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 Table of Contents  
Year : 2021  |  Volume : 28  |  Issue : 1  |  Page : 57-61

Quality of life and its determinants among sewage workers: A cross-sectional study in Puducherry, South India

1 Department of Preventive and Social Medicine, JIPMER, Puducherry, India
2 ICMR Regional Medical Research Center, Bhubaneshwar, Odisha, India

Date of Submission02-Nov-2020
Date of Decision27-Dec-2020
Date of Acceptance04-Jan-2021
Date of Web Publication25-Feb-2021

Correspondence Address:
Dr. Ganesh Kumar Saya
Department of Preventive and Social Medicine, JIPMER, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_351_20

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Background: There is a paucity of information on sewage worker's quality of life (QoL). Hence, we aimed to assess the QoL and its associated factors among sewage workers in Puducherry, coastal south India. Materials and Methods: A total of 210 sewage workers were included in the study. QoL was assessed using a validated Tamil version of WHO QoL-BREF. The association of QoL with age, educational status, residence area, self-reported chronic illness, use of protective measures, tobacco and alcohol use was assessed by univariate analysis. Multiple linear regression analysis was used to assess the independent factors associated with QoL. Results: Overall mean (standard deviation) score of QoL was 56.9 (9); mean score of social relationship domain was comparatively lower than physical, psychological and environmental domains. Current tobacco and alcohol uses were 17% and 67%, respectively, while alcohol use during work (entering sump) was 5%. At least one morbidity was present among 94 (45%) subjects. About half (47%) used at least one protective measure while entering the drainage sump. Age group above 50 years, below primary level education, presence of chronic illness, smokers and alcohol users had significantly lower QoL score. Conclusions: Social relationships' domain of QoL was very low among sewage workers. The majority of them do not use any personal protective devices and almost half had chronic illnesses.

Keywords: Health-related factors, quality of life, sewage workers

How to cite this article:
Madhumithra D, Saya GK, Olickal JJ, Kanungo S, Chinnakali P. Quality of life and its determinants among sewage workers: A cross-sectional study in Puducherry, South India. Niger Postgrad Med J 2021;28:57-61

How to cite this URL:
Madhumithra D, Saya GK, Olickal JJ, Kanungo S, Chinnakali P. Quality of life and its determinants among sewage workers: A cross-sectional study in Puducherry, South India. Niger Postgrad Med J [serial online] 2021 [cited 2021 Jul 30];28:57-61. Available from: https://www.npmj.org/text.asp?2021/28/1/57/310165

  Introduction Top

Quality of life (QoL) of sewage workers is an important health issue in occupational health. Sewage workers are one of the essential neglected occupation groups and require special attention. Sewage workers are employed by representatives of the public work department, municipal corporations and water board.[1] They are commonly exposed to various health hazards due to non-use or improper use of personal protective devices. They sometimes work in the sewage system with their bare hands for the removal of rubbish and unclogging of sanitation lines.[2] Workers descend the sewage sumps and use brooms or metal scrapers in their bare hands to clean drainage which helps to facilitate sewage water flow in the pipe system. Most sewage workers enter into the subterraneous system with little more than a helmet. This unfortunate reality exists despite the standard guidelines available for wearing gloves, masks and other protective devices.[3],[4]

A study among municipal waste collection workers found a higher proportion of health problems.[4] Studies from developed countries also showed that various illnesses are comparatively more prevalent in sewage workers than in the general population.[5],[6] However, there is a lack of studies to assess sewage workers' health problems in developing countries. They have an inbuilt stigma, lack of occupation safety measures, health problems and insufficient knowledge of existing laws.[1] Furthermore, the mortality among the sewage workers due to health problems is still high. A study in Mumbai-based Tata Institute of Social Sciences showed that 80% of sewer workers died by 60 years.[1]

Although sewage workers are paid for their work, their QoL may be lower than the general population due to the inbuilt nature of the working conditions. The QoL is increasingly being considered in occupation health research to assess the relationship between occupation, disease and QoL.[7],[8] Health and QoL of sewage workers are closely related and have improved in the last decades, especially due to government organisations' actions and efforts and the creation of sanitary agenda. However, sewage workers' working conditions have remained virtually unchanged for over a century, especially in developing countries. Because of the above, QoL is an essential occupational issue in this target group that was not addressed earlier. Hence, this study aimed to assess the level of QoL and the associated factors among sewage workers in Puducherry.

  Materials and Methods Top

Ethical clearance

The study protocol was approved by the Institutional Ethics committee (IEC) of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India (approval number JIP/IEC/2016/926 on 12 August 2016). Prior permission was obtained from the Public Works Department (PWD), Government of Puducherry. Written informed consent was obtained from all the participants.

Design and setting

This cross-sectional analytical study was conducted from June 2016 to February 2017 among PWD sewage workers in Puducherry, South India. PWD is the premier technical organisation in the Union Territory of Puducherry and is responsible for maintaining essential services such as water supply, maintaining water resources and sewerage system. It provides the necessary infrastructure regarding drainage facilities, cleaning services, pumping services to Puducherry residents.

Under the PWD drainage division, there were 210 sewage workers in employment. All of them were men and permanent employees. The workers were provided with self-protection aids such as gloves, masks, soaps, coconut oil and slippers. Periodically, the PWD conducts health camps for the workers' health checkup where the workers are immunised against communicable and infectious diseases.

Sample size estimation and sampling technique

Two hundred and ten sewage workers do drainage and sewerage works in the PWD department, Puducherry. Considering a standard deviation (SD) for QoL as 3.6,[9] and employing t-distribution to estimate sample size, with 95% confidence and a precision of 0.5, the calculated sample size for the study was 203 (this sample size was calculated using Statulator: An online statistical calculator[10]). However, we included all the workers for this study.

Method of data collection

The principle investigator collected data in the sewage workers' office by one to one interview in the Tamil Language. The study procedure was explained to the sewage workers. The sociodemographic and behavioural characteristics such as age, sex, marital status, area of residence, education, presence of self-reported chronic illness, use of personal protective devices, current use of alcohol, current and ever use of tobacco were collected using a semi-structured questionnaire. The checklist for the use of different personal protective devices was included in the questionnaire. Self-reported tobacco use in any form during the preceding month of the interview and self-reported alcohol use at least once (minimum one standard drink) in the last 1-year period was considered for an operational definition of current tobacco use and alcohol use.

A pre-tested structured questionnaire was used for the study. QoL was assessed using a validated Tamil WHO QoL-BREF questionnaire. This questionnaire has 26 items, capturing four domains: physical, psychological, social and environmental.[11] Each item is a five-point response scale. A higher score (0–100) suggests a better QoL in each of the domains. The mean score in each domain and the total average mean score were calculated.

Statistical analysis

The data were entered into EpiData Manager version 3.1 software and analysis was done through Statistical Package for the Social Sciences (SPSS) version 19.0 (IBM PASW Statistics, Country office Bangalore, India). Age was summarised as mean and SD. Categorical variables such as educational status, residence, marital status, chronic illness, use of protective measures, tobacco and alcohol usage were summarised as percentages and later categorised into groups to identify associations. Comparison of QoL with age, education, chronic illness, tobacco use, alcohol use and protective measures was analysed using a one-way ANOVA or independent t-test. Multiple linear regression analysis was used to estimate the relationship between independent variables and the QoL by including the variables with P < 0.2 in unadjusted analysis and the unadjusted β coefficient was estimated. P < 0.05 was considered statistically significant.

  Results Top

All 210 sewage workers participated in the study. All were males, married, unskilled workers, working for 8 h a day. The mean age of the participants was 47.2 95.2 years. Among them, 60% (n = 125) were 41–50 years old, 55% (n = 116) had middle level school education and 64% (n = 135) resides in rural area. The current tobacco users were 17% (n = 36); ever tobacco users were 29% (n = 60) and two-third (67%, n = 141) were current users of alcohol. Alcohol consumption, while entering sump, was reported by 5% (n = 10) of the participants. About half (46.7%, n = 98) of them used at least one protective measure while entering the drainage sump. Nearly half of them (44.8%, n = 94) were using footwear, 19% (n = 40) were using gloves, 10% were using a facemask and none were using goggles and waterproof suits [Table 1].
Table 1: Sociodemographic details and substance use by sewage workers (n=210)

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The distribution of self-reported chronic illnesses is depicted in [Figure 1]. Almost one-third (30%, n = 54) had diabetes mellitus and 26% (n = 47) had hypertension. The QoL scores of sewage workers are depicted in [Table 2]. The mean (SD) total score was 56.9 (9). The physical domain secured the highest mean (SD) domain score (62.0 [10.8]) and the social relationships domain secured the lowest domain score (49.3 (18.6)). The mean (SD) QoL rating and health satisfaction was 2.9 (0.8).
Figure 1: Distribution of self-reported chronic illness present among sewage workers in Puducherry (n = 210)

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Table 2: Quality of life scores of sewage workers in Puducherry, India (n=210)

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Participants aged above 50 years had low QoL scores than younger age groups (<50 years). Similarly, below primary level education, comorbidity, tobacco use and alcohol use were associated with low QoL scores. In the physical domain, the participants aged <40 years, above primary level education and in the absence of chronic illness had a significantly higher score than their counterparts. Psychological domain score was significantly higher in above primary level educated (vs. up to primary level) and the absence of chronic illness group (vs. presence of comorbidities). However, there was no significant difference across variables in the social domain. The presence of chronic illness and current alcohol use was significantly associated with QoL's environmental domain [Table 3].
Table 3: Associated factors of quality of life among sewage workers in Puducherry, India (n=210)

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Multiple linear regression analysis of the total QOL score with different sociodemographic and behavioural characteristics is depicted in [Table 4]. With one unit increase in age, the change in QoL score was −0.2. Compared to individuals with above primary school education, the primary school educated had 0.9 less than QoL scores. Current tobacco users and current alcohol users had a 2.6 and 2.5 lower QoL score than their counterparts. Individuals using at least one personal protective measure reported a high QoL score. The presence of chronic illness had a significant effect on the QoL score (β = −3.4, P = 0.009).
Table 4: Multiple linear regression analysis of the associated factors of overall mean quality of life score (n=210)

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  Discussion Top

We found that QoL among sewage workers was average and comparatively lower than other population groups. Nearly half of the sewage workers had a self-reported chronic illness and most of them do not use any personal protective devices. The study finding will be useful for the concerned authorities to develop a plan of action to improve the QoL and improve the use of personal protective measures among sewage workers.

This is the first study conducted among sewage workers that assessed QoL and its associated factors to the best of our knowledge. There are some studies to assess QoL in other groups, like industrial workers and the elderly. A study among software-industrial workers in Kolkata, India, showed a significant difference between QoL's mean score in different domains across the Information Technology enabled service sub-sectors.[12] A study conducted among the elderly in Malaysia showed a comparatively higher overall mean score (59.1) and the mean score in the social relationship domain (56.8) and psychological domain (61.7) than our study.[13] Another study in southern Brazil among the elderly also showed a higher mean score (67.3) than our study.[14] This study also highlighted a far higher social relationship score (74.5) than our study. The social relationship domain among sewage workers is low compared to the elderly population, which may be due to cultural differences, social stigma, caste problems, economic status, educational status and inferiority complex among study participants. Further qualitative studies may explore social factors influencing QoL in this group. The psychological domain was also comparatively low due to job performance, work nature, low literacy and insecure work.

About one in every six sewage workers had a habit of tobacco use and these findings were concurrent with the study in the Netherland.[15] This showed that many sewage workers had tobacco use. This could be due to their lower education level, working environment and peer pressure. More than two-thirds were alcohol consumers and few of the workers also reported alcohol consumption when entering into the sump. Substance abuse among our study participants was less than the study from Mumbai, which reported that 97.3% of the participants had tobacco or alcohol use.[2] In this study, age group above 50 years and education below primary level have lower QoL than their counterparts among sewage workers, while another study among elderly showed no association between age group and QoL, but education levels were associated.[15]

In general, chronic morbidity conditions affect QoL. Hypertension and diabetes were significantly associated with QoL in contrast to another study among the elderly.[16] This variation may be due to the difference in the study population. QoL score was comparatively less among smokers. A study in France showed that there was an association between smoking and health-related QoL.[17] Similarly, QoL was found to be significantly higher among alcohol non-users than users. A similar study in Taiwan among youth alcohol users showed low QoL.[18]

A cross-sectional study design involving all sewage workers in this area and using a validated tool is the study's strength. We should be careful while generalising the results to other parts because of the different administrative and managerial processes of a sewerage system, training given, regular examination of the workers and different personal characteristics. There may be a chance for subjective bias during the face-to-face interview period. Another limitation of the study was that some chronic illnesses were self-reported. We could not study personal hygiene among sewage workers. We could not observe the use of personal protective measures due to feasibility constraints.

  Conclusions and Implications Top

Overall QoL among sewage workers was average and comparatively lower than other studies. Age group above 50 years, below primary level education, with diagnosed diabetes and hypertension, smokers and alcohol users had significantly lower QoL score. Sewage workers also have a higher chronic disease burden and most do not use personal protective devices. Measures on the adoption of personal protective devices, reduction of substance use and screening for chronic diseases may help to improve this vulnerable group's QoL. The study will be useful for concerned policymakers for adopting newer strategies based on study findings to improve QoL. Ergonomics with standard work measures should be adopted. Based on study findings, health education about the importance of personal protective measures and occupational health safety, conducting health camps to screen for morbidities and counselling services to overcome alcohol and tobacco use may be recommended.


We thank the Public Health Division of Public Work Department, Government of Puducherry, and sewage workers who participated in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Praxis Institute for Participatory Practices. Down the Drain! A Study on Occupational and Health Hazards and the Perils of Contracting Faced by Sewerage Workers in Delhi. 1st ed. New Delhi: Praxis Institute for Participatory Practices; 2014. Available from: https://praxisindia.org/pdf/file/down%20the%20drain%20report%20web%20version.pdf. [Last accessed on 2017 Jun 08].  Back to cited text no. 1
Giri PA. A study on morbidity profile of sewage workers in Mumbai city. Int J Collab Res Intern Med Public Health 2010;2:450-63.  Back to cited text no. 2
Mumbai Sewer Workers, Photos of India's Sewer Workers. Available from: http://www.news.com.au/finance/work/at-work/mambais-sewer-divers-make-your-job-look-like-the-greatest-profession-in-the-world/news-story/5410f843aac8a29feb6365796cece96f. [Last accessed 2016 Mar 19].  Back to cited text no. 3
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Agner DT. Quality of life (QoL) in relation to occupational skin diseases. In: Rustemeyer T, Elsner P, John SM, Johansen JD, Maibach HI, editors. Kanerva's Occupational Dermatology. 1st ed. Berlin, Heidelberg: Springer; 2012. p. 13-7.  Back to cited text no. 7
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Jha A, Sadhukhan SK, Velusamy S, Banerjee G, Banerjee A, Saha A, et al. Exploring the quality of life (QOL) in the Indian software industry: A public health viewpoint. Int J Public Health 2012;57:371-81.  Back to cited text no. 12
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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