Health status and occupational risks in informal waste workers in Nepal:Results from a cross-sectional study conducted in the Kathmandu valley.

Research Report.

Summary; Solid waste management is a major environmental and public health issue in Nepal, in particular in the Kathmandu Valley where 620 tonnes of solid wastes are produced daily. The municipalities are responsible for waste management, but they have not implemented robust waste management systems thus far. This has led to an increase in informal waste workers (IWWs), i.e. people who work in waste recovery activity outside any official framework. These workers face significant occupational health risks (e.g. cuts, bites, infections, effects of chemical exposure). In Nepal, data is scarce regarding this population and their health risks. In this context, Médecins du Monde has initiated a project with three main objectives: (i) to strengthen the waste workers' individual and collective capacity to respond to their health needs; (ii) to improve accessibility and quality of health care for waste workers and their families; and (iii) to improve the involvement and level of recognition of environmental health issues and the informal waste sector by the relevant stakeholders. In the context of this latter objective, a research study was conducted to characterise the health status and occupational risks of IWWs in the Kathmandu valley. This report presents the results of this study, as well as some recommendations based on the findings. A cross-sectional survey of IWWs was conducted in the Kathmandu valley and at the main landfill site, Sisdole, in the adjacent Nuwakot District. A convenience sample of adult IWWs recruited at their workplace were surveyed. After obtaining written informed consent, nine local enumerators conducted face-to-face individual interviews with participants, using a bespoke standardised demographic health assessment questionnaire. All of the interviews were conducted in Nepali or Hindi. Interviews were carried out in November - December 2017. Prior ethical approval was obtained from the Nepal Health Research Council. The collected survey data were subsequently analysed using Statistical Package for Social Science (SPSS). In total, 1278 IWWs participated in the survey and were included in the analysis. The great majority (95%) were surveyed in the Kathmandu Valley. Almost half of them (48%) were of Indian origin, most were male (78%) and their literacy level was low (50% were illiterate). A third of respondents (33%) reported that they had been ill in the previous three months and respiratory ailments were common. Four out of 10 participants were smokers and 42% consumed alcohol. Most respondents (62%) reported having government health services in their area, but the vaccination coverage of participants and of children living with them was low. Most of them did not know their infectious disease status (for HIV, hepatitis B and hepatitis C) and the uptake of antenatal care for female IWWs was poor. More than a quarter of the IWWs (27%) had some evidence of depression. They worked long hours, mostly every day, and had low earnings and little social protection. The risk of infection is high; more than a third (38%) reported handling medical waste. Two thirds (66%) had been injured at work in the past 12 months, with the most common reported injury being cuts. Compared with the Nepali population, they had lower literacy levels as well as higher prevalence of smoking and of alcohol consumption. Their children had lower rates of vaccination uptake and female waste workers had poorer uptake of antenatal care. Study participants of Indian origin seemed to have specific challenges, with a poorer healthcare access and less involvement in group co-operatives compared to Nepali IWWs. In terms of risk perception, the majority (73%) of the participants considered waste work as a risky job. More than two-thirds (68%) admitted to not using any form of personal protective equipment (PPE) (e.g. facemasks, gloves) but more than half (52%) reported using other means of protection (such as their own clothing). This highlights a potential issue of accessibility, practicality and affordability of PPE for this population subgroup. Multivariate analysis showed that males, older IWWs and those of Indian origin were less likely to use PPE. There were positive associations between receipt of information on occupational risks, risk perception and PPE use that indicate the importance of information provision on occupational risks and how this improves risk perception, which is associated with increased PPE use. This study highlights the vulnerability of IWWs and suggest the need for better protection of this population. Consequently, the following recommendations are proposed: 1. Health promotion, as well as Information, Education and Communication (IEC) activities: ■ Increase health promotion activities in relation to health protection, hygiene practices, as well as sexual and reproductive health in the IWW communities; ■ Provide robust information on occupational health risks to the IWW communities. 2. Healthcare access ■ Improve the uptake and coverage of routine childhood vaccinations within IWW communities; ■ Improve the uptake of vaccinations against occupational risks for IWWs (i.e. for tetanus and hepatitis B); ■ Improve access to HIV, hepatitis B and hepatitis C testing for this population; ■ Understand any barriers to healthcare access for Indian IWWs. 3. Community mobilisation ■ Support community mobilisation activities in order to increase the IWWs ability to address the various health concerns as well as access to social protections; ■ Support advocacy activities with regards to improving the healthcare access rights for migrant Indian waste workers.4. Knowledge production ■ Better understand the attitudes of IWWs regarding health as well as the expectations and access to the health system; ■ Better understand the attitudes, beliefs and practices of IWWs with regards to PPE use, in order to increase the level of protection; ■ Conduct further qualitative research work to understand the factors that affect IWWs behaviour in relation to how they protect themselves from risks, what factors may lead to behaviour change and to explore community-based solutions that will increase the level of protection - a focus on IWWs of Indian origin might provide data to better understand the specific challenges in this subgroup; ■ Identify the enablers of PPE use and potential barriers such as cost, practicality and usability.