OCCUPATIONAL DERMATOSES AMONG HOSPITAL CLEANING WORKERS IN SARAWAK GENERAL HOSPITAL

Ayu Akida Abdul Rashid

Master of Public Health 2010

pusat hidmat M kJumat Akade UNIVERS111 MALAYSlA SARAW,

P.KHIDMAT MAKL.UMAT AKADEMIK

1IIIIIIIIIfirii111111111 1000246466

OCCUPATIONAL DERMATOSES AMONG HOSPITAL CLEANING WORKERS IN SARA W AK GENERAL HOSPITAL

AYU AKIDA ABDUL RASHID

A thesis submitted in fulfillment of the requirements for the degree ofMasters ofPublic Health.

Faculty of Medicine and Health Sciences

UNIVERSITI MALAYSIA SARAWAK

2010

ABSTRACT

OCCUPATIONAL DERMATOSES AMONG HOSPITAL CLEANING WORKERS

Ayu Akida Abdul Rashid

(Occupational dermatoses are a burden to the society and may present as a long term burden to

sufferers of the condition. Numerous studies have investigated occupational dermatoses among

various occupations, yet little work has been done locally to examine the patterns ofoccupational

dermatoses among hospital cleaning workers and the consequences of the disease on the work

environment and the sufferers themselves. This study aimed to identify the prevalence of

oocupational dermatoses among hospital cleaning workers and to examine the factors exposed

towards the particiPan0 Consequences and coping strategies of the sufferers of the condition is

also explored. This study adopts the mixed-method where both qualitative and quantitative

approaches are utilized. Data were collected from 138 hospital cleaning wQrkers of Sarawak

General Hospital using a self-administered questionnaire, followed by a brief physical

examination of the skin and a question-guided interview of those who were identified to have

occupational dermatoses. Results indicated that the prev~lence of occupational dermatoses

among the study group was 27.5 percent (n=38) with a majority of 65.8 percent (n=25) having

dermatitis, while the rest has occupational urticaria. Wet work, food preparation outside work

and presence of atopic symptoms are related to acquiring occupational dermatoses.

Recommendations for future studies were presented.

,.....

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A BSTRAK

PENYAKIT KULIT BERPUNCA DARIPADA PEKERJAAN DIKALANGAN PEKERJA

PEMBERSIH HOSPITAL DI HOSPITAL UMUM SARA WAK

Ayu Akida Abdul Rashid

Penyakit kulit yang berpunca daripada pekerjaan adalah suatu beban kepada masyarakat dan

mampu menyebabkan penghidapnya mengalami kesan jangka panjang yang tidak diingini.

Pelbagai kajian telah dijalankan di kalangan pelbagai jenis pekerjaan, namun hanya sebilangan

kecil yang telah dijalankan pada peringkat tempatan untuk mengkaji pola penyakit tersebut di

kalangan pekerja pembersih hospital dan kesan daripada penyakit tersebut terhadap

persekitaran sekeliling dan terhadap penghidapnya. Kajian ini bertujuan untuk mengenalpasti

prevalens penyakit kulit berpunca daripada pekerjaan dikalangan pekerja pembersih hospital

dan mengkaji faktor-faktor yang mendedahkan pekerja kepada penyakit tersebut. Kesan dan

kaedah untuk menangani penyakit ini juga dikaji. Kajian ini menggunakan kaedah 'mixed­

method' yang menggunakan kedua-dua cara kualitatif dan kuantitatif. Data telah diambil

daripada J38 orang peserta kajian yang terdiri daripada pekerja pembersih hospital melalui

boring kaji selidik yang diisi oleh individu itu sendiri, diikuti oleh pemeriksaan jizikal secara

ringkas terhadap kulit yang terdedah serta temuduga berasaskan panduan soalan kepada

peserta kajian yang telah dikenalpasti menghidap penyakit kulit yang berpunca daripada

pekerjaan. Keputusan kajian menunjukkan bahawa prevalen penyakit kulit ini adalah 27.5

peratus (n=38) dengan sebilangan besarnya adalah penghidap dermatitis dengan 65.8 peratus

(n=25). Yang selebihnya menghidapi urtikaria. Pekerjaan basah, penyediaan makanan dan

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penghidap masalah alahan adalah berkaitan dengan mendapat penyakit yang dikaji. Usulan

untuk masa de pan juga disertakan.

iii

DECLARATION

No portion of the work referred to in this thesis has been submitted in support of an application

for another degree ofqualification of this or any other university or institution ofhigher learning.

Signature: ~ Name: AYu. A-\(.\I?A Af:,OuL R-A-:{HIO

Date: ~ I J u IV C .;). 0 I 0

IV

ACKNOWLEDGEMENT

First and foremost, I would like to offer my sincerest gratitude to my supervisor, Dr. Zabidah

Putit, who has supported me throughout with her knowledge, guidance and patience. One simply

could not wish for a better supervisor.

I would also like to thank the lecturers of the Department of Community Medicine and Public

Health ofthe Faculty of Medicine and Health Sciences, for lending their support and guidance in

completing my thesis .

A special thanks to Stellar Focus Sdn Bhd, who gave me the permission to carry out my research

involving their employees. Not forgetting the participants of my study, who has been

tremendously generous in providing me with their patience to participate in the study.

To all my course mates, who have endured the difficulties of our course together, I thank you

with all my heart for the moral support and friendship.

Finally, I thank my family, who has been my pillar of strength during this trying period. Thank

you for understanding and giving me the support I needed to complete my thesis.

v

LIST OF TABLES

Page Table 1: Demographic characteristics of study group 27

frequency ofurticarial episode, most recent urticarial episode and contact with

rubber gloves, animals and others

based on demographic details

on demographic details

Table 2: Occupational demographic characteristics of the study group 28

Table 3: Characteristics of respondents with occupational dennatitis 31

Table 4: Frequency and percentage ofrespondents with urticaria in relation to 32

Table 5: Distribution of respondents affected with occupational dermatoses 35

Table 6: Distribution of respondent affected by occupational dennatoses based 37

Table 7: Person Chi-square analysis ofatopic symptoms of respondents 38

Table 8: Distribution ofrespondents affected by occupational dermatoses based 39

on exposure factors

Table 9: Person Chi-square analysis ofatopic symptoms of respondents 40

vi

LIST OF GRAPHS

Page

Graph 1: General health (self-assessment) of respondents 29

Graph 2: Percentage of respondents with eczema based on major activity at 30

work

Graph 3: Percentage of respondents with urticaria based on major work 33

activity

vii

KEY TO TRANSCRIPTIONS

The following abbreviations and conventions have been used in the presentation of research findings:

Italics Represent the interview data from the study participants. The original text was in Malay and was translated by me. However, where it is not possible to translate adequately, the spoken Malay language is retained.

Names Pseudonyms are used for the study participants.

.,/1.. Indicates material deleted from the interview excerpts .

A pause during the participants interview.

[ ] Denotes researcher's alteration for clarity

viii

Pu at Khidmat Maklumat Akad~n I UNTVERSITI MALAYSIA SARAWAK

TABLE OF CONTENTS

ABSTRACf

ABSTRAK ii

DECLARATION iv

ACKNOWLEDGEMENTS v

LIST OF TABLES vi

LIST OF FIGURES vii

KEY TO TRANSCRIPTIONS viii

TABLE OF CONTENTS ix

Chapter 1 Introduction 1.1 Introduction

1.1.1 Background 2 1.2 Purpose ofStudy 3 1.3 Statement ofProblem 4 1.4 Research Questions 5 1.5 Objectives ofstudy 6 1.6 Hypothesis 6 1.7 Conceptual Framework 7 1.8 Operational Definition 7

Chapter 2 Literature Review 2.1 The Global & Local Scene 10 2.2 Deciphering Occupational Dermatoses 12 2.3 Cleaning Work & Workers 13

Chapter 3 Methodology 3.1 Introduction 17 3.2 M ethodo 10gy 17

3.2.1 Study Design 18 3.2.2 Instrument for Measurement 19 3.2.3 Population and Sampling 20 3.2.4 Inclusion Criteria 21 3.2.5 Exclusion Criteria 21 3.2.6 Ethical Consideration 22 3.2.7 Data Collection 22 3.2.8 Data Analysis 23 3.2.9 Dependent Variable 24 3.2.10 Independent Variable 24 3.2.11 Conclusion 24

ix

Chapter 4

Chapter 5

Chapter 6

REFERENCES APPENDICES

Results 4.1 Introduction 26 4.2 Descriptive Analysis 26

4.2.1 Occupational Dennatitis 30 4.2.2 Occupational Urticaria 32

4.3 Chi-square Analysis 33 4.3.1 Demographic Details 34 4.3.2 Atopic Symptoms 36 4.3.3 Exposure Factors 38

4.4 Consequences and Coping Strategies 40 4.4.1 Introduction 40 4.4.2 Consequences of Occupational Dennatoses 41

4.4.2.1 Biological Consequences of Occupational Dennatoses 41

4.4.2.2 Psychological Consequences of Occupational Dennatoses 43

4.4.2.3 Social Consequences ofOccupational Dennatoses 46

4.4.2.4 Economic Consequences of Occupational Dennatoses 48

4.4.3 Coping Strategies ofOccupational Dennatoses 50 4.5 Summary 54

Discussions 5.1 Introduction 55 5.2 Discussion ofFindings 55 5.3 Consequences and Coping Strategies of Occupational

Dennatoses 59 5.3.1 Consequences 59 5.3.2 Coping Strategies 63

Conclusion 6.1 Introduction 65 6.2 Summary 65 6.3 Conclusions 66 6.4 Limitations 66 6.5 Recommendations 67

69 APPENDIX A: Self-administered Questionnaire 74 APPENDIX B: Borang Kaji Selidik 83 APPENDIX C: Interview Guide For Participants 92 APPENDIX D: Consent Fonn 94 APPENDIX E: Letter of Approval to Conduct Research 97

x

I

CHAPTER 1

INTRODUCTION

1.1 Introduction

Occupational dermatoses have long been a silent issue in the Malaysian scene. It is deemed

by many as an unnecessary consequence of work and to the professional body, it poses as a

challenge to manage. Many are unaware and subsequently ignorant of the impact that the

condition may be to a worker. It is a common disorder but it is often overlooked by ,I

physicians.

Occupational dermatoses are any skin disorders that are directly caused or significantly

aggravated by workplace exposures. According to the Worker & Environment Health Unit of

MOH Malaysia (2008), occupational dermatoses carry the meaning of skin diseases primarily

caused by occupation. It encompasses from contact dermatitis to occupational skin cancer.

A big portion of workers affected by occupational dermatoses are those involved in

occupations that require a person to be in contact with chemicals, those dealing with wet

work and those in contact with any agents that may pose as possible irritants (Soder et aI.,

2007). These are usually those involved in professions such as health care workers, cleaning

and kitchen employees, hairdressers, cosmetologists and food service. Despite current

knowledge on the pathogenesis, diagnosis, treatment and preventive measures of

occupational dermatoses, affected workers often endure over a long period of time and will

1

require extensive dennatological care (Schwanitz et aI., 2002). These conditions are usually

diagnosed often too late into its progress and may be difficult to manage effectively.

Possible consequences of occupational dermatoses are numerous, ranging from cosmetic

disfigurement to life endangering conditions (Nixon, 2005). This is a threat to the

productivity of a country as those affected are mainly from the productive age and thus

measures must be taken to overcome these problems (Soder et aI., 2007). However, in order

for these measures to take place, awareness of the condition must be instilled upon those

involved and what better way to do this other than to expose the prevalence of this condition

in our working community.

This chapter provides the context of the study. It briefly describes the demographics of

participants involved and explains how the particular research emerged. It provides a review

on issues related to the focus of the study. It also presents the review of the relevant literature

and its context, while at the end, research questions, hypotheses and objectives of the study

will be delineated.

1.1.1 Background

This research was conducted among cleaning service workers in Sarawak General Hospital.

Sarawak General Hospital was chosen as the place of study as the cleaning service workers

are allocated work at different workstations, including the general wards, specialized wards

such as intensive care units, clinics, operating theatres, laboratories and other facilities within

2

the hospital grounds. Their job description carries them through various cleaning tasks and

exposes them to diverse cleaning agents and other physical aspects of cleaning. They are

supplied with a cleaning cart and equipped with personal protectiveequipments, which are

mainly aprons and gloves.

Currently, cleaning services of the Sarawak General Hospital are contracted out to private

cleaning companies. The hospital cleaning workers are employed by one local cleaning

company, which provides cleaning services to the hospital at all wards and facilities at the

hospital. There are approximately 240 cleaning service workers, with a predominance of

female workers. Female workers make up approximately eighty percent of total employed

hospital cleaning workers. The remaining twenty percent are male workers. From anecdotal

reports, it was gathered that about half of these workers have been with the company for

more than three years while the other half have been working for the company for less than

the time. They are from various age groups and most live in Kuching. They are supervised by

assigned supervisors who will delegate them to their workstations and determine their

working hours and schedule.

11 Purpose of Study

The purpose ofthis study was to gather in detail all the necessary data regarding occupational

dermatoses among hospital cleaning workers. This data would then be utilized to explore

certain aspects of occupational dermatoses, encompassing socio-demographic determinants

of sufferers, common skin manifestations, exposure and exacerbating factors, as well as the

3

consequences and coping methods. As an establishment that thrives on being clean and

hygienic, it is imperative that a hospital is ensured of these qualities in those who are

responsible in maintaining the cleanliness of the hospital. However, the standards set for this

is easily compromised if the workers who are responsible for the cleaning tasks are

handicapped by occupational skin conditions.

"The Sick Worker Effect" is a condition that is often overlooked among workers but it has a

considerable amount of influence on how a work is performed and consequently may be

affected in terms of quality or productivity (Sterling et.al., 1990). It is because of this

particular reason that this study would like to explore; to explore the link between

occupational dermatoses and the consequences that a worker could suffer from. From this

relationship, the details and extent to which these skin conditions can be to an affected

individual is explored. Thus, preventive measures can be taken up early and suited to the

affected group, rather than generalizing all preventive measures without taking into account

the specific needs of these groups.

1.3 Statement of Problem

Occupational dermatoses are very much on the rise as reported by many developed and

developing countries (Rantanen, n.d.). It is a public health concern especially as it involves

the productive age group (Meding et al., 2005). Although it is one of the most common

occupational diseases, it is still poorly managed, in terms of investigations, treatment and

prevention. The main factors that point out the importance of occupational dermatoses as

4

Pus:u Khidmat Maklumat Akademik UNlVERSITI MALAY fA SARAWAK

diseases that have a public health impact are that it is common, often with poor prognosis and

that they result in a striking economic impact for society and for the affected individual since

they affect employment and other activities outside the scope of one's career (Koch, 2001).

They are also diseases that are modifiable to public health interventions (Nixon, 2005).

With the lack of epidemiologic information on occupational dermatoses available in

Malaysia, this study would be very beneficial for future needs. Therefore, this study was an

attempt to identifY the prevalence of occupational dermatoses among hospital cleaning

workers and the factors influencing its prevalence, with special focus on the consequences

and coping methods of the problem to the study group.

1.4 Research Questions

In view of the scope of the problem, the study aimed to know the factors that influence the

occurrence of occupational dermatoses among hospital cleaning workers and the

consequences and coping strategies of the affected cleaning workers with regards to their

skin problem. In due course, all this was gathered in hopes of gaining better insight on how

occupational dermatoses may affect the work performance of a hospital cleaning worker and

the impact to their surroundings. Hopefully, it would be able to answer the pressing research

question of: Will occupational dermatoses affect work performance, how much so and what

are the consequences? This has led to the formation of the specific objectives ofthe study.

5

1.5 Objectives of the Study

1.5.1 General Objectives

To gain knowledge on occupational dermatoses among hospital cleaning workers.

1.5.2 Specific Objectives

15.2.1 To assess the prevalence ofoccupational dermatoses among hospital cleaning

workers ofSarawak General Hospital.

1.5.2.2 To identify the socio-demographic factors influencing the prevalence ofoccupational

dermatoses.

1.5.23 To determine the types ofexposures related to occupational dermatoses among

hospital cleaning workers in Sarawak General Hospital in order to assess the potential

for dermal exposures.

1.5.2.4 To explore the outcomes ofoccupational dermatoses and subsequently the coping

methods among the proposed study group.

1.6 Hypothesis

Hypothesis 1: Socio-demographic difference is not related to developing occupational

dermatoses

Hypothesis 2: Exposure factors are not related to developing occupational dermatoses.

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1.7 Conceptual Framework

The diagram below shows the framework between the dependent and independent variable of

the study.

~

i Environment I

I

I

I Individual

Iworker

+ OCCUPATIONAL

DERMATOSES

I Type of work i I

I

I Outcome I

I

Based on framework for occupational injury by International Labour

1.8 Operational Definition

1.8.1

1.8.2

Occupational Dermatoses

Occupational dermatoses are any abnormality of the skin induced or aggravated by

the work environment.

Exposure Factors

Exposure factors are any elements in the surrounding that may cause or form the

foundation ofdeveloping occupational dermatoses.

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1.8.3 Hospital Cleaning Workers

Hospital cleaning workers are the workers who are employed to carry out specific

cleaning tasks at the hospital.

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CHAPTER 2

LITERATURE REVIEW

Occupational dennatoses or occupational skin disease, as it is widefy known as, is a group of

diseases that affects the skin, occurring among workers. It is a consequence ofexposure from

the workplace or the work itself According to The National Skin Centre of Singapore (1995),

an occupational skin disease (OSD) is any skin disorder which is caused by a person's work.

In fact, it also states that a person who has pre-existing skin disorders but condition is

worsened by occupation are also considered to occupational dennatoses or skin disease.

Occupational dennatoses can be seen in vanous fields or sectors of work. The ones

commonly implicated are those involving chemical usage, wet work and use of personal

protective equipments. It is also often seen in certain industries especially fanning,

manufacturing and health care, among others. Singapore has shown that the most common

industry with dennatoses complaints are those related with wet work (Yen and Goon, 2006).

In Northern Bavaria, high-risk occupations for an occupational skin disease include cooks,

painters and varnishers, metal processors, mechanics, assemblers, construction and cement

worlcers, housekeepers, restaurant business and cleaners (Dickel et aI., 2001). Malaysia has

yet to come up with such a list of industries commonly associated with occupational

dennatoses among workers.

9

1.1 The Global and Local Scene

On a global scale, there are a staggering number ofapproximately 68 to 157 million new cases of

occupational diseases per year cumulatively which is caused by various exposures at work

(WHO, 1998). From this figure, a third of these new cases will go on to be chronic diseases of

various body organs owing to assorted work exposures (WHO, 1998). In industrialized countries

in the western hemisphere, the annual rate of new occupational skin diseases is estimated at

approximately 0.5-1.9 new diseases per 1000 employed persons per year (Diepgen 2003;

Diepgen and Coenraads 1999). The World Health Organization (2001) has projected that a large

number of occupational diseases go undiagnosed and unreportedl• European Agency for Safety

and Health at Work (2001) also reported a something of similar effect, and that is the number

and extent of skin disorders is often underestimated. Hence, the number of cases reported may

just be the tip ofthe iceberg with the major bulk being still unnoticed.

Worldwide, occupational dermatoses have gained importance in work-related diseases, coming

in second place to occupational respiratory diseases. They are among the most frequent work­

related diseases in most industrialized countries (Diepgen, 2003). According to the European

Occupational Diseases Statistics (2001), in 2001 skin diseases accounted for 11.2 percent of all

occupational diseases in Europe. Similarly, occupational skin diseases have headed the list of

reported occupational diseases in Austria and Germany for many years (Winker et aI., 2007).

In 2001, skin diseases represented almost one-third of the occupational diseases reported in

Gennany (Dickel et al. 2004). In neighboring Singapore, the incidence for occupational skin

10

diseases diagnosed at the National Skin Centre was 62.5 cases for the year 2003 (Yen and Goon,

2006). In Northern Bavaria, it was observed that that the overall incidence rate was 6.7 cases per

10,000 workers per year in all occupational groups (Dickel et aI., 2001).

According to the 2008 Annual Report from the Department of Occupational Safety and Health

Ministry of Human Resources (n.a., 2008), the most frequent work-related investigations in

Malaysia in the year 2008 were for occupational noise induced hearing loss with 169 cases

compared to only 120 cases in 2007. This is followed by occupational skin diseases which

recorded 70 cases compared to 192 cases in 2007. The findings are different from 2007 in which

occupational skin diseases was the commonest occupational disease investigated followed by

occupational noise induced hearing loss. However, this data did not actually mention the

prevalence of each of the condition, merely the number of investigations done on each of the

work-related ailments. Thus, the decline in number of investigations done in 2008 as compared

to those done in 2007 in a way may reflect the level of consciousness towards occupational

dennatoses.

Elsewhere, there has been an increasing awareness of occupationa] dermatoses. Despite the

current knowledge on the management of this condition, affected employees suffer frequently

over a long time period and will therefore require extensive dermatological care (Schwanitz et al.,

2002). It is hoped that early detection may actually enable the healthcare providers to provide the

necess8l)' care for the skin conditions affecting workers. It may actuaUy reduce the cost of

treating a skin condition, which may be very difficult to treat in the long run, as occupational

dennatoses have a tendency to be chronic in nature (Meding et al., 2005). In 1985, Mathias

11

(1985) reported that the total annual costs ofoccupational contact dennatitis were estimated to be

from $222 million to $1 billion in the US (as cited by Chew and Maibach, 2002). This clearly

implies that occupational dennatoses may be a potential economic burden to a country if it is not

dealt with early.

1.1 Deciphering Occupational Dermatoses

Early recognition and diagnosis of occupational dennatoses is necessary to reduce the suffering

from this often preventable and debilitating condition (Nixon, 2005). Hence, it is imperative that

a gargantuan effort is made to explore and understand the factors that may cause this condition.

Wet work, use of cleaning chemical agents and the use of personal protective equipments (PPE)

have been implicated in causing occupational dennatoses (English, 2004). Although this has

been established, there have been many contradictory issues over the years. A good example of

this is the use of personal protective equipments. It has been suggested as one of the ways in

which it is thought to shield from occupational dennatoses (Koch, 2001). This includes the use

of gloves, face shields, goggles, aprons and boots. However, in many instances, workers are

adversely affected by the protective equipments, for example allergies to latex gloves. According

to a study, among those who had skin disease, there were significantly more who used rubber

gloves than among the rest (Hansen, 1982). Thus, it may imply here that the use of protective

pves may be the source or root of the problem for occupational dennatoses. It may deter the

cleaning service workers from using them in their subsequent work. In fact, a study done in

Singapore by researchers at The National Skin Centre found that the use of PPE is associated

12