Chapter 2 Review of Literature - Information and Library...

Chapter 2 Review of Literature

Health problems of Industrial working women in Ernakulam District: An Economic Evaluation 23

The research in Occupational Health (OH) gained momentum since the last

two decades. Much of the work has been done in the developed countries, and only a

few studies have been conducted in developing countries like India. Out of them,

some studies confine to certain area while, some others cover a particular aspect.

Moreover, whatever studies have been conducted in this field are scattered and spread

over given periods of time. An attempt has been made in this chapter to review the

available literature relating to various aspects of the employed women’s health

hazards. Review of literature helps to know the works that have taken place so far in

the field concerned and the relevance of the present work. Review should motivate the

view by stating that prior literature review justifies the study, puts it into context and

also acquaints the researcher with the phenomenon under study. The literature study

sensitized the researcher to the relevant content in the literature. After the research

findings have been analyzed and interpreted, they can be related to the existing

knowledge in the literature about the phenomenon under study (Talbot 1995; 430).

Scientific technology and information is growing rapidly by the addition of

new material every minute, on top of a great edifice already constructed by earlier

researchers. Therefore, before beginning any new project or any new area to study, it

is essential to find out the works already accomplished in the field and the present

status of the study. A large number of studies were conducted on the health problems



different industrial sectors. The overall review is made under the following three

heads, as 2.1, 2.2 and 2.3.The study on gender disparity in occupational health

discussed under the head 2.1, the work environment and occupational diseases among

the women workers are discussed under 2.2 and the cost of illness study of work

related diseases among the labour force is discussed under the head 2.3.

2.1 Gender Disparity in Occupational Health

Gender represents a set of complex relation and historically determined social

processes, modified by social responses from time to time (Ashokan and Ibrahim,

2008). In particular, gender differences and discrimination have become an issue of

concern in the provision and utilization of health care services. Formal and informal,

traditional, non-traditional, paid and unpaid work plays an important part in

determining women’s and men’s relative wealth, health, power and prestige. This

generates gender inequalities in the distribution of resources, benefits and

responsibilities. The workplace can be a setting where gender inequalities are both

manifested and sustained with consequent impacts on health.

All over the world, women and men suffer discomfort, disease, injuries and

death from their work. Male – female differences in education, socialization and

upbringing may lead to differences in the way workers manage their illness

(Alexanderson, 1998) their perception of risk (Gustafson, 1998) and the propensity to

take leave or to seek treatment (Alexander et al, 1994, 1996). These effects, coupled

with exposure differences and consequent differences in types of illness, may explain

why women’s work related sick leave lasts longer on the average than men’s (Islam et

al, 2001).

Relatively rigorous criteria were used for selecting component studies. Selected

occupational attributable risks identified by Nurminen and Kajalainen in 2001

included 18percent for asthma, 12percent for chronic obstructive pulmonary disease

and 17percent for cardio vascular diseases. It also calculated that 4percent (1800) of

all the deaths in 1996 were attributed to occupational factors. They estimated that the

number of occupational deaths was larger than those for suicide (1947) or diabetes

(593).However, two biases could have affected the findings. First is the criteria by



which occupational exposure were accepted as causes of diseases and second is the

dichotomous classification of exposures (present or absent), when for almost all

hazards, the risk may vary according to the intensity and duration of exposure.

The key findings of a report published by European Union-OSHA in 2003

addressing “Gender issues in safety and health at work” show the broad range of

specific points and topics that are linked to gender aspects in health at work. The work

was done by Kauppinen, Kumpulainen and Houtman in cooperation with other

European OSH experts. Musculoskeletal disorders are very commonly encountered in

certain occupational sectors that employ predominantly women/ eg, nursing, assembly

lines) and are considered to be one of the major causes of absenteeism and morbidity

among the female working population. Although this condition may manifest through

a variety of syndromes(lower back-pain, carpal tunnel syndrome, shoulder bursitis,

etc), it is well known that a number of factors related to activities in the workplace or

specific tasks, are highly associated with the development of musculoskeletal

disorders in different parts of the body.(Polyehronakis et al. 2008: 43)

In a 1989 study of a major Swedish industrial company Frankenhauser et al

recorded physiological and psychometric stress indicators in a group of employees at

middle management level who did work which could be considered as mentally

stressful. It appeared that the women took longer to recover after work than men. This

was interpreted as reflecting the difficulties of the women, due to home and family

commitments, in securing the necessary recovery time at the end of their working day.

Occupational Health is to assure as far as possible every working man and

women in the nations safe and healthy working conditions and to preserve our human

resources (OSHA, 1982). According to the findings of the study by the NIOH,

Ahmedabad, the main hazard in the beedi industry is tobacco dust, which was found to

cause, among others, burning of the eyes, conjuctivits, rhinitis, mucosal dryness,

occupational dermatitis, bronchitis and emohysema. (NIOH, 1994)

In less developed countries, there are numerous hazards and regulations may be

non-existent or ignored (Takaro et al, 1999). For example, in Maquiladoras industry in

Latin America, women are exposed to chemicals, ergonomic hazards, noise and stress



(Cedillo et al, 1997). In one study, 17percent of women had a cumulative trauma

disorder diagnosed on physical examination (Messarvy et al, 1997). Almost twice as

many women as men reported such disorders.

Investigation related to the gender differences in respiratory findings by

occupation was the main purpose of the study conducted by Neil Schacheter et al in

2009. Result of the research reveals that there was high prevalence of acute and

chronic respiratory symptoms in all the ‘dusty’ studied groups compared to controls.

Significantly less chronic cough, chronic phlegm as well as chronic bronchitis was

found among women than among men after the adjustments for smoking, age and

duration of employment.

Women faced unique challenges in the occupation arenas, because of their

gender and were caught in a conflict between sex role expectations of fulfilling one’s

occupational potential. This may be the main reason that women often select

occupations that are more compatible with family roles are the main content of the

study done by Farmer et al in 1971.

There is an important link between women’s status and population parameters,

such as fertility and infant child mortality. O’Nell (1979) centered his work on the

health status of women. His study highlights that the health status of women reflects

their mental and social conditions as affected by the prevailing norms and attitudes of

society as well as their biological and physiological problems. Frequent and closely

spaced child bearing and heavy workload on women are regarded as major causes of

poor health status of women.

Employment outside the home is an important source of social support and

self-esteem and helps women to avoid social isolation in the home (Romito, 1994,

Razavi, 2000). Many jobs, especially those available to women in low income

countries or to poor, less- educated women in high-income countries, expose women

to harmful working environments.

There are so many studies related to occupational hazards and their effects

among women by Karl Messing and Evert. An early study by them in 1983 looked

into the work conditions and related health effects in male and female job ghettos in



fish processing plants in Quebec, Canada. They concluded that women were generally

required to work at a faster rate than men, with their additional responsibilities at

home such as housework and taking care of children having synergistic effects on

their health. Significant gender related lung function differences occurred in the textile

industry but not in the food processing industry or among farmers.

In general, women are exposed to some psychosocial risk factors at work, such

as negative stress, psychological and sexual harassment and monotonous work, more

often than men has been revealed through the study of Arcand et al, in 2000. Due to

their low status in the work hierarchy, women exert less control over their work

environment, a condition associated with cardiovascular, mental and musculoskeletal

ill health (Hall, 1989). Brisson et al, 1999 concentrates on the combination of paid and

unpaid work affects women’s health. Consequently, work related fatigue, repetitive

strain injury, infections and mental health problems are more common among women

than men according to Ostlin,2000.

Due to health and nutritional condition, nearly half a million maternal deaths

occur each year in developing countries. This unequal treatment makes women more

vulnerable to disease. This is particularly true in poor countries where deaths from

infectious disease are preventing (Breydon and Chant, 1989). Congruously, the high

rates of fertility and infant child mortality deplete women’s health. Repeated

pregnancies lead to severe anemia, frequent illness and in many cases maternal deaths

(Royston E, 1978; Seager and Olson, 1986; Kazl, 1989). Royaton’s study in 1978

reveals that two-thirds of women in Asia, one-half of women in Africa and one-sixth

of Latin American women are anemic.

A study conducted among the floricultural workers in Colombia reported the

adverse health effects of pesticide exposure include poisoning, cancer, skin diseases,

abortions, premature births and malformed babies (Restrepo et al, 1990). It also

noticed that the pesticides and chemicals are also widely used in high income

countries, where agricultural women workers are often excluded from occupational

health and safety legislation.



A Swedish study reveals that women and men are often offered different

rehabilitation measures for similar work related health problems. Men, more often than

women, receive in their rehabilitation programme, and women receive rehabilitation

benefits for a shorter period of time than men (Backstrom, 1997; Burell, 2002).

Women in non-traditional jobs are at special risk; those in traditional jobs are

also subject to discrimination on the basis of sex. In both situations, women may be

reluctant to argue for full protection for their health, especially where the health

problems concerned imply male/female differences, whether social or biological. It

has been shown that women in food processing in France and Canada subjected to

cold and or to irregular schedules have specific, sometimes incapacitating problems

associated with their menstrual periods. (Mergler and Vezina, 1985; Messing

et al, 1992, 1993).

A study conducted specifically to investigate the gynecological health

problems experienced by the women beedi workers in Indore found that all but one

woman worker reported some kind of problem. Exhaustion and dizziness werethe

most common problems. In addition, an earlier study had reported frequent

miscarriages among women beedi workers. (Patel, 1994).

A study dealt with health hazards in hospital setting in Mumbai, observed

certain effects on the predominantly female nursing staff. They contracted certain viral

infections like rubella while working in the infectious disease hospital. If the nurse is

pregnant, the fetus can be deformed or have a hearing impairment, etc. Hepatitis B or

HIV contracted easily especially in casualty wards where emergency cases were also

handled. Exposure to radiation in the X –ray laboratory during orthopaedic surgery

etc. needle pricks in the blood bank or while giving injections, and autopsy rooms all

come with their own set of health hazards. (Parhar, Maya 1997).

There are only a few studies conducted on the topic of Occupational Health in

Kerala. A comprehensive study by Narayana in 2004 points out the fact that in rural

Kerala has higher levels of reported illness (about forty percent higher) compared with its

urban population, which is another exception among the Indian states. Moreover, rural

Kerala records higher levels of both chronic and acute morbidity across all age groups.



A study on the health status of people in rural Kerala by A Ashokan and P

Ibrahim (2009) reveals that three fifths of its female population suffers from illness

related to chronic morbidity.

2.2 Work Environment and Occupational Diseases among the Women

Workers

Working conditions have greatly evolved in recent decades in developing

countries. This evolution has been accompanied with the appearance of new forms of

work organization that may be sources of stress and health risk for labour force. As

population are growing, these issues are particularly worrying in terms of the health

and health care expenditure. A look at the economic literature on the relationship

between working condition and health reveals that it has two distinct strands, not

opposite just parallel. One argument is by labour economists. Freeman (1978) said

that “subjective variables like job satisfaction which economists traditionally view

with suspicion contain useful information for predicting and understanding behavior,

but that they also lead to complexities due to their depending on psychological states”.

But afterwards, working conditions have been included in different economic analyses

through their impact on the health of individuals (see Faragher, Cass and Cooper

(2005) for a large review not only economic). Case and Deaton (2003) question the

evolution of health during the life cycle, and the influence of education, employment,

income and working condition in this evolution. They use the intertemporal model of

health capital put forward by Grossman (1972), which analyses the health level and

deterioration rate during the life cycle. The underlying idea of this representation is

that deterioration of health capital is a biological process, but that characteristics

related to consumption, healthcare and more generally living conditions, act on this

capital and its deterioration over time. This deterioration can depend on working

conditions. In this model, health status is explicitly linked to current and past working

conditions. This representation thus puts forward the idea that health status at the end

of working life results from current working conditions, as well as all previous work

(Currie and Madrian, 1999; Blanchet and Debrand, 2008), labour turnover (Clark,

Georgellis and Sanfey, 1998; Souza-Poza and Souza-Poza.2007),wages (Clark and

Oswald,1996).



Second strand of literature reflects the growing interest in the impact of

working condition on individual health status. According to the model of Karasek and

Theorell (1991), workplace organization determines some of the psycho-social

characteristics of work, which themselves have an influence on the health of the

workers. The authors develop the idea that a low level of control combined with a

strong demand represents a risk for health. They make the hypothesis of an intrinsic

effect of the work organization on health that is different from the individual’s own

characteristics. They show, for example, a high prevalence of symptoms of heart

disease among people who say they have both a low level of control and a high level

of demand. Other studies have shown the influence of these factors on the risk of

developing heart disease (Bosma et al, 1998) or mental illnesses (Stansfeld et al,

1999) and on the self-reported health status (Ostry et al, 2003).

California Occupational and Environmental Health Centre (COEH) conducted

several researches on the work environment and the physical health risk of

individuals. A study done by them says that a variety of work place physical

exposures (noise, heat, cold, heavy lighting) and chemical exposures(lead, carbon

monoxide, carbon disulfide) increase the risk of cardio vascular diseases. The

evidence that psychosocial work factors are an important cause of CVD among men

and women is strongest and most consistent for job strain.

The Indian Toxicology Research Centre studied the incidence of skin disease

among the workers in the tan yard was very high as compared to those not working in

the tan yard. This study was conducted among 266 tannery workers using case control

method; 166 tanneries formed the case while 99 workers of the same factory but in

different departments formed the control group. This study done by Parikh in 1984 has

confined itself to identifying the skin diseases to the exclusion of all other diseases.

With technology replacing human labour, peripheral production is left to the

human hands of women, making them vulnerable to double burden of domestic and

paid work. Dungo in 2001 point out the shift to technological production in the

manufacturing industries also has an implication to subcontracting work or home

work. Another study of Lu in 2004 make sure that women workers in the electronic

sector had high blood lead levels and experience work stress, musculoskeletal



disorders and carpal tunnel syndrome. A study by Mahoney in 2010 says that female

electronic workers on 8 hour as well as 12 hour shift schedules reported complaints of

sleep problems and tiredness.

The European Foundation’s (1996) Working Conditions Report indicated that a

high proportion of workers across the European Union work long hours (49percent

work more than 40 hours per week, and 23percent more than 45hours). The data also

revealed that health problems (stress and back ache) increased with the hours worked.

Compressed work weeks, with 12 hour working days, have been associated with

feelings of increased fatigue (Rosa and Colligan, 1986). Rosa et al (1989) have shown

that after seven months adaptation to a 3-4 day/12 hour rotating shift schedule there

were reductions in sleep and decrements in subjective alertness compared to previous

work on a 5-7 day/8 hour schedule. The increases in self reported stress which also

occurred were attenuated by the shortened work week.

Feminization of workforce in industries in the Philippines specifically in

garment manufacturing, microchip, computerized manufacturing and electronics

industry, operating inside export processing zones reported certain occupational risks

and disbenefits to these women workers including low salaries and deficient

enforcement of health and safety regulations has been pointed out by Edralin and

(2001) and Estrella – Gust(2000).

Nearly a quarter of workers report suffering headache or/ and muscle pain in

shoulders/neck or/ upper and lower limbs related to their work. These perceptions are

linked to known risk factors for electronic equipment assembly, and supermarket

check - out staff. What all these occupations have in common is that (excessive)

repetitive movements of the upper limbs are required to perform their work tasks

(Schneider and Irastorza 2010: 37).

Difficult working condition are detrimental to health, reduce the productivity

of workers, increase their absenteeism rate and the probability of them losing their job

and incite them to leave the employment market as soon as possible has been revealed

through the study of Blanchet and Debrand in 2005. Focusing on hours of work,

Spurgeon, Harrington and Cooper’s(1997) research analyses that there is sufficient



evidence to raise concerns about the health risks of long working hours(over fifty

hours per week). This is despite, the well-known fact that prolonged exposures to

physical risk factors are strongly associated with musculoskeletal disorders (Bernard,

1997). Shift work has been well studied and results show physical health problems of

fatigue (Johnson, 1997), sleeping, eating and/ or digestion problems, higher accident

rates at work(Simon,1990,) coronary heart disease(Tenkanen et al,1997) and, mental

health and relationships problems(White and Keith, 1990).

In 1956, an epidemiological study in the cotton industry in the United

Kingdom documented the occurrence of respiratory problems like byssinosis

(Schilling, 1956). There are few studies on respiratory problems among cotton textile

workers in India (Murlidhar et al, 1995; Mathur et al, 1993; Barjatiya et al, 1990;

Jaiswal, 2004). Murlidhar et al, (1995) examined 273 cotton textile workers in

Mumbai and found that 54 of 179 workers (30percent) in dusty situation and 16 of 94

workers (17percent) in non-dusty sections had respiratory problems.

A study conducted in call/contact centers in the Philippines by EILER (2009),

reported that women workers usually worked at night to coincide with the regular

business hours of their clients in Northern America or Europe. Unfortunately, this

work schedule for call center women workers had been documented to cause negative

impact on health such as sleep disorders, eating disturbances, and gastrointestinal

diseases. Another study of the same researcher in call centers revealed certain

occupational health risks such as graveyard shifts, long working hours, period of break

time, very cool temperatures in work area, irrational behavior of customers and high

work stress. Majority of these workers experienced sleeping problems, eye strain,

overall fatigue, headache, chest and back pains, voice problem and mental stress.

In the electronics industry, about 57 Filipino women were afflicted by Stevens

Johnson Syndrome (SJS) in Taiwan (OHSC, 2002). Another study consisting of 399

female workers in a semiconductor manufacturing industry showed related

reproductive health problems among women(OHSC,2002) and that women often

complained of symptoms related to respiratory and skin disorders(OHSC,2002).



Work related disease often have a long latent period (Nelson et al, 2005;

Nurminen and Karjalainen, 2001) and might be the result of different work related

factors like working time(Caruso et al 2006) and workload (Akerstedt et al, 2004;

Hamet and tremblay, 2002).Exposures occurring now usually lead to ill health in the

future. This is because wither the level of exposure is underestimated or the risk posed

by exposures (Single or Combination) is not properly recognized ( Morrell et al,1998).

Several studies of occupational health has been conducted in Latin American

Countries to investigate many types of occupationally related chronic diseases, since

workers who become sick generally leave the work force, the latency period before

the diseases are manifested clinically are long, and in many cases, the diseases do not

develop until after the worker has retired was the result of the study done by

Hernsberg S, in 1981.

An environmental hygiene study of 41 small scale ceramic industries in Gujarat,

India reports that the dust concentration markedly in excess of the threshold limit value

(TLV) (ACGIH, 1989) with about 80 percent of particles found to be of reparable size

was the result of the study done by Parekh et al in 1982. Another study discussed by

Phoon et al in 1984 with the same fact that five out of six stone quarries were far in

excess of permissible dust levels and thus the poor working conditions are seen in a high

percentage of small industries. This study belonging to fourteen different types of

industries in Singapore, had found working conditions to be very poor.

Women’s increased participation in paid employment not only strengthens

their social status and their individual and family’s financial situations, but also is

beneficial to their mental and physical health (Waldron et al, 1998). A study from the

Philippines showed that women who engaged in paid work improved the quality of

their diets (Bisgrove and Popkin, 1996). Despite this general observation, many jobs,

especially those available to women in low-income countries or to poor, less-educated

women in high-income countries, expose women to harmful working environments.

Another study that looked at the prevalence of Bysinosis- an occupational lung

disease among workers in a Cotton mill in Managua, found that female workers had a

much higher prevalence than male workers (Valazquez et al, 1991). This result was



attributed to different exposure between sexes in both workplace and non-workplace

setting.

An important study on working conditions and labour welfare of three different

units i.e., Birlas, Tatas and Larson and Turbo in the areas of manpower management

shows a clear picture regarding the occupational health hazards like dust and gas.

Birla management expressed that due to high temperature workers abstain from duty

during summer. Such a complaint comes from the foundry section of L & T.

However, in OPM the workers complained about poor physical conditions of work.

All the 3 units have appointed safety officers as required by the Factories Amendentment

Act 1976. However, it is L & T whose safety measure are distinguishable from the other

two units. The safety by A.K.Mahapatro and G.C.Patro in 1988 makes sure that health

measures and safety measures are important for an industry to survive in long run.

The Indo- Dutch Environmental and sanitary Engineering Project under Ganga

action plan in Kanpur and Mirzapur within the framework of Indo – Dutch bilateral

development cooperation has been identified occupational hazards among the weaving

population than in the comparison group. This study by Sukla, Das and Ory in 1991. It

is a cross- sectional study show the relationship between work related diseases and

other factors to which the working population is exposed in their working environment

is brought out. A socio economic unit (SEU) in the project supports technical

interventions by encouraging the community to participate in project activities.

Environmental hygiene was undertaken to assess dust exposure risk in Slate

Pencil industry situated in Central part of India. The Study done by Ghodasara,

Rathod, Sathawara, Saiyed, Parikh and Kashyap in 1991 shows that at certain working

locations, total airborne dust concentration was observed in the range of 7.43 to

117.00 mg/m3 and reparable dust concentration was observed 4.08 to 18.39 mg/m3,

these values are many times higher than the threshold limit values (TLV) of silica

bearing dust. An exhaust system was installed on cutting machines to control the dust

pollution. After the installation of this system total airborne and respirable dust levels

were reduced remarkably.



One of the earliest investigations on work conditions of women in export zones

in the Philippines says that the risks and unfavorable work conditions such as hazard

exposure, wage violations and harassment by management has been done by Aganon

in 1994 and a subsequent study in 1997 noted that adverse working conditions such

as night shifts, fixed overtime work, health and safety problems, lack of reproductive

rights, sexual and verbal harassment by employer, exposure to hazards and weak or

absence of labour organizing in the export zones.

A cross-sectional study shows the relationship between disease and other

factors to which the working population is exposed in their working environment is

brought out. This study conducted by Sukla, Kumar and Ory (1991) found that greater

occupational morbidity among tannery workers when compared to non-tanning

operations.

A higher level of nutritional stress among the working women in Utter Pradesh

in India reveals that the household chores are much more labour and energy intensive

in the typical Indian (especially rural) setting and the additional demands of outside

work cannot but add to the physical strain has been revealed by Khan et al in the year

1988.

A study of the health status of Kerala state (Panikar and Soman, 1984)

highlights that respiratory and skin infections, diarrheal disorders and hook work

infestation are much more prevalent in the coastal areas of the state.

Exposure to physical hazards such as noise and shift work among pregnant

women was associated with lesser birth weight and the elevated risk of spontaneous

abortion for shift work in general, rotating or changing schedules and night work is

the result of the study conducted by Nurminen in 1995.

A study conducted in the construction industry reveals that mental or physical

job demands, low job control, and lack of social support at work have direct and

synergistic effects on burnout. This study is based on the Demand-Control –Support

model(Johnson and Hall, 1988) and expanded by hypothesizing that burnout mediates

the relationships between the potentially demanding working conditions on the one

hand, and health complaints on the other.(Janssen, Bakker and De Jong, 2001).



A high prevalence (63percent in men and 48percent in women) in cardroom

workers of Lancashire Cotton Mills processing coarse cotton reveals from the study

that the occurrence of the disease is explained by the type of cotton processed,

concentration of cotton dust in the work environment, duration of exposure and

smoking habits has been explained by Reach and Schilling.

In 1981, Nicaraguan Physicians conducted an investigation into neurological

disease in Mercury exposed workers employed in a multi nationally owned Managua

ChloralkaliPlang; 56 (37 percent) out of 152 exposed workers exhibited symptoms of

Mercurialism. Women are however, relatively at ease in arguing for protection for

possible damage to their fetus from dangerous conditions (Turcotte, 1992). This may

be because protecting children is seen as an appropriate maternal role. Also, according

to an analysis of jurisprudence on reproductive hazards in Quebec, Canada, policy

makers are sensitive to safety issues for the fetus and take the view that “a pregnant

worker has a member of the public in her womb”(Lippel, 1998).

The work problems of female workers in garment subcontracting company,

which included low income seasonality and irregularly of work has been discussed by

Pined and Ofreneo in 1990. Lorenzo’s study found nerve conduction abnormalities

among battery workers exposed to lead. Ramos and Florencio conducted a study on

nutrient supplementation among 59 anemic women in a garment factory. In another

study, Santillan found that Government labourers suffered from infectious and

parasitic diseases. Among these, Tuberculosis was the greatest concern.

There are several studies conducted among fish processing workers about their

work related diseases. The important diseases among them are prevalence of skin

rashes, allergies and protein contact dermatitis (Jeebhay et al 2000), eczema (Veien et

al 1983), Raynaud’s phenomena in hands (Mackiewicz and Piskorz 1977), warts

(Kilkenny and Marks,1996) and occupational asthma(Rodriguez et al,1997) have been

reported among the fish processing workers. There are reports of musculoskeletal

discomfort (Olafsdottier and Rafnsson, 2000) among the workers.

A study done by Migrante (2010) reported that in the case of women migrant

workers, they are subjected to sexual and physical abuses, and maltreatment from their



employers. Additionally, women workers face double hazards from both their work

and household responsibilities, thus, increasing their vulnerability to occupational

illnesses. Another study conducted by the same author says that, women workers in

export processing zones complained of work hazard exposures, chemical exposures,

and musculoskeletal disorders due to prolonged standing at work, job security, work

stress and persistent fatigue.

In the light of these developments, this review tried to analyze the contemporary

nature and development of women’s work in view of occupational health.

2.3 Cost of illness Studies of Work Related Diseases among the Labour

Force

There is several cost of illness studies conducted in International context but

majority of the health expenditure studies in India covered the household health

expenditure both in rural and urban population and the general population. However,

health expenditure studies of workers engaged in various economic activities or by

occupational groups are scanty. The following section presents empirical evidence on

the extent of total costs of illness studies, direct and indirect cost studies, which gives an

overall view regarding the economic consequences of diseases and its impacts on

health.

From a gender perspective the time lost to productive activities is often greater

when women are sick. A study of people living with AIDS found that men lost an

average of 2,376 working hours(or 297 days) over a period of 18 months whereas,

women lost 3,432 hours(or 429 days) of productive time (Rugalema, 1998). This is

due to largely to the relatively long hours that women work, particularly when

household maintenance activities are included.

The methods for valuing the economic costs of occupational injury and illness

and found most studies tended to underestimate the true economic costs from a social

welfare perspective, particularly how they accounted for occupational fatalities and

losses arising from work disabilities has been revealed from the study of Weil(2001).

Many of the estimates of costs of occupational disease and injury depend on a

combination of methodological assumptions, extrapolation methods, and known and



unknown biases, Weil found that there were significant divergences between

theoretical and actual valuation in the area of occupational fatalities, workplace

disabilities and non workplace disabilities.

A study based on the data from the Commonwealth Fund’s 2007 Biennial

Health Insurance Survey in the United States reports that more than half of women

surveyed had problems getting care because of cost issues including skipping a needed

medical test, prescription medication or other treatment. It also shows that getting and

paying for healthcare is an even higher problem for women than for men. Health care

costs impact women to a greater degree than men in general, because women have

lower average income and higher out-of-pocket health costs than men.

The National Safety Council, using the Census of Fatal Occupational Injuries

(CFOI) for 1997, estimated the costs of occupational injuries to be Dollar 127.7

billion (NSC, 1998). This included wage and productivity losses of dollar 63.4 billion

medical costs of dollar 20.7 billion and administrative expenses of dollar 11.9 billion.

The main objective of the Babson’s (1973) study is to derive a methodology

for costing treatments. The study has outlined in considerable detail the methods of

attributing hospital resources to treatments in the given disease categories. The author

argues that the study justifies considerable optimism regarding the feasibility of

disease costing. The collection of cost data also affords considerable opportunity for

more general observations regarding the efficiency of hospitals.

Studies have shown that decrease in health status of population is associated

with increase in health expenditure. Barbara Wolfe and Mary Gabay(1987) studied the

relationship between health status and Medical Expenditures, using data from 22

countries over a period of 20 years from 1960 to 1980. The authors formulated a

simultaneous model using a variety of indicators of life style as well as health style.

The life style indicators included butter consumption Kg/per person/ year, Number of

persons injured in road accident, liver cirrhosis mortality by sex and consumption of

tobacco. The study showed that decline in health status increased the medical

expenditure. Further, the authors asserted that more persons working in occupation



that are risky to mean more health hazards and therefore, greater utilization of medical

care and high expenditure.

The first person to measure work accident costs in his studies of individual

accidents during the 1920s was Heinrich (1959). He used his work to argue that most

work accident costs are hidden, visible costs were termed direct costs and were said to

include insurance compensation and medical expenses. Hidden costs were termed

indirect costs, and these costs are linearly related so that indirect costs are typically

four times than direct costs.

The costs and economic benefits of maintaining patients on long term dialysis,

the costs and benefits for home treatment compared against the cost for hospital

treatment has discussed in an article written by Buxton M J and West R R in 1975.

The study was not linked to a clinical trial. Market values were used for the health

service costs. There was a large gulf between the long term maintenance

haemodialysis and the economic benefit.

A seminal work on catastrophic health expenditures in 59 countries published

by Lancet (Xuetal, 2003) indicated that there was wide variation in the proportion of

households facing catastrophic payments as the availability of health services

requiring payment, low capacity to pay, and the lack of prepayment or health

insurance. The authors concluded that individual, particularly poor households, can be

protected from catastrophic health expenditures by reducing a health system’s reliance

on out-of-pocket payments and providing more financial risk protection.

The Centers for Disease Control and Prevention (CDC) in Washington State

estimated that in 2003 the national costs of cardiovascular disease were £351 billion

comprising £209 billion for direct health care expenditures and £142 billion in indirect

costs associated with lost productivity from death and disability (Centers for Disease

Control and Prevention, 2004). This is equivalent to £360 billion in 2004£.

Also in 2003, the National Heart, Lung and Blood Institute (NHLBI) estimated

that the national costs of cardiovascular disease in 2004 would be £368.4 billion,

including £226.7 million for direct health care costs(personal health care expenditures

for hospital and nursing home care and physician and other professional services),



£33.6 billion for indirect morbidity costs and £108.1 billion for indirect mortality costs

associated with premature death (National Heart, Lung and Blood Institute, 2003).

This is equivalent to £378.21 billion in 2004£.

Another study from Burkina Faso (Su et al, 2006) identified the key

determinants of catastrophic health expenditure as economic status, household

healthcare utilization especially for modern medical care, illness in an adult household

member and presence of a member with chronic illness.

It is really a challenge to derive a methodology for costing inpatient treatment.

For this, Harper D R in 1979 considered only the changes in hospital resource use. All

patients passing through the professional surgical unit of the Aberdeen Royal

Infirmary in a six month period in 1971 were studied. The key to the measurement

procedure was the derivation of units of resource use for the different categories of

resources.

The main purpose of Cooper and Rice’s (1976) study was to indicate the costs

to society from different forms of illness. The economic costs of illness were

considered to be due to the direct resource treatment and the indirect costs or loss in

output due to disability and premature death. The study found that the total cost of

illness for 1972 was US dollar 189 billion at a 4percent discount rate.

There is considerable and clear evidence that the direct costs of healthcare

impose a far greater burden on poor families than on high income households. A study

in Thailand found that annual household direct costs were equivalent to 21.2percent of

annual household income in the lower income quintile, but only 2.1percent for highest

income quintiles (Pannarvothai and Mills, 1997).In this study, the greater relative

burden on poor households is not only attributable to the lower income levels, but also

to the lower insurance coverage in the lowest income quintile households (33percent)

compared with the highest income quintile (62percent).

A study conducted in Orissa, India based on the gender inequalities in

household health expenditure reveals that the per capita health expenditure, per capita

male health expenditure and per capita female health expenditure of rural Orissa are

46.34, 43.98 and 47.07 per cent of the PHE, PMHE and PFHE of urban area



respectively. It indicates that irrespective of sex and gender, urban people are

spending more than rural because of their high income and more consciousness about

health and they are more prone to illness due to environmental pollution

(HimanshuSekhar Rout 2005).

The empirical evidence shows that the costs of drugs often contribute a

sizeable share of direct cost. Drugs accounted for 62percent of direct costs of mild

malaria and 70percent for severe malaria in Ghana. (Asenso-Okyere and Dzalor,

1997). Similarly drugs contributed 63percent of the costs of treating lymphatic

filariasis in India (Babu et al; 2000). In the case of an average of all health care direct

costs; irrespective of type of illness, drugs accounted for 33percent in Srilanka

(Russell, 2001).

A ratio of 6:1 for the indirect to direct costs of work injury and diseases in

Quernsland, Australia has been estimated by Mangan in 1993. He calculated

production losses and other related costs, using a formulae developed by Andreoni

(1986) and net present value of future earnings losses, using a formulae developed by

Miller et al (1987). However, his analysis excluded social security costs, because

these transfer payments are not true economic losses, in the sense that they entail a

decline in Gross National Product. Newhouse (1994) argues that medical care expense

is inherently random and highly skewed, so that the appropriate solution is partial

capitation with reinsurance of high cost outliers.

A study conducted in two districts of Madhya Pradesh examined the direct and

indirect expenditures incurred by households on availing health care. The direct

expenditure in the study included doctor’s fees, medicines, diagnostic test,

hospitalization and surgery, while indirect expenditure included transportation cost,

expenditure on rituals, bribes and tips. The study pointed out that households in rural

and urban areas spent as much as 30percent and 32 percent respectively of their per

capita consumption of non-food items alone and of which, health care comprises

8.95percent and 10.5 percent in rural and urban households respectively. The

proportion of direct to indirect expenditure is estimated as 81:19. Among the direct

costs, the study found that doctor’s fees and medicine constituted 91percent has been

revealed through the study of Alex George and Sunil Nandraj in 1995.



An estimation of the personal cost of illness from five major water related

diseases in Uttar Pradesh shows the per capita costs, which included loss of

productivity besides treatment costs were estimated as Rs.73.53 for enteric fever,

Rs.53.33 for acute diarrheal diseases and Rs.73.64 for Conjunctivitis. The loss of

income was found to be high in the case of conjunctivitis(Rs.68.73), followed by

enteric fever(Rs.56.63) acute diarrheal diseases(Rs.48.46), Scabies(Rs.10.96) and

infective hepatitis(Rs.1.63) was the result of the study put forwarded by Verma and

Srivastava in 1990.

The public health care services were less successful in protecting patients

against the direct costs of acute illness requiring treatment outside the home because

people across income groups even from the poorest income quartile, preferred to use

private providers. The study was conducted in Sri Lanka by Russell (2005) also

reveals that in rural areas, income poverty is wider and deeper and the direct costs of

illness likely to be higher due to transport costs. Protection against medical costs is

therefore likely to be even more important for poverty reduction and livelihood

sustainability in rural areas of the country.

The inter-state variations in the utilization of health services for in-patient care

and has raised the important issue of the cost of treatment and the burden of treatment

that fall on the lower strata of people according to Krishnan T N in 1994. To him the

discussion of healthcare financing and provision include access to healthcare and the

quality of services, the importance of building stocks and capital formation in health

services, cost effectiveness and the role of technology in determining cost of health

care. Taking the average cost of treatment for each state based on the information

provided by the NSS, Krishnan has estimated the relative burden of treatment as a

ratio of average cost to the per capita state domestic income (only direct burden of

treatment).

Indirect costs differ considerably, both in absolute terms and relative to direct

costs, between different types of illness. Certain chronic illnesses can impose a

considerable burden on households. A study in India found that chronic lymphatic

filariasis patients lose up to 19 percent of productive workdays per year (Babu et al.

2002). Lost productive time costs are not only experienced by those who are ill, but



also by other household members. The burden on other household members can be

particularly severe in long term terminal illness such as AIDS (Hansen et al, 1998]. A

number of researchers have noted that the time costs of healthy household members

are often as large as the time costs of those who are ill. (Sauerborn et al, 1996 a).

From a gender perspective the time lost to productive activities is often greater when

women are sick. A study conducted by Rugalema in 1998 about the people living with

AIDS found that men lost an average of 2,376 working hours(or 297 days) over a

period of 18 months, whereas, women lost 3,432 hours(or 429 days) of productive

time. This is due largely to the relatively long hours that women work, particularly

when household maintenance activities are included.

A study in Netherlands estimated the indirect costs of back pain on the basis of

two approaches: the traditional view of human capital method and the modern view of

friction cost method (Van Tulder et al, 1995). The result of the study reveals that the

short-term indirect cost estimated by the human capital method were more than 3

times as high as the indirect costs estimated by the friction cost.

Indirect costs differ considerably, both in absolute terms and relative to direct

costs, between different types of illness. Certain chronic illness can impose a

considerable burden on households. A study in India found that chronic lymphatic

filariasis patients lose up to 19percent of productive workdays per year (Babu et al,

2002). Lost productive time costs are not only experienced by those who are ill, but

also by other household members. The burden on other household members can be

particularly severe in long term terminal illness such as AIDS (Hansen et al, 1998). A

number of researchers have noted that the time costs of healthy household members

are often as large as the time costs of those who are ill (Sauerborn et al, 1996 a).

The prevalence of ailments and hospitalization in Kerala was examined using

data from 52nd National Sample Survey Data on Health care in 1995-96. This survey

shows the burden of ill health was higher in rural areas and in urban areas. It also

points out that the people who were more likely to have a better lifestyle had a higher

level of morbidity and hospitalization and were seen some regional differences with

levels of morbidity and hospitalization higher in the comparatively developed regions

of Southern Kerala than in Northern Kerala.



A new concept of ‘potentially lost production’ as a consequence of disease,

whereby short-term absence and long term disability wound have spend in full

productivity revealed through the findings of Koopmanschap and Rutten in 1996. It

also reveals that generally indirect costs estimated on the bases of standard labour

wages which cannot be collected empirically.

The burden of occupational injury and illness is substantial among America’s

139 million workers. The National Institute for Occupational Safety and Health

(NIOSH) estimates that 3.6 million occupational injuries and illness are treated

annually in US hospital emergency rooms. Total direct and indirect costs estimated to

range between dollar 128 and dollar 155 billion. Health care expenditure tends to be

less than 10 per cent of household income on average has pointed out by Prescott and

Ranson in 2002. They estimate that 10percentof household income being consumed

by healthcare expenditure as the cut off point for catastrophic expenditure levels. An

empirical study of Leigh et al(2000) using 1992 data, estimates that the cost of

occupational morbidity and mortality was more than five times the cost of HIV/AIDS,

three times the cost of Alzheimer’s disease, 91percent of the cost of cancer, and

82percent of the cost of heart disease.

The Centers for Disease Control and Prevention(CDC) estimated that in 2003

the national costs of cardiovascular disease were dollar 351 billion comprising dollar

209 billion for direct healthcare expenditures and dollar 142 billion in indirect costs

associated with lost productivity from death and disability. This is equivalent to dollar

360 billion in 2004. Another study in 2003, the National Heart, Lung and Blood

Institute(NHLBI) estimated that the national costs of cardiovascular disease in 2004

would be dollar 368.4 billion, including dollar 226.7 million for direct health care

costs(Personal health care expenditures for hospital and nursing home care, drugs,

home care and physician and other professional services), dollar 33.6 billion for

indirect morbidity costs and dollar 108.1 billion to indirect mortality costs associated

with premature death (National Heart Lung and Blood Institute, 2003).

There is an estimation of 4percent (1800) of all the deaths in 1996 were

attributed to occupational factors. They estimated that the number of occupational

deaths was larger than those for suicide (1947) or diabetes (593). Relatively rigorous



criteria were used for selecting component studies. Selected occupational attributable

risks identified by Nurminen and Kajalainen in 2001 included 18percent for asthma,

12percent for chronic obstructive pulmonary disease and 17percent for cardio vascular

diseases. However, two biases could have affected the findings. First is the criteria by

which occupational exposures were accepted as causes of diseases and second is the

dichotomous classification of exposures (Present or absent), when for almost all

hazards, the risk may vary according to the intensity and duration of exposure.

A recent pilot study by the Bureau of Labour Statistics (BLS) in U S used a

cost of illness method to estimate the costs of fatal occupational injuries by state. The

study found such estimates would benefit safety and health professionals and aid the

overall education and prevention efforts aimed at eliminating workplace fatalities. The

direct and indirect cost of migraine headache in the U S are significant. In 1994, the

associated healthcare costs for migraine headache were approximately dollar 1billion.

Estimates range from dollar 17 billion in 1986 to dollar 13 billion in 1944 for annual

losses associated with lost workplace productivity secondary to migraine.

There are a number of Indian studies, which have estimated the direct and

indirect cost of specific chronic diseases. Shobhana et al (2000) calculated the costs of

diabetes among the sample population of Chennai and found that out-of-pocket

spending due to diabetes during hospitalization was INR 5,300 per event. Further,

Murthy and Sastry (2005a) estimated that the direct and indirect costs of treatment of

COPD in Hyderabad district of Andra Pradesh found that treatment costs for a patient

with severe COPD was nearly INR 33,000 in 2001.

In India, the relative role of household income in influencing health

expenditure was documented by many studies. For instance, Ravi Duggal and

SuchetaAmin (1989) carried out a study in Jalgaon district of Maharashtra to find out

how much the common person in India spent from his or her own pocket when they

fell ill. The under five population and the elderly population has the highest morbidity.

In absolute terms, the per capita expenditure on health care for the high income

households was found to be 8 times greater than the low income households,

However, Yesudian (1988) in his study in Madras, showed that the small amount

spent on health care by the lower strata formed a bigger percentage of their total



income. D.K.Mishra et al (1993) in their study in Madya Pradesh too showed that

household health expenditure formed only 2 per cent of income of comparatively high

income households, the expenditure on curative care formed 10 per cent of their

income. These findings are supported by the studies of NCAER (1992; 1994;and

1995). The study showed although the relatively richer spent considerably more but

they spent only about 3percent of their annual income on health care. On the other

hand the poor spent about 9-12 percent of their household income.

It has to be kept in mind that in a healthcare system like Kerala, out-of-pocket

payments constitute the bulk of health expenditure. This has been recognized by

Kunhikannan and Aravindan (1996), who, based on a micro survey of household for

the years 1991 to 1994, found that the increase in the per capita total expenditure on

medical care was twice that of the increase in general consumption expenditure.

Another study conducted by the same in 2000 based on a survey of 5000 individuals

in Kerala, found that medical expenditure per morbid person per episode had

increased a growth of 89.8 percent over a period of 8 years. They coined the term

‘mediflation’to describe this large increase in medical expenditure.

A study done by Dembe (2001) provides an extensive list of non-economic

consequences for the injured or ill worker, although many of these will have some

financial cost associated. Dembe cited some studies which found injured workers face

significant disruption in their working lives and in their subsequent labour market

experiences. The study reveals that the longer the delay before injured or ill workers

return to work, the greater the impact on work quality, motivation, satisfaction and the

ability to handle job responsibility compared to those missing less than one week.

Dembe also found studies that used economic analysis to show indirect costs

associated with lost productivity far exceed direct health care expenditure for injuries

and illnesses, However, Dembe concluded that cost studies are hampered by an

absence of a standardized assessment tool for measuring the impact of an injury or

illness on work activities.

Isolated attempts have been made to relate the incidence of occupational

diseases to socio economic factors or examine the nature of health care expenditure of



workers. (Sarkar et al. 2003b). The Study reveals that the poor health of the mine

worker will necessitate a correspondingly large amount of expenditure on health care.

To measure the burden of disease in terms of the number of days lost due to

illness and the costs incurred by the households through cost of treatment and through

loss of household income has made by an attempt by Krishnaswami P in 2004. The

study concludes that acute morbidity is the major cause in the total number of days of

work lost and that the average cost of treatment of acute illness is high among the

households.

2.4 Conclusion

It is evident from the above analysis that there are many studies which have

been undertaken about the economic consequences of general population as well as

work related diseases among women workers at international level, but very few

studies conducted at national or regional levels with an economic perspective. The

subject area and findings of the above studies reveal that there is a noticeable absence

of research work on the economic consequences of the physical ailments of working

women in traditional and nontraditional industrial sectors especially at the regional

level. Therefore, the present study, which is a moderate attempt in this direction,

assumes significance.

Chapter 2 Review of Literature - Information and Library...

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