knowledge, attitude and practices related to occupational health

J Occup Health 2007; 49: 528–534Journal of

Occupational Health

Received Sep 1, 2005; Accepted July 31, 2007Correspondence to: P. Parimalam, Department of Family ResourceManagement, Home Science College and Research Institute, TamilNadu Agricultural University, Madurai 625 104, India(e-mail: [email protected])

Knowledge, Attitude and Practices Related to Occupational HealthProblems among Garment Workers in Tamil Nadu, India

Paramasivam PARIMALAM1, Narayani KAMALAMMA2 and Anind Kumar GANGULI3

1Department of Family Resource Management, Home Science College and Research Institute, Tamil NaduAgricultural University, 2Department of Home Science, Gandhigram Rural University and 3Occupational HealthServices, BHEL, India

Abstract: Knowledge, Attitude and PracticesRelated to Occupational Health Problems amongGarment Workers in Tami l Nadu, Ind ia :Paramasivam PARIMALAM, et al. Department of FamilyResource Management, Home Science College andResearch Institute, Tamil Nadu AgriculturalUniversity, India—The garment manufacturingprocess is a labour intensive task. The workers in thisare employed in three different sections namely cutting,stitching and finishing. As these workers performrepetitive tasks throughout the workday, they faceseveral work related problems. The aim of this studywas to assess the level of awareness of healthproblems among garment workers and their attitudesand practices to prevent the same. In a cross-sectionalstudy (n=216) the workers employed in the threesections had high levels of knowledge of the healthproblems, but the knowledge of personal protectiveequipment differed by section. More than one half ofthe workers in all the sections were aware of thebenefits of personal protective equipment (PPE), butonly a few workers in the cutting section were usingPPE. There was a wide gap between their knowledgelevel and practice with protective devices.(J Occup Health 2007; 49: 528–534)

Key words: Garment workers, Knowledge, Attitude andpractice, Health problems, Protective devices

The objective of Occupational Health and Safety is toassure as far as possible that every working man andwoman in the nation has a safe and healthy workingenvironment so as to preserve human resources. Thoughthis objective has been achieved to a great extent in the

developed countries, developing countries still have farto go in satisfying this requirement. One of the mainreasons for this is the lack of studies on workers engagedin both organized and unorganized sectors with referenceto the health and safety measures.

The garment manufacturing units in Madurai arerelatively small not exceeding 15 to 50 machines, withthe total number of workers ranging from 17 to 56 perunit. They provide employment opportunities for bothrural and urban populations and cater to the needs of thedomestic and export markets. The manufacturing ofready-made garments is highly labour intensive. Theworkers in these manufacturing units are employed inthree sections, namely cutting, stitching and finishing.They work for more than 9 hours a day and perform thesame activities throughout the day.

Our ear l ier s tudies indicated that garmentmanufacturing workers had neurological, respiratory andmusculoskeletal problems1). There was also evidenceindicating that the workers had accidents either due tolack of safety devices or non-use of personal protectiveequipment. The frequency and severity of such accidentsvaried by section and category of work.

Several studies have reported on knowledge, attitudeand practices (KAP) of workers employed in differentsectors, but the present study is the first of this kind togive a picture of KAP among garment manufacturingworkers in Madurai with reference to Occupational Healthand Safety. The aim of the present study was to assessthe level of awareness of health problems among garmentworkers and attitudes and practices for preventing theseproblems.

Methodology

The study was conducted in Madurai city, Tamil Nadu.Garment production and sales have become one of themajor commercial activities of this city. As per the recordsmaintained by the Ready-made Garment Manufacturer’s

Occupational Health / Safety in the World

529Paramasivam PARIMALAM, et al.: KAP of Garment Workers Regarding Health Problems

Association and the District Industries Center, there were98 registered small scale garment manufacturing units inMadurai. On personal verification through visits andtelephone enquiries, 37 units were found to be defunct.Of the remaining 61 units, all those employing both maleand female workers were shortlisted. There were 54 unitsand a letter indicating the purpose of the study andrequesting their co-operation was sent to all of them.However there was a positive response from only 24 units,of which 3 units were dropped from the study due totheir closure or other reasons. The researchers met theowners/proprietors of the chosen units by priorappointment and sought permission to gather the requireddata. Repeated visits were made to certain units and thepurpose of the study was explained clearly to ensure co-operation from the decision makers in providing essentialinformation about company culture and work practices.Three units persistently denied provision of informationand hence they were excluded from the study.

There were 648 workers in the remaining 18 chosenunits and they were employed in 3 different sections,namely cutting, stitching and finishing. Two hundredand sixteen workers were chosen for the study by astratified random sampling method based on the natureof their activities.

MethodsA combination of several methods was used to assess

the KAP of the workers. Primary data collection was byinterview of the workers, supervisors / managers followedby other methods such as observation, hazardidentification and risk assessment, and also from therecords and reports maintained in the units. To gatherinformation about the health problems of the workers, aninterview schedule was prepared which consisted ofdetails of health problems faced by the workers, incidenceand severity of accidents, awareness about the use ofpersonal protective equipment (PPE), attitude and practicein preventing the health and safety hazards at worksite.Knowledge about the health problems was explored byasking the workers to identify the body parts that wereaffected by continuous work in garment units.Knowledge about personal protective equipment wasassessed by questioning the workers about the differentPPEs used in the garment units and if the workers hadquoted at least two of the PPEs, such as flexible metallicgloves, thimbles, ear muffs, dust protectors, they weresaid to have good knowledge about PPE. The prepareddraft schedule was tested by jury analysis for contentvalidity and the suggestions of the experts wereincorporated. Then it was pretested by administering itto twenty workers in factories and tested for its reliabilityand validity. The internal consistency of the instrumentand its completeness were also verified.

Data collectionData were gathered from the respondents by face-to-

face confidential interview with the workers at the worksite. This enabled the workers to provide informationabout the health problem, work organization, environmentand use of protective devices etc. Hazard identificationand risk assessment and observation of workplacesenabled the researchers to cross-check and verify theinformation provided by the workers and supervisors inthe chosen units. Accident details and their severity werealso collected from the records maintained in the units.The data thus collected were analysed using SPSS 11.0in respect to knowledge, awareness level, and attitudeand practices in preventing hazards. Chi square analysiswas performed to analyse the association between thevariables. Regression analysis was performed to identifythe relationships among the variables and the underlyingfactors that influenced KAP.

Result

Of the 216 workers engaged in garment manufacturingwork, 27 workers were employed in cutting, 131 workersin stitching and 58 in the finishing section. The overviewof the three sections is given in Fig. 1. The ratio ofmanpower requirement in the cutting, stitching andfinishing sections was 1:5:2. One half of the workershad low socio-economic status.

Cutting section workersThe cutting section workers were of relatively young

age (28.2 ± 8.3 yr). Almost equal numbers of males andfemales were employed in the cutting section. Theworkers had nearly ten years of service in the cuttingsection.

KAP and the health problems of garment workers arepresented in Tables 1 and 2. With regard to the knowledgeof health problems of workers, 93% of the workers hadexperienced health problems of some kind or other whileworking in the garment manufacturing units. Theresponses for the health problems were recorded in theform of the Nordic questionnaire. The majority of theworkers expressed breathing difficulty as the predominanthealth problem. The dust and the loose fibres in thecutting section, particularly those from knitted materials,might be causative factors. The other reported problemsincluded neural problems like headache (18%),dermatological problems (11%), hearing disability (11%)and musculoskeletal problems like stiff neck, shoulderpain or back pain, which were expressed by 34% ofworkers.

All the workers had some knowledge of personalprotective measures to prevent the health problems whileworking in the garment manufacturing units. Though allthe workers were aware of the benefits of the personalprotective measures, only a few workers (4%) were using

530 J Occup Health, Vol. 49, 2007

them, such as hand gloves made of flexible metallicstrings to protect their fingers from accidental cuts andinjuries; Fig. 2 shows an example of working without aPPE in the cutting section. This is evident from the datathat 52% of the workers had cut their fingers during theirperiod of work in the garment manufacturing units, whichwe mainly attributed to non-use of PPE. None of theworkers were using dust protectors in the form of finemesh cloth to protect themselves from inhalation of dustparticles, especially while working with knitted clothmaterials, and a high percentage of workers expressedbreathing difficulty as a health complaint.

The reasons stated by the workers for non-use of PPEswere lack of availability of the safety devices, high costand PPE not supplied by the owners of the units. Twelveper cent of the workers stated that the use of hand gloveshampered their grip and did not allow them to cut assmoothly as with non-metallic blade guards.

Stitching section workersSixty-seven per cent of the workers were females and

33% were males. The workers in this section did nothave any change of job, unlike the other sections. Theworkers in this section were young (28.2 ± 6.8 yr) withten years of service, indicating that the workers hadentered this section at a relatively young age. Ninety-eight per cent of the workers were aware of the healthproblems of continuous stitching. Eighty-five per centof the workers reported having headache and 21%expressed breathing difficulty. Hearing disability wasreported by 35% of the workers, which was attributed tothe increased noise level from the embroidery machines,which when compounded with the number of sewingmachines made the environment noisy for the workers.Musculoskeletal problems such as low back pain andshoulder pain (83%) were reported as the most commonlyoccurring health complaints. These problems may havebeen caused by constrained posture coupled withinconvenient work height. Epidemiological studies have

a. Cutting section

b. Stitching section

c. Finishing section

Fig. 1. Overview of different sections in garment units.

Table 1. Distribution of knowledge, attitude and practices of garment workers

Characteristics Cutting Stitching Finishing(n=27) (n=131) (n=58)

Age (yr) 28.2 ± 8.3 28.2 ± 6.8 25.5 ± 7.0Sex Male 51.4 32.8 42.8 Female 48.6 67.2 57.2Mean years of service 9.9 ± 7.4 10.3 ± 6.0 4.6 ± 3.7Knowledge on health problems 92.6 98.4 96.5Knowledge on PPE 100.0 76.3 63.4Benefits of PPE as perceived 100.0 76.3 59.3Usage of PPE 3.7 – –


also demonstrated a strong association between postureat work and musculoskeletal problems. However themajority of the workers were unaware of the fact thatadopting a correct work posture would help to minimizetheir musculoskeletal discomforts. This fact needs to beemphasized when educating workers.

The injury statistics revealed that needle piercing wasone of the most commonly occurring accidents (78%),which ranged from once to more than thrice during theirservice. Defective work posture, fatigue, lack ofconcentration on work, poor co-ordination of leg and handoperation, and inadequate lighting might be factorscontributing to such a type of accident. That this kind ofaccident could be prevented by use of a metallic handcovering known as a ‘thimble’ was reported by 76% ofthe workers. Use of earmuffs to protect workers fromexcessive noise exposure was reported by only 22% ofthe workers. Thus the workers had a fair knowledge ofpersonal protective equipment.

The benefits of use of PPE were reported by 76% ofworkers. Workers reported that use of a thimble on theright hand forefinger would protect their finger fromneedle piercing (74%). The reasons stated for non-useof a thimble was that it did not suit every individualworker, improper fitting (58%), it did not aid in having a

grip, in directing the fabric (28%), and non-availabilityof thimbles at the worksite (62%). None of the workersin the chosen units wore a thimble or had practiced useof ear muffs. However when the workers felt excessivenoise, puffing cotton in the ears was practiced by 63% ofthem.

Finishing section workersThe percentage of male and female workers in the

finishing section were 43% and 57% respectively.Ninety-seven per cent of the workers had knowledge ofhealth problems about the various tasks involved in thefinishing section. As these workers were involved inoperations such as checking, the workers developedproblems such as numbness in the hands and fingers(25%). One tenth of the workers had respiratory problemssuch as breathing difficulty and asthma. Musculoskeletalproblems were more common among the workers (34%).The reasons stated for such kinds of musculoskeletalproblems were the repetitive nature of the job ( 56% ),improper or lack of furniture and constrained workposture (38%).

Sixty-three per cent of the workers had knowledgeabout PPE. Trimmer piercing in the palm (45%) andhand and wrist injury by ticketing guns (19%) were theaccidents most frequently found in this section. This maybe due to the speed and repetitive nature of the work inthis section. The periodicity of such occurrences wasmore than twice in a month and could be prevented byjob rotation and by educating the workers about properwork posture.

The benefits of the use of PPE were reported by 59%of workers in the finishing sections but none of theworkers were using any kind of PPE. Improper fitting(23%) and non-availability (18%) were the reasons statedby the workers for nonuse of PPE.

The results of Chi square analysis clearly indicate astrong association between the health problems (neural,dermatological, hearing and respiratory) and the sectionsin which they were employed. This indicates that theworkers health problems were mainly due to the natureand the type of work that they performed in their sections.

Table 2. Health problems of garment workers (in percent)

Health problems Cutting Stitching Finishing Chi-square(n=27) (n=131) (n=58)

Neural 18.5 84.7 25.0 81.32*Hearing disability 11.1 34.4 6.9 19.41**Dermatological 11.1 9.9 6.9 0.56NS

Respiratory 84.0 21.4 10.3 56.95*Musculoskeletal discomforts 33.3 83.2 34.5 53.85*

*p<0.05, **p<0.01. NS: Non-significant.

Fig. 2. Non-use of PPE.


Relationship between KAP and health problemsChi square analyses was carried out to analyse the

association between the variables such as age, sex, workexperience, knowledge of health problems and benefitsof PPE with the health problems. Age as an independentvariable was classified into four groups, namely, thosebelow 20 yr, 20–29 yr, 30–39 yr and above 40 yr. Workexperience was categorized into five groups: less than 5yr of work experience, 5–10 yr, 11–15 yr, 16–20 yr, morethan 20 yr of work experience. Knowledge on healthproblems and benefits of PPE were categorized into twogroups: ‘yes’ and ‘no’. Age and work experience werefound to be associated with the majority of the healthproblems such as neural problems, hearing disability andmusculoskeletal discomforts. This indicates that withadvancing age and with increasing work experience theremight be a chance for the workers to develop healthcomplaints by working in the garment units. Knowledgeabout health problems was not associated with neuralproblems, hearing disabil i ty, respiratory andmusculoskeletal problems. This indicates that knowledgeof health problems alone is not sufficient to prevent thehealth problems and there might be other factors thatinfluence the workers health problems. Knowledge of

the benefits of PPE was not found to be associated withthe majority of health problems.

A multiple regression analysis was performed toinvestigate the functional relationship between the KAPvariables and the contribution of each variable to thehealth problems of workers. In the multiple regressionmodel, six independent variables namely, age (X

1) (below

20 yr=1, 20 to 25 yr=2, 25 to 30 yr=3, 30 to 35 yr=4,more than 35 yr =5), sex (X

2) (male=1, female=2), work

experience (X3) (less than 5 yr =1, 5 to 10 yr=2, 11 to 15

yr=3, 16 to 20 yr=4 and more than 20 yr=5), knowledgeof health problems (X

4) (yes=1 and no=0), knowledge of

PPE (X5) (yes=1 and no=0), benefits of PPE (X

6) (yes=1

and no=0), and five dependent variables (health problems)were considered. Each of the dependent variables wasanalysed with all the independent variables. The resultsshowed that the model was statistically significant forneural problems (R2=0.11, p<0.01), dermatologicalproblems (R2=0.11, p<0.01) and respiratory problems(R2=0.07, p<0.01) : however the values of R2 were low.This indicates that there are other variables, which mightinfluence health problems.

Table 4. Regression analysis of KAP and health problems

Health problems Regression equation R2 Value

Neural (Y1) Y1=5.41–4.71X1NS– 0.984X2**+9.11X3

NS– 0.11**0.97X4

NS+2.05X5NS–0.39X6

NS

Hearing disability (Y2) Y2=0.739+2.17X1NS–3.12X2

NS+1.15X3*+ 0.08 NS

0.28X4NS+0.13X5*–6.97X6

NS

Dermatological (Y3) Y3=0.624–5.87X1NS+1.58X2

NS+1.02X3*+ 0.11**0.43X4**+0.11X5**–5.00X6

NS

Respiratory (Y4) Y4=1.25–6.45X1NS+3.44X2

NS+4.26X3NS+ 0.07*

0.25X4NS–6.78X5

NS–0.20X6NS

Musculoskeletal (Y5) Y5=1.43–1.56X1NS–0.11X2

NS+2.32X3NS– 0.10 NS

0.17X4NS+0.21X5**+4.54X6

NS

*p<0.05, **p<0.01. NS: Non-significant.

Table 3. Chi-square analysis between KAP and health problems

Parameters Health problemsNeural Hearing disability Dermatological Respiratory Musculo skeletal

Age 8.75** 12.43** 7.42 0.28 10.06**Sex 8.87** 0.04 0.01 0.77 0.62Mean years of service 16.57** 14.23** 7.93** 4.49 18.58**Knowledge on health problems 0.32 2.16 13.06** 2.47 1.07Benefits of PPE 1.20 1.90 2.61 11.23** 0.30

*p<0.05, **p<0.01.


Discussion

The garment manufacturing process involves variousstages. The sequences of activities that are carried out inthe cutting section are fabric laying, pattern laying, andmarking, cutting, numbering, sorting and bundling.Sewing of garments and embroidering is done in thestitching section. The activities in the finishing sectionare quality inspection, ironing and packing. The entireprocess from fabric laying to packing is labour intensiveand hand tools such as hand-held cutting machines,trimmers, ticketing guns etc., were used by the workers.All the workers in the units performed stereo-typedoperations pertaining to their own sections. A number ofstudies related to KAP of different category of workershave been reported in the literature, but this is the firstsystematic study to reveal KAP and the underlying factorsthat influence the health problems of garment workers.A study of printing workers in Hong Kong by Yu andcolleagues indicated that safe practice did not depend onknowledge and attitude but was positively associated withbeing informed of safety precautions and being suppliedwith chemical information by supervisors2). A similarstudy conducted among 205 salt workers also revealedthat the workers had good knowledge about the healthproblems and the protective measures, but a huge gapcould be observed between the knowledge and usage ofPPE, mainly due to the non-availability of safety devices,high cost and safety devices not provided by the saltmanufacturers3). A comparative study of tobacco useknowledge, attitude and practice among college studentsin China and United States revealed that Americanstudents scored higher in knowledge and that they werealso more likely to smoke cigarettes and use tobaccoproducts than their Chinese counterparts4). All thesestudies indicate that though the respondents had goodknowledge about the problems, several factors influencedthe practices. The present study highlights the knowledgethat the workers have about the health problemsassociated with employment in garment manufacturingunits, and their attitudes and perception of personalprotective measures and usage of personal protectiveequipment, which could help health planners, policymakers, industrialists and researchers to promoteoccupational health and safety at the worksite.

Work in the garment manufacturing units led to adverseeffects such as neural problems, problems with thesenso ry o rgans , muscu loske le t a l p rob lems ,dermatological problems and respiratory problems.Though the workers had good knowledge about the healthproblems while working in garment manufacturing units,they could not lower the incidence of such problems.Individual anthropometric variations, health conditionsof workers, work methods, workstation design, workenvironment, constrained work posture and other

occupational risk factors such as force, frequency orrepetitiveness of movement, task duration and so on arebelieved to have an influence on the health problems ofthe workers. Other factors such as nonavailability of PPE,lack of suitability of PPE and employers not providingPPE also might have an impact on the health problems.

The present study also revealed the nature and type ofaccidents occurring in each section. Use of protectivemeasures during working hours would help to preventsuch accidents. Knowledge about the personal protectiveequipment among the workers varied with section.Cutting section workers had better knowledge aboutpersonal protective equipment, because accidents likecutting of fingers and hands lead to partial impairment,while accidents occurring in other sections were not sopronounced. The reasons for the occurrence of such kindsof accidents were primarily due to lack of and non-use ofsafety measures, lack of availability of personal protectiveequipment, non affordability, improper maintenance ofprotective devices, improper designing of tools and lackof safety education for workers.

Personal protective equipment like hand gloves,earmuffs, and thimbles were not readily acceptable tothe workers due to improper fitting and hindrance of theirwork efficiency. The blade guards of the cutting machinesshould be redesigned as enclosures or interlocking guardsto prevent injuries to finger and hands. Thus, there is aneed for improving the devices or redesigning the devicesto ensure the workers use them effectively. This wouldhelp to ensure improved occupational health and safetypractices among the workers5, 6).

Thus, there is a need to develop evidence-basedmethods, which can assess the occupational health risks,and to develop intervention to improve the quality ofprotective devices and also enable health personnel asproviders of quality assured information to give betteradvice to their workers7). All the workers need to betrained in the use of personal protective devices.Wherever there is a threat to the workers health, the useof personal protective equipment should be mademandatory and strict vigilance is needed to enforce theirusage. A holistic participation of the industry officials,management, and workers would play an important rolein improving the occupational health and safety ofindustrial workers.

Acknowledgment: The authors wish to thank Dr. M.R.Duraisamy, Assistant Professor, for his assistance inanalyzing the data. Thanks are also due to the workerswho voluntarily participated in the study.

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