Symptoms, Pathologies, Accidents and Expectations, Regarding the Occupational Doctor and Safety Technician, in a Representative Sample of Portuguese Tattoo Artists

Introduction/Objectives: As Tattoo is being more accepted, more professionals dedicate to it. A study was designed with the aim of analysing the perception of Tattoo Artists regarding their Occupational Health/Safety team (opinion about the support provided); as to find out what type accidents, symptoms and occupational diseases they have, in order to provide a better service. Methods: This is a mixed exploratory study, containing a quantitative observational (analytical, cross-sectional) and a qualitative component (Case Study). For the statistical analysis, predominantly non-parametric tests were used. The project was approved by the Ethics Committee and informed consent was obtained. Results: In terms of symptomatology/illnesses, musculoskeletal pathology is the most reported. In terms of accidents, cuts stand out. Several statistically significant relationships were found between the variables analysed. Discussion/Conclusions: The Occupational Health and Security services are considered insufficient by most of the Tattoo artists. It would be desirable that the Occupational Doctor has concrete knowledge regarding Tattooing, in particular semiology/pathology; makes recommendations in pharmacology and/or indicates which exams could be useful. In relation to the Safety Technician, it would be desirable also to have specific knowledge about the sector, making plausible suggestions for improvement.


Introduction
Tattooing consists of the permanent introduction of a pigment into the dermis by means of a needle [1] [2] [3]. It is a booming activity in the last decades, as it has been progressively accepted by the society, in most countries. The increase in demand for Tattoos, which covers all strata of society, ages and genders, has driven the growth of supply, multiplying the number of studios and Tattoo artists. In Portugal, for example, in the nineties there were two [4] [5] or three [6] [7] studios, all in Lisbon; currently, the National Statistics Institute (INE) revealed that in 2019 (data available in 2021), 800 workers were registered in the tax authorities with the Economic Activity Code (CAE) associated with Tattooing.
The exponential expansion of the sector was not, however, followed by the development of Occupational Health and Safety knowledge adapted to this sector, and it is common for some companies to provide generalist basic services, which contribute to the development of an idea that these have little practical use, existing only due to a legal imposition. From this perspective, it is not surprising at all that some Tattoo studios devalue the work of the Occupational Doctor and Safety Technician [1].
The available literature regarding Tattooing focuses almost entirely on the existing risks for the tattooed person and not for the Tattoo Artist, with few articles describing specific aspects, such as symptoms existing in the last ones related to their professional activity, but there are no generalized studies of the sector, that can give a global view of it.

Objective
Taking into account these premises and given the scarcity of data on these items in the scientific literature, a study was designed with the aim of analysing the perception of these professionals regarding their occupational Health and Safety; for example, to find out what type of occupational accidents they have, as well as what symptoms and occupational diseases they perceive, in addition to their opinion of the services provided by the Occupational Doctor and the Safety Technician, in order to improve the services done by the Health and Safety team.

Methods
This is a mixed exploratory study, containing a quantitative observational component, analytical and cross-sectional, with a qualitative side, where a Case Study was conducted. Initially, it was constituted an online survey created by using the Google Forms tool, which was available between April 2020 and March 2021. Its dissemination was carried out through contact with companies/professionals providing this service; as well as the main national magazines of the sector, companies supplying products and equipment of the sector and organizing committees of the main national annual congresses of Tattooing. Based on Occupational Diseases and Environmental Medicine the number of professionals registered, it was made an attempt to obtain a representative sample of the population under study, considering a sampling error of 5% and a confidence range of 90%. For the statistical analysis, after checking the normality of the variables with the Shapiro-Wilk test, predominantly nonparametric tests were used. In a more advanced phase, a Case Study was structured, using interview techniques with the Tattoo artists, to deepen the questions related to their perception about the occupational Health and Safety services.
The research project was approved by the Ethics Committee of the Faculty of Arts of the University of Porto (Portugal) and informed consent was obtained.
As inclusion criteria, were considered age equal to or greater than 18 years old, working as a tattoo artist and mastering the Portuguese language, regardless of nationality. As exclusion criteria were considered the failure to fill in more than half of the questions and the insertion of contradictory answers.
As a research question, it was stipulated: What are the symptoms, pathologies and accidents existing in Tattoo Artists and what are their expectations towards the professionals of the Health and Safety at Work team?

Presentation and Discussion of the Results
Around 26% of the population of registered Tattoo artists in Portugal answered the survey, with a total of 207 validated questionnaires. Table 1 shows the main socio-demographic and professional characteristics of the sample.
These professionals are young workers (M = 33.67 ± 7.04 years) and, as shown in the literature, are predominantly male (66.7%). In terms of education, prevails the secondary education (59.4%), although there is a significant number of Tattooists with higher education (30.0%); Portuguese nationality is the majority (91.8%), although the remaining ones work in Portugal and speak fluent Portuguese.
At a professional level, more than half have been working for less than five years as a Tattoo artist, although there are also individuals who have been doing it for more than twenty years. The majority of the professional practice is carried out in their own establishment (72%), with Tattooing being seen by the majority as an exclusive job (60.9%); however, those who have another job also normally consider Tattooing as their main activity (69.1%). Table 2 summarises the main characteristics of the sample regarding the occurrence of accidents at work, symptomatology associated to work activity and occupational disease.

Work-Related Accidents, Symptomatology and Occupational Illnesses
Regarding accidents, the ones that happen due to cutting seem to be the main problem, something already experienced by more than half of the individuals in the sample; follows chemical agent spillage and lastly, in a residual manner, a burn was reported. The vast majority (74.24%) had no work restrictions after the Occupational Diseases and Environmental Medicine  (Table 2), from the Tattoo Artist's subjective perspective and without specifying the limitation in a concrete way. Analysing the symptoms associated to the professional activity, the main complaints reported were myalgia, visual fatigue, stress and eye irritability; less frequently: nasal irritability, cough and headache. Therefore, it is not surprising that they consider that the professional activity aggravates some disease situations they experience, such as musculoskeletal pathology (Herniated Disc) and mental disorders (Depression/Burnout and/or Anxiety), with Eczema, Rhinitis, Occupational Diseases and Environmental Medicine Urticaria and Asthma also appearing with less relevance. At the same time, they also consider it likely that some of these illnesses may have appeared due to the effects of work on health, essentially in terms of musculoskeletal pathology and mental illness (Depression, Burnout and/or Anxiety), in this line of thought and on a residual basis, Rhinitis, Eczema and Asthma also appear, with the absence of any reference to pathologies caused by biological agents. However, the vast majority do not consider being in a situation of suffering from an occupational illness, something which was only recognised by Social Security in three cases ( Table 2).
After the descriptive analysis of the variables under study, some relationships were explored (Table 3). On this table it is possible to verify that there were no relevant statistical differences that allow associating the occurrence of occupational accidents or the resulting limitations with the different socio-demographic and professional characteristics of the Tattoo artists.
The number of years working as a Tattoo artist stands out as a preponderant factor for both the symptoms experienced and the situations of suspected occupational disease. Thus, the statistical differences identified highlight that the ones who have worked for more years (p = 0.004), frequently report muscle pain, complain of musculoskeletal pathology, referring that the professional activity not only makes the situation worse (p = 0.011), but may also be in the origin of this problem (p < 0.001); this last inference is also shared by older Tattoo   Table 3. Relationship between socio-professional characteristics of Tattoo artists and their safety and health.

Age
Years This study also evidences nasal irritability, a symptom associated to older tattoo artists (p = 0.003), more professionally experienced (p = 0.040) and female (p = 0.006), possibly since male gender is generally more reluctant to mention/value symptoms.
The existence of declared Occupational Illnesses is associated to Professional Experience (p = 0.046), meaning that an organism that is more aged/fragile and/or exposed for more years to the same labour Risk Factors will more likely

Interaction with the Occupational Health and Safety Team
The main characteristics of the interaction between the Tattooists and the Occupational Health and Safety teams can be consulted in Table 4  (…) he handed me some papers to fill in… even the COVID protocol I said I had already done… and I never saw him again… I even asked him for the procedures manual… currently I work by myself and I know how to proceed, but if I have other colleagues they will have to know how to proceed… they will have to know what to do in case of a prick… in case of a liquid spillage on the skin… and to this day I am still waiting (…) Anyway, the number of Tattoo artists who had never contacted the Safety Technician is also high. In this case, the lack of training is also the main cause for their absence, as one of the interviewees states:  Eventually, factors such as increased risk perception, fragility regarding ageing The frequency with which the Safety Technician's intervention is perceived, directly influences the Tattoo artists' perception of the quality of their performance (rho = 0.253; p = 0.003). This assessment is also directly proportional to the value given to the Occupational Physician (rho = 0.406; p = 0.001). Therefore, Tattoo artists who are more attentive and receptive to Occupational Health and Security, more easily simultaneously value the items included in it, such as training and the elements working in the team [12]. However, Tattoo artists with more schooling education were more likely to evaluate the Safety Technician's intervention as negative (p = 0.010) and more likely to consider that it does not change the context where they work (p = 0.034), while those with less schooling education were more likely to consider that it positively changes the work environment. It may be thought that individuals with more knowledge possibly have a better notion of the functions of the Safety Technician and, therefore, are more critical and demanding in relation to his/her performance. The same happens in relation to training, as can be seen: (…) I've only learnt what the occupational doctor is because of the Ink Talents training courses… I looked for and hired a company and now I have an occupational doctor… honestly I think it's a bit of a hurry… it was like measuring my blood pressure, looking at my eyes… it's that thing… if I really have a problem… if I say everything is fine with me, I will pass the check-up… for me an ideal occupational doctor would be to do more re-search… talk a bit about diseases and symptoms associated with Tattooing (…) Finally, those who consider that the Medicine/Science standards are not adequate are more likely to think that the intervention of the Safety Technician worsens working conditions (p = 0.014).

Conclusions
This research combined quantitative and qualitative techniques in order to identify not only the profile of Portuguese Tattoo artists regarding the occurrence of occupational accidents, symptoms and occupational disease; but also to portray the occupational Health and Safety through the perception of the Tattooists. Occupational Diseases and Environmental Medicine In terms of accidents, cutting stands out; despite this, there is no evidence that there has been any type of disease associated to any biological agent in the evaluated sample.
In terms of symptoms and illnesses, musculoskeletal pathologies are the most common among workers, due to both repetitive movements and the forced postures maintained. In second place, but also with emphasis, are the emotional problems which, with the pandemic and the confinement, may have been intensified. Eye fatigue, a symptom mentioned by a large majority of individuals, should also be highlighted. However, evidence of the presence of declared occupational disease is vestigial.
Despite of being mandatory by law, many Tattoo artists have never had a consultation with the Occupational Doctor, nor have they submitted their workplaces to the evaluation of a Safety Technician; this situation is eased by both the lack of professional information/training, and because of the lack of preparation of the occupational services to properly monitor the needs of the sector, something that allows to keep a climate of mistrust/disbelief of the potential of these services.
Considering the Limitations of the investigation, taking into account the method used to obtain the sample, it is possible that the Tattoo artists who made up the sample are not totally representative of the professionals practising in Portugal, as the willingness to participate in the project may be associated to a greater concern with Occupational Health and Safety issues, and so, the Tattooists less compliant with the recommendations may not have been included. Furthermore, it was not possible to confirm whether the individuals who responded to the survey were actually Tattoo Artists; however, completing the form took more than twenty minutes, so it would be unlikely that there were individuals who did not work in the sector and were motivated to do this procedure, as they would not have any benefit in doing so.
As for the number of individuals interviewed, this was small, so the results could be different, with a larger sample, although part of the answers has started to be repeated in some situations.
When discussing the data, it was rarely possible to compare with the literature, given the scarcity of published articles on the topic.
As for most of the companies providing external Occupational Health services, it would be desirable for the Occupational Doctor to have specific knowledge regarding Tattooing, namely associated semiology and pathology; as well as the possibility to make practical and effective recommendations in the context of eventual pharmacological support and/or which auxiliary diagnosis exams could be useful and how to obtain them, according to the legislation. On the other side, in relation to the Safety Technician, it would obviously be desirable that he also have specific knowledge in relation to the sector, making plausible suggestions for improvement of the workplace, based on a mathematical evaluation of risk, coherent and prioritising the most relevant areas to act in at the moment, according to the combination of criteria such as the gravity of possible conse-Occupational Diseases and Environmental Medicine quences of not correcting, the probability of occurrence of these consequences, the cost associated to correction and direct technical difficulties in alterations. There should also be a direct, routine and fast interaction between these two professionals, in order to provide a quality and effective service that motivates the customer to collaborate.