a) Living and lifestyles.

Most participants were in shared accommodations with three to ten fellow migrants. They mentioned having a designated bunk bed within their shared rooms. The following two quotes represent their views on living in a room with other people:

“When I was in Qatar, I used to share a room with other 10–12 people…the room was given by a company.” (IDI #1)

Some also mentioned problems with facilities, including toilets:

“So for 10 people there was a single kitchen room and toilet. So, sometime you have to wait for a long queue to use toilet.” (IDI #8)

In response to inquiries about additional amenities like internet access, air conditioning, and drinking water in their accommodation, participants shared that these facilities were supplied by their companies. They further noted the easy availability of drinking water at their accommodations; however, a small number of participants, particularly newcomers, relied on tap water, perhaps for the first few weeks, supplied in their residences before switching to commercial drinking water due to unpleasant taste. Some avoided drinking tap water due to the fear of getting kidney stones, often buying expensive bottled water:

“While I was in Saudi Arabia for a few months, I drank tap water, it was not good in taste. Later my friends told me if we drank too much tap water it would cause kidney stones and they were also not drinking tap water. So eventually I started to drink mineral water [commercially produced water bottles].” (IDI #9)

A participant who had worked in both Qatar and Malaysia expressed that:

“…we didn’t need to buy water in Qatar. But, in Malaysia, I had to buy water. I was working as a security guard in a college, so during my duty hours I drank water in the canteen of the college, but we needed to put coins in a water dispenser to buy drinking water while we were in the room.” (IDI #6)

While an interviewee, who had worked in Malaysia, mentioned the need to boil local water, he said:

“There was a water vending machine…outside of our place. We used to buy water from that machine. You have to put shillings paisa [= small coins] in the machine and it will provide good quality water. Many others also drank tap water after boiling it, but I used to buy water.” (IDI #8)

Participants suggested that consuming energy drinks or carbonated beverages gave them energy and that it was widespread among Nepalese migrants:

“Coke was more preferred, I used to drink one or two litres of coke per day.” (IDI #2)

One person mentioned getting a free sugary carbonated drink every day:

“…generally, drinking coke was regular and every day. Our clients used to give us one to two litres of coke daily for free.” (IDI #4)

Most prepared meals in a shared kitchen although few also used their company canteen where they had to pay. There was a practice of preparing excess meals so that they could take some as snacks to work the next day:

“We used to take leftover food from the dinner and take that to work the next day and have a lunch in between 12 to 1 PM. There was no time to prepare the daytime lunch but at night we used to cook ourselves.” (IDI #4)

Most said that they ate green vegetables regularly, eating fruit was seen as expensive and hence rare, for example:

“…I used to eat green vegetables…but I rarely ate fruits. I used to eat meat and fish once a week both in the same quantity.” (IDI #7)

Participants reported consuming alcohol frequently, typically on their days off, with some engaging in daily alcohol consumption.

“During holidays I drank alcohol. There were some Nepalese who used to drink alcohol daily. But, for me I only drank on holidays.” (IDI #5)

“We used to drink alcohol during our days off….I used to drink 2–3 bottles of beer in one sitting.”(IDI #2)

Regarding the specific types of alcohol consumed, participants mentioned that bottled alcohol and beer were the preferred choices abroad, although a minority opted for locally produced alcohol while in Nepal.

“I used to drink alcohol while I was abroad. In Nepal, I used to drink alcohol made from millet, but I used to drink packaged (seal packaged) alcohol abroad.” (IDI #7)

Likewise, chewing tobacco was common, most disclosed their longstanding consumption of Gutka (a small sachet of tobacco mixed with betel nuts), starting from an early age. Notably, one participant mentioned that consuming Gutka contributed to his enhanced mental alertness.

“For the purpose of remaining mentally active as well, I used to eat about 5–6 Gutka a day while working abroad. But nowadays I consume 2–3 Gutka daily. Before going abroad, I used to consume 6–7 packets per day.” (IDI #2)

b) Work environment.

Each participant confirmed their daily work often exceeded their standard 8-hour shift. All routinely worked overtime, extending their normal working hours. Additionally, some even worked overtime on their scheduled days off, for example, one participant said:

“… I used to work 12 hours daily…it depends on you, for how long you will work. Company provided 4–5 holidays in a month, but sometimes I used to do overtime in those holidays.” (IDI #3)

Most reported getting adequate breaks and rest times whilst working long hours. However, one who worked as a security guard in Malaysia reported an absence of facilities for taking rest while on duty:

“For the first six months, I could not take rest while on guard duty. It was difficult at that time; the temperature was also high. But later after I started to know people and some languages, it was a little easier for me. I found some places to sit and rest.” (IDI #6)

Another participant shared about the working conditions of Nepalese migrants:

“Situation for Nepalese in the Gulf countries who are working as labourers is very bad. There are no good facilities for food. We were lucky ones who got a good working environment. But for many people living there, the situation is very bad. They don’t get enough sleep. The duty hour is sometimes around 12–14 hours. Some had to work under the direct sun for a long time.” (IDI #4)

The majority of our participants were employed as labourers in construction companies or factories. They indicated that the use of personal protective equipment (PPE) was contingent upon the specific regulations set by their respective companies. A participant diagnosed with kidney stones who worked as a mason in a construction company (where airborne cement dust was prevalent) reported using safety equipment while working.

“We were provided with helmets, goggles, masks for our safety and had to wear them all the time.” (IDI #3)

Another participant employed in a glass factory in Saudi Arabia revealed that wearing a mask was not mandatory in the factory.

“…After cutting the glass there used to be a large amount of water, small pieces of glass, and glass dust. It was very difficult to work there. While working we used to wear gloves and helmets only, we didn’t wear masks.” (IDI #1)

This perspective was echoed by another working in a factory in Malaysia, where the requirement of wearing a mask depended on proximity to operating machinery:

“For working near a machine, you need to wear masks. If you are not working near the machine or in other office spaces, you do not have to wear the mask.” (IDI #8)

Most participants reported easy access to drinking water in their workplaces. However, it was noted that in certain companies, a supervisor’s approval might be necessary to take a drink break. Many did not have to purchase water at work, as water dispensers were readily available, for example:

“…different places inside the office had water dispensers…some are even filled with electrolyte solutions, and we could take it when needed.” (IDI #3)

Interestingly, one mentioned that supervisors actively encouraged them to stay hydrated, particularly on hot summer days, by urging them to drink ample water at work.

“When it was very hot supervisors used to suggest drinking more water.” (IDI #6)

Most indicated unhindered access to toilets despite extended working hours. Nevertheless, a few employed in Malaysia recounted troubling incidents related to restroom access during work hours. For instance, a guard shared his experience as:

“While working as a security guard in Malaysia, I needed to inform to the supervisor before going to the toilet. I also found that in some companies where Nepalese work they cannot go to drink water and toilet use without the permission of their supervisors. Those Nepalese working as cleaners in tall glass buildings have problems doing toilets when hanging in tall buildings. They carry some kind of plastic with them and urinate there. They told me it is difficult to do such things.” (IDI #6)

One participant, who had undergone kidney transplantation explained, that due to the continuous operation of machinery in the factory (automated function), workers were required to seek permission from supervisors or security personnel to use the restroom during their shifts. This person also revealed that certain companies employed strict security personnel who were reluctant to grant workers permission for restroom or drink breaks, for example:

“…A machine in our company ran 24 hours so someone must replace the person going to the toilet, when there was no one to replace them, we used to ask supervisors and seniors for help. In some companies, there are strict bouncers. Workers in those companies often get problems going to the toilet.” (IDI #8)

c) Exposure to pollutants.

Eight participants disclosed exposure to various pollutants. One participant, who experienced failure of both of his kidneys, had worked 12 years as a labourer in a steel factory in India, and three years in a glass factory in Saudi Arabia, recalled:

“In India, I used to work in a steel factory. My job was to apply shiny polish to the steel pieces. That polish used to smell. But there I used to wear a mask and all other safety equipment.” (IDI #1)

Another participant, who was employed as a barber and suffered from severe kidney infections, felt there was a link between CKD and having been exposed to various chemicals in the workplace, including lotions, highlighters, straightening creams, fragrances, and cosmetics with unpleasant odours. Despite developing allergies to these substances, he continued working as a barber for an extended period.

“…I had to use cosmetic products which generate both fragrances and bad odours. I later developed allergies that caused frequent sneezing and an uneasy sensation while working abroad.” (IDI #7)

A participant with a kidney transplant shared his experiences of working with metal solutions as follows:

“…I used to work in a factory that performed copper plating on a printed circuit board (PCB). My job was to dip the PCB into a copper solution. There was a good ventilation system in the factory however, there was always the smell of copper. Masks and safety equipment were compulsory for us.” (IDI #8)

Similarly, another participant working as a cleaner reported his experience as follows:

“I used to clean floors with detergent. The detergent used to give odour. The floor also gave off an odour after mopping. After a few years I got habituated to that odour.” (IDI# 10)

d) CKD experience.

None of the participants reported having developed any kidney-related symptoms or problems before going abroad. Among them, seven individuals received a diagnosis of kidney health problems while working overseas, while four participants were diagnosed after returning to Nepal. Additionally, one participant reported experiencing pain while employed abroad, which was subsequently diagnosed as kidney stones by a doctor in Nepal.

Out of the seven participants diagnosed with kidney disease abroad, three continued their work despite these kidney problems. Conversely, one participant promptly returned to Nepal and commenced dialysis. Another participant, who has now undergone a kidney transplant due to kidney failure while employed in Qatar, continued working for approximately two months before returning to Nepal for treatment:

“…I became very sick; I had a very high fever and alarmingly high blood pressure of 160/100. Later after staying for four days at the hospital doctors told me that both kidneys had failed. But I worked for about two months because doctors told me that my creatinine level was low and that with medications and a good diet, dialysis could be postponed for a few months. After returning to Nepal, Nepalese doctors in Dharan and Kathmandu also told me the same thing. Thus, I stayed on medication for about a year. After a year my body started to swell, and I started to feel difficulties while urinating. Then after I consulted doctors at Janakpur and started dialysis.” (IDI #8)

Similarly, another participant with severe infections in both kidneys reported working for four months even after his diagnosis. He shared his experience as:

“After I returned to UAE from Nepal, they did my medical tests, but they did not provide me the reports. Later doctors told me that I had a problem in both of my kidneys. Then, I did a series of tests for about four months, but the exact cause was not determined. At around four months, I did a biopsy of my kidneys which confirmed there was some kind of infection in both of my kidneys. Then doctors gave me some medications, but I never took a rest from my work in those four months.” (IDI #7)

Likewise, someone employed in Qatar recounted being hospitalized due to intense back pain, leading to a diagnosis of kidney stones. After an 11-day hospitalization for treatment, the participant resumed work upon discharge.

e) Use of painkillers and healthcare.

Participants had different experiences accessing and using medications while working abroad. The majority acknowledged relying on excessive pain relievers, with Paracetamol being the most commonly used. Some also mentioned receiving painkiller injections as prescribed by doctors, although they were unaware of the names or types of the injections.

“…There were Bengali shops where we could buy Paracetamols or other painkillers. If they did not work, then only we used to go to the hospital.” (IDI #3)

Some were self-medicating when in pain, using readily available over-the-counter drugs:

“We were like patients ourselves and doctors ourselves, we didn’t consult any doctors. We had a day shift and had to work for 10 hours so we didn’t have time to visit doctors. When we had body pain, we used to take painkillers like Ibuprofen which we used to bring from Nepal.” (IDI #3)

The majority had taken medications from Nepal. When questioned about the rationale behind this, they expressed a belief that medications abroad might not suit their specific needs. Additionally, factors such as limited time to consult doctors and the unavailability of certain medicines further motivated them to bring medications from Nepal, for example:

“I used to ask for cough syrup from Nepal because medicines in Qatar do not fit with my body. …Antibiotics are also not easily available there, so we ask for medicines from Nepal and use that as needed.” (IDI #7)

When seeking health care abroad, participants explained that generally companies and hospitals/clinics have agreements between them to provide treatment to workers. The company issues tickets [= referral slips] to the workers who need treatments and also arranges transport if needed. In some cases, referral provisions can be made for specialised care.

“…when we are sick, we notify someone from the company living in our quarter, and they then provide us a ticket to go to a clinic. You take the tickets to see doctors and buy medicines.” (IDI #5)

“After seeing my ultrasound report, the doctor told me that both of my kidneys were damaged. They referred me to another hospital where I was hospitalized for four days.” (IDI #8)

However, getting specialized care from the referral hospital was based on the nature of the employing company. The workers working in mediocre or small-scale companies were returned to Nepal when they felt ill for a prolonged period. One of the participants expressed:

“Getting healthcare at hospitals depends on the company, my company was good. There was one guy from [= district in Nepal] who felt very ill. The company sent him to the hospital from the site. He had pain in his stomach. After a few days, it was found that he had appendicitis, so he was sent to another hospital for surgery, he joined work after one week… so it really depends on the company. If he was employed in a low-scale company, then he would have been handed a ticket to return to Nepal.” (IDI #4)

f) Medical expenses for kidney health patients.

People held varied opinions on the reimbursement of costs abroad related to kidney treatment. Someone cited a specific instance where the medical expenses for 10–11 days of hospitalization for kidney stone-related pain were eventually covered by his employer.

“…We had to take our medical bills to the company and the company gave us money.” (IDI #3)

However, a migrant returning from Qatar mentioned that his company covered only half of the medical costs when his kidneys failed. In contrast, another one’s company did not offer any medical compensation at all, just a return ticket to Nepal. Additionally, another participant suffering from kidney infections spent 50,000 Nepalese rupees (equivalent to around USD 375) for kidney treatment and medication while abroad, receiving no reimbursement from the company for the medical expenses.

When questioned about the support received in Nepal, someone presently undergoing dialysis is benefiting from complimentary basic haemodialysis services provided under a scheme to support the poorest patients initiated by the Government of Nepal. Nonetheless, most expressed the challenges in accessing such support in Nepal. Those undergoing dialysis mentioned a weekly cost of 5,000 Nepalese rupees (approximately 37 USD), in addition to other expenses, such as local travel.

One participant with a kidney transplant had not received any assistance from any scheme. His kidney transplant was performed in India, and he continued to consult Indian doctors, rendering his costs ineligible for benefits under this scheme in Nepal.

g) Pre-departure training.

Despite the mandatory requirement of pre-departure training for prospective labour migrant workers in Nepal, most participants did not receive any form of pre-departure or post-arrival training. Intriguingly, two participants disclosed that the manpower agency (labour recruitment agent) in Nepal falsified their training certificate without them attending the training.

“…I didn’t attain pre-departure training, but the manpower company [recruitment agency] provided me with a certificate without any training which I could present in order to take the job.” (IDI #7)

A few with pre-departure training shared that the training primarily offered very basic information such as how to live abroad, where to eat, and what not to do there. They recalled that there was limited coverage on health issues, for example:

“…I took that training in Janakpur inside the office of the Chief District Officer. There was not much information about the diseases. However, it provided information on how to live and work abroad.” (IDI #8)

Participants acknowledged the importance of training before going abroad. They agreed that such training may be helpful to promote a healthy lifestyle abroad.

“…It would have been better if we had received such training. It would have been helpful if they told us to drink adequate water for our health, live in a safer environment, and protect ourselves from the heat.” (IDI #7)

“…it would be better to get information on types of diseases that will occur if we do not drink plenty of water while working abroad, especially in hot places.” (IDI #3)