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The outsourcing industry is currently a growing trend in the Philippines providing employment opportunities for many young professionals. The Philippine outsourcing industry has grown 46% annually since 2004 (Rivette, 2010) and is currently representing 21% of the $7.2 billion of total Business Process Outsourcing (BPO) revenues worldwide. With the increase in BPO employment opportunities, more and more young Filipino professionals are applying for and working as call center agents. Approximately 400,000 Filipinos are already employed as call center agents (Rivette, 2010) and with a growth rate of 46% annually, it can be estimated that another 200,000 Filipinos will be joining this work force next year. However, despite the economic benefits of the expansion of BPO in the Philippines, an increase in work-related diseases in call center companies have also been reported. The most researched work-related disease in call centers in the Philippines is on sexually transmitted infections, particularly HIV-AIDS. According to the study done by the UP Population Institute (2010), 20% of male call center agents are commercial sex workers while 14% of them give payment in exchange for sex. The study also showed that 1/3 of call center agents have had casual sex in the last 12 months. These statistics validate the increase in risky sexual behavior among call center agents in the Philippines. However, increase in risky sexual behavior is only a part of the lifestyle of most call center agents. Other poor lifestyle choices observed among call center agents is their patronage of fast food, smoking, consumption of alcohol, increased caffeine intake, decreased sleep, and decrease physical inactivity. Besides poor lifestyle choices, the nature of their work also predisposes them to stress and disturbances in their sleeping pattern. All of these factors predispose them to health problems particularly hypertension, obesity, and diabetes. A number of studies have already been conducted on the incidence of sexually transmitted diseases and call center agents in the Philippines but there are currently no studies yet on the incidence of other diseases among call center agents. This study would like to bridge this information gap because knowledge on the development of other diseases like hypertension and diabetes are also as important as knowledge on the increased transmission of STIs among call center agents.
In this study, the researchers would like to explore the association between the development of Diabetes Mellitus Type II among call center agents in the Philippines. As mentioned above, call center agents and their lifestyle predisposes them to developing diabetes. The researchers would like to address the problem of potentially developing Diabetes Mellitus because of the long-term complications of this disease on the quality of life. The researchers would want to specifically address Type II Diabetes Mellitus for the basic reason that this type of Diabetes develops primarily because of lifestyle factors. The researchers believe that knowledge on the association between call center agents and the development of Diabetes Mellitus Type II is highly significant because of the health implications of this disease and its potential to be prevented.
II. Significance of the Study
The increasing trend of call center agencies in the country provides job opportunities to the increasing supply of graduates in the country. Being employed as a call center agent in a call center agency is assumed to increase the risk of predisposition to different disease entities because of the radical lifestyle changes one undergoes. With the increasing number of employed call center agents, there is therefore an increase in the number of people who are at risk of acquiring diseases.
Few literature deals with call center agents that discusses the acquisition of certain diseases secondary to their occupation. This study aims to increase the fund of literature with regard to this.
Diabetes Mellitus, Type II is a chronic and debilitating disease. Also, as said, this is a life-long disease. Once a person acquires this disease, he or she will forever be predisposed to the co-morbidities and effects of the disease; which in turn, will decrease one’s number of productive life years. Prevention is the most cost-efficient approach when targeting populations. If the results of this study will show an association between being a call center and acquiring Diabetes Type II, we would be able to address the gap in knowledge with regards to the association of being an employed call center agent and acquiring Diabetes Mellitus, Type II. Also this would provide additional data for policy makers to address measures with regards to the prevention of this disease.
III. Scope of Limitations
The study will only include employees in call centers in Ortigas, Philippines. The study will be done for a period of 5(?) years and will only determine if an individual will develop Type II Diabetes Mellitus (DM) or not. The study will not quantify the degree and severity of the disease upon diagnosis. Fasting blood glucose (FBG) will be used in the diagnosis of DM, as it is the most reliable and convenient test for identifying DM in asymptomatic individuals (Fauci et al, 2008) and part of the guidelines used by the American Association of Clinical Endocrinologists (AACE Diabetes Mellitus Clinical Practice Guidelines Task Force, 2007). Individuals will be counted as cases if diagnosed with Type II DM through the course of the study. Cases will be provided with appropriate interventions (non-pharmacological, referral).
The study will exclude those who have the following at the start of the study: Type II DM, history of Diabetes in the immediate family, body mass index (BMI) above or below the normal value as per Asian standard, and more than or equal to 30 years of age. These exclusion criteria are the factors that can be controlled in selecting the individuals within the population that may predispose them to be identified as cases.
IV. Review of Related Literature
Call Center Industry
According to a review done by O’Maley (2008), the Philippines has been a major player in the outsourcing industry over the past ten years. Six major factors were identified to be the reasons why the Philippines participate radically in the said industry. One is the increasing government support for information technology investment despite the erratic political climate. Second is the continuous pooling of college graduates with good English communication skills and proficiency. It was stated in the review that 75% of the total population in the Philippines (according to a United Nations’ data) speak English fluently with a 94% literacy rate which gives a relative advantage in the industry as compared to other countries. Third is high knowledge about Information and Communications Technology (ICT). Fourth is the easy establishment of a reliable and reasonably priced telecommunication infrastructure. Fifth are the low costs but high quality locations of call center agencies. And lastly, sixth, the increasing trends of outsourcing globally.
In that same article written by O’Maley, it was said that the Philippines consistently ranks among the top five Business Process Outsourcing (BPO) locations globally. This shares a five-year-compounded annual growth rate of 38%. The Philippine BPO system was also coined as the major player in the growth of the service sector in the country.
The Philippines plays a major role in supplying the demand for more call center agents as an effect of the global trending of outsourcing worldwide. According to the Philippine National Statistic Office (2010), call center activities ranked first among all BPO activities covering almost half of the total industry with 219 (48%) call center establishments.
With the increasing number of call center agencies, it is logical to say that there is also an increasing need for call center agents to work for such industry. Call center activities employ majority of the workers among all BPOs. In 2008, call center agencies employed about 150,000 workers (Philippine National Statistics Office, 2010). There are about 400,000 Filipinos who are currently employed as call center agents according to Rivette (2010).
Call Center Agents
According to a policy provided by the Employment and Immigration Department of the Government of Alberta (2008), call center agents are the ones who “respond to questions and inquiries, build customer relationships, resolve customer problems and provide information about company policies, products and services over the phone and via electronic communication.”
Working conditions from one call center to another may differ. According to that same policy, call center agents usually work indoors but in a rather open environment to decrease privacy. Further, managers are allowed to record and monitor the conversations of an agent and his or her customer. Working shifts also differ from one agency to another. Some agencies provide services 24-hours a day, seven days a week.
Lifestyle of Call Center Agents and Associated Health Risk Factors
Because of the nature of their work, call center agents usually live a lifestyle that may put them at risk for development of certain diseases. First, call center “workers remained in a static sitting position 95% of the time” (Rocha, 2005) which makes them prone to physical inactivity that may lead to obesity. Development of obesity is of significance because it is a risk factor for the development of Diabetes Mellitus Type II according to the AACE Diabetes Mellitus Clinical Practice Guidelines Task Force of 2007.
Second, call center workers are exposed to a highly stressful environment. Call center workers “identified call-time pressures i.e., having to process a customer call within a specific number of seconds as having the strongest relationship to job stress” (Di Tecco et al, 1992). Another study identified “having to deal with difficult customers as the most significant source of job stress in 54.0% of call center agents handling inbound services and 54.4% of call center agents handling outbound services” (Lin et al, 2010). High levels of stress can lead to increased cortisol levels in the body which is of significance because of its effects on body metabolism. Abnormalities in body metabolism can lead to metabolic problems such as stress-induced obesity which may give rise to hypertension, hyperlipidemia, and hyperglycemia (Andrews, 2002).
Third, the usual diet of call center agents is high in cholesterol and fat and low in fiber which puts them at risk for dyslipidemia and hypercholesterolemia. In a study conducted by the UP Population Institute, they identified the usual lifestyle choices of young professionals in Metro Manila and Metro Cebu. They studied the economic, social and health status of 929 young professionals less than 35 years old working at call centers and non call centers. The study revealed that “there is a high level of consumption of chips, burgers, fries and fried chicken” among the workers and “a few number consume instant noodles and street food regularly”. It was found out that fried chicken was the most popular food choice among Business Process Outsourcing (BPO) workers with 78% saying that they consume it regularly. Chips were the next most popular food choice with 54% saying they consume it regularly, followed by fries at 53% and burgers at 49%. High caffeine intake was also reported in 2/3 of all young professionals drinking coffee daily. However, the study pointed out that call center workers drank more coffee than non-call center workers. Call center workers drank 2.3 cups of coffee daily while non call center workers drank 1.7 cups daily. Tea intake was also reported where 1/4 of all call center workers drank tea while only 1/5 of non-call center workers drank tea. The study also revealed that 50% of all young workers drink soda daily at an average of 1.5 bottles or cans daily.
The study also explored leisure activities of call center agents. Based on the UP Population Institute survey, 72% of call center agents said that their most common leisure activity is drinking compared to partying (62%) or videoke gimmicks (59%). The study said that overall “there is a very high level of current drinking among workers”, 85% for call center agents and 87% for non-call center agents. Fatty food and consumption of alcohol can increase triglyceride and cholesterol levels which is a risk factor for the development of diabetes (AACE, 2007).
Fourth, sleep deprivation is common among call center agents. In the same study, they also found out that instead of the recommended 8 hours of sleep, call center agents only get 6.2 hours of sleep each day. Sleep deprivation can lead to metabolic disturbances and hormonal changes causing obesity (Merck) and consequently diabetes.
Fifth, due to fatigue and lack of sleep, call center agents resort to smoking to cope with stress. They reported that “43% of call center employees smoke while only 21% of non call center agents smoke”. “A call center agent who smokes usually consumes 9 sticks a day on average”. Smoking is a known risk factor for the development of atherosclerosis leading to hypertension and cardiac disease. Since hypertension and cardiac disease are risk factors for the development of Diabetes Mellitus Type II (AACE, 2007), smoking may then predispose an individual in developing diabetes.
Diseases Associated with Call Center Employees
An increase in the turnover, absenteeism, and occupational diseases in call center employees resulted from lack of modernization of processes and organizational planning in call centers in Brazil (Rocha et al, 2005). A focused group investigation conducted in a call center employed with 200 individuals observed the “presence of complaints of muscular pain, stomach aches, sleep alterations and irritability” (Westin in Rocha et al, 2005). Work-related muscular disorders were found to be highly prevalent among the female than male call center employees, specifically on the neck/shoulder region (43%) and on the wrists/hands region (39%). It was observed that a combination of high demands and lack of work control among the female call center employees reflect a highly stressful job that predispose them to the increased risk of having musculoskeletal disorders (Theorell in Rocha et al, 2005). The limitations of the study done by Rocha et al (2005) are that the analyses were limited to one call center linked to a bank, cross-sectional design, small sample size, and symptom-based diagnosis (such as pain, numbing, dizziness, tingling sensation, stiffening, burning sensation).
In a study done by d’Errico et al (2010), the presence of musculoskeletal symptoms in the same region was assessed using the following inclusion criteria to preserved the specificity of the outcome, although it likely decreased its sensitivity: a) presence of musculoskeletal symptoms (pain, burning, stiffing, numbness or tingling) at any time during the last 28 days and b) consultation to a physical and or self-medication because of the symptoms. Also, the “presence of any disease known to be associated with musculoskeletal disorders such as hypertension, diabetes, systemic lupus erythematosus, gout, thyroid diseases, rheumatoid arthritis), previous injuries in the last five years, leisure physical activity, body mass index, smoking, marital status, educational level, gender, and age class were explored as potential confounders of the association between workplace factors and musculoskeletal symptoms.” It was found in this study that 45% of workers reported musculoskeletal symptoms wherein neck (39%) symptoms were the most prevalent, followed by the shoulder (22%), handwrist (10%), and elbow (4%). Neck/shoulder symptoms were associated with “low job control, elevated noise, poor desk lighting and impossibility to lean back while sitting.” Elbow/hand-wrist symptoms were associated with “short intervals between calls, insufficient working space, lack of forearm support, job insecurity, and long seniority in the industry.”
Other study that reported the presence of musculoskeletal symptoms among call center employees were done by Halford and Cohen (2003) wherein computer use factors and individual psychosocial factors were significantly associated with self-reporting of musculoskeletal disorder symptoms.
Sudhashree et al (2005) stated in a column letter that the call center industry in India ranked high for attrition due to health reasons such as sleeping disorders (83%), voice loss (8.5%), ear problems (8.5%), digestive disorders (14.9%) and eye sight problems (10.6%). Burnout stress syndrome, which includes chronic fatigue, insomnia, and complete alteration of biological rhythm of the body are routine cause for sickness absenteeism. Chronic level of stress also affects other systems of the body such as the cardiovascular and endocrine.
In a study done by Lin et al (2010) in a bank call center in Taiwan, call center employees have had prevalent complaints of musculoskeletal discomfort, eye strain, hoarseness, and sore throat. Also, it was found that those who perceived higher job stress had significantly increased risk of multiple health problems, including eye strain, tinnitus, hoarseness, sore throat, chronic cough with phlegm, chest tightness, irritable stomach or peptic ulcers, and musculoskeletal discomfort.
In the Philippines, there are no studies about the health risks and occupational diseases associated among call center employees. However, there is a report of a rise in the number of Filipinos infected with Human Immunodeficiency Virus (HIV) and includes the call center employees (Ruiz, 2010).
Diabetes Mellitus,Type II
Type II Diabetes Mellitus and Epidemiology
Diabetes mellitus (DM) is a group of metabolic disorders wherein there is an increase in blood sugar (hyperglycemia) resulting from absolute or relative deficiency of insulin, or both. There are many classifications of this disease entity based on the pathologic process that leads to hyperglycemia. In Type II DM, hyperglycemia resulted from a range of predominantly insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance (Fauci et al, 2008). It usually occurs among the older age group (> 30 years old) but there is an increasing diagnosis in the younger group (Tidy, 2009). “Most symptoms of diabetes appear very late in the stage of the disease. A lot of diabetics do not have symptoms when their blood sugars are elevated for the first time” (National Objectives for Health, 2005).
There is a dramatic increase in the prevalence of Diabetes Mellitus worldwide, from ~30million cases in 1985 to 177 million in 2000. Type II DM is increasing more rapidly because of “increasing obesity and reduced activity levels as countries become more industrialized,” as in the case of many developing countries in Asia (Fauci et al, 2008). A nationwide prevalence survey in the Philippines by the Department of Health showed that four (4.1%) out of one hundred Filipinos are diabetics, and the prevalence was higher in urban (6.8%) than in rural (2.5%) areas. The World Health Organization estimates that there will be a doubling of prevalence of diabetes in Southeast Asia every five to ten years. Using this as assumption, the prevalence of diabetes in the Philippines is around 8 to 16 percent (National Objectives for Health, 2005). Also, the death rate in diabetes has risen from 4.3 per 100,000 population in 1984 to 7.1 per 100,000 population in 1993. It is important to note that there is underreporting of deaths due to diabetes, as shown by local studies, because of misclassification as deaths due to cardiovascular or renal disease both of which are chronic complications of DM (National Objectives for Health, 2005; Fauci et al, 2008).
Type II Diabetes Mellitus Risk factors and Diagnostics
According to the American Association of Clinical Endocrinologists (AACE) Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus (AACE Diabetes Mellitus Clinical Practice Guidelines Task Force, 2007), there are several risk factors to developing prediabetes and Diabetes Mellitus. Such risk factors are (a) family history of diabetes, (b) cardiovascular disease, (c) overweight or obese state, (d) sedentary lifestyle, (e) Latino or Hispanic, Non-Hispanic black, Asian American, Native American, or Pacific Islander ethnicity, (f) previously identified impaired glucose tolerance or impaired fasting glucose, (g) hypertension, (h) increased levels of triglycerides, low concentrations high-density lipoproteins cholesterol, or both, (i) history of gestational diabetes, (j) history of delivery of an infant with a birth weight > 9 pounds, (k) polycystic ovary syndrome, and (l) psychiatric illness.
To diagnose Diabetes Mellitus, any one of the three criteria is sufficient in diagnosis the patient according to the AACE. These criteria are: (a) symptoms of diabetes such as polyuria, polydipsia, unexplained weight loss and casual plasma glucose concentration of greater than or equal to 200 mg/ dL, (b) fasting plasma glucose concentration of greater than or equal to 126 mg/ dL, and (c) 2-hour postchallenge glucose concentration of greater than or equal to 200 mg/ dL during a 75-gram oral glucose tolerance test.
Diabetes Mellitus Prevention
A study done by the Diabetes Prevention Program (DPP) showed that intensive changes in lifestyle, quantified as diet and exercise for 30min/day five times/week in individuals with impaired glucose tolerance (IGT) delayed the development of Type II DM by 58%. (Harrison’s, 2008). It was also found out that Metformin slowed down the progression or halted the development of Type II DM by 31% compared to placebo. People with a strong predisposition to diabetes due to family history or impaired glucose tolerance or impaired fasting glucose (IFG), are strongly advised to maintain a normal BMI and engage in regular exercise.
According to the recent ADA Consensus panel, individuals with IFG and IGT who are at a high risk for progression to diabetes (age < 60 years, BMI > 35 kg/m2, family history of diabetes in the first-degree, elevated triglycerides, reduced HDL, hypertension, or A1C > 6.0%) could be appraised for Metformin treatment but not other medications.
Acute complications of DM
The acute complications of diabetes are diabetic ketoacidosis (DKA) and hyperglycemic hyperoslomar state (HHS). Both disorders are associated with absolute or relative insulin deficiency, volume depletion, and acid-base abnormalities. These may lead to serious complications if not promptly remedied.
The usual signs and symptoms of DKA are nausea and vomiting, hyperglycemia, hypotension, Kussmaul respirations, fruity oder on the patient’s breath, excessive thirtst, and polyuria. DKA is characterized by hyperglycemia, ketosis, and metabolic acidosis that is accompanied by secondary metabolic abnormalities.
Hyperglycemic Hyperosmolar State
HHS may usually be seen in an elderly individual with Type II DM, with symptoms of polyuria, weight loss, and lessened oral intake that preceded mental confusion or coma. Physical examination shows profound dehydration and hyperosmolarity with concomitat hypotension, tachycardia, and altered mental state. In contrast to DKA, HHS does not present with nausea, vomiting, abdominal pain and Kussmaul signs.
Chronic complications of DM
The chronicity of the disease brings about systemic involvement that affects multiple organ systems. Complications may be divided into nonvascular and vascular complications. Nonvascular complications include gastroparesis, skin changes, and cataracts. Vascular complications can be further subdivided into micro and macrovascular. Microvascular changes, which result from long standing hyperglycemia include retinopathy, neuropathy, and nephropathy. Macrovascular changes include coronary artery disease and peripheral arterial diseases.
(NIkki, I’ll send you my draft. di ko lam kung tama. i Can’t do the framework here.)
Figure 1.Conceptual Framework
With the nature of the work and environment in a call center industry, the study aims to determine if working in a call center predisposes an individual to the development of Type II diabetes mellitus (DM). Specifically, it aims:
a. To determine the incidence of Type II Diabetes Mellitus within the period of study.
b. To determine the etiologic factors associated with the development of Type II Diabetes Mellitus.
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