|Year : 2010 | Volume
| Issue : 1 | Page : 13-19
Occupational stress among tunnel workers in Sikkim
Pragyan Basnet1, Shoyeta Gurung1, Ranabir Pal2, Sumit Kar2, Dharamvir Ranjan Bharati3
1 Intern, Department of Occupational Therapy, Sikkim Manipal Institute of Physiotherapy, Gangtok, Sikkim, India
2 Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
3 Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
|Date of Web Publication||16-Mar-2011|
Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences (SMIMS) and Central Referral Hospital (CRH), 5th Mile, Tadong, Gangtok, Sikkim - 737 102
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Job stress has been linked to a wide range of adverse effects on mental, physical and organizational health. Objective: The objective of this study was to determine the impact of job stress on mental, physical and social health of the underground construction workers in Sikkim. Materials and Methods: The study population comprised of tunnel workers and a comparable group of controls. Using the interview technique, data was collected using the SF-36 General Health Survey Questionnaire. Results: The study population comprised of individuals of whom more than half were below 40 years of age and was comparable to the group of controls. Majority reported good health, while poor health was reported by 22 % of the subjects under study Compared to their health status last year, 52% rated their health as somewhat worse. Majority reported that their physical health problems limited them in activities of daily life, viz., running, lifting heavy objects, participation in strenuous sports, climbing several flights of stairs, bending, stooping or kneeling and walking more than a mile, during the past four weeks. More than half of them had severe body ache in the past four weeks that interfered with both work outside home and housework. This was true for emotional problems also, which interfered with their normal social activities involving family, friends, neighbors or groups. The associations of occupational stress with physical, emotional and social life and with limitation of day-to-day activities among tunnel workers were found to be statistically significant. Conclusion: The results emphasize the importance of assessment of the effects of job stress and of fulfilling the need of underground workers for optimum preventive measures.
Keywords: Construction worker, health, underground
|How to cite this article:|
Basnet P, Gurung S, Pal R, Kar S, Bharati DR. Occupational stress among tunnel workers in Sikkim. Ind Psychiatry J 2010;19:13-9
Occupational health not only deals with work-related disorders or diseases, but it also encompasses all factors that affect workers' health. With changing scenario, there is need to understand the risk factors of modern occupational hazards.  Occupational health care in India has to compete with primary health care and curative health care for its budget. In the context of legislations, the major legal provisions for the protection of health and safety at workplace are the Factories Act and Mines Act. However, more than 90% of the Indian labor force does not work in factories; hence they fall outside the purview of the Factories Act, 1948 - the only act that deals with occupational health and safety.  In India, major occupational diseases, as well as related morbidity, of concern are silicosis, musculoskeletal injuries, coal workers' pneumoconiosis, chronic obstructive lung diseases, asbestosis, byssinosis, pesticide poisoning and noise-induced hearing loss,  apart from many others which are often neglected by us.
Lack of education, unawareness of hazards in one's occupation, general backwardness in sanitation, poor nutrition and climatic proneness to epidemics aggravate workers' health hazards in the work environment. 
The International Labour Organization (ILO) estimates that 40% of all costs associated with work-related injuries and diseases are due to musculoskeletal disorders.  Among these, low back pain is the most common. 
Job stress has been linked to a wide range of adverse effects on mental, physical and organizational health. Despite evidences that "systems" approaches are most effective in reducing the adverse impact of job stress, prevalent practice is dominated by worker- or individual-focused strategies in the absence of commensurate intervention to improve working conditions.  Successful management of stress at the workplace has become a topic of great interest over the last decade. In view of the escalating costs associated with workplace injuries and the increasing demands placed on workers in the work context, the need for effective stress management within acceptable time frames and at minimal cost is paramount. 
Implementing strategies for stress management interventions to improve physical and mental health, reduce costs to employers and facilitate the reintegration of injured individuals into the work environment is the need of the hour. 
Human labor is an integral to the growth of infrastructure, and the people who work at construction sites are at a great deal of risk to their health. The pressure of work, the deadlines they have to meet and the physical demands of the job take toll on the physical and mental health of the workers, along with their social life. In various studies, there have been findings of correlation of workplace environment with increased fatigue, stress, depression and general health complaints. ,,,,,
Managing occupational health problems is not just about providing things like health checks before someone starts work, first aid, welfare, general information about health, well-being and fitness for work, or managing sickness absence and return to work - there are many things you can do to reduce risks to workers' health.
The main aim of the study was to understand and analyze the general, psychological and social health of underground tunnel construction workers and to find out any deviation when compared with the control group with regard to impact of occupational stress.
| Materials and Methods|| |
Through 1 st December 2007 to 29 th February 2008, a study was done at an ongoing tunnel construction site among the construction workers with no interventions. At that time, the excavation work was over and the concrete work was in progress. The tunnel was located at an altitude of 630 m above sea level; the tunnel was 18 km long and its diameter was 9.5 m. The working temperature ranged from 35°C to 40°C. The machinery operated inside the tunnel was diesel powered. There was an elaborate ventilation system and lighting system which was developed inside the underground tunnel, and strict safety precautions for the workers were taken.
Fifty adults were recruited for the study, with ages between 25 and 50 years. All of them had worked at underground construction sites for more than one and half years, with all subjects performing the same task and having the same work schedule (8-hour shifts with one break of 60 minutes). History of any previous illness or medical conditions was not taken into account. The controls were selected from among the associates of those workers, matched for age and socioeconomic status, engaged in other professions. Since all the tunnel workers were recruited from the eastern district of Sikkim, we selected the controls from the same district but engaged in other occupations.
Content validity and reliability of study instruments
We used SF36 (short form with 36 questions), a well-documented, self-administered quality of life (QoL) scoring system that includes eight independent scales and two main dimensions and is validated and widely used.  By initial translation, back-translation, re-translation, followed by pilot study, the questionnaire was custom-made for the study at the institute with the assistance from the faculty members and other experts. The pilot study was carried out at the site, and the schedule was pre-tested and necessary modifications were made.
Data collection procedure
Institutional ethics committee approved the study. All the participants were explained about the purpose of the study and were ensured strict confidentiality. Then verbal informed consent was taken from all the workers prior to the commencement of the study. The participants were given the option not to participate in the study if they so desired. Then, by interview technique, the principal investigator collected the data. On an average, 4 to 5 interviews were conducted in a day. Details of the questionnaire were provided if required. The survey questions were asked individually to the workers, and they were told to answer the questions by selecting the best possible option from the list provided after each question. The questions were asked in either Hindi or Nepali. Information on occupational health was disseminated in health education sessions to complement the findings of the study.
The data collected were thoroughly screened and entered into Excel spreadsheets, and analysis was carried out using SPSS version 11 software. The procedures involved were transcription, preliminary data inspection, content analysis and interpretation. Percentages were used in this study to analyze health outcomes.
| Results|| |
Majority (44%) of workers were in the age range of 21-30 years, closely followed by 34% in the age group 31-40 years. Overwhelming majority of the subjects in the study population were less than 40 years of age. The control group was comparable to the study population [Table 1].
Most of the respondents felt that they had better health when compared with their health status last year; however, they responded somewhat differently, whereby majority of study subjects (52%) and controls (44.34%) rated their health as somewhat worse when compared with their health status a year ago [Table 2].
During the past four weeks many a times, more than half of them were worn-out and tired; yet the majority was full of pep, happy, yet calm and peaceful, and never reported being nervous, downhearted or blue. We had an inroad picture of the interference of physical and emotional health on the social activities of the workers; many of them felt that the physical and emotional health had interfered with their normal social life most of the time, while only a small minority felt that their emotional and physical health did not interfere with their social life; whereas on the other extreme, few of the workers felt that emotional and physical health interfered with their social activities. There were some on the borderline who felt that their social activities were affected only sometimes [Table 3].
Subjectively, 30% of tunnel workers felt that they were getting sick a little easier than others; on the contrary, a majority of them also felt that they were as healthy as anybody else they knew. Minority also felt that they expected their health to get worse. When asked if they felt their health was excellent, only a few of them answered in the affirmative, while most of them answered in the negative [Table 4].
|Table 4: Self-perception of vulnerability to illness among tunnel workers (n= 50)|
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On the amount of bodily pain endured by the workers during the past four weeks and the interference with their normal work due to the pain, it was seen that many workers endured moderate-to-severe bodily pain and a very few of them had very severe bodily pain. When the interference with their normal work due to bodily pain was assessed, for the most of them, pain moderately affected their work; and for many of them, pain interfered extremely with their normal activities, while for a minority of them, pain did not interfere with their normal activities [Table 5].
|Table 5: Self-perception of pain and its social impact among tunnel workers|
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Among tunnel workers, 74% had cut down the amount of time spent on work and other activities during the past four weeks; also, a majority also felt that they faced limitations in work and other activities and had difficulty in performing work and other activities, while many of them felt that they accomplished less than what they would have liked to during the past four weeks. It was observed that more than 60% had some kind of limitation due to their physical health. Sixty percent of them had cut down on the amount of time spent on work or other activities due to emotional problems, and nearly the same proportion felt that they had accomplished less than what they would normally do during the past four weeks, and were not as careful in the past four weeks as they would usually be while executing their duty. Majority had emotional problems that moderately interfered with their social activities. Among controls, 50% had cut down on the amount of time spent on work and other activities during the past four weeks, whereas 31.13% of controls faced limitations in work performance. As a result of emotional problems, majority of controls (43.40%) accomplished less than what they would have liked to. Majority of controls reported no interference with their social activities due to occupational stress. The relationships of occupational stress with physical, emotional and social life among tunnel workers were found to be statistically significant [Table 6].
|Table 6: Impact of occupational stress on physical and emotional health among study population|
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A large majority of the workers were moderately restricted in vigorous activities. When limitation in moderate and light work was assessed, it was found that a vast majority were not limited in these activities compared to others who felt that they were limited in some or the other way in these activities. Regarding climbing several flights of stairs, not many felt that they were facing moderate-to-severe limitations, compared to other workers who felt that they were not affected at all. When climbing one flight of stairs was assessed, 68% of the tunnel workers felt that they were not affected at all. In activities like bending, stooping and kneeling, 40% of the workers felt that they were somewhat limited in these activities, and quite a few felt they were severely limited in these activities while the rest felt they were not limited in these activities at all. Regarding walking, 40% felt that they were moderately limited in walks longer than a mile, and few felt that they were severely limited in this activity; whereas when walking for several blocks was assessed, the results showed that more than half had no limitations at all, and all felt they were not limited at all when walking a single block. Among controls, majority were having no limitations with regard to day-to-day activities. The association of occupational stress among tunnel workers with resultant limitations in day-to-day activities was statistically significant (chi-square: 22.57; d.f.= 9; P= .0024) [Table 7].
|Table 7: Impact of occupational stress on limitations in performing activities among study population|
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| Discussion|| |
In our study, majority reported good health, while poor health was reported by 22% of the workers. Compared to their health status last year, 52% rated their health as somewhat worse. Majority reported that their physical health problems limited them in activities of daily life, viz., running, lifting heavy objects, participation in strenuous sports, climbing several flights of stairs, bending, stooping or kneeling and walking more than a mile, during the past four weeks. More than half of the workers had severe body ache in the past four weeks that interfered with both work outside home and housework. This was true for emotional problems also, which interfered with their normal social activities.
A systematic review of disability management interventions with economic evaluations concluded that there was credible evidence supporting the financial benefits of disability management interventions for one industry cluster and several intervention components and features.  Researchers reported the impact of an occupational illness or injury on an injured worker can be severe. Respondents almost universally reported that occupational illness and related issues were associated with depression, anxiety and loss of identity and self-worth, and demonstrated how a work-related injury or illness can extend far beyond the physical impact for injured workers. Existing systems fail to adequately compensate or rehabilitate injured workers, leaving them to their own devices to deal with their losses, medical or otherwise. 
The study to determine whether from a health care perspective a specific occupational health intervention is cost effective in reducing sickness absence when compared with usual care of occupational health in workers with high risk of sickness absence showed that the intervention to reduce high risk of sickness absence is a cost-effective use of health care resources. 
Musculoskeletal disorders are among the most common causes of sickness absence, long-term incapacity for work and ill-health retirement. In UK, the trend is mostly towards nonspecific conditions (largely subjective complaints, often with little objective pathology or impairment). Understanding incapacity requires a bio-psychosocial model that addresses all the physical, psychological and social factors involved in human illness and disability.  In this cross-sectional questionnaire survey conducted at factories and offices in Mumbai, India; and in the UK about symptoms, disability and risk factors in groups of workers carrying out similar occupational physical activities in different 'cultural' settings, the findings supported the hypothesized impact of cultural factors on common musculoskeletal complaints. In other studies also, the Indian manual workers reported lesser pain in these anatomical sites when compared with each of the other occupational groups. ,,,
For Indian manual workers, pain is a common feature of normal everyday life. Disclosing such pain may be seen as a threat to self-identity, ability to work and potentially having serious socioeconomic consequences. However, explanations of this type do have inherent difficulties - such far-reaching statements about culture, whatever form they take, may justifiably be criticized for providing crude explanations that only serve to stereotype this topic, which has attracted much attention among those working in the field of ethnicity and health. 
Leigh et al. estimated that the annual incidence of occupational disease was between 924,700 and 1,902,300, leading to over 121,000 deaths in India.  A survey of injury incidence in agriculture conducted in northern India revealed an annual incidence of 17 million injuries per year (2 million moderate-to-serious events) and 53,000 deaths per year. 
A cross-sectional survey was conducted among Chinese offshore oil workers to explore the influence of occupational stress on mental health in the field of offshore oil production. The observation confirmed that occupational stress was a major risk factor for poor mental health among Chinese offshore oil workers. Reducing or eliminating occupational stressors at work would benefit workers' mental health.  A study conducted by the Department of Mining Engineering, Indian School of Mines University, Dhanbad, Jharkhand, India, observed that, amongst the latent endogenous construct, negative personality was positively influenced by job stress and negatively influenced by social support. 
The researchers at the Department of Mining Engineering, Indian Institute of Technology, Kharagpur, India, carried out a study to assess the relationships of job hazards, individual characteristics and risk-taking behavior with occupational injuries among coal miners. This case-control study compared 245 male underground coal miners with injury during the previous two-year period with 330 matched controls without injury during the previous five years. Handling material, poor environmental/ working conditions, and geological / strata control-related hazards were the main risk factors. They concluded that prevention should focus on handling material, poor environmental condition, especially addressing workers with no formal education, alcohol consumption, disease, big family size and risk-taking behavior. 
Herbert et al. opined that bridge and tunnel officers sustain potential exposure to a number of physical, chemical and work-organizational factors. They are at risk for both fatal and nonfatal occupational injuries due to moving vehicles, workplace violence, vehicular fires and physical hazards, such as slippery walking surfaces due to oil or ice on roadways. They recommended focused health surveillance and preventive efforts.  A systematic review to assess the association between leisure-time physical activity and musculoskeletal morbidity, with possible interactions with physical activity at work, concluded that encouragement to take part in leisure-time physical activities may constitute one of the means of reducing musculoskeletal morbidity in the working population, in particular, the sedentary workers.  A retrospective record study in an industry in eastern India explored whether job security had any association with higher susceptibility to occupational injury. Although two worker groups were very similar in relation to age, level of education, habits and nature of work, accident frequency and severity rates were found to be significantly higher among temporary workers. The higher accident risk among the temporary workers might have been due to the less effective experience and lack of job security.  Evidence is also now accumulating that individual beliefs and expectations are important predictors of outcome in people suffering from back and arm pain. Moreover, in Victoria, Australia, an attempt to modify people's beliefs about low back pain through a media campaign was associated with a reduction in incapacity for work attributed to back disorders. ,,
We evaluated the appropriateness of existing approaches to the assessment of health-related quality of life for tunnel workers with disabilities and highlighted the significance of addressing the requirements of these workers for best possible preventive measures.
Limitations of the study
It would have been better if we could have extended our observations to a range of socioeconomic and cultural settings to segregate the aspects of symptoms that we have observed. In India, public health sector emphasizes more on communicable diseases, malnutrition and reproductive health care. We have not used any instrument to measure occupational stress and mental health that could have been feasible to ascertain the influence of occupational stress on mental health in a better way.
Future directions of the study
In India, workers working in unorganized sectors are largely illiterate and unaware of the occupational hazards. So, we have to assess the burden of occupational hazards and changing occupational morbidity patterns, which are still looked upon as issues of minor concern, while formulating health strategy and health-related programs for the future.
| Conclusion|| |
Our results emphasize the importance of assessment of the burden of occupational hazards and various occupational morbidity patterns for redressing the need of underground workers for optimum preventive measures. Moreover, the insufficient scrutiny of employees' health is the most important reason for increased prevalence of these ailments. Multi-pronged health education programs at all levels, viz., workers, supervisors and owners/ management, are the need of the day.
| References|| |
|1.||Pandve HT, Bhuyar PA. Need to focus on occupational health issues. Indian J Community Med 2008;33:132. |
|2.||Pingle SR. Do occupational health services really exist in India? Available from: http://www.occuphealth.fi/NR/rdonlyres/04399102-514B-4444-AC38-C90DCC3D9A3D/0/7DoOHservicesreallyexistinIndia.pdf [last accessed on 2009 Nov 16]. |
|3.||Joshi TK, Smith KR. Occupational health in India. Occup Med 2002;17:371-89. |
|4.||Agnihotram RV. An overview of occupational health research in India. Indian J Occup Environ Med 2005;9:10-4. |
|5.||Rajgopal T. Musculoskeletal disorders. Indian J Occup Environ Med 2000;4:2-3. |
|6.||Saiyed HN, Tiwari RR. Occupational health Research in India. Ind Health 2004;42:141-8. |
|7.||LaMontagne AD, Keegel T, Vallance D. Protecting and promoting mental health in the workplace: Developing a systems approach to job stress. Health Promot J Austr 2007;18:221-8. |
|8.||Kendall E, Muenchberger H. Stress at work: Using a process model to assist employers to understand the trajectory. Work 2009;32:19-25. |
|9.||Jones DL, Tanigawa T, Weiss SM. Stress management and workplace disability in the US, Europe and Japan. J Occup Health 2003;45:1-7. |
|10.||Park J, Kim Y, Chung HK, Hisanaga N. Long working hours and subjective fatigue symptoms. Ind Health 2001;39:250-4. |
|11.||Rosa R. Extended work shifts and excessive fatigue. J Sleep Res 1995;4:51-6. |
|12.||Smith A, Johal S, Wadsworth E, Harvey I, Davey Smith G, Peters T. Stress and health at work, part IV: Interim findings of the Bristol Survey. Occup Health Rev 1999;80:28-31. |
|13.||Shields M. Long working hours and health. Health Rep 1999;11:33-48. |
|14.||Ettner S, Grzywacz J. Workers′ perceptions of how jobs affect health: A social ecological perspective. J Occup Health Psychol 2002;6:101-13. |
|15.||Siu O, Donald I. Psychosocial factors at work and workers′ health in Hong Kong: An exploratory study. Bull Hong Kong Psychol Soc 1995;34/35:30-56. |
|16.||Hays RD, Hahn H, Marshall G. Use of the SF-36 and other health-related quality of life measures to assess persons with disabilities. Arch Phys Med Rehabil 2002;83:S4-9. |
|17.||Tompa E, de Oliveira C, Dolinschi R, Irvin E. A systematic review of disability management interventions with economic evaluations. J Occup Rehabil 2008;18:16-26. |
|18.||Lax MB, Klein R. More than meets the eye: Social, economic, and emotional impacts of work-related injury and illness. New Solut 2008;18:343-60. |
|19.||Taimela S, Justén S, Aronen P, Sintonen H, Läärä E, Malmivaara A, et al. An occupational health intervention programme for workers at high risk for sickness absence: Cost effectiveness analysis based on a randomised controlled trial. Occup Environ Med 2008;65:242-8. |
|20.||Waddell G. Preventing incapacity in people with musculoskeletal disorders. Br Med Bull 2006;77-78:55-69. |
|21.||Adamson J, Atkin K. Commentary: Culture and pain in the work place: The domain of occupational epidemiology? Int J Epidemiol 2008;37:1189-91. |
|22.||Madan I, Reading I, Palmer KT, Coggon D. Cultural differences in musculoskeletal symptoms and disability. Int J Epidemiol 2008;37:1181-9. |
|23.||Bhopal R. Glossary of terms relating to ethnicity and race: For reflection and debate. J Epidemiol Community Health 2004;58:441-5. |
|24.||Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001;55:693-700. |
|25.||Ahmad WI, Bradby H. Locating ethnicity and health: Exploring concepts and contexts. Sociol Health Illn 2007;29:793-811. |
|26.||Leigh J, Macaskill P, Kuosma E, Mandryk J. Global burden of disease and injuries due to occupational factors. Epidemiology 1999;10:626-31. |
|27.||Mohan D, Patel R. Design of safer agricultural equipment: Application of ergonomics and epidemiology. Int J Ind Ergon 1992;10:301-9. |
|28.||Chen WQ, Wong TW, Yu TS. Influence of occupational stress on mental health among Chinese off-shore oil workers. Scand J Public Health 2009;37:766-73. |
|29.||Paul PS, Maiti J. The synergic role of sociotechnical and personal characteristics on work injuries in mines. Ergonomics 2008;51:737-67. |
|30.||Kunar BM, Bhattacherjee A, Chau N. Relationships of job hazards, lack of knowledge, alcohol use, health status and risk taking behavior to work injury of coal miners: A case-control study in India. J Occup Health 2008;50:236-44. |
|31.||Herbert R, Szeinuk J, O′Brien S. Occupational health problems of bridge and tunnel officers. Occup Med 2001;16:51-64. |
|32.||Hildebrandt VH, Bongers PM, Dul J, van Dijk FJ, Kemper HC. The relationship between leisure time, physical activities and musculoskeletal symptoms and disability in worker populations. Int Arch Occup Environ Health 2000;73:507-18. |
|33.||Saha A, Kulkarni PK, Chaudhuri R, Saiyed H. Occupational injuries: Is job security a factor? Indian J Med Sci 2005;59:375-81. |
|34.||Boersma K, Linton SJ. Expectancy, fear and pain in the prediction of chronic pain and disability: A prospective analysis. Eur J Pain 2006;10:551-7. |
|35.||Ryall C, Coggon D, Peveler R, Poole J, Palmer KT. A prospective study of arm pain in primary care and physiotherapy: Prognostic determinants. Rheumatology (Oxford) 2007;46:508-15. |
|36.||Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: Three part evaluation. Br Med J 2001;322:1516-20. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]