal. a recent study done in 2020 showed that the prevalence of gaming disorder was 8.5%.20 a study conducted in kathmandu, nepal among health sciences students in 2015 showed that 32.6% played online games on the internet.9 few studies on internet addiction among adolescent students in nepal showed gaming as a major purpose of internet use.7,9,10 likewise, a study conducted in india showed that the prevalence of igd was 3.50% which was similar to the study conducted in thailand 5.4%.11,12 this study found sex as a strong predictor of igd and prevalence was high among males than females among undergraduate health science students. a study conducted in india showed that the prevalence of igd was higher among male students than female students.11 majority of the shahi et al. internet gaming disorder among undergraduate health sciences students in the pokhara valley: a cross-sectional study 123 studies reported similar findings of high male prevalence like lemmens et al (6.8%), miller et al (3.1%).13,14 from this study, it is evident that sex acts as an important risk factor for igd. this may be because video games are marketed more towards males than females, there are not many games that attract girls, interactive online games and contents mainly rely on power, dominance, control and/or violence, which, may explain males’ attraction on the internet use and games. sociodemographic factors such as ethnicity, marital status, and family size were not associated with igd in this study. loneliness level at home was also significantly associated with igd. a study conducted in nepal showed that the respondents who felt much lonely at home were more addicted to the internet.10 previous studies have consistently confirmed the connection between loneliness and game addiction.15,16 this may be because playing online games may temporarily provide an escape from the negative feelings associated with social deficiencies such as dysfunctional family, lack of friends, and may make them free from loneliness. number of close friends was also significantly associated with igd. this study did not find any association between tobacco, alcohol consumption, and igd, this result was supported by a study done in thailand.12 the study shows no association between socioeconomic status, internet access, and igd. pawan taechoyotin et al support the findings.12 time spent on games was significantly associated with igd. a study done in thailand supports the findings. if the games are played in controlled duration, it has a positive effect on learning process, motivation, memory formation and gives rise to happiness in those who play game. however, excessive internet gaming activity may develop into igd.17 types of gamers were also significantly associated with igd. a similar study conducted in 2016 by gaetan et al showed that compared to irregular gamers, regular gamers have igd and express their emotions less, and have difficulty being emotionally reactive.18 types of games were also significantly associated with igd. this study shows that respondent who play action games were more likely to have a prevalence of igd, this might be because action games content rely on power, fights, control that will attract the gamers towards the action genre. a study conducted by bonaire et al in 2019 supports this finding.19 video games act as a medium for projecting and experiencing one’s emotional life by staging the emotional self and thus giving priority to gaming than other activities.18 conclusion the present study revealed 7.1% prevalence of igd among undergraduate health sciences students of pokhara metropolitan city. we found respondent’s sex, loneliness level at home, number of close friends, types of game played, time spent on a game per day, and type of gamer to be the contributing factors for developing igd. therefore, it is very important to focus on these factors to address igd and its psychological health effects on undergraduate heath sciences students. acknowledgments we'd like to express our 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shrestha n, sharma sc, joshi sk. gaming disorder among medical college students during covid-19 pandemic lockdown. kathmandu university medical journal (kumj). 2020;18(70):48-52. available from: https://doi.org/10.3126/kumj.v18i2.32956 21. ferreira f, jolliffe dm, prydz eb. the international poverty line has just been raised to $1.90 a day, but global poverty is basically unchanged. how is that even possible? [internet]. let’s talk development, world bank blogs. 2015 oct 4 [cited 2022 mar 3]. available from: https://blogs.worldbank.org/developmenttalk/interna tional-poverty-line-has-just-been-raised-190-dayglobal-poverty-basically-unchanged-how-even 22. choo h, gentile da, sim t, li d, khoo a, liau ak. pathological video-gaming among singaporean youth. annals of the academy of medicine, singapore. 2010;39(11):822-9. available from: http://hdl.handle.net/10497/16240 23. saunders jb, hao w, long j, king dl, mann k, fauthbühler m, et al. gaming disorder: its delineation as an important condition for diagnosis, management, and prevention. j behav addict. 2017;6(3):271-9. available from: https://doi.org/10.1556/2006.6.2017.039 24. dejan s, ana d, pal singh by, et al. assessing the symptoms of internet gaming disorder among college/university students: an international validation study of a self-report. psihologija. 2020;53:43-63. available from: https://doi.org/10.2298/psi190421015s 25. anderson ca, shibuya a, ihori n, swing el, bushman bj, sakamoto a, et al. violent video game effects on aggression, empathy, and prosocial behavior in eastern and western countries: a metaanalytic review. psychological bulletin. 2010;136(2):151-73. available from: https://doi.org/10.1037/a0018251 26. petry nm, rehbein f, gentile da, lemmens js, rumpf hj, mößle t, et al. an international consensus for assessing internet gaming disorder using the new dsm-5 approach. addiction (abingdon, england). 2014;109(9):1399-406. available from: https://doi.org/10.1111/add.12457 https://doi.org/10.1016/j.psychres.2018.12.158 https://www.google.com/search?q=bonnaire+c%2c+baptista+d.+internet+gaming+disorder+in+male+and+female+young+adults%3a+the+role+of+alexithymia%2c+depression%2c+anxiety+and+gaming+type.+psychiatry+res.+2019%3b272%3a521-30.&rlz=1c1chbd_ennp890np890&oq=bonnaire+c%2c+baptista+d.+internet+gaming+disorder+in+male+and+female+young+adults%3a+the+role+of+alexithymia%2c+depression%2c+anxiety+and+gaming+type.+psychiatry+res.+2019%3b272%3a521-30.&aqs=chrome..69i57.1609j0j7&sourceid=chrome&ie=utf-8 https://doi.org/10.3126/kumj.v18i2.32956 https://blogs.worldbank.org/developmenttalk/international-poverty-line-has-just-been-raised-190-day-global-poverty-basically-unchanged-how-even https://blogs.worldbank.org/developmenttalk/international-poverty-line-has-just-been-raised-190-day-global-poverty-basically-unchanged-how-even https://blogs.worldbank.org/developmenttalk/international-poverty-line-has-just-been-raised-190-day-global-poverty-basically-unchanged-how-even http://hdl.handle.net/10497/16240 https://doi.org/10.1556/2006.6.2017.039 https://doi.org/10.2298/psi190421015s https://doi.org/10.1037/a0018251 https://doi.org/10.1111/add.12457 type of the paper (article int. j. occup. safety health, volume 13, no 2 (2023), 199-205 https://www.nepjol.info/index.php/ijosh 199 original article evaluation of the knowledge of sun exposure and sun protective measures in healthcare workers aryal e1, shrestha pr2, gautam s3 1 associate professor, department of dermatology, kathmandu medical college, kathmandu, nepal 2 lecturer, department of dermatology, kathmandu medical college, kathmandu, nepal 3 resident, department of dermatology, kathmandu medical college, kathmandu, nepal abstract introduction: solar ultraviolet (uv) radiation has a great impact on human life. the sun has always played an important role in asian culture, so much so, that it is often prayed to as a god. prolonged sun exposure can cause extensive and chronic harmful effects. healthcare personnel is supposed to have good knowledge regarding sun protection as they play a key role in society disseminating knowledge to the general public. there are limited data regarding the knowledge of sun protection and sunscreen practice among health care workers. methods: this descriptive cross-sectional study was carried out from june to october 2020 on healthcare workers (medical staff) in kathmandu medical college teaching hospital. a questionnaire was distributed to the target study population without disturbing or hampering the healthcare worker’s duty. results: out of a total of 264 participants in the study, 84 (31.8%) were male and 180 (68.2%) were female. the knowledge of proper terminology for spf (sun protection factor) was noted in 196 (74.2%) and 57 (21.6%) agreed that the value of spf was related to age. no significant difference was noted regarding knowledge about the time of sun exposure for vitamin d synthesis. no significant differences were found in practices of sunscreen use for purposes of fairness, or prevention of tanning, wrinkle, mole, and skin cancer. conclusion: a higher level of education was associated with better knowledge and proper abiding practices regarding sunscreen use. as healthcare workers play a key role in distributing information in society, they should be targeted in education campaigns regarding sun exposure and sun protection measures; with these efforts focused more on nurses and medical officers. keywords: health personnel, knowledge, sunscreen, ultraviolet introduction solar ultraviolet (uv) radiation has a great impact on human life. sun has always been given importance in asian culture to the extent that it is often considered of god, similar to the greeks and romans worshipping apollo as the sun god and the god of light.1 even today, uv radiation via sunlight has important public health implications in the form of both beneficial and deleterious effects. sun exposure causes extensive intrinsic as well as extrinsic changes in the skin and has many acute and chronic harmful effects.2 nowadays, there is an increasing awareness about the benefit corresponding author: dr. eliz aryal associate professor, department of dermatology, kathmandu medical college. mobile no+9779849214203. e-mail: eliz_aryal@yahoo.com orcid id: https://orcid.org/0000-00023455-2095 date of submission: 22.02.2022 date of acceptance: 03.11.2022 date of publication: 01.04.2023 conflicts of interest: none supporting agencies: none doi: https://doi.org/10.3126/ijosh.v 13i2.43305 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:eliz_aryal@yahoo.com https://orcid.org/0000-0002-3455-2095 https://orcid.org/0000-0002-3455-2095 https://doi.org/10.3126/ijosh.v13i2.43305 https://doi.org/10.3126/ijosh.v13i2.43305 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ aryal et al. evaluation of the knowledge of sun exposure and sun protective measures in health care workers 200 of sunlight for the synthesis of vitamin d. results of photo aging, such as pigmentation, sagging, wrinkling, and photo-carcinogenesis are caused by an alteration to dna; which can be prevented with regular usage of sunscreen.2 during summer, the ultraviolet (uv) energy received on the earth's surface is made up of 3.5% ultraviolet b (uvb) and 96.5%ultraviolet a (uva) radiation.4uva penetrates up to the dermis whereas uvb affects the epidermis of the skin.3 regular sunscreen usage can prevent photoinduced and photo-aggravated dermatoses. food and drug administration have approved sunscreen for use in the prevention of sunburn, photo-induced pigmentation, aging, and carcinoma of the skin.4 the mechanism by which sunscreens inhibit the transmission of uv radiation into the skin is by absorbing, reflecting, or scattering such radiation.4 sunscreens have been recommended as preventive and protective measures against sunlight, with the efficacy increasing with a higher sun protection factor.4 health care personnel supposedly have good knowledge regarding sun protection and they play a key role in society disseminating knowledge to the general public. there are limited data regarding the knowledge of sun protection and sunscreen practice in health care workers. our study aimed to determine the knowledge of healthcare workers regarding the solar spectrum, sunscreen, the relation of vitamin d with sun exposure, the practice of using sunscreen and other sun protection methods. methods this descriptive cross-sectional study was carried out from october 2020 to july 2021 on healthcare workers (medical staff) in kathmandu medical college teaching hospital after taking ethical approval from irc. non-medical hospital staff and health workers with less than one year of experience in healthcare practice were excluded from our study. all health workers working in the hospital who voluntarily agreed to participate were included. participants were informed about the purpose of the study and its methodology. the questionnaire was self-designed and pilot testing was done on 15 participants to calculate the approximate time to complete it and to determine the clarity of the questionnaire. feedback was taken for further improvement and modification of the questionnaire. the researcher distributed the selfadministered questionnaire to the target study population without disturbing or hampering the healthcare worker’s duty. a researcher was available to clarify any issue and questionnaires were collected soon after responses were collected. the questionnaire consisted of three sections. the first section consisted of demographic variables including age, gender, education, and medical post. the second section consisted of knowledge regarding the sun, spf, vitamin d, and sunscreen and the third section consisted of questions regarding the practice of sun protective measures. data were entered and analyzed by spss version 20. analytical statistics was applied using the chisquare test for testing the difference or association between two categorical variables, similarly, descriptive statistics were applied to calculate frequency and percentage. results the participants in the survey aged between 24-67 years with a mean age of 34.74±7.839. out of a total of 264 participants in the study, 84 (31.8%) were male and 180 (68.2%) were female. in our study, the healthcare workers participating were nursing staff 41(15.5%), medical officers 81(30.7%), and consultant doctors, 142(53.8%). among them, 89(33.7%) health workers had skin problems at some point in their lives. the number of participants who knew about the different spectra of ultraviolet radiation was 175 (66.3%). (table 1). regarding the level of knowledge about sunscreen 212 (80.3%) agreed that sunscreen is expensive, (significant p<0.005). out of 264 participants, only 196 (74.2%) knew the proper terminology for spf (sun protection factor) and only 59 (21.6%) agree that the value of spf is related to age. similarly, 120 (45.4%) participants knew about the difference between physical and chemical sunscreen and it was not significant. (table 2). aryal et al. evaluation of the knowledge of sun exposure and sun protective measures in health care workers 201 table 1: socio-demographics data of participants variables n (%) gender male female 84(31.8) 180(68.2) education qualification nursing medical officer consultant 41(15.5) 81(30.7) 142(53.8) age range 20-29 30-39 40-49 50-59 > 60 81(30.7%) 120(45.5%) 52(19.7%) 5(1.9%) 6(2.3%) underlying skin condition yes no 89(33.7) 172(65.2) table 2: health worker level of knowledge regarding sunscreen variables nursing n (%) medical officer, n (%) consultant n (%) pvalue sunscreen is expensive agree disagree don’t know 36 (13.6) 3 (1.1) 2 (0.7) 74 (28) 5 (1.8) 2 (0.7) 102 (38.6) 14 (5.3) 26 (9.8) 0.002 meaning of spf sun protection factor sun prevention factor sun protection formula sun prevention formula don’t know 27 (10.2) 4 (1.5) 5 (1.8) 2 (0.73) 3 (1.1) 58 (21.9) 2 (0.75) 13 (4.9) 2 (0.75) 6 (2.2) 111 (42) 10 (3.7) 4 (1.5) 2 (0.75) 15 (5.6) 0.023 value of spf is related to age agree disagree don’t know 28 (10.6) 3 (1.1) 10 (3.7) 48 (18.1) 20 (7.5) 13 (4.9) 77 (29) 36 (13) 29 (10) 0.132 difference between physical and chemical sunscreen yes no 17 (6.4) 24 (9) 35 (13.2) 46 (17.4) 68 (25.7) 74 (28) 0.681 out of the total participants, 214 (81%) agreed that there is a relationship between sunlight and vitamin d synthesis , and it was significant. no significant difference was noted regarding knowledge about the time of sunscreen exposure for vitamin d synthesis. around 95 (45.5%) recommended that 20-30 minutes/week of sun exposure is required for vitamin d synthesis. similarly, regarding vitamin d deficiency, 90(34%) agreed that regular use of sunscreen can cause vitamin d deficiency. (table 3) regarding the knowledge about sunlight, only 172 (65.1%) were aware of different spectra of uv light. similarly, 96 (36.3%) knew that skin condition gets aggravated by exposure to ultra violet radiation. regarding outdoor activities among the three groups, consultants, 52( 19.6%) were more likely to spend lesser time outdoors and avoided sunlight exposure during peak hours. (table 4) table 3: health worker level of knowledge regarding vitamin d and sunscreen variables nursing n (%) medical officer n(%) consultant n(%) pvalue view on the relationship between sunlight and vitamin d agree disagree don’t know 37 (14) 2 (0.75) 2 (0.75) 75 (28.4) 1 (0.3) 5 (1.8) 107 (40.5) 24 (9) 11 (4.1) 0.020 is the area of sunlight exposure related to vitamin d synthesis yes no 28(10.6) 13 (4.9) 60 (22.7) 21 (7.5) 98 (37.1) 44 (16.6) 0.003 the exposure time required for vitamin d synthesis 20-30min/week 40-60min/week 60-90min/week 17 (6.4) 13 (4.5) 11 (4.1) 21 (7.9) 40 (15.1) 20 (7.5) 57 (21.5) 29 (10.9) 56 (21.2) <0.001 view on sunscreen use and vitamin d deficiency agree disagree don’t know 15 (5.6) 23 (8.7) 3 (1.1) 18 (6.8) 47 (17.8) 16 (6.06) 57 (21.5) 49 (18.5) 36 (13.6) 0.001 table 4: healthcare worker level of knowledge regarding sunlight variables nursing n(%) medical officer n(%) consultant n(%) pvalue know about the different spectra of uv light yes no 27 (10.2) 14 (5.3) 50 (18.9) 31 (11.7) 98 (37.1) 44 (16.6) 0.541 do you think skin condition is aggravated by uv light yes no 13 (4.9) 28 (10.6) 33 (12.5) 48 (18.1) 50 (18.9) 92 (34.8) 0.567 is sun exposure bad for the skin agree disagree don’t know 26 (9.8) 15 (5.6) 0 (0) 64 (24.2) 13 (4.9) 4 (1.5) 98 (37.1) 33 (12.5) 11 (4.1) 0.048 hours of outdoor activity you do in a week <15hr/week 15-30hr/week >30hr/week 26 (9.8) 15 (5.6) 0 (0) 45 (17) 29 (10.9) 7 (2.6) 87 (32.9) 41 (15.5) 14 (5.3) 0.249 avoid sunlight during peak hour always sometimes rarely never 15 (5.6) 26 (9.8) 0 (0) 0 (0) 20 (7.5) 57 (21.5) 1 (0.37) 3 (1.1) 52 (19.6) 57 (21.5) 26 (9.8) 7 (2.6) <0.001 according to the participants, 89 (33.7%) used coin size volume of sunscreen regularly and among them, 45 (17%) were consultant doctors. regarding the sunscreen application time, 91(34.4%) used it in the morning, while 51(19.3%) used sunscreen whenever they go out in sun. reapplication of sunscreen was done only by 73 (27.6%) participants. most of the participants i.e. 124 (46.5%) used spf of 30-50 and a majority of participants (62.1%), applied sunscreen only on the face followed by face and neck by 128( 48-4%) and arm 32 (12.1%). (table 5). no significant differences were found in the level of practice of sunscreen for precaution of fairness, or prevention of tanning, wrinkle, mole, and skin cancer. the most common reason for sunscreen application was to prevent sunburn 132(50%) and was significant. apart from sunscreen other sun protection methods reported were the use of an umbrella 149 (56.4%), wearing sunglass 125(47.3%), and wearing full sleeves 106(40%) which were not significant. (table 6). table 5: practice of sunscreen by healthcare workers. table 6. the practice of sun protection measures by healthcare workers. discussion healthcare workers are considered to be welleducated and knowledgeable. higher education level was known to be associated with increased use of sunscreen and other sun protection measures as they are aware of sun radiation damage to the skin.5 in our study, there were more female participants due to nursing female healthcare workers. among the three groups in our study, the knowledge about uv radiation, sunscreen, physical and chemical sunscreen and spf (sun protection factor) was found more in consultant doctors and was statistically significant. the subgroup among the healthcare professions that had a lower knowledge also had a lower education level. a similar outcome was found in other studies.6 in our research, we assessed the relationship between vitamin d syntheses with sun exposure. it was found that 81.8% of healthcare workers agree that there is a relationship between vitamin d and sunlight, while 186 (70%) believe that sunlight exposure is related to vitamin d synthesis, which is similar to a study by kaymalet al. 7 the study done by neale et al. also supported the theoretical risk of sunscreens may affect vitamin d levels.8 young et al. concluded that high uva-pf sunscreen enables significantly higher vitamin d variables nursing n (%) medical officer n (%) consultant n (%) pvalue the volume of sunscreen applied pea size coin size double coin size 11 (4.1) 16 (6.06) 0 (0) 29 (10.9) 28 (10) 6 (2.2) 35 (13.2) 45 (17) 7 (2.6) 0.118 time of application morning afternoon going out twice a day 16 (6.06) 3 (1.1) 7 (2.6) 1 (0.3) 22 (8.3) 7 (2.6) 30 (11.3) 5 (1.8) 53 (20) 11 (4.1) 14 (5.3) 10 (3.7) 0.001 reapplication yes no 7 (2.6) 34 (12.8) 30 (11.3) 51 (19.3) 36 (13.6) 106 (40) 0.044 use sunscreen indoor yes no 13 (4.9) 27 (10) 28 (10.6) 53 (20) 50 (18.9) 92 (34.8) 0.235 spf use 15-29 30-50 >50 5 (1.8) 22 (8.3) 1 (0.3) 20 (7.5) 37 (14) 8 (3.03) 15 (5.6) 65 (24) 9 (3.4) 0.007 area of application face neck arm other parts 25 (9.4) 19 (7.1) 5 (1.8) 0 (0) 57 (21.5) 32 (12.1) 2 (0.75) 2 (0.75) 82 (31) 77 (29.1) 25 (9.4) 0 (0) 0.172 0.091 0.004 variables nursing n (%) medical officer n (%) consultant n (%) pvalue reason for use of sunscreen fairness prevent tanning prevent sunburn prevent wrinkle prevent early aging prevent mole prevent skin cancer 11 (4.1) 18 (6.8) 17 (6.4) 12 (4.5) 10 (3.7) 5 (1.8) 4 (1.5) 25 (9.4) 33 (12.5) 50 (18.9) 38 (14) 28 (10.6) 22 (8.3) 24 (9) 7 (10.2) 44 (16.6) 65 (24.6) 54 (20.4) 49 (18.5) 37 (14) 30 (11.3) 0.128 0.178 0.036 0.150 0.447 0.144 <0.01 other sun protection measure used umbrella hat sunglasses full sleeves 15 (5.6) 13 (4.9) 18 (6.8) 17 (6.4) 48 (18.1) 33 (12.5) 47 (17) 41 (15.5) 86 (32) 50 (18.9) 60 (22) 48 (18.1) 0.233 0.567 0.068 0.047 203 aryal et al. evaluation of the knowledge of sun exposure and sun protective measures in health care workers 204 synthesis than a low uva-pf sunscreen because the former, by default, transmits more uvb than the latter. sunscreens (sun protection factor, spf 15) applied at a sufficient thickness to inhibit sunburn during a week-long holiday with a very high uv index still allow a highly significant improvement of serum 25-hydroxyvitamin d3 concentration. an spf 15 formulation with high uva protection enables better vitamin d synthesis than a low uva protection product. the former allows more uvb transmission.9 in this study, 87 (32.9%) participants avoided sunlight during peak hours, this may be due to indoor working hours. similarly, kaymak et al. found ‘not going out at peak times’ to be the most commonly adopted method with a figure of 45.3% and 53.0% in males and females.10 the outcome of this study shows that consultants were more likely to be familiar with the sun’s detrimental effects on skin and take protective measures, including sunscreen application. a greek study found the use of sunglasses (83.4%) as the most common sun protection measure in mediterranean inhabitants, followed by protective clothing (57.8%),11 in contrast to our study where other sun protection measures were less adopted. this can be due to a lack of knowledge, social and cultural norms, and economical barriers. using an umbrella was the least adopted method of sun protection in turkey,11 similar to that of our study. in saudi arabia, 95% of respondents reported wearing long-sleeved cloth and a head cover, clearly influenced by customs and traditional dressing practices.12 surprisingly, our study found that the knowledge about the relation of sun exposure with skin cancer is very low (21.9%), as opposed to many international studies, where the knowledge about sun exposure and its relation with skin cancer as well as adapted measures of sun protection was very high. for example, 85% in australia, 92 % in canada and the united states, and 92.5% in malta where as 55.5% in india reportedly were more aware.13,14 no significant difference was found among the three study groups (consultant, nursing, and medical officer) regarding the reason for using sunscreen. this is similar to the result of a study by ergin et al.15 conclusion a higher level of education was associated with better knowledge and behavior toward sunscreen and the solar spectrum. as healthcare workers play a key role in distributing information in society, especially nurses, medical officers should be targeted in education campaigns regarding sun exposure and protection. acknowledgments the authors would like to express their gratitude to the participants of the study and the hospital authorities for their support. references 1. mead mn. benefits of sunlight: a bright spot for human health. environ health perspect.2008;116: a160-7. available from: https://doi.org/10.1289/ehp.116-a160 2. pandas. nonmelanoma skin cancer in india: current scenario. indian j dermatol.2010;55:373-8. available from: https://doi.org/10.4103/00195154.74551 3. armstrong bk, kricker a.the epidemiology of uv induced skin cancer. j photochemphotobiol b.2001;63:8-18. available from: https://doi.org/ 10.1016/s1011-1344(01)00198. 4. rai r, shanmuga sc. update on photoprotection. indian j dermatol.2012;57:335-42. available from: https://doi.org/ 10.4103/0019-5154.100472. 5. afshar r, ali n, s golshahi. knowledge, attitude and behavior towards use among hospital personnel in comparison with laypeople in zanjan, iran. world applsci jour.2013;22(5):683-9. available from: https://doi.org/ 10.5829/idosi.wasj.2013.22.05.102 6. darling m, ibbotson sh.sun awareness and behaviour in healthcare professionals and the general public. clinexp dermatol2002; 27(6):442-.4. available from: https://doi.org/10.1046/j.13652230.2002.01110 7. diaz jh, nesbitt lt jr. sun exposure behavior and protection: recommendations for travelers. j travel https://doi.org/10.1289/ehp.116-a160 https://doi.org/10.4103/0019-5154.74551 https://doi.org/10.4103/0019-5154.74551 https://doi.org/%2010.1016/s1011-1344(01)00198. https://doi.org/%2010.1016/s1011-1344(01)00198. https://doi.org/%2010.4103/0019-5154.100472 https://doi.org/ 10.5829/idosi.wasj.2013.22.05.102 https://doi.org/10.1046/j.1365-2230.2002.01110 https://doi.org/10.1046/j.1365-2230.2002.01110 aryal et al. evaluation of the knowledge of sun exposure and sun protective measures in health care workers 205 med. 2013;20(2):108-18. available from: https://doi.org/10.1111/j.1708-8305.2012.00667 8. neale re, khan sr, lucas rm, et al.the effect of sunscreen on vitamin d: a review. br j dermatol. 2019;181: 907-15. available from: https://doi.org/ 10.1111/bjd.17980 9. young ar, narbutt j, harrison gietal.optimal sunscreen use, during a sun holiday with a very high ultraviolet index, allows vitamin d synthesis without sunburn.br j dermatol.2019;181:1052-62. available from: https://doi.org/10.1111/bjd.17888 10. nikolaou v, stratigosaj, antoniouc, et al. sun exposure behaviour and practices in a mediterranean population. a questionnaire based study.photodermatol photoimmunol photomed 2009;25:132-7. available from: https://doi.org/ 10.1111/j.1600-0781.2009.00424 11. eray yurtseven,tummer ullus,selcuk koksal,merve bosat.assessment of knowledge, behaviour and sun protection practice among health service vocational school students.int j environ res public health. 2021 ;9(7):2378-85. available from: https://doi.org/ 10.3390/ijerph9072378 12. khalid m, alghamdi, aeed s,alaklabi. knowledge, attitude and practices of the general public toward sun exposure and protection: a national survey in saudi arabia.2016;6(24):652-7. available from: https://doi.org/10.1016/j.jsps.2015.04.002 13. aquilinq s, gauci aa, ellul m, scerril.sun awareness in maltese secondary school students. j eur acad dermatol venereol.2004;18:670-5. available from: https://doi.org/ 10.1111/j.14683083.2004.01046 14. dev vk. assessment of knowledge and attitude towards sun exposure and photoprotection measure among indian patients attending clinic. indian joun of drugs in dermatology. 2019;5(2):949. available from: https://doi.org/10.4103/ijdd.ijdd_19_19 15. ergin m, ali i, mehmet b. assessment of knowledge and behaviour of mother with small children on effects of sun on health. pammedj.2011;4:72-8. available from: https://doi.org/10.3390/ijerph9072378 https://doi.org/10.1111/j.1708-8305.2012.00667 https://doi.org/ 10.1111/bjd.17980 https://doi.org/10.1111/bjd.17888 https://doi.org/ 10.1111/j.1600-0781.2009.00424 https://doi.org/ 10.3390/ijerph9072378 https://doi.org/10.1016/j.jsps.2015.04.002 https://doi.org/ 10.1111/j.1468-3083.2004.01046 https://doi.org/ 10.1111/j.1468-3083.2004.01046 https://doi.org/10.4103/ijdd.ijdd_19_19 https://doi.org/10.3390%2fijerph9072378 type of the paper (article int. j. occup. safety health, volume 13, no2 (2023), 155-162 https://www.nepjol.info/index.php/ijosh 155 original article covid-19 related symptoms and vaccination usage among informal waste workers of kathmandu, nepal khanal a1 1 department of energy and environment, teri school of advanced studies, new delhi, india abstract introduction: about 56% of the total population of nepal has been fully immunized against covid-19. but still, migrant workers outside of nepal are struggling to get covid vaccines. this study was intended to study the covid-19 symptoms among iwws of kathmandu and the usage of vaccines by them. methods: a cross-sectional study was conducted among 107 iwws of kathmandu valley from balkhu, sanepa, kalimati and teku areas. a convenience sampling method was used to find the respondents based on their willingness to participate in the study. a face-to-face interview was conducted using a structured questionnaire to collect data from iwws. results: following the covid-19 symptoms, most of the waste workers had a fever (89.7%) followed by cough (86%) and respiratory problems (55.1%). despite of majority of waste workers having covid-related symptoms, only 19.6% of waste workers had done covid tests. the majority of iwws of kathmandu were afraid to take the covid vaccine. around 77.6% of waste workers hadn’t still taken the covid vaccine with a majority (93.9 %) of them identified as indian nationals. conclusion: despite having covid-related symptoms, iwws haven’t gone for covid tests. though interested, the iwws need identity cards for vaccination which counts fewer waste workers being vaccinated. keywords: covid-19, informal waste worker, kathmandu, nepal, solid waste, vaccine introduction solid waste management has become a major challenge for different countries of the world. around 2.01 billion tons of municipal solid waste is generated globally and is predicted to reach 3.40 billion tons by 2050.1 the amount of solid waste generation in asia is in an increasing trend which will reach one-third of global waste by 2050.2 nepal is one of the least developed countries located in south asia which is also having greater challenges with solid waste management due to population growth.3,4 the rapid urbanization in kathmandu valley has caused an increase in waste generation with the government facing a difficult situation for effective management of municipal solid waste.5,6,7 a study conducted by the central bureau of statistics has recorded 1653 tons of municipal solid waste generation in nepal.8 in 2013, the per capita waste generation of nepal was 0.3 kg/day which is expected to reach 0.7 kg/day by 2025.9,1 corresponding author: ashish khanal department of energy and environment, teri school of advanced studies, new delhi, india telephone: +9779841075897 email: ashishkhanalk@yahoo.com orcid id:https://orcid.org/00000003-4175-977x date of submission: 29.04.2022 date of acceptance: 24.12.2022 date of publication: 01.04.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh.v 13i2.43929 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) mailto:ashishkhanalk@yahoo.com https://orcid.org/0000-0003-4175-977x https://orcid.org/0000-0003-4175-977x https://doi.org/10.3126/ijosh.v13i2.43929 https://doi.org/10.3126/ijosh.v13i2.43929 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ khanal a. covid-19 related symptoms and vaccination usage among informal waste workers of kathmandu, nepal 156 this shows that nepal is going to have a worst scenario of municipal solid waste in the coming years. solid waste management is a public issue and can only be managed effectively by the active participation of every stakeholder.10 a study conducted in 2014 recorded 8047 informal waste workers (iwws) inside kathmandu valley.11 however, no study has been conducted recently to identify the exact number of informal workers in kathmandu city. the informal waste workers are mobile and difficult to have their records due to the lack of governing and monitoring bodies in nepal. waste workers face significant occupational health risks due to the nature of their job. the waste workers are even vulnerable, coming in contact with covid-19-infected people as they move from one place to other for waste collection. a total of 446,721,132 coronavirus cases have been recorded with 6,020,572 deaths globally affecting 224 countries and territories as of march 7, 2022.12 nepal has recorded 977,501 coronavirus cases with 11,947 deaths as of march 7, 2022.13 the first case of covid-19 was reported on 13 january 2020 in nepal in an individual who had returned to nepal from wuhan, china.14 covid-19 is caused by coronavirus-2 (sars-cov-2) leading to severe respiratory problems, hyperinflammatory responses, vascular damage, angiogenesis and widespread thrombosis.15 the most common symptoms in the initial stage of covid-19 is upper respiratory tract infection, accompanied by fever, muscle fatigue and pain.15 covid-19 has affected everyone whether living in high, middle, or low-income countries with severe health threats.16 around half of the respondents had experienced covid-19-related symptoms during the pandemic with most of the facing fever, cough, aches and muscle pains.17 it was found that sars-cov-2 can survive on plastics and steel for 2-3 days, cardboard for <24 hours and copper for <4 hours.18 the waste workers have little knowledge about occupational safety and health and adopt fewer safety practices at their workplace.19,20 the iwws deal with recyclables on daily basis increases the risk of contamination by the covid-19 virus. the improper disposal of hazardous bio-medical waste (hbmw) causes a risk to public health and the surrounding environment.21 the quality and quantity of municipal solid waste (msw) were also greatly affected.22 there are different types of vaccines available with different storage and distribution systems and possible adverse effects confusing the public.23 thus, this study was intended to study the covid-19 symptoms among iwws of kathmandu and the usage of vaccines by them. a total of 56% of the total population of nepal have been fully immunized against covid.24 but still migrant workers outside of nepal are struggling to get covid vaccines. this study has included two types of iwws; one working at scrap centers and the other working as itinerant waste buyers (iwbs). the waste segregator at scrap centers have fixed working hours whereas most of the iwbs work independently, purchases the items from houses/institutions, and sells them to scrap center. whereas the iwbs are commonly called "feriya" or "kabadiwala" in nepal belonging to poor and marginalized social groups.25 despite the daily engagement of iwws with solid waste and the high risk of exposure to covid-19, their vaccine usage has not been assessed properly yet. this needs to be addressed with utmost concern. methods a cross-sectional study was conducted among iwws of kathmandu valley from balkhu, sanepa, kalimati and teku areas. those areas were chosen purposively as the iwws are more active and easily available in these areas of kathmandu.25 a pilot survey was conducted among 15 informal waste workers from four different scrap centers in december 2021. 93% of waste workers said that either they are afraid to take the covid-19 vaccine or are not allowed/asked for it. based on this, the alternatives for the questionnaire were derived. the sample respondents for this study included 107 waste workers excluding those involved in the pilot survey. a convenience sampling method was used to find the respondents based on their willingness to participate in the study. as the iwws are mobile, it's difficult to track their location. however, the iwws come to the scrap center at least once a day khanal a. covid-19 related symptoms and vaccination usage among informal waste workers of kathmandu, nepal 157 to sell the recyclables that they have collected. so the study was conducted among those iwbs and scrap center workers who were engaged with the scrap centers in the study sites and were willing to participate in this study. the face-to-face interview was conducted using a structured questionnaire to collect data from iwws. as the respondents were illiterate, verbal consent was taken and noted in the survey form by the researcher. the data analysis was conducted in the statistical package for social sciences (spss) version 20. a descriptive statistics, frequency (n) and percentage (%) were used for report generation. a pearson’s chi-square test of association was used to determine the relationship between two categorical variables. results out of 107 respondents, 53.3% were males and 46.7% were females (table 1). the respondents were from nepal (69.2%) and india (30.8%). a question was asked regarding their educational status, where 57% of respondents shared that they haven’t gone to schools or any educational institutions for formal education. however, it doesn’t claim that they mightn’t have been enrolled in any informal education, training, workshops, or seminars. table 1. demographic details of respondents variables frequency (n= 107) percentage (%) gender male 57 53.3 female 50 46.7 country of birth nepal 74 69.2 india 33 30.8 age group (years) 18-28 32 29.9 29-39 36 33.6 40-50 28 26.2 51-61 9 8.4 62 and above 2 1.9 education yes 46 43 no 61 57 education level primary 30 65.2 lower secondary 11 23.9 secondary 5 10.9 covid-19 related symptoms and vaccine usage multiple responses from waste workers on having covid-related symptoms in the last year were recorded (table 2). it was found that the majority of waste workers had a fever (89.7%) followed by cough (86%) and respiratory problems (55.1%). despite of majority of waste workers facing covid-related symptoms, only 19.6% of waste workers had done a covid test. it shows that 1.9% of waste workers got infected with covid. the number of waste workers infected with covid might be less due to the reason that a lesser number of people had gone for covid test. a majority (77.6%) of waste workers haven’t still taken the covid vaccine. from cross-tabulation (table 3), it was found that 78.9% of male and 76% of female waste workers hadn’t taken the covid vaccination. also, 93.9 % of indian waste workers hadn’t taken covid vaccine. a question was asked to find the reason for not having covid vaccination to date, where 67.5% of waste workers said they are afraid of its consequences whereas, 30.1% said they are either not asked by anyone or not allowed for a vaccine. apart from this, 50% of nepalese who were authorized to have vaccination didn't take the vaccine as they were afraid. also, the youths aged between 18-28 years were among the highest (80%) khanal a. covid-19 related symptoms and vaccination usage among informal waste workers of kathmandu, nepal 158 number of respondents who were afraid of having covid vaccine. table 2. covid-related symptoms and vaccination variables frequency (n= 107) percentage (%) covid related symptoms fever 96 89.7 fatigue 48 44.9 cough 92 86 respiratory 59 55.1 loss of smell 14 13.1 covid test yes 21 19.6 no 84 78.5 missing 2 1.9 covid detected yes 2 1.9 no 105 98.1 vaccination yes 24 22.4 no 83 77.6 reasons for no vaccination afraid 56 67.5 not asked 25 30.1 missing 2 2.4 the p-value (0.7% = 0.007) for the nationality of the people and their vaccination was found to be less than 5% (α value), which means a significant association between nationality and vaccination. it shows that the vaccination of people is dependent on their nationality. further, a test was conducted to find the strength of the association between the nationality of people and vaccination. the contingency coefficient value was found as 0.254 showing a weak association between the nationality of waste workers and vaccination. a similar case was with the nationality of waste workers and reasons behind not having the covid vaccine which shows an association (pvalue = 0.033) but was weak (contingency coefficient value = 0.245). however, the pearson chi-square test didn't show any association between gender, age group and education of waste workers with covid vaccination and reasons behind not having the vaccine. table 3. association of different characteristics with covid vaccination characteristics vaccinated (n= 107) p-value reasons for no vaccination (n= 83) p-value yes n(%) no n(%) afraid n(%) not asked n(%) gender male 12 (21.1) 45 (78.9) 0.715 29 (66) 15 (34) 0.735 female 12 (24) 38 (76) 27 (73) 10 (27) nationality nepali 22 (29.7) 52 (70.3) 0.007 37 (72.5) 14 (27.5) 0.033 indian 2 (6.1) 31 (93.9) 19 (63.3) 11 (36.7) age group 18-28 6 (18.6) 26 (81.4) 0.117 20 (80) 5 (20) 0.457 29-39 8 (22.2) 28 (77.8) 13 (52) 12 (48) 40-50 6 (21.4) 22 (78.6) 17 (74) 6 (26) 51-61 4 (44.4) 5 (55.6) 5 (100) 0 (0) khanal a. covid-19 related symptoms and vaccination usage among informal waste workers of kathmandu, nepal 159 62 and above 0 (0) 2 (100) 2 (100) 0 (0) education yes 8 (17.4) 38 (82.6) 0.278 24 (64.9) 13 (35.1) 0.456 no 16 (26.2) 45 (73.8) 32 (72.7) 12 (27.3) discussion the study found the majority of the waste workers had symptoms of fever (89.7%), cough (86%) and respiratory problems (55.1%) during the covid period which is higher than a similar study done among waste workers in bangladesh which found only 22.2% respondents having fever.17 in general, the most common symptoms in covid-19 patients include fever (81.2%), cough (58.5%) and fatigue (38.5%).26 but the difference could be due to the different time frames undertaken for the study. also, the types of respondents and the nature of their work make one symptom more common than the other. it was found that the majority of iwws from india hadn't taken the covid vaccine compared to iwws from nepal. a survey conducted in the united kingdom found a high level of covid-19 vaccine hesitancy among ethnic minority groups.27 as a majority of iwbs belong to the “madhesi” community, this could be the reason for vaccine hesitancy in kathmandu as well. it is found that there is greater vaccination hesitancy among people with lower education, unemployed people, youths and ethnic groups.28 however this study didn’t find any association between gender, age group and education of iwws with covid vaccination. a cross-sectional study conducted among 18,201 people in bangladesh, india, pakistan, and nepal found that vaccine acceptance was statistically similar in both genders in nepal.29 this is similar to the findings of this study which shows no difference between genders who had taken covid vaccination. this study found that there was a significant association between nationality and vaccination in the iwws of kathmandu. before 14th february 2022, people were required to show a nepali identity certificate (citizenship/passport/voter identity) for covid vaccination.24 this might have been the main reason the indian waste workers were deprived of having covid vaccine. the people of low-income countries have low levels of education, income, and occupation which may directly affect the vaccine-accepting processes of their people.30 a study conducted in lower-middle-income countries (india, nepal, nigeria and pakistan) found the average vaccine acceptance rate to be 80.3% where concerns about side effects were the most common reason for hesitancy.31 this study found that the most common reason for not having the covid vaccine was that the iwws were afraid to take a vaccine. the finding was similar to a cross-sectional study conducted in the benadir region, somalia which found that the majority (63.2%) of respondents refused to take the covid-19 vaccine whereas 64.4% believe it wasn’t safe.32 the reasons for vaccine hesitancy in the united kingdom were found to be concern about side effects and lack of trust.27 a study found that mild effects were seen in people in nepal after having the covid-19 vaccine and it was acceptable in the sense that the body will need some time to adopt the vaccination dose and gather an immune system to induce protective antibodies.33 a study conducted in the united states found that 67% of people would accept a covid-19 vaccine if it is recommended for them.34 a study has found that around 65%, 66%, 72% and 74% of people from bangladesh, india, pakistan and nepal, respectively are willing to be vaccinated against covid-19.29 as nepal government has allowed for covid vaccine for all (no identity cards) from february 202224, iwws should be notified and should be asked for vaccination. study limitations the study was limited to the core areas of kathmandu valley and only included the iwws. as iwbs were the respondents who mainly belongs to the terai region of nepal and neighboring india, the number of people taking the covid vaccine was less. the nepal khanal a. covid-19 related symptoms and vaccination usage among informal waste workers of kathmandu, nepal 160 government has recently allowed all foreign nationals eligible for covid vaccine, so the number might be high in the coming days. conclusion the waste workers of kathmandu seem to be reluctant to have covid tests and don’t want to take vaccines though they are having covidrelated symptoms. the majority of waste workers are afraid of taking a vaccine with indian nationals not being allowed for vaccination. though nepal government has recently relaxed the requirement of the national identity for the covid vaccine and the iwws are not unaware of it. government should convince the people to implement the vaccine for all campaigns irrespective of boundaries and territories. acknowledgments the author would like to express his gratitude to the participants of the study. references 1. kaza s, yao lc, bhada-tata p, van woerden f. what a waste 2.0: a global snapshot of solid waste management to 2050. world bank. 2018. 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https://doi.org/10.1016/j.eclinm.2020.100495 type of the paper (article int. j. occup. safety health, volume 13, no 2 (2023), 190-198 https://www.nepjol.info/index.php/ijosh 190 original article effects of emotional labor on musculoskeletal disorders among physical therapists in seoul jae kwang choi1, yeon hwan lee1 1department of safety engineering, seoul national university of science and technology, seoul, south korea abstract introduction: healthcare workers, including physical therapists, have some of the most important roles in the healthcare system, as observed during the coronavirus disease 2019 pandemic. physical therapists encounter emotionally and physically vulnerable patients, experience emotional labor, and are exposed to conditions that can lead to job stress and musculoskeletal disorders. we aimed to examine the relationships between physical therapists’ emotional labor, its effect on perceived job stress, and the risk of developing musculoskeletal disorders. methods: we conducted a 30-day survey among 230 physical therapists working in various settings from october 2 to november 1, 2019. questionnaires, including questions on musculoskeletal symptoms, perceived job stress, and emotional labor, were administered to the participants. results: the emotional labor sub-factors “overload and conflict in customer service” (β=0.201, p>0.001), “emotional inconsistency and impairment” (β=0.199, p>0.001), and “organizational support and protection system” (β=0.298, p>0.001) affected the job stress sub-factors “physical environment” (β=0.105, p>0.020), “insufficient compensation” (β=0.072, p<0.05), and “relational conflict” (β=0.083, p>0.024). these job stress sub-factors affected musculoskeletal disorders. conclusion: to prevent the long-term consequences of work-related strain, physical therapists should receive support for maintaining a healthy lifestyle and developing effective methods of communication with patients. encouragement of activities for psychological rejuvenation and sharing emotional difficulties with colleagues is also desirable. moreover, it is necessary to establish a direct line of grievance communication between physical therapists to hospitals. keywords: customer service conflict, customer service overload, emotional impairment, emotional inconsistency, job stress introduction emotions are a response to certain events or situations experienced in daily life and are an essential component of labor behavior.1 workers in the service and healthcare industries may experience “emotional labor” caused by interactions with customers and patients.2 the number of people working in these service sectors in south korea steadily increased from 7,245,658 in 2006 to 10,485,300 in 2015.3 in fact, the third work environment survey and the fourth national health and nutrition survey revealed that approximately 38–42% of all wage earners in korea are emotional laborers.4 morris and feldman defined “emotional labor” as the labor “exerted to express the emotions that an organization wants,” and classified emotional labor based on the frequency of appropriate emotional expression, degree of care required for a good emotional expression, variety of emotions expressed, and emotional inconsistency.5 physical corresponding author: yeon hwan lee, ms department of safety engineering seoul national university of science and technology 232 gongneung-ro, nowon-gu, seoul 139-743, korea phone: +82-10-5234-0692 fax: +82-02-2163-0925 e-mail: 38229@naver.com orcid id: https://orcid.org/00000001-5421-5179 date of submission: 14.04.2022 date of acceptance: 24.12.2022 date of publication: 01.04.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh.v13 i2.44002 copyright: this work is licensed under a creative commons attributionnoncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:38229@naver.com https://orcid.org/0000-0001-5421-5179 https://orcid.org/0000-0001-5421-5179 https://doi.org/10.3126/ijosh.v13i2.44002 https://doi.org/10.3126/ijosh.v13i2.44002 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ choi et al. effects of emotional labor on musculoskeletal disorders among physical therapists in seoul 191 therapists consider the patient’s physical condition alongside their emotional state to provide the best treatment. hence, physical therapists have to withhold their own emotions and cater to the patient’s needs, which is a surface behavior. if the surface behavior persists, the therapist may change jobs after experiencing emotional inconsistency and job exhaustion.6 physical therapists can become fatigued because of the extensive patient management needs. repeated occurrences of demanding emotional labor can lead to job exhaustion and affect interpersonal relationships, causing conflicts.7 based on the existing literature, we hypothesized that emotional labor could lead to emotional inconsistency resulting in cognitive inconsistencies and job exhaustion.8 this may cause various health problems, including cerebral hemorrhage, myocardial infarction, high blood pressure, musculoskeletal disorders, and depression.9 thus, job stress may affect the development of musculoskeletal disorders. therefore, we aimed to examine the relationships between physical therapists’ emotional labor, its effect on perceived job stress, and the risk of developing musculoskeletal disorders. methods a total of 230 physical therapists anonymously participated in our study between october 2 and november 1, 2019. of them, 209 physical therapists working in general hospitals (n=11), private hospitals (n=128), clinics (n=58), welfare centers (n=6), and rehabilitation centers (n=6) in seoul were included, while 21 were excluded owing to insufficient answers. a proportionate stratified sampling method was used based on the working characteristics of the population. this study was conducted in accordance with the principles of the helsinki declaration. informed consent was obtained from all study participants. the study participants agreed with the purpose and methods of the study and recognized the opportunities and risks of participating in the study. the sample size was calculated using the following formula, where “n” is the number of physical therapists registered with the korean orthopedic society (owhi korea, osteopathic health and wellness institute) under oco (osteopathic college of ontario), “n” is the sample size, “e” is the margin of error or confidence interval, “z” is the confidence level, and “p” is the observed percentage. n: 438, n: 205, e: 5%, z: 95%, p: 0.5 as shown in figure 1, the conceptual framework for the assessment of the relationship between excessive emotional labor and health suggested by park was implemented in the study.10 this is a parameter model that described the process of evaluating the results of emotional labor in three stages: contextual clues → emotional regulatory processes → long-term outcomes. figure 1. a conceptual framework for emotional labor and health choi et al. effects of emotional labor on musculoskeletal disorders among physical therapists in seoul 192 we used three sets of questionnaires to collect data regarding three variables from the study participants. for musculoskeletal symptoms, we adopted the “guideline for investigating factors for musculoskeletal strain work” from the korea occupational safety and health agency (kosha) guide (h-9-2018).11 the guideline uses a criterion from the national institute for occupational safety and health in the usa. questionnaires used for job stress and emotional labor were based on the kosha guide-h-67-2012 and kosha guide-h-163-2016.12,13 the job stress survey consisted of a total of 43 questions and contained eight sub-factors of job stress (appendix 4). the emotional labor survey consisted of a total of 24 questions and contained five sub-factors of emotional labor (appendix 2). all statistical analyses were performed using spss 25.0 (ibm corp., armonk, ny, usa). frequency analyses were performed for musculoskeletal disorder status, general characteristics, and job characteristics. the effects of job-related psychological factors on the occurrence of musculoskeletal disorders among physical therapists were analyzed by correlation analysis. a linear multivariate regression analysis was used to determine the relationship between the symptoms of musculoskeletal disorders and each type of emotional labor and between the symptoms of musculoskeletal disorders and each type of job stress. the level of significance was set at p<0.05. the variables used in the multiple regression analysis were as follows: five subfactors of emotional labor, eight sub-factors of job stress, and the presence or absence of musculoskeletal disorders. using these variables, the sub-factors of job stress and emotional labor that could cause musculoskeletal disorders were identified sequentially. results the general characteristics of physical therapists enrolled in the study are summarized below (table 1). approximately 73% (n=152) of the participants were women and 42.6% (n=89) were aged 20–30 years. the two most common departments in which the physical therapists worked were the orthopedic (45.45%, n=95) and neurology 21.1%, n=44) departments. a high proportion of participants had <5 years of experience (39.2%, n=82). regarding the work environment, the average daily working, standing, and sitting times were 8.35±2.131, 4.45±1.365, and 4.35±1.293 h, respectively (tables 1, 2). approximately 22 patients were treated daily. table 1. general characteristics of the participants (personal characteristics) characteristic response item frequency (n) percentage (%) sex male 57 27.3 female 152 72.7 age, years 20–29 89 42.6 30–39 84 40.2 40–49 30 14.4 50–59 6 2.9 >60 0 department (physical therapy unit) orthopedic 95 45.5 neurological 44 21.1 pediatric 11 5.3 others* 59 28.2 service experience, years <5 82 39.2 5–10 60 28.7 11–20 51 24.4 choi et al. effects of emotional labor on musculoskeletal disorders among physical therapists in seoul 193 21–30 13 6.2 >31 3 1.4 * other departments include welfare facilities, manual therapy rooms, and exercise clinics. table 2. general characteristics of the participants (working environment) survey question response item frequency (n) ratio (%) working time per day average time 8.35 0.9 number of patients treated per day average time 22.16 20.2 working posture average standing time 4.45 2.7 average sitting time 4.35 1.9 type of agency general hospital 11 5.3 private hospital 128 61.2 clinic 58 27.8 welfare center/ rehabilitation center 12 5.7 participation in education regarding musculoskeletal disease prevention yes 47 22.5 no 162 77.5 n, number table 3. results of the multiple regression analysis on the association between job stress and musculoskeletal disorder-related factors model unstandardized coefficients standardized coefficients t pvalue coefficient of determination f b standard deviation beta (constant) 1.615 0.575 2.807 0.005 0.076 4.125** physical environment 0.105 0.045 0.136 2.332* 0.020 job demand 0.023 0.016 0.079 1.431 0.153 job autonomy -0.030 0.048 -0.033 -0.616 0.538 relational conflict -0.083 0.037 -0.120 -2.268* 0.024 job insecurity -0.017 0.025 -0.035 -0.661 0.509 organizational system -0.031 0.030 -0.071 -1.029 0.304 insufficient compensation 0.072 0.029 0.164 2.540* 0.011 corporate culture 0.007 0.039 0.011 0.188 0.851 multiple regression analysis **p<0.01 t, a statistical indicator of the difference in sample means; f, a statistical indicator of the difference in several sample groups the results of the multiple regression analysis on the association between job stress and musculoskeletal disorder-related factors are shown above (table 3). table 4 presents the results of the correlation analysis between emotional labor and job stress factors. the analysis showed the highest positive correlation between the emotional labor subfactor “organizational support and protection system” and the job stress sub-factor choi et al. effects of emotional labor on musculoskeletal disorders among physical therapists in seoul 194 “organizational system” (r=0.462, p<0.01). other positive correlations were observed between the following: 1) emotional labor sub-factor “effort to control emotion and its diversity” and job stress sub-factors “physical environment” (r=0.309, p<0.01) and “job demand” (r=0.310 and p<0.01); 2) emotional labor sub-factor “overload and conflict in customer service” and job stress sub-factors “physical environment” (r=0.358, p<0.01) and “job demand” (r=0.326, p<0.01); 3) emotional labor subfactor “emotional inconsistency and impairment” and job stress sub-factors “physical environment” (r=0.353, p<0.01) and “insufficient compensation” (r=0.383, p<0.01); 4) emotional labor sub-factor “surveillance and monitoring by organization” and job stress sub-factors “job demand” (r=0.307, p<0.01) and “corporate culture” (r=0.343, p<0.01); and 4) emotional labor sub-factor “organizational support and protection system” and job stress sub-factors “organizational system” (r=0.462, p<0.01) and “corporate culture” (r=0.436 and p<0.01). table 4. results of correlation analysis between emotional labor and job stress factors correlation emotional labor job stress v1 v2 v3 v4 v5 v1 v2 v3 v4 v5 v6 v7 v8 emotional labor v1 1 0.491* 0.562 ** 0.312 ** 0.122 0.30 9** 0.310 ** 0.140 * 0.072 0.104 0.278 ** 0.287 ** 0.14 9* v2 1 0.567 ** 0.382 ** 0.213 ** 0.35 8** 0.326 ** 0.131 0.040 0.098 0.289 ** 0.295 ** 0.27 4** v3 1 0.444 ** 0.191 ** 0.35 3** 0.307 ** 0.160 * 0.009 0.183 ** 0.313 ** 0.383 ** 0.26 6** v4 1 0.245 ** 0.15 5* 0.307 ** 0.189 ** 0.153 * 0.174 * 0.303 ** 0.243 ** 0.34 3** v5 1 0.11 1 0.073 0.252 ** 0.435 ** 0.252 ** 0.462 ** 0.407 ** 0.43 6** job stress v1 1 0.370 ** 0.250 ** 0.059 0.235 ** 0.419 ** 0.406 ** 0.28 4** v2 1 0.357 ** 0.015 0.137 * 0.285 ** 0.160 * 0.24 7** v3 1 0.017 0.036 0.123 0.104 0.01 2 v4 1 0.244 * 0.359 * 0.201 * .029 4* v5 1 0.405 * 0.272 ** 0.30 9* v6 1 0.598 * 0.45 3* v7 1 0.40 1* v8 1 ** p<0.01, * p<0.05 emotional labor: v1, effort to control emotion and its diversity; v2, overload and conflict in customer service; v3, emotional inconsistency and impairment; v4, surveillance and monitoring by organization; v5, organizational support and protection system job stress: v1, physical environment; v2, job demand; v3, job autonomy; v4, relational conflict; v5, job insecurity; v6, organizational system; v7, insufficient compensation; v8, corporate culture choi et al. effects of emotional labor on musculoskeletal disorders among physical therapists in seoul 195 the results of multiple regression analysis on the association between job stress sub-factors and musculoskeletal disorders are presented below (table 5). physical environment (β=105, p>0.020) and insufficient compensation (β=0.072, p>0.011) were significantly associated with musculoskeletal disorders. table 5. reference values for job stress factor conversion scores by area stratified by sex area median value of korean workers the meaning of a score male female physical environment 44.5 44.5 a higher reference value indicates a worse physical environment job demand 50.1 54.2 a higher reference value indicates a higher job demand job autonomy 53.4 60.1 a higher reference value indicates a lower job autonomy relational conflict 33.4 33.4 a higher reference value indicates a higher conflict in relations job insecurity 50.1 50.1 a higher reference value indicates a higher relative instability of the job organizational system 52.4 52.4 a higher reference value indicates a less organized organization insufficient compensation 66.7 66.7 a higher reference value indicates a higher relative insufficiency of the compensation system corporate culture 41.7 41.7 a higher reference value indicates a more problematic corporate culture ※ the median value in korean workers in each area may change depending on the results of future studies. the emotional labor sub-factors “effort to emotional control and its diversity” (β = 0.074, p = 0.045), “overload and conflict in customer service” (β = 0.201, p <0.001), and “emotional inconsistency and impairment” (β = 0.087, p = 0.03) affected the job stress sub-factor “physical environment”; while the job stress sub-factor “physical environment” (β = 0.105, p = 0.020) affected the incidence of musculoskeletal disorders. the emotional labor sub-factors “overload and conflict in customer service” (β = -0.144, p = 0.017), “surveillance and monitoring by organization” (β = 0.134, p = 0.012), and “organizational support and protection system” (β = 0.248, p <0.001) affected the job stress sub-factor “relational conflict”, while the job stress sub-factor “relational conflict” (β = -0.083, p = 0.024) affected the incidence of musculoskeletal disorders. the emotional labor sub-factors “emotional inconsistency and impairment” (β = 0.199, p <0.001) and “organizational support and protection system” (β = 0.298, p <0.001) affected the job stress sub-factor “insufficient compensation”, and the job stress sub-factor “insufficient compensation” (β = 0.072, p <0.05)affected the incidence of musculoskeletal disorder (figure 2). choi et al. effects of emotional labor on musculoskeletal disorders among physical therapists in seoul 196 figure 2. model depicting the sequential influence of emotional labor and job stress on musculoskeletal disorders discussion in this study, three main findings were presented regarding the effect of physical therapists’ emotional labor on the incidence of musculoskeletal disorders. especially, it was found that physical therapists’ surface behavior, job exhaustion, and emotional management affected the physical burden, interpersonal relationships, and level of compensation, respectively, and eventually caused musculoskeletal disorders. as confirmed during the coronavirus disease 2019 pandemic, medical personnel are a key factor in healthcare systems. owing to the growing aging population, the role of physical therapists is becoming increasingly important. to provide good quality medical services, the emotional and physical health of physical therapists must be managed. to manage the emotional labor of physical therapists, it is necessary to develop and disseminate workers' self-protection manuals, including appropriate service standards and details of patient treatment procedures. appropriate job cycles and service standards, adequate numbers of treated patients, comfortable spaces for relaxation, and adequate rest time are necessary for creating a suitable corporate culture. future research should focus on document-based operational procedures, such as in-hospital treatment daily logs and customer complaint records, to identify relevant factors affecting the size and intensity of physical therapists' emotional labor. it is desirable to evaluate these factors using the korean emotional labor evaluation tool used in this study (appendix 2).13 globally, musculoskeletal disorders are the second most common group of disorders, with low back pain being the most common.14 this could be attributed to a decline in physical activity because of the development of mobile devices. recent data suggest that one in two adults from the usa complains of musculoskeletal disorders, which is comparable to the frequency of cardiovascular and respiratory diseases.15 approximately, 57.5%, 58%, and 55.5% of physical therapists in the usa, the uk, and australia, respectively, have musculoskeletal disorders.16,17 workload and excessive work-related activities are the most common causes of musculoskeletal disorders in this professional group (appendix 3).18 healthcare workers are more likely to experience job stress than non-health workers (appendix 4). stress triggered by emotional labor has a negative impact on organizational commitment and job satisfaction.19 this adverse effect might result in poor quality of care, which may affect patient outcomes. excessive workload increases the choi et al. effects of emotional labor on musculoskeletal disorders among physical therapists in seoul 197 frequency of medical disputes and increases competition among medical institutions, making clinicians, including physical therapists, more likely to experience high levels of emotional labor and job stress. 20 physical therapists need a lot of physical strength for activities such as lifting, moving, pushing, pulling, bending, and twisting movements while in contact with patients, putting excessive pressure on the musculoskeletal system (appendix 1).21 stretching to relax the tensed body may be an appropriate form of intervention. additionally, body relaxation through stretching has been reported to affect emotions.22 future studies should also examine the effects of interventions, such as self-developed stretching methods, that reduce musculoskeletal disorder symptoms related to emotional labor and job stress.23 this study has several strengths. to our knowledge, this is the first study to investigate the process, by which the emotional labor of korean physical therapists causes job stress and musculoskeletal diseases. therefore, our findings can be used to correct the misperception that telephone operators and service workers are the only emotional workers. however, our study has an important limitation. especially, the participants were all physical therapists who provided treatment based on osteopathy. as this study was inspired by and furthers the scope of the current published literature, it is expected that there will be followup studies targeting the examination of a wider range of occupational groups to expand our findings. references 1. 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musculoskeletal symptom and job stress for care helpers. j korean soc phys med. 2013;8(2):183–92. available from: http://dx.doi.org/10.13066/kspm.2013.8.2.183 23. choi jk, kim sk. body circulatory training. available from: https://vimeo.com/127443468 https://www.kosha.or.kr/kosha/data/guidancedetail.do https://www.kosha.or.kr/kosha/data/guidancedetail.do https://www.kosha.or.kr/kosha/data/guidancedetail.do https://doi.org/10.1186/s13063-017-2306-8. https://doi.org/10.1186/s13063-017-2306-8. https://doi.org/10.2471/blt.17.204891 https://doi.org/10.2522/ptj.20070127 https://doi.org/10.2486/indhealth.2015-0127 https://doi.org/10.1589/jpts.28.2358 https://doi.org/10.14474/ptrs.2018.7.4.191 https://doi.org/10.1007/s10067-006-0240-3 https://doi.org/10.1007/s10067-006-0240-3 http://dx.doi.org/10.13066/kspm.2013.8.2.183 https://vimeo.com/127443468 type of the paper (article int. j. occup. safety health, volume 13, no 4 (2023), 441-449 https://www.nepjol.info/index.php/ijosh 441 original article knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal jyoti s1,, lama p1, yadav a2, vaidya s3, joshi sk1 1department of community medicine, kathmandu medical college, sinamangal, kathmandu, nepal 2maa janki hospital pvt ltd., nepalgunj, 3nepal occupational safety and health society nepal, nepal abstract introduction: in this fast-developing world, food production has also been changing, making people suffer from various health issues because of pesticide poisoning. unsafe methods in handling pesticides, especially in middle and lowincome countries like nepal are still practiced, although the deleterious health effects either go unnoticed or are missed or are diagnosed late. few of the older less costly pesticides remain for years in soil and water although few of them have been banned they are still available in many developing countries. the study aimed to assess knowledge, attitude, and practice regarding pesticide use among agricultural workers and farmers' awareness of pesticide labels on pesticide bottles or packets. methods: a cross-sectional study among 74 conveniently selected agricultural workers, who used or ever-used pesticides within the last six months was conducted in lamatar village development committee, lalitpur district from january 2022 to february 2022. ethical clearance was obtained from the institutional review committee of kathmandu medical college. the questionnaire was adapted from literature about personal protective equipment with some modifications according to the local context. data was collected through a face-to-face interview. results: among the total 74 respondents 49 (66.2%) were females and only 25 (33.8%) were males. most of them had no formal education but could read and write. however, less than half 32 (43.2%) had adequate knowledge while the majority 49 (66.2%) had a negative attitude towards the use of pesticides. however, only 32 (43.2%) had good practice handling pesticides and its effect. conclusion: this study showed low knowledge regarding pesticides, their health effects, and poor practice however, a negative attitude towards the use of pesticides. but pesticide is still widely used because of the demand for more earnings. so, we would recommend that there is a need for time-to-time regular community-based training regarding how to safely handle pesticides and the availability of less harmful fertilizers products at retailers or consultancies. keywords: attitude, farmer, knowledge, pesticides, practice. introduction in nepal, one-third of the nation's gross domestic product is contributed to agriculture sectors and engages around 66% of the total nepalese population with a significant contribution to national economic growth.1 in this fast-developing world, food production has also been changing making suffer from various health effects because of pesticide poisoning, according to world health organization (who), 500,000– 1,000,000 people per year are affected.2 a study from india shows 70% of respondents knew about pesticide affects health, however, only 40% were aware that it also affects the environment. the respondent’s awareness of modes of entry was less as only 42% knew about it. among them, 70% of respondents have not used any protective equipment during pesticide spraying.3 in many developing countries and some corresponding author: dr. sabita jyoti, department of community medicine, kathmandu medical college, sinamangal, kathmandu, nepal tel.: +977 9819528831 e-mail: sabitajyoti19@gmail.com https://orcid.org/0000-00033853-4051 date of submission: 15.03.2023 date of acceptance: 04.06.2023 date of publication: 15.07.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh. v13i4.53257 copyright: this work is licensed under a creative commons attributionnoncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh https://orcid.org/0000-0003-3853-4051 https://orcid.org/0000-0003-3853-4051 https://doi.org/10.3126/ijosh.v13i4.53257 https://doi.org/10.3126/ijosh.v13i4.53257 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ jyoti et al. knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal 442 developed countries still, unsafe methods of handling pesticides are practiced especially in middle and low-income countries like nepal, although the deleterious health effects either go unnoticed and are missed or are diagnosed late.4 thus, understanding farmers' knowledge of pesticides and safety practices is vital to provide valuable information aimed at preventing or reducing the health and environmental hazards associated with pesticides.4 few of the older less costly pesticides remain for years in soil and water although few of them have been banned. however, few are still available in many developing countries as pesticides play a significant role in food production through protection or increased yields and also to increase the frequency of production on the same land.5,6 the person most at risk is those who are directly exposed (including agricultural workers who apply pesticides and anyone else in the immediate area during, and shortly after pesticides are spread). more than 1000 pesticides are used around the world to ensure food is not damaged or destroyed by pests and each of them has different properties and toxicological effects.5,6 pesticides such as dichlorodiphenyltrichloroethane (ddt) and lindane, are older as well as less costly and can remain for years in soil and water. this is the reason who has two aims firstly to ban the pesticides that are most toxic to humans, as well as pesticides that remain for the longest time in the environment; and secondly to protect public health by setting maximum limits for pesticide residues in food and water.6 pesticides are chemicals used to control any organism that might invade or damage crops, food stores, or homes. pesticides in either of its form whether insecticides or herbicides or rodenticides or fungicides are used for protecting harvested crops and seeds from fungal rot.7 the practices of pesticide handling and farmers' cognizance about pesticide use and overuse also play a vitally important role in safe spraying.8,9,10 so, the study aims to find knowledge, attitude, and practice of pesticide use among agricultural workers and also to assess the awareness of farmers about pesticides label on pesticide bottles or packets. methods a community-based cross-sectional study was conducted between january 2022 to february 2022 in lamatar village development committee, lalitpur district, nepal. ethical approval was taken from the institutional review committee (irc) of kathmandu medical college. all the participants were informed in detail about the study and written consent was taken. the inclusion criteria were both men and women who had been working as farmers for at least 6 months and were exposed to pesticides for at least 6 months. exclusion criteria were those involved in other professions and those who did not give consent. sample size formula: n= z2.p.q/e2 p = prevalence (not wearing any protective clothing during spraying pesticides) =0.26 10 q = 1-p = 0.74 e = allowable error i.e. 10% so, the total sample size (n) = 74 convenient sampling was taken and we took data from all the available farmers present at the time of data collection. data was collected using a questionnaire through face-to-face interviews. the questionnaire preparation was based on literature about the use of personal protective equipment with some modifications according to the local context. the questionnaire was divided into 5 parts, with questions on demographic information, knowledge, attitude, the actual use of personal protective equipment (ppe) during spraying, and awareness of farmers about pesticide labels on pesticide bottles or packets. the collected data was entered and statistical analysis was performed using statistical package for social sciences (spss) version 21. descriptive statistical tools like frequency, percentage, median, and interquartile range were used to express the results. to test the variable's distribution, a test of the normality of the data was performed. the data was considered as not normally distributed if the significance of the shapiro-wilk test was < 0.05. pearson chi-square test was used for bivariate analysis to determine the presence of an association between the dependent and independent variables. all tests were done with a significance level of 5% (p-value <0.05). jyoti et al. knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal 443 results there was a total of 74 participants, among them more than two-thirds 49 (66.2%) were females and 25 (33.8%) were males. the majority of the respondents belonged to the age group of 35-44 years (31.1%). the age range of participants was 23 to 77 years with a median age of 45 years and an interquartile range of 20 years, respectively. the majority of the respondents were hindu 72 (97.3%) and only two (2.75%) were buddhist by religion. the brahmin was highest 37 (50%) by ethnicity followed by janajati 27 (36.5%), madhesi 5 (6.8%), chhetri 4 (5.4%), and 1(1.4%) person did not know his/her ethnicity. most of them 23 (31.1%) had no formal schooling but could read and write. the agriculture/farmer was 70 (94.6%) by occupation while 2 (2.7%) were homemakers and 1(1.4%) person was private and 1(1.4%) was a government service worker in our study as we took convenient sampling. regarding the pesticide information, 57 (77%) of respondents had known from retailers while 14 (18.9%) from consultancies, and only 3 (4.1%) came to know from co-farmers. about new pesticides respondents had known from 45 (60.8%) retailers followed by co-farmers 22 (29.8%), and consultancies 7 (9.5%). half of the respondents mixed powder and liquid pesticides with bare hands 37 (50.0%) followed by using sticks 28 (37.8%) and 9 (12.2%) respondents used other methods sometimes using clothes sticks or plastic etc. among the respondents, 34 (45.9%) stored their pesticides in a store room within the house and 31 (41.9%) stored them outside the house and 9 (12.2%) on the roof. more than half 41(55.4%) did not know the mode of contact with pesticides in their body parts however, 32 (43.2%) of them knew about it. about 71 (95.9%) of respondents disposed of containers of powder or liquid pesticides by throwing them in a dustbin and 3 (4.1%) of them throw them in an open field. however, the majority of 68 (91.9%) respondents reused the sack/container of solid pesticides by washing it and 6 (8.1%) threw it. the majority of the respondents washed the pesticide equipment 47(63.5%) at nearby water sources, 12(16.2%) outside the home and 15(20.3%) at home. according to them 54(73%) thought pesticides were harmful to the soil as well as human health, and only 20(27%) thought it was not harmful. however, if they had any health issues or effects of pesticides, the majority 42(56.8%) had consulted with a doctor, 27(36.5%) had consulted with a healthcare worker and 3(4.1%) had treated with home remedies and 2(2.7%) of them ignore. the attitude of the respondents on pesticide use was evaluated by using a 5-point likert scale consisting of nine mixed types of questions (table 1). table 1: attitude response of respondents (n=74) statements strongly disagree (%) disagre e (%) neither agree nor disagree (%) agree (%) strongly agree (%) personal protective equipment (ppe) is not required when pesticides are used in a little amount 18 (24.3) 44 (59.5) 6 (8.1) 4 (5.4) 2 (2.7) good-quality pesticides are not dangerous 0 (0) 5 (6.8) 40 (54.1) 28 (37.8) 1 (1.4) using pesticides is essential for more production 1 (1.4) 4 (5.4) 8 (10.8) 45 (60.8) 16 (21.6) after pesticides exposure bathing is not required nor changing clothes 1 (1.4) 31 (41.9) 13 (17.6) 28 (37.8) 1 (1.4) ppe is important to prevent the body from pesticide poisoning 0 (0) 1 (1.4) 9 (12.2) 25 (33.8) 39 (52.7) bathing immediately after using pesticides decreases poisoning 0 (0) 1 (1.4) 18 (24.3) 47 (63.5) 8 (10.8) jyoti et al. knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal 444 using pesticides during smoking increases inhalation of pesticides 0 (0) 2 (2.7) 18 (24.3) 38 (51.4) 16 (21.6) during the use of pesticides, drinking and eating will have no problem 12 (16.2) 37 (50.0) 14 (18.9) 8 (10.8) 3 (4.1) using ppe is uncomfortable when i am using pesticides 1 (1.4) 21 (28.4) 34 (45.9) 16 (21.6) 2 (2.7) table 2: practice among respondents (n=74) statements always (%) sometimes (%) never (%) use a sprayer while using the mixture of powder and liquid pesticide 44 (59.5) 9 (12.2) 21 (28.4) when the sprayer nozzle is blocked do you clean it with the mouth 20 (27) 11 (14.9) 43 (58.1) immediately after spraying and dispersing pesticides take a bath 24 (32.4) 23 (31.1) 27 (36.5) wear a hat while spraying 41 (55.4) 6 (8.1) 27 (36.5) i don’t smoke or eat or drink 27 (36.5) 6 (8.1) 41 (55.4) i wear glasses when spraying liquid pesticides 5 (6.8) 5 (6.8) 64 (86.5) i wear boots when spraying liquid, powder and solid pesticides 23 (31.1) 8 (10.8) 43 (58.1) i wear long sleeve clothes, long gloves and a mask when spraying the pesticides 38 (51.4) 15 (20.3) 21 (28.4) i wash my hands and change clothes after using pesticides 41 (55.4) 27 (36.5) 6 (8.1) the practice of respondents is illustrated above (table 2).for cultivating crops for respondents' own families, they preferred the use of botanical pesticides 56 (75.7%) and 18 (24.3%) preferred chemical fertilizers. more than half 41(55.4%) did not look for the danger sign of pesticides however only 33(44.6%) looked for danger signs on pesticides. pesticide color code toxicity and the label was also ignored by more than half 42(56.8%), and an equal number of them did not look for the expiry date and read the manufacture date. though, 32 (43.2%) looked at the danger signs and read the manufacturer and expiry date. among respondents, 38 (51.4%) followed careful safe titer and correct dosage whereas, 36(48.6%) did not follow. figure 1: knowledge level of the respondents jyoti et al. knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal 445 the final score on knowledge was calculated according to the score obtained in fourteen different aspects of pesticides. the respondents' knowledge was classified into either adequate (above the median) or inadequate (below or equal to the median) based on the median score. out of the total respondents, nearly 32(43.2%) had adequate knowledge whereas, 42(56.8%) had inadequate knowledge. out of 25 males, 11(44%) had adequate knowledge and 14(56%) had inadequate knowledge. among 49 females, 21(42.9%) had adequate knowledge and 28(57.1%) had inadequate knowledge (figure 1). according to the respondents' scores on each statement of attitude, the final scores were calculated. the respondents were then classified into either having a positive attitude (above the median) or a negative attitude (below or equal to the median) based on the median score. out of the total respondents, the vast majority 49 (66.2%) had a negative attitude while the remaining 25 (33.8%) had a positive attitude. out of 25 males, 8 (32%) had a positive attitude and 17 (68%) had a negative attitude. among 49 females, 17 (34.7%) had a positive attitude and 32 (65.3%) had a negative attitude (figure 2). figure 2: attitude level of the respondents figure 3: the practice level of the respondents according to the score obtained in ten different aspects of pesticides, the final score on practice was calculated. the level of practice of the respondents was classified into either good (above median) or poor (below or equal to the median) based on the median score. out of the total respondents, nearly 32 (43.2%) had good practice while 42 (56.8%) had poor practice. out of 25 males, 10 (40%) had good practice and 15 (60%) had poor practice. among 49 females, 22 (44.9%) had good practice and 27 (55.1%) had poor practice (figure 3). jyoti et al. knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal 446 the chi-square test was applied to test the association between socio-demographic characteristics and respondents' knowledge levels. the test showed a significant difference in respondents' knowledge levels among different age groups (p=0.013). the test showed no significant difference in the knowledge level of respondents among gender, religion, ethnic groups, and education levels (p > 0.05) (table 3). table 3: socio-demographic characteristics and level of knowledge of respondents (n=74) characteristics class level of knowledge p value inadequate adequate age groups <35 10(100) 0(0) 0.013 35-44 11(47.8) 12(52.2) 45-54 12(63.2) 7(36.8) 55-64 6(54.5) 5(45.5) ≥65 3(27.3) 8(72.7) gender male 14(56) 11(44) 0.925 female 28(57.1) 21(42.9) religion hindu 40(55.6) 32(44.4) 0.211 buddhist 2(100) 0(0) ethnicity janajati 13(48.1) 14(51.9) 0.326 madhesi 3(60) 2(40) brahmin 21(56.8) 16(43.2) chhetri 4(100) 0(0) others 1(100) 0(0) education illiterate 7(58.3) 5(41.7) 0.396 no formal schooling but can read and write 10(43.5) 13(56.5) primary school 5(45.5) 6(54.5) middle school 6(60) 4(40) high school 7(70) 3(30) intermediate 5(83.3) 1(16.7) graduate (bachelor's) or postgraduate (master) 2(100) 0(0) discussion the consumption of fruits and vegetables is essential for health, as inadequate intake enhances the establishment of risk factors for various non-communicable diseases.11 similarly in children, even low-dose exposure to pesticides affects neurological and behavioral development, accidental exposure is associated with cancer, attention deficit hyperactivity disorder (adhd), and autism.7 however, there is wide use of pesticides in developing as well as developed countries.4 majority of the farmers in our study were females not in alignment with other studies. the reason is the women were available at their houses and field at the time of study whereas, the males did other work and mostly transported the crops to buyers.5,8,9,10,12 the age of farmers was between the age group of 35-40 years and this finding is similar to other studies.8,9 most of the farmers in our study were hindu 72(97.3%) and had no formal education 23(31.1%) and the majority 70(94.6%) are farmer/agricultural workers by occupation, this was similar to other studies.7,9 a study by rijal et al. has reported that information regarding pesticides is obtained from retailers 57(77%).9 in our study we had a similar finding to a study from india, 32(56%) of farmers had good knowledge regarding pesticides.10 mohanty et al. reported respondents were not using any protective equipment during pesticide spraying in our study also only 42(56.8%) were using ppe.3 bhandari g study jyoti et al. knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal 447 state higher use of mask, boot, and clothes which is not similar to our finding as in our study only 18(24.3%) were using a mask, 12(16.2%) were using gloves and only 3 (4.1%) used shoes or boot. however, more than half 41(55%) use other methods like clothes on the head which is similar to the report of mohanty et al., rijal et al., and bhandari g.3,9, 13 the majority of farmers 34 (45.9%) store pesticides within the house in store similar to the finding by sachan b et al. and other studies.8,9,14,15 maximum of 54 (73%) of farmers accept pesticides are harmful to the soil as well as human health and only 20 (27%) think it is not harmful which is not similar to finding from india.8 the farmers agreed 62(83.8%) that personal protective equipment(ppe) is required even if pesticide use is a little similar to the findings by sai mv et al. 10 and rostami f et al.17 however more than half 40(54.1%) of them are not sure whether good quality pesticides are less dangerous or not, this finding is not in alignment with findings from other studies; it could be because of the different settings and knowledge of farmers.8.10,17 pesticide use is essential for more production according to respondents as 61(82.4%) agree to it, this is similar with finding from other studies.8,9 the farmer knew bathing after pesticide exposure as well as changing clothes is necessary.16 more than half 49(66.2%) of them disagree that drinking and eating during pesticide spraying will not cause any problems.17 majority 54(73.3%) of them knew smoking while using pesticides increases its inhalation these are in line with those reported by rostami f et al. findings.17 most farmers (59.5%) use a sprayer while using a mixture of powder and liquid pesticide and never use a mouth to clean when the nozzle is blocked, this finding is in line with other studies.17,18 however, many of them 27(36.5%), do not take a bath immediately after spraying and dispersing pesticides nor wear glasses or boots when spraying this is not similar to the finding reported by rostami et al.17 the farmer wears a hat or clothes when spraying, and do not smoke or eat or drink, and also puts long sleeves clothes during spraying pesticides, which is in alignment with finding in other studies.8,9,14,16,17 the majority of the farmers 69(91.9%) wash their hands with soap and water similar to the study by bhandari and zyoud et al.16,18 for cultivating crops for their own family 56(75.7%) prefer botanical pesticides.14 more than half 41 (55.4%) did not look at danger signs or read and follow the pesticide label this finding aligns with other studies.8,9 pesticides color code toxicity and label is also ignored by more than half 42(56.8%) similar to the finding by rijal et al.9 conclusion this study showed low knowledge regarding pesticides among the respondents and the majority of them were females. females also had inadequate knowledge about its health effects and poor practice along with a negative attitude towards the use of pesticides, however still widely used because of the demand for more earnings. so, we would recommend that there is a need for time-to-time regular community-based training regarding safely handing pesticides and the availability of less harmful fertilizers products at retailers or consultancies. limitations since the study is conducted in a single setting the findings cannot be compared with other parts of the country. acknowledgments the authors are thankful to the faculty members at the department of community medicine, kathmandu medical college, and the study participants for their enormous support and help. references 1. food and agricultural organization nepal:programmes in nepal[internet].[cited 2021 dec 15].available from: https://www.fao.org/nepal/programmes-andprojects/en/ 2. world health organization. international https://www.fao.org/nepal/programmes-and-projects/en/ https://www.fao.org/nepal/programmes-and-projects/en/ jyoti et al. knowledge, attitude, and practice of pesticide use among agricultural workers of lamatar, lalitpur, nepal 448 programme on chemical safety, guidelines on the prevention of toxic exposures education and public awareness activities. geneva: world health organization. 2004[internet].[cited 2021 dec 15]. available from: https://www.who.int/teams/environment-climatechange-and-health/chemical-safety-and-health 3. mohanty mk, behera bk, jena sk, srikanth s, mogane c, samal s, et al.. knowledge attitude and practice of pesticide use among agricultural workers in puducherry, south india. j forensicleg med. 2013 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[cited 2023 jan 26]; 23(1):42. available from https://doi.org/10.4103%2fijoem.ijoem_153_18 18. zyoud se, sawalha af, sweileh wm, awang r, alkhalil si, al-jabi sw, et al. knowledge and practices of pesticide use among farm workers in the west bank, palestine: safety implications. environ health prev med. 2010 jul. [cited 2023 jan 28]; 15:252-61. available from: https://doi.org/10.1007/s12199-010-0136-3 https://doi.org/10.4103%2fijoem.ijoem_153_18 type of the paper (article int. j. occup. safety health, volume 13, no 3 (2023), 386-395 https://www.nepjol.info/index.php/ijosh 386 original article the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia rojak ob1, handayani y1 1program studi d-iv keselamatan dan kesehatan kerja, politeknik ketenagakerjaan, 13740, jakarta, indonesia abstract introduction: miscommunication can cause accidents in workplaces due to ineffective occupational safety and health (osh) communication. there are many factors of ineffective osh communication, one of which is the language barrier. the research aims to unveil the types of language barriers and their relation to the effectiveness of osh communication in indonesia. methods: a descriptive cross-sectional approach using a structured questionnaire was done in this research. the structured questionnaire survey was done among 102 workers in west java, indonesia. spearman rho was used to determine the correlation between language barriers and effective osh communication. the research was conducted between august and november 2022. results: all of the types of language barriers except vernacular correlate positively, strongly, and significantly to the effectivity of osh communication (0.50 ≤ r ≤ 0.699, p-value < 0.05). vernacular correlates positively, moderately, and significantly to the effectivity of osh communication (r 0.497, p-value < 0.05). conclusion: based on the findings, osh communication should be communicated accurately, clearly, and concisely in a language that everyone can understand. keywords: communication, language barriers, occupational health, occupational safety, osh introduction in indonesia, the social security administering body on employment (bpjamsostek) reports that the number of total work accidents has been increasing by 22.11% for the past three years, from 182,835 cases in 2019 to 234,370 in 2021.1 the number is apprehensive regardless not all of the cases cause fatality. the government has enacted act number 13 year 2003 concerning manpower affairs which stated in article 87 that any company is obliged to apply the osh management system to protect the safety of workers to achieve optimally higher productivity.2 to implement article 87, the government has established the regulation of the government number 50 year 2012 known as osh management system.3 this management system is in line with iso 45001:2018, an international standard regarding osh management systems. within the standard, there is an aspect of osh communication, which is routine communication regarding safety matters between stakeholders in an organization to improve safety in the workplace.4 this aspect is very important because corresponding author: octovianus bin rojak, lecturer, occupational safety and health study program, politeknik ketenagakerjaan, jalan pengantin ali no. 71a, ciracas, jakarta timur, daerah khusus ibukota jakarta 13740 indonesia tel.: +62 81384072088, e-mail: octovianus@polteknaker.ac.id orcid id: https://orcid.org/0000-0002-92942999 date of submission: 09.01.2023 date of acceptance: 06.05.2023 date of publication: 01.07.2023 conflicts of interest: none supporting agencies: politeknik ketenagakerjaan doi:https://doi.org/10.3126/ijosh.v13i3.49980 copyright: this work is licensed under a creative commons attributionnoncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:octovianus@polteknaker.ac.id https://orcid.org/0000-0002-9294-2999 https://orcid.org/0000-0002-9294-2999 https://doi.org/10.3126/ijosh.v13i3.49980 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ rojak et al. the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia 387 it has the purpose of eliminating hazards and minimizing osh risk.5 the communication can be implemented through several methods including newsletters, emails, memorandums, caution signs, signposts, and other indications of safety.6 another aim of safety communication is making sure that everyone comprehends their roles and responsibilities concerning osh, regardless of the safety managers play significant roles in ensuring all stakeholders are fully informed about osh policies, practices, concerns, and other information.4,7 it is revealed that osh communication mediates the association between safety culture and safety performance partially.8 however, as mentioned earlier, accidents still happened due to the ineffectiveness of osh communication. the ineffectiveness of communication can be caused by many factors, one of which is the language used. as conscious individuals who are aware of the existence of others, we utilize language as our primary tool to communicate and interact with them during every encounter.9–13 nevertheless, language remains the main impediment to effective communication due to the barriers it carries. language barriers cause adversities in the capital market, healthcare, scientific community, and safety of workers.14–17 language barriers avert people from comprehending each other which causes miscommunication; something that should be avoided especially when it comes to safety in the workplace. the tenerife tragedy, the deadliest accident in aviation history, is one of the examples of accidents due to miscommunication in the workplace. language barriers or sometimes known as linguistic barriers appeared when at least two parties who do not share the same language try to communicate but failed to interpret the messages, leading to the absence of communication.12 considered as one the most impeding factors to communication, language barriers derive from foreign languages, dialects, pidgins, accents, jargon, slang, word choice, literacy, lexical, grammar, and spelling.18 language barriers create difficulties for workers in communicating occupational hazards and understanding osh information, which may enhance the workers’ exposure to osh risks.17 in recent years, much research regarding language barriers has been conducted as well as safety communication. the research related to language barriers generally discusses immigrants' difficulties outside of indonesia in communicating which caused them to have difficulty in getting access to health care.9,10,19,20 meanwhile, the research regarding safety communication generally discusses the use of communication for improving safety.21–24 however, research regarding language barriers and their relation to effective osh communication in indonesia has not been widely disseminated. hence, this research aims to reveal the correlation between language barriers, consisting of foreign language, vernacular, jargon, word choice, and spelling, and effective osh communication in the indonesian context. methods the research employed a descriptive crosssectional approach using a structured questionnaire which was developed based on the colb-q questionnaire and safety communication with some modifications relevant to the research. 25–27 the population of the study comprised outsourced security guards who worked for pt abc, a security service company in indonesia. pt abc assigns its outsourced security guards to companies from various types of industries throughout indonesia. the sampling method used in this study was purposive sampling, with the inclusion of those assigned to the power plant, as it posed the highest level of risk based on the hazard identification, risk assessment, and control determination (hiradc) conducted by pt abc.28 the power plant mentioned was the def power plant, located in west java, indonesia. more than 70% of the stages of work carried out by the outsourced security guards in this power plant were classified as significant. one hundred and two (102) outsourced security guards were working at the def power plant who were the respondents in this research conducted between august and november 2022. rojak et al. the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia 388 to obtain the data for analysis, an online questionnaire was distributed to the respondents. the respondents filled out the consent form before proceeding to the questionnaire. since the respondents in this research are mostly indonesians, the questionnaire was prepared in indonesian, regardless of whether the original instrument was developed in english. next, the questionnaire was pre-tested to ensure validity by discussing it with two experts in the field of osh and a linguist. the questionnaire used a five-point likert scale item; (1) strongly disagree, (2) disagree, (3) neutral (neither agree nor disagree), (4) agree, and (5) strongly agree.28 after that, statistical analysis was used to test the validity (pvalue < 0.05; valid) and reliability (cronbach’s alpha > 0.7; reliable) of the items.29 the collected questionnaire was processed by the statistical software, minitab 21. the approach used to determine the correlation between language barriers and effective osh communication was spearman's rho. the correlation coefficients of 1.00 or -1.00 implied a perfect correlation, which had never been discovered in any social science research.30 thus, the intervals were used to interpret the correlation. the coefficient ranging from 0.70 to 1.0 (or -0.70 to -1.0) was considered a very strong relationship; the coefficient ranging from 0.50 to 0.699 (or -0.50 to -0.699) was considered a strong relationship; the coefficient ranging from 0.20 to 0.499 (or -0.20 to 0.499) was considered as moderate relationship; and the coefficient ranging from 0.00 to 0.199 (or 0.00 to -0.199) was considered as a weak relationship. the correlation between variables would be considered statistically significant if the p-value <0.05. the hypotheses for the research were (1) h0: there is no significant positive correlation between language barriers (consisting of foreign language, vernacular, jargon, word choice, and spelling) and effective osh communication and (2) ha: there is a significant positive correlation between language barriers (consisting of foreign language, vernacular, jargon, word choice, and spelling) and effective osh communication. results the demographic profile of the respondents consisting of age, educational level, and working experience are shown below (table 1). the age distribution of the respondents revealed that the majority (approximately 88%, n = 90) fell within the 20 to 50-year age range. additionally, a significant proportion of the participants (79%, n = 81) reported having a senior high school educational background. furthermore, more than half of the respondents (52%, n = 53) possessed work experience spanning a duration of 5 to 10 years. table 1: the age, educational level, and working experience of the respondents description characterization frequency age > 50 6 (6%) 40 to 50 27 (26%) 30 to 40 32 (31%) 20 to 30 31 (30%) < 20 6 (6%) total 102 (100%) educational level undergraduate degree 2 (2%) senior high school 81 (79%) junior high school 19 (19%) total 102 (100%) working experience > 10 years 4 (4%) 5 to 10 years 53 (52%) 3 to 4 years 36 (35%) 1 to 2 years 5 (5%) < a year 4 (4%) total 102 (100%) rojak et al. the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia 389 table 2: validity test of language barriers types of language barriers statement correlation p-value foreign language i can only understand osh procedures/instructions in indonesian. 0.629 0.000 toolbox meetings and/or safety induction and/or safety talks are easier to understand in indonesian than in foreign languages. 0.683 0.000 osh banners and/or bulletins are easier to understand in indonesian than in foreign languages. 0.73 0.000 osh promotion should use indonesian to make it easier to understand. 0.667 0.000 vernacular i have difficulty understanding when my colleagues speak their vernacular during working hours. 0.602 0.000 my colleagues have difficulty understanding when i speak my vernacular. 0.651 0.000 jargon i understand the abbreviations for osh, ppe, fire extinguishers, and first aid. 0.631 0.000 incidents and accidents are two different things. 0.671 0.000 word choice clear and concise writings on osh banners and/or bulletin boards make it easy for me to understand the information. 0.692 0.000 osh signs without writing are more difficult to understand. 0.629 0.000 the company's policy on osh should be written as concisely as possible so that it is easier to understand. 0.704 0.000 the colors of osh signs should vary to make them easier to understand. 0.725 0.000 spelling the misspelling on the osh banner and/or signs and/or bulletin boards makes it difficult for me to understand the information. 0.727 0.000 writing the wrong digits of accidents on the osh bulletin boards make me misunderstand the information. 0.684 0.000 table 3: validity test of effective osh communication description correlation p-value there is a written osh policy related to the prevention of work-related accidents & diseases at your workplace. 0.783 0.000 you know the person in charge of osh at your workplace. 0.685 0.000 information regarding osh (including work accidents) is easy to get at your workplace. 0.797 0.000 osh signs have been installed following the standards and technical guidelines at your workplace. 0.79 0.000 you receive instructions and training on emergency procedures appropriate to the level of risk. 0.715 0.000 emergency instructions/procedures and emergency liaison are clearly and conspicuously displayed at your workplace. 0.774 0.000 there is a procedure for reporting hazards related to osh at your workplace. 0.704 0.000 the warning signs for chemical hazardous substances are installed following the requirements of the relevant laws and/or standards. 0.707 0.000 training is provided to all workers, including new and transferred workers so that they can carry out their duties safely. 0.801 0.000 the employer/ management provides refresher training to you. 0.778 0.000 rojak et al. the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia 390 next, the result of the validity test for the variables used in this research is given in table 2 and table 3. from table 2 and table 3, the p-values for all of the items are less than 0.05. thus, all of the items are valid. the cronbach’s alpha values in table 4 are 0.8992 for language barriers and 0.9148 for effective communication, respectively. both values are more than 0.7 implying that all of the items are reliable. table 4: reliability test language barriers effective osh communication 0.8992 0.9148 the result of the correlation between language barriers, consisting of jargon, word choice, foreign language, spelling, and vernacular, and effective osh communication are presented below (figures 1 to 5). figure 1: correlation of jargon and effective osh communication among the various types of language barriers, jargon exhibited the strongest and statistically significant correlation with effective occupational safety and health (osh) communication, as indicated by a strong positive correlation coefficient (r = 0.664, p < 0.05) (figure 1). the incorporation of jargon in osh communication was commonly observed through the utilization of specific terminology, including osh, personal protective equipment (ppe), fire extinguishers, first aid, accidents, and incidents. consequently, the alternative hypothesis (ha) is supported and accepted. the subsequent factor identified in the study was word choice, which exhibited a strong and statistically significant positive correlation (r = 0.622, p < 0.05) with the effectiveness of osh communication, as illustrated in figure 2. this finding indicates that the selection of appropriate vocabulary plays a crucial role in facilitating successful osh communication. the aspects of word choice examined in the study encompassed clear and concise writing styles, the presence or absence of written content on osh signs, the extent of verbosity in written materials, and the use of colors. therefore, the study's hypothesis (ha) concerning the significant impact of word choice on osh communication is supported by the empirical evidence obtained. rojak et al. the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia 391 figure 2: correlation of word choice and effective osh communication among the language barriers encountered, the third type identified was the presence of a foreign language. the analysis revealed a strong and statistically significant positive correlation (r = 0.573, p < 0.05) between the use of a foreign language and the effectiveness of osh communication, as depicted in figure 3. the use of a foreign language encompassed various aspects, such as the utilization of non-native languages in osh procedures, instructions, toolbox meetings, safety inductions, safety talks, osh banners, bulletins, and osh promotional materials. consequently, the hypothesis (ha) positing the significant influence of foreign languages on osh communication is supported by the empirical findings. figure 3: correlation of foreign language and effective osh communication rojak et al. the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia 392 figure 4: correlation of spelling and effective osh communication within the context of this study, the fourth category of language barriers identified pertained to spelling errors. specifically, these errors manifested as misspelled words and/or digits found on various osh media, such as banners, safety signs, and bulletin boards. the analysis revealed a strong and statistically significant positive correlation (r = 0.530, p < 0.05) between spelling errors and the effectiveness of osh communication, as illustrated in figure 4. therefore, the hypothesis (ha) proposing a significant impact of spelling errors on osh communication is supported by the empirical evidence obtained in this study. the final category of language barriers identified in this study pertained to the utilization of vernacular languages spoken among colleagues during working hours. the analysis indicated a moderate, positive correlation (r = 0.497) that was statistically significant (p < 0.05) between the use of vernacular languages and the effectiveness of occupational safety and health (osh) communication. consequently, the alternative hypothesis (ha) is supported, as illustrated in figure 5. figure 5: correlation of vernacular and effective osh communication rojak et al. the correlations between language barriers and occupational safety and health communication: a descriptive study in indonesia 393 discussion communication becomes ineffective when two people or more speak different languages which have no similarity, especially in terms of lexical. it is also applied not only to foreign languages but also vernaculars. the respondents of this research have difficulty understanding osh communication when the messages are in a foreign language namely english because they speak indonesian daily; sometimes vernacular which causes the same problem again. the research is in line with several studies regarding the language barriers that affect migrant workers.9,17 distinct terms or expressions are something that people cannot avoid in the workplace; the failure to understand the terms or expressions will cause unintelligibility. in a workplace that has a high risk of accidents like a def power plant, unintelligibility should be avoided by using effective osh communication. other types of barriers that can lead to ineffective osh communication are wordy messages or writings, signs without descriptions and distinct colors, and misspellings or typos. clear, concise, and accurate messages are the most preferable messages in communicating osh to workers in every workplace. otherwise, the osh communication will become ineffective or fail. the result supports the study conducted by buarqoub on language barriers to effective communication regardless he did not specifically mention the rest of the language barriers in the context of osh.12 this research provides details on the types of language barriers in effective osh communication and specifically discusses the context of osh communication in indonesia. however, the respondents in this study are only from one company and all of them are males which may not represent the overall population of workers in indonesia. based on the overall findings, the language barriers and effective osh communication are strongly related, but the direct factors and causes are not scrutinized. conclusions osh communication is one of the most important aspects to encourage the workers’ safety but an ineffective communication system leads to miscommunication. ineffective osh communication can be attributed to several factors, including language barriers as one of the significant contributors. based on the results, the language barriers derived from a foreign language, vernacular, jargon, word choice, and spelling have a positive correlation with effective osh communication. thus, osh communication should be communicated clearly, concisely, and accurately in a language that everyone can understand. acknowledgments this research is fully supported by politeknik ketenagakerjaan (polytechnic of manpower). the authors fully acknowledged politeknik ketenagakerjaan for the approved fund which makes this important research viable and 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nurs. 2015 jul;18(3):66–7. available from: https://doi.org/10.1136/eb-2015-102129 30. urdan tc. statistics in plain english [internet]. 5th ed. new york: routledge; 2022 [cited 2022 nov 18]. available from: https://doi.org/10.4324/9781003006459 https://doi.org/10.1080/01446193.2018.1551617 https://doi.org/10.1016/j.ssci.2018.10.029 https://doi.org/10.1016/j.aap.2017.09.006 https://doi.org/10.1097/hcm.0000000000000165 https://doi.org/10.1007/978-94-007-0753-5_2888 https://doi.org/10.1007/978-94-007-0753-5_2888 https://doi.org/10.1016/j.pec.2018.04.007 https://doi.org/10.1016/j.aap.2010.06.021 https://doi.org/10.1007/978-3-030-64865-7 https://doi.org/10.1136/eb-2015-102129 https://doi.org/10.4324/9781003006459 type of the paper (article int. j. occup. safety health, volume 13, no 1 (2023), 69 – 77 https://www.nepjol.info/index.php/ijosh 69 original article assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study patel j 1, ghosh t1 1ergonomics and exercise physiology laboratory, department of health and wellness, sri sri university, cuttack, odisha 754006, india abstract introduction: excessive noise exposure is one of the majorly considered occupational stressors for industrial workers. the operation of steel weaving machinery producing a high level of noise such as weaving machines, crimping machines, and hydraulic press machines for a prolonged period increases the risk of developing noise-induced hearing loss (nihl). the main aim of the study was to assess the auditory health of the workers exposed to a high level of noise in a steel weaving factory and the prevalence of nihl among workers. methods: twenty six (26) subjects in the age group of 25-55 years from a steel weaving industry of chinsurah town, hooghly district of west bengal were randomly selected with 5 years of exposure for the study. the control group was selected from the same age group, socioeconomic status and geographical location and had no history of such exposure. the physiological parameters of the workers, noise levels in the workplace and auditory functions and the risk of nihl were assessed by standardized protocol and statistically analyzed. results: the study indicated that steel weaving factory workers had significantly reduced hearing functionality at 4000hz and 6000hz in the left ear respectively. it also revealed that the workers were exposed to high noise exposure of 131db near the weaving machine, 113db at the crimping machine, and 84db at the hydraulic press machine respectively. conclusion: a high level of noise exposure leads to deterioration in the hearing capabilities of steel-weaving industrial workers. implementation of ergonomic interventions in the workplace and the use of personal protective equipment (ppe) may decrease the prevalence of nihl and can help to prevent hearing loss in workers. keywords: auditory health, nihl, occupational stress, steel weaving factory workers introduction hearing loss is ranked the fourth highest cause of disability across the globe estimating 466 million people having disabling hearing loss.1 occupational noise exposure is the major stress undergone by industrial workers and is the second major selfreported occupational illness having social, functional and economic impacts on industrial workers.2-3 noise harm the health of individuals and the community exposed. it disturbs the work-rest cycle and biological rhythm of the individuals leading to damaged hearing and eliciting physiological, psychological and pathological reactions.4 occupational hearing loss is considered one of the majorly occurring occupational diseases. it is found about 49% of male miners undergo hearing loss at the age of 50. the figure rises to 70% by the age of 60. occupational hearing loss is faced by a large sector of the working force.5 it is estimated about 16% of the disabling hearing loss in adults develops on exposure to occupational noise.6 corresponding author: dr. tirthankar ghosh, professor, ergonomics and exercise physiology laboratory, department of health and wellness, sri sri university, cuttack, odisha 754006, india e-mail: tirthag@gmail.com orcid id: https://orcid.org/00000002-8953-5903 date of submission: 12.01.2022 date of acceptance: 08.07.2022 date of publication: 01.01.2023 conflicts of interest: none supporting agencies: none doi: https://doi.org/10.3126/ijosh.v13i1.4 2281 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) mailto:tirthag@gmail.com https://orcid.org/0000-0002-8953-5903 https://orcid.org/0000-0002-8953-5903 https://doi.org/10.3126/ijosh.v13i1.42281 https://doi.org/10.3126/ijosh.v13i1.42281 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ patel et al. assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study 70 hearing loss developing from chronic noise exposure leads to the gradual disruption of hearing sensitivity which on being unaware later develops into nihl.7 the occupation having a high risk of nihl includes heavy engineering, quarrying, tunneling, mining and textile machinery.2 nihl is defined as an incurable and irreversible disease with prevention being of primary importance. the early signs of occupational hearing loss can be detected by simple audiometric evaluations. a periodic audiometric examination can be considered the principal medical prevention of excessive noise exposure.8-9 according to osha if the noise level in the workplace is 85 db(a) or above for an average period of eight hours the employers must organize a hearing conversation program for the employees.10 occupational health diseases often have a long latency period, making it difficult to diagnose at the primary stage. 11 it is important to assess workers hearing functionality for preventing the risk of developing nihl.12 periodic hearing conservation program with audiometric screening tests in the workplace for the workers can increase the effectiveness of the hearing protection protocol and proper education for increasing awareness of risks of noise exposure. the present study was made to assess the auditory health of the workers exposed to the high level of noise in a steel weaving factory and the prevalence of nihl among workers and to compare the auditory health ( at varied frequencies) in both the ears of the workers working in steel weaving factory with the control group. methods the study was conducted on workers of a steel weaving factory in chinsurah town, hooghly district of west bengal. twenty-six steel weaving factory workers were randomly selected for the prevailing study as the experimental group. all the selected workers were having a minimum working experience of 5 years of their present occupation and were in the age group of 25-55 years. the control group was selected from the same socioeconomic and geographical locations. the consent of the workers was taken verbally before the study. a study was made based on the auditory complaints of the workers of a steel weaving factory for the study period. the questionnaire comprised of series of polar questions on hearing discomfort and using of ppes“do you recently have difficulty in hearing words clearly?”, “are you having difficulty in hearing while workingyes or no?”, “do you feel frustrated when you do not get words clearyes or no?”,” do you experience tinnitus after working with the machineyes or no?”, ” do you experience pain during working with noise-producing machineyes or no?”,”do you use ppe while workingyes or no?if no then “do you think of using ppes while working – yes or no?” the physiological parameters involving blood pressure, pulse rate, and mid-arm circumference of the steel weaving factory workers and the control group were assessed using a standardized protocol. the noise levels at the different areas of the steel weaving factory were taken during the working period using cel-231 type 2a sound level meter. three readings were taken near the operation of machinery in the beginning hours, in the middle and at the end of the working day. the locations from where the readings were taken were near the weaving machine, crimping machine and hydraulic press machine respectively. all the audiograms were assessed using arphi audiometer. bone and air conductance for both ear were performed from 1000hz to 8000hz respectively. hearing loss can be categorized into five types.13 mild hl: hearing threshold between 26-40 db hl. moderate hl: hearing threshold between 41-55 db hl. moderately severe hl: hearing threshold between 56-70 db hl. severe hl: hearing threshold between 71-90 db hl. profound hl: hearing threshold more than +90 db hl student “t” test was performed among the steel weaving factory workers and the control group to find out whether there is any significant difference between the physical parameters and thresholds of hearing for frequencies 1000 hz, 1500hz, 2000hz, 3000hz, 4000hz, 5000hz, 6000hz and 8000hz respectively for the chosen level of significance(p< 0.05). statistical analysis was performed using spss version 17 (chicago, illinois, usa). patel et al. assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study 71 results table 1 represents the demographic information of the male steel weaving factory workers denoted as the exposed group and the control group showing the mean age of the exposed group is 31.10 years, height and weight to be 162.93 cm and 64.62 cm while the mean age of the control group is 32.35 years, height and weight is 161.69 cm and 64.50 cm respectively. from table 1 it was observed that there was no significant change in age, stature, and weight between the exposed and control groups. the mean values of the physiological parameters including systolic pressure,diastolic pressure, pulse rate and mid arm circumference of the noise exposed group and control group is represented in table-2. it was observed that there was significance change in systolic pressure between exposed and control group. we have observed sound levels at various workplaces where different machineries ( weaving machine, cramping machine and hydraulic press machine) are operated. the mean noise levels near weaving machine, cramping machine and hydraulic press machine is found to be 131.83 db, 113db and 84.16 db respectively as shown in table 3. table 1. demographic information about the noise exposed group and control group parameters exposed group control group t value p value age(years) 31.10(±7.92) 32.35(±7.73) 0.58 0.57 height (cm) 162.93(±7.23) 161.69(±7.87) 0.59 0.57 weight (cm) 64.62(±9.52) 64.50(±9.11) 0.04 0.96 table 2. physiological parameters of the noise exposed group and control group table 3. noise levels in selected workplaces parameters exposed group control group t value p value systolic pressure(mm hg) 133.46(±10.89) 121.62(±5.66) 4.91 p<0.0001 diastolic pressure(mm hg) 79.04(±7.06) 80.08(±0.69) 0.75 0.46 pulse rate(bpm) 76.73(±6.84) 72.19(±4.14) 2.89 p=0.005 mid arm circumference(cm) 28.15(±2.18) 25.77(±2.09) 4.01 p=0.0002 workplace areas noise level(dba) near weaving machine 131.83±1.25 cramping machine 113±10 hydraulic press machine 84.16±0.76 patel et al. assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study 72 about 73% of the steel weaving factory workers responded to having difficulty hearing words clearly. 69% of the exposed population faced difficulty in hearing properly. from the study, it was observed that about 62% of the workers responded to being frustrated when do not get the words clear. 58 % of the workers agreed on experiencing tinnitus after working with machines and ear pain during working with noise-producing machines. only 31% of the study population used ppes while working and 38% of the steel weaving factory workers responded to not thinking of using ppes while working as mentioned in table 4. the mean hearing threshold level of both the right and left ear of the exposed group and control group at a varied frequencies of 1000hz, 1500hz, 2000hz, 3000hz, 4000hz, 5000hz, 6000hz and 8000hz respectively is shown in table 5. it was observed that there was a significant difference in hearing threshold levels at varied tested frequencies in the exposed and control group. table 4. frequency distribution of auditory complaints and practices auditory complaints and practices steel weaving factory workers do you recently having difficulty in hearing words clear? 19 (73%) are you having difficulty in hearing while working? 18 (69%) do you feel frustrated when you do not get words clear? 16 (62%) do you experience tinnitus after working with machine? 15 (58%) do you experience ear pain during working with noise producing machine? 15 (58%) do you use ppe while working? 08 (31%) do you think of using ppes while working? 10 (38%) table 5. hearing threshold of the noise exposed group and control group for the tested frequency frequency(hz) ear exposed group control group t value p value 1000 left 27.31(±2.54) 46.73(±4.89) 17.97 p<0.0001 1000 right 27.50(±2.55) 50.58(±4.08) 24.46 p<0.0001 1500 left 30(±4.00) 38.65(±5.20) 6.72 p<0.0001 1500 right 29.81(±4.11) 39.62(±5.81) 7.02 p<0.0001 2000 left 19.81(±3.86) 26.73(±5.46) 5.27 p<0.0001 2000 right 17.50(±2.55) 27.31(±6.20) 7.46 p<0.0001 3000 left 50.19(±4.57) 27.50(±2.91) 21.35 p<0.0001 3000 right 54.23(±3.65) 29.23(±5.03) 20.51 p<0.0001 4000 left 50.00(±5.2) 23.46(±3.67) 21.26 p<0.0001 4000 right 47.31(±5.51) 24.23(±3.92) 17.40 p<0.0001 5000 left 50.19(±4.57) 27.50(±2.91) 21.35 p<0.0001 5000 right 54.04(±3.74) 29.23(±5.03) 24.81 p<0.0001 6000 left 29.04(±3.47) 18.08(±3.76) 10.92 p<0.0001 6000 right 28.46(±5.43) 18.65(±3.62) 7.66 p<0.0001 8000 left 29.23(±5.94) 18.00(±3.67) 8.20 p<0.0001 8000 right 28.46(±5.43) 18.69(±3.62) 7.63 p<0.0001 patel et al. assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study 73 figure 1. mean hearing threshold levels of left ear of exposed group and control group for various tested frequency the mean hearing threshold level of the left ear of the noise-exposed group and control group at different tested frequencies (1000hz, 1500hz, 2000hz, 3000hz, 4000hz, 5000hz, 6000hz and 8000hz) is shown in fig 1. a significant change in hearing threshold level in the left ear is observed in the exposed and control group. the mean hearing threshold level of the right ear of the noise-exposed group and control group at different tested frequencies (1000hz, 1500hz, 2000hz, 3000hz, 4000hz, 5000hz, 6000hz and 8000hz) is shown in fig 2. a significant change in hearing threshold level in the right ear is observed in the exposed and control groups. figure 2. mean hearing threshold levels of the right ear of the exposed group and control group for various tested frequency discussion nihl is considered one of the completely preventable hearing losses having significant health coupled with economic consequences primarily observed in southeast asian countries.14 the present study showed the mean age of the steel weaving factory workers was 31.10 years within the age group of 25-55 years as shown in table 1. the result was found to be consistent with the studies that prevailed in thailand and pakistan with mean ages of 33.8 years and 34.3 years respectively. 15-16 most of the studies conducted in industrial workers in bhutan, thailand belong to the age group of 31-40 years.17-19 the workers of the steel weaving factory work in 8 hours shift duration. according to the factories act 1951 and standardized by international labour organization the working hours for continuous processes in myanmar should not 0 20 40 60 0 2000 4000 6000 8000 10000 h e a ri n g t h re sh o ld l e ve l( d b h l) frequency(hz) audiogram of left ear exposed group control group 0 10 20 30 40 50 60 0 2000 4000 6000 8000 10000 h e a ri n g t h re sh o ld l e ve l( d b h l) frequency(hz) audiogram of right ear exposed group control group patel et al. assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study 74 exceed 8 hours a day or 44 hours or 48 hours. in the study, a significant increase in blood pressure ( systolic blood pressure) was found in the noiseexposed group than the control group shown in table 2. dzhambov et al. in their study showed a significant increase in the blood pressure of the workers who were exposed to occupational noise.20 the study showed similar results in a taiwan study showing a positive correlation between blood pressure level and noise level.21 the noise levels in the workplaces where various types of machinery involving weaving machines (121.83 dba), cramping machines (113 dba), and hydraulic machines (84.16 dba) were measured as shown in table 3. the study showed the workers are exposed to highly hazardous noise levels for a prolonged period of 8 hours of work shift which may lead to hearing loss. kerdonfag p et al. mentioned in their study one time or prolonged period of exposure to loud noise can lead to hearing loss. continuous exposure to loud noise for a prolonged period increases the risk of progressive and irreversible hearing loss in both ears.22 the niosh denotes 85db(a) and more noise level as the restricting level for preventing hearing loss. the study made in thailand 19 stated a significant increase in the risk of developing hearing loss among workers who are exposed to high noise levels above 85db(a). the noise-exposed group of the present study can be at higher risk of hearing loss development than the control group. the noise level measurements were made on a weighted network based on the simplicity and accuracy of the scale in evaluating hearing hazard. the scale has been internationally adopted for the assessment of noise exposure.23-24 from the study it was found that only 31% of the steel weaving workers used ppe while working with weaving machinery shown in table 4. this may be due to poor awareness of nihl risk and protective measures of ppe at the workplace. a united states study has shown increased reporting of hearing loss in unprotected workers.25 a study on industries showed the implementation of noise-reduction measures and the use of hearing ppe reduced hearing damage in young workers.26 use of hearing protectors such as earmuffs, ear canal caps and ear plugs to reduce the noise level to a safer level should be promoted when engineering controls and work methods cannot be under feasibility.27 in the present study about 69% of the noise-exposed group have difficulty in hearing the words clearly. studies mentioned a loss of clarification of perceived speech and difficulty in distinguishing particular words is observed among individuals having nihl.28-29 among the 26 noiseexposed subjects 58% experience tinnitus after working in a noisy environment. teixeira et al. stated the development of tinnitus from exposure to loud noise. the workers having hearing loss fails to mark hearing ability changes till the occurrence of a large threshold shift. the irreversible characteristic of tinnitus and severity increased with continued exposure.30 about 62% of the exposed group feel frustrated due to poor perception of the words. this may be due to the development of tinnitus which leads to the development of annoyance and poor mood. tinnitus is considered one of the major problems for noise-exposed workers, primarily affecting mood, sleep, concentration, and quality of life.31 sheppard et al. stated inability to get speech properly in the everyday situation due to hearing loss have a severe social impact.32 in the present study we found from the audiometric results shown in table 5 the steel weaving factory workers significantly differed from the control group and were at significantly higher risk of developing bilateral nihl than the control group in varied tested frequencies of 1000 hz, 1500hz, 2000hz, 3000hz, 4000hz,6000hz and 8000 hz respectively. narasimhan et al. mentioned 4000hz frequency to be severely affected by chronic noise exposure along with higher frequency ( 3 khz-6khz) than the lower frequencies (500hz2khz).33 based on the hearing threshold level of the exposed group and control group at higher frequencies of 3khz8khz shown in table 3, referring to the olusanya et al. categorization of hearing loss the noise-exposed group has the probability of developing mild hearing loss as the noise-exposed workers of the steel weaving factory are exposed to chronic noise level for a prolonged period and not using ppe for convenience while working can have a cumulative effect on the increased risk of developing bilateral nihl. patel et al. assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study 75 conclusion from the results and analysis of the study, it can be concluded that the steel weaving factory workers are exposed to hazardous noise levels in the workplace for an extended period of 8 hours of work shift, which may result in hearing loss. about 69% of the noise-exposed populations reported complaints of difficulty in hearing and more than 58% of the workers complained of tinnitus showing the probability of the development of hearing loss. only 31% of the steel weaving workers use ppe while exposed to chronic noise indicating poor awareness of noise exposure effect and nihl risk in the workplace. the audiometric results showed the noise-exposed workers have the highest mean hearing threshold levels in 3khz -5khz than the control group suggesting the probability of developing mild hearing loss which gradually can develop into bilateral nihl. significant increases in blood pressure observed in the noise-exposed workers increase the risk of the development of hypertension. occupational nihl is considered one of the completely preventable hearing losses with significant health and economic consequences mostly occurring in developing countries. since noise levels in the workplace are uncontrollable, the use of ppe while working on steel weaving machinery can help workers avoid hearing loss. strict enforcement of the self-protective measures use of noise-canceling earmuffs, ear canal caps, and ear plugs should be encouraged and periodic hearing conservation with audiometric screening tests can help to check the risk of nihl. acknowledgments we authors acknowledge all the workers of the steel weaving factory in chinsurah town, hooghly district of west bengal for their support and assistance throughout the research work. references 1. world health organization. addressing the prevalence of hearing loss.[ internet] geneva: world health organization; 2018 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https://doi.org/10.1016/j.shaw.2020.04.003 patel et al. assessment of noise-induced hearing loss (nihl) of weaving factory workers in west bengal, india a pilot study 77 ac. cellular mechanisms of noise-induced hearing loss. hearing research. 2017 jun 1;349:129-37. available from: https://doi.org/10.1016/j.heares.2016.11.013 30. teixeira lr, azevedo tm, bortkiewicz a, da silva dt, de abreu w, de almeida ms, et al. who/ilo workrelated burden of disease and injury: protocol for systematic reviews of exposure to occupational noise and of the effect of exposure to occupational noise on cardiovascular disease. environment international. 2019 apr 1;125:567-78. available from: https://doi.org/10.1016/j.envint.2018.09.040 31. møller ar. sensorineural tinnitus: its pathology and probable therapies. international journal of otolaryngology. 2016 oct;2016. available from: https://doi.org/10.1155/2016/2830157 32. sheppard a, ralli m, gilardi a, salvi r. occupational noise: auditory and non-auditory consequences. international journal of environmental research and public health. 2020 dec;17(23):8963. available from: https://doi.org/10.3390/ijerph17238963 33. narasimhan s, rajagopalan r, justin margret j, visvanathan g, jayasankaran c, rekha k, srisailapathy cs. audiometric notch as a sign of noise induced hearing loss (nihl) among the rice and market flour mill workers in tamil nadu, south india. hearing, balance and communication. 2022 jan 2;20(1):21-31. available from: https://doi.org/10.4103/0971-7749.10343 https://doi.org/10.1016/j.heares.2016.11.013 https://doi.org/10.1016/j.envint.2018.09.040 https://doi.org/10.1155/2016/2830157 https://doi.org/10.3390/ijerph17238963 https://doi.org/10.4103/0971-7749.10343 type of the paper (article int. j. occup. safety health, volume 13, no 1 (2023), 47-54 https://www.nepjol.info/index.php/ijosh original article postural stress and risk conditions in manual load handling of chilean industrial workers urrejola-contreras gp1, pérez-casanova dc2, pérez-lizama ma1, gary-zambra b3 1 escuela de ciencias de la salud, universidad viña del mar, chile. 2 huérfanos 1977, santiago de chile, chile. 3 escuela de ingeniería y negocios, universidad viña del mar, chile. abstract introduction: although, there is a current regulatory framework for optimal manual handling of loads to preserve health conditions in the industrial sector, technical assessment and the use of certain instruments are still required for the diagnosis of occupational hazards. this study aimed to identify the occupational hazards associated with manual load handling in industry workers and estimate those resulting from postural stress. methods: fifty-two (52) industry workers took part in this cross-sectional study. all participants were evaluated using the manual handling guide and the reba assessment tool. subjects were characterized, and risks associated with different tasks were detected. results: 59.6% of workers were between 18 and 45 years old. lifting, lowering, and transporting loads activities had a repetitive task risk of 94%, exceeding the weight limit in 85.7% of cases. pushing and pulling activities, mostly showed a working postural risk of 82% and a high perception of initial effort (borg> 8). reba score warned to intervene immediately in both types of tasks. conclusion: risk from the manual handling of loads found in this study constitutes an alert that suggests reviewing compliance with the current regulation, as well as effective use of working pauses and the improvement of strategies to minimize physical efforts used by workers. keywords: ergonomic assessment, occupational health, posture load, work risk introduction important work procedures and processes are associated with manual load handling (mlh), most of which are involved in productive sectors such as agriculture, construction, and industry.1 an important aspect that has caught the attention of occupational health units, ergonomics departments, and public health centers is the collection of data that relate risks associated with mlh with postural load and the prevalence of musculoskeletal disorders in workers.2,3 although the approach to occupational health includes various disciplines, the study of the workplace continues to be a powerful diagnostic tool, as work in the industrial area continues to present serious problems about the adoption of poor harmful postures to carry out productive tasks.4 in fact, there are several instruments and methods available for the assessment of risk because of postural stress, including its application in different working environments5,6 to identify forced postures adopted by workers and use this information to design workplace adjustments as well as to promote hazard management strategies to minimize stress on the locomotor system.7 in chile, management derived from the analysis regarding load handling hazards in workers allowed the incorporation of new regulations about maximum weight to be lift by humans into the labor code in 2005 by law 20.001, which is ruled by the guide of manual handling risk assessment, however, it was modified through law 20,949; corresponding author: gabriela p. urrejola-contreras, research assistant, escuela de ciencias de la salud, viña del mar, chile. aguasanta 7055, viña del mar, chile. code postal: 2520000 phone:+56322462693 email: gabriela.urrejola@uvm.cl orcid id: https://orcid.org/00000002-8370-4550 date of submission: 07.12.2021 date of acceptance: 26.08.2022 date of publication: 01.01.2023 conflicts of interest: none supporting agencies: none doi: https://doi.org/10.3126/ijosh.v13i1.4 1264 copyright: this work is licensed under a creative commons attributionnoncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) mailto:gabriela.urrejola@uvm.cl https://orcid.org/0000-0002-8370-4550 https://orcid.org/0000-0002-8370-4550 https://doi.org/10.3126/ijosh.v13i1.41264 https://doi.org/10.3126/ijosh.v13i1.41264 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ urrejola-contreras et al. postural stress and risk conditions in manual load handling of chilean industrial workers 48 which reduced to only 25-20 kilos for maximum mlh limit in adult men and those under 18 years of age and /or women respectively since 2016 through the technical guide for assessment and control of risks associated with manual load handling.8 despite the existence of current regulations on risk assessment in mlh; recent studies have shown that the working population is exposed to work overload variables, physical-biomechanical factors, and perception of musculoskeletal discomfort;9 and in other cases it is noted that the maximum legal load limit should not be interpreted as a safety health value.10 this study aimed to evaluate the risk present in tasks that include manual load handling, as well as postural load in industrial workers. methods this is a cross-sectional study that took place in a furniture and mattress factory in the metropolitan region (santiago de chile) between april and august 2019 and by request of the occupational safety and health administration (law 16.744). the company has 180 workers with an indefinite employment contract and the investigation was carried out in a branch office that included 80 workers (the biggest of this company). workers in this area primarily perform mattress manufacturing activities through quilting, edge definition, and assembly processes. finally, they carry out the closure and the product is packaged to distribute to commercial stores for later sale. the manufacturing and assembly areas included in this study require manual load handling activities through lifting, lowering, transporting, pushing and dragging tasks. 20 workers were excluded from this study due to administrative work activities. the study included 60 male workers. to calculate the sample size of a finite population, the following formula was used: where: n: sample size to consider; n: population size; z: statistic that depends on n; p: probability of occurrence of the occupational risk t; q: probability that the event does not occur q = (1-p) and e: error. for this study, a significance level of 5% was considered, so that z corresponds to: 1.96. finally, a margin of error of 5% was used. calculations established a size sample of 51.7. therefore, the sample finally consisted of 52 subjects. workers were separated into two groups according to their functions and tasks performed after the evaluation (interview and job observation); 35 subjects performed lifting, lowering and transportation tasks, while 17 performed pushing and pulling activities. subject selection considered the following inclusion criteria: men between 18 and 65 years old, subjects who worked 44 hours a week, presented an indefinite employment contract, and whose tasks included lifting, lowering, transporting, pushing, and pulling actions. subjects perform functions for 8 hours a day and a 1-hour break was established for rest and feeding. exclusion criteria involved working in the administration department or those with jobs outside the branch office. tasks performed by workers were mostly carried out manually and physically, however, some of them used the help of machinery. the assessment involved a technical visit by a professional with training in ergonomics and 3 years of experience in assessing risks associated with work and in the implementation of the current technical standard for manual load handling. the evaluation considered the reba observational method, based on the observation of postures used in the execution of the task in the subject's workplace. the observation is captured by images. in addition, a 20-minute interview was conducted with each worker in which a structured questionnaire was applied on basic aspects related to age, sex, type of tasks performed, number of hours and breaks during the working day, and exposure times. the questionnaire was reviewed by experts in job evaluation. in addition, the technical guide for the evaluation and control of risks associated with manual handling of the load was applied. the information collected was recorded in an excel spreadsheet for later analysis. this made it possible to analyze the jobs individually. additionally, according to the type of tasks performed by the workers, the advanced ergonomic instrument reba11 was used to specify the risk associated with the postural load. this tool includes a systematic full body assessment of the postural risk to which the worker is exposed and involves dynamic and static postural load factors as well as person-load interaction by examining separately; right and left upper and lower extremities, trunk position, and variation of posture in the cervical region.12 later, the data collected were compared and analyzed. urrejola-contreras et al. postural stress and risk conditions in manual load handling of chilean industrial workers 49 the work was reviewed by the university’s ethics committee and was approved according to the ethical criteria, instruments applied, and protection of the information. confidentiality certificates were used for each of the participants authorizing the subsequent use of the data resulting from the evaluation with full protection of the information of the company and each of its workers. data of the number of workers by type of task, the percentage of vertebral asymmetry, and the deficit in maintaining the vertical position during lifting, lowering and transportation tasks were described as discrete variables. likewise, for the tasks of pushing and pulling, the borg scale was described as the percentage of poor posture. on the other hand, the comparison of the repetition of the activity between both types of tasks was analyzed according to the student’s test. the reba method was used to evaluate the observation of the posture of each body segment of both hemibodies during a task from the analysis of the images obtained in the workplace. based on observation and image analysis, reba suggests scores, and the sum of them gives a final score for each hemibody, which will be categorized according to the level of risk suggested by the method (fig 1 a b). data obtained from the reba score suggested levels of intervention for each hemibody and was compared according to the student’s test. group a group b figure 1a. reba group a and b body diagrams figure 1b. reba scoring sheet urrejola-contreras et al. postural stress and risk conditions in manual load handling of chilean industrial workers 50 results a total of 52 persons participated in this study. the largest number of workers were engaged in activities involving lifting, lowering, and carrying loads in comparison to pushing and pulling activities. for both activities, there was greater involvement of workers between 18 and 45 years of age. regarding task description, evidence showed a greater number of tasks evaluated, involving lifting, lowering, and transporting loads, which also presented a lower average time duration corresponding to 40.64 seconds. however, the longest exposure time was longer for the tasks that involved pushing and pulling activities, reaching an average of 84.27 minutes. regarding the presence of observed risk conditions, repetitiveness in both activities was positive, reaching 94% for lifting, lowering, and load transport activities. in its counterpart, the highest static load was observed in 82% of pushing and pulling activities. however, there are no significant differences in repeatability between these two types of tasks (t-test, p> 0,05). the postural instability factor was only observed in two-thirds of the workers during lifting, lowering, and carrying loads, meanwhile, it was absent in pushing and pulling activities (table 1). table i: characterization of the activity carried out by a worker workers characterization lifting, lowering, transport pushing and pulling n n total number of workers 35 17 age 18 to 45 years 20 11 age> 45 years 15 6 task characterization n n number of tasks 10 7 mean ± sd mean ± sd task duration (seconds) 40.64±38.57 96.36±73.11 exposure time (minutes) 41.58±35.13 84.27±52.90 risk conditions present in workers % (n) % (n) repeatability factor 94 (49) 58 (30) static postural load on one or more parts of the body 65 (34) 82 (43) postural instability 65 (34) 0 (0) when examining the weight load limit according to the current regulation, 85.7% of subjects developed their task with excess load, being more prominent in lifting, lowering, and transportation activities. between 70 and 100% of subjects evaluated experienced risk conditions associated with their type of task. for the lifting, lowering, and transportation activities, asymmetry of the spine and the deficit in maintaining the vertical position were observed. for pushing and pulling activities, showed a high perception of initial effort (borg> 8), and poor posture. when comparing both types of tasks, the duration of the work cycle and time exposure were considered for analysis. using these data, the average number of repetitions for each worker estimated according to their performed activities was 103 times for lifting, lowering, and transport, and 86 times for pushing and pulling (fig 2). int. j. occup. safety health, volume 13, no 1 (2023), 47-54 https://www.nepjol.info/index.php/ijosh figure 2. load limit, risk conditions and repeatability of the activity. a. 85.7% of the workers who carry out lifting, lowering, and transport are over the load limit, while 100% of the workers who carry out the push and pull activity are over the load limit. b. presence of asymmetry (100%) and vertical position (77%) in lifting, lowering and carrying and presence of poor posture (82%) and effort (94%) in pushing and pulling. c. repeatability in work activity both for lifting, lowering and transporting (103 times) and for pushing and pulling (86 times). data are represented as means ±sem. when analyzing the risk estimation for postural load using the reba assessment tool when applied to both hemibodies, the same trend was observed in terms of the achieved score and suggested levels of action for lifting, lowering and transportation activities as well as for pushing and dragging. a slightly higher score out of 12 points was recorded for lifting, lowering, and carrying compared to the pushing and pulling activities, which cataloged risk as “very high”. regarding the level of action suggested when comparing the two groups of tasks, the same trend was observed on both sides of the body, suggesting an “immediate intervention” (fig 3). when analyzing and comparing the breakdown of the scores obtained by applying the reba method for each body segment and the variables of load/strength and type of grip in each group of evaluated tasks, it was evidenced that for lifting, lowering and transporting the highs overall scores were derived from the higher contribution made by the referred score of the arm segment, while for pushing and pulling activities the higher score is due to the higher estimate of trunk load, and levels of load/force used. in both types of tasks, the load estimation turned out to be homogeneous for each right and left half body (fig. 4). figure 3. reba score and level of action by laterality. the evaluation of the risk estimates for postural load determined that, for the activity of lifting, lowering and transport, both for right and left laterality it obtained a score out of 11 with a level higher than 3, which suggests immediate intervention. for the push and pull activity, the reba score (10,8 right laterality and 11,2 left laterality) associated with action levels 3,5 and 3,8 respectively indicate the need for immediate intervention. data are represented as means ±sem. over 25 kg low 25 kg 0 10 20 30 40 n u m b e r s o f w o r k e r s 29 17 6 lifting, lowering and transport pushing and pulling 0 100 200 300 400 n u m b e r o f r e p e ti ti o n s o f t h e a c ti v it y lifting, lowering and transport pushing and pulling a sy m m et ry v er ti ca l po si ti o n b ad p os tu re b or g 8 o > 0 50 100 150 p e r c e n ta g e lifting, lowering and transport pushing and pulling c b a urrejola-contreras et al. postural stress and risk conditions in manual load handling of chilean industrial workers 52 figure 4. scoring of the reba method by the task group a. higher scores were observed in the arms, forearms, and wrist, while for group b the segments that gave the highest score in the assessment correspond to the trunk, neck, and legs, in both considering the level of load/force exerted and type of grip. data are represented as means ±sem. discussion the novelty of this study is that a highly variable and versatile work system is assessed in terms of the tasks performed by the subjects and allowed each of them to be specifically evaluated. the foregoing was based on the difference and specificity of the tasks performed by the subjects, where not all perform the same activity in the same work circuit, and also the tasks performed by each of the workers vary during the work circuit. the selected instruments were appropriate in characterizing the sample and in investigating the risk conditions present in both groups of tasks examined. in the first place, although there is repetitiveness both in lifting, lowering and transportation, as well as for pushing and pulling activities, the differences found may be related to the different productive rhythms, whereas in the case of lifting, lowering, and transportation, the duration of work cycle is practically double.13 a second relevant aspect, common for both types of activities, is the presence of risk as a result of postural load, static load, and/or unstable posture. in this sense, the risk conditions were related to the asymmetry of the spine, the difficulty to maintain a vertical cervical position and the adoption of poor posture and/or functional compensation during a task 14, fringes were also found in other studies in which the main issue originates from poor technique and/or training for workers regarding the use of mechanical advantage for their body segments to perform motor skills.15 on the other hand, for pushing and pulling activities, considerate is worth noting that most workers scored initial effort with the borg scale> 8, while 85.7% of subjects who participated in lifting, lowering and transportation activities reported having approached the human load limit (25 kilograms). although workloads used for both activities are within the norm, they require a great effort from the worker to put a load into motion 16,17. regarding evaluation using the reba assessment tool for both types of activities for each hemibody, data revealed different score contributions according to the body region involved in the process. once again, the score resulting from the load magnitude and/or the exerted force stands is highlighted in both activities. for lifting, lowering and transportation, the highest score by body segment was observed in the arms, forearms, and wrists, which could be explained to a greater extent by working angles of 45 and/or 90 degrees in the lateral and frontal planes, in addition to movements in another plane such as rotations 18, working angles that are responsible for imposing greater load and stress on the tissues involved.19. in its counterpart, for pushing and dragging, the topographic regions mostly involved in the scoring were the trunk, neck, and legs, which are regions commonly implicated in maintaining a posture in a flexing, antigravity pattern and/or used for coupling between the body and load.20 a study on ergonomics evaluation of manual lifting task on biomechanical stress conducted in india showed that heavier weights produced higher stresses than lower weights, and the loading rate was found to be same at waist or knee level. it was observed to be linearn ec k l eg s t ru nk l oa d/ fo rc e fo re ar m w ri st a rm g ri p 0 2 4 6 8 p u n ta je r e b a right side left side n ec k l eg s t ru nk l oa d/ fo rc e fo re ar m w ri st a rm g ri p 0 1 2 3 4 5 p u n tu a c io n r e b a right side left side lifting, lowering and transport pushing and pulling urrejola-contreras et al. postural stress and risk conditions in manual load handling of chilean industrial workers 53 ly increasing after waist level.21 the study proposes the following measures which should be adopted by occupational health units to improve working conditions: a) evaluate and train the best technique to perform different tasks to make more efficient use of biomechanics and mechanical advantage22, b) evaluate mechanical assistance to push loads of greater magnitude or the conformation of task teams to minimize the initial push and/or drag effort 23, c) review and incorporate the use of working pauses combined with the rotation of workers in different jobs to reduce the repetitiveness component and improve the recovery of tissues and joint structures involved in the execution of activities, and by reducing the stress imposed on the musculoskeletal system in the tasks performed.24 a limitation of this study was not to consider or preliminarily assess clinical aspects such as signs and symptoms associated with musculoskeletal disorders and organizational aspects, including those that determine the productive rhythms, criteria that would have allowed to clarify if the detected risks compromise occupational health as well as the development of sustainable work 25. another limitation was the size of the sample (n=52), however, this study considers it important for future or continuity work to increase the sample by assessing other company branches and the inclusion of women to improve representativeness, and be able to transfer the obtained results to other productive sectors with more statistical significance. in this sense, the main implications and applications of the study show that in terms of risk prevention associated with the manual handling of loads, the implementation of the technical guide for the evaluation and control of risk factors could include sections in which variables are established. of risk for different tasks because not all present the same risks, for example in the observed variables of postural load, and repetitiveness. a better application could be to separate and classify the type of tasks and from this categorize the risks as well as their evaluation, management, and control measures. conclusion this work concludes the presence of associated risks derived mainly from the postural load in the manual load handling, as well as indicators that constitute an alert, including the absence of pauses/rest times or a change of activity during the work cycle. although there is a 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[cited 20th july 2021]; 38(6):58. available from: http://link.springer.com/10.1007/s13593-018-0534-2 type of the paper (article int. j. occup. safety health, volume 13, no. 3 (2023), 272-281 https://www.nepjol.info/index.php/ijosh 272 short communication lassa fever infection among healthcare workers during the 2018 outbreak in nigeria ogbaini-emovon e1, erah f2, osagiede ef 2,3*, nnadi c2, ogbetere y2, tobin e. a1, asogun d2, okonofua m1, akpede g4, akhideno p5, erameh c5, rafiu mo5, ovienria w6, ephraim-ogbaini c7, ojide ck8, unigwe u9, ireye f10, günther s11, duraffour s11, and okogbenin s12. 1institute of lassa fever research and control, irrua specialist teaching hospital, irrua, nigeria, 2department of community medicine, irrua specialist teaching hospital, irrua, nigeria, 3department of community medicine, niger delta university teaching hospital, okolobiri, nigeria, 4department of paediatrics, irrua specialist teaching hospital, irrua, nigeria, 5department of internal medicine, irrua specialist teaching hospital, irrua, nigeria, 6department of ophthalmology, irrua specialist teaching hospital, irrua, nigeria, 7department of obstetrics and gynaecology, irrua specialist teaching hospital, irrua, nigeria, 8department of medical records, irrua specialist teaching hospital, irrua, nigeria, 9department of medical microbiology, alex ekwemen federal teaching hospital, abakaliki, nigeria, 10department of medicine, university of nigeria teaching hospital, ituku-ozalla, nigeria, 11nigeria centre for disease control, abuja, nigeria, 12edo state ministry of health, benin city, nigeria. abstract introduction: healthcare workers (hcws) are potentially exposed to infection during viral hemorrhagic fever outbreaks. in the wake of 2018, nigeria experienced an unprecedented surge in cases of lassa fever (lf), which affected hcws. to guide infection prevention and control (ipc) strategies in similar settings, we characterize hcws' infection and describe the gaps in ipc standards and practices during the outbreak. methods: data was collected using a structured questionnaire, interview, and review of case notes of 21 hcws with laboratory-confirmed lassa fever who were treated at the irrua specialist teaching hospital (isth) irrua and the alex-ekwemen federal teaching hospital, abakaliki (aefetha), between 1st january and 27th may 2018. information collected was the patients' socio-demographic characteristics, date of potential exposure and onset of illness, nature and type of exposure, clinical features, outcome, use of personal protective equipment (ppe), and personnel ipc training. the obtained data were analyzed using descriptive statistics with microsoft excel. results: the study included 21 hcws, and 12 (57.14%) were doctors. the case fatality rate was 23%. nearly two-thirds (62%) of the hcws could describe a likely procedure leading to their exposure and infection. among 13 hcws, 85% had multiple blood and body fluids exposure, while 15% had needle stick injury or scalpel cut. about one-fifth of the participants had received some ipc training. conclusion: limited ipc adherence and inappropriate risk assessment were identified as factors leading to lassa fever exposure and infection among hcws. there is an urgent need to provide ipc training for all hcws and to ensure an adequate supply of ipc materials to all healthcare facilities as part of emergency preparedness, especially in lf endemic areas. keywords: healthcare workers, lassa fever infection, nigeria, preventable calamity, 2018 outbreak corresponding author: emmanuel friday osagiede, department of community medicine, irrua specialist teaching hospital, irrua, nigeria. email: drosagiedeef@gmail.com tell: +2348039433810 (ef osagiede). orcid id: https://orcid.org/00000001-5254-6783 date of submission: 08.12.2022 date of acceptance: 08.05.2023 date of publication: 01.07.2023 conflicts of interest: none supporting agencies: this work was supported by grant gu 883/4-1 from the german research foundation (dfg), the global health protection program of the german government (ghpp), and the foundation for innovative new diagnostics (find). doi:https://doi.org/10.3126/ijosh.v13 i3.44269 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:drosagiedeef@gmail.com https://orcid.org/0000-0001-5254-6783 https://orcid.org/0000-0001-5254-6783 https://doi.org/10.3126/ijosh.v13i3.44269 https://doi.org/10.3126/ijosh.v13i3.44269 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ ogbaini-emovon et al. lassa fever infection among healthcare workers during the 2018 outbreak in nigeria 273 introduction lassa fever (lf), an acute viral hemorrhagic disease caused by the lassa virus, remains a public health challenge in west africa, with an estimated 100,000–3,000,000 new infections and approximately 5000 deaths per year.1 since 1969, when the disease was first reported in the lassa community in north eastern nigeria, among two missionary nurses who became ill and died, several outbreaks and sporadic cases have been reported with the increasing incidence among healthcare workers.1–4 the reservoir for the lassa virus is the multimammate rat of the genus mastomys natalensis. this peri-domestic rat is ubiquitous in many households in the endemic area of subsahara africa.5 two modes of transmission have been recognized, namely primary and secondary transmission. primary transmission is via consuming contaminated food, inhaling aerosolized droplets from the rat, direct contact with rat excreta with broken skin or mucous membrane, and hunting and consuming rats as food in endemic areas.6,7 secondary transmission from human–to–human may occur through direct contact with blood and body fluids or inhalation of droplets from infected patients at the community level or in healthcare settings. nosocomial outbreaks involving transmission between patients and healthcare workers are associated with high mortality and are driven by poor understanding and compliance with standard precautions and other infection prevention and control measures.4,8,9 in lassa fever endemic areas, it is difficult to distinguish between cases of primary and secondary infections acquired through occupational exposure. also, direct estimation of the lassa fever infection rate and risk factors among healthcare workers is cumbersome because about 80% of infections are asymptomatic, and some symptomatic infections occurring in healthcare workers may be self-limiting and mimic other febrile illnesses in endemic areas and, therefore, may not be recognized or reported.1,5 a mathematical modeling research suggests that while outbreaks are primarily fuelled by independent zoonotic transmission events from infected rodent hosts, approximately 20% of cases may result from the secondary human-to-human transmission, typically in hospital settings.3 most available literature on lassa fever in hcws is based on serologic surveys conducted during outbreaks, and therefore the causal relationship between exposure and infection was challenging to establish. this study described cases of lassa fever infection among hcws during the 2018 outbreak in nigeria, with specific reference to laboratory-confirmed cases that were treated at the irrua specialist teaching hospital (isth) and the alex ekwemen federal teaching hospital abakaliki (aefetha) two major lassa fever treatment centers in nigeria. methods we conducted a review of all cases of infected healthcare workers in nigeria during the 2018 lassa fever outbreak between 1st january and 27th may 2018. a total of 21 hcws who had laboratory-confirmed cases, treated either at irrua specialist teaching hospital (isth), irrua, or alex ekwemen federal teaching hospital, abakiliki (aefetha) were interviewed using a structured questionnaire, and their case notes were reviewed. the data collected included socio-demographics, date of likely exposure and onset of illness, nature, and type of exposure, clinical features and outcome, infection prevention and control (ipc) practices at the point of care, and personnel ipc training. data collected were analyzed using descriptive statistics with microsoft excel to identify exposure risk and gaps in infection prevention and control (ipc) measures during patient care in their various healthcare facilities. results a total of 21 hcws were treated in the two treatment centers, and about three-fifths (57.14%) of them were doctors, while one-fifth (19.0%) were nurses, and the other two were one laboratory technologist and one dental technologist. male to female ratio was 1.6: 1, and the mean age of respondents was 37.76 ± 9.45 years. fourteen cases ogbaini-emovon et al. lassa fever infection among healthcare workers during the 2018 outbreak in nigeria 274 were treated at aefetha (eight doctors, five nurses, and one laboratory technologist), while seven received treatments at isthi (four doctors, two nurses, and one dental technologist). all the respondents were staff of tertiary healthcare facilities located in the lassa fever endemic states of edo, ebonyi, ondo, nasarawa, and kogi (table 1). more than two-thirds (71.43%) were from fetha/aefetha (alex ekwemen federal teaching hospital, abakaliki), three (14.29%) from isth (irrua specialist teaching hospital), irrua, while other health facilities recorded one case each. table 1: the distribution of lassa fever-infected hcws by their health facility and state in nigeria. institution frequency percentage aefetha, ebonyi state 15 71.43 isthi, edo state 3 14.29 fmck, nasarawa state 1 4.76 fmcl, kogi state 1 4.76 fmco, ondo state 1 4.76 total 21 100 key: aefetha (alex ekwemen federal teaching hospital, abakaliki), isthi (irrua specialist teaching hospital, irrua), fmck (federal medical centre, keffi), fmcl (federal medical centre, lokoja) and fmco (federal medical centre owo). key: *multiple responses reported, **patient/dead body. figure 1: the various exposure-prone activities performed by respondents nearly two-thirds (61.90%) of the hcws were able to describe a likely procedure leading to exposure and infection. exposure to blood through the drawing of blood from the patient(s) 2 3 3 5 10 13 11 11 8 4 3 0 2 4 6 8 10 12 14 f re q u e n c y number of performed exposure activities* ogbaini-emovon et al. lassa fever infection among healthcare workers during the 2018 outbreak in nigeria 275 they managed was recorded in all those whose possible source of exposure could be identified. also, there were multiple sources of exposure in these respondents. another exposure to blood and body fluids was experienced by 11 (84.62%) of the hcws who were able to describe the likely exposure-related procedure, while two (15.38%) reported exposure through needle stick injury or scalpel cut. in terms of infection prevention and control capacity, about one-fifth of the respondents had received ipc training, which did not include practical demonstrations. amongst them, one respondent received one-day training while others got a maximum of three days. more than two-thirds (71.4%) of the respondents reported regular use of ppe when attending patients. . key: *multiple responses reported. figure 2: factors leading to lassa fever exposure and infection in hcws. overall, the challenges and gaps identified by respondents as contributory factors to exposure and infection at the place of work were lack of ipc training, inappropriate risk assessment when attending to patients, lack of ppe, and lack of running water/hand sanitizer. the commonest clinical feature at the time of presentation by the respondents was fever (85.71%). others were headache (57.14%), abdominal pain and general body pain (38.1%), weakness and sore throat (33.33%), vomiting and cough (23.81%). the least common clinical features were body swelling and seizure (9.52%). the mean incubation period estimated as the period between the time of likely exposure to the time of onset of illness was ten days, while the median number of days between the onset of symptoms and testing for lassa fever was 12 days. the case fatality rate was 23.8%. 17 10 6 6 0 2 4 6 8 10 12 14 16 18 no ipc training inappropriate risk assessment lack of running water/hand sanitizers lack of ppe frequency factors leading to lassa fever exposure and infection in hcws* ogbaini-emovon et al. lassa fever infection among healthcare workers during the 2018 outbreak in nigeria 276 key: *multiple responses applicable. figure 3: clinical features of respondents at the time of presentation. discussion this study, to our knowledge, is the first, in recent times, to interrogate and characterize hcws infected with lassa fever during an outbreak situation and analyze the gap to guide infection prevention and control strategies in this population. the number of lassa fever-infected hcws described in this study represents about half [21(47.0%)] of the 45 hcws infected nationwide in 2018, as reported by the nigeria centre for disease control (ncdc).3 the infected hcws represented 7(2.4%) of the 291 and 14(23.3%) of the 60 confirmed lassa fever cases treated at isth and aefetha, respectively, during the year. the proportion of infected hcws among the confirmed cases treated at aefetha was higher than that of isth because, in january 2018, there was a nosocomial outbreak of lf at aefetha with the death of 3 hcws (2 doctors and a nurse). a similar situation of a nosocomial outbreak of lf was reported in south-eastern nigeria in 1989.2 the proportion of infected hcws among confirmed cases in this report is also similar to what was reported during the 2013-2016 ebola virus disease (evd) outbreak in west africa.10,11 both lassa and ebola viruses are transmissible from human to human in healthcare settings where hcws are under-protected. the most affected healthcare professionals in this study are the medical doctors, followed by the nurses and laboratory technologists. the higher rate of infections among these professionals probably reflects their greater involvement in invasive procedures compared with other hcws. for instance, the majority of the respondents reported drawing blood as one of the performed activities. venepuncture is a procedure mainly performed by medical doctors, nurses, and laboratory technologists in many nigerian hospitals, and 85% of those who recalled a likely exposure incidence leading to infection stated having direct contact with blood or body 18 12 8 8 7 7 5 5 4 3 3 3 2 2 0 2 4 6 8 10 12 14 16 18 20 f re q u e n cy clinical features at presentation* ogbaini-emovon et al. lassa fever infection among healthcare workers during the 2018 outbreak in nigeria 277 fluids.12,13 the clinical profile of the infected hcws in this study is expected and in keeping with the nonspecific nature of the disease. likely, lassa fever was not suspected early, which may account for the delay in requesting laboratory tests, as observed in this study. in practice, most febrile illnesses are presumptively treated with antimalaria and antibiotics as the first line of treatment, and lf is considered only after treatment failure.14 it is, however, worrisome that physicians would not request lf testing early enough, especially in outbreak settings when a high index of suspicion is expected of them. the case fatality rate would probably have been lower if diagnosis and treatment with ribavirin were initiated early, as the clinical outcome of lf is known to depend on the stage of the disease at presentation.15,16 nevertheless, this study's case fatality rate among infected hcws is lower than in previous experiences.4 in the past, there was no laboratory diagnostic capacity in nigeria, and samples were transported outside the country with a delay in the return of laboratory results. recent improvements in lf diagnostics in nigeria, through the establishment of molecular diagnostic laboratories, development of testing algorithms, and guidelines for case management, through the collaborative efforts of the ncdc and isth, might have contributed to a reduction in mortality. this study also identified risk situations and factors contributing to hcw exposure to lf infection. the most frequently cited deficiency was the lack of or inadequate training on ipc. previous studies in nigeria and other countries have recorded similar perceptions among health workers.17–20 education and training is one of the core components of the who national guidelines for implementation of ipc programme.21 preservice and in-service training of healthcare workers in multidisciplinary sessions that would encourage collaboration across health professionals have been recommended. whenever possible such training should be integrated to leverage existing programmes such as orientation programmes for new staff and regular hospital seminars and workshops. several studies have demonstrated that compliance with standard precautions was improved significantly after training programs.22,23 risk assessment is important in determining whether a febrile patient may have lf infection and deciding on the need for isolation and the level of personal protective equipment to be worn. inappropriate risk assessment of potential lf patients was the second most cited contributory factor to hcws exposure in this study. a high index of suspicion is required to quickly identify, triage, and isolate suspected lf cases, pending definitive diagnosis. this is especially important because the initial manifestations of lf may be non-specific. during outbreaks, exposure to unrecognized patients has been reduced by the use of standard precautions and is thus recommended.24–27 effective implementation of infection control is at the core of breaking a chain of transmission during outbreaks of viral hemorrhagic fevers and cannot be performed without the required ipc supplies and equipment. this study revealed that lack of running water, hand hygiene products, and ppe contributed equally to hcws' exposure, and in most situations, both were lacking or inadequate at the point of patient care. overall, these findings are consistent with previous studies and still pose a challenge to vhf outbreak response in africa.17,28,29 strong health systems rely on a well-equipped, protected, and capable workforce to respond to outbreaks and emergencies. in previous outbreaks of vhfs in africa, including the 2013-2016 ebola outbreak in west africa, many healthcare workers paid the supreme price while providing care for patients under grossly inadequate work conditions of weak infrastructure, lack of training, and deficient supply of ppe. there is a critical need to recognize that health worker protection and support is key to the capability of health systems to respond to outbreaks, and emergencies, and to meet the routine health need of the population. capacity building of the health workforce, strengthening health infrastructure, the supply of ipc commodities, and the ogbaini-emovon et al. lassa fever infection among healthcare workers during the 2018 outbreak in nigeria 278 institutionalization of ipc practices and standards across all levels of healthcare should be considered as an essential component of emergency preparedness, particularly in lassa endemic areas. thankfully, since 2017, the isth, in collaboration with the ncdc, has embarked on yearly training programmes on ipc and case management of lf for all categories of hcws in nigeria. the ncdc recently issued national guidelines for lassa fever case management and infection prevention and control.30 put together, these are laudable initiatives to guide the management and control of lassa fever at the healthcare facility level and to reduce nosocomial transmission, including health workers' infections. beyond the direct occupational risks described in this study, other factors such as psycho-social stress, fatigue due to long hours of work or excessive workload, workplace disharmony, and poor remunerations are all potential indirect determinants of exposure to harm in the workplace which should be addressed. this study has some limitations. first, it assumed that hcws infections occurred in the workplace without excluding the possibility of nonoccupational exposure, particularly rodent-tohuman transmission at the community level. second, there was difficulty in obtaining goodquality data on exposure history and ipc practices from patients who were seriously ill or had died. in such cases, some information was obtained from co-workers and proxies in addition to what was documented on the patient case notes. third, data on ipc practices were based on patient interviews and might have been affected by recall bias. studies involving direct observation of the practice of standard precautions among healthcare workers in their workplaces, including an on-site survey of the infection prevention and control materials available to workers, are warranted to provide a more precise assessment. despite these limitations, this study uniquely draws a direct connection between exposure and infection in healthcare settings where ipc infrastructure and supplies are deficient and hcws training is neglected. preventing occupational lf infection places responsibilities on both hcw and the employer. hcws at all levels in the health system (hospitals, clinics, laboratories, etc.) should mandatorily be taught the basics of lf and other highly infectious diseases, including practical training on ipc hand hygiene, use of ppe, prevention of needle sticks and sharp injury, safe blood collection, environmental cleaning and decontamination of surfaces and equipment, safe management of linens and medical waste. they should report any risky exposure forthwith in the workplace to their immediate supervisor or employer for appropriate post-exposure prophylaxis. all hcws who develop febrile illness in lassa fever endemic areas or living in an area of lassa fever outbreak should seek immediate medical attention. ipc programmes and governance structures, such as ipc teams and committees, should be constituted at all healthcare system levels to provide leadership for ipc implementation and ensure compliance with recommended standards. employers are responsible for ensuring employees are welltrained and equipped with the required preventive measures. administrative controls (such as guidelines, standard operating procedures, and policies) and engineering controls (such as the provision of running water, isolation areas, and waste management facilities), and provisions of ppes must be in place to minimize occupational risk. it is gladdening that healthcare worker protection and security is beginning to receive global attention following the recent evd outbreak in west africa, which prompted who and ilo to recommend that hcws with evd resulting from workplace activities should have the right to compensation, as well as free rehabilitation and access to curative services.31 implementing similar strategies for lf and cementing them into the national policy for ipc and emergency preparedness will go a long way to strengthen and increase the health workforce's confidence and immortalize all those who lost their lives for the patients under their care. conclusion this study reported limited ipc adherence ogbaini-emovon et al. lassa fever infection among healthcare workers during the 2018 outbreak in nigeria 279 practices and inappropriate risk assessments among hcws who cared for lf patients during the outbreak. these were some of the factors that led to their lf exposure and subsequent high infections. it is, therefore, of urgent importance to provide ipc training for all hcws. the relevant ipc materials should be made available to all healthcare 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[internet]. geneva: ilo/who; 2014 sep. available from: http://www.ilo.org/safework/info/publications/w cms_301830/lang--en/index.htm. https://www.who.int/csr/resources/publications/clinical-management-patients/en/ https://www.who.int/csr/resources/publications/clinical-management-patients/en/ https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html.%20cdc.%202019.%20p.%201–232 https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html.%20cdc.%202019.%20p.%201–232 https://apps.who.int/iris/bitstream/handle/10665/130596/who_his_sds_2014.4_eng.pdf https://apps.who.int/iris/bitstream/handle/10665/130596/who_his_sds_2014.4_eng.pdf https://doi.org/10.1186/s12879-015-1166-7 https://researchexperts.utmb.edu/en/publications/serologic-survey-among-hospital-and-health-center-workers-duringhttps://researchexperts.utmb.edu/en/publications/serologic-survey-among-hospital-and-health-center-workers-duringhttps://researchexperts.utmb.edu/en/publications/serologic-survey-among-hospital-and-health-center-workers-duringhttps://ncdc.gov.ng/themes/common/docs/protocols/92_1547068532.pdf https://ncdc.gov.ng/themes/common/docs/protocols/92_1547068532.pdf http://www.ilo.org/safework/info/publications/wcms_301830/lang--en/index.htm http://www.ilo.org/safework/info/publications/wcms_301830/lang--en/index.htm type of the paper (article int. j. occup. safety health, volume 13, no 2 (2023), 180-189 https://www.nepjol.info/index.php/ijosh 180 original article effect of lifting weight, height and asymmetry on biomechanical loading during manual lifting vijaywargiya a1, bhiwapurkar mahesh k1, thirugnanam a2 1 mechanical engineering dept., op jindal university raigarh, chhatisgarh, india 2 biotechnology & medical engineering, national institute of technology rourkela, india abstract introduction: in india, physical manual activities in asymmetrical postures overtax the human musculoskeletal system, which may exceed workers' physical limitations. thus the purpose of this study was to examine the physical stresses experienced by the subject, based on subjective and biomechanical loading estimates while lifting weights to various heights, in an asymmetric direction and propose the safe limit for manual lifting. methods: a laboratory experiment was conducted utilizing twelve male subjects in the age group of 20 to 25 years who lifted 5 different weights between 10 to 20 kg from below the knee to various lifting heights (below the knee to ear level). the lifting task was performed in three asymmetric angles (45, 90, and 135-degree) using free-style lifting techniques. an anova technique was used to analyze the influence of three parameters (lifting weight, lifting height and asymmetric angle) on two responses; subjective estimates and biomechanical loading. the subjective estimate was obtained using workload assessment by body discomfort chart. the biomechanical loading (loading rate) was estimated from ground reaction force data, obtained from the force plate. results: both the responses; subjective estimates and biomechanical loading followed a consistent pattern in predicting physical stress. the result revealed that lifting weights with higher destination heights and asymmetry angles increased the physiological workload and discomfort. experiments have shown that the loading rate is reduced by 8 to 10% for each increase in the 45-degree angle of asymmetry. conclusion: in general, safe lifting of 15 kg weight up to ear level and 15 kg weight up to shoulder level are recommended for 45and 90-degree asymmetry respectively to prevent any chronic injuries. a maximum of 12.5 kg lifting weight up to shoulder level is also proposed. keywords: asymmetric posture, loading rate, manual material handling, workload assessment. introduction construction workers are frequently exposed to forceful and repetitive exertions with awkward postures, which lead to work-related musculoskeletal disorders (wmsds) such as strains, tendonitis, and back and wrist injuries.1 moreover, back pain is the most prevalent and costly musculoskeletal disorder as a result of poor working conditions.2 in the construction field, the worker experiences frequent bending and/or twisting of the body, lifting the load above and below the shoulder and knee level.3 considering the presence of heavy equipment, physically corresponding author: vijaywargiya anurag mechanical engineering department, op jindal university raigarh, chhatisgarh, india telephone: +919755547130 email: anurag@opju.ac.in orcid id: https://orcid.org/0000-00033878-3998 date of submission: 29.04.2022 date of acceptance: 19.12.2022 date of publication: 01.04.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijos h.v13i2.43180 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:anurag@ https://orcid.org/0000-0003-3878-3998 https://orcid.org/0000-0003-3878-3998 https://doi.org/10.3126/ijosh.v13i2.43180 https://doi.org/10.3126/ijosh.v13i2.43180 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 181 demanding tools, and changing work environments, the job sites in the construction industry are more crucial to society, the economy and the business environments.4 asymmetry occurs when an external load is handled in a non-sagittal plane. a lifter must usually twist his or her trunk off the sagittal plane while performing an asymmetric lifting task. twisting the trunk in asymmetric lifting is hazardous in several investigations5. large compression spinal force combined with axial shear torsional force impacted the intervertebral discs as well as trunk muscular activity during asymmetric lifting.3,6 second the maximal voluntary isometric strength was reduced during asymmetric lifting, also average upward acceleration and peak velocity or human lifting capability were lower in asymmetric lifting.4,7,8,9 third, poor posture stability and asymmetric muscular stresses on the spine can be caused by asymmetric lifting.7 in the building construction field, indian workers often employ two hand lifting techniques while twisting their torsos, especially during loading and unloading in restricted workplaces or for irregular material handling. restricted workplaces may cause low back pain. the study investigated that lifting at a low height, such as below the knee or even from the floor, results in twice the amount of spinal loading10. it is commonly agreed that the cause of lower back pain and injury is frequently related to the posture of lifting, the load, muscle fatigue, etc.11,12 in the literature, the loading conditions resulting from symmetric lifting are well documented, yet free-style asymmetric lifting above the subject’s waist-level height has not been intensively studied.13 it was also observed that previous studies of asymmetric lifting were limited to a 90degree asymmetric angle, but none of the studies investigated lifting task parameters at a 135degree asymmetric angle.5,14 in line with this motivation, the purpose of the present experimental study is to evaluate the risk of asymmetrical lifting for two lifting task parameters; weight load and destination heights based on subjective and biomechanical loading estimates while lifting objects asymmetrically. the lifting task was considered similar to the task used in the construction industry in india. the present ergonomic study may help workers to avoid hazards that cause injuries, illnesses, and fatalities in the construction field. the construction industry's safety and health performance might be considerably improved if appropriate and acceptable information about workplaces, manual jobs, and ongoing training and education is provided. methods in the present study twelve healthy male university students (mean age 23.5 ± 1.78 years, weight 70.67 ± 2.57 kg, and height 1.76 ± 0.027 m), were participated in the study. the inclusion and exclusion criteria were designed to reflect a healthy and working population. none of the participants had experience in manual lifting tasks, and none had a history of neurological disorders, back pain, or any other musculoskeletal injury. the subject's mean height and weight were found to be approximately the same due to the closed age group. before the experiment, each subject reviewed and signed an informed consent form approved by the university’s institutional review board. all of the subjects had been trained for the task before the actual experiment began. the remuneration was given to the subject for their participation. the lift's origin was in the sagittal plane, and asymmetrical lifting was investigated at 45°, 90°, and 135° departures from the sagittal plane to the right. the lifting cycle began with the pan being lifted (dimension 30×30×25 cm) of a concrete-cement mixture, from the below knee height (origin) to a bench at the desired destination level. subjects performed a lifting task with 5 different lifting weights, in which 10, 12.5, 15, 17.5 and 20 kg, the pan was lifted to 5 different vertical lifting heights; below the knee, knee, waist, shoulder and ear level of the subjects. the subjects were restricted to move their feet during the lifting cycle. for asymmetric lifting, the individual completed an initial symmetric lifting, then a desired asymmetric body turn to the right, and finally placed the container on the table. this manual lifting task was found to be consistent with the vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 182 building construction industry for performing the concreting operation. experimental setup the experimental study was performed in the biomechanics lab of the national institute of technology rourkela; nit rourkela.15 the study was carried out using laboratory simulated experiments in september 2019. the kistler’s multiaxial force platform (500×590×50 mm) measures grfs and was used in this study (model aa9260). the analog output from the force platform passed through an internal amplifier and reached kistler’s data acquisition system (type 5691a1), where data was collected with a sampling frequency of 1000 hz to generate a digital signal. the nyquist theorem was used to determine the sampling frequency. for smoothing data, the butterworth filter was used, which attenuated frequencies over the set cut-off frequency while allowing frequencies below the cut-off to pass through. finally, the data was reflected in bioware software. figure 1. schematic diagram and laboratory set-up of the force plate biomechanical evaluation the manual lifting task was evaluated using data obtained from the force plate and subjective workload assessment chart. the vertical ground reaction force (grf) (fz) beneath feet produced during lifting was measured using force platforms. fz always thrusts the body upward through the feet. the setup arrangement is shown in figure 1. the ratio of peak loading and time to peak loading during human activities is referred to as the loading rate (lr). loading rate (lr) was calculated by determining the time required for the vertical force to rise by lifting the weight from the origin to the destination. the peak rate of vertical grf (lr) indicates the possibility of chronic damage as a result of these activities.16 lr = fzmax−fzmin t2−t1 (equation 1) fzmax and fzmin are the peaks and the lower value of fz of one lift and (t2-t1) is the time between these values. finally, the magnitude of the loading rate obtained from grf was compared to subjectively evaluated physical discomfort and overall workload. the subjective evaluation was performed by giving a questionnaire to each subject, figure 2.17 the questionnaire includes a chart for measuring physical discomfort as well as a rating scale for the total workload. after executing the lifting task for each test condition, the subject was asked to rate the level of discomfort in each of the body parts, figure 2. the degree of discomfort is measured on a five-point scale that ranges from no sensation or soreness (zero) to extreme pain or soreness (4). following the discomfort assessment, the subject was asked to rate the overall workload for the task. the overall workload scale is also a five-point scale, with ‘1’ being very light and ‘5’ being very hard. the physiological workload was thought to be a major risk factor for wmsd.7 vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 183 figure 2. the body discomfort and overall workload questionnaire.17 test procedure the weight was lifted using an open circularshaped plastic pan with no handles. to make lifting easier, the weight of the concrete mixture (cement, sand, and grit) was placed in the pan. the pan is similar to that used in construction fieldwork. before the lifting task, the subjects were given thorough instructions and requested to complete two to three trials while standing on a force plate. each participant was required to lift a load in 75 different combinations of lifting parameters (5 weights, 5 destinations and 3 asymmetrical angles) in an asymmetrical freestyle. a total of these 75 lifting tasks were randomly assigned to each subject during data collection to prevent order effects. after each lifting task, a sufficient rest period was given to allow the muscles to recuperate. the subjects were told to lift the weight with both hands while keeping their feet in the sagittal plane. during the lifting cycle, the subject was instructed to maintain a fixed, symmetrical foot position. the fz was measured for each test condition for all the subjects against a time scale (in seconds). response data analysis a repeated measures anova was performed using the statistical package for social sciences (spss inc., chicago, usa, version 16) to evaluate the subject’s response. the loading rate and overall workload were tested for the effect of lifting asymmetry, lifting weight, lifting heights and additional contrast tests (pairwise tests) for significant asymmetry effects. a p-value of 0.05 was considered significant. the repeatedmeasures design was well suited because each subject's assessments were collected repeatedly for all of the test situations. wilcoxon signed-ranks test was also carried out on all the data to determine whether the independent variables had a significant effect on the dependent variables. for interpreting the anova, two further statistical measures were used: partial eta squared and the observed power. partial eta squared (η2p) is a way to measure the effect size of different variables and to understand the major effects or interactions18. an observed power of 0.95 in the range of 0 to 1 indicates a 5% possibility of detecting a false positive result. results within-subject test of statistical analyses was performed to determine the general effects of lifting weight, lifting height and asymmetry angle on the loading rate and overall workload. vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 184 table 1. within-subjects effect of test parameters on loading rate and overall workload sources loading rate overall workload df f sig.(p) η2p o.p df f sig.(p) η2p o.p w 4 10535.25 .00 .99 1.0 4 509.17 .00 .98 1.0 h 4 29785.34 .00 1.0 1.0 4 330.10 .00 .97 1.0 a 2 9523.67 .00 .99 1.0 2 165.32 .00 .94 1.0 w * h 16 2127.95 .00 .995 1.0 16 14.07 .00 .56 1.0 w * a 8 27.04 .00 .711 1.0 8 11.48 .00 .51 1.0 h * a 8 446.85 .00 .97 1.0 8 45.47 .00 .81 1.0 w * h * a 32 29.36 .00 .73 1.0 32 20.37 .00 .65 1.0 wlifting weight, hlifting height, a-asymmetry, dfdegree of freedom, o.p-observed power table 1 interprets the main effects and interaction effects for the judgment of responses. the anova result revealed that all the main and interaction effects are statistically significant. the results show that the highest contribution comes from the individual variables, followed by the contribution of the interaction variable, with a high value of observed power (o.p). the table clearly showed that each increase in lifting asymmetry significantly impacted the loading rate and overall workload (p<0.05). this effect was consistent for lifting weight and lifting height conditions. the vertical reaction force was measured for all 12 subjects for all experimental conditions. one such sample plot of one subject lifting the weight of 17.5 kg at shoulder height for one minute has been shown in figure 3. figure 3. vertical force-time graph of sample reading the value of the mean loading rate and overall workload of all 12 subjects was plotted as shown in figures 4 & 5. the plot indicates that the loading rate was significantly increased with increasing lifting weight and also by increasing destination heights for all three asymmetry angles. there is no significant difference in loading rate predictions between the knee and waist height for all the asymmetric lifting weights (p>0.05). when the destination was raised above this lifting height to ear height, however, the loading rate increased dramatically (p<0.05). moreover, when subjects lifted different weights to below knee height, no significant effect was detected (p>0.05). it has also been seen that the least loading rate was observed for lifting the smallest (10 kg) weight and that there was no significant difference in loading rate for all other asymmetric lifting heights (p>0.05). this was also confirmed by the least overall workload, figure 5. plot 4 demonstrated that there is a substantial reduction in loading rate with an increase in lifting asymmetry irrespective of lifting weight and lifting height (p<0.05). the mean overall workload for all 12 individuals was plotted in fig. 5. it was interesting to find that the mean loading rate and the overall workload rating were well correlated to some extent. the overall workload yields an almost similar rating vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 185 between the knee and waist height for all of the asymmetric lifting weights (p>0.05). the rating of overall workload showed a significant rise while lifting asymmetrically more than about 12.5 kg weight (p<0.05). the result also clearly demonstrated that the overall workload increased with an increasing asymmetric angle for all lifting weights and heights (p<0.05). the mean degree of discomfort for each body part was calculated for all 12 individuals. from the subjective rating of discomfort for 45-degree asymmetry, it was observed that lifting above 15 kg weight irrespective of lifting height, brings pain in the upper arms and back. the intensity of pain increased with increasing weight and lifting heights. in the case of 90-degree asymmetry, it was observed that lifting above 15 kg weight at shoulder height causes extreme pain (rating 4) in both arms and knees. an increase in lifting weights to 20 kg, raised this pain in the back and wrist. further, lifting weights between 15 to 20 kg at ear height brings intense pain (rating 4) in the shoulder. in the case of 135-degree asymmetry, lifting 15 kg weight to shoulder height causes strong pain (rating 3) in the shoulders, upper arms and mid to lower back. extreme pain (rating 4) was experienced in the upper arms when lifting the same weight at ear height. moreover, a further increase in weight brings intense pain to ear height. figure 4. mean loading rate plot with variation in weight (kg) and asymmetric lifting height 0 100 200 300 400 500 600 below knee knee waist shoulder ear m e a n l o a d in g r a te i n n /s lifting heights_asymmetric angle 45 10 12.5 15 17.5 20 0 100 200 300 400 500 600 below knee knee waist shoulder ear m e a n l o a d in g r a te i n n /s lifting height_asymmetric angle 90 10 12.5 15 17.5 20 0 100 200 300 400 500 600 below knee knee waist shoulder ear m e a n l o a d in g r a te i n n /s lifting height_asymmetric angle 135 10 12.5 15 17.5 20 vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 186 figure 5. mean workload plot with variation in weight (kg) and asymmetric lifting height. discussion one of the prime beneficiaries of ergonomics is the construction industry, with its physically demanding work. excessive physical demands beyond one’s capabilities may lead to productivity, safety and health issues in construction. the study's major goal is to reduce worker fatigue as well as the danger of subsidence by employing the most optimal lifting parameters during lifting tasks. the present study will mimic occupational conditions adopted in the building construction field. the results can help further progress in the existing occupational lifting guidelines and raise awareness of musculoskeletal or chronic stresses in the workplace as a worldwide problem. in the present study, lifting weight and lifting height had a major impact on the loading rate. based on the result obtained, in general, the heavier weights did produce a higher loading rate than the lower ones throughout the process of lifting despite the lifting height. it has been observed that lifting weights with higher vertical lifting heights and asymmetry angles increased the physiological workload and discomfort. from the body discomfort and overall workload responses, the biggest complaints rated by subjects are mid to lower back followed by the upper arm and then shoulder, forearm and knee, among the other body parts. while lifting the weight from the origin, trunk flexion was rare, and lifting was primarily accomplished through knee flexion. this lifting becomes more stressful, at the 0 1 2 3 4 5 below knee knee waist shoulder ear o v e ra ll w o rk l o a d lifting height_asymmetric angle 45 10 12.5 15 17.5 20 0 1 2 3 4 5 below knee knee waist shoulder ear o v e ra ll w o rk l o a d lifting height_asymmetric angle 90 10 12.5 15 17.5 20 0 1 2 3 4 5 below knee knee waist shoulder ear o v e ra ll w o rk l o a d lifting height_asymmetric angle 135 10 12.5 15 17.5 20 vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 187 shoulder or ear height, due to the dynamic trunk motion. lifting while bending creates a variety of back problems. it multiplies the weight of the object being lifted by the upper body's weight. bending and/or extending your upper body increases the effective load on your back, causing lower-back stress and muscular fatigue. the most prevalent movements that produced back injuries were bending and twisting. when the subject lifted the weight in a restricted posture, without moving both feet, such confined workspaces increase low back pain in the subjects' bodies19. during asymmetric lifting, lateral bending action on the lumbar column and a rotation of each vertebra on its adjacent vertebra happen. this vertebral rotation has a high risk of injury.20 aside from the rotational consequences, imbalanced back muscle loading can provide highly concentrated stress, which can overstrain a specific muscle or muscles required to support the column.20 in the present study, various combinations of factors were explored to determine the least and the most exerting task conditions. for example, when the lifting weight was increased from 12.5 to 20 kg, for the same lifting height, the mean loading rate increased by about 32 to 40%. similarly, when the lifting height was increased from knee to ear height for the same lifting weight, the loading rate increased by around 24 to 30 percent. this outcome applies to each asymmetric angle studied. the result revealed that there is no significant difference in loading rate for lifting the smallest (10 kg) weight irrespective of lifting heights. thus lifting 10 kg weight from origin to ear height for an asymmetrical angle up to 135-degree is safe, as the spinal force generated was less than the recommended limit according to the niosh lifting criterion.21 from the observed data, it is interesting to find that the mean loading rate and the overall workload rating are well correlated to some extent. both are predicated on the idea of subjects exerting more effort when performing dynamic lifting tasks. in the previous study by the author, the experiment was conducted for a symmetric posture with the same lifting weight and height conditions.22 the result found a higher loading rate and less perceived discomfort as compared to the present asymmetric lifting study. in asymmetrical lifting tasks, the subject had to lift the pan and then turn the body through given degrees before placing the lifting weight on the table. therefore, the cycle time for asymmetrical lifting was longer than for symmetrical lifting, leading to the occurrence of a lower loading rate. according to the findings of the present study, each increase in the 45-degree asymmetric angle reduces the loading rate by 8 to 10%. the results from the present study are consistent to some extent with the results of previous asymmetric studies.23-25 this study revealed that asymmetric lifting led to a lower loading rate while the overall workload increased as compared to symmetric lifting. regardless of whether the lift origins are on the left or right side, the revised niosh lifting equation reduces lifting weight limits by around 10% for every 30 degrees of asymmetry involved in the lift.23 several studies have shown reductions in maximum acceptable weights ranging from 8 to 22% when the load is asymmetrically applied to the trunk.24,25 the recommended weight limit is a weight limit below which virtually all healthy employees may accomplish for an extended period without increasing their risk of low back pain, according to the revised niosh lifting equation.21 although the loading rate and overall workload rating are two independent variables, the study found that they followed a similar pattern in predicting physical stress as a result of lifting tasks. therefore, the safe limit for various task parameters has to be established to prevent/reduce injuries to workers engaged in lifting tasks. the safe limit has been proposed based on results obtained from loading rate and subjective rating, assuming alarming levels for perceived difficulty and workload as rating ‘2’. for example, if the weight is to be lifted from the origin to all given vertical destinations, then the weight should not exceed 15 kg at a 45degree asymmetric angle. for a 90-degree asymmetric angle, this is restricted up to shoulder level. in the case of a 135-degree asymmetric angle, a maximum of 12.5 kg weight is permissible to lift safely up to shoulder level to prevent any chronic injuries. vijaywargiya et al. effect of lifting height, weight and asymmetry on biomechanical loading during manual lifting 188 limitations of the study the majority of the construction workers in india are male, specifically lifting tasks in a constraint posture. therefore, only male participants in a similar age range were chosen as the study's subjects. the study's limitations are that it did not take into account the participants' other existing health conditions, as well as their physical attributes like height, weight, and bmi. the authors believe that these factors contribute to the participants' different physical characteristics, such as height and weight. analysis of these factors' effects on the physical capabilities of the subjects requires much more in-depth research. another limitation of this study is that the participants were all male university students with no experience in manual lifting tasks. investigating a broader spectrum of the population would result in a reliable generalization of our findings. conclusion the workers were exposed to various risk hazards which affect health and safety issues in the building construction works. there has been a paucity of research on the physiological and subjective workloads of indian male construction workers. this assessment of the physiological and subjective workload of mmh operations is essential for recommending remedial measures and assisting in the implementation of ergonomic guidelines for construction workers. even though both responses are distinct, the study found that they followed a consistent pattern in predicting physical stress as a result of lifting tasks. the physiological demands were shown to be increased while lifting loads with a greater vertical distance. experiments have confirmed that the loading rate decreases linearly as the angle of asymmetry increases. each increase in the 45degree asymmetric angle reduces the loading rate by 8 to 10%. the subjects are most susceptible to pain in the lower back followed by the upper arm and then shoulder, forearm and knee. in general, safe lifting of 15 kg weight up to ear level and 15 kg weight up to shoulder level are recommended for 45and 90-degree asymmetry respectively to prevent any chronic injuries. a maximum of 12.5 kg lifting weight up to shoulder level is also proposed. acknowledgments the authors would like to express their gratitude to the participants of the study and the nit rourkela authorities for their support. references 1. boschman js, van der molen hf, sluiter jk, fringsdresen mh. 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https://pubmed.ncbi.nlm.nih.gov/?term=fatkhutdinova+l&cauthor_id=15385649 https://pubmed.ncbi.nlm.nih.gov/?term=verbeke+g&cauthor_id=15385649 https://pubmed.ncbi.nlm.nih.gov/?term=pirenne+d&cauthor_id=15385649 https://pubmed.ncbi.nlm.nih.gov/?term=johannik+k&cauthor_id=15385649 https://pubmed.ncbi.nlm.nih.gov/?term=somville+pr&cauthor_id=15385649 https://dx.doi.org/10.1093/occmed/kqh091 type of the paper (article int. j. occup. safety health, volume 13, no 1 (2023), 19-28 https://www.nepjol.info/index.php/ijosh 19 original article effects of gasoline and smoking on lipid profile and liver functions among gasoline exposure workers in iraq mohammed chinar m1, al-sulaivany bassim a1, fattah yousif m1, al-habib omar am2, haji mohammed b1 1 department of biology, faculty of science, university of zakho, kurdistan region, iraq, 2 college of science, nawroz university, duhok, kurdistan region, iraq abstract introduction: the rapid and recent rise in the pandemic of cardiovascular disease implies that the environment plays a significant role. numerous biological systems, such as the cardiovascular, blood-forming organs, liver, and kidneys, can be affected by gasoline and smoking. because filling station employees, repair service workers, gasoline truck drivers, and refinery workers are all at a greater risk of being exposed to gasoline fumes. even though gasoline and smoking have been investigated for so many years, few studies have looked into the effects of gasoline exposure combined with smoking on a variety of physiological mechanisms. as a result, we propose that combining gasoline exposure with smoking is a risk factor for cardiovascular diseases and impaired hepatic function. methods: the study included 95 male adult volunteers who worked with gasoline and were exposed to different fuel derivatives as study group and age and sex-matched seemingly healthy non-exposed people as the controls. questionnaire interviews were used to collect socio-demographic data and a standard technique was used to collect the blood samples. the levels of cholesterol, hdl4, ldl-c, triglyceride, and vldl were measured, as well as for liver enzymes alp, ast, alt, indirect bilirubin, direct bilirubin, and total bilirubin were measured. results: our data suggest that smoking with gasoline exposure causes an increase in total and bad cholesterol levels, as well as a significant shift concerning the control group in lipid profile and liver enzymes. the exposed group had higher levels of alp, and ast and significantly increased. in the nonsmoker exposed group d-bilirubin decreased in comparison to the control and exposed smoker group. conclusion: this research concluded that the liver enzymes (alp, ast, alt) were higher among workers who smoke and are exposed to gasoline than in control subjects, similarly, the bad cholesterol also increase. therefore, people who smoke and are handled with gasoline are at a higher risk of having heart and hepatic diseases. keywords: bilirubin, cardiovascular, cholesterol, gasoline, hepatoxicity. introduction waste management is identified as one of many severe environmental problems. waste problems can surely disrupt the environment around the community, such as soil pollution. a polluted environment will also have an impact on public health. there are several causes for the increase in waste, specifically the increase in population, the level of community activity, the socio-economic level of the community, technological advances, and also the pattern of people's lives.1 technological boosts also increase the amount of corresponding author: chinar m. mohammed department of biology, faculty of science, university of zakho, kurdistan region, iraq telephone: 9647507365420 email: chinar.mohammad@uoz.edu.krd orcid id: https://orcid.org/0000-00015945-550x date of submission: 23.02.2022 date of acceptance: 12.08.2022 date of publication: 01.01.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh .v13i1.43367 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) mailto:chinar.mohammad@uoz.edu.krd https://orcid.org/0000-0001-5945-550x https://orcid.org/0000-0001-5945-550x https://doi.org/10.3126/ijosh.v13i1.43367 https://doi.org/10.3126/ijosh.v13i1.43367 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ mohammed et al. effects of gasoline and smoking on lipid profile and liver functions among gasoline exposure workers in iraq int. j. occup. safety health, volume 13, no 1 (2023), 19-28 https://www.nepjol.info/index.php/ijosh 20 waste. it can be seen from the use of personal devices and frequently updating them to the latest ones.2 the world population is rapidly increasing gasoline, a highly flammable liquid mixture, is the primary contaminant in the environment and is mainly utilized for the internal combustion of vehicles.1 the majority of them are made up of hydrocarbons (aromatic, saturated, and unsaturated) and non-hydrocarbons (n, s, o2, vanadium, and nickel).2 because the gasoline vapor concentration in the atmosphere (approximately 2000 ppm) is not healthy when breathed even for a brief time (seconds), filling station personnel, service station attendants, gasoline truck drivers, and refinery workers are all at heightened risk from exposure to gasoline fumes.3 the most common method of exposure is inhalation, but cutaneous absorption is also possible. it is important to note that production employees, distribution, and gasoline usage are all in danger of acute or chronic toxicity.4 smoking tobacco involves thousands of compounds that have detrimental and poisonous effects on the body. alterations in lipid profile, increased insulin resistance, decreased nitric oxide (no) availability, endothelial dysfunction, increased insulin resistance, platelet dysfunction, high blood viscosity, alternations in fibrinolysis, ongoing inflammatory responses with rising inflammatory markers, and more recently free radicals-mediated oxidative stress play a vital role in the mediation of atherothrombosis appear to play an important role in the mediation of atherothrombotic.5 smoking cigarettes raises plasma catecholamine levels, which causes lipolysis and the production of free fatty acids, which the liver absorbs. the lipid-driven inflammatory disease of the artery wall is known as atherosclerosis.6 low-density lipoproteincholesterol (ldl-c) and very low-density lipoprotein-cholesterol (vldl-c) are toxic to cells, while hdl-c (high-density lipoproteincholesterol) is a protective factor against coronary atherosclerosis.5 tobacco smoking has been linked to higher levels of total cholesterol, triglycerides, ldl–c, vldl, and lower levels of hdl–c, according to a previous study.7,8,9 other research, however, has yielded contradictory outcomes.10 cigarette smoking appeared to accelerate atherosclerosis in part due to its effect on lipid profiles.11,12 it's also been discovered that the amount of cigarettes smoked is closely tied to the chance of developing cardiovascular diseases ldlc, idl-c, and vldl are all potentially atherogenic apob-containing lipoprotein particles. non-hdl-c is a progressive measure that includes all possibly atherogenic apob-containing lipoprotein particles.13 the liver is the body's main gland, and it plays a variety of roles in the control of numerous physiological activities. as a result, fatal liver disease could be the major cause of mortality. druginduced liver damage would be one of those lifethreatening disorders that necessitate extensive clinical and surveillance assessments.14 breathing small quantities of gasoline fumes can cause nasal and throat irritation, as also headaches, dizziness, nausea, vomiting, confusion, and breathing difficulties. dermal contact with gasoline can cause rashes, redness, and swelling, along with many other symptoms. although allergic reactions (hypersensitivity) have been observed, they are uncommon.15 long-term exposure to gasoline can cause hepatotoxicity, and the severity of benzene poisoning is dependent on the amount, route, and length of time of exposure, as well as the exposed person's age and pre-existing medical condition.16 the most typically requested tests for heart and liver investigations are lipid profile and liver function tests (lfts).17 as a result, the goal of this study was to determine the impact of gasoline exposure combined with smoke on the lipid profile parameters and liver function tests in gasoline station workers in zakho, duhok city, kurdistan region, iraq. methods the study included 95 male adult volunteers from zakho city, who worked with gasoline and were exposed to different fuel derivatives and provided mohammed et al. effects of gasoline and smoking on lipid profile and liver functions among gasoline exposure workers in iraq int. j. occup. safety health, volume 13, no 1 (2023), 19-28 https://www.nepjol.info/index.php/ijosh 21 informed consent to participate in the research. age and sex-matched seemingly healthy non-exposed people from various locations in zakho served as the controls. participants with the following criteria were excluded from the study: people diagnosed with cardiovascular disorders, those with a family history of malignancies, subjects with chronic renal and respiratory disease, individuals on corticosteroid therapy, radiotherapy or chemotherapy, liver damage or disease, and those who were already taking medication that affected their cardiovascular and liver functions. questionnaire interviews were used to collect data over three months, concentrating on sociodemographic information, periods of exposure, time of working (hours/day), health conditions, and habits of smoking. a standard technique was used to collect the blood. to reduce errors, the blood sample container was tagged with the participant's name. a blood sample was collected from the peripheral vein on the arm of each of the volunteers by venipuncture using a sterile 10ml needle and syringe. 7mls of venous blood was taken and 4mls were transferred immediately into a sterile labeled plain vial while 3mls were transferred into welllabel potassium edta anticoagulant vials. the blood in the plain vial was allowed to clot and retract. it was centrifuged at 18000g, serum extracted, for heart and liver enzyme assay. this investigation was carried out after the research and ethical committee of zakho university's department of biology faculty of science proved (5/238) its permission. to get authority to conduct biochemical analysis in the central laboratories, an official letter of request was issued to bedare hospital. after describing the study's goal, all research participants gave their written informed consent to participate willingly. data obtained were presented as median ± s.e.m. one-way anova followed by bonferroni post hoc test comparison was used to compare among control, non-smoking exposure, and smoking exposure groups. all statistical tests were twotailed and a (p≤0.05) was considered statistically significant. all the calculations and statistical analyses were performed using graphpad prism 7 (graphpad software, san diego, california, usa). results the information about the participants' demographics was acquired from a record based on the service station employees. the participants' ages ranged from 23 to 53 years for nonsmokers (mean 33.43 years), 31.82 for smokers in the exposed group, and 20 to 53 years for the unexposed group (mean 40.03 years). workers were employed for 3 to 35 years and were exposed to various fuel derivatives for at least 10 hours per day (table 1). figures 1, 2, and table 2 show the mean level of cholesterol (mg/dl), hdl-4 (mg/dl), ldl-c (mg/dl), triglyceride (mg/dl), vldl (mg/dl), and liver enzymes of workers exposed to gasoline including smokers and non-smokers in comparison to the unexposed group. the mean results of the exposed non-smoker group provided the following values for cholesterol (161.9 ± 2.95), hdl-4 (39.03 ±1.23), ldl-c (120.2 ±1.16), triglyceride (177.9 ±37.54), and vldl (20.08 ±1.12). whereas, in the case of the exposed smoker group, mean values of (165.7 ± 3.19), (39.38 ±1.26), (118.7 ±2.41), (121.2 ±6.55), and (23.38±1.39) were obtained for cholesterol (mg/dl), hdl-4 (mg/dl), ldl-c (mg/dl), triglyceride (mg/dl), and (vldl (mg/dl), respectively. for control were cholesterol (126.9 ± 6.01), hdl-4 (44.98 ±0.64), ldl-c (102.2 ±2.28), triglyceride (107.3 ±2.597), vldl (22.11 ±1.288). comparing the two sub-groups with the control indicated, the (cholesterol, hdl-4, and ldl-c) parameters were significantly different, whilethe parameters for (triglyceride and vldl) were insignificant. mohammed et al. effects of gasoline and smoking on lipid profile and liver functions among gasoline exposure workers in iraq int. j. occup. safety health, volume 13, no 1 (2023), 19-28 https://www.nepjol.info/index.php/ijosh 22 table 1. some of the demographic criteria for participation figure 2. comparison graph for levels of total plasma cholesterol (a), ldl-4 (b), hdl-c (c), triglycerides (d), and vldl (e) in the non-smoker (nse) and smoker (se) group compared with non-exposed controls (cnt); *: p<0.05. figure 2. comparison graph for levels of liver enzyme: alp (a), ast(b), alt (c), ind-bil(d), d-bil (e), total bill (f) in the non-smoker and smoker group compared with non-exposed controls; *: p<0.05 demographic criteria control non-smoker exposure smoker exposure age 40.03 33.43 31.82 weight 75.33 79.64 75.61 years/work 11.43 16 exposure hours 10 10 packet no 1-4 packet mohammed et al. effects of gasoline and smoking on lipid profile and liver functions among gasoline exposure workers in iraq int. j. occup. safety health, volume 13, no 1 (2023), 19-28 https://www.nepjol.info/index.php/ijosh 23 table 2. the effect of gasoline inhalation on lipid profile parameters among smoker and nonsmoker gasoline exposure workers values are means±sem (n=96), a p<0.05, significant change concerning the control group, ***changes between p<0.01 and p<0.001, sem: standard error of the mean, hdl-c, high-density lipoprotein cholesterol; ldl-c, low-density lipoprotein cholesterol, vldl: very-low-density lipoprotein cholesterol. the blood alp level for the exposed group of smokers was 140.7± 11.85 mg/l higher than the exposed group of non-smokers which was 98.14 ± 4.99 mg/l, both of them were significant when compared with the control. on the other hand, the ast concentration for the exposed group of smokers was 38.1 ± 1.95 mg/l which was insignificantly higher than the mean value for the non-smokers exposed group 34.93 ±0.49 mg/l, both of them were insignificant when compared with control. the mean levels of alanine transaminase (alt) of all participants were evaluated. the result revealed a significant (p=0.05) increase in alt in the smoker and non-smoker exposed groups (34.93±0.49 and 38.1±1.95 mg/l), respectively, when compared with the control (26.54 ± 1.98 mg/l). however, the d-bill concentration for the exposed group of smokers was 0.2556 ± 0.017 mg/l which was insignificantly higher than the mean value for non-smokers in the exposed group (0.2082 ±0.02 mg/l). the result of the study revealed a significant decrease (p≤0.001) in the mean ind-bill in the nonsmoker-exposed group. a significant decrease was noted between both control and non-smokers exposed groups for both total bilirubin and indirect bilirubin. data from table 3 indicated indirect bilirubin in the exposed group of smokers increased significantly in comparison to the control. on the other hand, the mean of total bilirubin decreased significantly in the non-smoker smoke-exposed group in comparison to the control (0.911± 0.062 control, 0.4369± 0.044 non-smokers, and 0.4805± 0.046 smokers). (figure 2, table 3). table 3. the effect of gasoline inhalation on liver function among smoker and nonsmoker gasoline exposure workers. values are means ± sem, a p<0.05, significant change concerning the control group, *, ** and *** changes between p<0.01 and p<0.0001, sem: standard error of the mean, alp: alkaline phosphatase, ast: aspartate aminotransferase, alt: alanine aminotransferase, d-bill: direct bilirubin, ind-bill indirect bilirubin, tot-bill: total bilirubin. parameter control non-smoker exposure smoker exposure p-value cholesterol (mg/l) 126.9 ± 6.01 161.9 ± 2.95 *** 165.7 ± 3.19 *** < 0.0001 hdl4 (mg/l) 44.98 ±0.64 39.03 ±1.23 *** 39.38 ±1.26 ** < 0.0001 ldl-c (mg/l) 102.2 ±2.28 120.2 ±1.16 *** 118.7 ±2.41 *** < 0.0001 triglyceride (mg/l) 107.3 ±2.597 177.9 ±37.54 121.2 ±6.55 0.0603 vldl (mg/l) 22.11 ±1.288 20.08 ±1.12 23.38±1.39 0.1829 parameter control non-smoker exposure smoker exposure p-value alp (mg/l) 66.92 ± 2.38 98.14±4.99 * 140.7± 11.85 *** < 0.0001 ast (mg/l) 25.67 ± 1.81 29.45 ± 0.89 37.69 ± 7.24 0.1391 alt (mg/l) 26.54 ± 1.98 34.93 ±0.49 ** 38.1 ± 1.95 *** < 0.0001 d-bill (mg/l) 0.254 ± 0.02 0.208 ±0.015 0.256 ± 0.017 0.1444 ind-bill (mg/l) 0.5385± 0.04 0.2628 ± 0.03 *** 0.3626 ± 0.04 ** < 0.0001 tot-bill (mg/l) 0.911± 0.062 0.4369± 0.044 *** 0.4805± 0.046 *** < 0.0001 mohammed et al. effects of gasoline and smoking on lipid profile and liver functions among gasoline exposure workers in iraq int. j. occup. safety health, volume 13, no 1 (2023), 19-28 https://www.nepjol.info/index.php/ijosh 24 discussion the risks of gasoline exposure are caused by chemicals in the gasoline mixture, such as xylenes toluene, ethylbenzene, benzene, and methyl tertiary butyl ether (mtbe). the cns is the most common systemic impact of acute gasoline exposure, but respiratory tract irritation and hematological effects such as anemia and hypothermia can also occur at high concentrations. chronic sniffing of gasoline has been linked to cardiac problems, as well as gasoline being a hepatotoxic substance.17 recently, it has been indicated by rahimi et al (2020), that gasoline elevated proteinuria, liver enzymes, and fatty liver changes among exposed workers.18 through an oxidative process known as cyp450 2e1, gasoline hydrocarbons that are inhaled are digested in the liver, releasing free radicals and quinine metabolites such as hydroquinone, benzoquinone, phenol, and 1,2,4 benzenetriol. by these free radicals and hazardous metabolites, lipid peroxidation and damage to the hepatic plasma membrane are caused.19 assessment of cardiac parameters and liver enzymes may provide significant information regarding the effects of gasoline and smoke products on the heart cells and liver in iraq because there are no legal guidelines or supervision for fuel components.2 because of the predictive relationship between blood lipids and cardiovascular disorders, particularly coronary artery disease, measuring blood lipids in the clinical laboratory has become increasingly relevant. total cholesterol, triglycerides, hdl cholesterol, and ldl cholesterol are frequently measured in lipid profiles during health screenings. the total cholesterol, ldl-c, increased statistically significantly as a result of this investigation. smoking is linked to significantly higher total cholesterol and low-density lipoprotein levels in the blood (ldl). triglycerides were found to be greater in the non-smoker exposure group. smoking, on the other hand, lowers hdl cholesterol levels in the blood, which is a strong preventive factor against the development of atherosclerosis. these findings could be linked to exposure and inhalation of the hydrocarbon component of gasoline and cigarette smoke, both of which can produce oxidative stress due to reactive oxygen species (ros). tobacco smoke contains around 5000 hazardous chemical constituents, including polycyclic aromatic hydrocarbons (pahs), free radicals, and oxidative gases.20 as a result, in addition to inducing ros intracellularly, the components of cigarette smoke suppress intracellular antioxidant systems, resulting in oxidative stress.21 pollutants in the environment, such as gasoline fumes, have been shown to increase oxidative stress in cells. when breathed, fumes from petroleum products can be degraded as xenobiotics through a sequence of reactions and biotransformations. during these reactions and biotransformations, ros are created as undesirable by-products. free radicals, which are produced by cigarette smoke, are thought to have harmful consequences, causing oxidative stress.22 oxidative stress occurs when the cell's ros and antioxidant systems are out of equilibrium. under healthy settings, the cell produces ros through oxygen metabolism, which is crucial for cellular signaling and is also harmless. excessive formation of reactive oxygen species (ros) causes lipid peroxidation, dna strand breakage, and other impairments to the structure and functionality of cells when oxidative stress is present.23 extrinsic and intrinsic ros can accumulate inside cells. inhaled hazardous gases are the principal source of exogenous ros (e.g., cigarette smoke, car exhaust fumes, and environmental pollutant). peroxisomes, mitochondrial respiration, the nadph oxidase system, and inflammatory cells, among other sources, create endogenous ros.24 the findings of this study, like those of many others, showed that cigarette smoke contributes to oxidative stress. in a case-control study involving 78 smoking and 82 nonsmoking men, karademirci et al.(in press) found that the total antioxidant status (tas), vitamin c, and vitamin e values were considerably higher in the nonsmoker group than in the smoker group. the smokers had increased total oxidant status and oxidative stress index values.25 other animal investigations have shown that cigarette smoke intake results in diminished and faulty antioxidant defense (decreased glutathione mohammed et al. effects of gasoline and smoking on lipid profile and liver functions among gasoline exposure workers in iraq int. j. occup. safety health, volume 13, no 1 (2023), 19-28 https://www.nepjol.info/index.php/ijosh 25 peroxidase and superoxide dismutase activity, increased lipid peroxidation, and mitochondrial dysfunction) that causes a rise in h2o2 production.26 as a result of this imbalance, oxidative stress caused by tobacco smoking causes greater heart damage.27 the communication of no with free radicals in smoke reduces no's bioactivity, influencing its vasodilatory, antithrombotic, antioxidant, and antiinflammatory effects, as well as its effects on endothelium permeability and myocardial function.18,28 in recent years, academics have been particularly interested in the physiological impacts of gasoline and smoking. in four primary studies, demographic data, smoking status, and other background information were gathered.19 in five investigations, the frequency of cigarette smoking was recorded in both exposed and unexposed groups.29 in terms of liver function measures, our findings revealed that non-smokers and smoke-exposed individuals had higher alp, ast, and alt levels than unexposed workers. furthermore, the average levels of alp and alt were considerably higher in the smoker group, with no significant variations in ast levels between the exposed and unexposed groups. smoking has been linked to an increase in liver enzymes and the development of chronic renal disease.30 furthermore, smoking has been linked to liver cancer and chronic renal disease, as well as an increase in liver enzymes.31 nicotine's poisonous components (co, cyanide, potassium nitrate, cadmium, chloroform, vinyl chloride, and copper) are to be regarded.32 some components of the smoke can inhibit the establishment of intracellular junctions, which can lead to tissue damage.33 the rates of ind bill and total bill were increased, according to the findings. even though d-bill was not statistically significant, it did indicate a little rise in the smoking exposure group, suggesting that environmental hazardous chemicals may hurt the liver. this data can be attributed to enzyme leakage, primarily as a result of enhanced cell membrane permeability. in addition, the liver is responsible for the metabolism of hazardous chemical compounds, which explains why the organ is susceptible to metabolic-induced hepatotoxicity.34 in addition, multiple investigations found that employees subjected to organic solvents had much higher liver enzymes than controls, supporting the current findings. similar to our data, two of the investigations have reported an elevation in alt and ast among the exposed than the unexposed group.35 furthermore, another study reported an increase in alt and ast among the exposed group and similar concentrations in direct bilirubin and alp in both exposed and unexposed persons.36 while, on the other hand, akinosun et al. record lower concentrations of alt, ast, total protein, total albumin, and total bilirubin in both exposed and unexposed groups.37 workers in refueling stations had higher levels of alt and ast enzymatic activity than those in the control group.38 contrary to popular belief, exposure to a variety of organic solvents does not affect the levels of liver enzymes such as alt and ast.39 some investigations, however, have found that exposure to a mixture of organic solvents did not affect the levels of liver enzymes like alt and ast.40 furthermore, the hallmark liver alterations (e.g., elevated alp, als, and alt) are depending on the method of administration (e.g., inhalation vs. cutaneous absorption), dose, and exposure period.41 another study conducted by mohammed in sulaimaniya city (iraq) discovered changes in the hematological and biochemical profiles of gasoline station personnel, smokers, and non-smokers who were occupationally exposed to gasoline in connection to the observed lead levels.42 conclusion based on the findings of this study, we can conclude 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biochemical and blood lead level profile among gasoline exposed station workers in sulaimaniya city. aro-the scientific journal of koya university. 2014. 2(1):6-11. available from: https://doi.org/10.14500/aro.10036 42. mohammed c, al-habib o. mechanisms underlying the relaxation induced by bradykinin in rat aorta. international journal of medical research & health sciences. 2018, 7(6): 105-13. available from: https://www.ijmrhs.com/medicalresearch/mechanisms-underlying-the-relaxationinduced-by-bradykinin-in-rat-aorta.pdf https://doi.org/10.1002/ijc.2910340607 https://doi.org/10.1001/jama.281.11.1019 https://doi.org/10.1542/peds.2004-2173 https://doi.org/10.3803/enm.2013.28.1.26 https://doi.org/10.4314/jasem.v11i2.55040 https://doi.org/10.1016/j.canlet.2005.03.044 http://www.bioline.org.br/pdf?oe06012 https://saspublishers.com/article/6756/ https://doi.org/10.1158/1055-9965.epi-06-0262 https://doi.org/10.1016/j.toxrep.2020.12.025 https://www.researchgate.net/profile/sirwan-mohammed-2 https://www.researchgate.net/journal/aro-the-scientific-journal-of-koya-university-2307-549x https://www.researchgate.net/journal/aro-the-scientific-journal-of-koya-university-2307-549x https://doi.org/10.14500/aro.10036 https://www.ijmrhs.com/medical-research/mechanisms-underlying-the-relaxation-induced-by-bradykinin-in-rat-aorta.pdf https://www.ijmrhs.com/medical-research/mechanisms-underlying-the-relaxation-induced-by-bradykinin-in-rat-aorta.pdf https://www.ijmrhs.com/medical-research/mechanisms-underlying-the-relaxation-induced-by-bradykinin-in-rat-aorta.pdf type of the paper (article int. j. occup. safety health, volume 13, no 3 (2023), 321-330 https://www.nepjol.info/index.php/ijosh 321 original article heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross-sectional study parmar hk1, gawde nc2 1master of public health in health policy, economics and finance, tata institute of social sciences, mumbai, india 2assistant professor, centre for public health, school of health systems studies, tata institute of social sciences, mumbai, india abstract introduction: global warming is likely to affect certain groups such as workers in heat-producing industries. with limited research exploring such an important area, this study aimed to explore the heat stress vulnerability and adaptive strategies of indoor small-scale factory workers. methods: this was a cross-sectional study and a mixed-method approach was used. the study setting was small-scale factory units. the quantitative component included environmental and biological monitoring from six units of steel rolling mills and foundry in the summer and winter seasons. the study was conducted during the period of november-2018 and may 2019. heat stress was measured among workers using a portable wet bulb globe temperature (wbgt) meter. the physiological parameters of workers were also measured. the qualitative component included in-depth interviews of workers and supervisors from eleven units. results: the maximum temperatures recorded at steel rolling mills and foundry crossed occupational safety and health administration (osha) threshold (27.5℃) in summer as well as winter. the mean wbgt at the steel rolling mill recorded 31.5℃. the physiological measurements of workers also crossed the threshold level for heart rate and oral temperature in steel rolling and foundry units. the units had mechanisms to dissipate heat but lack a temperature monitoring mechanism inside the units. the workers wore lighter or fewer clothes as an adaptive measure but uncomfortable ppes in foundry units were avoided. conclusion: heat stress in small-scale industry units was found high and there is a high need to develop specific strategies for such vulnerably high heat-exposed groups. keywords: foundry, heat stress, osha, steel rolling mill, wet bulb globe temperature (wbgt) introduction global climate change has been one of the greatest challenges in the world in this century and much of this is anthropogenic. human modifications of the environment have increased greenhouse gases and are a major process fueling global warming which is a key component of global climate change. the world is already witnessing record-breaking temperatures across several geographies and the heat waves have become frequent events in many regions. the intergovernmental panel on climate change 5th assessment report also indicates an increase in frequency, length and intensity of heatwaves over most land areas in the future. 1,2 the effects of global climate change on humans can be devastating. during the past two decades, the number of people exposed to heat waves has corresponding author: hardik parmar, indian institute of public health gandhinagar, opposite air force head quarters, near lekawada bus stop, gandhinagar-382042, india. mobile: +91 9723222892 email: hardikparmar23@outlook.com orcid id: https://orcid.org/00000001-6372-9577 date of submission: 24.04.2022 date of acceptance: 23.03.2023 date of publication: 01.07.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh.v13i 3.44241 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) mailto:hardikparmar23@outlook.com https://orcid.org/0000-0001-6372-9577 https://orcid.org/0000-0001-6372-9577 https://doi.org/10.3126/ijosh.v13i3.44241 https://doi.org/10.3126/ijosh.v13i3.44241 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 322 increased dramatically and consequently, heatrelated health events and hazards have also increased.3,4 the workplaces especially those of high heat-inducing nature (steel rolling mill, foundry) can compound risks posed by heat stress and the potential consequences of heat stress on workers are substantial.5 occupational heat stress risk is projected to become particularly high in middle and low-income tropical and subtropical regions.6 india is prone to climate and weather-sensitive health events and heat-related illnesses significant problems in india.7 the study on analysis of summer temperature, frequency, severity, and duration of heatwaves and heat-related mortality between 1960 and 2009 showed that mean temperature across india has risen more than 0.5℃ over that period with the increase in heatwaves and increase of probability of heat-related mortality in india by 146%.8,9 the western region of india is most susceptible to heatwaves and showed rising mortality due to extreme heatwaves in the months of summer over the years the changing trend in heat-related mortality was also observed across several years -1972, 1988, 1998 and 2003 in which there were more than 10 heat waves days on average across india, with a corresponding surge in heat-related mass mortality of between 650 and 1500 people.10 however, the impacts of such heat stress on occupational safety and health remain understudied.5,11 occupational heat stress is the net load to which a worker is exposed from the combined contributions of metabolic heat, environmental factors, and clothing which results in an increase in heat storage in the body.12 therefore, occupational heat stress in industries especially those that have high heat-inducing nature of the environment is critical to understand as workers who are working in such an environment are vulnerable to heat stress and the economic burden is substantial.13 in india, despite widespread recognition of this problem, a limited attempt has been made to estimate health impacts related to occupational heat stress. this has been reflected in the least control over reducing heat exposure at the workplace.14 heat stress due to climate change can compound heat exposures at the workplace, especially in vulnerable occupational settings. in india, several small-scale industries produce heat and can be particularly vulnerable during the summer months. however, these industries operate in resource-constrained settings with minimal resources for occupational safety and health. studies on the effects of heat stress on the workers working in these small-scale industries are limited and warrant more evidence.15 this paper empirically measures the exposure to heat stress among the workers in a foundry, steel rolling mill units in the city of ahmedabad, one of the metropolises badly affected by heat waves in the past decade10. therefore, the objective of the study was to explore the heat stress vulnerability of indoor small-scale factory workers of foundry and steel rolling units and their adaptive strategies in ahmedabad. methods ahmedabad, a city with more than 5 million residents is prone to extreme weather from heat waves (45℃) in summer and cold waves (8℃) in winter. heatwaves are very common, and the night temperature also remains high during the heat waves. with more than 250,000 workers in about 65,000 small-scale industrial units, ahmedabad is a busy manufacturing hub. foundry, steel rolling and ceramic are the most common types of small-scale industries which usually employ 5 to 50 workers. the study adopted a mixed methods design. the qualitative component of the study included in-depth interviews of workers and managers of small-scale industries which explored the vulnerabilities faced by workers and adaptive strategies employed by them. for this qualitative component, a purposive sampling technique was employed. a total of 30 workers and 7 supervisors from 11 units of steel rolling mill and foundry were purposively selected for in-depth interviews to provide insights into heat stress and adaptive strategies. all the units sampled in our study were visited and physical observation of the nature of the parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 323 working environment, working and living conditions of workers was conducted. in addition, areas covered by units for production, space for working, ventilation mechanism of units, and other factory-level facilities and measures for heat coping mechanisms were also observed. the workers' practices and behavior for heat coping and use of protective equipment (like gloves, shoes, and protective goggles) were also captured in observation. the quantitative component included ambient temperature measurement of sample units and vital physiological parameters of the workers. for the assessment of ambient heat inside small-scale units, six units (three units each of the foundry and steel rolling mill) were selected. the reasons for selecting a smaller number of units for quantitative components than qualitative components include challenges in getting approval by the concerned authority for ambient temperature measurement inside units during that period as well as not feasible to cover more units during that limited period. the ambient heat of these units was measured using a portable heat stress wbgt meter. the measurements included the globe temperature (tg), air temperature (ta) and relative humidity (rh) and the combined index as the wet bulb globe temperature. the measurements were recorded in all six units between 2 pm and 6 pm and at regular intervals during those working hours. to understand the effect of heat waves on the same, the readings were done in two seasons; once in may (summer) and once in december (winter) months. the foundry units had two dedicated areas and hence the measurements were done in both these areas separately. the physiological measurement of 30 workers (16 workers in a steel rolling mill and 14 workers in a foundry) were taken. the smaller sample size for quantitative components is due to resource constraints, organizational level barriers such as approval to conduct the study at those small-scale units as well as a smaller number of workers available in the units of steel rolling mill and foundry during the summer months largely due to migration to hometown. the physiological parameters of workers are also measured between 2 pm and 6 pm while they are actively involved in work which included heart rate using a pulse oximeter, skin temperature using an infrared thermometer, and oral temperature using a digital thermometer. the study approval was taken from the institutional review board of tata institute of social sciences (tiss) by giving undertaking of all ethical guidelines. the study followed ethical principles as laid down in the declaration of helsinki. being an observational study, the risks posed were minimal. all participants were informed about the purpose and process of the research and the role of the researcher. they were explained that their participation was voluntary and they had the right to leave the study at any time before the transcripts were analyzed. in addition, prior consent for the permission of audio recording for interviews was taken. the transcripts were anonymized to protect the identity of the units as well as the participants. written informed consent was obtained before they participated in the study. the qualitative data was transcribed and the transcripts were read and re-read. the data were analyzed using a thematic approach which helped draw codes and themes related to the perceptions of heat stress and the mechanisms employed to adapt to it and cope with it. the respondents were asked clearly defined open-ended questions and were open and free to not answer any of the questions. the maximum and minimum temperature along with the mean and standard deviation (sd) of wbgt were measured for may and december months and have been tabulated. since both types of units included heavy work, the osha threshold of temperature above 27.5℃ on wbgt has been used for defining heat stress. for workers, minimum and maximum physiological parameter readings and mean and standard deviation (sd) were calculated and presented for both types of units in both seasons (summer and winter). a heart rate of 110/minute and an oral temperature of 37.6℃ were considered as the threshold for these biological measurements in parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 324 line with osha recommendations. results the heat stress in the form of wbgt and its three components is presented in table 1 to table 4. it is important to note that the mean ambient temperatures inside the units during work hours of 2:00 pm-6:00 pm were higher than the maximum recorded temperatures for the city on the same day. (ahmedabad’s minimum and maximum temperature was 16.3℃ 31.0℃ respectively in winter (1-2 dec 2018) and 26.0℃ 41.8℃ in summer (1st may to 4th may 2019) on the day of ambient and physiological measurement). table 1: measurement of wet bulb globe temperature (wbgt) in two types of industrial units, ahmedabad wet bulb globe temperature in steel rolling and foundry units type of industrial unit season maximum wbgt recorded (℃) minimum wbgt recorded (℃) mean (wbgt) (℃) standard deviation (wbgt) steel rolling mill (n=3) winter 28.3 24.3 26.5 1.04 summer 32.9 30.3 31.5 0.66 foundry mill (general area) (n=3) winter 24.8 20.4 21.8 1.36 summer 27.4 25.7 24.1 0.38 foundry mill (furnace area) (n=3) winter 28.7 20.6 26.5 3.81 summer 28.5 26.2 27.4 0.92 the heat stress (wbgt) was more in the summer for both types of units. in the steel rolling mill, the heat stress in summer was in the hazardous range. the heat stress (wbgt) in the foundry was not high in the summer or winter months. however, within the foundry unit, the heat stress was significantly higher (3.9℃) near the heating furnace than in a general area in the winter season. there was also a standard deviation of 3.81 between the maximum and minimum wbgt recorded near the furnace area of the foundry. it is important to note that the furnace did not operate for the whole day. instead, the units were starting the furnace only after 3.30-4:00 pm. this explains the readings are lower than the steel rolling units in both summer and winter seasons. the difference in maximum wbgt recorded in the steel rolling mill between summer and winter was 4.6℃ while the difference in minimum wbgt recorded in the foundry between summer and winter was 2.6℃ in the general area and 0.2℃ near the furnace area (table 1). table 2: measurement of ambient air temperature (ta) in two types of industrial units, ahmedabad ambient air temperature in steel rolling and foundry units type of industrial unit season maximum ambient (air) temp. recorded (℃) minimum ambient (air) temp. recorded (℃) mean ambient (air) temperature (℃) standard deviation (ambient temp.) steel rolling mill (n=3) winter 40.6 30.2 37 2.24 summer 49.4 42.6 46.5 1.88 foundry mill (general area) (n=3) winter 36.4 27.8 31.05 2.59 summer 41.4 36.9 39.7 1.21 parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 325 foundry mill (furnace area) (n=3) winter 44.1 28.7 35.6 7.38 summer 41.7 39.8 40.7 0.69 table 3: measurement of globe temperature (tg) in two types of industrial units, ahmedabad globe temperature in steel rolling and foundry units type of industrial unit season maximum globe temp. recorded (℃) minimum globe temp. recorded (℃) mean globe temperature (℃) standard deviation globe temperature steel rolling mill (n=3) winter 45.2 33.1 40.6 2.6 summer 53.8 46.5 50.6 1.81 foundry mill (general area) (n=3) winter 36.8 27.5 31.7 2.75 summer 42.3 36.8 39.9 1.33 foundry mill (furnace area) (n=3) winter 39.3 31.4 35.1 2.78 summer 46.9 40 43.5 2.49 table 4: measurement of relative humidity (rh)in two types of industrial units, ahmedabad relative humidity in steel rolling and foundry units type of industrial unit season maximum relative humidity (%) recorded (℃) minimum relative humidity (%) recorded (℃) mean relative humidity (%) standard deviation relative humidity (%) steel rolling mill (n=3) winter 37.9 11.6 23.1 5.71 summer 24.4 10.5 15 3.57 foundry mill (general area) (n=3) winter 32.5 18.5 25.4 4.49 summer 25.3 12.4 16.9 3.78 foundry mill (furnace area) (n=3) winter 29.4 16.1 23.05 6 summer 18.1 13.6 15.2 1.91 the maximum and minimum ambient air temperature (ta) along with mean ambient air temperature was higher in steel rolling mills than in foundry units in both winter and summer (table 2). the maximum and minimum globe temperature (tg), as well as the mean globe temperature, was higher in the steel rolling mill than in foundry units in both winter and summer (table 3). the mean relative humidity (rh) was higher in foundry units than in steel rolling mills in both winter and summer (table 4). however, within foundry units, relative humidity was higher in the winter season than in the summer. the standard deviation (sd) of relative humidity is on the higher side in the winter season for both types of units [steel rolling mill 5.71; foundry (furnace area) 6.0]. parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 326 table 5: physiological measurements of workers in industrial units, ahmedabad physiological measurements of workers in steel rolling and foundry units type of industrial unit season heart rate oxygen saturation spo2 oral temperature (℃) skin temperature (forearm) (℃) skin temperature (trunk) (℃) min max recorded minmax recorded minmax recorded minmax recorded minmax recorded steel rolling mill (n=16) winter 70-129 95-99 35.2-39.3 32.5-34.8 33.4-35.5 summer 68-134 97-99 36.3-39.9 31.3-36.5 32.1-37.9 foundry mill (n=14) winter 97-120 96-99 35.8-36.8 31.7-35.7 31.4-35.0 summer 88-131 98-99 36.4-39.3 30.4-34.9 31.2-37.3 table 6: mean and standard deviation (sd) of physiological measurements of workers in industrial units, ahmedabad physiological measurements of workers in steel rolling and foundry units type of industr ial unit season heart rate oxygen saturation spo2 oral temperature (℃) skin temperature (forearm) (℃) skin temperature (trunk) (℃) mean sd mean sd mean sd mean sd mean sd steel rolling mill (n=16) winter 91 15.41 97.5 1.62 37.1 0.93 33.75 0.75 34.3 0.51 summ er 103.6 21.63 98.3 0.67 37.5 1.15 34.4 1.45 35.05 1.95 found ry mill (n=14) winter 107.2 7.02 98.2 0.97 36.4 0.34 34.1 1.3 33.1 1.16 summ er 109.2 12.5 98.3 0.48 37.2 0.68 32.5 1.41 34.4 1.87 table 5 and table 6 show the maximum and minimum recorded physiological parameters of workers along with mean and standard deviation (sd). the maximum heart rates of workers crossed the osha threshold (>110 /minute) in both units in both seasons. the maximum oral temperatures also crossed the osha threshold (> 37.5℃) in workers of both steel rolling and foundry units. the oxygen saturations of workers were all above 95% in both seasons in sample units (table 5). the mean heart rate of foundry workers in the winter season was significantly higher than steel rolling mill workers during the working hours between 2:00 pm6:00 pm. the mean oral temperature in foundry units was higher than the osha threshold (> 37.5℃) in the winter season (table 6). organizational level ambient heat controlling mechanism and facilities for workers: the units were of medium size appx. 4000 to 5000 sq. ft. and had fans, exhaust fans, vents and ventilation in the unit. however, there were no systems to record/monitor the temperature inside them. the mechanisms at the organization level to dissipate heat included fans and ventilation. the heat furnaces in foundry units were started only after 4 pm. water facilities were present in the units and units had a water cooler for drinking water purposes. there was an adequate water supply for workers to cleanse themselves during or at the end of duty. one of the units, a foundry parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 327 also was providing glucose water to employees during the summer months. the factories provided personal protective equipment such as gloves and shoes. foundries that had electric furnaces also had given protective eyewear to the workers who would work near the electric furnace. factories were registered with the employees state insurance corporation; a state-run health protection scheme for the employees and thereby the workers had some financial health protection. heat coping and adaptive strategies of workers: the workers had their coping strategies to cope with high heat and controlling body temperature. workers used to consume more water and could take small breaks from work during work hours which were allowed by the factory managers. almost all of the workers were men. only in one foundry unit, four women were working which too was away from the heating furnace to carry sand toward the molding area. the nature of work for women in foundry units involves lifting sand and moving towards the molding area which is away from the heating furnace. men were found using a piece of cotton cloth or napkin (gamcha) to wrap around the head and face as protective measures to control head temperature and prevent burn against excessive heat. the usual clothes at work included a shirt and trousers. men workers often used to remove their shirts and work in undershirts and fold the trouser up to the knees. there were their mechanisms to cope with excessive heat. protective gear and usage among workers: provisions of safety gear and protective equipment were poor from the organizational level although in some units despite the provision and availability of protective gear the utilization of safety gear among workers was generally poor. there were no specific protective gears to protect against the heat wave. rather the protective gear of gloves and shoes became uncomfortable to wear during summer months and practically no one in the foundry units was found using the gloves or shoes. one of the workers quoted, “we are being provided gloves, masks, shoes from factory owner but we are using gloves sometimes only as those protective aids are not useful or comfortable to work with.” the foundry workers mentioned that the gloves made their hands sweaty which made it difficult to hold on to the equipment. hardly anyone in the foundry used shoes because they felt that barefoot would be better than using shoes to prevent injury. a worker in the foundry unit explained for nonuse of protective shoes, “if we wear shoes in a foundry there are high chances of burn injury if the hot melted iron falls on shoes. if hot iron falls onto shoes, by the time we react and remove the shoes the melted iron will make a hole in the shoe and penetrate the skin and cause severe burn injury. on the other hand, chappals (slippers) are relatively safe as we can quickly remove them in case of hot iron accidentally falling on the foot.” the workers in steel rolling mills however were found using gloves throughout to protect themselves from handling hot metals. difficulty in breathing and suffocation was the chief barrier to using a protective mask. discussion the hazardous working environment, poor ventilation, heat as well as a poor standard of protective equipment contribute to an adverse working environment and high perceived heat among small-scale industrial workers.16 the study shows that the atmospheric temperature significantly affects the working environment and ambient temperature inside high heat-inducing working units. the steel rolling mills had very high heat stress in the summer months. heat stress was also high in the furnace area of the foundry units. the lower heat stress in the furnace area of foundry units compared to the steel rolling mills could be because the furnaces did not operate throughout the day but only after 4 pm which can affect the average temperature. the heat stress in ambient air starts reducing after 4 pm. the effects of heat stress were also evident in the biological monitoring of the workers as the maximum heart rate and an oral temperature of workers crossed the osha threshold level in both foundry and steel rolling units in the winter and summer parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 328 seasons. further, mean oral temperature also crossed the threshold (>37.5℃) in foundry units in the winter season. heart rate along with body temperature has been recommended by the american conference of governmental industrial hygienists (acgih) as a possible measure of heat stress. heart rate monitors with alarm systems could be developed to notify workers of slowing down their activities or taking a break from work which contribute to preventing heat-related illness.17 the mitigation strategies included timing of using the furnace, ventilation, water coolers, etc. at the industrial unit level. however, there has been no measurement of temperature within the units. the personal protective equipment (ppes) used to protect workers against injury and other hazards were found to complicate the heat stress and workers did not want to use ppes because of the discomfort and inconvenience caused due to them, especially during the summer months. mitigation strategies employed by individual workers included drinking water, taking small breaks, use of cotton gear (gamcha) to reduce the effects of excess heat. these strategies have been in use across several occupational settings in india.18 however, the workers also did not use ppes to reduce heat stress but this step could make them more prone to injuries. literature shows that the use of ppe was much better in colder places such as nepal than in the hot and humid city of visakhapatnam.18,19 hence, the use of ppes may be related to heat waves and heat waves can potentially change the behavior of workers. the ppes’ use was lower in foundry units than in a steel rolling mill. workers in steel rolling mills could not perform the work without the ppes (gloves) as they had to handle hot material continuously and for a longer time and therefore used the ppes more frequently. in contrast, the foundry workers could perform their work without gloves as they had to handle hot items intermittently. the use of ppes was much lower among them and they resorted to cotton cloth for holding hot objects to avoid the inconvenience and discomfort associated with the use of ppes. the quality of ppe determines its use; heavy ppes were cited as a major reason for its non-use in saudi arabia.20 the national policy on safety, health, and environment at the workplace of the government of india provides a framework for developing and maintaining a safety culture and environment at the workplace.21 the major legal provisions for the protection of health and safety includes the factories act, of 1948 which has provisioned for the structure and layout of the industry to maintain a proper temperature.22 despite that, many industries have an inadequate provision of cooling systems, natural shades, or shed with fans in the working place which is due to the poor regulatory framework. although, this was not the case for this study’s units; there are other units that operate in congested areas and can potentially get severely affected by heat waves. there is a need to record heat stress in these industries as a self-regulatory mechanism and a need to invest in engineering interventions to protect workers from occupational heat stress. ahmedabad municipal corporation (amc) with a partner organization has rolled out a heat action plan (hap) for protection against high heat and heatwaves. the plan focuses largely on the general population and outdoor workers.23 recent evidence highlights the plight of those who live/work indoors in urban areas where the heat stress could be higher and most heat-health warning systems are based upon outdoor climate only.24 response to climate change also needs multi-faceted interventions including adaptation measures. structure of industrial units, ventilation, scheduling of heat generating processes at a time of day when a heat wave is not at peak, breaks during work, monitoring heat stress through simple gadgets, availability of drinking water, and appropriate and comfortable ppes will help address the issue.25 the intervention could be a mix of educative, regulatory, and internal control mechanisms to reduce the effect of heat waves on workers. this study has a few limitations. it is an exploratory study that documents heat stress in small-scale industrial units. however, it is limited to measurements in fewer settings. the sample parmar et al. heat stress vulnerability among small-scale factory workers and adaptive strategies in ahmedabad: a cross sectional study 329 size for workers was also small and generalizations are not possible. however, the study is among the first to explore the high heat stress in small-scale units which do not have their setup for occupational safety and overall regulatory governance is weaker. it is important that most of these units do not have any environmental monitoring and there are hardly any occupational safety and health measures apart from esis-linked insurance and the provision of ppes. acknowledgments we would like to express our gratitude to the centre of environmental health, tiss for providing fellowship to support our research work on this important area of occupational environment and its associated health consequences. references 1. ipcc. climate change 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flouris ad, casanueva a, gao c, foster j, et al. sustainable solutions to mitigate occupational heat strain – an umbrella review of physiological effects and global health perspectives. environ heal a glob access sci source. 2020;19(1):1–24. available from: https://doi.org/10.1186/s12940-020-00641-7 https://doi.org/10.1016/j.envres.2021.110781 https://doi.org/10.3402/gha.v3i0.5635 https://www.researchgate.net/publication/292150747_5_nag_pk_dutta_priya_nag_anjali_kjellstrom_tord_sep_2013_extreme_heat_events_perceived_thermal_response_of_indoor_and_outdoor_workers_international_journal_of_current_research_and_review_vol_05_1765-7 https://www.researchgate.net/publication/292150747_5_nag_pk_dutta_priya_nag_anjali_kjellstrom_tord_sep_2013_extreme_heat_events_perceived_thermal_response_of_indoor_and_outdoor_workers_international_journal_of_current_research_and_review_vol_05_1765-7 https://www.researchgate.net/publication/292150747_5_nag_pk_dutta_priya_nag_anjali_kjellstrom_tord_sep_2013_extreme_heat_events_perceived_thermal_response_of_indoor_and_outdoor_workers_international_journal_of_current_research_and_review_vol_05_1765-7 https://www.researchgate.net/publication/292150747_5_nag_pk_dutta_priya_nag_anjali_kjellstrom_tord_sep_2013_extreme_heat_events_perceived_thermal_response_of_indoor_and_outdoor_workers_international_journal_of_current_research_and_review_vol_05_1765-7 https://www.researchgate.net/publication/292150747_5_nag_pk_dutta_priya_nag_anjali_kjellstrom_tord_sep_2013_extreme_heat_events_perceived_thermal_response_of_indoor_and_outdoor_workers_international_journal_of_current_research_and_review_vol_05_1765-7 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https://pubmed.ncbi.nlm.nih.gov/11423886/ https://www.ilo.org/asia/wcms_182422/lang--en/index.htm https://www.ilo.org/asia/wcms_182422/lang--en/index.htm https://labour.gov.in/sites/default/files/factories_act_1948.pdf https://labour.gov.in/sites/default/files/factories_act_1948.pdf https://www.nrdc.org/sites/default/files/ahmedabad-heat-action-plan-2016.pdf https://www.nrdc.org/sites/default/files/ahmedabad-heat-action-plan-2016.pdf https://doi.org/10.3390/ijerph16040560 https://doi.org/10.1186/s12940-020-00641-7 int. j. occup. safety health, volume 13, no 3 (2023), 375-385 https://www.nepjol.info/index.php/ijosh 375 original article prevalence and factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center in nepal karki p1, joshi yp1,2, khanal sp3, gautam s1, paudel s4, karki r1, acharya r5 1department of public health, manmohan memorial institute of health sciences, kathmandu, nepal 2faculty of science health and technology, nepal open university, lalitpur, nepal 3central department of statistics, tribhuvan university, kathmandu, nepal 4department of public health, cist college, naya baneshwor, kathmandu, nepal 5 school of medical science, kathmandu university, kavrepalanchok, nepal abstract introduction: musculoskeletal disorders (msds) are injuries or pain in the human musculoskeletal system which could lead to temporary or permanent impairments. the nature of nursing jobs makes nurses vulnerable to msds. this study aimed to assess the prevalence and potential risk factors associated with msds among nurses. methods: in between march to june 2021, a cross-sectional study was conducted among 165 nurses using self-administered questionnaires. a standardized nordic questionnaire was used to measure msds. pearson’s chi-square test and binary logistic regression at a 5% level of significance were performed to identify factors associated with upper extremities and spinal musculoskeletal disorders (umsd) and lower extremities musculoskeletal disorders (lmsd). variables associated with umsd and lmsd in bivariate analysis were subjected to multiple logistic regression. results: the prevalence of umsd and lmsd experienced by nurses was 86.1% (95% ci: 79.4%-90.9%) and 66.1% (95% ci: 58.9%-74.3%), respectively. among several factors, working in same position for long periods (aor: 4.16, 95% ci: 1.213.4), not receiving training in injury prevention programs (aor: 3.15, 95% ci: 1.09.2), not enough rest breaks during the day (aor: 4.65, 95% ci: 1.3-15.9) and moderate to higher job stress (aor: 3.62, 95% ci: 1.2-10.8) were found to be significantly associated with umsd. not having enough rest breaks during the day (aor: 2.19, 95% ci: 1.0-4.7) was significantly associated with lmsd. conclusion: higher prevalence of msds among nurses is a serious concern that threatens individual health as well as the overall healthcare system. sensitization and capacity enhancement programs on the issue could prevent msds among nurses. keywords: ergonomics, musculoskeletal disorder, nepal, nurses occupational health, prevalence, risk factors introduction musculoskeletal disorders (msds) are injuries or pain in the human musculoskeletal system such as muscles, nerves, tendons, joints, and structures supporting limbs, neck and back resulted due to sudden or sustained exposure to stressors such as external forces, repetitive motions, vibrations, and awkward positions.1 msds are the most serious public health hazard, which could result in individuals' temporary or permanent impairment.2 globally, msds have become a leading cause of disability.3, 4 the healthcare sector is known to have a significant risk of msds.5-7 healthcare personnel such as physicians, nurses, and paramedics are exposed to repeated stress corresponding author: pratima karki, mph graduate, department of public health, manmohan memorial institute of health sciences, kathmandu, nepal tel.: 9844700662 e-mail: pratima.karki216@gmail.com orcid id: https://orcid.org/0000-00029287-616x date of submission: 26.01.2023 date of acceptance: 06.04.2023 date of publication: 01.07.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh.v13i3 .51792 copyright: this work is licensed under a creative commons attributionnoncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:pratima.karki216@gmail.com https://orcid.org/0000-0002-9287-616x https://orcid.org/0000-0002-9287-616x https://doi.org/10.3126/ijosh.v13i3.51792 https://doi.org/10.3126/ijosh.v13i3.51792 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 376 and frequent strains while performing daily patient care activities which can lead to chronic sickness and musculoskeletal problems.8, 9 even among healthcare professionals, nurses are suggested to have a higher risk of msds.10-12 the nature of the nursing job requires activities such as manual lifting heavy loads and patients, bending over patients, transporting patients from bed to the floor, pulling and pushing equipment, and sometimes working in confined spaces and awkward postures making them more prone to injury.9, 13, 14 the presence of msds not only affects the quality of life of the nurses but also could lead to increased work resistance, absenteeism, early retirement, transfer to another job, and even disability which ultimately results in financial hardship on an individual as well as to the family and society in general.15-17 studies throughout the world suggest that the 12month prevalence of msds in the nursing population varies between 21.0% and 91.9%.6,9,18-20 in south asia, this prevalence lies between 21.0% and 89.2%.19,21,22 in nepal, limited studies have assessed musculoskeletal pain or disorders in the general population while few have targeted healthcare professionals focusing only on lower back pain. from these limited studies, the prevalence of lower back pain among nurses was observed to be around 60.0%-78.0%.24-26 however, there is no evidence illustrating the overall rate of msds experienced by nurses in seven days and/or twelve months duration as well as its impact and determinants in these vulnerable populations. the occurrence of msds in the nursing population could impact the overall health system of the nation as nurses are one of the major health workforces. identifying these risk factors is critical for understanding the causative linkages of these disorders and implementing the most effective preventative measures in the workplace. for this reason, this study aimed to measure the prevalence and potential risk factors associated with musculoskeletal disorders among nurses working in a tertiary care center in nepal. methods the cross-sectional study was conducted among the nurses working at dhulikhel hospital between march and june 2021. dhulikhel hospital situated in dhulikhel municipality of kavre district is one of the biggest tertiary hospitals in nepal. the hospital provides a wide range of preventive and curative services with a total of 336 nurses working actively in its 22 departments. the sample size was calculated using the cochrane formula for estimation of proportion, n=z2pq/ d2, using a past prevalence of msd among nurses at a 95% confidence interval (ci) and at a 5% margin of error. the msd prevalence of 89.1% from a past study was taken for the estimation of sample size.23 the initial sample size was estimated at 149 nurses which was optimized to 165 after adjusting the 10% non-response rate. nurses were selected randomly using a systematic random sampling technique. for this, every kth (336/149=2.74≈2.25) i.e. 3rd nurse from the provided sample frame was approached to be enrolled as a participant. the nurses who reported a prior history of medically diagnosed musculoskeletal problems before starting their job and nurses who were pregnant or had a child under two years of age were excluded from the study to control confounding and to assure the observed msd is associated with the nature of their job. a self-administered questionnaire was used for data collection. the questionnaire used for data collection consisted of four sections including questions related to the socio-demographic profiles of the nurses, perceived stress scale,27 to measure job stress, questions related to ergonomic factors, and standardized nordic questionnaire (snq)28 to measure musculoskeletal disorders.29 snq consists of diagrammatic marking of nine anatomical regions for precision. it also reports whether the discomfort has prevented the participants from doing their normal work and if they have consulted a physician during the last 12 months for their condition.28 the nursing incharge arranged a private place where the selected nurses were invited for orientation. the questionnaire was distributed and explained to the nurses, and their informed consent was acquired during the orientation. the nurses were allowed to fill out the questionnaire at their time of convenience. the anthropometric measurements (height and weight) of the selected nurses were also taken at the time of distribution of the questionnaire. it was ensured that the complete response for each of the questions was acquired from the participants before collecting all the questionnaires. thus, a 100% response rate was achieved from 165 nurses. the collected data were entered and analyzed through statistical package for social sciences version 22. the data were summarized in terms of frequency and proportion. pearson’s chi-square tests and binary logistic regression were performed to identify the factors associated with umsd and lmsd at a 5% level of significance. the variables which were significant in bivariate analysis were subjected to multivariate analysis to assess the adjusted odds ratio. crude odds ratio karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 377 (cor) has also been reported along with the adjusted odds ratio for those variables which were significant in bivariate analysis for each model. for the multivariate analysis, the variance inflation factor (vif) test was performed to check multi-collinearity among independent variables.30,31 the hosmer-lemeshow test (hl test) for goodness-of-fit was performed and nagelkerke r square was reported. the study was ethically approved by the institutional review committee of manmohan memorial institute of health science (registration no: mmihs-ir 580) and the institutional review committee of kathmandu university school of medical sciences (approval no: 33/2020). written informed consent was obtained from all the participants before conducting the study and all the information was kept confidential. results the prevalence of umsd and lmsd experienced by the nurses in the past 12 months was found to be 86.1% and 66.1% respectively. likewise, in the context of msd experienced by nurses in the past week, 53.9% reported having umsd, and 33.3% reported having lmsd. lower back pain was the predominant msd in the last 12 months at 75.8% followed by neck pain and upper back pain at 60.0% and 51.5% respectively (table 1). table 1: prevalence of musculoskeletal disorders (n=165) body region msd in 12 months msd in 7 days n (%) 95% ci n (%) 95% ci neck yes 99(60.0) 52.8-67.3 41(24.8) 20.0-31.4 no 66 (40.0) 32.7-47.2 124(75.2) 68.6-80.0 shoulder yes 75(45.5) 38.3-54.4 31(18.8) 12.2-26.1 no 90(54.5) 45.6-61.7 134(81.2) 73.9-87.8 elbows yes 12(7.3) 4.2-12.0 4(2.4) 0.6-4.8 no 153(92.7) 88.0-95.8 161(97.6) 95.2-99.4 wrists/hands yes 71(43.0) 36.4-50.3 27(16.4) 11.5-21.2 no 94(57.0) 49.7-63.6 138(83.6) 78.8-88.5 upper back yes 85(51.5) 44.9-59.8 37(22.4) 15.9-29.1 no 80(48.5) 40.2-55.1 128(77.6) 70.9-84.1 lower back yes 125(75.8) 68.6-81.8 69(41.8) 33.9-49.6 no 40(24.2) 18.2-31.4 96(58.2) 50.4-66.1 hips/thighs yes 58(35.2) 27.5-42.9 26(15.8) 10.4-21.7 no 107(64.8) 57.1-72.5 139(84.2) 78.3-89.6 knees yes 64(38.8) 31.5-47.9 30(18.2) 13.3-24.8 no 101(61.2) 52.1-68.5 135 (81.8) 75.2-86.7 ankles/feet yes 61(37.0) 29.2-44.2 32(19.4) 13.9-26.6 no 104(63.0) 55.8-70.8 133(80.6) 73.4-86.1 overall umsd yes 142(86.1) 79.4-90.9 89(53.9) 45.6-61.7 no 23(13.9) 9.1-20.6 76(46.1) 38.3-54.4 overall lmsd yes 109(66.1) 58.9-74.3 55(33.3) 26.1-41.1 no 56(33.9) 25.7-41.1 110(66.7) 58.9-73.9 karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 378 out of the total nurses who experienced low back pain in the past 12 months, a majority (62.4%) reported the pain has affected their daily activities, whereas, only less than a quarter (20.0%)consulted physicians for treatment. likewise, only 16.1% of the nurses with chronic neck pain were consulting a physician for their condition while almost half (44.4%) reported that chronic neck pain has impacted their daily activities (table 2). in bivariate analysis, general characteristics of the participants such as age, marital status, education, and bmi were not found to be significantly associated with umsd. however, the participant’s age was found to be significantly associated with lmsd at a 5% level of significance (p<0.05) (table 3). table 2: impact on daily activities due to msds in 12 months and physician consultation (n=165) body regions limit normal activities consulted physician yes (%) no (%) yes (%) no (%) neck (n=99) 44 (44.4) 55 (55.6) 16 (16.1) 83 (83.9) shoulder (n=75) 34 (45.3) 41 (54.7) 9 (12.0) 66 (88.0) elbows (n=12) 6 (50.0) 6 (50.0) 0 (0.0%) 12 (100.0) wrists/hands (n=71) 32 (45.1) 39 (54.9) 5 (7.0) 66 (93.0) upper back (n=85) 48 (56.5) 37 (43.5) 11 (13.0) 74 (87.0) low back (n=125) 78 (62.4) 47 (37.6) 25 (20.0) 100 (80.0) hips/thighs (n=58) 33 (56.9) 25(43.1) 6 (10.3) 52 (89.7) knees (n=64) 31 (48.4) 33 (51.6) 11 (17.2) 53 (82.8) ankles/feet (n=61) 44 (44.4) 55 (55.6) 16 (16.1) 83 (83.9) table 3: association between general characteristics with umsd and lmsd (n=165) variable umsd  (pvalue) lmsd  (pvalue) yes (%) no (%) yes (%) no (%) age(years) <25 58(90.6) 6(9.4) 3.048 (0.218) 48(75.0) 16(25.0) 9.891 (0.007) 25 -30 65(85.5) 11(14.5) 51(67.1) 25(32.9) >30 19(76.0) 6(24.0) 10(40.0) 15(60.0) marital status married 62(86.1) 10(13.9) 0.000 (0.987) 42(58.3) 30(41.7) 3.402 (0.065) single 80(86.0) 13(14.0) 67(72.0) 26(28.0) education pcl nursing 124(86.1) 20(13.9) 0.002 (0.961) 96(66.7) 48(33.3) 0.185 (0.667) bsc nursing 18(85.7) 3(14.3) 13(61.9) 8(38.1) bmi normal 93(86.1) 15(13.9) 0.413 (0.813) 76(70.4) 32(29.6) 4.575 (0.102) underweight 13(81.2) 3(18.8) 7(43.8) 9(56.2) overweight/obese 36(87.8) 5(12.2) 26(63.4) 15(36.6) in the context of work-related factors, rest breaks during the day and work schedules were found to be associated with both umsd and lmsd at p<0.05. moreover, training in injury prevention, treating a large number of patients in a day, and job stress were found to have a statistically significant relationship with umsd. similarly, participants' work experience was found to be associated with lmsd (table 4). in context of ergonomic factors, working in awkward or cramped positions, carrying/lifting/ moving heavy materials or equipment, performing same task repeatedly, and working in same position for long periods were found to be associated with umsd at p<0.05. however, no association was found between lmsd and ergonomic factors (table 5). karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 379 table 4: association between work-related factors with umsd and lmsd (n=165) variable umsd  (pvalue) lmsd  (pvalue) yes (%) no (%) yes (%) no (%) work experience < 5 years 91(85.0) 16(15.0) 7(12.1) 0.261 (0.610) 79(73.8) 28(26.2) 8.199 (0.004) ≥ 5 years 51(87.9) 30(51.7) 28(48.3) work shift rotation 121(85.8) 20(14.2) 0.049 (0.826) 97(68.8) 44(31.2) 3.231 (0.072) fixed 21(87.5) 3(12.5) 12(50.0) 12(50.0) training in injury prevention yes 37(74.0) 13(26.0) 8.699 (0.003) 29(58.0) 21(42.0) 2.079 (0.149) no 105(91.3) 10(8.7) 80(69.6) 35(30.4) treat large number of patients in a day no 26(74.3) 9(25.7) 5.134 (0.023) 20(57.1) 15(42.9) 1.576 (0.209) yes 116(89.2) 14(10.8) 89(68.5) 41(31.5) rest breaks during the daya enough 31(72.1) 12(27.9) 9.458 (0.002) 21(48.8) 22(51.2) 7.695 (0.006) not enough 111(91.0) 11(9.0) 88(72.1) 34(27.9) assist patients at gait activities rarely 47(82.5) 10(17.5) 0.943 (0.331) 37(64.9) 20(35.1) 0.051 (0.821) frequently 95(88.0) 13(12.0) 72(66.7) 36(33.3) work at or near your physical limits rarely 57(85.1) 10(14.9) 0.091 (0.762) 43(64.2) 24(35.8) 0.178 (0.673) frequently 85(86.7) 13(13.3) 66(67.3) 32(32.7) work with confused/ agitated patients rarely 34(79.1) 9(20.9) 2.369 (0.124) 24(55.8) 19(44.2) 2.723 (0.099) frequently 108(88.5) 14(11.5) 85(69.7) 37(30.3) work scheduleb normal 18(72.0) 7(28.0) 4.856 (0.028) 12(48.0) 13(52.0) 4.287 (0.038) overtime 124(88.6) 16(11.4) 97(69.3) 43(30.7) job satisfaction satisfied 76(81.7) 17(18.3) 3.347 (0.067) 56(60.2) 37(39.8) 3.248 (0.072) dissatisfied 66(91.7) 6(8.3) 53(73.6) 19(26.4) job stress low stress 44(75.9) 14(24.1) 7.755 (0.005) 35(60.3) 23(39.7) 1.303 (0.254) moderate/high stress 98(91.6) 9(91.6) 74(69.2) 33(30.8) arest breaks during the day: enough ≥30 minutes, not enough < 30 minutes bwork schedule: normal ≤8 hours a day, overtime >8 hours a day karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 380 table 5: association between ergonomic factors with umsd and lmsd (n=165) variable umsd  (pvalue) lmsd  (pvalue) yes (%) no (%) yes (%) no (%) work in awkward or cramped positions rarely 53(79.1) 14(20.9) 4.550 (0.033) 41(61.2) 26(38.8) 1.192 (0.275) frequently 89(90.8) 9(9.2) 68(69.4) 30(30.6) lift or transfer dependent patients rarely 53(81.5) 12(18.5) 1.828 (0.176) 41(63.1) 24(36.9) 0.426 (0.514 frequently 89(89.0) 11(11.0) 68(68.0) 32(32.0) carry, lift, or move heavy materials or equipment rarely 32(74.4) 11(25.6) 6.571 (0.010) 26(60.5) 17(39.5) 0.812 (0.367) frequently 110(90.2) 12(9.8) 83(68.0) 39(32.0) repeated task rarely 19(73.1) 7(26.9) 4.337 (0.037) 13(50.0) 13(50.0) 3.551 (0.060) frequently 123(88.5) 16(11.5) 96(69.1) 43(30.9) perform manual orthopedic techniques rarely 38(79.2) 10(20.8) 2.682 (0.102) 29(60.4) 19(39.6) 0.962 (0.327) frequently 104(88.9) 13(11.1) 80(68.4) 37(31.6) work in the same position for long periods rarely 45(77.6) 13(22.4) 5.354 (0.021) 39(67.2) 19(32.8) 0.056 (0.814) frequently 97(90.7) 10(9.3) 70(65.4) 37(34.6 for multivariate analysis, the variance inflation factor (vif) test among the independent variables was performed where the highest reported vif was 1.793so there was no issue of multicollinearity. nurses reporting moderate to higher job stress were found to have three times more odds (aor: 3.621, 95% ci: 1.2-10.8) of experiencing umsd as compared to nurses who reported lower job stress. likewise, nurses reporting not having enough rest breaks had a four-fold increase in odds of umsd (aor: 4.657, 95% ci: 1.3-15.9) as compared to nurses who reported having enough rest breaks. the odds of umsd were found 4.16 times higher (aor: 4.163, 95% ci: 1.2-13.4) among nurses who reported working in the same position for a long duration of time. similarly, nurses who did not receive training in injury prevention were thrice more likely to have umsds (aor: 3.150, 95% ci: 1.0-9.2) in comparison to those who had received training. (table 6). in the context of lower extremities musculoskeletal disorders, not having enough rest breaks during the day was found to increase the odds of lmsd among nurses by two folds (aor:2.193, 95% ci:1.0-4.7) as compared to nurses reporting enough rest breaks while adjusting with all the associated factors (table 7). karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 381 table 6: multivariate analysis for umsd among the nurses (n=165) variables cor 95%ci p-value aor 95%ci p-value work in awkward/ cramped positions rarely ref ref frequently 2.612 1.0-6.4 0.037 1.399 0.4-4.6 0.582 carry/lift/ move heavy materials/ equipment rarely ref ref frequently 3.151 1.2-7.8 0.013 2.276 0.7-6.6 0.132 repeated task rarely ref ref frequently 2.382 1.0-7.7 0.044 1.557 0.3-6.2 0.530 work in the same position for long periods rarely ref ref frequently 2.802 1.1-6.8 0.024 4.163 1.2-13.4 0.017 training in injury prevention yes ref ref no 3.689 1.4-9.1 0.005 3.150 1.0-9.2 0.036 treat large number of patients in a day yes 2.868 1.1-7.3 0.028 1.155 0.3-3.8 0.815 no ref ref work schedulea normal ref ref overtime 3.014 1.0-8.3 0.033 0.718 0.1-2.7 0.632 rest breaks during the dayb enough ref ref not enough 3.906 1.5-9.7 0.003 4.657 1.3-15.9 0.014 job stress low ref ref moderate/high 3.465 1.3-8.6 0.007 3.621 1.2-10.8 0.022 nagelkerker r square 0.332; hosmer lemeshow chi-square 5.449, p=0.709 ci: confidence interval, cor: crude odds ratio, aor: adjusted odds ratio table 7: multivariate analysis for lmsd among the nurses (n=165) variables cor 95%ci p-value aor 95%ci p-value age <25 4.500 1.6-11.9 0.003 2.100 0.6-7.1 0.234 25-30 3.060 1.2-7.7 0.019 1.943 0.6-5.4 0.210 >30 ref work experience <5 years 2.633 1.3-5.1 0.005 1.993 0.8-4.6 0.108 ≥5 years ref ref work schedulea normal ref ref overtime 2.444 1.0-5.7 0.042 2.007 0.7-5.0 0.140 rest breaks during the dayb enough ref ref not enough 2.711 1.3-5.5 0.006 2.193 1.0-4.7 0.048 nagelkerker r square 0.149; hosmer lemeshow chi-square 6.411, p=0.379 ci: confidence interval, cor: crude odds ratio, aor: adjusted odds ratio karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 382 discussions a higher rate of umsd and lmsd were observed among the nurses at 86.1% and 66.1% respectively. the finding is in line with the studies from india where the 12 months msd among nurses was found to range between 81% to 89.2%.19,20 similarly, a higher rate of msds was observed among nurses of both developing as well as developed nations such as nigeria, zimbabwe, vietnam, and china where more than threefourths of the nurses were found to have experienced any form of msd in the past 12 months.9, 32-34 furthermore, lower back pain, neck pain and upper back pain were the major forms of msds among nurses. the past studies from two of the major tertiary hospitals of nepal; sahid gangalal national heart centre and tribhuvan university teaching hospital revealed that 78% and 64.5% of the nurses experienced lower back pain.24,25 despite a higher prevalence of these disorders among the nurses which has affected their daily activities, only a few of them sought treatment. a similar observation was seen in the study from bangladesh where out of all nurses who experienced lower back pain only 36.2% reported seeking medical care for their condition.35 this indicates many of the nurses are troubled by musculoskeletal pain and discomfort which has heavily impacted their work efficiency but very few are seeking proper medical attention. the reason behind this poor health-seeking behavior among healthcare professionals needs to be further studied. these findings point to a significant and under-researched occupational health problem among nepalese nurses. the ergonomic factors such as working in awkward/cramped positions, carrying heavy material and/or equipment, performing repeated actions, and working in the same positions for a long period were found to be associated with umsds in bivariate analysis. this is in line with the findings from past studies suggesting that working in the same position for a long time duration has been perceived to be a major contributor to work-related msds among the nursing population.9,36,37 findings from past studies showed that working in awkward/cramped positions is significantly associated with msds among nurses.34,38 it was also noted that nurses not receiving enough rest during the day were four times more likely to experience umsd and twice times more likely to experience lmsd as compared to nurses having enough rest. similar to this finding, rest breaks were found to be a protective factor for msds in the studies from saudi arabia and china.34, 38 the positive association between rest breaks and msds has been observed in other occupations as well. for instance, a randomized control trial performed among agriculture workers noted the nature of rest breaks could significantly result in the alleviation of musculoskeletal pain in the neck, shoulder, back, and upper limbs.39 the continuous exertion of force and repeated movements could lead to inflammation and pain in body tissues resulting in reduced motor function, or muscle/bone discomfort and inducing risk of injuries. thus, proper rest breaks during work should be ensured among nurses to prevent them from such discomforts and assure their efficiency. training in injury prevention can be another crucial intervention to prevent msd as the nurses who did not receive training in injury prevention were found to have three-fold higher odds of msd. similar observations were made by the study from zimbabwe where ergonomic training was significantly associated with work-related musculoskeletal disorders among nurses (p<0.05).33 in line with current findings, studies suggest education and training on ergonomics and msds could be an effective intervention for msd prevention among nurses.40-42 this finding emphasizes the importance of ergonomic training and msd education. hospitals should provide training for their employees to improve their injury prevention abilities and thereby lower the risk of msds. thus, providing proper training and educational programs on msds targeting nurses and other health professionals might be a crucial strategy to reduce the risk of msd in this vital health workforce. the nurses who reported experiencing moderate or high stress were thrice more at odds of experiencing umsd as compared to nurses with a low level of stress. this is in line with past studies from china, thailand, uganda and canada where a significant association between mental stress and musculoskeletal discomfort was observed among the nurses.14,21,34,43 tension and stress cause muscle strain and hardness. furthermore, anxious nurses are more likely to notice any form of discomfort that occurs in their body as a result of attending to negative thoughts when they selfreport their msds.21 this finding suggests that hospitals should arrange recreational activities to reduce stress and anxiety among nurses to reduce the risk of experiencing msds. despite being one of the few studies examining the prevalence and risk factors for msds among nursing population this study is not free from its karki et al. prevalence & factors associated with occupational musculoskeletal disorders among the nurses of a tertiary care center of nepal 383 limitations. the information of msds is selfreported by the participants rather than medical diagnosis thus there are some chances of reporting bias though the study population was nurses. the study was conducted in one of the major tertiary hospitals of nepal which might not provide a complete representation of all nepalese nurses working in primary healthcare centers and/or small health units. however, the nurses selected in this study were working at different departments and wards of dhulikhel hospital so the diversity of the selected participants aids in the generalizability of the results. the findings of this study are expected to provide fruitful insights to the concerned stakeholders to focus on occupational health. conclusion there is a high prevalence of msds among nurses which could impact the overall healthcare system. working in the same position for a long duration, not receiving training in injury prevention, not having enough rest breaks, and job stress were the major factors found to be associated factors with musculoskeletal disorders among nurses. thus, providing healthcare professionals with training related to injury prevention and educating them about ergonomics and posture could reduce their risk of msds. references 1. bernard bp. a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. musculoskeletal disorders and workplace factors. 1997. available from: 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patient-handling devices on reducing musculoskeletal injuries to nursing personnel. human factors. 2012;54(4):60825. available from: https://doi.org/10.1177/0018720812438614 42. clari m, garzaro g, di maso m, donato f. upper limb work-related musculoskeletal disorders in operating room nurses: a multicenter crosssectional study. 2019;16(16). available from: https://doi.org/10.3390/ijerph16162844 43. murray e, franche rl, ibrahim s, smith p, carnide n, côté p, et al. pain-related work interference is a key factor in a worker/workplace model of work absence duration due to musculoskeletal conditions in canadian nurses. journal of occupational rehabilitation. 2013;23(4):585-96. available from: https://doi.org/10.1007/s10926-012-9408-7 https://doi.org/10.1186/s13104-017-2492-1 https://doi.org/10.17532/jhsci.2021.1209 https://doi.org/10.4103/0019-5278.146896 https://doi.org/10.7759/cureus.8382 https://doi.org/10.5271/sjweh.3696 https://doi.org/10.5271/sjweh.432 https://doi.org/10.1177/0018720812438614 https://doi.org/10.3390/ijerph16162844 https://doi.org/10.1007/s10926-012-9408-7 type of the paper (article int. j. occup. safety health, volume 13, no 3 (2023), 301-312 https://www.nepjol.info/index.php/ijosh original article covid-19 prevention practices and associated factors among workers in yirgalem agro-industry park, sidama regional state, ethiopia: a cross-sectional study gudeta ky1, ababe td2, melese s3 1 school of social and population health, yirgalem hospital medical college, yirgalem, ethiopia 2 school of nursing, hawassa university college of medicine and health sciences, hawassa, ethiopia 3 school of midwifery, hawassa university college of medicine and health sciences/ethiopia abstract introduction: the covid-19 outbreak resulted in millions of cases and deaths with an incredible pace of spread. it has been a global public health crisis since december 2019. though the work behaviors of some organizations can facilitate more ways for the mode of transmission, the potential work areas for the risk of infection are not identified yet. designing intervention strategies based on the risky assessment findings of a specific population or organization is better. the problem is more significant in developing countries. this study aimed to assess the prevention practices and associated factors of covid-19 among workers in yirgalem agroindustrial park, sidama regional state; ethiopia, 2020 methods: cross-sectional study was conducted from june 15th to august 15th, 2020. yirgalem agro-industrial park had 233 workers during the study period and data were collected from all of them. collected data were entered into epi data 3.1 and exported to spss 22 for analysis. factors associated with the practice of prevention were then analyzed. results: among the respondents, 91.8%, 75.1%, and 48.9% had good knowledge, positive attitudes, and good practice toward covid-19 prevention strategies respectively. multivariate regression revealed that age, spiritual or sin, training, knowledge, attitude, opposition to wearing, ordinary residents, and hoping leaders can win against covid-19 were predicted practices of covid-19 prevention strategies conclusion: the practice of covid-19 prevention strategies was so poor and needed adequate attention. age, spiritual/sin as a cause, prior training, knowledge, attitude, opposing mask-wearing, and belief in whether to defeat covid-19 or not were identified as the predictors. it is so important to revamp the current practices and assure the implementation of the standard as expected. keywords: attitude, covid-19, ethiopia, knowledge, practice, yirgalem agroindustry introduction coronaviruses are viruses of a large family that is known for resulting in illness ranging from the common cold to more severe disease like middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars).1,2 the most aggressive human coronavirus is the one that causes fatal lung disease, severe acute respiratory syndrome (sars), and it is called sars-cov. world health organization called the current coronavirus “2019 ncov” i.e. 2019 novel coronavirus or covid-19. globally, it resulted in more than three million attacks and closer to a million deaths within a short period with incredible spread. its recent outbreak occurred in wuhan, corresponding author: gudeta kaweti yadeto, lecturer, school of social and population health, yirgalem hospital medical college; yirgalem, ethiopia tel.: +251-912067140, e-mail: k.gudeta2019@gmail.com orcid id: https://orcid.org/0000-0003-3268-3013 date of submission: 30.01.2023 date of acceptance: 27.04.2023 date of publication: 01.07.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh.v13 i3.50966 copyright: this work is licensed under a creative commons attributionnoncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) mailto:k.gudeta2019@gmail.com https://orcid.org/0000-0003-3268-3013 https://doi.org/10.3126/ijosh.v13i3.50966 https://doi.org/10.3126/ijosh.v13i3.50966 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 302 china for the first time.3 according to the 2020 world health organization data, it is a global pandemic disease resulting in enormous public health impact and tremendous economic and social crisis which is generating stress throughout the population. everybody in the population is susceptible to this disease. however, some factors increase susceptibility. since there is no identified treatment yet, delaying transmission or reducing the risk of the outbreak is paramount important in decreasing its diversified impacts on different sectors. various modes of prevention like wearing masks, hand hygiene practices, social (physical) distancing, case detection, contact tracing, and quarantines have been recommended to reduce its risk of transmission.4 during the first week of the covid-19 pandemic attack, the prevention methods were misperceived in the usa. there was also, unawareness, not engaging in social distancing, and negligence in practicing protective behaviors.5 this may be due to unawareness as finding from china evidenced peoples’ knowledge, attitude, and practice towards covid-19 positively affects adherence to control measures. in this region, most chinese of high economic status especially women were knowledgeable about covid-19, hold an optimistic attitude and have appropriate practices for its prevention.6 since its emerging time, the world has been striving to find a solution to tackling the infection. nevertheless, all trials and efforts brought no solution for this pandemic infection to date. though developed countries are found to be the unique victim of the problem, developing countries including ethiopia are significantly vulnerable to the disease. the spread of the infection is escalating vigorously and covid-19-related deaths have been reported in 52 african countries.7 the potential work areas for the spread of the infection are not clearly stated. on top of this, many things including the mode of transmission, the reservoir, and sources of infection remain unclear about covid-19. due to the gap in data, risk assessment of the infection is still vague.8 thus, this study aims to assess the risky behaviors of covid19 infection that will serve as input for the reduction of the infection in the organization, particularly in manufacturing companies. the covid-19 infection does have various modes of transmission. the work behaviors of some organizations can facilitate more ways for this mode of transmission. thus, any prevention and intervention strategies shall base on these correspondent risky behaviors to bear effective results. in yirgalem agro-industry park, different categories of people in terms of educational status, socio-economic differences, and cultural practices were involved in the job. the foreigners who might have traveled to their home country where there is a high epidemiologic distribution of the disease were also part of the workers in this industrial park. besides, it is believed that behaviors (practices) like overcrowding in a certain place, transportation of many passengers in a single bus, daily traveling of workers with a possible risk of contact, and greeting practices like hugging each other and hand-shaking are common among the workers. again, nothing is known concerning the knowledge, attitude, and practice towards the infection prevention of covid-19 in the area. this study aimed to assess the prevention practices and associated factors of covid-19 among workers in yirgalem agro-industrial park, sidama regional state; ethiopia. the finding of this study will also be inferred for a similar organization like other factories and an interventional project will be designed with hawassa university and yirgalem hospital medical college to tackle the spread of the infection. other government and non-government organizations that are concerned with the subject matter can use the result of this study to design their intervention strategies. moreover, as there is a significant gap concerning this disease, the study finding will serve as baseline information for the country as well as other parts of the world and other researchers interested in the related issues can use it as scientific literature. methods an institutional based cross-sectional study was conducted in yirgalem agro-industrial park, southern ethiopia to assess risky behavior for covid-19 at the workplace. the yirgalem industrial park is found in abosto kebele, dale gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 303 woreda, sidama regional state; about 320 kilometers far from the capital of ethiopia. it had many sheds from which few of them engaged in active work. the functioning sheds were involved in producing juices and other manufacturing. the study period was from june 15th to august 15th, 2020. all workers of yirgalem agro-industrial park were taken as the source population and all active workers during the study period were the study population. the data extraction tool was developed after reviewing various literature and who protocols that were developed for the assessment of potential risk factors for the 2019 novel coronavirus. the tool incorporated the knowledge, attitude and practice questions. the consistency of the tool was checked by translating the tool to the local language and then back to english as well as through conducting a pretest on 5% of the sample size. the training was given on the objective of the project, how to approach participants, handle the information and keep confidentiality. data collectors used personal protective equipment and kept recommended covid-19 protocols during interviews. in this study, workplace behavior was measured as “risky” if industry park workers did not adhere to all covid19 prevention protocols. completeness and clarity of the collected data were assured daily by the supervisor. the outcome variable was covid-19 prevention practice. potential risk factors were selected based on different literature. accordingly; suspected risk factors include age, sex, mask utilization, place of residence, religion, educational status, marital status, droplet, smoking, isolation, crowd ness, distancing, prickling nose/eyes, touching the mouth, workers health status, etc. the overall assessment was based on the primary data collected from the eligible participants involved in the study. the census method was used for data collection. yirgalem agro-industrial park had 233 workers during the study period which was an addressable population size the collected data were cleaned, coded and entered into epi data version 3.1. then, it was exported to spss version 22 software packages for analysis. any errors identified during analysis were corrected using the assigned code numbers. presence of missing values and outliers were checked through descriptive analysis. the knowledge, attitude and practice score of the respondents were analyzed based on their respective questions. then their score was analyzed as good or adequate knowledge, poor or inadequate knowledge, favorable/unfavorable attitude, and good or poor practices based on their average mean score. factors associated with the practice of covid-19 prevention were primarily analyzed using binary logistic regression and then variables with p-value <0.25 were analyzed in multivariable logistic regression analysis with a 95% confidence interval and finally p-value <0.05 was considered statistically significant. the odds ratios together with their corresponding 95% confidence intervals were interpreted accordingly to ensure the quality of the data to be collected; a pretest was done on 5% (12 industrial workers) before the actual study and followed by required modification. supervision was done by the principal investigator during the whole process of data collection. daily evaluation of the data for completeness was undertaken accordingly. then, all the collected data were checked for completeness and consistency during the data management, storage and analysis. ethical clearance was received from the institutional review board of hawassa university, college of medicine and health science. a consent format was distributed and informed consent was obtained from each respondent before data collection. the confidentiality of the study participants was not disclosed. all collected data were first coded and then locked in a separate room before undertaking data entry. no personal identifier was included in the data collection formats results a total of 233 study populations participated; giving a response rate of 100%. the majorities 143 (61.4%) of the study participants were males and more than half (56.2%) of them were unmarried. the minimum and maximum ages of the study participants were 18 and 80 with a mean and standard deviation of 28.25 ± 7.4 years. more than gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 304 three fourth (81.5%) of the study participants live in yirgalem town and the majority (55.8%) were followers of the protestant religion. other religions indicated in the table include apostles, wakefata and pagan. around one-third (38.2%) of the study, participants had the educational status of attending college and above while few (4.7%) of them had no formal education. primary, secondary and college and above level education in ethiopia represents grades 1-8, grades 9-10 and profession-specific education respectively (table 1). table 1: socio-demographic characteristics of the respondents by sex, age, marital status, religion and residents, yirgalem, sidama region, ethiopia 2020 (n = 233) characteristics frequency (%) sex male 143(61.4) female 90(38.6) age 15-24 63(27) 25-34 116(49.8) 35-44 34(14.6) ≥45 20(8.6) marital status unmarried 131(56.2) married 102(43.8) religion protestant 130(55.8) orthodox 51(21.9) muslim 17(7.3) catholic 14(6) others 21(9) residence yirgalem 191(82) hawassa 23(9.9) other 19(8.2) education no formal education 11(4.7) primary education 61(26.2) secondary education 72(30.9) college & above 89(38.2) according to the finding of the knowledge assessment; almost all (91.8%) participants had good knowledge and about three fourth (72.5%) of the study participants did not know as children need to take measures to prevent covid-19. the mean knowledge score of the participants was 20.23±1.46. more than 6% of the study participants did not consider crowdedness as one way of covid-19 transmission (table 2). 2). gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 305 table 2: knowledge of the participants towards covid-19 prevention, yirgalem, sidama region, ethiopia, 2020 (n=233) characteristics frequency (%) spread via droplet yes 206(88.4) no 27(11.6) smokers are at risk yes 210(90.1) no 23(9.9) isolation is effective way yes 211(90.6) no 22(9.4) ordinary resident should wear mask yes 220(94.4) no 13(5.6) children not need to take measure yes 64(27.5) no 169 (72.5) individuals needs to void crowded place yes 218 (93.6) no 15(6.4) contacted person need to be isolated yes 222(95.3) no 11(4.7) washing hand is advised yes 222 (95.3) no 11(4.7) distancing yes 227(97.4) no 6(2.6) avoid prickling eyes, nose and touching the mouth yes 218(93.6) no 15(6.4) all develop severe disease yes 161(69.1) no 72(30.9) according to the findings of the attitude assessment; the majority (75.1%) of the study participants had a positive attitude on covid-19 prevention strategies and about 24.5% of the study participants did not think that covid-19 will be controlled. the mean attitude score of the study participants was 20.89±5.45. more than half (54.1%) of the respondents said that the cause of covid-19 is sin while about half (42.9%) of the study respondents said that traditional medicine can cure this disease. more than one-third (52.8%) of the study participants said that the who can win the challenges of attitude (table 3). about half (48.9%) of the respondents were not practicing covid-19 prevention strategies. for instance, 24.3% of the study participants were not wearing personal protective equipment while 39.9% of them occasionally wear their protective equipment. only 29.6% and 31.3% of the study participants always use alcohol/water and soap after touching a man and a product respectively as per the recommendations. one-third (33%) of the study respondents always practice recommended hand hygiene and 25.5% of the study respondents use alcohol/water and soap before touching a man as per the recommendation (table 4). gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 306 table 3: attitude of the participants towards covid-19 prevention, yirgalem, sidama region, ethiopia, 2020 (n=233) characteristics frequency (%) do you think covid-19 will be controlled disagree 57(24.5) neutral 29(12.4) agree 147(63.1) who@ can win disagree 82(35.2) neutral 28(12) agree 123(52.8) the cause of covid-19 is sin disagree 77(33) neutral 30(12.9) agree 126(54.1) you oppose wearing a mask disagree 58(24.9) neutral 26(11.2) agree 149(63.9) affected by covid-19 information disagree 88(37.8) neutral 27(11.6) agree 118(50.6) traditional medicine cures covid-19 disagree 90(38.6) neutral 43(18.5) agree 100(42.9) table 4: practice of the participants towards covid-19 prevention, yirgalem, sidama region, ethiopia, 2020 (n=233) characteristics rarely occasionally most of the time always as recommended practice recommended handhygiene 10 (4.3%) 25(10.7%) 121(51.9%) 77(33%) use alcohol/water & soap before touching a man 19 (8.2%) 65(27.9%) 90(38.6%) 59(25.3%) use alcohol/water & soap after touching a man 17(7.3%) 61(26.2%) 86(36.9%) 69(29.6%) use alcohol/water & soap after touching the product 24(10.3%) 61(26.2%) 75(32.2%) 73(31.3%) wear ppe 57(24.5%) 93(39.9%) 33(14.2%) 50(21.5%) int. j. occup. safety health, volume 13, no 3 (2023), 301-312 https://www.nepjol.info/index.php/ijosh according to the findings of bivariate analysis sex, age, marital status, educational status, spiritual cause or sin, training, good knowledge, positive attitude, mask wearing, and traditional medicine as a cure were significantly associated with covid19 prevention practices. but, after running a multivariate analysis, age, spiritual cause or sin, training, knowledge, attitude, mask-wearing, ordinary residents mask wearing and winning chance of covid battle were remain significantly associated with the covid-19 prevention practices at 95% confidence interval and p-value <0.05. the odds of practicing covid-19 prevention strategies among workers of age 45 years or more was about 7 times (aor=6.86; 95% ci: 1.51-31.21) compared to workers aged 15 years to 24 years. there were 75% fewer odds of practicing covid-19 prevention strategies among workers who agree that the cause of covid-19 is spiritual or sin (aor=0.25; 95% ci: 0.11-0.56) compare to workers who disagree that the cause is spiritual or sin. the odds of practicing covid-19 prevention strategies were 55% less among trained workers (aor=0.45; 95% ci: 0.22-0.92) compared to the workers who hadn’t taken covid-19-related training. there were 97% fewer odds of practicing covid-19 prevention strategies among workers who had poor knowledge (aor=0.03, 95% ci: 0.010.27) compared to workers who had good knowledge. similarly, there were 88% fewer odds of practicing covid-19 prevention strategies among workers who had negative attitudes (aor=0.12; 95% ci: 0.05-0.34) compared to industrial park workers who had a positive attitude toward covid-19. the odds of practicing covid-19 prevention strategies among industrial park workers who were neutral to opposing mask-wearing were reduced by 78% compared to workers who disagree to oppose mask-wearing (aor=0.22; 95% ci: 0.06-0.85). there were 90% fewer odds of practicing covid-19 prevention strategies among workers who said ordinary residents should wear masks compared to their counterparts (aor=0.10; 95% ci: 0.01-0.79). the odds of practicing covid-19 prevention strategies among workers who said leaders can win the covid-19 battle was three times (aor=3.03, 95% ci: 1.30-7.07) more compared to their counterparts (table 5). table 5: multivariate logistic regression analysis results for practicing covid 19 prevention strategies, yirgalem, sidama region, 2020 (n = 233) variables categories practice crude or (95% ci) adjusted or (95% ci) good n (%) poor n (%) sex female 36(40) 54(60) 0.56(0.33-0.95)* 0.53(0.26-1.08) male 78(54.5) 65(45.5) 1 1 age 15-24 21(33.3) 42(66.7) 1 1 25-34 60(51.7) 56(48.3) 2.14(1.13-4.06)* 2.07(0.86-4.98) 35-44 20(58.8) 14(41.2) 2.86(1.21-6.76)* 2.19(0.69-6.91) ≥45 13(65) 7(35) 3.71(1.29-10.69)* 6.86(1.51-31.21)* residence yirgalem 97(50.8) 92(49.2) 1 1 hawassa 11(47.8) 12(52.2) 0.89(0.37-2.11) 1.43 (0.45-4.53) other 6(31.6) 13(68.4) 0.45(0.16-1.23) 0.51(0.44-1.79) marital status unmarried 55(42) 76(58) 0.53(0.32-0.89)* 0.62(0.30-1.28) married 59(57.8) 43(42.2) 1 1 educational status no formal 5(45.5) 6(54.5) 0.59(0.17-2.09) 2.15(0.30-15.28) gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 308 below college 57(42.9) 76(57.1) 0.53(0.31-0.92)* 1.36(0.66-2.81) college/above 52(58.4) 37(41.6) 1 1 caused by spiritual or sin disagree 52(67.5) 25(32.5) 1 1 neutral 18(60) 12(40) 0.72(0.30-1.73) 0.85(0.27-2.67) agree 44(34.9) 81(65.1) 0.26(0.14-0.47)*** 0.25(0.11-0.56)** get trained yes 66(55.9) 52(44.1) 1 1 no 48(41.7) 67(58.3) 0.56(0.34-0.95)* 0.45(0.22-0.92)* knowledge poor 2(10.5) 17(89.5) 0.12(0.02-0.48)** 0.03(0.01-0.27)*** good 112(52.3) 102(47.7) 1 1 attitude negative 17(29.3) 41(70.7) 0.33(0.18-0.63)** 0.12(0.05-0.34)*** positive 97(55.4) 78(44.6) 1 1 oppose mask wearing disagree 37(63.8) 21(36.2) 1 1 neutral 10(38.5) 16(61.5) 0.36(0.14-0.92)* 0.22(0.06-0.85)* agree 67(45) 82(55) 0.46(0.25-0.87)* 0.42(0.17-1.01) residents should wear mask yes 105(47.7) 115(52.3) 0.41(0.12-1.36) 0.10(0.01-0.79)* no 9(69.2) 4(30.8) 1 1 leaders can win covid battle disagree 45(54.9) 37(45.1) 1.50(0.86-2.64) 3.03(1.30-7.07)* neutral 14(50) 14(50) 1.24(0.54-2.81) 0.99(0.32-3.05) agree 55(44.7) 68(55.3) 1 1 isolation & treatment reduce spread yes 100(47.4) 111(52.6) 1 1 no 14(63.6) 8(39.4) 1.94(1.78-4.82) 1.79(0.47-6.78) traditional medicine can cure covid disagree 53(58.9) 37(41.1) 1 1 neutral 27(62.8) 16(37.2) 1.18(0.56-2.49) 2.49(0.86-7.20) agree 34(34) 66(66) 0.36(0.20-0.65)* 0.58(0.27-1.25) discussion an institutional based cross-sectional study was conducted to examine the status of preventive practices and associated factors at yirgalem agroindustrial park. according to the findings of this study, 91.8% of the study participants had good knowledge, 75.1% had a positive attitude, and about half (48.9%) of them had good preventive practices for the prevention of covid-19. having good knowledge (91.8%) was higher than the studies conducted in jimma university medical center (41.3%), amhara region (70%), gondar 82.8%, uganda (82.4%), china (89%), and pakistan (90.7%) (41.3%).6,9-13 the reason behind the variations might be the time difference at which those studies were conducted. the studies in jimma, gondar, and amhara were conducted in the early stage of the pandemic, thus, the awareness of the disease had not this much disseminated in the early stage. the study in pakistan was almost similar and its study time could also justify it. the finding was lower than the study conducted in pakistan 93.2% and nigeria 99.5%.14,15 the possible reasons for this variation might be due to changes in the study period, settings, population, and data collection mechanism. the major stated covid-19 prevention strategies by the study participants were distancing, isolation of suspected individuals, wearing a mask, hand washing, and avoiding touching the nose/mouth before washing hands which was consistent with the recommended strategies for covid-19 prevention.4,5 this could be taken as the existence of better awareness of covid-19 prevention strategies among the industry park workers. majorities (88.4%) of the participants stated as covid-19 spreads through respiratory droplets which was almost in line with findings gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 309 from jimma university medical center (95.1%).9 the report that indicated all individuals infected by novel coronavirus can develop the severe disease (69.1%) was supportive of the findings from bangladesh where young children can even develop the complication to the extent of getting died of it.16 the proportion of people believing that the covid19 pandemic will be controlled at the end (63.1%) was slightly higher compared with the proportion of people believing the same in the bangladesh study (41.7%).16 changes in the study period, settings, and variations in study participants might be the justification for the differences. more than three fourth (75.1%) of the study participants had a positive attitude towards covid 19 which was almost in line with the study conducted in pakistan (82.16%), (90%), but it was lower than the study finding in ethiopia (94.7%).10,14,17 the justification for this variation might be due to the study population and setting. a study from nigeria reported as a significant number of the participants (25.06%) had shown poor attitudes toward covid-19.18 however, the majority of the respondents in this study had a positive attitude toward the covid-19 pandemic and this is higher than those having a moderate attitude in iran.19 unlike the current study, study in nigeria was conducted in the early stage of the pandemic when lack of awareness may be the reason for having a poor attitude. in addition, the reason for the variation from a study in iran may be the category of attitude classification which was in the likert scale while this study only dichotomized the attitude, thus, the percentage distribution may be less when the class of the category is increased attitude, thus, the percentage distribution may be less when the class of the category is increased. there were differences in proportion between practices of covid-19 prevention strategies in this study (48.9%) and findings from northern ethiopia, and addis ababa where 62%, 67%, and 49% of the respondents had good practice of prevention strategies respectively.11,20,21 the reason for the difference can be the variation in profession that the study in amhara was conducted on health professionals who have direct professional linkage with that issue and this may support them to have relatively better practices. on the other hand, respondents in addis ababa were an urban population that might have good access to information and technology. late nationwide training on covid-19 prevention strategies following its spread could be considered as the reason for almost closer proportion with the findings of addis ababa. practicing covid-19 prevention strategies was significantly associated with age, belief in the spiritual cause, prior training, knowledge, attitude, opposing mask-wearing, and belief in defeating covid-19. the odds of practicing covid-19 prevention strategies among workers of age 45 years or more was about 7 times compared to workers aged 15 years to 24 years (aor=6.86; 95% ci: 1.51-31.21). this finding was consistent with the study conducted in northwestern ethiopia and uganda.12, 13 this might be since chronic medical illness increases with age and the existence of those chronic illnesses increase the severity of covid-19. adherence to covid-19 prevention strategies might be due to the fear related to this fact. there were 75% fewer odds of practicing covid-19 prevention strategies among workers who agree that the cause of covid-19 is spiritual or sin (aor=0.25; 95% ci: 0.11-0.56) compare to industrial workers who disagree that the cause is spiritual or sin. covid-19 is zoonotic and tends to be transmitted between animals to humans and humans to humans through droplets, close contact, or other means, and as stated those study participants who didn’t know this reality was not practicing covid-19 prevention strategies.17 the odds of practicing covid-19 prevention strategies were 55% less among untrained industrial park workers (aor=0.45; 95% ci: 0.220.92) compared to the workers who took covid-19related training. this finding was consistent with the finding of a study conducted in zambia.22 it is also logical to believe that having prior covid-19 training increases workers' awareness and is basic for practicing covid-19 prevention strategies. there were 97% fewer odds of practicing covid-19 prevention strategies among workers who had poor knowledge (aor=0.03, 95% ci: 0.01-0.27) compared gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 310 to workers who had good knowledge. this study finding was in line with the study conducted in northern ethiopia.13 this might be since getting awareness or knowledge on covid-19 prevention strategies precedes the practice of covid-19 prevention strategies. the attitude of a human being is the result of his or her judgment towards something.23 the majority of people who judged something as positively could practice the event better and the reverse is true for the majority of people who judged something negatively.24 our study supported such facts and reported that the odds of practicing covid-19 prevention strategies among workers who had negative attitudes were 88% less compared to industrial park workers who had a positive attitude toward covid-19. this finding was consistent with various studies conducted in ethiopia, egypt, china, and saudi arabia and all studies revealed that favorable attitudes towards covid-19 preventive measures were significantly associated with good adherence to covid-19 mitigation measures.20,25-27 the odds of practicing covid-19 prevention strategies among industrial park workers who were neutral to opposing mask-wearing were reduced by 78% compared to workers who disagree to oppose mask-wearing (aor=0.22; 95% ci: 0.06-0.85). this might be due to the reason that mask-wearing is among the first line of covid-19 prevention strategies and being neutral for mask-wearing means that those industrial workers had less likely to implement or practice other covid-19 prevention strategies. there were 90% fewer odds of practicing covid-19 prevention strategies among workers who said ordinary residents should wear masks compared to their counterparts (aor=0.10; 95% ci: 0.01-0.79). this indicates the awareness gap among the respondents because ordinary people are expected to have less risk of exposure compared to those people around riskprone areas. the odds of practicing covid-19 prevention strategies among workers who said leaders can win the covid-19 battle was three times (aor=3.03, 95% ci: 1.30-7.07) more compare to their counterparts. this indicates that the hope in world leaders and technology motivated those people to adequately practice covid-19 prevention strategies. limitations of the study this study has its limitation. generalization of the study findings to other agro-industrial workers in the country is impossible since this study was conducted only in one institution (i.e. yirgalem agro-industrial park). some degree of selection bias may not be ruled out since the participation was voluntary and the chance of participating is high among those who had a better understanding or attitude towards the practice of covid-19 prevention strategies. this could lead to an overestimation of the practice. as this is an institutional-based cross-sectional study, the limitations that come up with this type of study design need to be taken into consideration in interpreting the results/findings. conclusions according to the findings of this study, 91.8% of the study participants had good knowledge, 75.1% had a positive attitude and about half of them (48.9%) had good preventive practices for the prevention of covid-19. practicing covid-19 prevention strategies was significantly associated with age, belief in spiritual/sin as a cause, prior training, knowledge, attitude, opposing mask wearing and belief in whether to defeat covid-19 or not. the top management of the yirgalem agro industry is better to conduct awareness creation/intensive training activities on covid-19 prevention strategies and then enforce policies for effective implementation. acknowledgments first of all, we would like to acknowledge research and technology transfer directorate office for the provision of this chance that initiated us to develop this research project. hawassa university college of medicine and health sciences also deserve gratitude for the support that it contributed to the accomplishment of this proposal in different aspects. references 1. campione e, lanna c, cosio t, rosa l, conte mp, iacovelli f, et al. lactoferrin against sars-cov-2: in vitro and in silico evidences. frontiers in pharmacology. 2021;12(1524). available from: gudeta et al. covid 19 prevention practices and associated factors among workers in yirgalem agro industrial park; sidama, ethiopia 311 https://doi.org/10.3389/fphar.2021.666600 2. ludwig s, zarbock a. coronaviruses and sarscov-2: a brief overview. anesth analg. 2020;131(1):93-6. available from: https://doi.org/10.1213/ane.0000000000004845 3. yue h, bai x, wang j, yu q, liu w, pu j, et al. clinical characteristics of coronavirus disease 2019 in gansu province, china. annals of palliative medicine. 2020;9(4):1404-12. available from: https://doi.org/ 10.21037/apm-20-887 4. adhikari s, pantaleo np, feldman jm, ogedegbe o, thorpe l, troxel ab. assessment of communitylevel disparities in coronavirus disease 2019 (covid-19) infections and deaths in large us metropolitan areas. jama network open. 2020;3(7):e2016938-e. available from: https://doi.org/10.1001/jamanetworkopen.2020.1693 8 5. wise t, zbozinek td, michelini g, hagan cc, mobbs d. changes in risk perception and self-reported protective behaviour during the first week of the covid-19 pandemic in the united states. r soc open sci. 2020;7(9). available from: 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gebrewahd gt, demoz gt. knowledge, attitude, practice and psychological response toward covid-19 among nurses during the covid-19 outbreak in northern ethiopia, 2020. new microbes and new infections. 2020;38:100787. available from: https://doi.org/10.1016%2fj.nmni.2020.100787 21. belete zw, berihun g, keleb a, ademas a, berhanu l, abebe m, et al. knowledge, attitude, and preventive practices towards covid-19 and associated factors among adult hospital visitors in south gondar zone hospitals, northwest ethiopia. plos one. 2021;16(5):e0250145. available from: https://doi.org/10.1371/journal.pone.0250145 22. chawe a, mfune rl, syapiila pm, zimba sd, vlahakis pa, mwale s, et al. knowledge, attitude and practices of covid-19 among medical laboratory professionals in zambia. 2021;10(1). epub 2021-02-11. available from: https://doi.org/10.4102%2fajlm.v10i1.1403 23. caroline n. teachers’ attitude towards implementation of learner-centered methodology in science education in kenya. educational research and reviews. 2017;12(20):996-1007. avaialble from: https://doi.org/10.5897/err2017.3326 24. kassie ba, adane a, abebe kassahun e, ayele as, kassahun belew a. poor covid-19 preventive practice among healthcare workers in northwest ethiopia, 2020. advances in public health. 2020;2020. available from: https://doi.org/10.1155/2020/7526037 25. shi y, wang j, yang y, wang z, wang g, hashimoto k, et al. knowledge and attitudes of medical staff in chinese psychiatric hospitals regarding covid-19. brain behav immun health. 2020;4(100064):29. available from: https://doi.org/10.1016/j.bbih.2020.100064 26. al-hazmi a, gosadi i, somily a, alsubaie s, bin saeed a. knowledge, attitude and practice of secondary schools and university students toward middle east respiratory syndrome epidemic in saudi arabia: a cross-sectional study. saudi j biol sci. 2018;25(3):572-7. available from: https://doi.org/10.1016/j.sjbs.2016.01.032 27. eyeberu a, debella a, mengistu da, arkew m, hailu s, oljira a, et al. perceived self efficacy in implementing covid-19 preventive measures among residents of harari regional state, eastern ethiopia: a community-based cross-sectional study. frontiers in epidemiology. 2022;2:849015. available from: https://doi.org/10.3389/fepid.2022.849015 https://doi.org/10.2196/26980 https://doi.org/10.3855/jidc.13248 https://doi.org/10.1371%2fjournal.pone.0238492 https://doi.org/10.1016%2fj.nmni.2020.100787 https://doi.org/10.1371/journal.pone.0250145 https://doi.org/10.4102%2fajlm.v10i1.1403 https://doi.org/10.5897/err2017.3326 https://doi.org/10.1155/2020/7526037 https://doi.org/10.1016/j.bbih.2020.100064 https://doi.org/10.1016/j.sjbs.2016.01.032 https://doi.org/10.3389/fepid.2022.849015 int. j. occup. safety health, volume 13, no 3 (2023), 282-292 https://www.nepjol.info/index.php/ijosh 282 original article ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a crosssectional study edosomwan hs1, nwanzu cl1 1 department of psychology, delta state university, abraka, nigeria abstract introduction: caring behavior is a unique behavior that can promote patients’ well-being, the performance of healthcare workers, and the general effectiveness of healthcare institutions. the mechanism and possible predictors of caring behavior are under-researched in health and organizational behavior literature. based on the aforementioned, this study examined the predictive effect of ethical sensitivity (dimensions included) on caring behavior, and gender differences in caring behavior and ethical sensitivity among public healthcare workers in delta state, nigeria. methods: a cross-sectional research design and a quantitative approach for data collection were adopted. simple random sampling was adopted for selecting the participating hospitals while the convenience sampling technique was utilized for selecting the healthcare workers. two instruments with good psychometric properties were used for the data collection. the simple linear regression and independent sample t-test were used for testing the hypotheses via the ibmspss v.25. results: the participants comprised 150 healthcare workers from public-owned hospitals consisting of 73(48.7%) males and 77(51.3%) females with a mean age of 40.60 years and a standard deviation of 9.30. the results of the study indicated that ethical sensitivity positively and significantly predicted caring behavior. also, two dimensions of ethical sensitivity, moral strength, and moral responsibility positively and significantly predicted caring behavior while a sense of moral burden did not. finally, there was no significant gender difference in caring behavior and ethical sensitivity. conclusion: this study highlights the role of ethical sensitivity, moral strength, and moral responsibility in predicting higher levels of caring behavior among healthcare workers. thus, it was recommended that hospital administrators, health policymakers, and practitioners seeking to boost the caring behavior of healthcare workers should focus on enhancing factors such as sensitivity to ethical standards. also, administrators of medical education can nurture intending healthcare workers (medical students) on the importance of ethics in the medical profession. keywords: caring behavior, ethical sensitivity, gender, healthcare workers, moral responsibility, moral strength, sense of moral burden introduction healthcare workers are crucial to nations around the world and they represent about 12% of the working population worldwide.1 healthcare workers work long hours and their job is usually challenging since they have to deal with human suffering daily. despite this, it is their professional duty to ensure that the health of a patient is well managed.2 caring behavior is regarded as an essential attribute in the healthcare profession because of the salient role it plays in the caregiverpatient relationship. achieving an efficient and optimum healthcare delivery largely relies on the service process and the interaction between healthcare workers and patients.3 caring behavior is crucial in establishing and maintaining a sound therapeutic alliance, and it fosters the efficacy of the treatment process.4 corresponding author: henry samuel edosomwan research assistant, department of psychology, delta state university, abraka, nigeria. phone: +2347066709392 email:edosomwanofficial@gmail.com orcid id: https://orcid.org/00000002-4338-9066 date of submission: 20.10.2022 date of acceptance: 03.04.2023 date of publication: 01.07.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh.v13i2 .49009 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:edosomwanofficial@gmail.com https://orcid.org/0000-0002-4338-9066 https://orcid.org/0000-0002-4338-9066 https://doi.org/10.3126/ijosh.v13i2.49009 https://doi.org/10.3126/ijosh.v13i2.49009 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 283 therefore, the relevance of the interaction between healthcare workers and health seekers cannot be overemphasized because it has been observed to aid the treatment process.5 this relationship is built on effective care, interpersonal communication, information disclosure, and caring behavior which are important in ensuring and maintaining quality therapeutic relationships between healthcare workers and health seekers.6,7 at a minimum, quality healthcare is built on the availability of necessary resources as well as a health workforce that is capable and well-motivated. caring behavior is an interpersonal process that is built on sensitivity to the need of others and involves highly practical behaviors such as assuring humanistic presence, general respect for patients’ needs, positive communication, providing professional skill and knowledge where necessary, and most importantly paying attention to the need of the patient.8 caring behavior in the healthcare profession conveys concern for the safety and well-being of the patient and ensures that significant attention is given to the patient's needs during the treatment process.9 caring behavior is very important largely because healthcare professionals are constantly in direct contact with patients. the absence of caring behavior in the healthcare profession has detrimental effects on health seekers. in the nigerian public healthcare system, workplace attitude marked by emotional incompetence, reduced interpersonal communication, and caring behavior has been major contributors to the reported challenges within the health sector.10,11 these attitudes (emotional incompetence, reduce interpersonal communication, and caring behavior) can impact the quality of healthcare services, hence, discouraging patients from seeking care in publicowned health institutions. however, caring behavior has not been given as much attention in health and organizational literature as it should be, especially in the nigerian context where there exists evidence of reduced care among healthcare workers.11 on reviewing various kinds of literature it shows that researchers are recognizing its perceived importance in quality healthcare delivery still its antecedents and predictors have not been fully established in the global workspace, especially in nigerian health organizations. a few gaps in the literature necessitated this study. first, with recent reports in the literature indicating a shift from the regular sample utilized for studying caring behavior in the population of healthcare workers,12 it becomes pertinent to examine other core healthcare units and possible variables that contribute to caring behavior in a bid to promoting the health and well-being of health seekers. the extant literature indicates that a significant number of studies have been focused on the caring behavior of nurses and other nursing caregivers with less attention given to other core healthcare personnel that have direct contact with patients.3,6,8 in most nigerian hospitals, health seekers have to meet record personnel who takes their record on behalf of the hospital, medical doctors responsible for drug prescription, a pharmacist in charge of giving the prescribed drugs or medications, and nurses who administer the drugs.12 these processes are likely the same all over the world as the healthcare professional is highly regulated and controlled because of its essence to humanity. the inclusiveness of other core professionals in the healthcare sector reflects the caring behavior within the hospital. second, studies examining the dimensionality of the ethical sensitivity scale (moral burden, strength, and responsibility) and its effects on caring behavior are lacking in the literature. finally, the impact of gender on ethical sensitivity and caring behavior is also lacking in the nigerian healthcare literature. the existence of these gaps in knowledge, if unattended can disempower health and hospital administrators in taking the right proactive and reactive steps in promoting caring behavior and ethical sensitivity. based on this, the present study assessed caring behavior among healthcare workers and how it was influenced by ethical sensitivity, and its dimensions (moral burden, moral strength, and moral responsibility). the study also examines the likely differential effect of gender on caring behavior and ethical sensitivity. studies on caring behavior are lacking in nigeria, especially concerning the selected individual and demographic variables. ethics are the foundation on which the medical profession is built providing the basis for ethical patient care.13 therefore, the role of ethical sensitivity in the management and delivery of quality healthcare services cannot be undermined. ethical sensitivity refers to the attentiveness to the moral values involved in a conflict-laden situation and self-awareness of one's personal role and obligation in a given situation e.g., during patient care.14 it is the personal predisposition that guides healthcare workers in making an ethical decision which entails using their skills, feelings, cognitive capacity, and ethical knowledge.14 healthcare professionals face a variety of challenges that require ethical knowledge and a critical step to edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 284 take in increasing the ethical sensitivity of healthcare professionals is to increase their awareness and recognition of ethical issues especially those that have direct implications for patient care. 13 it has also been observed that personal disposition can influence care-related behavior among healthcare workers. 15 healthcare workers need to understand basic ethical principles related to healthcare and integrate these principles with their moral values to deal with ethical problems. reduced ethical sensitivity may bring about ethically inappropriate behavior and conflicts with the obligations of the healthcare profession. hence, the abundance of ethical sensitivity may promote favorable workplace behavior that may have a positive impact on patients and colleagues at work. consequently, it is hypothesized that ethical sensitivity is likely to have a positive impact on caring behavior. previous studies have reported that higher levels of ethical sensitivity significantly contribute to compassion levels,16 perceptions and quality of nursing,17 occupational professionalism,18 and greater empathetic behavior.19 also, the literature indicates that incompetency in ethical sensitivity threatens patient care and desensitizes healthcare workers when they are confronted with ethical situations or challenges.20,21 thus, there is a strong ground to believe that ethical sensitivity and its dimensions have the potential of predicting caring behavior among healthcare workers. gender has also been shown to influence varieties of workplace variables in healthcare institutions. although there are inconsistent findings regarding gender influence on caring behavior, the role it plays cannot be overlooked. previous studies outside nigeria have shown that gender influences the caring behavior of healthcare workers.22 individuals who reported higher masculinity and femininity have been shown to have higher caring behavior. 23 shmilovitz, itzhaki and koton found a significant gender difference in caring behavior with females reporting more caring behavior than males. 24 similarly, a study found that gender is not a significant factor in understanding and dealing with the need of patients in nigerian public hospitals.25 these inconsistencies necessitated further examination of the observed difference between gender and caring behavior. sensitivity to ethical practices might also be influenced by gender. this is based on the notion that males are more prone to assertiveness and rule-breaking compared to their female counterparts using the gender role theory.26 males are usually pushier and hence more likely to break ethical standards. hence, females are more likely to be ethically sensitive than their male counterparts. recent literature gives support for this proposition.27,28 consequent to the salient literature reviewed and the bid to fill the gaps earlier identified in the literature, this study is guided by the following hypotheses: h1: ethical sensitivity will positively and significantly predict caring behavior. h1a: sense moral burden will positively and significantly predict caring behavior. h1b: moral strength will positively and significantly predict caring behavior. h1c: moral responsibility will positively and significantly predict caring behavior. h2: there will be a significant gender difference in caring behavior. h3: there will be a significant gender difference in ethical sensitivity. methods a cross-sectional study was adopted using a quantitative approach to data collection. the cross-sectional research design is appropriate because the sample was drawn from all participating public-owned hospitals in delta state, nigeria. this design was also deemed appropriate because of its capacity and flexibility in measuring several variables and testing multiple research questions and hypotheses at a single point in time. also, the time constraint, the size of the sample, and the resource available at the time led to the selection of this method. a required sample size to test for statistical power and inference was adopted. this was estimated using the g*power software.29 using the adequate number of predictors outlined in the research hypotheses, a standardized alpha of 0.01, with a medium effect size (f2) of 0.15, and a power level of 0.97. the g*power analysis suggested a required sample size of 101 participants. as recommended by bartlett, kotrlik, and higgins, it is advisable to increase the required sample size by 50% to enhance statistical inference.30 based on this recommendation, an additional sixty (60) participants were added to the overall sample totaling 161. this was evenly distributed across all the participating public owned hospitals. after the data collection, the researchers discovered that some questionnaires were not properly filled out by some of the respondents. this was attributed to the unwillingness of the participants to continue participation after giving their consent or merely a lack of motivation to respond to the items on the questionnaires. as a result, 150 questionnaires edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 285 were used for the final statistical data analysis and test of hypotheses. the questionnaire contained two psychometrically standardized instruments and questions eliciting sociodemographic information from the participants. the sociodemographics include gender, age, marital status, medical experience, current organizational tenure, and educational qualification. item coding and mean scores of the participants’ responses were used for the data analysis. ethical clearance was obtained from the institutional ethical committee of delta state university before the commencement of the study. confidentiality was maintained throughout the process of data collection. the researchers sought the permission of the participating hospitals (through a formal written letter stating the essence of the research and why health workers should participate in it) before administering the questionnaires. verbal consent was taken from healthcare workers for participating in the study. considering the constraint of resources, probability sampling was used for selecting the participating public-owned institutions via the use of random numbers assigned to hospitals to give some form of randomization to the process. the hospitals assigned to the random numbers selected were utilized for the study. also, the convenience sampling technique was used for selecting the healthcare workers from the selected hospitals. the researchers ensured that participants were selected from the core units of the healthcare profession. one hundred and seventy (170) questionnaires were distributed, and one hundred and sixty-two (162) questionnaires were retrieved. the return rate was 95.29% and among them, 150 responses were used for the analysis. two instruments were used for assessing the two major variables in the study. one for caring behavior and the other for ethical sensitivity. caring behavior was assessed with the instrument developed by wu et al.31 the inventory measures healthcare workers caring behavior toward patients. the caring behavior inventory was adapted to accommodate all participating healthcare workers such as doctors, nurses, and others within the field with direct contact with patient care. the inventory comprises 24 items that yielded four factors with each constituting a specific and significant domain of caring behavior: assurance (measured with 8 items), knowledge and skill (measured with 5 items), respectfulness (measured with 6 items), and connectedness (measured with 5 items). according to nwanzu and babalola, the assurance domain entails giving time to the need and security of patients, knowledge, and skill has to do with information and proficiency in the healthcare profession, with regard to patient’s well-being, respectfulness entails the act of having courteous regard for patients, while connectedness covered optimistic and constant readiness on the part of the healthcare worker to help patients. 9 examples of the items include: “i attentively listen to my patient”; “i allow the patients to express feelings about his/her disease and treatment”; “i am usually patient and tireless with the patients”. the scale was measured on a five-point likert format ranging from strongly disagree (1), disagree (2), neutral (3), agree (4), and strongly agree (5). the overall scores for each of the dimensions represent the composite construct of caring behavior. a reliability coefficient alpha of .96 was reported for the overall scale. ethical sensitivity was assessed with the index of ethical sensitivity questionnaire developed by lutzen et al.14 the scale was specifically developed for measuring ethical sensitivity during ethical decision-making among healthcare professionals working in a variety of healthcare settings. the ethical/moral sensitivity questionnaire comprises 9-item that yielded three factors each constituting a specific and significant domain of ethical sensitivity in healthcare settings: sense of moral burden (measured with 4 items), moral strength (measured by 3 items), and moral responsibility (measured with 2 items). examples of the items include: “i always feel a responsibility that the patient receives good care even if the resources are inadequate”; “i have a very good ability to sense when the patient is not receiving good care”; “my ability to sense a patient's needs means that i often find myself in a situation in which i feel inadequate”, representing each of the significant domain respectively. a likert-type response was adopted for the instrument. specifically, a 5-point likert format was adopted ranging from strongly disagree (1) to strongly agree (5). since the present study was focused on ethical sensitivity as a composite and the specifics, the mean scores reflecting the whole and the dimensional construct were utilized such that higher scores indicate high ethical sensitivity and lower scores indicate low ethical sensitivity. the same applies to the dimensions. the scale has been found to possess good psychometric properties. preliminary statistical analyses such as the normality test, cronbach’s alpha, correlation, and common method bias tests were conducted to edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 286 check the suitability of the data and see if it meets the assumptions of the parametric statistical test. the first groups of hypotheses (h1, h1a, h2b, and h1c) were tested with the simple linear regression analysis while hypotheses two (h2) and three (h3) were tested with the independent sample t-test. the decision rule to be used in testing the hypotheses is, if the critical value (p) > 0.05 for a two-tailed test, reject the null hypothesis, if not accept the null hypothesis. the data were analyzed with the ibm-spss statistics v.25. results the sociodemographic profiles of the respondents are given in table 1. the participants had a mean age of 40.60 years (sd= ±9.30). the study sample comprised 77(51.3%) females and 73(48.7%) males and a majority of the participants were married. participants between 31-40, 60(40.7%) years of age, and those who have spent below 12 years (66.7%) in their various hospitals made up a significant proportion of the research sample. all the participants reported that they have received formal education with most of them having bachelor’s degrees or an equivalent certificate at a descriptive value of 115(77.1%). the correlation analysis shown in table 2 indicates that age (r = .284, p <.01), organizational tenure (r = .174, p <.05), and educational qualification (r = .288, p <.01) were all associated with the caring behavior of healthcare workers. the demographic characteristics of the participants have no association with ethical sensitivity. table 1.: sociodemographic characteristics of the respondents n frequency percent gender 150 male 73 48.7 female 77 51.3 age 150 under 31years 22 14.7 31-40years 61 40.7 41-50years 53 35.3 51 years and above 14 9.3 marital status 150 married 88 58.6 single 51 34.0 separated/divorced 7 4.7 widowed 4 2.7 medical experience 145 less than 5years 40 27.5 6-10years 49 33.8 11-20years 31 21.4 21-30years 11 7.6 31 years and above 14 9.7 organizational tenure 150 under 12years 100 66.7 12-22years 29 19.3 23 years and above 21 14.0 educational qualification 149 bachelor’s degree/equivalent certificate 115 77.1 postgraduate 34 22.9 edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 287 table 2.: association between sociodemographic characteristics and the scores on caring behavior and ethical sensitivity descriptive statistics caring behavior ethical sensitivity mean sd correlation p-value correlation p-value gender 1.513 .501 .033 .689 .004 .959 age 40.606 9.302 .284** .000 .009 .917 marital status 1.513 .711 .060 .465 -.035 .670 medical experience 2.379 1.236 .148 .075 .109 .191 organizational tenure 1.460 9.126 .174* .033 .104 .206 educational qualification 2.973 .993 .288** .000 -.096 .243 note: *correlation is significant at .05 level (2-tailed); **correlation is significant at .01 level (2-tailed); gender, marital status, and educational qualification were collected at nominal levels while age, medical experience, and organizational tenure were coded in years (continuous level) and later categorized. the cronbach’s alpha, a test of normality, and multicollinearity (for the predictors) for the prestatistical tests were all within the normal range. the internal consistency of the instruments was largely satisfactory as they met the literature requirement for a reliable scale. specifically, cronbach’s alpha values for the sense of moral burden, moral strength, moral responsibility, and caring behavior were .65, .74, .70, .67, and .91 which were considered satisfactory. the values for the variance inflation factor (<10) and tolerance (>0.40) were also within normal range. the descriptive statistics and normality test were within the acceptable range for a regression-based model. table 3 also shows the descriptive statistics and the correlation coefficient of the research variables. a modest value was attained for the mean and standard deviation of all the variables. the table also shows a significant relationship for most of the key study variables. specifically, moral strength (r = .20, p <.05), moral responsibility (r = .19, p < .05), and the composite value for ethical sensitivity (r = .21, p < .05) were significantly related to caring behavior among healthcare workers while the sense of moral burden did not (r = .10, p > .05). it is also important to know that the observed correlation values were below .80 indicating that common method variance and multicollinearity did not affect the results of the analysis. note: *correlation is significant at .05 level (2-tailed); **correlation is significant at .01 level (2-tailed); the cronbach’s alpha for each variable is placed in parentheses. a simple linear regression was performed to examine the effect of ethical sensitivity on caring behavior among healthcare workers and the results are presented in table 4. the statistics in the table offered support for the hypothesis: ethical sensitivity positively and significantly predicted caring behavior, (b= .20, 95% ci [.03, .27], t = 2.58, p= .011). the observed b value suggests that for every unit increase in ethical sensitivity, a .20 increase in caring behavior is expected and the r2 of .04 indicates that ethical sensitivity accounts for 4% of the variation in caring behavior. the analysis of variance (anova) test, f(1, 148) = 6.68, p= .011, indicates that the regression was statistically significant, meaning caring behavior can be predicted from ethical sensitivity. hence, the first hypothesis was accepted. there was no table 3.: mean, standard deviation, and correlation coefficient of research variables m sd 1 2 3 4 5 6 7 8 9 1 sense of moral burden 3.94 .81 [.65] 2 moral strength 4.59 .59 .15 [.74] 3 moral responsibility 4.60 .67 .17* .67** [.70] 4 ethical sensitivity 4.30 .52 .80* .68** .66** [.67] 5 assurance 4.39 .60 .10 .13 .15 .16* [.87] 6 knowledge and skill 4.50 .49 -.04 .16* .13 .07 .36** [.86] 7 respectfulness 4.50 .57 .10 .14 .10 .16 .26** .47** [.85] 8 connectedness 4.53 .46 .09 .19* .18* .19* .24** .41** .50** [.73] 9 caring behavior 4.47 .39 .10 .20* .19* .21* .76** .71** .73** .65** [.91] edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 288 support for hypothesis h1a as the regression analysis indicates that a sense of moral burden did not significantly predict caring behavior (b= .10, 95% ci [-.02, .13], t = 1.29, p > .05). the results also indicated that moral strength significantly predicts caring behavior (b= .21, 95% ci [.03, .24], t = 2.60, p= .010). the b value suggests that for every unit increase in moral strength, a .21 increase in caring behavior occurs while the r2 of .04 indicates that moral strength accounts for 4% of the variation in caring behavior. the test for anova, f(1, 148) = 6.77, p= .010, indicates that the regression is statistically significant, meaning caring behavior can be predicted from the moral strength of healthcare workers. therefore, we did not fail to accept hypothesis h1b. finally, the results in table 4 showed that the moral responsibility of healthcare workers significantly predicts caring behavior (b= .19, 95% ci [.02, .20], t = 2.40, p= .018). the b value suggests that every unit's increase in moral responsibility leads to a .19 increase in caring behavior. also, the r2 of .03 indicates that moral responsibility accounts for 3% of the variation in caring behavior. the test for anova, f(1, 148) = 5.75, p= .018, indicates that the regression is statistically significant, meaning that the caring behavior of healthcare workers can be predicted from moral responsibility. therefore, hypothesis h1c was accepted. table 4.: simple regression analysis showing ethical sensitivity, and its dimensions predicting caring behavior b se t r2 adj r2 f p 95% ci lower upper ethical sensitivity .20* .06 2.58 .043 .037 6.68 .011 .03 .27 sense of moral burden .10 .04 1.29 .011 .005 1.68 .196 -.02 .13 moral strength .21* .05 2.60 .044 .038 6.77 .010 .03 .24 moral responsibility .19* .05 2.40 .037 .031 5.75 .018 .02 .20 note: *p < .05 level (2-tailed). an independent sample t-test was conducted to check for gender differences in the caring behavior and ethical sensitivity of healthcare workers. for the first condition (gender difference in caring behavior) as seen in table 5, there was no significant difference in the scores for males (m = 4.461, sd = 0.405) and the scores for females (m = 4.488, sd = .392) on caring behavior, t(148) = -.405, p = .686. hence, the hypothesis (h2) which stated that there will be a significant gender difference in caring behavior was rejected. for the second test of difference (gender difference in ethical sensitivity) as displayed in table 5, there was no significant difference in the scores for males (m = 4.304, sd = .523) and females (m = 4.309, sd =.528) on ethical sensitivity, t(148) = -.051, p = .959. therefore, the hypothesis (h3) which stated that there will be a significant gender difference in ethical sensitivity was rejected. table 5.: independent sample t-test for gender difference in caring behavior and ethical sensitivity caring behavior n m sd t-value p-value mean difference 95% ci cohen’s d lower upper male 73 4.461 .405 -.405 .686 -.027 -.155 .102 -.066 female 77 4.488 .392 ethical sensitivity male 73 4.304 .523 -.051 .959 -.005 -.174 .165 -.008 female 77 4.309 .528 discussion this study examined the predictive relationship between ethical sensitivity and caring behavior among public healthcare workers in delta state, nigeria. specifically, the study explored the composite concept of ethical sensitivity, its dimensions which include a sense of moral burden, moral strength, and moral responsibility, edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 289 and how they impact the caring behavior of healthcare workers. also, the study examined gender differences in caring behavior and ethical sensitivity. three research hypotheses were developed (with the first having three other hypothetical statements to further explore the dimensions of ethical sensitivity). the descriptive statistics, normality and reliability tests were within the normal range for a regression-based model.32,33 the correlation analysis of the demographic variables on caring behavior and ethical sensitivity revealed that the age, number of years spent in the hospital (organizational tenure), and educational qualification of a healthcare worker were all associated with the caring behavior while the demographic characteristics of the participants have no association with ethical sensitivity. the first hypothesis which stated that ethical sensitivity will positively and significantly predict caring behavior was supported. ethical sensitivity was found to be a positive and significant predictor of caring behavior among healthcare workers. this implies that an increase in ethical sensitivity will necessitate an increase in the caring behavior of healthcare workers. the finding is in line with similar studies in the literature. previous studies have reported that sensitivity to ethical practices is significantly related to empathy, general compassion levels, and the occupational professionalism of healthcare workers.16,18,19 thus, ethical sensitivity fosters the caring behavior of healthcare workers. further analysis of the dimensions of ethical sensitivity showed that of the three dimensions, two significantly predicted caring behavior. specifically, moral strength and moral responsibility showed predictive abilities i.e., they both predicted caring behavior. this indicates that moral strength and moral responsibility are two defining factors in ethical sensitivity. hence, the feeling of responsibility to the patient and the moral capacity to carry out assigned tasks, especially those that deal primarily with patient care are necessary factors for caring behavior. the second hypothesis which stated that there will be a significant gender difference in caring behavior was not supported as the results of the study did not offer support for this proposition. male and female healthcare workers do not differ in their levels of caring behavior. the finding is consistent and also inconsistent with previous literature. consistent with the current finding is the work of onuoha and idemudia who found that gender is not a significant factor when it comes to comprehending and handling the need of patients in the hospital. 25 the current finding is not consistent with previous literature such as the work carried out by liu et al. on gender role orientation and its impact on caring behavior and the ability to think critically. 23 the researchers reported a significant gender difference in caring behavior. the finding is in line with that of talebian et al. and shmilovitz, itzhaki and koton.22, 24 the researchers reported a significant gender difference in caring behavior with females reporting more caring behavior than males. the third hypothesis which stated that there will be a significant gender difference in ethical sensitivity was also not supported as the results were not in line with the research hypothesis. the finding was not consistent with studies outside the current context (nigeria). studies show that gender could be a factor in sensitivity to ethical practices.27,28 the reason for the current findings can be attributed to individual and organizational factors, and possibly issues prevalent in the nigerian healthcare sector. hence, factors such as uniform education and training for male and female healthcare workers, support from their supervisors, workload, job satisfaction levels, and cultural and emotional intelligence are to be considered. these factors should be investigated alongside the current variable to get more stable and robust results on gender differences in caring behavior. this study provides valuable insight into the circumstances under which healthcare workers will care more for their patients which will further inform policies developed by hospital administrators, medical educators, and healthcare practitioners. like many studies of this nature, this study has some limitations. first, the crosssectional nature of the study restricted the findings to correlation rather than the establishment of causal relationships. perhaps, longitudinal studies to test the causal direction between the various dimensions of ethical sensitivity and caring behavior are needed. second, all the variables were obtained through self-report measures. data on a variable like caring behavior can be obtained via supervisor rating or possibly through coworker reports in order to have a true picture of the behavior. conclusion this study has successfully examined the empirical link between the ethical sensitivity of healthcare workers and their caring behavior toward patients. in conclusion, ethical sensitivity fosters caring behavior. also, the dimensions of edosomwan and nwanzu. ethical sensitivity and its association with caring behavior among healthcare workers in delta state, nigeria: a cross-sectional study 290 ethical sensitivity (moral strength and moral responsibility) promote caring behavior. through this study, new knowledge has been added to the healthcare literature on 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covid-19 infection rate by using bacterial aerosol in healthcare workers in a tertiary care hospital in thailand during sars-cov-2 pandemic senthong p1, choosong t2*, saejiw n1, yingkajorn m2, surasombatpattana s2, pipitsuntornsarn n2, chusri s2 1faculty of science and industrial technology, prince of songkla university, surat thani campus, 84000, surat thani, thailand 2faculty of medicine, prince of songkla university, 90110, songkhla, thailand abstract introduction: severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a worldwide transmission and healthcare worker is the risk group. therefore, the infection rate and health risk assessment from exposure to airborne transmission for healthcare workers were performed. methods: this cross-sectional study was carried out on 106 healthcare workers at four selected service areas in songklanagarind hospital, thailand, from february to september 2021. the n6 impactor was used with simultaneous measurement of temperature, relative humidity, and wind speed. the general characteristics of subjects and hospitals were collected by questionnaire and presented by descriptive statistics. results: most of the participants were female and they worked more than 8 hours per day. the bacteria concentration was highest in the pediatric outpatient department (1837.46±177.52 cfu/m3). the lowest chronic daily intake and hazard quotient with no threshold (4.86±3.81, 95%ci: 3.59, 6.13) were at covid-19 intensive care unit due to negative pressure ventilation in this room was effective in reducing the airborne concentration of the pathogens. overall, the hospital’s hazard index with no threshold (30.87±35.25, 95%ci: 23.91, 37.83) was higher than 1.0, indicating that bacterial bioaerosol may affect healthcare workers’ health. the highest confirmed covid-19 case was at acute respiratory infection clinic (19.29±10.67 cases/week). the probability of infection by sars-cov-2 in healthcare workers was high at acute respiratory infection clinic (1.0) and covid19 intensive care unit (0.998±0.002, 95%ci: 0.998, 0.999). conclusion: therefore, inhalation reference concentration for hospitals should be as low as possible and appropriate ventilation systems should be implemented with adherence to standards to protect healthcare workers. keywords: covid-19, infection rate, occupational exposure assessment, tertiary care hospital introduction the coronavirus disease 2019 (covid-19) is an infectious pneumonia caused by severe acute respiratory syndrome coronavirus 2 (sars-cov2). sars-cov-2, bioaerosol, could be transmitted from an infected person to others through direct human-to-human contact and via respiratory droplets/aerosols.1,2,3,4 the infection fatality rate of covid -19 in hospitals was 0.2% (norway), 0.95% (connecticut, usa), 50.2% (mexico) and 64.1% (germany).5,6,7,8 bioaerosol is an important factor in determining indoor air quality (iaq), especially in hospitals because of related adverse health corresponding author: thitiworn choosong , associate professor, department of family and preventive medicine, prince of songkla university, hat yai, 90100 songkhla, thailand tel.: +66 74-45 1167, e-mail: thicho@hotmail.com, cthitwo@medicine.psu.ac.th orcid: https://orcid.org/00000001-9749-7137 date of submission: 11.09.2022 date of acceptance: 07.06.2023 date of publication: 20.07.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh.v13i 4.49325 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) https://www.nepjol.info/index.php/ijosh mailto:thicho@hotmail.com mailto:cthitwo@medicine.psu.ac.th https://orcid.org/0000-0003-3565-0575 https://orcid.org/0000-0001-9749-7137 https://orcid.org/0000-0001-9749-7137 https://doi.org/10.3126/ijosh.v13i4.49325 https://doi.org/10.3126/ijosh.v13i4.49325 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 430 effects that can include infectious diseases, acute toxic effects, allergy, asthma and nowadays is sars-cov-2.9,10,11 sars-cov-2 are enveloped positive-stranded rna viruses with the rna packaged within an outer fatty or lipid membrane and require host cells. patients with covid-19 have co-infections with bacterial pathogens such as pseudomonas aeruginosa, staphylococcus aureus and stenotrophomonas maltophilia.12,13,14,15 bacterial and fungal aerosols are the most common microorganisms in hospital environments, with standard values up to 500 cfu/m3.16 however, the american conference of governmental industrial hygienists (acgih) suggests that there is no occupational health limit for bioaerosol level.17 there were several factors can affect the density, distribution and diversity of bioaerosols in a hospital environment, such as season, temperature, humidity, building construction and materials, room design, indoor ventilation system, work shifts, types of ward, disinfection, and the numbers and activities of patients, visitors, and healthcare workers.18,19,20 also the ultraviolet germicidal irradiation system can make a difference, especially in the limited space of an icu.21 therefore, the concentrations of bacteria and fungi in all hospital environments exceeded the standards, indicating that these bioaerosols may affect a healthcare worker’s health and also patients.22,23 air ventilation systems can reduce and control the transmission of bioaerosols in hospitals. bozic et al. (2019) reported that the concentration of bacteria and fungi in hospital areas with heating, ventilation, and air conditioning (hvac) systems (400 and 220 cfu/m3) was lesser than in areas without hvac systems (700 and 350 cfu/m3).24 while hospital areas with hvac systems had low levels of bioaerosol contamination but without hvac systems they tended to have medium levels (500-999 cfu/m3).25 in addition, a relationship between the concentrations of bacteria and fungi and relative humidity has been found.26 in the context of infection rate in hospitals, the probability of infection should be investigated. the wells-riley model was a quantitative infection risk assessment method to determine respiratory infectious diseases, especially indoor air environment and have been used since 1974.27,28 mers, sars, and covid-19 are the most serious respiratory infection disease. for the wells-riley model, the infectious airborne particles were assumed to be the random distribution and can demonstrate the important removal mechanisms for airborne infectious agents.28 songkla is one of the provinces that were severely impacted by covid-19 in 2020-2021. this study was carried on at songklanagarind hospital, hat yai, songkhla province, thailand. to the best of the authors’ knowledge, the probability of infection and occupational health risk from exposure to sars-cov-2 have never been reported for this hospital. therefore, this study aimed to determine the probability of infection from the airborne transmission of sars-cov-2 using walk-in suspected covid-19 patients and to analyze occupational health risks from exposure to sars-cov-2 for healthcare workers based on bacterial concentrations in different ventilation systems in songklanagarind hospital healthcare environment. methods study area and general characteristics to deal with the large numbers of covid-19 patients, songklanagarind hospital has measures to control the sars-cov-2 airborne transmission indoors, such as hand washing with alcohol, use of disinfectants for surface cleaning, assessments of body temperature, patient screening, and isolation of acute respiratory infection clinic. in this study, the internal medical outpatient department (mopd), the acute respiratory infection clinic (ari), the pediatric outpatient department (popd) and covid-19 intensive care unit (cvicu) were purposively sampled for investigating the infection rate and bacterial concentrations in this university hospital. study subject and confirmation covid-19 case a cross-sectional study was carried out with voluntarily participating healthcare workers who work at the internal medical outpatient department (mopd), the acute respiratory infection clinic (ari), the pediatric outpatient department (popd) and covid-19 intensive care unit (cvicu) between february and september of 2021. ethical permission for the study was obtained from the ethics committee of the prince of songkla university (rec no. 63-255-9-2). informed consent was taken from all subjects after the purpose of the study was explained to them. standard ethical considerations were followed during the study, with total confidentiality of any obtained data. the infectious disease doctor and researcher diagnosed the walk-in suspected covid-19 patients by using the laboratory results. the total number of whom have been diagnosed senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 431 with covid-19 (confirmed covid-19 case) were collected from the hospital information system (his) database of songklanagarind hospital. questionnaire data collection was by use of a designed questionnaire organized into two sections. the first section covered general characteristics such as gender, age, and weight. the second section included work characteristics (work experience, work hours per day, workdays per week, the number of suspected and confirmed covid -19 cases per day and contact frequency with suspected and confirmed covid -19 cases). environmental, bioaerosol sampling and analysis the bioaerosols were collected by using a singlestage (n6) viable cascade impactor (model te-10890, tisch environmental, usa). the aerodynamic diameter was less than 0.65 µm. air sampling was done for 5 min at a flow rate of 28.3 l/min at 1.5 m above the floor level, to sample airborne bacteria. the indoor bioaerosol was determined from a total of 3 samples for each study site, which were placed at the center of each ward, and represented the morning period (09:0012:00) of hospital services during june – september 2021. the total amount of bacteria was cultured using trypticase soy agar medium and incubated at 37oc for 2 days.29 the concentration of airborne bacteria was presented as cfu/m3. to investigate the environmental factors, wind speed, temperature (oc) and relative humidity (% rh) were measured simultaneously with bioaerosol sampling by direct-reading instruments (velocical, tsi, germany). health risk assessment, hazard quotients and hazard index the main exposure route of healthcare workers was inhalation. the health risks of bioaerosols for full-time healthcare workers in hospitals were calculated based on the following equation. cdi = (ca x ir x et x ef x ed) / (365 x at x bw) (1) here cdi represents chronic daily intake (mg/kgday), ca denotes the concentration of bioaerosols in the hospital (mg/m3), ir is the inhalation rate (m3/h), et is the exposure time (h/day), ef and ed are exposure frequency (day/year) and exposure duration (year); 40 years for occupational health exposure assessment.30 in addition, at and bw are average lifetime (years) and body weight (kg). an average lifetime for non-carcinogenic assessment was 40 years. however, the estimated working year for thai registered nurses was 38 years.31 the non-carcinogenic bioaerosols were assessed by hazard quotient (hq), which is the ratio of cdi and an inhalation reference concentration (rfc, mg/kg/day), and no threshold, 50, 100, and 500 were used in this study, as follows. hq = cdi / rfc (2) hq ≤1.0 is considered acceptable, while hq >1.0 is adverse for the non-carcinogenic effects of concern. the non-cancer health impacts were represented by the hazard index (hi), which is calculated by summing all of the hq at a specific location. hi = ∑hq (3) if hi ≤ 1.0 there is an acceptable hazard, while if hq >1.0 there are likely adverse health effects. probability infection the wells-riley model was used in this study to determine the relationship between the air exchange rate and the probability of infection.32 pi = c/s = 1e -iqpt/q (4) here pi represents the probability of infection (-), c is the number of susceptible individuals to become infected (-), s is the number of susceptible individuals (-), i is the number of infectious individuals (-), p is the pulmonary ventilation rate of a person (m3/h), q is the generation rate of infection quanta (h-1), t is the exposure time (h), and q is the room ventilation rate with clean air (m3/h). the room ventilation rates were calculated by wind velocity for mopd, ari, popd and cvicu. statistical analysis the descriptive statistics used in this study included mean, standard deviation, percentage senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 432 and 95% confidence interval. the pearson correlation coefficient (r) and linear regression between relative humidity and temperature was performed. results during the study period, mopd has the highest number of patients (178±48.6 subjects, min = 122, max = 238) but cvicu has the lowest number of patients (7 subjects). cvicu has 17 beds (inpatient department) but popd, mopd and ari (out-patient department) have no bed. healthcare workers in ari and cvicu were 150.85±24.09 and 31.24±10.04 subjects (volunteer and rotate shift) while popd and mopd were routine and daytime shifts with only 19 and 33 subjects, respectively. the patient waiting hall and service area of the popd, mopd, ari and cvicu were 576, 432, 108 and 576 m2, respectively. mopd and ari had nearly the same velocity rate and temperature, whereas cvicu had the lowest velocity rate and temperature. the relative humidity conditions were in the range of 65.4072.15% (table 1). table 1: general characteristics of four study areas during the study period parameter popd mopd ari cvicu no. of patient (averagesd, minmax) 54.7 9.87 (48 – 66) 17848.6 (122 – 238) 13.02.42 (8 – 16) 7 no of bed 1-4 bed per room totally 17 beds no. of health care workers 19 33 150.8524.09 31.2410.04 service outpatient, patient with appointment and walk-in outpatient, patient with appointment and walk-in outpatient with walk-in inpatient with intensive care patient waiting hall and service area (m2) 576 (w=24, l=24) 432 (w=24, l=18) 108 (w=6, l=18) 576 (w=24, l=24) velocity (m/s) (averagesd) 0.110.03 0.340.08 0.370.18 0.040.04 temperature (oc) (averagesd) 26.740.25 30.441.05 30.941.01 22.451.29 relative humidity (%) (averagesd) 65.492.52 72.154.20 67.31 4.09 65.40  6.76 the distribution of general characteristics of participants is shown below (table 2). a questionnaire was completed by 106 healthcare workers at the four selected areas mopd, ari, popd, and cvicu. most of the participants are female (94.33%), and the mean age was 38.60 ± 11.09 years. cvicu had the most subjects (35.9%) working in rotated shifts. the work hours and workdays of participants are normally 8-9 hours per day and 5-6 days per week. healthcare workers from popd (18.33±10.23), mopd (18.24±12.01) and ari (18.38±11.95) had similar work experience levels, while cvicu had the least (8.24±5.99) years of experience. popd staff had the largest number of suspected and confirmed covid -19 cases per day (≥ 5 cases per day: 82.2%) and the highest contact frequency with suspected and confirmed covid -19 cases (≥ 5 times per day: 82.2%). senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 433 table 2: general characteristics of subjects voluntarily participating in this study (n=106) parameter popd mopd ari cvicu subject (n, %) 19 (17.9%) 18 (17.0%) 31 (29.2%) 38 (35.9%) job type routine and daytime shift routine and daytime shift volunteer and rotate shift volunteer and rotate shift gender -male -female -not specified 1 (5.3%) 18 (94.7%) 0 (0%) 0 (0%) 18 (100%) 0 (0%) 3 (9.7%) 28 (90.3%) 0 (0%) 1 (2.6%) 36 (94.8%) 1 (2.6%) age (years, mean ± s.d.) < 40  40 -not specified 42.68±9.83 7 (36.8%) 12 (63.2%) 0 (0%) 44.06±11.07 6 (33.3%) 12 (66.7%) 0 (0%) 41.43±12.20 13 (41.9%) 17 (54.9%) 1 (3.2%) 31.54±6.64 31 (81.6%) 6 (15.8%) 1 (2.6%) weight (kgs) 57.67±9.78 58.89±7.70 59.21±17.23 54.89±9.67 work experience (years) < 10  10 -not specified 18.33±10.23 4 (21.1%) 14 (73.7%) 1 (5.3%) 18.24±12.01 4 (22.2%) 13 (72.2%) 1 (5.6%) 18.38±11.95 7 (22.6%) 22 (70.9%) 2 (6.5%) 8.24±5.99 24 (63.2%) 14 (36.8%) 0 (0%) working hour per day < 8  8 8.37±0.60 6 (31.6%) 13 (68.4%) 9.00±0.97 13 (72.2%) 5 (27.8%) 8.52±0.63 14 (45.2%) 17 (54.8%) 8.63±0.79 17 (44.7%) 21 (55.3%) workday per week  5 > 5 5.24±0.54 15 (78.9%) 4 (21.1%) 5.56±0.70 10 (55.5%) 8 (44.5%) 5.42±0.56 19 (61.3%) 12 (38.7%) 5.47±0.73 17 (44.7%) 21 (55.3%) number of suspected and confirmed covid -19 cases per day < 5  5 -uncountable -not specified 3 (15.8%) 16 (82.2%) 0 (0%) 0 (0%) 11 (61.1%) 2 (11.1%) 1 (5.6%) 4 (22.2%) 13 (41.9%) 10 (32.3%) 3 (9.7%) 5 (16.1%) 8 (21.1%) 29 (76.3%) 0 (0%) 1 (2.6%) contacting frequency of suspected and confirmed covid -19 < 5  5 -uncountable -not specified 3 (15.8%) 16 (82.2%) 0 (0%) 0 (0%) 7 (38.9.2%) 2 (11.1%) 8 (44.4%) 1 (5.6%) 14 (45.2%) 9 (29.0%) 2 (6.5%) 6 (19.3%) 31 (81.6%) 7 (18.4%) 0 (0%) 0 (0%) note: data are presented as mean±sd, or n (%) ari had the most confirmed covid-19 cases, 19.29±10.67 per week, while popd and mopd had no confirmed covid-19 cases. cvicu showed the lowest concentration (259.72±161.61 cfu/m3) of total bacteria while popd had the highest concentration (1,837.46±177.52 cfu/m3). all the hospital areas were generally contaminated with bacteria. relative humidity and temperature are the most widely studied factors affecting airborne virus infectivity. the averages temperatures of cvicu, popd, mopd, and ari were 22.45±1.29, 26.47±0.25, 30.44±1.05, and 30.94±1.01 celsius degree, respectively, while their percentage of relative humidities were 65.40±6.76, 65.49±2.52, 72.15±4.20, and 67.30±4.09 (table 1). the relationship between relative humidity and temperature had a wide range of correlations (r2 = 0.11 to 0.95) in this study (figures 1a-d). the negative correlation was found at mopd and ari senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 434 clinics which used general and mechanical (fan) ventilation while the positive correlation was found at cvicu and popd clinics which had a negative pressure room and using air change per hour controlling unit, respectively. a high potential for covid-19 contamination (low temperature and low relative humidity) may occur when the relationship between temperature and relative humidity was matched at cvicu in a negative pressure room (figure 1b). figure 1: the relationship between temperature (celsius) and relative humidity (%) in all sampling locations cvicu and ari had the same room ventilation rate, but the ventilation systems were different, and popd had the lowest rate. the probability of covid-19 infection from patient to healthcare personnel was quite low in the outpatient department, while the cvicu and ari had a higher probability (table 3). the results of the occupational health exposure assessment are summarized in table 4. the cdi of popd was the highest (81.77 cfu/kgs/day) while cvicu was the lowest (4.86 cfu/kgs./day). the overall hi for hcw in this study was higher than 1.0, when using the no threshold for inhalation rfc while it seemed to be a safe workplace when using the recommendation for bioaerosol in hospitals less than 50, 100, and 500 cfu/m3 except popd.16,17,25 y = 3.915x 39.226 r² = 0.1512 61 62 63 64 65 66 67 68 69 70 71 72 26.2 26.4 26.6 26.8 27 27.2 27.4 27.6 r e la ti v e h u m id it y ( % ) temperature (celsius) a) popd: 08:30-11:30 y = 3.5015x 13.213 r² = 0.4438 40 45 50 55 60 65 70 75 80 85 20 21 22 23 24 25 26 r e la ti v e h u m id it y ( % ) temperature (celsius) b) cvicu: 10:30-14:00 y = -3.8451x + 189.19 r² = 0.9205 50 55 60 65 70 75 80 85 28 29 30 31 32 33 r e la ti v e h u m id it y ( % ) temperature (celsius) c) mopd: 8:00 12:30 y = -3.9651x + 190 r² = 0.9542 40 45 50 55 60 65 70 75 80 29 30 31 32 33 r e la ti v e h u m id it y ( % ) temperature (celsius) d) ari: 9:30 12:30 senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 435 table 3: the probability of infection and general characteristics of service areas of a tertiary care hospital general characteristic the probability of infection ventilation system total bacteria (cfu/m3) inconclusive covid-19 cases per week confirmed covid-19 cases per week q (m3/h) probability of infection* popd (n=19) mechanical ventilation with an air handling unit 1837.46±132.32 (95%ci: 1777, 1901) 0 0 1,058 0 mopd (n=18) mechanical ventilation with wall fan 618.37±14.84 (95%ci: 610, 626) 0 0 1,231 0 ari (n=31) dilution ventilation 690.22±16.59 (95%ci: 684, 696) 1 19.2910.67 1,337 1.0 cvicu (n=37) mechanical ventilation with a negative pressure 263.44±125.66 (95%ci: 221, 305) 1.800.84 5.861.86 1,498 0.9980.002 (95%ci: 0.998, 0.999) total (n=105) 0.650.48 (95%ci: 0.55, 0.74) *calculation based on the generation rate33,34 of infection quanta (q) was 300 h-1 table 4: the occupational health exposure assessment, hq and hi for healthcare workers parameter popd (n=18) mopd (n=17) ari (n=29) cvicu (n=37) ca (cfu/m3) 1837.46±132.32 618.37±14.84 690.22±16.59 263.44±125.66 ir (m3/hour) 0.83 0.83 0.83 0.83 et (hour/day) 8.37±0.60 9.00±0.97 8.52±0.63 8.63±0.79 ef (day/week) 5.24±0.54 5.56±0.70 5.42±0.56 5.47±0.73 ed (year) 18.33±10.23 18.24±12.01 18.38±11.95 8.24±5.99 bw (kgs.) 57.67±9.78 58.89±7.70 59.21±17.23 54.89±9.67 at (day) 13,870 13,870 13,870 13,870 cdi (cfu/kgs/.day) 81.7743.95 (95%ci: 95.91, 103) 29.5518.48 (95%ci: 20.04, 39.05) 33.2522.04 (95%ci: 24.87, 41.63) 4.863.81 (95%ci: 3.59, 6.13) hazard quotients (hq) -no threshold a 81.7743.95 (95%ci: 95.91, 103) 29.5518.48 (95%ci: 20.04, 39.05) 33.2522.04 (95%ci: 24.87, 41.63) 4.863.81 (95%ci: 3.59, 6.13) hazard index (hi) for hcw (n=101) 30.8735.25 (95%ci: 23.91, 37.83) -50 cfu/m3 b 1.640.88 (95%ci: 1.20, 2.07) 0.590.36 (95%ci:0.40, 0.78) 0.670.44 (95%ci:0.50, 0.83) 0.100.08 (95%ci:0.97, 0.12) hazard index (hi) for hcw (n=101) 0.620.71 (95%ci: 0.48, 0.76) -100 cfu/m3 c 0.820.44 (95%ci: 0.60, 1.04) 0.300.18 (95%ci: 0.20, 0.39) 0.330.22 (95%ci: 0.25, 0.41) 0.050.04 (95%ci: 0.04, 0.06) hazard index (hi) for hcw (n=101) 0.310.35 (95%ci: 0.24, 0.38) -500 cfu/m3 d 0.160.08 (95%ci: 0.12, 0.21) 0.060.04 (95%ci: 0.04, 0.08) 0.070.04 (95%ci: 0.05, 0.08) 0.010.01 (95%ci: 0.01, 0.0) senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 436 parameter popd (n=18) mopd (n=17) ari (n=29) cvicu (n=37) hazard index (hi) for hcw (n=101) 0.060.07 (95%ci: 0.05, 0.08) remarks: cdi = chronic daily intake, ca = concentration of bioaerosols, ir = inhalation rate, et = exposure time, ef = exposure frequency, ed = exposure duration, at = average lifetime, bw = body weight (kg); a means no threshold for bioaerosol, b-d means recommendation for bioaerosol in hospital should be less than 50, 100 and at 500 cfu/m3, respectively.16,17,25 discussion environmental status of sars-cov-2 service areas in songklanagarind hospital working conditions in the hospital, especially indoor air quality, are important because of the closed space having inadequate ventilation. therefore, pathogens are accumulated inside the hospital. the hospital had various ventilation systems with air handling units (ahu), mechanical ventilation, dilution ventilation, and negative pressure. the concentrations of bacterial bioaerosol were lowest in the cvicu with negative pressure ventilation, while the popd had the highest concentration with ahu. in addition, cvicu and ari had similar room ventilation rates with clean air, but in ari the general ventilation system had bacterial concentration higher than cvicu by approximately two-fold because cvicu had negative pressure ventilation. a similar finding that negative pressure ventilation in hospitals was effective in reducing airborne concentrations of pathogens has been reported earlier.35 the ventilation system provides sufficient ventilation in such areas. in general, a well-functioning ventilation system provides temperature and humidity conditions that lower biological viability.36,37 the bacterial bioaerosol concentration in mopd (618.37±24.9 cfu/m3) was less than in popd (1,837.46±177.52 cfu/m3), approximately 3-fold so because mopd had higher room ventilation rate than popd. furthermore, previous studies have shown that sars-cov-2 is found on surfaces of an air exhaust outlet, in air filters, and building ducts of hospitals with covid-19 patients.35,36 to reduce the risk of sars-cov-2 transmission, the ventilation system could be maintained with cleaning at regular intervals and replacement of filters. the ventilation rates should be designed with appropriate recirculation of air. the bacterial bioaerosol concentrations in this study (259.721,837.46 cfu/m3) are lower than in earlier reports from the republic of srpska (35-6,295 and 30-6,295 cfu/m3), but higher than in previous reports from iran (127-1,783 cfu/m3) and from taiwan (1-423 cfu/m3) due to various factors, such as season, room design, ventilation system, temperature, relative humidity, work shift, type of ward, disinfection, and the numbers and activities of patients, visitors, and healthcare workers.22,24,25,37 the probability of infection and determination of covid-19 infections via bacterial concentrations to find out the relationship between ventilation system type by using indoor airflow and the probability of infection of hcws (who move around their service area), the wells-riley model was used in this study.32 the number of infectious individuals (i) was calculated from the weekly number of covid-19 patients who visited a doctor during the sampling period. therefore, the probability of infection rates was high at the covid-19 service areas when using 300 h-1 for the quantum generation rate for sars-cov-2.33,34 then the probability of infection by airborne transmission of sars-cov-2 virus approached 1 in the suspected (ari) and confirmed covid-19 (cvicu) patient service areas, while the probability of infection approached 0 in the routine outpatient departments of the hospital. even if there were no sufficient evidence that the sars-cov-2 virus can be transmitted by heating, ventilation, and air conditioning (hvac) systems, the ventilation system of suspected and confirmed covid-19 patient service areas should be considered for improvement.37 senthong et al. health risk assessment and covid-19 infection rate by using bacterial aerosol in healthcare workers …. 437 sars-cov-2 are enveloped positive-stranded rna viruses with the rna packaged within an outer fatty or lipid membrane and require host cells. patients with covid-19 have co-infections with bacterial pathogens such as pseudomonas aeruginosa, staphylococcus aureus and stenotrophomonas maltophilia.12,13,14,15 in this study, we determined the occupational (health) risk assessment via bacterial concentrations, and the cdi was lowest at cvicu that had a negative pressure room. this result was consistent with the risk level falling to a minimum when the maximum levels of filtration, maintenance and sanitizing in an hvacsystem are established.9 however, the bacterial pathogens should be identified in the next study for a complete occupational exposure assessment of the hcw. the occupational exposure assessment in hospital areas showed that overall, the hospitals’ hi >1.0, indicating that bacterial bioaerosol may affect healthcare workers’ health. the inhalation of rfc in a hospital should be as low as possible to protect patients and hcws. to decrease the airborne virus transmission indoors, the hospital design could include room isolation, open halls, air conditioning units, and negative pressure rooms combined with hospital management policies, including wearing a sealed mask by patients, their relatives, and hcw, hand washing with alcohol, use of disinfectants for surface cleaning, assessments of body temperature, patient screening, and isolated acute respiratory infection clinic.32,37,38,39 however, there was no question of wearing a mask of hcw in this study. according to the hospital policy, all hcws have to wear and seal their mask during the working period. this study was limited due to health risk assessment was measured from bacteria aerosol, and did not assess from sars-cov-2. several studies have failed to collect viable sars-cov-2 in air samples. sampling of airborne viruses is technically challenging for many reasons, including the limited effectiveness of some sampling methods for capturing fine particles, viral dehydration during collection, viral damage due to impact forces (leading to loss of viability), and viral retention in the sampling equipment.40 the results may be used as a basis for preventive work for hcws from covid-19 infection in hospitals. although the results are based on health risk assessment from bacteria concentration, they do provide interesting points for future investigations, and also the health risk assessment from sars-cov-2 concentration needs further studies. conclusions the probability of sars-cov-2 infection via bacterial concentrations for an hcw was high at suspected and confirmed covid-19 patient service areas. the negative pressure room showed the lowest hi. the highest bacterial contamination and hi exceeding 1 was with the poorest room ventilation employing an ahu system. the inhalation rfc for hospitals should be as low as possible to protect patients and hcws. therefore, to control the sars-cov-2 airborne transmission indoors in a hospital, patient screening for separation of covid-19 patients from other patients and ventilation system management adhering to standards, especially in room ventilation rates, should be pursued. acknowledgments our team would like to thank the prince of songkla university (rdo6405059m) and all participants in this study. references 1. maveddat a, mallah h, rao s, ali k, sherali s, nugent k. severe acute respiratory distress syndrome secondary to 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paper (article int. j. occup. safety health, volume 13, no 2 (2023), 258-271 https://www.nepjol.info/index.php/ijosh review article the impact of leadership on the psychosocial safety climate of organizations: a scoping review laloo e1, coman r2, hanley n3, bakand s4 1, 2, 3 university of wollongong faculty of the arts, social sciences and humanities, school of health and society, australia. 4 honorary senior lecturer, university of wollongong faculty of the arts, social sciences and humanities, school of health and society, australia. abstract growing evidence suggests that work-related psychological injuries are a concern worldwide. while previous efforts to address psychological injuries mainly focused on the individual level of analysis, the psychosocial safety climate (psc) theory emphasizes the analysis and prevention of psychological injuries at the organizational level. while there is abundant evidence of the impact of leadership on other climate constructs, scant attention has been paid to the impact of leadership on psc. this study is a scoping review of the extant literature to determine the state of the discipline in relation to the impact of leadership on the psychosocial safety climate of organizations. three databases were searched, supplemented by a pearling exercise and google scholar searches, which yielded 14 studies that met the selection criteria. our study shows that while much work has been done about the behavior of managers and organizational infrastructure to yield high levels of psc, there is a dearth of studies on the impact of specific leadership styles on the psc of organizations. we recommend further studies of leadership, especially the impact of post-heroic leadership styles, on the psychosocial safety climate of workplaces. keywords: psychosocial safety climate, leadership, management, psychological hazards, scoping review, workplace psychological injuries introduction globally there is growing evidence that psychological injuries are significant contributors to the burden of disease.1 this injury type is also becoming more prevalent in the workplace and is predicted to be one of the major trends in occupational injuries.2 this increasing trend has led to clarion calls from scholars to address this insidious phenomenon in the workplace.3 while many jurisdictions now address physical and psychological safety in the workplace, the evidence suggests that safety authorities are yet to have the same success with psychological injuries as they have had with physical injuries.4 the prevalence of psychological injuries in the workplace also appears to be a universal problem, and finding solutions to this problem is therefore of interest to all.5 one of the challenges that corresponding author: eugene laloo, phd candidate, university of wollongong faculty of the arts, social sciences and humanities, school of health and society, university of wollongong, nsw 2522 australia. e-mail: eal990@uowmail.edu.au orcid: https://orcid.org/00000003-0586-9330 date of submission: 21.02.2022 date of acceptance: 05.01.2023 date of publication: 01.04.2023 conflicts of interest: none supporting agencies: none doi:https://doi.org/10.3126/ijosh .v13i1.42418 copyright: this work is licensed under a creative commons attribution-noncommercial 4.0 international license issn: 2091-0878 (online) issn: 2738-9707 (print) issn: 2091-0878 (online) issn: 2738-9707 (print) mailto:eal990@uowmail.edu.au https://orcid.org/0000-0003-0586-9330 https://orcid.org/0000-0003-0586-9330 https://doi.org/10.3126/ijosh.v13i1.42418 https://doi.org/10.3126/ijosh.v13i1.42418 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 259 practitioners and scholars however experience is that the true extent of psychological injuries in workplaces is not always known. while workplace safety regulators record psychological injuries, these statistics do not provide an accurate account of the epidemiology of psychological injuries as they are retrospective and only capture psychological hazards where official claims have been made. access to workplaces is also often restricted, frustrating research into this phenomenon.6 owing to these shortcomings, studying psychological injuries at the individual level is likely not to provide a true representation of the problem. in this review, we study psychological injuries through the psychosocial safety climate (psc) theory. psc is a climate construct that refers to an organization’s priority for protecting workers’ psychological health. this priority is reflected through enacted policies, procedures, and practices so that when workers view these collectively, they form an opinion of the organization’s psychosocial safety climate.7 this theory further posits that work conditions and worker health and engagement can be predicted when the psychosocial safety climate of an organization is known.6,7 the level of psc in an organization is said to indicate the extent to which management prioritizes psychological hazards in the workplace, so in an organization with a high psc, management prioritizes psychological health more than in an organization with a low psc.6 the predictive nature of this construct allows it to serve as a lead indicator for psychological hazards as it predicts the likelihood of psychological injuries occurring in the workplace.8 while many other climate constructs exist, psychosocial safety climate was tested and found to be distinctly different from other climate constructs, including safety climate, team psychological climate, and perceived organizational support and team climate.9,10 the literature thus shows that psychosocial safety climate, as a newly introduced construct, is a valid construct for predicting psychological injuries. as senior managers are the purveyors of policies, procedures and practices that determine the psc of organizations, we posit that leadership directly impacts psc. while there have been reviews on the impact of leadership on psychological safety (the individual-level construct), no such reviews have been done to scope the literature on the impact of leadership on psychosocial safety climate (the organization-level construct). it is our view that a scoping review of the impact of leadership on the organization-level construct (psc) is warranted as such a review will contribute to the field as it will set out what is known and identify the gaps in the literature. the purpose of this review is therefore to scope the extant literature to determine the antecedents of leadership for the promotion of a positive psychosocial safety climate in workplaces and in so doing advance the understanding of the field. methods this scoping review follows the model proposed by arksey and o’malley (2005), with the exclusion of the optional ‘consultation with stakeholders’ step.11 searches were conducted in scopus, web of science, emerald insight, and google scholar. this was followed by a pearling exercise to identify possible sources in the reference lists of the selected articles. search terms used included psychosocial safety climate, psc, leader*, manage*, with the boolean operator and and or with truncation. a schematical representation of the search strategy is provided in appendix a. the initial search yielded 107 results. after removing duplicate articles, titles and abstracts were reviewed, and 14 papers met the selection criteria. selection criteria a scoping review does not require the reviewer to consider the quality of selected papers and therefore allows for a much wider search to describe the breadth of the field.11 papers written in english and published after 2010, the year in which psc was introduced into the literature, were included. as this literature review solely focuses on leadership’s impact on the organizational-level construct, only studies that addressed psc were included. results the initial search yielded 107 results. after laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 260 removing duplicate articles, titles and abstracts were reviewed, and 14 papers met the selection criteria (see table 1). we conducted a thematic analysis on the 14 papers in the data set and through the process of manual coding, identified four themes covered in the literature.12 our first theme is management support. papers under this theme primarily focus on the behavior that leaders should display to bring about a positive psychosocial safety climate. our second theme focuses on the hard and soft systems that should be in place for the promotion of psc. we refer to this theme as infrastructure for psc. our third theme was the impact of psc on managerial quality, and the final theme was that of leadership. while it may appear as if this theme is similar to our first theme, we believe leadership transcends management, and papers on this theme elucidate leadership styles that impact psc. of the studies conducted, most occurred in the north americas.13-17 three studies were conducted in australia, with a further three in europe.18-23 while the aforementioned studies were conducted in high-income countries, two studies were conducted in an upper-middle-income country (malaysia) and a lower-middle-income country (vietnam).25,26 the final paper by dormann et al. (2019) can be described as an opinion piece.27 research conducted using quantitative methods dominates the dataset, with eight papers employing cross-sectional or longitudinal studies. five papers presented research findings based on qualitative data or mixed-methods studies.14,15,17,19,22 management support management support has been studied the most in relation to psc, with 57% (8/14) of the studies in the dataset reflecting this theme. psc is determined by policies and procedures, and can therefore be described as what organizations say they do for the prevention of psychological stress. 24 psc support is related to work engagement, through the mediating effect of management support. in other words, the psc said to be applicable in a workplace brings about work engagement, but only if management offers demonstrated support for employees’ psychological health.26 while yulita and colleagues’ (2017) study was conducted in a cohort of malaysian teachers, similar findings were made in an australian study among ambulance staff across two states where it was found that psc contributes to better mental health outcomes in workers.19 in this study the behavior of managers, referred to as manager psc, accounted for a higher variance in the mental health of workers (13%, for both well-being and common mental health disorders). this finding is in support of the finding of yulita et al. (2017) of enacted psc on the psychological health of workers. interestingly petrie et al. (2018) also studied observed management support and found that this construct did not have the same effect as manager psc on mental health.19 observed manager support only resulted in a 10% variance in wellbeing and a 7% variance in symptoms of common mental disorders. these findings confirm the importance of manager support as a modifiable factor influencing employee mental health. the difference between what organizations say they do (enacted psc) and what is observed, observed management support, as noted by petrie et al. (2018) can be problematic and was highlighted by zinsser and zinsser (2016).14 they found that although management support for psychological hazards was demonstrated, workers’ perceptions of management support differed from management support captured in the psc-12, the validated scale for the measurement of psc.28 in this study, workers equated management support with the visibility of managers (p. 60).14 this seems to support the finding of petrie et al. (2018) that observed management support has a lesser effect on workers’ mental health than manager psc.19 the work of nguyen et al. (2017), however, seems to refute this.25 these authors studied workers’ perceptions of management support, known as perceived organizational support (pos), and how it impacts the psc of an organization. in this study, the impact of psc and pos is studied on perceptions of bullying, employee well-being, and engagement. nguyen et al. (2017) hypothesized that the overarching beliefs of support for mental laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 261 health in the workplace will influence perceptions of bullying, employee well-being and engagement.25 this study appears to be the first study among a heterogeneous group of public sector workers and does not focus on one segment of the workforce only, as was the case with zinsser and zinsser (2016), petrie et al. (2018), and yulita et al. (2017).14,19,26 the study of nguyen et al. (2017) is, therefore, more generalizable.25 whether the results of this study would be applicable in a western context remains to be seen, as it was conducted in vietnam, where relationships in the workplace might be characterized by a high power distance culture and where acceptance of the hierarchy is more prevalent than in western settings.25 geisler et al. (2019) went further and studied the impact of psc on the retention of workers in a cohort of social workers.22 while previous studies focused on the link between psc and engagement, geisler et al (2019) demonstrated that support from superiors and the social community at work was positively related to social workers’ organizational commitment, compared with work engagement and job satisfaction. in other words, high levels of psc improved the retention rate of the social workers in this study.22 while much of the emphasis of psc is on workers, st-hilaire and gilbert (2019) also studied the effect of psc, but in this study, the focus was on the mental health of managers.15 they argue that managers’ mental health problems frustrated their ability to implement preventative interventions for subordinates’ mental health. since managers are the conduits of psc, that is, they are part of the mechanism to facilitate the organization’s espoused psc, this is a very interesting finding as it suggests that an organization’s psc should be such that it prevents psychological hazards among managers first, before it can prevent psychological hazards among workers. st-hilaire and gilbert’s (2019) study makes a valuable contribution as they argue for a more systemic and collective view of workplace mental health, one in which managers’ mental health is included. by doing so, the mental health of all, workers and managers, will be improved.15 while the focus of the aforementioned studies was on the mental health of workers, mansour and tremblay’s (2018) work saw a shift in the impact of psc on constructs external to the workplace, namely, work-family conflict and family–work conflict.16 these authors measured two dimensions of work–family conflict, namely a time-based measure and a strain-based measure. to clarify: a time conflict occurs when the time spent on one role makes it difficult to fulfill the requirements of another role, while a strain-based conflict exists when the strain of functioning in one role makes it difficult to operate in another role. mansour and tremblay (2018) examined the specific contributions of psc through familysupportive supervisor behavior (fssb) to reduce both work-family conflict (wfc) and family– work conflict (fwc).16 in this regard they examined whether the relationship between family-supportive supervisor behavior (fssb) and work-family conflict (wfc) is weaker in organizations where the level of psc is high, as opposed to those where the level of psc is low. the findings of this study indicated that psc is negatively and directly associated with work–family conflict time (wfc time), family–work conflict time (fwc time), work-family conflict strain (wfc strain), and family-work conflict strain (fwc strain). in other words, in an organization with low levels of psc, the time spent on work activities makes it difficult for workers to fulfill their family commitments. also, in organizations with low psc, the strain that workers endure makes it difficult to function effectively in their respective family roles. the theme of management support was further explored by mclinton et al. (2018) in what these authors called high-risk and low-risk psc environments.20 they found that in teams with low-risk psc, managers ensure workers feel valued and supported. in doing so, these managers are good role models for safety. in teams with high-risk psc, workers view managers as not making their staff feel valued, providing support when requested, or exhibiting good role modeling (pp. 241-242).20 further elements that this study identified are the ‘conflicting pressures’ laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 262 that workers experience in high-risk psc environments. as this research was conducted in a healthcare setting, this factor appears to be very industry-specific and therefore goes beyond the four factors identified in the psc-12.28 mclinton et al. (2018) found that in low-risk psc teams, workloads are spread to not cause psychological harm.20 in these teams, managers also create policies and procedures that are realistically achievable. in high-risk psc teams, on the other hand, workers are forced to choose between workloads and working unsafely. infrastructure to support psc when the literature is studied, the importance of organizational and environmental factors, and how they relate to psychosocial factors in the workplace, becomes evident. this theme focuses on the systems that should be in place to ensure positive psc. in the dataset, einarsen et al. (2019), for instance, studied the impact of human resources practices, perceived financial resources and organizational size on what they call ‘ethical infrastructure against workplace bullying’ (p. 673).21 the construct of ‘ethical infrastructure’ in relation to workplace bullying appears very closely related to the psychosocial safety climate. for instance, they described ethical infrastructure against workplace bullying as referring to formal and informal systems in organizations that prevent organization members from committing acts of bullying. while formal ethical structures for the prevention of bullying consist of policy documents and compliance programs, informal systems are the subtle messages about the organization’s values and behavior in relation to bullying. in this study, einarsen et al. (2019) found that high-quality human resources practices, as operationalized by policies, procedures, and training, affected an ethical infrastructure against workplace bullying. that is, owing to the highquality human resources practices, workers perceived the organization as having the infrastructure to protect them against bullying. interestingly, the study also found that financial resources and organization size did not predict an ethical infrastructure against workplace bullying.21 martin et al. (2018) also addressed the theme of infrastructure for positive psc. in their qualitative study with managers who manage staff with mental health issues, they noted some aspects that demonstrate the lack of a good infrastructure for high psc.18 managers noted that they often ‘felt out of their depth’, that they had limited knowledge and understanding of mental health issues, and that these challenges were exacerbated by a lack of organizational support and insufficient guidance about the appropriate actions to take (p. 452).18 one of the tenets of high psc is that psychological health is given the same attention as production goals.7 the study by martin et al. (2018) noted that 37.5% of participants found it challenging to balance the needs of employees with mental health issues with the commercial needs of the organization (p. 454).18 this paper is the first to indicate that while managers are required to ‘act appropriately’ once psychological hazards are brought to their attention, the reality is that managers may need support in doing this.18 while the previous studies mentioned some elements of an infrastructure needed for high levels of psc, the study of teo et al.(2020) went beyond just one element of infrastructure for psc and studied the impact of high-performance work systems (hpws) on bullying in the workplace.17 hpws are integrated systems of hr practices that include selective staffing, self-managed teams, decentralized decision-making, extensive training, flexible job assignments, open communication, and performance-contingent compensation. the integration of these hr systems leads to knowledge resources that ultimately lead to increased financial performance.29 of particular interest is that the study of teo et al. (2020) was the first to examine psc as a moderator, finding psc moderated the impact of hpws on workplace bullying. 17 these authors found that the positive impact of hpws practices was moderated by high levels of psc. in other words, in a workplace characterized by high-performance work practices, the presence of a safe psychosocial work climate reduced exposure to workplace bullying and increased effective commitment.17 laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 263 psc’s impact on management quality whereas previous studies have focused on describing the impact of leadership behavior on employees’ psychological health, biron et al. (2018) aimed to identify the effect of psc on managerial quality, with the psychosocial mechanisms in the managers’ work environment explaining this association.13 while at first glance st-hilaire and gilbert’s (2019) study on the impact of psc on the mental health of managers may seem to fall into this category, their study primarily focuses on managers as a subset of workers and does not address the quality of managers’ practice.15 biron et al. (2018) is therefore the only study in the dataset that explores the relationship between psc and the quality of managerial practice. biron et al’s (2018) work is all the more noteworthy for the following reason. previous authors have already shown that espoused psc and enacted psc are important for employee psychological health and work engagement. 14,19,26 biron et al. (2018), however, had a different direction from the previously mentioned studies. their research found that psc is temporally before managerial quality. they found that the relationship between psc at t1 and managerial quality at t2 were stronger than the relationship between managerial quality at t1 and psc at t2.13 psc thus has a strong influence on the quality of management in an organization. while their finding is interesting, they comment that management quality is also called leadership quality (p. 229).13 the reader is therefore left to conclude that this finding is also applicable to leadership. we dispute this view and believe that management and leadership are two dissimilar constructs and findings applicable to management cannot simply be transferred to leadership without giving due consideration to the difference between the two constructs.30 leadership dollard and jain (2019) were the first to address the link between a specific leadership style and psc.23 in their work, these authors elucidated the relationship between ethical leadership and psc and concluded that ethical leadership is required for effective occupational safety and health management, particularly as it relates to psc. an interesting feature of dollard and jain’s (2019) study is that they did not use any of the ethical leadership questionnaires to measure ethical leadership.31 instead, they used data from the corruption perception index for 31 european countries and contrasted this with leadership for psc, work conditions, and worker health and well-being. dollard and jain (2019) found that corruption had a 17% effect on psc. in other words, countries with high levels of corruption have a lower level of psc. an interesting observation in this study is dollard and jain’s (2019) inference that ethical leadership is the leadership model that should prevent corrupt public values from impacting worker health.23 this is not an unreasonable conclusion, as the basis of ethical leadership is the ethical behavior that leaders are required to have, including characteristics like honesty, trustworthiness, fair and principled decision-making, and care for people and the broader society.32, 33 similarly, it could also be argued that authentic leadership could be the leadership model that would prevent corrupt social values from entering the workplace, as this leadership style also draws on, and promotes an ethical climate.34 dollard and jain’s (2019) study only infers that ethical leadership could have a positive association with psc, as the study did not measure the dyadic relationship between leaders and followers. 23 in the selected studies, dormann et al. (2019) also comments on leadership and its impact on psc.27 of importance is dormann et al’s. (2019) assertion that scholars still do not know what leadership style is likely to build psc (p. 442).27 in the development of climate theories such as safety climate, researchers analyzed different leadership styles to determine the leadership style most likely to promote a certain organizational climate. it is therefore very interesting to note that dormann et al. (2019) proposes a different development path for determining the relationship between leadership and psc.27 they argue that it would be possible to identify a construct empirically, which they call leadership for psychological safety (lps), and that this would provide a better laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 264 explanation for the emergence of psc. while we do not challenge that lps is possible to be identified, we are of the view that discarding the testing of contemporary leadership styles in relation to psc is premature and should be investigated by researchers. table 1: articles forming part of this review authors publication focus of study study design variables studied findings 1 biron et al 13 internation al journal of workplace health manageme nt impact of psc on managerial quality. interventio n study, followed by longitudina l study (n=192) managerial quality is affected by managers’ own psychosocial work factors and is in turn affected by the organizational psc. job control was found to be a significant mediator of the relationship between psc and managerial quality. psc is positively related to managerial quality. job control partially mediated the effect of psc on managerial quality. 2 zinsser and zinsser 14 research in human developme nt explores the extent to which psc exists in a preschool context. focusgroup interviews. explores the extent to which psc applies to preschool contexts. examples of management practices and policies and procedures that reflect a degree of valuing of teacher well-being and psychological safety are presented. the study also highlighted that participants’ understanding of management support differed from that contained in the psc-12. 3 st-hilaire and gilbert 15 organizati onal dynamics the mental health of managers with an emphasis on what leaders should know to manage the mental health of managers. interviews. emphasizes what leaders should know to help with the mental health of managers. mental health support for managers who are required to implement leadership policies is lacking. argues for a more systemic and collective view of workplace mental health, one in which managers’ mental health is included. by doing so, the mental health of all, workers and managers, will be improved. 4 mansour and tremblay 16 personnel review tests the direct and indirect effects of manager psc on work-family conflict. crosssectional. (n=562) direct and indirect effects of psc on wfc/fwc-time and wfc/fwc-strain via familysupportive supervisor behavior (fssb). when senior managers value employees’ psychosocial safety, consider it a priority, act quickly to correct problems affecting employees’ psychological well-being and put in place a good system of communication at all levels, a favorable effect on the work environment is created. therefore, managers and supervisors should show more support to workers’ family issues and encourage workers to talk about their difficulties at work or/and at home. this support can make workers more resourceful and therefore more capable of successfully balancing work and family. 5 teo et al 17 internation al journal of hospitality manageme nt adoption of highperformance work systems (hpws) to eliminate workplace bullying. longitudin al (n=467 and n=203) the role of hpws is examined in enhancing the commitment of employees. high-performance work systems play a key role, together with psychosocial safety climate (psc) and perceived organizational support (pos), in preventing employee exposure to workplace bullying in the hospitality sector. 6 martin et al 18 internation al journal of workplace health manageme nt challenges faced by managers who are required to manage employees with mental health issues. semistructured interviews. engagement of employees. for psc to be high, policies should include support for managers. understanding managers’ experience is critical to the successful implementation of human resources policies regarding employee health and well-being. implementation of human resources policies for mental health should consider support for managers as part of the implementation strategy. 7 petrie et al 19 plos one manager support in determining the mental health of ambulance personnel. crosssectional (n=1622) items to determine manager behavior were developed by the authors. mb accounted for a 10% variance in wellbeing and a 7% variance in symptoms of common mental health disorders, while manager psychosocial safety climate accounted for a larger proportion (13%) of both employee mental health outcomes. findings confirm the importance of manager support as a potentially modifiable factor influencing employee mental health. https://www-scopus-com.ezproxy.uow.edu.au/sourceid/17800156772?origin=resultslist https://www-scopus-com.ezproxy.uow.edu.au/sourceid/17800156772?origin=resultslist https://www-scopus-com.ezproxy.uow.edu.au/sourceid/17800156772?origin=resultslist https://www-scopus-com.ezproxy.uow.edu.au/sourceid/17800156772?origin=resultslist https://www-scopus-com.ezproxy.uow.edu.au/sourceid/17800156772?origin=resultslist https://www-scopus-com.ezproxy.uow.edu.au/sourceid/17800156772?origin=resultslist https://www-scopus-com.ezproxy.uow.edu.au/sourceid/17800156772?origin=resultslist laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 265 authors publication focus of study study design variables studied findings 8 mclinto n et al 20 safety science how psc theory manifests in healthcare, by studying the factors that shape psc in healthcare. mixed methods (n=27) leadership style and manager support. findings suggest that psc theory might at a broad level apply to a wide range of industries, such as through key themes like ‘communication’ and ‘group expectations’. concerning leadership, improving the frontline-to-management disconnect is highlighted as a source for psc improvement. 9 einarsen et al 21 personnel review organization size, financial resources and high-quality human resources management practices on workplace bullying. crosssectional, (n=429) how the mentioned variables predict the existence of a welldeveloped ethical infrastructure against workplace bullying. high-quality human resources management created an ethical infrastructure for the prevention of bullying. organizational size and financial resources did not predict an ethical infrastructure for the prevention of bullying. 10 geisler et al 22 human services organizati ons: manageme nt, & governanc e impact of psc, job demands, job resources and assessment for quality of work related to work engagement. crosssectional. (n=831) how (psc), job demands, job resources and assessments for quality of work related to social workers’ work engagement, job satisfaction, and organizational commitment. to improve the understanding of factors contributing to the retention of social workers by investigating the relationship between specific work environmental factors and positive work attitudes. quality of work was strongly related to job demand, job resources and assessment for quality of work. psc was found to be related to social workers’ job satisfaction. 11 dollard and jain 23 psychosoci al safety climate: a new work stress theory (edited book) compared the corruption perception index of 31 european countries against psc and employee wellness. interviews corruption and psc. corruption of public values undermines leadership for psychosocial safety climate and suggests that ethical leadership is required to improve psc. 12 nguyen et al 25 public manageme nt review existence of psc in the public sector. crosssectional n=274 to study psc and its impact on the public sector. the impact of psc and perceived organizational support (pos) is studied on perceptions of bullying, employee engagement and well-being. overarching beliefs of support for mental health in the workplace influence perceptions of bullying, employee well-being and engagement. 13 yulita et al 26 safety science explores organizational level psc (also known as espoused psc) and enacted psc (operationalized as management support) and their relationship with worker psychological health and motivation. diary questionnai res the climate created by psc brings about an environment where managers provide support. management support also mediates engagement. organizational psc was positively related to daily enacted managerial support. for work engagement, espoused psc was related to work engagement through enacted managerial support. for emotional exhaustion, enacted managerial support moderated the negative relationship between espoused psc and daily emotional exhaustion. the beneficial effects of espoused psc were evident when high levels aligned with high levels of enacted managerial support. psc acts as a safety signal. when highespoused psc is coupled with repeated, unequivocal and stable managerial support, employees feel safe in protecting themselves from emotional exhaustion in their environment 14 dormann et al 27 psychosoci al safety climate: a new work stress theory (edited book) psc review summary of chapters in an edited book provides a summary of all chapters in the edited book and an opinion on the direction of the study of leadership in relation to psc. suggests a new leadership construct, leadership for psychological safety (lps) that would better facilitate psc in organizations. int. j. occup. safety health, volume 13, no 2 (2023), 258-271 https://www.nepjol.info/index.php/ijosh discussion this scoping review set out to determine what is already known in terms of management and leadership concerning psc. while some authors treat management and leadership as interchangeable constructs, we are of the view that these are separate constructs.30 it was interesting to note that the search yielded more articles related to the impact of management practices on psc than articles related to the impact of leadership on psc, demonstrating that this is an under-researched topic. concerning management, the review has identified the support that managers should provide to workers as critical for the establishment of psc. the psc that is stated by an organization is related to engagement, but only if managers offer demonstrated support to workers. similarly, management support was found to account for a higher variance in the mental health of workers. we would argue that management support can be demonstrated under various leadership styles. transformational leadership, for instance, identifies organizational needs and employee safety needs. this leadership style stimulates and satisfies the higher needs of workers to achieve organizational goals.35 this leadership style was found to contribute to the establishment of a safety culture. since psc originated from the safety culture study field, we are of the view that it would be prudent to explore the impact of this leadership style on this construct.7 one study found that managers’ mental health thwarts their ability to implement mental health interventions. support for managers’ mental health is therefore of utmost importance as managers are often responsible for the implementation of psc interventions. a smaller proportion of the selected studies, 21% (3/14), related to the theme of infrastructure to support psc. in this regard, high-quality human resource practices were found to engender an ethical infrastructure for the prevention of bullying. the size and financial resources of an organization were not found to contribute to the psc of an organization. the lack of infrastructure was also highlighted concerning managers’ providing support to staff with mental health issues. in this regard, infrastructural issues hindering managers from providing support to staff include the lack of information to deal with mental health issues adequately and the lack of organizational support. one paper has gone beyond single elements of infrastructure and has studied the impact of highperformance work systems (hpws) on bullying. within an environment of hpws, psc was found to reduce the impact of bullying. while this result is promising, especially given the fact that many organizations strive to implement some form of hpws, this study was limited to the hospitality industry in the usa.17 as psychological injuries in the workplace appears to be a universal problem, the literature will therefore benefit from more empirical studies to further test the association of hpws with psychological hazards, like bullying and burnout. 5 an interesting observation in the selected studies was the fact that researchers have also studied the impact of psc on managerial quality and found that psc improved managerial quality. in our view, the authors of this study, however, erroneously concluded that this is also true for leadership.13 earlier in this review we noted the difference between management and leadership, and would therefore argue that further research is needed to determine the impact of psc on leadership. of the studies that solely focused on leadership’s impact on psc, the dataset only contains one empirical study and one opinion piece that relate to leadership and psc. dollard and jain (2019), in a study of 31 european countries, found that corruption had a significant effect on psc. 23 this they established by studying the link between the corruption levels in european countries and the psc at an organizational level in these countries. their study found that psc played a significant role in preventing the corruption of public values from infiltrating organizations.23 dollard and jain (2019) thus concluded that ethical leadership is likely to be the leadership model that will prevent corruption from infiltrating organizations. this study did not specifically test ethical leadership at the organizational level and one could argue that laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 267 other leadership styles, like authentic leadership, also have an ethical foundation and could therefore contribute to higher levels of psc. the empirical testing of different leadership models, therefore, seems to be a natural progression in the testing of a psychosocial safety climate. lastly, dormann et al. (2019) acknowledge the lacunae in relation to studies that investigate the impact of leadership on psc. these authors, however, go further and claim that notions of transformational leadership may not contribute to psc, and suggest that a different leadership style, leadership for psychological safety (lps), could be identified empirically and that this leadership style is likely to contribute to psc.27 while we do not disagree with this assertion, we believe that, as with the development of safety climate, various contemporary leadership styles should be explored concerning psc to advance the field. limitations the limited number of papers included in the data set was surprising, especially when compared with leadership studies conducted on psychological safety, at the individual level of analysis. by limiting the date range to publications from 2010 it is possible that sources that are aligned with the idea of psc, but do not use that particular term, might have been missed. searching all databases is not possible, and we acknowledge that by limiting our search it is likely that some literature may have been omitted. to mitigate this, a pearling exercise was conducted and we could not identify other sources. while the results were surprising, as only 14 papers satisfied the selection criteria, it is noted that all papers in the dataset were peer-reviewed. it could therefore be argued that papers in the dataset are of high quality, as they exclude grey literature not subjected to reviewer scrutiny.36 we also acknowledge the debate among scholars about conceptualizing organizational climate as an individual-level construct (psychological safety), or a group-level construct (which includes psc). for organizational-level constructs to be measured, respondents’ scores need to be aggregated to form the group-level construct. with the aggregation of respondents’ scores, there is an opportunity for variability that exists within groups not to be reflected in the overall score attributed to the organizational climate construct.37 recent developments in the literature however provide support for studying organizational climate at the group level. 38 conclusion the literature has shown that psc holds promise for the promotion of psychological health in organizations. as psc is promoted by the leadership of organizations, the impact of leadership on this construct is therefore an area of research that requires further study. this review has shown that there are few research papers on leadership, with most of the work conducted in management support and some on the infrastructure required to promote psc. concerning leadership, however, there appears to be a dearth of information on the dyadic relationship between followers and leaders in relation to psc. before the final review of this paper, one article on the impact of leadership and psc was published: ‘how psychosocial safety climate (psc) gets stronger over time: a first look at leadership and climate strength’. as the title suggests, this study is the first to give insights into how one of the contemporary leadership styles (transformational leadership) impacts psc. in this work, the authors introduce a new construct, psc leadership, into the literature, and through a longitudinal study conclude that transformational leadership has a smaller impact on psc.39 questions relating to other contemporary leadership styles and their impact on psc remain unanswered. our view is therefore that further investigation of the different leadership theories, in relation to psc, will benefit the development of the field. this review can potentially serve as an impetus for further studies to test the dyadic relationship between leaders and followers to explain how leadership impacts the psychosocial safety climate in organizations. laloo et al. the impact of leadership on the psychosocial safety climate of organizations: a scoping review 268 references 1. harnois g , gabriel p. mental 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