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Farwin A, Low A, Howard N, Yi H. "My young life, finished already?": a qualitative study of embedded social stressors and their effects on mental health of low-wage male migrant workers in Singapore. Global Health 2023; 19:47. [PMID: 37422664 DOI: 10.1186/s12992-023-00946-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Increasing evidence shows low-wage migrant workers experience a high prevalence of mental health disorders and adverse health outcomes. Significant disparities in health services usage among migrant workers create added vulnerability to health complications. However, much remains unclear about how vulnerabilities are constructed in migrant worker populations. Additionally, no studies in Singapore have attempted to critically examine the degree to which social environment and structures affect the health and wellbeing of migrant workers. Therefore, this study aimed to critically situate the socio-structural factors creating conditions of vulnerability among migrant workers using a social stress perspective. METHODS We conducted semi-structured individual and group interviews with migrant workers focused on individual life experiences, community experiences (individual and collective social capital), health (mental and physical health concerns) and stress response behaviours. We used a grounded theory approach to identify sources of stress and stress responses and uncover pathways to social vulnerabilities. RESULTS Findings from 21 individual and 2 group interviews revealed that migrant workers were embedded in a cycle of chronic stress driven by structural factors that were mutually reinforced by stressors arising from their social environment. Socio-structural stressors enacted as poor living, working and social conditions resulted in their negative quality-of-life appraisal. Stressors arising from being "foreign" resulted in anticipated stigma, concealment, and healthcare avoidance. These factors synergistically created a persistent mental health burden for migrant workers. CONCLUSIONS Findings highlight the need to address the mental health burden placed on migrant workers and create avenues for migrant workers to seek psychosocial support to manage their stressors.
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Affiliation(s)
- Aysha Farwin
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Amanda Low
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Natasha Howard
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, 117549, Singapore
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Huso Yi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore, 117549, Singapore.
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Ho KY, Lam KKW, Bressington DT, Lin J, Mak YW, Wu C, Li WHC. Use of a positive psychology intervention (PPI) to promote the psychological well-being of children living in poverty: study protocol for a feasibility randomised controlled trial. BMJ Open 2022; 12:e055506. [PMID: 35977772 PMCID: PMC9389124 DOI: 10.1136/bmjopen-2021-055506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Poverty has a detrimental influence on psychological well-being of children. Existing evidence shows that positive psychology interventions are possible to mitigate such impact. Despite criticisms that positive psychology resembles a scientific Pollyannaism that promotes overly positivity, positive psychology is not the scientific Pollyannaism that denies the difficulties and emotions that people may experience. Whereas, positive psychology acknowledges the difficulties and emotions, alongside with building up human resilience, strength and growth to face adversity. This study examined the feasibility of implementing a positive psychology intervention among Hong Kong Chinese children living in poverty. METHODS A feasibility randomised controlled trial will be conducted. A convenience sample of 120 children aged 13-17 years will be recruited from a community centre in Kwai Tsing district. Participants who are randomised into the experimental group will join a 1.5-hour workshop covering four positive psychology techniques: (1) gratitude visits/letters, (2) three good things, (3) you at your best and (4) using signature strengths. A booster intervention will be provided at 1 week. Control group participants will not receive any intervention. Assessments will be conducted at baseline and at 1-week, 1-month, 3-month and 6-month follow-ups. ANALYSIS Descriptive statistics will be used to calculate the feasibility measures. Effect sizes on psychological outcomes (ie, self-esteem, depressive symptoms and quality of life) will be estimated by mixed between-within subjects analysis of variance using partial eta squared with poverty (yes, no) entering into the model as a factor. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Hong Kong Polytechnic University Institutional Review Broad. We will obtain parental consent as our subjects are below 18 years old. Findings from this study will be disseminated via international publications and conferences. TRIAL REGISTRATION NUMBER NCT04875507.
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Affiliation(s)
- Ka Yan Ho
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
| | | | | | - Jessie Lin
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
| | - Yim Wah Mak
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
| | - Cynthia Wu
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
| | - William H C Li
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Cherian KM, Samuel Johnson AK, Chacko A, Babu BP, Joseph MR, David A, Varghese SM. Assessment of Squalor in Migrant Colonies of Thiruvalla Province of Kerala, India using Rapid Survey Technique. Indian J Occup Environ Med 2021; 25:114-118. [PMID: 34421249 PMCID: PMC8341416 DOI: 10.4103/ijoem.ijoem_200_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/05/2020] [Accepted: 09/18/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Domestic squalor refers to households that are extremely cluttered, in a filthy condition, and where the accumulation of items such as personal possessions, rubbish, excrement and decomposing food creates an environment that jeopardizes the health and wellbeing of the occupant(s). In India, an estimated 258 million are migrants. They are more likely to live in squalor due to inferior socio-economic status and no permanent residence. This poses a threat to the health of the migrants and the neighbors. Objective: To assess the squalor and morbidity pattern among the migrants of Migrant colonies in Thiruvalla using Rapid survey technique. Methodology: The state of squalor in migrant colonies was assessed by Lot Quality Assurance Sampling Methodology using the Environment Cleanliness and Clutter Scale (ECCS). The sample size for each lot/colony was '14' dwellings according to LQAS table. The details were collected from 14 inhabitants of different dwellings of the same colony. The inhabitants were selected randomly and were excluded if he belonged to the same dwelling. Fifteen colonies were randomly selected to achieve the sample size of 210 (15*14). The study was done in Tiruvalla municipality. Results and Conclusion: Only two colonies (n = 15) were squalor free. Majority of the dwellings (n = 210) were having an ECCS score between 13 and 15. Common ailments affecting migrants include Common cold, Skin disorders, and dental caries and gastritis. Squalor was found in most of the migrant colonies as they are living in inhuman conditions.
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Affiliation(s)
- Koshy M Cherian
- Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Abel K Samuel Johnson
- Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Avira Chacko
- Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Bichu P Babu
- Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Marina Rajan Joseph
- Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Alice David
- Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Sangeetha M Varghese
- Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
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Bava NP, Sreekumar S, Mathew G, Sushan A, Sheeja AL, Parvathy P. Strategies for COVID-19 control among migrant labourers in a developing country setting: Pathanamthitta model from Kerala. J Family Med Prim Care 2021; 10:2342-2347. [PMID: 34322435 PMCID: PMC8284236 DOI: 10.4103/jfmpc.jfmpc_2357_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/16/2021] [Accepted: 03/17/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The ongoing pandemic of Covid-19 is a public health emergency with serious implications world-wide including India. Vulnerable population like migrants are often left out of epidemic preparedness planning and reaching out these marginalized population is a challenge. OBJECTIVE To describe different strategies implemented for control and prevention of Covid-19 among migrants in Pathanamthitta. RESULTS Strategies for Covid-19 control among migrant labourers were planned and implemented with intersectoral coordination and community participation. Line listing and risk stratification, mobilisation of community volunteers, contactless active symptomatic surveillance using technology, IEC activities for awareness generation in multiple languages, sample collection, testing and distribution of personal protective equipment's were initially implemented. Setting up of a call centre facility assisted with M health technology exclusively for addressing concerns of migrants was first and one of its kind in the country. In addition to that special measures were taken to improve adherence and wellbeing of migrants which included addressing medical needs of migrants including psychological needs, ensuring food security, migrant hostels for the providing shelter, basic health care, isolation facilities and arranging transportation facilities for more than 10,000 stranded migrants. The success of these strategies was evident from the fact that not even a single migrant labourer was tested positive in the district during this period. CONCLUSION Pathanamthitta district being in a resource constraint setting showed a very effective model by implementing technology assisted strategies tailored to the needs of population.The success of these highly effective and replicable strategy underlines the need to incorporate principles of primary health care in crisis management.
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Affiliation(s)
- Nooh P. Bava
- Hon. District Collector, Pathanamthitta District, Kerala, India
| | - S Sreekumar
- FHC Vadasserikara, Pathanamthitta District, Kerala, India
| | - Geethu Mathew
- Department of Community Medicine, Believers Church Medical College (BCMCH), Thiruvalla, Kerala, India
| | - Abey Sushan
- District Programme Manager, National Health Mission, Pathanamthitta District, Pathanamthitta District, Kerala, India
| | - A. L Sheeja
- District Medical Officer, Pathanamthitta District, Kerala, India
| | - P Parvathy
- FHC Thannithode, Pathanamthitta District, Kerala, India
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Kumar J, Saya GK, Kanungo S. Prevalence and health risk score of tobacco and alcohol use by using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test among construction workers in Puducherry, India. Ind Psychiatry J 2021; 30:47-54. [PMID: 34483524 PMCID: PMC8395547 DOI: 10.4103/ipj.ipj_6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 01/15/2021] [Accepted: 04/11/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Construction workers are one of the important neglected occupation groups. The study aimed to assess the prevalence and health risk score of tobacco and alcohol use and its association with sociodemographic factors and self-reported morbidities among construction workers. MATERIALS AND METHODS A cross-sectional study was conducted among 400 male construction workers in a tertiary care medical institution in Puducherry, India. A semi-structured questionnaire based on the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) guidelines for assessment and health risk score of alcohol and tobacco use was used. The association of current tobacco and alcohol use with associated factors was analyzed by univariate analysis. RESULTS About 371 male construction workers participated. The mean (standard deviation) age of construction workers was 28.28 (9.04) years. The prevalence of current tobacco and alcohol use was 60.1% (223/371) and 47.7% (177/371), respectively. Out of 133 smokers, 60.9% (81) were used only bidi, 27.1% (36) only cigarette, and 12% (16) both bidi and cigarette. Most of the workers (126/151 [83.4%]) used khaini among smokeless tobacco users. The majority (204/241 [84.6%]) of ever smokers and nearly half of alcohol users (103 [49.8%]) had moderate risk based on ASSIST score. Higher current tobacco consumption is associated with higher age group, married, lower education status, unskilled occupation, contractual workers, migrants from other states, more duration of work in construction field, and the presence of self-reported health problems (P < 0.05). Current alcohol consumption is associated with more duration of work in construction field and the presence of self-reported health problems (P < 0.05). CONCLUSIONS Tobacco and alcohol use is high, and health risk due to substance use is also more in construction workers.
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Affiliation(s)
- Jaswant Kumar
- Department of AYUSH, Alwal, Azamgarh, Uttar Pradesh, India
| | - Ganesh Kumar Saya
- Department of Preventive and Social Medicine, JIPMER, Puducherry, India
| | - Srikanta Kanungo
- Indian Council of Medical Research-Regional Medical Research Centre, Bhubaneswar, Odisha, India
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Tirukkovalluri SS, Arumugam B, Gunasekharan N, Suganya E, Ponsuba TA, S D. Social determinants in access to tobacco prevention and cessation support services among migrant construction workers in Urban Chennai, India. J Family Med Prim Care 2020; 9:1991-1998. [PMID: 32670953 PMCID: PMC7346955 DOI: 10.4103/jfmpc.jfmpc_1072_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/05/2019] [Accepted: 01/20/2020] [Indexed: 12/02/2022] Open
Abstract
CONTEXT In spite of the high burden of tobacco consumption among migrants, disparities in the awareness of tobacco-related harms, health-seeking behaviors, and intention to switch to lower risk alternatives remain understudied area. AIMS Assess the social determinants in access to tobacco prevention and cessation support services among migrant construction workers in urban Chennai, India. SETTINGS AND DESIGNS A community-based, cross-sectional study design. MATERIALS AND METHODS A questionnaire adapted from GATS survey was used among migrants working across 13 construction sites of Chennai during May-September 2019. A counseling session was provided for the migrant workers who were willing to quit. STATISTICAL ANALYSIS USED Data entered in MS Excel was analyzed using SPSS and multivariate analysis was performed. RESULTS Among 345 migrants, 338 (98%) were currently using tobacco and smokeless tobacco (57.4%) consumers. In spite of awareness (84.6%) about tobacco ill-effects on health, only 48% care providers enquired of the tobacco use in the previous one year. Pictorial health warnings were seen by 315 migrants (91.3%) in the past one month, but only 110 migrants (34.9%) considered quitting. The majority (341 migrants, 98.4%) have not heard of the lower risk alternatives such as nicotine gums and lozenges and only 89 migrants (26.33%) agreed to try lower risk alternatives for tobacco on trial basis. Migrant construction workers who were using tobacco less than 5 years (P = 0.001) were more likely to try lower risk alternatives. CONCLUSIONS Reappraising social determinants in access to tobacco prevention and cessation support services to migrant construction workers may be a promising strategy to reduce health harms of tobacco intake.
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Affiliation(s)
| | - Balaji Arumugam
- Department of Community Medicine, Tagore Medical College Hospital, Chennai, Tamil Nadu, India
| | - N Gunasekharan
- Dean, Tagore Medical College Hospital, Chennai, Tamil Nadu, India
| | - E Suganya
- Department of Community Medicine, Tagore Medical College Hospital, Chennai, Tamil Nadu, India
| | - T Akhshaya Ponsuba
- Department of Community Medicine, Tagore Medical College Hospital, Chennai, Tamil Nadu, India
| | - Divyadharshini S
- Department of Community Medicine, Tagore Medical College Hospital, Chennai, Tamil Nadu, India
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Yang SY, Hsu DJ, Yen CM, Chang JH. Predictive factors of life quality among packaging workers in Taiwan. Health Promot Int 2019; 34:751-759. [PMID: 29788221 DOI: 10.1093/heapro/day029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The semiconductor plants on the top of high-tech industrial chain hire many packaging workers to carry out miscellaneous packing tasks for various product orders from different companies and countries. Under tremendous workload the quality of life (QoL) of such packaging workers need to be concerned. The aim of this study was to explore factors influencing their QoL. This study recruited 247 packing workers (162 male and 85 female; mean age: 35.6 years old) in 2015 and 2016 from a semiconductor plant in Taiwan by convenience sampling. The questionnaire comprised four parts: demographics, the World Health Organization Quality of Life (WHOQOL-BREF), an occupational burnout inventory and the Nordic Musculoskeletal Questionnaire. The four domains of the WHOQOL-BREF were defined as outcome variables. Predictive factors included gender (reference: male), age (reference: ≤ 35), BMI (reference: ≤ 25), educational level (reference: below university), marital/partner status (reference: married/cohabiting), years of work (reference: ≤ 5), work shift (reference: day shift), personal burnout, work-related burnout, over-commitment to work and the number of body parts with discomfort (0-9). The findings showed that physical QoL was negatively correlated with night -shift work, personal burnout, and number of body parts with discomfort. Psychological QoL was negatively correlated with night shift work and personal burnout. Environment QoL was negatively correlated with being male, night shift work and personal burnout. The results showed that the QoL among the packaging workers could be improved by reducing musculoskeletal discomfort, personal burnout and by improving work schedules.
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Affiliation(s)
- Shang-Yu Yang
- Institute of Allied Health Science, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Der-Jen Hsu
- Department of Safety, Health and Environmental Engineering, National Kaohsiung University of Science and Technology, Kaohsiung, Taiwan
| | - Chun-Ming Yen
- Department of Safety, Health and Environmental Engineering, National Kaohsiung University of Science and Technology, Kaohsiung, Taiwan.,Advanced Semiconductor Engineering Inc., Kaohsiung, Taiwan
| | - Jer-Hao Chang
- Institute of Allied Health Science, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Rabanipour N, Roohafza H, Feizi A, Sarrafzadegan N. Demographic, Life Style and Job-Related Determinants of Quality of Life of Industrial Manufacturing Employees: An Application of Multilevel Latent Class Regression on a Large Cross-Sectional Study. Ethiop J Health Sci 2019; 29:847-858. [PMID: 30700952 PMCID: PMC6341431 DOI: 10.4314/ejhs.v29i1.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Employees are one of the key elements of an organization and measure the quality of life (QoL) provides reliable assessment of health and wellbeing in this population. This study aimed at investigating the QoL in a large sample of Iranian industrial manufacturing employees and its determinants. Methods In a cross-sectional study conducted was in 2015, 3063 people were selected among 16000 Esfahan Seal Company's employees using multistage cluster sampling. QoL was evaluated by EQ-5D questionnaire, mental health by GHQ-12, physical activity by IPAQ, job stress by Effort-Reward Imbalance questionnaire. Self-report questionnaire was used for gathering demographic characteristics. Multilevel latent class regression analysis was used for data analysis using R (3.4.3). Results The mean (SD) age of the study participants was 36.74 (7.31), and 91.5% of them were males. The mean (SD) sleep duration was 7.11 (1.17), and 95.4% of the participants had normal mental health. Latent class analysis classified employees into two classes (high (82.4%) and low QoL (17.6%)). Also employees' job categories classified into high and low QoL classes (79.55% and 20.45%, respectively). Latent class regression showed that lower age (OR=0.93; P< 0.0001), being male (OR=1.75; p=0.009), lower levels of education (OR=2.1; P< 0.0001), normal mental health (OR=12.4; P< 0.0001), higher sleep duration (OR=1.2; P< 0.0001) and lower BMI (OR=0.96; P=0.016) were significant predictors of being in high QoL class. Conclusion Our study provides data about the QoL of industrial manufacturing employees along with its significant determinants. The findings picture the ways for improving QoL, finally increasing the efficiency and productivity of workforce by directing health policies appropriately.
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Affiliation(s)
- Najmeh Rabanipour
- Department of Biostatistics and Epidemiology, School of health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Roohafza
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- Department of Biostatistics and Epidemiology, School of health, Isfahan University of Medical Sciences, Isfahan, Iran.,Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nizal Sarrafzadegan
- Isfahn Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Zabeer S, Inbaraj LR, George CE, Norman G. Quality of life among migrant construction workers in Bangalore city: A cross-sectional study. J Family Med Prim Care 2019; 8:437-442. [PMID: 30984651 PMCID: PMC6436273 DOI: 10.4103/jfmpc.jfmpc_424_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context The construction industry is one of the oldest industries in India, which employs a large number of workers of poor socioeconomic status. Bangalore has seen significant rise in the number of migrants from various parts of the country to work in construction industry. These workers suffer from lack of good accommodation, basic sanitation, health facilities, stressful working conditions, and poor social life. Quality of life (QoL) among a population is an essential step to understand and improve health status, well-being, and mental health of the population. Materials and Methods A cross-sectional study was done to assess QoL among migrant construction workers in Bangalore. We interviewed 400 workers using questionnaire containing sociodemographic profile and WHOQOLBREF scale. Factors associated with QoL were tested using independent "t" test and Chi-square test and P < 0.05 was considered as statistically significant. Results The mean age of the workers was 26.38 + /4.3 years and majority of them were men (95.2%). The smokers had higher mean score in psychological domain with a significant P value. Those who lived in huts had higher mean score (60.4+/9.71) in the social domain as compared with those who lived in pucca houses (59.7 + /12.5). Those who were married, worked as nonlaborers, lived in pucca houses, earned higher income had higher mean scores in the environmental domain compared with those who were unmarried, laborers, lived in huts, and earned lower income. Conclusion Migrant construction workers had poor physical, social, and psychological QoL, whereas QoL in environmental domain is better compared with studies done across the country and it was significantly associated with higher income, education, better accommodation, and type of work. We recommend strategies to improve their physical, social and psychological well-being of this vulnerable population through strict legislations.
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Affiliation(s)
- Shaik Zabeer
- Department of Family Medicine and Community Health, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Leeberk R Inbaraj
- Department of Family Medicine and Community Health, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Carolin E George
- Department of Family Medicine and Community Health, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Gift Norman
- Department of Family Medicine and Community Health, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
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