Pattern of occupational injury and its effect on the health of male police officers in Calicut, India

Context: Police officers play an important role in the society by ensuring security and are an occupational group at high risk for sustaining injuries, which is associated with an increased risk of adverse physical and mental health. Studies suggest that they die at an earlier age than expected for the general population for all causes of death. Risks for occupational injury and illness among policemen have not been tracked adequately; the relationships between chronic disease and mortality have not been adequately evaluated and health and hazard surveillance system have not been yet developed in India. Objectives: The main objective was to document the pattern of injuries and associated factors among police officers and to study its effect on their health. Materials and Methods: The study was cross sectional and covered 900 policemen (n = 900). Details of injury and related history were elicited using a semi structured questionnaire. Anthropometric and biochemical measurements were carried out using standard techniques. Multivariate analysis was done to identify associated risks and to assess the impact of injury on the physical and mental health of policemen. Results: Injury was reported by 20% of the policemen. The main cause of injury was encounters (52.7%) followed by accidents (35.5%). Commonest type of injury was laceration (43.2%) followed by fractures (36.7%). The injury group had higher prevalence of smoking, frequency of alcohol consumption, less satisfaction levels, and also reported more joint pain and body aches. Though the perceived stress and metabolic syndrome were high it was not statistically significant. Conclusions: Our study indicates high susceptibility of police officers to injury. Availability of equipments for personal protection of police should be improved and its compliance ensured for the safety of the police and the community.

Keywords: Injury, Mental health, personal protection, police, work-related violence

Police officers play an important role in the society by ensuring security. International and national reports reveal high level of criminal activities. ^[1],[2] A physically and mentally fit police force is necessary to tackle this problem. Unfortunately, available studies indicate that police officers have an increased risk of premature death and may be more prone to certain diseases. ^[3] The prevalence of injury was reported to be high among police officers. The incidents causing injuries include encounters like arresting of convicts, mob control, and controlling protest marches. They are also at risk of falls while chasing criminals and gunshot injuries. Police officers are prone to accidents during transportation of suspects/prisoners, chasing criminals, and escorting very important persons (VIPs). ^[4] Since police force has over night work shifts for long days they have high prevalence of shift work sleep disorders with symptoms of insomnia and excessive sleepiness which make them vulnerable to work-related errors and accidents leading to injuries. ^[5] The injuries include cuts caused by sharp weapons, fractures usually by blunt force, sprains and burns. ^[5] Frequent sustaining of injuries and the need for medical treatment is associated with an increased risk of adverse mental health. ^[6] Police officers who suffered more than one injury had a relative risk of 4.9 for increased alcohol consumption and 4.4 relative risk for psychological distress symptoms compared to those who suffered no injuries. ^[6] Injuries especially musculoskeletal may decrease the involvement of police officers in physical exercises. Post trauma stress (PTSD) may also be an important factor responsible for the development of this attitude. A study done among police officers at Buffalo United states revealed that officers with severe PTSD symptoms had a relative risk of approximately three for developing metabolic syndrome which was not affected by age. ^[7] Offenders/culprits infected with hepatitis B pose a significant risk to exposed police and custodial officers. Police can be infected if a hepatitis B-infected person spits or bites an officer, if a contaminated sharp cuts skin, or if contaminated crime scene evidence infects officers. ^[8] Police officers are also at risk for tetanus infection following injury from sharp metals. ^[8] Adequate personal protection is important for the modern police force. Plight of the police officers who are forced to use rudimentary protective equipments even during dangerous encounters have been reported in India. ^[9] Risks for occupational injury and illness among policemen have not been tracked adequately; the relationships between chronic disease and mortality have not been adequately evaluated and health and hazard surveillance system have not been yet developed in India. In a country like India with resource constraints, it is imperative that appropriate cost effective techniques be developed to ensure safety of police officers, which require a detailed data base of injuries among them.

The study was conducted in a cross sectional design and subjects were all the police officers of Calicut Town., Kerala state, India. The township has 25 police stations with 1200 police personnel in total. The project proposal was approved after two rounds of discussions by the investigators with the police commissioner. The protocol was approved by Indian Medical Association’s Ethical committee. The proforma for data collection and screening was prepared by epidemiologists and after pretesting, required modifications were done. It included details about sociodemographic characteristics, anthropometric and biochemical parameters, medical history, details of injuries sustained during the service, levels of physical activity and smoking and alcohol status. Screening was conducted at Calicut General Hospital and written informed consent was collected prior to data collection from each participant. The multidisciplinary screening team included physicians, epidemiologists, nurses, lab technicians. Training was given for the persons involved in data collection. Blood investigations and laboratory examinations were done at the public health laboratory of Calicut General Hospital. The study period extended for eight weeks. Each week, 120 police officers were selected and instructed to report at the General Hospital on prescribed days from Monday to Saturday (20 persons X 6 days). They were asked to report at 8 am on empty stomach (12 h overnight fasting) and underwent following blood investigations total cholesterol, high density lipoprotein (HDL), cholesterol and triglycerides], fasting plasma glucose and antigens (HBSAg). The same policemen underwent screening on the following Sunday.

Screening camps: Four stations were organized:

1 ^st station: The proforma was given and after briefing, personal data was self-administered and cross checked.

2 ^nd station: Dietary history, personal habits, and addiction details were collected. Details of tetanus vaccination in the last 5 years and hepatitis vaccination were elicited.

3 ^rd station: Blood pressure and anthropometric measurements were done.

4 ^th station: Detailed morbidity history was taken. After medical examination by doctors, required counselling, prescriptions, and references were given.

Data collection

The details of injury sustained during the service period were collected from recall by the investigators directly. The cause, type, treatment, and outcome details were elicited using a validated semistructured questionnaire. Impact of the injury on the police men was studied in terms of perceived stress, perceived job satisfaction, addiction to smoking and alcohol. Stress and satisfaction was assessed psychometrically using Numerical Analogue Scale ranging from 0 to 10.

Anthropometric measurements

Standing body height was measured with a commercial stadiometer in centimeters (cms) (to the nearest 0.5 cm). A digital scale, with an accuracy of ±100 gram (g), was used to measure body weight and recorded in kilograms (kg). The waist circumference was measured in a horizontal plane, midway between the inferior margin of the ribs and the superior border of the iliac crest using a standard inelastic measuring tape. The measurements were taken thrice and the mean was taken in all cases. All the instruments used for measurement were calibrated twice weekly. Systolic and diastolic blood pressures were measured using a standard Sphygmomanometer with adult cuffs and recorded in millimeters mercury (mm Hg). The measurements were repeated twice at an interval of 3 min in the sitting position and the mean was taken.

Biochemical measurements

Blood samples (3 mL) were drawn from the midcubital vein after 12 h overnight fasting for the measurement of lipid profile [total cholesterol, HDL, cholesterol, and triglycerides] and fasting plasma glucose levels. Plasma glucose was measured using the glucose oxidase peroxidase method; serum total cholesterol and triglycerides by standard enzymatic procedures; and HDL cholesterol by direct assay method. They were recorded in milligrams per deciliter (mg/dL). Metabolic syndrome was diagnosed using the modified National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII) criterion, which considers ethnic differences in central obesity. HB S Ag screening test was done by commercially available rapid test kit according to the manufactures instructions [TULIP diagnostics (P) LTD, India) which have sensitivity of 87.3% and specificity of 100%. The recorded information was cross checked for any disparity/personal errors and corrections were made. The data were coded and entered in the computer by trained data entry operator under the supervision of epidemiologist at Medical Education Unit-Calicut Govt. Medical College.

Statistical analysis

Statistical analysis was performed using SPSS 16.0 program (Statistical Package for Social Sciences) for Windows 7 (SPSS Inc., Chicago, IL, USA). Prevalence is reported in percentage. P value was calculated to determine whether the differences were statistically significant.

Value less than 0.05 was taken as cut off for the same.

Twenty-five police stations covered in our study had a combined police force of 1200. Nine hundred officers attended the study giving a response rate of 75%. There were 823 men and 77 women. Since there is gender-wise differences in study variables analysis was done for men and women separately. The analysis of male police officers data is included in this paper. The age ranged from 26 to 58 (mean: 41.3 ± 6.8 years). They were predominantly middle-aged with 85% belonging to the age group of 30-50. The duration of service ranged from 1 to 34 years (mean 15.3 + 7.6 years). One hundred and sixty-nine policemen (20.5%) reported injury during their service period. On an average, 16 injuries were reported by the study population annually. The rate of injury for 10 years was calculated to be 20%. The calculated rate could be an underestimation due to recall bias as only major injuries would be recalled by the subjects. Also, the officers who were permanently disabled or killed in the incidents were not covered in our study. Injuries/accidents accounted for 27.8% of the hospitalizations. The number of injuries was significantly correlated with service years (r = 0.2, P-value <0.0001). Proportionally, most of the injured belonged to lower ranks-Constables and assistant subinspectors (70%). Causes of injuries are listed in [Table 1] and the pattern of injuries is represented in [Table 2]. Perceived job-related stress and satisfaction were assessed and were stratified into two groups-low and high taking five as cut-off, higher satisfaction was reported by those who had not sustained any injuries as compared to those who did (67% vs. 62%). Comparisons of relevant characteristics of the population are listed in [Table 3]. The prevalence of alcohol consumption was similar in the two groups. However, those with injuries were found to engage in drinking more frequently than those who did not suffer any injury (27% weekly vs. 17%). Complains of joint pain and body ache were more prevalent among those who sustained injury. While 34.7% and 26.6% of the injured reported joint pain and body ache respectively, the values were 21.4% and 20.1% among those who did not. The differences were statistically significant after adjusting for age (P-value <0.05). It was assumed that those with injuries would engage less in physical activities and, therefore, become susceptible to gaining weight. The prevalence of metabolic syndrome was higher among those injured (17.8% vs. 14.8%). Hepatitis B and tetanus are two vaccine preventable diseases to which police officers are at risk. In our study, 31.6% were found to be immunized to tetanus during the 5-year recall period. The vaccination rate was higher among those injured. Only 16 (1.9%) of the policemen were ever vaccinated against hepatitis B and the rates were similar in the two groups. All the police men were tested for HBsAg but none were positive The policemen with injuries were more likely to be rewarded than those without injuries (40.2 vs. 22.8%) Analysis revealed statistically significant difference between the two groups after adjusting for age (P-value <0.01). Our study revealed that among those who were injured, the ones who were awarded for their service reported less stress than those who did not (mean 6.5 vs. 5.8) (P = 0.09). However, the awarding did not have any influence on the perceived job satisfaction among the two groups.

Our study was aimed at assessing the health status of the police force of Calicut, a South Indian City. Detailed Information about injuries and associated factors was collected as part of the study using a semistructured questionnaire. To ensure commitment of the police officers and instill confidence to tackle criminals, it is important that the police officers be provided with adequate protection to injuries. Types of injuries and incidents exposing the police officers to these injuries need to be recorded and reported/documented. At the same time, the effect of these incidents on the physical and mental health of the officers needs to be studied. It was revealed that 28% of hospitalizations were due to accidental injury; this was only 8% in the general population of Kerala. ^[10] Though the correlation was poor (r = 0.20), we found significant increase in the number of injuries with increase in service years. Most of the injuries occurred in the initial years of service. It should be kept in mind that remote incidents of injury may not have been recalled (recall bias); minor incidents which did not require hospitalization may also have been forgotten. In our study, occupation related injury was reported by 20% of the officers. Encounters accounted for more than half of these injuries. A South African study and studies from the West have also revealed similar finding. ^[11] Majority of the policemen were injured by direct physical force while capturing criminals, controlling mob, and so on. Like their counterparts elsewhere risk of road traffic accidents (RTAs) was found to be high and 30% of the injured had sustained injuries from RTAs. ^[4] Accidents occurred during transportation of suspects/prisoners, chasing criminals, and escorting VIPs. It could be attributed to a combination of human and mechanical factors. The police officers are often overworked and sleep deprived; the vehicles of old make and poor maintenance. The commonest type of injury was laceration, fracture being second. This was similar to other studies. ^[4] However, unlike the west gunshot injury cases were found to be low (1%). Sprain and burns were also reported by 20.7% and 3.6% officers, respectively [Table 2]. Many investigators have documented sleep problems among police men and showed how these sleep problems and shift work directly relate to sustaining injuries especially accidents. ^[4],[5] They were found to be at risk of exhibiting adverse work-related outcomes including falling asleep while driving, making an error or safety violation attributed to fatigue and uncontrolled anger toward suspects. ^[5] Police persons usually have over time works and night shifts continuously. Researchers have shown that the risk increases considerably after a person has been on duty for 9 h or more. After 10 h on duty, the risk increased by approximately 90% ; after 12 h, 110%. ^[12] A study found that the attributable risk of injury during midnight shift exceeded that during day shift by 72%. ^[13]

Impact of the injury on the police men was studied in terms of perceived stress, perceived job satisfaction, addiction to smoking and alcohol. Group analysis reveals higher satisfaction levels among those not injured (P = 0.04). Though perceived stress levels were not high, indirect measures of stress like smoking and frequency of alcohol use were indeed high among those injured. However, a causal relation can only be proposed as our study was cross sectional and suffers from lack of assessment of temporal relation.

Hepatitis B and tetanus are two vaccine preventable diseases directly related to injuries. As of now, there are no routine immunization programs against these diseases among police officers. All the 900 police officers included in our study underwent test for HBS Ag and none of them tested positive. Thequestion as to whether whole police personnel should be immunized begs the wider issue of debate. ^[14] Some authors have recommended a program of surveillance and routine immunization against hepatitis B. ^[15]

We also found high prevalence of musculoskeletal problems like joint pain (24.1%) and body ache (21.4%) among policemen. They were reported more by those who had sustained injuries. It has been hypothesized that these problems might result in decreased physical activity and predispose the policemen to the development of obesity and other cardio vascular risk factors including metabolic syndrome. The prevalence of metabolic syndrome, one of the cardiovascular risk factors was found to be high among the police officers (17%). However, injury was not found to be a significant contributor toward the same [Table 3].

Following suggestions have been put forward to prevent violence to police officers. ^[4],[16] Increasing staffing levels of police officers. Efficient and effective deployment of available manpower. Better training of the officers. Research indicates that when an officer is prepared for the possibility of assault, the probability of the officer being injured decreases by 8.8%. Altering officer training to include human awareness training and effective communication skills. There should be more emphasis on tactics and strategies for defusing trouble.

Police force is an occupational group susceptible to multiple health hazards including injuries. Since our study was done with the aim of providing baseline information on prevalence rates of injuries and associated factors for the intervention programs; further prospective studies are needed. In conclusion, encounters, RTAs, injury rate are higher among police person than general population. Among those injured majority are major injuries like laceration and fracture with prolonged health effects both physical and mental in their life time. Our study reflects the need for injury surveillance and providing adequate training, devices to protect them from direct physical violence. It is also important to ensure compliance among policemen for the use of these equipments. Concern regarding the personal protection of the policemen needs to be addressed urgently to ensure safety of the officers and the community as a whole.

The Health Of Police (HOPE) study was conducted with the help of members of Indian Medical Association (IMA)-Kerala chapter and Kerala Police Association-Calicut district chapter. We thank Mr Anoop Kuruvilla-Police Commissioner, Calicut; Dr. Sashidharan, President IMA, Dr. Prabhakaran K. V., secretary IMA; other office bearers of the organization, staff of Calicut General Hospital and all the participants who cooperated with the study.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.140223

[Table 1], [Table 2], [Table 3]