Prevalence and risk factors for work-related musculoskeletal disorder among female domestic workers employed in private homes in South India: A cross-sectional study

INTRODUCTION

Female domestic workers (FDWs) are a substantial group of the informal working population employed in a “hidden” nature of work in private homes.^[1] In 2010, the International Labour Organization (ILO) estimated that 52,000,000 women and adolescent girls are employed as live-in or live-out domestic workers in private houses. In addition, the National Sample Survey Organization has reported that 4,200,000 women residing in urban slums were employed as domestic workers during 2004–2005 in private homes.^[2]

FDWs remain outside the region of policy-making on social and labor issues and have been largely restricted to the informal economy. These women are unreached by any conventional policies as they work behind the closed doors of private households and are shielded from public view and attention.^[3] This “urban women’s workforce” faces several health issues not only in their homes but also at their workplaces.^[4]

Studies have shown that poor living conditions, lack of basic facilities, and stress influence the physical health of women leading to poor appetite, lack of sleep, increased blood pressure, and fatigue. Domestic workers are involved in monotonous, repetitive, and backbreaking tasks by performing household chores as a worker in their homes as well as in private homes.^[5,6] These factors increase their hardships by paving the way to adverse health and crisis in their reproductive health, which is economically crippling. In the case of chronic illness, these workers not only bear the burden of their medical treatment costs but also fall into job insecurity.^[7,8] Studies have reported that women’s general health and well-being are often not perceived as a high priority by either the women themselves or their families. Fear of job security also prevents reporting of work-related illness or injury to the employer.^[9]

A systematic review of the health of FDWs provides substantial evidence that the musculoskeletal strain and pain experienced by domestic workers were due to tasks such as lifting heavy objects or caring for elderly persons.^[10] There are scarce data on the work-related musculoskeletal disorders (WMSDs) of this marginalized group in workplaces. Hence, the objective of the study is to determine the prevalence of WMSDs when compared with non-domestic workers residing in urban slums of Bengaluru, South India.

MATERIALS AND METHODS

RESULTS

A total of 408 domestic workers consented to participate in the study with a response rate of 98.3%. Fear of the employer at the workplace restricted seven domestic workers from participating in the study. A comparative group of 408 non-domestic workers was recruited from neighborhoods of domestic workers.

Most of the study participants were from the working population age group of 25–45 years, 172 (66.4%) domestic workers, and 201 (49.2%) non-domestic. More than 61% (251) of domestic workers obtained an education of 5 or <5 years. The mean (SD) years of education attended were 4.19 (4.12) years in domestic workers and 5.65 (4.53) years in non-domestic workers. The mean (SD) family income of domestic workers was Rs. 7828.19 (2519.7)/month and for non-domestic workers was Rs.7245.10 (2441.5)/month. However, <5% (20) of the domestic worker’s families had an income of <Rs. 5000/month [Table 1]. Mean (SD) years of service of domestic workers were 10.77 (8.58) years [Table 2] and mean (SD) working hours were 6.12 (1.99) h. More than 86% (353) of domestic workers worked all 7 days a week without rest. Nearly, 50% (201) of domestic workers worked in more than three houses per day [Table 2].

Based on the ILO classification, domestic tasks performed by the study participant were grouped into five tasks, namely, house cleaning, kitchen cleaning, housekeeping, clothing care, and handling chemicals.^[15] House cleaning tasks involved activities such as dusting the roof, sweeping the floor, dusting windows, cleaning carpets, and cleaning pets. The mean (SD) hours spent per year on house cleaning tasks was 1266.1 (1021.2) by domestic workers and 251.6 (284.2) by non-domestic workers. Kitchen cleaning tasks involved activities such as cleaning the kitchen, cleaning the stove, cleaning the fridge, and washing dishes. Mean (SD) hours per year in kitchen cleaning tasks performed by domestic workers were 2166.1 (1825.0) and non-domestic workers were 483.8 (185.1) in [Table 3].

Psychosocial distress was reported in 89 (21.8%) and 94 (23%) of domestic and non-domestic workers, respectively. The mean (SD) was 10.83 (5.38) for domestic workers and 9.30 (6.45) for non-domestic workers [Table 1].

Self-reported neck pain over 12 months was reported among 80 (19.6%) domestic workers and 44 (10.8%) non-domestic workers. The domestic workers had twice higher odds of getting neck pain as compared to the non-domestic worker (OR = 2.0, 95% CI 1.4–3.0). Moreover, 97 (23.8%) domestic workers reported shoulder pain over 12 month periods and compared to the non-domestic worker they had a 1.6 times higher risk (OR = 1.6, 95% CI 1.1–2.2). Elbow pain over 12 months in domestic workers was reported among 49 (12%), which is 2.4 times higher than the risk of getting elbow pain in non-domestic workers (OR = 2.4, 95% CI 1.4–4.0). Upper back pain and ankle pain over 12 months was 1.5 (OR = 1.5, 95% CI 1.1–2.1) and 2.1(OR = 2.1, 95% CI 1.5–3.0) times higher in the domestic worker than the non-domestic worker, respectively. These differences were statistically significant at P < 0.05. Wrist pain had a reportable risk but was not statistically significant at <0.05. Lower back pain and knee pain were significant at <0.1. Pain in the hip was higher in non-domestic workers than in domestic workers [Table 4].

Further, analysis was done to find the risk factors associated with WMSDs among domestic workers. Pain in the neck (OR 1.7, 95% CI 1.0–2.8), shoulder (OR 3.6, 95% CI 2.2–5.9), elbow (OR 2.1, 95% CI 1.1–4.0), upper back (OR 2.2, 95% CI 1.4–3.3), lower back (OR 2.2, 95% CI 1.4–3.5), knee (OR 5.4, 95% CI 3.5–8.5), and ankle (OR 1.7, 95% CI 1.1–2.7) were significantly (P = 0.05) at a greater risk for more than 10 years of service among FDW’s. Significant high risk in the neck (OR 1.9, 95% CI 1.2–3.1), shoulder (OR 1.8, 95% CI 1.2–3.0), and upper back (OR 1.5, 95% CI 1.0–2.3) were reported among domestic workers with more than 36 years of age than the younger age of 18–35 years [Table 5].

A multivariate binary logistic regression was performed to assess the effect of age, years of service, psychosocial distress, hours per year of house cleaning, and clothing care tasks among domestic workers with neck pain and lower back pain. In multivariate analysis [Table 6], domestic workers who were involved in the clothing care task for more than 1460 h/year had more than 2.4 times the risk to develop neck pain than domestic workers involved for <108 h/year (Adjusted OR 2.4 CI% 1.1–5.4). Similarly, domestic workers involved in clothing care for 1459–109 h/year had twice the risk of developing neck pain compared to the workers involved <108 h/year (Adjusted OR 2.0 CI% 1.0–4.1). Domestic workers with lower back pain [Table 7] reported distress of 2.13 times significantly higher than domestic without lower back pain (Adjusted OR 2.1 CI% 1.3–3.6). These were all statistically significant at P < 0.05.

DISCUSSION

Domestic workers’ job involves cleaning, cooking, and caring for children and the elderly at their employer’s home. Each type of task has its inherent risks and exposure factors that influence the musculoskeletal and reproductive health of the worker. To date, minuscule data are available on the WMSD among FDWs employed in private houses.^[16] Our study was the first of its kind in our country to assess the WMSD issue among an informal group of employees.

Both domestic and non-domestic workers were of a comparable age group with a median age of 35.94 years and 36.68 years, respectively. More than 65% of the domestic worker belonged to the working population age group between 25 and 45 years. More than 60% of the domestic workers had an education <5 years, implying that women with low education take up jobs like domestic workers in urban cities. The most interesting fact is that more than 50% of our domestic workers’ family incomes were above Rs. 10,000 and it should be attributed to the contribution made by the domestic worker toward the economic growth of their family.

The housekeeping and kitchen cleaning tasks were the most repetitive tasks performed by the study participants. The median hours spent on performing house cleaning tasks were 936 h/year, kitchen cleaning tasks were 1709 h/year, housekeeping tasks were 1338 h/year, clothing care were 730 h/year, and handling chemicals were 730 h/year. These results are in parallel to the occupational history data collected by Medina-Ramo et al. 2003 in her study, which was reported in times per year.^[17]

A higher prevalence of WMSD’s was reported as knee pain (38.2%), upper back pain (31.9%), lower back pain (27.5%), ankle pain (26%), shoulder pain (23.8%), and neck pain (19.6%) in domestic workers. This can be ascribed to the repetitive nature of movements performed, while doing domestic tasks at home and work such as sweeping the floor, dusting the roof, mopping the floor, and washing the clothes using both hands. In 2009, a qualitative study by Ahonen et al. reported more frequent muscle strain and back pain in FDW.^[18] A systematic review of the health of FDWs has attributed to the nature of work performed by the domestic worker and its association with WMSDs. In the review, musculoskeletal strain and pain were experienced by domestic workers due to tasks such as lifting heavy objects or taking care of elderly persons.^[10] However, age, gender, and physical work conditions may have a confounding effect on WMSDs.^[19]

In 2011, Bihari et al. studied musculoskeletal pain among women aged 10–70 years in the general population in the villages of the National Capital Region, India. These women were involved in agriculture, dairy work, labor, and those involved in household chores. Our study participants had a higher prevalence of WMSDs compared to that of women in the general population.^[11] Similarly, the prevalence of lower back pain among Dutch women was more or less parallel to our study group.^[20]

FWDs with more than 36 years of age and more than 10 years of service had a positive association with almost all joint pains in the univariate logistic regression analysis. This substantiates other work of the literature published on the degeneration of physical function, where workers above 45 years of age and more years of exposure to repetitive ergonomic hazards have a higher risk of WMSDs.^[9] Increased hours of involvement in house cleaning (Adjusted OR 1.3 CI% 0.6–2.8) and clothing care (Adjusted OR 2.4 CI% 1.1–5.4) tasks had a significantly higher risk of association with neck pain after adjusting for the effect of age and years of service among domestic workers. This can be attributed to the monotonous repetitive nature of work at home and workplace performing overhead activities with the neck and shoulder and also maintaining the head in an upward position to clean the ceiling.

Similar to other studies such as Akrouf et al. 2010, our study has also reported a significant association between low back pain and psychosocial stress among domestic workers.^[21] This can be due to the combination of high demanding jobs (poor work pace and increased time pressure) and low job control among domestic workers.^[22] The other possible reasons could be the intimidating working environment, job insecurity, prolonged working hours, and extra working hours in more private homes by a domestic worker.^[23-25]

CONCLUSION

Neck and lower back pain were significantly due to house cleaning and clothing care tasks, respectively. These tasks need to be performed with the necessary adaptation and precautions in a workplace setting. A better understanding of the FDW’s WMSDs can help bring awareness and be a source of information for employers, policymakers, and government officials to encourage the implementation of social security schemes for FDWs in the future.