Health Status of Working Women in a Tertiary Care Center,North Kerala,India: During the COVID-19 Pandemic

Abstract

Introduction:

Women constitute about one-half of the workforces in most countries and spend a significant proportion of their time at the workplace, contributing to a lot of physical and mental stress. The health-care professional in the workforce was the most affected during the COVID-19 pandemic. COVID-19 and noncommunicable diseases (NCDs) and associated risk factors have a substantial correlation. According to numerous studies from around the world, people who already have established risk factors such as diabetes, hypertension, obesity, or other vascular risk factors, are more likely to contract COVID-19 and experience complications or even pass away from it.

Objectives:

The objective is to assess the health status of working women in a tertiary health-care center in Kerala during the COVID-19 pandemic.

Methodology:

The study was done in a tertiary health-care center in Kozhikode district, Kerala, South India. This center comprises medical, paramedical and nursing institutes. A total of 262 women were included in the study, and data were collected using a semi-structured questionnaire.

Results:

This study demonstrated that working women’s stress was prevalent. It reveals that 94 (99.4%) women experience stress, 60.7% experience depression, 72.5% do not engage in daily physical activity and 80.8% of women were at risk of having NCDs.

Conclusion:

This study was an attempt to explore the health status of the women’s working health status during COVID-19 time. It found that some women are hypertensive, depressed and have stress-related disorders such as anxiety and worries. Mental health is directly linked with physical activity. The stress levels were controlled for those who were involved in physical activity on regular basis. Hence, we should work on this area to help improve these conditions.

Keywords

Early detection noncommunicable diseases and COVID-19 women’s health working women

Introduction

Women’s participation in the labor force has increased since the early 19^th century due to increased education and employment opportunities. More women participate in the paid labor market to improve their family economics and societal participation. This phenomenon has altered the traditional role of a woman as a homemaker. Women spend a significant proportion of their time at the workplace.^[1] The working environment is becoming a significant part of their daily life, leading to physical and mental stress. According to the World Health Organization (WHO), hazardous environmental exposure from living and working environments is the top risk factor for chronic disease mortality.^[2] According to the WHO, stress can be defined as a state of worry or mental tension caused by a difficult situation. Stress is a natural human response that prompts us to address challenges and threats in our lives. Everyone experiences stress to some degree. The way we respond to stress, however, makes a big difference to our overall well-being.^[3,4]

During the COVID-19 period, traditional role shifts took place due to a staffing shortage at the workplace. Research studies have shown burnout and physical and psychological issues during the peak COVID-19 times. Women were comparatively more affected, as they had the dual responsibility of managing work and home.

Noncommunicable diseases (NCDs) are currently rising, and estimated that more than 40 million globally have NCDs. NCDs are coronary heart diseases, hypertension, diabetes, obesity, cancer, and mental health issues. Unfortunately, NCDs have been the leading cause of death in women in the past three decades, with two out of three women dying, especially in low- and middle-income countries. NCDs are not exclusive diseases of men. For example, heart disease was the number one cause of death in women in the United States in 2017, where 299,578 women died due to heart disease.^[5] As more women enter the workforce, one strategy is to focus on NCD prevention by providing health education on risk factors in the workplace. Increasing evidence suggests women become vulnerable in the workplace. Even though women share the working environment with men, they carry different health risks due to the biological and psychological differences between men and women. Previous studies show that working women’s risk of NCDs is increasing.^[6] According to the WHO, human papillomaviruses (HPVs), an incredibly prevalent virus spread through sexual contact, are associated with 99% of cervical cancer occurrences. Although the majority of HPV infections are self-limiting and symptomless, persistent infections can lead to cervical cancer in females. The fourth most frequent malignancy in women is cervical cancer. Around 311 000 women globally lost their lives to cervical cancer in 2018, according to estimates of the disease’s 570 000 new cases. Most occurrences of cervical cancer can be avoided using primary (HPV vaccine) and secondary prevention strategies (screening for and treating precancerous lesions).^[7]

COVID-19 and NCDs and associated risk factors have a substantial correlation. According to numerous studies from around the world, people who already have established coronary heart disease, heart failure, chronic renal, liver, or respiratory disease, as well as cancers or their risk factors such as diabetes, hypertension, obesity, or other vascular risk factors, are more likely to contract COVID-19 and experience complications or even pass away from it.^[8] Therefore, the present study aims to identify NCDs prevalence and associated risk factors among working women, especially during the COVID-19 period. Furthermore, this study highlights and estimates the measurable elements among working women in the health sector. Although multiple factors affect working women, we have chosen a few parameters, which can be measured again among the same group once the COVID-19 pandemic has settled down. This study has multiple other studies linked with the same population in terms of being a cohort group.

Methodology

This was a cross-sectional study. The study is done in a tertiary health-care center in Kozhikode district, Kerala, South India. This center comprises medical, paramedical, and nursing institutes. Women working in nursing, pharmacy, sanitation, dentistry, clinical sections, physiotherapy, and the preclinical section in a tertiary center are participants. They form the sampling frame for the present study. The sample size is calculated using an epitools epidemiological calculator. The final sample selected for the study was 262 participants–inclusion criteria: Those women willing to participate and present in the institution during the study. Pregnant females were excluded. Study period: March 2021–August 2021. Data collection: A semi-structured questionnaire, which includes socio-demographic data, risk factors for noninfectious disease, the prevalence of diabetes mellitus (DM), hypertension, body mass index (BMI) assessment, and a community-based risk assessment tool, was used for collecting data.

Results

Among the 262 study participants, 155 (59.4%) were young women (18–35), 105 (40.2%) were middle-aged women (36–55), and 1 (0.4%) was an older woman (56–70). The mean age of the studied population is 32.97 ± 8.74 years, and the median is 31 years. Of the study population, 155 (59.4%) belong to the upper middle class, 41 (15.7%) belong to the lower middle class, 36 (13.8%) belong to the upper lower level, whereas 29 (11.1%) belong to the upper class, according to BG Prasad’s classification 2020.^[6] Among 262 participants, 162 (59.3%) have no diabetic family history, whereas 93 (34.1%) have one parent diabetic, and 18 (6.6%) have both parents diabetic [Table 1].

Table 1.

Sociodemographic details of the study participants

Parameter	Category	Frequency (%)
Age group	Young woman (18–35)	155 (59.4)
	Middle-aged woman (36–55)	105 (40.2)
	Older women (56–70)	1 (0.4)
Socioeconomic status	Upper class	29 (11.1)
	Upper middle	155 (59.4)
	Lower middle	41 (15.7)
	Upper lower	36 (13.8)
	Lower class	0
Family history of diabetes	No diabetes in parents	151 (59.3)
	One parent is diabetic	93 (34.1)
	Both parents are diabetic	18 (6.6)
Fast food consumption	Daily	75 (4.3)
	3–5 times in a week	52 (18.6)
	Once a week	59 (21.1)
	Monthly	64 (22.9)
	Rarely	12 (4.2)
Perceived stress	High stress	1 (0.2)
	Moderate stress	94 (99.4)
	Low stress	5 (0.4)
Depression level	Severe	11 (4.2)
	Moderate	148 (56.5)
	Low	81 (30.9)
Symptoms of cervical cancer	People who are at risk of acquiring cervical cancer	11 (4)
Symptoms of cervical cancer	People who are not at risk of acquiring cervical cancer	89 (96)

It reveals that 94 (99.4%) women experience moderate stress, while 5 (0.4%) experience low work pressure, and only 1 (0.2%) have high stress. Among the study participants, ten (3.8%) had risk factors related to cervical cancer, and 89 (96%) were not at risk of acquiring cervical cancer. When assessing depression status, majority (60.75) of them have depression [Table 1].

Among the study subjects, 26 (10%) were underweight, 66 (24.9%) were overweight, and 72 (27.6%) belonged to the obese category. As a result, the population’s mean BMI is 23.06 ± 3.28, and the median is 23.23, as shown in Figure 1.

It noted that 45 (27.4%) only perform regular exercise, while 217 (72.5%) do not engage in daily physical activity. Among those who performed physical exercise regularly, 5 (6.9%) did regular vigorous exercise or strenuous activities, 26 (36.1%) did regular moderate exercise or moderate physical activity, and 41 (56.9%) did regular mild exercise or mild physical activity, as shown in Figure 2. Those who had the habit of regular outdoor physical activity had restrictions due to containment zones in the state. Since there were more cases reported every day were in high numbers compared to rest of the Indian states. Hence, there was a longer duration of containment zone periods in the Kerala state. This had adversely affected the physical activity habits of the people. Those who were working out inside the homes such as zoomba, yoga, and other aerobic activities at home, did not feel any difference in their activity levels. This is reflected in their mental status too. Mental health is directly linked with physical activity. The stress levels were controlled for those who were involved in physical activity regularly.

Among the study participants, 57% had hypertension, 5% had Grade 2 hypertension, 1% had Grade 3 hypertension, and 1% had Grade 4 hypertension, as in Figure 3. A total of 67% had hypertension. This level of hypertension in this group was not measured previous to the current study.

According to the community-based assessment checklist (CBAC) for early detection of NCDs,^[17] A conclusion was made that 80.8% of the women were at risk for developing NCDs, as shown in Figure 4. Among 262 participants, 95 (34.1%) performed a self-breast examination, and 163 (58.4%) were aware of the self-breast test and its importance, as shown in Figure 5.

Among 262 participants, 13 (4.8%) have DM, 15 (5.6%) have hypertension. Thirty-one (11.5%) have thyroid dysfunction, 37 (13.8%) have allergies, 9 (3.3%) have varicose vein, 0 (0%) have cataracts, 2 (0.7%) have cancer, and 170 (62.7%) have no significant NCDs, as shown in Figure 6.

Figure 1.

The BMI of study partcipants. BMI: Body mass index

Figure 2.

Distribution of regular exercise among study participants

Figure 3.

The distribution of study participants based on the grading of hypertension

Figure 4.

The risk assessment of NCD. NCD: Noncommunicable disease

Figure 5.

The distribution of self-breast examination among study participants

Figure 6.

Distribution of study participants according to noncommunicable diseases

Discussion

Kerala as a state had reported the first COVID-19 incident case in India. And also, the Kerala state health services are robust.^[9] The reporting of COVID-19 positive cases has multiple factors, including patient awareness and willingness to test, positive test being reported to the state health system. The COVID-19 pandemic has altered many things in the entire world such as online classes, wearing masks in public places, social distancing, and containment zones. These restrictions and uncertainties have altered the mental status of every individual in the world. We wanted to measure how much health is affected by the COVID-19 pandemic to the health-care workers.

The study assessed the health status of working women in a tertiary health-care center in Kerala in 2021. Participants of this study were 262 females aged between 18 and 70 years. The majority of the women were young, between 18 and 35 years (59.4%). As the majority of the Indian workforce is young, this could be the reason for these findings and the majority of the people had a professional degree (42.9%). According to the modified BG Prasad’s classification, 2021. The study included people from different socio-economic statuses such as upper class (11.1%), upper-middle-class (59.4%), lower middle class (15.7%), and upper lower class (13.8%). About more than half, i.e. 55.2% of people, were willing to start health promotion activities regarding identifying risk factors and creating awareness of NCD.^[6]

Our study demonstrated that about 61.7% were unaffected by NCDs. About 38.3% of women had NCDs such as hypertension (5.7%), DM (4.6%), thyroid dysfunction (11.9%), allergy (13.8%), varicose vein (3.4%), cataract (15.7%), and cancer (0.8%).^[9] According to the study by Idris et al.^[5] a systematic review of NCDs among working women published in Industrial Health 2020, the prevalence of NCD was DM 8.9%–16%, hypertension 16.6%–66.4%, and nonskin cancers were 3.7%. Hence, this study had given us an opportunity to early detect hypertensive cases among the health-care workers.

The study pattern came out with results of a family history of diabetes showed that 6.10% having both parents with diabetes since the offspring of a parent having a lifetime risk of type 2 diabetes is 40%, 39.50% had one parent with diabetes, and 59.4% having no diabetes in parents, The study aligns with Malini et al.’s^[10] assessment of risk factors for type 2 DM among working women in Berhampur Orissa 2009. It demonstrates that 58% of cases with diabetes had a positive family history of diabetes.

Health-care workers faced heightened workloads and stress during the COVID-19 pandemic. Exercise can help them to burn out by reducing stress and improving mood, which was particularly important during this challenging time. A study conducted by DS Malini et al.^[10] assessed risk factors for developing type 2 DM among working women in Berhampur Orissa, 2009. Our study shows that about 82.80% of people did not exercise regularly. This shows strong evidence that physical inactivity increases the risk of many adverse health conditions like NCDs.^[11]

Daily diet has a great influence on the health of medical workers, especially during the COVID-19 period with heavy work intensity and physical and mental exhaustion. We have taken the diet pattern as one of the factors because this is also interconnected with weight gain and mental health. This results in loss of sleep and change in thyroid hormone levels. In this study, majority of working women, i.e. 96.2% of women, are on a mixed diet, but more than half are not on a balanced diet. Almost everyone eats vegetables daily; fruits, pulses, meat, fish, and eggs weekly, but they consume a minimal amount of dry fruits, nuts, green leafy vegetables, milk, and ragi. Only 22% consumed the healthy foods. It indicates that, even though they are health workers, 78% of them have regular consumption of unhealthy foods. A healthy diet boosts good cholesterol formation and decreases unhealthy triglycerides. According to the study conducted by Idris et al.,^[5] a systematic review of NCDs among working women published in Industrial Health 2020, the prevalence of an unhealthy diet includes 44.92%–69.9%.^[7] Our study demonstrated that about 96.6% of people have a mixed diet, whereas only 3.6% are on a vegetarian diet. It also demonstrated that there was daily (4%), 3–5 times in a week (20%), once in a week (21%), monthly (22%), and rarely (33%) intake of fast food by the participants. Fast food consumption can increase type 2 DM, coronary heart disease mortality, and obesity.

Cervical cancer is a leading cause of morbidity and mortality among women in low- and middle-income countries. Where more than 80% are diagnosed at an advanced stage and have poor treatment outcomes. Almost all cervical cancers are caused by HPV can be passed from one person to another during sex. There are many types of HPV. Some HPV types can cause changes in a woman’s cervix. These changes can lead to cervical cancer over time.^[12] In our study, the participants informed that 3.8% of people were at risk of cervical cancer and were referred to a hospital for treatment. Bleeding between periods, bleeding after menopause, and bleeding after coitus are some symptoms of cervical cancer.

The population’s mean BMI is 23.06 ± 3.28, and the median is 23.23. Our study used the waist-to-hip ratio to determine the risk for obesity. In a study conducted by Mi-Jung et al.,^[13] the association between occupational characteristics, overweight, and obesity among working Korean women between 2010 and 2015. 6.8% of subjects were underweight, 20.1% were overweight, and 22.2% were individuals with obesity. Our study demonstrates that 24.9% are overweight, and 27.6% belong to the obese category.

Financial stability is one of the factors that are demanded in the ongoing inflation. The other factor of how many roles an educated female can take up is not measurable on any scale. The COVID-19 pandemic was the most distressing event in everybody’s life in the entire world. No such event could have happened to a nuclear family in recent times. The role of educated and employed females in the family and the workplace is highly demanding. Now, even though the females working in other sectors have gotten relief by having an opportunity to carry on work from home, this is not the case among the females who are employed in the health sector. Even though the health sector has undergone an arduous task during the COVID-19 pandemic. Our study demonstrated that working women’s stress was prevalent, where the Majority (99.4%) experienced moderate stress. A significant source of stress for working women as their number of working hours increased due to a shortage of staffing, working by wearing personal protective equipment (PPE), and often affected by COVID-19 disease.^[14,15]

Psychological stress and inadequate coping ability contribute to virtually all diseases. In particular, there is a direct link between stress, depression, hypertension, and coronary heart disease.^[15] Mental stress has also been associated with psychosomatic symptoms such as sleep problems, gastrointestinal symptoms, and joint, back, or muscular pain. In women working within the health-care system, sleep problems were connected with decreased resilience to stress.^[16] They were physically and mentally tired.

The management of mild-to-moderate mental health disorders, particularly depression and stress, may benefit greatly from physical activity. Increased aerobic exercise or strength training has been proven to dramatically improve depressive symptoms, despite the fact that people with depression often engage in less physical activity than those who are not sad. Regular exercise is associated with less depression.^[16] According to the CBAC for early detection of NCDs,^[17] an analysis of the risk factors for NCDs, 80.8% of women were at risk. Only 19.2% had no risk for NCDs. During the COVID-19 pandemic, there is no role for screening the NCDs. As there is a lack of awareness regarding increasing NCDs among working women, specific arrangements to identify the workplace’s risk factors need initiation. It can increase understanding of the significance of NCDs and create awareness to prevent NCDs and remain healthy.

Recommendation

The mental health status of women should deal with proper interventions, as shown by the studies. Frequent drinking of water is significantly less among them, which can increase. Therefore, regular drinking of water should be considered. Working women should maintain good oral hygiene. They should have a calcium-rich diet such as green leafy vegetables and fish. Apart from household activities and their work, they should spend some time exercising at least 30 min a day. The practice of self-breast examination is deficient even though they know it and ensure that they are more careful about this issue and other related disorders. Iodine-rich food such as fish, seafood, and eggs should be a part of the diet to avoid thyroid disorders. This study found that some women are hypertensive, underweight, and have depression- and stress-related disorders such as anxiety and worries. Hence, we should work on this area to help improve these conditions.

Conclusion

The COVID-19 pandemic has altered many things in the entire world such as online classes, wearing masks in public places, social distancing, and containment zones. These restrictions and uncertainties have altered the mental status of every individual in the world. We wanted to measure how much health is affected by the COVID-19 pandemic to the health-care workers. The present study participants are a cohort group. The interventions to improve the health status of the current cohort group are planned based on the findings of the study. There will be postinterventional studies and longitudinal studies on the same cohort. We can improve the health status of the current participants only by knowing how many of the participants fall in low, moderate, and high risk before the intervention. Hence, this study has given a profile of the health status of working women in a tertiary care center during the COVID-19 pandemic in North Kerala.

Footnotes

Acknowledgements

We would like to thank all the participants who consented to the data collection.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Institutional Ethical Committee Approval Number

Ethics Committee approval No: MMCH&RC/IEC/2020.

CRediT Author Statement

The study conception, design, data collection, analysis and interpretation of results and draft manuscript preparation was done by Dr. J Robinson and Dr. K S Premlal. All authors reviewed the results and approved the final version of the manuscript.

Data Availability

Data Supporting this study are included within the article.

Use of Artificial Intelligence

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