Musculoskeletal Disorders in Unstructured, Unregulated Work: Assessment Methods and Injuries

Abstract

Unstructured and unregulated work is expanding fast among low- and middle-income countries (LMICs). Furthermore, accumulation of urban waste resulting from overconsumption is a global concern. Hence, waste management and recycling have received increased attention. One specific waste category pertaining to electrical and electronic waste (e-waste) is growing at a higher rate than other waste streams. Recycling of e-waste is largely informal and disproportionately relies on LMICs, exposing workers to various occupational and environmental health risks. In order to promote safer work practices and limit a broad range of occupational health and safety concerns associated with informal manual work, the broader psychosocial and sociocultural environment also deserves attention. This symposium will discuss contemporary issues in informal, unregulated, unstructured work in LMICs, primarily in Africa and South America. The goal of the symposium is to call attention to both, the unique occupational context of informal work, and the need for new ergonomics methods to address occupational exposure assessment and musculoskeletal injury prevention adapted to informal work in limited resource settings.

Full text

Musculoskeletal Disorders in Unstructured, Unregulated
Work: Assessment Methods and Injuries
Clive D’Souza1[0000-0003-1652-3001], Bernard Martin1[0000-0001-5033-1607], Julius N. Fobil2[0000-
0003-3079-5337], Andrew Todd3[0000-0002-2286-434X], and José Orlando Gomes4[0000-0001-6838-
714X]
1 Center for Ergonomics, Department of Industrial & Operations Engineering, University of
Michigan, Ann Arbor, MI 48109-2117, USA
crdsouza@umich.edu
2 Department of Biological, Environmental & Occupational Health Sciences, School of Public
Health, University of Ghana; P.O. Box LG13, Accra, Ghana
3 Department of Human Kinetics and Ergonomics, Rhodes University, Grahamstown, South
Africa
4 Department of Industrial Engineering, Federal University of Rio de Janeiro, Rio de Janeiro,
Brazil
Abstract. Unstructured and unregulated work is expanding fast among low-
and middle-income countries (LMICs). Furthermore, accumulation of urban
waste resulting from overconsumption is a global concern. Hence, waste man-
agement and recycling have received increased attention. One specific waste
category pertaining to electrical and electronic waste (e-waste) is growing at a
higher rate than other waste streams. Recycling of e-waste is largely informal
and disproportionately relies on LMICs, exposing workers to various occupa-
tional and environmental health risks. In order to promote safer work practices
and limit a broad range of occupational health and safety concerns associated
with informal manual work, the broader psychosocial and sociocultural envi-
ronment also deserves attention. This symposium will discuss contemporary is-
sues in informal, unregulated, unstructured work in LMICs, primarily in Africa
and South America. The goal of the symposium is to call attention to both, the
unique occupational context of informal work, and the need for new ergonom-
ics methods to address occupational exposure assessment and musculoskeletal
injury prevention adapted to informal work in limited resource settings.
Keywords: Electronic Waste, Informal Work, LMIC, Musculoskeletal Disor-
ders, Exposure Assessment.
1 Introduction
The ILO estimates that nearly two billion people, or about 61% of the world’s em-
ployed population, make their living in the informal economy [1]. Particularly notable
is that LMICs and emerging countries employ 93% of the world’s informal worker

2
population. The informal sector makes up 85.8% of employment in Africa compared
to 25.1% in Europe [1].
Informal work is characterized by work conducted in unstructured and unregulated
conditions, and is typically based on casual employment, kinship or personal and
social relations rather than contractual arrangements with formal guarantees. This
implies a lack of social protection, worker rights and decent working conditions. Spe-
cific to human factors and ergonomics (HF/E), this also means that informal work has
little to no implementation of occupational health and safety (OHS) guidelines. Con-
sequently, informal workers are exposed to significant risk for adverse health effects,
including acute injuries, musculoskeletal disorders (MSDs) from cumulative trauma,
and work disability through poor working conditions and environments.
1.1 Informal Waste Processing
Accumulation of urban waste resulting from overconsumption is a global concern.
Informal workers mostly perform the collection, processing and recycling of urban
waste in LMICs. This is a source of livelihood for low skill, low-wage workers [2].
Waste from used electrical and electronic equipment, commonly known as e-waste,
is growing at a higher rate than the regular municipal waste streams. High demand
and overconsumption of electronic and electrical appliances (e.g., computers, cell-
phones) has created a global crisis in e-waste management [3]. Globally, generation
of e-waste in 2019 was 53.6 million tons (MT) and projected to reach 74.7MT by
2030 [3]. Recycling of e-waste disproportionately relies on LMICs [4,3]. Vast
amounts of e-waste from Europe and North America make their way into LMICs each
year disguised as donations that end up at dumpsites [3,4]. E-waste processing in
LMICs is almost exclusively informal and conducted by low-skilled workers, with
little attention to OHS practices, e.g., PPE use, proper work tools and/or workstations
[2,5,6].
1.2 Goals of this Symposium
The goal of this symposium is to call attention to both, the unique occupational con-
text of informal work, and the need for new ergonomics methods to address occupa-
tional exposure assessment and MSD prevention adapted to informal work in limited
resource settings. The symposium will discuss contemporary issues in informal, un-
regulated, unstructured work in LMICs, primarily in Africa and South America.
The specific objectives of the symposium are to:
 Discuss specific examples and lessons from first-hand experience of conducting
research with informal e-waste processing in Ghana, and waste collection in
South Africa as case examples.
 Present the contextual factors that pose unique challenges to conducting ergo-
nomic research in unstructured, informal work settings,
 Identify research needs and knowledge gaps related to MSD risk assessment and
injury prevention specific to informal worker populations in LMICs.

3
2 Methodology
2.1 Overview of the Interdisciplinary Panel
This symposium brings together an interdisciplinary panel of researchers. The sympo-
sium organizers, Profs. Clive D’Souza and Bernard Martin are experienced in the
field of occupational ergonomics, assessment of physical work exposures, and MSD
prevention. Prof. Julius Fobil is an expert in environmental epidemiology, the expo-
sure assessment, surveillance and control of environmental pollution, waste manage-
ment research in LMICs, and co-leads the West Africa-Michigan CHARTER II for
GEOHealth. Mr. Andrew Todd is a senior lecturer and experienced in embedding
HF/E research within real-world contexts to ensure validity of findings. His particular
focus is on the informal economy in South Africa, with an emphasis on understanding
waste pickers and the challenges faced in their work. Prof. José Orlando Gomes con-
ducts research on ergonomic work analyses in the wild/real-world in several domains
including complex systems, with a particular focus on methodology oriented to reduc-
ing the gap between work-as-imagined versus work-as-done.
2.2 Informal, Unstructured Work Settings
A growing number of studies call attention to the musculoskeletal health effects of
informal, unstructured work encountered in manual processing/recycling of municipal
solid waste, medical waste, and e-waste. The informal waste processing sector is
plagued by high rates of MSD symptoms, particularly in the low back, shoulders,
neck, and knees [7]. A survey of 340 solid waste collectors (e.g., sweepers, garbage
collectors, garbage van and tricycle drivers) in Accra, Ghana found high pain preva-
lence in the back (73.5%), wrist (48.2%) and neck (44.7%), with 80 to 90 % of the
respondents developing pain symptoms subsequent to joining their current job [8].
Studies from India, Egypt, Colombia, Philippines, and Iran indicate similar MSD
trends among urban waste workers [7-9]. These studies also identify potential risk
factors including heavy material handling (e.g., lifting, carrying, pushing-pulling),
bending and repetitive tasks, and prolonged sitting and standing, environmental fac-
tors (e.g., heat, harsh outdoor conditions), personal factors (e.g., low literacy, smok-
ing, drug use) and psychosocial factors (e.g., work stress, poor job security) [7].
Case Example: Informal E-Waste Processing in Ghana: Agbogbloshie is the larg-
est dumping grounds for e-waste in sub-Saharan Africa and among the busiest infor-
mal e-waste recycling sites in the world [4,3]. Multiple recent studies conducted at
Agbogbloshie report high rates of work-related MSD symptoms, e.g., chronic body
pain, discomfort, from informal e-waste recycling [6,5,10]. Studies on e-waste work-
ers in other LMICs suggest similar trends [11,12]. Studies also report high rates
(96%) of acute injuries e.g., cuts, lacerations, and scars among e-waste workers [10].
Most e-waste workers in Ghana are young, typically between 14 to 40 years old.
They regularly work between 10 to 12 hours per day or 300 to 360 hours per month,
[5,4]. Work continues every day of the week, with workers taking either Fridays or

4
Sundays off based on religious affiliation [13,6]. These conditions suggest limited
rest/recovery, increased cumulative fatigue and MSD risk. Not surprisingly, workers
at this dumpsite have a short work tenure (i.e., high turnover) of 3 to 7 years [4].
E-waste workers at Agbogbloshie also self-medicate on painkillers, traditional
medications, and other substances (e.g., smoking cannabis) to treat body pain
[5,14,10]. Overuse or abuse of such treatments may potentially mask symptoms of
underlying work-related MSDs reported in some studies.
The majority of studies on exposure assessment in the informal waste sector are
based either on observational or self-reported data. Observational methods used in
ergonomics are mostly suited to repetitive jobs with structured sampling. Adaptive
sampling methods suited to informal work settings are few [13]. Body-worn video
cameras are another option, but labor intensive to code video and/or image stills, may
not capture all of the relevant work methods (e.g., hand tools) and body postures, and
potential privacy concerns. Understanding cause-effect relationships between expo-
sures and MSD causation from informal work needs prospective studies, however,
these methods require extensive resources and trained personnel – which is scarce.
Informal waste recycling worksites present challenges to research, such as difficul-
ties in collecting work-related, time-varying, job-specific exposure data and guide the
design of locally-adapted strategies for injury prevention. Overcoming these research
challenges will require new ergonomics perspectives, exposure assessment tools and
methods suited to informal work settings.
2.3 The Big Picture: Effects on Environmental Health
Lessons learnt from the GEO-Health Project include the many studies conducted as-
sessing health effects of exposure to particulate matter, rare metals and toxic chemi-
cals associated with informal e-waste processing in Ghana and other countries in Af-
rica [6,14,10]. Some key findings include:
 High levels of particulate matter affecting lung function and respiratory ailments
 Traces of aluminum, copper, iron, lead, and zinc in soil and/or air samples
 Toxic chemicals in the soil and vegetables resulting in non-communicable diseases
 Cancer, asthma, neurodevelopmental conditions, obesity, and chronic diseases due
to noxious exposure in early childhood
 Restricted thyroid function, cellular expression and function, adverse neonatal out-
comes, changes in temperament and behavior.
Environmental health challenges within the informal sector economy are pervasive,
largely understudied and may require simple innovative methods for resolution com-
pared to the formal sector while amendable to the application of interdisciplinary
collaborations and broader systems approaches. The HF/E community could benefit
from learning about these research experiences in allied OHS professions in terms of
research methodology as well as identifying opportunities for taking a systems ap-
proach to OHS in the informal work sector.

5
2.4 Cultural Sensitivity, Trust and Community Embedded Research
Informal worker populations and stakeholder audiences can be very diverse in terms
of linguistic, cultural, and economical background. Researchers administering ques-
tionnaires may need to be fluent in multiple languages to provide explanations in the
local dialect to minimize translation errors and information loss. For example, in a
study with e-waste workers, questionnaires were administered in English, with expla-
nations given in Dagbani – the local dialect spoken by e-waste workers [13]. Similar-
ly, in the South African study on waste pickers, questionnaires needed translation
from English to isiXhosa. The lead researcher being a native English-speaker and
unable to speak isiXhosa necessitated use of translators. Significant barriers were
uncovered in translating ergonomics terminology into isiXhosa. Achieving consisten-
cy and reliability may need careful adaptation and piloting.
Certain worker groups in Africa still maintain a strong ethnic/tribal identity with a
hierarchical structure, tribal Chiefs and noblemen. Research conducted with such
worker populations requires approval and buy-in from tribal leaders. For example,
research conducted at the Agbogbloshie e-waste dumpsite was preceded by a durbar
(i.e., public gathering) with tribal leadership, representatives of the scrap dealers asso-
ciation, and available e-waste workers. The research team explained the study objec-
tives and procedures in order to obtain buy-in from local/tribal leaders [13].
In post-apartheid countries like South Africa, low wage informal worker popula-
tions still bear a distrust of white-majority academic institutions. The distrust may
stem from the long history of oppression and inequality [15]. Rhodes University
(where the current research was undertaken) was initially established as an “Oxford in
the bush” based on imperialistic western values [15]. Within this context there is need
for carefully consideration of ergonomics methods for assessing exposures and MSD
risk that rely on direct observations, video and/or photographs of workers and what
this means on the part of communities in relation to academic institutions. Research
with informal traders and waste pickers in South Africa reported reluctance to study
participation due to data privacy concerns, i.e., unsure of where the data would end up
and if it could be used against them at a later time [16]. These issues present challeng-
es to obtaining reliable and valid data on exposure to potential MSD risk factors, hin-
ders the embedding of researchers within the system, and impedes efforts to under-
stand work-as-done vs. work-as-described or work-as-imagined. This made it difficult
to gain a systemic understanding of the interactions leading to MSDs in waste pickers.
Stakeholder engagement is critical to conducting participatory research. Wilson
(2014) warned against the charlatans of manual handling research of the past who
took a narrow non-systems approach [17]. He contended “….a musculoskeletal disor-
ders (MSD) investigation or improvement which does not account for psychologi-
cal/emotional/social influences, on MSD causation or success of solutions, is not
properly E/HF” [17]. Accordingly, good ergonomics research requires a systems ap-
proach focused on understanding interactions holistically within context whilst ac-
knowledging emergence. To achieve this, Wilson (2014) argued an embedded ap-
proach as necessary, suggesting that any research not conducted “in the wild” should
not have a primary role in HF/E [17]. Engagement with stakeholders should focus not

6
just on external research goals but also align with internal objectives of the stakehold-
ers. Workplace interventions focused on worker safety but perceived as reducing
earnings/employment may get disused or abandoned. For example, adoption of a new-
ly introduced powered wire-stripper/shredder at Agbogbloshie to isolate metal from
insulated cables/wire required e-waste burners to fundamentally alter their work be-
haviors and overcome concerns of lower yield and decreased income – aspects that
relied on mutual trust. From a South African research perspective, a key lesson learnt
was to shift the focus from doing research on people to doing research with people.
This strongly aligns with principles of both sociotechnical systems theory and partici-
patory ergonomics that emphasize valuing all stakeholders within the system [18,19].
2.5 Ergonomics and the Global Divide
Outreach and communication strategies with informal worker populations need to
consider the context and purpose of the interaction. Informal workers may be hesitant
to seek information about safer working conditions due to language barriers and low
agency. Hence, outreach is critical. The design of communication products needs to
follow principles of plain language and effective design, writing, and translation.
Engagement of stakeholders such as community leaders and/or local health workers
can also benefit in translating and communicating OHS research into prevention prac-
tices. The HF/E community needs to develop innovative approaches for action-
oriented research and for disseminating case studies on the successes/failures of en-
gaging informal worker communities to prevent workplace injuries and illnesses.
The lack of trained HF/E researchers and practitioners also hampers research on
MSD causation and prevention. This spans formal and informal work settings, and
government and regulatory agencies. Lack of HF/E training opportunities, for stu-
dents in university curricula and for working professionals in government and indus-
try, often results in a limited use or even misuse/misapplication of HF/E methods,
analysis tools and workplace interventions borrowed from developed countries.
Cross-country collaborations and research partnerships can help to build capacity for
training-the-trainers in LMICs and address some of these gaps in HF/E education,
training and practice.
3 Conclusion
Informal waste workers face substantial risk from hazardous exposures and work
conditions. The high rates of MSDs and work disability among informal workers is
likely a confluence of multiple factors, including high physical work demands, young
worker population, long work hours, low literacy, polluted work environment, limited
PPE and work tools, and psychosocial stressors [13,5-7].
New ergonomics methods are required to address risk assessment and injury pre-
vention adapted to informal work in limited resource settings. The HF/E community
needs to foster international collaborations to help address some of the disproportion-
ate OHS burden experienced by workers in the informal sector, particularly in

7
LMICs. Interventions aimed at MSD prevention needs to consider the six key HF/E
components proposed by Wilson (2014), namely, a systems focus, concern for con-
text, interactions, holism, recognizing emergent properties, and embedded HF/E prac-
tice [17].
Acknowledgements
Symposium organizers C.D. and B.M. were partially supported by the training grant T42-
OH008455 from the National Institute for Occupational Safety and Health (NIOSH), US Cen-
ters for Disease Control and Prevention (CDC).
J.N.F. was supported by the 1⁄2 West Africa-Michigan CHARTER in GEOHealth with
funding from the US National Institutes of Health / Fogarty International Center (NIH/FIC)
(paired grant nos. 1U2RTW010110-01 and 5U01TW010101) and Canada’s International De-
velopment Research Center (IDRC; grant no. 108121-001).
The views expressed do not necessarily reflect the official policies of nor endorsement by
NIH, NIOSH, CDC, and/or the Canadian and US Governments.
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