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ORIGINAL ARTICLE
Year : 2022  |  Volume : 26  |  Issue : 3  |  Page : 157-164
 

How Covid-19 affected the work prospects and healthcare-seeking of women domestic workers in Kolkata City, India? A longitudinal study


1 Department of Community Medicine, Midnapore Medical College, Paschim Medinipur, West Bengal, India
2 Department of Community Medicine, Medical College, Kolkata, West Bengal, India
3 Department of General Medicine, Ramakrishna Mission Seva Pratishthan, Kolkata, West Bengal, India

Date of Submission14-Dec-2021
Date of Decision10-Jan-2022
Date of Acceptance24-Mar-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Dr. Shibaji Gupta
1C-1003, Avishikta 2, 369/3, Purbachal Kalitala Road, Kolkata - 700 078, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoem.ijoem_346_21

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  Abstract 


Background: Self-negligence, societal neglect, and lack of access to adequate health care make domestic workers vulnerable to ill-health. COVID-19 has adversely affected the work prospects of people across social classes and their health care-seeking opportunities as well. We studied the impact of COVID-19 pandemic on work prospects and health care-seeking behavior of a vulnerable section of the society – the women domestic workers. Methods: A longitudinal analysis on 292 randomly selected women domestic workers residing in slums of “Kalikapur” locality of Kolkata city, West Bengal (India). Data were collected using a predesigned and pretested schedule twice: in early-2020 (before severe impact of COVID-19) and mid-2020 (during the pandemic ravaging India). Paired t-test and McNemar's test were used to check for significant changes. Result: Of all the participants, 57.2% lost jobs partially while 2.7% were completely jobless in mid-2020; the average daily work-hour decreased by 25.7%. Their average monthly pay significantly reduced (P < 0.05); mean family income in mid-2020 was lesser as well, compared to earlier (P < 0.05). Compared to early-2020, 15.8% more participants were sole bread-winners for their families during COVID-19. Number of participants visiting health practitioners significantly reduced (P < 0.05) in mid-2020. Rise in over-the-counter medicine use (P < 0.05) and increased tendency to ignore symptoms (P < 0.05) during COVID-19 was noted. Conclusion: The COVID-19 pandemic has affected work prospects and health care-seeking behavior of women domestic workers negatively. Most of them faced wage reduction, many becoming sole-earners for their families. This necessitates continued formulation and implementation of strategies ensuring social benefits including healthcare. Awareness about affordable healthcare and ill-effects of bad practices like self-medication should also be built.


Keywords: Coronavirus disease 2019, domestic work, health care-seeking behavior, job opportunity, occupational health, unorganised sector


How to cite this article:
Gupta S, Das D, Bhattacharya SK, Gupta SS. How Covid-19 affected the work prospects and healthcare-seeking of women domestic workers in Kolkata City, India? A longitudinal study. Indian J Occup Environ Med 2022;26:157-64

How to cite this URL:
Gupta S, Das D, Bhattacharya SK, Gupta SS. How Covid-19 affected the work prospects and healthcare-seeking of women domestic workers in Kolkata City, India? A longitudinal study. Indian J Occup Environ Med [serial online] 2022 [cited 2022 Dec 7];26:157-64. Available from: https://www.ijoem.com/text.asp?2022/26/3/157/357027





  Introduction Top


A domestic worker is “a person who is employed for remuneration whether in cash or kind, in any household through any agency or directly, either temporary or permanent, part time or full time basis to do the household work, but does not include any member of the family of an employer”.[1]

Domestic workers comprise a significant part of the global workforce in informal employment. Globally there were 67.1 million domestic workers in 2013, with almost two-third of all domestic workers concentrated in Asia and Latin America-Caribbean region.[2],[3] Women comprise of about 83% of all domestic workers in the world. They comprise of 81% of such work force in the Asia-Pacific region.[3] Hence, “even though a substantial number of men work in the sector … it remains a highly feminized sector.”[2] Almost 90% of the total employment in the Indian economy has been accounted for by the unorganised/informal sector, with the proportion of women workers on the rise in the last few decades.[4],[5] Women domestic workers occupy the largest segment of unorganised women workers in India.[4]

It is estimated that there are nearly 4.2 million domestic workers in India. Domestic work though remains unrecognised as a formal form of occupation, often without clear terms of employment, and excluded from the scope of labor legislation.[2],[6] The code on social security introduced in 2020 has also left domestic workers out of its ambit.[7] The International Labor Organization (ILO) Convention on Domestic Work, passed in 2010, that outlines the basic rights of domestic workers, is yet to be ratified by the Government of India.[8],[9] Lack of strong laws, rules, and regulations invariably means deprivation of domestic workers specially with regards to economic stability and social security, including basic rights to access quality health care.[10] India yet does not have a dedicated law addressing the interests of domestic workers.[11]

The COVID-19 pandemic has affected 81% of the world's workforce, which include domestic workers.[5] Many domestic workers in Mumbai (India) had to go unpaid during the COVID-19 pandemic.[12] About half of domestic workers surveyed in Delhi (India) reported a loss in income.[13] Due to no formal registration with social security board, many women domestic workers in Delhi were denied government relief – 51% of them faced difficulty in buying food and health care access issues were faced by 36%.[14] The International Domestic Workers Federation has reported similar phenomenon from other parts of the world.[15] Such studies from the Eastern part of India were rare to be found.

Poor working and living conditions along with ignorance and neglect toward health, predispose women domestic workers to ill-health. Their medical benefits are usually nonexistent and sometimes totally dependent on their employers. Many a time they do not get any medical help from their employer. Medical insurance covering work-related sicknesses are normally absent too. Insecurity surrounding their employment status and lack of control of the conditions of their employment, in addition to the limited access to appropriate healthcare facilities, often demotivate them to seek health care due to fear of potential expense and/or loss of employment and income.

Presently, not many studies in India are available in the public domain, that have been conducted, focussing on the health care-seeking of women domestic workers during the COVID-19 pandemic. Reports published on domestic workers usually lay stress on their socioeconomic vulnerabilities, but research on their health care-seeking aspect are lesser in number.

The present study assesses the impact of COVID-19 on the work prospects and health care-seeking behavior of women domestic workers. The researchers believe that, the results of the study will help policy makers to reduce the health risks in women domestic workers through development and implementation of adequate policies and strategies to help deliver suitable and acceptable health services to them. Also, the results would help developing policies and guidelines to secure work prospects of this vulnerable section of the society and ensure their accessibility to adequate social security measures.


  Materials and Methods Top


This longitudinal study was conducted in the preselected slums of the city of Kolkata, the capital of the West Bengal state in India.

All women domestic workers residing in the slums of the Kalikapur locality of the city, working for at least the last 6 months were line listed. The formula n0 = z2pq/e2 was used to calculate sample size, which was further corrected for finite population using the formula n = n0/[1 + {(n0 − 1)/N}].[16] A study on domestic workers from an Indian city found 14% of its participants to be seeking health advice.[17] Considering proportion (p) of domestic workers seeking treatment for their health to be 14%, q = 100 − p, a relative error (e) of 20%, and N (total eligible population) = 437, the sample size (n) was 252 after finite population correction. Adding 25% for probable non-response and non-availability, the final sample size was 314.05 ≈ 315.

Data were collected over a period of 4 months in total, in two independent phases (January–February 2020 and June–July 2020). The COVID-19 pandemic was yet to become a serious hazard in India during the first phase of data collection. During the second phase of data collection, the first wave of the pandemic was ravaging the country. A total of 315 women domestic workers were selected by simple random sampling using random number table and approached during both the phases. Candidates unavailable in spite of attempts on three consecutive days during any phase of data collection due to absence or illness were excluded. Candidates available during the first phase, but unavailable during the second phase of data collection were excluded from the analysis as well.

A total of 292 participants were interviewed during both the phases of data collection. Interview was conducted at their home after obtaining informed consent, for which an anonymous data collection schedule was used. Sociodemographic details were collected during first phase. Details of work and health care-seeking behavior were collected during both the phases. For the purpose of the study, health care-seeking behavior for acute symptoms were considered; while chronic illnesses were ignored.

Data were concurrently entered into MS EXCEL®2016. Statistical Packages for Social Science (SPSS)® version 16 (SPSS Inc, Chicago, IL, USA) was used for suitable statistical operations. For checking the statistical significance of necessary comparisons, paired t-test and McNemar's test were used wherever applicable.

Permission for conduction of the study was granted by the Ethics committee of a Medical College in Kolkata.


  Result Top


Sociodemographics

Most of the study participants (46.2%; 135/292) were aged 35 years or less. Majority (86.3%; 252/292) were Hindus and belonged to the general unreserved caste (61.6%; 180/292). Of the participants, 29.8% (87/292) were illiterate and 74.3% (217/292) were presently married. A large proportion of the respondents (46.6%; 136/292) had been domestic workers for 11 years or more [Table 1].
Table 1: Sociodemographic characteristics of the study participants (n=292)

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Impact of COVID-19 on work

A comparison between the data obtained regarding work and income related details of the study participants in early 2020 and in mid-2020 is presented below and in [Table 2]:
Table 2: Distribution of participants according to change in work pattern and income before the onset and during COVID-19 (n=292)

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Majority worked in four households in the first phase (31.2%, 91/292) while in the second phase, most were found to work in three households (34.6%, 101/292). Of the participants, 57.2% (167/292) partially lost their jobs (indicated by a drop in the number of households they worked for) while 2.7% (8/292) were jobless in mid-2020. The rest (40.1%, 117/292) retained their jobs, but in many instances were restricted in terms of entry to a household and the work they performed. As reported by the respondents, in houses with available setback area, they were often obliged to clean utensils or wash clothes while staying outside the residence proper. Some households asked them to change clothes before entering. In many instances, they were relieved from duties that the employers perceived to carry a higher chance of exposure, such as cooking, dusting, and cleaning households. The average daily work hour of the study participants decreased in mid-2020 (mean = 5.3 h, SD = 2.1 h) compared to early 2020 (mean = 7.2 h, SD = 1.8 h). Though most participants continued earning between 4001 and 8000 rupees a month in mid-2020 (69.2%, 202/292) like in early 2020 (53.4%, 156/292), 61.3% (179/292) reported a reduction in their monthly wages. Their mean income was INR ₹7838.4 (SD = ₹2120.9) in early 2020 compared to ₹6065.4 (SD = ₹2176.7) in mid-2020 (P = 0.000 using paired t-test). All received regular wages in the first phase of the survey, while in the second phase, 27.4% (80/292) faced intermittent delays in receiving wages.

A majority (81.8%, 239/292) reported a reduction in family income during the pandemic. The mean family income during the pandemic in mid-2020 was ₹10664.4 (SD = ₹3920.8) compared to mean income of ₹14561.6 (SD = ₹4341.1) before the pandemic in early 2020 (P = 0.000 using paired t-test). As unemployment among other family members rose, the participants became sole-earners for their families from 20.5% (60/292) instances in early 2020 to 36.3% (106/292) cases in mid-2020. Socioeconomic class was assessed using the B.G. Prasad Scale (modified on December 2019).[18] In the beginning of 2020, 52.1% (152/292) belonged to Class-III. The proportion rose to 58.9% (172/292) in mid-2020, at the cost of higher socioeconomic class' proportions [Table 2].

COVID-19 and Health care-seeking behavior

Before the pandemic, in early 2020, 58.9% (172/292) had suffered from acute episode (s) of illness at some point of time during the preceding 3 months. Gastrointestinal symptoms (25.3%, 74/292) and musculoskeletal issues (21.6%, 63/292) were the most commonly reported following generalized symptoms like fever and weakness (26.4%, 77/292). Among the 102 participants (i.e., 34.9% of all participants) who sought medical advice from a medical practitioner at least once during the time frame, modern medicine experts were consulted the most (81.4%, 83/102), followed by registered AYUSH (ayurveda/yoga/unani/siddha/homeopathy) practitioners (17.6%, 18/102) and unregistered medical practitioners (4.9%, 5/102). A majority (59.8%, 61/102), however, delayed treatment seeking by 2 days or more, post development of symptoms. Most respondents (68.6%, 70/102) completed the treatment regime. In 63.7% (65/102) cases, the average cost per visit incurred by an individual was within ₹250. This cost includes doctor's fees, transportation charges, and costs of medicines and investigations, as and when applicable. None reported loss of pay during illness or due to absence as a result of visiting medical practitioners. Some received assistance from their employers to meet their medical expenses (11.8%, 12/102). Of all the participants, 24.7% (72/292) resorted to over-the-counter medications; 5.1% (15/292) used medicines from old prescriptions and 6.2% (18/292) chose to ignore the symptoms in the preceding 3 months. Among those who never visited a practitioner, lack of time (87.2%, 82/94) and fund constraints (30.8%, 29/94) were the common reasons cited behind not visiting a medical practitioner [Table 2] and [Table 3].
Table 3: Health care-seeking behavior of study participants

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During the second phase of data collection in mid-2020, 62.7% (183/292) reported to have suffered from acute illness at some point of time during the preceding 3 months. This proportion was not significantly different from early 2020 (P = 0.185). Of all the participants, 3.8% (11/292) had suffered from COVID-19. However, among the respondents, 27.7% (81/292) were found to have visited a medical practitioner – a significantly poorer proportion compared to early 2020 (P = 0.044). Compared to earlier, a larger proportion delayed seeking such care by 2 days or more postsymptoms (67.3%, 54/81). Most consulted modern medicine practitioners (80.2%, 65/81). However, a larger proportion visited AYUSH experts (23.4%, 19/81). Some visited unregistered practitioners as well (11.1%, 9/81). In 60.5% (49/81) cases, the average cost incurred by a participant was within ₹250 per visit. None lost wages in the process of visiting a practitioner, while 9.9% (8/81) received financial help from the employers. Though most respondents (58.0%, 47/81) completed treatment regime, the proportion was lesser compared to before. A significantly increased proportion of respondents tried ignoring their symptoms (11.0%, 32/292) this time, compared to earlier (P = 0.034). A larger proportion (32.2%, 94/292) resorted to over-the-counter medications as well when compared with early 2020 (P = 0.025). Of the participants, 7.2% (21/292) used old prescriptions or previously bought medicines – however, not significantly different from early 2020 (P = 0.307). Along with lack of time (75.6%, 96/127) and money (40.2%, 51/127), movement restrictions imposed due to COVID-19 (38.6%, 49/127) and fear of getting COVID-infected at a clinic/health facility (77.2%, 98/127) were common constraints noted against seeking medical attention from medical practitioners [Table 2],[Table 3],[Table 4].
Table 4: Impact of COVID-19 on health care-seeking behavior of the respondents (n=292)

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  Discussion Top


The COVID-19 pandemic has affected the livelihoods of people, cutting across social classes in India. However, the informal sector workers including domestic workers are the most affected. This is due to lack of employment protection and social security, coupled with their struggle to meet their basic necessities and increased threat of infection[5],[19] The nature of occupation also makes domestic workers too busy and overburdened to focus on health needs. As per a report published by ILO, domestic workers in Asia work for the highest average number of hours in a day.[3] Domestic workers in India working in multiple houses and their long working hours have been reported in many studies including the present one.[17],[20],[21],[22],[23]

The misery brought about by the pandemic is evident from a few recent reports that are available. The ILO estimated a decline in working hours by 6.7% in the second quarter of 2020 – equivalent to 195 million full-time workers.[5] A study on women domestic workers from three Indian cities reported that 50.4% of its participants experienced reduced wages during the pandemic, some did not receive any wages; 45% lost their jobs during March–June 2020.[23] As reported by the International Domestic Workers Federation, 62% domestic workers in Maharashtra partly lost their jobs, while 24% became completely jobless. Many were not allowed to enter the buildings during the pandemic.[24] A Delhi-based survey reported that 61.4% respondent women domestic workers lost their jobs and 16.8% with significant fall in income.[25] As per our study, most domestic workers (57.2%) partially lost their jobs, while 2.7% were jobless in mid-2020. The rest retained their jobs, but in many instances were restricted in terms of entry to a household and the work they performed. Some of our participants (n = 9) from the first phase were not available for data collection during the second phase indicating probable shifting out due to inability to sustain in the city. Hence, the actual number of those going jobless could be more. Fear of them spreading infection and entry restrictions imposed by several households including housing complexes could have been the important reason behind their exclusion from work. In a multicity study, 57% respondents complained of being projected as virus-carriers and hence stigmatized.[23] During the pandemic, in mid-2020, our survey found, 36.3% were the only earning member in their families – showing a rise by about 15% from the findings of early January. A Delhi-based survey found, fear among employers of contracting COVID-19 from domestic workers was a major hindrance toward employment of this workforce. There was also a significant decline in the number of households that appointed them during the pandemic.[25] In Maharashtra, 49% among the domestic workers surveyed, turned out to be sole-earners for their family. Therefore, a disruption in their employment meant serious survival issues for all members of such families.[24]

Vulnerabilities arising out of hard physical work, long working hours, economic instability, negligence toward own health, and inadequate social protections (including insufficient access to affordable health services) pre-dispose toward ill-health.[26] As per our findings, about 60% participants had recent history of suffering from acute symptoms during both the phases of data collection. However, about half of the participants who suffered from acute illness sought a medical practitioner for help. Workers of the unorganised sector, which include domestic work, have been known for similar tendencies. Rockefeller foundation in their 2013 report highlighted that lower incomes, disaggregated workplaces, and lack of power to determine working conditions resulted in restriction in health care access.[26] Many women informal workers were found to be unable to leave work for basic health care, maternity leave or prenatal care, or mental health services, despite facing increased health concerns.[26] A study from Thrissur showed only 7 out of the 37 domestic worker participants to undergo regular treatment for illness.[17]

The COVID-19 pandemic and the resulting restrictions imposed have only aggravated the situation. This study found a significant rise in the proportion of participants resorting to over-the-counter drugs ongoing COVID-19 pandemic compared to before; and number of respondents visiting a practitioner also reduced to a large extent in mid-2020. This is likely due to the challenges associated with reaching a hospital during lockdown, associated with the fact that many clinics were shut or functioning at a lower capacity.[27] Added to this is the fear of getting COVID-infected at health facilities from patients and health-care staffs, as reflected by our findings. The social discrimination and stigma associated with COVID-19 could also have repelled them from undertaking adequate treatment measures that could have led them to such a diagnosis. A diagnosis of COVID-19 could also have meant discontinuity in work and wage. Also, money is an important factor behind decision to care seek[28] and over-the-counter medications often provide an apparently cheaper and time-saving alternative.[29] In our study, with more than half of the participants reporting a reduced family income amidst the pandemic, this could be a reason why a larger number of them rejected the scope of visiting a health practitioner or facility for medical advice. The above factors could have also forced a significantly larger section of participants to ignore symptoms during the second phase of the survey. Some medicines advertised as beneficial without proper scientific basis, might have influenced people to use them – thereby promoting over-the-counter drug using tendency.[27] Hence, creating awareness regarding the potential harms of self-medication and neglect of health is essential. Strict implementation of laws that limit easy availability of over-the-counter medicines, along with adaptation of the community education strategy are needed. Regular vigilance should also be maintained.

This study and other similar research find domestic workers living in a difficult state of affairs, with a bulk of them suffering from employment loss and many facing survival crisis amidst the pandemic. Restricted access to government welfare schemes, largely as a result of them being left out in Code on Social Security introduced in 2020, and discrimination faced at workplace make the situation harsher.[7] Economic hardships combined with movement restrictions imposed to contain the spread of the COVID-19 have turned them away from seeking adequate and appropriate healthcare too. During the pandemic, 55% of respondent women domestic workers were found to have struggled to access healthcare services in Delhi.[25] Thus, at the end of the day, the pandemic has made this vulnerable group even more susceptible to danger.

Policies should be reoriented to provide immediate relief to workers with the intention of protecting the livelihoods and economic viability of all sectors, as well as to ensure that conditions for prompt and job-rich recovery prevail, once the pandemic is controlled.[5] With the intention to ease this crisis from the domestic worker's point-of-view, ensuring that social security measures reach the domestic workers is critical in this juncture. Urgent steps should be taken to bring domestic workers under the ambit of Social Security Boards along with formal registration of their jobs. Records available from resources like police verification forms, resident welfare associations, union memberships, and placement agencies may be utilized to obtain the data necessary for registration. Both the central and state governments have announced various cash transfer and food ration schemes to counter the large-scale unemployment and loss of income during lockdown. Such provisioning of free ration kits should be extended as private households are not likely to call domestic workers back to work as easily as before.[7],[23] The Government of India has already announced relief packages such as 'Pradhan Mantri Garib Kalyan Package' with the intention to help the informal sector.[23] India is yet to have a separate law dedicated to protect the interest of domestic workers.[11] The “Unorganized Workers Social Security Act, 2008”, however, enables the Government to formulate and implement various welfare schemes targeted toward the unorganized sector, including domestic workers.[30] This act has been criticized for not focusing on issues like nationwide minimum wage, unequal pay, allowance in case of job-loss, and improving working conditions of unorganized workers. Moreover, the Advisory Boards as per the act have been vested with no executive power.[30],[31] The Ministry of Labor and Employment, Government of India, is in the process of formulating a National Policy on Domestic Workers, which would facilitate inclusion of domestic workers into the ambit of existing laws and give them the rights to minimum wages, skill enhancement, accessible social security, protection against abuse and exploitation, and grievance redressal.[11] Associations like the West Bengal Domestic Workers Society and Domestic Workers Rights Union Mumbai have been raising voice for ensuring the welfare and rights of domestic workers during the pandemic.[32] Raising community awareness about government sponsored health schemes like the “Ayushman Bharat” and “Swasthya Sathi” should also be done.[33],[34] Non-governmental Organizations (NGOs) and community volunteers may be roped in to do this much needed duty. NGO's such as The National Domestic Workers' Movement, HOPE, and ActionAid have been working for domestic workers. They have been active in the process of getting domestic work recognized and also providing workers with all forms of assistance including necessary legal help.[35],[36],[37]

Strengths and limitations

Being a field-based study of longitudinal design, this study effectively manages to highlight the work and health related vulnerabilities of women domestic workers, in view of the COVID-19 pandemic. Also, the research adds valuable evidence in its domain, since existing data on domestic workers are currently inadequate. As limitations, recall bias and social desirability bias could have affected the results of the study. Also, due to resource constraints and associated movement restrictions during the pandemic, women domestic workers from slums of no more than one locality of Kolkata city could be chosen.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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