The effects of work on the dietary behaviour of mortuary workers in selected regions of Ghana

INTRODUCTION

Diet has a substantial impact on human health and daily task performance. Societal demands and dietary choices are of fundamental importance with respect to the severity of environmental impacts.¹ The dietary behaviour of workers is influenced by a complex network of individual, environmental, societal, biological, and psychological factors. The degree to which people are tempted to make unhealthy food choices depends on factors such as the physical environment (food available in the environment) and “internal” factors (how people make food choices).² The dietary choices of employees are closely linked to the stress levels they experience in their occupations. Numerous studies have demonstrated a strong correlation between workplace stress and increased alcohol intake, a heightened risk of problematic drinking patterns, and a greater likelihood of developing alcohol dependence.³ The work schedule of mortuary workers encompasses numerous responsibilities, such as receiving cadavers, carrying out various preservation procedures, and delivering the deceased to families for burial or cremation. This demanding work environment can be highly stressful and presents a variety of potential hazards.⁴ For example, mortuary workers are continuously exposed to formaldehyde and corpses, some of whom may have suffered traumatic injuries and exhibit unpleasant odors.^5,6 Therefore, mortuary workers constantly work under conditions and in an environment where only a few people will be comfortable working.⁷

There are significant disparities in the mortuary industry between developed and developing countries.⁸ The mortuary industry in developed countries serves a variety of economic sectors, forms a significant part of the healthcare system, and fosters communal cohesiveness.⁹ All efforts are made to keep the working conditions in the industries conducive. However, the situation differs in developing countries such as Ghana, where the industry is faced with difficulties, including unfavourable working conditions, a lack of recognition, and insufficient logistics.⁷

Existing research has neglected mortuary enterprises, resulting in a significant gap in understanding various aspects of the field. This includes the impact of visual experiences on worker appetites, factors that lead to alcohol consumption, and the consumption of heavily spiced food, among other topics. To address this gap, this study sought to explore the influence of the work environment on the dietary practices of mortuary workers in Ghana.

METHODS

Study design

This study employed a descriptive, exploratory qualitative research approach to gain an in-depth understanding of the dietary practices of mortuary workers.¹⁰ Through qualitative research, the study explores how working conditions and the environment influence nutritional intake.

Study setting

The research was conducted in nine healthcare facilities located in Ghana's Volta, Bono East, and Oti regions, including a range of hospital types. These facilities were selected because they all have mortuary workers who provide post-death services to their communities. The inclusion of facilities from three different regions allowed the researchers to gain a complete through understanding of the phenomenon from various geographical perspectives.⁵

Study population and sample

The study focuses on mortuary workers who work in teaching, regional, municipal, and district hospitals in the Volta, Bono East, and Oti regions of Ghana. Purposive sampling was used to recruit individuals who can provide rich data through semi-structured interviews.¹¹ Data saturation was achieved after interviewing mortuary workers from the nine mortuary facilities in the selected regions.¹⁹ The study included mortuary workers who had worked in the selected facilities for at least one year and gave their consent.

Inclusion and exclusion criteria

The study included mortuary workers who were directly involved in mortuary operations, worked in one of the nine selected facilities, had at least one year of work experience, were available during the data collection period, and provided informed consent. Individuals were excluded if they had less than one year of experience, were unavailable or unwilling to participate, did not provide or withdrew consent, or were temporary staff, interns, or trainees.

Data collection method

Data collection involved an individual semi-structured interview guide that was used to gather socio-demographic data and explore participants' apprehensions and issues related to their work and its influence on their eating habits.¹¹

Interviews were conducted in English, with participants using Twi or Ewe based on their understanding.⁵ The interviews were recorded and transcribed, while non-verbal behaviours were documented in field notes. Data was collected between October 2019 and March 2020.

Data analysis

Data collection and analysis were done simultaneously to ensure that themes that emerged from the data were saturated.¹¹ Transcripts were read severally to understand the participants’ world. The data analysis followed the thematic content analysis approach and data was managed manually. Data was coded and categorized, and themes were developed. The researchers reviewed and discussed categories and themes to ensure that the participants’ responses were religiously represented. Field notes were also examined to add depth to the analysis.

Rigour

The study's trustworthiness was ensured by implementing the principles of authenticity, reliability, conformability, and transferability.¹⁴ To ensure research quality, participant-generated data were cross-checked for accuracy (member tests), enhancing credibility and confirmability. All participants were interviewed using the same manual for consistency (reliability). Peer debriefing also ensured comprehensive data coverage. Transferability was guaranteed by providing detailed documentation, enabling other researchers to replicate the study.

Ethical considerations

The research received ethical approval from a university’s ethical committee. Additionally, the hospital administrations where the research was conducted provided approvals to engage mortuary staff. Informed consent was obtained from all participants. Participating mortuary workers were informed about the purpose of the study and their right to withdraw without penalty was clearly explained to them. Privacy and confidentiality were safeguarded by using pseudonyms to protect respondents' identities during the study.

RESULTS

Participants demographic information

A total of 19 participants took part in the study.

Of the 19 participants, 14 were married, 2 were single, 2 were divorced, and 1 was widowed.

Participants’ ages were between 25-65 years. The years of work experience varied between 1 and 38 years. The minimum educational level of participants was basic education, and the maximum was a diploma in a preceptorship.

Emerging themes

The data revealed three key themes: (1) Corpse appearance influenced the appetite of the participants, (2) alcohol use as a coping mechanism, and (3) exposure to corpses influenced food preferences of mortuary workers. These themes reflect the dietary challenges faced by mortuary workers, as quoted by the participants.

Theme one: corpse appearance affect appetite

Of the 19 participants, 17 shared how the sight of dirty and unpleasant corpses affected their appetite and eating habits. Some mentioned eating less, while others completely gave up on certain food. Yes, I can eat, but I can’t eat much after seeing some corpses. For instance, working on uncleaned corpses in the morning. This is because of the nauseating effect of seeing such bodies. I have to wait till after 3:00 pm before I can eat something small. I struggle with food, but food must enter my stomach.

Ehhh!, it's not a joke at all! The nasty things you see here can make you pass your food even when you see it. Most of the corpses brought in are not well cared for before they are brought in, and you must take care of them before preservation.

These participants mentioned that apart from the sight, smell of corpses, blood, and other fluids, are nauseating and impact their appetites. Some attendants shared this perspective. It is very nasty when the policemen and the doctors bring a body from the river or lagoon. The smell of these corpses is different and more nauseating, yet we have to work on the body by injecting it with formalin. The time you spend working on the body and inhaling the smell will make you lose appetite.

My appetite is affected because of the sight of the bodies and sometimes the smell of blood. The reason is that the smell of the blood of an accident body can provoke nausea in my stomach. Sometimes you feel like vomiting.

The smell of blood is disgusting sometimes. It makes you feel sick. Sometimes I feel like throwing out.

Two of the 19 participants reported that their work with corpses doesn't affect their appetite, and they can eat without delay after handling them or completing their tasks.

Work does not affect my eating; I eat my usual foods and eat whenever I want to. I eat every meal. So, for me, there is no change in appetite. I can finish work now, wash my hands, clean the area, and eat. I have no problem.

For me, I can take the meat. Just that, I don’t take meat on certain occasions. I eat my usual food.

Theme two: the use of alcohol as a coping mechanism

Some participants in the study admitted to using alcohol to cope with their work due to the challenging nature of dealing with corpse sights and smells.

Sometimes, the sight of the corpse makes me take a drink before working on them. Otherwise, it is challenging to work on those bodies.

Some of the bodies brought to the mortuary are difficult to (with)stand and work on. It just means that some alcohol can help me continue my work.

The nature of the corpses and the cause of death have been cited by another participant as the reason for taking alcohol.

The nature of the corpse makes me drink alcohol; the body is broken into pieces, the head is crushed, the intestines out, and many more. In our facilities, we don’t have pathologist, hence suturing and putting the body parts together lies on us, the mortuary workers alone. Mostly, the alcohol makes the work less burdensome for me.

Some participants use alcohol to stimulate their appetite and aid their eating, even though it doesn't prevent them from reflecting on the bodies they work on. I take alcohol to eat, to boost my appetite, especially when the scent makes me feel nauseated. The alcohol is to stimulate my appetite. The danger of it is that, as time goes on, you become used to it and start depending on alcohol to the extent that if you don’t take it, you cannot eat.

No, taking alcohol does not mean that I will not remember what I saw. I need to help myself a bit by feeding. There should be some little food in my stomach, that’s all!

Some of the corpses we work on, if you don’t take in any alcohol at all, you cannot eat.

A participants indicated that they prefer the smell of alcohol on their skin to the foul smell emanating from the corpses:

Sometimes, we have to bathe the alcohol or use it to clean our skin. You will prefer to have the smell of alcohol on your skin to the terrible and offensive scent of the corpse.

Some participants admitted taking alcohol after work. This is due to the strict restriction on alcohol consumption at the workplace due to the job policy:

I take alcohol after work, not during work. We cannot drink while at work, it is against the regulations that are given to us, so I take it when I am at home. This makes me take one vault, and it will become a habit if I am not careful.

I drink over the weekends, not because of the effects of the job, but to be happy myself that I have been able to survive another week in this terrible job. As for the workplace, we cannot drink there. It is against the rule and regulations.

One participant, who typically avoids alcohol, noted that the nature of their work compels them to drink. They emphasized that the demands of working with corpses leave no choice but to consume alcohol.

For me, I don’t really drink alcohol. It is not good for my health but when you are to work on some corpses, no one will tell you to get some alcohol in your system before working. The condition surrounding the corpses for example dead and decaying corpses from the bush, corpses with mixing body parts will push you to drink.

One participant advised colleagues not to get used to alcohol or smoking, since these can harm them: My advice to other mortuary workers is not to drink or smoke.

The work is difficult, so drinking alcohol most of the time can harm you.

Theme three: Food preference

Mortuary workers have developed dietary habits to cope with their work-related challenges, often avoiding meat and favouring fish as their primary source of protein. Participants who are unable to take a meat-inclusive diet had this to say:

Yes! I used to enjoy my meat a lot. Now it’s a no-no for beef. The preferred protein is fish. I use it for pepper soup with lots of ginger. I am enjoying what I can tolerate now. Life goes on!

I eat Akple [local food made from maise] and dry fish soup or stew; I cannot take meat these days because of how some of the corpses look.

Yes! I can’t eat meat anymore, but I can take light soup and or stew made with fish.

This participant reported he could take a small amount of meat since the sight of beef is no more appetizing:

Yes, I can eat a small amount of meat, just because sometimes I feel for beef but I cannot eat enough meat as I desire; the sight of meat now is something else.

Others prefer to eat hot peppers / chillis (fresh ground chillies and tomatoes) and avoid soups.

Now I prefer hot pepper/chilli foods. Most of the time, I like more spicy food. These days, I go with spicy food, more ginger and those spices, you know now!

One participant was afraid of hot pepper because hot pepper does not sit well if one works with Formalin.

The concentration of the pepper in the soup should not be too high because of the Formalin we work with. If you take too much pepper with your food and work with formalin, it will worry your heart.

DISCUSSION

The study results explored the effects of work on the eating behaviour of mortuary workers at nine health facilities in Ghana. Mortuary workers are primarily responsible for the post-death care of corpses, such as keeping them for burial or autopsy. Their responsibilities expose them to all forms of difficulties including psychological challenges which ultimately influence their dietary behaviors. Most of the participants in this study indicated that the sight of corpses made them lose appetite.

The dietary habit of mortuary workers was negatively affected due to the smell of blood, the odor from the dead bodies, and even the Formalin as evidenced by Kershaw et al and Mattes et al. This is also in line with a study conducted by Clohessy et al where other factors influenced workers’ dietary patterns in their work environment. However, two of the participants indicated that the sight of a corpse does not affect their appetite for food.

This means that not all mortuary workers are affected by their work. One of the participants even revealed that he could eat immediately after working on a corpse. This is similar to an article written by 21 where a morgue attendant disclosed that his training began when he was just 9 years old with his uncle, who fed him while he dressed corpses as a test or assessment. "If one throws up the food while around the dead body, it means that you have failed the first exam, but if you continue eating regardless of the smell of the body, then you have passed".

The study also revealed that some participants consume alcohol to withstand the corpses. This indicates that participants’ alcohol consumption is aimed at influencing their perception of the corpses.²² Some even stated that the smell of the bodies affected them, so they consumed alcohol not only to forget the experience, but also to help them eat some food. This is similar to Darvishpor et al where participants used alcohol as a means of coping by ‘trying to forget”.¹¹

Additionally, in this study, most of the participants revealed that they resorted to eating fish instead of meat. This is likely because they perceive meat as dead bodies. However, a participant could eat meat, but in a small quantity. This is similar to a study conducted by Piazza et al where constant exposure to the handling of dead animals led to their abstinence from meat. Furthermore, some participants had to add more spices to the meal.^23-25

This could be linked to the nauseating odours from the corpses they work on. This is verified by the study conducted by Darvishpor et al showing that consumption of hot red chilli peppers was associated with a 13% reduction in instantaneous hazard of death.¹¹ However, this has the potential to be harmful to human health if eaten in excess. Research conducted by Lv et al showed that “too much” consumption of spicy meals was inversely related to total and specific cause mortality in China.²⁰ However, a participant in this study was afraid of hot pepper due to its effect on him whenever he worked with formalin. Research by National Cancer Institute indicates that when formaldehyde levels in the air exceed 0.1 ppm, some people may have unpleasant effects such as burning feelings in the throat. This irritation in the throat is aggravated when one takes pepper. This shows how mortuary workers' dietary behaviours are influenced by their work.^18,26-28

Limitation

Not many studies have been conducted extensively in this area of research. The study relied solely on self-reported data, which may be subject to recall bias or social desirability bias. Despite these limitations, this study provides valuable insights into the dietary challenges faced by mortuary workers in Ghana. The findings underscore the need for targeted interventions to address the unique dietary needs of this vulnerable population, ultimately promoting their overall health and well-being.

CONCLUSION

The findings of this study indicate that mortuary workers' exposure to corpses had a significant impact on their dietary practices, potentially leading to nutritional deficiencies. Moreover, participants reported using alcohol to stimulate their appetite, which could result in long-term adverse health consequences. Furthermore, the nature of their work prevented them from consuming certain foods, such as meat. The study further highlights the need for interventions to address the dietary challenges faced by mortuary workers, including the provision of on-site nutritious meal options, access to counselling services, and the implementation of policies that support work-life balance and promote overall well-being. Therefore, we recommend periodic psychological therapy, regular nutritional check-ups, education on proper diet, and support for mortuary workers from the government, hospital management, and all stakeholders in the country.

ACKNOWLEDGMENTS

The researchers wish to thank the participants and Mr. Francis Mawougnon Sagbo, the research assistant who supported this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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