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Assessment of Respiratory Morbidities among Police
Personnel in Kochi city, Ernakulam
Ms. Elsa Mary
Dissertation submitted in partial fulfillment of the requirement
For the award of the degree of
Master of Public Health
Achutha Menon Centre for Health Sciences Studies
Sree Chitra Tirunal Institute for Medical Sciences & Technology
Thiruvananthapuram, Kerala
October 2013
ii
ACKNOWLEDGEMENT
I am grateful to my guide Dr. Manju. R. Nair who patiently took me through each and
every step of this research and for her constant support and encouragement throughout the
study. She was ready to answer my queries and doubts at any time. I thank her for
boosting my confidence level and being with me in my good and bad times.
I owe special thanks to Dr. K. R. Thankappan, Dr. V. Ramankutty, Dr. P. Sankara Sarma,
Dr. T.K Sundari Ravindran, Dr. Mala Ramanathan, Dr. Ravi Prasad Varma, Dr. Kannan
Sreenivasan, Dr. Biju Soman and Ms. Jissa V.T for their valuable comments and
suggestions during the course of my research work. I extend a word of thanks to Dr.G.K
Mini for her help in data analysis.
I take this opportunity to thank the District Police Chief , Kochi city, Sri. K.G.James
I.P.S. for permitting me to conduct the study. I extend my sincere thanks to the Deputy
District police chief, Sri.Muhammed Rafique, Assistant Commissioners of Police, Sri.
K.S Baby Vinod, Sri. N. Binoy ,Circle Inspectors, Sri.M. M Stalin, Sri. Jayakumar for
their extreme help and co-operation during my study. I would also like to thank “Kerala
State Council for Science, Technology & Environment” for giving financial assistance for
the study. Last but not the least I thank all the participants of my study
I thank all my friends for being a helping hand for me at any time of my work and who
were with me to share my pains and pleasures. Special word of thanks to Mr.
Kamaruddeen for his support .
I would like to express my heartfelt thanks to my mom and my brother for their
unconditional love and support without them this research was never possible.
Finally, I thank the God Almighty for showering his blessings and strengthening me in
each and every step of this research.
Elsa Mary
iii
CERTIFICATE
I hereby certify that this dissertation titled “Assessment of respiratory morbidities among
police personnel in Kochi city, Ernakulam” is a bonafide record of original research work
undertaken by Ms. Elsa Mary in partial fulfillment of the requirements for the award of
the degree of „Master of Public Health‟ under my guidance and supervision.
Dr. Manju. R. Nair
Scientist C
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences &Technology
iv
DECLARATION
I declare that this dissertation entitled “Assessment of respiratory morbidities among
police personnel in Kochi city, Ernakulam” is my original research work. It has not been
submitted to any other university or Institution for the award of a degree. Any
information sought from any person has been duly acknowledged in the work.
Ms. Elsa Mary
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences &Technology
v
DEDICATION
I dedicate this piece of work to my parents Mr. N.D Samuel,
Mrs. Mary Samuel and my brother Mr. Eby Samuel who were my
support and my confidence all throughout . . . .
vi
TABLE OF CONTENTS
Topic Page
Number
ACKNOWLEDGEMENT
CERTIFICATE OF GUIDE
ABSTRACT
Ii
iii
xi
CHAPTER 1 INTRODUCTION
1.1 Background
1
1
CHAPTER 2 REVIEW OF LITERATURE.
2.1 Occupational lung diseases – Global scenario.
2.2 Occupational lung diseases – Indian scenario.
2.2.1 Sources and components of traffic related air pollution.
2.2.2 Air pollution and mechanism of lung injury.
2.2.3 Nature of air pollutants and their effect on respiratory morbidity.
2.3 Air pollution and respiratory morbidities.
2.4 Factors associated with respiratory morbidities due to occupational
exposure.
2.5 Pyramid of health effects.
2.6 Major morbidities studied.
2.7 Measurements used in studies
2.8 Methodological challenges faced
2.9 Air pollution and occupation.
2.10 Traffic police as a vulnerable group.
2.11 Kerala scenario
2.12 Rationale of the study
2
3
5
6
6
7
8
9
10
11
12
13
13
14
15
vii
CHAPTER 3 METHODOLOGY
3.1 Study objective
3.2 Methodology
3.2.1 Study design
3.2.2 Study setting
3.2.3 Study population
3.2.4 Inclusion criteria
3.2.5 Exclusion criteria
3.2.6 Sample size
3.2.7 Sample selection procedure
3.2.8 Data collection technique.
3.2.9 Data collection process
3.3 Operational definition of variables.
3.4 Independent and dependent variables.
3.5 Ethical consideration
17
17
17
18
18
18
18
19
19
21
21
22
24
CHAPTER 4 RESULTS
4.1 Familial and past history of chronic respiratory disease.
4.2 Work related factors.
4.2.1 Use of Personal protective equipment.
4.3 Other self reported morbidities among police personnel.
4.4 Prevalence of respiratory morbidity among police personnel in Kochi city
in the past one year.
4.4.1 Prevalence of chronic respiratory morbidity among police personnel.
4.5 Bivariate analysis- Chronic respiratory morbidity with independent
variables.
4.5.1 Socio-demographic characteristics associated with chronic respiratory
morbidity.
4.5.2 Association of chronic respiratory morbidity with work related
factors.
4.5.3 Association of use of face barriers of any kind with other variables.
27
27
29
30
30
31
32
32
33
35
viii
4.6 Multiple logistic regression analysis.
4.7 Bivariate analysis- Peak Expiratory Flow reading with independent
variables.
4.8 Peak Expiratory flow reading.
36
37
38
CHAPTER 5 DISCUSSION
5.1 Comparison with other occupational groups exposed to air pollution.
5.2 Comparison with respiratory morbidities among industrial workers.
5.3 Socio- demographic factors.
5.3.1 Housing characteristics: distance of residence from main road.
5.3.2 Place of residence
5.4 Work related factors.
5.4.1 Number of years of service in the city.
5.4.2 Type of shift
5.4.3 Use of PPEs during traffic duty.
5.4.4 Routine medical checkups.
5.5 Peak flow restriction
5.6 Other self reported morbidities.
5.7 Limitations of the study.
5.8 Strength of the study.
5.9 Conclusion
5.10 Policy implications.
41
42
42
43
43
43
43
44
44
46
46
47
48
48
48
49
REFERENCES
GLOSSARY OF ABBREVIATIONS
ANNEXURE
50
65
ix
LIST OF TABLES
4.1 Distribution of the study population based on housing characteristics 26
4.2 Characteristics of the study sample based on work related factors. 28
4.3 Use of Personal Protective Equipments among Police personnel 29
4.4 Other self reported morbidities among police personnel 30
4.5 Prevalence of respiratory morbidities studied 31
4.6 Association of Chronic Respiratory Morbidity with Socio - demographic
characteristics
33
4.7 Association of chronic respiratory morbidity with work related factors 34
4.8 Association of Chronic Respiratory Morbidity by use of face barriers of
any kind
34
4.9 Association of Use of any face barriers with other variables 36
4.10 Factors associated with chronic respiratory morbidity – Results of
multiple logistic regression analysis
37
4.11 Association of peak expiratory flow readings with work -related factors 38
4.12 Variation of peak expiratory flow readings in different age group and
service years in the city by sex
39
.
x
LIST OF FIGURES
4.1 Distribution of age group 25
xi
ABSTRACT
“Assessment of respiratory morbidities among police personnel in Kochi city,
Ernakulam district, Kerala”
Background: Among the 11 million cases of occupational diseases globally, 1.9 (17%)
million cases are contributed by India. Growing traffic pollution in India has become the
fifth largest killer in the country. Most studies on occupational health in India are done in
industrial settings whereas few studies have looked into occupational groups exposed to
air pollution. Traffic police personnel by nature of their job are continuously exposed to
toxic pollutants from automobiles. The study aimed to assess the respiratory morbidities
among police personnel in Kochi city and to find out the factors associated with
respiratory morbidity among them.
Methodology: A Cross sectional study was done among police personnel from all the 4
traffic stations and 4 randomly selected law and order stations in the city. Cluster
sampling method was used. A structured interview schedule and peak flow meter reading
were the main tools. The outcome was a single composite variable created out of four
main chronic respiratory morbidities. Analysis was done in SPSS 17 version.
Results: The prevalence of chronic cough, chronic phlegm, chronic wheeze, peak flow
restriction and any form of chronic respiratory morbidity were 6.3, 12.3,4, 25.2 and 34.8
percentages respectively. Work related factors like number of service years in the city
[OR: 1.17 -3.06], nature of shift [OR:1.13- 3.02], working hours near roadside per
day[OR: 1.17- 3.19] were significantly associated with the outcome.
Conclusion: Police personnel working in traffic have significantly higher prevalence of
respiratory morbidity. Appropriate use of face mask was nearly 0.3% (1). Periodic
monitoring of this group can detect early signs of dysfunctions and measures including
supply of appropriate and acceptable personal protective equipments could be taken.
1
CHAPTER 1
INTRODUCTION
1.1 BACKGROUND
Health of a person is largely affected by the environment in which they work, thus
making occupation an important determinant of health.1 Occupational hazards cause early
deaths to millions of people worldwide and also result in avoidable morbidity that
adversely affect the quality of life. The World health report 2002 placed occupational
risks as the tenth leading cause of morbidity and mortality.2 More than 80% of the global
burden of occupational disease as well as injury is borne by people in the developing
countries3 since they are home to about 70% of world‟s work population.
4
The comparative risk assessment1 carried out by the WHO and the ILO in 2002,
highlighted the enormous burden of mortality and morbidity due to occupational risk
factors globally. Even with the limitations of data availability and underreporting, they
accounted for about 37% of back pain, 16% of hearing loss, 13% of obstructive lung
disease, 11% of asthma, 10% of injuries, 9% of lung cancer, and 2% of leukemia among
the exposed worker population. The workers in the developing countries are
disproportionately more affected than the developed economies due to several factors
including the presence of largely informal sector work force, weak or absent regulatory
frameworks, migration, cheaper and more hazardous production processes and low
awareness.5, 6
Occupational lung diseases rates as one of the most common work related illnesses and
therefore an issue of great priority in the industrialized countries and also increasingly in
the developing countries.7
2
CHAPTER 2
REVIEW OF LITERATURE
2.1 OCCUPATIONAL LUNG DISEASES – GLOBAL SCENARIO
Occupational lung diseases is a major contributor of the global occupational disease
burden and is a main focus of occupational health programs worldwide.8
Estimates
indicate that work-related occupational exposure to air borne particulates accounts for
about 386000 deaths and nearly 6.6 million DALYs worldwide.9 The bulk of this is
contributed by Chronic Obstructive Pulmonary disease (COPD) followed by asthma and
pneumoconiosis.9
Occupational lung diseases broadly includes those that are specific to
certain occupations like the farmer‟ lung, asbestosis etc and those that are aggravated by
the work related exposures like occupational asthma.10
The nature of some jobs and the related exposures predispose certain groups of workers to
considerably larger risk of developing occupational lung diseases. Those in the textile,
asbestos, steel, coal mining industries, construction workers, farmers, firefighters, spray
painters and mill workers who are exposed to a range of dusts, mineral particles and
noxious chemicals are the some of the most affected groups.11-24
The most common
occupational lung diseases seen among the exposed workers have been bronchial asthma,
byssinosis, silicosis, pneumoconiosis, mesothelioma10
, chronic bronchitis etc. Various
studies have shown the prevalence of byssinosis among textile workers ranges from
10.5% to 43.2%,11-13
chronic respiratory morbidity among mill workers ranges from 7.5%
to 42.66%,11,22
the prevalence of lung parenchyma changes among the construction
workers to be 15.4%.18
Most of the occupational health studies have thus been among
those exposed to industrial exposures.
3
However there are other groups who are less studied and who are continuously exposed to
ambient air pollution. Exposures in the “dusty trades” are estimated to cause about 15
percent of the COPD.25, 26
Besides the workers within the classic industrial settings, certain categories of workers
are highly vulnerable to develop occupational lung diseases due to chronic exposure to
high levels of ambient air pollution. Some of the workers studied include bus drivers, taxi
drivers, postal workers, shopkeepers, street vendors, garbage collectors, toll booth
workers, street sweepers, traffic wardens and police personnel.27
Though not working in
settings with exposures to specific toxins or substances, these workers the nature of work
they do, are exposed to considerable amounts of traffic related ambient air pollution.
They were found to have mainly chronic respiratory diseases like chronic cough, chronic
phlegm, wheezing, Dyspnea along with decreased lung function in various studies.28-36
The major share of the traffic related air pollution is due to the emissions from
automobiles37
which in many cities of the developing world do not follow emission
standards.38
Rapid industrialization and urbanization have aggravated the rising levels of
ambient air pollution in the cities especially in the developing countries including the
Asian countries.39
2.2 OCCUPATIONAL LUNG DISEASES - INDIAN SCENARIO
Among the 11 million cases of occupational diseases globally, 1.9 (17%) million cases
happen in India and contributes also to about 17% (0.12 million) of the mortality due to
occupational diseases out of 0.7 million deaths.40
Studies done in India regarding
occupational lung diseases have been mostly among industries with high exposures of
dust – inorganic and organic, asbestos, steel, coal, textile workers etc. The major
4
morbidity reported among them were byssinosis, chronic respiratory morbidity
accounting for about 31%, lung function abnormalities accounting for 45 %.41-43
Some of
the major occupational morbidities of concern in India include silicosis, coal workers‟
pneumoconiosis, chronic obstructive lung diseases, asbestosis, byssinosis, bronchial
asthma .44
There are however some studies from across the country which have examined the effect
of occupational exposure to ambient air pollution which is mostly traffic related. A study
among street sweepers in Maharashtra found that about 8% of the workers suffered from
chronic respiratory morbidities including chronic bronchitis, asthma and bronchiectasis
compared to 1.4% among class -four workers.36
Increasing traffic pollution in India is a major hazard especially to those living and
working in cities and the rising ambient air pollution poses considerable risk to large
population who either reside or commute to these cities for work. The growing number of
vehicles is considered one of the major reasons for worsening air quality standards in the
country; highlighted by the fact that India was the fifth largest motor vehicle
manufacturer in the world in the year 2011-2012.45
There are major occupational groups27
who are continuously exposed to traffic air
pollution by the nature of the work they do and are at great risk of developing
occupational respiratory morbidity. Some of the major research in this area has focused
on such groups with high exposure to automobile as well as traffic related air pollution.
Studies have looked into the exposures and specific risks of various such occupational
groups in India which indicate high levels of chronic occupational respiratory
morbidities.28-36
5
2.2.1 Sources and components of traffic related air pollution
Pollutants from automobiles, industries, during fuel combustion, heating of engines are
the main sources for outdoor pollution.46,47
Motor vehicles such as automobile, trucks and
buses are the primary sources of air pollution everywhere in India and they are the main
contributor to air pollution in cities.
The major traffic generated pollutants that are responsible for causing these acute and
chronic respiratory morbidities are mainly the particulate matter, ozone, nitrogen
dioxides, volatile organic compounds, sulphur dioxide, carbon monoxide, polycyclic
aromatic hydrocarbons, lead etc.48
It is thus composed of various gaseous air pollutants
and suspended particulate matter (SPM) of different sizes and composition. Poorly
maintained vehicles which lack exhaust after treatment system are responsible for major
part of pollutant emission. Road transport is the main contributor to emission of Nitrogen
dioxide and benzene in cities. Tail pipe emissions of primary particles from road transport
account for 30% of the fine particulate matter (less than 2.5µm in aerodynamic
diameter).49
The various processes that lead to road transport emissions are distinguished by four main
components: 49
1. Hot emissions: exhaust emissions under thermally stabilized engine operation.
2. Cold start emissions: exhaust emission during transient operation after engine start
up.
3. Emissions originating from direct fuel evaporation.
6
4. Particulate emissions produced by the wear on vehicle components like tyres,
brakes, clutch and road abrasions.
2.2.2 Air pollution and mechanisms of lung injury
Air pollution mainly causes respiratory morbidities as the most common route of
vehicular emissions to enter the human body is through inhalation. Exposure to air
pollutants causes injury to the airway including the terminal bronchioles and causes
decrease in lung function leads to acute and chronic respiratory diseases.47
The acute
effects include irritation to eyes, nose, throat, upper respiratory infection, bronchitis,
pneumonia. It also causes head ache, nausea, allergic reaction and aggravation of existing
cardio vascular diseases and asthma and the chronic effects include chronic respiratory
diseases (COPD), and Air pollution is also linked to cause some adverse effects such as
ischaemic heart disease and cerebrovascular diseases.48
2.2.3 Nature of air pollutants and their effect on respiratory morbidity.
Air pollutants comprise of gaseous pollutants, odour and suspended particulate matter
(SPM) such as fumes, dust, mist and smoke.50
The major air pollutants are PM
(Particulate matter), Ozone (O3), NO2 (Nitrogen dioxide) and Sulphur dioxide (SO2).
These pollutants cause respiratory morbidities, reduced lung function, and even cause
cardiac problems; on chronic exposure it even causes lung cancers and COPD.48
Sulphur
Dioxide gases cause the airways to constrict and causes increase resistance to inflow and
out flow of air result in wheezing and shortness of breath.
The other factors which influence the ambient concentration of traffic pollutant are
related to meteorological conditions, vehicle volume, vehicle type (heavy and light) and
driving patterns. In urban areas of industrialized countries, traffic generated emissions
7
accounts for more than 50% of the total emission of particulate matter.51
World Health
Organization in 1996 estimated 60% of airborne urban pollution is produced by diesel
and gasoline engines.52
2.3 AIR POLLUTION AND RESPIRATORY MORBIDITIES
The commonly reported respiratory symptoms associated with traffic pollution in children
as well as among occupational groups exposed to traffic pollution include bronchitis,
asthma, wheezing, breathlessness, dry cough and cough with phlegm and other nasal
problems.53,54
The traffic fumes emitted from the vehicles also causes reduced lung
function among the susceptible subjects.28-36
Studies have shown that the prevalence of respiratory morbidity is 28% among traffic
police personnel when compared to 11% among the administrative workers who are not
exposed to the air pollutants.71
Similar studies were conducted in India which showed
significant decrease in lung function and presence of lung obstruction among the traffic
police personnel.28-36
A comparative cross sectional study in Nagpur among 273 street sweepers and 142 class
four workers in office showed the prevalence of chronic bronchitis was significantly high
among street sweepers (7.5%) than the comparison group (1.4%).36
Other morbidities like
conjunctivitis, bronchial asthma, frequent upper respiratory tract infections were also
reported mainly among street sweepers.34
Work related symptoms like head ache, fever, dizziness, eye irritation, weakness were
also reported among road side vendors in a study conducted in Bangkok.35
8
2.4 FACTORS ASSOCIATED WITH RESPIRATORY MORBIDITIES DUE TO
OCCUPATIONAL EXPOSURE
1) DURATION :
Respiratory morbidities due to traffic pollution get increased with time. The initial acute
symptoms due to air pollution get worsen and cause chronic respiratory morbidities.55
The factors include duration of work hours, years of residential living in polluted cities.56
Police personnel posted in the traffic duty are exposed to these pollutants for 6-8 hours a
day. Studies show that police personnel who are exposed to traffic for longer period of
time have increased respiratory problems.55
2) INTENSITY
Evidence shows that the concentration of air pollutants is higher in the city area (where
industries and vehicle load is high) when compared to the residential area.57
The highest
emission rates from vehicles happen during motor idling, deceleration and at lower
speeds. High amount of carbon monoxide and hydrocarbons are released during motor
idling and slower speeds. Thus the pollutant concentration is high at road intersections
which are traffic light controlled; sharp turns in city area which slows down the traffic
thereby enhancing the pollution emission.37
Studies show that personal exposure level to CO was highest especially where traffic is
directed, schools are guarded and other outdoor tasks performed.58
Higher particulate
emissions and carbon monoxide concentration were measured high during the rush hour
than during the non-rush hour periods.51
9
Also the concentrations of nitrogen dioxide, black smoke (or soot) and ultra fine particles
(PM 0.1) are markedly higher in those areas which are within 300-500m from the major
urban highways.49
3) PERSONAL PROTECTIVE EQUIPMENTS
OSHA guidelines have recommended the usage of mask or respirator for any worker who
are exposed to air borne particulates in their work environment and also for those who are
exposed to toxic pollutants emitted from the auto mobiles.59
The use of mask or respirator
in work place whenever required is necessary in order to protect the health of the
employee.
But reports show that even with the provision of masks, the police personnel do not wear
it during traffic duty as they are unaware of the impact of air pollution on their health.60
4) OTHER FACTORS CAUSING RESPIRATORY DISEASES :
The other factors contributing to respiratory morbidities include smoking, passive
smoking, cooking fuel used in homes, place of residence, past childhood respiratory
infection, any history of past respiratory morbidities like asthma, COPD, any chest
injuries.61, 62
2.5 PYRAMID OF HEALTH EFFECTS:
Air pollution has an effect on both respiratory as well as cardiac systems. The health
effects of air pollution can be viewed as a pyramid with the mildest effect at the bottom
and severe effect at the top of the pyramid.
10
It is evident from the pyramid that as the severity of effect decreases, the number of
people who gets affected out of air pollution increases.48
2.6 MAJOR MORBIDITIES STUDIED (ACUTE AND CHRONIC):
Cross sectional study design as well as comparison within cross sectional design was
adopted by most of the studies to assess the respiratory morbidities among those exposed
to traffic pollution. These studies have mainly looked into acute respiratory problems like
upper respiratory tract infections, cough, wheezing, bronchitis, breathlessness, phlegm,
sore throat etc. 28-36
They have also assessed the lung function and degree of lung
obstruction. A study done by Sreedevi V, et al. 2008 in Hyderabad, to evaluate the
genotoxic effects of vehicular exhaust among traffic police showed significant
chromosomal aberrations among traffic police when compared to comparison group. The
study concluded that the cytogenetic damage can be due to the cumulative effect of
smoking, age, duration of exposure to vehicular exhaust.63
Chronic respiratory conditions
like chronic bronchitis, bronchial asthma etc. were reported high among the industrial
workers.
11
2.7 MEASURMENTS USED IN STUDIES.
Most studies have used respiratory questionnaires like the BMRC (British Medical
Research Council), ATS –DLD (American Thoracic Society- Division of Lung Disease)
Respirator Medical evaluation questionnaire32
to assess the symptoms of in the subjects
studied. They have been translated and validated in many languages. Some studies have
studied ambient air pollution monitoring station to measure the level of pollutants and
aero- dynamic monitors to measure the Particulate matter30
to assess the dose response
curve .
Studies in occupational and environmental respiratory morbidity use different methods to
assess the respiratory health status of the subjects. They have mostly been ventilation
functions of the lung using mainly computerized spirometers, pneumotachometers and
portable peak flow meters.
Spirometers are the most widely used, non invasive and considered a relatively accurate
method to assess restriction/obstruction of lung function and tends to have low intra-
subject variability in forced vital capacity (FVC) and forced expiratory volume (FEV).78
Pneumotachometers are pressure based flow meters that are used less frequently in
epidemiological studies and more in clinical settings.
However these spirometers require higher levels of expertise in use and interpretation,
accurate and frequent calibration besides the fact most of them are not portable and are
costly and are less commonly available in the public and private health care systems
Portable and fully electronic spirometers are now available in the market but are very
expensive.
12
Portable peak flow meters are another type of flow meters used to measure peak
expiratory flow in individuals in both research and clinical settings. However studies have
indicated that the accuracy, variability and reproducibility of peak flow metres have been
found to be lower than the spirometers in assessing pulmonary function and cannot be
considered a replacement for spirometry. They are cheaper and simpler to use and are
recommended in routine clinical practice.79
Studies have looked into the level of agreement of various brands of portable peak flow
meters with calibrated pneumatograph have shown varying degrees of agreement thereby
concluding that portable peak flow measurements could be used with the limitations but
cannot replace the spirometric assessment and some studies have found the portable peak
flow meters tend to overestimate the flow in the range of 200-400 l/ mt.80-86
It is also suggested that comparison between study findings of lung function between
studies with different methods should consider the differences in the distribution of
observations while interpreting the normal abnormal values of lung function. This is also
applicable when results from different types of the same peak flow metres.78
2.8 METHODOLOGICAL CHALLENGES FACED:
Exposure measurement: Studies could not measure the individual exposure to pollutants.
It was difficult to determine the actual pollutant concentration to which the people are
exposed. Also In many studies, it was difficult to attribute an effect to a single pollutant.65
High cost of personal monitoring, involvement of wide range of pollutants and suitable
monitoring technologies only for small number of pollutants has made it difficult to
directly measure the exposure to transport-related air pollution. Thus indirect exposure
13
assessment methods have to be relied upon like spatial modeling exposures using GIS
techniques, distance to the roads or source intensity etc.27
2.9 AIR POLLUTION AND OCCUPATION:
The various occupational groups exposed to air pollution include drivers, hawkers, toll
booth workers, traffic police personnel1, road side vendors, street sweepers.
27 Children
and elderly are the vulnerable groups who get affected due to high pollution.53,54
Also
people who live near the busy roads, road users especially pedestrians are highly exposed
to the traffic air pollutants.
Various Studies have shown higher prevalence of respiratory morbidities and decreased
pulmonary function test among these occupational groups .28-36
2.10 TRAFFIC POLICE AS VULNERABLE GROUPS
Policemen those working in the traffic as well as general law and order are a major group
who are continuously exposed to high levels of air pollution and are thus a highly
vulnerable occupational group to develop occupational lung diseases.
Traffic police as well as law and order police personnel are the worst sufferers because by
nature of their job63
, they are continuously exposed to the toxic pollutants emitted from
the automobiles. They have to work in the traffic for a minimum of 8 hours per day doing
traffic control as well as patrolling duties and 6-7 days a week. This is carried throughout
the year which mainly predisposes them to severe respiratory morbidities like bronchitis,
pneumonia, decreased lung function and even other health problems which include
hearing impairment, eye related problems, etc30
.
14
Thus exposure to toxic pollutants generated by vehicles during fuel combustion result in
various respiratory morbidities among certain occupational groups.
In 2003-04, a comparative cross-sectional study 30
done in Jalgon city, India among 60
non smoking traffic police and 60 healthy young adults showed 40% of traffic police had
frequent cough, 10% had shortness of breath and 27% suffered from irritation in
respiratory tract. The odds ratio for all the above symptoms was greater than 1 and
showed significant prevalence of respiratory problems among traffic police. The study
also concluded that traffic police have more respiratory impairment than the control group
based on the spirometric analysis done.30
Various other studies done among traffic police
in India also showed decreased lung function and its evident with increase duration of
work period.32,33
Most of the above mentioned studies have presented their results on the
basis of relatively small sample size ranging from 30 to 80. Thus there is a need to
conduct the study with larger sample size.
Policing forms one of the major work forces in the country. According to National data
on Police, the total police strength in the country is about 20.64 lakhs as on January 1
2011. The data also shows the sanctioned population per policemen is 576 where as in
actual it is about 761. 65
2. 11 KERALA SCENARIO
Kerala with its active participation towards industrialization has led to the emergence of a
number of large factories with high production capacities. According to the economic
survey by the central pollution control board in 2003, Kerala ranked fourth position in
terms of industrial units in the country.66
15
Vehicles as well as industries are responsible for deterioration of air quality in the state.
Both create noise and they emit air pollutants. The number of vehicles has increased more
than 20 times since 1975. Presently the state has over 25 lakh licensed vehicles on the
road. 72% of the total vehicles in the state are transport vehicles and 77% of these
personal vehicles are scooters and motor cycles.67
Vehicular emissions and noise from the vehicles are severe in Ernakulam, Kozhikode and
Trivandrum districts of Kerala. The road infrastructure development is not keeping pace
with the sudden increase in the number of vehicles which is leading to high traffic
congestion in the state and thereby reducing the air quality standards. Majority of the
large and medium industries and maximum number of vehicles are in the Ernakulam
district, making it the worst polluted place in the state.67
2.12 RATIONALE FOR THE STUDY:
Ambient air pollution is a major problem in Kerala especially in big industrialized cities
like Kochi. Almost no studies on occupational respiratory morbidities have been done
among those exposed to traffic pollution in the state.
Policing is considered as one of the major groups who are exposed to toxic fumes and
exhaust from vehicles throughout their work. The major functions of police is Social
service, helping people who need emergency assistance, law and order maintenance like
traffic control, crowd control, resolving disputes and crime control. Thus there are many
health and safety issues surrounding them as they are involved in many activities.68, 69
Limited studies28-34
have looked into the respiratory health issues among the police
personnel in India and in Kerala there has been only one study among police which
addresses the general health status.70
16
Thus the health of police personnel, who largely serves the need of the public, is very
7important because it could also affect the well being of the community he is serving.
Ernakulam district, being the commercial capital of Kerala – with the highest density of
automobiles and as well as the most industrialized, therefore has one of the worst levels
of air pollution in the State.67
Therefore this study was conceptualized to assess the respiratory morbidities among the
police personnel in the Kochi city.
17
CHAPTER 3
OBJECTIVES AND METHODOLOGY
3.1 STUDY OBJECTIVE:
Primary Objective:
1. To assess the prevalence of respiratory morbidities among police personnel in
Kochi city, Ernakulam District.
2. To find out the factors associated with respiratory morbidity among them.
Secondary Objective:
1. To understand the other self reported morbidities among them.
3.2 METHODOLOGY:
3.2.1 Study Design:
The study was a cross sectional survey.
3.2.2 Study Setting:
The study was conducted in all the four traffic police stations and selected law and
order police stations in Kochi city, Ernakulam District. Four law and order police
stations were randomly selected from 21 stations in the city. From each station all the
police personnel who meet the eligible criteria were included in the study. Permission
to conduct the study was obtained from the District police chief, Kochi city.
18
3.2.3 Study Population:
The study population comprised of all police personnel within the age group of 25-54
years working in the city at least for past one year and currently continuing the same
post from January 2012. List of these police personnel was obtained from each
police station from the concerned authorities.
3.2.4 Inclusion Criteria:
Police personnel within the age group of 25- 54 years with one year of service in the
city and currently continuing the same post from January 2012 were included in the
study.
3.2.5 Exclusion Criteria:
Police personnel with previous history of respiratory illnesses (asthma, TB, COPD)
and chest injuries, surgeries, cardiac failure before joining the job were excluded
from the study.
3.2.6 Sample Size:
A study conducted among 290 police personnel showed 28% of them who were
assigned to traffic duty reported respiratory symptoms whereas only 11% of the
administrative workers were reported to have respiratory symptoms.71
The sample size was calculated in open epi version “3”, with an anticipated
prevalence of respiratory morbidities which is 28%71
. Keeping the confidence limit
at ± 7% with a design effect 2, the sample size was 253. The final sample size was
calculated accounting for a non- response rate of 20% as 304, which was again
rounded off to 310.
19
3.2.7 Sample Selection Procedure:
Cluster sampling method was followed in the study. Each police station formed a
cluster. There are a total of 4 traffic police stations and 21 law and order police
stations in Kochi city.
All the four traffic police stations in the city were included in the study. List of the
police personnel working in each station was obtained from the concerned authority.
All the police personnel fulfilling the eligibility criteria from each station were
included in the study. Interview of the available personnel (fulfilling eligibility
criteria) was done at their convenience. The un-interviewed personnel were
contacted through phone for an appointment and information was sought on when
they are available in the station to interview. Each station was visited at-least 4-6
times to cover all personnel from that particular station. Any personnel who
couldn‟t participate in the interview were tried again for another 2 times and he/she
was dropped from the study if there is no response from his/her side for the third
time. I moved on to the other stations once the interview from each station got over.
After covering all the four traffic police stations, the remaining samples were taken
from four randomly selected Law and Order police stations. Lottery method was
used to select four law and order police stations. All the personnel from the selected
station who fulfilled the eligibility criteria were included in the study. The same
procedure mentioned earlier was done to conduct the interview.
3.2.8 Data Collection Technique:
The data was collected through a structured interview schedule using validated
questionnaire.
A) Interview Schedule: A structured interview schedule using combined and
modified version of the following was used.
20
- WHO Steps Instrument ( Core And Expanded )
- ATS DLD – 78 Questionnaire
- OSHA Respiratory Questionnaire.
The above three are standard questionnaire which is internationally accepted and
validated. The ATS DLD -78 was designed to assess the prevalence of chronic respiratory
symptoms and disease which is a modified version of BMRC (British Medical Research
Council) questionnaire. This questionnaire has undergone extensive testing and has been
reviewed by a large body of experts.72
It has been used after translation into local
languages in number of studies.73-76
In a study done in Pakistan, the ATS-DLD 78
Questionnaire was translated into „sindh‟ language and back translated to English and was
validated.75
B) Peak Flow Meter Measurements :
Peak flow rate was measured using a portable Mini Wright Peak flow meter® (Clement
Clare, London, UK). All the study subjects were asked to take a maximal deep breath,
place the peak flow meter in their mouth and expire out through the mouth as hard and as
fast as possible into the apparatus in the standing position after demonstrating the
procedure to them.. The best of three efforts was taken as the peak flow value for
analysis and was entered into the peak flow metric analysis sheet, which contains a scale
for specific age, sex and height. The respondent‟s value was compared with the reference
value and thereby and was interpreted as having a normal or obstructive pattern.
21
Data Collection Process:
Total number of police stations selected 8 ( 4 Traffic and 4 Law and Order)
Total strength of police personnel from the
selected stations 487
Number eligible to participate Traffic Law and
Order
Total
188 172 360
Number of personnel participated in the study 174 128 302
Number of personnel interviewed 310
Non- Response 2.6% (8)
3.3 OPERATIONAL DEFINITION OF VARIABLES :
1. Current Tobacco use: Those who use tobacco (smoke form) in the last one
month were defined as current tobacco user.
2. Frequent cough: Cough on most days for 3 consecutive months or more
during a year.
3. Chronic cough: Cough for 3 or more consecutive months in two consecutive
years.
4. Frequent phlegm: Bringing up phlegm for most days for 3 consecutive
months or more during a year.
5. Chronic phlegm: Bringing up phlegm for 3 or more consecutive months in
two consecutive years.
6. Frequent wheeze: Whistling sound heard on expiration within 2 years.
22
7. Chronic wheeze: Whistling sound heard on expiration more than 2 years.
8. Grade 1 Dyspnea: Breathlessness when walking upstairs or hurrying on level
ground
9. Grade 2 Dyspnea: : Breathlessness when walking on level ground compared
to people of same age or stop for breathing when walking at own pace on
level
10. Peak flow restriction: Peak flow meter reading less than the normal range
based on age, sex and height of the respondent.
11. Chronic respiratory morbidity: Presence of any one of the chronic
respiratory symptoms (Chronic cough [OR] Chronic phlegm [OR] Chronic
Wheeze ).
3.4 INDEPENDENT AND DEPENDENT VARIABLES:
Dependent variables:
Chronic respiratory morbidity: Presence of any one of the chronic
respiratory symptoms in the past one year.
Independent variables:
Current work department in Police.
Individual characteristics:
o Age,
o Sex,
o Marital status,
o Education.
Work related factors:
o Number of years of service in the city.
o Number of years of service in current post.
23
o Number of working days in a week.
o Average number of working hours near road side per day.
o Nature of shift frequently posted.
o Frequent posting location.
o Type of duty.
o Use of facemask during traffic duty.
o Type of face mask.
o Reason for not using face mask.
Confounding Variables:
Age
Housing characteristics:
o Place of residence
o Nature of area of residence
o Distance of residence from main road.
Personal habits: Current Tobacco use (smoke form).
Non occupational exposure:
o Passive smoking in work place.
o Passive smoking in home.
o Cooking fuel used.
Co morbidities:
o Hypertension.
o Diabetes.
24
3.5 Ethical Considerations.
Clearance was obtained from the Institutional Ethics Committee.
Confidentiality:
Identity of the respondent was kept anonymous from the stage of data entry. The SPSS
sheet contained data with interviewer ID number. List of the police personnel and their
details, data collection forms from the respondents were kept strictly confidential and was
not revealed during data analysis.
Privacy:
The interview was conducted in the concerned police stations and privacy was strictly
ensured. Any findings detected was not informed or passed on to other officials at any
circumstance.
Consent:
Permission was sought from the District police chief, Kochi city to conduct the study
from the month of June to August. Informed written consent in Malayalam was obtained
from the respondent before the commencement of the interview.
Referral:
Respondents detected with severe respiratory morbidity were referred to the near-by
government health centre where they usually do their periodic health checkups.
25
CHAPTER-4
RESULTS
The study was done among 302 police personnel (Response rate: 97.4%) who have
worked in the Kochi city at least for the past one year. The mean age of the study
population was 40.45 ± 6.30 years (range: 25- 54 years). Almost half (49%) of the study
population belong to the age group 35-44 years.
Figure 4.1 Distribution of age group.
60
149
30
0
20
40
60
80
100
120
140
160
25-34 years 35-44 years 45-54 years
The mean number of years of service in the city among the study population was 8.09±
6.25 years (Range: 1-30). Majority of the respondents, 90% (271) were CPOs (Civil
Police Officers) and 10% (31) of them were from the grade of Assistant Sub Inspectors
(SI) and Sub Inspectors (SI). 90% (272) of the respondents were males and 10% (30)
were females. Among the study subjects 49.7% (150) had educational qualification
graduation and above and the remaining 50.3% (152) had higher secondary education.
26
Table 4.1 Distribution of the study population based on Housing characteristics.
Variable (N =302) Frequency (%)
Place of residence
Panchayath
Municipality and corporation
188 (62)
114 (38)
Nature of area of residence
Residential area
Others: *
251 (83)
51 (17)
Distance of residence from main road
> 300 meter
200-300 meter
132 (44)
170 (56)
Cooking fuel used
LPG Only
LPG and wood
Only wood
158 (52)
144 (48)
0 (0)
*Others:( Industrial area, railway track, fly over, coastal region, bus station, freezing plant, paper
company)
27
In this study, 14% (43) of the respondents reported that they are current smokers. Out of
them 77% (33) of them turned out to be daily smokers. The mean number of
cigarettes/beedi used per day was 7.14± 6.9 (range: 1-30).
All the respondents (100%) reported that their households had a separate kitchen with
ventilation. About 50% (138) of them reported the presence of passive smoking in their
office and work place within the last one week while 2% (6) of them reported passive
smoking in their home.
4.1 Familial and Past history of chronic respiratory disease.
The presence of familial history of chronic respiratory disease for either father or mother
was reported by 23% (69) of the respondents and 8% (25) of them reported history of
severe respiratory morbidity within three years which made them to stay away from job.
4.2 Work related factors.
Work related factors like number of working years in the city, current department of
work, frequent shift posted, frequent posting location, number of working hours near road
side, use of personal protective equipments were looked into.
More than half of the respondents, 58% (174) were from the traffic department whereas
42 % (128) of them were from the law and order department. Majority of the respondents,
90% (271) of them were working in post of Civil Police Officers (CPOs) and the rest 10%
(31) were Sub Inspectors (SI) and Assistant Sub Inspectors (SI).
Number of working years in the city and working hours near road side per day was
categorized into two groups based on the median value.
28
The mean number of service years in the city among the respondents was 8.09 ± 6.25
years (range:1-30). The mean number of working years in the current post is 5.93 ± 4.84
years (range: 1- 25). The mean number of working hours spent near road side per day on
duty was 5.89± 2.39 hours (range:1-12).
Table 4.2: Characteristics of the study sample based on work related factors.
Variable (N=302) Frequency (%)
Current work department
Law and order
Traffic
128 (42)
174 (58)
Nature of shift
Day shift
24 hours duty
166 (55)
136 (45)
Posting Location
Crowded junctions
Highways and crowded junctions
Highways
223 (74)
56 (19)
23 (7)
Type of Duty
Traffic Duty
Patrolling duty
Other: (Combined duties*)
147 (49)
128 (42)
27 (9)
Number of working years in the city
≤ 6 years
>.6 years
152 (50.3)
150 (49.6)
Working hours near road side per day
≤ 6 hours
>.6 hours
207 (69)
95 (31)
*combined duties – patrolling with law and order, patrolling with border checking duty.
29
4.2.1 Use of Personal Protective Equipment
Major proportion of the respondents (87%) reported that they never use face mask while
traffic as well as patrolling duty. Only 1 personnel out of 39 reported the use of respirator
as face mask. 38% of the respondents reported that it is uncomfortable to use the face
mask.
Table 4.3 Use of Personal Protective Equipments among Police personnel.
Variable (N=302) Frequency (%)
Use of face mask during traffic duty:
No
Yes
263 (87)
39 (13)
Type of face mask: (n=39)
Respirator
Others: (disposable mask, kerchief)
1 (3)
38 (97)
Reasons for not using face mask
Unavailable : Yes
No
Uncomfortable : Yes
No
Unnecessary : Yes
No
117 (39)
185 (61)
116 (38)
186 (62)
7 (24)
231 (76)
Undergo regular health check-up:
Yes
No
126 (42)
176 (58)
About 47% (54) of the subjects who reported wearing face mask was uncomfortable also
specified the reason. 83% of them (45) reported it hinders their wireless communication
process and 15% (8) of them mentioned the problem of differential tanning of the face
that the mask causes.
30
4.3 Other self reported morbidities among police personnel.
From the study, 21% of the police personnel reported to have hypertension, 14 % reported
of having diabetics and nearly 20% had the problem of varicose veins. The most
prevalent musculo-skeletal problem reported among police personnel was low back pain
which was about 50%.
Table 4.4 Other self reported morbidities among police personnel.
Variable (N=302) Frequency (%)
Hypertension 63 (21)
Varicose vein 61 (20)
Diabetes 41 (14)
Musculo-skeletal
Low back pain 151 (50)
Shoulder pain 114 (38)
Knee pain 104 (34)
Neck pain 86 (29)
Elbow pain 35 (12)
Ankle pain 34 (11)
Wrist pain 15 (5)
Hip pain 13 (4)
4.4 Prevalence of Respiratory morbidity among police personnel in Kochi city in the
past one year
From the study, 7% (20) reported to have frequent cough and 6% (19) reported to have
chronic cough. Phlegm was reported to be a major problem among the respondents.
Nearly 15% (45) of them reported frequent phlegm and 13% (38) of them reported to
have chronic phlegm. 10% (30) reported the problem of frequent wheezing and 4% (12)
had chronic wheezing. 18% (55) of the respondents reported Grade 1 Dyspnea while 9%
31
(27) reported to have Grade 2 Dyspnea. 25% (76) of the respondents presented with peak
flow restriction, which meant their peak flow readings are less than the Normal range
according to ones age, sex and height.
Table 4.5 Prevalence of respiratory morbidities studied.
Variables (N=302) Frequency (%)
Frequent respiratory morbidities
Frequent cough 20 (7)
Frequent phlegm 45 (15)
Frequent wheeze 18 (6)
Any one of the frequent respiratory morbidities 71 (24)
Dyspnea
Grade 1 Dyspnea
Grade 2 Dyspnea
55 (18)
27 (9)
Chronic respiratory diseases
Chronic cough 19 (6)
Chronic phlegm 37 (12)
Chronic wheeze 12 (4)
Any of the chronic respiratory morbidities 55 (18)
Peak flow restriction 76 (25)
4.4.1 Prevalence of Chronic respiratory Morbidity.
In the study, chronic respiratory morbidity is considered as the presence of any one of the
chronic symptoms which are chronic cough, chronic phlegm or chronic wheeze. The
prevalence of chronic respiratory morbidity among police personnel was found to be 18%
(55).
32
4.5 Bivariate Analysis – Chronic respiratory morbidity with independent variables.
Bivariate analysis was done for all the independent variables with chronic respiratory
morbidity, peak flow restriction and for each chronic respiratory morbidity separately.
The results of bivariate analysis done for individual chronic respiratory morbidity are
given in Appendix 1.
4.5.1 Socio - demographic characteristics associated with chronic respiratory
morbidity
Bivariate analysis done for each socio- demographic factors like age, sex, education,
place of residence, nature of residence, distance of residence from the main road and
cooking fuel. Among the above factors, education, nature of residence, distance of
residence from main road and type of cooking fuel had no significant association with
chronic respiratory morbidity. Chronic respiratory morbidity was significantly higher for
those aged between 45 -54 years when compared with those in age group 25-34 years.
Females have 2.52 times higher odds of getting chronic respiratory morbidity when
compared to males. Those personnel who reside in Municipality and corporation area
have 56% less chance of getting chronic respiratory morbidity.
33
Table4.6: Association of Chronic Respiratory Morbidity with Socio - demographic
characteristics.
Variables [N=302] Chronic Respiratory Morbidity
[n (%)]
Odds Ratio
(95% CI)
Age group 25 -34 yrs (n=60)
35 -44 yrs (n=149)
*45 -54 yrs (n=93)
5 (8)
29 (20)
21 (23)
1
2.65 (0.97- 7.23)
3.20 (1.13 – 9.04)
Sex * Males (n=272)
Females (n=30)
45 (17)
10 (33)
1
2.52 (1.10- 5.74)
Place of residence*
Panchayath (n=188)
Municipality & corporation (n=114)
42 (22)
13 (11)
1
0.44 (0.22 – 0.87)
* P- Value < 0.05, 1- Reference Category.
4.5.2 Association of Chronic respiratory morbidity with work related factors.
Table 4.7 shows that police personnel who worked in the traffic department, with higher
seniority, worked in the city for more than 6 years, posted in the day shift frequently for
past one year, worked near road-side for more than 6 hours per day and who did traffic
duty had higher chronic respiratory morbidity.
34
Table 4.7 Association of chronic respiratory morbidity with work related factors.
Variables [N=302] Chronic Respiratory Morbidity
[n (%)]
Odds Ratio
(95% CI)
Current work department
Law and order (n=128)
Traffic (n=174)
19 (15)
36 (21)
1
1.49 (0.81 - 2.75)
Designation
CPOs (n= 271)
Assistant SI and SI (n=31)
46 (17)
9 (29)
1
2.00 (0.86 -4.62)
Number of service years in city**
≤ 6 years (n=152)
>6 years (n= 150)
16 (11)
39 (26)
1
2.98 (1.58 – 5.62)
Nature of shift posted
24 hrs duty (n=136)
Day shift (n=166)
19 (14)
36 (22)
1.70 (0.92 – 3.13)
Working hours near road side / day
≤ 6 hours (n=207)
>6 hours (n=95)
33 (16)
22 (23)
1.58 (0.86 -2.90)
Type of duty
Patrolling duty (n=154)
Traffic duty (n=148)
24 (16)
31 (21)
1.43 (0.79 – 2.58)
*P-Value < 0.05, ** P- Value < 0.01,1- reference category.
Table4.8: Association of Chronic Respiratory Morbidity by use of face barriers of
any kind.
Use of face mask** Chronic respiratory morbidity (n
(%)
Odds ratio(95%
CI)
No (n=263)
Yes (n=39)
42 (16)
13 (33)
2.63 (1.25 -5.53)
35
Table4.8 shows that chronic respiratory morbidity is significantly high among those who
use face mask on traffic duty.
4.5.3 Association of use of face barriers of any kind with other variables.
Table 4.9 shows that use of face barriers on traffic duty is significantly higher among
females when compared to men. It is evident from the table that there is no significant
difference in use of face barriers based on educational qualification. Police personnel who
have worked in the city for more than 6 years are highly using any kind of face barriers
on traffic duty. Significant use of face barriers on duty is seen among personnel who get
both frequent as well as chronic respiratory morbidities. The table also shows significant
association of use of any face barriers on traffic duty with any morbidity diagnosed
during medical checkup in the past one year.
36
Table 4.9: Association of Use of any face barriers with other variables
Variables (N= 302) Use of any face barriers
Frequency (%)
Sex* Males (n= 272)
Females (n= 30)
31 (11)
8 (28)
Education Up to HS (n=152)
Degree and above (n=150)
19 (13)
20 (13)
Number of service years in the city*
≤ 6 yrs (n=152)
> 6 yrs (n=150)
13 (9)
26 (17)
Type of duty Patrolling (n=154)
Traffic (n=148)
15 (10)
24 (16)
Diagnosed with any morbidity in past one
year during medical checkup **
No (n=247)
Yes (n=55)
25 (10)
14 (26)
Any frequent respiratory morbidity*
No (n=231)
Yes (n=71)
24 (10)
15 (21)
Any chronic respiratory morbidity**
No (n=247)
Yes (n= 55)
26 (11)
13 (24)
*P-Value <0.05, **P-Value <0.001
4.6 Multiple logistic regression Analysis:
All those independent variables which became significant at 10% level (P-value <0.1) on
bivariate analysis were taken for multivariate analysis. Thus the independent variables
included in the multivariate analysis were age, sex, place of residence, distance of
residence from the main road, history of chronic respiratory morbidity either father or
37
mother, hypertension, designation, Number of service years in the city, nature of shift
posted in past one year and use of face barriers of any kind on duty.
After multiple logistic regressions, the variables which were found significant and highly
associated with chronic respiratory morbidity were Number of service years in the city,
sex and place of residence.
Table 4.10: Factors associated with chronic respiratory morbidity – Results of
multiple logistic regression analysis.
Variables Adjusted Odds Ratio (95%
CI)
Number of service years in the city**
≤ 6 yrs
>6 yrs
1
3.35 (1.61-6.95)
Sex** Males
Females
1
4.11 (1.52-11.08)
Place of residence*
Municipality and corporation
Panchayath
1
2.43 (1.08-5.44)
1-Reference category, *P-value < 0.05, **P-value<0.01
Table 4.10 shows that police personnel with service years more than 6 in the city have
three times higher chance of getting chronic respiratory morbidities adjusted for all other
factors. Also female police officers have 4 times higher odds of getting chronic
respiratory morbidities when compared to males when adjusted for others.
4.7 Bivariate analysis – Peak Expiratory Flow reading with independent variables
Peak flow restriction showed a significant association with increase in age. Police
personnel aged more than or equal to 40 years had significantly higher odds of getting
peak flow restriction when compared to those aged less than 40 years [OR: 2.04 (1.19-
38
3.49)]. Similarly Police personnel with familial history of chronic respiratory morbidity
(either father or mother) significantly had higher odds of getting peak flow restriction
when compared to those without any familial history [OR: 2.21 (1.24-3.94)]. Factors like
tobacco use, use of any face barriers on traffic duty, place of residence showed no
significant association with peak flow restriction. Some of the work related factors which
came to be significantly associated with peak flow restriction is given in the Table 4.11
Table 4.11 Association of peak expiratory flow reading with work -related factors.
Variable (N=302) PEF Reading#
[n (%)]
Odds Ratio(95% CI)
Current work department*
Law & Order (n=128)
Traffic (n=174)
24 (19)
52 (30)
1
1.84 (1.06 - 3.20)
Designation**
CPOs (n=271)
Assistant SI and SI (n=31)
61 (23)
15 (48)
1
3.22 (1.51- 6.90)
Work hours near road side per day*
≤ 6 hours (n=207)
> 6 hours (n=95)
45 (22)
31 (33)
1
1.74 (1.01 -2.99)
Nature of shift posted*
24 hours duty ( n = 136)
Day shift (n= 166)
25 (18)
51 (31)
1
1.96 1.14- 3.39)
1– Reference category, *P-value < 0.05, **P-value # Peak flow restriction – fall in the peak flow
meter reading below the normal range according to age, sex and height of a person.111
4.8 Peal Expiratory flow reading.
The mean peak flow meter reading among male police personnel was 532.7± 68.9
Liters per minute ( L/mt) and female police personnel was 362.3± 65.2. The mean
difference in the peak flow meter reading among different age group (ANOVA) and
service years in the city (Independent t -test) were analyzed separately for males and
females.
39
Table 4.12 Variation of peak expiratory flow reading in different age group and
service years in the city by sex.
Variable (N=302) Frequency (n) Mean Peak Flow Meter
Reading (Litre /Minute) p-value
Age group
Males
25-34years
35-44years
45-54years
272
54
128
90
541.8 ± 67.3
545.4 ± 69.1
509.1± 64.1
<0.001
Females
25-34years
35-44years
45-54years
30
6
21
3
381.7 ± 77.8
360.9 ± 64.5
333.3 ± 50.3
0.58
Work years in city
Males
≤6years
>6years
272
138
134
538.6 ± 73.8
526.6 ± 63.3
0.15
Females
≤6years
>6years
30
14
16
374.3 ± 79.1
351.9 ± 50.5
0.35
Table 4.12 shows mean peak flow meter reading was significantly different among
different age group in males. But this difference was not significant among females. Also
the mean difference in the peak flow meter reading was not significant among males as
well as females in terms of work years in the city.
40
CHAPTER- 5
DISCUSSION
Occupational morbidity studies in India have mostly been among industrial workers
exposed to occupational hazards. Workers who are continuously exposed to high levels of
ambient air pollution due to the nature of their job, however has attracted less attention.
This study was done in this context, among 310 police personnel in Kochi city,
Ernakulam district, to assess the prevalence of respiratory morbidities and the factors
associated with it.
The overall prevalence of chronic respiratory morbidity was 18%. This overall prevalence
of chronic respiratory morbidity among the study population is higher compared to
prevalence figures reported by community based studies in India, which range 2% to
8.5%.87-89
A large multi-centric study carried out by the ICMR carried out in 2006
reported a prevalence of 5 percent among men and 3.2 percent among women.90
Data regarding chronic respiratory morbidity available from population based studies
from other developing countries include those from a study done among the elderly91
in
Bangkok with a prevalence of 7.1 percent , 4.65 percent among adults in Iran92
. A high
prevalence of chronic respiratory morbidity of about 17 percent was reported from among
Korean adults over 45 years of age.93
The prevalence of chronic cough, chronic phlegm and chronic wheeze were separately
analyzed in the present study and was found to be 6.3%, 12.3% and 4 % respectively.
Prevalence figures of chronic cough have been reported from community based studies
from various parts of India. It ranges from 2.2 percent,94
2.4 percent in rural areas and 1.7
41
percent in urban areas (across different study sites in India),90
2.5 percent in Mysore95
.
However the operational definitions for chronic cough and phlegm used by the different
studies vary from “cough at night”, “cough in the morning” and “phlegm in the
morning”, cough and phlegm “without a cold”, “on most days” and “for at least 3
months” from the current study that used the definition as cough/ phlegm for three or
more consecutive months.
The prevalence of chronic phlegm in the present study was 12.3%. In comparison the
figures from other studies in India have reported a chronic phlegm prevalence of 1.9% to
4.4 percent 9, 2.6%
8 and 1.2 percent.
95
The prevalence of cough was found to be between 2.4 and 5.6 per cent in the rural areas
and 1.7 to 5.4 per cent in the urban areas in different centers in India.95
5.1 Comparison with other occupational groups exposed to outdoor air pollution.
The chronic respiratory morbidity prevalence which was 18% among the police personnel
in this study was higher in comparison with other occupational groups that are similarly
exposed to air pollution that is mostly traffic related. A study done among street sweepers
in Nagpur, India showed a prevalence of 6% 36
. Another study done among traffic police
in Bangkok found that the prevalence of cough and phlegm among them was 18.6%. 96
The low prevalence among street sweepers could be due to the fact that the duration of
exposure to ambient air pollution among them may be lower than that of the traffic police
due to the differences in the work timings. Mostly street sweepers carry out their work in
the early morning or late evening that may be before or after the rush hours of traffic.
42
5.2 Comparison with respiratory morbidities among industrial workers.
Many studies have examined the prevalence of chronic respiratory morbidities in India
among industrial workers97-100
The prevalence of chronic respiratory morbidity have been
high ranging from 12 % to 42%. Therefore it indicates that the morbidity among the
traffic personnel seems to be as high as some of the industrial workers in India. Similar
studies dong among industrial workers outside India have reported chronic respiratory
morbidity prevalence figures ranging from 6% to 14%.101,102
This highlights the burden
of respiratory morbidity among traffic policemen in the current study that warrants
attention.
5.3 Socio- demographic factors.
In this study, chronic respiratory morbidity among women traffic personnel was found to
be nearly three times as higher when compared to males. This could be due to the fact that
by the women are exposed to higher indoor pollution due to biomass fuels due to the
gender based segregation of domestic work. The other reasons could be the more
sensitive cough receptors and bronchial hyper-responsiveness (effect of female sex
hormones on airway smooth muscles) among women. Tobacco smoking was reported by
14% of the male traffic personnel. Though studies have linked tobacco and chronic
respiratory morbidity103,104
there was no relationship noted between tobacco use and
chronic respiratory morbidity in the current study. The fact that the prevalence of tobacco
use among the police personnel was much lower than the overall figures for men in
Kerala105
raises the possibility of underreporting of tobacco use. It is also noted here that
observationally during the study, some of them who had reported non use were smoking
in the adjoining rest room. The possible links between tobacco use among men and
43
biomass fuels among women could be explored in connection with the respiratory
morbidity among this group in the future.
5.3.1 Housing characteristics: Distance of residence from main road:
Residing close to the main roads is a predisposing factor for respiratory morbidity.106
In
the current study, it was found that the respondents whose residential area within 200 to
300 meter from the main road has lesser chance of getting chronic respiratory morbidity
than those who reside more than 300 meter from the main road. The possible explanation
would be the persons confronted with respiratory morbidities would have deliberately
moved to areas are distant from the main road and also due to the fact that the majority of
the respondents were living in rural areas which could relatively have lesser air pollution
levels.
5.3.2 Place of residence: Contrary to many studies107,108
the police personnel from rural
areas in this study had higher prevalence of chronic respiratory morbidity. The only
plausible logic could be that they would have to travel longer distances to work; however
this needs to be further explored.
5.4 Work- related factors:
5.4.1 Number of years of service in the city: The study has showed that the police
personnel who worked in the city for more than six years had 2.98 times higher odds of
having chronic respiratory morbidity when compared to those who worked in the city for
less than or equal to six years. The peak flow restriction was high among those whose
service years were more than six years in the city. Similar study conducted among traffic
police in Patiala city, India also showed that the peak expiratory flow rate (PEFR) were
lower in those with more than eight years of service in the city.33
The increased years of
44
service could indicate higher total exposure for a longer duration of time and therefore
adversely affecting the lung function.
5.4.2 Type of shift: The study showed that 22% of the police personnel posted frequently
during the day shifts in the last one year had higher chronic respiratory morbidity when
compared to 14% of those who did 24 hours duty for 3 days in a week. This may be due
to the reason that personnel posted to day shift are posted to specific locations where they
have to be present from morning 8.am to evening 7.pm (the rush hours of traffic) whereas
those on 24 hour duty do not have to be in a specific location and move from one place to
another while on patrol in vehicles.
5.4.3 Use of Personal Protective Equipments during Traffic duty: Out of the 302
police personnel, only one person reported the use of an appropriate respirator during
their duty hours. Of those who reported to use of face masks (n=39), 97% of them used
only some kind of face barriers like kerchiefs or disposable masks that do not offer
adequate protection. This could explain the high chronic respiratory morbidity among
those who reported any kind of face barriers during traffic duty. Though the police
personnel seem to think that the barriers offered them protection from air pollution, the
fact is that other than the prescribed respirators, kerchiefs and disposable tissue masks
does not reduce their exposure to ambient air pollutants. A study from Bangkok
highlights this by its finding that policemen, who used the prescribed face masks, had
significantly lower respiratory morbidity when compared to those who did not use them96
.
The current study also found that the use of face barriers of any kind during duty was
significantly higher among the female police personnel. This has to be read along with the
fact that in the present study the female police officers had higher chronic respiratory
morbidity. Higher morbidity could have led to the higher use which cannot be assessed
45
with the current study design. It could also be due to the higher risk perception among
women.
The use of face barriers of any kind was also found to be higher among those who had
more than six years of service in the city. Those with six years or more of service in the
city had higher prevalence of respiratory morbidity in the bivariate analysis and therefore
could have used face barriers as a as a precaution during their duty time. Other factors
like educational qualification had no significance with usage of any face barriers during
traffic duty. This could be due to the fact that the police personnel irrespective of their
education were not trained of the specific risks posed to them by air pollution to which
they are occupationally exposed to and regarding the specific personal protective
equipments. This is an area of potential intervention for the protection of the traffic police
force from avoidable occupational respiratory morbidity.
Police personnel who were diagnosed with any morbidity in the past one year (n=55)
were found to use face barriers of any kind significantly more than those who did not
have any morbidity. Of those police personnel who had reported any morbidity 35% had
respiratory problems like bronchial asthma, allergic cough, dyspnea and sinusitis.
In addition to the above findings, the policemen revealed two major reasons for non use
of face masks while on traffic duty. They were the lack of supply of PPE (Personal
protective equipment) from the department and lack of comfort during use. About 47%
of the subjects who reported wearing face mask was uncomfortable also specified the
reason. 83% of them reported it hinders their wireless communication process and 15% of
them mentioned the problem of differential tanning of the face that the mask causes.
46
The findings regarding the low use of PPEs by the traffic personnel and the reasons for
their non use could be of relevance to higher authorities for an appropriate, effective,
comfortable and acceptable PPEs for this work force vulnerable to high levels of
respiratory morbidity.
5.4.4 Routine medical checkups: The study revealed that more than half of the
respondents do not attend for periodic medical health checkups. They reported
unofficially during the interview that though the periodic checkups are officially
mandatory , they are not taken seriously and are merely customary as far as the personnel
and the medical officers are concerned This exposes a huge gap that can be addressed by
the higher authorities by making the mandatory checkups more structured, serious and an
opportunity for monitoring the health of its personnel .Police personnel have to work for a
minimum of 6-8 hours per day and they do have duties on all 7 days in a week which also
disregards their need for training regarding occupational health issues and PPEs and also
regular monitoring through health checkups.
Various studies 30, 31, 70
have pointed the need for creating awareness among the police
personnel to undergo regular and effectively carried out health check-ups.
5.5 Peak Flow restriction
The overall prevalence of peak flow restriction among police personnel in this study was
25%. That indicates this is higher than the overall self reported chronic respiratory
morbidity in this study which was 18% . This prevalence of 25% peak flow restriction in
this study is similar to the study 96
conducted in Bangkok where 21% of the traffic police
personnel had abnormal air flow on Spirometry. The peak flow restriction among the
police personnel was significantly associated with working in the traffic department, age
47
above 40 years, higher seniority, working near road sides for more than six hours per day
and those who were posted in the day shift frequently in the past one year. All these could
be surrogate indicators of higher duration and higher magnitude of the exposure to air
pollution that is mostly traffic related, they are exposed to by the nature of their work .
It is to be interpreted with caution since portable peak flow meter has limitations
compared to more reliable measurements such as FEV1 or forced vital capacity (FVC).
The portable peak flow meters could have greater diurnal variations, greater intra-subject
variability109
, greater sensitivity to upper airway function and expiratory effort variations
according to mood, self motivation etc. The peak flow meter tends to overestimate the
lung function and therefore tend to underestimate degree of pulmonary
impairment.110
Therefore this can only be taken as preliminary evidence and needs to be
followed up with serial monitoring using more validated and standardized techniques.
5.6 Other self reported morbidities.
The prevalence of other self morbidities were self reported hypertension 21%, and
diabetes 14% This is comparable with other studies in India 31,70
conducted among traffic
police where the prevalence of hypertension ranged from 17.9% -25%. About one in two
police personnel reported low back ache and is higher than that reported by a similar
study conducted among police force in Kerala70
which reported a low back ache
prevalence of 32%. This also stresses the need to focus on the risk of specific
occupational morbidity that the traffic police personnel are vulnerable to due to the
nature of their occupation.
48
5.7 Limitations of the study.
The study has used only surrogate measures to capture exposure assessment. There might
have been recall bias for the respondents. Validation of the peak flow meter could not be
done with other methods like Spirometry due to resource constraints and clinical
validation by experts could not be carried out since the policemen could not spare time
from their busy schedule. Peak expiratory flow measurement done on a single day was
used and not serial measurements across several days due to limitations of time and
resource constraints. The time of recording the readings varied from 7.am to 12.00pm
and could have induced variability.
5.8 Strengths of the study:
The study was conducted in an occupational group that is exposed to considerable
occupation related air pollution but is less studied. The study was conducted using an
adequate sample size. Respiratory morbidity was assessed using a standard tool of
American Thoracic Society - Division of Lung Diseases (ATS- DLD). The study was
done by a single researcher and chance for inter-observer bias was reduced.
5.9 Conclusion
The overall prevalence of chronic respiratory morbidity among police personnel within
age group of 25- 54yrs in Kochi city was high compared to the general population and
comparable to industrial workers of India. About one in four had a peak flow restriction
indicating some respiratory impairment which needs further exploration. The female
personnel and those with higher number of years of service were found to have higher
chronic respiratory morbidity even when adjusted for other factors. The major self
49
reported morbidities among police personnel were low back pain 50%, hypertension 21%
and diabetes 14%.
5.10 Policy Implications.
The high prevalence of respiratory morbidity in traffic policemen is a matter of concern
since it may be due to their occupational exposure to vehicular exhaust related air
pollution. Pre employment as well as periodic medical surveillance could be made more
structured including serial lung function measurements using validated and standardized
spirometry to detect those at risk and initiate appropriate preventive measures. The study
also reveals high levels of low back ache among the police personnel suggesting the need
for an occupational health assessment and remedial measures.
Periodic monitoring of this group can detect early signs of dysfunctions and measures
including supply of appropriate and acceptable personal protective equipments could be
taken. Such interventions will improve the overall health and productivity of a critical
work force like the traffic police.
50
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65
GLOSSARY OF ABBREVIATIONS
COPD Chronic Obstructive Pulmonary Disease
PM Particulate Matter
OSHA Occupational Safety and Health Administration
BMRC British Medical Research Council
ATS-DLD American Thoracic Society-Division of Lung Disease
PEF Peak Expiratory Flow
WHO World Health Organisation
ILO International Labour Organisation
DALY Disability-Adjusted Life Year
SPM Suspended Particulate Matter
GIS Geographic Information System
O3 Ozone
NO2 Nitrogen Dioxide
SO2 Sulphur Dioxide
ICMR Indian Council of Medical Research
FEV1 Forced Expiratory Volume in one second.
FVC Forced Vital Capacity.
66
ANNEXURE - 1
Table 1: Association of Chronic Phlegm with the independent variables
Variable (N=302) Chronic Phlegm
n (%)
Crude OR (95%
CI)
Adjusted OR
(95% CI)
Age group(in years)
25-34 (n=60)
35-44 (n=149)
45-54 (n=93)
2 (3)
18 (12)
17 (18)
Sex* Males (n=272)
Females (n=30)
31 (11)
6 (20)
1
1.94 (0.73- 5.12) 1
3.81 (1.05-13.77)
Place of residence *
Municipality & Corporation(n=114)
Panchayath (n= 188)
6 (5)
31 (17)
1
3.55 (1.43-8.81)
1
4.06 (1.27-12.91)
Distance of residence from main
road
200 -300 meter (n=170)
> 300 meter (n=132)
15 (9)
22 (17)
1
2.06 (1.02-4.16)
Current work department
Law and order (n=128)
Traffic (n=174)
10 (8)
27(16)
1
2.16 (1.009-4.65)
Working years in the city**
≤ 6 years (n= 152)
>.6 years (n= 150)
7 (5)
30 (20)
1
5.17 (2.19-12.20)
1
6.48 (2.42-17.34)
Work hours near road side / day
≤ 6 hours (n= 207)
>.6 hours (n= 95)
19 (9)
18 (19)
1
2.31 (1.15-4.64)
Frequent shift posted
24 hours (n=136)
Day shift (n=166)
11 (8)
26 (16)
1
2.11 (1.002-4.44)
Type of duty
Patrolling (n=154)
Traffic (n=148)
13 (8)
24 (16)
1
2.09 (1.02-4.29)
*P-value <0.05, **P-value <0.01, 1- Reference category
Table 2 : Association of Chronic wheeze with Independent variables
Variable (N=302) Chronic wheeze
n (%)
Crude OR
(95% CI)
Adjusted OR
(95% CI)
Sex** Males (n= 272)
Females (n=30) 7 (3)
5 (17)
1
7.57 (2.23-25.61)
1
7.92 (2.05-30.55)
Frequent posting location
Crowded Jn.(n=223)
*Highways (n=23)
Both crowded Jn and highways(n=56)
6 (3)
3 (13)
3 (5)
_ _ _ _
1
8.26 (1.53-44.57)
1.57 (0.35- 7.02)
*P-value <0.05, **P-value <0.01, 1- Reference category
67
ANNEXURE-2
CONSENT FORM FOR PARTICIPATION IN RESEARCH
Dear Sir/Madam,
I am Elsa Mary 2nd
year Master of Public health student of Achutha Menon Centre for
Health science Studies, under Sree Chitra Tirunal Institute for Medical sciences and
Technology, Trivandrum. As a part of my study I am undertaking a research project on
the topic “Assessment of respiratory morbidities among police personnel in Kochi city,
Ernakulam district”.
Purpose of the study:
The purpose of the study is to find out the respiratory morbidities among the police
personnel and to find out the factors associated with it. I request your cooperation and
help for this study.
Participation is required from your side:
If you are willing to participate in the study you have to answer some questions regarding
your social, demographic characteristics, personal habits, family history, occupational
history and mainly on your health conditions. Also you have to blow through a small tube
like apparatus to test your lung function. There is absolutely no harm associated with the
procedure. On the whole it will take 30 minutes of your time.
Benefits from participation:
Though you may not benefit directly from the study, it is possible that the findings of the
study based on your health conditions may be a great help to make strategies for
protecting the police personnel from work related respiratory morbidities.
Voluntariness:
Your participation in this study is voluntary and you can withdraw from this at any point
of time.
Confidentiality
All information provided by you will remain strictly confidential and used for research
purpose only. Your identity won‟t be revealed to anyone. All copies of filled interview
schedule and consent forms will be kept under the custody of principle investigator and
will be destroyed when they are no longer needed. The study may be published in
scientific journal, but your identity will not be revealed.
In case you have any questions or doubts please feel free to clarify these. I will try my
level best to answer any query you have now or in the future. My contact number is
8086911350 and my email id is [email protected]. If you need any clarification
regarding my credentials, you can contact Dr. Anoop Kumar T, Member secretary,
Institutional Ethics Committee, SCTIMST whose contact number is 0471-2520256/257
and email id is [email protected].
68
CONSENT FORM
I……………………………………………………………………………………………
…… declare that (tick the boxes):
1. I have read the information sheet provided to me regarding this study and I have
clarified all doubts that I had [ ]
2. I also understand that my participation in this study is entirely voluntary and I am
free to withdraw from this study at any point of time [ ]
3. I understand that my identify will not be revealed and no information will be
released to third parties or when published. [ ]
4. I voluntarily agree to take part in the study. [ ]
As part of the requirement, I need your signature/thumb impression which indicates your
willingness to participate. Will you kindly sign or give thumb impression below?
Signature of the participant
__________________________
Signature of the investigator
__________________________
Signature of the witness (If needed)
______________________
Name and Address of the witness (If needed)
Thank you sparing your valuable time
Date:
Time and place:
69
INTERVIEW SCHEDULE
Date of Interview:
Identification Number: (Dummy number to be allotted)
Current department of work : (1) Traffic (2) Law and order (3) Crime (4) Vigilance (5) Narcotics Control Bureau
(6) Others (Specify): _______________
1. SOCIO – DEMOGRAPHIC FACTORS
Sl no Questions Responses
1. Age ( in completed years) _____________yrs.
2. Sex (1) Male (2) Female
3. What is your marital status? (1) Single (2) Married (3) Widowed (4) Separated/ Divorced
4. Place of residence (1) Panchayat (2) Municipality (3) Corporation
5. Is your residence located near any one of the following: (multiple options possible)
1. Industrial area 2. Railway track 3. Fly over 4. Power plant. 5. Others (specify):________
6. How far is your residence away from main road?
(1) 200m-300m (2) > 300m
7. How long have you lived in the current location?
______________ yrs
8. Education ( highest level attained) (1) SSLC (2) Higher secondary (3) Graduate (4) Post graduate (5) ____________
9. Cooking fuels used in your house: (multiple options possible)
(0) LPG (1) Kerosene (2) Electricity (Induction cooker/
heater/hot plate)
CONFIDENTIAL For research purpose
only ANNEXURE- 3
70
(3) Wood (4) Others (specify):_________
10. Does your house have a separate kitchen?
(0) No (1) yes
10(a) If yes, to above does it have any of these: 1. Ventilation (0) No (1) Yes
2. Windows (0) No (1) Yes
3. Chimney (0) No (1) Yes
4. Exhaust Fan (0) No (1) Yes
5. Cooker hood (0) No (1) yes
2. PERSONAL HABITS (Questions 11 to 13 adopted from WHO STEPS Questionnaire)
11. TOBACCO USE
11(a) Do you currently smoke any tobacco products? (If No, then go to 12. If yes then skip 12 and 13.)
(0) No (1) yes
11(b) If yes to 11(a), do you currently smoke tobacco products daily?
(0) No (1) yes
11(c) On an average, How many cigarettes or beedis do you smoke per day?
______________
12. During the past one week, on how many days did someone smoke in closed areas in your work place (in the building, in a work area or specific office) when you were present?
______
13. During the past one week, on how many days did someone smoke in your home when you were present?
______
71
3. FAMILY HISTORY (Questions 14 to 18 adopted from ATS-DLD questionnaire)
14. Were either of your parents ever told by a doctor that they had a chronic chest illnesses/ lung condition such as:
(a)
Chronic bronchitis
FATHER MOTHER
(0)No
(1)Yes (3)Don’t know (0)No (1)Yes (3)Don’t know
(b)
Emphysema(
cough, sputum
production and
difficulty to
breathe)55
(c) Asthma
(d) Lung cancer
(e) Other chest
conditions
4. PAST HISTORY
15(a) During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed?
(0) No (1) yes
(b) IF YES to 15(a) Did you produce phlegm with any of these chest illnesses?
(0) No (1) yes
16. Did you ever have lung trouble before the age of 18?
(0) No (1) yes
16(a) If yes, what was the condition? (0) Asthma (1) Tuberculosis (2) Bronchitis (3) *Sinusitis( nasal block with
severe head ache and yellowish secretions)46
(4) Others(specify):______________
17. Have you ever had any of the following Conditions?
If yes, was it confirmed by a
doctor?
At what age did it start?
If you no longer have it, at what age did it stop?
(a) *Bronchitis
(0) No (1) yes
(0)No (1)yes
(b) Asthma (0) No (1) Yes
(0) No (1) yes
72
(c) Tuberculosis
(0) No (1) Yes
(0) No (1) yes
(d) *Pneumonia
(0) No (1) Yes
(0) No (1) Yes
*Bronchitis: Cough with or without phlegm for a period of 3 consecutive months in the last one year.49 *Asthma: Recurrent attacks of breathlessness or wheezing and worsens during physical activity or at night.47*Pneumonia: A group of symptoms involving cough with sputum, fever and breathing difficulty.48
18
Have you ever had:
(a) Any other chest illnesses? (0) No (1) Yes
If yes specify: _________
(b) Any chest operations/chest injuries
(0) No (1) Yes If yes specify: __________
19. Have you had any treatment for:
(a) High BP (0) No (1) Yes
(b) Diabetes (0) No (1) Yes
(c) Varicose veins (0) No (1) Yes
20 Have you ever had trouble (pain or discomfort) in your:
(a) Neck (0) No (1) yes
(b) Lower back (0) No (1) Yes
(c) Shoulders (0) No (1) yes
(d) Elbows (0) No (1) yes
(e) Hip (0) No (1) yes
(f) Wrists (0) No (1) yes
(g) Knees (0) No (1) yes
(h) Ankles/ feet (0) No (1) Yes
73
5. OCCUPATIONAL HISTORY
21(a) What is the total number of years you have been working in the city?
_____________Yrs
(b) Duration of years working in the current post?
____________yrs
(c) Number of working days per week _____________days
(d) Working hours per day (It excludes rest, time for food and others).
_____________hours
22 In which shift are you frequently posted in the past year?
(0) Morning shift (8-1pm) (1) Afternoon shift(2- 7pm) (2) Night shift.
23 In which of these locations were you posted most frequently during last one year?
(0) High ways (1) Crowded junctions (2) Others (specify):_________
24 Do you carry out your work mostly at the
same location?
(0) No (1) Yes
25. What nature of job have you done mostly
in the last one year?
1) Traffic duty 2) Patrolling duty 3) others (specify):______
26. On an average, how many hours are you
required to work outdoors/roads?
_____________hours
6. USE OF PERSONAL PROTECTIVE MEASURE
27(a) Do you wear a protective face mask during traffic duty?
(0) No (1) yes
(b) If yes, what type of mask you use?(multiple options possible)
(0) Respirator (1) Disposable face mask (2) Others(specify):
(c) Do you use the face mask daily? (0) No (1) yes
(d) How long you use the mask per day? (0) Less than 2hrs/day (1) 2-4 hrs/day (2) Over 4hrs/day
(e) If respirator, how frequent you clean the mask?
(0) 1 day (1) 2-3 days (2) 1 week
(f) What are the reasons for non use of masks?(Multiple options possible)
(0) Unavailable (1) Uncomfortable (2) Unnecessary (3) Others (specify):_________
74
7. OTHER QUESTIONS
28(a) Do you undergo routine medical check-ups as a requirement?
(0) No (1) Yes
(b) Have you been diagnosed with any morbidity in the past one year during medical check-up?
(0) No (1) yes
(c) If yes, what condition was diagnosed?
8. RESPIRATORY MORBIDITY ASSESSMENT (Questions 29 to 33 adopted from ATS- DLD questionnaire)
29 COUGH
(a) Do you usually have cough? (Count a cough with first smoke or on first going out of doors. (Excluding clearing of throat).
(0) No (1) yes
(b) Do you usually cough for - 4-6 times per day - 4 or more days out of the week
(0) No (1) yes (0) No (1) yes
(c) Do you cough on getting up or as first thing in the morning?
(0) No (1) Yes
(d) Do you cough the rest of the day or at night also?
(0) No (1) Yes
IF ANY OF A-D ABOVE IS YES, ANSWER THE FOLLOWING. IF NO TO ALL, SKIP THE 29(e) AND 29(f)
(e) Do you have such cough for most days for 3 or more consecutive months per year?
(0) No (1) Yes [8] Does not apply
(f)
For how many years have you had this cough?
_____________yrs (88) Does not apply
30 PHLEGM
(a) Do you bring up phlegm from your chest? (Exclude the phlegm from nose. Count the swallowed phlegm)?
(0) No (1) yes
(b) Do you bring up phlegm like this, or more days out of a week?
(0) No (1) yes
(c) Do you bring up phlegm like this, twice or more every day?
(0) No (1) yes
(d) Do you usually bring up phlegm on getting up or as first thing in the morning?
(0) No (1) yes
(e) Do you bring up phlegm rest of the day or at night?
(0) No (1) yes
IF ANY OF A-E ABOVE IS YES, ANSWER THE FOLLOWING. IF NO TO ALL, SKIP THE 30(f) AND 30(g) (f) Do you have such phlegm for most days [4
and more days] for 3 or more consecutive months per year?
(0) No (1) Yes [8] Does not apply
75
(g) For how many years have you had trouble with phlegm?
____________yrs. [88] Does not apply
31 COUGH AND PHLEGM
(a) Have you had episodes of cough and phlegm lasting for 3 weeks or more each year?
(0) No (1) yes
(b) If yes, how long you had at least 1 such episode per year?
____________yrs. [88) Does not apply
32 WHEEZING
(a) Does your chest ever sound wheezing or whistling in the past 1 year?
(0) No (1) yes
(b) Was it associated with cough? (0) No (1) yes
(c) Was it present most of the days and night?
(0) No (1) yes
(d) If YES to any of A-C above how many
years it has been present? (0) No (1) yes
(e) Has any attack of wheezing made you feel short of breath in the past 1 year?
(0) No (1) yes
(f) Did you require medicines or treatment for these attacks?
(0) No (1) yes
(g) Are you currently taking medicines for asthma [Inhaler/ tablets/ others]?
(0) No (1) yes
33. BREATHLESSNESS
(a) Do you have breathlessness on any strenuous work?
(0) No (1) yes
(b)
Do you have breathlessness when walking upstairs/slope or hurrying on level ground?
(0) No (1) yes
IF YES TO 33(b)
(c) Do you have breathlessness when walking for 15 minutes on the level compared to people of your age?
(0) No (1) yes
(d) Do you ever have to stop for breath when walking at your own pace on the level?
(0) No (1) Yes
(e) Do you ever have to stop for breath after walking for a few minutes (100 yards) on a level ground?
(0) No (1) yes
(f) Do you have breathlessness with minimal work like dressing?
(0) No (1) yes
76
PEAK FLOW METER FINDING:
Identification Number: ____________
Age: _______yrs. Sex: ____________ Height: _________cm
Reference value for police men based on above parameters: ___________ L/Min.
INFERENCE:
Non- obstructive pattern [0]
Obstructive pattern [1]
