Introduction

The leather industry is a vital component of Bangladesh’s economy, generating significant export earnings and employing hundreds of thousands of workers directly and indirectly1. Bangladesh is among the world’s top exporters of leather and leather products, with tanneries concentrated in the Hemayetpur Tannery Industrial Estate in Savar, Dhaka2,3. While the sector is economically important, it is also recognized as one of the most hazardous occupational settings, primarily due to the heavy reliance on chromium-based tanning and the extensive use of chemicals such as formaldehyde, sulfuric acid, and ammonia4,5. Prolonged exposure to these substances has been linked to multiple adverse health outcomes, including skin diseases, respiratory problems, eye disorders, gastrointestinal issues, and musculoskeletal complications6,7.

Globally, tannery workers are considered a high-risk occupational group. Epidemiological studies from South Asia, Africa, and Latin America have consistently reported a higher prevalence of occupational health problems among this group than among workers in other manufacturing sectors8,9. For instance, research in India and Pakistan revealed elevated cases of respiratory illness, dermatitis, and chemical intoxication among tannery workers due to prolonged contact with chromium and other hazardous compounds10,11. Similar findings have been reported in Bangladesh, where between 30% and 50% of tannery workers suffer from skin and respiratory conditions, figures substantially higher than national averages for comparable industrial laborers12,13.

In Bangladesh, occupational risks are further compounded by structural and institutional weaknesses. Many workers have low levels of education, with a substantial proportion lacking formal schooling, which restricts their ability to understand hazard information or adopt safe practices4,14. Although occupational health and safety (OHS) training is mandated, coverage remains irregular and inadequate, especially among contractual or temporary workers. Personal protective equipment (PPE) is often unavailable, poorly maintained, or inconsistently used due to discomfort, lack of knowledge, or weak enforcement of safety protocols15,16. These gaps contribute to a cycle of unsafe practices, elevated exposure, and preventable illness among tannery workers.

Another critical barrier is the weak safety culture within the tannery sector. Studies indicate that management frequently underprioritizes occupational safety, leaving workers uncertain about their employer’s responsibility for health protection and reluctant to report hazards4,17. While many workers recognize that tannery work carries serious health risks, awareness has not consistently translated into protective behavior due to systemic challenges, economic pressures, and lack of empowerment18,19. Furthermore, very few workers are aware of government safety regulations, highlighting a disconnect between policy frameworks and workplace realities12.

Despite the well-documented hazards, limited research has systematically examined how sociodemographic characteristics, workplace practices, attitude, and knowledge influence workers’ own perceptions of occupational health risks in Bangladesh’s leather sector. Much of the literature has emphasized environmental contamination or community impacts of tanneries, with fewer studies focusing directly on workers’ concerns and their determinants. Understanding these perceptions is vital, as workers who are more concerned about health risks are often more likely to adopt protective behaviors, advocate for safety improvements, and utilize healthcare services20,21.

This study addresses this gap by investigating the factors associated with occupational health concerns among tannery workers in Bangladesh. To strengthen the conceptual foundation of this study, we adopted the Knowledge, Attitude, and Practice (KAP) framework, a well-established model for examining how workers’ knowledge, attitude, and practices interact to shape occupational health outcomes22,23,24,25,26. Applying the KAP framework enables the study to move beyond descriptive associations by providing a structured explanation of the cognitive and behavioral determinants of health concern. This theoretical grounding fills a gap in the existing literature from Bangladesh, India, and Pakistan, where studies have primarily focused on documenting health effects rather than understanding the underlying behavioral mechanisms that shape health concerns.

Drawing on data from workers at the Savar Tannery Industrial Estate, we examined how sociodemographic, knowledge-related, attitude, and practice variables influence workers’ concerns about health risks. By identifying the factors of concern, the study provides evidence to inform targeted interventions to improve occupational health awareness, promote safe practices, and strengthen workplace safety culture in one of Bangladesh’s most hazardous yet economically significant industries.

Conceptual framework

The KAP model provides the conceptual basis for this study22,23,24,25,26. The Model proposes that workers’ health behaviors arise from an interconnected progression: knowledge about hazards influences attitudes toward risk, which, in turn, shape safety practices. In the tannery context, knowledge includes awareness of harmful chemicals, safety guidelines, and PPE use; attitude includes perceived severity of occupational hazards and health concerns; and practice relates to the application of protective behaviors, such as PPE use and hygiene routines. By structuring the analysis within the KAP framework, the study offers a theoretically grounded assessment of how informational, perceptual, and behavioral factors collectively determine health concern. It represents a conceptual advance over other studies8,9 to explain occupational health perceptions.

Methods

Research design

This cross-sectional study was performed at the Bangladesh Small and Cottage Industries Corporation (BSCIC) Tannery Industrial Estate in Hemayetpur, Savar, Dhaka. The estate serves as the country’s primary center for leather processing and contains several tanneries involved in extensive chromium-based tanning operations3. This location was chosen because tannery workers have significant occupational exposure to hazardous compounds, such as chromium and other heavy metals, making it a suitable site for evaluating occupational health risks. The research focused on adult tannery workers (aged 18 and older) involved in tanning, chemical handling, or operating associated equipment.

Figure 1 shows the flow chart of the research design. The flow-chart begins with the identification of the research problem and existing gaps, followed by the development of the conceptual framework that guided the study. It then outlines the preparation and validation of survey instruments, including expert review. The next stage depicts the sampling strategy and field survey implementation at the BSCIC Tannery Industrial Estate. It is followed by data cleaning and processing, which ensures accuracy and reliability before analysis. The flow-chart also illustrates the statistical procedures applied, including descriptive statistics and both stepwise and hierarchical ordinal logistic regression conducted in R. Finally, the diagram shows the integration of results and the subsequent preparation of the manuscript. This visual representation enhances clarity and transparency, enabling readers to easily follow the methodological progression from conceptualization to analytical interpretation.

Fig. 1
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Flow-chart illustrating the sequential stages of the research design.

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Survey tools

The survey items were grounded in an extensive review of published literature on occupational health risks, worker perceptions, and KAP-based assessments in high-risk industries13,18,19,27,28,29,30,31. Relevant peer-reviewed studies from Bangladesh and comparable industrial contexts guided the development of questions on chemical exposure, PPE use, safety practices, and health concerns. The preliminary questionnaire was developed in both Bengali and English using KoboToolbox32. The draft was pre-tested through a pilot survey, and the pilot results were excluded from the final analysis. In addition, we have calculated the Cronbach alpha value for the KAP section. All sections show an alpha value greater than 0.60. A Cronbach alpha greater than 0.60 indicates reliable internal consistency in the questionnaire33,34. The face-to-face survey was conducted in Bengali and focused on factors that might influence self-reported health concerns. The questionnaire consisted of five sections. The first section gathered sociodemographic and workplace characteristics information from respondents. The second section addressed knowledge of health risks and safety practices, while the third section explored respondents’ attitudes. The fourth section examined workplace safety and health practices, and these four sections were treated as independent variables. The final section, which served as the dependent variable, included the question: “How concerned are you about your health due to tannery work?” with the response options (Very concerned/Somewhat concerned/Not concerned).

Data management

The study was done from June to July 2025. Employees were approached during breaks or at convenient spots within the estate. A probability-based sampling design was not feasible due to restricted access to several tannery buildings, variability in shift schedules, and management-imposed entry limitations. Therefore, a non-probability sampling strategy, combining convenience and snowball techniques, was used to recruit workers who were present and willing to participate during data collection hours. Worker availability varied considerably by department and shift; therefore, recruitment occurred across multiple sites and shifts to improve demographic representativeness. About 456 workers were approached, of whom 400 completed the survey, yielding a response rate of 87.7%. To enhance representativeness, participants were recruited from all major operational units. Although proportional sampling by site size was not possible, we ensured that no single department dominated the sample. Despite these precautions, potential selection bias cannot be completely ruled out, and we have acknowledged this limitation. The sample size for this self-reported study was determined using Morgan’s Table35. Morgan’s table is widely used for sample size determination and provides a statistically appropriate sample size based on a known population. In this study, Morgan’s table indicated that a minimum of 384 participants was required to achieve a representative sample with 95% confidence; therefore, our final sample of 400 workers exceeded this threshold, ensuring adequate statistical power. To ensure data quality, missing values, inconsistencies, and outliers were systematically addressed. Missing responses were checked immediately during field data collection, and incomplete surveys were excluded before data entry. After entry, data were screened for logical inconsistencies, which were corrected using field notes or removed when verification was not possible. Outliers were carefully checked, and values determined to be non-plausible or due to data-entry errors were corrected or omitted. These procedures ensured that the final dataset was clean, reliable, and ready for statistical analysis.

We used the ‘R’ program, version 4.2.236, for statistical analysis. Descriptive statistics have been calculated when necessary. A stepwise ordinal logistic regression model was used, and a hierarchical ordinal logistic regression analysis was conducted to determine the factors influencing the dependent variable. The study objectives justified the use of both stepwise and hierarchical modeling approaches. Stepwise regression was employed to identify the most parsimonious set of predictors based on statistical contribution to the Model, thereby minimizing overfitting and improving interpretability in the presence of numerous categorical variables. Hierarchical modeling was used to examine the incremental effect of conceptually grouped predictors (sociodemographic, knowledge, attitude, and practice factors) on workers’ health concern levels, allowing assessment of theoretical model-building progression and improvement in Model fit at each stage. Together, these complementary approaches provided a rigorous and transparent analytic framework consistent with the study’s conceptual design. Similar analytical approaches have been widely used in other high-risk, labor-intensive sectors, further supporting the appropriateness of ordinal logistic regression for this study28,37,38,39. These studies demonstrate that logistic regression is a well-established, robust method for examining multilevel predictors of health concern and safety behavior in physically demanding and hazardous industries. Therefore, its use in the present research aligns with methodological standards in high-quality occupational health literature and enhances the reliability and comparability of our findings.

All key assumptions of ordinal logistic regression were examined before model interpretation. The proportional odds assumption was assessed using the Brant test, which indicated no violation (p = 0.45). The overall Model satisfied the proportional odds assumption, supporting the use of the proportional odds framework. Multicollinearity was evaluated using generalized variance inflation factors (GVIFs), and all adjusted GVIFs were below 2, indicating no problematic multicollinearity among predictors. Model fit was assessed using the Akaike Information Criterion (AIC), pseudo-R² indices, and the likelihood ratio test. The final Model demonstrated strong fit (AIC = 397.32; BIC = 537.02), with substantial explanatory power (McFadden R² = 0.584; Cox–Snell R² = 0.683; Nagelkerke R² = 0.794), and significantly improved fit (p < 0.001).

Results and discussion

Sociodemographic and workplace characteristics

Table 1 presents the sociodemographic and workplace characteristics of tannery workers. The tannery workforce is predominantly young, with 44.8% aged 18–30, indicating that the industry is a significant source of employment for younger individuals. National surveys of the Bangladeshi leather industry consistently report a workforce dominated by young workers: 66% of surveyed tannery workers are aged 18–35, and virtually none have formal training or a high school education. It suggests that the sector attracts youth with limited alternative employment opportunities and inadequate skills development4,14. Comparable studies confirm that approximately one-third (33%) of tannery personnel in Bangladesh belong to the 19–30 age group, reinforcing the industry’s role as an entry point for young labor migrants seeking urban employment14.

The predominance of male workers (82%) in Bangladeshi tanneries reflects persistent gender disparities across the country’s formal industrial sectors, where male participation typically exceeds female participation, and women’s access is limited by both social norms and workplace conditions40. Reasons for this imbalance in tanneries include the physical demands of the work, employers’ reluctance to grant maternity leave, and inadequate facilities for women, such as a lack of separate toilets and child care support. These barriers not only discourage female participation but also result in a highly masculinized labor force, unlike the ready-made garment sector, which has seen a recent rise in female employment4,41,42.

Regarding education, low attainment is evident: 24.5% of tannery workers have no formal schooling, and only 39.8% have completed primary education. This finding is consistent with other studies conducted on tannery workers in Bangladesh, which reported that 45% had primary-level education14. This education deficit is significant because it restricts workers’ ability to understand and adopt safe practices, thereby heightening their vulnerability to occupational health risks. Studies have linked lower educational backgrounds to reduced knowledge of chemical hazards and a higher likelihood of skin diseases, respiratory problems, and injuries among tannery workers4,5,14.

A significant portion (46.8%) of workers have 1–5 years of industry experience, indicating high turnover, while only 9.3% have over 10 years of experience. It may reflect the harsh working conditions and low wages that discourage long-term employment. Moreover, many workers are married (66%) and live with their families (61%), indicating financial pressures that may prevent them from reporting health issues. The occupational distribution, where 29.3% engage in leather processing and 27% in chemical handling, directly connects to major health hazards documented in both clinical and epidemiological research. Tannery work is associated with intense exposure to heavy metals (notably chromium), organic solvents, and dust, resulting in elevated rates of skin diseases, respiratory problems, headaches, and eye disorders6,7,12. Chronic conditions stem from inadequate use of PPE and lack of safety training, compounding risks for both acute intoxication and long-term illnesses. Notably, 29.8% of workers reported experiencing health issues related to their work, emphasizing the occupational health hazards present in the industry. Other field studies have revealed that 31–51.6% of tannery staff experience occupational skin diseases, and 44% suffer from respiratory complaints, figures far higher than in other manufacturing sectors6,7,12. These results illustrate the need for urgent improvements in industrial safety, wage security, and access to healthcare to reduce health vulnerability among tannery laborers in Bangladesh. Although 76.8% of tannery workers report receiving OHS training, its effectiveness is undermined by its irregularity and by the 23.3% who are entirely untrained. Multiple studies confirm that training programs in Bangladesh’s leather sector are inconsistent, often missing large segments of temporary or contractual laborers who are most vulnerable to accidents and chemical exposures12,27. Further, the content and delivery of OHS education do not always adequately address key hazards or reinforce proper PPE use, resulting in suboptimal knowledge and behaviors, even among “trained” workers.

Table 1 Sociodemographic and workplace characteristics of tannery workers (n = 400).
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Knowledge of health risks and safety practices

Table 2 presents knowledge of health risks and safety practices among tannery workers. The finding that 79.3% of tannery workers are aware of health risks reflects moderate advancement in occupational health education, likely aided by targeted interventions and peer learning in Bangladesh’s leather sector43. Workers’ identification of skin diseases (36.8%) and respiratory issues (22.5%) as primary hazards is well supported by epidemiological data: most tannery workers in Bangladesh reported skin diseases and respiratory symptoms (including asthma, chronic cough, and infections)5,7,13,18. However, knowledge alone has not translated into reduced illness or the adoption of safe practices, partly due to gaps in safety training, limited access to protective equipment, and weak enforcement of occupational health standards. Across South Asia, similar trends persist; workers in tanneries consistently identify skin and respiratory complaints as the most common threats, yet report difficulty accessing preventive resources or formal care for occupational illnesses8,44.

Many tannery workers are aware that tannery chemicals pose health risks, but a significant number (41.5%) remain unclear about which specific chemicals are harmful. Among the most commonly identified hazardous substances are ammonia, chromium, and formaldehyde, all of which are prevalent in tannery operations12,16. A large proportion (57%) of workers believe that both inhalation and skin contact contribute to health risks, and 63.8% are aware of the necessary safety measures for handling hazardous materials. However, a significant number of workers (33.5%) are not aware of the proper use of PPE. This knowledge gap likely contributes to inadequate protection against toxic exposures, as PPE use is often inconsistent or improper despite moderate knowledge of chemical hazards. The findings underscore the critical need for improved, focused training programs to increase specific chemical hazard recognition and correct PPE utilization among tannery workers in Bangladesh.

Knowledge of first aid procedures and emergency contacts is relatively high, with 64.3% and 75% of workers, respectively, reporting knowledge in these areas. However, the fact that an overwhelming 93.8% of workers are unaware of government safety regulations highlights a significant gap in worker education and empowerment regarding their legal rights and workplace protections. Regarding PPE, boots (29.3%) and face masks (18.3%) are considered necessary by many workers, whereas fewer acknowledge the need for gloves and goggles. This uneven perception of PPE importance likely reflects limited training content and resource availability, contributing to inconsistent PPE use and increased vulnerability to health hazards.

Table 2 Knowledge of health risks and safety practices among tannery workers (n = 400).
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Attitude regarding occupational health risk

Table 3 presents attitudes toward occupational health risks among tannery workers. When asked about the seriousness of occupational health risks in the tannery, 79.3% of workers acknowledged them as extremely serious. This recognition of danger indicates that most workers are conscious of the hazardous conditions inherent in tannery work6,18. Despite this knowledge, the perception that safety measures are insufficient (52%) indicates widespread dissatisfaction with the protection actually provided in their workplaces. This gap between knowledge and effective safety implementation points to systemic weaknesses in enforcing occupational health standards and providing adequate safety equipment4,12.

Furthermore, with 58.5% of workers uncertain whether management prioritizes safety, there is evident mistrust or a communication breakdown between workers and employers regarding commitment to health and safety. This uncertainty undermines attitudes and underscores the need for stronger management accountability, transparent safety policies, and greater worker engagement in safety programs within Bangladesh’s tannery sector. Many workers (44%) regarded PPE as very important for protecting their health, while 46.8% considered it somewhat important. Most workers (71.5%) believe that following safety protocols can reduce health risks, and a majority (73%) expressed willingness to participate in additional health and safety training. However, a smaller proportion (39.5%) believes that their employer is fully responsible for ensuring workplace safety, while a substantial number (40.3%) feels that workers’ rights are not adequately protected in the tannery.

Table 3 Attitude towards occupational health risk (n = 400).
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Workplace safety and health practices

Table 4 presents the safety and health practices among the tannery workers. The use of PPE among workers varies significantly, with only 38.5% always using it while working. A significant portion (33.8%) use it sometimes, while 22% use it rarely. This partial and inconsistent use of PPE aligns with other research findings showing that many tannery workers do not regularly use gloves, masks, boots, or goggles, thereby increasing their exposure to chemical and physical hazards15,27. Many workers (58.8%) adhere to safety guidelines while handling hazardous materials, but 30% report doing so only sometimes. It indicates incomplete compliance, which may be due to inconsistent training, resource constraints, or a negative workplace culture. Despite these safety measures, 42.5% of workers reported not receiving proper medical assistance for work-related health issues, underscoring significant deficiencies in occupational health support and access to care5,15. Washing exposed skin after work, particularly handwashing, is practiced regularly by 49.3% of tannery workers, while 17.8% wash their hands rarely, indicating varying levels of basic hygiene. However, more comprehensive measures to prevent exposure to toxic substances are largely neglected, as 71.8% of workers do not take additional precautions, pointing to gaps in protective behavior beyond simple washing.

Regarding health monitoring, the majority (64%) only seek health check-ups when symptomatic, suggesting limited proactive health surveillance and potential delays in identifying occupational illnesses early. When feeling unwell due to workplace exposures, 58.3% report to supervisors and leave work, demonstrating some adherence to safety protocols but possibly taking reactive rather than preventive actions. Notably, 60.5% have refused to work under unsafe conditions, indicating significant worker concern and activism regarding their health and safety rights, reflecting both the hazardous nature of their work and a willingness to assert their right to safe employment. These behaviors underscore the crucial importance of enhancing attitude and ensuring accessible healthcare services in the tannery sector. This result highlights key issues, including the lack of attitude, inconsistent PPE usage, and the need for more comprehensive training and health monitoring to protect tannery workers from occupational health risks. Addressing these challenges could improve both workforce health and productivity.

By interpreting these findings through the KAP framework, this study demonstrates that health concerns among tannery workers are shaped not only by exposure-related factors but also by knowledge deficits, attitudinal dispositions toward safety, and actual workplace practices. This theoretically informed interpretation extends prior research from Bangladesh, India, and Pakistan, which has primarily focused on documenting health conditions without examining the behavioral mechanisms that influence workers’ health concerns.

Table 4 Workplace safety and health practices (n = 400).
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Concern regarding health

In Fig. 2, the health risks associated with tannery work were assessed among workers. A significant proportion of workers (87.5%) reported some level of concern about the potential health impacts. Among these, 42.5% of the workers were very concerned, while 45% were somewhat concerned. Only 12.5% of workers reported being not at all concerned. These results suggest a widespread recognition of health risks among tannery workers. This concern can be linked to the well-documented health hazards tannery workers face, including exposure to hazardous chemicals, such as chromium, which is commonly used in the leather-tanning process6,8,12,44. Prolonged exposure to such chemicals can lead to a range of respiratory, dermal, and systemic health problems, as demonstrated in previous studies. The fact that most workers are concerned about health risks aligns with the existing literature, which emphasizes the high rates of occupational diseases in this industry, particularly respiratory issues and skin conditions6,8,12,44. Additionally, studies have shown that inadequate protective measures and insufficient knowledge of risks exacerbate these health concerns45.

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Concerned regarding health due to tannery work (n = 400).

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Associated factors

In Table 5, the stepwise backward ordinal logistic regression model revealed several significant factors influencing concern about health risks. For sociodemographic factors, male workers were significantly more likely to express concern about health risks compared to female workers, with an adjusted odds ratio (aOR) of 2.05 (p = 0.01; CI: 1.19–3.52). It means male workers are more than twice as likely to be concerned about the potential health risks in their work environment. These findings are consistent with previous studies that have highlighted gender-based differences in perceptions of occupational health20,46. Studies in Pakistan, where men dominate tanning roles involving liming, dehairing, and chrome tanning, also document higher concern and higher respiratory problems among male workers47. These findings are reinforced by work from India showing that male tannery workers in Kanpur experience significantly higher chromium exposure and morbidity, suggesting that gendered exposure differences drive heightened health concern48. This pattern aligns with risk-perception theory, which suggests that individuals more frequently exposed to hazards generally show heightened concern. Individuals who are more regularly exposed to hazards or have direct experience with them tend to perceive greater risk and express heightened concern. Research demonstrates that personal experiences with hazardous events, such as disasters or occupational incidents, significantly increase individuals’ awareness and concern for those risks, impacting their attitudes and behaviors toward safety and adaptation49,50. In Bangladesh’s tanneries, an overwhelmingly male-dominated, physically demanding, chemically intensive environment, men typically undertake high-exposure tasks (e.g., processing, chemical mixing). From a psychosocial perspective, these roles reinforce a “risk awareness norm,” making male workers more attuned to immediate and long-term health risks. In contrast, women, often assigned administrative or lighter tasks, may experience lower direct exposure and therefore lower perceived risk. Additionally, cultural norms that encourage men to self-evaluate the risks they face may amplify their expressed concern.

Workers with more than 10 years of experience in the tannery industry were significantly more likely to express concern about health risks, with an aOR of 3.37 (p = 0.033; CI: 1.10–10.29). This finding suggests that long-term exposure to the tannery environment, with its associated chemical and physical risks, increases knowledge of potential health complications6,31. Workers with more experience may have observed or personally experienced the cumulative effects of prolonged exposure, making them more aware of the importance of maintaining their health. It aligns with core constructs in KAP and Protection Motivation Theory51.

Married workers were also more likely to be concerned about health risks compared to their unmarried counterparts, with an aOR of 1.61 (p = 0.039; CI: 1.02–2.53). It suggests that married workers may have a heightened concern for their long-term health due to their familial responsibilities. Being married may increase the sense of responsibility towards one’s spouse and children, prompting a stronger recognition of health risks to safeguard their well-being21.

In terms of knowledge, workers who were aware of the health risks associated with tannery work were significantly more likely to be concerned, with an aOR of 2.75 (p = 0.022; CI: 1.16–6.55). Additionally, workers who knew which chemicals in tanneries could harm their health were more likely to express concern (aOR = 2.90, p = 0.00; CI: 1.35–6.23). This relationship highlights a broader body of evidence showing that knowledge, including specific chemical knowledge, is pivotal for worker concern and the adoption of protective behaviors in hazardous occupational settings15,19. These findings align with the KAP model, in which knowledge serves as the cognitive foundation for risk appraisal. The psychometric paradigm also suggests that individuals who understand “dread factors” such as toxicity, carcinogenicity, and invisibility of chemicals perceive greater personal danger, which directly elevates concern.

Workers who had no idea how chemicals affect their health were less likely to express concern, with an aOR of 0.27 (p = 0.002; 0.11–0.63). Tannery workers experience health problems from handling chemicals. For instance, a study conducted in Dhaka, Bangladesh, documented a high prevalence of health problems among tannery workers, including musculoskeletal diseases (65.5%), gastrointestinal issues (38.9%), skin diseases (37.9%), respiratory diseases (26.6%), and eye diseases (17.7%)16. Knowledge about proper PPE use also contributed to concern, with workers who were aware of its use being more likely to be concerned (aOR = 3.17, p < 0.001; 1.61–6.24). Knowledge of PPE not only increases awareness of hazards but also enhances “risk controllability perception.” Workers who understand proper PPE use are better able to assess whether they are adequately protected, often leading to concern when they realize that protective practices are inconsistent or insufficient. Our results echo the evidence that limited chemical hazard knowledge and inadequate PPE use remain challenges in the sector, contributing to these health outcomes. Similar studies highlight that workers with greater health risk knowledge and PPE training are more concerned about their health risks, which often translates into increased adoption of protective measures16,19,27. Despite knowledge of hazards, PPE use remains insufficient due to factors such as limited access, discomfort, or inadequate training, underscoring the need for targeted interventions that address workers’ practical and educational needs10.

Similarly, those who knew who to contact in case of an emergency were more likely to show concern (aOR = 3.22, p = 0.002; CI: 1.54–6.74). In terms of emergency preparedness, knowledge of whom to contact in case of chemical exposure or emergencies significantly increases concern and may improve response behaviors. This observation aligns with sector-wide calls for strengthened health and safety systems, including clear emergency protocols, regular health surveillance, and accessible occupational health services13.

Regarding attitude, workers who believed that occupational health risks in tanneries were extremely serious were significantly more likely to be concerned, with an aOR of 18.07 (p = 0.001; CI: 3.40–96.12). Workers who believed that following safety protocols could reduce occupational health risks were also more likely to express concern (aOR = 17.68, p < 0.001; CI: 3.59–87.08). These findings strongly support our conceptual framework, which highlights perceived severity and perceived efficacy as major determinants of health concern. In environments where risk is high and protective measures can be effective, these attitudinal factors can strongly influence workers’ willingness to adopt safety practices or demand better protective measures, highlighting the policy importance of both raising awareness and ensuring the practical efficacy and availability of PPE and protective protocols16,30.

Our study’s findings on the strong association between attitude and health concern among tannery workers are consistent with studies from other industrial contexts globally. Research indicates that a positive attitude, characterized by shared values and behaviors that prioritize safety, plays a crucial role in reducing workplace injuries and enhancing employee health and well-being52. Furthermore, an effective attitude is linked to improving employee satisfaction, engagement, and retention, which collectively boost workplace productivity. Studies indicate that attitude improvements require continuous safety training, management support, supervision, and the provision of comfortable, adequate PPE17,53.

Behavioral factors such as PPE usage were strongly associated with concern. Workers who never or rarely used PPE were less likely to express concern about health risks, with aORs of 0.11 (p = 0.005; CI: 0.02–0.52) and 0.32 (p = 0.001; CI: 0.16–0.64), respectively. Similarly, workers who rarely or sometimes washed their exposed skin after work had lower odds of being concerned about their health, with aORs of 0.03 (p < 0.001; CI: 0.01–0.08) and 0.10 (p < 0.001; CI: 0.05–0.21), respectively. Workers who only received health check-ups when they felt sick were more likely to be concerned (aOR = 2.07, p = 0.005; CI: 1.24–3.45). These findings are corroborated by research in Bangladesh and other similar settings, where inadequate PPE use and poor hygiene have been linked to lower health concerns among tannery workers11,19. Moreover, PPE quality itself is a concern in South Asian industries; protective clothing in Pakistan has been shown to fail basic chemical-resistance standards, potentially reducing workers’ trust in PPE and lowering perceived control54. Awareness and PPE compliance directly influence workers’ perceived health risks by shaping how they evaluate the likelihood and severity of occupational hazards. Higher awareness enhances recognition of exposure pathways and their long-term consequences, leading to greater perceived risk and more consistent use of protective equipment. Conversely, inconsistent PPE use and poor hygiene practices often indicate an underestimation of hazards, reflecting gaps in training or normalization of unsafe behavior. In many low-resource settings, the predominance of reactive rather than preventive health check-ups further underscores reduced health concern and limited institutional support for occupational health monitoring. Together, these patterns show that health concern is strengthened when workers understand hazards and translate that understanding into protective behavior, while low awareness and irregular PPE adherence signal diminished perceived vulnerability.

In Table 6, the hierarchical multiple ordinal logistic regression model provided additional insights into the factors predicting health concern. Sociodemographic factors continued to show significant results. In Model I, workers with more than 10 years of experience in the tannery industry were significantly more likely to express concern. In the case of Model IV, married workers were also more likely to be concerned (aOR = 5.38, p < 0.001; CI: 2.80–10.36). Knowledge of health risks remained a significant predictor of concern. Workers who were aware of the harmful chemicals used in tanneries had significantly higher odds of concern (aOR = 6.76, p < 0.001; CI: 2.92–15.60). Those who knew how to use PPE also had higher odds of being concerned (aOR = 3.12, p < 0.05; CI: 1.23–7.88). Across all model levels, the persistence of knowledge and attitude variables demonstrates a theoretically coherent pathway where knowledge shapes attitudes, and attitudes shape concern, consistent with the sequential logic of the KAP model.

The belief that occupational health risks in tanneries were severe remained a significant predictor. Workers who believed that following safety protocols could reduce health risks were very likely to be concerned (aOR = 80.15, p < 0.001; CI: 43.01–149.29). It suggests a strong cognitive-emotional appraisal of risk severity, reinforcing the idea that health concern is not merely statistical but deeply shaped by belief systems and workplace experiences55,56. Regarding behavioral factors, workers who rarely or sometimes washed their exposed skin after work were also less likely to express concern about health risks, with aORs of 0.04 (p < 0.001; CI: 0.01–0.20) and 0.27 (p < 0.01; CI: 0.10–0.70), respectively. It again supports the behavioral attenuation, in which low perceived severity and low knowledge result in weaker protective behaviors and lower expressed concern57,58.

These findings underline the importance of knowledge, attitude, and practices in shaping workers’ concerns about the health risks associated with their work in tanneries. Interventions aimed at increasing knowledge, promoting PPE usage, and enhancing attitude could significantly reduce health concerns among tannery workers.

Table 5 Stepwise backward ordinal logistic regression model predicting concern about health due to tannery work (n = 400).
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Table 6 Hierarchical multiple ordinal logistic regression predicting concern about health due to tannery work (n = 400).
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Strengths and Limitations

This study is among the few to systematically examine occupational health concerns and their associated factors among tannery workers in Bangladesh, a group facing high exposure to chemical and physical hazards. A significant strength of the study is its relatively large sample size, which increases the robustness of statistical analyses and enhances representativeness across different tannery departments. The use of hierarchical and stepwise ordinal logistic regression models also allowed us to capture both individual-level and workplace-level influences on workers’ perceptions of health risks. Furthermore, the study design incorporated a structured, pre-tested questionnaire developed with input from occupational health experts, ensuring the data collection was contextually relevant and reliable.

Nevertheless, some limitations should be acknowledged. First, the study relied on self-reported data, which may be subject to recall bias or social desirability bias, particularly regarding health problems and safety practices. Because the study relies on perception-based responses, self-report bias may also affect how workers evaluate both their level of concern and their safety practices. Second, the cross-sectional design prevents causal inference between exposures and outcomes, so observed associations should be interpreted as correlational rather than causal. In addition, the possibility of reverse causality cannot be ruled out; for example, workers who are already highly concerned about their health may be more likely to report certain knowledge, attitudes, or practices, rather than these factors leading to greater concern. Third, convenience and snowball sampling were employed due to restricted access in certain tannery areas, which may limit the generalizability of the findings to the entire tannery workforce in Bangladesh. Additionally, the representation of tannery departments could not be matched to the population distribution in proportion due to operational constraints. These factors introduce potential selection bias, which should be considered when interpreting the findings. Fourth, the study focused on workers’ perceptions and self-reported health concerns rather than objective clinical or biomedical assessments; therefore, the actual prevalence of occupational diseases may be underestimated or overestimated.

Despite these limitations, this research offers novel insights into the interplay among sociodemographic factors, knowledge, attitudes, and practices that influence occupational health concerns among tannery workers. The findings highlight critical gaps in safety training, PPE usage, and enforcement of occupational health regulations, underscoring areas for policy and workplace interventions. By centering workers’ voices, this study provides urgently needed evidence to inform health promotion strategies and labor protections in one of Bangladesh’s most hazardous industries.

Conclusion

Grounding the analysis in the KAP framework allowed this study to demonstrate how knowledge gaps, attitudinal factors, and unsafe practices collectively shape workers’ concern about health risks, providing a behavioral explanation that goes beyond previous descriptive accounts in the regional literature. However, these findings should be interpreted as associations rather than causal pathways, given the cross-sectional design. This study highlights the significant occupational health risks faced by tannery workers in Bangladesh, where exposure to hazardous chemicals, limited safety training, and inconsistent PPE use contribute to widespread concern about health outcomes. While the results identify factors statistically associated with workers’ concern, they do not establish direct causal relationships between these factors and health outcomes or behaviors.

Our findings demonstrate that sociodemographic characteristics, knowledge of chemical hazards, attitude, and behavioral practices such as PPE use and hygiene are associated with, rather than determinants of, workers’ self-reported health concerns. Therefore, the conclusions drawn should be viewed as indicative patterns that require further investigation through longitudinal or experimental designs. These results underline the critical importance of strengthening occupational health and safety programs in the tannery sector. The recommendations should be understood as potential areas for improvement rather than definitive, evidence-based prescriptions. Interventions may prioritize consistent and context-specific OHS training, improved availability and use of protective equipment, and more vigorous enforcement of workplace safety regulations. Additionally, fostering a positive attitude and enhancing worker empowerment can play a central role in reducing occupational vulnerabilities.

Policymakers, industry leaders, and public health authorities must work collaboratively to address structural gaps and protect the health and well-being of tannery workers. Nevertheless, any policy or programmatic actions informed by this study should consider the limitations of cross-sectional data. By identifying the factors shaping workers’ health concerns, this study provides preliminary evidence to guide future research and support efforts to create safer, more sustainable labor conditions in one of Bangladesh’s most economically essential yet hazardous industries.