Background
In many developing countries, the demand for information and computer based technology has largely been satisfied through the importation and shipment of used electronic products [
1]. Consequently, there has been a surge in electrical and electronic waste (e-waste) materials in the waste stream of these countries [
2‐
4]. In Ghana, the widespread inability to afford new electronic products, coupled with the quest to keep pace with the global advancement in electronic technology, has led to massive importation of mostly second-hand electronic gadgets from developed countries, primarily from Europe and North America [
5,
6]. Studies have shown that where e-waste exists, informal recycling activities are performed under dangerous conditions [
7‐
10].
Ghana’s e-waste dump at Agbogbloshie is reported to be the biggest in sub-Saharan Africa, one of the largest worldwide, and has thus attracted the attention of many international environmental groups, researchers, and journalists [
11]. The dump is currently a site for trade in products recovered from the waste stream [
12,
13]. Informal workers scavenge the waste, dismantle the scrap in proximity to open-air burning to recover precious components such as gold, copper, silver, aluminum, iron, and brass for sale [
14]. The livelihood of many people depends on the income generated from these activities [
15,
16].
It is important to note that there are socioeconomic and cultural dynamics that come to play within such an informal work environment and these can be burdensome for individuals involved in such work activities, the family and the community health as a whole. In addition, there are issues of poor living arrangements and hazardous working conditions. In spite of the dangers associated with this type of work, the high job demands and the associated low wages result in an effort-reward imbalance that creates dissatisfaction among these e-waste workers.
In Ghana, e-waste workers are prone to various illnesses and injuries from numerous hazards [
17]. Some of the conditions may be subclinical and asymptomatic and may only be detected incidentally during clinical investigations. Non-use of formal channels of health care [
18] may result in delay in diagnosis of some of these medical conditions with detrimental effects. Also in the event of injuries, refusal to seek appropriate medical care could make such individuals prone to a number of ailments [
19] such as severe wound infections, poor wound healing, deformities associated with poor management of wounds and the risk of tetanus infection.
Reasons for health seeking behavior are varied among individuals in times of ill health [
20]. Barriers to formal quality health care can therefore be removed to partly motivate vulnerable workers [
21] in the informal sector such as e-waste workers to have access to quality and affordable health care that will help in the early diagnosis and adequate treatment of diseases and injuries. This study therefore sought to describe health-seeking behavior, and social and other factors affecting this behavior, among e-waste workers.
Theoretical background
This study draws on the health belief model (HBM), a useful tool in understanding and predicting health care seeking behaviour [
22] to explain the findings. The model proposes that health-related behavior depends on an individual’s perception of four critical areas; severity of a potential illness, susceptibility to that illness, benefits of taking a preventive action and barriers to taking that action. The assumption therefore is that health seeking behaviour is influenced by certain cognitive variables as well as established mechanisms to minimize the occurrence of disease within the social system.
HBM suggests that individuals are faced with alternative actions but usually choose one that is most likely to yield positive outcomes [
23]. Consequently, changes in health behaviour occur under these circumstances, and in this case, e-waste workers are likely to seek care in times of ill-health when they hold certain beliefs about that ill-condition. These beliefs include perceived susceptibility to a particular health problem, in this case – whether the e-waste workers are at risk of ill health, perceived seriousness or severity of the health condition and its social consequences, belief in effectiveness of the new behaviour as the right thing to do, cues to action such as witnessing the death or illness of colleague e-waste workers, perceived benefits of preventive action and barriers to taking action.
It is believed that the combined effect of these beliefs influences to a large extent the likelihood of an individual to perform the behavior. The HBM can therefore be said to explain the relationship between an e-waste workers’ beliefs and behaviour by providing a way to understand and predict how they behave as far as their health is concerned.
Discussion
The findings of this qualitative study indicated that injuries and illnesses were major concerns among e-waste workers, with dismantling and burning being the main activities causing the majority of the injuries. Cuts and burns were common among participants, as has been reported in other studies on e-waste workers at Agbogbloshie [
27,
29,
30]. Other commonly reported conditions were chest pains and respiratory symptoms attributed to work place factors. This is consistent with findings in China and Brazil where e-waste workers have made similar health complaints as a result of the e-waste activities they undertake [
31,
32]. Self-reported chest and respiratory symptoms had also been indicated as common complaints amongst the e-waste workers [
33,
34]. These symptoms could be as a result of exposure to smoke and fumes of metals such as lead and cadmium. The fumes from these substances could cause multiple disorders, organ malfunction or even cancers [
33‐
37]. In this survey, most of the e-waste workers lived on site near their work area. E-waste sites are usually overcrowded coupled with poor living conditions that make them vulnerable to ill health conditions [
37].
Most e-waste workers were involved in the activity only for a relatively short period of time, and often gave up the job due to the onset of health problems, consistent with other studies [
38]. The effects of chronic exposure to chemicals arising from e-waste processing activities may not be immediately felt as long latencies can exist between exposure and adverse health outcomes. As such, and with increased activities at Agbogbloshie there is an increased need to improve worker access to health facilities for screening, early detection, and appropriate intervention. Our findings suggest that E-waste workers coming south to Accra from the Northern Ghana are typically very healthy upon arrival, but after a short period, illnesses likely resulting from their work activities make them go back to the North to seek treatment for their ailments. This is the trend in China that has been referred to as the “countryside exporting good health and re-importing ill health” [
39].
With respect to health seeking practices, the workers accessed health care from multiple sources with a pattern of seeking health care from a succession of types of health provider until the problem was resolved. These included self treatment, traditional medicine, use of drug stores and use of formal health care services in hospitals or clinics. The use of Chemical Shops was the most predominant choice for health care.
Self treatment involved the use of self prescribed concoctions or substances obtained from herbal medicines during illnesses and injuries. Some of the self treatment practices included application of detergents and lubricants to wounds. Anecdotal information has it that these substances help wash off dirt from wound surfaces and also protect wounds from deterioration. Among the e-waste workers, they hold the opinion that these substances are effective for the purpose of their wounds being protected from other infections. However, they may contain chemicals that may be detrimental in the long term. Traditional medicine involved herbal preparations or natural remedies usually recommended by herbal practitioners or local medicine men. Chemical Shops were a popular choice for obtaining treatment as e-waste workers had the opportunity to talk to the attendants who would then dispense some medication to them. In addition, they were provided with services such as wound care and had built relationships where they could go for medication on credit and paid back later. Formal health care was health care obtained from private or government hospitals or clinics with a qualified clinician.
Though participants’ characteristics such as age, sex, marital status, educational level as well as income were important determinants of health seeking behaviour, the study focused on service and illness characteristics [
38].
Determinants for health seeking varied across individuals depending on the type of health care desired, but generally service and illness characteristics were the most important determinants for first point of call at a health facility. Subsequent choice of health care was determined by perceived benefit of treatment, severity of the ailment, accessibility of the service, quality of service, ease of communication with provider and cost of health care. Severity of ailment was a very important characteristic of health seeking behaviour. The notion among the workers was that mild illnesses and injuries did not require hospital treatment and could be treated with other forms of treatment. However, this practice could result in delay in accessing adequate treatment and for that matter tended to hinder prompt treatment.
Some of the self treatment practices such as the use of detergents and lubricants on wounds were motivated by their perceived benefits. The low educational level of the workers must have influenced such perceptions, probably pointing to the need for health education to improve their health seeking practices.
Accessibility was an important factor in determining choice of health care. Self treatment, traditional treatment and treatment at the Chemical Shops were generally considered to be easily accessible whilst formal health care at hospitals and clinics were not. As found in one study in the Dangme West District of Ghana, herbal remedies were commonly used because of accessibility and cost effectiveness [
40]. There were no formal health care facilities in the area and considering the amount of commercial activities taking place at the site and the population, health authorities may consider the provision of a facility onsite.
Quality of service was one of the service characteristics which predominantly determined health seeking behaviour especially the use of drug stores among the e-waste workers. Good quality service is a key motivation for repeat visit during subsequent health challenges.
Additionally, good communication and good inter-personal relationship between health service providers and clients were important factors that enabled the e-waste workers to freely express their concerns especially when they visited the Chemical Shops. The e-waste workers were able to discuss their health problems with the Chemical Shop owners, who in turn prescribed medicines. With the formal health care provider, however, it took time and potentially several visits for a patient to access a doctor. Besides, the discriminatory tendencies and mistrust of medical professionals deter most migrant workers from attending the hospitals [
31].
The most important determinant of health seeking was cost of health care. E-waste workers resorted to self treatment or traditional medicine because of low cost of treatment. The Licensed Chemical shops/drug stores were also patronized instead of hospitals because of lower cost of their services. Cost has been cited as the main reason for self medication rather than lack of access to medical care in general [
41]. Perceived high cost of health care at formal health care facilities were the main barriers to accessing formal healthcare by the e-waste workers. It has been reported that cost and perceived quality of health care were the most important factors in health decision making [
42]. Despite the fact that cost was a major barrier in accessing formal health care by the workers, the level of NHIS patronage was very low as well. Studies have shown that the high cost of health services and the lack of health insurance have made e-waste workers not patronize health care services from regulated clinics where they can be assured of supervised treatment [
43]. Most of the e-waste workers interviewed did not have a valid NHIS membership card. Cost was again cited as the main reason for non registration, non renewal or replacement of expired or lost membership cards. In effect, e-waste workers could not access the formal health care when they were ill because they would be expected to pay out-of-pocket health expenses [
31] while evidence shows that individuals on NHIS are significantly more likely to visit clinics and seek formal health care when sick [
44]. In order to obtain access to the formal health care, e-waste workers need education on the need for registration with the NHIS as well the importance of retaining their cards and being in good standing for good health promotion.
Competing interest
The authors declare that they have no competing interest including financial to report.
Authors’ contributions
KDB: Conceived study, Interpretation of data and drafting of script. EA: Interpretation of data and drafting of script. JS: Drafting of script. RS: Drafting of script. RN: Drafting of script. NB: Drafting of script. JNF: Drafting of script. All authors read and approved the final manuscript.