|Year : 2022 | Volume
| Issue : 2 | Page : 148-155
A cross-sectional study of musculoskeletal disorder and their environmental determinants among cycle rickshaw pullers of Delhi: A geographical information system-based analysis
Nitesh Kumar, SK Rasania, Anita Shankar Acharya, Nazish Rasheed
Department of Community Medicine, Lady Hardinge Medical College, India
|Date of Submission||07-Jul-2022|
|Date of Decision||07-Dec-2022|
|Date of Acceptance||09-Dec-2022|
|Date of Web Publication||31-Dec-2022|
Dr. Nitesh Kumar
Flat 204, B14.15 Maitri Apartment Nawada, New Delhi - 110 059
Source of Support: None, Conflict of Interest: None
Introduction: Rickshaw pulling is among the major activities in the informal sector. Cycle rickshaw pulling involves the task of prolonged sitting, fixed posture, and vibrations which could increase the risk of developing many health problems including one of the major problems of musculoskeletal disorder (MSD). Rickshaw pulling remains important for urban transport system, and such activities contribute in terms of employment and transportation services. The injury and illness resulting from work leads to lower productivity and quality employment which force them to increase their daily hours of working. The work environment and various other environmental determinants for MSD were assessed. The spatial variability of these environmental determinants and MSDs of cycle rickshaw pullers was studied in Delhi.
Material and Methods: A cross-sectional study was conducted among cycle rickshaw pullers of Delhi. Five districts were randomly selected, and out of 448 study subjects, a total of 425 were included in the study. Consent was obtained before the study. The Nordic Musculoskeletal Questionnaire instrument for MSDs was used. The spatial distribution of MSD and risk factors was studied using QGIS software.
Results: MSD was observed in 51.5% of the cycle rickshaw pullers and the prevalence increased with age from 9.6% to 34.7%. A statistically significant association of MSD with duration of work, sleeping hour, and sleeping place was observed. Poor road condition and posture were also having an association with MSD.
Conclusion: Every second cycle rickshaw puller was having MSD. Lifestyle, road conditions, harsh environmental condition, strenuous physical exertion, and ergonomics of the cycle rickshaw were important factors contributing for MSD.
Keywords: Environmental determinants, musculoskeletal disorder, rickshaw pullers
|How to cite this article:|
Kumar N, Rasania S K, Acharya AS, Rasheed N. A cross-sectional study of musculoskeletal disorder and their environmental determinants among cycle rickshaw pullers of Delhi: A geographical information system-based analysis. Indian J Community Fam Med 2022;8:148-55
|How to cite this URL:|
Kumar N, Rasania S K, Acharya AS, Rasheed N. A cross-sectional study of musculoskeletal disorder and their environmental determinants among cycle rickshaw pullers of Delhi: A geographical information system-based analysis. Indian J Community Fam Med [serial online] 2022 [cited 2023 May 28];8:148-55. Available from: https://www.ijcfm.org/text.asp?2022/8/2/148/366547
| Introduction|| |
Rickshaw pulling is among the major activities in the informal sector. It is estimated that close to 99,000 sanctioned rickshaws ply in Delhi. Cycle rickshaw word originated from the Japanese word “Jinrikisha” where Jin stands for human, riki for power or force, and sha for vehicle, giving rise to the literal meaning “human-powered vehicle.” In India, rickshaws were used in 1880 for the first time in Shimla and it was introduced in Delhi in 1940.
Rickshaw pulling remains important for urban transport system in most of the cities across the country, and such activities contribute significantly in terms of employment and transportation services.
Rickshaw is a substitute for limited privately owned vehicle for short-distance transportation such as carrying people for medical purpose, children for schools, and small loads of freight in congested areas. It is road safe with low cost of travel and also eco-friendly as it does not cause air pollution and provide a decent means of employment for the people who come from village to city just for a simple reason to provide food for their family members.
Cycle rickshaw pulling involves prolonged sitting, fixed posture, and vibrations, which could directly lead to the risk of developing many health problem, including one of the major problems of musculoskeletal disorder (MSD). Factors such as poor posture, irregular working hours, prolonged duration of work, improper dietary habits, sleep hours, and work-related stress factors not only lead to MSDs but also lead to lower productivity and quality employment due to injuries, illness, and disability resulting from cycle rickshaw pulling. Despite all these, the rickshaw pullers have to earn their living by transporting people and goods from one destination to another by peddling for miles, day and night, often carrying heavier loads than their physical capacities and ignoring their health which affects their musculoskeletal system.
Over the period, rickshaw designs have evolved to great extent. The old traditional design of cycle rickshaw was built with ordinary bicycles, and this bicycle was welded and bolted to a heavy wood chassis-seat with some steel components, these configuration made them heavy (80 kg), misaligned and uncomfortable. This cycle rickshaw design increased the physical load and many health issues like MSD resulting in reduced work efficiency. The need for modification was not just to improve their earning but also to work on a cycle rickshaw with ergonomically suitable design which will reduce the MSDs. The new design (1999) of cycle rickshaw was developed in Agra by the Institute for Transportation and Development Policy. Even with better-designed cycle rickshaw health and well-being of cycle rickshaw pullers is a challenge. The conditions in work environment hamper the well-being, working capacity, and even the lifespan of cycle rickshaw pullers. Although they provide significant help to millions of people, the plight of these people remains miserable.
In our study to assess the variability of environmental risk factors and MSDs among cycle rickshaw pullers, geospatial technique was used. Geospatial technology has a range of applications in health care, but perhaps, one of its most interesting functions is its ability to collect information about several factors including its capability for data analysis and displaying the results with the help of multilayered maps.
These multilayered maps can inform and educate professionals and the community about an area's true state of health care. It can provide in-depth information on disease within a specific region and various risk factors affecting the health of the population. There is a paucity of studies to find out the relationship of environmental determinants and MSD and none on the cycle rickshaw pullers. Furthermore, spatial variability in these environmental determinants among the cycle rickshaw pullers was never studied in any previous studies to the best of our knowledge. Hence, this study will shed light on the same. The objective of this study was to determine the prevalence of MSDs among cycle rickshaw pullers of Delhi. Also, other objective of the study was to assess environmental determinants of MSDs and their spatial variations using the geographical information system (GIS).
| Material and Methods|| |
This was a cross-sectional study conducted from November 2019 to March 2021. The data collection was done from January 2020 to March 2021.
There are 11 districts in Delhi, out of which five districts were randomly selected by lottery method which were East, West, North, South, and Central parts of Delhi.
As this study was a part of a bigger study, i.e., “An epidemiological study of work related diseases and their environmental determinants among cycle rickshaw pullers of Delhi,” in which the primary objective was to find out the prevalence of work-related diseases with special focus on respiratory disorders among cycle rickshaw pullers of Delhi, and for this, a sample size was calculated based on the respiratory disorder prevalence of 28% from a study done by Batra et al. using N = Z2p q/l2 where (prevalence) P = 28, q = 100 − 28 = 72 (allowable error), l = 20%, and Z2 = 4. The sample size comes out to be a minimum of 257 study subjects. After adding design effect of 1.5, the sample size comes to be 385. Assuming the nonresponse rate of 10%, the calculated minimum sample size was 425.
Study population included cycle rickshaw pullers aged 18 years and above, persons engaged in rickshaw pulling for minimum of the last 1 year in Delhi were included in the study. Persons with congenital musculoskeletal morbidities and previous limb surgeries before coming into this profession of rickshaw pulling were excluded from the study.
MSDs: injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs.
Those rickshaw pullers were considered to be suffering from MSD if they had one of the symptoms (pain, numbness, tingling, aching, stiffness, or burning) over the past 1 week and over the past 1 year, i.e., point and period prevalence of MSDs, respectively, was derived.
The five randomly selected districts were East, West, North, South, and Central districts of Delhi, and from each district, one ward was selected randomly by lottery method. In each ward, metro stations and rickshaw stands were randomly selected by lottery method, and on each rickshaw stand/metro station, cycle rickshaw pullers usually stand in queue waiting for passengers. Each of these cycle rickshaws had a number given by the owner; hence, a a systematic random sampling was done. From these available numbers, one was selected by random number table for the first cycle rickshaw and then every second cycle rickshaw puller was selected from the cue. In case if any rickshaw pullers did not consent, subsequent cycle rickshaw puller standing in the queue was selected. A total of 85 study subjects were randomly selected from each ward in a district, so as to reach a sample size of (85 × 5) 425 by the end of the study.
A pretested, prevalidated semi-structured interview schedule for assessing sociodemography, substance use, and health-seeking behavior was used. The Nordic Musculoskeletal Questionnaire (NMQ) instrument for musculoskeletal symptoms was used to assess the nature and severity of self-rated musculoskeletal symptoms. The questionnaire was translated into Hindi and included items about the experience of musculoskeletal problems in nine body areas (neck, shoulders, elbows, wrists/hands, upper back, lower back, hips/thighs, knees, and ankles/feet). Environmental determinants were also assessed which included physical environment, work environment and personal environment. In physical environment questions related to living condition, road and vehicle conditions were assessed. The work and personal environment were assessed by questions related to duration of work in years, number of trips in a day, number of rest breaks in a day, resting place, substance abuse and sleeping habits.
The statistical analysis was performed by Statistical Package for the Social Sciences (SPSS) version 16.0 software (Chicago IL, USA) (reference: Released SI SPSS Statistics for Windows, Version 15.0 Chicago SPSS Inc.). Suitable tests of significance were applied for comparison, and P < 0.05 was considered statistically significant.
QGIS software version 3.10, (Stellenbosch and Johannesburg, South Africa) accessible from (https://qgis.org/en/site/forusers/download.html) for GIS Mapping was used, and it is a freely available software used for collection, analysis, and interpretation of the data. Latitude–longitude details of the working location of the study subjects were obtained using Epicollect android application for Georeferencing.,,
The ethical clearance for the study was taken from the Institutional Ethics committee of Lady Hardinge Medical College Delhi. During data collection the required information was collected from the patients after obtaining their due written consent.
| Results|| |
The study subjects were recruited till sample size was reached. A total of 448 subjects were studied, in which 5 refused to give consent and 18 were excluded as per the exclusion criteria. Hence, out of 448 study subjects, only 425 were included in the study. The illiteracy among the study subjects was very high (71%), and most of the study subjects were migrants (65%). More than half of the study subjects belong to middle class, i.e., 236 (55.5%) and none to upper class according to the BG Prasad Scale. Among 425 study subjects, nearly one-third of the study subjects (32%) belonged to the age group of 30–39 years, and more than half of the study subjects (56%) were above 40 years of age, with a mean age of the study subjects being 41 ± 9.8 years. The age distribution of the study subjects was similar in East, North, and Central districts, in which more two-third of the study subjects were of age <45 years. However, South and West districts of Delhi had less than half of the cycle rickshaw pullers with age <45 years. Despite the older age of cycle rickshaw pullers in South and West districts relative to other districts, the prevalence of MSD was less in comparison to other districts.
MSDs were observed in more than half (51.5%), i.e., 219 of the study subjects out of 425 in the past 1 year. The point prevalence of MSD was 41.6% (177), and the period prevalence of MSD in the past 1 year was 51.5% (219). Of the total 219 with MSD, least were aged 18-30 years at 9.6% and majority belong to > 50 years age group at 34.7% (p< 0.001) [Table 1].
|Table 1: Distribution of musculoskeletal disorder in the study subjects according to age group|
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The proportion of MSD in cycle rickshaw pullers was more than 50% in East (60%) and Central districts (54.1%) in comparison, to South, West, and North districts [Figure 1].
|Figure 1: Prevalence of musculoskeletal disorder among cycle rickshaw pullers in randomly selected districts of Delhi|
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MSDs related to nine body regions were assessed out of which mainly involved body regions for MSD in cycle rickshaw pullers were knee (42.9%), lower back (28.8%), shoulder (15.5%), and hip and thigh (15.1%). Furthermore, on assessing the period prevalence [Figure 2], among the study subjects in the past 1 year from the date of interview, it was observed that knee (52.9%), lower back (31%), shoulder (22.4%), and ankle (17.4%) regions were mainly contributing for the period prevalence of MSD [Figure 2].
|Figure 2: Distribution of body region involvement of musculoskeletal disorders and their point and period prevalence|
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On assessing the environmental determinants, it was observed that rickshaw pullers working for more than 8 years had MSD in more than half (55.3%) of the study subjects and this association was statistically significant (p< 0.05) [Table 2]. Furthermore, on assessing the number of trips, the mean number of trips cycle rickshaw pullers drive per day was 23 trips. Nearly two-third (65.9%) of the study subjects with MSDs were driving more than 23 trips in a day which was having a statistically significant association [P < 0.05, [Table 2]].
|Table 2: Association of work and living environment of study subjects with musculoskeletal disorder (N=425)*|
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On assessing the sleeping habits of rickshaw pullers, those who were sleeping for 6 h or less in a day were proportionately having more MSD in comparison to those sleeping for more than 6 h in a day and this association was statistically highly significant (p< 0.001). In our study, posture of cycle rickshaw pullers had a highly significant association with MSD [Table 2]. The study subjects driving rickshaw in any posture other than sitting were having more MSD. Road conditions were also assessed and roads were designated as good, average, and poor on the basis of perception and response of cycle rickshaw pullers. It was observed that poor road condition had a highly significant association with MSD [Table 2].
On analyzing the the distribution of environmental determinants using geospatial map, it was observed that rickshaw pullers in Central and West districts were driving cycle rickshaw for more than twelve years [Figure 3], and MSD prevalence was more than 45% in these districts. Nearly two-third (65.9%) of the study subjects with MSD s were driving more than 23 trips in a day which was statistically significant (P < 0.05) and these were located in Central, West, and South districts of Delhi [Figure 4]. In comparison to Central and West districts, rickshaw pullers in South district had less MSD prevalence despite driving more than 23 trips per day. The study subjects located in East, West, and Central districts of Delhi were sleeping for <6 h [Figure 5], in which MSD prevalence was more. On analyzing the place where most of the rickshaw pullers sleep [Figure 6], it was observed that rickshaw pullers who were sleeping in contractor's rickshaw shed, footpath, railway station/bus stand, subway, under flyover staircases, and rain basera were located more in Central and East districts (>45%) which is found similar to MSD prevalence [Figure 7].
|Figure 3: District-wise distribution of mean duration of cycle rickshaw pulling (in years)|
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|Figure 4: District-wise distribution of mean number of trips of cycle rickshaw pulling per day|
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|Figure 5: District-wise distribution of mean number of sleep hours of cycle rickshaw pullers of Delhi|
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|Figure 6: District-wise percentage of cycle rickshaw pullers sleeping in place other than house|
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|Figure 7: District-wise distribution of cycle rickshaw pullers sleeping in place other than house (in percentage)|
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| Discussion|| |
The profession of cycle rickshaw pulling demands constant physical exertion and this increases the chances of MSDs. It was observed that more than half (51.5%) of the study subjects were having MSD. The period prevalence of MSD was 42.9% in knee, lower back (28.8%), shoulder (15.5%), and ankle (11.9%), and this pattern was also observed in point prevalence of MSD [Figure 2]. Hossain et al. in their study among garment workers in Bangladesh observed that they had a period prevalence of 27.1% and body regions, mainly involved were lower back, shoulder, neck, and hip thigh regions, which were similar to our study although the period prevalence in our study was found to be more than this study as the study subjects are different (ready-made garment workers), also study was done in Bangladesh so difference in the study location also could be one of the reasons. MSDs in these body regions were more frequently reported with an increase in age and these findings were similar to our study. Rahman et al. in their study among cycle rickshaw pullers found the prevalence of MSD was found to be higher than our study, i.e., 91%, in which knee, lower back, leg, and shoulder were the regions mainly involved, the reason could be due to difference in the study sample size and study location. The involved body regions could be related to the posture of the rickshaw pullers. In our study, posture of cycle rickshaw pullers had a highly significant association with MSD [Table 2] which can be related to the poor rickshaw conditions. Furthermore, advancement of age and duration of rickshaw pulling had a statistically significant association (P < 0.05) with MSD, and these findings were comparable to our study. Onawumi and Lucas conducted a study among taxi drivers in Nigeria, more than half (67%) of drivers reported discomfort in the neck, and about 18% and 20% reported symptoms in right and left wrist joints, respectively. Jadhav found that lower back pain and neck pain as the most prevalent musculoskeletal impairments among bus drivers.
Although many studies have been done, none of them have studied the prevalence of MSDs among cycle rickshaw pullers and its geospatial variation using GIS.
In our study, spatial analysis helped in understanding the variation in the exposure of various environmental determinants among cycle rickshaw pullers. GIS-based analysis of MSDs among cycle rickshaw pullers has shown that the point prevalence of MSD was more in Central district, i.e., >50%, and the period prevalence more (>50%) in Central and East districts of Delhi among cycle rickshaw pullers [Figure 7] and [Figure 8]. This could be due to variability among the study subjects and the work environment. Although East district had a prevalence >50%, here mean years of working were <12.5 years [Figure 3] and [Figure 7]. On analyzing the overall data, it represented that cycle rickshaw pulling for more than 8 years had a statistically significant association with MSD, but spatial analysis represents that despite the lower mean duration of work, the higher prevalence of MSD in East district could be due to other determinants related to work environment. While spatially analyzing the average number of trips taken by the cycle rickshaw pullers in a day [Figure 4], the average number of daily trips was more in Central, West, and South districts, but the prevalence of MSD [Figure 7] was more in East and Central districts. Despite lower number of trips in East district, the highest prevalence of MSD was observed. Furthermore, in South district, despite the older age of cycle rickshaw pullers relative to other districts, the prevalence of MSD was less in comparison to other districts, which can be related to the variability in other environmental determinants [Figure 2] such as duration of work, sleep hours, sleeping place, distance traveled by rickshaw pullers per trip, and road conditions. The observed findings have shown an association with variation in these environmental factors.
|Figure 8: District-wise distribution of point prevalence of musculoskeletal disorders in cycle rickshaw pullers|
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On analyzing sleeping habits, it was observed that study subjects living in East, West, and Central districts were having a mean sleep duration <6 h and also nearly half of the study subjects in East and Central districts were sleeping in place other than their house and rickshaw pullers in these two districts were having a high MSD prevalence. A significant association was found between poor road condition and MSD [Table 2]. Lack of proper resting place and lack of efficient ergonomically design rickshaw along with road conditions were acting as a determinant for MSD among cycle rickshaw pullers of Delhi [Figure 5] and [Figure 6].
On analyzing the sleeping hours, the rickshaw pullers [Figure 5] who were sleeping for <6 h in a day were proportionately having more MSD and this association was statistically significant (P < 0.001). The duration of sleeping is affected by the place of sleeping. Hence, duration of work, number of trips per day, daily sleep hours, sleeping place, age, and other environmental factors affect the MSDs among cycle rickshaw pullers. Furthermore, nearly three-fourth of the cycle rickshaw pullers (72.0%) with MSD were not having a static posture (i.e., sitting posture) while pulling the cycle rickshaw and this had a statistically significant association with MSDs. Other than these, one of the important factors such as socioeconomic status of the study subjects was assessed in our study and it was observed that socioeconomic status act as an important factor for MSD. As more than half of the study subjects with MSD were belonging to middle class (55.5%) as per the BG Prasad Scale with a statistically significant association (P < 0.05) and nearly half of the rickshaw pullers with MSD were having no other option but to sleep in the rickshaw (48.5%) or footpath (59.4%) and this association was statistically significant (P < 0.05). As most of the study subjects migrated from other states (65%) to earn their living, nearly two-third of them had no other option but to live in rented house and the rest lived in contractor's rickshaw shed, footpath, subway, and rain basera.
As majority of rickshaw pullers were migrant workers, so lockdown due to COVID-19 resulted in the migration of many of the study subjects to their native place. Hence, study subjects could not be assessed during that period. As the study was a cross-sectional study, so causal inference is difficult to obtain. Data were based on the perception of the study subjects and laboratory investigation were not done.
| Conclusion|| |
Every second cycle rickshaw puller was having MSD. Poverty, strenuous physical exertion in an overtly polluted environment, long working hour with lack of proper sleep, and sleeping place were affecting the health of cycle rickshaw pullers. Furthermore, the lifestyle and road conditions, harsh environmental condition, and ergonomics of the cycle rickshaw were important factors determining the health of cycle rickshaw pullers. These environmental determinants increase the possibility of MSD among cycle rickshaw pullers. Geospatial analysis usage helps in understanding the spatial variation in the prevalence of MSD and distribution of environmental determinants.
A better ergonomically designed cycle rickshaw along with protective gear and training should be provided. Rickshaw pullers may be provided with battery rickshaw at subsidized rates as battery rickshaw will not only reduce the physical exertion but also its fast and popular mode of transport. E-rickshaws have the potential to reduce the fuel oil consumption for passenger transportation which may lead to both economic and environmental benefits.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]