A descriptive, cross-sectional survey was conducted from November 2016 to January 2017 in different wards in Kalyani. It was done by the researchers of the College of Medicine and JNM Hospital, Nadia district, West Bengal, India. Ethical clearance was obtained from Institutional Ethics Committee (IEC) and the study was initiated after getting approval from the governing body of the institute. The participants were ensured about strict maintenance of anonymity, confidentiality and protection of all gathered information and use only for research. Kalyani, which is the sub-divisional headquarter of Nadia district was selected purposively out of 19 districts of West Bengal. In Nadia district, beedi work was one of the major occupations at the household level. Kalyani municipality was selected by simple random sampling. This municipality has 20 wards and caters a population of nearly one lakh [12,13]. In the absence of comprehensive nationwide database on the background information of either registered or unregistered beedi rollers, investigators used an incomplete database available from a local Non Government Organization (NGO). The present study was conducted in the four wards among all the resident beedi workers, available during the survey time. No sample size was determined as complete enumeration was done. The workers who had left the job, physically unwell, not in current occupation for at least one year and did not provide consent were excluded. More than 500 beedi workers were registered with the NGO as evident from an office copy. Data collection was done by the investigators by an interview and general examination with a predesigned data collection tool. The study was explained to each participant individually and a verbal informed consent was obtained. The interview and clinical examination was mostly conducted at their home while closely observing their working condition. Two weeks were allotted for each ward. Initially, one worker was identified in each ward to approach the ward to get help identify other workers. Body weight was measured using a standard portable weighing scale to the nearest 0.1 kg with minimum clothing and without shoes. Height was measured without shoes with help of a wooden stand with steel tape attached to the nearest 0.1 cm. BMI as (kg/m²) was calculated by dividing observed weight (in kg) by height (in square meters) [14]. BP was recorded with calibrated standardised sphygmomanometer in the sitting posture in right upper arm; two readings at five minutes intervals. If high BP (≥140/90 mmHg) was noted, a third reading was taken after 30 minutes; lowest reading was considered as final. All participants were advised to avoid tea, coffee, smoking, alcohol, and take rest at least 30 minutes before examination [15]. The total procedure for each individual involved 15-20 minutes and data from five to six participants was collected everyday. Adequate privacy was maintained during anthropometric measurements and examinations. A predesigned, semi structured proforma was used to collect data on sociodemographic profile, awareness of hazards, systemic symptoms along with general and anthropometric examination. The proforma was then translated into their local language. After face and content validation by experts, back translation and retranslation was done. During the survey, 125 workers were approached; seven did not give consent, 10 workers were in this occupation for less than one year so not included. The workers who left the job were also not included. Finally, 103 workers participated in the study. The social class, housing status in terms of overcrowding, inadequate lighting and ventilation, awareness of hazards were assessed as per the practical guide book of the concerned department that conducted the study [16]. The self-reported systematic hazards of musculoskeletal, eye, respiratory, cardiovascular system etc., along with presence of high BP and BMI were also assessed in the study. Updated BG Prasad classification (May 2016) was used to determine social class [17]. Overweight was considered with BMI 25 kg/m² or more but less than 30 kg/m² and obesity with BMI 30 kg/m² or more [18]. Hypertension was defined as Systolic Blood Pressure (SBP) more than 140 mmHg and Diastolic Blood Pressure (DBP) more than 90 mmHg [19]. Awareness on hazards of beedi smoking and anyavailable health scheme was enquired. Workers were examined for presence of pallor, clubbing and abnormal gait. The skin of hands was inspected for sensation, tanning, hypopigmented patch.

Data were coded and entered into SPSS Version 16.0 for analysis; descriptive statistics was used for independent variables. Chi-square and Fisher’s exact test was calculated to find statistical association between age group, education, social class and hypertension as well as obesity. Odds Ratio (OR), 95% Confidence Interval (CI) was measured by using StatCalc Epi Info version 6.0. An alpha level of 5% was considered significant.

The study had 103 Hindu beedi workers. Mean (±SE) age of workers was 38.69 (±8.53) years. Nuclear family structure was more prevalent (n=60, 58.30%). The average (SE) monthly family income was Rs. 6177.67±270.90. More than half (57.28%) started beedi rolling in the age range 15 to 25 years [Table/Fig-1]. Nearly, one-third were in this job profile for more than 20 years. The women worked at home by sitting in uncomfortable posture for long hours. Overcrowding was noted in (n=36, 34.95%) houses, dampness and inadequate lighting was noticed nearly in one in every four houses, while inadequate ventilation was present in (n=21, 20.4%) houses. Regarding safety measures, only (n=30, 29.12%) workers washed their hand after beedi rolling while none ofthem wore any gloves or masks. The response to the awareness level on any benefitting laws was nil among the respondents. [Table/Fig-2] showed that eyes were most commonly affected followed by musculoskeletal system in majority of participants. Dull aching headache was the most common symptom followed by lower back pain, neck pain, difficulty invision, palpitation. Epigastric pain after taking food and hyperacidity was in (n=41, 39.81%) and (n=62, 60.19%) respectively. More than half workers had lower limb weakness (n=54, 52.4%) and vertigo (n=60, 58.20%), (n=23, 22.33%) had difficulty in hearing. Pallor was noted in 20 participants and clubbing was observed in (n=9, 8.74%) workers. Skin of the hands showed loss ofsensation among five workers. SBP ranged from 90-178 mmHg and DBP ranged from 46-110 mmHg. More than one-third was in pre hypertension stage. Isolated systolic and diastolic hypertension was recorded in (n=17, 16.50%) and (n=5, 4.85%) women respectively. Mean (±SE) body weight was 57.12 kg (10.68) and mean BMI (±SE) was 25.90 kg/m² (±4.35); overweight and obesity as noted in (n=46, 44.66%) and (n=14, 13.59%) workers respectively. In bivariate analysis, both high BP (p-value <0.01) and BMI (p-value<0.05) were significantly associated with increasing age but lower education had strong association with high BP (70.9% vs. 41.2%). The variables considered were sociodemographic and economic attributes. The proportion of musculoskeletal symptoms was significantly more among workers who rolled more than 500 beedi per day. Eye problems were more among the workers who were in the profession for more then 20 years and had worked for more than six hours a day (p-value <0.05) [Table/Fig-3,4]. It was noted that both systolic and diastolic blood pressure of the respondents showed ups and downs with advancing age whereas in case of BMI, it was seen that many of the workers were overweight with increasing age [Table/Fig-5,6].

[Table/Fig-5]:

Line diagram showing trends of blood pressure with age.

[Table/Fig-6]:

Scatter diagram of BMI variation with age.

Occupational health hazards are showing an upward trend throughout the world and India is no exception [1,2]. There is a huge impact on their health due to long hours of sitting in uncomfortable posture and regular, consistent exposure to tobacco dust and fumes. Despite a hazardous profession, their health and working conditions have rarely been brought into limelight of public discussion and awareness.

The mean (SE) age of workers 38.69 (±8.53) years was comparable with coastal Karnataka Study 40.8 (±11.3) years, while the mean age was more in some other studies [20-24]. Publication from West Bengal and south India reported nearly similar proportion of marriage (91% and 88% vs. 97%) [7,22]. Majority of respondents lived in nuclear family comparable to South Indian studies, though Murshidabad study reported difference in family type with more in favour of joint one and this may be due to geographical difference [7,20,22]. In our study, hypertension was significantly more in respondents with lesser education maybe due to less awareness about the lifestyle correlates. The illiteracy rate in present study found to be quite similar with South India and Mumbai study [20,23]. The illiteracy rate of Murshidabad study was less (6.7%), the difference might be due to the difference in the eligibility criteria of an illiterate, as we included those women who can read or read and write only, in addition to those without any letter introduction [7]. There was wide variation in age group distribution in their study population [Table/Fig-7]. Mumbai slum study using BG Prasad’s scale had revealed similar social class structure as present study [Table/Fig-8] [23]. Overcrowding was present in almost all the houses in the south Indian study [22].

Mean duration of work, average working hours and rolled beedi per day was quite similar to our study. Most of the women joined this job due to financial burden and family tradition [20,22-25]. The starting age of beedi rolling was similar to previous studies. Women worked on daily wages like in the previous studies [22,23].

Morbidity profile: Beedi rolling is an important cause of significant health hazards as cited by the International Labour Organisation that there is exacerbation of different health hazards like asthma, anaemia, giddiness, vertigo, postural problems, eye problems among beedi workers [23]. Mangalore study reported less prevalence of breathlessness and palpitation than our study [26]. Other research groups also found breathlessness and ischaemic heart disease [20-22]. Cough, common cold, sore throat, sneezing were reported in earlier studies with variable proportions (9-76% vs. 30%) [7,20,22,26-28]. Previous studies reported wide variety of eye symptomsas found in our study [21-23,25]. Mittal S et al., study also reported similar eye problems [25]. Musculoskeletal system was the most commonly involved system in addition to eye. Earlier studies also supported the findings [7,21-24,26]. The study of Murshidabad district showed that some symptoms were more among their workers while the proportion of some morbidity corroborated with our findings. The improvement of respiratory symptoms in workers of present study might be as a result of less pollution and better housing condition than the reference study [Table/Fig-8]. The prevalence of pallor reported was less than the South India study (19.41% vs. 40%). The difference was attributed to the gap between laboratory findings and observation [Table/Fig-9] [20]. Skin diseases like allergy, callosities, tanning was also reported from other studies [24,25,27]. The mean height (1.50 mm vs.1.48 mm) of the workers was close to present study, but the weight was more in current one (51.82 kg vs. 57.12 kg) [21]. The proportion of beedi workers with high BP in a study from West Bengal was similar to current study (65.80% vs. 66%) [7]. Age, education status, social class, number of working hours, duration of work was associated with different health hazards. The present study also revealed similar results [21,25, 27].

The present study revealed that more than one third respondents are not literate and the living condition is inadequate. The workers rarely practiced any safety measures and were completely unaware of any laws benefitting them. Some morbidity are significantly more with increasing working hours cum years, age of workers and also with more number of beedi rolling. Many workers of the unorganised sectors still lived with morbidities without self concern.

The study would be more appreciable if some aspects on the social security measures could be included. As the study was a self-financed study within stipulated time, therefore, the subclinical cases could not be identified. The recall bias of the participants may not reveal the actual morbidity scenario. Therefore, a multi-centric elaborative study can be done in future including integrating laws and policies. Qualitative research will be the best kind of research for exploring the specific issues.

The present research highlighted the role of women in household finance. The most common system involved was musculoskeletal followed by eye, respiratory system. Awareness regarding adverse effects of beedi rolling and safety measures were very poor among the workers.