Occupational risks in a representative sample of Portuguese tattoo artists: comparison between self-perception and risk assessment methods

Introduction In recent decades there has been a growth in the demand for tattoos and in the number of tattoo artists. Objectives A study was designed to compare the results obtained in the application of risk assessment instruments by the Occupational Safety and Health team with those of the risk perception of the same variable in a sample of tattoo artists. Methods A risk chart was prepared and the William Fine method, the integrated risk assessment approach, and the methodology for risk assessment and accidents at work were applied for general risk assessment, whereas the Ovako Working Posture Analysis System and Rapid Entire Body Assessment were applied for ergonomic risk assessment. Tattoo artists’ perception was registered in an online questionnaire. Results The most valued risk factors by tattoo artists were forced/maintained postures and repetitive movements; conversely, interaction with old machines and/or in poor condition and monotonous work. Divergences were found when comparing the results of risk assessment with those of risk perception, since the first highlights chemical and biological agents. This may be justified by the fact that tattoo artists give more relevance to issues capable of causing faster and/or more intense semiology. Conclusions If the Occupational Safety and Health team is attentive and prepared to deal with these differences, it will achieve better performance.


INTRODUCTION
2][3] In the last decades, a significant growth has been observed in the demand for tattoos worldwide, stimulating the supply, as confirmed by the increase in the number of facilities and professionals in this area.However, this evolution was not accompanied by support from the area of Occupational Safety and Health, which continues to provide tattoo artists with standard services, little adapted to their characteristics, thus possibly leading to the perception that these services have little utility, which makes that they are not always used, 1 despite knowing about their legal obligation.
Tattoo artists are exposed to several occupational risk factors, in which they need to have training.[10] Forced/maintained postures resulting from prolonged shifts (in situations of large tattoos and/or with several appointments in a row, without intervals) and the performance of repetitive movements (tattooing and cleaning the skin from excess pigment, a number of times subsequently) may give rise to orthopedic diseases, due to muscle, tendon, and/or joint wearing out.Other risk factors is working in a poorly illuminated environment, which may lead to visual fatigue and/or reduced visual acuity, due to visual demand; handling of electric tattooing machines for long periods, with continuous exposure to noise 4,9 (nearly 15 decibels) and to low intensity vibrations, 4,9 which may be associated with hearing loss and vascular/neurological disturbances, respectively; as well as with exposure to psychosocial factors, with stress standing out (associated with management of tattoo appointments, with an empty schedule, or with guidance on clients' expectations about the final product presented, which is potentially irreversible).
Risk perception, in turn, describes how an individual perceives susceptibility to a specific damage, secondary to a threatening event, and depends on beliefs, attitudes, values, and personality; therefore, it is subjective. 11Risk assessment, conversely, is more objective.Taking this difference into account, the results for perception are usually different from those of the risk assessment. 12

OBJECTIVES
Considering these premises and the scarce scientific literature, both on the objective assessment of occupational risks present in the sector and on subjective risk perception by tattooists, an exploratory study was designed aiming to compare the results obtained in the application of certified risk assessment instruments, namely the William Fine method, the integrated risk assessment (MIAR) approach, and the methodology for risk assessment and accidents at work (metodologia de avaliação do risco e acidentes de trabalho, MARAT), with workers' self-perception from a representative sample of professional Portuguese tattoo artists, by means of an online survey.
Therefore, by comparing the differences between a more objective professional assessment and a more subjective personal assessment, the Occupational Safety and Health team will be more able to obtain better performance, since they will understand more clearly how to approach, disseminate, train, and guide.

METHODS
Initially, a generic risk chart was created covering the tasks usually performed by tattoo artists during professional practice.Subsequently, the William Fine method, the MIAR approach, and the MARAT were applied to assess general risk, and the Ovako Working Posture Analysis System (OWAS) and the Rapid Entire Body Assessment (REBA) for ergonomic risk assessment in particular.
To measure tattoo artists' perception on the different occupational risk factors, an online questionnaire was created and made available from April 2020 to March 2021, using the Google Forms platform.It was directly disseminated in tattooing companies/professionals, national magazines of the sector, companies that supply products and equipment, and organizing committees of national tattooing congresses Based on the number of professionals registered in the Portuguese tax office, this study sought to obtain a representative sample of the study population, considering a sampling error of 5% and a confidence interval (CI) of 90%.
With regard to statistical analysis, after checking for the normality of the variables with the Shapiro-Wilk test, the chi-square and the Kruskal-Wallis tests were predominantly used to investigate the differences between the variables, as well as the Spearman's correlation coefficient.
The investigation project was approved by the Research Ethics Committee of Faculdade de Letras da Universidade do Porto, and all participants provided free informed consent.

RESULTS AND DISCUSSION
A total of 207 tattoo artists answered the questionnaire, which accounts for 25.9% of the professionals registered in Portugal.

GENERAL RISK ASSESSMENT
Although the three methods used (William Fine method, MIAR and MARAT) value different aspects, it was interesting to observe the homogeneity of results.The highest risk category includes possible contacts with chemical agents, sharp objects, and potentially contaminated blood, as well as cleaning of skin (of the excess pigment).
Although the MIAR approach indicated two items that the other techniques did not include in this category (contact with blood during cleaning/disinfection/ sterilization of working surfaces and instruments).The method that most valued the occupational risk factors in general was the MIAR approach (9 items in the highest risk category and 37 in the lowest risk category), the opposite being the William Fine method (7 and 46, respectively). 13

ERGONOMIC RISK ASSESSMENT
According to the OWAS method, it was observed that the tasks of making the drawing on paper or searching from a design on the computer and inserting it on decal sheets obtained the lowest risk level(1); all the other tasks were classified into the action category 2, except for the possibility of the tattoo artist having to help the client, which obtained a rating of 4, in view of its load bearing.However, when weighting the time that each task usually occupies in percentage in relation to the work shift, the situation changed, i.e., the action level other condition may have biased the results: or only and exactly a single moment is assessed with rigor (running the risk of biasing whether professionals have positioned themselves correctly or not and not considering the risk that other postures would bring the same task, in other moments of tattooing and/or even with other tattoo artists), or, in an attempt to prevent against such, consider the most serious possibility.Since the objective was to portray the tattoo sector globally (and not one studio or tattoo artist in particular), it was decided to cover all situations and, when there are several possible ones, always consider the most serious. 14oreover, even though these methods allow some subjectivity to be mitigated in the risk assessment, it cannot be eliminated.In situations of doubt between two hypotheses of the scale, an evaluator may choose one hypothesis at one time and, in another equivalent task, choose the other.This can even happen when repeating the evaluation of exactly the same task at different times.Even so, these methods constitute a valuable aid in risk assessment. 14

SELF-PERCEPTION TOWARDS OCCUPATIONAL RISKS
With regard to the characterization of the sample of tattoo artists assessed, age ranged from 20 to 52 years, with a median of 34 years and a mode of 36 years.In terms of sex, as described in the scientific literature, there was predominance of the male sex (66.7%).In relation to schooling, elementary (10.6%) and high school (59.4%) education still prevail, although higher education accounted for 30%.Even though all participants worked in Portugal and mastered the Portuguese language, 8.2% did not have Portuguese nationality.
Professionally, the tattoo artists assessed were very heterogeneous, including workers with little professional experience (less than 1 year) and other very experienced ones (more than 30 years), with a median of 5 years.Exclusive dedication to tattooing prevails (60.9%), but only 58% of individuals received previous training to start working professionally, ranging from those who attended short courses, who did an internship, and who worked as trainees of other tattoo artists.
When participants were asked whether they considered to be exposed to occupational risks, they were unanimous in acknowledging the presence of these risks.However, when they were asked to classify exposure to risk based on an exhaustive list of potential risk factors related to professional practice, it was observed that, although some of them stood out, all risk factors were assigned with some risk classification (Table 1).
The most valued risk factors were forced/maintained postures and repetitive movements; in an opposite situation there were interaction with old machines and/ or in poor condition and monotonous work.
When associating the two highest levels of risk perception (medium and high), forced/maintained postures (96.6%) and repetitive movements (90.6%)  1, which may be associated with a valuation of the subject that led tattoo artists to previously take the required precaution measures, thus not emphasizing the potential current risk, by comparison with other risk factors that were left unnoticed at an initial stage and currently are perceived as more intense.
The next risk factor is eyestrain (63.1%), resulting from handling the tattooing machine often without the required lighting and for long periods.Finally, but still with a percentage above 50%, there is handling of chemical agents (51.7%), associated both with the inks and with cleaning of skin, work instruments, and work surfaces (Figure 1).
In the opposite direction, associating the two lowest levels of risk perception (null and low), there are, in an ascending order, monotony associated with the tasks (12.9%); handling of tattoo machines in poor state of conservation (19.3%); and exposure to noise (24.6%) which is of low intensity and thus is not usually interpreted as a risk factor that requires relevant measures to be taken (Figure 1).Moreover, it is possible that, generically, some workers give a greater value to risk factors with more immediate and/or intense consequences and/or symptoms rather than other factors that (despite leading to significant situations) do not lead to significant symptoms or relevant interaction with quality of life at that time.

RELATIONSHIP OF SOCIODEMOGRAPHIC AND PROFESSIONAL VARIABLES WITH RISK PERCEPTION
Results reveal that the sex is important in risk perception, since the female sex usually perceives risk more intensely, as described in the literature, 12,15,16 which was more noticeable in relation to chemical agents (p = 0.035), forced/maintained postures (p = 0.008), and to stress (p = 0.007).
With regard to age, it was observed that older age groups have a more intense perception of exposure to occupational risk, emphasizing the performance of repetitive movements (p = 0.013), which are more likely  to cause painful symptoms in older individuals (with lower functional capacity), and handling of chemical agents (p = 0.019).An analysis of professional experience revealed that professionals who work for a longer time in the sector usually classify risk as more intense, with a statistically significant difference for repetitive movements (p = 0.005), noise (p = 0.036), and eyestrain (p = 0.018), which may explained by the probable presence of symptoms such as musculoskeletal pain, visual fatigue, and reduced auditory acuity in individuals whose period of exposure was longer.
Simultaneously, professionals who work exclusively in the sector of tattooing perceive the several risk factors more intensely, perhaps because they are more exposed, especially the performance of repetitive movements (p = 0.010) and exposure to stress (p = 0.050), in which differences are statistically significant.Professionals who work simultaneously in another job are more likely to devalue some factors, such as vibrations (p = 0.003), which were classified as null risk by most professionals, a finding that may be justified by their shorter exposure to hazard.

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An assessment of the intensity of perception towards eyestrain showed that it is positively correlated with the valuation attributed to prolonged shifts (rho = 0.297; p < 0.001), repetitive movements (rho = 0.306; p < 0.001), and stress (rho = 0.278; p < 0.001).
It was also found that valuation of isolated work as a risk factor was positively and moderately correlated with monotonous work (rho = 0.446; p = 0.001) and stress (rho = 0.205; p = 0.004), whereas monotonous work was correlated with prolonged shifts (rho = 0.189; p = 0.007) and stress (rho = 0.300; p < 0.001).
Finaly, perception of chemical risk was found to be positively and moderately correlated with biological risk (rho = 0.313; p < 0.001).

CONCLUSIONS
The job of tattoo artist is still little regulated and standardized, being accessible to any person who wants to start working as a self-employed or at some preexisting studio, taking into account that training addressing risk factors associated with professional practice is scarce or reduced.Simultaneously, it is also a labor area still little or not investigated in the context of Occupational Safety and Health.This exploratory study, in addition to making it possible to assess the risk perceptions expressed by Portuguese tattoo artists, allowed for building a chart of risks, with the application of different previously certified instruments.
For risk assessment (global or ergonomic), it is recommended to use methodologies that enable develop a mathematical hierarchy of the list of problems, guiding tattoo artists with regard to the required changes to be done, both from the structural point of view and in procedures.However, comparing the results for risk assessment with those for risk perception, it is observed that results are divergent, i.e., the first emphasizes chemical and biological agents, whereas the latter highlights forced/maintained postures and repetitive movements.
Biological agents, from the professionals' point of view, seem to be less valued (comparatively), but, even so, are more emphasized than other risk factors.However, this risk has the potential of causing irreversible damage, being thus necessary to develop techniques that increase safety and effectively protect workers' health, in addition to promoting appropriate professional training.Nonetheless, this alleged lower valuation may be justified by the fact that, in the past, biological agents were one of the most highlighted risk factors (comparatively to the others) and that this could have provided an appropriate approach, so that tattoo artists consider that the actual risk is lower, given the protective measures currently implemented in all studios.
This may be justified by the fact that tattoo artists eventually give more relevance to issues capable of causing faster and/or more intense semiology, compared with risks that have later and/or milder consequences.If the Occupational Safety and Health team is attentive and prepared to deal with these differences, they will be more able to achieve better performance.

Figure 1 .
Figure 1.Percent distribution of perception of severity of exposure to occupational risk factors.

Table 1 .
Valuation of occupational risks by tattoo artists

Table 2 .
Statistical correlations between tattoo artists' perception towards different occupational risk factors