ASSESSMENT OF EXPOSURE TO FLOUR DUST, RESPIRATORY EFFECTS AND

CONTROL MEASURES AMONG BAKERY WORKERS IN EDO CENTRAL

SENATORIAL DISTRICT, EDO STATE, NIGERIA

A DISSERTATION

BY

DR. MERCY AIGUOMUDU

DEPARTMENT OF COMMUNITY MEDICINE
IRRUA SPECIALIST TEACHING HOSPITAL
IRRUA, EDO STATE

TO

FACULTY OF PUBLIC HEALTH

NATIONAL POSTGRADUATE MEDICAL
COLLEGE OF NIGERIA

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF

FELLOWSHIP OF THE COLLEGE IN PUBLIC HEALTH

MAY, 2018
 NATIONAL POSTGRADUATE MEDICAL COLLEGE OF
NIGERIA

1 Name of candidate: AIGUOMUDU OSADEBAMEN MERCY

2 Faculty of candidate: Faculty of Public Health

3 Name of Training Institution: Irrua Specialist Teaching Hospital

4 Address of Training Institution: Km 87, Benin-Auchi Way Express, Irrua, Edo State.

5 Month and Year Part 1 was Passed: June, 2013

6 Part 2 Examination Date: May, 2018

7 Title of Dissertation: Assessment of exposure to flour dust, respiratory effects and

control measures among bakery workers in Edo Central Senatorial District, Edo

State, Nigeria.

ii
 DECLARATION

I, Dr. Aiguomudu Mercy, hereby declare that this research dissertation is an original work. It

is being submitted for the award of Fellow of the National Postgraduate Medical College of

Nigeria (NPMCN). This dissertation has not been submitted before for any award or

examination at this or any other institution.

…………………………………
Dr. Aiguomudu Mercy

iii
 CERTIFICATION

We certify that this work was carried out by Dr. Aiguomudu Mercy of the Department of

Community Medicine, Irrua Specialist Teaching Hospital, Irrua, under our Supervision.

……………………………………………….
Supervisor,
Prof. Antoinette N. Ofili
MBBS, FWACP, FMCPH
Department of Community Health,
University of Benin Teaching Hospital,
Benin-City, Edo State.

………………………………………………….
Supervisor,
Professor S.O. Abah
MBBS, FWACP
Department of Community Medicine,
Irrua Specialist Teaching Hospital,
Irrua, Edo State.

……………………………………………
Head of Department,
Dr A.D Asogun
MBBS, FWACP
Department of Community Medicine,
Irrua Specialist Teaching Hospital,
Irrua, Edo State.

iv
 DEDICATION

I dedicate this work to God almighty, for giving me the strength to accomplish this task.

v
 ACKNOWLEDGEMENT

I am indeed grateful to my supervisors, Prof A.N Ofili and Prof S.O Abah, for their support

and guidance throughout this work. My profound gratitude goes to my parents, husband and

children for their understanding and patience.

vi
 TABLE OF CONTENTS

Pages

Introduction ii
Declaration iii
Certification Iv
Dedication v
Acknowledgement vi
Table of Contents vii-ix
List of Abbreviations x
Operational Definition xi-xii

Summary xiii-xiv

CHAPTER ONE: INTRODUCTION

1.1 Introduction 1-4

1.2 Statement of the Problem 4-6
1.3 Justification of the Study 6-7
1.4 Research Questions 8
1.5 Research Hypotheses 8-9
1.6 General Objectives 9
1.7 Specific Objectives 9
1.8 Scope of Study 9-10

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction 11
2.2 Regulation of Bakeries and Work-Related Hazard in Nigeria 11-15
2.2.1 Occupational Health Services for Bakery Workers 15-16
2.2.2 Health Promotion and Hazard Prevention in Bakery Settings 16-19
2.2.3 Medical Examinations in Bakeries 19-22
2.2.4 Control of Hazards in Bakeries 22-25

vii
2.3 Exposure Levels to Flour Dust 25-29
2.4 Prevalence and Risk Factors for Respiratory Symptoms 29-35
2.5 Abnormality of Lung Function Test due to Exposure to Flour Dust 35-39
2.6 Control Measures for Flour Dust Exposure 39-43
2.7 Conceptual Framework 43-44
CHAPTER THREE: METHODOLOGY
3.1 Study Area 45-46
3.2 Study Design 46
3.3 Study Population 36-47
3.3.1 Inclusion Criteria 47
3.3.2 Exclusion Criteria 48
3.4 Study Duration 49
3.5 Sample Size Determination 49-50
3.6 Sampling Technique 50-51
3.7 Research Assistants 51
3.8 Study Instruments 51-53
3.9 Pretesting 53
3.10 Methods of Data Collection 53-59
3.11 Data Management 59
3.11.1 Interpretation of Spirometry 59
3.11.2 Interpretation of Checklist 59-60
3.11.3 Measurement of Variables 60-61
3.11.4 Statistical Analysis 61
3.12 Ethical Consideration 61-62
3.13 Limitations 62-63
CHAPTER FOUR: RESULTS 64
Section A 65-70
Section B 71-80
Section C 81-93
Section D 94-103

viii
Section E 104-114

CHAPTER FIVE: DISCUSSION 115-125

CHAPTER SIX: CONCLUSION AND 126-127

RECOMMENDATIONS
REFERENCES 128-139

APPENDICES 140-163

ix
 LIST OF ABBREVIATIONS

ACGIH - American Conference of Governmental Industrial Hygienists

AM - Arithmetic Mean

ATS - American Thoracic Society

B.T.P.S - Body Temperature and Ambient Pressure Saturated with Water

Vapor

ERS - European Respiratory Society

FVC – Forced Vital Capacity

FEV1 – Forced Expiratory Volume in the First Second

FEV1/FVC - Forced Expiratory Ratio

GM - Geometric Mean

GSD - Geometric Standard Deviation

HSE - Health and Safety Executive

IOM - Institute of Occupational Medicine

LGA – Local Government Area

PM: - Particulate Matter

PM2.5: - Particulate Matter less than 2.5µm in diameter

PM7: - Particulate Matter less than 7µm in diameter

PM10: - Particulate Matter less than 10 µm in diameter

OA - Occupational Asthma

TSP - Total Suspended Particulate

TLV - Threshold Limit Values

x
 OPERATIONAL DEFINITION

Atopy

It is the genetic predisposition to develop allergic diseases such as allergic rhinitis, asthma

and atopic dermatitis. It is typically associated with heightened immune responses to

common allergens, especially inhaled allergens and food allergens.

Dust

They are small solid particles, conventionally taken as those particles below 75μm in

diameter, which settle out under their own weight but which may remain suspended for some

time.

Forced vital capacity

The maximal volume of air exhaled with maximally forced effort from a maximal inspiration,

i.e. vital capacity performed with a maximally forced expiratory effort, expressed in liters at

body temperature and ambient pressure saturated with water vapor (B.T.P.S).

Forced expiratory volume in the first second (FEV1)

The maximal volume of air exhaled in the first second of a forced expiration from a position

of full inspiration, expressed in liters at B.T.P.S.

FEV1/FVC ratio

The ratio of forced expiratory volume in the first second and the forced vital capacity. It gives

the pattern of respiratory dysfunction which could either be a restrictive or an obstructive

defect.

Inhalable particulate matter

It is that fraction of a dust cloud that can be breathed into the nose or mouth. They are of a

diameter of 10µm or less (PM10) and can induce adverse health effects.

xi
Respirable particulate matter

It is that fraction of inhaled airborne particles that can penetrate beyond the terminal

bronchioles into the gas-exchange region of the lungs. They are of 2.5µm or less in diameter

(PM2.5). They therefore comprise a portion of PM10.

Occupational Asthma

It can include one or the combinations of work-related respiratory symptoms (wheezing,

cough, dyspnea, chest tightness), specific immunological sensitization, variation in serial

peak-flow measurements and increased nonspecific bronchial responsiveness. The symptoms

may resolve after some time away from work.

Spirometry

A method of assessing lung function by measuring the volume of air that a subject can expel

from the lungs after a maximal inspiration as a function of time.

xii
 SUMMARY
Introduction: Exposure to flour dust in the workplace can lead to ill health of workers and

ultimately decreased productivity. Despite these effects, little attention has been given to the

evaluation of the health of workers in the flour processing industry in Nigeria. This study

sought to investigate the exposure levels to flour dust, respiratory effects and control

measures among bakery workers in Edo Central senatorial district, Edo State.

Methods: A cross sectional analytical study utilizing a total population survey, involving 118

bakery workers from 10 bakeries who were matched for sex, age, weight and height with 118

workers in water packaging companies was carried out. A semi-structured interviewer

administered questionnaires and spirometry were used for data collection. Dust monitoring

was done in both the study and comparison sites with the aid of a portable dust meter. A

walkthrough and observational checklist was used to assess the availability of control

measures. Data analysis was done using IBM SPSS Statistics version 20. Ethical clearance

was obtained from the Ethics and Research committee of Irrua Specialist Teaching Hospital.

Results: Particulate mass concentration was higher in the study than control groups with a

mean concentration of PM10 of 0.50 ± 0.20mg/m3 in study sites and 0.18 ± 0.09mg/m3 at

control sites and the difference was statistically significant (t = 2.908) (P = 0.016). The mean

value of PM10 (0.74mg/m3) was particularly higher at the mixing points in the bakeries than

at baking and dough preparation sites and this was statistically significant (F = 6.012) (P =

0.009). Prevalence of respiratory symptoms was higher in the study group with runny nose

and sneezing 40.7%, cough 31.4%, sputum production 26.3%, chest tightness 22.9%,

breathlessness 16.1%, wheeze 5.1% and asthma 5.1%. In the control group, prevalence of

respiratory symptoms ranged between 0.8% and 5.1%. The difference in the prevalence of

respiratory symptoms between study and control groups was statistically significant. (P <

0.0001). Mean pulmonary function values were significantly lower in the study group for

xiii
percent predicted FEV1 = 73.08 ± 13.94 (P = 0.000) and percent predicted FVC = 79.25 ±

9.70 (P = 0.000) compared to controls, percent predicted FEV1 = 82.54 ± 10.99 and percent

predicted FVC = 87.60 ± 8.41. An obstructive pattern of lung function was exclusively

found in the bakery workers (14.4%), while none of the control group had an obstructive

pattern. Majority (100%) of the bakeries surveyed had good process controls while 80% had

poor structural controls and 90% had poor behavioral and administrative controls.

Conclusion: This study showed a higher exposure to particulate flour dust and a higher

prevalence of respiratory symptoms and reduced spirometry parameters among bakery

workers and inadequate control measures in the bakeries in Edo Central Senatorial district.

The results indicate high levels of exposure to inhalable dust and thus have strong

implications for improved dust control in the flour industry. Adequate control of flour dust

exposure should be employed in bakeries to reduce the prevalence of respiratory disease

among bakery workers.

xiv
 CHAPTER ONE

INTRODUCTION

1.1 INTRODUCTION

Wheat flour is one of the basic materials used daily for domestic and industrial purposes

globally. Locally, it has various uses, ranging from bread production to pastries such as cakes,

doughnuts, eggrolls and pies. Exposure to flour dust occurs commonly in bakeries,

confectionary, flour mills and animal feed plants.1 Workers in these industries are exposed to

flour dust in varied proportions depending on the nature of work done. From mixing flour and

ingredients, dough making and baking in bakeries; milling, packing and cleaning in mills to

milling and feeding in agriculture.1 In Nigeria, bakery workers and flour mill workers are the

occupational groups most commonly exposed to flour dust. The major routes of exposure to flour

dust include inhalation, inadvertent ingestion, ocular and dermal contact. Inhalation, ocular, and

dermal contact are occupationally significant routes.1 While inhalation may give rise to upper or

lower respiratory tract symptoms, dermal contact may result in occupational dermatitis and

ocular contact in occupational conjunctivitis.2

Bakery workers are exposed to varying amounts of flour dust during their work processes. The

flour becomes easily airborne during job tasks, such as weighing, sieving, mixing ingredients,

dough-making, baking and cleaning, some of which give rise to peak exposures. Exposure to

flour dust can result in harmful effects on the respiratory tract and diminished pulmonary

function among bakery workers. Flour dust causes allergic rhinitis and occupational asthma in

workers who are exposed, and is thus referred to as a respiratory sensitizer. Apart from causing

allergy, it can also act as an irritant and cause respiratory, nasal and eye symptoms which may be

short term. Among workers exposed to flour dust, the irritant symptoms caused by flour dust

1
have been observed to be more than the allergic ones.3 There are allergenic proteins (albumins

and globulins) in wheat flour responsible for the IgE mediated hypersensitivity reaction.4,5

Manifestation of respiratory symptoms and occupational asthma may result after a period of

exposure required to acquire immunologically mediated sensitization.6 This time period could be

a few months, years or even decades.7 A median duration of 1 year (1month - 4.2 years) has been

recorded between the start of work in a bakery and the onset of chest symptoms and 0.5 year

(1month – 3.3 years) for the onset of eye and nose symptoms.8 Manifestation of respiratory

symptoms are related to periods at work and workers experience relieve when they are off work

at weekends or holidays. Overtime time, symptoms may persist even when the bakery worker is

away from work.9

Exposure to flour dust is the most important risk factor for the development of respiratory

symptoms and occupational asthma. A study showed that 11.5% of subjects with occupational

rhinitis developed occupational asthma and of these, 11.6% were exposed to flours and grains.10

Other risk factors include age, sex, atopy and cigarette smoking.11 Particle size and immune

status of the individual are also important. A large amount of flour dust particles is over 10µm in

diameter and therefore lodge in the upper respiratory tract. However, in dusty situation, up to

20% of airborne flour particles are of a diameter that can be deposited in the bronchial airways

and alveoli.12 These flour particles lower the ability of macrophages to eliminate them, penetrate

the lung interstitial, cause irritation and set up an inflammatory response. Fibrosis occurs

following inflammation, this decreases the diffusion of oxygen across the lung surface and leads

to a reduction in lung function.13

2
Airborne flour dust is a major contributor to morbidity among workers in the food processing

industry. In studies among bakery workers, 10%-28% of workers were sensitized to flour

allergens while the prevalence of Baker’s asthma was reported to be between 5% and 17%.
5,8,14,25
Development of occupational asthma depends on the dose of flour dust and the duration of

exposure as explained by exposure-response studies. 15,16

Bakery workers have been observed to have long working hours in shift work and may work for

at least 6 days in a week. This is largely due to the fact that bread is in high demand locally. Also

bakery workers like other industrial workers in developing countries have been observed to be

largely of low educational background, and therefore may not be aware of their rights and

responsibilities for health and safety.17

In Nigeria, the Factories Act (1990) makes provision for the health, safety and welfare of

workers. However, the laws under this act have not been enforced due to lack of government

commitment and the unavailability of manpower.17 The National Council for Occupational

Safety and Health is empowered to enforce the Labor, Safety, Health and Welfare Bill of 2012,

which seeks to involve stakeholders at all levels even within the industries, to work together and

ensure the safety of employees at the workplace.18

In addition, the exposure standards set for flour dust in Nigeria are not sufficiently protective in

preventing sensitization to flour dust allergens. The Federal Environmental Protection Agency of

Nigeria sets a limit of 0.25mg/m3 as the threshold limit value for all nuisance particulates thought

to be inert including flour dust.19 Nuisance particles are regarded as primarily having aesthetics

effects, however, flour dust has been given a sensitization notation by the American Committee

of Governmental Industrial Hygienists (ACGIH) because of its allergenic potentials. The ACGIH

sets a value of 0.5mg/dl as the threshold limit value for flour dust.20 In the UK, a maximum

3
exposure limit (MEL) for flour dust is set at 10 mg/m3 [8 hour time-weighted average (TWA)]

with a short-term exposure limit (STEL) of 30 mg/m3 (15 min reference period).21

1.2: STATEMENT OF THE PROBLEM

Studies have shown that wheat flour dust exposure causes an increase in the prevalence of

respiratory symptoms and lung dysfunction.22,23 Prevalence of probable occupational asthma in

epidemiological studies ranges between 4-13% in studies of industrial bakeries in which a

similar definition of occupational asthma was used.22 There are no globally accepted definitions

of occupational asthma, definitions depend on the purpose of its use.24 Prevalence of respiratory

symptoms among workers exposed to flour dust can be as high as 60% of the population

depending on the definition of the symptom and the (sub)population under investigation.25

Among 392 workers in a Korean bakery, the prevalence of rhinitis was 31.6% and of asthmatic

symptoms was 13.5%.26 In France among 44 bakery workers and 164 control subjects, the

prevalence of one or more respiratory symptoms was 59% and 35% among bakery workers and

controls respectively.27

A study in Ibadan, Nigeria, among 91 flour millers, 30 internal controls and 121 external

controls, 54% of the flour millers reported at least one respiratory symptom, compared to 30% of

internal controls and 19% of external controls. The prevalence of cough among flour millers was

40%.28 They also observed that a higher proportion of production workers (29%) had at least one

abnormal spirometer test than 10% of internal controls and 15% of external controls.29

Health problems resulting from exposure to flour dust may appear to occur less frequently than

other major disabling diseases, because they are not being recognized. Also, records of

occupational diseases are poor in Nigeria, primarily because industries do not report cases to the

relevant government agency and health surveillance systems are non-existent as in most

4
developing countries.30,31 While regulations are being enforced in some industrialized countries

(the United Kingdom and the Netherlands) to reduce exposure levels of flour dust to levels

below recommended limits, little or nothing is being done in Nigeria. 23,32

Recent studies of the global burden of disease over the last two decades indicate that

occupational lung diseases caused by exposure to airborne particulates presents a major health

challenge with significant potential for acute morbidity, long-term disability, and adverse social

and economic impacts particularly in developing countries.33 They are severe enough to affected

individuals to cause workplace absence, change of job, disability and eventual work cessation.34

Employees with high intensities of exposure to flour dust are at increased risk of developing both

work-related symptoms and positive skin tests irrespective of their age, sex, atopic state and

smoking status.11 It has been noted that prevention strategies in bakeries, even in some developed

countries, have been poor.35 Improvements in the work environment can contribute significantly

to decreasing the risk of sensitization for the unaffected worker and also reduce the risk of

precipitating symptoms in the already sensitized workers. These improvements include

engineering controls, specific work practices and personal protective equipment.

In several countries, strategies to prevent exposure to excessive amounts of wheat flour dust in

bakeries and thus reduce harmful effects have not been applied adequately, despite strong

evidence which supports institution of control measures.35 Engineering controls such as process

enclosure, local exhaust ventilation and adequate general ventilation are not being provided by

employers because they consider them to be expensive. They may rather choose to apply cheaper

methods such as making personal protective equipment available, rather than deal with allergen

exposure at source as would have been expected in the hierarchy of controls.36 However,

provision of these equipment does not equate use because the bakery workers may not be

5
sufficiently motivated to utilize such behavioral measures. Administrative controls such as

improved work practices, education and training of bakery workers are likewise important.

In Nigeria, small and medium scale industries are unlikely to provide occupational health

services or conduct medical surveillance programs.37 Some authors have observed that the use of

protective equipment among workforce in small scale industries, such as saw-mill and flour mill,

in Nigeria is poor.31,38 However, the nature of the problem with wheat flour dust exposure among

bakery workers in Nigeria, such as measurement of exposure levels, prevalence of respiratory

symptoms and dysfunction and availability of control measures have not been adequately

studied. 28,38

In developed countries, occupational hygiene surveillance programs employ either; direct

observation of work processes; exposure assessment of dust levels; or direct sampling and

environmental measurement of specific occupational allergens.39 For medical surveillance,

questionnaires, spirometry and immunological tests such as skin prick tests are commonly used

so as to detect respiratory effects and dysfunction early on before it becomes severe or

irreversible.40

1.3 JUSTIFICATION OF STUDY

There is overwhelming evidence that workplace exposure to flour dust should be controlled

because of the consequences to worker’s health.32,41 However, this is still a challenge in

Nigeria.28,29 This may not be unconnected to poor enforcement of regulations and lack of

awareness of managers and employees on the effects of uncontrolled exposure. In Nigeria, few

researchers have assessed exposure to flour dust in bakeries through dust sampling combined

with subjective and objective evaluation of health outcomes with questionnaires and measuring

respiratory function.28,29,38,42 Exposure assessment will serve to produce baseline values for

exposure levels and thus make recommendations for the need to improve control measures, if
6
they are found to be inadequate or to develop new ones. While estimating the prevalence of

respiratory symptoms and lung function abnormalities due to exposure to flour dust and the

availability of control measures, this study will contribute to advancing the health of bakery

workers who are exposed and may suffer dire consequences.

While industrialized countries have set exposure limits for particulate flour dust and relevant

authorities are making efforts to reduce exposures below these limits, this is not the case for

bakeries in Nigeria where regulations are not being enforced. It is widely accepted that the

exposure standards for ‘general’ dust are not appropriate for assessing the relevance of elevated

exposures to flour dust which has a highly allergenic nature.4,51 This study will therefore provide

some data that may be useful for policy makers in setting exposure limits for particulate flour

dust in Nigerian bakeries.

Diagnosis of occupational asthma requires an objective assessment of airflow limitation. A

stepwise approach has been suggested where subjects who report respiratory symptoms or those

of asthma are further investigated, after having been identified with a questionnaire. Further

tests include skin prick test, measurement of immunoglobulins (IgE), spirometry and bronchial

challenge tests.43 These other tests will detect some cases of respiratory dysfunction or

occupational asthma that would have been missed by respiratory questionnaire.44 In Nigeria,

there is a paucity of studies on the burden of occupational respiratory disease among bakers. 28,38

To the researcher’s knowledge, there are no published studies on availability of control measures

to reduce exposure to flour dust. Even exposure assessments have rarely been documented

among bakery workers. This study proposes to assess flour dust exposure levels in bakeries and

respiratory disorders among bakery workers. It will also evaluate existing control measures with

a view of making recommendations to appropriate authorities (employers, health inspectors and

occupational health services).

7
1.4 RESEARCH QUESTIONS

1. What is the magnitude of particulate flour dust exposure in bakeries in Edo Central

Senatorial District?

2. What are the effects of exposure to flour dust on respiratory symptoms and pulmonary

functions of bakery workers in the study area?

3. What is the relationship between exposure levels of flour dust and respiratory symptoms in

bakery workers in Edo Central Senatorial District?

4. Do independent variables (age, sex, weight, smoking status, atopy and duration of

employment) have an influence on respiratory symptoms of bakery workers in the study

area?

5. What is the pattern of airway disease among bakery workers in Edo Central Senatorial

District?

6. What are the flour dust control measures available in bakeries in the study area?

1.5 RESEARCH HYPOTHESES

Null hypotheses

1. H0 = There is no difference in flour dust exposure levels for the different job tasks in

bakeries (weighers/mixers/sievers, dough makers, bakers, packaging and manager).

2. H0 = There is no difference in respiratory symptoms between flour dust exposed group

and unexposed (control) group.

3. H0 = There is no difference in lung function between flour dust exposed group and

unexposed group.

8
Alternative hypotheses

1. HA = there is a difference in flour dust exposure levels for the different job tasks in

bakeries (weighers/mixers/sievers, dough makers, bakers, packaging and manager).

2. HA = There is a difference in respiratory symptoms between flour dust exposed group and

unexposed (control) group.

3. HA = There is a difference in lung function between flour dust exposed group and

unexposed group.

1.6 GENERAL OBJECTIVE

To assess exposure levels to flour dust, respiratory effects and control measures among bakery

workers in Edo Central Senatorial District.

1.7 SPECIFIC OBJECTIVES OF THE STUDY

1. To determine particulate flour dust exposure levels in bakeries in Edo Central Senatorial

District.

2. To determine the prevalence of respiratory symptoms among bakery workers in Edo

Central Senatorial District.

3. To assess lung function parameters in bakery workers in Edo Central Senatorial District.

4. To assess availability of flour dust control measures in bakeries in Edo Central Senatorial

District.

1.8 SCOPE OF THE STUDY

This study will measure flour dust exposure in bakeries and will pay particular attention to

assessing the respiratory effects (symptoms and lung function) due to inhalation/exposure to

9
flour dust and availability of control measures. It will not assess other effects of exposure to flour

dust such as those due to contact to the skin, eyes or oral ingestion.

10
 CHAPTER TWO

LITERATURE REVIEW

2.1 INTRODUCTION

Sensitization to flour is often regarded as a prerequisite for the diagnosis of baker’s asthma. The

Dutch expert committee on occupational standards estimates that a person, who starts working in

the bakery or flour milling industry for the first time, has a chance of 1% for ever becoming

sensitized to flour dust, if exposed to an average of 0.12 mg/m3 of inhalable dust.45 Sensitization

which is IgE mediated is known to occur in those who are already predisposed (atopic subjects)

or it can lead to an onset of allergic symptoms which culminant in occupational asthma.9 The

most important risk factor for the development of occupational asthma is exposure. The higher

the level of exposure, the more likely the sensitized person is to develop occupational asthma.46

Various authors have consistently reported that rhinitis is a significant risk factor for adult onset

asthma, and that the appearance of ocular-nasal symptoms could be used to identify workers at

increased risk of developing occupational asthma.9,47

2.2 REGULATION OF BAKERIES AND WORK-RELATED HAZARDS IN NIGERIA

There are interventions in the workplace, which are either political or legal that are aimed at

controlling exposures to hazards. These interventions are usually developed at a regional or

national level and could be in the form of regulations, policies or programs with a central

implementing body. This body could be the government, trade or professional associations or

employer and employee groups. The International Labor Organization in 1981 set forth the

Occupational Safety and Health Conventions for all branches of economic activity which states

that, “each member shall, in the light of national conditions and practice, and in consultation with

the most representative organizations of employers and workers, formulate, implement and

periodically review a coherent national policy on occupational safety, occupational health and
11
the working environment. The aim of the policy shall be to prevent accidents and injury to health

arising out of, linked with or occurring in the course of work, by minimizing, so far as is

reasonably practicable, the causes of hazards inherent in the working environment.” National,

regional and local governments utilize this principle as a framework for the development of

policies for the prevention of work related injuries, diseases and death.48 It also implies that

organizations are also to have their stated policy directions on occupational health and safety at

the workplace.

There are sets of regulations, rules and legal provisions that help in protecting the health, safety

and welfare of people in the workplace,30 and are called Occupational Safety and Health

Regulations.18 In Nigeria, regulations to ensure the health and safety of workers are contained in

two acts; the Factories Act of 1987 (now 1990) and the Employee Compensation Act.30 Under

the Factory Act, every new or existing factory are to be registered under the Director of Factories

who issues a certificate of registration. Issues relating to general provisions for health such as

cleanliness, avoidance of overcrowding, ventilation, lighting, drainage of floors and sanitary

convenience are stated under this Act.49 Also, included in this Act are provisions for safety such

as, in the use of machinery, precautions in places where dangerous fumes, inflammable dust, gas

or vapor are present. There are special regulations as to the protection of employees against the

inhalation of dust or fumes generated in production processes, by all practicable means.

Accidents and industrial diseases are to be notified to the Inspector of Factories under this Act.

The Act empowers the factory Inspector to issue a prohibition notice to a factory when there is a

risk to the safety and health of persons employed within the factory.49

The Factories Act has been observed in violation by factory owners who wait for the

enforcement authority to point out their shortcomings before steps are taken to correct them. In

so doing, accidents, injuries and fatalities which could have been prevented may have occurred.
12
The Labor, Safety, Health and Welfare Bill of 2012, seeks to repeal the Factories Act and serve

as a comprehensive OSH legislation for the workplace. It seeks to ensure compliance to health

and safety regulations by: introduction of safety advisers in organizations and introduction of

competent and effective safety and health committee. Organizations will be mandated to

formulate safety polices and appoint competent safety persons who will be responsible for safety

issues in the organizations. These grass-root OSH committees and the safety & health

representatives are to monitor, regulate and maintain the safety of the employees in the

workplace. This approach is preventive and collectively participatory and is in tandem with

International Labor Standards.18

In Nigeria, the Employee Compensation Act, 2010, which repeals the Workmen Compensation

Act, provides comprehensive compensation to employees who suffer from occupational diseases

or injuries arising from accidents at the workplace or in the course of employment. The principle

underlying this Act is that the employer has a duty of care and a duty to protect the health,

welfare and safety of workers at work. The strength of this Act includes; the entitlement to

compensation for the injured or deceased worker regardless of who is at fault, the creation of

collective liability wherein all employers both in private and public sectors of the economy

collectively share the responsibility for funding the costs for workers’ compensation insurance

and the payment of compensation claims. A noticeable shortcoming of this Employee

Compensation Act 2010 is that a section of it provides that neither the employee nor his

dependants shall be entitled to compensation for a disability or death unless the employee was

free from the disease before being first exposed to the agent causing the disease in the

workplace. It therefore implies, that some employers may evade payment of compensation on

this ground. However, it can be contended that there is no justification for this provision because

13
under some sections of the Labor Act, the employer has the duty to medically examine every

worker before commencement of work or as soon as possible thereafter.50

Other regulatory agencies in Nigeria involved in inspection of facilities, laboratory tests of

products and approval of facilities and products include the National Agency for Food and

Drugs, Administration and Control (NAFDAC), the Standards Organization of Nigeria (SON),

the Federal environmental protection agency (FEPA) and State Environmental Protection

Agency (SEPA). NAFDAC, investigates production facilities and the raw materials for food in

Nigeria, and certifies these sites and their products safe. SON ensures that local products meets

national standards. FEPA formulates policy on environmental issues; prescribes standards and

makes regulations into air quality, water quality, atmospheric protection and control of hazardous

substances and collaborates with State government to establish SEPA and action plans for

environmental protection.51 Enforcement of OSH regulations at the local government level can

help to improve OSH in Nigeria.

Regulations may also take the form of enforcement of maximum exposure limits for flour dust.

However, there is no generally acceptable occupational exposure limits for flour dust. Different

countries have set different limits enforceable under their jurisdiction. In Sweden, a

recommended limit value for flour dust exposure is 3 mg/m3 (8-h TWA). In the UK, a maximal

exposure level is equal to 10 mg/m3 (8-h TWA) and 30 mg/m3 (15-min TWA).21 ACGIH

recommends a TLV to achieve for inhalable flour dust of 0.5mg/m3 (8-h TWA).20 Therefore,

since occupational exposure limits protecting all workers cannot be identified, the proper

preventive measures, good manufacturing practices and efficient health surveillance systems

should be introduced in bakeries and other environments contaminated with flour dust.1

Work related hazards in bakeries as in other industries, are usually due to unsafe working

conditions and unsafe acts/behaviors. In order to ensure the safety and health of workers in the
14
bakeries, the employers and employees must have access to information on the nature of health

hazards and how they can be controlled. Employers have the responsibility to provide

information, instruction, training and supervision, in order to minimize worker’s exposure to

hazards and the corresponding risks.52 The main occupational health risks in bakeries include

musculoskeletal injuries from manual handling and lifting of flour bags and other heavy objects,

work-related upper limb disorders resulting from repetitive tasks, noise induced hearing loss

from noise generating processes such as depanning and slicing and occupational asthma and

respiratory ill-health from exposure to flour dust. Other risks are exposure to high temperatures

in the oven area which may result in contact burns, fire outbreaks which may occur through

explosion from settled dust, contamination of baked foods by unclean machines and hands and

rodents and pest infestation.53,54

2.2.1 OCCUPATIONAL HEALTH SERVICES FOR BAKERY WORKERS

In Nigeria, workers in small-scale industries, particularly those in the informal sector have little

or no access to occupational health services. For this category of workers, more than 60% of the

total Nigerian workforce, government hospitals, private general practice clinics, chemist shops

and dispensaries are the main sources of health care for their general health problems. 31

Occupational health services for bakery workers should aim to connect with other health

professionals outside the bakeries to provide necessary flow of health information and

comprehensive health care (preventive, curative, rehabilitative and compensation). They should

link health surveillance for specific hazards and specific diseases with health promotion activities

and possibly research in occupational health.55 At a minimum they should include pre-

employment examinations which aim at assessment of employee’s health before the start of

employment as a basis for follow-up and recognition of diseases that can affect work ability.

There may be need to exclude especially susceptible employees from work that is hazardous to
15
their health such as excluding asthmatics from work with sensitizers such as flour dust. When

pre-employment examination was not carried out at the start of employment, there would be no

evidence that a worker with occupational asthma did not have asthma before starting work. The

employer may avoid payment of compensation to the worker on this ground. However, there is

no justification for this, because pre-employment examination should have been done in the first

place.56 Occupational health professionals should provide advice on the adaptation of work to

workers by advising the employer and workers on modification of the job, equipment and

working environment to allow workers perform their duties effectively and safely. They can

provide information and organize health education and training on awareness of hazards, existing

risks and ways workers can protect themselves from hazards while emphasizing the

responsibilities of employers and employees.55

Insufficient knowledge on the management of risks at the workplace may be responsible for the

exposure of bakery workers to hazards. In Nigeria, it is common place for information on health

and safety at workplace to be passed on informally by employers and fellow employees. The

formal occupational health units are found mostly in large scale companies while small scale

ones cannot afford on-site occupational health clinics. It is the duty of employers to inform

employees of workplace hazards, their likelihood of occurrence and consequences with measures

aimed at controlling them. 37

2.2.2 HEALTH PROMOTION AND HAZARD PREVENTION IN BAKERY SETTING

The workplace is significant both in affecting people's health and as a context in which to

promote health. The workplace is a key setting for health promotion for a number of reasons.

First, the workplace gives access to a target group, healthy adults, especially men, who are often

difficult to reach in other ways. Employees in the workplace are a captive audience for health

promotion because workers can be encouraged to participate in health programmes as there are
16
established modes of communication.57 The second reason for promoting health in the workplace

is to ensure that people are protected from the harm to their health that certain jobs may cause.57

Thirdly, there are economic benefits associated with healthy workplaces. Research has shown

that employees who have three or more risk factors (e.g. smoking, overweight, excessive alcohol

intake, physical inactivity) are likely to have 50% more sickness absence from work than

employees with no risk factors and thus reduced productivity.58 Fourthly, the workplace provides

a resource for health that is relevant to a large percentage of the adult population. Creating a

healthy environment at work will benefit employees’ health and have positive spin-offs for their

families and communities. The traditional focus on the workplace has centered on hazards and

illnesses, but a health-promoting approach to the workplace has great potential. When the

working environment is conducive to health, productivity is more than when the working

circumstances are adverse to health.17,57

The relationship between work and health is complex. In general, attention has focused on the

effects of work on health, although it is also acknowledged that poor health will have negative

effects on the capacity for paid employment. There is evidence that paid work is good for health

and unemployment can be linked to ill health.59 Work is beneficial for health because it provides

an income, a sense of self-worth and social networks of colleagues and friends. However, work

may also harm health, and most research has concentrated on this aspect of the relationship. The

different partners and stakeholders responsible for workplace health promotion are the workers

and their trade unions or staff associations, employers and managers, occupational health staff,

health and safety officers, public health specialists and environmental health officers.57 Worker’s

organizations such as trade unions are to ensure that employees work in safe and healthy

conditions. Through trade unions workers can make a demand on management for their health

and safety.17

17
There is widespread acceptance of the requirement to provide safe working conditions. Health

promotion programs in the workplace are still not widespread and are more likely in large

workplaces. Programs include smoking cessation, alcohol counselling, weight management,

exercise and fitness interventions, general health screening and stress management courses.57

Wellness promotion activities can be incorporated into occupational health programs in bakery

settings. They can include health education, stress management at work and home. The aim of

health promotion at the workplace is to change unhealthy lifestyles such as alcohol and drug

abuse, smoking and encourage a healthy diet and regular exercise. This will improve health

status and wellbeing of the workers and thus their productivity. Since emphasis is on personal

health habits rather than protection of workers against occupational hazards, health promotion at

the workplace has also being referred to as public health services delivered in the workplace.55

The best method of preventing adverse health outcomes in bakeries is to provide an environment

that is free from hazards. This involves reducing the amount of flour dust in the environment to

the lowest level. This can be through systemic, technical, organizational or personal measures.

Systemic measures require designing suitable systems of work and maintaining plant and

equipment in safe and hygienic conditions; cleaning workplaces to reduce flour dust generation,

easy to clean surfaces, facilities for changing and cleaning work clothes, facilities for hand

washing.1 Technical measures include reduction of the release of flour dust such as immediate

processing of materials, shielding of equipment to reduce dust emissions, replacement of manual

processing with automation, a system for air filtration such as mechanical fans or air

conditioning. Organizational measures include isolation of workplaces, restriction of entry into

areas with high dust concentration, dissemination of information and training to promote safe

working habits, medical surveillance, proper labelling and safe storage of materials. Personal

measures include respiratory protection, personal protective equipment which should be used as

18
the last possible prevention measure only when reducing the level of risk to an acceptable level is

not possible.1

Occupational health services should provide prevention, diagnosis or treatment for occupational

illnesses. Hazard prevention in bakeries can take the form of either primary, secondary or tertiary

prevention. If bakery workers have the knowledge of workplace hazards, then proactive

measures can be taken to avoid exposure and prevent the occurrence of disease or injury.

Primary prevention of hazards, is aimed at individuals with the potential for exposure but have

not yet developed the disease.60 Secondary prevention is aimed at individuals in whom the

disease has started but have not developed symptoms or they are reversible. The process can be

reversed before symptoms develop. Identifying and withdrawing sensitized atopic individuals

from exposure is a form of secondary prevention. Tertiary prevention targets individuals with

symptomatic disease and the goal is to control or cure the disease.60 The need for secondary and

tertiary prevention is evidence of failure of the system to control exposure. For example, bakers

with rhinitis and sensitization to flour should be identified and relocated to working areas with

less exposure. Allergen-specific immunotherapy and other immunomodulatory treatments may

benefit those with uncontrolled severe baker’s asthma. Due to the fact that atopy is an important

risk factor for developing baker’s allergy, the identification and exclusion of atopic workers may

also be one of the possible strategies for prevention.1

2.2.3 MEDICAL EXAMINATION IN BAKERIES

The aim of medical examination is to ensure the worker is fit for employment and that he

remains fit throughout his period of employment. When there are early deviations from good

health, they are detected and treatment in the form of preventive or curative medicine is given.

Medical examination is for the mutual benefit of both the employer and employee. The employee

19
may need to continue employment after treatment or discontinue to the best interest of the

worker or management.17

Medical surveillance at bakeries should consist of pre-employment medical examination and

periodic medical examination. The aim of these examinations is to positively enquire about any

early symptoms of nasal and respiratory ill health. The benefits are twofold. Firstly, early

identification of cases will enable their optimum management and, secondly, a long-term check

is provided on the adequacy of dust control measures.61 Pre-employment medical examination

may include a questionnaire and skin prick test. The questionnaire enquires about present or past

nasal symptoms, asthma or chest illness. Baseline information on the health of the worker are

provided which can be used for follow-up. This examination can be conducted by a nurse or

medical practitioner to state the fitness of the worker. However, only the medical practitioner

can declare a worker unfit for employment. Skin prick tests can also be done at the beginning of

work at the bakery, to search for atopy.17

Periodic medical examination should be carried out at regular intervals after the initial medical

examination. It can be accomplished by a questionnaire which should be completed by all

workers at least annually to enquire about any developing symptoms. Skin prick test can also be

done at least annually to search for immunologic sensitization to flour allergens. If the worker is

found to be ill during this examination, he should be referred for a thorough medical

examination. As a part of medical surveillance, an individual case health management should

also be introduced among bakery workers. For example, bakery workers with rhinitis and

sensitization to flour should be identified and relocated to working areas with less exposure.

Bakery workers with sensitization to flour and no respiratory symptoms should have annual re-

examination.1

20
A surveillance program demonstrated that the use of a simple questionnaire model can help to

accurately detect or predict the probability of flour sensitization and work-related allergy among

bakery workers. In the program, 90% of bakery workers with asthma were effectively identified

in this way. This method can be incorporated into an already existing medical surveillance

system.1

In the bakery industry in the United Kingdom, health surveillance of workers is recommended

and this is done by a trained, responsible person, who understands their purpose and can keep

records. Employees who have symptoms are then referred to an occupational health professional

who can advise on any adverse findings from surveillance. If an occupational health specialist is

not available, the worker is referred to a doctor who may arrange for assessment by a specialist

chest or occupational health physician.61 During pre-employment screening, workers are asked

about present or past asthma or chest illness; the newly employed are advised of symptoms to

look out for and symptoms they must report. The Health and Safety Executive recommends that

follow-up screening should also be carried out at 6 weeks, 12 weeks and then annually after

employment. In this follow-up screening, workers are asked if they experience sore eyes, sore

throat, blocked or runny nose, coughing, breathlessness, chest tightness wheezing when at work.

Improvement of symptoms when not at home, during shifts or holidays is enquired about.

Employees are encouraged to report these symptoms at any time they occur. Employees’

sickness absence records are also checked for any pattern of respiratory illness. A record of the

information gathered is properly kept. If properly carried out, the findings of such a health

surveillance will be a good indicator of whether dust levels are causing ill health. The Health and

Safety Executive recommends that if no occupational ill health is detected over a period of years,

then health surveillance may be limited to a simple enquiry about past or present asthma, advice

on symptoms to watch out for and an annual positive enquiry to check that no symptoms have

21
gone unreported. This should be accompanied with proper record keeping of all enquiries

made.61

2.2.4 CONTROL OF HAZARDS IN BAKERIES

The first process in controlling hazards in the workplace is recognition that a workplace health

hazard exists. This may be apparent because of illness occurring in a worker or the workers or

managers recognized a hazardous situation even before someone became ill. Once the hazard has

been recognized, the problem will have to be defined before an assessment of the hazard can be

conducted. The problem definition could be the need to determine if exposures are high enough

to cause disease, issues of compliance with exposure standards, need for evaluating effectiveness

of new controls or need to build a database of exposure.60

An assessment of the hazard involves a qualitative exposure assessment and a qualitative health

assessment. An exposure assessment seeks to characterize the workplace by providing

information on all workers, tasks, agents, potential exposures and potential health effects. The

work processes should be understood and the potential exposures that can result from them. The

agents used in the workplace should be listed, the job descriptions, tasks and number of workers

noted. Also, the health effects data, current regulations and exposure limits should be examined.

This information can be obtained with a checklist to improve comprehension and organization.60

The qualitative health assessment involves determination of the illnesses or injuries that can

occur in the workplace. They may be recognized when workers are ill and preventive measures

may be put in place before the disease develops in the worker. Then an exposure profile can be

conducted to determine whether adverse health conditions exist and the relationship between

exposure and disease.60

22
There may be need to conduct a quantitative exposure assessment when information on baseline

exposure is needed, compliance with existing regulations is to be determined or a diagnosis is to

be made. A quantitative health assessment may be necessary at this point to determine that a

potential for illness or injury exists and there are reasons to suggest a workplace exposure is

related to disease but there is paucity of data on this association. Also, the need to institute

environmental controls will have to be justified. The health assessment may include the use of

questionnaires to survey workers on exposure and health status, physical and laboratory

examination of workers and evaluation on a group of workers to assess the relationship between

an agent and a disease condition.60

The next stage is to design interventions. This can be either at the level of exposure control,

medical intervention and surveillance or policy interventions. Exposure control are best done at

the source of the exposure rather than when exposure has reached the worker by employing a

hierarchy of controls. Different control measures should be combined to increase effectiveness of

hazard control.17,60

There can also be political and legal interventions that would control exposure. These

interventions include regulations, policies, and programs that are implemented on a regional or

national level. The policies may be developed and promoted by the government, trade

associations, or by employer and employee groups.17,60

As with any health and safety problem, the hierarchy of control measures should be followed.

Where possible, removing the hazard is the best option. Reliance on individual protection

through personal protective equipment (PPE) should normally be a last resort. The hierarchy of

control measures includes: eliminating hazardous agents by substitution which can be practiced

by limiting the generation of dust during dough preparation by using oil on the dough table

23
instead of dusting with flour.60,62 The application of local exhaust ventilation to get rid of flour

dusts from the point of dust generation. The breathing zone of workers can be kept free of flour

dusts which are drawn into the hood of the local exhaust ventilation by suction and conveyed

through ducts into collecting units.25,62

Segregation of harmful work processes such that the different tasks (mixing, dough making and

baking) are done in areas that are physically separated from other departments in the bakery.

This will protect workers not involved in dust generating activities. The number of those at risk

of exposure is thereby reduced.25,63 Limitation of time of exposure can be practiced in bakeries

by changing worker’s tasks from time to time such that a worker does not remain in a high dust

generating task such as mixing throughout the period of work within the bakery.17 Adequate

ventilation within the bakery will help to maintain an adequate dilution of flour dusts and reduce

their nuisance or harmful effects. Mechanical fans can be fixed in the ceilings in sufficient

numbers to improve their effectiveness.25

Cleanliness of the bakery is important to eliminate flour dusts from accumulating in the

workplace. This can be achieved by wet sweeping of the floor and use of wet mops at regular

times of the day and flour spillages cleaned immediately. Empty bags of flour should not lie on

the floor but should be kept neatly in the storeroom, which should also be clean and free of

damaged bags.25,63 Personal cleanliness helps to keep floor dusts away from personal clothes so

these are not contaminated and carried home where family members can become exposed. Work

clothes should be cleaned regularly so that flour does not remain on them which can encourage

inhalation of dusts.17

Personal protection is the last line of action in the control of hazards at work. All effort should

first be made to eliminate hazards at all work processes without the workers’ contribution.

24
However, personal protective equipment is needed to supplement other control measures. These

devices should be acceptable to the workers such as face mask, head gear and aprons and

workers should be trained in the correct way of using them. These personal protective devices

are more likely to be used if management provides them for the workers.17

2.3 EXPOSURE LEVELS TO FLOUR DUST

Assessment of exposure to environmental agents in the work place is an important aspect of an

epidemiological study. Bakers are exposed to varying amounts of flour dust and related allergens

during the process of flour handling. Exposure depends on the type of bakery, the production

process and the presence of ventilation. Exposure may thus cause airways sensitization and

trigger series of events leading to occupational asthma. Following the growth of small and

medium sized businesses in Nigeria and the high demand for bakery products, there has been a

proliferation of bakeries in the country. This has resulted in an increasing number of workers

potentially at risk of developing symptoms.28,42 Although exposure to inhalable flour dust among

workers in bakeries is very well documented in other parts of the world,29,32 and health problems

of other workers in Nigeria also documented, there is a paucity of information on the problems

of flour exposed workers in bakeries in the country.28,38

Exposure to flour dust occurs mainly in bakeries, where mixing, dough-making and bread-

forming, as well as cleaning are the dustiest tasks, and in mills, where milling, packing, cleaning

and maintenance are associated with exposure. Other occupations involving flour dust exposure

include confectionery (weighing, mixing, production), pasta and pizza bakeries, animal feed

plants, malt factories (drying, sieving, packing) and agriculture (milling, feeding).45

A study was done in UK bakeries to assess exposure to flour dust and current use of control

measure. The aim of the study was to estimate levels of exposure in UK bakeries and produce a

25
bench marking baseline of current control measures. A total of 208 long-term personal inhalable

dust samples (8 hour time weighted average -TWA) were collected from workers in 55 bakeries

between October 2002 and December 2003, in England, Wales and Scotland.32 Personal samples

were collected in the workers’ breathing zone using IOM sampling heads with glass fibre filters,

which was weighed before and after sampling was undertaken and the personal dust exposure

calculated (in mg/m3). The highest median exposures were from the mixers/sievers and weighers

5.2 mg/m3 (75th percentile at 9.7 mg/m3). 17% of the samples exceeded the UK MEL of

10mg/m3. Bakery size was the major factor having an influence on exposure levels, p < 0.001,

(with medium/large bakeries having higher inhalable flour dust concentrations than micro/small

bakeries). Other factors included bakery location and presence of a safety representative. This

study however reached this conclusions on determinants of exposure by using a regression model

which may not reflect the actual situation.32

In the Netherlands, datasets were compiled from four field studies done between 2000 and 2005.

These studies were designed to obtain a detailed overview of personal exposure levels to flour

dust across all jobs performed in four major flour processing sectors in the Netherlands:

traditional bakeries, industrial bakeries, flour mills and bakery ingredient producers. The current

use of control measures was also explored. Nine hundred and ten personal exposure samples

were included in the database. Exposure to flour dust was highest in flour mills; 2.7 (4.5) mg/m3

(GM) while industrial bakeries had the least exposure 1.0 (3.5) mg/m3. Tasks, such as dough

making, sprinkling flour and processing dough were associated with higher exposure levels to

flour dust in both traditional and industrial bakeries, while wrapping and cleaning were

associated with lower exposure levels. An exposure modelling showed significant variations in

exposure between companies and workers but did not explain the day to day differences in

exposure. This was due to the fact that frequency of exposure and time spent on different

26
activities was not taken into account which could obviously have varied for different companies

and workers. The strengths of this study includes the use of questionnaire information and

exposure models that enabled the researchers to generate individual exposure predictions for the

total population at risk in the study area.25

In a Korean study to evaluate the prevalence of serum specific antibodies in relation to work

related respiratory symptoms in a bakery, an exposure assessment was done. Dust samples were

collected with personal inhalable IOM dust sampler in the breathing zone of workers for an 8-

hour shift. Eighty-seven separate dust samples were collected from each department. Workers in

the mixing, weighing and sieving departments had the highest wheat dust exposure levels (GM

3.04 mg/m3).26

In Shiraz, Southern Iran, an analytical cross-sectional study was done at a local wheat flour mill.

Personal monitoring for airborne inhalable and respirable dust was done using a portable dust

sampler for 35 male workers. Inhalable and respirable dust concentrations were estimated to be

11.68 and 32.45 mg/m3, respectively. This exposure level was very well above the threshold

limit value of 0.5 mg/m3 for flour dust.64

An analytical cross-sectional study was done in South African bakeries to assess personal

inhalable exposure to flour dust and fungal α- amylase. By stratified random sampling, 109

workers were selected from 18 bakeries with an equal representation of all 5 job titles (baker,

bakery manager, bakery supervisor, confectioner and counter hand). Personal sampling was

performed on all subjects using an inhalable dust sampler. Bread bakers had the highest average

GM flour dust concentration (1.33 mg/m3) while counter hands had the lowest average

concentration (0.28 mg/m3). In this study, bread bakers were involved in dough making which

involves emptying bags of flour into the mixer, weighing ingredients and dusting steel tables and

bread with flour. Such tasks usually generate a high amount of dust compared to the task of
27
counter hands which involves serving customers stocking the counter and wrapping products

which is a relatively less dusty job.41

In 2004, an analytical cross-sectional study on respiratory symptoms of wheat flour millers was

carried out in Ibadan, Nigeria to relate particulate dust exposure with respiratory symptoms of

flour millers. Respondents consisted of a study group and two control groups. The study group

consisted of 91 production workers employed in the largest of the three flourmill factories in the

city. The workers were all males and were directly involved in flour milling. The first control

group consisted of 30 male support employees of the maintenance department of the flour mill

factory and included mechanics, drivers, caterers, welders, electricians and other artisans and

they served as internal controls. The other control group consisted of 121 civic employees of the

maintenance section of the University of Ibadan. They had never been employed in a wheat

flourmill or related industry and they served as external controls. Both control groups belonged

to a similar socioeconomic class as the study group and all groups were matched for age, sex,

weight and height. Respondents with a previous history of chronic respiratory disease prior to

commencement of their employment were excluded from participating in the study. The study

instruments included a standardized medical and occupational questionnaire and a portable air

sampler for dust sampling. Dust sampling was done in the production and maintenance units of

the flourmill. The production workers were more exposed to varying levels of grain dust during

the production process compared to the maintenance staff. They conducted an area sampling of

total suspended particulate matter between 4 – 6 hours working period. There were 8 sampling

locations (5 in the production unit and 3 in the maintenance unit) and ten samples of total

suspended particulate (TSP) were collected from each location. A portable air sampler with a

membrane filter was used and placed as near to the breathing zones of the workers as possible.

But, calibration of the instrument used was not stated.28

28
Results were expressed as means ± standard error of the mean (SEM) because the means were

derived from a series of average measurements. Total suspended particulate concentration was

considerably higher (p < 0.001) in the production unit; mean of 2.4 ± 2.0 mg/m3 compared to 0.4

± 0.3 mg/m3 in the maintenance unit. These values exceeded the Federal Environmental

Protection Agency standard of 0.25mg/m3 and likewise, exceeded the ACGIH threshold limit

value of 0.5mg/m3.19,20 The authors conducted an area sampling of dust exposure as a proxy for

personal sampling. This would have underestimated the personal dust exposures of the workers.

Also the sampling of total suspended particulate (TSP) may have underestimated the flour

exposure levels, because this is not specific for flour dust nor for the component of flour dust that

will give a measure of the particulate matter that is inhaled and thus harmful to the worker’s

health.28

2.4 PREVALENCE AND RISK FACTORS FOR RESPIRATORY SYMPTOMS

Several studies have shown that there is a high prevalence of occupational airway disease and

occupational asthma among workers exposed to flour dust.16,26,48,55 Flour dust is known to cause

sensitization, allergic rhinitis and occupational asthma amongst bakers and millers.16 Flour dust

can also act as an irritant and may give rise to short-term respiratory, nasal and eye symptoms, or

it may provoke an asthma attack in individuals with pre-existing disease.3 The onset of asthma in

bakers is usually preceded by nasal symptoms, such as sneezing, rhinorrhea and itchy eyes. In a

Finnish study, it was stated that 11.5% of those with occupational rhinitis developed

occupational asthma and 11.6% of them were exposed to flours and grains.47 The latent period

between the onset of exposure and the onset of respiratory symptoms varies between a few

months and a few years.65

The probability of sensitization and development of symptoms increases with increasing

exposure (dose and duration of exposure)1,2,31,32,62 Age has been considered an inconsistent risk
29
factor in the development of respiratory symptoms. In adults, the risk of new-onset asthma,

decreases with increasing age.66 Another author stated that, among farmers, increasing age,

increases the risk of symptoms.67 Therefore, age does not appear to be associated with work

related respiratory symptoms. Concerning gender, it was stated that gender is not associated with

work related symptoms among bakery workers.68 The increased risk of occupational asthma with

gender observed in some occupations is due to the distribution of gender according to work type,

where males or females are found in some particular jobs. Smoking is also an inconsistent risk

factor in the development of occupational asthma. One author stated that smoking increases the

risk of sensitization in bakery workers.69 However, another author stated that smoking does not

appear to increase the risk of asthma.11

A study was conducted in Sudan to assess the effect of exposure to flour dust on respiratory

symptoms and lung function of bakery workers at a number of bakeries in Khartoum state. The

study included bakery workers at eight bakeries in Khartoum state (the cases), and healthy non-

smoking control subjects matched for age, sex, height, and area of residence (the controls).16, 50 A

total of 36 bakery workers and 40 control subjects who were aged 18 to 65 years, working in the

bakeries for at least 8 hours per day were included in the study. Those with skeletal

abnormalities, neuromuscular diseases, history of smoking, known cases of bronchiectasis or

asthma were excluded from the study. Exclusion criteria for the controls were similar to those of

cases. Also controls who previously worked at bakeries were excluded. A total of 36 bakery

workers was randomly selected from bakeries in the state. Forty control subjects were selected in

this study. However, a scientific sampling method was not applied and the population from

which controls were selected was not stated by the researchers. Consent was obtained from all

participants; however ethical clearance was not discussed. A structured questionnaire was used

to collect information on anthropometric and respiratory symptoms at the bakeries for the cases.

30
However, the study did not utilize a standardized occupational and respiratory questionnaire for

the cases nor state what was used for the controls. Recent studies have suggested the use of

standardized questionnaire items which have improved specificity compared to those

questionnaires whose design have not undergone such extensive reviews and field testing to

increase their validity.70 The prevalence of respiratory symptoms among the bakery workers in

this study was 25% and the authors stated that difference was significantly increased compared

to controls whose prevalence of respiratory symptoms was 5%. However, the level of statistical

significance was not stated by the authors.

An analytical cross-sectional study was carried out in a local wheat flour mill in Shiraz, Southern

Iran to investigate the respiratory effect of exposure to high air borne concentration of wheat

flour dust. The study subjects were 35 male workers of the flour mill with a history of past and

present exposure to flour dust. Simultaneously, 32 healthy workers from a cola producing

company in the vicinity of the plant, with almost identical demographic characteristics were

selected by simple random sampling technique as the control group. However, the researchers

did not state the inclusion and exclusion criteria for the participants. The sample size for this

study was small compared to similar studies and this may affect the generalizability of the

results.

The study instruments included a respiratory symptom questionnaire, a personal dust sampler

and a portable spirometer. A questionnaire by American Thoracic Society was administrated to

all of the subjects.64 Symptoms such as cough, phlegm, productive cough, wheezing and dyspnea

were significantly more prevalent among exposed subjects. Prevalence of cough, phlegm and

wheezing and dyspnea were 42.9%, 60%, 34% and 80% respectively for exposed workers

compared to 3.1%, 6.3%, 3.1% and 59.4% respectively for the unexposed group. The prevalence

of dyspnea was however observed to be high among the unexposed control group, although it
31
was higher in the flour mill workers. However, the authors did not investigate any associations

between working in the cola plant and prevalence of dyspnea and they did not give an

explanation for this observation. This observation of high prevalence of dyspnea among the

control group and the flour mill workers may be due to an interviewer bias in the manner in

which the presence or absence of dyspnea was elicited. This observation is also in variance with

the work of researchers in Ibadan who noted that prevalence of severe symptoms as dyspnea was

low as such workers would have left the job earlier.28 However, the researchers in the flour mill

at Shiraz, did a logistic linear regression analysis which showed that after adjusting for important

confounders, there was statistically significant association (P < 0.05) between exposure to flour

dust and the prevalence of wheezing, productive cough, phlegm, and dyspnea.64

In the Korean study to evaluate the prevalence of serum specific antibodies in relation to work

related respiratory symptoms in a bakery, of 392 workers interviewed with a respiratory

questionnaire, the prevalence of rhinitis and asthmatic symptoms was 31.6% and 13.5%

respectively.26 However, the prevalence of baker’s asthma was 1.53%, this was however lower

than previous reports. In this study, diagnosis of baker’s asthma was based not only on self-

reported symptoms but also on further testing such as positive response to both methacholine

challenge test and specific bronchial provocation test. This must have introduced a selection bias,

as some subjects did not undergo these tests for fear of losing their jobs. It may then be

responsible for the lower prevalence of baker’s asthma reported in this study. The prevalence of

baker’s asthma has been estimated to be between 4-13% in studies where bronchial hyper-

responsiveness and sensitization to flour allergens have been used as a definition of occupational

asthma.26

A study was done in Egypt to assess the effect of exposure to flour dust on respiratory symptoms

and lung function in mill workers. 200 male flour mill workers exposed to flour dust were
32
matched by sex, age, residence, body mass and social class with 200 unexposed office workers

(Internal controls).71 Respiratory diseases were significantly higher in flour mill workers than

controls. Asthma was diagnosed in 12.5% of mill workers and 4% of controls and the difference

was significant (p ≤0.02). However, 10% of asthma in mill workers was work-related but

controls who had asthma already had the disease before their present employment. Other

diseases were chronic bronchitis; 30% vs. 6%, chronic obstructive pulmonary disease (40%

versus 0.0%) in mill workers and controls respectively and the difference was significant (p <

0.0001). Workers with longer duration (> 10 years) of employment had significantly (p< 0.002)

higher prevalence of respiratory symptoms (96.2%) than those employed for ≤ 10 years (83.3%).

duration of employment influenced the prevalence of respiratory symptoms. The prevalence of

symptoms, shortness of breath, wheezes and cough was significantly higher in flour mill workers

than controls (p < 0.0001). Also, the authors reported a significant (p < 0.0001) association

between the presence of respiratory symptoms and the site of work. In this study, 96.8% of those

in the packing unit, with high level of dust exposure had respiratory symptoms compared to

66.7% of those working in all other units (with lower flour dust exposure). Also, there was a

significant (p < 0.029) association between presence of respiratory symptoms and age of

workers. Wherein, 93% of those less than 40 years had respiratory symptoms compared to 83.3%

of those more than 40 years. More smokers (100%) had symptoms than non-smokers (60%). The

author used a self-designed questionnaire rather than a standardized questionnaire that had

proven validity.71

In a study into the occupational health problems of bakery workers in Ile-Ife, Nigeria, the

authors reported shortness of breath, coughing and sneezing as the most prevalent symptoms

among the workers due to flour dust exposure.42 Another study in Ibadan, used a modified

version of BMRC questionnaire to assess the prevalence of respiratory symptoms among flour

33
mill workers and controls.28 The prevalence of respiratory symptoms was greater among the

production workers compared to the external controls. This was statistically significant for cough

and sputum production (p< 0.001), breathlessness, wheeze and shortness of breath with wheeze

(p< 0.05). Only sputum production was significantly more prevalent among the production staff

compared to the internal controls (p< 0.01). Fifty-four percent of the production staff reported at

least one respiratory symptom, compared to 30% among the internal controls and 19% among

the external controls (unexposed group). The prevalence of cough and sputum production among

the production staff was quite high (40% and 56% respectively). The more disabling conditions

such as breathlessness, wheeze, chest pain, hemoptysis and chronic bronchitis were quite low

and varied between 2% and 14%. The authors noted that subjects who developed more disabling

symptoms might have changed jobs or left the flourmill earlier.28 This phenomenon has been

described in literatures as the ‘healthy worker effect’.72 The higher concentration of dust in

production unit (2.4 ± 2.0mg/m3) compared to maintenance (0.4 ±0.3mg/m3) explains the higher

prevalence of respiratory and non-respiratory symptoms among the production workers.28

Another analytical cross-sectional study was done among bakery workers in Ibadan, Nigeria to

assess occupationally induced lung impairment as a result of exposure to grain or flour dust.

Eighty bakeries were involved from which five hundred non-smoking male subjects were

selected as the study group. A control group of five hundred University College Hospital office

workers, doctors, medical students and students of medical records, physiotherapy and

occupational therapy who had no respiratory symptoms and were non-smokers were chosen. A

modified form of British Medical Research Council questionnaire of respiratory symptoms was

used to assess the symptoms of the bakery workers. The most commonly recorded symptom

among the bakery workers was sneezing and running nose in 53.30%, followed by periodic

breathlessness and chest tightness in 23.16% and cough and phlegm in 21.52%, during the

34
working hours. Sneezing and running nose were the most common acute symptoms. The authors

established that bakers have varied respiratory symptoms due to persistent inhalation of flour

dust. This study did not measure the particulate dust exposure levels in the bakeries nor

administer the same respiratory questionnaire to the control group to estimate frequency of

respiratory symptoms as was done among the bakery workers. They initially chose a control

group without respiratory symptoms. This will therefore make it impossible to ascertain that the

frequency of symptoms so observed in the bakery workers were not same in the unexposed

control group.38

It is to be noted from the studies reviewed that there are large discrepancies in the prevalence of

work-related symptoms and occupational asthma among bakery workers exposed to flour dust.

This could be due to effect of various factors such as different definition of asthma, work

practice, and potential biases. Information bias could result from using different methods to

collect the data, such as symptom questionnaires or objective tests, such as spirometry, skin-

prick and non-specific bronchial challenge tests.43 Also, in some studies, sources of bias were not

taken into account, such as the presence of atopics, lack of knowledge of job history or healthy

worker effect. However, despite these variations and the presence of confounding factors, most

of the studies reviewed showed an increased incidence of respiratory symptoms with increasing

exposure levels to flour dust. Therefore, in further studies, it would be important for uniform

methods to be used to assess the prevalence of occupational asthma and other respiratory

symptoms, so as to allow for comparison of results.

2.5 ABNORMALITY OF LUNG FUNCTION TEST DUE TO EXPOSURE TO

FLOUR DUST

According to studies by different authors flour dust exposure not only causes respiratory

symptoms but also leads to abnormality in lung function.32,73 In fact, a reduction in some lung
35
function parameters may be observed earlier than onset of respiratory symptoms.71 A study in

bakeries in Khartoum state, Sudan found that exposure to flour dust causes increased respiratory

symptoms and impairment of lung function if exposure continues for three years or more.62 In

the study in Shiraz, Iran, lung function parameters were also assessed. Pulmonary function tests,

including mean percentage predicted vital capacity (VC) and FVC, FEV1 and PEF were

measured with a portable calibrated Vitalograph (UK) following guidelines of the American

Thoracic Society. For evaluation of pulmonary function changes across shift, the tests were

measured twice (Saturday morning, following two days’ rest, before commencement of work,

and Saturday afternoon, after 8 hour of exposure). All parameters of pulmonary function (VC,

FVC, FEV1, and FEV1/FVC ratio) were significantly lower for exposed subjects compared to

their non-exposed counterparts (p < 0.05). A multiple linear regression analysis showed that after

adjustment for age, BMI and smoking status, there was a statistically significant association

between exposure to flour dust and pulmonary function. Fluctuations in lung functional

capacities from Saturday morning to Saturday afternoon were an important finding of this study.

Exposed subjects performed significantly better in their pulmonary function tests on Saturday

morning, after being away from the workplace for the weekend. These observations demonstrate

that exposure to flour dust induces acute reversible and chronic irreversible functional

impairments of the lungs.64

In Jalgaon city, India, a study to assess the influence of work environment on lung function,

observed significant reduction in PEFR, FVC, and FEV1 in flour mill workers compared to

controls. Lung function was also decreased with increase in job duration. Thirty-two percent

(32%) had normal peak expiratory flow rate (PEFR), 23% had a mild restrictive defect and 29%

had air flow obstruction.74 In flour producing factories studied in Kerman, Iran, all lung volumes

were reduced among workers exposed to flour compared to controls, the difference was

36
significant. Also, lung volumes decreased with increasing age and job duration. There was also a

significant inverse relationship between dust levels and lung volumes. Lung volumes decreased

with increased dust exposure even after adjusting for age and work duration. However, the

numbers of subjects in study and control groups were relatively small; 35 exposed and 20

unexposed. This may affect the generalization of this study.75

In a study in Sudan to assess the effect of exposure to flour dust on respiratory symptoms and

lung function of bakery workers, a pulmonary function test was conducted with a portable

spirometer. All study subjects and controls were males. For those who worked at the bakeries for

less than three years there were no significant differences in FEV1 or FVC, percent predicted

when compared with controls. However, bakery workers who worked at the bakeries for three

years or more have significantly lower FEV1 and FVC, percent predicted when compared with

controls. In studying a group of bakery workers who worked for three years or more, and with a

mean age of bakery workers of 29.3 years, the authors noted that a disability at this age will have

considerable socioeconomic impact on the workers and their dependants.62

In Ile-Ife, the main problem of bakery workers was noted to be obstruction of airways due to

bronchoconstriction as a reaction to exposure to flour dust. The authors observed that the mean

values of FEV1 and FVC decreased significantly during a work shift in bakery workers.76

In one study, the lung function of flour mill workers in Ibadan was also assessed.29 The

production workers recorded significantly lower mean lung functions for all parameters except

FVC when compared with the external controls (p<0.01) even after adjustments were made for

differences in age, height, weight and smoking habits. They also observed that a higher

proportion of production workers (29%) had at least one abnormal spirometry test result with

corresponding figures of 10% and 15% for maintenance and external controls respectively. FEV1

was the most common abnormal individual test of lung function. The more prevalent pattern of
37
airway disease among production workers and internal controls was airway obstruction, with

19% and 10% of production and internal controls respectively presenting with evidence of

airway obstruction. Also, 11% of civic workers (external controls) presented with some evidence

of restrictive defects. However, the reason for this was not very clear, as 8% of the production

staff also presented with this pattern of defect. The higher concentration of dust in production

unit (2.4 ± 2.0mg/m3) compared to the maintenance unit (0.4 ±0.3mg/m3) explains the lowered

mean lung function of the production staff. The authors stated that this remained even after

controlling for the effects of previous employment in mining jobs, age, duration of current

employment or smoking habits.29

Another study among bakery workers in Ibadan, Nigeria also assessed pulmonary function of the

bakers and an unexposed control group. The mean values of the PEFR, FEV1, FVC and

FEV1/FVC ratio were significantly lower among the bakery workers than the control. The

authors therefore concluded that environmental pollution of the workplace was responsible for

the impaired lung function and the varied respiratory symptoms observed in the bakery

workers.38

When conducting lung function tests, it is important to compare results of individuals with a

particular occupational exposure with the expected results of subjects without the stated

exposure, but similar in the personal characteristics that determine lung function such as sex,

size, age and possibly race. These are termed host factors that could be responsible for between

individual variations. There are also environmental factors that could be responsible for between

individual variations. These include exposure to environmental and occupational pollutants such

as airborne irritants (nitrogen and Sulphur oxides), tobacco smoke, dusts, chemicals and gas.

Low socio-economic status could also have adverse effects on lung function because it can be

38
associated with living in polluted urban-industrial areas, increased indoor air pollution, increased

rates of respiratory illness and decreased access to health care.77

2.6 CONTROL MEASURES FOR FLOUR DUST EXPOSURE

It is necessary for exposure to flour dust to be reduced because of its allergenic potential. In

some countries efforts are being made to reduce the exposure levels to as far below

recommended limits as reasonably practicable. Although occupational exposure limits will not

usually protect the hyper-susceptible worker, they will help assess health risks and decide

whether certain exposure levels are acceptable or not, and whether existing controls are

adequate. Exposures in excess of these limits will require immediate action through

improvement of existing controls or implementation of new ones. In Nigeria, where industrial

regulations are not being implemented, it is important to assess if work practices cause undue

exposure and provide necessary recommendations for improving workers’ knowledge of possible

control measures. Different authors have suggested that reducing the exposure to flour dust can

reduce the burden of allergic or irritant respiratory disease.78,79

A combination of approaches for controlling dust exposure include substitution of products,

engineering controls (such as process isolation, process modification, exhaust ventilation), use of

behavioral controls (personal protective equipment) and administrative controls (such as

improved work practices).35 Controlling flour dust exposure levels can either be by making

changes to plant and equipment (engineering controls) or by changing work practices. First

measure is to prevent dust from becoming airborne in the first place by providing or improving

local exhaust ventilation to extract dust on machines and at processes that emit dust. Simple

changes to work practices has been proposed to greatly reduce exposures.2

39
It has been suggested that workers’ knowledge of the nature of the substance with which they

work with is important to protect them from harmful exposures. The absence of a cloud of dust

in the working environment does not mean that flour dust concentration in the workplace is low

and the workers are protected. This knowledge of the allergenic potential of flour dust must be

transferred from the employer or safety representative if one exists, to the employees. This was

argued in a UK study to assess baseline of current control measures and exposure levels in UK

bakeries. The authors noted that there was a potential useful route for knowledge transfer from

Health and Safety Executive (HSE) and the bakery associations to the bakeries. 32 They also

recognized the fact that workers should have some form of training on flour dust as have other

authors.7 From their observations that many of the bakeries surveyed did not employ good

working practices, they proposed that with appropriate knowledge and use of good control

practices, training and supervision, exposure levels would be substantially reduced. It has been

demonstrated that local ventilation placed at flour generating points, such as weighing stations,

dough making machines, dough brakes, and bread machines, can reduce dust exposures to

concentrations below 1 mg/m.3,80,81

In a Dutch study to explore the current use of control measures, a walk-through survey was

carried out in all companies, using a standardized checklist to register relevant exposure

determinants (job and tasks performed, specific control measures). Workers were followed

throughout their shift and information on tasks performed and specific work characteristics was

registered. The Dutch researchers found that, changing work practices such as, limiting the use

of bagged flour products and the enclosure of silos when dumping flour, strongly decreased

exposure. However, the use of dusting flour also led to significantly higher exposure to flour

dust. The authors observed that exposures decreased when using substitutes like oil, dust-free

flour or a stainless steel worktable. Also, the use of a vacuum cleaner reduced flour dust

40
exposure. However, in this study, the overall number of effective control measures identified

were low. The use of the control measures was restricted to a few cases and were not introduced

in all tasks. This reduced the power of the study in evaluating control measures.41

A study was conducted in the UK to produce a benchmarking baseline of current control

measures and exposure levels, and also to assess the provision of training and the knowledge of

the UK regulations amongst the bakeries. In this study, bakeries that had an appointed safety

representative were more likely to be aware of the maximum exposure limits (odds ratio 7.69,

confidence interval 1.84-32.20) for flour dust, and to have some form of training on flour (odds

ratio 8.69, confidence interval 2.46-30.64) compared with those without safety representatives.

The authors observed that Health and Safety Executives and bakery associations were in a

position to transfer knowledge to the bakeries. However, there was no association between

having a safety representative and having ‘adequate’ control measures. It was then suggested

that, either information was not passed to all of the employees, information was not understood

or was ignored or that exposures could potentially be reduced further. However, in this study,

individual interview of the workers was not conducted hence the authors were unable to get

information on employee’s knowledge of risks in the workplace, signs and symptoms of work

related ill-health and whether they were trained on the correct use of control measures. Forty-

eight percent of the bakeries surveyed had adequate control measures, were exposed to lower

dust concentrations than those where control measures were deemed ‘inadequate’ (P < 0.0001).

Seventy-six percent of those individuals working in bakeries with adequate control measures

were exposed to dust concentrations below 5 mg/m3, compared with half (49%) of those workers

in bakeries without adequate control. Another control measure observed was for individuals not

to spend all their time undertaking dusty job activities. This may have accounted in part for the

41
lower exposures observed in the micro/small bakeries where many of the workers undertook

general baking duties and had varied activities.32

In a study conducted in South Africa, a structured walk-through survey of all bakeries was used

to obtain detailed information with regard to work tasks, raw products used, and specific control

measures implemented in relation to flour dust exposures in each bakery. In this study, an

inventory of control measures in bakeries revealed a paucity of adequate measures (poor local

exhaust ventilation systems, uncovered dough mixer tubs, and absence of vacuum cleaners) to

reduce exposure to flour dust in most bakeries. Results of flour dust levels stratified by presence

of control measures demonstrated no differences in average exposure levels when using process

and behavioral control measures (divider oil, personal protective equipment, and training). Also,

only 39% of bakery managers interviewed provided specific health and safety information to

their workers on the precautions to reduce exposure to flour dust. The study suggested that active

involvement and commitment of government and industry is fundamental to reducing dust levels

and the disease burden associated with high flour dust levels.41

Another study in South African supermarket bakeries was done to assess the effectiveness of

interventions using different control measures to reduce airborne flour dust exposures. Fifteen

bakeries were studied after being grouped into two intervention groups and a control group. The

interventions groups were one that used a mixer tub with lid and dust control measures and

another that used dust control training only, the control group operated its baking activities as

usual. Personal dust samples were collected pre-intervention and post-intervention after one year

of follow up for different job tasks. Managers and bakers had the greatest reduction in flour dust

exposure while counter hands had the least reduction. Among bakers, use of mixer lid was

associated with the greatest reduction in dust exposure followed by use of divider oil and then

focused training. However, the greatest reduction was observed when all the control measures
42
were combined.82 This study quantified flour dust levels using different engineering controls and

training on dust control and demonstrated their effectiveness but did not assess the effect of flour

dust exposures on the health of the workers.

2.7 CONCEPTUAL FRAMEWORK

2 .5

10

Figure 1.1: Conceptual Framework That Will Be Studied

The bakeries are the source of generation of flour dust and bakery workers are exposed to flour

dust during different tasks such as mixing, dough preparation and baking. During these activities,

43
flour dust becomes easily airborne, thus workers are exposed to varying concentrations of flour

dust through inhalation.

Following exposure of bakery workers, harmful effects can occur such as increase in respiratory

symptoms (runny nose and sneezing, cough, sputum production, chest tightness, shortness of

breath, wheeze and asthma) and impaired lung function.11,13 However, application of control

measures at the point of dust generation can reduce these harmful effects. These control

measures are a constellation of engineering, administrative and behavioral controls (use of

personal protective equipment). 35,78

Exposure levels to flour dust, respiratory effects and control measures will be assessed in this

study. General area sampling of particulate matter PM2.5 and PM10 will be done to assess the

levels of workers’ exposure to flour dust in the bakeries.28 A questionnaire adapted from the

British Medical Research Council will be used to assess the prevalence of respiratory symptoms

while spirometry will be used to evaluate the pattern of respiratory impairment (obstructive or

restrictive) among the bakery workers.28,29 An observational checklist will be used to assess the

availability of control measures in the bakeries surveyed.

44
 CHAPTER THREE
METHODOLOGY

3.1 STUDY AREA

This study was carried out in Edo Central Senatorial District. It is one of three senatorial districts

amongst which are Edo North and Edo South in Edo State, in the South-South geopolitical zone

of Nigeria. The Edo Central Senatorial District is bounded in the north by Etsako West and

Etsako Central LGA. It is bounded in the west by Uhunmwonde LGA and in the south and the

east by Delta State.83 The population of Edo Central Senatorial District is projected to be about

779,670 people by the end of 2016 based on the figure (591,534) from the Population and

Housing Census of 2006 with a male/female ratio of approximately 1:1.84

Edo Central Senatorial district is made up of five LGAs namely, Esan Central, Esan North-East,

Esan South-East, Esan West and Igueben with administrative headquarters in Irrua, Uromi,

Ubiaja, Ekpoma and Igueben respectively. The occupation of the people is mainly farming,

trading and civil service.

There are 12 bakeries registered with the National Agency for Food, Drug Administration and

Control and the corresponding Local government in Edo Central Senatorial District. Information

about the number of bakeries was obtained by making enquiries from one bakery to another, as

there are no bakery associations in the area.

Industries are classified in a directory of the Ministry of Commerce and Industry according to

labour size. Those with a staff strength of 1-50, 51-1,000 and 1,000 and above are classified as

small, medium and large scale respectively).37 There was only one medium sized bakery with

about 90 workers directly involved in the baking process. The other nine were small scale

bakeries each with an average number of eight workers, except for one with 32 workers. In all,

45
there were 192 workers in the ten bakeries, however only 118 participated in the study because

the others did not give consent or were excluded from the study.

Twelve bakeries were identified in Edo Central Senatorial District, of which there were five at

Uromi, five at Ekpoma and two at Irrua. The tasks were distributed among the workers as

mixing, dough making and baking, packaging, cleaning (or maintenance) and managerial.

The number of Water packaging companies in the Senatorial district with evidence of NAFDAC

registration was obtained from the secretaries to the association of water packaging companies in

the respective LGAs. There were 33 water packaging companies in the district: 10 in Ekpoma, 8

in Uromi, 9 in Irrua, 3 in Ubiaja and 4 in Igueben. The range of workers per water company was

7-10, depending on the size of the company.

3.2 STUDY DESIGN

An analytical cross-sectional study design was utilized for this study.

3.3 STUDY POPULATION

This study consisted of two groups; a study and a control group. The study group comprised

bakery workers (mixers, dough makers and bakers) exposed to flour dust who were engaged in

various tasks in the baking process. The control group consisted of workers in water packaging

companies in Edo Central Senatorial District. This control group was chosen because they are

involved in an industrial trade just as bakery workers and they are neither exposed to flour dust

nor have any heavy dust exposures in their working environment.85 The study group was

matched with the control group in terms of some important characteristics that influence lung

function such as age, sex and height.86

46
The bakery workers were mostly involved in bread production. The various tasks in the bakery

included mixing/weighing/sieving, dough making, baking, packaging, cleaning (or maintenance)

and managerial. The distribution of tasks depended on the size of the bakery; a worker may be

involved in more than one task in small bakeries while tasks are specified in larger bakeries. The

number of bags of flour used by a bakery varied from 8-12 50kg bags per day depending on the

size of the bakery.

3.3.1 INCLUSION CRITERIA

Study group

Those included in the study group were:

1. Bakery workers and apprentice workers aged ≥ 18 years

2. Both male and female genders

3. Those who have worked for ≥ 6 months in the selected bakeries in Edo central senatorial

district.

Control group

The inclusion criteria for the control group were:

1. Water company workers aged ≥ 18 years

2. Both male and female genders

3. Those who have worked in the water factories for ≥6 months.

47
3.3.2 EXCLUSION CRITERIA

Study Group

The following categories of workers were excluded from the study group:

1. Respondents with a previous history of chronic respiratory problems (such as bronchial

asthma, chronic bronchitis, emphysema) before their present employment.

2. Subjects with obvious abnormalities of the vertebral column or the thoracic cage such as

scoliosis, kyphosis, flail and funnel chest.

3. Subjects with a known history of neuromuscular disease, malignancy and those who have

undergone major abdominal or chest surgery.

4. Workers who are not directly involved in the baking process, such as sales representatives,

maintenance staff and drivers were excluded from the study.

Control group

Exclusion criteria for the control group were:

1. Respondents with a previous history of chronic respiratory problems (such as bronchial

asthma, chronic bronchitis, emphysema) prior to the commencement of their present

employment.

2. Subjects with obvious abnormalities of the vertebral column or the thoracic cage such as

those with kyphosis, scoliosis, flail and funnel chest.

3. Subjects with a known history of neuromuscular disease, malignancy and those who have

undergone major abdominal or chest surgery.

4. Respondents who have worked in any dusty job (such as bakery, mining, road construction)

in previous occupations were excluded.

48
3.4 STUDY DURATION

The study was carried out over a period of twelve months. Conceptualization, ethical clearance

and approval by the National Postgraduate Medical College were achieved within six months.

Data collection and analysis were done over a period of four months and presentation of research

findings and final write-up was done in two months. (Appendix 1).

3.5 SAMPLE SIZE DETERMINATION

The Kelsey formula for calculating the minimum sample size when comparing proportions

between two independent populations was used.87

• n = 2(Z α + Z β) 2 ṕ (1 - ṕ) / ( p1 - p2 )2

• n = number per group

• p1 = prevalence in the first group

• p2 = prevalence in the second group

• ṕ = ( p1 + p2 )/2

• Z α= standard normal deviate for two tail test based on α level (α = 0.05) then Z α = 1.96

• Z β = standard normal deviate for two tail test based on beta level (β = 0.10) Z β = 1.28

• p1 = prevalence of respiratory symptom in exposed group = 40% 28

• p2 = prevalence of respiratory symptom in unexposed group = 19% 28

• ṕ = (p1+ p2 )/2 = (0.40 + 0.19)/2 = 0.295

• Therefore,

• n = 2 (1.96 + 1.28)2 0.295(1 – 0.295)/(0.40 – 0.19)2 = 99

Assuming a non-response of 10%; 10% of 99 = 9.9 ≈ 10

From the above calculation minimum sample size for study group is 109 and with proposed

matching that for control group is also 109. However, a total population survey was done
49
because of the limited number of bakeries and bakery workers in Edo Central senatorial district.

For the study group, 118 persons met the selection criteria and were subsequently matched with

another 118 persons for the control group.

3.6 SAMPLING TECHNIQUE

The bakeries identified in Edo Central Senatorial District were twelve, however only ten

consented to participating in this study. They were five at Uromi, three at Ekpoma and two at

Irrua. In selecting participants in the bakeries, workers were categorized into those exposed to

dust generating tasks and those unexposed using a list provided by the manager from each

bakery. Maintenance workers, drivers, marketing staff and others not directly involved in baking

process were not selected for the study. The control group was selected from Water packaging

companies in Edo Central Senatorial District. Out of the five LGAs, three LGAs were selected

by balloting. Of the selected LGAs, workers in the twelve water packaging companies that gave

consent and met the criteria for matching were selected.

First, the participants that met the study criteria were recruited from the ten bakeries. A total

population survey was done which resulted in 118 bakery workers being recruited. They were

grouped according to sex, age group using a 10-year range, height using a 5cm range and weight

using a 5kg range.28,88 These workers served as basis for selecting and matching the water

company workers. The number of bakery workers in each age group was recorded. The number

of males and females in each age group was also recorded. The ranges of their weight and height

were recorded. This was done for each age group in the bakery. These grouping was then applied

to the control group which was matched for age, sex, weight and height with the study group by

a 1:1 ratio. Any worker who met the inclusion criteria for recruitment in the water company was

placed into the group that matched his/her age, sex, weight and height. This grouping was

50
continued until 118 workers were selected in the twelve water companies that were involved in

the study.

3.7 RESEARCH ASSISTANTS

Research assistants included four Community Health Extension Workers and two Environmental

Health Officers in the Department of Community Medicine, Irrua Specialist Teaching Hospital,

Irrua. They were trained for 2 days on how to administer the research instruments with minimal

errors, to ensure the reliability and validity of the study instruments.

3.8 STUDY INSTRUMENTS

The study instruments that were used in this study included a structured questionnaire, an

observational check-list, and devices such as weighing scale and calibrated height meter, a

spirometer for lung function assessment and a portable dust meter for quantitative assessment of

particulate matter.

All subjects (both study and control groups) completed a modified British Medical Research

Council Questionnaire.89 It reliably relates respiratory symptoms and lung function. The

questionnaire (Appendix 2) had four sections:

1. Socio-demographics of respondents

2. Prevalence of respiratory symptoms among bakery workers and controls

3. Assessment of availability of control measures among bakery workers

4. Spirometric assessment of both study and control groups.

Reproducibility was achieved by having the questions asked by interviewers who were

previously trained for two days and were also involved in the pretesting of research instruments.

51
An observational checklist (Appendix 3) was used to collect information on presence of

structural/engineering controls, process controls, administrative controls (cleaning methods) and

behavioral controls (use of personal protective equipment). A direct reading, portable Dust Meter

- AEROCET 531(Appendix 4) was used to measure the particulate mass concentration per cubic

meters of sampled air.90 This instrument provides particle size fractions for five mass ranges;

particulate mass (PM), PM1, PM2.5, PM7, PM10 and Total suspended particulate (TSP). PM2.5,

PM10 were measured in this study. PM10 and PM2.5 are particles suspended in the air with a

diameter of less than 10 micrometers and less than 2.5 micrometers respectively.

The operating principle of the dust meter is that it counts individual particles utilizing scattered

laser light and calculates the equivalent mass concentration using a proprietary algorithm. It has

an iso-kinetic probe that helps reduce count errors related to the sample flow velocity and the

aerodynamics of small particles. When sampling indoors or outdoors, the opening of the

isokinetic probe should always face upward. (However, when sampling in an area in an area that

has a constant airflow, such as a clean room, the opening of the iso-kinetic probe will be aligned

to the air movement). Measurement results were expressed in milligrams per cubic meter of air.

The instrument was factory calibrated against a reference test dust. However, the secondary

calibration of the instrument was ensured by requesting the calibration certificate from Ambah

Projects, from where the instrument was hired and it was found to be within the validity period

of its calibration certificate. The AEROCET 531 can compare quite favorably with expensive

reference methods such as the use of filters connected to air sampler pump with later weighing of
26,90
the filters using gravimetric methods. The dust sampling was done in both the study and

control groups for purpose of comparison of effect of flour dust exposure on lung function.

Assessment of lung function was done for bakery workers and the control group by the

researcher using a compact, rechargeable battery operated and fully portable diagnostic
52
spirometer - Micro 1 spirometer MS10 (Appendix 5).91 It is accurate according to the

requirements of the ATS/ERS Task Force: Standardization of Lung Function Testing 2005.91,92

It uses a digital volume transducer, which is an extremely stable one. It measures expired air

directly at B.T.P.S. (Body Temperature and Pressure with Saturated water vapor). This enables

the avoidance of inaccuracies of temperature corrections. The transducer is insensitive to the

effects of condensation and temperature thus there is no need for the spirometer to be calibrated

individually before performing a test.91

3.9 PRETESTING OF STUDY INSTRUMENTS

The study instruments were pre-tested on thirty bakery workers in neighboring Owan West LGA.

The research assistants participated in the pre-testing in order to be acquainted with the use of the

instruments under field conditions and revisions were made to the questionnaire where

necessary. The validation of the spirometer and dust meter was ensured by requesting their

calibration certificates from the hiring company. (Appendix 6). However, for the checklist, since

it was designed by the researcher, three experts in the field of occupational medicine were given

the checklist to rate the items for their relevance, appropriateness and adequacy (content

validity). Their opinions were judged to determine if they were consensual and their feedbacks

were used to improve the checklist. 93

3.10 METHODS OF DATA COLLECTION

A questionnaire administered by the same trained interviewers for both groups was used to

collect information on demographic characteristics of respondents, presence of respiratory

symptoms for both bakery workers and controls, availability of control measures for bakery

workers and spirometry assessment for both groups. The questionnaire included a detailed

occupational history and smoking history and the histories of nasal symptoms, cough, sputum,

53
chronic bronchitis, asthma, wheezing and breathlessness. Cough and sputum was said to be

present if the subject had the symptoms either during the day or at night for 5 or more days in a

week.28 Chronic bronchitis was defined as presence of cough every day or production of sputum

for at least 3 consecutive months over the previous 2 successive years.28 Breathlessness was

considered to be present when the subjects complained of being short of breath when walking or

climbing a flight of stairs. Chest tightness was defined as feeling tight in the chest when at

work.28 Wheeze was defined as ability of subjects or others nearby to hear a whistling sound

when subject is breathing. Subjects were considered to have asthmatic symptoms if they had

wheezing with/without episodic breathlessness or chest tightness that was related to work.

Symptoms were assessed whether they improved when away from work.28 Non-smokers were

defined as subjects who had never regularly smoked one or more cigarettes a day for as long as

one year. Current smokers were subjects who reported regular smoking of one or more cigarettes

a day for at least one year. Ex-smokers were subjects who reported smoking one or more

cigarettes a day regularly in the past but who had quitted smoking at least one year prior to the

study.28

The height, weight and lung function parameters of subjects were measured. The purpose of

height and weight measurements was for comparison of the lung function of study group with

that of the control group, who had similar weight and height, which are important host factors

that may be responsible for between individual variations in spirometry parameters. The height

and weight measurements were also used to calculate the predicted spirometry value for each

individual by the Micro 1 spirometer.91

Weight and height measurements: The height was measured by the research assistants using a

stadiometer with a fixed vertical backboard and an adjustable headpiece. The procedure was

briefly explained to the subject. The subject was asked to remove any hair ornaments from the
54
top of the head. He was asked to stand up straight against the backboard with his body weight

evenly distributed and both feet flat on the platform. He stood with heels together and toes apart

(toes pointing slightly outwards). The back of the head, shoulder blades, buttocks and heels made

contact with the backboard. With the subject looking straight ahead, the stadiometer headpiece

was lowered so that it rests firmly on top of his head, with enough pressure to compress the hair.

With the subject standing as tall as possible and taking a deep breath, holding this position, the

reading was taken. The subject was then told to relax and the headpiece slide away.94

Body weight of the subject was measured by the research assistants, in Kilograms (kg) with a

calibrated beam scale, Surgifield Medical England (SM -120), with a capacity of 120 kg. The

scale was calibrated daily before use, by placing known weights and then the average reading

taken. The scale was calibrated to zero reading before each weighing session by the researcher.

The scale was placed on an even floor with the subject standing in the center with light clothing

and without footwear, arms by the sides and looking straight ahead. When the subject was

properly positioned and the device became stable, the reading was taken.94

Dust Sampling General area air sampling was carried out by the researcher who was trained by

an instrument technician from which the device was hired (the device is automated). The dust

meter was applied by the researcher to areas in the bakery where flour processing takes place;

sieving, weighing ingredients and mixing, processing dough and baking. These measurements

were all taken on the same day in each bakery as the processes were being carried out. Dust

sampling was only done in nine of the bakeries. Dust sampling could not be done in the tenth

bakery because baking was not done on the day for dust sampling and two days afterwards due

to logistic reasons. Four water companies were randomly selected out of twelve for dust

sampling.

55
Samples of PM2.5 and PM10 were collected using the AEROCET 531 dust meter. To begin

sampling with the dust meter, sampling location number (01-99) was assigned to each sampling

event. This was useful in searching the database. The operation mode was set at MANUAL. The

sampling interval for particulate mass sample was 2 minutes. At the end of each sample, the

result was shown on the screen. Data records were recalled when needed.90 The sampling for

each bakery was task based sampling. A cognizance visit was made to the bakeries at the start of

the study. Work processes, work schedules and sampling locations were identified. The sampling

was done according to specific job tasks; weighing, mixing and baking. The device was placed

on a raised platform and as near to the breathing zones (within 30cm from the nose and mouth)

of workers as possible. This distance was chosen because the sampling height can affect the

AEROCET 531 reading. Taking a sample near the floor can give results several times higher

than a sample taken at eye level.90 The sampling was done at source of dust generation and 2

meters in either direction. The sampling was done twice, prior to start of activity (to determine

residual dust levels) and at peak of activity. At each location, the average measurements for each

task were calculated.63

Spirometry

The Micro 1 Spirometer was used to measure the lung function of both the bakery workers and

the controls.91 Spirometry was done by the researcher who was trained on the procedure by a

respiratory physician in Internal Medicine Department of Irrua Specialist Teaching Hospital.

Assistance in the training was sought from an instrument technician in the same department.

The device was switched on and the type of test to be done selected (in this case, forced

spirometry). The subject’s details were entered; sex, height, age and ethnic origin. These details

produced predicted values for the subject according to a correction factor. This correction factor

was set according to the ethnic origin and altered the predicted value set on the volume indices
56
by the percentage applied for people of African descent (87%), as was the case in this study. 95

The flow/volume graph will come up and show the area that the subject is expected to be within

as he blew into the spirometer. (However, this particular model used, did not produce

flow/volume graphs). All lung function tests were done at a fixed time of the day (0900-1400

hours) to minimize any diurnal variation.91

In performing the test, the subjects: were seated, asked to breathe in until the lungs were

completely full, sealed their lips around the mouthpiece and blew out as hard and as fast as

possible until they could not push any more air out and then breathe in fully immediately after

the expiratory maneuver, thus completing the Flow Volume loop. At the end of the test, values

for percent predicted FEV1, FVC. FEV1/FVC and PEFR were displayed.91 During the test, a

maneuver quality check was displayed to allow for making a decision whether to accept or reject

a blow. ‘Good blow’ was displayed on the screen when the subject performed an acceptable

maneuver. ‘Slow start’ appeared when the subject did not blast out the air quickly and evenly

during the forced expiration. ‘Poor effort’ appeared when the time to reach peak flow was greater

than 120msec, indicating a sluggish effort during the forced expiration. When the forced

expiratory time was less than 6 seconds and the change in exhaled volume during the last half

second was more than 100ml, ‘abrupt end’ appeared which meant the patient stopped exhaling

prematurely. When the expiratory flow exhibited a secondary peak, ‘cough detected’ was

displayed.91 For this test, only ‘good blow’ was accepted.

The process was repeated to perform another FVC test. The best three tests were saved on a

memory location on the device when the appropriate command was selected. To be sure the

subject had blown his maximal values during the test, he was allowed to blow at least thrice.

These were used to assess the reproducibility of the test. The best FVC and FEV1 were taken

from three technically satisfied forced expiratory maneuvers where the best two recordings were
57
within 5% of each other for the FVC. The best test was shown against the predicted value, giving

the percentage of predicted. The spirometer corrects all measurements to conditions of body

temperature and pressure saturated with water vapor (B.T.P.S). The results for each subject were

saved and stored in the memory of the instrument.91

Validity: Before starting a test session, the following checks were ensured; that all the required

demographic information of the subject had been entered and the accuracy of the Micro 1

spirometer unit had been checked recently. The accuracy of the device was checked at intervals

with a 3-L syringe. This calibration check was done by connecting a 3-L syringe to the

spirometer and injecting the syringe volume into the transducer evenly without pausing. A check

mark was displayed on the spirometer screen indicating that the calibration was accurate.92

Observational checklist

An observational check-list (adapted from the works of Elms and Meijester) was used to assess

the availability of control measures.25,32 It included information on a series of engineering

controls and process controls (specific work practice). These work practices are known to

encourage safer handling of flour and were based on a similar approach developed for bakery

workers in the Netherlands and the UK.25,32 The availability of control measures were assessed

by checking the “yes” or “no” response column on the checklist. These responses were filled by

the researcher during the production processes by observing the activities as they took place in

the mornings and afternoons.

The engineering controls to be assessed included physically separating departments, presence of

local exhaust ventilation and general ventilation (mechanical fans and windows), and closure of

mixing tube. Specific work practice included shaking of bags during emptying of flour, dropping

flour from a height or throwing with force. During ingredients mixing; raising dust when loading

58
ingredients into mixer, mixers started on slow speed until wet and dry ingredients were

combined. On dough table; use of sprinklers to spread dusting flour, hand throwing of dusting

flour and use of oil instead of flour on dough table. Damage to ingredients bags and creation of

airborne dust when folding and disposing of empty bags were also noted and appropriately ticked

off on the checklist. Cleaning methods; these include the spillages of flour cleaned up

immediately or otherwise; and use of wet sweeping or otherwise. In terms of personal protection:

use of face masks (percentage of employees using face mask) by less or more than 50 percent of

employees and also use of overalls for task with high dust generation was assessed and indicated

on the checklist. The presence of a safety representative or otherwise was also observed and

noted on the checklist.25,32

Chronogram

The sequence of events per bakery and water company was

1st day: Cognizance visit

2nd day: Questionnaire and spirometry

Day 3: Questionnaire, spirometry, checklist application and dust measurement. (Appendix 7a and

7b).

3.11 DATA MANAGEMENT

3.11.1 INTERPRETATION OF SPIROMETRY

Three basic patterns of the spirometry results were recognized:

Normal lung function–FVC and FEV1 ≥ 80% of predicted and FEV1/FVC ratio ≥ 70%

Obstructive lung function - FEV1 < 80% of predicted and FEV1/FVC ratio < 70%.

Restrictive lung function - FEV1 < 80% of predicted and FEV1/FVC ratio > 70%.23

59
3.11.2 INTERPRETATION OF CHECKLIST

The interpretation of the checklist items was done according to a scoring system developed by

the researcher. There were 26 items on the checklist. The presence of an item was noted by a

YES response and its absence by a NO response. A score of 1 was assigned for every YES

response and 0 for every NO response. The maximum obtainable score was 26. The presence of

control measures was assessed as either good or poor according to the four types of control

measures in the checklist; structural controls, process controls, cleaning and housekeeping and

personal protective devices. A minimum score of 3 for structural control was regarded as good.

While a score less than 3 was regarded as poor structural control. For process control, a

minimum score of 5 was regarded as presence of good process control, while a score less than 5

was regarded as poor. For cleaning and housekeeping, a minimum score of 3 was regarded as

good administrative control while a score less than 3 was regarded as poor. Personal protective

devices or behavioral control was regarded as good with a minimum score of 3 and poor with a

score less than 3. Overall, a bakery with a minimum score of 14 was considered as having good

control measures while anyone with a score less than 14 was considered as having poor control

measures. This scoring was developed by the reasearcher based on the minimum requirement for

each type of control measure as discussed in the literature.32

3.11.3 MEASUREMENT OF VARIABLES

Outcome variables were respiratory symptoms and lung function of the respondents. Socio-

demographic characteristics (such as sex, age, weight, height, duration of employment in the

bakery, educational level, job task performed), particulate dust exposure levels, specific control

measures, risk factors such as atopy and smoking status were independent or explanatory

variables. Frequencies and proportions were derived for qualitative variables. Means and

60
standard deviation were derived for quantitative variables. Respiratory symptoms among study

and exposed groups were expressed as proportions (percentages). Presence of control measures

in the bakeries were assessed by a ‘yes or no’ response and were expressed as proportions.

Continuous variables which were normal or slightly normal such as age, weight, height and lung

function parameters (FEV1, FVC, and FEV1/FVC ratio) were expressed as means (± standard

deviation). Where continuous data were skewed, median values (and interquartile range) were

stated as well. Lung function parameters were transformed to qualitative variables expressed as

proportions to obtain the frequencies of respondents with abnormal lung function. Flour dust

exposure levels in the bakeries were expressed as means.

3.11.4 STATISTICAL ANALYSIS

Data were coded and entered into a spreadsheet and analyzed using IBM SPSS (Statistical

Package for Social Sciences) Statistics Version 20.96 Data cleaning was done before analysis.

Statistical level of significance was set at p < 0.05. Statistical analysis of the difference between

proportions was done using the chi-square test. (When the expected cell frequencies were less

than 5, comparisons of proportions were achieved with the Fisher’s exact test). Statistical

comparison of means was done using the Student’s t-test. The mean pulmonary function test

results were compared between bakery workers and controls.

A binary logistic regression model was used to determine the relationship between outcome

variables and selected independent variables in order to determine predictors of the outcome

variables (respiratory symptoms and obstructive lung function). Results were presented in

Tables.

3.12 ETHICAL CONSIDERATIONS

61
Institutional approval: the study protocol was reviewed and approved by the National

Postgraduate Medical College of Nigeria. (Appendix 8).

Ethical approval to conduct this research was obtained from the Ethics and Research Committee

of Irrua Specialist Teaching Hospital. (Appendix 9)

Permission for field work was obtained from the heads of the different bakeries and water

companies and the Chairmen of Esan West, Esan Central and Esan North East Local

Government Areas.

A signed informed consent was obtained from the participants before commencement of the

research work. (Appendix 10).

3.13 LIMITATIONS

1. Comparison of exposure limits with values from other studies was done with constraints

because most published work utilized methods for personal dust sampling as opposed to

general air sampling which was done in this study. The most commonly used instruments

were gravimetric samplers as opposed to direct reading instruments which have not been

widely used in published studies.

2. The exposure levels for particulate matter could not be associated with individual respiratory

effects and lung function because they were measured on a general area basis and not

personal sampling.

3. Contribution of risk factors to the development of respiratory symptoms and lung

dysfunction could not be evaluated extensively because of the small numbers of smokers,

asthmatics and atopic individuals in the study.

62
4. The use of respiratory questionnaire may have introduced some form of recall bias as it is

largely dependent on subject’s ability to recall symptoms experienced in the past. This was

minimized by asking for symptoms experienced within the last six months.

5. The spirometry procedure was highly tasking and participant’s effort-dependent. Their co-

operation had to be sought relentlessly and this may have contributed to the observed results.

A restrictive defect may not be due to dysfunction, but an inability of subject to put in

enough effort when performing forced spirometry.

63
 CHAPTER FOUR
RESULTS

A total of two hundred and thirty-six (236) participants comprising of 118 bakery workers from

10 bakeries and 118 workers from water packaging companies who were group matched for sex,

age, weight and height using frequency matching technique were studied. The results are

presented in sections as follows:

SECTION A: Socio-demographic characteristics of respondents.

SECTION B: Particulate mass concentration in study and comparison groups
SECTION C: Prevalence of risk factors and respiratory symptoms among participants

SECTION D: Lung function parameters of bakery workers and controls

SECTION E: Availability of control measures among bakery workers

64
 SECTION A

SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

65
Table 1: Socio-demographic characteristics of study participants

Variable Study Group (n=118) Control Group (n=118) X2 P value

Frequency (%) Frequency (%)

*Age (years)
15-24 39 (33.1) 39 (33.1) 0.000 1.000
25-34 45 (38.1) 45 (38.1)
35-44 24 (20.3) 24 (20.3)
45-54 9 (7.6) 9 (7.6)
55-64 1 (0.8) 1 (0.8)
Sex
Male 62 (52.5) 62 (52.5) 0.000 1.000
Female 56 (47.5) 56 (47.5)
Level of Education
No Formal Education 0 (0.0) 0 (0.0) 21.331 0.000
Primary 32 (27.1) 10 (8.5)
Secondary 74 (62.7) 75 (63.6)
Tertiary 12 (10.2) 33 (28.0)
Address of Respondents
Ekpoma 54 (45.8) 54 (45.8) 15.381 0.002

Irrua 11 (9.3) 31 (26.3)

Igueben 2 (1.7) 0 (0.0)
Uromi 51 (43.2) 33 (28.0)
Marital Status
Single 62 (52.5) 65 (55.1) 3.071 0.381
Married 52 (44.1) 52 (44.1)
Widowed 1 (0.8) 1 (0.8)
Separated/Divorced 3 (2.5) 0 (0.0)
Tribe
Bini 3 (2.5) 0 (0.0) 13.494 0.019
Esan 81 (68.6) 100 (84.7)
Igbo 5 (4.2) 5 (4.2)
Igalla 7 (5.9) 1 (0.8)
Others 22 (18.6) 12 (10.2)
Religion
Christianity 118 (100) 118 (100)
Islam 0 (0.0) 0 (0.0)
*Mean age (±SD): study group; 29.75 (±9.33) years, control group; 29.85 (±9.55) years.

As shown in table 1, bakery workers were the study group, while water company workers were

the control group. Respondents within the age group 25-34 were highest in number and

comprised approximately two-fifth of both the study and control group. This was followed

closely by those in the age group 15-24 which comprised a third of both the study and control

66
group. There was no statistically significant difference between the ages of both groups because

they had been matched for age using a frequency matching technique. There were more males in

the study than females and they comprised 52.5% of both groups. Approximately two-third of

the study group (62.7%) and control group (63.6%) had secondary school education. Only a

tenth (10.2%) of the study group and a third (28.0%) of the control group had tertiary education.

There was a statistically significant difference in the educational level of respondents (p=0.000).

About half of the bakery workers (52.5%) and water company workers (55.1%) were single,

while less than half (44.1%) of both study and control group workers were married. About half

of the study group (45.8%) and half of controls (45.8%) were from Ekpoma while 9.3% of

bakery workers were from Irrua and 26.3% of controls were from Irrua. Respondents from

Uromi were 43.2% from study group and 28.0% from controls. There was a statistically

significant difference in the place of residence. (p=0.002). Majority of the respondents in both

groups were of Esan origin (68.6% of study group and 84.7% of controls) and the difference in

their tribe was statistically significant (0.019). All respondents in this study were Christians.

67
Table 2: Job description and duration of work of study group

Job Description and Study group

Duration of Work
Frequency Percentage
n = 118 (100%)
Job Description
Mixer 23 19.5
Dough maker 68 57.6
Baker 27 22.9

* Duration of Work
<1 year 63 53.4
1 – 5 years 39 33.1
>5 years 16 13.6
*Median duration of work for study group was 11 months (Q1 = 8 months,
Q3 = 36 months) Q1 is 25th percentile; Q3 is 75th percentile.

From Table 2, more than half (57.6%) of the study participants were dough makers, a quarter

(22.9%) were bakers and 19.5% were mixers. A larger proportion of the study group (53.4%)

had worked for less than one year, 33.1% had worked for 1 – 5 years and about a tenth (13.6%)

had worked for greater than 5 years.

68
Table 3: Job description and duration of work of control group

Job description and Control group

duration of work
Frequency Percentage
n = 118 (100%)
Job Description
Operator 26 22.0
Production manager 3 2.5
Packaging 89 75.4
* Duration of Work
<1 year 52 44.1
1 – 5 years 60 50.8
>5 years 6 5.1
*Median duration of work for control group was 12 months (Q1 = 8 months, Q3 = 15 months).
Q1 is 25th percentile; Q3 is 75th percentile.

From Table 3, job description varied among the control group, 75.4% were involved in

packaging of water, 22.0% were operators and 2.5% were production managers. A larger

proportion in the control group (50.8%) had worked for 1-5 years, 44.1% had worked for less

than one year and only 5.1% had worked for greater than 5 years.

69
Table 4: Comparison of mean age, weight and height of study and control group
Study group Control group t value p value
Age(years)
Mean +SD 29.75(+9.33) 29.85(+9.55) 0.007 0.934
Weight(kg)
Mean + SD 64.22(+10.63) 62.47(+8.90) 1.871 0.173
Height(cm)
Mean + SD 1.66(+0.09) 1.66(+0.10) 0.421 0.521

The study and control groups were comparable in terms of age, height and weight (Table 4).

There was no statistically significant difference in the mean values of their ages, weight and

height between the study and control groups. They had been group matched for these variables.

70
 SECTION B

PARTICULATE MASS CONCENTRATION IN STUDY AND CONTROL GROUPS

71
Table 5: Frequency distribution of PM2.5 in task environment in study group

PM2.5 in task environment (mg/m3)

Bakery Mixing Dough Baking

preparation
number

1 0.100 0.07 0.07

2 0.06 0.07 0.05

3 0.07 0.07 0.06

4 0.06 0.06 0.06

5 0.07 0.07 0.06

6 0.01 0.04 0.05

7 0.09 0.18 0.20

8 0.20 0.18 0.04

9 0.07 0.08 0.08

From Table 5, in the bakeries surveyed, the minimum concentration of PM2.5 for the mixing task

was 0.01mg/m3 and the maximum was 0.20 mg/m3. For dough preparation, the lowest value

obtained for PM2.5 was 0.04 mg/m3 and the highest value was 0.18 mg/m3 while for baking task,

the minimum concentration of PM2.5 was 0.04 mg/m3 and the maximum concentration was 0.20

mg/m3.

72
Table 6: Frequency distribution of PM10 in task environment in study group

PM10 in task environment (mg/m3)

Bakery Mixing Dough Baking
number preparation

1 0.50 0.39 0.40

2 0.72 0.57 0.27
3 0.78 0.30 0.29
4 0.39 0.38 0.34
5 0.29 0.29 0.27
6 2.22 0.20 0.22
7 1.24 0.74 0.77
8 0.92 0.41 0.32
9 0.07 0.07 0.07

As shown in Table 6, in the bakeries surveyed, the minimum concentration of PM10 for the

mixing task was 0.07 mg/m3 and the maximum was 2.20 mg/m3. For dough preparation, the

lowest value obtained for PM10 was 0.07 mg/m3 and the highest value was 0.74 mg/m3 while for

baking task, the minimum concentration of PM10 was 0.07 mg/m3 and the maximum

concentration was 0.77 mg/m3.

73
Table 7: Mean particulate mass concentration in task environment in study group

Task environment in study group

Particulate size Mixing Dough Preparation Baking

PM2.5 (mg/m3)

Mean ± SD 0.07 ± 0.02 0.07 ± 0.04 0.07 ± 0.05

PM10 (mg/m3)

Mean ± SD 0.74 ± 0.34 0.40 ± 0.17 0.35 ± 0.18

From Table 7, the mean concentration of PM2.5 was uniform at the mixing, baking, and dough

preparation points (0.07 mg/m3). The mean concentration of PM10 was highest at the mixing

points, (0.74 mg/m3) than at the dough preparation (0.40 mg/m3) and baking (0.35 mg/m3) areas.

74
Table 8: Mean particulate mass concentration in study group

Particulate matter

Task environment PM2.5 (mg/m3) PM10 (mg/m3)

Mixing 0.07 ± 0.02 0.74 ± 0.34

Dough preparation 0.07 ± 0.04 0.40 ± 0.17

Baking 0.07 ± 0.05 0.35 ± 0.18

Mean ± SD (mg/m3) 0.07 ± 0.04 0.50 ± 0.20

As shown in Table 8, there was a higher concentration of PM10 (0.50 ± 0.20 mg/m3) than PM2.5

(0.07 ± 0.04 mg/m3) at the study sites when the concentration at the mixing, dough preparation

and baking sites were averaged.

75
Table 9: Frequency distribution of PM2.5 in task environment in control group

PM2.5 in task environment (mg/m3)

Water company Production Packaging 1 Packaging 2

number

1 0.02 0.02 0.02

2 0.02 0.02 0.02

3 0.06 0.06 0.06

4 0.05 0.05 0.05

As shown in Table 9, the concentration of PM2.5 at the control sites was uniform at the

production and packaging areas for all the 4 water companies sampled for particulate flour dust.

In water company 1 and 2, the concentration was 0.02 mg/m3. In water company 3, the

concentration was also 0.06 mg/m3 and in water company 4, the concentration was 0.05 mg/m3.

76
Table 10: Frequency distribution of PM10 in task environment in control group

PM10 in task environment (mg/m3)

Water Production Packaging 1 packaging 2

company

number

1 0.12 0.14 0.16

2 0.08 0.08 0.08

3 0.29 0.29 0.29

4 0.22 0.22 0.22

As shown in Table 10, the concentration of PM10 at the control sites for water company 1 was

0.12 mg/m3 at the production area, 0.14 mg/m3 at the packaging area 1 and 0.16 mg/m3 at

packaging area 2. The concentration of PM10 at the control sites was uniform at the production

and packaging areas for 3 of the water companies sampled for particulate flour dust. In water

company 2, the concentration was 0.08 mg/m3. In water company 3, the concentration was also

0.29 mg/m3 and in water company 4, the concentration was 0.22 mg/m3.

77
Table 11: Mean particulate mass concentration in control group

Water company number

Particulate 1 2 3 4 Mean ± SD

size (mg/m3)

PM2.5 0.02 0.02 0.06 0.05 0.04 ± 0.02

PM10 0.14 0.08 0.29 0.22 0.18 ± 0.09

As shown in Table 11, in the control group, there was a higher mean concentration of PM10 (0.18

± 0.09 mg/m3) than PM2.5 (0.04 ± 0.02 mg/m3) when the concentration at the 4 water companies

sampled was averaged.

78
Table 12: Comparison of mean particulate matter between study and control groups
Size of Study group Control group t value P value
particulate
Mean ± SD Mean ± SD

PM2.5 (mg/m3) 0.07 ± 0.04 0.04 ± 0.02 1.855 0.093

PM10 (mg/m3) 0.50 ± 0.20 0.18 ± 0.09 2.908 0.016

From Table 12, the study group had a higher mean concentration of PM2.5 (0.07 ± 0.04 mg/m3)

than the control group (0.04 ± 0.02 mg/m3). The study group also had a higher mean

concentration of PM10 (0.50 ± 0.20 mg/m3) than the control group (0.18 ± 0.09 mg/m3). There

was no statistically significant difference in the mean concentration of PM2.5 between the study

and control groups (p=0.093). However, there was a statistically significant difference in the

mean concentration of PM10 between the study and control groups (p=0.016).

79
Table 13: Comparison of mean particulate matter concentrations between task environments in
the study group

Type of Job Task

Particulate Mixing Dough Baking F Value P Value
Making
Mean ± SD Mean ± SD Mean ± SD
PM2.5 (mg/m3) 0.07 ± 0.02 0.07 ± 0.04 0.07 ± 0.05 0.034 0.967

PM10 (mg/m3) 0.74 ± 0.34 0.40 ± 0.17 0.35 ± 0.18 6.012 0.009

As shown in Table 13, there was no statistically significant difference in the mean concentration

of PM2.5 between the different task environments in the bakeries (F= 0.967), (p=0.967),

However, there was a statistically significant difference in the mean concentration of PM10

between the different task environments, (F= 6.012), (p=0.009)

80
 SECTION C

PREVALENCE OF RISK FACTORS AND RESPIRATORY SYMPTOMS AMONG

PARTICIPANTS

81
Table 14: Some risk factors for developing respiratory symptoms among study participants

Risk Factor Study Group Control Group X2 P Value

Frequency (%) Frequency (%)

Current smoker (n=118)

Yes 7 (5.9) 3 (2.5) 1.504 0.498
No 111(94.1) 115 (97.5)
Ex-smoker (n=118)
Yes 5 (4.2) 2 (1.7) 1.368 0.497
No 113(95.8) 116 (98.3)

Atopy (n=118)
Yes 2 (1.7) 0 (0) 2.790 0.341
No 116 (98.3) 118 (100)

Table 14 shows that current smokers were 7 (5.9%) among bakery workers and 3 (2.5%) among

the control group. Only 2 (1.7%) of the bakery workers and none of the controls reported that

they had atopy. These differences between the presence of risk factors between study and control

groups were not statistically significant.

82
Table 15: Prevalence of respiratory symptoms in study and control groups

Symptoms Study group Control group

Frequency Percentage Frequency Percentage
n = 118 (100%) n = 118 (100%)
Runny nose/sneezing 48 40.7 6 5.1
Cough 37 31.4 2 1.7
Sputum 31 26.3 3 2.5
Asthmatic symptoms
Chest tightness 27 22.9 5 4.2
Breathlessness 19 16.1 2 1.7
Wheeze 6 5.1 1 0.8
Asthma (self-report) 6 5.1 2 1.7
Total 174 147.6 21 17.7
*Multiple response question (Total number of responses > n or < n and percentages > 100% or < 100%)

As depicted in Table 15, the most prevalent symptom among the study group was runny nose

and sneezing 40.7%, followed by cough 31.4%, sputum production 26.3%, chest tightness 22.9%

breathlessness 16.1%, wheeze 5.1% and asthma 5.1%. However, fewer workers in the control

group had these symptoms ranging from 0.8% for wheeze, 1.7% for cough, breathlessness and

asthma to 5.1% for runny nose and sneezing. Runny nose and sneezing were the most prevalent

symptom in both study and control groups. For all symptoms assessed, the proportions were

higher in the study group than in the controls.

83
Table 16: Risk factors and prevalence of at least one respiratory symptom among study and
control group
Variable *At least one X2 P value
respiratory symptom
Yes No
Frequency Percentage Frequency Percentage
(100%) (100%)

Current Smoker
Study group
(n=118)
Yes 6 85.7 1 14.3 1.576 0.419
No 71 64.0 40 36.0
Control group
(n=118)
Yes 1 33.3 2 66.7 1.228 0.277
No 11 91.7 104 98.1
Ex-smoker
Study group
(n=118)
Yes 2 40 3 60 1.383 0.340
No 75 66.4 38 33.6
Control group
(n=118)
Yes 0 0.0 2 100.0 0.433 1.000
No 12 10.3 104 89.7
Atopy
Study group
(n=118)
Yes 1 50.0 1 50.0 0.199 1.000
No 76 65.5 40 34.5
Control group
(n=118)
Yes 0 0.0 0 0.0
No 12 100.0 106 100.0
*At least one respiratory symptom: the presence of any respiratory symptom (runny nose/sneezing, cough, sputum,
chest tightness, difficulty in breathing, wheeze and asthma) was regarded as presence of at least one respiratory
symptom.

Among current smokers in study group, 6 (85.7%) had at least one symptom and 1 (14.3%) had

no symptom, (Table 16). In the control group, among current smokers, 1 (33.3%) developed at

least one respiratory symptom while 2 (66.7%) had no symptoms. The association between

84
current smoking status and development of at least one symptom was not statistically significant

in both study and control groups, (P = 0.419) and (P = 0.277) respectively. Among ex-smokers in

the study group, 2(40.0%) had at least one respiratory symptom, the remaining 60.0% had no

respiratory symptom. Among ex-smokers in the control group, none had any respiratory

symptom. The association between ex-smoking status and development of at least one symptom

was not statistically significant in both study and control groups, (P = 0.340) and (P = 1.000)

respectively. In the study group, among those with atopy, 1(50.0%) had at least one respiratory

symptom and the other 50.0% had no symptom. There was none with atopy in the control group.

The association between presence of atopy and development of at least one respiratory symptom

was not statistically significant (P =1.000).

85
Table 17: Comparison of respiratory symptoms between study group and control group

Respiratory Study Control X2 P value

Symptoms group group
Frequency Percentage Frequency Percentage
n = 118 (100%) n = 118 (100%)
Runny 48 40.7 6 5.1 42.359 <0.0001
nose/sneezing
Cough 37 31.4 5 4.2 37.629 <0.0001
Sputum 31 26.3 3 2.5 26.94 <0.0000
Asthmatic
symptoms
Chest tightness 27 22.9 2 1.7 17.498 <0.0001

Shortness of 19 16.1 2 1.7 15.106 <0.0001

breath
Wheeze 6 5.1 1 0.8 3.681 0.055
Asthma (self- 6 5.1 2 1.7 2.163 0.281
report)
Total 174 147.6 21 17.7
*Multiple response question (Total number of responses > n or < n and percentages > 100% or < 100%)

From Table 17 above, the higher prevalence of respiratory symptoms among the bakery workers

(study group) compared to those working in water factories (control group) were statistically

significant (p< 0.0001) for all symptoms assessed except wheeze which was not statistically

significant (p= 0.055) and self-reported asthma which also was not statistically significant (p=0.281).

86
Table 18: Association between presence of at least one respiratory symptom and participant

group

*At least one Study group Control group X2 P value

symptom
Frequency Percentage Frequency Percentage
(n = 118) (100%) (n = 118) (100%)
Yes 77 65.3 12 10.2 76.213 0.000
No 41 34.7 106 89.8
*At least one respiratory symptom: the presence of any respiratory symptom (runny nose/sneezing, cough, sputum,
chest tightness, difficulty in breathing, wheeze and asthma) was regarded as presence of at least one respiratory
symptom.

From Table 18, at least one respiratory symptom was reported by two third (65.3%) of bakery

workers and a tenth of controls. The difference was found to be statistically significant. (P =

0.000).

87
Table 19: Association of at least one respiratory symptom with work tasks and duration of work
among bakery workers

Variable Respiratory symptom* X2 P value

(N = 118)

Yes No

Frequency (%)

Work task

Mixers (n=23) 14 (60.9) 9 (39.1) 4.767 0.190

Dough makers (n=68) 41 (60.3) 27 (39.7)

Bakers (n=27) 22 (81.5) 5 (18.5)

Duration of work (years)

<1 43 (68.3) 20 (31.7) 1.331 0.514

1-5 25 (64.1) 14 (35.9)

>5 9 (56.3) 7 (43.8)

*At least one respiratory symptom: the presence of any respiratory symptom (runny nose/sneezing, cough, sputum,
chest tightness, difficulty in breathing, wheeze and asthma) was regarded as presence of at least one respiratory
symptom.

From Table 19, there were higher frequencies of at least one respiratory symptom among bakers

and those who had worked for less than 1 year. However, there were no statistically significant

differences between the occurrence of at least one respiratory symptom and work tasks (p=

0.190). There was also no statistically significant difference between occurrence of at least one

respiratory symptom and duration of work (p= 0.514).

88
Table 20: Prevalence of at least one respiratory symptom and duration of work among control
group

Duration of *At least one symptom X2 P Value

Work
(N = 118)
Yes No
Frequency (%) Frequency (%)
< 1 year 9 (17.0) 44 (83.0) 3.581 0.167
1-5 years 2 (3.3) 58 (96.7)
> 5 years 1 (20.0) 4 (80.0)
*At least one respiratory symptom: the presence of any respiratory symptom (runny nose/sneezing, cough, sputum,
chest tightness, difficulty in breathing, wheeze and asthma) was regarded as presence of at least one respiratory
symptom.

Table 20 shows that from among the control group, for those who had worked for less than one

year, 17.0% developed at least one respiratory symptom, and 20.0% of those who had worked

greater than 5 years developed at least one respiratory symptom. This association was however

not statistically significant (P = 0.167).

89
Table 21: Association between some respondents’ characteristics and respiratory symptoms in
study group

Respiratory symptoms
Variables Yes No Total X2 P value
Frequency Frequency Frequency (%)
(%) (%)

Age
≤ 34 years 53 (64.6) 29 (35.4) 82 (100.0) 0.046 0.831
≥ 35 years 24 (66.7) 12 (33.3) 36 (100.0)
Sex
Male 44 (71.0) 18 (29.0) 62 (100.0) 1.881 0.170
Female 33 (58.9) 23 (41.1) 56 (100.0)
Level of education
Primary 19 (59.4) 13 (40.6) 32 (100.0) 1.307 0.560
Secondary 51 (68.9) 23 (31.1) 74 (100.0)
Tertiary 7 (58.3) 5 (41.7) 12 (100.0)
Job title
Mixer 14 (60.9) 9 (39.1) 23(100.0) 4.069 0.131
Dough maker 41 (60.3) 27 (39.7) 68 (100.0)
Baker 22 (81.5) 5 (18.5) 27 (100.0)
History of work at
other dusty job
24 (74.4) 7 (22.6) 31 (100.0) 2.744 0.098
Yes
53 (60.9) 34 (39.1) 87 (100.0)
No
Duration of work
(years)
43 (68.3) 20 (31.7) 63 (100.0) 0.845 0.655
<1
25 (64.1) 14 (35.9) 39 (100.0)
1-5
9 (56.3) 7 (43.8) 16 (100.0)
>5
Use of PPE
Yes 50 (57.5) 37 (42.5) 87 (100.0) 8.847 0.003
No 27 (87.1) 4 (12.9) 31 (100.0)

PPE – personal protective equipment

90
Table 21 is the bivariate analysis of some respondents’ characteristics (age, sex, level of

education, job title, history of work at other dusty job, duration of work and use of personal

protective equipment) and presence of respiratory symptoms in study group. Only the use of

personal protective equipment had a statistically significant association with the presence of

respiratory symptoms.

91
Table 22: Predictors of respiratory symptoms in study group
Variables β co-efficient Odds ratio (95% CI) P value

Age

≤ 34 years Reference

≥ 35 years -0.339 0.712 (0.238-2.131) 0.544

Sex

Male Reference

Female 0.192 1.212 (0.356-4.118) 0.758

Level of education

Tertiary Reference

Primary -0.372 0.689 (0.135-3.524) 0.655

Secondary -0.834 0.434 (0.092-2.049) 0.292

Job title

Baker Reference

Mixer 0.895 2.448 (0.586-10.233) 0.220

Dough maker 0.629 1.875 (0.425-8.277) 0.407

History of work at other dusty job

Yes Reference

No 0.418 1.519 (0.452-5.104) 0.499

Duration of work (years)

>5 Reference

<1 -0.165 0.848 (0.219-3.284) 0.811

1-5 0.182 1.200 (0.293-4.912) 0.800

Use of PPE

Yes Reference

No 1.536 4.647 (1.410-15.314) 0.012

*CI- Confidence interval **PPE – personal protective equipment

Table 22 shows the result from binary logistic regression applied to determine the effects of

socio-demographic and work variables on the occurrence of respiratory symptoms among bakery

workers. The non-use of personal protective equipment is shown to be a statistically significant

predictor with those who did not use personal protective equipment been 4 times more likely to
92
develop respiratory symptoms compared to workers who used personal protective equipment (P

= 0.012).

93
 SECTION D

LUNG FUNCTION PARAMETERS OF STUDY AND CONTROL GROUPS

94
Table 23: Lung function parameters among study and control groups

Parameter Study group Control group t value P value

Mean ± SD Mean ± SD

FEV1 (%) 73.08 ± 13.94 79.25 ± 9.70 3.951 0.000

FVC (%) 82.54 ± 10.99 87.60 ± 8.41 3.972 0.000

FEV1/FVC (%) 89.64 ± 14.00 91.61 ± 4.86 1.441 0.152

FEV1 (%)= Percent predicted forced expiratory volume in one second

FVC (%) = Percent predicted forced vital capacity
FEV1/FVC (%) = Percent predicted ratio of forced expiratory volume in one second and forced vital capacity.

From Table 23, the mean pulmonary lung function was lower for bakery workers compared to

controls for FEV1 and FVC and these differences were statistically significant. (P = 0.000)

despite the two groups being of comparable ages. FEV1/FVC was lower for bakery workers

compared to controls but the difference was not significant (P = 0.152).

95
Table 24: *Pattern of lung function among study participants

Study group (n=118) Control group (n=118)

Frequency (%) Frequency (%)

Lung function test

Normal 73(61.9) 105(89.0)

Obstructive 17(14.4) 0(0.0)

Restrictive 28(23.7) 13(11.0)

Total 118 (100.0) 118 (100.0)

df = 2 X2 = 28.241 P value = 0.000

*Pattern of lung function

Normal lung function–FVC and FEV1 ≥ 80% of predicted and FEV1/FVC ratio ≥ 70%
Obstructive lung function - FEV1 < 80% of predicted and FEV1/FVC ratio < 70%.
Restrictive lung function - FEV1 < 80% of predicted and FEV1/FVC ratio > 70%.

From Table 24, the prevalence of normal lung function was higher in the water companies than

in the bakeries (89.0% versus 61.9%) while the reverse was the case for restrictive lung function

(11.0% versus 23.7%). Among the bakery workers, 14.4% had obstructive lung function. There

were no subjects with obstructive lung function in the water companies. The differences were

statistically significant. (P = 0.000).

96
Table 25: Association of lung function with place of work (bakery or water company)

Study group (n=118) Control group (n=118y)

Frequency (%) Frequency (%)

Lung function test

Normal 73(61.9) 105(89.0)

Abnormal 45(38.1) 13 (11.1)

Total 118(100.0) 118(100.0)

df = X2 =23.408 P = 0.000

*Abnormal lung function is the presence of obstructive or restrictive defect on spirometry.

As shown in Table 25, more than a third (38.1%) of bakery workers had one abnormal test of

lung function compared to about a tenth (11.1%) of controls, and this difference was statistically

significant (P = 0.000).

97
Table 26: Association of lung function with duration of work among bakery workers

Duration of work

< 1 year 1-5 years > 5 years

Lung function test

Normal 39(61.9) 24(61.5) 10(62.5)

Obstructive 7(11.1) 5(12.8) 5(31.3)

Restrictive 17(27.0) 10(25.6) 1(6.3)

Total 63(100.0) 39(100.0) 16(100.0)

df = 4 X2 = 6.195 P value = 0.185

As shown in Table 26, obstructive lung function was highest (31.3%) among those who had

worked for more than 5 years and least (11.1%) among those who had worked for less than one

year, while the reverse was the case with restrictive lung function, being highest (27.0%) among

those who had worked for less than one year and least (6.3%) among those who had worked for

greater than five years. While the proportion with normal lung function was high and fairly

uniform across the different work periods. However, the differences in lung function with

duration of employment was not found to be statistically significant (P =0.185).

98
Table 27: Association of lung function with duration of work among control group

Duration of work

< 1 year 1-5 years > 5 years

Lung function test

Normal 43(80.1) 58(96.7) 4(80.0)

Restrictive 10(18.9) 2(3.3) 1(20.0)

Total 53(100.0) 60(100.0) 5(100.0)

df = 2 X2 = 7.984 P value = 0.018

From Table 27, among the water company workers, none had an obstructive lung pattern.

Restrictive pattern was least observed among those who had worked between 1 and 5 years

(3.3%) and more prevalent among those who had worked greater than 5 years (20.0%). The

prevalence of a normal pattern was high across the different work periods. These differences

were found to be statistically significant (P =0.018).

99
Table 28: Association between some respondents’ characteristics and obstructive lung function
in study group
Respiratory symptoms

Variables Yes No Total X2 P value

Frequency (%) Frequency (%) Frequency (%)

Age

≤ 34 years 11 (13.4) 71 (86.6) 82 (100.0) 0.215 0.643

≥ 35 years 6 (16.7) 30(83.3) 36 (100.0)

Sex

Male 9 (14.5) 53 (85.5) 62 (100.0) 0.001 0.972

Female 8 (14.3) 48 (85.7) 56 (100.0)

Level of education

Primary 6 (18.8) 26 (81.3) 32 (100.0) 1.128 0.613

Secondary 9 (12.2) 65 (87.8) 74 (100.0)

Tertiary 2 (16/7) 10 (83.3) 12 (100.0)

Job title

Mixer 6 (26.1) 17 (73.9) 23(100.0) 4.975 0.076

Dough maker 10 (14.7) 58 (85.3) 68 (100.0)

Baker 1 (3.7) 26 (96.3) 27 (100.0)

History of work at
other dusty job
3 (25.0) 9 (75.0) 12 (100.0) 2.494 0.114
Yes
9 (8.5) 97 (91.5) 106 (100.0)
No

Duration of work

<1 year 7 (11.1) 56 (88.9) 63 (100.0) 3.920 0.129

1-5 years 5 (12.8) 34 (87.2) 39 (100.0)

>5 years 5 (31.3) 11 (68.8) 16 (100.0)

Use of PPE

Yes 16 (18.4) 71 (81.6) 87 (100.0) 5.418 0.020

No 1 (3.2) 30 (96.8) 31 (100.0)

PPE – personal protective equipment

100
Table 28 shows the outcome of bivariate analysis to determine the association of some

respondents’ characteristics (age, sex, level of education, job title, history of work at other dusty

job, duration of work and use of personal protective equipment) with presence of obstructive

lung function in the study group. Only the use of personal protective equipment was significantly

associated with the presence of obstructive lung function (P= 0.02).

101
Table 29: Predictors of obstructive lung function in study group
Variables β co-efficient Odds ratio (95% CI) P value

Age

≤ 34 years Reference

≥ 35 years 0.112 1.119 (0.244-5.134) 0.885

Sex

Male Reference

Female 0.543 1.721 (0.338-8.772) 0.513

Level of education

Tertiary Reference

Primary -0.513 0.599 (0.070-5.091) 0.639

Secondary -0.040 0.961 (0.122-7.548) 0.970

Job title

Baker Reference

Mixer -2.208 0.110 (0.011-1.081) 0.058

Dough maker -1.701 0.183 (0.016-2.128) 0.175

History of work at other dusty job

Yes Reference

No 0.418 1.519 (0.452-5.104) 0.499

Duration of work (years)

>5 Reference

<1 0.979 2.661 (0.501-14.119) 0.250

1-5 0.749 2.116 (0.388-11.524) 0.386

Use of PPE

No Reference

Yes -1.980 0.138 (0.016-1.213) 0.074

CI – confidence interval, PPE – personal protective equipment

Table 29 shows the outcome of binary logistic regression to determine the effects of socio-

demographic and work variables on the lung function of bakery workers (study group). The odds

of having an obstructive lung function was about two times more in those who had worked
102
between one and five years than those who had worked greater than five years. However, this

difference was not statistically significant (P=0.386). No variable was a significant predictor of

obstructive lung function among the bakery workers.

103
 SECTION E

AVAILABILITY OF CONTROL MEASURES IN BAKERIES

104
Table 30: Hazards reported by respondents

Identification of Study group Control group X2 P value

hazards
(n = 118) (n= 118)
Frequency (%) Frequency (%)

Noise
Yes 58 (49.2) 45 (38.1) 2.911 0.088
No 60 (50.8) 73 (61.9)
Heat
Yes 90 (76.3) 20 (16.9) 83.434 0.000
No 28 (23.7) 98 (83.1)
Flour dust/general
dust
Yes 50 (42.4) 12 (10.2) 31.589 0.000
No 68 (57.6) 106 (89.8)
Chemicals
Yes 44 (37.3) 30 (25.4) 3.859 0.049
No 74 (62.7) 88 (74.6)

Noise and heat were reported as hazards by almost 50% and over 76% respectively among the

bakery workers while they were about 38% and 17% among the water factory workers (Table

30). There was a statistically significant difference in the reporting of heat as a hazard among

study and control groups (P=0.000). Only 42.4% of bakery workers reported flour dust as a

hazard and 10.2% of controls reported general dust as a hazard. This difference was statistically

significant. (P=0.000).

105
Table 31: Status of PPE and training among study and control groups

Control measures Study group Control group X2 P value

(n = 118) (n = 118)
Frequency (%) Frequency (%)

Received training on control measures

Yes 31 (26.3) 23 (19.5) 1.537 0.215
No 87 (73.7) 95 (80.5)
Provision of PPE
Yes 83 (70.3) 76 (64.4) 0.945 0.331
No 35 (29.7) 42 (35.6)
Self-purchase of
PPE
Yes 24 (20.3) 13 (11.0) 3.878 0.059
No 94 (79.7) 105 (89.0)
Use PPE
Yes 87 (73.7) 86 (72.9) 0.022 0.883
No 31 (26.3) 32 (27.1)

Table 31 shows that only 26.3% of bakery workers had received training on control measures in

the work place. The proportions of those who use of PPE were about the same among study and

control groups (73.7% and 72.9% respectively).

106
Table 32: Reported use of personal protective equipment (PPE)
Variables Study group Control group
(n =118) (n = 118)
Frequency (%) Frequency (%)
Use face mask*
Yes 12 (10.2) 21 (17.8)
Head gear*
Yes 68 (57.6) 69 (58.5)
Apron*
Yes 94 (79.7) 63 (53.4)
Gloves*
Yes 33 (28.0) 30 (25.4)
Goggles*
Yes 1 (0.8) 3 (2.5)
Booths*
Yes 2 (1.7) 49 (41.5)
Total 210 (178.0) 235(199.1)
*Multiple response question (Total number of responses > n and percentages > 100%

From Table 32, head gear and apron were the most commonly used PPE in both study and

control groups. Among the few persons who were provided face masks in the study group, none

was provided with a respirator.

107
Table 33: Reason for not using personal protective equipment (PPE)

Variables Study group Control group

(n =118) (n = 118)
Frequency (%) Frequency (%)
Reason for not using the
complete set of PPE
Not provided 75 (63.6) 65 (55.1)
Not comfortable 17 (14.4) 17 (14.4)
Not necessary 26 (22.0) 36 (30.5)

According to Table 33, non-provision of personal protective equipment was the most common

reason for not using the complete set of personal protective equipment in both study and control

groups (63.3% and 55.1% respectively). Personal protective equipment was considered to be

unnecessary amongst 22% of the study group and 30.5% of the control group.

108
Table 34: Observed structural control measures in bakeries surveyed

Structural controls Frequency (n= 10)* Percentage (100%)

Segregation

Yes 3 30.0

No 7 70.0

Local Exhaust Ventilation

Yes 1 10.0

No 9 90.0

Mechanical fans

Yes 1 10.0

No 9 90.0

Adequate ventilation of
rooms

Yes 6 60.0

No 4 40.0

Solid lid on mixer

Yes 0 0.0

No 10 100.0

Good lighting

Yes 4 40.0

No 6 60.0

*Ten bakeries were surveyed.

109
Table 34 shows that adequate room ventilation and good lighting were the most available

structural control measures in the bakeries studied (60.0% and 40.0% respectively). Local

exhaust ventilation and mechanical fans were provided in only 10% of the bakeries.

110
Table 35: Observed process controls in bakeries
Process controls Frequency (n=10) Percentage (100%)
Use of oil instead of flour on dough table
Yes 10 100.0
No 0 0.0
No shaking of bags during emptying
Yes 4 40.0
No 6 60.0
No dumping of flour from a height or throwing with force
Yes 7 70.0
No 3 30.0
Use of sprinkles to spread dusting flour
Yes 0 0.0
No 10 100.0
Workers tip flour with open end of bag facing away
Yes 10 100.0
No 0 0.0
No raising dust when loading ingredients into mixer
Yes 3 30.0
No 7 70.0
Mixers started on low speed
until wet and dry ingredients were combined
Yes 10 100.0
No 0 0.0
No creation of airborne dust
when folding and disposing of empty bags
Yes 3 30.0
No 7 70.0
Stainless steel worktable
Yes 10 100.0
No 0 0.0
No damage to ingredient bag
Yes 9 90.0
No 1 10.0
*Ten bakeries were surveyed.

From Table 35, of the 10 process controls, 4 were observed in all the bakeries, (100.0%); oil

used on dough table, open end of bags faced away, mixers started on low speed and stainless

steel work table. Use of sprinklers to spread dust flour and not raising dust when loading

ingredients were the least process controls complied with (0.0% and 30.0% respectively).

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Table 36: Observed administrative controls in the bakeries

Cleaning and Housekeeping Frequency (n= 10)* Percentage (100%)

Use of wet sweeping during cleaning

Yes 1 10.0

No 9 90.0

No dust stirred up during cleaning

Yes 1 10.0

No 9 90.0

Spillage of floor cleaned up immediately

Yes 1 10.0

No 9 90.0

Workroom is being cleaned daily

Yes 9 90.0

No 1 10.0

Empty bags are stored outside workroom

Yes 6 60.0

No 4 40.0

*Ten bakeries were surveyed.

Apart from daily cleaning of work rooms, all other administrative controls were poorly adhered

to in the bakeries (Table 36). Daily cleaning of work rooms was done in 90.0% of bakeries.

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Table 37: Observed behavioral controls in the bakeries

Behavioral controls Frequency (n=10)* Percentage (100%)

Face mask used by more than 50% of employees

Yes 0 0.0
No 10 100.0
Use of face mask during mixing
Yes 2 20.0
No 8 80.0
Use of face mask during cleaning
Yes 0 0.0
No 10 100.0
Face mask is clean
Yes 2 20.0
No 8 80.0
Use of overalls for tasks with high dust generation
Yes 4 40.0
No 6 60.0
*Ten bakeries were surveyed.

As shown in Table 37, use of face mask by more than 50% of employees was found in none

(100.0%) of the bakeries. Use of overalls was observed in only 40.0% of bakeries. Face mask

was used during mixing in only 20% of bakeries.

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Table 38: *Grading of available control measures in bakeries

Type of control measure Grade

Good Poor
Frequency (%) Frequency (%)
(n = 10) (n = 10)
Structural 2 (20.0) 8 (80.0)

Process 10 (100.0) 0 (0.0)

Administrative 1 (10.0) 9 (90.0)

Behavioral 1 (10.0) 9 (90.0)

*Grading of structural, administrative and behavioral controls; the presence of more than three of these controls in a
bakery was regarded as good while the presence of three or less was regarded as poor.
Grading of process controls; the presence of more than five of these controls was regarded as good while the
presence of five or less was regarded as poor.

Table 38 shows that 100.0% of bakeries had good process controls, 80.0% had poor structural

controls while 90.0% had poor behavioral and administrative controls.

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 CHAPTER FIVE
DISCUSSION
The present study provides evidence of the flour dust causing symptoms and lung function

abnormalities among exposed workers in the bakery industry. The study assessed the respiratory

morbidity associated with exposure to flour dust among bakery workers which has been

documented only by few studies in Nigeria.28,38,42 The findings show that bakery workers are

exposed to levels of particulate flour dust higher than regulatory limits (FEPA) and the necessary

preventive strategies are inadequate in the surveyed bakeries. Previous studies suggest that dust

control measures can substantially reduce flour dust levels in bakeries and there is a need to

pursue more rigorous methods to significantly reduce flour dust exposures in bakeries.

Inhalation of particulates adversely influences the lives of people all over the world. Flour dust

inhalation is one example causing workers respiratory morbidity and reduced job productivity. It

has thus become important for this problem not to be overlooked in Nigeria where industrial

safety and health have been neglected by employers and regulators and employees themselves

are indifferent towards such issues.54

Respondents in this study were mostly young people with secondary school education as their

highest educational attainment. This may be due to the nature of bakery work requiring less

professional training; and can be undertaken by people who learn on the job either informally or

through a formal apprenticeship. Educational attainment may influence worker’s knowledge of

hazards and measures to control them. A study in Aba, Nigeria also found bakery workers were

mostly youths of low educational attainment and another in Ibadan, Nigeria had similar

findings.38,54 This findings are consistent with reports that Africa’s working age population are

very young and rapidly rising.97

115
Almost half of the study participants had worked for less than one year and only a few had

worked for more than five years. This finding was similar to one in Aba, Nigeria.54 This high

turnover rate of bakery workers in Nigeria may be due to relatively young age, low pay and odd

hours of work.54 They work for relatively long hours and six days a week which may impact

their health and productivity negatively in the long term.

A higher concentration of particulate matter was found in the study sites than control areas.

There was a statistically significant difference in particulate matter concentration (PM10)

between study and control sites (p<0.01). The average mean inhalable particulate exposure in the

bakeries in the present study was 0.20-1.24 mg/m3 and was lower than that obtained in bakeries

in South Africa, 0.11-7.29mg/m3 and comparable to that obtained in traditional bakeries in the

United Kingdom (0.5-1.2mg/m3).22,41 The higher concentration of PM10 found in the study sites

in this study may be responsible for the occurrence of more respiratory symptoms among the

bakery workers than water company workers. Workers exposed to higher particulate matter

levels have been found to experience more respiratory symptoms than controls as in the Ibadan

study.28 In this study, workers were uniformly exposed to PM2.5 while mixers had higher

exposure PM10 compared to dough makers and bakers. This is consistent with a study in South

Africa where job task was an important determinant of particulate dust exposure with bread

bakers having higher mean dust exposure than confectioners and supervisors.41 Similarly, in a

study in the United Kingdom, which did personal sampling using gravimetric samplers, inhalable

dust concentrations was higher amongst mixers, followed by cleaners and then bakers/dough

makers.32 Similarly, in the present study, mixing task was associated with a higher concentration

of inhalable particulate matter than baking and dough preparation. There was a statistically

significant difference in particulate matter concentration (PM10) between the task environments

(p<0.01).

116
However, caution should be exercised in comparing these exposures because different techniques

and instruments were used in deriving them. This study used area sampling, which could

underestimate exposure, as opposed to personal dust sampling used in these other studies. Also, a

portable dust meter was used in this study as opposed to gravimetric methods used in the other

studies. However, the mean inhalable particulate matter (PM10) concentration of 0.5mg/m3

recorded in this study exceeded the Federal Environmental Protection Agency standard of

0.25mg/m3.19 This means that bakery workers in this study are exposed to higher levels of

particulates than the Nigerian Federal regulatory limits.

Bakery workers who had worked for a shorter duration had a higher prevalence of respiratory

symptoms than those who had worked for a longer period but the differences were not

statistically significant (p=0.514). This may have occurred by chance because it was observed in

a study in Egypt that workers with a longer period of employment had a higher prevalence of

respiratory symptoms than those with a shorter period of work (p<0.002).71 Smoking was not

associated with the development of respiratory symptoms in this study. This may be due to the

small number of smokers in the present study. There are differing views about the association of

smoking and development of symptoms among bakery workers. In one study, smoking was

noted to increase the risk of sensitization in bakery workers69 while another study noted that

smoking does not increase the risk of asthma.11

In this study, the study and control groups were suitably matched for several demographic

variables that could confound the presence of respiratory symptoms. However, runny nose,

cough, chest tightness and shortness of breath were all found to be of higher prevalence among

the study group than the control group and the association was statistically significant

(p<0.0001). This can be explained by the exposure to and persistent inhalation of particulate

flour dust in the bakeries and the relative absence of such dust particulates in the water

117
companies. Similarly, in a study in Ibadan, Nigeria, the authors also found more respiratory

symptoms among flour mill workers than controls who were civic workers and never employed

in a dusty occupation.28 Another reason for the higher prevalence of respiratory symptoms

among bakery workers may be due to the observation that these workers exposed to a dustier

environment than water company workers were commonly not using protective devices as

observed in other studies.28

The most prevalent symptom among the study group was runny nose and sneezing, followed by

cough and sputum production. In comparison, fewer workers in the control group had these

symptoms. The difference in the prevalence of these symptoms between study and control group

was statistically significant (p<0.0001). This is consistent with a study in Ibadan, Nigeria where

the most prevalent symptom among bakery workers was also sneezing and runny nose.38 This

can be explained by the irritant nature of flour dust which tends to give rise to short term nasal

symptoms such as sneezing and rhinorrhea.3 Similarly, a study in Egypt found a statistically

significant higher prevalence of cough, shortness of breath, wheeze and asthma among flour mill

workers than controls.71 The prevalence of more severe symptoms in this study (breathlessness,

chest tightness and wheeze) was lower than symptoms of upper airway irritation, (runny nose

and sneezing, cough and sputum production). This may be due to these workers representing a

“survival population” where those workers with more severe symptoms are unable to continue

work in the bakery and have left the industry earlier.28

Statistics from the UK has it that bakers are the second most at risk occupational group for

asthma, this account was given by physicians’ reports.98 However in our study, prevalence of

asthma among flour exposed workers was estimated based on self-report. This has implications

on determination of actual prevalence of disease. Firstly, individuals’ acknowledgement of their

symptoms was based on the definition which bordered on presence of wheeze at work with or
118
without presence of breathlessness or chest tightness.28 Individuals with these symptoms in this

study were relatively high; breathlessness at work (16.1%), chest tightness (22.9%), wheeze

(5.1%) and those who expressly admitted to having asthma by responding to the question “ have

you ever been told by a physician that you have asthma since you starting working here?” were

5.1%. When the prevalence of chest tightness and breathlessness at work among the study group

was compared with the controls, the differences observed were statistically significant (P<0.000).

However, the differences in the prevalence of wheeze and asthma were not statistically

significant. A study in Basrah, Iraq also had similar prevalence of breathlessness (14.3%). This is

consistent with another study in flour mills in Nigeria, with a prevalence of breathlessness (14%)

and wheeze (7%). Secondly, the issue of a recall bias cannot be overlooked here. Individuals

who have worked for a long time may have difficulty remembering their symptoms or may have

become so used to them that they are no longer considered important when inquiries are made

about them. While individuals who have worked for a shorter time may over blow the presence

of symptoms as they are experienced as disturbing or new happenings. The researcher made an

attempt to reduce this misinformation by specifying in the questionnaire that respondents give

answers based on symptoms experienced within the last six months of being in present

employment. Thirdly, and probably of utmost importance here is the fact (as reported in previous

studies) that workers who experience severe or disabling symptoms may have exited the

workplace earlier due to inability to cope with the demands of the job. This group represents an

often unrecognized group of factory workers because routine medical examination is not being

carried out in most small and medium scale establishments.37 Workers are therefore not

identified as having problems at the time of self-induced exit or employer motivated exit from

their jobs either due to inability to cope or absenteeism and low productivity.

119
In the present study, the prevalence of a decreased lung function parameter (either decreased

FEV1 or FVC) was higher in bakery workers (38.1%) than controls and the difference was

statistically significant (p=0.000). This is comparable with the 37% reported among workers in

flour mill in Casablanca.99 It is higher than the prevalence of abnormal lung function of 29%

reported in the Ibadan study among flour millers.29 This can be explained by the finding that

exposure to high amounts of dust for long periods can decrease lung function and this reduction

was more in exposed workers than unexposed matched controls.100

The mean percent predicted FEV1 and FVC was lower in the bakery workers compared to

controls and the difference was statistically significant, which meant that on the average, the

control group had better lung function than the study group. There was a similar finding among

bakery workers in Sudan. In that study, bakery workers who had been employed for 3 years or

more had a lower mean predicted FEV1 and FVC than controls.62 In a study in Ibadan, Nigeria,

the mean values of FEV1, FVC and FEV1/FVC% were reduced in bakery workers than controls

and the difference was statistically significant.38 In another study in Ibadan, flour mill workers in

the production unit had lower mean lung function parameters except for FVC when compared to

controls, and the difference was also statistically significant.29 However, in contrast to all the

above studies, some authors have reported no difference in the lung function parameters between

flour mill workers and controls.101

It is important to note that in the present study, obstructive pulmonary defect was only found

among the study group of bakery workers, it was not found in the control group of water

company workers. This suggests that there is a relationship between exposure to flour dust and

obstructive airways disease as observed in other studies.102 Bakery workers are also exposed to

higher concentrations of particulate matter as recorded in this study than controls working in a

dust-free environment. Also, in the present study, obstructive lung function was highest among
120
those who had worked greater than 5 years and least among those who had worked less than 1

year. Although this difference was not statistically significant, it was supported by findings in a

study in Sudan that lung function decreased with increased duration of exposure among bakery

workers.62

The predominant pattern of lung function abnormality among bakery workers in this study was

restrictive pattern found in about a quarter (23.7%), this is in contrast to what was found in other

studies where bakery workers or flour mill workers had predominately obstructive pattern of

dysfunction. In India, 29% of flour mill workers had an obstructive defect while 23% had a

restrictive defect.74 This proportion is comparable to the finding in this study even though

restrictive defect is predominant. In Ibadan, 19% of flour mill workers in the production unit had

an obstructive defect while 8% had a restrictive defect.29 It is important to note that restrictive

disease cannot be diagnosed by spirometry alone and will require further evaluation in a

pulmonary laboratory.103

The availability of control measures was evaluated by participants’ responses and by an

observational and walkthrough survey. In the bakeries, less than half of the workers knew that

flour dust was a hazard to bakery workers. If workers have the knowledge of workplace hazards,

then they can take proactive measures to avoid exposure to such hazards. Employers can

influence the exposure status of their workers by putting in place measures to reduce such

exposures. A study in the United Kingdom noted that when workers are aware of potential

hazards such as flour dust and the exposure limits according to the country’s regulations, it goes

a long way to reduce exposure.32

In the present study, only about a quarter of respondents had received any form of training on

hazards at the workplace. In the United Kingdom study, about half of bakeries provided some

121
form of training on flour dust for new employees.32 The extent of training provided to employees

is important in creating awareness about possible hazards at the workplace. 32,30.

A large proportion of workers in bakeries studied were provided with personal protective

equipment by their employers, and they attested to using them. However as noted in Greek and

Dutch studies, provision did not equate to utilization.104,25 As observed in this study, workers

were often found not using any form of personal protective equipment. A low usage of personal

protective devices may be explained by the fact that adopting behavioral change is an important

factor when considering the use of protective devices. Unless a worker perceives a situation as a

hazard from which he can sustain harm or injury (which may be severe), and he knows that he

can take actions to prevent the harm, only then will he change his behavior to avoid such a

condition (as explained by the ‘Health Belief Model’)105. In the present study, bakery workers

who did not use personal protective equipment were 4 times more likely to develop respiratory

symptoms than workers who used these equipment (p=0.013).

Structural controls such as segregation of departments were barely available in the bakeries

surveyed. Work was commonly done in a large room without demarcation of work processes

such that mixing, a dust generating task was done in one place as other tasks that generated less

dust. This makes all other workers exposed to particulate flour dust. In South African bakeries,

segregation of departments led to a decrease in exposure to allergenic dough improvers and flour

dust.41

Local exhaust ventilation was not available in any of the bakeries. Similarly, in a Netherlands

study, less than a fifth of bakeries had proper local exhaust ventilation and they were generally

lacking in a South African study.25,41 Local exhaust ventilation when placed at flour dust

generating sites, has the tendency to reduce dust concentrations to below 1 mg/m3.81 The absence

122
of local exhaust ventilation observed in this study may not be unrelated to cost as they are

expensive to procure and most of the bakeries in this study are small-scale.

About half of surveyed bakeries could be said to have adequate general ventilation as assessed

by the presence of windows placed on opposite sides for cross ventilation. Some bakeries had a

large open space between the roof and the upper wall all-round the perimeter of the building that

allowed for exit of dust. However, mechanical dust extractors on walls were only found in one

bakery. Adequate ventilation is important in bakeries as it ensures the dispersion of dust, and in

particular given that most of the bakeries lacked exhaust ventilation. In a United Kingdom study,

majority of bakeries had some form of mechanical ventilation with most having extraction fans

on the wall.32 Small scale bakeries may not be able to procure extraction fans but they can do

well to improve ventilation by reviewing their building designs.

Solid lids on mixers were absent in all surveyed bakeries, however most of the bakeries used a

tub for mixing flour and it was done manually. Only one bakery used a mixer that was operated

mechanically, but it had no solid lid on it. Solid lids are important fittings on mixers because

they prevent the creation of high dust exposures when flour is added to the mixer and the dough

is being mixed.41 In the bakeries surveyed in this study, a worker who is performing the mixing

task is commonly found bent over with his hands dipped in flour, manually turning the

ingredients with the flour in a tub and covered with dust from head to waist, most times without

an apron, head gear or hand gloves. The dough mixer thus needs to be protected from inhaling

this particulate matter. It will require a creation of awareness among bakery workers and mixers

in particular of the effects of undue exposure to flour dust so they can be proactive in protecting

themselves. This knowledge may be handed over to them by their managers or better still the

bakery associations as they may not be able to employ the services of safety representatives,

which were absent in all the bakeries surveyed.32

123
Majority of the bakeries had good process controls. However, dust was still generated in a large

proportion of bakeries by shaking bags when emptying flour, during folding and disposing of

empty bags and raising dust when loading ingredients into the mixer. These are all behavioral

which can be easily corrected with the on-the-job training. Training of bakery workers in work

practices that avoided dust generation was found to reduce peak exposures in the Netherlands.25

The administrative controls employed in a bakery are an important work practice that affects the

amount of dust generated. The bakeries in this study commonly employed the use of dry brushes

to sweep spilled flour instead of wet sweeping and spillages were not cleaned up immediately.

Similarly dry sweeping was done in majority of bakeries surveyed in the United Kingdom

studies while wet sweeping was practiced in South African supermarket bakeries.32,41

Workers in the bakeries commonly wore aprons and headgears, only a few used face masks. The

majority of the workers were probably not aware of the importance of personal protective

equipment to a bakery worker and would rather work without them for varied reasons. These

devices which are behavioral control measures such as respiratory protective equipment must be

worn in high dust exposure tasks such as mixing. They were provided in surveyed the United

Kingdom bakeries, but whether they were wore or adequately maintained could not be

determined in the study.32

When the availability of control measures was graded, all the bakeries had good process controls,

a few had good structural controls, administrative and behavioral controls were generally poor.

Overall, control measures were inadequate in majority of the bakeries surveyed in this study. In

contrast, approximately half of the bakeries in the UK study had adequate control measures.32

But can we expect more from bakeries in third world countries comparing the economic,

infrastructural and educational barriers in this region? Needless to say, the effects of exposure to

124
flour dust and the control measures investigated in this study are simple, inexpensive and easy to

pass on by knowledgeable individuals to the nooks and crannies where these predominantly

cottage industries are located.

In conclusion, this study has provided baseline measures of exposure levels to flour dust in

bakeries in the study area. This will serve as important data for exposure limits to be

recommended in bakeries. However, further studies will seek to measure exposure levels to flour

dust for the average working hours of full shift to provide an actual estimate of the overall daily

exposure to flour dust for a bakery worker. The detailed information gathered with the

availability of control measures will also be used in further studies to explore interventions

aimed at reducing flour dust exposures.

125
 CHAPTER 6

CONCLUSION

1. A higher concentration of PM10 than PM2.5 was recorded at flour mixing points in this

study. Mixing was associated with higher exposure to flour dust than working on the

dough table and baking. The levels obtained were higher than recommended levels

proposed in Nigeria.

2. Exposure to flour dust is responsible for a number of respiratory symptoms among

bakery workers compared to controls. Some of these symptoms are mild and a source of

discomfort to the workers and may be ignored and in some cases, may result in abnormal

lung function such as obstructive disease.

3. In this study, both restrictive and obstructive lung dysfunction were recorded with a

higher prevalence among bakery workers than controls.

4. Control measures were generally inadequate in the surveyed bakeries especially the

structural, behavioral controls and administrative controls. Availability of process

controls were good in all the bakeries.

126
 RECOMMENDATIONS

GOVERNMENT

1. Mechanisms for inspection of work places by factory directorate of Ministry of Labor for

compliance to recommended standards of dust emission reduction should be put in place.

BAKERY MANAGEMENT

1. Management should provide some occupational health services for their workers to

include health information on hazard identification and prevention for optimal health and

productivity of the employees.

2. Workers should undergo pre-employment screening and periodic surveillance of their

health in order to recognize those with symptoms and lung dysfunction and appropriate

secondary and tertiary prevention taken.

3. Control measures to reduce dust emission should be put in place that are within the

company’s capacity for sustenance.

BAKERY WORKERS

1. Bakery workers should be proactive in protecting their health by adhering to safe work

processes and adopting behavioral measures such as use of personal protective

equipment.

127
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 Appendix 1

WORK PLAN

This research work, after approval, proceeded in 3 stages. These stages are preparation for data

collection; data collection, analysis, interpretation; and write-up of the research. The detailed

activities in all stages highlighted above are presented in the table below.

Stage 1: Preparation for data collection

SN Activity Action Duration

1 Advocacy and mobilization of study Researcher 1 week

population

2 Recruitment of research assistants Researcher 1 week

3 Procurement of data collection materials Researcher 1 week

including dust meter and spirometer

4 Training of research assistants Researcher 1 week

5 Pre-testing of questionnaires and checklists Researcher, research 1 week

assistants

6 Analysis and correction of pre-tested Researcher, research 1 week

instruments assistants

Stage 2: Data collection, analysis and interpretation

1 Data collection Researcher, research 4 weeks

assistants

2 Data entry, cleaning and analysis (Some data Researcher, research 1 week
entry will run concurrently with data assistants
collection)

140
3 Interpretation and documentation of results Researcher 1 week

Stage 3: Research write-up and critique

1 First draft write-up including discussion, Researcher 2 weeks

conclusion and recommendation

2 Presentation to the department for critique Researcher 1 day

3 Supervisors input and corrections Supervisor 2 weeks

4 Effecting of corrections and final write up Researcher 2 weeks

TOTAL DURATION FROM EXPECTED DATE OF RECEIPT 20 WEEKS

OF APPROVED PROPOSAL TO SUBMISSION OF THE
DISSERTATION

141
 Appendix 2: Questionnaire

Questionnaire to assess the prevalence of respiratory symptoms and availability of control

measures among bakery workers and controls in Edo Central Senatorial District, Edo

State.

(Adapted from British Medical Research Council Respiratory Questionnaire)

Section 1: SOCIO-DEMOGRAPHICS OF RESPONDENTS

Respondent’s number:…….. Date ……………

Tick as appropriate

1. Address (Town): ……………………………

2. Place of work 1. Bakery [ ] 2. Water packaging company [ ]

3. Age at last birthday: [ ]

4. Sex: 1. Male [ ] 2. Female [ ]

5. Marital status: 1. Single [ ] 2. Married [ ] 3. Widowed [ ] 4. Separated/Divorced [ ]

6. Tribe: --------------------------------------------------------------------------------------

7. Level of educational: 1. No formal education [ ] 2. Primary education [ ]

3. Secondary education [ ] 4. Tertiary education [ ]

8. Religion: 1. Christianity [ ] 2. Islam [ ] 3. African Traditional Religion [ ] 4. Others

……………………………….

Occupational history

9. What is your position/job title? ……………………………………………

10. How many hours do you work in a day? ……………………………………

11. How many days do you work in a week? .....................................

142
12. Number of months employed in this occupation? ...............................

13. Have you worked at any other dusty job (apart from this one)? Yes / No

14. If yes, Specify………………………………………………………………

15. How long have you worked at other dusty job? ……………………………

Section 2: To determine the prevalence of respiratory symptoms among bakery workers

and controls

I am going to ask some questions, mainly about your chest. I should like you to answer Yes or

No whenever possible.

Running nose/sneezing

1. Do you usually have runny nose or sneezing for some days when at work? Yes [ ] No []

If yes,

2. Does this runny nose or sneezing improve when you are away from work for some days?

Yes [ ] No [ ]

Cough

3. Do you usually cough first thing in the morning? Yes [ ] No [ ]

4. Do you usually cough at all during the rest of the day or at night? Yes [ ] No [ ]

If yes,

5. Does the cough improve when you are away from work for some days? Yes [ ] No [ ]

6. Do you usually cough every day for as much as three months each year?

Yes [ ] No [ ]

Sputum

7. Do you usually bring up sputum from your chest first thing in the morning? Yes [ ] No [ ]

143
8. Do you usually bring up any sputum from your chest during the rest of the day or at

night? Yes [ ] No [ ]

If yes,

9. Does the sputum improve when you are away from work for some days? Yes [ ] No

[]

10. Do you bring up sputum from your chest, every day for as much as three months each

year? Yes [ ] No [ ]

Chest Tightness

11. When at work do you ever get a feeling of tightness in your chest? Yes [ ] No [ ]

If yes,

12. Does this feeling of tightness in the chest improve when you are away from work for

some days? Yes [ ] No [ ]

Breathlessness

13. Do you get short of breath when hurrying or climbing stairs? Yes [ ] No [ ]

14. When at work, do you ever feel short of breath? Yes [ ] No [ ]

If yes,

15. Does this shortness of breath improve when you are away from work for some days? Yes

[ ] No [ ]

Wheezing

16. Do you or others nearby hear a whistling sound from your chest when you are at work?

Yes [ ] No [ ]

17. Does this whistling sound improve when you are away from work for some days? Yes [ ]

No [ ]

144
Past history of asthma/atopy

Have you ever had or been told that you have asthma since you starting working here?:

18. Asthma Yes [ ] No [ ]

19. Hay fever Yes [ ] No [ ]

Tobacco smoking

20. Do you smoke? Yes [ ] No [ ]

If No

21. Have you ever smoked as much as one cigarette a day for as long as a year? Yes [ ] No

[]

22. Have you been regularly smoking one or more cigarettes a day for at least one year? Yes

[ ] No [ ]

23. Did you ever smoke one or more cigarettes a day regularly in the past but have quit

smoking at least one year prior to the study? Yes [ ] No [ ]

SECTION 3: To Assess Availability of Control Measures among Bakery Workers

1. What hazards are you exposed to at work? Tick all that apply

a. Noise b. Heat c. Cold d. Flour dust/general dust e. Chemicals

2. Have you received any training on control of hazards at work? Yes [ ] No]

3. Are you provided with any personal protective equipment? Yes [ ] No [

4. Did you purchase your own personal protective equipment? Yes [ ] No [ ]

5. Do you use your personal protective equipment? Yes [ ] No [ ]

If yes,

6. Which personal protective equipment do you use? Tick all that apply

a. Face mask b. Head gear c. Apron d. Googles e. Gloves f. Booths

145
7. If you use face mask, what type do you use? …………………

8. How often do you use the personal protective equipment?

I. Always II. Sometimes III. Never

9. If you do not use personal protective equipment, give reasons why you do not use them?

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………….......

Section 4: Spirometry measurements

Anthropometry

Weight……(kg) Height ……..(m)

Spirometer measurements

Forced Vital Capacity (FVC) …………………………….(L)

Forced expiratory volume in the first second (FEV1) ……………………(L)

FEV1/FVC ratio …………………………….

146
 Appendix 3:

Observational checklist for assessing control measures (Adapted from works by Elms 28

and Meijester 35)

Bakery number……………..

Checklist number …………….

Number of employees …………

Average daily production ……….

S/N CHECKLIST QUESTIONS YES NO REMARKS

A STRUCTURAL/ ENGINEERING
CONTROLS

1. Segregation of work processes

2. Local exhaust ventilation

3. Mechanical fans

4. Adequate ventilation of rooms

5. Solid lid on mixer

6 Good lighting

PROCESS CONTROL

7. Use of oil instead of flour on dough table

8. No shaking of bags during emptying

9. No dumping flour from a height or throwing

with force

10 Use of sprinklers to spread dusting flour

11. Workers tip flour with the open end of bag

facing away

12. No raising dust when loading ingredients into

mixer

147
13 Mixers started on slow speed until wet and dry
ingredients are combined

14. No Creation of airborne dust when folding

and disposing of empty bags

15. Stainless steel worktable

16. No damage to ingredients bags.

CLEANING AND HOUSEKEEPING

17. Use of wet sweeping during cleaning

18. No dust stirred up during cleaning

19. Spillages of flour cleaned up immediately

20. Workroom is being cleaned daily

21 Empty bags are stored outside workroom

PERSONAL PROTECTIVE EQUIPMENTS

22. Use of face mask by more than 50 percent of

employees

23. Use of face mask during mixing

24. Use of face mask during cleaning

25. Face mask is clean

26. Use of overalls for tasks with high dust

generation

Percentage of staff using face mask ……………%

Does bakery have a safety representative? Yes [ ] No [ ]

148
Appendix 4a: Dust meter

149
 Appendix 4b:

Direct reading instrument results for particulates in Bakery

Bakery number ……. Day…… Date……… Sample duration ………..

Sample 1 Start of Activity Time:…………(hrs)

Particulate Mass: PM2.5

Airborne Concentration (mg/m3)

Stations Concentration Average
At source 2m to right 2m to left

Mixing

Dough Preparation

Baking

150
 Appendix 4c

Direct reading instrument results for particulates in Bakery

Bakery number ……. Day…… Date……… Sample duration ………..

Sample 2 Peak of activity Time:…………(hrs)

Particulate Mass: PM ……………………………….

Airborne Concentration (mg/m3)

Stations Concentration Average
At source 2m to right 2m to left

Mixing

Dough Preparation

Baking

151
 Appendix 4d

Direct reading instrument for water packaging company

Company No: ………… Date: ……………….

Sample 1 Time: ……………….

Airborne Concentration

PM2.5 …………………. mg/m3

PM10…………………… mg/m3

Sample 2 Time: ……………….

PM2.5 …………………. mg/m3

PM10…………………… mg/m3

152
Appendix 5: Spirometer

153
Appendix 6: Calibration certificate

154
 Appendix 7a: Chronogram of activities for bakeries
Bakery number Day Activities Time

1 – 10 1 Cognizance visit 9am – 1pm

1–2 2 Questionnaire, 9am – 3pm

Spirometry

Questionnaire,
3 9am – 3pm
Spirometry

Checklist, Dust
measurement

3–4 4 Questionnaire, 9am – 3pm

spirometry

Questionnaire,
5 9am – 3pm
Spirometry

Checklist, Dust
measurement

5–6 6 Questionnaire, 9am – 3pm

Spirometry

Questionnaire,
7 9am – 3pm
spirometry

Checklist, Dust
measurement

7– 8 8 Questionnaire, 9am – 3pm

Spirometry

Questionnaire,
9 9am – 3pm
Spirometry

Checklist, Dust
measurement

9 - 10 10 Questionnaire, 9am – 3pm

Spirometry, Checklist

Questionnaire,
11 9am – 3pm
Spirometry

Checklist, Dust
measurement

155
 Appendix 7b: Chronogram of activities for water packaging companies
Water company number Day Activities Time
1 - 12 12 Cognizance visit 9am – 1pm
1–2 13 Questionnaire, Spirometry 9am – 3pm

Questionnaire, Spirometry,

14 Dust measurement 9am – 3pm

3–4 15 Questionnaire, Spirometry 9am – 3pm

Questionnaire, Spirometry,

16 Dust measurement 9am – 3pm

5–6 17 Questionnaire, Spirometry 9am – 3pm

18 Questionnaire, Spirometry 9am – 3pm

7– 8 19 Questionnaire, Spirometry 9am – 3pm

20 Questionnaire, Spirometry 9am – 3pm

9 - 10 21 Questionnaire, Spirometry 9am – 3pm

22 Questionnaire, Spirometry 9am – 3pm

11 -12 23 Questionnaire, Spirometry 9am – 3pm

Questionnaire, Spirometry 9am – 3pm

156
Appendix 8: Approval from National Postgraduate Medical College

157
Appendix 9: Institutional approval

158
 Appendix 10

IRRUA SPECIALIST TEACHING HOSPITAL, KM 87, BENIN-AUCHI

EXPRESS WAY, IRRUA, EDO STATE

INFORMED CONSENT FORM

HREC Research approval number …………………………………..............................

This approval will elapse on…………………………………………………….………

Title of the research:

Assessment of exposure to flour dust, respiratory effects and control measures among bakery

workers in Edo Central Senatorial District, Edo State, Nigeria.

Name and affiliation of researcher of applicant:

This study is being conducted by Dr. Aiguomudu Mercy, of the department of Community

Medicine, Irrua Specialist Teaching Hospital, Irrua.

Sponsor of the research:

This study is sponsored by the researcher, Dr. Aiguomudu Mercy.

Purpose of the research:

The purpose of this study is to assess the effects of flour dust on the health of bakery workers

and to provide solutions on how to protect them from harmful exposures. In this study, exposure

levels to flour dust will be measured in the bakeries in Edo Central Senatorial District using a

dust meter. A questionnaire will be used to assess the prevalence of and risk factors for

159
respiratory symptoms and a spirometer will be used to measure lung functions in both study

groups. Availability of control measures in the bakeries will be assessed by an observational

checklist.

Procedure of the Research:

The participants in this study are of two groups, one exposed to flour dust and the other

unexposed water company workers. Both groups will be required to complete a questionnaire on

respiratory symptoms with the necessary information. You will also have your lung function

tested with a portable device. You will blow air into the device while following instructions from

the operator. You will also have an examination of your chest and measurement of height and

weight. The amount of flour dust the bakery workers are exposed to will be measured with a

device that will be placed in the working environment. The researchers will also observe the

bakery workers as they perform some sessions of baking. We expect to have a minimum of 109

participants in both groups of this study.

Expected duration of research and of participants’ involvement: You will be involved in this

research for at least 3 months but not more than six months.

Risks: This study and the procedures involved will pose minimal risk to you such as the

discomfort of blowing into a spirometer, the psychological stress of completing the questionnaire

which will be administered by an interviewer.

Costs to the participants of joining the research: Your participation in this research will not

costs you anything financially but may cost loss of man hours of work as it will take you 30-40

minutes to complete the questionnaire in one day, another 20 minutes to do the spirometer test

and 5 minutes to do a physical examination on another day.

160
IRRUA SPECIALIST TEACHING HOSPITAL, KM 87, BENIN-AUCHI

EXPRESS WAY, IRRUA, EDO STATE

Benefits:

You will be informed on how to protect your health in the workplace and limit your exposure to

excessive amounts of dust. You will also have the opportunity of getting a physical examination.

Confidentiality:

All the information collected in this study will be given code numbers and no name will be

recorded or used for any publication in this study.

Voluntariness:

Your participation in this study is entirely voluntary.

Alternative to participation:

If you choose not to participate in this study, it will not bring you any trouble at work.

Due inducements:

You will be compensated for the time you spent on this study, but you will not be paid any fees

for participating.

Consequences of participants’ decision to withdraw from research:

You can choose to withdraw from this study at any time you do not feel comfortable to continue

participation. Please note that some information obtained from you before you chose to withdraw

may have been modified or already used in reports. These cannot be removed anymore, however

we will make good efforts to comply with your wishes as much as practicable.

IRRUA SPECIALIST TEACHING HOSPITAL, KM 87, BENIN-AUCHI

EXPRESS WAY, IRRUA, EDO STATE

Modality of providing treatments and actions to be taken in case of injury:

161
If you suffer any injury in the course of participating in this study, you will be treated at Irrua

Specialist Teaching at no cost to you. The researcher will be responsible for the cost of this

treatment.

What happens to research participants and communities when the research is over?

You will be informed of the outcome of the research by the researchers at the end of the study.

During the course of this research, you will be informed of anything that may affect your

continued participation or your health.

Statement of person obtaining informed consent:

I have fully explained this research to ____________________________________ and have

given sufficient information, including risks and benefits, to make an informed decision.

DATE _______________________ SIGNATURE _______________________

NAME ____________________________________________________________________

Statement of the person giving consent

I have read the description of the research or have had it read to me. I understand that my

participation is voluntary. I know enough about the purpose, methods, risk and benefits of the

research study to judge that I want to take part in it. I understand that I may freely stop being part

of this study at any time. I have received a copy of this consent form and additional information

sheet to keep for myself.

IRRUA SPECIALIST TEACHING HOSPITAL, KM 87, BENIN-AUCHI

EXPRESS WAY, IRRUA, EDO STATE

DATE _______________________ SIGNATURE _______________________

NAME ___________________________________________________________________

WITNESS SIGNATURE _______________________

WITNESS NAME _________________________________________________________

Further enquiries should be directed to:

162
The Chairman,

Health Research Ethics Committee,

Irrua Specialist Teaching Hospital, Irrua.

Phone No: +234 803 426 3359

Email: isth.rec.2015@gmail.com

Dr. Aiguomudu Mercy

The Principal Investigator

Department of Community Medicine

Irrua Specialist Teaching Hospital, Irrua.

Phone No: +234 816 426 9336

E-mail: mercyaig@yahoo.com

163
164