SN Comprehensive Clinical Medicine
https://doi.org/10.1007/s42399-020-00441-7
MEDICINE
A Comparative Study of Prevalence of Morbidities among Municipal
Solid Waste Workers in Mumbai
Pradeep S. Salve 1
Accepted: 28 July 2020
# Springer Nature Switzerland AG 2020
Abstract
Paper investigates the association between labour intensive work of solid waste collection and street sweeping with the development of skin disease, respiratory disease, eye infection, musculoskeletal disorders (MSDs) and MSDs-related disabilities
during the service. A primary survey was conducted with 540 municipal employees adopting multistage stratified systematic
sampling in 6 out of 24 municipal wards in Mumbai. The data was collected between March and September 2015, and analysis
was performed in STATA13. The prevalence of self-reported morbidities among municipal workers varies from 7 to 46% in the
reference period of the past 6 and 12 months. Adjusted odds of major morbidities show that the waste collectors significantly
more likely to have injury/accident (OR = 11.36; p < 0.01), skin disease (OR = 4.971; p < 0.01), eye infections (OR = 3.03;
p < 0.01) and MSDs (OR = 2.04; p < 0.05) in reference to comparison group. Similarly, street sweepers significantly more likely
to have injury/accident (OR = 4.08; p < 0.01), skin disease (OR = 4.50; p < 0.01), respiratory disease (OR = 2.63; p < 0.01),
MSDs (OR = 2.17; p < 0.01) and disability (OR = 1.92; p < 0.05) in reference to comparison group. Propensity score matching
method analysis suggests that the waste collecting and street sweeping occupation significantly increases the prevalence of
morbidities among exposed workers than the matched non-exposed workers. The mean expenditure on treatment of morbidities
show that street sweepers spends significantly (p < 0.05) higher amount of money for injury/accident, eye infections and MSDs
followed by waste collectors compared with comparison group. Workers associated with the street sweeping and waste collecting
occupation has higher burden of developing morbidities and health expenditure compared with other occupation.
Keywords Municipal solid waste . Waste collector . Street sweeper . Musculoskeletal disorder . Mumbai
Introduction
The management of solid waste generated by the overcrowded
population in metropolitan cities encompasses a wide range of
activities including waste collection, transportation of collected
waste to the disposal field, sorting recyclable materials and
disposing off before it pollutes environment. In developing
countries, solid waste management (SWM) department is
mainly labour intensive and required continues engagement.
Waste collectors in developing countries manually handle
the solid waste and dump community garbage containers into
the operational trucks. These workers are at the risk of
This article is part of the Topical Collection on Medicine
* Pradeep S. Salve
pradeep8889@gmail.com; pradeep_salve@biari.brown.edu
1
Population Research Centre, JSS Institute of Economic Research,
Dharwad, Karnataka 580 004, India
development of health problems during waste collection on
the field, transportation of collected waste and recycling and
disposal on landfill. About 90% of municipal solid waste
(MSW) disposed unscientifically in open grounds and manage
improperly creating landfills in India [33]. Mumbai is the capital of garbage generation which contributes 8069 metric tons
of waste and 2266 metric tons dry solid waste per day in 24
administrative wards of the Municipal Corporation of Greater
Mumbai (MCGM) [5]. Approximately 3.77 million tons of
solid waste systematically reclaimed on landfill by workers
during the year 2013–2014. The huge labour force of 35,100
including 28,018 formal and 7000 informal employees such as
waste collectors and street sweepers are working in the SWM
of Mumbai every day [9, 25]. Considering at the national level,
this number of labour force may increase in multiple folds with
possible vulnerabilities of developing health risk.
As the waste collection is labour intensive, it involves considerable heavy lifting, pulling, pushing and manual handling
of heavy containers which increases the risk of health hazards.
Previous studies found that work-related health problems like
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respiratory disease, skin infection, eye flu and gastrointestinal
disorders are more common among workers engaged in SWM
compared with the general workforce [26, 28]. Similarly,
studies conducted in Danish, Taiwan and Florida found that
SWM workers are more exposed to chronic respiratory problems, musculoskeletal disorders (MSDs), injuries caused by
sharp objects, strains/sprains, contusions, fractures and dermal
problems than other workers [15, 16, 18, 22, 36]. Further,
studies conducted in developing countries depicted the high
prevalence of MSDs including low back pain, knee pain and
shoulder pain due to the heavy and repeated physical activities
compared with the general population [1, 24].
In the Indian context, the study conducted in Gujarat involving 292 waste collectors and 93 workers working in back
offices highlighted that waste collectors have potential risk for
the development of chronic respiratory symptoms, MSDs and
injuries compared with the other workers [19]. Similarly, morbidities such as anaemia, hypertension, upper respiratory tract
infections and chronic bronchitis found to be higher among
street sweepers than the comparing group [29, 34]. The survey
conducted in Kerala found out that respiratory diseases, eye
diseases, dermatological problems, nail infection/injury and
water vector-borne disease were common to workers [20].
Likewise, the study carried out in Chandigarh with municipal
street sweepers, waste collectors and waste processing
workers is the evidence that workers mainly suffered from
the respiratory problems (coughs and breathlessness), injuries,
vomiting and MSDs [27].
Multiple and frequent episodes of morbidities among municipal workers cause the economic burden during the
treatment-seeking behaviour. Particularly in developing countries, episodes of out-of-pocket expenditure (OOPE) on health
cause indebtedness and lead to financial burden of health expenditure on family which subsequently force people into below poverty line. Households having financial burden due to
poor health condition used the combination of savings, borrowing money and selling consumable assets as a coping strategy [4, 30, 35], although there are past studies that identify the
vulnerability of developing various fatal and catastrophic morbidities among MSW workers [19, 27, 29]. But in addition to
this, our study attempts to refill the research gap by highlighting the major morbidities and OOPE during treatment of respective morbidities. Particularly, the present study compared
the morbidity condition and incurred OOPE among waste
collectors and street sweepers with comparison group workers
in MCGM.
Materials and Methods
This study is based on the primary survey which was conducted with MSW workers engaged in waste collecting and loading it into the garbage compactors (waste collectors) and street
sweepers in 6 out of 24 municipal wards in MCGM. A group
of workers was selected as the comparison group has more or
less similar socioeconomic characteristic but not exposed to
street sweeping or waste collection [14]. The non-exposed
comparison group of workers includes back-office personnel,
peons and ‘D’ class employees at various municipal offices.
Considering their socioeconomic characteristics, we have selected them as the comparison group workers which represent
the general population. The sample size was determined using
the prevalence of major morbidity that found among MSW
workers in Indian context. The cross-sectional study conducted with SWM workers in Kerala reported that the prevalence
of major morbidities varies from 30 to 47%. The prevalence of
eye disease (30%) was the lowest among major morbidities;
therefore, the expected prevalence of morbidity was consider
at least 30% for the sample estimation [20]. The determined
sample size was calculated using formula given by Cochran
[6].
The determined sample size for a group was 180 workers,
and therefore, three groups were 540 workers. The survey was
carried out by employing multistage stratified systematic sampling design; at the first stage, 24 municipal wards were arranged in the ascending order of percentage of slum population in respective wards. Then it was stratified into 3 strata
with low, middle and highest slum population. Each stratum
includes a total of eight wards, and out of eight wards, we
randomly selected 2 wards as the representative of other wards
in that strata for our sample selection. Finally, 90 workers
systematically (30 waste collectors, 30 street sweepers and
30 compare group) selected from each ward with the help of
the listing provided by MCGM. The inclusion criteria for
workers in the survey were at least 5 years working experience
in the SWM department of MCGM. Interviews were conducted according to the availability of workers at their working
places during March to September 2015. The statistical software was used for the primary data entry (CSPro 6.0) and
statistical analysis (STATA 13).
The standardized questionnaires such as American
Thoracic Society and the Division of Lung Disease (ATSDLD-78) and Standardized Nordic Questionnaire (SNQ) were
used to cover the different morbidities among workers. The
ATS-DLD-78 inquires the chronic respiratory symptoms like
coughing, wheezing, shortness of breath, chronic bronchitis,
asthma and TB symptoms in past 6 months [7], whereas the
SNQ covers the MSDs symptoms which includes the pain in
nine anatomical parts such as pain in the neck, shoulders,
upper back, elbow, lower back, knee, hip/thigh and wrist/
hand with the reference period of past 7 days and 12 months
[21]. The morbidities are self-reported and recoded based on
the response of the workers. In the past 12 months, workers
prevented from doing day-to-day normal activities at home or
away from home due to MSDs were recoded as disabled.
Subsequently, questionnaire covers detail expenditure on the
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treatment during the illness including money spend on the
doctor’s fees, surgery, medicine, X-ray-ECG-EEG, transportation and other expenditure during the illness. In addition to
this, the detail information on substance use, mental health,
job satisfactions and socioeconomic characteristics were also
covered.
The descriptive statistics were used to access the occupational and socioeconomic characteristics of MSW workers.
Further, the Chi-square test was applied to assess the association between type of workers, morbidities and the background
characteristics of workers. To examine the burden of expenditure during treatment seeking, the one-way ANOVA was
employed at the 5% level of significance among three groups
of workers. In case of significance of ANOVA test, post hoc
(Tukey’s) test was performed to test the significance between
the group differences. Additionally, the study adopted the
nearest neighbourhood method of propensity score matching
(PSM) to assess the exposure of the street sweeping and
waste-collecting occupation on the development of morbidities. The PSM analyses the causal relationship between the
occupation of individual and its related morbidities by controlling the matched socioeconomic, occupation and demographic variables. Further, to understand the individual risk
factors of morbidity and disability among street sweepers
and waste collectors, multiple logistic regression analysis
was performed.
Ethical Consent
This paper is a part of the PhD thesis work conducted during
2013–2018 in the International Institute for Population
Sciences (IIPS). The prior permission for data collection was
taken from the MCGM. The ethical clearance certificate was
approved by the Ethical Review Committee of IIPS (SREC12/
3144) prior to field work. While conducting the survey on the
field, full confidentiality of information was maintained, and
workers were assured about the secrecy of information shared
during the interviews.
Results
Socioeconomic Characteristics
Table 1 presents the descriptive statistics on demographic and
socioeconomic characteristics of study group by type of occupation. The mean age of workers working in municipal corporation found to be more or less similar among waste collectors (36 years), street sweepers (37 years) and the comparison
group workers (38 years) (Table 1). Similarly, the mean years
of working of waste collectors (10 years) and street sweepers
(10 years) found to be similar to the comparison group
workers (11 years). Majority of waste collectors (60%) and
street sweepers (60%) have less than 10 years of schooling
than the comparison group workers (9%). More than threefourths (78%) of waste collectors followed by street sweepers
(86%) belong to the scheduled castes compared with the comparison group workers (52%). The prevalence of substance
use was found to be high among workers; for instance, 47%
of waste collectors followed by street sweepers (44%) consumed alcohol compared with comparison group workers
(22%). Majority of the comparison group workers belong to
the rich standard of living index compared with the waste
collectors (19%) and street sweepers (31%).
Occupational-Related Morbidities
Table 2 presented the prevalence rate of major morbidities
among municipal workers which varies from 7 to 46% in
the past six and 12 months. Results distinctly depicted that
the waste collectors have a higher prevalence of injury/
accident (43%), skin disease (18%), respiratory disease
(18%), eye infections (24%), MSDs (45%) and disability
(36%) followed by street sweepers (25%, 19%, 29%, 14%,
46% and 43%) compared with the comparison group workers
(8%, 7%, 17%, 14%, 33% and 32%, respectively) (Table 2).
The street sweeping and waste collecting occupation are
stinky and dangerous work performed by municipal workers
in the different urban areas in India. The prevalence rate of
injury/accident found to be high among waste collectors, and
in the case of street sweepers, the respiratory-related diseases
found to be higher than waste collectors and comparison
group workers in the past 6 months. The possible causes
may be due to the exposure of dust particles and air pollution
on the public roads. Looking at the respiratory disease, street
sweepers were more vulnerable for developing the respiratory
infections than the waste collectors and comparison group
workers during the past 6 months. Particularly, the prevalence
of asthma (21%), chronic cough (14%), continuous running
nose (13%) and breathlessness (28%) found to be higher
among sweepers compared with the waste collectors (9%,
8%, 3% and 12%) and comparison group workers (12%,
8%, 8% and 16%), respectively.
The waste collectors and street sweepers found to be
more vulnerable for development of MSDs due to the
continuous activities of pulling, pushing and lifting of
heavy waste materials and community dust bins. In particular, street sweepers reported higher prevalence of pain
in the upper back (34%), low back (33%), shoulder
(32%), wrist/hand (29%), elbow (27%), hip/thigh (27%)
and neck (17%) followed by waste collectors (32%, 39%,
26%, 19%, 11%, 19%, and 13%) compared with the comparison group workers (27%, 29%, 11%, 19%, 9% and
11%), respectively, in last 12 months. Similarly, workers
engaged in street sweeping occupation reported the higher
prevalence of MSDs-related disabilities for the upper back
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Table 1 Demographic and
socioeconomic characteristics of
study groups by type of
occupation
Characteristics
Type of workers
Waste collectors
Street sweepers
Comparison group
19–34
35–58
Mean age ± SD
Year of working
p < 0.01
Less than 10 years
Above 10 years
Mean years of working ± SD
Years of schooling
p < 0.001
Non-literate
Less than 10 years
Above 10 years
Mean years of schooling ± SD
Marital status
p < 0.04
Currently married
Other*
Caste
p < 0.001
SCs/STs
None of above
Mean net salary ± SD
53.3
46.7
36 ± 8.6
45.6
54.4
37 ± 9.1
34.4
65.6
38 ± 7.4
67.8
32.2
10 ± 7.9
60.0
40.0
10 ± 8.5
51.1
48.9
11 ± 6.5
10.6
49.4
40.0
8 ± 3.7
14.4
45.6
40.0
8 ± 4.1
0.0
8.9
91.1
12 ± 2.2
92.2
7.8
88.3
11.7
95.6
4.4
78.3
21.7
12,105 ± 4741.1
85.6
14.4.
11,487 ± 4007.1
51.7
48.3
16,511 ± 3711.6
Mean gross salary ± SD
Substance use
Smoking
Alcohol
Tobacco
Job satisfaction
p < 0.001
Good
Average
Bad
Body Mass Index
p < 0.05
Underweight
Normal
Overweight
Mean BMI ± SD
Standard of Living Index p < 0.001
Poor
Middle
Rich
20,809 ± 4188.9
21,219 ± 4624.8
22,391 ± 3982.4
17.8
47.2
46.1
11.7
43.9
46.1
11.1
21.7
34.4
17.2
58.9
23.9
17.8
65.0
17.2
30.6
61.1
8.3
6.1
61.1
32.8
23.52 ± 3.4
6.7
58.9
34.4
23.62 ± 4.4
1.1
50.6
48.3
25.14 ± 3.4
46.1
35.0
18.9
37.2
32.2
30.6
16.7
33.9
49.4
N = 180
N = 180
N = 180
Age
p < 0.001$
Total
$, p value of Chi-square; SCs, scheduled castes; STs, scheduled tribes; OBCs, other backward castes; other*, not
married and widowed/widower; , Rupees; ± SD, standard deviation
(27%), low back (27%), wrist/hand (26%), shoulder
(24%), elbow (23%), hip/thigh (17%) and neck (11%)
followed by waste collectors (25%, 31%, 14%, 16%,
5%, 23% and 6%) compared with the comparison group
workers (19%, 18%, 13%, 9%, 6%, 8% and 9%),
respectively.
Table 3 present the adjusted odds ratio for major morbidities by type of workers. Results depicted that the
waste collectors significantly more likely to have injury/
accident (OR = 11.36; p < 0.01), skin disease (OR = 4.971;
p < 0.01), eye infections (OR = 3.03; p < 0.01) and MSDs
(OR = 2.04; p < 0.05) in reference to the comparison
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Table 2 Prevalence of
morbidities among study groups
in past 6 and 12 months
Morbidities
Waste collectors
Street sweepers
Comparison group
Injuries/accident#
Fracture @
Laceration* @
Contusion on job @
Other injury @
43.3
15.6
36.6
14.4
13.3
25.0
2.2
20
2.7
7.7
8.3
1.1
2.7
5.6
2.7
Skin disease
Rashes/infective
Itching
Dermatitis
Respiratory disease
Dust allergy
Dyspnoea
Episode of asthma
Chronic cough
Running nose
Breathlessness
Eye
Soreness/infection
Redness
Watering
Itching
MSD$
Neck
18.3
13.8
14.4
9.4
17.7
2.2
2.8
9.4
7.8
3.3
11.6
24.4
14.4
17.7
18.8
13.3
45.0
13.3
18.8
9.4
17.2
14.4
28.8
3.3
3.3
20.6
13.8
12.7
27.7
13.8
5.0
7.7
12.2
12.2
46.1
16.7
6.6
3.8
6.1
4.4
16.6
1.1
2.2
12.2
7.7
8.3
15.5
14.4
7.2
8.8
12.2
10.5
33.3
10.6
Shoulder
Elbow
Wrist/hand
Upper back
Low back
Hip/thigh
Knee
Ankles/feet
Disability$
Elbow
Wrist/hand
Upper back
Low back
Hip/thigh
Neck
Shoulder
Knee
Ankles/feet
26.1
10.6
18.9
31.7
38.9
34.4
3.3
3.3
36.1
5
13.9
25
30.6
22.8
5.6
15.6
2.2
1.7
31.7
26.7
29.4
33.9
33.3
26.7
1.7
3.9
43.3
23.3
26.1
26.7
26.7
16.7
10.6
24.4
0.6
1.7
11.1
8.9
18.9
27.2
29.4
20
3.9
2.2
32.2
5.6
13.3
18.9
17.8
7.8
9.4
9.4
3.3
2.2
Total
180
180
180
@, health conditions; *Laceration with needles and glass materials; #Due to multi-response question, total will not
be add up to 100%; MSDs, musculoskeletal disorders, Disability; $ reference period past 12 months
group workers (Table 3). Similarly, street sweepers significantly more likely to have injury/accident (OR = 4.08;
p < 0.01) followed by skin disease (OR = 4.50; p < 0.01),
respiratory disease (OR = 2.63; p < 0.01), MSDs (OR =
2.17; p < 0.01) and disability (OR = 1.92; p < 0.05) in reference to the comparison group workers.
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Table 3 Adjusted odds ratio for
major morbidities by the types of
workers
Characteristics
Injury/
accident $
Types of workers
Comparison group®
Waste
11.36***
collectors
(5.07–25.44)
Street
4.08***
sweepers
(1.87–8.89)
Skin
Respiratory
Eye
MSDs
Disability
4.97***
1.24
3.03***
2.04**
1.32
(1.90–13.00)
4.50***
(0.56–2.74)
2.63***
(1.41–6.51)
1.35
(1.04–4.02)
2.17***
(0.66–2.64)
1.92**
(1.79–11.28)
(1.26–5.51)
(0.63–2.89)
(1.14–4.14)
(0.99–3.71)
® Reference category; level of significance *p < 0.10, **p < 0.05, ***p < 0.01; 95% confidence interval. MSDs,
musculoskeletal disorders and related disabilities; the model additionally controls for age, schooling, working
years, substance use, mental health, job satisfaction, BMI, wealth index and location of work; $, health condition
Table 4 depicted the average exposure effect among exposed (AEEE) and highlighted the morbidities significantly
found higher among waste collectors than the matched nonexposed group workers. For instance, morbidities such as
injury/accident (34%), MSDs (23%), eye disease (19%), skin
infection and disability (15% each) and respiratory disease
(10%) found to be higher among waste collectors compared
with the matched non-exposed workers (Table 4). Similarly,
the finding suggested that the street sweepers significantly
have higher morbidities than the matched non-exposed group
workers. Mainly, the morbidities such as MSDs (18%), respiratory disease (17%), disability (16%), injury/accident (15%)
and skin disease (12%) found significantly higher among
street sweepers compared with the matched comparison group
workers. The PSM matching method analysis suggests that
the waste collecting and street sweeping occupation significantly increases the prevalence of major morbidities among
exposed workers than the matched non-exposed workers.
Table 5 demonstrated the treatment-seeking behaviour and
health expenditure for major morbidities among exposed
groups. For instance, 87% of comparison group workers seek
medical care for injury and accident compared with the 85%
of street sweepers and 61% of waste collectors in the past
6 months (Table 5). Similarly, all (100%) comparison group
workers have sought medical treatment for the skin disease
compared with the street sweepers (91%) and waste collectors
(58%). A similar pattern is observed for respiratory disease,
eye infections and MSDs among workers. For instance, 92%
of comparison group workers seek treatment for eye infections
compared with the 60% of street sweepers and 43% of waste
collectors. Analysis of mean expenditure on morbidities
depicted that workers working as street sweepers in MCGM
spends significantly (p < 0.05) higher amount of money on the
treatment for injury/accident followed by waste collectors
compared with the comparison groups workers. For instance,
street sweepers spend 5685 (± 6057.6) on the treatment of
injury/accident followed by 4209 (± 4320.4) of waste collectors compared with comparison groups workers 3363 (±
2579.6), respectively (Table 5). Street sweepers suffering
from respiratory and eye infections spend significantly
Table 4 Average exposure effect (AEE) and average exposure effect among exposed (AEEE) of waste collecting and street sweeping occupation on
major morbidities
Major morbidities
Waste collectors
AEE
Injury/accident @
Skin
Respiratory
Eye
MSDs
Disability
Street sweepers
AEEE
AEE
AEEE
Coef.
95% conf.
Coef.
95% conf.
Coef.
95% conf.
Coef.
95% conf.
0.33***
0.15***
0.04
0.15***
0.19***
0.09*
(0.21 to 0.43)
(0.07 to 0.24)
(− 0.03 to 0.12)
(0.07 to 0.24)
(0.09 to 0.29)
(− 0.00 to 0.19)
0.34***
0.15***
0.10***
0.19***
0.23***
0.15***
(0.23 to 0.45)
(0.09 to 0.21)
(0.03 to 0.18)
(0.12 to 0.27)
(0.14 to 0.33)
(0.05 to 0.24)
0.15***
0.14***
0.16***
− 0.01
0.18***
0.18***
(0.06 to 0.23)
(0.05 to 0.23)
(0.07 to 0.25)
(− 0.08 to 0.06)
(0.09 to 0.28)
(0.87 to 0.27)
0.15***
0.12***
0.17***
− 0.00
0.18***
0.16***
(0.05 to 0.25)
(0.06 to 19.55)
(0.09 to 0.25)
(− 0.07 to 0.06)
(0.08 to 0.28)
(0.07 to 0.25)
Level of significance *p < 0.10, **p < 0.05, ***p < 0.01; Coef., coefficient, conf., confidence interval, MSDs, musculoskeletal disorders; @, health
condition
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Table 5 Treatment-seeking behaviour and mean expenditure (standard deviation) for major morbidities among study groups along with the results of
ANOVA and post hoc (Tukey’s) tests
Morbidities
Injury/accident @
Skin
Respiratory
Eye
MSDs
Waste
collectors
Street
sweepers
Comparison
group
Waste collectors Street sweepers Comparison group p value for ANOVA
Yes
(N)
Yes
(N)
Yes
(N)
Mean (SD)
Mean (SD)
Mean (SD)
61.5
57.6
62.5
43.2
61.8
78
33
32
44
89
84.8
91.2
82.7
60.0
84.3
46
34
52
25
83
86.7
100
93.3
92.0
90.2
15
12
30
25
61
4209 (4320.4)
2136 (1896.5)
2105 (1792.6)
1693 (2384.8)
4515 (6039.2)*
5685 (6057.6)*
2292 (1871.5)
4157 (3928.6)
2410 (1579.9)*
4392 (4761.1)*
3363 (2579.6)
1427 (1317.6)
3060 (2214.3)
1100 (568.2)
2298 (1757.5)
< 0.05
0.40
< 0.05
< 0.05
< 0.05
N, number suffered from morbidity; @, health condition; MSDs, musculoskeletal disorders; SD (standard deviation); , mean rupees
*Significantly different from comparison group workers
(p < 0.05) higher amount of money on medical treatment
followed by waste collectors compared with the comparison
group workers. Considering the expenditure for MSDs, waste
collectors and street sweepers significantly (p < 0.05) spend
higher amount of money for the medical treatment compared
with the comparison group workers. For instance, waste collectors suffering from MSDs spend 4515 (± 6039.2) on treatment followed by street sweepers 4392 (± 4716.1) compared
with the comparison group 2298 (± 1757.5) in past
12 months.
The results of Table 6 present the mean health expenditure
for multiple morbidities among study groups. The finding of
expenditure on multiple morbidities revealed that street
sweepers suffered from any two major morbidities significantly (p < 0.05) spend higher money on the treatment followed by
waste collectors compared with the comparison group
workers (Table 6). For example, street sweepers spend 8500
(± 9647.8) on the treatment of any two diseases followed by
waste collectors 7565 (± 8879.3) compared with the comparison group workers 4486 (± 3192.3). Similarly, for any three
and above major morbidities, street sweepers significantly
(p < 0.001) spend higher money 10,168 (± 7882.2) on the
treatment followed by waste collectors 5821 (± 6744.4) compared with the comparison group workers 5560 (± 3579.3).
Looking at the overall expenditure by additional one disease,
the expenditure on the treatment among waste collectors and
Table 6 Mean health expenditure
for multiple major morbidities
among study groups along with
the results of ANOVA and post
hoc (Tukey’s) tests
street sweepers increases continuously compared with comparison group workers.
Discussion
The age and mean working years found to be more or less
similar among all three workers’ groups. Majority of
workers working as waste collectors and street sweepers
were non-literate, and two-thirds of them belonged to the
scheduled caste category. In India, waste collecting occupation or cleaning of public places is considered as poor
people’s line of works traditionally. Scheduled caste people
were socially and economically weakened and consistently
restricted to inhuman practice of manual scavenging [32].
The manual scavenging has been prohibited by the law but
at the same time people associated with cleaning work were
not disengaged over the period. The lack of education, poor
housing and insufficient diet affects their health rigorously.
In addition, contextual vulnerability such as tobacco
chewing, smoking and regular consumption of alcohol affects their immune system and resulted in further health
deterioration. The prevalence of substance use was common among workers; for instance, 47% of waste collectors
followed by 44% of street sweepers consume alcohol daily
Multiple morbidities$
Waste collectors
Mean (SD)
Street sweepers
Mean (SD)
Comparison group
Mean (SD)
p value for ANOVA
Any one
Any two
Any three and above
2400 (1861.2)
7565 (8879.3)*
5821 (6744.4)
3990 (4970.1)
8500 (9647.8)*
10,168 (7882.2)*
2655 (1854.8)
4486 (3192.3)
5560 (3579.3)
0.29
< 0.05
< 0.001
, rupees; SD (standard deviation); $, multiple response of major morbidities (injury/accident, skin, respiratory,
eye, MSDs). *Significantly different from comparison group workers
SN Compr. Clin. Med.
compared with the comparison group workers (22%).
Workers associated with waste collecting shows higher
prevalence of injury/accident followed by street sweepers
compared with the comparison groups workers. The waste
collector’s direct exposure to the sharp and hazard waste
materials resulted in injury/accident, skin disease and eye
infections compared with comparison group workers.
Particularly, the development of laceration due to sharp
objects, fracture, rashes-itching, eye redness-watering, pain
in upper back, lower back and hip/thigh found to be higher
among waste collectors compared with the comparison
group workers. Previous studies of workers associated
municipal solid waste collection evidence the similar pattern of morbidities with compared to the general population
[12, 13]. Likewise, workers associated with the street
sweeping occupation reported higher prevalence of the skin
disease, respiratory disease, MSDs and MSD-related disabilities compared with the comparison group workers [8,
27]. Particularly, street sweepers suffered with skin itching,
dermatitis, episodes of asthma, chronic cough, breathlessness, watering-itching eye, pain in the shoulder, upper
back, low back and wrist/hand compared with the comparison group workers. The previous study validated our findings and evidence that the prevalence of all respiratory disease found to be comparatively high among MSW workers
than in control group; particularly the shortness of breath
was the major respiratory problem among municipal
workers [2, 3, 10, 17]. The PSM method highlighted that
the occupation of street sweeping and waste collecting significantly raised the prevalence of injury/accident, skin disease, respiratory disease, MSDs and related disabilities
among exposed group workers compared with the matched
non-exposed group workers. The physical body posture and
workload during the working hours might be the major risk
factor for developing MSDs among street sweepers and
waste collectors as suggested by previous studies [11, 23].
Waste collectors and street sweepers bear higher burden of
OOPE due to multiple illnesses compared with comparison
group workers. Waste collectors significantly incurred
higher burdern of expenditure followed by street sweepers
compared with the comparison group workers. Similarly,
workers having any three and above major morbidities spend
significantly higher amount of money on treatment compared
with those who have any one disease. In the larger context,
medical and industrial waste is not segregated from domestic
waste which makes waste collectors and street sweepers vulnerable to a wide array of health risks. Workers suffered from
health hazards due to the contents of materials they handle,
emissions from waste materials and the inadequate used of
protective measures. The work condition and workplace make
them vulnerable to development of multiple communicable
and non-communicable diseases. Health deteriorates continuously after the retirement which leads to long-term disability
and causes premature death. For instance, past studies suggested that the majority of workers associated with solid waste
collection die because of communicable diseases and mainly
due to the tuberculosis before the completion of 58 years of
age [31]. The majority of workers spend higher proportion of
their mean expenditure on medicine items followed by doctor
fees, medical tests and transport facilities. And the households’ savings followed by the money borrowed from friends
and relatives were mainly used as the major source of medical
expenditure. Although workers are formal employees of
MCGM, but the reimbursement of health expenditure through
insurance policy was observed negligible for all the three
types of workers. However, the study has estimated the prevalence of different morbidities/health conditions among waste
collectors and street sweepers but at the same time we acknowledge the limitations of the study. We have used the
self-reported morbidities which are subject to the recall bias,
may cause the inflated risk estimates and sometimes faced
difficulties in demonstrating the cause-effect relationships.
Policy Implications
The study deals with the policy implication based on the results and suggests immediate possible actions with the following recommendations. The MCGM may adopt the job rotation
system between waste collectors and street sweepers to reduce
the workload and the risk of developing morbidities. Workers
working in the high slum concentration areas may be shifted
to low slum concentration areas since the workload varies by
place of work. The burden of morbidities may be reduced by
taking the preventing measures and providing proper medical
care at an early stage. Considering the municipal worker’s
occupation, the preventive measures mainly includes the use
of protective gears/safety tools during working hours and the
adaptation of personal hygiene practices. The MCGM have a
provision of regular medical check-up in civil health facility
for workers, but we observed poor implication of the policy.
Therefore, we suggest to regulate the medical check-up with
provision for private health facility. The MCGM need to
mechanized the SWM department particularly sewer and
community dustbins which need manual handling; this may
reduce the direct exposure of workers to the filthy waste. To
reduce the burden of medical expenditure corporation may
introduce the family health insurance facility for workers.
Compliance with Ethical Standards
Conflict of Interest The author declared no conflict of interest.
Ethical Approval This paper is a part of the PhD thesis work conducted during 2013–2018 in IIPS. The prior permission for data
collection was taken from the MCGM. The ethical clearance certificate approved by the Ethical Review Committee of IIPS (SREC12/
3144) prior to field work.
SN Compr. Clin. Med.
Informed Consent Oral and written informed consent was taken wherever applicable. While conducting the survey on the field, full confidentiality of information was maintained and workers were assured about the
secrecy of information share during the interviews.
18.
19.
20.
References
21.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Abou-ElWafa HS, El-Bestar SF, El-Gilany A-H, Awad EE-S.
Musculoskeletal disorders among municipal solid waste collectors
in Mansoura, Egypt: a cross-sectional study. BMJ Open. 2012;2(5):
e001338.
Abou-Elwafa HS, El-Bestar SSF, El-Gilany AH, Awad El-Toraby
E-S, El-Toraby lSA, E. E. Respiratory disorders among municipal
solid waste collectors in Mansoura, Egypt: a comparative study.
Arch Environ Occup Health. 2014;69(2):100–6. https://doi.org/
10.1080/19338244.2012.744737.
Athanasiou M, Makrynos G, Dounias G. Respiratory health of municipal solid waste workers. Occup Med. 2010;60(8):618–23.
Bhojani U, Thriveni B, Devadasan R, Munegowda C, Devadasan
N, Kolsteren P, et al. Out-of-pocket healthcare payments on chronic
conditions impoverish urban poor in Bangalore, India. BMC Public
Health. 2012;12(1):990. https://doi.org/10.1186/1471-2458-12990.
Chaini, M. N., & MEDC. B Ward - Aspects of solid waste management - a solutions approach (F. Report, ed.). Mumbai : Maharashtra
Economic Development Council. 2005
Cochran WG. Sampling techniques. New York: John Wiley and
Sons; 1977. p. 428.
Comstock GW, Tockman MS, Helsing KJ, Hennesy KM.
Standardized respiratory questionnaires: comparison of the old
with the new. Am Rev Respir Dis. 1979;119(1):45–53. https://
doi.org/10.1164/arrd.1979.119.1.45.
Darboe B, Kao M-Y, Tsai D. Respiratory symptoms among municipal waste workers in the Gambia: types of solid waste and
working conditions. Int J Health Promot Educ. 2014;53(1):17–27.
https://doi.org/10.1080/14635240.2014.923284.
Davis B. Solid waste management in Mumbai. In: Mukherjee N,
editor. Understanding our civic issues; 2013. Mumbai.
Farshid Khodaparast-kazerouni JHMN. Assessment of respiratory
symptoms and lung functional impairments among a group of garbage collectors. Int J Occup Hygiene. 2013;5(2):76–81.
France N, Esper J, Voyi KVV. Postural analysis of a developing
country’s municipal solid waste handlers and a reference group of
hospital general hands using the RULA method. Global J Health
Sci. 2017;9(10):194. https://doi.org/10.5539/gjhs.v9n10p194.
Gellin GA. Dermatoses acquired by solid-waste handlers. Am J Ind
Med. 1985;8(4–5):363–70.
Gellin GA, Zaυon MR. Occupational dermatoses of solid waste
workers. Arch Environ Health. 1970;20(4):510–5. https://doi.org/
10.1080/00039896.1970.10665631.
Gordis L. Epidemiology: with Student Consult (5th Editio). Canada:
Elsevier Health; 2014.
Hansen J, Ivens UI, Breum NO, Nielsen M, Würtz H, Poulsen OM,
et al. Respiratory symptoms among Danish waste collectors. Ann
Agric Environ Med. 1997;4:69–74.
Inyang MP. Health and safety risks amongst the municipal solid
waste collectors in Port Harcourt metropolis of the Niger Delta
region of Nigeria. International Conference “Waste Management,
Environmental Geotechnology and Global Sustainable
Development". Slovenia. 2007.
Issever H, Ince N, Ince H, Bayraktarli R, Isik E, Ayvaz O, et al.
Respiratory functions of the people working in solid waste storage
centers in Istanbul. Nobel Medicus. 2011;7(1):29–36.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Ivens U, Lassen J, Kaltoft B, Skov T. Injuries among domestic
waste collectors. Am J Ind Med. 1998;33(2):182–9.
Jariwala ND, Christian RA. A study of prevalance of morbities in
door to door waste collecting workers of Surat City, Gujarat. Indian
J Public Health Res Dev. 2013;4(4):123–7.
Jayakrishnan T, Jeeja M, Bhaskar R. Occupational health problems
of municipal solid waste management workers in India. Int J
Environ Health Eng. 2013;2(1):42.
Kuorinka I, Jonsson B, Kilbom HV, Biering-Sørensen F,
Andersson G, Jørgensen K. Standardised Nordic questionnaires
for the analysis of musculoskeletal symptoms. Appl Ergon.
1987;18(3):233–7.
Lora F, James E, Huren A, Bean J. Occupational health and safety
amongst municipal solid waste workers in Florida. Waste Manag
Res. 1999;17(5):369–77.
Massaccesi M, Pagnotta A, Soccetti A, Masali M, Masiero C,
Greco F. Investigation of work-related disorders in truck drivers
using RULA method. Appl Ergon. 2003;34(4):303–7. https://doi.
org/10.1016/S0003-6870(03)00052-8.
Mehrdad R, Majlessi-Nasr M, Aminian O, Sharifian S,
Malekahmadi F. Musculoskeletal disorders among municipal solid
waste workers. Acta Medica Iranica. 2008;46(3):233–8.
Municipal Commissioner. (2014). Administration report of the
Municipal Commissioners of greater Mumbai. Mumbai.
Poulsen OM, Breum NO, Ebbeh N, Hansen M, Ivens UI, Lelieveld
V, et al. Collection of domestic waste. Review of occupational
health problems and their possible causes. Sci Total Environ.
1995;170(1–2):1–19.
Ravindra K, Kaur K, Mor S. Occupational exposure to the municipal solid waste workers in Chandigarh, India. Waste Manag Res :
International Solid Wastes and Public Cleansing Association,
ISWA. 2016;34(11):1192–5. https://doi.org/10.1177/
0734242X16665913.
Rushton L. Health hazards and waste management. Br Med Bull.
2003;68(1):183–97.
Sabde YD, Zodpey SP. A study of morbidity pattern in street
sweepers: a cross-sectional study. Indian J Community Med.
2008;33(4):224–8.
Saksena P., & David B. Evans. Impact of out-of-pocket payments
for treatment of noncommunicable diseases in developing countries: a review of literature. Discussion. 2011; (2), 9.
Salve P, Bansod D, Kadlak H. Safai Karamcharis in a vicious cycle:
a study in the perspective of caste. Econ Polit Wkly. 2017;52(13):
38–41.
Sarkar J. Caste occupation and change. Delhi: B. R. Publication
Corporation; 1984.
Sharholy M, Ahmad K, Mahmood G, Trivedi RC. Municipal solid
waste management in Indian cities - a review. Waste Manag.
2008;28(2):459–67. https://doi.org/10.1016/j.wasman.2007.02.
008.
Srinivasan R, Padmavathi R, Avinash Akolkar SS, Pitani
Ravishankar TV, Subhashini A, Kalpana B. Respiratory functions
of conservancy workers working in solid waste management sector
of Chennai, India. F1000Research. 2012;1:1–9.
Van D, Van L, Por I, Hardeman W, Meessen B. Out-of-pocket
health expenditure and debt in poor households: evidence from
Cambodia. Tropical Med Int Health. 2004;9(2):273–80.
Yang CY, Chang WT, Chuang HY, Tsai SS, Wu TN, Sung FC.
Adverse health effects among household waste collectors in
Taiwan. Environ Res. 2001;85(3):195–9. https://doi.org/10.1006/
enrs.2000.4235.
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