Household-related variables and reported illness in street vendors and their children in a South African city

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Urbsix3rev 6/09/2000

THE REPRODUCTIVE AND OCCUPATIONAL HEALTH OF WOMEN STREET

VENDORS IN JOHANNESBURG, SOUTH AFRICA

Introduction

`

A substantial majority of urban people living in developing countries are poor and a large

proportion earn their living by working in the 'informal sector'. The International Labour

Organisation's (ILO's) World Employment Programme estimated that employment in the

informal sector is around 60-70% of total employment in Nairobi and Kumasi, 53%-58% in

Bogota, 50% in Jakarta and Lagos, 43% in Calcutta, Bombay and Ahmedabad, and 30% in

Abidjan1. The term 'informal' sector first came to the attention of scholars and economists when

Hart described, in great detail, the informal income opportunities in urban Ghana in the early

seventies2. He argued for a re-examination of terminology and suggested that both formal and

informal economic activities contributed to the global economy and that ignoring the 'informal'

income generating activities, including the less desirable ones such as theft and prostitution, was

a denial of economic realities. The new-found interest in this sector led to a vigorous ideological

debate with optimistic predictions for the role of the informal sector in the resolution of the

world's economic crises. However, the simple informal-formal divide in economic activity was

not embraced by all3,4. Lisa Peattie argues that the "fuzzy" concept of an informal sector, which

had enjoyed a "meteoric career in the world of policy", was useful for highlighting phenomena

that had previously been ignored, but obscures the analysis of important issues5.

While the informal sector provides employment and is linked to the formal sector, it has not

proved to be the solution to the world's economic woes6. In general, the income generated by

informal economic activities is quite variable and ranges from very low levels, to levels far

greater than those generally obtaining in the formal economic sector. It would be a mistake

therefore to conflate the informal sector with poverty although the Johannesburg study reported

here specifically focuses on poor workers in this sector.

The informal sector has been defined as "very small-scale units producing and distributing 1

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goods and services, and consisting largely of independent, self-employed producers in urban

areas of developing countries, some of whom also employ family labour and/or a few hired

workers or apprentices; which operate with very little capital or none at all; which utilise a low

level of technology and skills; which operate at a low level of productivity, and which generally

provide very low and irregular incomes and highly unstable employment to those who work in

it"7 . In most definitions of the 'informal sector' some or all of the following are included : legal

status, size of workforce and some aspects of management, administration, accounting, cash

flow or profits. More recently it has been argued that the informal sector should be viewed as 'a

process of income-generation characterised by one central feature : it is unregulated by the

institutions of society, in a legal and social environment in which similar activities are

regulated'8 . This definition means that the boundaries of the informal sector will vary

considerably depending on the geographical and historical context within which it is discussed.

Government policy in the past focused almost exclusively on the regulation of the informal

sector which threatened to distort the market, and this preoccupation led to extensive studies

designed to gain information on informal economic activities. Interventions often failed to

recognise the inter-relationships between different informal sector activities9. The changing

nature of the 'informal sector', a function of a much larger socio-economic system, similarly,

often goes unrecognised10. It is, therefore, reasonable to predict that the nature of the informal

sector will change over time, as the socio-politico-economic history of the world community

undergoes change.

Women in the informal sector - the global situation

Women, together with out-of-school youth and children, are a particularly vulnerable group in

the informal sector. It has been estimated that women make up 25% to 30% of the labour force

in the informal sector. While the informal sector has common features in most parts of the

world, the range of informal economic activities varies from region to region globally. For

example, the urban informal sector in Pakistan is characterised by the large numbers of small-

scale production and service activities that are either individually or family owned11. It has been

estimated that home-based workers constitute 53% of all employed women in the urban areas 2

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and 77% to 83% of employed women in the urban informal sector in Pakistan. In other words,

of the estimated 2 million Pakistani women working in the urban informal sector, only 500,000

work outside their homes12. In 1990 71.4% of the Indonesian labour force was involved in the

informal sector with the proportion of women increasing steadily13. The situation in Latin

America is similar with the 32% of women employed in Brazil accounting for 65% of the

labour force in the informal sector. A survey of women in some urban centres of Nigeria

reported that 70% of the women were engaged in the informal sector. This very high rate of

involvement in the informal sector reflects the poor state of the formal economies of African

countries and contrasts with that of South-East Asia. Not much is known about the health risks

of women in the informal sector in Africa but occupational health risks in Asia are better

understood. There have been reports of nicotine poisoning in women working in the cigarette

industry in India14. A recent study of both men and women informal sector workers in Dar es

Salaam revealed that workers in the informal sector are exposed to biological, mechanical,

ergonomic, physical and psycho-social hazards against which they are poorly protected15.

The comparative neglect of the role of women in the informal sector has been recognised since

198716. The time taken by, the location and nature of their work, have a direct effect on the

ability of women working in the informal sector to address their own and their families' health

needs. Work in the informal sector is often very time-consuming despite the small profits that

are generated. At the same time the proportion of women with middle level education entering

the informal sector has increased over time, a feature which reflects the increasing need for

women to work, and the decreasing opportunity for women with reasonable educational levels

to find work in the formal sector. The tendency for women in the informal sector to be involved

in trading is usually regarded as a function of its convenience and compatibility with their

family roles and it has been recommended that women in the informal sector engage in a greater

variety of activities in order to enhance their potential for generating greater incomes17. Another

aspect of women's involvement in the urban informal sector is the dependence of poor families

on the income of women. This dependence has been demonstrated in Indonesia, where it was

found that low income families are more dependent on the income of women, either exclusively

or in combination with the income of male spouses, than middle income families18. 3

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Despite the financial benefits that accrue to the families of women working in the informal

sector, concern has been expressed about the nature of informal sector activity indulged in by

women. It has been stated, in reference to women's role in batik making in Indonesia, that this

activity not only encourages the double burden that women carry as home makers and

productive workers, but that it also limits their capacity to participate in other, more lucrative,

activities19. Women working in the informal sector are also subject to social problems, such as

greater marital instability, which has an effect on their well-being18. The role of gender in the

informal sector manifests itself in other ways. Women's engagement in less lucrative activities

than men is often a reflection of gender inequality. The history of the informal sector in

Johannesburg, South Africa, demonstrates that the activities of women have not been related to

their usual gender roles, but has instead been a function of gender inequality in the informal

sector. In Johannesburg, women only participated in washing and coffee-cart trading when men

ceased engaging in these activities, because of their declining lucrativeness, and moved on to

other, more financially rewarding, sectors of the informal economy20 . On the other hand,

women's participation in the informal economic sector enables them to be more independent. In

Khayelitsha, Cape Town, it was noticed that households without any adult males were generally

headed by women who were more educated and economically independent. Involvement in the

informal economic sector therefore offers women an escape from male domination21.

The Brazilian experience indicates that migrants are over-represented in the informal sector in

urban areas22 . These rural migrants remit money and goods to their poor families in the rural

areas, so that the rural economy is intimately linked to the urban informal sector. With the

global increase in female migration, this link is likely to strengthen and become more

pronounced over time.

While the informal sector affords many women an alternative to marriage, certain cultural

practices, such as the seclusion of women, inhibit the participation of women in the informal

sector23,24. Women, are thus often subject to gender inequality despite the promise of economic

independence which involvement in the informal economy holds.4

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The informal sector in South Africa

The system of apartheid served to distort many aspects of urbanisation, including the

development of the urban informal economy in South Africa. The government's policies of

influx control, which debarred Africans from migrating to the cities legally, mass arrests and the

forced removal of 'illegal' Africans in the urban areas, led to a slowing down of the process of

urbanisation. It was imperative for the successful implementation of apartheid, therefore, that

the emergent urban informal economic sector be repressed, as it provided the unwelcome in-

migrants with a means of survival. Rogerson and Preston-Whyte aver that the informal sector

was 'discovered' in South Africa in the 1970's and it has attracted much attention since25. In

1985 approximately 39% of the urban African population were involved in informal sector

activities which contributed between 5% and 8% to the country's Gross Domestic Product

(GDP), in spite of the vigorous attempts by government to stifle the sector26.

The relationship between involvement in the informal economic sector and the health of the

participants is rarely mentioned in the literature. Informal sector workers indulge in hazardous

activities, such as extracting the lead from old unused batteries, welding and spray-painting,

without adopting any protective measures. The pilot survey of occupational health and safety in

the informal sector in Tanzania revealed that very few wood workers wore protective

respirators, for example15. While violence against women is discussed extensively, the risk of

occupational violence for street traders has not received any attention to date

The reproductive health and occupational health risks of street vendors in the informal

sector in Johannesburg, South Africa - - a case study

This study was conducted in Johannesburg, South Africa's most populous city. The population

of greater Johannesburg was estimated to be approximately 4 million people in 1992 and

following the liberalisation of South Africa, the city has experienced increasing in-migration

from the rural areas, as well as surrounding countries. This rapid increase in the urban

population has been accompanied by sluggish economic growth and a burgeoning informal

sector. 5

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The aim of this component of the study was not only to describe the women who are active in

the urban informal trading sector, but also to discuss their fertility experience, gynaecological

illnesses, access to cervical cancer screening services, and occupation-related health problems,

including violence. A further aim was to contribute to our pool of knowledge about these

women internationally as very little was known about the health of street traders. The study was

aimed at alerting policy-makers and planners in the city of Johannesburg to the plight of these

women.

The city of Johannesburg has two major areas in which informal trading takes place. These are

the Central Business District (CBD) and Hillbrow, an area of high-rise buildings known as the

most densely populated square mile in South Africa.

Methods

The first step in the process was to involve the women working as informal sector hawkers in

the city. There are a number of Hawkers' Associations in Johannesburg and their support was

sought prior to conducting the study. Interviews with key informants, both in the health services

and the informal trading sector, provided a better understanding of the health and health-related

issues confronting women in the informal trading sector. Key informants included the head of

the urbanisation programme of the Johannesburg City Council's Directorate of Health, Housing

and Urbanisation, the officials of the hawkers' associations, as well as 10 women working in the

informal trading sector. Several important themes emerged from the interviews. These included

environmental conditions while trading, employment issues, health status, health service

utilization patterns and delivery, reproductive health and family composition. This paper

discusses reproductive and occupation-related health issues, which include violence and abuse.

The general illness experience, household composition and health services utilisation patterns

have been discussed elsewhere27.

A questionnaire was developed over a period of two months and included sections on social

demography including migration history, income generating activities, educational and 6

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training levels, child care, household health service utilization, household composition, acute

and chronic illness, reproductive health issues such as fertility history and contraceptive use,

infant mortality, aspects of occupational health, exposure to hazards such as violence and

knowledge and use of health services. The questionnaire was translated into Sotho and Zulu

by 2 separate groups of interviewers and back-translated into English. The interviewers were

mature women with a minimum of ten years of formal education and fluent in English, one

N'Guni and one Sotho language. A pilot study, during which 36 women street vendors in

Hillbrow and the CBD were interviewed, assessed the logistics and questions for their

suitability. Ambiguous questions were modified or excluded from the final questionnaire.

The city was divided into 323 street blocks (a block included all the pavements around the four

sides of buildings) in which informal sector trading took place. A sampling frame was created

by 6 trained fieldworkers physically mapping all street traders in the area, three weeks prior to

the commencement of the study. This mapping process involved establishing the borders of the

study areas as well as enumerating and numbering the street blocks. The first block number was

assigned randomly and subsequent numbers assigned to the next block on the right. After the

blocks were assigned numbers, the street traders were then placed on the map according to the

position they occupied in a block. The area that was mapped in Hillbrow covered 106 street

blocks and blockwise mapping of this area indicated that there were approximately 219 women

and 234 men involved in street trading in this area. The study area in the CBD covered 217 city

blocks in which approximately 1087 women and 913 men traded.

The traders were highly mobile and some would move from block to block within the city at

different times of the day or even day of the week. The sampling unit therefore was a street

block and not an individual trader. Sample size calculations indicated that for a power of

80% and a confidence level of 95%, 250 women were needed for the study. However, in

view of the cluster sampling method, this number was doubled. Based on a ratio of 1:4, 30

blocks were randomly selected in Hillbrow and 106 blocks in the CBD, and all of the 466

women trading in these street blocks were approached for interview. However, 44 either

refused to participate or provided only partial interviews, giving a response proportion of just 7

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over 90%. Before conducting the interviews the consent of the 'block captains' had to be

obtained. 'Block captains' are men whose permission have to be sought before a woman can

trade in that particular block of the city - - a classic example of male domination in the

informal trading sector. They, in essence, controlled the pavements of the inner city of

Johannesburg. Analysis for the effect of cluster sampling on the estimates using the Stata

programme revealed a design effect ranging between 0.904 and 1.13 indicating no evidence

of homogeneity for any of the variables used in the analysis28, 29.

Results

Demography

The median age of the 422 respondents was 29 years (mean age 30 years), with 45% between

the ages of 20 years and 29 years, and 33% between 30 and 39 years of age (Table 1). Most of

the women regarded themselves as single (66%) and 23% were married, with the remaining

11% either divorced, widowed or refusing to disclose their marital status. Of all the women

64% (271) had a relationship with a man and of these 232 had been in this relationship for

longer than five years.

The women were comparatively well educated -- 29% had primary school education and 58%

secondary school education (7 to 12 years of formal schooling). Of the remainder, 7% had no

education and 5% did not respond to the question. Literacy was inversely related to age. Three-

quarters of the women over the age of 40 years were able to write compared to 91% of the

women under 40 years of age (Chi square=27;df=1;p=0.00003).

A fairly large number of women (37%) did not work for themselves. In most cases they worked

for a man, usually a family member. The relationship between age and self-employment is a

linear one (Chi square test for trend 36.9;df=1;p= <0.0000001) with younger women less likely

to work for themselves than older women. Almost half (48%) of the women earned less than

115 U.S. dollars per month which was well below the minimum living wage of 340 dollars per

month. A significantly larger proportion of foreign-born women (23.4%) earned a weekly 8

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income above $70 than South African-born women (10.3%) (Chi square=7.5;df=1;p = 0.006).

Most of the women work every day of the week and almost all work more than 6 hours per day.

Approximately 45% work for more than 8 hours per day.

A substantial proportion of women traders were not born in South Africa. Foreign-born women

made up 15% of the sample, women born in Johannesburg 26%, and South African born

women coming from outside of Johannesburg accounted for 59% of the sample. Of the 64

foreign-born respondents 29 were born in Zimbabwe, 12 in Mozambique, 9 in Botswana, 6 in

Lesotho, 6 in Swaziland and 2 were born in Ghana. Most of the women sold food (60%) and

clothing (29%). The rest sold curios, spices, cassettes and cosmetics.

Reproductive health

Thirty percent of the women were nulliparous and 54% had fewer than four children. Bivariate

analysis revealed that the number of pregnancies was significantly positively related to the age

of the woman (Chi square=25.8;df=2;p=0.00000), while education was significantly inversely

related to the number of reported pregnancies. Only 9% of women with secondary education

had more than three children as opposed to 20% of those with primary education (p<0.05). Of

those women who had been pregnant over the preceding 5 years, most, i.e. 86% had attended

for antenatal care. The quality of this care was not established and the number of antenatal visits

were not recorded. However, it was significant that 57% of the women had their first pregnancy

before the age of 20 years and had more pregnancies than the rest. The proportion of women

who had teenage pregnancies was inversely related to age - - 65% of the women between 20 and

29 years had a teenage pregnancy compared to 48% of those over 40 years. A multivariate

model which included education, income, place of birth and self-employment (Table 2) showed

that women over the age of thirty years were less likely than the rest to have more than three

pregnancies. The model also illustrates that women with secondary schooling were three times

more likely to have more than three pregnancies than those with primary or no education. There

were no differences in reported fertility between South African born and foreign born women.

Of the 404 women who responded to the question, 57 (13.5%) reported that they had difficulty 9

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in conceiving at some point in their lives. Of the 193 women who were not using contraception

47 reported difficulty in becoming pregnant, i.e. 24.3%. Of the latter 43 had not had a

pregnancy in the preceding five years. According to a modified Larsen-Menken method 22% of

the women were infertile30. Reported infertility was associated with age as 16% over thirty

reported infertility compared to 7% under thirty. This difference was not statistically significant,

however. Women who were nulliparous were significantly more likely to report infertility

(24%) than women with more than six pregnancies (4%) (Chi square= 4.13;df=1;p=0.04).

Similarly, women who had received treatment for a gynaecological illness over the year

preceding the survey were more likely to report infertility (Chi square=15.91;df=1;p=0.00006).

Level of education and place of birth were not associated with reported infertility.

Miscarriages were reported by 58 (13.7%) of the women. A logistic regression model with age,

secondary education, the use of contraception and infertility as independent variables shows that

women with secondary school education were significantly less likely to have had more than

one abortion, while women who did not report infertility were significantly more likely to have

had more than one abortion, and women over the age of 30 years were marginally significantly

less likely to have had two abortions (Table 3). There were no significant differences in the

number of abortions reported by women born in South Africa and those born outside South

Africa.

More than half (53%) of the women used contraception and a logistic regression model with

age, education, income, abortion and infertility as independent variables and the non-use of

contraception as the dependent variable, showed that women over 30 years and those who

reported infertility were significantly more likely not to use contraception. Women who

reported infertility were almost seven times more likely not to use contraception than the rest.

Women earning more than $50 per week were marginally more likely to use contraception

while women with education were significantly more likely to use contraception than the rest

(Table 4). Most of the women used injectable contraceptives. The nature of the contraceptive

method changed with age - - the younger women (those under 30 years of age) tended to be on

injectable contraceptives while the ones between 30 and 39 years tended to be on oral 10

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contraception. Those over 39 years tended to be on injectable contraception. Multiple logistic

regression analysis revealed that women over 30 years and women with more than $50 income

per week were less likely than other women to use injectable contraceptives when the effects of

education, place of birth and self-employment were controlled for. Education was associated

with reported side-effects of contraception. Of the 245 women with secondary education, 22%

complained of side-effects of contraception while a third of those with no education reported

side-effects. This difference was statistically significant (p=0.03).

Only 10% of the women had heard of PAP smears, while 5% had actually had PAP smears

done and 79% had not had PAP smears (data was incomplete in 16% of the women). Women

who were literate were significantly more likely to know that PAP smears were used for the

detection of cancer (p<0.05) and to have had a PAP smear (Chi square=23.6;df=1;p=0.008).

Similarly, education was significantly associated with PAP smear awareness. Thus, 14% of

those with high school education, 4% of those with primary school education and 3% of those

with no education, had heard of PAP smears. Educational level was also inversely related to the

likelihood of having had a PAP smear. Of those who had secondary education 7% had had a

PAP smear while 3% of those with primary schooling had had a PAP smear and none of those

without education had had a PAP smear (Chi square=12.6;df=6;p=0.04).

A multiple logistic regression model which included age, education, weekly income,

contraception non-use, antenatal care and infertility as independent variables and lack of

awareness of PAP smears as the dependent variable showed older women were less likely to

have heard of PAP smears and that women who did not practice contraception were more likely

not to have heard of PAP smears (Table 5). In contrast to the bivariate analysis, women with

primary school or no education were less likely not to have heard of PAP smears. Women who

reported no infertility were marginally significantly less likely to have heard of PAP smears

than those who did report infertility.

Almost 18% of the women reported having had treatment for a gynaecological illness1 during 1 The term ‘womb trouble’ is often used to describe pelvic inflammatory disease. Gynaecological illness refers mainly to

11

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the preceding year. Age and income were important predictors of reported gynaecological

illness (Table 6). Women over the age of 30 years and those with a monthly income exceeding

$200 per month were more likely to report gynaecological illness when education, place of birth

and self-employment were controlled for.

Occupation-related hazards

Most of the women sold food (60%) and clothing (29%). The rest sold curios, spices, cassettes

and cosmetics. More than half (51%) of the women lifted heavy weights as part of their work

and 12% worked with heavy equipment. Women over the age of 30 years (Chi square=

4.09;df1;p=0.04) and women earning more than US$70 per week (Chi square= 5.64; df1;

p=0.017) were significantly more likely to report lifting heavy weights than the rest. A small

proportion (5.6%) of the women worked with fire. Respondents under the age of 20 years were

significantly more likely to work with fire and be exposed to smoke (Chi square

=4.5;df1;p=0.03). Significantly more women earning over US$70 per week reported working

with fire and being exposed to smoke as part of their work (Chi square= 13.6;df1;p=0.0002).

Occupational injuries and iIllnesses

Over half of the women (54%) reported some illness or injury related to their work.

Respondents under the age of twenty years were significantly less likely to have suffered from

an illness or injury related to the nature of their work (Chi square= 9.3;df1;p=0.002). Women

over the age of 40 years were significantly more likely to complain of a work-related illness or

injury (Chi square= 6.9;df1;p=0.008). A significantly larger proportion of women who were

self-employed reported work-related illness or injuries (Chi square= 8.97;df1;p=0.002). Almost

half (47%) of the women reported that they had received burns during their work; 12% reported

having sustained cuts; 3% had sustained both burns and cuts; 21% complained of

headaches;11% complained of musculoskeletal problems; 2% complained of visual

disturbances; and 4% had other complaints2. The type of health problem was related to age. A

significantly greater proportion (75%) of women under the age of 19 years complained of burns

this condition.2 The total does not add up to 47% as some women had more than one complaint.

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(Chi sq= 3.;df1;p=0.0001). Equally, a significantly smaller proportion (35%) of women over the

age of forty complained of burns (Chi sq= 3.8;df1;p=0.05). Older women (over 40years) were

significantly more likely to complain of headaches (Chi sq= 13.3;df1;p=0.0002). Women who

sold food were significantly more likely to have suffered burns during their work (Fisher’s exact

test p = 0.00004). Women selling curios were more likely to sustain cuts but the difference was

not statistically significant owing to small numbers. Of those who reported illness or injury,

32% received treatment.

The working environment

A minority (4%) of the women reported bad or very bad relations with the police. A

significantly larger proportion (7%) of the women who travelled to their work by train reported

poor relationships with police (Chi sq= 5.63;df1;p=0.01). Only 3% of the women reported poor

relations with formal traders in the city and a greater proportion of women born in

Johannesburg (6%) reported strained relations with traders but the difference was not

statistically significant (Fisher’s exact test p=0.06). A significantly greater proportion of

widowed women (18%) reported strained relations with traders in the area (Fisher’s exact test p

= 0.05). More than half (52%) of the respondents reported that they were not comfortable with

the working environment, for reasons ranging from lack of shelter and dirt (34%), noise (26%)

and having to clean the area themselves (24%). Only 2% reported that they felt unsafe.

Violence and abuse while trading in the streets

Approximately one-in-four women reported some form of abuse while working. Of the 422

women interviewed 34 (8%) reported that they had been verbally abused while selling in the

streets. Women who earned more than US$ 400 per month were significantly more likely to be

abused verbally than the rest (Chi square =10.28;df1; p=0.001). Approximately 7% of the

women reported that they had been sexually harassed, i.e. they had been touched in a way that

made them feel uncomfortable, while a small proportion (1.4%) was offered money for sex.

Significantly fewer women who were born in foreign countries reported being touched in a way

that made them feel uncomfortable (Fisher's exact test p = 0.048). Street vendors are also

vulnerable to physical abuse. Twelve women (7%) reported being threatened by someone while 13

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selling in the streets, and 3% of the women reported that someone had on occasion attempted to

stab them with a sharp instrument or strike them. Women earning more than US$400 per month

were significantly more likely to be threatened with stabbing of hitting (Chi square=

4.59;df=1;p=0.03). Only 6 women reported that they had been physically assaulted while

trading on the streets, however. Women born in Johannesburg were significantly more likely to

have been physically assaulted than the rest (Fisher's exact test p = 0.042).

The risk of robbery is ever present. A substantial proportion (29%) of the women reported that

they had been robbed of money or goods while trading in the streets. Younger women (under

the age of 19 years) were significantly less likely to be robbed (Chi square =5.23;df=1;p=0.02).

Women with secondary schooling (32%) were more likely to be robbed than those with primary

schooling, but the difference was not statistically significant (Chi square= 3.71;df1;p=0.53).

Discussion

Demography

Women in the informal trading sector were younger than women in the general population,

which is not surprising given the strenuous nature of the work and the long hours required to

earn rather meagre incomes31. It also reflects young school leavers’ difficulty in finding

employment in South Africa at present. The youth of the women is also a function of the

selective migration of younger women from neighbouring countries and rural areas within

South Africa to the city as occurs in many parts of the world32 . It is interesting that the average

age of these women was significantly lower than that of women involved in informal sector

trading in Khayelitsha, Cape Town33.

As is often the case, marital status was difficult to define and, consonant with the youthfulness

of women traders in inner city Johannesburg, they were mainly single. It is, however, significant

that most of the women had been in a relationship with a man for more than five years, which

means that even women who regard themselves as being single are in stable, ongoing

relationships with men. This clearly has implications for their independence.

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The educational level was high but this is not unusual as prior evidence suggests that women

who migrate to urban areas tend to be more educated and therefore have a greater potential to

earn a living in the more competitive urban areas34. Years of schooling, specially at the primary

level, have been associated with higher female incomes in some studies but in the Gambia

market women, who had higher levels of education, left their small children in the care of

siblings which resulted in higher rates of child mortality, which is contrary to the generally

accepted view that higher levels of maternal education reduces child mortality35,36,37,38. The

inverse relationship between literacy and age is symptomatic of the lack of schooling in older

generations and the level of education of women in this study is similar to that of women street

vendors in other parts of South Africa33.

While the informal sector offers women economic independence from men, a considerable

proportion of women in this study were employed by men. This merely reflects the gender

relations in a segment of the economic life of the country which may well have been expected to

offer greater independence to women. It is well known that women are engaged in less lucrative

income generating activities than men and the nature of hawking, the long hours and the poor

returns confirm this20. The level of income has been shown to be an important determinant of

access to health information and health care such that its importance even in this group of

women cannot be underestimated.

Reproductive health

Fertility was inversely related to age which is similar to the findings in a study conducted in

Khayelitsha, South Africa in 199039. However, the proportion of women with more than five

pregnancies (5%) is significantly lower than in Khayelitsha-based informal sector traders

(22.6%) 33. However, these women are different from women in the general population in a

number of ways. Firstly, the mean number of pregnancies reported are fewer than in studies

elsewhere in South Africa31 Secondly, the relationship between reported fertility and education

is complex40,41,42. The finding that women with secondary education were more likely to have

more than three pregnancies appears counter-intuitive. Women with secondary education in this

study were younger than those with primary or no education. Why should older women in the 15

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informal trading sector tend to fewer children when older women in South African society

generally have more children? A possible explanation is that older women who are infertile or

have few children are over-represented in the informal retailing sector in the city centre as they

are relatively unencumbered by childcare needs.

The reported infertility rate is almost twice as high when compared with a community based

study in Khayelitsha, Cape Town although it was not different from that in women street

vendors in the same study33. As mentioned before, the urban informal trading sector attracts

women who are less handicapped by childcare and who can spend long hours trading in the

streets. It is also likely that women who suffer from infertility are less likely to have the

economic support of a male partner as women who are infertile are sometimes ostracised by

their families and communities43. Street trading therefore offers such women an opportunity to

fend for themselves. The positive association of infertility with reported gynaecological illness

is not surprising. Women suffering from infertility are likely to seek gynaecological attention,

but are equally more likely to have had pelvic inflammatory disease, the commonest cause of

infertility in Africa.

The abortion rate reported in this study is similar to that found by Chimere-Dan in a

community-based study in Soweto and Mamelodi44. The Abortion and Sterilisation Act and the

lack of access to abortion services for African women were major debates in South Africa at the

time of the study. The class differences in abortion rates suggest easier access in the case of

educated women - - which may, in turn, reflect their desired family size. The proportion of

women using contraception and the pattern of contraception, especially the use of injectable

contraceptives, found in this study is similar to that found in other South African studies and

reflects the former government’s family planning policy45, 46.

The proportion of women (90%) who had not heard of PAP smears is appalling and much

higher than the figure (54%) found in the informal sector traders in Khayelitsha, Cape Town

about four years earlier, although it must be remembered that the Khayelitsha study described

only the most senior women in households29. Similarly, the proportion of women who had PAP 16

page17


smears done was significantly smaller in this study (5%) when compared with informal traders

in Khayelitsha (40%). The relationship between an awareness or experience of PAP smears and

education that was found in this study is both striking and complex. Unless information,

education and communication (IEC) programmes take account of women's levels of literacy and

education they will fail. It was not surprising to find that women who were not using

contraception were less aware of PAP smears, which are usually done at family planning clinics.

Cervical cancer accounted for 25% of cancer deaths in African women in South Africa a decade

ago and needs to be addressed urgently47. Unfortunately, screening programmes have been

targeted at groups who were affluent, white, had greater access to health care, and the lowest

risk of cervical cancer48.This situation has to be reversed if the epidemic of cervical cancer in

South Africa is to be curtailed. This study shows that women in the informal sector need to have

their level of awareness of the risk of cervical cancer raised.

The fact that women with greater incomes were more likely to report gynaecological illness

may reflect their greater awareness of gynaecological disease. However, it may be that women

in the informal sector who earn greater incomes have a greater prevalence of gynaecological

disease. As has been found in Latin America, bringing extra income into the house does not

necessarily translate into better health49.

Occupational Health

Reported complaints reflected the nature of the informal occupational activities, and it was thus

not surprising to find that burns, cuts and musculoskeletal problems predominated, a finding

similar to

that of surveys conducted in India.50 Similarly, older women found the lifting and carrying more

hazardous than younger women. It was reassuring that more than a third of the women reporting

an illness or injury sought and obtained treatment. However, the burns and injuries are largely

preventable and efforts should be made to reduce their risk. An important finding is the

frequency of headaches which may be reflection of stress associated with poverty,

marginalisation and the nature of the work, which is often associated with abuse, violence and

robbery.17

page18


Violence and abuse

The proportion of women reporting some form of abuse is lower than the proportion (46%) of

critical care nurses reporting sexual harassment in a United States study.51 However, the

proportion (3%) that reported assault while at work is identical to the proportion of public

servants that reported being assaulted in Los Angeles County.52 While the risk of physical abuse

may appear similar, women street vendors are more vulnerable than women in other

occupational settings because they lack access to the regulatory structures in the formal sector.

The protection provided by the male block captains is therefore crucial. A parallel study has

shown that most women do not report incidents of abuse to law enforcement agencies, largely as

a result of disillusion with police action53. This needs to be changed and increased confidence

will only result from more effective policing.

The findings in this study are not unlike that in other countries. While there are some

dissimilarities with countries in South-East Asia, there are some general themes, such as the

low income earned, the long hours worked, the nature of the informal sector activities,

occupational health risks and the gender relations. How can one ensure the social protection

and health of informal sector workers in the presence of de-regulation? The health risks in the

informal sector has to be seen in the context of the global economy and government's fiscal and

economic policies. In South Africa, where unemployment is estimated at 23%, vigorous

attempts have been made by government to stimulate the growth of small, medium and micro-

enterprises, totally unaccompanied by any concerns for the health and safety of workers. Any

efforts at systematic surveillance, early detection and reduction of health risks will need

strategies that engender trust between workers in the informal sector and local, regional and

central government agencies.. The situation in South Africa has been aggravated by the

explosive urbanisation that followed the abolition of apartheid legislation. Coherent urban

planning, such that the needs of informal sector workers are catered for, is required urgently.

Such planning should include the provision of shelter, water and infrastructure to cope with the

rapid increase in numbers in the urban areas. Changes in local government policy have seen a

shift from hostility to acceptance of the informal sector over the past few years. Different 18

page19


sections in local government now provide support for street vendors and special locations have

been set aside for street trading. In spite of these positive developments, the health needs of

street vendors are not a priority. It is hoped that the results of this study, which have been made

available to local government, will heighten awareness and trigger actions to alleviate the plight

of the city's street vending women.

TABLE 1 : DEMOGRAPHIC FEATURES (PERCENTAGES)

N = 423

AGE(yrs)

19

page20


<19 20-29 30-39 40+ TOTAL

8 45 32 15 100

MARITAL STATUS

Married Single Widowed Divorced Other

23 66 2 4 5

WEEKLY INCOME (US dollars)

<14 15-25 26-50 27-75 >75

14 44 20 10 12

MONTHLY INCOME (US dollars)

<50 52-100 101-200 201-300 >300

10 38 22 11 13

EDUCATION

no education primary secondary unknown

7 29 58 6

LITERACY

yes no

91 9

PLACE OF BIRTH

Johannesburg 28

outside Jhb 72

South African 85

Foreign 15

TABLE 2 : DETERMINANTS OF FERTILITY (>3 PREGNANCIES)

TERM Odds Ratio 95 % C.I.

AGE 30+YRS 0.182 0.111, 0.297 *

20

page21


(<30YRS)

2m educ 3.33 2.06, 5.38 *

(<2m educ)

JHB born 0.715 0.421, 1.21

(not JHB born)

Self-employed 1.16 0.680, 1.97

(not self-employed)

Incwk $50+ 0.935 0.518, 1.69

(<$50)

Constant 2.38 1.40, 4.02 *

* = significant

TABLE 3 : LOGISTIC REGRESSION ANALYSIS : ABORTION

TERM Odds Ratio 95% C.I.

Age >30yrs 0.506 0.249, 1.03 #

(<30yrs)

Second educ 0.369 0.147, 0.923 *

(No second educ)

No family planning 1.50 0.731, 3.07

(Use family planning)

No infertility 2.61 1.08, 6.31 *

(Reported infertility)

Constant 0.396 0.157, 1.00

* = significant

# = marginally non-significant

TABLE 4 : LOGISTIC REGRESSION ANALYSIS : NON-USE OF CONTRACEPTION


Age 30+yrs 1.85 1.11, 3.07 *

(<30yrs)

Education 0.349 0.156, 0.783 *

(no education)

21

page22


Income >$50/wk 0.618 0.378, 1.01 #

(<$50/wk)

Abortion 2+ 1.13 0.550, 2.33

(abortion <2)

Infertility 6.86 3.08, 15.3 *

(no infertility)

Constant 1.18 0.618, 2.25

* = significant; # = marginally non-significant

TABLE 5 : DETERMINANTS OF LACK OF PAP SMEAR AWARENESS


Age 30+yrs 2.73 1.20, 6.22 *

(<29 Yrs)

No secondary educ 0.268 0.102, 0.706 *

(Secondary educ)

No contraception 4.80 1.69, 13.6 *

(Used contraception)

Received antenatal care 1.08 0.271, 4.34

(No antenatal care)

No infertility 0.336 0.107, 1.05 #

(Reported infertility)

$50+ weekly 0.805 0.298, 2.17

(<$50 weekly)


TABLE 6 : DETERMINANTS OF GYNAECOLOGICAL ILLNESS

TERM Odds Ratio 95% CI

Age(30+yrs) 1.61 0.94, 2.77 #

22

page23


(<30 Yrs)

Education 0.76 0.37, 1.55

(No education)

Born in Jhb 0.72 0.39, 1.33

(Born outside Jhb)

Self-employed 1.22 0.69, 2.18

(Not self-employed)

$200+/mnth 1.79 1.00, 3.22 *

(<$200/mnth)


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Documents

Household-related variables and reported illness in street vendors and their children in a South African city