Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

THE RELATIONSHIP OF HEALTH DISORDERS TO THE LIFESTYLE AND CHRONOTYPE AMONG MALL WORKERS IN METRO MANILA

A Thesis Proposal Presented to the Faculty of St. Lukes College of Nursing Trinity University of Asia

In Partial Fulfillment of the Requirements for the Degree of Bachelor of Science in Nursing

Submitted by: Batch Viverezante 3Nu03- Group 5 Macaraig, Kristel Cammil T. (Leader) Laada, Gerrilyn S. Magaling, Frances Rexjean C. Manapol, Paola Mae S. Mape, Shannon Monique M. Marao, Rodelen C.

October, 2012/March, 2012

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Chapter 1 Background of the Study

Introduction
Shopping has been a part of the daily activities of the Filipino people. This reflects the consumerist nature of the Filipinos that led to a great expansion in the retail industry. The mall and retail industry in the Philippines comprise nearly 11% of Gross National Product, and 33% of the entire service sector, which is huge.

In Metro Manila alone, there have been an approximate number of 110 malls which do not yet include supermarkets. This only includes the SM malls and tiangge. Therefore, there is also an increase in the employment of mall workers. According to statistics, 2 out of 10 Filipinos are employed in the retail industry (Cua, -2009). And due to this information, we can conclude that most large establishments are concentrated in Metro Manila.

The retail industry became an important contributor to the Philippine economy as it accounts for roughly 15% of the Philippines total Gross National Product (GNP) and 33% of the entire services sector. It employs some 5.25 million people, representing a significant 18% of the Philippines work force. These results may be attributed from the ff. reasons: getting in is easy; it has lower demands with regard to credentials; and many job opportunities are offered even though they may only take a number of months (philippinecountry.com, 2006). These features can be said as practically beneficial to those people without jobs but despite its many economical advantages it can also impose some dangers or risks to ones well-being.

One of the main concerns when it comes to these kinds of workers is inconsistent shifts in their working hours. This disparity therefore confuses their circadian rhythm. The chronotype will determine which type of day a worker functions best. It has been defined as the totality of
factors, associated with circadian rhythms, that determine if an individualis most alert in the morning or ev ening (PU, 2012). This will tell whether they are morning people or evening people. Morning

people are those who wake up early and are most alert in the first part of the day. Evening people are those who are more alert in the late evening hours and go to bed late. The most common problem with these rotating shifts is the adjustment to their working days. This adjustment may interfere with their sleep and eating habits. These people are known
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to have very little or no exercise at all. They are also known to be eating processed foods so much because of their workplace. They tend to have poor dietary habits. This workplace as well causes a stressful atmosphere.

These workers are also reported to have an increased risk for other conditions which may affect their health and well-being. Most of these problems include: digestive upsets due to irregular schedule of eating and consistent ingestion of processed foods; musculoskeletal disorders due to prolonged hours of standing, respiratory diseases, hearing loss, circulatory
diseases, stress related disorders and communicable diseases and others (WHO, 2013).

This study was chosen to help these workers to be aware of the possible health disorders or diseases that they may get from their jobs. This will help them know how to prevent these health issues and apply interventions such as exercise, eating well, getting enough sleep, change their schedule if possible, and see a doctor.

This study aims to dig into the issues pertaining to health disorders brought about by the daily practices and lifestyle of mall employees and their work and sleep patterns.

Statement of the Problem

What is the relationship of health disorders to lifestyle and chronotype among mall employees in Metro Manila?

Objective of the Study

The study will be conducted: 1. To describe the demographic profile that includes the personal data and type of work of mall employees. 2. To describe the Health Disorders mall workers are susceptible or at risk to and to look into health disorders presently dominant among affected mall workers. 3. To describe their lifestyle and chronotype. 4. To relate the Health Disorders to their lifestyle, chronotype and type of work.

Hypothesis of the Study

There is a significant relationship in the lifestyle practices, chronotype and health disorders among the mall workers in Metro Manila.
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Significance of the Study

This study aims to bring awareness among mall workers regarding the possible health risks theyre susceptible to on their job. It also aims to serve a means of health education to them which may bring forth prevention of impending health risks. This may help them be informed with the kind of lifestyle suitable for them so as not to develop any health disorders. Health Educators, which includes nurses and student nurses, are the ones bearing the role of informing or communicating with local citizens about health matters. This study aims to give additional information on the risks or present illnesses being encountered by mall workers which may serve as guide as to the points that can be focused on in health teaching in the promotion of health. This study can help in informing the mall management on the present health concerns and condition of the workers that may add in improving the health prevention strategies or practices, policies being required by these establishments. As for future researchers, this study may serve as basis for inquiries in the goal of developing further nursing management applicable.

Scope and Delimitations

This study will focus on shift workers in the mall specifically the guards, saleslady, and the food, retail and cinema workers. It will include two hundred (200) regular mall employees with the age range of twenty-one (21) to thirty-five (35) years of age, both male and female as its participants. We choose these age range because it is the common age where people start working. We also choose non-contractual mall employees because they are the ones who have adjusted well on their work and they can easily perceive their health statuses. Respondents for this study will be limited to the mall workers within Metro Manila such as Makati City, Mandaluyong City and Quezon City. This study will also be limited to tackling perceived health disorders that most commonly affects the said type of employees.

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Chapter 2: Framework of the Study

Theoretical Framework
The study will be founded upon the theory of Sister Callista Roy which is Adaptation Model. This theory viewed humans as biopsychosocial beings constantly interacting with a changing environment and who cope with their environment through biopsychosocial adaptation mechanisms. (Travelbee, 2008) There are five major concepts in this theory. The first concept is adaptation which is the goal of nursing and at the same time the coping or modification of stimuli with the positive changes in the environment. It utilizes conscious effort in order to attain balance between self and environment which includes stimuli. Second concept is person or the adaptive system. It is an open, adaptive unit comprised of different parts which functions together to come up with mechanisms to be able to cope with stressors of the environment with the use of their own innate skills (Wolfe, 2011). The next concept is environment. It acts as the source of the stimuli. There are three types of stimuli coming from this entity, namely; the focal stimuli which deals with a person instantly; the contextual stimuli, which impacts what the focal stimulus results to; and lastly, the residual stimulus, which creates unclear effects on a present situation (Wills, 2002). Fourth concept is health which is the outcome of adaptation. This is the process of being and becoming an integrated and whole person (Wales, 2012). Finally, the fifth concept is nursing. In this aspect, nurses encourage an effective adaptation of the four modes that Roy was proposing.

In connection with the preceding discussion, there are 4 modes which serve as mechanism that helps in attaining or maintaining adaptation within a person.
First is the physiologic mode which is pertained to survival mode as well. This mode comprises the factors which maintain the physical integrity of a person. These factors may be nutrition, oxygen, fluids, and temperature regulation.
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The next mode is the self-concept which is about growth. This maintains a persons psychic integrity. This consist the insights of the physical and personal well-being. Third is the role function mode which is about continuity of adaptation. In here, social integrity is maintained. When adapting becomes a continuous routine in a persons lifespan, they are also efficiently adapting in this specific mode. Last is the interdependence mode which maintains social integrity. In this mode, there is an emphasis on achieving balance between independence and dependence in a persons social interaction with others. The difference between the dependent and independent behaviors is that dependent is passive while independent is active. Passive interaction is consisted of a onesided gain in attention and affection. Active interaction involves an action-reaction mechanism that says, in every action, there is an equal or opposite reaction. This is the response of a person to an interaction. Transactional patterns fall into the interdependence mode. (Clements and Roberts, 1983) As a whole, the aforementioned aspects play a major role in the improvement of a persons health, quality of life and promoting death with dignity (Cortez, 2008). With all this being said, Sister Callista Roys Adaptation theory is best related to the study since the researchers aim to correlate health risks of mall shift workers to their chronotype and lifestyle practices by assessing how well they adapt to changes in their working environment and how it affects their health status.

(Roy, & Andrews, 1999 as cited in Cortez, 2008). The Roy Adaptation Model. Stamford, CT:
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Conceptual Framework

Perceived Health Status

Non-contractual employees

Lifestyle

Demographic Profile: Age, civil status, Religion, work

Chronotype

This model shows a man inside a bubble that acts as the perceived health status. There are two factors which may affect the standing of the bubble which is the chronotype and lifestyle. In this model, it can be drawn that the study will be focusing on finding out or probing around the relationship the two variables have with the mall workers perceived health status.

Literature Review:
Overview of the Retail Industry and Work Environment: Shopping or going to the malls has been part of every Filipinos life. It is one way of family gathering because it is fun and enjoyable. Over the years, the number of mall establishments has been growing and as the number of mall establishment grows the demand on the number of workers grows as well. (Cua, M., 2009)
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Mall workers in the Philippines are mostly contractual workers. A Contractual worker is one who is hired to work for a specific period of time on an hourly basis or a contracted amount. (Rabinowitz C., 2012) This includes part-time, seasonal, temporary faculty, students, staff and administrative employees. Here in the Philippines contractual workers, work for six months at a certain company and after six months they have to reapply again to get a different kind of job if they want to work for the same company again. Hiring contractual workers like these mall workers make the companies save money because contractual workers do not have the same benefits like a regular worker, like health benefits. Mall workers in the Philippines are exposed to different kinds of people for hundreds or thousands of Filipinos go to the mall every day. Each of them is exposed to people with different health status. Malls are an air-conditioned and closed door place which makes the bacteria spread easily and make the mall workers vulnerable to acquiring infections. As mall workers, they are entitled to attend to whatever the customers are demanding. They stand all throughout their shift which makes them vulnerable to body pain and stress. Muscle aches or muscle pain can cause by injury, strain or over use of muscles from exercise or physically-demanding work like for mall workers for instance, they have to stand for eight hours and walk back and forth to entertain different customers. Muscle pains can also be a sign of conditions affecting the body, like flu (Butterworth-Heinemann, 2008). Other health hazards depend where they are assigned to work in the mall like as a saleslady, mall security guard, janitor etc. Mall workers are also exposed to stress because they face different kinds of people with unique personalities and with different demands each day. Sometimes customers have bad tempers and they cannot do anything about it since The customer is always right also, conflict with co-workers and lack of cooperation from them add up to the vulnerability. Stress is defined as a negative concept that can have an impact to ones physical and mental wellbeing. People as complex unique individuals can be the only one who can define stress. Stress can make or break a persons wellbeing. Minor hassles can also add up to stress and it can put our body at increased risk of numerous health problems including heart disease, digestive problems (e.g. irritable bowel syndrome), sleeping problems, depression and obesity. Thats why it is very important to learn healthy ways to cope with the stressors in our life. (MFMER, 2010)

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Overview of Chronotype Chronotype is used to characterize a persons sleep patterns. The two types of chronotypes are morning and evening. Chronotype appears to have a role in persons more general physiology, whether one is a morning or evening person it influences the sleep pattern. It also contributes to the cause of sleep reduction of one person. Chronotype may also change depends on the lifestyle of a person, when he refers to sleep and when ones energy is at full. (Smith and Bronwyn 2012) Mall establishments hire employees who are active early in the morning until late at night. The employees are divided into two, the opening and the closing. The opening is the workers whose shifts are early in the morning until afternoon; the closing workers start their shift late afternoon until late at night. They have to be alert during the phase where in they are interested in relaxing and preparing to sleep. Although an individual has difference in preference of sleeping and wakefulness schedule, night sleep is the ones appropriate to be followed because it is what the human species are intended to be scheduled. (Gamud and Mendoza 2012) Munich Chronotype Questionnaire (MCTQ) Self-rated scale to assess individual phase of entrainment on work and work-free days, developed in ages 6 to > 65 years ; tool to collect primary sleep times, such as bed- and rise-times, plus the clock time of becoming fully awake as well as sleep latency and inertia, in addition to other time points and rate themselves as one of the seven chronotypes (J Biol 2006) Morningness Eveningness Questionnaire (MEQ) Assess morningness and

eveningness of a person. Questions are framed in a preferential manner, where the respondent is asked to indicate when, for example, he/she would prefer to wake up or start sleep, rather than when he/she actually does. (ibid)
MEQ Scoring

16 - 30 Defenitive evening

31 - 41 Moderate evening

42 58 Intermediate

59 - 69 Moderate morning

70 86 Definite morning

Sleep and Wake up time for each Chronotype

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Score

16-30 Definite evening 2:00-3:00 AM (2:00-3:00h)

31-41 Moderate Evening 12:45-2:00 AM (00:45-2:00h)

42-58 Intermediate Morning 10:45-12:45 PM (22:45-00:45)

59-69 Moderate Morning 9:30-10:45 PM (21:30-22:45h)

70-86 Definite Morning 9:00-9:30 PM (21:00-21:30h)

Sleeping time

Shift Work System Shift work is defined as a method of organization of working time in which workers succeed one another at the workplace so that the establishment can operate longer than the hours of work of individual workers. The types of shift work are permanent, continuous or discontinuous, and with or without night work. Permanent shifts have regular, consistent one shift. Continuous shift covers the whole week while discontinuous have interruptions. The schedule of work of with or without night work can vary considerably (International Agency for Research on Cancer, 2010).

Frank Scheer PhD, a neuroscientist at Harvard Medical School and Brigham and Women's Hospital in Boston said that, "There is strong evidence that shift work is related to a number of serious health conditions, like cardiovascular disease, diabetes, and obesity," as stomach problems, depression, and an increased risk of accidents or injury also to be considered in connection to shift work. The main effect of shift work on the body is the interruption in the circadian rhythm. Circadian rhythm is defined as the pattern of physiological processes in a near 24-hour period cycle, and disrupting it causes negative effects on the body.

Short term effects of shift work on the health of a person are similar to changes that occur when a person experiences sleepless nights or sleep disturbances such as gastrointestinal symptoms, insomnia, and feeling of being unwell. These effects cause little alarm but shift work have long term effects also such as cardiovascular diseases, diabetes and metabolic syndrome, obesity, depression and mood disorders, gastrointestinal problems, problems in fertility and pregnancy, and even cancer.

Shift work interrupts the circadian rhythm that causes metabolic and hormonal changes. One significant change is the decrease in the amount of leptin, a hormone that controls appetite

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and satiety. The decrease in amount of leptin levels increases appetite and decreases activity levels that can, later on, lead to obesity and cardiovascular problems.

The research conducted by Dr. Scheer also showed that circadian misalignment can increase the risk for high blood sugar or development of diabetes.

Other effects of shift work to the performance of the workers may include reduced productivity, increase in errors, and absenteeism and presenteeism or being present at work but not functioning well because of conditions or issues.

The effects of shift work may sound distressing. In order to prevent these, workers can change their lifestyle by eating well and doing exercise to keep healthy, getting enough sleep, changing their schedule by changing how they work at night, and seeing your doctor for any suggestions that can help in the issue of disturbed sleeping pattern and in monitoring the health status and providing immediate action for any health issues and concerns. (Griffin, R. M., 2005)

Perceived Health Status: Perceived health status is a subjective overview of the health of an individual. The selfassessment of an individual is important key in identifying their health status. (qol.thoracic.org, 2007) There are several factors to be considered for an individual to identify his or her health status. Some of these factors are age, gender, income, and education (statcan.gc.ca, 2010) Short form 36 Health Survey or SF36 is a survey done by RAND Corporation to attain the measure of health status. This survey consists of eight scaled scores including vitality, physical functioning, bodily pain, general heath perceptions, physical, emotional, and social role functioning, and mental health. (Wales, J., 2012) With more than 76, 000, 000 surveys taken and over 19, 000 licenses issued to date, the SF Health Surveys are the most widely used tools in the world for measuring patient-reported outcomes. (qualitymetric.com, 2012)

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Taking into consideration the health perception of mall workers is important in identifying how they can manage their health in relation to their work. Their perceived health status can also be a contributor on their current or possible health conditions.

Definition of terms: Shift Work- is the arrangement of the scheduled time of shift of employees to maximize the operating time without extending the regular number of hours that the employees should work. Lifestyle- involves physical activities, exercise, nutrition, and vices. Perceived Health Status- is the subjects insight regarding his or her health condition. Chronotype This reflects at what time of the day their physical functions are active. This will tell whether the respondents are under definitive evening, moderate evening, intermediate, moderate morning or definitive morning types. Demographic Data This is inclusive of the respondents age, gender, marital status, religion and location.

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CHAPTER 3: Methodology

Research Design
The research study generally utilized Correlational Quantitative design to know the effects of the mall employees shift work to their lifestyle and health status.

The researchers will interview a group of respondents which is the regular mall employees who are in the range of 21 to 35 years old, both male and female, and are working for at least 6 months. They will be interviewed to get a number of information about their shift, their lifestyle, if they are encountering health problems, and health complaints that they had during work. All of the respondents are different in terms of their jobs in the malls. At the end of the interviewing part, we will find the relationship between their shift work and their health complaints or lifestyle.

Questionnaires will be distributed to assess their chronotype which may be definite morning, moderate morning, intermediate, moderate evening or definite evening types. This
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study is efficient to quantify those who fall under each category. This study will be used to determine the frequency of each category.

Research Locale
The researchers will conduct the study in three different malls in Metro Manila particularly in Quezon City, Makati City and Mandaluyong City. These places have been the center of developed commercial industry in the country. Therefore, these places have more jobs to offer. More population results in being susceptible to diseases

Research Participants
Two hundred (200) shift workers currently employed in a mall particularly guards, saleslady, retail, cinema and food workers it will consists of non-contractual shift workers who have working experience for at least six months at the mall. The target population is mall shift workers. Upon selecting the sample population, purposive sampling will be done. The criteria for the mall shift workers are within the age group of twenty-one (21) to than thirty-five (35) years with at least six months of work experience for non-contractual mall shift workers regardless of the gender, civil status and educational attainment.

Research Instrument
In this research, four (4) types of questionnaire will be used to be able to collect the necessary information. The use of Morningness-Eveningness Questionnaire (MEQ), Short Form 36 (SF36), and questionnaire about the lifestyle and demographic data of the respondents will be utilized. Morningness-Eveningness Questionnaire (MEQ) will be used in this research. This questionnaire is often reffered to as chronotype that discusses about the preference in sleep timing of an individual (Mongrain et al, 2006). Morningness - eveningness refers to the individual differences in daily preferences, sleep-wake pattern for activity, and alertness in the morning and evening (Susman et al., 2007). It consists of twenty-six (26) questions that will be scored to determine the preferred time to wake up or sleep of a person. The researchers will also use Short Form 36 (SF36). SF36 is used to determine the perceived health status of an individual. It generates 8 subscales. The 8 subscales are: physical
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functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role-limitations due to emotional problems, and mental health (LaRocca, 2011). Questionnaire about the lifestyle of the respondents will also be used. It will include questions about their diet, physical activity, their stress management, vices, and how they manage their weight. Demographic questionnaire will include the name of the respondent which is optional, their location or city they are at, age, and their civil status. And some questions about their work will also be included in this questionnaire.

Data Gathering

Production of Questionnaire and Criteria for the interview

Validation of the research tool

Obtain the Collages approval to conduct the study

Obtain Permission to the authorities of the mall

Data gathering

Analysis of the data gathered

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Data Analysis
The collection of the data acquired will be tabulated and analyzed through the use of one way-ANOVA. Cross-tabulation with Pearson R will also be utilized to find out the connection or interrelation among the variables being tested in the study. As for the interview, its open-ended content will be analyzed and interpreted systematically and summarized

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