Toward Inclusive Primary Health Care: Understanding Health Needs of Informal Women Workers Through a Socioecological Framework

Toward Inclusive Primary Health Care: Understanding Health Needs of Informal Women Workers Through a Socioecological Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Toward Inclusive Primary Health Care: Understanding Health Needs of Informal Women Workers Through a Socioecological Framework Ankit Sheth, Rakesh Balachandar, Ankit Viramgami, Anuj Dave, Ekta Ram, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7422965/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted 16 You are reading this latest preprint version Abstract Background: Informal women workers (IWWs) face disproportionate occupational health risks due to hazardous work environments, poor social protection, and systemic inequities. However, limited research captures their lived experiences across multiple social-structural levels. The study was conducted to explore the physical, mental, and occupational health challenges of IWWs across five the most prominent informal sectors employing women workers, from Ahmedabad, India, and identify multi-level determinants using the Socioecological Model (SEM). Methods: We conducted five focus group discussions (FGDs) with 41 IWWs from agriculture, construction, street vending, waste recycling, and home-based work in Ahmedabad, India. Data were thematically analyzed and mapped across SEM levels—ranging from intrapersonal to policy-level determinants. Findings: Participants reported musculoskeletal disorders, dermatological conditions, stress, substance use, and heat-related illnesses —underscoring the need for integrated care. Delayed health-seeking behavior, inadequate sanitation, absence of maternity leave, and poor access to first aid reflecting critical service gaps. Structural barriers included limited access to welfare schemes and lack of formal contracts and mistrust in public healthcare leading to high out-of-pocket costs further restricted and shaped the care-seeking preferences. Interpretation: Our findings highlight the urgent need for gender-responsive occupational health integration into primary healthcare. The study informed a national policy roundtable that convened key stakeholders to co-develop actionable recommendations to improve occupational health coverage for informal women workers in India. Funding: Financial support was provided by Women in Informal Employment: Globalizing and Organizing (WIEGO) to cover minimal research expenses; the funder had no role in study design, data collection, analysis, or interpretation. Informal Sector Musculoskeletal Diseases Occupational Health Female Focus Groups Health Policy Figures Figure 1 Research in Context Evidence before this study We conducted a systematic review to identify published literature on the occupational health challenges faced by informal women workers (IWWs) in India. We searched PubMed, Scopus, and Embase databases without language restrictions for studies published between January 1, 2000, and December 31, 2023. Search terms included combinations of MeSH and free-text terms such as “informal women workers”, “occupational health”, “India”, “health challenges”, and “women in informal sector”. Studies were included if they assessed physical, mental, or occupational health issues among IWWs, excluding commentary articles and predictive modelling studies. Risk of bias was assessed using relevant tools based on study type. Due to heterogeneity in study designs and lack of uniform measurement tools, meta-analysis could not be conducted. However, descriptive synthesis revealed high burden of musculoskeletal disorders, mental stress, and reproductive health concerns, with limited access to social protection and healthcare. Added value of this study This is one of the first studies to integrate qualitative data with a socioecological framework to explore multi-level health determinants for IWWs across five occupational groups in urban India. The study adds value by highlighting not only occupational exposures but also systemic, gendered, and policy-level barriers that impact access to healthcare and social safety nets. The inclusion of lived experiences and worker-driven recommendations enhances the contextual relevance and applicability of findings. Implications of all the available evidence Combined with existing evidence, our findings reinforce the urgent need to integrate occupational health services within primary healthcare systems, particularly targeting informal women workers. Structural inequities, such as lack of identification mechanisms, poor sanitation infrastructure, and exclusion from social protection must be addressed to improve access and outcomes. This study provides actionable insights for policymakers, including recommendations on gender-sensitive occupational health integration, data collection at the primary health centre level, and capacity building of frontline healthcare providers. INTRODUCTION Occupational health is a critical yet overlooked dimension of public health, particularly for informal sector workers who face hazardous environments without adequate protections. Informal employment—untethered from labour laws, social security provisions, and formal contracts—excludes workers from even basic occupational health and safety (OHS) standards.[1] In India, nearly 93% of the workforce is informal, with over 95% of women engaged in such work, reflecting pronounced gender-based vulnerabilities.[2] These women form the backbone of agriculture, construction, home-based manufacturing, waste recycling, and street vending, yet their occupational health remains poorly documented and insufficiently addressed. Informal women workers (IWWs) face multiple health risks, including musculoskeletal disorders, respiratory illnesses, reproductive complications, skin infections, and mental health problems, driven by poor ergonomics, dust and chemical exposure, extreme temperatures, and inadequate infrastructure.[3-6] Gender further compounds these risks through wage disparities, job insecurity, and limited access to public services.[7] Poor nutritional status is also common, with implications for child health.[8] Environmental exposures add further strain. Outdoor workers are increasingly vulnerable to heat-related illnesses, dehydration, and injuries due to rising temperatures, air pollution, and water scarcity.[9-11] Despite growing evidence, occupational health policy and research in India remain largely focused on the formal workforce, leaving IWWs underrepresented in health planning and service delivery. Some studies have documented sector-specific hazards, but few have used a multi-level framework to examine the broader social, environmental, and policy determinants that shape IWWs’ health. This limits understanding of how structural inequities—such as the absence of contracts, legal entitlements, and employment benefits—intersect with occupational exposures to restrict healthcare access, social protection, and policy inclusion. Moreover, the lived experiences of IWWs are rarely integrated into occupational health discourse or system planning, despite their importance for designing contextually appropriate, gender-responsive interventions. This study addresses these gaps by applying the Socioecological Model (SEM) to examine the multi-layered health challenges of IWWs in Ahmedabad, Gujarat—a rapidly industrializing region with socioeconomic diversity and a dense informal labour force. Through focus group discussions (FGDs) across key occupational groups, it seeks to generate evidence grounded in workers’ experiences to inform socially attuned, gender-equitable occupational health policies and services. METHODS Study Design and Setting This qualitative study employed FGDs to explore the multi-level influences on health challenges and healthcare access among IWWs in Ahmedabad, Gujarat (India). The study was conceptually guided by the SEM, examining intrapersonal, interpersonal, organizational, community, and policy-level determinants.[12] Sites were purposively selected from urban and peri-urban areas where the target occupational groups lived and worked. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).[13] Study Participants Participants were recruited from five occupational groups accounting for most informal women’s employment: agricultural workers, construction workers, street vendors, home-based workers, and waste recyclers.[2] Women aged 18 years and above who were currently employed in any of these occupation were eligible. Exclusions were serious illness, lack of fluency in Gujarati, or refusal of written consent. Accredited Social Health Activists (ASHAs) and Self-Employed Women’s Association (SEWA) coordinators assisted with community engagement and participant identification. Prior approval were taken from local authorities and community leaders. Sample Size and Composition Five FGDs were conducted, one per occupational group, with 6–10 participants each (total n = 41). Group sizes balanced diversity and interaction. Discussions lasted 45–60 minutes in community venues ensuring privacy and comfort. Data Collection Tools and Procedure A semi-structured FGD guide was developed specifically for this study following a review of relevant literature and the domains of the Socioecological Model (SEM). The guide is provided in English as Supplementary File 1 to ensure transparency and replicability. Questions were framed under the five SEM levels.[12] The guide included questions on i) intrapersonal (knowledge, attitudes, beliefs, personal experiences), ii) interpersonal (family dynamics, social and peer support), iii) organizational (workplace safety, sanitation, safety protocols), iv) community (neighbourhood conditions, local norms, community organisations), and v) policy (awareness and experiences with health and labour policies). Each FGD was moderated by a trained qualitative team comprising one male (AD) and two female interviewers (ER, ZK), all fluent in Gujarati and experienced in community-based research. AD and ER hold Master’s in Public Health (MPH), ZK is a trained research coordinator with grassroots experience. Senior researchers AS (MD) and MT (MBBS) oversaw design, quality assurance, and methodological guidance. Written consent was obtained before audio-recording. Moderators maintained reflexive field notes to capture perspectives and reduce bias. Discussions encouraged open sharing in a respectful environment. Data Management and Analysis FGDs were transcribed verbatim and translated into English (AD, ER). Transcripts were reviewed for accuracy before analysis. Thematic analysis followed Braun and Clarke’s approach: familiarisation, initial coding, theme identification, theme review, and final naming/definition.[14] Coding was carried out independently by two researchers (AD and ER) using Microsoft Excel. Two researchers (AD, ER) independently coded transcripts in Microsoft Excel. Codes were organised under SEM levels to ensure theoretical alignment. Themes were compared across occupational groups to identify shared and occupation-specific patterns. Discrepancies were resolved by discussion with the broader team (MT, AS), and final themes were agreed upon by all (AD, ER, MT, AS). Researcher Credentials The qualitative team comprised public health professionals and medical doctors with occupational health expertise. AD and ER (MPH) and ZK (field research coordinator) conducted FGDs and transcription; AS (MD) and MT (MBBS) provided senior oversight. Participant Feedback on Findings Due to time and logistical constraints, transcripts and themes were not returned to participants for comment. RESULTS A total of 41 women informal workers participated in five FGDs representing agricultural workers (AW, n=10), construction workers (CW, n=6), street vendors (SV, n=8), home-based workers (HW, n=10), and waste recyclers (WR, n=7). Mean ages ranged from 35.4 to 49.6 years, with work experience from <1 year to 27 years (Table 1). Analysis generated themes under the five SEM domains (Figure 1). Key findings are presented below, highlighting major thematic patterns within and across occupational groups. 1. Intrapersonal Factors 1.1 Physical Health Challenges Across all groups, musculoskeletal disorders from repetitive work, static postures, and heavy lifting were prevalent. AW and WR reported respiratory symptoms from dust and fumes; CW and AW noted skin damage from cement and chemicals—conditions normalized amid lacking protective equipment and training. “Cement often causes cracks in my hands…it burns my hands a lot.” – CW 6 “We suffer from throat irritation and breathing difficulties due to dust, during castor harvesting.” – AW 6 “Pulling heavy carts gives us leg, stomach, and back pain. My sister fainted once had to be hospitalized.” – SV 5 1.2 Mental Health and Stress Economic insecurity, long hours, and domestic responsibilities drove psychological stress. Anxiety about children's education and financial insecurity were prominent concerns. “We invest a lot of money in crops, but there is always stress whether we will even recover half of it.” – AW 7 “We earn barely enough to feed our families, yet we have to pay school fees. It’s stressful.” – CW 4 1.3 Menstrual and Reproductive Health Severe menstrual pain was reported, yet women continued working due to lack of paid leave and societal expectations. Poor sanitation worsened hygiene challenges. “It really pains a lot during periods. If anyone has severe pain, she may take a day's unpaid leave ….but we can’t afford it every month. Some of us think that taking leave actually increases mental stress, so it's better to go to work.” – WR 3 1.4 Substance Use as a Coping Mechanism Tobacco or chhikni powder were used as a coping strategy to deal with physical fatigue, especially among CW and WR. “I'm addicted to chhikni powder. I enjoy using it while working, it gives me stimulation.” – CW 2 “It (substance) started bitter, but now it relieves my stress every time I take it.” – WR 4 1.5 Climate and Weather-Related Illness Outdoor workers described heat stress, rashes, dizziness, and nosebleeds in summer. “Last summer, I had a nosebleed from the heat. Hopefully, this year will be better.” – SV 3 “The heat creates many problems for us. We often sit under the shade whenever possible. We wear sarees to cover our heads to reduce the discomfort, but without shade and seating arrangements, it’s still difficult.” – CW 6 1.6 Health-Seeking Behaviour IWWs often choose private clinics over government health centers, perceiving their medicines as more effective. This preference, driven by trust and efficacy concerns, increases out‑of‑pocket costs, strains finances, and can delay or reduce use of public services, hindering integration of occupational health into primary care. “We do take medicines from the sub-centre here in the village……however, we feel that government medicines take a longer time to show effect, whereas the medicines from private clinics provide instant relief.” – AW 8 2. Interpersonal Factors 2.1 Familial Support and Gender Roles Lack of emotional and practical support within their households was reported, which increased burden and led to exhaustion and emotional distress. “There is so much pressure. We handle everything at home and then face deadlines at work. It’s overwhelming.” – HW 3 “We usually sat outside in the sunlight to reduce electricity bills. Sometimes, the bill increases suddenly….our family members scold us, saying we are wasting electricity. The sewing machine has a foot motor which does not work on mini light (low electricity).” – HW 6 2.2 Addictive Behaviours in Family Members Substance abuse among male family members contributed to household conflict, financial instability, and physical or emotional abuse. “Sometimes, when our husbands come home after drinking alcohol, they fight with us” – HW 9 3. Organizational Factors 3.1 Lack of Safety Equipment and Support Workers reported inadequate or absent logistic support, including PPE and sewing machines. Most purchased their own equipment without external support. “We have a sewing machine, we can do it, but we have other people who want to do it, but they don't have a sewing machine. So, if they give us anything like that it would helpful.” – HW 1 “They don’t give us anything to wear on our hands. If we wear gloves while making cement products, then there won’t be a problem.”– CW 6 3.2 Absence of First Aid Injuries were typically managed informally using cloth or improvised remedies at the worksite, with formal medical care deliberately delayed by the workers until after completing their job tasks. This pattern reflects the economic pressures and absence of paid sick leave, where immediate care is deprioritized in favour of securing daily wages and avoiding income loss. “When we get injured, we cover injured part with whatever cloth we have at that moment. After finishing our work, we go to the hospital.” – CW 3 3.3 Inadequate Work-Rest Cycles Participants highlighted that work breaks were infrequent or absent, and combining household duties with paid work contributed to fatigue and burnout. “If we have to stand for long hours, our legs hurt a lot. Even when climbing bricks, our whole body aches. The owner only gives us half an hour to sit during meals.……they don’t let us rest when we are tired.” – CW 7 3.4 Poor Water, Sanitation and Hygiene (WASH) Facilities Basic facilities such as clean drinking water, functional toilets, and handwashing stations are either inadequate or completely absent. These forces outdoor workers to use open spaces for toileting. “During periods, when we need to use the washroom frequently and are far from the place, sometimes we have to go outside, behind trees.” – WR 3 “There are no toilets on farms. We just use open areas.” – AW 4/5 3.5 Lack of Maternity Leave Pregnant workers reported working up to their eighth month due to the absence of maternity leave or any financial security during pregnancy. “We work even during pregnancy, up to the 8th month. The employer will never pay a single penny when we are off from work, maternity leaves are not a chance. We never get maternity leaves.” – CW 2 4. Community-Level Factors 4.1 Barriers to Public Healthcare Access Despite being eligible for services at urban health centres (UHCs), and awareness of the Pradhan Mantri Jan Arogya Yojana (PMJAY)—India’s government-funded health insurance scheme, women often chose private clinics due to the long distances, long wait times, and perceived inefficiency of public services. For daily-wage earners, long waiting periods often translate into wage loss, further disincentivizing public healthcare services uptake. “Some of us have the Ayushman Bharat (PMJAY) card, while a few others do not have this card.” – SV 3 “We avoid going to the UHC—it’s far and always crowded. We can’t afford to lose a day’s wage waiting.” – SW 2 4.2 Role of NGOs and Local Initiatives Participants acknowledged support from local organizations like SEWA for health awareness and seasonal relief “SEWA gave us ORS and health tips in the summer. Nothing came from the government.” – CW 4 4.3 Social Stigma and Discrimination Workers, particularly waste recyclers reported feeling humiliated and socially excluded, which affected their dignity and mental health. “Some people make fun of us….Oye kachara wala ben (In English: Hey, garbage collector) come here, pick this up, collect it, take this. Some see us as if we have come to steal something. ‘Why did you come here?’, ‘Did you come here to steal?’, ‘Why did you take this?’…If anything disappears then they just blame us that you took this thing from here.” – WR 1 5. Public Policy-Level Factors 5.1 Demand for Financial and Social Protection Participants voiced strong demand for social security mechanisms such as pensions, work-from-home opportunities, and tools (like sewing machines) to enable dignified and sustainable income generation. “We need pensions for when we can’t work anymore, and work-from-home options to support ourselves.” – CW 6 “Many women want to do home-based work but don’t have machines. If the government could provide them, it would help a lot.” – HW 4 DISCUSSION This qualitative study employed the multi-level SEM to examine the multifaceted health challenges faced by IWWs across five major occupational groups—agricultural workers, construction workers, street vendors, home-based workers, and waste recyclers—in Ahmedabad, India. The findings demonstrate a convergence of occupational, environmental, structural, and gender-based vulnerabilities that together shape the physical, mental, and social well-being of these women. Musculoskeletal disorders (MSDs) emerged as a predominant health concern, commonly linked to poor ergonomics, prolonged static postures, and repetitive tasks.[3, 15] These findings are supported by a systematic review that reported a higher prevalence of MSDs among IWWs.[16] Home-based workers, in particular, described headaches and dizziness from sustained visual and manual strain.[3] Exposure to pesticides in agriculture and cement dust in construction was linked to respiratory conditions, skin irritation, and cracked skin.[17] The hazards of such work intensifies in the absence of personal protective equipment (PPE).[18] Some participants reported unconventional coping strategies, such as applying nail polish to soothe cement-induced skin damage, underscoring both poor health literacy and limited access to occupational health services. Mental health challenges were initially underreported, but upon probing, participants disclosed persistent anxiety, restlessness, and emotional exhaustion—driven by financial insecurity, job instability, caregiving responsibilities, and unsafe workplaces. These findings align with prior studies linking informal employment to increased risk of poor mental health.[19] Wage structures varied across occupations, with home-based workers paid per piece, and construction and agricultural workers on daily wages. Street vendors and waste recyclers relied on uncertain earnings from sales. This economic vulnerability often forced women to continue working despite health issues, further compounding physical and psychological strain.[17, 20] Climate and environmental exposures significantly influenced occupational health, especially for outdoor workers. Heat-related illnesses such as dehydration, dizziness, and heat stroke were common in summer, while respiratory symptoms and injuries increased during winter and monsoon conditions. Street vendors reported reducing fluid intake to avoid using non-existent toilet facilities, heightening the risk of dehydration and heat stroke.[21, 22] Moreover, urban informal workers also faced water scarcity and poor sanitation.[23] Evidence indicates that each 1 °C rise in temperature can increase sickness probability by 5–7% and medical costs by 14%.[24] Climate-related health risks were closely intertwined with socioeconomic disadvantage and inadequate urban infrastructure. Healthcare access was marked by mixed use of public and private services. Although most participants were aware of public health schemes, a clear preference emerged for private clinics, perceived to offer higher-quality and faster-acting medicines despite higher out-of-pocket costs. Public facilities were considered inefficient and time-consuming, with long wait times leading to income loss for daily-wage workers. Similar patterns have been noted in Ghana and Delhi, where informal workers opt for private care due to concerns about quality and timeliness in public services.[25, 26] Awareness of the Pradhan Mantri Jan Arogya Yojana (PMJAY) – part of the Ayushman Bharat program – was high, but utilization was limited. PMJAY is India’s government-funded health insurance scheme.[27] For serious treatments, participants relied more on government-subsidized health entitlement cards to reduce inpatient costs, while routine and minor ailments were managed in private facilities. Lack of preventive and outpatient coverage under many government schemes was a notable gap, given these represent a large share of healthcare costs for IWWs. Community health workers and NGOs were regarded as valuable for health education and linking workers to available services. This study also revealed widespread socio-economic and workplace barriers similar to report from earlier studies such as low and irregular wages,[28] long working hours, no paid leave and minimal social protection.[29] Many were sole earners, making withdrawal from work practically impossible. Workplace sanitation was frequently inadequate, with no toilets or clean drinking water . Some women restricted water intake to avoid needing toilets. These findings align with prior evidence on infrastructure gaps severely affecting IWWs.[30, 31] Underpayment, lack of formal employment contracts, and high production pressure were widespread.[24] Maternity protection was absent; participants reported working into the third trimester without accommodations or financial security.[5] Safety and immediate care provisions were minimal. First aid facilities were rarely available; instead, women relied on self-medication or home remedies, risking complications from untreated conditions. These practices reflected both low health literacy and weak integration with formal health systems. Worker recommendations reflected a desire for both economic and occupational health interventions. Home-based income-generating opportunities—especially for older women—were suggested to reduce physical strain while sustaining livelihoods. Requests for pension schemes, financial security programs, and logistical support (including sewing machines and PPE) were common. Barriers to accessing government welfare benefits included limited literacy, migratory status, and lack of identity documentation. Although India has enacted welfare policies such as the Unorganized Workers’ Social Security Act (2008)[32] and launched platforms like e-Shram to register informal workers,[33] our findings indicate limited awareness and uptake of these schemes. Similarly, while Pradhan Mantri Shram Yogi Maan Dhan Yojana[34] offers pension support, Ayushman Bharat provides health insurance,[27] and Pradhan Mantri Matru Vandana Yojana offers maternity incentives,[35] these programs are underutilized by the target study group due to awareness gaps, administrative barriers, and poor alignment with the lived realities of IWWs. Strength and limitations A key strength of this study lies in its use of the Socioecological Model (SEM) to systematically explore the multi-level determinants of health among IWWs across five major occupational groups in Ahmedabad, yielding occupationally nuanced and gender-sensitive insights. Focus group discussions in the local language enabled rich, context-specific narratives from a population that is often underrepresented in health systems research. Limitations include its focus on a single district, which may not reflect regional diversity, and potential underreporting of sensitive issues like mental or reproductive health due to stigma. As a qualitative study, findings are not generalizable but provide transferable evidence to guide localized, gender-responsive health policies and interventions. Policy Translation and Engagement As an immediate step toward policy translation, the findings were presented at a national roundtable discussion convened in collaboration with key stakeholders, including representatives from the Ministry of Labour and Employment (MoLE), National Health Systems Resource Centre (NHSRC), International Labour Organization (ILO), Central Board of Welfare Education for Workers (CBWE), V. V. Giri National Labour Institute (VVGNLI), ICMR-NIOH, Lok Swasthya SEWA Trust (LSST-SEWA), Women in Informal Employment: Globalizing and Organizing (WIEGO, UK), Worker Unions and workers. Discussions, grounded in the lived experiences of IWWs, produced priorities including integrating occupational health into Ayushman Bharat and primary care, expanding social protection, addressing climate-related heat impacts (especially on women’s health), and building primary healthcare capacity in occupational risk assessment. Participants also urged inclusion of informal sector OHS modules in medical and nursing curricula, highlighting the value of participatory, community-driven research in shaping health and labour policies for vulnerable workers. CONCLUSION Informal women workers in India experience a complex interplay of health risks shaped by occupational, environmental, and structural inequities. This study highlights the need for a gender-responsive, occupation-informed public health approach that moves beyond individual-level interventions and addresses systemic barriers in work and health environments. Bridging the gap between informal employment and accessible, quality healthcare will require not only service expansion but also structural reforms that recognize the contributions and vulnerabilities of this critical segment of the workforce. By prioritizing these workers within both health and labour policy frameworks, India can take a crucial step toward more inclusive and equitable health systems. Declarations Ethical Approval and Consent to participate The study was approved by the Institutional Human Ethics Committee of ICMR-National Institute of Occupational Health (ICMR-NIOH/EC/2024/5) and conducted in accordance with the Helsinki Declaration. All participants provided informed written consent, including permission for audio recording and anonymized use of their responses. Confidentiality and privacy were maintained throughout the study. Consent for publication Not applicable. No identifying images, personal, or clinical details of participants are included in this manuscript. Declaration of interests All authors declare no competing interests Author’s Contributions All authors collaboratively developed the study design and the semi-structured discussion guide. AD, ER and ZK were responsible for field coordination, data collection, transcription, and initial thematic coding of the focus group discussions. MT and AS reviewed the transcripts and resolved discrepancies in thematic coding and interpretation through iterative discussion. The first draft of the manuscript was prepared by AD and ER. AS and MT provided critical input during manuscript revision. AV and RB contributed to methodological refinement and reviewed the manuscript for intellectual content. The final version of the manuscript was reviewed and approved by all authors. Funding The authors being full time research faculties of the non-profit occupational health research institutes, conducted and reported this study within their independent capacity. AS (Author) received grant from WIEGO (Women in Informal Employment: Globalizing and Organizing, UK) to support the minimal expenses incurred during generating the evidence on health challenges faced by informal women workers in India, and part of this grant is planned to offset the article processing charges. WIEGO received funding from Co-Impact to support the research. WIEGO had no role in the data collection, analysis, or in interpretation of the results. Acknowledgement We express our sincere gratitude to the Lok Swasthya SEWA Trust (LSST-SEWA) for their vital collaboration throughout this study. The participation of LSST-SEWA was integral not only in facilitating access to informal women workers across diverse occupational groups but also in co-developing the study design and guiding the implementation of the focus group discussions. We are especially grateful to Mirai Chatterjee, Director, SEWA Social Security, and Susan Thomas, National Health Coordinator, SEWA, for their active involvement in the conceptualization and facilitation of the research. Their deep institutional knowledge and commitment to advancing the health and social security of informal women workers significantly enriched the study. We also acknowledge Kuhika Seth (WIEGO) for her valuable inputs during the early stages of conceptualizing this study. We further acknowledge the key stakeholders, including representatives from the Ministry of Labour and Employment (MoLE), National Health Systems Resource Centre (NHSRC), International Labour Organization (ILO), Central Board of Welfare Education for Workers (CBWE), V. V. Giri National Labour Institute (VVGNLI), LSST-SEWA, WIEGO, Worker Unions and workers for their participation and recommending our key observations in the national round table meeting . 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Ruma G. Health Insecurities Informal Employment Ruma Ghosh. Unpublished; 2010. About PM-JAY - National Health Authority | GOI [Available from: https://nha.gov.in/PM-JAY. Singh SA, Kumari A. Challenges and Opportunities: Women's Working Conditions in India's Unorganized Sector. Rochester, NY: Social Science Research Network; 2024. Bhan G, Surie A, Horwood C, Dobson R, Alfers L, Portela A, et al. Informal work and maternal and child health: a blind spot in public health and research. Bull World Health Organ. 2020;98(3):219-21. Joshi N. Low-income women’s right to sanitation services in city public spaces: a study of waste picker women in Pune. Environment and Urbanization. 2018;30(1):249-64. Rajaraman D, Travasso SM, Heymann SJ. A qualitative study of access to sanitation amongst low-income working women in Bangalore, India. Journal of Water, Sanitation and Hygiene for Development. 2013;3(3):432-40. Kar S. The Unorganized Workers Social Security Act, 2008 - An Approach to Provide Basic & Contingent Social Security to the Unorganized Workers in India. SSRN Journal. 2014. Kannan DS. E-Shram Scheme: Empowering Unorganized Workers with Essential Social Security. International Journal of Research Publication and Reviews. Pradhan Mantri Shram Yogi Maandhan Yojana [press release]. Ministry of Labour and Employment. Pradhan Mantri Matru Vandana Yojana [Available from: https://www.myscheme.gov.in/schemes/pmmvy;#details. Table Table 1: Demographic details of the participants Sector No. of Participants Age (years) Mean (SD) Work Experience (Range in years) Agricultural Workers * 10 38 (9.2) 1.7–27 Construction Workers 6 35 (11.1) 1–18.4 Street Vendors 8 49 (10.3) 5.1–17 Home-Based Workers 10 44 (7.5) 2.5–13 Waste recyclers 7 39 (7.9) 0.4–15 *All participants resided and engaged in work at urban locations, except for the agricultural workers, who were from the rural locations Additional Declarations No competing interests reported. Supplementary Files COREQchecklistIWWs.pdf SupplementaryFiel1ThematicGuide.pdf Cite Share Download PDF Status: Published Journal Publication published 06 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 06 Oct, 2025 Reviews received at journal 04 Oct, 2025 Reviews received at journal 24 Sep, 2025 Reviews received at journal 22 Sep, 2025 Reviews received at journal 07 Sep, 2025 Reviewers agreed at journal 04 Sep, 2025 Reviewers agreed at journal 31 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviewers invited by journal 25 Aug, 2025 Editor assigned by journal 25 Aug, 2025 Editor invited by journal 25 Aug, 2025 Submission checks completed at journal 22 Aug, 2025 First submitted to journal 22 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7422965","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508102192,"identity":"6261acae-89fc-45fd-b44c-fca8f779abb2","order_by":0,"name":"Ankit Sheth","email":"","orcid":"","institution":"ICMR – National Institute of Occupational Health","correspondingAuthor":false,"prefix":"","firstName":"Ankit","middleName":"","lastName":"Sheth","suffix":""},{"id":508102193,"identity":"564fa696-c586-4fbf-89a3-380089dd58a8","order_by":1,"name":"Rakesh Balachandar","email":"","orcid":"","institution":"ICMR – Regional Occupational Health Centre (South)","correspondingAuthor":false,"prefix":"","firstName":"Rakesh","middleName":"","lastName":"Balachandar","suffix":""},{"id":508102195,"identity":"a6639590-ddc6-48f7-acb9-f7e6afcee6aa","order_by":2,"name":"Ankit Viramgami","email":"","orcid":"","institution":"ICMR – National Institute of Occupational Health","correspondingAuthor":false,"prefix":"","firstName":"Ankit","middleName":"","lastName":"Viramgami","suffix":""},{"id":508102201,"identity":"da03cbd5-9b47-48dc-a6d5-bddf6674c6b6","order_by":3,"name":"Anuj Dave","email":"","orcid":"","institution":"ICMR – National Institute of Occupational Health","correspondingAuthor":false,"prefix":"","firstName":"Anuj","middleName":"","lastName":"Dave","suffix":""},{"id":508102202,"identity":"da38683b-35b4-4eb4-83e7-d3a64cec2dd3","order_by":4,"name":"Ekta Ram","email":"","orcid":"","institution":"ICMR – National Institute of Occupational Health","correspondingAuthor":false,"prefix":"","firstName":"Ekta","middleName":"","lastName":"Ram","suffix":""},{"id":508102207,"identity":"0fc9df94-e3da-49f8-8dfe-9f4756d0e70c","order_by":5,"name":"Zulekha Khalil","email":"","orcid":"","institution":"Self-Employed Women’s Association (SEWA)","correspondingAuthor":false,"prefix":"","firstName":"Zulekha","middleName":"","lastName":"Khalil","suffix":""},{"id":508102209,"identity":"4dc1ad03-75bd-4a69-a918-14156ec71d6f","order_by":6,"name":"Mahendra Thakor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYFACHiBmAzGYDxyACyYQpYWNLYFkLTwGxDlLt/3swccFZffkGeR7Ph74mXOPQd69x4Dh4Q7cWszO5CUbzzhXbNjAxrvhYO+2YgbDM2cMGBLP4NFyIMdMmrctgRGk5TDjtgQGwxlpCQyJbXi0nH9j/huoxb6BjecBkVpu5JgxA7UkArUwgLXISyQfIKDljbE0z7mE5Da2NAOgXxJ4DHgOHziA32E5hp95yhJs+5kPP/7wc1uCnHx7Y+PDn3i0wAEblOYxOMDAcIAIDUhAvoE09aNgFIyCUTD8AQDoGU+O2MBxpgAAAABJRU5ErkJggg==","orcid":"","institution":"ICMR – National Institute of Occupational Health","correspondingAuthor":true,"prefix":"","firstName":"Mahendra","middleName":"","lastName":"Thakor","suffix":""}],"badges":[],"createdAt":"2025-08-21 06:38:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7422965/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7422965/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13855-7","type":"published","date":"2025-12-06T15:57:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90472325,"identity":"d754b114-24b9-439a-80b6-3c55122f147b","added_by":"auto","created_at":"2025-09-03 06:34:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":116095,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIllustration of the multi-layered socioeconomic model representing the various layers (viz. public policy, community, organizational, interpersonal and intrapersonal factors) associated with the health challenges of the IWW.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis socioecological model is intended as a conceptual framework to illustrate the multiple, interacting levels of influence on the health of informal women workers. While the diagram uses a concentric format for visual clarity, it does not imply a strict hierarchical or encapsulating relationship among the levels. In reality, these levels often interact dynamically and bidirectionally, with each exerting influence independently or in conjunction with others.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7422965/v1/280771b0d607f4c56ba513c2.png"},{"id":97725017,"identity":"41b6a51a-560f-4db8-96c9-f939ce7f886c","added_by":"auto","created_at":"2025-12-08 16:14:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1025472,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7422965/v1/9c285646-acfa-4db3-8175-a9fb626e3aca.pdf"},{"id":90472326,"identity":"e1c8f0be-d536-47d9-9c0f-69e3ce796696","added_by":"auto","created_at":"2025-09-03 06:34:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":91466,"visible":true,"origin":"","legend":"","description":"","filename":"COREQchecklistIWWs.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7422965/v1/dc40ea74ef830eed9e766753.pdf"},{"id":90472331,"identity":"5f5bb2c5-a0a1-4889-b53a-1806cb97307f","added_by":"auto","created_at":"2025-09-03 06:34:26","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":66454,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiel1ThematicGuide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7422965/v1/5b48e27cd0625bf21ce0a29f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Toward Inclusive Primary Health Care: Understanding Health Needs of Informal Women Workers Through a Socioecological Framework","fulltext":[{"header":"Research in Context","content":"\u003cp\u003e\u003cstrong\u003eEvidence before this study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a systematic review to identify published literature on the occupational health challenges faced by informal women workers (IWWs) in India. We searched PubMed, Scopus, and Embase databases without language restrictions for studies published between January 1, 2000, and December 31, 2023. Search terms included combinations of MeSH and free-text terms such as “informal women workers”, “occupational health”, “India”, “health challenges”, and “women in informal sector”. Studies were included if they assessed physical, mental, or occupational health issues among IWWs, excluding commentary articles and predictive modelling studies. Risk of bias was assessed using relevant tools based on study type. Due to heterogeneity in study designs and lack of uniform measurement tools, meta-analysis could not be conducted. However, descriptive synthesis revealed high burden of musculoskeletal disorders, mental stress, and reproductive health concerns, with limited access to social protection and healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdded value of this study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is one of the first studies to integrate qualitative data with a socioecological framework to explore multi-level health determinants for IWWs across five occupational groups in urban India. The study adds value by highlighting not only occupational exposures but also systemic, gendered, and policy-level barriers that impact access to healthcare and social safety nets. The inclusion of lived experiences and worker-driven recommendations enhances the contextual relevance and applicability of findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications of all the available evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCombined with existing evidence, our findings reinforce the urgent need to integrate occupational health services within primary healthcare systems, particularly targeting informal women workers. Structural inequities, such as lack of identification mechanisms, poor sanitation infrastructure, and exclusion from social protection must be addressed to improve access and outcomes. This study provides actionable insights for policymakers, including recommendations on gender-sensitive occupational health integration, data collection at the primary health centre level, and capacity building of frontline healthcare providers.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eOccupational health is a critical yet overlooked dimension of public health, particularly for informal sector workers who face hazardous environments without adequate protections. Informal employment—untethered from labour laws, social security provisions, and formal contracts—excludes workers from even basic occupational health and safety (OHS) standards.[1] In India, nearly 93% of the workforce is informal, with over 95% of women engaged in such work, reflecting pronounced gender-based vulnerabilities.[2] These women form the backbone of agriculture, construction, home-based manufacturing, waste recycling, and street vending, yet their occupational health remains poorly documented and insufficiently addressed.\u003c/p\u003e\n\u003cp\u003eInformal women workers (IWWs) face multiple health risks, including musculoskeletal disorders, respiratory illnesses, reproductive complications, skin infections, and mental health problems, driven by poor ergonomics, dust and chemical exposure, extreme temperatures, and inadequate infrastructure.[3-6] Gender further compounds these risks through wage disparities, job insecurity, and limited access to public services.[7] Poor nutritional status is also common, with implications for child health.[8]\u003c/p\u003e\n\u003cp\u003eEnvironmental exposures add further strain. Outdoor workers are increasingly vulnerable to heat-related illnesses, dehydration, and injuries due to rising temperatures, air pollution, and water scarcity.[9-11] Despite growing evidence, occupational health policy and research in India remain largely focused on the formal workforce, leaving IWWs underrepresented in health planning and service delivery.\u003c/p\u003e\n\u003cp\u003eSome studies have documented sector-specific hazards, but few have used a multi-level framework to examine the broader social, environmental, and policy determinants that shape IWWs’ health. This limits understanding of how structural inequities—such as the absence of contracts, legal entitlements, and employment benefits—intersect with occupational exposures to restrict healthcare access, social protection, and policy inclusion. Moreover, the lived experiences of IWWs are rarely integrated into occupational health discourse or system planning, despite their importance for designing contextually appropriate, gender-responsive interventions.\u003c/p\u003e\n\u003cp\u003eThis study addresses these gaps by applying the Socioecological Model (SEM) to examine the multi-layered health challenges of IWWs in Ahmedabad, Gujarat—a rapidly industrializing region with socioeconomic diversity and a dense informal labour force. Through focus group discussions (FGDs) across key occupational groups, it seeks to generate evidence grounded in workers’ experiences to inform socially attuned, gender-equitable occupational health policies and services.\u003c/p\u003e\n"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis qualitative study employed FGDs to explore the multi-level influences on health challenges and healthcare access among IWWs in Ahmedabad, Gujarat (India). The study was conceptually guided by the SEM, examining intrapersonal, interpersonal, organizational, community, and policy-level determinants.[12] Sites were purposively selected from urban and peri-urban areas where the target occupational groups lived and worked. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).[13]\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy Participants\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eParticipants were recruited from five occupational groups accounting for most informal women’s employment: agricultural workers, construction workers, street vendors, home-based workers, and waste recyclers.[2] Women aged 18 years and above who were currently employed in any of these occupation were eligible. Exclusions were serious illness, lack of fluency in Gujarati, or refusal of written consent. Accredited Social Health Activists (ASHAs) and Self-Employed Women’s Association (SEWA) coordinators assisted with community engagement and participant identification. Prior approval were taken from local authorities and community leaders.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSample Size and Composition\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFive FGDs were conducted, one per occupational group, with 6–10 participants each (total n = 41). Group sizes balanced diversity and interaction. Discussions lasted 45–60 minutes in community venues ensuring privacy and comfort.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData Collection Tools and Procedure\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA semi-structured FGD guide was developed specifically for this study following a review of relevant literature and the domains of the Socioecological Model (SEM). The guide is provided in English as Supplementary File 1 to ensure transparency and replicability. Questions were framed under the five SEM levels.[12] The guide included questions on i)\u0026nbsp;\u003cstrong\u003eintrapersonal\u003c/strong\u003e (knowledge, attitudes, beliefs, personal experiences), ii) \u003cstrong\u003einterpersonal\u003c/strong\u003e (family dynamics, social and peer support), iii) \u003cstrong\u003eorganizational\u003c/strong\u003e (workplace safety, sanitation, safety protocols), iv) \u003cstrong\u003ecommunity\u003c/strong\u003e (neighbourhood conditions, local norms, community organisations), and v) \u003cstrong\u003epolicy\u003c/strong\u003e (awareness and experiences with health and labour policies).\u003c/p\u003e\u003cp\u003eEach FGD was moderated by a trained qualitative team comprising one male (AD) and two female interviewers (ER, ZK), all fluent in Gujarati and experienced in community-based research. AD and ER hold Master’s in Public Health (MPH), ZK is a trained research coordinator with grassroots experience. Senior researchers AS (MD) and MT (MBBS) oversaw design, quality assurance, and methodological guidance.\u0026nbsp;\u003c/p\u003e\u003cp\u003eWritten consent was obtained before audio-recording. Moderators maintained reflexive field notes to capture perspectives and reduce bias. Discussions encouraged open sharing in a respectful environment.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData Management and Analysis\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFGDs were transcribed verbatim and translated into English (AD, ER). Transcripts were reviewed for accuracy before analysis. Thematic analysis followed Braun and Clarke’s approach: familiarisation, initial coding, theme identification, theme review, and final naming/definition.[14] Coding was carried out independently by two researchers (AD and ER) using Microsoft Excel.\u0026nbsp;Two researchers (AD, ER) independently coded transcripts in Microsoft Excel. Codes were organised under SEM levels to ensure theoretical alignment. Themes were compared across occupational groups to identify shared and occupation-specific patterns. Discrepancies were resolved by discussion with the broader team (MT, AS), and final themes were agreed upon by all (AD, ER, MT, AS).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResearcher Credentials\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe qualitative team comprised public health professionals and medical doctors with occupational health expertise. AD and ER (MPH) and ZK (field research coordinator) conducted FGDs and transcription; AS (MD) and MT (MBBS) provided senior oversight.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eParticipant Feedback on Findings\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eDue to time and logistical constraints, transcripts and themes were not returned to participants for comment.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 41 women informal workers participated in five FGDs representing agricultural workers (AW, n=10), construction workers (CW, n=6), street vendors (SV, n=8), home-based workers (HW, n=10), and waste recyclers (WR, n=7). Mean ages ranged from 35.4 to 49.6 years, with work experience from \u0026lt;1 year to 27 years (Table 1). Analysis generated themes under the five SEM domains (Figure 1). Key findings are presented below, highlighting major thematic patterns within and across occupational groups.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1. Intrapersonal Factors\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e1.1 Physical Health Challenges\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAcross all groups, musculoskeletal disorders from repetitive work, static postures, and heavy lifting were prevalent. AW and WR reported respiratory symptoms from dust and fumes; CW and AW noted skin damage from cement and chemicals—conditions normalized amid lacking protective equipment and training.\u003c/p\u003e\u003cp\u003e“Cement often causes cracks in my hands…it burns my hands a lot.” – \u003cem\u003eCW 6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“We suffer from throat irritation and breathing difficulties due to dust, during castor harvesting.” – \u003cem\u003eAW 6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“Pulling heavy carts gives us leg, stomach, and back pain. My sister fainted once had to be hospitalized.” – \u003cem\u003eSV 5\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e1.2 Mental Health and Stress\u003c/em\u003e\u003c/p\u003e\u003cp\u003eEconomic insecurity, long hours, and domestic responsibilities drove psychological stress. Anxiety about children's education and financial insecurity were prominent concerns.\u003c/p\u003e\u003cp\u003e“We invest a lot of money in crops, but there is always stress whether we will even recover half of it.” – \u003cem\u003eAW 7\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“We earn barely enough to feed our families, yet we have to pay school fees. It’s stressful.” – \u003cem\u003eCW 4\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e1.3 Menstrual and Reproductive Health\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSevere menstrual pain was reported, yet women continued working due to lack of paid leave and societal expectations. Poor sanitation worsened hygiene challenges.\u003c/p\u003e\u003cp\u003e“It really pains a lot during periods. If anyone has severe pain, she may take a day's unpaid leave ….but we can’t afford it every month. Some of us think that taking leave actually increases mental stress, so it's better to go to work.” – \u003cem\u003eWR 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e1.4 Substance Use as a Coping Mechanism\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTobacco or chhikni powder were used as a coping strategy to deal with physical fatigue, especially among CW and WR.\u003c/p\u003e\u003cp\u003e“I'm addicted to chhikni powder. I enjoy using it while working, it gives me stimulation.” – \u003cem\u003eCW 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“It (substance) started bitter, but now it relieves my stress every time I take it.” – \u003cem\u003eWR 4\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e1.5 Climate and Weather-Related Illness\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOutdoor workers described heat stress, rashes, dizziness, and nosebleeds in summer.\u003c/p\u003e\u003cp\u003e“Last summer, I had a nosebleed from the heat. Hopefully, this year will be better.” – \u003cem\u003eSV 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“The heat creates many problems for us. We often sit under the shade whenever possible. We wear sarees to cover our heads to reduce the discomfort, but without shade and seating arrangements, it’s still difficult.” – \u003cem\u003eCW 6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e1.6 Health-Seeking Behaviour\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIWWs often choose private clinics over government health centers, perceiving their medicines as more effective. This preference, driven by trust and efficacy concerns, increases out‑of‑pocket costs, strains finances, and can delay or reduce use of public services, hindering integration of occupational health into primary care.\u0026nbsp;\u003c/p\u003e\u003cp\u003e“We do take medicines from the sub-centre here in the village……however, we feel that government medicines take a longer time to show effect, whereas the medicines from private clinics provide instant relief.” – \u003cem\u003eAW 8\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e2. Interpersonal Factors\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e2.1 Familial Support and Gender Roles\u003c/em\u003e\u003c/p\u003e\u003cp\u003eLack of emotional and practical support within their households was reported, which increased burden and led to exhaustion and emotional distress.\u003c/p\u003e\u003cp\u003e“There is so much pressure. We handle everything at home and then face deadlines at work. It’s overwhelming.” – \u003cem\u003eHW 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“We usually sat outside in the sunlight to reduce electricity bills. Sometimes, the bill increases suddenly….our family members scold us, saying we are wasting electricity. The sewing machine has a foot motor which does not work on mini light (low electricity).” – \u003cem\u003eHW 6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e2.2 Addictive Behaviours in Family Members\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSubstance abuse among male family members contributed to household conflict, financial instability, and physical or emotional abuse.\u003c/p\u003e\u003cp\u003e“Sometimes, when our husbands come home after drinking alcohol, they fight with us” – \u003cem\u003eHW 9\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e3. Organizational Factors\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.1 Lack of Safety Equipment and Support\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWorkers reported inadequate or absent logistic support, including PPE and sewing machines. Most purchased their own equipment without external support.\u003c/p\u003e\u003cp\u003e“We have a sewing machine, we can do it, but we have other people who want to do it, but they don't have a sewing machine. So, if they give us anything like that it would helpful.” – \u003cem\u003eHW 1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“They don’t give us anything to wear on our hands. If we wear gloves while making cement products, then there won’t be a problem.”– \u003cem\u003eCW 6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.2 Absence of First Aid\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInjuries were typically managed informally using cloth or improvised remedies at the worksite, with formal medical care deliberately delayed by the workers until after completing their job tasks. This pattern reflects the economic pressures and absence of paid sick leave, where immediate care is deprioritized in favour of securing daily wages and avoiding income loss.\u003c/p\u003e\u003cp\u003e“When we get injured, we cover injured part with whatever cloth we have at that moment. After finishing our work, we go to the hospital.” – \u003cem\u003eCW 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.3 Inadequate Work-Rest Cycles\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants highlighted that work breaks were infrequent or absent, and combining household duties with paid work contributed to fatigue and burnout.\u003c/p\u003e\u003cp\u003e“If we have to stand for long hours, our legs hurt a lot. Even when climbing bricks, our whole body aches. The owner only gives us half an hour to sit during meals.……they don’t let us rest when we are tired.” – \u003cem\u003eCW 7\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.4 Poor Water, Sanitation and Hygiene (WASH) Facilities\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBasic facilities such as clean drinking water, functional toilets, and handwashing stations are either inadequate or completely absent. These forces outdoor workers to use open spaces for toileting.\u003c/p\u003e\u003cp\u003e“During periods, when we need to use the washroom frequently and are far from the place, sometimes we have to go outside, behind trees.” – \u003cem\u003eWR 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“There are no toilets on farms. We just use open areas.” – \u003cem\u003eAW 4/5\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.5 Lack of Maternity Leave\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePregnant workers reported working up to their eighth month due to the absence of maternity leave or any financial security during pregnancy.\u003c/p\u003e\u003cp\u003e“We work even during pregnancy, up to the 8th month. The employer will never pay a single penny when we are off from work, maternity leaves are not a chance. We never get maternity leaves.” – \u003cem\u003eCW 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e4. Community-Level Factors\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e4.1 Barriers to Public Healthcare Access\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDespite being eligible for services at urban health centres (UHCs), and awareness of the Pradhan Mantri Jan Arogya Yojana (PMJAY)—India’s government-funded health insurance scheme,\u0026nbsp;women often chose private clinics due to the long distances, long wait times, and perceived inefficiency of public services. For daily-wage earners, long waiting periods often translate into wage loss, further disincentivizing public healthcare services uptake.\u003c/p\u003e\u003cp\u003e“Some of us have the Ayushman Bharat (PMJAY) card, while a few others do not have this card.” – \u003cem\u003eSV 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“We avoid going to the UHC—it’s far and always crowded. We can’t afford to lose a day’s wage waiting.” – \u003cem\u003eSW 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e4.2 Role of NGOs and Local Initiatives\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants acknowledged support from local organizations like SEWA for health awareness and seasonal relief\u0026nbsp;\u003c/p\u003e\u003cp\u003e“SEWA gave us ORS and health tips in the summer. Nothing came from the government.” – \u003cem\u003eCW 4\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e4.3 Social Stigma and Discrimination\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWorkers, particularly waste recyclers reported feeling humiliated and socially excluded, which affected their dignity and mental health.\u003c/p\u003e\u003cp\u003e“Some people make fun of us….Oye kachara wala ben (In English: Hey, garbage collector) come here, pick this up, collect it, take this. Some see us as if we have come to steal something. ‘Why did you come here?’, ‘Did you come here to steal?’, ‘Why did you take this?’…If anything disappears then they just blame us that you took this thing from here.” – \u003cem\u003eWR 1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e5. Public Policy-Level Factors\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e5.1 Demand for Financial and Social Protection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants voiced strong demand for social security mechanisms such as pensions, work-from-home opportunities, and tools (like sewing machines) to enable dignified and sustainable income generation.\u003c/p\u003e\u003cp\u003e“We need pensions for when we can’t work anymore, and work-from-home options to support ourselves.” – \u003cem\u003eCW 6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“Many women want to do home-based work but don’t have machines. If the government could provide them, it would help a lot.” – \u003cem\u003eHW 4\u003c/em\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis qualitative study employed the\u0026nbsp;multi-level SEM\u0026nbsp;to examine the multifaceted health challenges faced by IWWs across five major occupational groups—agricultural workers, construction workers, street vendors, home-based workers, and waste recyclers—in Ahmedabad, India. The findings demonstrate a convergence of occupational, environmental, structural, and gender-based vulnerabilities that together shape the physical, mental, and social well-being of these women.\u003c/p\u003e\u003cp\u003eMusculoskeletal disorders (MSDs) emerged as a predominant health concern, commonly linked to poor ergonomics, prolonged static postures, and repetitive tasks.[3, 15] These findings are supported by a systematic review that reported a higher prevalence of MSDs among IWWs.[16] Home-based workers, in particular, described headaches and dizziness from sustained visual and manual strain.[3] Exposure to pesticides in agriculture and cement dust in construction was linked to respiratory conditions, skin irritation, and cracked skin.[17] The hazards of such work intensifies in the absence of personal protective equipment (PPE).[18] Some participants reported unconventional coping strategies, such as applying nail polish to soothe cement-induced skin damage, underscoring both poor health literacy and limited access to occupational health services.\u003c/p\u003e\u003cp\u003eMental health challenges were initially underreported, but upon probing, participants disclosed persistent anxiety, restlessness, and emotional exhaustion—driven by financial insecurity, job instability, caregiving responsibilities, and unsafe workplaces. These findings align with prior studies linking informal employment to increased risk of poor mental health.[19] Wage structures varied across occupations, with home-based workers paid per piece, and construction and agricultural workers on daily wages. Street vendors and waste recyclers relied on uncertain earnings from sales. This economic vulnerability often forced women to continue working despite health issues, further compounding physical and psychological strain.[17, 20]\u003c/p\u003e\u003cp\u003eClimate and environmental exposures significantly influenced occupational health, especially for outdoor workers. Heat-related illnesses such as dehydration, dizziness, and heat stroke were common in summer, while respiratory symptoms and injuries increased during winter and monsoon conditions. Street vendors reported reducing fluid intake to avoid using non-existent toilet facilities, heightening the risk of dehydration and heat stroke.[21, 22] Moreover, urban informal workers also faced water scarcity and poor sanitation.[23] Evidence indicates that each 1 °C rise in temperature can increase sickness probability by 5–7% and medical costs by 14%.[24] Climate-related health risks were closely intertwined with socioeconomic disadvantage and inadequate urban infrastructure.\u003c/p\u003e\u003cp\u003eHealthcare access was marked by mixed use of public and private services. Although most participants were aware of public health schemes, a clear preference emerged for private clinics, perceived to offer higher-quality and faster-acting medicines despite higher out-of-pocket costs. Public facilities were considered inefficient and time-consuming, with long wait times leading to income loss for daily-wage workers. Similar patterns have been noted in Ghana and Delhi, where informal workers opt for private care due to concerns about quality and timeliness in public services.[25, 26]\u003c/p\u003e\u003cp\u003eAwareness of the Pradhan Mantri Jan Arogya Yojana (PMJAY) – part of the Ayushman Bharat program – was high, but utilization was limited. PMJAY is India’s\u0026nbsp;government-funded health insurance scheme.[27] For serious treatments, participants relied more on government-subsidized health entitlement cards to reduce inpatient costs, while routine and minor ailments were managed in private facilities. Lack of preventive and outpatient coverage under many government schemes was a notable gap, given these represent a large share of healthcare costs for IWWs. Community health workers and NGOs were regarded as valuable for health education and linking workers to available services.\u003c/p\u003e\u003cp\u003eThis study also revealed widespread socio-economic and workplace barriers similar to report from earlier studies such as low and irregular wages,[28] long working hours, no paid leave and minimal social protection.[29] Many were sole earners, making withdrawal from work practically impossible. Workplace sanitation was frequently inadequate, with no toilets or clean drinking water . Some women restricted water intake to avoid needing toilets. These findings align with prior evidence on infrastructure gaps severely affecting IWWs.[30, 31] Underpayment, lack of formal employment contracts, and high production pressure were widespread.[24] Maternity protection was absent; participants reported working into the third trimester without accommodations or financial security.[5]\u003c/p\u003e\u003cp\u003eSafety and immediate care provisions were minimal. First aid facilities were rarely available; instead, women relied on self-medication or home remedies, risking complications from untreated conditions. These practices reflected both low health literacy and weak integration with formal health systems.\u003c/p\u003e\u003cp\u003eWorker recommendations reflected a desire for both economic and occupational health interventions. Home-based income-generating opportunities—especially for older women—were suggested to reduce physical strain while sustaining livelihoods. Requests for pension schemes, financial security programs, and logistical support (including sewing machines and PPE) were common. Barriers to accessing government welfare benefits included limited literacy, migratory status, and lack of identity documentation.\u003c/p\u003e\u003cp\u003eAlthough India has enacted welfare policies such as the\u0026nbsp;Unorganized Workers’ Social Security Act (2008)[32] and launched platforms like e-Shram to register informal workers,[33] our findings indicate limited awareness and uptake of these schemes. Similarly, while Pradhan Mantri Shram Yogi Maan Dhan Yojana[34] offers pension support, Ayushman Bharat provides health insurance,[27] and Pradhan Mantri Matru Vandana Yojana offers maternity incentives,[35] these programs are underutilized by the target study group due to awareness gaps, administrative barriers, and poor alignment with the lived realities of IWWs.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStrength and limitations\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA key strength of this study lies in its use of the Socioecological Model (SEM) to systematically explore the multi-level determinants of health among IWWs across five major occupational groups in Ahmedabad, yielding occupationally nuanced and gender-sensitive insights. Focus group discussions in the local language enabled rich, context-specific narratives from a population that is often underrepresented in health systems research.\u003c/p\u003e\u003cp\u003eLimitations include its focus on a single district, which may not reflect regional diversity, and potential underreporting of sensitive issues like mental or reproductive health due to stigma. As a qualitative study, findings are not generalizable but provide transferable evidence to guide localized, gender-responsive health policies and interventions.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePolicy Translation and Engagement\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAs an immediate step toward policy translation, the findings were presented at a national roundtable discussion convened in collaboration with key stakeholders, including representatives from the Ministry of Labour and Employment (MoLE), National Health Systems Resource Centre (NHSRC), International Labour Organization (ILO), Central Board of Welfare Education for Workers (CBWE), V. V. Giri National Labour Institute (VVGNLI), ICMR-NIOH, Lok Swasthya SEWA Trust (LSST-SEWA),\u0026nbsp;Women in Informal Employment: Globalizing and Organizing (WIEGO, UK), Worker Unions and workers.\u0026nbsp;\u003c/p\u003e\u003cp\u003eDiscussions, grounded in the lived experiences of IWWs, produced priorities including integrating occupational health into Ayushman Bharat and primary care, expanding social protection, addressing climate-related heat impacts (especially on women’s health), and building primary healthcare capacity in occupational risk assessment. Participants also urged inclusion of informal sector OHS modules in medical and nursing curricula, highlighting the value of participatory, community-driven research in shaping health and labour policies for vulnerable workers.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eInformal women workers in India experience a complex interplay of health risks shaped by occupational, environmental, and structural inequities. This study highlights the need for a gender-responsive, occupation-informed public health approach that moves beyond individual-level interventions and addresses systemic barriers in work and health environments. Bridging the gap between informal employment and accessible, quality healthcare will require not only service expansion but also structural reforms that recognize the contributions and vulnerabilities of this critical segment of the workforce. By prioritizing these workers within both health and labour policy frameworks, India can take a crucial step toward more inclusive and equitable health systems.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch4\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe study was approved by the Institutional Human Ethics Committee of ICMR-National Institute of Occupational Health (ICMR-NIOH/EC/2024/5) and conducted in accordance with the Helsinki Declaration. All participants provided informed written consent, including permission for audio recording and anonymized use of their responses. Confidentiality and privacy were maintained throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No identifying images, personal, or clinical details of participants are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors collaboratively developed the study design and the semi-structured discussion guide. AD, ER and ZK were responsible for field coordination, data collection, transcription, and initial thematic coding of the focus group discussions. MT and AS reviewed the transcripts and resolved discrepancies in thematic coding and interpretation through iterative discussion. The first draft of the manuscript was prepared by AD and ER. AS and MT provided critical input during manuscript revision. AV and RB contributed to methodological refinement and reviewed the manuscript for intellectual content. The final version of the manuscript was reviewed and approved by all authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors being full time research faculties of the non-profit occupational health research institutes, conducted and reported this study within their independent capacity. AS (Author) received grant from WIEGO (Women in Informal Employment: Globalizing and Organizing, UK) to support the minimal expenses incurred during generating the evidence on health challenges faced by informal women workers in India, and part of this grant is planned to offset the article processing charges.\u0026nbsp;WIEGO received funding from Co-Impact to support the research. WIEGO had no role in the data collection, analysis, or in interpretation of the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our sincere gratitude to the\u0026nbsp;Lok Swasthya SEWA Trust (LSST-SEWA)\u0026nbsp;for their vital collaboration throughout this study. The participation of LSST-SEWA was integral not only in facilitating access to informal women workers across diverse occupational groups but also in co-developing the study design and guiding the implementation of the focus group discussions. We are especially grateful to\u0026nbsp;Mirai Chatterjee, Director, SEWA Social Security, and\u0026nbsp;Susan Thomas, National Health Coordinator, SEWA, for their active involvement in the conceptualization and facilitation of the research. Their deep institutional knowledge and commitment to advancing the health and social security of informal women workers significantly enriched the study. We also acknowledge\u0026nbsp;Kuhika Seth (WIEGO)\u0026nbsp;for her valuable inputs during the early stages of conceptualizing this study.\u003c/p\u003e\n\u003cp\u003eWe further acknowledge the key stakeholders, including representatives from the Ministry of Labour and Employment (MoLE), National Health Systems Resource Centre (NHSRC), International Labour Organization (ILO), Central Board of Welfare Education for Workers (CBWE), V. V. Giri National Labour Institute (VVGNLI), LSST-SEWA, WIEGO, Worker Unions and workers for their participation and recommending our key observations in the national round table meeting .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on reasonable request from the corresponding author.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWomen and men in the informal economy: a statistical picture. Third edition ed. Geneva, Switzerland: International Labour Office; 2018 2018. 1 p.\u003c/li\u003e\n\u003cli\u003eHill E. Worker Identity, Agency and Economic Development: Women\u0026apos;s Empowerment in the Indian Informal Economy. London: Routledge; 2010 2010/07/02/. 208 p.\u003c/li\u003e\n\u003cli\u003eNag A, Vyas H, Nag P. Occupational health scenario of Indian informal sector. 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Protect Labourers from Adverse Impact of Climate Change; 2024.\u003c/li\u003e\n\u003cli\u003eAkazili J, Chatio S, Ataguba JE-O, Agorinya I, Kanmiki EW, Sankoh O, et al. Informal workers\u0026rsquo; access to health care services: findings from a qualitative study in the Kassena-Nankana districts of Northern Ghana. BMC Int Health Hum Rights. 2018;18(1).\u003c/li\u003e\n\u003cli\u003eRuma G. Health Insecurities Informal Employment Ruma Ghosh. Unpublished; 2010.\u003c/li\u003e\n\u003cli\u003eAbout PM-JAY - National Health Authority | GOI [Available from: https://nha.gov.in/PM-JAY.\u003c/li\u003e\n\u003cli\u003eSingh SA, Kumari A. Challenges and Opportunities: Women\u0026apos;s Working Conditions in India\u0026apos;s Unorganized Sector. Rochester, NY: Social Science Research Network; 2024.\u003c/li\u003e\n\u003cli\u003eBhan G, Surie A, Horwood C, Dobson R, Alfers L, Portela A, et al. Informal work and maternal and child health: a blind spot in public health and research. Bull World Health Organ. 2020;98(3):219-21.\u003c/li\u003e\n\u003cli\u003eJoshi N. Low-income women\u0026rsquo;s right to sanitation services in city public spaces: a study of waste picker women in Pune. Environment and Urbanization. 2018;30(1):249-64.\u003c/li\u003e\n\u003cli\u003eRajaraman D, Travasso SM, Heymann SJ. A qualitative study of access to sanitation amongst low-income working women in Bangalore, India. Journal of Water, Sanitation and Hygiene for Development. 2013;3(3):432-40.\u003c/li\u003e\n\u003cli\u003eKar S. The Unorganized Workers Social Security Act, 2008 - An Approach to Provide Basic \u0026amp; Contingent Social Security to the Unorganized Workers in India. SSRN Journal. 2014.\u003c/li\u003e\n\u003cli\u003eKannan DS. E-Shram Scheme: Empowering Unorganized Workers with Essential Social Security. International Journal of Research Publication and Reviews.\u003c/li\u003e\n\u003cli\u003ePradhan Mantri Shram Yogi Maandhan Yojana [press release]. Ministry of Labour and Employment.\u003c/li\u003e\n\u003cli\u003ePradhan Mantri Matru Vandana Yojana [Available from: https://www.myscheme.gov.in/schemes/pmmvy;#details.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Demographic details of the participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSector\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork Experience (Range in years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgricultural Workers *\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e38 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e1.7\u0026ndash;27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstruction Workers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e35 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e1\u0026ndash;18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStreet Vendors\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e49 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e5.1\u0026ndash;17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome-Based Workers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e44 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e2.5\u0026ndash;13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWaste recyclers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e39 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e0.4\u0026ndash;15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*All participants resided and engaged in work at urban locations, except for the agricultural workers, who were from the rural locations\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Informal Sector, Musculoskeletal Diseases, Occupational Health, Female, Focus Groups, Health Policy","lastPublishedDoi":"10.21203/rs.3.rs-7422965/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7422965/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformal women workers (IWWs) face disproportionate occupational health risks due to hazardous work environments, poor social protection, and systemic inequities. However, limited research captures their lived experiences across multiple social-structural levels. The study was conducted to explore the physical, mental, and occupational health challenges of IWWs across five the most prominent informal sectors employing women workers, from Ahmedabad, India, and identify multi-level determinants using the Socioecological Model (SEM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted five focus group discussions (FGDs) with 41 IWWs from agriculture, construction, street vending, waste recycling, and home-based work in Ahmedabad, India. Data were thematically analyzed and mapped across SEM levels—ranging from intrapersonal to policy-level determinants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported musculoskeletal disorders, dermatological conditions, stress, substance use, and heat-related illnesses —underscoring the need for integrated care. Delayed health-seeking behavior, inadequate sanitation, absence of maternity leave, and poor access to first aid reflecting critical service gaps. Structural barriers included limited access to welfare schemes and lack of formal contracts and mistrust in public healthcare leading to high out-of-pocket costs further restricted and shaped the care-seeking preferences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterpretation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings highlight the urgent need for gender-responsive occupational health integration into primary healthcare. The study informed a national policy roundtable that convened key stakeholders to co-develop actionable recommendations to improve occupational health coverage for informal women workers in India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial support was provided by Women in Informal Employment: Globalizing and Organizing (WIEGO) to cover minimal research expenses; the funder had no role in study design, data collection, analysis, or interpretation.\u003c/p\u003e","manuscriptTitle":"Toward Inclusive Primary Health Care: Understanding Health Needs of Informal Women Workers Through a Socioecological Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-03 06:34:22","doi":"10.21203/rs.3.rs-7422965/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-06T06:21:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-04T16:29:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T11:58:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-22T13:44:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T08:01:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8454430528984746756830991363947149241","date":"2025-09-04T15:18:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167208448602761255875917453766885692783","date":"2025-08-31T15:52:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40592953986531406509340178087309245244","date":"2025-08-28T16:36:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50746610402402041783075263499738256026","date":"2025-08-28T05:34:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27493003258816180390743358792899849119","date":"2025-08-26T04:13:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126301250697952261012604381496704630508","date":"2025-08-25T17:49:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-25T17:41:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-25T17:34:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-25T09:21:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-23T03:52:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-23T03:49:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b3f92a3d-5ed4-4bf3-b129-32f48767cc69","owner":[],"postedDate":"September 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:13:40+00:00","versionOfRecord":{"articleIdentity":"rs-7422965","link":"https://doi.org/10.1186/s12913-025-13855-7","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-12-06 15:57:43","publishedOnDateReadable":"December 6th, 2025"},"versionCreatedAt":"2025-09-03 06:34:22","video":"","vorDoi":"10.1186/s12913-025-13855-7","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13855-7","workflowStages":[]},"version":"v1","identity":"rs-7422965","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7422965","identity":"rs-7422965","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}