Musculoskeletal disorders and other occupational health outcomes among sanitation workers in Nepal: A community based cross-sectional survey exploring the risk factors, knowledge, and practices

Khatri et al. BMC Public Health (2025) 25:1273 https://doi.org/10.1186/s12889-025-22282-6 BMC Public Health Open Access RESEARCH Musculoskeletal disorders and other occupational health outcomes among sanitation workers in Nepal: A community based cross-sectional survey exploring the risk factors, knowledge, and practices Samip Khatri1* , Gita Kumari Shah1 , Pratibha Bhandari1 , Sweta Koirala1 , Kalidas Neupane1, Niraj Bhattarai1 , Sagar Gyawali1 , Bipan Bahadur Tiwari1 , Sonam Magar1 , Antra Kapar1, Monika Chaudhary1, Subash Wagle1, Sanjay Kumar Shah2, Sara Hagedorn Kragh3, Kurt Rasmussen4 , Erik Jørs5,6 and Dinesh Neupane1,3,7 Abstract Background Sanitation workers play a crucial role in waste management and are at risk of significant occupational health hazards. This study aims to assess work-related musculoskeletal disorders along with other occupational health outcomes, knowledge and practices pertaining to occupational health risks among sanitation workers in five municipalities of Nepal and identify factors associated with musculoskeletal disorders. Methods A community-based quantitative cross-sectional survey was conducted among 790 sanitation workers using a non-probability sampling method. The study was conducted from December 2023 to December 2024, which involved structured face-to-face interviews with the participants and their health assessments by trained medical doctors. The study assessed socio-demographic characteristics, occupational health outcomes such as musculoskeletal disorders, and knowledge and practices pertaining to occupational health risks. A stepwise backward selection method was employed for conducting multiple logistic regression to identify the significant predictors of musculoskeletal disorders. Odds ratio and 95% CI were used to estimate the magnitude of association. p-value less than 0.05 was considered significant. Results Of the total estimated sample size, 93% of the participants attended the health camp and completed the survey. Musculoskeletal disorders were observed in 36% (95% CI:35.5–39.7) of sanitation workers, with the highest prevalence among sweepers (38.8%), while needlestick injuries were common among the waste collectors (7.2%). Knowledge scores on occupational health risk prevention were moderate (70.7%), with 70.1% of workers reporting the use of personal protective equipment (PPE). Predictors of musculoskeletal disorders included age (OR:1.02, 95% *Correspondence: Samip Khatri Full list of author information is available at the end of the article © The Author(s) 2025. 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To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Khatri et al. BMC Public Health (2025) 25:1273 Page 2 of 14 CI:1.00-1.03), belonging to an underprivileged ethnic group (OR:2.14, 95% CI:1.01–5.53), education level (grade1–5) (OR:1.49, 95% CI:1.03–2.16) and employment in Pokhara municipality (OR:1.43, 95% CI:0.94–2.18). Conclusion Sanitation workers in Nepal face significant work-related occupational health risks, particularly musculoskeletal disorders, influenced by socio-demographic and job-specific factors. It is essential to implement targeted training programs for occupational safety, enforce workplace safety regulations, and conduct routine health screenings of sanitation workers by the municipality. Keywords Knowledge and practice, Musculoskeletal disorder, Needle stick injury, Personal protective equipment, Sanitation worker Background Sanitation workers play a key role in keeping the environment clean and promote human health by collecting waste directly from households, shops and small companies. The definition of sanitation workers encompasses a vast array of services with regional differences in terminology [1–4]. Despite the existence of several legal frameworks, the term sanitation worker has not been operationalized [5–8]. Various authors from Nepal have used different terminologies, such as informal waste workers, municipal solid waste handlers, waste workers, and sanitary workers to address these workers [9– 12]. The term sanitation worker includes all individuals, whether formally employed or not, who are responsible for cleaning, maintaining, operating or emptying sanitation systems at any stage of the sanitation chain [13]. Their jobs also include cleaning toilets, emptying pits and septic tanks, cleaning sewers and manholes, operating pumping stations and treatment plants, and collecting, transporting and disposing health care and household waste. Often engaged in the informal sector, as an invisible, discriminated workforce, they are some of the most vulnerable workers exposed to occupational and environmental health hazards, while facing profound risks to their health and wellbeing, including illness, injury, and even death [14]. Musculoskeletal disorder is one of the common public health problem among the sanitation workers, which impacts their quality of life and contributes to their absenteeism, increased work restriction, transfer to other jobs, or disability more than any other group of diseases, with considerable economic toll on the individual, organization and society as a whole [15–18]. They are at risk of injuries due to heavy labor, poor posture, work-nature in confined spaces along with psychosocial stress [19, 20]. These risks are further exacerbated by different factors such as poverty, illness, malnutrition, poor housing conditions, child labor, substance abuse, social stigma, and societal neglect [13, 21]. Various empirical evidence suggests that age [18, 22], sex [23], education [18], work experience [24], substance abuse [22], mental health [22], working duration [25], location of work (slum vs. not slum) [24], job roles [26], body posture [25], body mass index [27], level of stress [23] and history of injuries [23] are the significant predictors of musculoskeletal disorders [28]. Besides musculoskeletal disorders, sanitation workers are also at risk of various other occupational health conditions, such as gastrointestinal problems, respiratory (...truncated)