Working conditions and related neuropsychiatric problems among shoemakers in Turkey: Do child workers differ from others?

Abstract

Objective:

In this cross-sectional study, we investigated working conditions and related neuropsychiatric problems of shoemakers, including child workers, working in poor conditions with high health risks. Clinical diagnosis was not the objective of this study.

Materials and Methods:

We collected data from 318 workers ranging from 8-66 years of age. We evaluated working conditions, neuropathy symptoms and signs; urinary 2,5-hexanedione was used to estimate hexane exposure. We used the Zung depression scale for adult shoemakers to evaluate depression.

Results:

All workshops employed fewer than 10 workers with median daily work duration of 12h. Smoking and alcohol consumption were high among all workers including children. Peripheral neuropathy symptoms and signs were observed in 88 workers (27.8%) and it was related to alcohol consumption. Sixty-eight workers (47.9%) had depression and it was associated with daily work duration.

Conclusion:

Extremely poor, unhygienic, working conditions and a high prevalence of neuropsychiatric disorders were the main problems observed among shoemakers. A high number of child workers increased the scale of these observed problems.

INTRODUCTION

Shoes have played an important role in human culture throughout history.[1] Shoemakers and their health, however, have attracted less attention than the shoes themselves. Mass production in the shoe industry started in the late 1850's; however, changes in production methods did not improve poor working conditions and related occupational health problems among shoemakers, particularly in less developed countries.[2,3] Mitra et al. studied working conditions of children shoemakers in Calcutta, India and showed poverty was the main cause of poor working conditions.[4,5] The study concluded that these conditions increased health-related problems, decreased workers’ production capacity and pushed them farther below the poverty level. Various risk factors -including leather dust, petroleum products, metals and solvents-deteriorate shoemakers’ health.[3] Other studies report chemical exposures, noise, vibration, stress and ergonomic problems as main causes of health problems, including various cancers, musculoskeletal injuries and neuropsychiatric disorders.[6–9] We do not have sufficient information from Turkey on working conditions and health status of shoemakers, especially among child workers.

Based on reports of the increased risk of leukemia in 1971, The International Labor Organization banned benzene use, which has been replaced with hexane in the shoe and leather industry.[10,11] This change, however, has created different occupational problems including hexane-induced peripheral neuropathy. Takeuchi described this pathology earlier.[11] Shoemakers have higher alcohol consumption rates and psychiatric problems possibly related to poor working conditions and the solvent exposure.[9,12–15]

In this cross-sectional study, we aim to investigate working conditions and related neuropsychiatric health problems of shoemakers in different age groups, including child workers, in Izmir, Turkey. Due to the nature of this study and the settings of the population, use of objective clinical diagnostic techniques was impractical and it was not the primary goal for this study.

MATERIALS AND METHODS

We collected data between February and June 1997 from a 138 randomly selected workshops, which were 23.5% of a total of 587 registered shoemaker workshops in Izmir. The study group included 318 male workers ranging from 8 to 66 years of age. We collected data on demographic and occupational information, smoking and alcohol use and neuropathy related motor, sensorial and cerebellar symptoms, using face to face implemented questionnaires. We evaluated working conditions including ventilation systems, lighting, occupational hygiene and safety measures, chemical storage units, work area per workers (m²), occupational training and personal protective equipment use according to national standards from the Occupational Health and Safety Regulations of the Turkish Ministry of Labor. These national standards were adopted from European and International standards.[16] We received Dokuz Eylul University School of Medicine Ethical Committee approval for the study and all participating workers gave an informed consent before the data collection.

We did not use objective clinical diagnostic techniques for the study. This was not the primary goal for this study and due to the setting of the study population it was impractical. However, a trained physician gave a standard neurological examination in the field and neuropathy was evaluated on a clinical basis.[17] A list of symptoms related to weakness, sensation or autonomic complaints were assessed. For neuropathic deficits, the neuropathy disability score, reflex score, tactile vibratory, joint position, pin prick test and atrophy evaluation were completed and neurological abnormalities such as tremor and ataxia were noted. We asked workers if they had been previously diagnosed with any diseases predisposing them to polyneuropathy. One worker had a type-1 diabetes diagnosis and we excluded him from the laboratory analysis of the study to prevent a confounding effect. We used a validated Turkish version of the Zung depression scale to evaluate depression status and 142 adult shoemakers volunteered to participate in depression evaluation. Zung Depression Scale is a self-rating depression scale contains 20 statements, evaluated by a Likert-scale rated from 1 to 4.[18] Weighted clinical scores categorized as normal (<50), borderline depression (50-59), moderate depression (60-69) and severe depression (≥70).

We used urinary 2,5-hexanedione measurement to estimate hexane exposure levels. We calculated estimated n-hexane levels according to Takeuchi and Saito's regression equation between 2,5-hexanedione and n-hexane (2,5-hexanedione = 0.078 + 0.053 n-hexane).[11] For this purpose, 5 ml urine samples were collected from each worker. Because of the irregular working hours and increased risk of alcohol consumption in the afternoon hours, urine samples were collected before noon, after minimum four-hours of work activities. Collected samples sealed with paraffin, labeled and stored at -70ŶC until the analysis. Personal identifiers and other work and health related data were masked before the laboratory analysis. Urine samples were analyzed by standard spectrophotometric methods to measure 2,5-hexanedione level as a surrogate for hexane exposure and creatinine corrected concentrations were used in our analysis.[19–21]

We controlled data for age, smoking, alcohol, work duration and other possible confounders by using the Mantel-Haenszel approach and analyzed our data using continuity corrected chi-square and trend analysis in SPSS statistical package version 10.0.

RESULTS

All 138 workshops were small enterprises with fewer than 10 workers; 114 workshops (82.6%) were run by one to three workers. Eight workshops (5.8%) were run by only one child worker. None of the workshops met the national occupational health and safety standards. Workshops occupied a small room of the main buildings located in the old section of the city of Izmir, where buildings were not well-maintained. An average work area size was less than 2 m² per worker and the volume of the workshops was significantly lower than 10 m³, which is the required minimum for one worker. Lighting, ventilation and fire hazards were the prominent problems. Workers used simple tin stoves and they burned scrap plastic, fabric and wood for heating in the winter. All production materials, fabrics, plastics and chemicals - including solvents- were stored in the workshops quite close to the stoves. Although there were relatively lower fire hazards in the summer time, ventilation remained a problem. None of the workshops had proper industrial ventilation systems. Few of them had residential type ventilators. We did not observe any designated separate eating or resting facilities, showers or lockers. There were few restrooms available and hygienic conditions were extremely poor. We did not find any records on occupational health and safety services. None of the workshops had records of workers’ mandatory health examinations.

Average daily working duration for all workers was 11.6±2.5 hours (median 12 hours) and it did not differ by age groups [Figure 1]. Distribution of workers by demographic and occupational variables is presented in Table 1. More than 25% of the shoemakers were child workers under 18 years of age. The mean age of workers were 28.9 years (range 8-66 years) [Figure 2]. Compared with shoemakers over 18 years of age, we observed unfavorable differences among child workers. Child workers were 7.4 times less likely to have primary education (95% CI= 1.9-29.3). Smoking and alcohol consumption among children were 19.8% and 9.9%, respectively. Child workers were 9.4 times less likely to be covered by social security (95% CI 2.1-57.6). During the study the minimum legal monthly wage was $212.85 and only 7.4% of child workers earned this amount (χ²_Yates’ = 164.48 P< 0.001).

Figure 1.

Daily working duration of shoemakers by age groups

Table 1.

Demographic and occupational features of shoemakers by age groups

Figure 2.

Age distribution of shoemakers

The 4h mean urinary 2,5-hexanedione level was 3.2±2.9 mg/L. Based on Takeuchi and Saito's regression equation, this was equal to 116.8 ppm n-hexane exposure daily, which was above the American Conference of Governmental Industrial Hygienist's time weighted average limit. Most of the shoemakers (86.4%) had high exposure levels; high exposure in child workers and others were 80.6% and 88.2%, respectively (P>0.05).

The most prevalent neurological symptoms were muscular leg cramps (35.0%), imbalance in walking (23.0%) and hand tremors (21.8%). The peripheral neuropathy rate increased by age, but the difference was not significant [Table 2] and the most prevalent type was sensorial neuropathy (68.2%). Neuropathy among shoemakers working more than 8h per day compared to shoemakers working less than 8h were non-significantly higher (χ² = 3.440 P= 0.0637). We did not observe any significant relation between peripheral neuropathy and urinary 2,5-hexanedione levels; however, neuropathy was significantly related to alcohol consumption (χ² = 6.105 df 1 P= 0.0134). We confirmed this relationship after controlling by age groups, daily working duration and urinary 2,5-hexanedione levels.

Table 2.

Distribution of shoemakers based on age groups, peripheral neuropathy and depression

Almost half (47.9%) of the adult shoemakers had depression. Depression was slightly higher among workers in the 18-44 age group (P=0.144) [Table 2]. Although there were 25 (17.6%) workers with moderate or severe depression, we did not observe any significant relationship between depression and possible predictors such as marital status, education, income, social security, alcohol consumption and tenure period, except daily working hours. Shoemakers working more than 8h per day however, had significantly higher depression scores compared with others working less than 8h per day (χ² = 4.662 P= 0.031).

DISCUSSION

Shoemakers including child workers were working long hours under poor conditions as a cheap labor force. The working conditions were extremely poor and dangerous in all workshops; more than 25% of the workforce was child workers, below 18 years of age. One of the identified reasons of child labor is they are a cheap and abundant source for the labor force.[5,22] As in the carpet industry, the shoemaking industry is also subject to a common argument called “nimble fingers”.[23] Some claim that the small and quick hands of child workers are necessary for better quality products [Figure 3]. It is important to mention that this fallacious argument should not be used any longer to justify the use of children in any industry. Although illegal child labor was condemned, it is a continuing problem in many countries.[23–25] A study in the 1990's reported that Turkey has the cheapest work force throughout the European countries.[26] Unfortunately in the following years, working conditions did not improve significantly. This continuing trend keeps child workers under the risk of physical, social and psychological development problems. Lack of education, smoking and alcohol consumption were objective signs of this burden. One out of five children in our study group showed signs and symptoms of peripheral neuropathy. Little information is available on the incidence or severity of illness caused in children by toxic exposures in the work environment. However, children differ from adults in their biologic and psychological characteristics and -since they are undergoing process of growth- they are more sensitive to occupational exposures.[25,27,28]

Figure 3.

Nimble fingers

Turkey has been a member of International Labor Organization/International Program on the Elimination of Child Labor (ILO/IPEC) since 1992.[29] However, national regulations have not been enforced effectively to prevent children from working under these poor conditions. The Turkish Labor Act establishes the minimum age for employment at 15 years, but it allows children at least 13 years old to perform “light work” that does not harm their health and development or interfere with their education. It also prohibits children below 16 years from working in heavy and hazardous work.[16] Unfortunately shoemaking is not among the heavy and hazardous category of industries. In 1995, 37% of the male Turkish population between the ages of 10-19 participated in the labor force.[30] The majority of these children come from poor families and they are less likely to start school and more likely to drop out. Only 30% of them reach sixth grade and fewer than 20% finish primary education.[31] The healthy social development of a child is possible only with proper education, sufficient family support and a healthy environment.[4] Lacking these factors not only deteriorates the health of a child, but it also creates an environment that fosters long term psycho-social problems.

Over 90% of all shoemakers were working more than 10h per day without any proper personal protection or ventilation systems. The majority of shoe products in Turkey have been produced in small workshops, where primitive production techniques, high exposure levels and poor working conditions were prevalent.[3] Effective ventilation and use of personal protective equipment plays a highly important role in decreasing exposure levels.[19,32]

In this study, we determined a 27.8% peripheral neuropathy diagnosed on a clinical basis. A study from Italy reported that the prevalence of peripheral neuropathy in shoemakers was 11.7%.[15] Poor working conditions and high exposure levels probably explain this high prevalence. Solvent exposure was known to result in peripheral neuropathy and some other neurological disorders.[33,34] Duration of working hours increases the incidence of neuropathy. The age and alcohol consumption are two important factors and should be considered during investigation of peripheral neuropathy as we observed in this study.[35,36]

Due to financial and logistic limitations and the difficulty of implementation of those tests in the field studies, we did not use direct diagnostic techniques such as nerve conduction velocity test to prove neuropathy diagnosis. However, the observed high rate of clinical neuropathy reflected the poor working conditions in our study population, including children.

We did not see a correlation between the urinary levels of 2,5-hexanedione and clinical neuropathy in our group. We suspect two factors might affect our observations: 1) First of all, 2,5-hexanedione excretion reaches its highest levels four to seven hours after the end of exposure.[37] Due to working conditions, social structure and possible alcohol consumption in the afternoon hours, we elected to collect urine samples before the lunch break and after a minimum of 4-hours of work activity; and 2) the second factor is the plausibility of asymptomatic sub-clinical neuropathy.

Almost half of the volunteer adult shoemakers showed different levels of depression. We observed a mild or severe depression in 17.6% of the participants and this rate was close to the upper range of the previous reports.[12] Besides the solvent exposure and related metabolic changes, other burdens such as low income, limited social opportunities, monotonous working conditions, family problems and low social expectations were reported in the etiology of depression.[9,12,13]

A high number of child workers, poor, unhygienic, dangerous working conditions and a high prevalence of neuropsychiatric disorders were the main problems observed among shoemakers in Turkey. Improving working conditions, enforcing legal regulations-especially against illegal child work-providing personal protective equipment and training and implementing engineering controls to lower exposure levels will significantly affect the health and productivity of shoemakers.