This cross-sectional study was conducted at various welding sites situated in an around Mangalore city of South India from 10^th to 28^th February 2015. Ethics and Research Committee of this medical college gave approval for this study. Sample size was calculated as 144, based on the proportion of utilization of eye goggles among welders as 41.1% as stated in another Indian study [18] and 20% relative precision with 95% confidence intervals. The welding sites chosen were those of the unorganized sector defined as any shop or roadside cabins or garage or fabrication unit which is not a part of industrial complex or independent working unit such as a factory or workshop [20]. Unorganized sector was chosen as workers employed here have no organized occupational health service and their compliance with safety measures is not known [21].

At a welding site one participant was chosen using simple random sampling method. Written informed consent was obtained from each participant after explaining to them the nature and purpose of the study. Participants below the age of 18 years, participants with less than one year of prior work experience and non-consenting participants were excluded from this study. In case the chosen participant was found to be ineligible, then another welder from the same site was chosen by repeating the simple random sampling method.

Data was obtained by interviewing each participant in person at their workplace using a structured interview schedule with both closed and open ended questions.

The schedule was formulated by the investigators. The schedule was translated into Kannada and Hindi versions with help of language experts and back translated into English by independent language experts. Pilot testing of the interview schedule was done among a group of ten non randomly chosen welders, who were not included in the final study. Few questions on work profile of the participants were modified following pilot testing.

Questions regarding sociodemographic details, type of welding, years of work experience, duration of work in a day, work shift pattern, posture adopted while working and details of training before job placement were enquired from the welders.

Data on awareness regarding occupational injuries and first aid practices, usage pattern of personal protective measures, reasons for non-usage of PPGs if any, personal habits like usage of tobacco products or alcohol during working hours and periodicity with medical checkups were also enquired.

Morbidity pattern related to work in the past year and number of such morbidities over the past month suffered by the welders was also noted down by the investigators. These details were later verified from medical reports if available with participants on the following day. If medical reports were not available then only the symptoms as reported by the participants were noted down under list of morbidities. Clinical examination of the participant comprising of general physical examination and systemic examination was also done by the investigators.

Current tobacco users were those who used any form of tobacco product at least once daily and alcohol user was defined as a person who consumed any amount of alcohol at least once in a week [22].

Often users of gears was defined as those using it at least four days in the preceding week, occasional users were those using it less than three days in the preceding week [18].

The investigators later inspected the work site and assessed overcrowding, lighting, ventilation, presence of exhaust fans and the first aid kit. Overcrowding was self-assessed based on number of persons per room criteria [23]. Ventilation was considered adequate if the room had minimum of two windows while lighting was considered adequate if the welders could do their routine activities without using artificial sources of light during day time [23]. Socioeconomic status was assessed using modified BG Prasad’s socio economic classification [24].

Data entry and analysis was done using SPSS software version 16.0. Data was expressed in terms of proportion and percentages. Statistical tests like Chi-Square, unpaired t-test and ANOVA were used for testing association. The probability of significance was set at 5%.

A total of 155 welders from as many welding sites took part in this study. Mean age of the participants was 29.6±9.7 years [Table/Fig-1].

Mean number of hours of work per day was 8.3±1.05. Working hours in a day ranged from six to 12 among welders. Mean work experience was 10.14±9.38 years. It ranged from 1 to 48 years. Mean number of continuous working hours without a break was 4.91±0.74 hours among 131 welders [Table/Fig-2].

Overcrowding at the site was present at 10.3% sites, ventilation status was inadequate at 6.9% sites and exhaust ventilation was not present at 25.9% sites. [Table/Fig-3].

Awareness of occupational health hazards associated with welding was present among 97(62.6%) welders [Table/Fig-4].

First aid kit was present at 60 (38.7%) working sites. Inspection of the contents of the first aid kit was permitted at 27 sites. Contents of the kit included antiseptic cream 24 (88.9%), bandages 24 (88.9%), lubricant eye drops 20 (74.1%), cotton 8 (29.6%) and pain killer medications 5 (18.5%).

Out of the 36 welders who used to undergo prophylactic examination, 28 (28.9%) were aware of occupational health hazards of welding compared to 8 (13.8%) who were not aware (χ²=4.62, p=0.032).

The most common morbidity among participants was wounds 119 (76.8%) [Table/Fig-5]. Among the participants, two did not suffer from any morbidity over the past one year. A total of 20 (12.9%) welders did not suffer from any ocular morbidity.

A total of 38 (24.5%) welders suffered from work related morbidities over the past one month. Mean number of work related morbidities over the past month were 3.5±2.8 (95% CI 2.6101–4.4425). It ranged from 1 to 10 morbidities. Among these welders, six experienced one episode, 13 experienced two episodes, seven experienced three episodes, four experienced four episodes and eight experienced ≥5 episodes. Majority of the welders, 13 (34.2%) out of 38, reported having had two morbidities over the past one month. Co-morbidities like renal calculi, hypertension and diabetes mellitus was reported by two workers each.

Unavailability of protective gears was seen at some of the sites visited by the investigators. It was for face shields at 44 (28.4%), masks at 89 (57.4%), eye goggles at 4 (2.6%), ear muffs at 140 (90.3%), aprons at 144 (92.9%), hand gloves at 36 (23.2%), boots at 120 (77.4%) and respirators at all the sites.

Hand gloves 25 (21%) and aprons 2 (18.2%) were the protective gears not worn by majority of welders [Table/Fig-6].

Non-usage of most essential protective gears such as face shields, masks or eye goggles was seen among 18 (11.6%) welders. Non-usage of protective gears of face and eyes was seen among greater proportion of welders unaware of occupational hazards related with welding 11 (19%) in comparison to those aware about the same 7 (7.2%) (χ²= 4.88, p=0.027).

Reasons for irregular use of protective gears as told by the participants was ignorance of its importance 84 (54.2%) and inconvenience to wear and work as stated by 3 (1.9%) participants.

Eye goggles was used always by 6 (54.5%) proportion of gas welders, 87 (77%) proportion of electric welders, 15 (88.2%) proportion of both types of welders and 5 (50%) proportion of other welders (χ²=7.58, p=0.056). Four welders were not provided with eye goggles at their work places.

Welder’s arc eye or flash burns was reported among 29 (69%) welders who did not use eye goggles every time compared to 22 (19.5%) out of 113 welders who used it every time (χ²=34.1, p<0.001).

Among the welders, 12 (7.7%), 36 (23.2%) and 29 (18.7%) were current smokers, tobacco chewers and alcoholics respectively. Smoking during work was reported by four and tobacco chewing by 17 welders.

Mean number of morbidities over the past one month was found to be associated with duration of continuous working hours and overcrowding at work place [Table/Fig-7].

The mean number of morbidities encountered in the past one month among gas welders (n=5) was 2.2±1.1, electric welders (n=26) was 3.5±2.7 and welders doing both types of welding (n=7) was 4.6±3.8 (F=1.063, p=0.356).

Mean number of morbidities encountered in the past one month was slightly more among welders with work experience more than 20 years (p=0.322). This was probably due to the significant age difference in them (n=4, 38.25±6.65 years) compared to those with ≤20 years of work experience (n=34, 27.9±8.55 years) (t=2.319, p=0.026).

Welding is an occupation involving tremendous health risks. The severity of this risk is determined by several work related issues.

Majority of welders in this study were electric welders as also reported in other studies [21,25,26]. Electric arc welding is reported to produce a greater levels of ultraviolet radiations thus putting welders at greater risk of morbidities [27,28]. The electric arc produces UV light which causes “arc eye” or acute photo kerato-conjunctivitis [29].

Certified training was received by 12.3% welders in this study. This was similar to the observations made in other studies where only 0.4% to 19.1% [6,21,30] welders underwent institutional training.

Apprenticeship programmes graduate trainees based on mastery of skills, and not based on completion of a specific training period [21]. As majority of welders were trained through apprenticeship, they may not have received adequately hands-on training regarding safety measures and knowledge about occupational hazards.

The average working hours per day in a Nigerian study was 7.3±1.4 hours ranging from 5 to 12 hours per day which was lesser than our observations [31]. Similarly, the former study reported that 15.3% participants worked for a long time without rest compared to 20.6% welders who worked continuously for ≥5 hours in a day in the present study [31]. Working beyond normal working hours was reported among 49.7% compared to 57.1% welders in the Nigerian study [31]. From most of these observations we infer that work load was intense among welders in this study. The labour ministry should therefore enforce working guidelines to reduce work load among welders employed in unorganized sector.

A study done in Baroda, India reported that ventilation at 34% work sites surveyed was absent [20]. Considering that harmful fumes are formed as a byproduct of welding process, ventilation needs to be adequate, to avoid respiratory and other ailments among welders.

Occupational morbidities in the preceding year were reported by 98.7% welders compared to 85.3% reported in a Nigerian study [21] and 100% among welders in a study done in Puducherry, India [30].

The most common morbidities in this study were wounds followed by watering and redness of the eyes and back ache. In the study done in Puducherry, India it was abrasions followed by lacerations of extremities, foreign body sensation in the eyes and flash burns over the past year [30].

A study done in Nigeria reported arc eye injuries followed by foreign body sensation in the eyes and body pain as the most common morbidities among welders [19]. Few other studies reported foreign body sensation in the eyes as the most common morbidity among welders [26,32].

Flash burns of eyes was reported in 32.9% cases compared to 17% to 82.8% reported in other studies [19,21,30,32].

History of metal fume fever was reported by 13.5% welders in this study compared to 43.8% reported in another study done in Nigeria [19]. This condition which affects an estimated 30% of welders results from the inhalation of freshly formed oxides, most commonly that of zinc [1].

Foreign body sensation in the eyes was reported in 31.6% cases in this study compared to 70% [19], 93.3% [30] reported in other studies.

In this study, 98.7% welders suffered from one or other morbidities over the past one year compared to 96.4% in a Nigerian study [19].

In this study, duration of continuous work per day, number of persons working together and overcrowding at the site was associated with more number of morbidities in the previous month. Similarly, another Nigerian study reported, work experience less than five years, more than eight hours of work in a day and irregular use of personal protective equipment to be associated with occupational accidents among welders [21].

Awareness of occupational health hazards associated with welding was present among 77.9% to 91.6% welders in other studies [18,19,21,33] compared to 62.6% reported in this study.

Awareness of eye morbidities reported by 68% welders in this study was less than the proportion of 76.1% [18] and 98% [34] mentioned in previous studies.

In a study done in Baroda, India [20] goggles was available at 59% sites, face shield at 77.8% sites and mask at 3.4% sites compared 97.4%, 71.6% and 42.6% availability respectively at sites in this study. Non-usage of any of the recommended protective gears ranged from 4.3% to 61.7% as reported in other studies [18,20,25,26,33].

Usage rate of face shield most of the times in the present study was reported by 66.7% welders compared to 5% to 6.3% by welders in other studies [26,33], masks by 45.5% compared to 0% to 43.5% in other studies [6,19,21,26,33], eye goggles by 74.8% compared to 6% to 86.7% in other studies [6,19,21,26,33,34], ear muffs by 40% compared to 0% to 10.3% in other studies [19,21,33], aprons by 36.4% compared to 16.7% to 31.2% in other studies [19,21,33], hand gloves by 54.6% compared to 20.8% to 50.3% in other studies [19,21,33] and boots by 91.4% compared to 34.5% [21] and 40.7% [33] in other studies.

Welders should be educated to use all protective devices always to minimize the risk of occupational injuries. It would also be appropriate for government to impose a legislation making compulsory use of PPGs always during welding procedures [6].

Reason for poor compliance with protective gear stated by majority of welders in this study was ignorance of its importance as also reported in other studies [20,26,35]. Other reasons stated in previous studies was inconvenience to wear and work [20,26,35], unable to see clearly with eye goggles [26], unavailability [20,26], not trained to use it properly [18,26], not required [20] and not compulsory [18]. Few participants in this study also complained about inconvenience to wear the equipment at work.

Such problems have been solved with availability of more user friendly safety gears now a days. For instance, face shield can be strapped to head while working, leaving both hands free, one to hold the metals to be fused and the other to hold the welding gun. Improvement in the design of eye goggles has improved the visibility and reduced the discomfort during usage. Goggles with auto-darkening filters have come up which change automatically from clear to darkened state after the welding arc is struck [36].

Only 11% welders in this study practiced periodic medical examinations. A Nigerian study reported that only 12.1% among welders wearing reading glasses obtained the same after examination by an ophthalmologist. In majority of cases, it was reported to be purchased over the counter followed by from technicians [25]. From these observations it infers that, welders need to be advised the importance of periodic medical examination by a doctor considering the risk involved in this profession.

In this study, only 38.7% welding sites had first aid kits. Another study done at Puducherry, India observed that none of the welding sites had any first aid kits [18]. Another concern was welders not being trained in basic first aid and other safety measures at work place as reported in a Nepalese study and by 20.5% welders in this study [33]. Thus, all welders should not only be educated about first aid practices against common occupational injuries but should also be provided with first aid kits and trained to use the same.

Institutional training over apprenticeship needs to strengthen with refresher training to improve usage of protective gears. Safety policies need to be instituted and employers need to provide ergonomically suitable and affordable PPGs at work site. Health inspectors need to check efficacy and compliance with safety devices at work places periodically.

The labour ministry should also enforce working guidelines and safe working environment for welders employed in unorganized sectors. Injury surveillance system would help in timely reporting, enquiry and implementation of preventive measures following occupational injuries.

There is a possibility of recall bias involved while participants reported morbidities suffered in the past. Moreover information on socioeconomic status and working pattern was not revealed by some welders.

The period prevalence of morbidity was high among the welders surveyed. Ignorance of health hazards associated with occupation and non-usage of protective gears was reported by number of welders. Therefore, health education of welders and safety policies needs to be strengthened at welding sites.