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 Table of Contents  
Year : 2021  |  Volume : 65  |  Issue : 1  |  Page : 22-27  

Hazardous practices related to blood borne viral infection transmission among male barbers: A study in a rural area of West Bengal

1 Senior Resident, Community Medicine, IQ City Medical College, Durgapur, West Bengal, India
2 Director Professor, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
3 Senior Medical Officer (Equated to Associate Professor), Department of Maternal and Child Health, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
4 Associate Professor and Head, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India

Date of Submission15-Feb-2020
Date of Decision02-Jun-2020
Date of Acceptance19-Oct-2020
Date of Web Publication20-Mar-2021

Correspondence Address:
Soumit Roy
Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_87_20

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Background: Barbers are occupationally predisposed to blood borne viral infection (BBVI) such as human immunodeficiency virus, hepatitis B and C. Unhygienic workplaces, improper disinfection and inadequate wound-care can increase the susceptibility of both clients and barbers to BBVI. There is paucity of studies on practices regarding BBVI among barbers, especially in India. Objectives: To identify the pattern and predictors of practices related to BBVI transmission among male barbers in a rural area of West Bengal. Methods: A cross-sectional study was conducted from June 2017 to August 2019 in Indas block of Bankura district among 138 male barbers, who were permanent residents and worked for >6 months. Barbers, randomly selected from 10 Gram Panchayats according to probability proportionate to size, were interviewed. Two barbering sessions were observed. Data were analyzed using SPSS version 16 software. Univariate and multiple linear regression was carried out to identify predictors of better practices. P < 0.05 was considered for statistical significance. Results: Dangerous practices such as reuse of blades (8, 5.8%) and face-towel (77, 55.8%), sale/distribution of used blades (77, 55.8%), improper disinfection of sharps (79, 57.2%), reuse of alum without disinfection (129, 93.5%), and improper wound care (71, 51.4%) were observed. Predictors of better practice regarding BBVI were better attitude regarding BBVI (B = 0.172, standard error [SE] = 0.046, P = 0.000) and increased years of schooling (B = 0.054, SE = 0.021, P = 0.012). Conclusion: Inimical infection control practices were noticed. They are serving the general people and therefore they should be imbibed with correct BBVI knowledge and must do away with all hazardous practice during their barbering activities.

Keywords: Barber, blood borne viral infection, human immunodeficiency virus, infection control, viral hepatitis

How to cite this article:
Roy S, Dasgupta A, Bhattacharyya M, Paul B, Bandyopadhyay S, Pal A. Hazardous practices related to blood borne viral infection transmission among male barbers: A study in a rural area of West Bengal. Indian J Public Health 2021;65:22-7

How to cite this URL:
Roy S, Dasgupta A, Bhattacharyya M, Paul B, Bandyopadhyay S, Pal A. Hazardous practices related to blood borne viral infection transmission among male barbers: A study in a rural area of West Bengal. Indian J Public Health [serial online] 2021 [cited 2021 Aug 2];65:22-7. Available from:

   Introduction Top

Blood borne viral infection (BBVI) is a major public health problem causing significant morbidity and mortality throughout the world.[1] Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are common causative agents of BBVI. Exposure to contaminated body fluids especially in broken skin or mucous membrane, unsterile injecting practices, unsafe sexual contact, mother-to-child transmission and unsterile tattooing or body piercing practices are the common sources of BBVI.[2],[3] Male barbers, especially in rural areas, provide services of haircutting, shaving, or trimming of hair and nails and other beauty treatments to varied groups of clientele across age, religion, or gender. Barbers are occupationally predisposed to BBVI as they handle sharp instruments such as razors, clippers, combs, and hairpins which can accidentally penetrate the skin.[4],[5],[6] Often serological status of clients is not known to them. Blood and body fluids on equipment or working surfaces, even invisible to bare eyes, carry risk of BBV transmission. Unhygienic workplaces, improper disinfection techniques of instruments and inadequate wound care can increase susceptibility of both clients and barbers to BBVI.[5],[7] Another possible source of infection is usage of same alum for multiple customers by the barbers.[8]

There is scarcity of studies on practice regarding prevention of BBVI transmission among barbers especially in India. Previous studies were mostly conducted in urban settings, while none on rural barbers. Most of such studies only focused on HIV infection while very few were centered on other BBVIs.

With the above background, the present study was conducted to identify the pattern and predictors of practices related to BBVI transmission among male barbers in a rural area of West Bengal.

   Materials and Methods Top

Study design, setting and study population

A cross-sectional workplace-based study was conducted from June 2017 to August 2019 among male barbers in Indas block of Bankura District. Indas block is one of the 22 blocks in the district and was selected purposively. Indas block comprises of 10 Gram Panchayats (GP). The study period had three phases. Initial 6 months were spent as preparatory phase for this study followed by 1 year long data collection period and 6 months' period for analysis and preparation of results.

Barbers who were permanent residents and worked for > 6 months in the block were considered as study population. Barbers who denied to give informed written consent were excluded. During the preparatory phase, GP-wise line-listing of shop barbers was conducted from the tax records in GP offices which was supplemented by inclusion of roadside barbers who were identified with help of local leaders. Total 396 barbers were identified in the study area.

Sample size and sampling technique

A previous study in Kanpur in 2009 showed that 50.56% barbers conducted disinfection of instruments.[9] Now taking estimated prevalence of good practices P = 0.5056, 95% confidence level, 10% relative error and assuming normality, calculated sample size using the formula (Zα/2)2p (1 − p)/L2 = 376. After finite population correction, and considering 1.5 design effect and 10% nonresponse rate, final sample size (n) = 376 × 0.22 × 1.5 × 1.1 ≈ 138.

Thus, total 138 barbers were selected. Number of selected barbers from each GP was calculated according to probability proportionate to size method. They were selected by simple random sampling from each GP.

Tools, techniques and data collection

Multiple visits were conducted to workplaces of barbers. Minimum two barbering sessions were observed using a predesigned pretested checklist and barbers were interviewed with the help of a predesigned and pretested schedule with the following domains:

  1. Sociodemographic (age, education, socioeconomic status), behavioral (substance abuse, tattooing/body piercing) and occupational characteristics (type of workplace, job experience, types of services, types of instrument used, work-hours, number of customers/day, occupational injury)
  2. Knowledge, attitude, and practice (KAP) regarding BBVI: KAP was scored. Practice score was considered as outcome variable. For each correct answer/practice one mark was given whereas zero mark was coined for each incorrect response. Higher the score better was the KAP.

Knowledge had 8 items each for HIV, Hepatitis B and C. These included one item for transmission from asymptomatic carrier/case and seven items for modes of transmission (needle sharing, transfusion of infected blood, sexual contact, perinatal transmission, sharing of food, handshakes, and mosquito bites). Raw knowledge score was standardized to 10 separately for HIV, hepatitis B and C, using this formula

Mean of these three score was considered as final knowledge score. Source of their knowledge was also asked which was not included in scoring.

Both attitude and practice had three domains named as general cleanliness, use of sharps and wound care. Attitude score comprise of 14 items (three items for general cleanliness, five items for use of sharps, and six items for wound care). Whereas practice score had 19 items (six items for general cleanliness, seven items for use of sharps, and six items for wound care). All domain scores of attitude and practice was standardized to 10 for equal weightage of final score using the above mentioned formula.

Mean of domain score was considered as final score for both attitude and practice.

Ethical considerations

Approval of Institutional Ethics Committee of All India Institute of Hygiene and Public Health was obtained during preparatory phase (Ref no: PSM/IEC/2017/6, Date: November 15, 2017). Informed written consent was obtained from each participant prior to the data collection and all ethical principles are strictly adhered throughout the process.

Statistical analyses

Data were analyzed using MS Excel version 2000 and Statistical Package for the Social Sciences version 16 (SPSS for Windows version 16.0, SPSS Inc., Chicago, USA). Univariate and Multiple linear regression was carried out for identification of explanatory factors associated with better practice. Cochran Q-test and Wilcoxon Signed-Rank test were also conducted. P < 0.05 was considered for statistical significance. Biologically plausible covariates showing homoscedasticity (measured by Breush–Pagan Test) and significant association in univariate model were included in multiple linear model.

   Results Top

Background characteristics

Majority of the subjects (78, 56.5%) belonged to 28–47 years of age. Mean (standard deviation [SD]) years of schooling were 7.1 (3.4) years and 11 participants (7.8%) did not receive any formal education. Nearly half (65, 47.1%) belonged to class IV (989.5 to 1979) socioeconomic status in modified BG Prasad scale (corrected to May 2018). Substance abuse was present in terms of tobacco (87, 63.1%) and alcohol (28, 20.2%). No injectable drug abuse was reported. Nearly one-fifth (30, 21.7%) had tattooing/body piercing; mostly it was done by roadside artists (28, 93.3%) without proper precautions being taken (29, 96.7%).

Occupational differentials

Mostly (128, 92.8%) they were working in a structured barbershop and rest had no fixed place to serve. Mean (SD) job duration was 19.4 (11.2) years. Majority were working >48 hours/week (91, 65.9%) and serving 11–20 customers per day (84, 60.8%). Common services provided by them were hair-cutting and shaving (138, 100%), hair-trimming (88, 63.8%) and beauty treatment (103, 74.6%). Six participants (4.3%) were also performing body piercing. Some (41, 29.7%) were providing nail-cutting services to customers with fixed-blade knife. None was using fixed-blade razors. Nearly one-third (53, 38.4%) got injured during work in last 3 months.

Knowledge regarding blood borne viral infection transmission

Majority (126, 91.3%) had heard about at least one BBVI. Differential knowledge was observed for HIV/AIDS (125, 90.6%), hepatitis B (104, 75.4%), and C (56, 40.6%) which was statistically significant (Cochran Q-test, P = 0.000). Most of them knew that an asymptomatic infected person can transmit BBVI (89, 64.3%). Majority had knowledge regarding BBVI transmission through needle sharing (102, 73.9%), blood transfusion (94, 68.1%), sexual contact (96, 69.5%), and perinatal transmission (87, 63.0%). Some of them had misconception regarding transmission of BBVI through handshakes (38, 27.5%), sharing of food (60, 43.4%), and mosquito bites (73, 52.8%). Mean (SD) knowledge score was 3.5 (2.3) which was ranged from 0 to 7.4.

The most common source of information was informal discussions with family members, friends, and neighbors (101, 73.1%). Almost one-fourth of the study subjects were informed about BBVI by health-care providers (33, 23.9%) or through mass media (31, 22.4%). None of them had formal training. Although majority (134, 97.2%) received informal training but the training mostly lacked lesson on infection control (124, 92.5%).

Attitude regarding prevention of blood borne viral infection

Majority showed positive concern for hand washing before work (125, 90.6%), usage of soap during hand-washing (110, 79.7%) and denied reuse of face towel for different customers (110, 79.7%). While almost everyone expressed that new blades should be used for each customer (136, 98.6%) and even for child customer (127, 92.0%), one-fourth opined for reuse of blades for nail-cutting (36, 26.1%). Few (33, 23.9%) agreed that used blades should be disinfected prior to disposal. Most (123, 89.1%) agreed on cleaning of sharps after each use but two-third (94, 68.1%) opined for disinfection of sharps after each use. Majority opined for alum usage after every shave (135, 97.8%), even for different customers (114, 82.7%). Mostly (124, 89.9%) they agreed that washing of alum is necessary before use though 106 (76.8%) negated need of disinfection. Majority stated that barbers should wear gloves during work (99, 71.7%) and should properly cover hand wounds before service (111, 80.4%). Mean (SD) attitude score was 7.2 (1.6) which was ranged from 1.7-9.4. Domain-wise attitude score was described in [Table 1].
Table 1: Domain-wise and total score of attitude and practice (n=138)

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Practice regarding prevention of blood borne viral infection

Only 20 barbers (14.5%) washed their hand properly before service. Hazardous practices such as reuse of contaminated face towel (77, 55.7%) and blades (8, 5.8%) for different clients, indiscriminate throwing of soiled cotton (119, 86.2%), improper cleaning of instruments (124, 89.9%) and lack of disinfection of sharps (79, 57.2%) and alum (129, 93.5%) were observed. Visible contamination of razor (16, 11.6%) and alum (19, 13.8%) were also noticed. None of them were practicing disinfection of blades before disposal. Majority (77, 55.8%) were also engaged in unsafe disposal of used blades such as sale to scrap dealers or distribution to customers for nail-cutting or domestic use. Inadequate care of own wounds were seen in 71 (51.4%) subjects. None were using gloves or any other personal protective equipment [Table 2]. Practice score was normally distributed (Shapiro–Wilk test, P = 0.698) with a mean (SD) of 4.2 (0.9) and range from 2.1 to 6.5. Practices regarding wound care was relatively poor (median score = 2) compared to practices regarding use of sharps (median score = 5.71, Wilcoxon signed-rank test, P = 0.000) and practices related to general cleanliness (median score = 5, Wilcoxon signed-rank test, P = 0.000). No significant difference was observed in median scores of practices related to general cleanliness and use of sharps (Wilcoxon signed-rank test, P = 0.098) [Table 1].
Table 2: Hazardous practices regarding prevention of blood borne viral infection transmission (n=138)

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Predictors of better practice

Better practice was associated with increased years of schooling (B = 0.072, standard error [SE] = 0.023, P = 0.002), increased work-hours (B = 0.078, SE = 0.034, P = 0.023), higher knowledge (B = 0.099, SE = 0.031, P = 0.001) and higher attitude score (B = 0.219, SE = 0.045, P = 0.000) in univariate linear models. All four variables showed homoscedasticity and included in final model. Multicollinearity was absent as variance inflation factors were < 5. In multiple linear model better attitude regarding BBVI (B = 0.172, SE = 0.046, P = 0.000) and years of schooling (B = 0.054, SE = 0.021, P = 0.012) were found significant predictors of better practice whereas knowledge score (B = 0.052, SE = 0.030, P = 0.086) and work duration (B = 0.055, SE = 0.031, P = 0.078) lost their significance. The model fitting was good (P = 0.452 in lack of fit test). Coefficient of determination (r2) was 0.231 (unadjusted) and 0.208 (adjusted). F change of r2 was significant (P < 0.001) what suggested the model had a significant predictive capability and addition of predictors improved model fit. Cook's distance range (0.00–0.107) nullified chances of influencing outlier. Durbin Watson statistic of 1.702 indicated independence of observation. Residuals were also normally distributed and homoscedasticity was present [Table 3].
Table 3: Univariate and multiple linear regression: Predictors of better practice (n=138)

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   Discussion Top

Several literatures had suggested various modes of transmission of BBVI through barbering practices.[4],[5],[6],[7] However, still lack of awareness and poor infection control practices regarding BBVI was observed among barbers of this block. Low educational status, lack of professional training regarding prevention of BBVI might have contributed to this poor knowledge. As most of them knew about those diseases through informal public discussions risk of dissemination of inappropriate and inadequate knowledge, could not be ruled out. Thus, transmission of appropriate, adequate information regarding various BBVI and prevention of BBVI transmission in workplace through an accessible medium is highly needed. Dangerous practices such as re-usage of blades, sale/distribution of used untreated blades, improper disinfection of sharps, re-usage of alum without any disinfection etc., were quite prevalent in this area. Practices related to wound care were the worst compared to those related to general cleanliness and use of sharps. Although they had a high injury proneness mostly they avoid proper care of their wound or use of gloves/covering while handling customers. Waheed et al. showed that HCV could survive alum since alum has no antiviral effect.[8] Thus rampant use of alum without disinfection might potentiate risk of BBVI in this area. Attitude regarding BBVI and years of schooling were found as significant predictors of infection control practices. Thus, the improvement of literacy especially regarding knowledge of BBVI might help in improving the practice. Repeated behavioral change communication interventions are highly needed for marked improvement of attitude which in turn will lead to improvement of their practice.

Nath et al. and Ramadurg et al. found similar age profile like current study, but higher educational profile. This might be a rural-urban variation.[9],[10] Similar socio-demographic profile of barbers were observed in studies from other low and middle income countries.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] Prevalence of abuse of alcohol and tobacco (20.1% and 63.1%) was comparable with findings of rural males in West Bengal (25.1%and 58.3%) in National Family Health Survey 4.[27] No injectable drug abuse was found in our study. However, injectable drug abuse was noted among barbers from Ghana (8%) and Iran (0.8%).[15],[21] These country-specific patterns of substance abuse might be correlated with their socio-cultural attributes. Nearly one-fourth barbers in studied block had tattooing/piercing.[15] Similar result was observed by Khairkhah et al. (19.6%) in Tehran and Adoba et al. (15%) in Obuasi.[15],[21] Lower prevalence (2.2%) of tattooing was seen by Jokhio et al.[16] Mariano et al. observed that tattooing was associated with HCV transmission.[5] Tohme et al. found a significantly higher risk of HCV infection in tattooing fromnonprofessional settings with nonsterile equipment.[28]

Some studies in Pakistan noted that barbers were involved in risky surgical procedures like circumcision.[23] Altough there was difference of job experience and number of customers served which was probably a local variation, occupational differentials were more or less same worldwide.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[29] High injury proneness of barbers in the current study could be related to nature of job. Moreover improper training, inadequate personal protection, long work-hours and relatively overcrowded workplace could potentiate the injury-risk. High injury proneness was supported by other studies.[12],[21],[24]

Poor knowledge of BBVI was also observed in majority of the studies except for Biadgelegn et al. and Arulogun et al. in Ethiopia and Nigeria.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[29] This difference might be an effect of IEC activities by local government. Nath et al. found differential knowledge regarding HIV and hepatitis similar to the current study.[9]

Nath et al. and Eltayeb et al. reported use of fixed-blade razors.[9],[14] However Ramadurg et al. found no use of fixed-blade razors which was concordant to our study.[10] Nath et al. showed that in Kanpur, shop barbers were using new blades but not roadside barbers. Improper disinfection of instruments and unsafe disposal of blades was also observed by them.[9] These findings were conjunct with our study. However, stratified analysis between shop barbers and roadside barbers could not be done since there were very few roadside barbers in our study. Ramadurg et al. found that 28.9% barbers in Bagalkot did not practice hand-washing. However, disinfection of instruments and use of new blades was noticed in all barbershops. This discordance could be attributed to better knowledge regarding infection control.[10] Poor infection control practice was observed in most of the studies conducted in LMICs.[11],[12],[13],[14],[18],[19],[20],[21],[22],[24],[25],[26] Daka D found that good practice was associated with working >8 h/day and possession of ultraviolet sterilizer.[23] The current study also noticed association of better practice with increased work duration, though it was flattened in multivariable model.

There is dearth of the studies regarding practices related to BBVI transmission among barbers, especially in India. Lack of evidence regarding infection control in barbershops especially in underprivileged rural areas hinders the administrators to formulate strategies to prevent transmission of those deadly viruses. In spite of intensive search the researchers could not find any such similar studies in Indian background which was conducted among rural barbers in their workplaces. Robust sampling technique and use of inferential statistics were the key features of the current study which lacked in most of the previous studies. Moreover, direct observation of barbering sessions enabled the researchers to identify actual practices which were mostly absent in prior studies.

However, there were several drawbacks of this study. Only male barbers were included due to relative lack of female barbers in the study area. Thus, risk of female hairdressers could not be assessed. The sample size was inadequate to conduct further stratified analysis especially between shop barbers and roadside barbers. A self-reported questionnaire was used thus possibility of recall and social desirability bias could not be overruled.

   Conclusion Top

Poor knowledge regarding BBVI and unpropitious barbering practices were observed in the studied block. Despite injury-proneness, they were reluctant to provide proper wound care. None of them had carried out disinfection of blades before disposal rather a substantial proportion were practicing either sale or distribution of those blades. These hazardous practices could be eliminated by awareness generation through repeated Social and Behavioral Change Communication activities. Moreover, provision of mandatory formal training regarding appropriate infection control measures and periodic monitoring and supervision by the local administrators was also recommended.


We are thankful to Director, All India Institute of Hygiene and Public Health, Kolkata for permission to conduct the study. We extend our sincere thanks to all the local leaders from different Gram Panchayets of Indas block who helped us to make the sampling frame needed for this study and to identify the workplaces of study participants. We are also deeply indebted to all the study participants for their sincerest cooperation and perseverance. We convey our gratitude to Mr. Debasis Roy, Social worker, for his immense support during data collection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3]


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