Evaluation of occupational health and safety intervention for the waste and sanitation workers in Bangladesh during COVID-19

Abstract

Waste and sanitation workers in South-Asian countries are vulnerable to injuries and diseases, including COVID- 19. In Bangladesh, an intervention was implemented during COVID-19 to lower these workers’ occupational health risks through training and PPE distribution. We assessed how the intervention affected their occupational health behaviors using a randomized cluster trial in 10 Bangladeshi cities, including seven intervention and three control areas. We conducted 499 surveys (Control-152, Intervention-347) and 47 structured observations (Control:15, Intervention:32) at baseline and 499 surveys (Control:150, Intervention:349) and 50 structured observations (Control:15, Intervention:35) at endline. To evaluate the impact of intervention at the endline, we used the difference in difference (DID) method. Compared to control, workers from intervention areas were more likely to have increased knowledge of using/ maintaining PPEs (adjusted DID: 21%, CI: 8, 33), major COVID-19 transmission causes (adjusted DID: 27%, CI: 14, 40), and preventive measures (adjusted DID: 12%, CI: -0.6, 25), and improved attitude about using PPEs (adjusted DID: 36%, CI: 22, 49), washing PPEs (adjusted DID: 20%, CI: 8, 32). The intervention was more likely to improve workers’ self-reported practice of taking adequate precautions after getting back from work (adjusted DID: 37%, CI: 27, 47) and changing/cleaning masks every day (adjusted DID: 47%, CI: 0.03, 94), and observed practices of maintaining coughing etiquette (DID: 20%, CI: 0.2, 40) at workplace and handwashing before wearing PPEs (DID: 27%, CI: 2, 52), after finishing work (DID: 31%, CI: -7, 69) & during work intervals (DID: 30%, CI: -33, 93). There was not much improvement in observed practices of mask use (DID: 1%, CI: -40, 42), handwashing before meals (DID: 2%, CI: -61, 65), and after toilet (DID: 7%, CI: -41, 55). This intervention has improved the knowledge, attitude and practice of the workers about critical occupational risk mitigation, which may be replicated in similar settings. Future interventions need to address occupational health-related injuries and health complications, introduce regular health checkups/insurance for the workers, create a balance between the quality and comfort of the PPEs and ensure a mechanism to ensure a regular supply of PPEs.

Full text

International Journal of Hygiene and Environmental Health 255 (2024) 114288
1438-4639/© 2023 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Evaluation of occupational health and safety intervention for the waste and
sanitation workers in Bangladesh during COVID-19
Dewan Muhammad Shoaib
a
,
*
, Tanvir Ahmed
b
,
c
,
1
, Kazy Farhat Tabassum
a
, Mehedi Hasan
a
,
Fazle Sharior
a
, Mahbubur Rahman
a
, Make Farah
b
, Md Azizur Rahman
b
, Alauddin Ahmed
b
,
James B. Tidwell
d
,
e
, Mahbub-Ul Alam
a
,
f
a
Environmental Health and WASH, Health System and Population Studies Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka,
1212, Bangladesh
b
ITN-BUET Centre for Water Supply and Waste Management, BUET, Dhaka, 1000, Bangladesh
c
Department of Civil Engineering, BUET, Dhaka, 1000, Bangladesh
d
Harvard Kennedy School of Government, Cambridge, MA, 02138, USA
e
World Vision, Inc., Washington, DC, 20002, USA
f
School of Civil Engineering, University of Leeds, Leeds, LS2 9JT, United Kingdom
ARTICLE INFO
Keywords:
Evaluation
Waste and sanitation workers
Occupational health and safety
Use of PPE
COVID-19
ABSTRACT
Waste and sanitation workers in South-Asian countries are vulnerable to injuries and diseases, including COVID-
19. In Bangladesh, an intervention was implemented during COVID-19 to lower these workers’ occupational
health risks through training and PPE distribution.
We assessed how the intervention affected their occupational health behaviors using a randomized cluster trial
in 10 Bangladeshi cities, including seven intervention and three control areas. We conducted 499 surveys
(Control-152, Intervention-347) and 47 structured observations (Control:15, Intervention:32) at baseline and
499 surveys (Control:150, Intervention:349) and 50 structured observations (Control:15, Intervention:35) at
endline. To evaluate the impact of intervention at the endline, we used the difference in difference (DID) method.
Compared to control, workers from intervention areas were more likely to have increased knowledge of using/
maintaining PPEs (adjusted DID: 21%, CI: 8, 33), major COVID-19 transmission causes (adjusted DID: 27%, CI:
14, 40), and preventive measures (adjusted DID: 12%, CI: -0.6, 25), and improved attitude about using PPEs
(adjusted DID: 36%, CI: 22, 49), washing PPEs (adjusted DID: 20%, CI: 8, 32). The intervention was more likely
to improve workers’ self-reported practice of taking adequate precautions after getting back from work (adjusted
DID: 37%, CI: 27, 47) and changing/cleaning masks every day (adjusted DID: 47%, CI: 0.03, 94), and observed
practices of maintaining coughing etiquette (DID: 20%, CI: 0.2, 40) at workplace and handwashing before
wearing PPEs (DID: 27%, CI: 2, 52), after nishing work (DID: 31%, CI: -7, 69) & during work intervals (DID:
30%, CI: -33, 93). There was not much improvement in observed practices of mask use (DID: 1%, CI: -40, 42),
handwashing before meals (DID: 2%, CI: -61, 65), and after toilet (DID: 7%, CI: -41, 55).
This intervention has improved the knowledge, attitude and practice of the workers about critical occupational
risk mitigation, which may be replicated in similar settings. Future interventions need to address occupational
health-related injuries and health complications, introduce regular health checkups/insurance for the workers,
create a balance between the quality and comfort of the PPEs and ensure a mechanism to ensure a regular supply
of PPEs.
1. Introduction
The waste and sanitation workers in South Asian countries often face
vulnerability to various occupational injuries and diseases and are
nancially and culturally marginalized (Islam, 2016; World Bank, 2019;
WaterAid Bangladesh, 2020). Many workers live in overcrowded,
* Corresponding author.
E-mail addresses: shoaib.shuvo17@gmail.com, dshoaib@emory.edu (D.M. Shoaib).
1
Contributed equally to the rst author.
Contents lists available at ScienceDirect
International Journal of Hygiene and Environmental Health
journal homepage: www.elsevier.com/locate/ijheh
https://doi.org/10.1016/j.ijheh.2023.114288
Received 12 July 2023; Received in revised form 25 October 2023; Accepted 1 November 2023

International Journal of Hygiene and Environmental Health 255 (2024) 114288
2
resource-poor urban settings with unhygienic water and sanitation fa-
cilities, leading to diverse health problems (World Bank et al., 2019).
They also come across various hazardous compounds and toxic gases at
their workplace, putting them at risk for multiple health issues such as
respiratory disorders, skin diseases, infectious diseases, musculoskeletal
disorders, injuries, and even death (Center for Water and sanitation, C.,
CEPT University, 2020; Oza, 2022; SNV, 2017). Like many
low-and-middle-income countries (LMICs), waste and sanitation
workers in Bangladesh handle waste without using any personal pro-
tective equipment (PPEs), increasing their susceptibility to injuries and
diseases (Black, 2019; World Bank, 2019; WaterAid Bangladesh, 2020).
The workers lack formal training on occupational health and safety,
have insufcient knowledge about their health risks, and rarely take
adequate safety measures at the workplace (Asibey et al., 2019; Degavi,
2021; Sharior, 2023; World Bank, 2019).
The COVID-19 pandemic has become a burden for their existing
occupational health situation. Although the waste and sanitation
workers served as the frontline workers during the pandemic, they
became the overlooked group for COVID-19-specic training, support,
and protective equipment distribution (Hoque, 2020; Mahase, 2021;
WaterAid, 2021). Approximately 40% of sanitation workers in South
Asian countries, including Bangladesh, Nepal, India, and Pakistan, re-
ported not having handwashing stations in their workplace, which
resulted in inconsistent handwashing practices during COVID-19
(WaterAid, 2021; WaterAid Bangladesh, 2020). Around 33% of the
waste workers in Nepal did not receive any PPEs during COVID-19
(WaterAid, 2021). In India, roughly two-thirds of sanitation workers
have not received COVID-19 prevention-related instructions or training
to ensure workplace safety (Nigam et al., 2020). Moreover, around 80%
of waste workers perceive that they are at risk of getting infected with
COVID-19 because of their job nature. Medical waste handlers are at the
highest risk, with around 61% considering themselves highly susceptible
to COVID-19 (WaterAid, 2020).
Bangladesh is one of the hotspots of COVID-19, with 1,699,964
positive tested cases and 28,238 reported deaths till 25 January 2022
(WHO, 2022). A previous study in Bangladesh showed that around 50%
of the waste and sanitation workers and their family members experi-
enced symptoms related to COVID-19 (Hoque, 2020). Since the waste
and sanitation workers work in people’s homes, highways, healthcare
facilities, and other institutions, they are exposed to infection and the
chance of spreading the disease through them is high (WaterAid
Bangladesh, 2020). Inadequate PPEs with a lack of standard operating
guidelines, the lack of hygiene knowledge and occupational health
safety training, and insufcient hygiene facilities at the workplace have
long been the leading causes of the high burden of infections among
workers (FANSA and WSSCC, 2015; Hoque, 2020; WaterAid, 2020;
World Bank, 2019; Zaqout, 2020). Therefore, it is necessary to ensure
the safety of waste and sanitation workers and their families to mitigate
the risk of spreading any infection, especially COVID-19 (WaterAid,
2021; WaterAid Bangladesh, 2020).
To address the issue and ensure the occupational health and safety of
the workers, the Department of Public Health Engineering Bangladesh,
in collaboration with the International Training Network Centre of
Bangladesh University of Engineering and Technology (ITN-BUET),
provided a capacity-building intervention considering their occupa-
tional health and safety (OHS), and infection prevention and control
(IPC). The intervention included PPE delivery to the workers to ensure
PPE use and training to enhance their personal and occupational safety
management behaviour.
While the high risk of infection and diseases among waste and
sanitation workers and the recommendations for interventions have
been identied through several studies in different LMIC settings (Alam,
2022; Oza, 2022; Ramitha, 2023; Sharior, 2023; Ye, 2022), very few
studies looked at evaluating the specic interventions to see whether the
interventions work and in which areas they work and where they do not.
Few studies that evaluated interventions were specically focused on
medical waste handlers in hospital settings (Elnour, 2015; Hosny et al.,
2018; Tabash, 2016) and largely missed other types of waste and sani-
tation workers. In Egypt, one such intervention (including education and
skill training) was evaluated, which improved waste
management-related knowledge attitude and practice of the medical
waste handlers (Hosny et al., 2018). In India, another educational
intervention signicantly improved the waste management knowledge
of nursing and sanitation staff (Elnour et al., 2015). During COVID-19,
the Bangladesh government took several initiatives (including
providing safety equipment, infrastructure repairment, instructions on
adhering to the guidelines, and monitoring of the waste management
system) to ensure OHS of the waste and sanitation workers across all 64
districts of Bangladesh (Department of Public Health Engineering) but
we do not know how well those initiatives worked. This scenario is also
true for most of the LMICs where we do not know whether the in-
terventions (both before and during COVID-19) are adequate to ensure
the OHS of the workers and where we need more attention. Evaluating
the intervention would allow us to understand the areas that need to be
improved and tailor the intervention based on evidence, which would
ultimately help in reducing intervention delivery costs, and improve the
sustainability of the intervention. Thus, the objective of our study was to
evaluate the effect of the intervention on occupational health
safety-related knowledge, attitude, and practice of the waste and sani-
tation workers in selected study sites.
2. Material and methods
2.1. Study design and site selection
We conducted a randomized cluster trial with a baseline study
(Alam, 2021, 2022) before and an endline study after the intervention in
10 cities of Bangladesh that included three city corporations and seven
municipalities. A city corporation is an autonomous governing entity of
a local government structure connected with the state government
through the district administration. A municipality is an administrative
body of local government directly connected with and governed by the
state government. Bangladesh has 12 city corporations and 329 mu-
nicipalities (Star Online Report, 2018; LGED. About LGIs, 2018). Among
the ten cities that we selected, seven were intervention areas with two
City Corporations (Mymensingh City Corporation and Cumilla City
Corporation) and ve Municipalities (Satkhira Municipality, Laksham
Municipality, Cox’s Bazar Municipality, Moulvibazar Municipality, and
Bhola Municipality), and three were control areas with one City Cor-
poration (Rangpur City Corporation) and two Municipalities (Sirajganj
Municipality, and Manikgonj Municipality). We selected the seven
intervention areas purposively from the 14 areas (3 City Corporations
and 11 Municipalities) where ITN-BUET, CWIS-FSM support sell, and
Department of Public Health Engineering (DPHE) provided the inter-
vention considering the diversity of geographical locations. The three
control areas were selected purposively considering the similarities in
socio-economical and geographic characteristics of much of the inter-
vention areas. The selected areas also ensured representation from all
the divisions of Bangladesh (Table 1).
2.2. Population group selection
We reached ve types of frontline waste and sanitation workers in
the study: septic tank/pit emptiers, solid waste collectors, drain
cleaners, road sweepers, and medical waste handlers. As the workers
were involved in more than one job at a time (e.g., the pit emptier was
also engaged in drain cleaning), we categorized them based on their
level of involvement. For instance, we selected them as road sweepers if
the workers were primarily involved in sweeping while other tasks were
secondary. We reached both listed workers (listed in the city ofces as
waste and sanitation workers) and non-listed workers (working indi-
vidually/informally/for private organizations) from both control and
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
3
intervention areas.
2.3. Sample size calculation
We estimated the sample size based on the prevalence of 22% of the
waste and sanitation workers who did not maintain hygiene practices at
their workplaces and expected a 12% improvement in hygiene practices
(WaterAid, 2021) among the workers as an effect of the intervention
compared to the control areas. To estimate the required sample size, a
two-independent sample test of equity of proportions (Chow et al.,
2017) was carried out with the consideration of a ratio of 0.4 of the
control group size to the intervention group size since, in our study, 7 of
the ten localities were intervention regions and 3 were control areas.
Therefore, according to the sample size calculation, we need 339
workers from the intervention areas and 136 from the control areas after
adjusting for the 15% non-response rate. Thus, a total sample of 475
workers was needed for both groups to achieve 80% power at a 0.05
signicance level.
2.4. Baseline and endline data collection
The eld enumerators collected data at baseline (pre-intervention)
and endline (post-intervention) through surveys and structured obser-
vations in both intervention and control areas. Before initiating the data
collection, the eld enumerators collected the lists of waste and sani-
tation workers ofcially enlisted under the City Corporation and Mu-
nicipalities in the selected study areas. Then, they estimated the total
number of workers who were not enlisted (informal workers) but were
working at the frontline as waste and sanitation workers by discussing
with respective authorities and the enlisted workers. After that, they
compared it with the number of listed workers and reached the partic-
ipants based on population proportion to size (listed vs. non-listed) in
each area. The listed workers were selected randomly from the list
collected from city ofces for the survey, and the non-listed workers
were selected using snowball sampling. The observation participants
were selected purposively from the survey participants, considering the
diversity of the age-gender group and work type.
The eld enumerators conducted face-to-face interviews and struc-
tured observations. For the observation, the enumerators accompanied/
reached the workers at their workplace and stayed with them during
work. Field enumerators collected the baseline data from 20 October
2020 to 15 November 2020 and the endline data from 30 June 2021 to
05 August 2021, roughly after one month of intervention provision.
2.5. Intervention delivery
The intervention reached the selected cities’ workers from December
2020 to May 2021. Thirty-ve master trainers (experts in waste man-
agement program and research, WASH, and behavior change pro-
fessionals) were recruited, who organized a two-day online training of
trainers (ToT) sessions (4 hours a day) for the 381 city-level trainers
(city ofcials involved in waste and sanitation management in the city
corporations and municipalities) from each intervention area. After
completion of ToT, ITN-BUET delivered the intervention to 4900
frontline waste and sanitation workers through the city ofcials that
received the ToT. The intervention contained a 4-hour face-to-face
training session, PPE distribution involving DPHE, and a practical
demonstration of properly using PPEs. The training contained topics on
how infectious diseases (especially COVID-19) spread and the necessary
measures to tackle them. A particular emphasis is given on handwash-
ing, how to disinfect themselves and their equipment after work, what
the workers can do if they get infected with infectious diseases, and how
to use PPEs with practical demonstration and practice about properly
wearing them (ITN-BUET, 2021). Each training participant received a
guideline (developed with pictures and visualizations to make it easily
understandable) on maintaining OHS and IPC (ITN-BUET, 2020). The
PPEs delivered to the workers (face masks, hand gloves, goggles, safety
shoes, safety gumboot, safety helmet, apron, and reective jacket) were
considered based on their work types. For instance, drain cleaners
received only masks, gloves, goggles, safety gumboots, and reective
jackets as they needed these PPEs only.
2.6. Outcome variable
The primary outcome variable of this study is the practice of the
workers in using and cleaning PPEs and masks. The secondary outcome
variables included the workers’ knowledge, attitude and practice
regarding key COVID-19 preventive and workplace safety measures.
2.7. Data analysis
Descriptive statistics of the waste and sanitation workers’ socio-
demographic characteristics were computed for the baseline, endline
period, and their underlying intervention and control group and sum-
marized in tables comparing study arms. Then, a balance test is con-
ducted to assess for any differences in the socio-demographic
characteristics of the respondents between the treatment and control
groups at baseline. We calculated proportions for categorical variables,
means for symmetric continuous variables and medians for skewed
continuous variables to test for these differences. Then, we performed a
chi-squared test of homogeneity to compare the difference of pro-
portions for categorical variables, a two-sample t-test was performed to
test the difference in means for continuous variables, and quantile
regression was used to test the equality of medians between the inter-
vention and control group. To evaluate the impact of the intervention at
the endline, we used the difference in difference (DID) method. We
assessed the parallel trend assumption through visual inspection of the
line graph for the intervention and control group over the pre and post-
Table 1
Study areas based on control and intervention group.
Group Areas Areas that received
the intervention
Purposively Selected
study areas
Intervention
Areas
City
Corporation
1. Mymensingh City
Corporation
2. Rangpur City
Corporation
3. Comilla City
Corporation
1. Mymensingh City
Corporation
2. Comilla City
Corporation
Municipalities 4. Lakhsmipur
Municipality
5. Satkhira
Municipality
6. Mongla
Municipality
7. Cox’s Bazar
Municipality
8. Moulvibazar
Municipality
9. Munshiganj
Municipality
10. Bhola
Municipality
11. Patuakhali
Municipality
12. Laksam
Municipality
13. Ishwardi
Municipality
14. Sakhipur
Municipality
3. Satkhira
Municipality
4. Cox’s Bazar
Municipality
5. Moulvibazar
Municipality
6. Bhola
Municipality
7. Laksam
Municipality
Control Areas City
Corporation
N/A 8. Rangpur City
Corporation
Municipalities N/A 9. Sirajganj
Municipality
10. Manikgonj
Municipality
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
4
intervention period, which illustrated no time-varying difference be-
tween the intervention and control groups. We used a logistic regression
model to assess the impact of the intervention on the binary outcome
measures. And we t a generalized linear model with an identity link to
obtain the DID estimates for those variables exhibiting separation and
multicollinearity problems. The average marginal effects of these
models are reported for ease of interpretation. DID estimates with 95%
condence intervals (CI) to test post-versus pre-intervention imple-
mentation changes between the intervention and control groups. We
have adjusted the regression models with the covariate’s education,
religion, caste, accommodation, and monthly income of the re-
spondents, which showed a signicant difference at baseline between
intervention and control groups. All the variables are considered sta-
tistically signicant at p <0.5.
2.8. Ethical considerations
The study participants went through an informed consent process.
During data collection, our eld staff maintained the government-
guided COVID-19 prevention measures (e.g., mask use and social
distancing). The study protocol received ethical approval from the ITN-
BUET ethical review panel.
3. Results
3.1. Socio-demographic characteristics of the respondents
The data collectors conducted 499 surveys (Control:152; Interven-
tion:347) and 47 structured observations (Control:15; Intervention:32)
in baseline, 499 surveys (Control:150; Intervention:349), and 50 struc-
tured observations (Control:15; Intervention:35) in endline with the ve
types of frontline waste and sanitation workers.
Participants from the intervention and control areas in both baseline
and endline had similar socio-demographic characteristics regarding
gender, age, religion, education, income, and accommodation facilities.
Female workers were mostly involved only in road sweeping; thus, most
of the workers we reached were male. Around half were Muslims, and
the remaining half were Hindus (mostly Harijan/Dalit caste). We found
the highest numbers of workers between the ages of 20 and 40. Most
workers could write their names or have completed only primary edu-
cation. They mostly lived in rented houses or government-provided
accommodation facilities with an average monthly income
Table 2
Socio-demographic characteristics of waste and sanitation workers.
Indicators Baseline Endline
Intervention n (%)
N =347
Control n (%)
N =152
Difference (p-
value)
Intervention n (%)
N =349
Control n (%)
N =150
Difference (p-
value)
Work type
Septic tank/Pit-emptier 51 (15) 25 (16) −1 (0.617) 80 (23) 31 (21) 2 (0.578)
Solid waste collector 118 (34) 55 (36) −2 (0.638) 142 (41) 52 (35) 6 (0.206)
Drain cleaner 89 (26) 40 (26) 0 (0.875) 123 (35) 39 (26) 9 (0.043)
Road sweeper 131 (38) 43 (28) 10 (0.041) 138 (40) 36 (24) 16 (0.001)
Medical waste handler 58 (17) 20 (13) 4 (0.314) 58 (17) 30 (20) −3 (0.364)
Respondent’s gender
Male 285 (82) 118 (78) 4 (0.240) 279 (80) 125 (83) 3 (0.376)
Female 62 (18) 34 (22) −4 70 (20) 25 (17) 3
Respondent’s age
<20 15 (4) 14 (9) −5 (0.086) 15 (4) 7 (5) −1 (0.341)
20–30 136 (39) 48 (32) 7 144 (41) 47 (31) 10
31–40 103 (30) 39 (26) 4 97 (28) 51 (34) −6
41–50 58 (17) 30 (20) −3 45 (13) 26 (17) −4
51–60 22 (6) 16 (10) −4 32 (9) 13 (9) 0
>60 13 (4) 5 (3) 1 16 (5) 6 (4) 1
Respondent’s age
Mean (±SD) 35 (12.18) 37 (13.37) −1.2 (0.242) 35 (12.23) 37 (12.39) 0 (0.112)
Respondent’s religion
Islam 186 (54) 64 (42) 12 (0.014) 192 (55) 75 (50) 5 (0.530)
Hinduism 161 (46) 87 (57) −11 156 (45) 75 (50) −5
Other 0 (0) 1 (0.66) −1 1 (0.29) 0 (0) 0.3
Respondent’s caste
Harijan/Dalit 123 (35) 85 (56) −21 (0.000) 139 (40) 74 (49) −9 (0.049)
Others 224 (65) 67 (44) 21 210 (60) 76 (51) 9
Respondent’s Education
No formal education 50 (14) 31 (20) −6 (0.001) 64 (18) 19 (13) 5 (0.000)
Can sign only 128 (37) 30 (20) 17 129 (37) 77 (51) −14
1-8th class 150 (43) 76 (50) −7 146 (42) 38 (25) 17
Above 8th class 19 (5.48) 15 (9.87) −4 10 (2.87) 16 (11) −8
Household members
less or equal 2 members 9 (2) 10 (6) −4 (0.197) 12 (4) 7 (5) −1 (0.259)
3-5 members 202 (58) 83 (55) 3 210 (60) 98 (65) −5
6-7 members 89 (26) 38 (25) 1 81 (23) 34 (23) 0
More than 7 members 47 (14) 21 (14) 0 46 (13) 11 (7) 6
Accommodation
Government facilities 122 (35) 85 (56) −21(0.000) 126 (36) 53 (35) 1(0.000)
Non-Government facilities 3 (1) 1 (1) 0 10 (3) 0 (0) 3
Own facilities 68 (20) 42 (27) −7 67 (19) 56 (37) −18
Rent 153 (44) 21 (14) 30 128 (37) 40 (27) 10
Other 1 (0.29) 3 (2) −2 18 (5) 1 (1) 4
Monthly income (BDT)
Mean (±SD) 8881 (4847.83) 7179 (5918.91) −1071 (0.002) 7966 (4768.15) 7143 (4633.87) 134 (0.033)
Workers trained in occupational health safety 70 (20) 29 (19) 1 (0.778) 305 (87) 19 (13) 74 (0.000)
Workers trained on PPE use 51 (15) 21 (14) 1 (0.796) 305 (87) 3 (2) 85 (0.000)
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
5
(individual) of 7000–9000 BDT (82–105 USD). The baseline status of the
respondents in receiving OHS training, availability of safety guidelines,
and training on PPE were also similar in intervention and control areas,
which then improved in the intervention areas at the endline (Table 2).
3.2. Effect on the knowledge and attitude of the workers
Compared to the control areas, the workers from intervention areas
were more likely to have improved knowledge regarding the availability
of occupational health and safety guidelines (adjusted DID: 57%, CI: 44,
69), the importance of using and maintaining protective equipment
(adjusted DID: 21%, CI: 8, 33), the concept of communicable diseases
(adjusted DID: 13%, CI: 0, 26), the signicant causes of COVID-19
transmission (adjusted DID: 27%, CI: 14, 40), and key COVID-19 pre-
ventive measures (adjusted DID: 12%, CI: −0.6, 25). A particular posi-
tive association is seen between the intervention and the improved
knowledge in the intervention areas on used utensils (adjusted DID:
22%, CI: 12, 32) and social gathering (adjusted DID: 24%, CI: 11, 37) as
means of COVID-19 transmission, and using goggles (adjusted DID:
10%, CI: 2, 18) and maintaining social distancing (adjusted DID: 22%,
CI: 9, 35) as key COVID-19 preventive measures. Despite showing
improvement in knowledge among the workers in the endline inter-
vention areas, understanding coughing (adjusted DID: −12%, CI: −21,
−3), sneezing (adjusted DID: −3%, CI: −14, 8), and spittle (adjusted
DID: 5%, CI: −7, 17) as major COVID-19 spread mechanisms, and
knowledge to avoid touching nose, eyes, and mouth with unclean hands
(adjusted DID: −1%, CI: −13, 11), maintaining coughing etiquette
(adjusted DID: −11%, CI: −20, −2), and vaccination (adjusted DID: 2%,
CI: −2, 6) as important COVID-19 prevention measure are less likely to
be associated with the intervention provision because a similar change is
also seen in endline control areas. Workers’ understanding about
considering air (adjusted DID: −24%, CI: −36, −12) and water (adjusted
DID: −22%, CI: −36, −8) as means to spread communicable to did not
improve while their knowledge of considering touch as a means to
spread communicable diseases improved (adjusted DID: 16%, CI: −1,
33) (although this was not statistically signicant). Moreover, the
intervention seems to have no effect in changing the workers’ knowl-
edge of wearing face masks, gloves, and handwashing as COVID-19
preventive measures. Similarly, the slight improvements in knowledge
of the workers from the intervention areas in properly understanding the
terms social distancing (adjusted DID: 4%, CI: −8, 16), quarantine
(adjusted DID: 3%, CI: −20, 26), and isolation (adjusted DID: 5%, CI:
−31, 41) than the workers from control areas seems to have less asso-
ciation with the intervention.
Workers’ improved attitude towards using PPEs (adjusted DID: 36%,
CI: 22, 49), washing PPEs (adjusted DID: 20%, CI: 8, 32), cleaning
working equipment regularly (adjusted DID: 20%, CI: 7, 33), and
keeping open sores, cuts, and wounds covered with clean, dry band-aids
(adjusted DID: 13%, CI: 2, 24) can be attributed to the impact of the
intervention. Their attitude towards handwashing before and after using
toilets (adjusted DID: 9%, CI: −3, 22) and taking meals (adjusted DID:
−4%, CI: −18, 9) seems to be less associated with the intervention. The
intervention also did not improve workers’ perception towards consid-
ering cleaning equipment using anti-germ products (adjusted DID: −7%,
CI: −15, 0.7). On the other hand, a signicantly improved percentage of
workers at endline intervention areas reported that they believe OHS
interventions can reduce health risks at the workplace (adjusted DID:
58%, CI: 26, 89), which is more likely to be contributed as a resulting
factor of the intervention (Table 3)
3.3. Effect on workers’ reported practice of maintaining OHS measures
3.3.1. Reported practice
A noticeable improvement was seen in the practice of taking
adequate precautions by the workers after returning home from work
(adjusted DID: 37%, CI: 27, 47), which seems to have resulted from the
intervention. Necessary precautions like keeping distance from family
members before cleaning (adjusted DID: 22%, CI: 9, 35), washing hands
rst (adjusted DID: 39%, CI: 26, 52), and washing clothes (adjusted DID:
31%, CI: 18, 46) after returning home appear to be more associated with
the intervention. The availability of PPEs was highly improved in
intervention areas after the intervention provision. However, the use of
PPEs among the workers who had PPEs available such as face masks
(adjusted DID: −1%, CI: −10, 8), hand gloves (adjusted DID: −4%, CI:
−17, 9), gumboot (adjusted DID: −1%, CI: −13, 11), and apron
(adjusted DID: −6%, CI: −38, 26) stayed similar in both intervention
areas and control areas. The common problems with PPEs that the
workers faced were suffocation, heat and sweat, and unt sizes. The
intervention did not signicantly affect their proper PPE disposal prac-
tices (adjusted DID: 2%, CI: −16, 20). Workers’ reported improved
practices of changing/cleaning masks every day (adjusted DID: 47%, CI:
0.03, 94), cleaning working equipment regularly (adjusted DID: 26%,
CI: 17, 35), wearing PPEs while cleaning waste management vehicles
(adjusted DID: 26%, CI: 17, 35) appear to be highly associated with the
intervention (Table 4).
3.3.2. Observed practice
The intervention appears to have improved the handwashing prac-
tices of the workers before wearing PPEs (DID: 27%, CI: 2, 52), after
nishing work (DID: 31%, CI: −7, 69) and during work intervals (DID:
30%, CI: −33, 93). However, it did not improve the adherence to proper
handwashing protocols (DID: 22%, CI: −42, 86) and handwashing
practices before having snacks/meals (DID: 2%, CI: −61, 65), and after
using the toilet (DID: 7%, CI: −41, 55). Workers’ improved practices of
maintaining COVID-19 prevention measures such as coughing etiquette
(DID: 20%, CI: 0.2, 40), not sharing while smoking or drinking (DID:
11%, CI: −27, 49), maintaining social distance at the workplace (DID:
13%, CI: −19, 46), handwashing before touching face (DID: 31%, CI: 8,
54) were more likely to have positive associations with the intervention.
while, although improved in endline intervention areas, the practice of
mask use (DID: 1%, CI: −40, 42) was less likely to be associated. The
intervention might have improved the practices of cleaning equipment
after work (DID: 9%, CI: −8, 26) but did not improve the practice of
disinfecting the equipment (DID: −14%, CI: −34, 6) by the workers.
Also, the observed practices of the workers in keeping waste in desig-
nated places seemed to be motivated by the intervention (DID: 9%, CI:
−8, 26) (Table 5).
4. Suggestions to improve OHS situation
The main demands from the workers were to increase their OHS-
related measures in both baseline and endline. These included getting
free medical facilities (Intervention-baseline: 55%, endline: 74%;
control-baseline: 49%, endline: 56%) or health insurance (Intervention-
baseline: 16%, endline: 27%; control-baseline: 3.95%, endline: 15%),
receiving a regular and increased supply of PPEs (Intervention-baseline:
35%, endline: 43%; control-baseline: 46%, endline: 45%), and having
the opportunity to use upgraded waste and sanitation management
technologies (Intervention-baseline: 23%, endline: 20%; control-
baseline: 20%, endline: 23%) (Table 6)
5. Discussion
We conducted the study to understand the effect of an occupational
health safety intervention on the waste and sanitation workers in
Bangladesh. We found that the intervention improved workers’ knowl-
edge of communicable diseases, including the key COVID-19 trans-
mission and prevention components, their understanding of the
importance of using and maintaining PPEs, and workers’ attitudes to-
ward using and washing PPEs and work equipment. The intervention
also improved workers’ practice of regularly changing/cleaning masks
and equipment, maintaining hygiene after returning home from work,
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
6
Table 3
Knowledge and attitude of the workers on maintaining occupational health and safety.
Indicators Intervention Control DID (95%
CI)
Adjusted DID
(95% CI)
Baseline n
(%)
N =347
End line
n (%)
N =349
Difference
(95% CI)
Baseline n
(%)
N =152
End line
n (%)
N =150
Difference
(95% CI)
Workers know about the availability of occupational
health safety guidelines
104 (30) 264 (76) 45 (39, 51) 63 (41) 44 (29) −12 (−23,
−1)
57 (45,
69)
57 (44, 69)
Know about the importance of using and maintaining
PPEs
211 (61) 323 (93) 32 (26, 38) 82 (54) 93 (62) 8 (−3, 19) 24 (11,
37)
21 (8, 33)
Know about communicable diseases 169 (49) 253 (73) 24 (17, 31) 82 (54) 97 (65) 11 (−0.2, 21) 13 (0,
26)
16 (3, 29)
Know how communicable diseases spread N¼169 N¼253 N¼82 N¼97
Through air 150 (89) 234 (92) 3 (−2, 8) 64 (78) 96 (99) 21 (12, 30) ¡17
(-28, -6)
¡24 (-36,
-12)
Through water 71 (42) 116 (46) 4 (−5, 13) 7 (8.54) 44 (45) 36 (25, 48) ¡32
(-48, -16)
¡22 (-36,
-8)
Through touch 105 (62) 205 (81) 19 (10, 28) 49 (60) 63 (65) 5 (−9, 19) 14 (−3,
31)
16 (−1, 33)
Through vectors 21 (12) 22 (8.7) −3 (−9, 2) 2 (2.44) 1 (1.03) −1 (−5, 2) −2 (−9,
5)
−3 (−10, 4)
Don’t know 2 (1.18) 0 (0) −1 (−4, 2) 16 (20) 2 (2.06) −17 (−22,
−12)
16 (10,
22)
16 (10, 22)
Workers’ knowledge of how COVID-19 spread
Coughing 306 (88) 327 (94) 6 (1, 11) 118 (78) 143 (95) 18 (10, 25) ¡12
(-21, -3)
¡12 (-21,
-3)
Sneezing 253 (73) 309 (89) 15 (9, 21) 113 (74) 132 (88) 13 (4, 22) 2 (−8,
12)
−3 (−14, 8)
Spittle 136 (39) 211 (60) 21 (14, 28) 30 (20) 58 (39) 19 (9, 29) 2 (−10,
14)
2 (−10, 14)
Used utensils 73 (21) 127 (36) 15 (8, 22) 25 (16) 12 (8) −8 (−15,
−1)
23 (13,
33)
22 (12, 32)
Social gathering 194 (56) 197 (56) 0 (−7, 7) 81 (53) 47 (31) −22 (−33,
−11)
22 (9,
35)
24 (11, 37)
Workers have key knowledge of ways of COVID-19
transmission (considered coughing, sneezing, and
social gathering)
142 (41) 172 (49) 8 (1, 15) 70 (46) 38 (25) −21 (−31,
−11)
29 (16,
42)
27 (14, 40)
Worker’s knowledge of how to prevent COVID-19
Wearing face mask 325 (94) 331 (95) 1 (−2, 4) 138 (91) 143 (95) 4 (−1, 10) −3 (−10,
3)
−3 (−11, 5)
Goggles 13 (3.75) 65 (19) 15 (10,20) 7 (4.61) 18 (12) 7 (1, 13) 7 (−0.1,
15)
10 (2, 18)
Using hand gloves 148 (43) 151 (43) 0 (−7, 7) 44 (29) 48 (32) 3 (−7, 13) −2 (−15,
10)
−2 (−14, 10)
Hand washing 253 (73) 256 (73) 0 (−6, 6) 97 (64) 114 (76) 12 (2, 22) −12
(−24,
0.4)
−11 (−23, 1)
Not touching the eye, nose, or face with unclean hands 81 (23) 129 (37) 14 (7, 21) 40 (26) 59 (39) 13 (3, 23) 0.6 (−11,
13)
−1 (−13, 11)
Maintaining social distance 194 (56) 255 (73) 17 (10, 24) 81 (53) 75 (50) −3 (−14, 8) 20 (7,
33)
22 (9, 35)
Washing cloths 67 (19) 86 (25) 5 (−0.8, 11) 36 (24) 31 (21) −3 (−12, 6) 8 (−2,
19)
7 (−4, 18)
Cleaning fruits and vegetables 24 (6.92) 43 (12) 5 (1, 9) 8 (5.26) 21 (14) 8 (2, 15) −3
(−11,4)
−1 (−9, 7)
Using the elbow while coughing or sneezing 31 (8.93) 21 (6.02) −3 (−7, 1) 20 (13) 34 (23) 9 (1, 17) ¡12
(-21, -3)
¡11 (-20,
-2)
Cleaning toilets 17 (4.9) 3 (0.86) −4 (−6, −2) 5 (3.29) 12 (8) 4 (−0.4, 9) ¡8 (-15,
-3)
¡8 (-13, -3)
Washing shoes or other equipment 14 (4.03) 5 (1.43) −2 (−5,
−0.1)
11 (7.24) 7 (4.67) −2 (−7, 3) 0 (−5, 5) −1 (−6, 4)
Medicine 5 (1.44) 10 (2.87) 1 (−0.7, 3) 3 (1.97) 2 (1.33) −0.6 (−3, 2) 2 (−1, 5) 3 (−1, 7)
Vaccination 2 (0.58) 20 (5.73) 5 (3, 7) 0 (0) 4 (2.67) 3 (−0.9, 7) 2 (−2, 6) 2 (−2, 6)
Workers have key knowledge on preventing COVID-19
transmission (Considered wearing a face mask, Hand
washing, and Maintaining social distancing)
145 (42) 200 (57) 15 (8, 22) 55 (36) 63 (42) 5 (−5, 15) 10 (−3,
23)
12 (−0.6, 25)
Worker’s knowledge of when to wear a face mask
When we go out of home 312 (90) 336 (96) 6 (2, 10) 142 (93) 146 (97) 4 (−0.7, 8) 2 (−3, 8) 3 (−3, 9)
When we meet anyone 90 (26) 186 (53) 27 (20, 34) 34 (22) 62 (41) 19 (8, 29) 8 (−4,
20)
4 (−8, 16)
When caring the patients 30 (8.65) 88 (25) 16 (11, 22) 9 (5.92) 22 (15) 8 (1, 15) 8 (−1,
17)
7 (−1, 15)
When we feel sick/cough/sneeze 45 (13) 105 (30) 17 (11, 23) 10 (6.58) 47 (31) 24 (16, 33) −7 (−17,
3)
−7 (−17, 3)
When we handle waste 188 (54) 216 (62) 8 (0.4, 15) 67 (44) 90 (60) 16 (5, 27) −8 (−21,
5)
−11 (−24, 2)
(continued on next page)
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
7
handwashing before-during-after work, maintaining coughing etiquette
and social distancing at the workplace, and disposing of waste in
designated areas. The intervention also ensured the availability of
necessary PPEs to the workers and successfully impacted the use of those
diverse PPEs. On the other hand, the intervention was less effective in
improving workers’ understanding of social distancing, quarantine, and
isolation, their attitude towards handwashing before and after using
toilets and having meals, and their practice of disposing of PPEs,
handwashing before taking food and after using the toilet, using the
mask, and disinfecting equipment.
The intervention made the occupational health and safety guidelines
available to the workers in the intervention areas. It ensured that the
workers understood what the guideline contained, which may have
impacted the improved adherence to guidelines in intervention areas
more than in control areas. It may have impacted the workers’ knowl-
edge, attitude, and practices.
To improve the worker’s occupational health and safety, context-
specic and appropriate intervention, especially training, has been
recommended in different LMIC settings, including Bangladesh (Alam,
2021; Asibey et al., 2019; Degavi, 2021; Gebremedhin, 2016; Repon
et al., 2015; Tsukiji, 2020; World Bank, 2019). Interventions are rec-
ommended to be low-cost and implemented considering the
context-specic occupational hazards that need to be addressed
(Emmatty et al., 2019). To reduce COVID-19 exposure and related
occupational hazards, the International Labour Organization (ILO)
suggested training provisions on properly using and disposing of PPEs by
waste workers and regularly communicating with them about COVID-19
situation updates and mitigation strategies (Papandrea, 2020).
The intervention from ITN-BUET was designed so that the workers
receive training from the people they know or work with, as it might
have a better chance of meeting the workers’ contextual demands. This
initiative also reduced the chance of potentially spreading misinforma-
tion, which was largely a concern during COVID-19 (Organization,
2020). The intervention also used more pictorials and visualizations so
that the workers, regardless of their literacy status, could easily grasp
the meaning, which might also have contributed to the impact.
Improvement in workers’ understanding of COVID-19 transmission and
preventive measures suggests that even after massive and intensive mass
media interventions, interpersonal communication that directly ad-
dresses the workers, such as training, can signicantly improve the
workers’ knowledge of important OHS issues. On the other hand, the
workers’ understanding of mask use and correctly knowing
COVID-19-related terms such as social distancing, quarantine, and
isolation have not changed much as the workers from both intervention
and control areas were already similarly exposed to these issues. During
the COVID-19 pandemic, massive mass media interventions across the
globe focused on COVID-19 and the importance of mask use (Bakebillah,
2021; Srivastava, 2020), and it seems like the workers already had a
Table 3 (continued )
Indicators Intervention Control DID (95%
CI)
Adjusted DID
(95% CI)
Baseline n
(%)
N =347
End line
n (%)
N =349
Difference
(95% CI)
Baseline n
(%)
N =152
End line
n (%)
N =150
Difference
(95% CI)
When we can’t maintain social distance anyway 45 (13) 112 (32) 19 (13, 25) 6 (3.95) 37 (25) 20 (13, 28) −1 (−11,
8)
−1 (−10, 8)
Correctly mentioned social distancing 219 (63) 275 (86) 23 (16, 29) 99 (65) 84 (82) 17 (6, 27) 6 (−6,
18)
4 (−8, 16)
Correctly mentioned quarantine 85 (78) 84 (50) −28 (−38,
−18)
23 (62) 10 (21) −41 (−60,
−21)
13 (−8,
35)
3 (−20, 26)
Correctly mentioned isolation 24 (59) 22 (63) 4 (−17, 26) 16 (55) 9 (56) 1 (−29, 31) 3 (−34,
40)
5 (−31, 41)
Opinion on health & hygiene precautions needed at work
Washing hands before and after the toilet 196 (56) 235 (67) 11 (4, 18) 99 (65) 100 (67) 2 (−9, 13) 9 (−4,
22)
9 (−3, 22)
Use PPE 179 (52) 271 (78) 26 (19, 33) 88 (58) 68 (45) −13 (−24,
−2)
39 (26,
52)
36 (22, 49)
Washing PPE 90 (26) 187 (54) 27 (20, 34) 29 (19) 38 (25) 6 (−3, 15) 21 (9,
33)
20 (8, 32)
Cleaning working tools 221 (64) 239 (68) 4 (−3, 11) 85 (56) 62 (41) −15 (−26,
−4)
19 (6,
32)
20 (7, 33)
Avoid touching face, eye, or mouth with unclean hands 146 (42) 211 (60) 18 (11, 25) 66 (43) 103 (69) 25 (14, 36) −7 (−20,
6)
−6 (−19, 7)
Washing hands with soap and water before eating or
drinking.
177 (51) 187 (54) 3 (−5, 1) 73 (48) 88 (59) 11 (−0.5, 21) −8 (−21,
5)
−4 (−18, 9)
Keep open sores, cuts, and wounds covered with a clean,
dry band-aid.
47 (14) 74 (21) 7 (1, 13) 38 (25) 29 (19) −6 (−15, 3) 13 (2,
24)
13 (2, 24)
Consider it necessary to clean the working equipment
with anti-germ products
312 (90) 337 (97) 7 (3, 11) 124 (82) 146 (97) 15 (8, 22) ¡9 (-17,
-1)
−7 (−15,
0.7)
Benets of OHS training N¼70 N¼305 N¼29 N¼19
Operation & maintenance 40 (57) 300 (98) 41 (29, 53) 19 (66) 17 (89) 23 (1, 45) 18 (−7,
41)
17 (−6, 39)
Use of PPEs 23 (33) 301 (99) 66 (54, 78) 11 (38) 8 (42) 4 (−24, 32) 62 (31,
93)
56 (25, 88)
Safety measures 38 (54) 300 (98) 44 (32, 56) 22 (76) 16 (84) 8 (−16, 32) 36 (10,
62)
34 (14, 54)
Reduce health risk 34 (49) 301 (99) 50 (38, 62) 18 (62) 11 (58) −4 (−32, 24) 54 (23,
85)
58 (26, 89)
Capacity building 23 (33) 81 (27) −6 (−18, 6) 17 (59) 9 (47) −11 (−39,
17)
5 (−26,
36)
14 (−16, 45)
Increase knowledge 30 (43) 111 (36) −7 (−19, 5) 15 (52) 10 (53) 1 (−28, 30) −8 (−40,
24)
4 (−26, 34)
Increase condence 7 (10) 60 (20) 10 (2, 18) 7 (24) 11 (58) 34 (7, 61) −24
(−52, 4)
−22 (−51, 7)
Learn about infectious diseases 10 (14) 108 (35) 21 (11, 31) 1 (3) 4 (21) 18 (−1, 37) 3 (−18,
24)
1 (−21, 24)
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
8
Table 4
Reported practice of the workers in maintaining OHS and COVID-19 prevention measures.
Indicators Intervention Control DID
(95% CI)
Adjusted
DID (95%
CI)
Baseline n
(%)
N =347
End line n
(%)
N =349
Difference
(95% CI)
Baseline n
(%)
N =152
End line n
(%)
N =150
Difference
(95% CI)
N =104 N =264 N =63 N =44
Maintain OHS guidelines at work 56 (54) 212 (80) 26 (15, 37) 49 (78) 37 (84) 6 (−9, 21) 20 (2,
38)
3 (−16, 22)
Health and safety precaution taken by the workers during COVID-19 after returning home
Make distance from family 81 (23) 195 (56) 32 (25, 39) 54 (36) 69 (46) 10 (−0.5, 21) 22 (9,
35)
22 (9, 35)
Wash hands rst 127 (37) 229 (66) 29 (22, 36) 65 (43) 45 (30) −13 (−24,
−2)
42 (29,
55)
39 (26, 52)
Wash cloth 170 (49) 258 (74) 25 (18, 32) 106 (70) 88 (59) −11 (−21,
−0.3)
36 (23,
49)
31 (18, 46)
Taking bath with soap 323 (93) 301 (86) −7 (−12,
−2)
143 (94) 127 (85) −9 (−16,
−2)
2 (−6,
10)
3 (−5, 11)
Necessary precautions taken by the workers after
returning home during COVID-19 (Considered
keeping distance from family before cleaning,
washing hand, cloth, and taking bath)
26 (7.49) 108 (31) 23 (17, 29) 31 (20) 11 (7.33) −13 (−21,
−5)
36 (27,
45)
37 (27, 47)
Availability of PPEs 209 (60) 333 (95) 35 (30, 41) 73 (48) 77 (51) 3 (−8, 14) 32 (19,
45)
26 (13, 38)
Types of PPEs available to the workers N¼209 N¼333 N¼73 N¼77
Hand sanitizer 49 (23) 248 (74) 51 (44, 58) 13 (18) 13 (17) −1 (−13, 11) 52 (37,
67)
48 (35, 62)
Face Mask 194 (93) 319 (96) 3 (−1, 7) 71 (97) 73 (95) −2 (−8, 4) 5 (−2,
12)
5 (−1, 11)
Hand Gloves 153 (73) 260 (78) 5 (−3, 12) 42 (58) 18 (23) −34 (−49,
−19)
39 (22,
56)
35 (18, 52)
Face shield/protective glass 13 (6.22) 111 (33) 27 (21, 33) 4 (5.48) 0 (0) −5 (−11,
−1)
32 (24,
40)
32 (19, 45)
Gum boot 136 (65) 260 (78) 13 (5, 21) 40 (55) 24 (31) −24 (−38,
−8)
37 (19,
55)
38 (22, 54)
Half apron 32 (15) 142 (43) 27 (19, 35) 20 (27) 11 (14) −13 (−27, 1) 40 (24,
56)
39 (25, 53)
Apron (clinical waste handler) 41 (20) 43 (13) −7 (−13,
−0.3)
6 (8.22) 12 (16) 7 (−4, 18) ¡14
(-27, -1)
¡11 (-23, 1)
Helmet 3 (1.44) 83 (25) 23 (18, 28) 6 (8.22) 2 (2.6) −6 (−13, 1) 29 (19,
39)
33 (23, 43)
Currently using any PPEs 188 (90) 320 (96) 6 (1, 11) 68 (93) 76 (99) 6 (−0.7, 12) 0 (−7, 7) 0 (−9, 9)
Current usage of different types of PPEs according to their availability
Hand sanitizer
N =49 48
(98)
N =248
245 (99) 1 (−3, 5) N =13 11
(85)
N =13 13
(100)
15 (5, 25) −14
(-25, -3)
¡15 (-25,
-5)
Face Mask
N =194
176 (91)
N =319
310 (97) 6 (2, 10) N =71 66
(93)
N =73 72
(99)
5 (−1, 11) 1 (−7, 9) −1 (−10, 8)
Hand Gloves 139 (91) 253 (97) 6 (2, 10) 38 (90) 18 (100) 9 (−3, 21) −3 (−16,
10)
−4 (−17, 9)
Face shield/protective glass 13 (100) 11 (100) 0 4 (100) –
Gumboot 122 (90) 250 (96) 6 (1, 11) 36 (90) 23 (96) 6 (−6, 18) 0.6 (−13,
13)
−1 (−13,
11)
Half apron 30 (94) 137 (96) 2 (−6, 10) 18 (90) 11 (100) 10 (−5, 25) −8 (−25,
9)
−7 (−24,
10)
Apron (clinical waste handler) 35 (85) 42 (98) 12 (0.5, 24) 5 (83) 11 (92) 8 (−26, 42) 4 (−31,
39)
−6 (−38,
26)
Helmet 3 (100) 81 (98) −2 (−19, 15) 6 (100) 2 (100) 0 (−23, 23) −2 (−31,
27)
2 (−27, 31)
Regular shoes – 88 (97) –
Gas detectors – 2 (100) –
Reective jacket – 99 (93) –
N¼209 N¼333 N¼73 N¼77
Feel problem with PPE 104 (50) 77 (23) −27 (−35,
−19)
38 (52) 16 (21) −31 (−46,
−16)
4 (−12,
20)
8 (−8, 24)
Problem with PPEs
Doesn’t t 38 (18) 59 (18) −0.4 (−6, 6) 19 (26) 1 (1.30) −24 (−35,
−15)
24 (12,
36)
30 (17, 43)
Suffocation 93 (45) 37 (11) −34 (−41,
−27)
35 (48) 7 (9) −39 (−52,
−26)
5 (−10,
20)
9 (−6, 24)
Heat & sweat 9 (4.31) 7 (2.10) −2 (−5, 1) 3 (4.11) 9 (12) 8 (−1, 17) ¡10
(-19,
-0.7)
¡9 (-17, -1)
PPE disposal after use/management of damaged PPE
(continued on next page)
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
9
better understanding of those. Thus, there was no noticeable difference
in this aspect. Nonetheless, the mass media interventions also mainly
focused on improving people’s knowledge of COVID-19 transmission
and preventive measures, which improved even further among the
waste and sanitation workers after the intervention.
Workers from the intervention areas could also easily perceive the
benet of the training compared to workers in control areas indicating
the appropriate reach of the intervention to the workers. The learnings
Table 4 (continued )
Indicators Intervention Control DID
(95% CI)
Adjusted
DID (95%
CI)
Baseline n
(%)
N =347
End line n
(%)
N =349
Difference
(95% CI)
Baseline n
(%)
N =152
End line n
(%)
N =150
Difference
(95% CI)
N =104 N =264 N =63 N =44
Burn to re 19 (9.09) 49 (15) 5 (0.2, 11) 15 (21) 17 (22) 1 (−12, 14) 4 (−10,
18)
2 (−11, 15)
Throw it away 84 (40) 128 (38) −2 (−10, 6) 60 (82) 55 (71) −11 (−24, 2) 9 (−6,
24)
9 (−7, 26)
Throw in the respected bin 117 (56) 191 (57) 1 (−7, 9) 18 (25) 19 (25) 0.01 (−13,
13)
1 (−15,
17)
1 (−15, 17)
Can’t remember 5 (2.39) 13 (3.9) 1 (−2, 4) 0 (0) 6 (7.79) 8 (2, 14) −6 (−12,
0.03)
−4 (−10, 2)
Return to ofce 6 (2.87) – – 3 (4.11) – – –
Properly disposed PPEs (Considered burning and
throwing in the respected bin)
127 (61) 216 (65) 4 (−4, 12) 30 (41) 33 (43) 2 (−14, 18) 2 (−16,
20)
2 (−16, 20)
Frequency of changing/cleaning mask (in days) N¼31 N¼8 N¼17 N¼33
1 day 9 (29) 7 (88) 58 (30, 86) 11 (65) 23 (70) 5 (−22, 32) 53 (14,
92)
47 (0.03,
94)
2–3 days 13 (42) 1 (12) −29 (−58,
−0.6)
4 (23) 9 (27) 4 (−21, 29) −33
(−71, 5)
−13 (−59,
33)
N¼312 N¼337 N¼124 N¼146
Cleaning working equipment regularly 288 (92) 322 (96) 3 (−0.4, 7) 120 (97) 104 (71) −26 (−34,
−18)
29 (20,
38)
26 (17, 35)
Reasons for not cleaning working equipment and PPE N¼35 N¼12 N¼28 N¼4
Use one-time PPE 2 (5.71) 1 (8.33) 3 (−6, 12) 1 (3.57) 1 (25) 21 (−7, 49) −18
(−50,
14)
−43 (−110,
24)
Lack of cleaning agents 6 (17) 5 (42) 25 1 (3.57) 0 (0) −4 - -
High cost of cleaning 2 (5.71) 4 (33) 27 1 (3.57) 0 (0) −4 - -
No facility to wash – – – 1 (3.57) 0 (0) −4 - -
Cleaning agent not provided by recruiter 16 (46) 4 (33) −12 (−46,
22)
13 (46) 2 (50) 4 (−37, 45) −16
(−69,
37)
−2 (−61,
57)
Do not take off PPEs during cleaning waste related
vehicles every day
10 (2.88) 103 (30) 27 (22, 32) 13 (8.55) 12 (8) −0.5 (−6, 6) 27 (19,
35)
26 (17, 35)
Table 5
Observed practice of the workers in maintaining OHS and COVID-19 prevention measures.
Indicators Intervention Control DID (CI)
Baseline n
(%)
N =32
Endline n
(%)
N =35
Difference
(CI)
Baseline n
(%)
N =15
Endline n
(%)
N =15
Difference (CI)
Washed hands N =5 N =17 N =11 N =6
Before Wearing PPE 0 (0) 3 (18) 18 (−0.4, 35) 1 (9.09) 0 (0) −9 (−26, 7) 27 (2, 52)
After wearing PPE 1 (20) 4 (24) 4 (−36, 44) 2 (18) 0 (0) −18 (−40, 4) 22 (−24, 68)
After nishing work 4 (80) 16 (94) 14 (−13, 41) 11 (100) 5 (83) −17 (−43, 10) 31 (−7, 69)
During intervals of work 3 (60) 12 (71) 11 (−37, 58) 4 (36) 1 (17) −19 (−61, 21) 30 (−33, 93)
Before having snacks/meals 2 (40) 12 (71) 31 (−17, 78) 6 (55) 5 (83) 28 (−13, 71) 2 (−61, 65)
After using toilet/urinate 1 (20) 3 (18) −2 (−36, 32) 1 (9.09) 0 (0) −9 (−43, 25) 7 (−41, 55)
Washed hands following proper handwashing steps 2 (40) 6 (35) −5 (−50, 40) 3 (27) 0 (0) −27 (−72, 18) 22 (−42, 86)
COVID precautions observed
Wear face mask 13 (41) 24 (69) 28 (5, 51) 7 (47) 11 (73) 27 (−7, 61) 1 (−40, 42)
Wear goggles 0 (0) 3 (8.57) 8 (−1, 17) 0 (0) 1 (6.67) 6 (−8, 20) 2 (−15, 19)
Used elbow/cloth while sizing/coughing 2 (6.25) 7 (20) 14 (−1, 29) 1 (6.67) 0 (0) −6 (−18, 6) 20 (0.2, 40)
Didn’t share cigarettes/drinking cup 16 (50) 12 (34) −16 (−39, 7) 6 (40) 2 (13) −27 (−56, 3) 11 (−27, 49)
Maintained social distance 7 (22) 10 (29) 7 (−11, 25) 1 (6.67) 0 (0) −6 (−33, 21) 13 (−19, 46)
Washed or sanitized hands before touching face, mouth,
eye
0 (0) 4 (11) 11 (0.8, 21) 3 (20) 0 (0) −20 (−40,
0.2)
31 (8, 54)
Organized at work
Kept equipment organized 29 (91) 31 (89) −2 (−16, 12) 12 (80) 12 (80) 0 (−28, 28) −2 (−34, 30)
Throw waste in designated places 31 (97) 35 (100) 3 (−6, 12) 14 (93) 13 (87) −6 (−20, 8) 9 (−8, 26)
Washed equipment after work 20 (63) 22 (63) 0 (−23, 23) 13 (87) 12 (80) −7 (−33, 19) 7 (−28, 42)
Disinfect equipment after work 5 (16) 3 (8.57) −7 (−22, 8) 0 (0) 1 (6.67) 7 (−5, 19) −14 (−34, 6)
Wash gum boot after work 6 (19) 11 (31) 12 (−8, 32) 3 (20) 7 (47) 27 (−5, 59) −15 (−53,
23)
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
10
from the training events might have improved their attitude (in inter-
vention areas) towards the importance of using and washing PPEs,
cleaning waste management tools regularly, and injury management.
On the other hand, the workers’ attitude towards handwashing before
critical handwashing time, such as before meals and after using the
toilet, did not show any association with the intervention. Different
development agencies and the government of Bangladesh have been
working on improving people’s handwashing, including waste and
sanitation workers, for many years, and previous large-scale trials
observed low improvement in handwashing with soap practices
(Wichaidit et al., 2019). Thus, it is unsurprising that this short training
period did not improve the workers’ handwashing (with soap) attitude
before meals or after defecation. Future interventions need to nd
additional techniques (in addition to this intervention) to address the
issue of handwashing with soap.
During COVID-19, the family members of the waste and sanitation
workers were particularly in danger of getting infected (Alam, 2021,
2022; WaterAid, 2020; WaterAid Bangladesh, 2020)]. The knowledge
dissemination at the training session seems to have helped the workers
improve their practices (reported) of taking measures to keep their
families safe from COVID-19. Despite not changing their handwashing
attitude during key times, the workers began to wash their hands
immediately after returning from work to keep their families safe in
intervention areas.
Fear arousal was one of the primary incentives for people to maintain
protective conduct among threat perception indicators during CVOID-
19 (Sand et al., 2022). Hence, it can be argued that fear of COVID-19
might have impacted the worker’s decision more signicantly than the
impact of the intervention, thus, it will not be applicable in
non-COVID-19 contexts. However, Both control and intervention groups
were impacted by the fear of COVID-19, and we measured the changes
(which is considered as the effect of the intervention) based on the
difference in changes from intervention areas to control areas, thus
allowing the interpretation to be more intervention effect specic. For
instance, in the case of the use of PPEs, we have seen that it was
improved by 6% in both intervention and control areas; although it was
improved in the intervention areas, we can’t attribute this as an inter-
vention effect as similar improvement was also seen in the areas without
intervention (control areas). On the other hand, the practice of keeping
physical distance from the family members before cleaning (when the
workers return from work) improved in both intervention areas and
control areas. However, in intervention areas, the improvement was
signicantly larger (32%) than it was in control areas (10%), indicating
a clear impact of the intervention. In that case, COVID-19 fear might
have caused a 10% improvement in both intervention and control areas,
but the remaining 22% improvement in the intervention areas can be
attributed to the effect of the intervention.
Ensuring the availability of appropriate PPEs (including consider-
ation of gender appropriateness) to the waste and sanitation workers
was recommended as a crucial measure to reduce occupational health
risks, including COVID-19 infection and transmission (PAHO, 2020;
Papandrea, 2020). The intervention increased the availability of
different PPEs such as masks, hand sanitizer, gloves, goggles, gumboot,
regular shoes, and reective jackets to the workers in intervention areas
rather than in control areas, and the workers’ started wearing those PPEs
in intervention areas. However, the workers in the control areas also
wore the PPEs that were available to them then. This practice in both
intervention and control areas indicates that the availability of PPEs
ensures its use in many cases. In Nepal, the unavailability of PPEs was
the major driver for the waste workers’ inadequate PPE-wearing prac-
tices (Adhikari et al., 2021). Thus, it can be inferred that future inter-
vention needs to continue providing PPEs and ensuring regular supply to
the workers. Moreover, the workers’ common complaints about the
PPEs they received in intervention areas, including the inappropriate
tting of the PPEs, suffocation, and feeling of heat and sweating, need to
be addressed in the future. Dissatisfaction about PPEs and the irregu-
larity of their use among waste and sanitation workers were reported to
be caused by their lack of comfortability in PPE design, particularly
when the hot climate of tropical areas is not considered. Also, PPEs are
often purchased in bulk without regard for the workers’ tting issues
(Somani and Hueso, 2020). Future interventions must consider
providing comfortable PPEs and ensuring their regular supply to the
workers. More intensive research is required to produce contextually
appropriate PPEs.
Changing behaviour is a complex process and it is normal to expe-
rience many lapses and relapses when trying to change behavior because
it can be an inherently unstable and unsteady process (Alam, 2023;
Bouton, 2014). In order to improve waste management and OHS
behaviour, previous researchers have emphasized training as a crucial
intervention element (Joshi, 2015; Tudor et al., 2005). However, to have
a sustainable behaviour change among the workers, regular monitoring
from the municapility ofce, and provision of continuous intervention
might be needed.
The study had a few limitations. We conducted the study just one
month after the intervention provision to see the immediate effect.
However, the impact of the intervention might be different after six
months or a year, which can be explored in the future to realize the long-
term impact of the intervention. Also, we selected the study sites (both
intervention and control areas) purposively; thus, it does not fully
represent the situation of the sanitation workers in the country. None-
theless, we selected the sites from all eight divisions, considered the
cultural and geographical diversities, and ensured representation from
large cities (city corporations) and small towns (municipalities). More-
over, during observation of the workers’ practices at the workplace, the
workers did not perform all activities at all times, resulting in a few
observations in certain aspects. Also, many sanitation workers (espe-
cially drain cleaners and septic tank/pit emptiers) were working late at
night, making it harder for the researchers to reach the workers at the
workplace because of security concerns and the unavailability of safe
transportation. These affected the number of observed practices.
6. Conclusion and recommendations
The study aimed at evaluating the effect of the OHS intervention on
the waste and sanitation workers and identify the areas of improvement.
The study found that the intervention was successful in improving the
critical measures such as knowledge about spread and prevention of
infectious disease and key COVID-19 prevention strategies, attitude to-
wards using PPEs, and practice of taking preventive measures after they
return home from work to ensure occupational health safety of the waste
Table 6
Opinion of the workers on improving their OHS status.
Indicators Intervention Control DID (CI)
Baseline n (%)
N =347
Endline n (%)
N =349
Difference (CI) Baseline n (%)
N =152
Endline n (%)
N =150
Difference (CI)
Upgrade technology 79 (23) 69 (20) −3 (−9, 3) 31 (20) 35 (23) 3 (−6, 12) −6 (−17, 5)
Health insurance 54 (16) 93 (27) 11 (5, 17) 6 (3.95) 23 (15) 11 (5, 17) 0 (−9, 9)
Free medical facility 190 (55) 259 (74) 19 (12, 26) 75 (49) 84 (56) 6 (−5, 17) 13 (−0.4, 26)
Increase and maintain the PPE supply 123 (35) 150 (43) 8 (0.3, 14) 70 (46) 67 (45) −1 (−12, 10) 9 (−4, 22)
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
11
and sanitation workers. This intervention can be adapted for other cities
of Bangladesh and other low-middle income country settings with
additional actions taken to make the intervention context-appropriate.
Based on the endline evaluation ndings, we recommend the fol-
lowings actions.
•Organize refresher training for workers and their supervisors at least
once a year and orientation events following the health safety
guidelines for the new workers on maintaining occupational health
and safety.
•In future interventions, address occupational health-related injuries
and health complications such as joint or back pain with regular
health checkups/insurance.
•Create a balance between the quality and comfort of the PPEs,
especially for the safety of gumboots in future designs, and create a
mechanism to maintain an adequate supply of these once damaged.
•Workers should be encouraged to be responsible for using PPEs
regularly through on-job training and supervision.
•A detailed study and intervention should be considered to address
the occupational health safety problems of the workers holistically.
These may include improved salary structure, stable job contracts,
decent workplaces, insurance, medical facilities, better education
and training facilities, improved accommodation, WASH access, and
proper protective equipment use.
Author contributions
DMS and TA with MA prepared the initial draft of the manuscript.
KFT, MH, FS, MR, MF, MAR, AA, and JBT reviewed the study design,
tools for data collection, and the manuscript. DMS, MH, FS, and KFT
monitored the data collection activity. KFT and MH conducted data
cleaning and analysis. MF, MR, DMS, MA and TA was involved in data
analysis and provided intellectual input. All authors thoroughly
reviewed the manuscript and provided scientic input. MA supervised
the entire study.
Funding and acknowledgments
This research study was funded by the Bill and Melinda Gates
Foundation (BMGF) and administered by the Centre for Water Supply
and Waste Management of International Training Network of
Bangladesh University of Engineering and Technology (ITN-BUET) -
(Grant/Award Number INV-007345 to ITN-BUET). icddr,b acknowl-
edges with gratitude the commitment of BMGF to its research efforts.
icddr,b is also grateful to the Governments of Bangladesh, and Canada
for providing core/unrestricted support.
Declaration of Competing interest
The authors declare no conicts of interest.
References
Adhikari, B., et al., 2021. Solid waste management practices and challenges in seven
cities of Nepal before and during lockdown against COVID-19 pandemic. Nepal J.
Environ. Sci. 9 (1), 11–19.
Alam, M.U., 2021. Health and Safety of Waste and Sanitation Workers during the
Pandemic: a Case Study in Selected Cities of Bangladesh. Dhaka.
Alam, M.-U., et al., 2022. Hygiene knowledge and practices and determinants of
occupational safety among waste and sanitation workers in Bangladesh during the
COVID-19 pandemic. Hygiene Environ. Health Adv. 4, 100022.
Alam, M., et al., 2023. Evaluation of Hygiene and Behaviour Change Coalition for
COVID-19 Prevention: Inclusion of Disability and Ageing.
Asibey, M.O., Amponsah, O., Yeboah, V., 2019. Solid waste management in informal
urban neighbourhoods. Occupational safety and health practices among tricycle
operators in Kumasi, Ghana. Int. J. Environ. Health Res. 29 (6), 702–717.
Bakebillah, M., et al., 2021. Community’s misconception about COVID-19 and its
associated factors in Satkhira, Bangladesh: a cross-sectional study. PLoS One 16 (9),
e0257410.
Black, M., et al., 2019. The health risks of informal waste workers in the Kathmandu
Valley: a cross-sectional survey. Publ. Health 166, 10–18.
Bouton, M.E., 2014. Why behavior change is difcult to sustain. Prev. Med. 68, 29–36.
Center for Water and sanitation, C., CEPT University, 2020. Improving Safety of
Sanitation Workers in Wai Municipal Council. Center for Water and Sanitation.
Chow, S.-C., et al., 2017. Sample Size Calculations in Clinical Research. chapman and
hall/CRC.
Degavi, G., et al., 2021. Prevention of occupational hazards among sanitary workers:
knowledge, attitude, and practice survey in bulehora, west guji zone, oromia,
Ethiopia. Risk Manag. Healthc. Pol. 14, 2245–2252.
Department of Public Health Engineering, B., Bangladesh Strategic Paper to Respond to
Water, Sanitation and Hygiene (WASH) Issues during & after the COVID-19
Outbreak.
Elnour, A.M., et al., 2015. Impacts of an Educational Intervention Program on the
Attitude of Kosti, Rabak, and Eduiem Hospitals’ Nursing and Sanitation Staff with
Regard to Healthcare Waste Management.
Emmatty, F.J., Panicker, V.V., 2019. Ergonomic interventions among waste collection
workers: a systematic review. Int. J. Ind. Ergon. 72, 158–172.
FANSA, WSSCC, 2015. LEAVE NO ONE BEHIND: Voices of Women, Adolescent Girls,
Elderly, Persons with Disabilities and Sanitation Workforce.
Gebremedhin, F., et al., 2016. Assessment of knowledge, attitude and practices among
solid waste collectors in Lideta Sub-city on prevention of occupational health
hazards, Addis Ababa, Ethiopia. J. Public Health 4, 49–56.
Hoque, S.N., 2020. Hardship of the Waste Workers in Bangladesh during Coronavirus
Pandemic Revealed. Available from. https://practicalaction.org/news-media/2020/
08/25/hardship-of-waste-workers-in-bangladesh-during-coronavirus-pandemic-
revealed/.
Hosny, G., Samir, S., El-Sharkawy, R., 2018. An intervention signicantly improve
medical waste handling and management: a consequence of raising knowledge and
practical skills of health care workers. Int. J. Health Sci. 12 (4), 56.
Islam, M.S., et al., 2016. Faecal contamination of commuters’ hands in main vehicle
stations in Dhaka city, Bangladesh. Trans. Roy. Soc. Trop. Med. Hyg. 110 (6),
367–372.
ITN-BUET, 2020. IPC and Health Hygiene for Sanitation and Waste Worker. ITN-BUET.
ITN-BUET, 2021. Training of Trainers (ToT) Manual on Sanitation and Waste Workers’
Occupational Health and Safety (OHS) and Infection Prevention and Control (IPC).
ITN-BUET.
Joshi, S.C., et al., 2015. Staff perception on biomedical or health care waste
management: a qualitative study in a rural tertiary care hospital in India. PLoS One
10 (5), e0128383.
LGED. About LGIs., 2018 Available from https://proinfo.lged.gov.bd/lged/about-lgis/.
Mahase, E., 2021. Sanitation Workers: Covid-19’s Forgotten Frontline. British Medical
Journal Publishing Group.
Nigam, D., Dubey, S., 2020. Condition of Sanitation Workers in India: A Survey during
COVID-19 and Lockdown.
Organization, W.H., 2020. Social Media & COVID-19: A Global Study of Digital Crisis
Interaction Among Gen Z and Millennials.
Oza, H.H., et al., 2022. Occupational health outcomes among sanitation workers: a
systematic review and meta-analysis. Int. J. Hyg Environ. Health 240, 113907.
PAHO, 2020. Recommendations of Protective Measures for Sanitation Workers.
Papandrea, D., In The Face of a Pandemic: Ensuring Safety and Health at Work. Geneva:
ILO, 2020..
Ramitha, K., 2023. Solid waste workers in India and the COVID-19 pandemic: a review of
intersecting challenges. Int. J. Occup. Saf. Health 13 (1), 126–139.
Repon, A., Faruq, O., Mamtaz, R., 2015. Occupational Safety and Health Guidelines for
Faecal Sludge Management. SNV Netherlands Development Organisation.
Sand, G., Bristle, J., 2022. Motivating protective behavior against COVID-19: fear versus
hope. J. Aging Health, 08982643221089427.
Sharior, F., et al., 2023. Occupational health and safety status of waste and sanitation
workers: a qualitative exploration during the COVID-19 pandemic across
Bangladesh. PLOS Water 2 (1), e0000041.
SNV, 2017. City Cleaners: Stories of Those Left behind. SNV.
Somani, Prerana, Hueso, Andr´
es, 2020. Boots, Gloves, Masks. Is Providing PPE Enough to
Protect Sanitation Workers? Available from: https://washmatters.wateraid.org/blo
g/boots-gloves-masks-is-providing-ppe-enough-to-protect-sanitation-workers.
Srivastava, K.C., et al., 2020. Facade of media and social media during COVID-19: a
review. Int. J. Res. Pharm. Sci. 142–149.
Star Online Report, 2018. Mymensingh Becomes City Corporation. The daily star.
Tabash, M., et al., 2016. Impact of an intervention programme on knowledge, attitude
and practice of healthcare staff regarding pharmaceutical waste management, Gaza,
Palestine. Publ. Health 138, 127–137.
Tsukiji, Makoto, et al., 2020. Waste Management during the COVID-19 Pandemic from
Response to Recovery.
Tudor, T., Noonan, C., Jenkin, L., 2005. Healthcare waste management: a case study
from the national health service in cornwall, United Kingdom. Waste Manag. 25 (6),
606–615.
WaterAid, 2020. Safety and Wellbeing of Sanitation Workers during COVID-19 in South
Asia.
WaterAid, 2021. Sanitation Workers: the Forgotten Frontline Workers during the COVID-
19 Pandemic.
WaterAid Bangladesh, Risk and Vulnerability of Sanitation and Waste Workers during Covid-
19 Pandemic in Five Major Cities of Bangladesh, 2020. Dhaka).
WHO, 2022. WHO Health Emergency Dashboard. WHO.
Wichaidit, W., et al., 2019. Effectiveness of a large-scale handwashing promotion
intervention on handwashing behaviour in Dhaka, Bangladesh. Trop. Med. Int.
Health 24 (8), 972–986.
D.M. Shoaib et al.

International Journal of Hygiene and Environmental Health 255 (2024) 114288
12
World Bank, et al., 2019. Health, Safety and Dignity of Sanitation Workers: an Initial
Assessment. World Bank.
Ye, Q., et al., 2022. Health concerns among waste collectors during pandemic crisis.
Environ. Sci. Pollut. Control Ser. 29 (5), 6463–6478.
Zaqout, M., et al., 2020. Sustainable sanitation jobs: prospects for enhancing the
livelihoods of pit-emptiers in Bangladesh. Third World Q. 42 (2), 329–347.
D.M. Shoaib et al.